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Scope of this report
| Covered by this report? | If ‘no’, where you can find information about this part of the pathway | |
|---|---|---|
| Underpinning functions | ||
| Uptake and coverage | Yes | Not applicable |
| Workforce | Yes | Not applicable |
| IT and equipment | Yes | Not applicable |
| Commissioning | Yes | Partly |
| Leadership and governance | Yes | Not applicable |
| Pathway | ||
| Cohort identification | No | Bowel cancer screening hub |
| Invitation and information | No | Bowel cancer screening hub |
| Testing | No | Bowel cancer screening hub |
| Results and referral | No | Bowel cancer screening hub |
| Diagnosis | Yes | Not applicable |
| Intervention / treatment | Yes | Not applicable |
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 10 March 2023 to the Cumbria and Morecambe Bay Screening Service which is commissioned by the Public Health Commissioning teams of NHS England North West (lead commissioners) and NHS England North East North Cumbria. 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, promote continuous improvement in bowel cancer screening and support reducing health inequalities. This is to make sure all eligible people have access to a consistent high quality, effective, equitable and safe 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(s) and external organisations
- discussion with the commissioner in advance of the visit
- information shared with the North West SQAS as part of the visit process
The screening service
The Cumbria and Morecambe Bay bowel cancer screening service started inviting men and women aged 60 to 69 years for faecal occult blood test screening in March 2008 in Cumbria and June 2008 in North Lancashire. In 2010, the service extended the age range to include 70 to 74 year olds. Bowel scope screening (BoSS) began in October 2015, inviting men and women aged 55 before the service was decommissioned in 2021. In June 2019, the new faecal immunochemical test (FIT) screening was introduced. In May 2022, the centre age extended to include 56 year olds, and to 58 year olds in September 2022.
University Hospitals of Morecambe Bay NHS Foundation Trust (UHMB) is the host trust for the service. They also have an associate trust, North Cumbria Integrated Care NHS Foundation Trust (NCIC). Service co-ordination and administration for the service takes place at Westmorland General Hospital (WGH) but office space for administration and nursing staff is also provided from Cumberland Infirmary (CI).
The service delivers 10 to 11 specialist screening practitioner (SSP) clinics each week, depending on demand. Clinics are currently run as telephone assessments, as a result of the Covid-19 pandemic. The service offers face to face appointments to those participants who need or request it. Four colonoscopy lists are carried out at WGH each week, one list at the Royal Lancaster Infirmary (RLI) site and four lists at CI.
Pathology for the programme is processed and reported on for the programme by both trusts at the RLI and CI sites. Radiology computerised tomography colonography (CTC) services for the programme is performed and reported on at four sites: RLI; CI; Furness General Hospital (FGH); West Cumberland Hospital (WCH).
The population invited is from the North East and North Cumbria Integrated Care Board (ICB) and the Lancashire and South Cumbria ICB. The current eligible registered population is approximately 149,000.
The commissioner of the Cumbria and Morecambe Bay bowel cancer screening service is NHS England North West (lead commissioners) and NHS England North East North Cumbria. The public health commissioning team of NHS England North West is led by the head of public health and a principle screening and immunisations manager.
Findings
The programme showed great resilience to recover from the pause in screening caused by the Covid-19 pandemic. It has since gone on to extend the programme invitation to 56 and 58 year olds.
The clinical director and lead SSP, though relatively new to the roles, provide strong clinical leadership to programme. However, another key member of the senior leadership team, the programme manager, has not been in work for some time and this has affected the programme’s ability to plan for this visit.
The programme has not been able to appoint a lead radiologist for several years and this has led to this element of the pathway not being fully integrated into the wider programme team and its associated opportunities for quality improvement and service development.
This is a service that generally meets or exceeds the achievable threshold for the programme’s standards and provides a good quality of endoscopy for screening participants. However, colonoscopist capacity needs to grow to meet the demands of the service as it is frequently supported by the insourcing of colonoscopists.
Two recommendations from the last visit in May 2017 are still outstanding: to increase the number of screening colonoscopists; for Cumberland Infirmary to achieve JAG accreditation. Comments regarding these issues can be found within the report.
Immediate concerns
The QA visit team identified no immediate concerns. However, there were several items of required evidence unavailable at the time of the visit. It was agreed that the programme would produce a workplan to address these gaps in evidence and QA would revisit the screening centre within the year to monitor progress.
High priority findings
The QA visit team identified four high priority findings as summarised below:
- The programme’s Clinical Director needs protected time within their job plan so that they can appropriately lead the screening centre, support their team and develop the service.
- UHMB requires a named lead radiologist and radiographer for the programme to have overview of the service and make sure that the requirements of the programme are met.
- The screening centre needs to increase the number of accredited colonoscopists available at each trust so that it can meet the rising demand and growth of the programme.
- The CTC referral system at UHMB needs to be able to clearly identify BCSP patients so that they can be appropriately managed according to programme protocols.
Examples of practice that can be shared
The QA visit team identified several areas of practice for sharing, including:
- The Lead SSP has developed a handbook for the SSPs that provides them with an excellent resource to plan out their duties and detail their role and the associated programme requirements of them.
- An induction folder for new BCSP reporting pathologists has been developed by the lead pathologist.
- A biomedical scientist is being trained to undertake and extended role which will include BCSP reporting to provide resilience within the pathology service at RLI.
