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 | Not applicable |
| Leadership and governance | Yes | Not applicable |
| Pathway | ||
| Cohort identification | Yes | Not applicable |
| Invitation and information | Yes | Not applicable |
| Testing | Yes | Not applicable |
| Results and referral | Yes | Not applicable |
| Diagnosis | No | Bowel Cancer Screening Centre reports |
| Intervention / treatment | No | Bowel Cancer Screening Centre 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 7 and 8 September 2022 to the Southern Bowel Cancer Screening Programme Hub which is commissioned by NHS England Surrey and Sussex 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 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 Southern Bowel Cancer Screening Hub is located in the Surrey Research Park in Guildford, Surrey. It is hosted by Royal Surrey County Hospital NHS Foundation Trust and operates as part of Berkshire and Surrey Pathology Services (BSPS). The hub commenced screening in 2006 with guaiac faecal occult blood test (FOBt) screening and moved to faecal immunochemical testing (FIT) in June 2019.
The hub covers a total population of approximately 15.7 million across the South of England and works in partnership with 18 local screening centres, 13 integrated care boards (ICBs) and 1579 GP practices. NHS England (Surrey and Sussex) are the lead commissioners for the service.
The hub is situated in a well laid out building with clear areas for each function and adequate space to work in and for the hub to expand further for age extension. All members of staff were friendly, approachable and care about the service they provide. Observational sessions were held during the visit in both the laboratory and helpline areas.
From April 2021 to March 2022 the hub invited over 1.7 million people for FOBt screening, analysed over 1.2 million kits and scheduled nearly 23,300 specialist screening practitioner (SSP) appointments.
Findings
The service has shown resilience during Covid-19 with the hub being able to support increased invitations for all screening centres as required to support restoration and recovery. There is a leadership team who have good support within the Trust and pathology service.
There is adequate space within the hub to support the continued roll out of age extension within the programme however the hub should look at staffing levels to ensure there is resilience within the team for age extension and the implementation of Lynch screening which is intended to commence in April 2023.
The hub achieves or exceeds all the national Bowel Cancer Screening Programme (BCSP) standards relating to the hub pathway.
All recommendations from the last visit in October 2016 were completed within 12 months.
Immediate concerns
The QA visit team identified no immediate concerns.
High priority findings
The QA visit team identified 6 high priority findings as summarised below:
- Produce a formal plan for age extension including a review of staffing to accommodate existing and future workloads
- Train additional staff in the management of invitation plans to provide resilience within the team
- Review communication channels to enable staff to feel more aware of issues and matters arising and feel comfortable in raising items for discussion
- Review the process for how non-conformities are fed back to staff, considering severity and frequency and ensuring positive feedback on performance is also included
- Ensure national guidance and FAQs for helpline staff are clearly defined with older but relevant information supplemented with local documents that reflect current guidance and practice
- Update the standard operating procedure for managing emails to include the requirement to obtain 3 patient identifiers when accessing an individual’s screening record and ensure this is embedded in practice.
Examples of practice that can be shared
The QA visit team identified several areas of practice for sharing, including:
- A comprehensive use of competency assessment for new staff and for ongoing training, leaving staff feeling well supported
- Good process for management of non-conformities
- Use of a hub score card which allows a quick view of hub performance
- The hub and management have clarity of the complex governance arrangements in place between the multiple organisations. There is good support and visibility of the hub across the organisations.
