Scope of this report

Summary

Bowel cancer screening aims to reduce mortality and the incidence of bowel cancer both by detecting cancers and removing polyps, which, if left untreated, may develop into cancer.

The findings in this report relate to the quality assurance visit on Thursday 17 November 2022 to Barking, Havering and Redbridge bowel cancer screening service which is commissioned by London NHS England Public Health Commissioning team. Any commissioning findings are outside the scope of this report and will be followed up directly with the commissioner.

Quality assurance purpose and approach

Quality assurance (QA) aims to achieve and maintain national standards and promote continuous improvement in bowel cancer screening. This is to ensure all eligible people have access to a consistent high-quality service wherever they live.

QA visits are carried out by the NHS England Screening Quality Assurance Service (SQAS).

The evidence for this report comes from the following sources:

• Monitoring of routine data collected by the NHS England
• data and reports from external organisations
• evidence submitted by the provider
• information collected during pre-review visits to Barking Havering and Redbridge bowel cancer screening service on 12 October 2022
• information shared with the London SQAS as part of the visit process.

The screening service

Barking Havering and Redbridge bowel cancer screening programme (BHR BCSP) is provided by Barking Havering and Redbridge University Hospitals NHS Trust (BHRUT). The screening service was formed from North East London Bowel Cancer Screening Centre from which it became independent in 2015.

London was one of the first regions to be impacted by COVID undergoing several lockdowns from March 2020.  This resulted in bowel cancer screening services in London being paused at the end of March 2020. London screening services restarted in late April/early May 2020 following a series of restoration meetings. BHR BCSC has been able to recover by achieving invitation rates of up to two hundred and two percent of the former invitation rate and was fully recovered along with most screening services in London by September 2020.

Programme management, administration, specialist screening practitioner (SSP) assessments, diagnostic tests (colonoscopies and computed tomography colonoscopies (CTCs)) and pathology are undertaken at Queen’s Hospital with additional colonoscopies offered at King George’s Hospital (KGH) which is part of the same Trust. Both endoscopy sites (Queens and KGH) are JAG accredited.

Bowel scope screening was decommissioned from January 2021.  BHR BCSP started its four-year age extension roll out plan inviting fifty-six-year-olds from July 2021 and fifty-eight-year-olds from May 2022. It is expected that all bowel cancer screening services across the country will fully age extend to fifty-year-olds by 2024.  Discussions are shortly going to take place between NHS England (London) and NHS England (Essex) teams around the future bowel cancer screening arrangements for the Epping Forest population and the possibility of transferring to the BHR BCSP.  From April 2023 lynch syndrome screening surveillance will be introduced into the programme. 

Findings

The screening service was able to recover quickly clearing the backlog and maintaining the screening service despite all the challenges.  This was due to a high level of staff dedication and team work.

A substantive Director of Bowel Cancer Screening was appointed in November 2021 with clear reporting lines in the governance structure to escalate risk and incidents.  There is also a clinical programme manager who is supported by a lead specialist screening practitioner.  The screening service has not got in place various deputies including a deputy director of screening, deputy programme manager and deputy lead specialist screening practitioner. 

The screening service is well led with effective communication between team members. 

The screening service has managed to recruit and accredit two further substantive colonoscopists and could further increase resilience by recruiting more substantive colonoscopists to reduce the reliance on locum staff.

The screening service still relies on a lone radiologist and pathology is also under resourced. This poses a risk to the screening service particularly as the screening service expands with new programme developments including age extension, the potential transfer of Epping Forest population and the increase in surveillance cases from lynch syndrome screening in April 2023.

Diagnostic test uptake is low across London but Barking, Havering and Redbridge bowel cancer screening programme (BHR BCSP) is one of two screening services that has the highest diagnostic test uptake in London averaging 78.06%.  The dedication of the specialist screening practitioners (SSP) and their interaction with patients at the SSP assessment will have contributed to this high diagnostic test uptake rate.  

BHR BCSP also meets all other KPIs: caecal intubation with photographic evidence, Adenoma Detection Rate (ADR), and polyp retrieval rates.

