NHS England » Screening quality assurance visit report – Lancashire Bowel Cancer Screening Service

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
Workforce	Yes
IT and equipment	Yes
Commissioning	Yes	Partly
Leadership and governance	Yes
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
Intervention/treatment	Yes

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 24/25 January 2024 to the Lancashire Screening Service which is commissioned by the Public Health Commissioning teams of NHS England North West. 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 SQAS as part of the visit process .

The screening service

The Lancashire bowel cancer screening service started inviting people aged 60 to 69 years for faecal occult blood test screening in April 2008. In April 2010, the service extended the age range to include 70 to 74 year olds. Bowel scope screening began in April 2014, inviting people aged 55. The centre managed to roll out eight lists across three sites, before the service was decommissioned in 2021. In June 2019, the new faecal immunochemical test (FIT) screening was introduced. In August 2022, the centre age extended to include 56 year olds with further extensions to 58 year olds in November 2022 and 54 year olds in April 2023.

Blackpool Teaching Hospitals NHS Foundation Trust (BTH) is the host trust for the service. It has associate trusts at East Lancashire Hospitals NHS Trust (ELH) and Lancashire Teaching Hospitals NHS Foundation Trust (LTH).

The service delivers around 20 specialist screening practitioner (SSP) clinics each week, depending on demand. These clinics are face to face appointments and distributed across the geography. The SSP and programme administrative team moved to new office accommodation in January 2024 at Blackpool Football Club Stadium.

The service currently delivers 13-14 colonoscopy lists per week from Blackpool Victoria Hospital (part of BTH), the Royal Preston Infirmary and Chorley and South Ribble Hospital (part of LTH) and Burnley General Hospital (part of ELH). The radiology services provide computed tomographic colonography (CTC) for the programme at all the above hospitals as well as at the Royal Blackburn Hospital (ELH). Pathology is carried out at laboratories at the Blackpool, Blackburn and Preston sites.

The population invited is from (but not exclusively) Lancashire and South Cumbria ICB. The local authorities (districts) covered by the programme include Blackburn with Darwen (unitary), Blackpool (unitary), Burnley, Chorley, Fylde, Hyndburn, Pendle, Preston, Ribble Valley, Rossendale, South Ribble, West Lancashire and Wyre. The current registered population (all age) is approximately 1.5 million.

The commissioner of the Lancashire bowel cancer screening service is NHS England North West. 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 clinical director, programme manager and lead SSP, as a senior management team, provide supportive and consistent leadership to a programme team, covering a large geographical area.

Underlying issues of capacity in endoscopy and pathology, mean that the service has been unable to meet the programme standards for diagnostic test wait and pathology reporting turnaround times. More detail on these is provided in the report. However, this is a service that generally performs well against the endoscopy quality standards.

The programme has a range of appropriate policies and procedures in place to ensure patients are kept safe and receive appropriate care as they move through the pathway.

As often seen in programmes with multiple trusts involved in the delivery, some aspects of the service are trust specific and do not have oversight as an overall pathway element. This can lead to gaps in quality improvement work such as expected audits in the radiology and pathology pathway elements.

Four recommendations from the last visit in November 2018 are still outstanding: sub-contract with an associate trust; a pathology audit programme; dose and positive predictive value audits from the radiology services; CTC referral process checks audit. Comments regarding these issues can be found within the report where necessary.

Immediate concerns

The QA visit team identified no immediate concerns. However, the underlying issue concerning endoscopy capacity is one that needs urgent attention and the commissioner is due to hold a multi-stakeholder meeting to address this.

High priority findings

The QA visit team identified five high priority findings as summarised below:

The programme does not have sufficient endoscopy capacity to meet the screening demands of the local population. Currently this amounts to a shortfall of four-five lists each week and has led to the service not meeting the programme’s diagnostic test waiting times standard for several years. There are no sub-contracts in place with the two associate trusts to provide the capacity the programme requires and this needs to be quickly addressed with the support of commissioners.
The service does not meet the pathology turnaround time programme standard. This is mainly due to capacity issues at ELH.
The programme requires a detailed workforce and estate plan to provide a clear strategy to ensure it has the resilience to deal with further age extension and any future changes to the programme.
The programme needs to reinstate the large/complex polyp multidisciplinary team (MDT) meeting and clarify its process for the management and referral of these polyps.
Colonoscopy under general anaesthetic is currently not available for Lynch Syndrome patients in the programme.

