NHS England » Screening Quality Assurance visit report – Tees 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	Not applicable
Workforce	Yes	Not applicable
IT and equipment	Yes	Not applicable
Commissioning	Yes	Partly
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 7 July 2022 to Tees bowel cancer screening service. The service is commissioned by NHS England North East North Cumbria (NENC) which is part of NENC and Yorkshire 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 and 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 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 PHCT in advance of the visit
information shared with North East Yorkshire and Humber SQAS as part of the visit process.

The screening service

Tees screening service provides bowel cancer screening for an eligible population of approximately 147,450 and registered population of 844,196 across the geography. The Clinical Commissioning Groups covered by the centre are County Durham, Tees Valley, and North Yorkshire.

On 1 July 2022 NHS North East and Cumbria (NEC) Integrated Care System (ICS) replaced NHS County Durham and Tees Valley CCG and Humber and North Yorkshire ICS replaced North Yorkshire CCG.

The screening service started inviting men and women aged 60 to 69 years for faecal occult blood test screening in February 2007. In 2010 the service age extended the range covered to include 70 to 74 year olds. Bowel scope screening began in March 2013, inviting men and women aged 55. The centre was a pilot site and had fully rolled out, however bowel scope screening was decommissioned in April 2021. In June 2019, the new faecal immunochemical test (FIT) screening was introduced. In August 2021 the centre age extended to include 56 year olds, and they were the first centre in the North of England to do so.

North Tees and Hartlepool NHS Foundation Trust are the host Trust for the service. There are no associate Trusts involved in service delivery.

Service co-ordination and administration takes place at University Hospital of North Tees (UHNT). The following table identifies the hospital and health centre sites involved in providing the Tees screening service.

Trust/Site	Admin	SSP	Colonoscopy	Radiology	Pathology
North Tees and Hartlepool NHS Foundation Trust
University Hospital of North Tees	Yes	Yes	Yes	No	Yes
University Hospital of Hartlepool	No	No	Yes	Yes	No
Community Health Care Sites
Redcar Primary Care Hospital	No	Yes	No	No	No
The Friarage Hospital	No	Yes	No	No	No
The Linthorpe Surgery	No	Yes	No	No	No

Specialist screening practitioner (SSP) clinics were held at five satellite sites. This provision stopped when the bowel cancer screening programme (BCSP) was paused as a result of Covid-19. All SSP assessments are currently carried out via telephone or tele-conferencing. However, the service is looking to return to some face-to-face appointments soon.

The screening programme hub based in Gateshead 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.

This element of the pathway is outside the scope of this QA visit.

Findings

The service has shown good resilience during Covid-19 and the Clinical Director (CD) ensured that the bowel cancer screening programme remained high on the agenda at Trust level throughout recovery. The CD is supported by a good leadership team, and they have close working relationships with Trust management. This has all been integral to the service getting their screening invitation rate back to pre-covid levels and being the first service in the North of England region to age extend to the 56 year olds.

This is a service that meets or exceeds many of the key performance indicators and provides a service of good clinical quality to the local population. Not all colonoscopists achieved the programme standard of carrying out 120 colonoscopies per year in 2021 and this was highlighted as an issue at the last visit. However, an action plan is now in place to address this. The diagnostic procedure uptake rate has been just below the acceptable threshold of 81% since 2019. In response to this, an audit looking at the reasons why patients do not progress along the pathway has been carried out. This is a good start to understanding what action is needed to achieve this programme standard.

The service state that there is an annual process in place for the review and ratification of policies and procedures. However, evidence provided and discussions at the visit indicated that practice and policy can differ at times across all disciplines. Now that the service has restored following the pandemic and age extended, there is now opportunity to focus on business as usual activities, including policy review.

There were a few items of evidence missing from the upload completed in May 2022 and SQAS has provided details of these in the report.

All recommendations from the last visit in July 2016 were completed within 12 months.

Immediate concerns

The QA visit team identified no immediate concerns.

High priority findings

The QA visit team identified 4 high priority areas as summarised below:

The service report reviewing standard operating procedures (SOPs), work instructions and policies annually but the evidence provided does not demonstrate that this happening consistently or effectively. Documentation should reflect BCSP guidance, and the Trust should ensure there is a robust review and approval process in place.
The team are keen to improve diagnostic test uptake and reduce health inequalities. To do this they should develop the work already underway by conducting a health equity audit and collaborating with key stakeholders.
The Trust should ensure that the SSPs are supported to meet both local and national BCSP training and education requirements. A training needs analysis should be undertaken to understand the areas where SSPs are reporting they require additional support.
To support the delivery of the BCSP computed tomography colonography service a second reporter is needed, along with clarification on the arrangements for administrating intravenous contrast, and a SOP for managing adverse events and incidents.

Examples of practice that can be shared

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

The Programme Manager attends all the SSP meetings and the Lead SSP attends the administration meetings. This supports cohesive team working.
Training is a regular agenda item at the monthly SSP meetings. The team run bespoke sessions on topics including advanced polypectomy and cardiac conditions.
The endoscopy department run an efficient, well attended complex polyp multidisciplinary team meeting which is led by a patient focused Nurse Endoscopist
The team are up to date with reviewing all planned surveillance patients in line with current British Society of Gastroenterology guidelines. There is a detailed and robust SOP in place to support this process.
The screening team notifies the radiology department about patients who have additional needs. This enables the department to prepare, and they allocate a double slot.
A Biomedical Scientist is in training to take on an extended role. This involves taking on tasks usually performed by medically qualified staff, which will eventually free up consultant time.
The pathology department use coloured cassettes to identify BCSP samples. The department introduced this process to improve turnaround times.

