Scope of this report
| Topic | 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 | Partly | Not applicable |
| 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 22 March 2023 to Heart of England Screening Service which is commissioned by Vaccination & Screening Programmes NHS England – Midlands Region (West) 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, promote continuous improvement in bowel cancer screening and support reducing health inequalities. This is to ensure 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 and external organisations
- discussion with the commissioner in advance of the visit
- information shared with the Midlands and East SQAS as part of the visit process.
The screening service
The Heart of England screening service provides bowel cancer screening for an eligible population of approximately 80,555 and a residential population of 1,087,579 across 100 GP practices in the geography. There are three Integrated Care Systems (ICBs) that cover Heartlands, Solihull, Sutton Coldfield, Lichfield, Tamworth and Burntwood – NHS Birmingham and Solihull, NHS Staffordshire and Stoke on Trent and NHS Coventry and Warwickshire.
The screening service started inviting men and women aged 60 to 69 years for faecal occult blood test screening in February 2007. In November 2011 the service extended the age range covered to include 70 to 74 year olds. Bowel scope screening for men and women aged 55 began in November 2016, however it was decommissioned in April 2021. In June 2019, the new faecal immunochemical test (FIT) screening was introduced. The centre began inviting 56 years olds as part of the age extension plan on 31 March 2022 and are preparing to invite 58-year-olds before the end of March 2023.
University Hospitals Birmingham NHS Foundation Trust are the host Trust for the service. The Trust formed on 1 April 2018 following the merger of UHB with Heart of England NHS Foundation Trust, which includes Queen Elizabeth, Birmingham Heartlands, Good Hope and Solihull Hospitals. There are no associate Trusts involved in service delivery.
Service co-ordination takes place at Good Hope Hospital. The following table identifies the hospital sites involved in providing the UHB screening service.
| Site | Admin | SSP | Colonoscopy | Radiology | Pathology |
| Good Hope Hospital | Yes | Yes | Yes | Yes | No |
| Solihull Hospital | No | Yes | Yes | Yes | No |
| Heartlands Hospital | No | Yes | No | No | Yes |
Colonoscopy is provided at two sites, but job plans do not allow for colonoscopists to cover across sites. All SSP assessments are currently carried out via telephone unless a face to face appointment is deemed necessary. The service is looking to provide virtual clinics soon.
The screening programme Midlands and Northwest Hub based in Rugby undertakes:
- the invitation (call and recall) of individuals’ eligible for FIT screening
- the testing of screening samples, and
- onward referral of individuals needing further assessment.
Activities carried out by the hub are outside the scope of this QA visit.
Findings
During the visit the SQAS team were provided with the opportunity to have open and honest conversations with all members of the screening team and Trust management.
The service has a dedicated team and showed good resilience during the COVID-19 pandemic in recovering the programme. The Clinical Director (CD) is supported by the Lead SSP (LSSP) and Programme Manager (PM) and they have a good working relationship. There are issues with BCSP colonoscopist job plans which impacts on the ability to utilise all the scheduled BCSP colonoscopy lists. The service is currently meeting the demand by using ‘retire and return’ consultants and are able to provide additional weekend lists when required.
The service meets or exceeds most of the key performance indicators and provides a service of good clinical quality to the local population. Diagnostic test waits standard has been in standard since January 2023, although this was not the case for the most part of the last five years. Only 3 out of 7 BCSP colonoscopists achieved the programme standard of carrying out 120 colonoscopies per year in 2021 and 2022. BCSP radiologists also have not achieved the standard to carry out 120 CTC cases per year. Action plans are needed to address these issues.
Since the last QA visit there has been significant organisational change. As a result, some governance arrangements and meeting structures still need formalising. These structures are important to share practice, discuss policies, performance, incidents and operational issues and ensure consistency in practice.
The BCSP team is aware of the lack of audits and the need to re-establish health promotion and health inequality work and is keen to address these.
With BCSP programme expansion, current and future operational delivery planning and ensuring resilience within the service is key. This will require additional Trust support for continued success.
Immediate concerns
The QA visit team identified no immediate concerns.
