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 NHS England Public Health Commissioning Team West Midlands |
| 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 | Partly – 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 18 July 2024 to the University Hospitals North Midlands Bowel Cancer Screening Service, that is commissioned by NHS England West Midlands 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 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.
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 on 6 June 2024
- information shared with the SQAS as part of the visit process
The screening service
The North Midlands Bowel Cancer Screening Programme provides bowel cancer screening to an eligible population of approximately 901,000 (aged 54-74 years) across 81 GP practices in the geography. The residential population is 1.13 million.
The North Staffordshire BCSP is commissioned by NHS England, West Midlands and is covered by Staffordshire and Stoke-on-Trent Integrated Care System.
The screening service started inviting men and women aged 60 to 69 years for faecal occult blood test screening in North Staffordshire in September 2008.
Bowel scope screening for men and women aged 55 started in September 2016 and was decommissioned in April 2021. In June 2019, the new faecal immunochemical test screening kit was introduced.
As part of the age expansion plan the service began inviting ages 56 in December 2021, ages 58 in November 2022 and ages 54 in December 2023. Work is underway to invite the age 50 and 52 cohorts from November 2024.
University Hospitals North Midlands is the host trust for the service. Bowel screening services are provided at the Royal Stoke University Hospital and County Hospital sites.
There are no associate trusts involved in service delivery and none of the BCSP activity is outsourced. Service co-ordination and administration takes place at the Royal Stoke University Hospital.
Face-to-face specialist screening practitioner assessment clinics, colonoscopy and pathology services are provided at both the Royal Stoke University Hospital and County Hospital sites and radiology computerised tomography colonography services are provided from the Royal Stoke University Hospital.
The screening programme North Midlands hub based in Rugby 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 a dedicated and enthusiastic team that showed resilience during the Covid-19 pandemic and early recovery of the programme.
There is good engagement from all specialities and with the divisional team.
Developing the bowel cancer screening operational team meeting functions should be reviewed to encourage attendance and improve shared learning.
Pathology waiting times have recently and sustainably improved after the impact of the merger of pathology services with Mid Cheshire NHS Trust and East Cheshire NHS Trust a clear recovery plan and strong leadership have facilitated this improvement.
To ensure resilience and stability for the future expansion of the programme, the service should focus on and review its current screening workforce.
The service has developed a strong health inequalities profile and are involved in multiple health promotion initiatives.
To continue this work the service should update the health equity audit including the patient pathway to develop an action plan with clear roles and responsibilities.
Immediate concerns
The QA visit team identified no immediate concerns.
Urgent recommendations
The QA visit team identified one urgent recommendation. The service were advised to submit an incident report requesting the following item was addressed:
- provide an incident report relating to a complex procedure undertaken without appropriate consent
An initial incident report has been submitted and this will be managed as part of the usual incident reporting process with the screening quality assurance service and commissioning team colleagues.
High priority findings
The QA visit team identified 2 high priority findings summarised in the points below:
- the service requires a detailed workforce 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
- update incident reporting protocols in line with BCSP guidance to include appropriate reporting against all categories and specialties
Examples of practice that can be shared
The QA visit team identified several areas of practice for sharing, including:
- a patient pathway tracker enables good management of clinical bookings and identifying individual patient pathways
- a broad spectrum of health inequalities work
- development of national radiographer training programme and involvement of lead radiographer in BCSP
- development of the complex polyp service with development potential for aspirant screeners
- strong recovery plan for pathology with variety of skill-mix opportunities
- introduction of virtual interpretation services in endoscopy to reduce risk of cancellations due to interpreter availability
Recommendations
The following recommendations are for the provider to action unless otherwise stated.
