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 | |
| Leadership and governance | Yes | |
| Pathway | ||
| Cohort identification | Yes | |
| Invitation and information | Yes | |
| Testing | Yes | |
| Results and referral | Yes | |
| Diagnosis | No | Screening centre QA visit reports |
| Intervention / treatment | No | Screening centre QA visit reports |
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 25 and 26 September 2024 to the North East Bowel Cancer Screening Programme Hub, which is commissioned by NHS England North East and Yorkshire 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(s) and external organisations
- discussion with the commissioner in advance of the visit
- information shared with the national bowel SQAS as part of the visit process
The screening service
The North East Bowel Cancer Screening Programme Hub is located in the Queen Elizabeth Hospital in Gateshead. It is hosted by Gateshead Health NHS Foundation Trust.
The hub commenced screening in 2007 with guaiac faecal occult blood test (FOBt) screening and moved to faecal immunochemical testing in June 2019.
The hub covers a total population estimated to be around 9 million across the North East, Yorkshire and Humber areas and works in partnership with 9 local screening centres, 4 integrated care boards and 1,037 GP practices.
NHS England North East and Yorkshire are the lead commissioners for the service.
The hub is situated within the Queen Elizabeth Hospital and the premises are shared with Point of Care Testing.
The layout of the hub is clear with specific areas for each function and adequate space to work.
Building works have recently been undertaken to provide additional laboratory space to accommodate the increase in workload associated with the continued expansion of the eligible population for bowel cancer screening.
All members of staff were welcoming, approachable and care about the service they provide.
Observational sessions were held during the visit in both the laboratory and helpline areas.
From April 2023 to March 2024, the hub invited 1,044,413 people for FOBt screening, analysed 768,723 kits, and scheduled 14,742 specialist screening practitioner appointments.
Findings
From the evidence and the information provided during the interviews there were no immediate or urgent concerns.
The hub achieves or exceeds all the national Bowel Cancer Screening Programme (BCSP) standards relating to the hub pathway.
The QA visit team identified training and quality as 2 key areas requiring development, and these areas should be addressed as part of the planned review of staff roles and responsibilities within the department.
Immediate concerns
The QA visit team identified no immediate concerns.
High priority findings
The QA visit team identified 5 high priority findings as summarised below:
- a review of staff roles and responsibilities within the department is planned.
- these plans should be formalised and should include clarity on the new operational support officer roles and formal allocation of quality and training roles.
- this will provide resilience and ensure sufficient time can be dedicated to these functions.
- a local business continuity plan is required detailing how the hub should respond to and escalate failures specific to the BCSP.
- this will ensure the hub can respond appropriately and minimise disruption to the screening service.
- a review of the audit schedule is required to ensure clarity of responsibilities and improve the timeliness of audits and associated actions.
- this will ensure timely identification of non-conformities and learning to prevent recurrence.
- there is a requirement for a training framework with clear responsibilities for management and co-ordination of training.
- training plans and competency assessments are needed for all work areas within the hub, along with a matrix to monitor timeliness of training and re-assessment.
- this will ensure all staff are appropriately trained and that there is a process to monitor compliance.
- the ceasing process should be reviewed to ensure clinical confirmation of a subject’s condition is obtained before ceasing due to no functioning large bowel.
- this will ensure compliance with national ceasing guidance.
Examples of practice that can be shared
The QA visit team identified several areas of practice for sharing, including:
- a registrations team investigate, escalate and resolve registration issues improving the quality of demographic data
- a broad spectrum of health inequalities work which has improved accessibility of screening, in particular for subjects with learning disabilities
- a well-designed laboratory with workflow carefully considered from receipt of test kit to analysis
- a dedicated phone line for screening centres to contact the hub for timely resolution of queries
Recommendations
The following recommendations are for the provider to action, unless otherwise stated.
