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 | Yes | Partly NHS England Public Health Commissioning Team East of England |
| 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 15 November 2022 to North Essex Screening Service which is commissioned by NHS England East of England Public Health Commissioning team (PHCT). 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 North Essex screening service provides bowel cancer screening for an eligible population of approximately 135,000 and a residential population of 800,000 across 52 GP practices in the geography. Contracting for the Mid-Essex population (400,000 residential population, approximately 78,000 eligible population) transferred from North Essex to South Essex bowel screening programme in November 2021. However, the transfer was delayed due to the pandemic and site availability in South Essex. The Suffolk and North East Essex Integrated Care System (ICS) covers North East Essex, Ipswich and East Suffolk.
The screening service started inviting men and women aged 60 to 69 years for faecal occult blood test screening in February 2009. In 2013 the service extended the age range covered to include 70 to 74 year olds. Bowel scope screening for men and women aged 55 began just ahead of the deadline in December 2016 with one weekly list which paused soon after and did not re-start. Bowel scope screening 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 in March 2022 and are preparing to invite 58-year-olds in early 2023.
East Suffolk and North Essex NHS Foundation Trust (ESNEFT) formed on 1 July 2018 following the merger of Colchester Hospital University NHS Foundation Trust and the Ipswich Hospital NHS Trust. There are no associate Trusts involved in service delivery.
Service co-ordination and administration takes place predominantly at Colchester Hospital. There is limited administrative support currently at Ipswich Hospital and this will be increased when the team expands. Specialist Screening Practitioners (SSPs) work across sites with the exception of one who is based at Ipswich hospital. Colonoscopy is provided at both hospitals, but job plans do not allow for colonoscopists to cover across sites. SSP assessments returned to face-to-face appointments in June 2022 along with the offer of telephone or video conferencing. Pathology and radiology services are provided at both sites.
The screening programme Eastern hub based in Nottingham 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
The service has a dedicated team and showed good resilience during the Covid-19 pandemic in recovering the programme. There are several long term vacancies across gastroenterology at ESNEFT and the service adapted to meet the demands of recovery by introducing insourcing for colonoscopy in the short term.
The service meets or exceeds many of the key performance indicators and provides good clinical quality to the local population. The diagnostic procedure rate meets the achievable standard of 81% whereas many services are not managing to meet the standard regionally and nationally. There has also been recent stability in the diagnostic test waits since the accreditation of a further colonoscopist.
Since the last QA visit there has been significant organisational change. As a result, some governance arrangements and meeting structures are still being embedded and need formalising. Some bowel cancer screening programme (BCSP) operational and Trust governance meetings are detailed clearly in a Trust governance procedure, but not all meetings are currently happening. These meetings are important to share practice, discuss policies, performance, incidents and operational issues and ensure consistency in practice. All BCSP leadership posts are filled and the team work cohesively together.
There is a plan for construction works at Colchester Hospital which will improve the gastroenterology capacity over the coming years. Work is due to start shortly which may impact on the current gastroenterology recovery and reception areas.
The service has returned to face to face SSP consultations. Telephone and video calls are still offered to patients if required, which maximises clinic uptake.
All recommendations from the last visit in July 2016 are complete with the exception of one the need for Joint Advisory Group (JAG) accreditation.
Immediate concerns
The QA visit team identified no immediate concerns.
Urgent recommendations
The QA visit team identified one urgent recommendation. A letter was sent to the screening director on 17 November 2022 asking that the following item is addressed:
- assurance of the continued delivery of bowel cancer screening lists, in line with programme standards if construction work to supply oxygen to the new orthopaedic building at Colchester Hospital impacts the use of the endoscopy recovery room.
A response was received informing the visiting QA team of steps taken to partially resolve the urgent recommendation. Since the visit the service have advised that the building work will be delayed into late 2023/2024. Further information is required for assurance of how building works will impact the bowel cancer screening programme, the timeframe for work and how any reduction in activity or risks will be mitigated.