There is a new health promotion specialist in post with a good health promotion plan in place working with various organisations such as community links, integrated care boards, cancer alliances and councils for voluntary and primary care.

Immediate concerns

The QA visit team identified no immediate concerns.

Urgent recommendations

The QA visit team identified 3 urgent recommendations. A letter was sent to the Director of Screening and programme manager on 19 November asking that the following item(s) are addressed:

• Urgent Recommendation No 01 – Make sure there is appropriate resource and funding available for pathology to enable the screening service to fully age extend, allowing bowel cancer screening programme pathologists to manage the increase in workload and maintain a high level of service for the bowel cancer screening programme.
• Urgent Recommendation No 02 – Establish an alternative pathway for screening positive patients who are deemed unfit for either colonoscopy or computed tomography colonoscopy (CTC) to be managed outside of the screening programme.  Minimal preparation CT without carbon dioxide insufflation cannot be performed as the only radiological test accepted within the bowel cancer screening programme is a full CT colonography.
• Urgent Recommendation No 03 – Make sure that all patient identifiable data is transferred between screening sites in line with information governance regulations using a hospital courier or electronic transfer.  Standard operating procedures to be updated with staff being made aware of the new process and reminding them of the importance in adhering to information governance regulations. 
• A response including an action plan was received informing the visiting QA of the steps taken to partially resolve the urgent recommendation(s).

Examples of practice that can be shared

The QA visit team identified several areas of practice for sharing, including:

• production of a detailed annual report
• daily task allocation for the administration team
• computed tomography colonography (CTC) radiographers participating in the Health Education England (HEE) pan London CTC training initiative
• use and updating of a daily patient tracking list (PTL)
• Good health promotion plan and activities to improve uptake

Recommendations

The following recommendations are for the provider to action unless otherwise stated.

Next steps

The screening is responsible for developing an action plan in collaboration with the commissioners to complete the recommendations contained within this report.

SQAS will work with commissioners to monitor activity and progress of the recommendations for 12 months after the report is published. After this point SQAS will send a letter to the provider and commissioners summarising progress made and will outline any further action(s) needed.

Appendix A: References

1. Bowel cancer screening accreditation Bowel cancer screening accreditation
2. Bowel cancer screening programme: guidelines for CTC imaging Bowel cancer screening imaging use
3. Bowel cancer screening programme: standards Bowel cancer screening programme standards
4. Bowel cancer screening: guidelines for colonoscopy Bowel cancer screening colonoscopy quality assurance
5. Bowel cancer screening: helping people with learning disabilities Bowel cancer screening helping people with learning disabilities
6. Bowel cancer screening: managing incidents Bowel cancer screening managing incidents
7. Bowel cancer screening: pathology guidance on reporting lesions Bowel cancer screening reporting lesions
8. Bowel cancer screening: programme overview Bowel cancer screening programme overview
9. Bowel cancer screening: programme specific operating model Bowel cancer screening programme specific operating model
10. Bowel cancer screening: specialist screening practitioner Bowel cancer screening specialist screening practitioner
11. Cancer screening: informed consent Cancer screening informed consent
12. Joint advisory group on GI Endoscopy The JAG
13. Key Performance Indicators NHS screening programmes Antenatal, newborn, young person and adult NHS population screening: reporting data definitions
14. Managing Safety Incidents in NHS Screening Programmes Managing safety incidents in NHS screening programmes
15. NHS BCSP Quality Assurance arrangements for the NHS Bowel Cancer Screening Programme, Draft version 2.1 (December 2010)
16. NHS England Serious Incident Framework – Supporting learning to prevent recurrence (March 2015) Serious incident framework
17. NHS population screening: pathway requirements specifications Bowel cancer screening pathway requirements specifications
18. PHE Screening inequalities strategy PHE Screening inequalities strategy
19. Public health profiles Public health profiles
20. Section 7a screening service schedules no 26 BCSP Schedules 2022-23 – NHS Public Health Commissioning & Operations – Future NHS Collaboration Platform