| No. | Recommendation | Reference | Timescale | Priority | Evidence required |
|---|---|---|---|---|---|
| Governance and leadership | |||||
| 01 | Appoint a deputy to provide leadership in the absence of the Hub Director. | 1 | 12 months | Standard | Confirmation of appointment |
| 02 | Develop a formal plan for, and undertake a review of, staff roles and responsibilities within the department. This should include: – clarified remit of the new operational support officer roles – formal allocation of training and quality roles – review and update of job descriptions (JDs) for all staff roles | 1 | 12 months | High | Action plan with timescales Copy of updated Hub Director and Hub Manager JDs and confirmation that JDs for all other staff roles have been reviewed and updated to reflect new roles and responsibilities. |
| 03 | Put in place arrangements to assure the Trust board of the quality and integrity of the screening programme, including producing an annual report for board sign off. | 1 | 6 months | Standard | Hub report covering the period 2022-2024 and evidence of board discussion |
| 04 | Develop or update standard operating procedures (SOPs) for: – data sharing requests – reporting and escalation of errors and incidents – hub assistance summary – electronic communications – public email correspondence – hand packing mail – re-booking appointments – returned mail – operational and failsafe report management – monitoring calls – temperature monitoring and mapping – kit service management – faecal immunochemical testing middleware – correction of test kit result input errors | 11 | 6 months | Standard | Screenshots or demonstration of the quality management system (QMS) confirming each SOP has been updated |
| 05 | Produce an action plan detailing how, within its areas of responsibility, the hub will reduce screening inequalities and provide an evidence base on which to focus new and ongoing activities. | 1 | 12 months | Standard | Action plan for reducing inequalities within the population the hub is responsible for |
| 06 | Review the frequency of meetings and alternative communication methods to ensure timely, documented communication of updates and changes to staff. | 1 | 6 months | Standard | Team meeting minutes evidencing regular occurrence of meetings Examples of alternative methods of communication being used to share key updates/messages to staff. |
| 07 | Develop a process for recording feedback from screening subjects, which is not captured by the existing compliments and formal complaints processes, and a mechanism for sharing this feedback with a view to influence service delivery. | 1 | 6 months | Standard | Feedback log including details of any actions taken in response. |
| Infrastructure | |||||
| 08 | Develop a formal succession plan for the Data Analyst role. | 1 | 6 months | Standard | Evidence of recruitment process and/or handover of roles and responsibilities |
| 09 | Increase BMS resilience for screening. | 1 | 12 months | Standard | Confirmation of recruitment and/or rotation of other BMS staff in the department |
| 10 | Develop a business continuity plan for the hub including different BCSP specific failures and timescales and contacts for escalation. | 1, 11 | 6 months | High | Copy of hub business continuity plan |
| 11 | Ensure the hub operates a fully functioning QMS by: – addressing the backlog of overdue document reviews and change requests awaiting implementation – ensuring all SOPs are controlled documents | 1, 11 | 6 months | Standard | Extract from, or demonstration of, Q-Pulse evidencing progress made |
| 12 | Review the audit schedule to assign roles, responsibilities and timescales. This should include newly appointed auditors and demonstrate progress in completing audits to schedule. | 1, 11 | 6 months | High | Audit schedule with assigned auditors and target completion dates. X2 audits completed to schedule |
| 13 | Develop a SOP for the management of hub specific non-conformities and ensure lessons learnt are consistently shared with the team. | 10 | 6 months | Standard | Copy of SOP X2 sets of meeting minutes or ad hoc communications to staff sharing learning from non-conformities. |
| 14 | Produce an action plan for the implementation of a staff training framework which should include: – appointment of a training lead/roles with responsibility for the management and co-ordination of training – production of a training plan covering all work areas of the hub – maintenance of the training and competency matrix with clear timescales for reassessment | 1, 11 | 3 months | Standard | Action plan with target timescales for completion |
| 15 | Implement the staff training framework | 1, 11 | 12 months | High | Job description/s with training responsibilities detailed. Training plan/s Matrix demonstrating timely training and reassessment of competencies |
| Identifying the right people and inviting them at the right time | |||||
| 16 | Ensure clinical confirmation of a subject’s condition is obtained before ceasing due to no functioning large bowel | 12 | 6 months | High | Written confirmation of change in practice from Hub Director Revised SOP |
| Informing individuals of the risk and benefits of screening | |||||
| 17 | Update the nationally agreed Lynch frequently asked questions (FAQs) to provide additional supportive information for helpline staff | 11 | 3 months | Standard | Updated FAQs document |
| Testing – efficiently and effectively testing participants kits | |||||
| 18 | Investigate the use of the analyser spoil code to understand the increase in use and work with the hub laboratory group to ensure consistent use across hubs | 10 | 3 months | Standard | Investigation report |
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
- Section 7a screening service schedules no 26 2024-2025 NHS Bowel Screening Programme No 26b Hub Service Schedule 2
- Bowel cancer screening: programme specific operating model Bowel cancer screening programme specific operating model
- Bowel cancer screening: programme overview Bowel cancer screening programme overview
- NHS population screening: pathway requirements specifications Bowel cancer screening pathway requirements specifications
- Bowel cancer screening programme: standards Bowel cancer screening programme standards
- Managing Safety Incidents in NHS Screening Programmes Managing safety incidents in NHS screening programmes
- Patient Safety Incident Response Framework Patient safety incident response framework and supporting guidance
- Bowel cancer screening: helping people with learning disabilities Bowel cancer screening helping people with learning disabilities
- Key Performance Indicators NHS screening programmes Antenatal, newborn, young person and adult NHS population screening: reporting data definitions
- Bowel cancer screening: Hub QA structural standards
- Bowel cancer screening: BCSP programme guidance (awaiting review and publication)
- Bowel Cancer Screening Consent and Ceasing Guidance Consent and ceasing guidance