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	North Tees and Hartlepool NHS Foundation Trust 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
2	Update the job descriptions of the Clinical Director (CD), Lead Colonoscopist and Screening Colonoscopist so they accurately describes the function and purpose of the role and accounts for programme changes	20	6 months	Standard	Copy of the job descriptions
3	Implement an effective system that ensures that procedures, policies, and protocols are reviewed annually, or when policy changes occur	20	Part 1 – 3 months Part 2 – 12 months	High	At 3 months – CD and Lead Specialist Screening Practitioner (SSP) to provide details of the system and how it is working in practice At 12 months SQAS will request to see a random sample of documents that were part of the evidence submission list
4	Finalise the annual report, ensuring Trust’s data sharing processes are adhered too, and share with the Trust board	20	6 months	Standard	Copy of annual report and evidence of Trust board discussion
5	Ensure the workforce plan: Meets existing and future needs of the service. Provides variation for staff and development opportunities. Covers all elements of the screening pathway including radiology and pathology.	20	6 months	Standard	Update copy of the workforce plan
6	Update the local incident policy to ensure it is consistent with national guidance	14	3 months	High	Copy of updated policy ratified through provider governance structure and issued to staff
7	Develop a computed tomography colonography (CTC) standard operating procedure (SOP) to include management of adverse events, incidents, and complications	2	3 months	High	Copy of SOP
8	The service should work with the Public Health Commissioning team to reduce screening inequalities in underserved and protected population groups by: Developing the current action plan to improve inequalities along the whole pathway. Implementing the action plan. Carrying out health equity audits (HEAs).	18, 20	12 months	High	Action plan presented to and monitored by the programme board with evidence that HEAs are being carried out
9	The service should develop the diagnostic uptake audit to understand patient demographics and provide details on how they plan to act on the findings	3, 18, 20	12 months	High	Copy of audit and action plan
10	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
11	Make sure that all BCSP CTC patients are provided with information to meet local and specific needs post procedure (document not available for review at the visit)	2	6 months	Standard	Copy of post procedure patient information leaflet
12	Implement a single method of communication for notifying SSPs that patients require a call back	20	3 months	Standard	Confirmation from the Programme Manager of the process
Infrastructure
13	Revise the administration roles so that they account for programme change and clearly define responsibilities	20	6 months	Standard	Copies of updated job descriptions
14	Lead SSP to carry out a training needs analysis for SSPs to identify areas where further supported is required	10, 20	6 months	High	Confirmation from the Lead SSP that a training needs analysis has been carried out and plan are in place to support the SSPs
15	Provide a copy of the job plan for the Lead Radiologist that specifies BCSP duties so they can be carried out and sustained (document not available for review at the visit)	2, 20	6 months	Standard	Copy of the job plan
16	A second radiologist to start reporting BCSP CTCs	2, 20	6 months	High	Lead Radiologist to confirm that a second radiologist has started reporting BCSP cases
17	All electronic pathology reports should be in a readable format	20	3 months	Standard	Confirmation from the BCSP CD that all reports are available in a readable format
Pre-diagnostic assessment
18	Update the SOP for patients who are unfit for colonoscopy and/or CTC	4, 20	3 months	High	Copy of updated SOP
19	Update the Patient Group Directive (PGD) for issuing bowel preparations to screening participants and ensure it meets the needs of the service	21	3 months	High	Copy of updated and signed document
20	Lead SSP to ensure that: The correct names for BCSP pathologists are entered onto the bowel cancer screening system (BCSS) Both pathologists’ names for polyp cancers are entered onto BCSS. SSPs understand the dataset requirements for pathology	7, 10, 20	6 months	Standard	Lead SSP to: Audit polyp cancer cases for 2021 and 2022 where only one pathologist’s name is entered. Provide training for SSPs, if required. Provide copies of updated SOP(s) if changes are made.
Diagnosis
21	Continue to support all colonoscopists to meet the national standard for colonoscopies performed	3, 4, 20	12 months	Standard	Evidence of discussion at the quarterly endoscopist meetings (minutes are a requirement for recommendation 22) CD to provide evidence of the standard being met
22	Maximise attendance at the quarterly endoscopy meetings	20	12 months	Standard	Minutes of three meetings
23	Put in place an intravenous (IV) contrast PGD for the CTC service, or provide details of the arrangement where radiographers are able to administer (IV) contrast without requiring a PGD	2	3 months	High	Copy of signed document or written confirmation from the Radiology Manager detailing the alternative arrangements
24	Update the SOP for bowel preparation and faecal tagging	2	6 months	Standard	Copy of updated SOP
25	Make sure that all CTC reports contain the minimum dataset information needed for entry onto BCSS	2	12 months	Standard	Audit of dataset with outcomes and action
26	Make sure that pathology samples requiring a second opinion are reviewed within region before submission to the national expert board	7	12 months	Standard	Lead Pathologist to audit a sample of cases to ensure local and national policy is being followed and provide an update to SQAS
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

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

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

NICE Patient group directions Medicine practice guidelines

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