Examples of practice that can be shared

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

The programme provides a high standard of reporting, management of, and learning from adverse events and incidents.
Health promotion work to help reduce inequalities in the uptake of screening has been at the heart of the service since its inception. The programme works with stakeholders on a list of projects that are nationally recognised, and some have been evaluated by academic institutions.
Appointment of a ‘case tracker’ at the pathology laboratory at ELH to manage queries relating to programme histology, thereby reducing pressure on consultant histopathologist time.
The programme has a member of the nursing team responsible for staff wellbeing which includes training staff, providing a comprehensive resource folder and ensuring the team are aware of trust related initiatives.

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
Governance and leadership
01	Put in place written agreements between the host trust (BTH) and the associate trusts (ELH and LTH) for the provision of an equitable screening service that meets the demands of the population	20	6 months	High	Sub-contracts signed by relevant parties
02	Ensure all pathology laboratories meet the programme standard for pathology reporting turnaround times	3, 7	12 months	High	Programme standard performance data
03	Amend the job plan of the programme’s lead radiologist to specify adequate sessions so that all BSCP leadership duties can be carried out and sustained	2, 20	12 months	Standard	Copy of the job plan
04	Update / amend BTH trust incident policy to include reference to managing screening incidents in accordance with “Managing Safety Incidents in NHS Screening Programmes”	14	6 months	Standard	Updated policy ratified through trust governance structure
05	Update the programme’s annual audit schedule to ensure it encompasses all expected audits along the BCSP pathway	20	6 months	Standard	Audit schedule with named lead for each audit, date next audit is due, and details of how discussion of audit findings will be shared
06	Undertake audits of complex polyps, endoscopic mucosal resections (EMR) and benign polyps undergoing surgery and take appropriate action on the findings	4	12 months	Standard	Copy of the audits
07	Carry out an audit of colorectal cancer reporting against RCPath dataset (ELH only)	7	12 months	Standard	Copy of the audit
08	Perform a data quality review of pathology and radiology data recorded in BCSS	2, 7, 20, 21	12 months	Standard	Summary of review findings and correction of data and drop downs in BCSS
09	Perform patient satisfaction surveys for CTC services at all sites	2	12 months	Standard	Report on the survey results
10	Ensure that processes relating to the filing of patient paper records by administrative staff, comply with trust information governance protocols	17, 20	3 months	Standard	Confirmation from the programme manager that processes have been checked for compliance with trust protocols
Infrastructure
11	Develop and implement a workforce and estate plan to ensure the programme has the resilience to meet the existing and future screening needs of its local population	20	6 months	High	Copy of the plan
12	Ensure all SSPs are enrolled to start on a university accredited academic module for BCSP (within 12 months from date of employment)	10, 20	3 months	Standard	Confirmation from the lead SSP
Pre-diagnostic assessment
13	Review patient information on clinic sites to include options for public transport accessibility	10, 20	3 months	Standard	Confirmation from the lead SSP
Diagnosis
14	Document a large/complex polyp management pathway and referral process and reinstate the complex polyp MDT meetings	4, 20	6 months	High	Confirmation from the clinical director that the MDT has been reinstated and a copy of the pathway and referral process
15	Define a process for clinical administration and patient reviews to take place in an appropriate setting with sufficient time for decision making	4, 20	6 months	Standard	Confirmation from the clinical director that this has been discussed and a process has been agreed
16	Develop a plan to provide colonoscopy under general anaesthetic for Lynch Syndrome patients within BCSP	22	6 months	High	Confirmation from the clinical director
17	Ensure the radiology service at LTH meets the requirement of the programme	2	3 months	Standard	Copy of the evidence items requested for the QA visit (Rad01, Rad 05, Rad07, Rad11)
18	Establish a process to cover when the single BTH radiologist is not able to report CTC for the programme	2	3 months	Standard	Confirmation from the lead radiologist (for the programme) and lead radiologist (BTH) that a process has been agreed that complies with programme guidance
19	Ensure that all CTC reporting templates contain the radiology minimum dataset information	2	6 months	Standard	Copy of sample reporting templates
20	Carry out radiation dose audits of 50 patients, once suggested changes to improve practice have been implemented (ELH and BTH)	2	12 months	Standard	Copy of the audits
21	Develop a formal induction and mentoring/support plan for histopathologists that begin to report BCSP cases (all sites)	7	6 months	Standard	Confirmation from lead pathologists at all sites
Referral – no recommendations made

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

How to use OBIEE for identifying data entry errors. NHS England (April 2022)

Colonoscopic surveillance for patients with Lynch Syndrome. NHS England (August 2023) (Futures)

Cookies on the NHS England website