High priority findings
The QA visit team identified three high priority findings as summarised below:
- the governance processes remain unclear and the BCSP service has experienced issues with escalation. Strong governance processes are required to ensure risk is managed in an appropriate way
- there are significant demand and capacity issues facing this service currently and in the future. There is a lack of resilience in the staffing and succession planning, as reflected in the service’s underutilisation of its endoscopy capacity
- only 3 of 7 BCSP colonoscopists achieved the programme standard of carrying out 120 colonoscopies per year in 2021 and 2022. BCSP radiologists also have not achieved the standard to carry out 120 CTC cases per year. The BCSP team should ensure that team members achieve national standards and job descriptions, job plans and action plans are able to facilitate this.
Examples of practice that can be shared
The QA visit team identified several areas of practice for sharing, including:
- BCSP CTC radiographers take part in the Higher Education England supported CTC training programme
- SSPs are scheduled to attend every BCSP CTC appointment with the patient in the radiology department
- polyp site checks are managed via an Excel spreadsheet that assists with planning for endoscopy capacity and analysis of previous data
- numerous research papers in the context of BCSP and complex polyps have been published
- very good, in-depth management of complex polyps standard operating procedure (SOP) and patient leaflet. Good practice to ensure patient is specifically consented with risk and benefit of more a complex procedure.
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 | University Hospitals Birmingham NHS Foundation Trust (UHB) to document how programme performance issues and risks are reported, escalated, and managed within the Trust governance systems | 20 | 6 months | Standard | Copy of the organisational chart and escalation pathway |
| 02 | Amend the job plan/job description of the Clinical Director (CD) to specify adequate PA sessions so that all BSCP duties can be carried out and sustained and account for programme changes | 20 | 3 months | Standard | A copy of the updated job plan/ job description |
| 03 | Put in place regular meetings with the CD, Programme Manager (PM) and Lead Specialist Screening Practitioner (LSSP) to discuss issues and escalation | 20 | 3 months | Standard | Copies of meeting minutes |
| 04 | Ensure the job descriptions for the PM and LSSP are ratified and signed off through a governance process | 20 | 3 months | Standard | A copy of the updated job description |
| 05 | UHB and Heart of England BCSP to put in place regular Trust governance and bowel screening meetings with clear lines of reporting to ensure clear routes of escalation for screening to meet the contract requirements | 20 | 3 months | Standard | Update the governance standard operating procedure (SOP) and submit with a revised meeting structure, showing lines of report, terms of reference and planned meeting dates Meeting agendas and minutes of next meeting covering: ongoing monitoring, incident, risk, performance and practice discussion |
| 06 | Expand the demand and capacity and BCSP workforce plans covering all specialties to look at future service needs, succession plans with particular emphasis on increasing endoscopy capacity | 20 | 6 months | Standard | A copy of the updated demand and capacity plan Workforce plan to meet activity demands and monitoring arrangements |
| 07 | Develop a standard operating procedure (SOP) detailing how the programme manages capacity to meet changes in service demands | 20 | 6 months | Standard | A copy of the SOP |
| 08 | Ensure a Screening QA Service (SQAS) new site application is approved for Heartlands Hospital’s before BCSP lists are held | 20 | 6 months | Standard | Approval from the National Screening QA Service office |
| 09 | Update the quality management system (QMS) with review dates following ratification and introduce a system to ensure all staff are notified of changes and aware of the latest SOPs | 20 | 6 months | Standard | A copy of the revised QMS index with sign off dates. Copies of agendas showing QMS as a standing item. |
| 10 | Ensure all SOPs link clearly to detailed processes, are version controlled and ratified | 20 | 6 months | Standard | A copy of a selection of SOPs |
| 11 | Develop a detailed BCSP annual report and present to relevant governance committees | 20 | 12 months | Standard | A copy of the annual report and evidence of Trust board and programme board discussions |
| 12 | Develop a SOP for the management of individuals who are assessed against the updated polyp surveillance guidelines to support this process. This should include details of SSPs and colonoscopists responsibilities for managing surveillance pathways | 22 | 3 months | Standard | A copy of the SOP |
| 13 | Develop a computed tomography colonography (CTC) SOP to include management of adverse events, incidents, and complications | 3 | 3 months | Standard | A copy of the SOP |