Recommendations
The following recommendations are for the provider to action unless otherwise stated.
| No. | Recommendation | Reference | Timescale | Priority | Evidence required |
| Service provider and population served | |||||
| No recommendations made in this section | |||||
| Governance and leadership | |||||
| 01 | Incorporate associate site level and clinician level data in the performance report for the associate trust to provide them with a monitoring mechanism of their own performance and contribution to the programme | 3, 20 | 6 months | Standard | Copy of the programme performance report produced for the associate trust |
| 02 | Ensure that the Clinical Director has sufficiently protected time in their job plan to lead the programme | 20 | 12 months | High | Copy of the updated job plan |
| 03 | Ensure that UHMB has a named lead BCSP radiologist and radiographer, with the positions detailed in their job plan | 2, 20 | 6 months | High | Confirmation from the lead radiologist and lead radiographer that they have been formally appointed as leads for BCSP at UHMB |
| 04 | Colonoscopists involved in the programme should receive their own BCSP performance data on a regular basis and have opportunity to discuss this with their clinical director and peer group of clinicians | 3, 4, 20 | 6 months | Standard | Confirmation from the clinical director that the data is being shared regularly |
| 05 | Ensure that adverse events and incidents that could occur across the whole pathway are considered and detailed in the screening centre SOP so that the reporting and management of such events is clear to radiology colleagues | 2, 6, 14, 20 | 6 months | Standard | Copy of the updated SOP to include radiology events |
| 06 | Update (and have them appropriately ratified) all administrative SOPs that form part of the programme’s quality management system | 15, 20 | 12 months | Standard | Copy of ratified SOPs: Admin01-10 |
| 07 | Limit the administrative use of patient tracking spreadsheets to failsafe mechanisms and only when data cannot be provided by BCSS | 20 | 3 months | Standard | Confirmation from the lead administrator that the use of spreadsheets has been appropriately limited |
| 08 | Obtain ‘dashboard user’ access to BCSS for all programme administrators to enable them to provide reports to the senior leadership and support programme wide audits | 3, 20 | 3 months | Standard | Confirmation that access has been obtained |
| Infrastructure | |||||
| 09 | Increase the number of screening colonoscopists at both trusts to ensure the programme has a sufficiently robust accredited workforce to manage the workload of the programme | 1, 3, 4, 20 | 12 months | High | Accreditation of additional colonoscopists |
| 10 | Radiographers and radiologists involved in the programme to attend BCSP relevant study sessions when applicable | 2, 20 | 12 months | Standard | SQAS will monitor attendance at events |
| Pre-diagnostic assessment | |||||
| 11 | Develop a process for the management of patients who decline their full SSP clinic assessment (potentially add this to SSP06) | 20 | 6 months | Standard | Copy of the updated SOP for managing patients that decline their SSP or diagnostic procedure appointment |
| Diagnosis | |||||
| 12 | Develop a process for the initial checking and monitoring of BCSP performance of colonoscopists employed through external agencies | 1, 3, 4, 12 | 6 months | Standard | Copy of the SOP |
| 13 | Document a large polyp management pathway and guidelines for consistency of practice that provides a clear process for the referral of patients to the complex polyp MDT meetings | 4, 20 | 6 months | Standard | Copy of the updated SOP |
| 14 | As a clinical team assess and discuss the use of sedation at colonoscopy and its impact upon patient comfort scores | 3, 4, 20 | 12 months | Standard | Copy of the meeting minutes where this topic is discussed |
| 15 | Patients being referred for CTC at UHMB sites must be clearly labelled as BCSP patients on the electronic referral system so that they can be managed according to programme protocols and reported by BCSP radiologists | 2, 20 | 6 months | High | Confirmation by the clinical director or lead SSP that the electronic referral system allows this |
| 16 | Ensure the programme’s radiology minimum dataset can be fully recorded from the CTCs carried out by UHMB through the use of a reporting template | 2, 3 | 6 months | Standard | Copy of the reporting template and confirmation from the lead SSP of its use |
| 17 | Provide sufficient BCSP pathologist capacity to enable timely reporting of histology so the programme achieves the expected programme pathology turnaround time standard of 7 days | 3, 7 | 3 months | Standard | Confirmation from the lead pathologist at NCIC that the newly appointed pathologists have started to report for BCSP |
| Referral | |||||
| No recommendations made in this section | |||||
Next steps
The screening service 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
- Bowel cancer screening accreditation Bowel cancer screening accreditation
- Bowel cancer screening programme: guidelines for CTC imaging Bowel cancer screening imaging use
- Bowel cancer screening programme: standards Bowel cancer screening programme standards
- Bowel cancer screening: guidelines for colonoscopy Bowel cancer screening colonoscopy quality assurance
- Bowel cancer screening: helping people with learning disabilities Bowel cancer screening helping people with learning disabilities
- Bowel cancer screening: managing incidents Bowel cancer screening managing incidents
- Bowel cancer screening: pathology guidance on reporting lesions Bowel cancer screening reporting lesions
- Bowel cancer screening: programme overview Bowel cancer screening programme overview
- Bowel cancer screening: programme specific operating model Bowel cancer screening programme specific operating model
- Bowel cancer screening: specialist screening practitioner Bowel cancer screening specialist screening practitioner
- Cancer screening: informed consent Cancer screening informed consent
- Joint advisory group on GI Endoscopy The JAG
- Key Performance Indicators NHS screening programmes Antenatal, newborn, young person and adult NHS population screening: reporting data definitions
- Managing Safety Incidents in NHS Screening Programmes Managing safety incidents in NHS screening programmes
- NHS BCSP Quality Assurance arrangements for the NHS Bowel Cancer Screening Programme, Draft version 2.1 (December 2010)
- NHS England Serious Incident Framework – Supporting learning to prevent recurrence (March 2015) Serious incident framework
- NHS population screening: pathway requirements specifications Bowel cancer screening pathway requirements specifications
- PHE Screening inequalities strategy PHE Screening inequalities strategy
- Public health profiles Public health profiles
- Section 7a screening service schedules no 26 BCSP Schedules 2022-23 – NHS Public Health Commissioning & Operations – Future NHS Collaboration Platform