No. | Recommendation | Pathway theme | Reference | Timescale | Priority | Evidence required |
Immediate concerns | ||||||
None | ||||||
Urgent recommendations | ||||||
01 | Submit incident assessment form to the Screening QA Service relating to a complex procedure undertaken without informed consent of the risks | Diagnosis | 4, 6, 11, 14, 16 | 14 days | Urgent | A detailed screening incident assessment form. |
No. | Recommendation | Reference | Timescale | Priority | Evidence required |
Service provider and population served | |||||
None | |||||
Governance and leadership | |||||
| 02 | An annual report should be developed from the information provided to the programme board and be presented internally to the trust. | 20 | 12 months | Standard | Copies of minutes of internal governance meetings where the annual report is discussed |
Programme leadership, management and co-ordination | |||||
03 | Develop a service and staffing demand and capacity plan to meet needs of the service for all specialties. | 3, 17, 20 | 3 months | High | Updated demand and capacity plan |
04 | Review roles and responsibilities of programme management, administrative and SSP teams to ensure appropriate division of roles, workload and support for key areas of work. | 20 | 6 months | Standard | Revised job descriptions |
05 | Review BCSP quarterly operational meeting to ensure greater attendance and shared learning of a wide range subjects including operational, performance and service improvements | 20 | 6 months | Standard | Revised Terms of Reference and minutes of first meetings in new structure |
|
06 | Update incident, AVI and non-conformance reporting protocols in line with BCSP guidance to include appropriate reporting against all categories and specialties. |
6, 14, 16 |
3 months |
High | Updated incident reporting standard operating procedure (SOP). |
| 07 |
Work with the public health commissioning team and other stakeholders (internally and externally) where appropriate, to finalise and complete a health equity audit with a health improvement action plan. |
3, 5, 17, 18. 19, 20 |
12 months |
Standard |
Health inequalities action plan |
|
08 |
Update the programme’s annual audit schedule to cover all professional areas involved in the BCSP pathway |
20 |
6 months |
Standard |
Audit schedule with named lead for each audit, including date next audit is due and details of how discussion of audit findings will be shared |
|
09 |
Adjust the timeframe for adding patients on to the ‘Patient Know’s Best’ system as part of the NHS app to one day prior to their scheduled appointment to minimise patient anxiety. |
20 |
3 months |
Standard |
Confirmation of updated process |
|
10 |
Review and update the quality management system and associated documents, to include a clear process for ongoing management. |
20 |
12 months |
Standard |
Revised QMS management SOP detailing: document control, updated numbering system and approval process for document updates and sign off. |
11 | Develop or update SOPs for: – right results – IT failure – non-attendance – out-of-area referrals – communications for patients re-admitted post-procedure – turnaround of histopathology results – referring histopathology reporting for second opinions or to the expert panel |
20 |
6 months |
Standard |
Copies of relevant SOPs |
| Infrastructure | |||||
|
12 |
Assess the number of pathologists reporting bowel cancer screening programme specimens to ensure compliance with accreditation |
7, 20 |
6 months |
Standard |
Copy of the review |
Pre-diagnostic assessment | |||||
|
13 |
Review SSP assessment clinic delivery as part of health equity audit to explore options to provide SSP assessment clinics by phone or video in addition to face to face appointments |
20 |
3 months |
Standard |
Details of review and impact assessment |
Diagnosis | |||||
|
14 |
Revise the consent pathway to discuss risks of high-risk procedures with patients ahead of the procedure |
4, 11, 16 |
3 months |
Standard | Copy of revised consent process |
|
15 |
Audit the reasons for patients undergoing multiple procedures, including completion CTC, assessing best interest |
4, 20 |
6 months |
Standard |
Copy of audit and follow up plan |
|
16 |
Review decreasing cancer and adenoma detection rates including consideration of post colonoscopy colorectal cancer rates |
2, 3,4, 7, 13, 20 |
3 months |
Standard |
Copy of findings and proposed action plan |
|
17 |
SSP and radiology teams to review patient pathway to improve the patient journey and reduce inequalities |
2, 8, 10, 18, 20 |
3 months |
Standard |
Risk assessment and review of patient pathway |
|
18 |
SSP and radiology teams to explore if the County Hospital site could be safely and appropriately offered to BCSP patients for CTC |
2, 8, 10, 18, 20 |
3 months |
Standard |
Options appraisal document |
|
19 |
Introduce a process to enable the lead radiologist and radiographer to have access to BCSS data on a quarterly basis to support audit |
20 |
3 months |
Standard |
Confirmation of process |
|
20 |
Audit the diagnostic criteria for standardisation of high grade dysplasia sessile serrated lesions and session hyperplastic polyps of all BCSP reporting pathologists to ensure |
7, 20 |
6 months |
Standard |
Copy of audit findings and follow up actions |
|
21 | Submit the outstanding visit evidence – provide 5 reports per pathologist of colorectal cancer resections with standard template proforma reports |
7, 9, 20 |
3 months |
High | 5 reports per pathologist |
Referral | |||||
|
22 |
Review the function of the post MDT outcome appointment for BCSP patients with a cancer diagnosis with the SSP to support the patient pathway |
10, 20 |
3 months |
Standard |
Review of pathway |
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 2023-24 – NHS Public Health Commissioning & Operations – Future NHS Collaboration Platform