| 14 | Complete a health equity audit and develop a health promotion strategy with support of PHC to reduce inequalities in the bowel screening population served by Heart of England screening service | 6, 18, 20 | 6 months | Standard | Copy of health equity audit and health promotion strategy |
| 15 | Establish an annual audit schedule covering all professional areas involved in the BCSP and arrangements to share and implement the learning from audits | 20 | 6 months | Standard | Audit schedule and minutes of the meeting where it was ratified/ evidence of actions taken |
| 16 | In addition to the audits in the BCSP guidelines for CTC imaging document, audits should be collected with respect to: CTC radiation dose patient experience survey a positive predictive value audit (either as part of a whole service CTC audit or as a focussed audit of BCSP cases within the service) | 3 | 12 months | Standard | Copies of audits |
| Infrastructure | |||||
| 17 | Amend the job description of the BCSP administration team staff to specify all BSCP duties carried out after changes were made during COVID-19 (copy not submitted with evidence) | 20 | 3 months | Standard | A copy of the job description |
| 18 | Amend the job plan/job description of the BSCP colonoscopists to specify adequate BCSP sessions, cross-site cover arrangements and clinical activity so that all BSCP duties can be carried out and sustained | 20 | 3 months | High | A copy of the job description |
| 19 | Expand the demand and capacity and BCSP workforce plans covering all specialties to look at future service needs, succession plans with particular emphasis on increasing endoscopy capacity to ensure a sustainable plan is in place to deliver the expanding service | 20 | 6 months | High | A copy of the demand and capacity plan and workforce plan |
| 20 | Adapt BCSP radiology lead job description for local use | 3 | 6 months | Standard | A copy of the job description |
| 21 | Develop/ revise job description/ job plan of Lead Pathology to specify adequate BCSP sessions/ PA so that all BSCP duties can be carried out and sustained (no evidence submitted for the visit) | 20 | 6 months | Standard | A copy of the job description/ job plan |
| 22 | Ensure all SSPs have access to the Trusts system for booking BCSP CTCs | 20 | 6 months | Standard | Confirmation of access for all SSPs |
| Pre-diagnostic assessment | |||||
| 23 | Demonstrate all SSPs have attended the required advanced communications course | 11, 20 | 12 months | Standard | Course booking/ certificate of attendance |
| 24 | Ensure all high grade and polyp cancers identified within the BCSP are double reported in accordance with Royal College of Pathology/BCSP dataset and recorded on BCSS. Update the SOP for recording double reporting on BCSS | 8 | 3 months | High | Confirmation from Lead Pathologist A copy of the SOP |
| 25 | Provide an updated SOP to include the process followed should interpreter services be required when taking a patients consent and reference the Trust policy for providing translation services | 20 | 3 months | Standard | A copy of the SOP |
| Diagnosis | |||||
| 26 | Review allocation of colonoscopy procedures to ensure all BCSP colonoscopists meet the national standard for the minimum number of 120 colonoscopies per year | 5, 13 | 12 months | High | Action plan Evidence of standard being met from BCSS |
| 27 | Demonstrate sustained achievement of national waiting times for individuals requiring a diagnostic test from SSP clinic | 4 | 12 months | High | Action plan detailing changes to be made Standard achieved in successive quarters (within 12 months of visit) |
| 28 | A SOP for the management of patients on anti-coagulation and anti-platelet therapies in accordance with British Society of Gastroenterologists (BSG) guidelines | 21 | 3 months | Standard | A copy of SOP and evidence of sign off by all relevant staff |
| 29 | Support all BCSP radiologists to carry out 120 CTC cases per year (symptomatic and screening) and collect individual audit data | 3 | 12 months | High | Confirmation of CTCs performed by each BCSP reporting radiologist in previous 12 months following annual audit |
| 30 | Develop a SOP for current practice regarding radiological assessment of fitness for bowel preparation | 3 | 3 months | Standard | A copy of the SOP |
| 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
- Midland Public Heath Commissioning Inequalities Strategy (Screening and Immunisations) 2021
- 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
- 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
- https://fingertips.phe.org.uk/Public health profiles Public health profiles
- Section 7a screening service schedules no 26 BCSP Schedules 2022-23 – NHS Public Health Commissioning and Operations – Future NHS Collaboration Platform
- BSG update in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: BSG and ESGE guidance update 2021 Update: Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: BSG & ESGE Guidelines Update – The British Society of Gastroenterology
- List of recommendations from the BSG/ACPGBI/PHE Post polypectomy and post-colorectal cancer resection surveillance guidelines List of recommendations from the BSG/ACPGBI/PHE Postpolypectomy and post-colorectal cancer resection surveillance guidelines – The British Society of Gastroenterology