High priority findings
The QA visit team identified seven high priority findings as summarised below across four areas:
- the service is heavily reliant on insourced colonoscopists to meet the requirements of the BCSP programme. Their future involvement in performance monitoring discussions against the programme standards will support shared learning. Service level agreements for insourcing and outsourcing of bowel cancer screening work do not sufficiently detail the BCSP criteria, performance management and governance arrangements for both colonoscopy and radiology
- at the time of the visit it was unclear if patients requiring surveillance procedures were on the correct pathway on the bowel cancer screening computer system (BCSS). It was also unclear if there was a full understanding of the required processes to manage surveillance patients. Practice should reflect BCSP guidelines and the Trust were required to give assurance and support staff to manage the surveillance patients. Since the visit the service have worked hard to review the surveillance cases on the bowel cancer screening computer system (BCSS) and engaged with the SQAS team to develop further understanding of the process
- an action plan is being developed to reinstate JAG accreditation at Colchester Hospital. As both Colchester and Ipswich endoscopy wide services require JAG accreditation, a system wide approach to submitting a single accreditation application will prevent duplication of work and promote quality improvement throughout ESNEFT endoscopy
- there are no BCSP representatives at Ipswich Hospital colorectal multi-disciplinary (MDT) meeting. ESNEFT should ensure appropriate representation of bowel cancer screening patients requiring MDT discussion.
Examples of practice that can be shared
The QA visit team identified several areas of practice for sharing, including:
- the team are working with the PHC and newly formed ICS on a pilot project to encourage screening attendance in the homeless community. This work is being considered as a model for national delivery
- ESNEFT has introduced a screening committee linking all the screening teams across the Trust. This forum provides opportunities for sharing practice and a joined up approach to supporting and managing the eligible screening populations
- the bowel screening management team work closely with endoscopy to plan and utilise lists to ensure endoscopy capacity is maximised across the symptomatic and screening programmes and protect bowel screening lists
- the pathology department have developed a clear and well managed quality management system (QMS) to manage audits and bowel cancer screening standard operating procedures (SOPs), work instructions and policies
- the bowel cancer screening programme pathology lead has developed an induction, SOPs, work instructions and policies ahead of new pathologists starting in early 2023.
Recommendations
The following recommendations are for the provider to action unless otherwise stated.
| No. | Recommendation | Pathway theme | Reference | Timescale | Priority | Evidence required |
| Urgent recommendations | ||||||
| 01 | ESNEFT executive team to provide assurance of the continued delivery of bowel cancer screening lists during construction work to the endoscopy reception and recovery areas at Colchester Hospital | Governance and leadership | 20 | 14 days | Urgent | Copy of the action plan for BCSP endoscopy provision with clear timelines |
| Service provider and population served | |||||
| No recommendations made in this section | |||||
| Governance and leadership | |||||
| 02 | Update the service level agreement (SLA) for insourced colonoscopists and develop a SLA for cross cover arrangements for outsourcing BCSP radiology reporting to specify: colonoscopists and radiologists must be bowel cancer screening programme (BCSP) accredited/trainedmeet the requirements of the BCSP guidelines all (including insourced) staff are included in performance monitoring | 20, 5 and 3 | 3 months | High | Copy of the revised and signed service level agreements in line with NHS standard contract and BCSP guidelines |
| 03 | Ensure a joined-up approach from the Trust and endoscopy departments as a whole for Colchester and Ipswich Hospitals to achieve JAG accreditation | 13 | 3 months | High | Submit a copy of the action plan and provide regular updates to the programme board |
| 04 | ESNEFT and North Essex 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 |
| Infrastructure | |||||
| 05 | Update the quality management system (QMS) with correct review dates 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. |
| 06 | Develop a BCSP annual report and present to relevant governance committees | 20 | 12 months | Standard | A copy of the annual report and evidence of ESNEFT board and programme board discussions |