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 | |||||
| 1 | Update the quality manual and hub organisational chart to show: clear governance links and reporting arrangements within the Trust and Berkshire and Surrey Pathology Services.recent changes to delivery within the Bowel Cancer Screening Programme | 1 | 6 months | Standard | Updated quality manual to include governance and reporting arrangements for the hub |
| 2 | Produce a formal plan for age extension including a review of staffing to accommodate existing and future workloads. | 1 | 3 months | High | Formal plan to include staffing review |
| 3 | Revise the ‘Managing Near Misses and Incidents’ standard operating procedure (SOP) to include notification of screening incidents to commissioners and add clarity around the differences between a reportable event and a screening incident. | 7, 15 | 3 months | Standard | Revised SOP |
| 4 | Produce an action plan that details how, within its areas of responsibility, the hub will reduce screening inequalities. | 1 | 12 months | Standard | Action plan for reducing health inequalities within the population the hubs is responsible for. |
| 5 | Ensure the process for re-booking specialist screening practitioner appointments following non-attendance is documented in a SOP. | 15 | 3 months | Standard | Copy of SOP |
| 6 | Train additional staff in the management of invitation plans to provide resilience within the team. | 15 | 3 months | High | Details of cover arrangements and training provided |
| 7 | Update the SOP for creating invitation plans to include: the requirement for joint agreement from commissioners, regional SQAS and screening centres for changes outside of the +/- 6-week standard, as part of the business-as-usual processcurrent national agreement to manage invitation plans outside of the +6-week standard due to restoration and recovery from the pause in screening due to Covid-19 | 15 | 3 months | Standard | Revised SOP |
| Infrastructure | |||||
| 8 | Review and update job descriptions for the senior management team to ensure they reflect current roles, responsibilities and cover arrangements. (Hub director, deputy hub director, hub manager, laboratory and quality lead, training and administration lead) | 1 | 6 months | Standard | Updated job descriptions |
| 9 | Review communication channels to enable staff to feel more aware of issues and matters arising and feel comfortable in raising items for discussion. | 1 | 3 months | High | Plan detailing how staff engagement will be improved and details of how this has been implemented |
| 10 | Update the business continuity plan to include detailed timescales for escalation, references to separate business continuity flowcharts and details of when to inform SQAS, commissioners and other key stakeholders. | 14, 15 | 3 months | Standard | Updated business continuity plan |
| 11 | Review the process for managing ipassport alerts ensuring team leaders are competent in using the system, aware of responsibilities for SOP review and prioritise time to ensure reviews are completed in a timely manner. | 15 | 6 months | Standard | Evidence of timely review of SOPs Competency assessment for using ipassport |
| 12 | Ensure all audits are included in the audit schedule and that there are clear procedures for their completion, with oversight from the laboratory and quality lead. | 15 | 6 months | Standard | Copy of audit schedule Assurance from Laboratory and Quality Lead that audit schedule includes all audits |
| 13 | Ensure non-conformities identified through audits are clearly documented within audit reports with actions, owners and timescales for completion assigned to them. | 15 | 6 months | Standard | Evidence of audit reports with non-conformities clearly identified |
| 14 | Ensure all SOPs and audit templates are controlled documents. | 15 | 6 months | Standard | Confirmation of the process for document control and demonstration via teams meeting of what has been put in place |
| 15 | Review the process for how non-conformities are fed back to staff, considering severity and frequency and ensuring positive feedback on performance is also included. | 14, 15 | 3 months | High | Output from the review of how non-conformities are fed back to staff |
| Identifying the right people and inviting them at the right time | |||||
| 16 | Ensure the process for verifying postcode changes made by Real Digital International is documented in a SOP. | 15 | 3 months | Standard | Copy of SOP |
| Informing individuals of the risk and benefits of screening | |||||
| 17 | Ensure national guidance and frequently asked questions for helpline staff are clearly defined, with older but relevant information supplemented with local documents that reflect current guidance and practice. FAQs and guidance updated to reflect SSP appointment modalityCurrent age extension cohortsgFOBt and bowel scope | 14, 15 | 3 months | High | Copy of updated guidance and FAQs |
| 18 | Update the SOP for managing emails to include the requirement to obtain 3 patient identifiers when accessing an individual’s screening record and ensure this is embedded in practice. | 15 | 3 months | High | Updated SOP Monthly email audit report including a check that 3 identifiers have been received |
| 19 | Revise the episode closing guidelines to provide further guidance on how the Bowel Cancer Screening System episode closure reasons should be utilised and audit the correct use of closure reasons as part of the monthly opt out audit. | 1, 14 | 6 months | Standard | Updated SOP |
| Testing – efficiently and effectively testing participants kits | |||||
| 20 | Update laboratory SOPs to include inter-laboratory comparison SOP to align with the nationally agreed SOP with regards to scheduling.amending results SOP to also include guidance around correcting results before they are issued to participants.disposal of FIT kits SOP which should reflect that sample dilution is no longer carried out within the programme. | 14, 15 | 6 months | Standard | Updated SOPs |
| Referral to specialist screening practitioner clinic | |||||
| 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
- Section 7a screening service schedules no 26 BCSP Schedules 2022-23 – NHS Public Health Commissioning & Operations – Future NHS Collaboration Platform
- 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
- Bowel cancer screening: managing incidents Bowel cancer screening managing incidents
- Managing Safety Incidents in NHS Screening Programmes Managing safety incidents in NHS screening programmes
- NHS England Serious Incident Framework – Supporting learning to prevent recurrence (March 2015) Serious incident framework
- Cancer screening: informed consent Cancer screening informed consent
- PHE Screening inequalities strategy PHE Screening inequalities strategy
- 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
- Public health profiles Public health profiles
- Bowel cancer screening: Hub QA structural standards
- Bowel cancer screening: BCSP programme guidance (awaiting publication)