| 07 | Expand the demand and capacity and BCSP workforce plans covering all specialties to look at future service needs, succession plans and particular emphasis on increasing endoscopy capacity. | 20 | 6 months | Standard | A copy of the demand and capacity plan and workforce plan |
| 08 | Develop an SOP detailing how the programme manages capacity to meet changes in service demands | 20 | 6 months | Standard | A copy of the SOP |
| 09 | Update SOPs for: management of patients on anti-coagulation and anti-platelet therapies in accordance with British Society of Gastroenterologists (BSG) guidelinesincident management SOP to reflect responsibility of all BCSP team and include non-conformance reportingfinalise the right result to right patient SOP and associated work instruction | 21, 7 and 14 | 3 months | Standard | A copy of the SOPs and evidence of sign off by all relevant staff |
| 10 | 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 ESNEFT | 6,18, 19, 20 | 6 months | Standard | Copy of health equity audit and health promotion strategy |
| 11 | Establish an annual audit schedule covering all BCSP specialties and arrange to share and implement learning from audits | 20 | 6 months | Standard | Copy of BCSP wide audit schedule, detailing leads for each audit, minutes of meetings where audits discussed and presented |
| 12 | Include contact information of CTC department at Colchester Hospital in patient information | 3 | 3 months | Standard | Copy of revised leaflet |
| 13 | Update bowel computer screening system (BCSS) to ensure all patients requiring a surveillance procedure are on the correct pathway in line with BSG surveillance guidance and update associated surveillance review and data input SOP to reflect appropriate roles and responsibilities. Share SOP with all relevant team | 20, 21 | 3 months | High | Summary of review process on BCSS with assurance that all patients are on the correct pathway. Engage with SQAS colleagues to access support Updated SOP to ensure timely management of surveillance |
| 14 | Ensure protected time for the Lead SSP to undertake managerial aspects of the role and plan to attend the required advanced communications course | 20 | 3 months | Standard | Revised job description Course booking/ certificate of attendance |
| 15 | Review of job descriptions for programme manager, lead SSP and audit co-ordinator to ensure appropriate division of roles and responsibilities | 20 | 3 months | Standard | Revised job descriptions |
| 16 | Radiology job plans to be updated to ensure adequate time for BCSP reporting | 3 | 3 months | Standard | Revised job plans |
| 17 | Assessment of office accommodation to be undertaken to ensure adequate and appropriate space available to the team to undertake their roles | 20 | 3 months | Standard | Copy of Estates assessment with action plan |
| Pre-diagnostic assessment | |||||
| No recommendations made in this section | |||||
| Diagnosis | |||||
| 18 | Introduce mechanism to routinely share performance data against the BCSP standards with whole team to include insourced colonoscopists. Involve insourced colonoscopists in in relevant BCSP team meetings. Detail arrangements in SLA. | 5, 20 | 3 months | High | Action plan detailing meetings and frequency data reviewed and discussed Updated SLA Submit data sharing requests of KPIs for locum consultants working with multiple services to SQAS. |
| 19 | Update the consent policy to reflect current practice | 12, 20 | 3 months | Standard | Updated SOP |
| 20 | Ensure all relevant staff are aware of the requirements of completing the pre procedure health checklist | 12 | 3 months | Standard | Updated SOP with evidence of sign off from all relevant staff |
| 21 | Make sure that all CT colonography reports contain the minimum dataset information needed for entry onto the BCSS | 3, 20 | 3 months | Standard | Audit of dataset with outcomes and actions Check on BCSS that complete radiology minimum dataset in place for all BCSP patients |
| 22 | Change data recording for pathology turnaround times to start from date of receipt in laboratory | 8 | 3 months | Standard | Revised SOP and spreadsheet |
| 23 | Ensure all high grade and polyp cancers identified within the BCSP are double reported in accordance with Royal College of Pathology/BCSP dataset | 8 | 3 months | Standard | Written confirmation from lead pathologist to SQAS |
| Referral | |||||
| 24 | Action plan to be put in place to allow attendance at the Ipswich MDT by BCSP team with accompanying SOP for handover of care | 20 | 3 months | High | Copy of action plan and SOP |
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
- Suffolk and North East Essex Integrated Care System (ICS) Five Year System Strategic Plan 2019/2024 CAN DO 5 Year Strategy Plan (sneeics.org.uk)
- 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 & 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