Bowel Cancer Screening Programme Eastern Hub Biennial Report July 2014

Transcription

1 Bowel Cancer Screening Programme Eastern Hub Biennial Report July 2014

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3 Contents Bowel Cancer Screening Programme, Eastern Hub Biennial Report Foreword 5 Executive Summary 6 1. Introduction 7 2. Organisation and Hub Services 8 The Programme Hub 8 The Screening Pathway 9 Hub Services 10 Call and Recall 10 Age Extension 10 Bowel Scope Screening 10 The Bowel Scope Screening Pathway 11 Electronic GP Communications 12 Helpline 13 Mailing Services 13 Returned Mail 13 Stakeholder Communications 13 Screening Centres and the Population Served FOBt Activity Analysis 15 Invitations and Test Kits 15 Managing Kit Returns 15 Uptake and Positivity 16 Uptake and Positivity by Age and Gender 17 Prevalent and Incident Rounds 19 Programme Attrition 21 Clinical and Colonoscopic Outcomes 22 Outcomes according to Screening Centre 24 Helpline Calls Data Analysis 26 Quarterly Reporting 26 KPI Reporting 26 Other Regular Reporting 26 The Bowel Cancer Screening System Management Structure and Staff 28 Staffing WTE 28 Staffing Structure Quality Assurance 30 CPA and QARC 30 EQA 30 Laboratory Practices 31 Adverse Incidents 31 User Feedback 32 Audits 34 Reader Positivity 35 Staff Training and Development Commissioning 37 Commissioning Research & Evaluation 39 Presentation at National/International Body events 39 ASCEND Going Forward 40 Immunochemical Testing 40 Hard to Reach Groups 40 3

4 10. Appendices 41 Appendix A: Glossary 41 Appendix B: Eastern Hub Summary Activity, Jan 2012-Dec Appendix C: Outcomes by CCG and Area Team, Jan 2012-Dec Appendix D: Outcomes by CCG and Area Team, Programme Start Dec Appendix E: Key Performance Indicators 47 Appendix F: Quarterly KPI Report for Screening Centres 48 Appendix G: Eastern Hub Weekly Activity Report 50 Appendix H: Weekly Activity Report Method of Measurement 51 Appendix I: Eastern Hub Bowel Scope Activity Report 52 Appendix J: Bowel Scope Activity Report Method of Measurement 53 Appendix K: Staff List 54 Appendix L: Audits 55 Appendix M: BCSP Datix Reported Incidents Appendix N: Poster Uptake of the BCSP in the Eastern region of England - trends by age and gender. 59 Appendix O: Poster - How often is bowel cancer detected from a positive 3 rd kit in the English BCSP? 60 Appendix P: Poster - Risk of bowel cancer increases with the number of windows positive on guaiac faecal occult blood testing. 61 4

5 Foreword Bowel Cancer Screening Programme, Eastern Hub Biennial Report In March 2007 we started sending out our first 600 invitations to year old people in Derbyshire. Now seven years later the Hub is sending out around 16,000 invitations and a similar number of test kits every week to an area with a population of almost 11 million, the same as Belgium or Portugal. Successful screening programmes don t stand still. Extension of the programme to year olds was completed in Bowelscope, the once only flexible sigmoidoscopy screening of 55 year olds, started in 2013 with the uptake in Norwich, our pilot site being much higher than anticipated. We are expecting the guaiac faecal occult blood tests to be replaced by a more accurate and sensitive faecal immuno-chemical test in From a small team of 7, including 4 Screening Officers operating out of a single small laboratory in 2007, the Hub now employs 41 staff working across 2 laboratories and 3 offices. This report, the Eastern Hub s second, covers the calendar years Of necessity some of the data included covers the earlier years of the programme. Professor Richard Logan, Eastern Hub Director 5

6 Executive Summary 1. The Eastern Hub of the NHS Bowel Cancer Screening Programme (BCSP) is one of the 5 Hubs responsible for screening the population aged for bowel cancer in England using faecal occult blood tests, and for inviting 55 year olds for flexible sigmoidoscopy screening (Bowelscope). 2. Extension of the programme to year olds across the whole of the Eastern Hub was achieved in September During the Hub was sending invitations and kits to around 16,000 people weekly (Figure 4). 4. Overall uptake of the BCSP has been between 51-62% and varies according to age, gender, ethnicity, measures of deprivation and screening round (Figure 5). 5. Of those sent test kits 42% of males do not return it, compared to 36% of females (Table 5). 2% opt out before receiving a kit. 6. Around 2.4% of people returning kits are found to have an abnormal test and are invited to attend one of the 14 Screening Centres across the Eastern region for assessment (Figures 5 and 7). 7. In 2013 only 1.3% of Eastern Hub subjects invited to attend a Specialist Screening Practitioner (SSP) appointment did not do so (Table 5). 8. The majority (92%) of people who attend an SSP appointment proceed to colonoscopy with a small number having less invasive investigation. Further details are shown on page 22 (Table 6). 9. The outcomes of colonoscopy and other investigations are shown on pages In the years a total of 1,326 people were found to have bowel cancers, of which over 75% will have been detected at an early curable stage. 10. Bowelscope, the once only flexible sigmoidoscopy screening of 55 year olds, started in May 2013 at our pilot site; the Norwich Screening Centre. By the end of ,349 people had been invited with the uptake being significantly higher than expected at 50%. 11. The Eastern Hub BCSP helpline receives approximately 400 calls/day. Feedback from this, letters and questionnaires shows that levels of satisfaction with the programme remain high (pages 32-33). 12. The staff employed in the Hub has increased from 33 staff, of whom 26 were Screening Officers in to 41, 33 being Screening Officers, in with income increasing from 6 million to 7.3 million. Report prepared by Andrew Field with support from Melanie Boulter, Richard Logan, Patrick McCormack, Fiona McLeod, Lucy Peck, Mike Vogler and Sharon Wilson. 6

7 1. Introduction Bowel Cancer Screening Programme, Eastern Hub Biennial Report After lung and breast cancer, bowel cancer (also referred to as colorectal cancer) ranks third equal with prostate cancer as one of the most common cancers in the UK with over 40,000 people being diagnosed every year. It ranks second only to lung cancer as a cause of cancer mortality in the UK, accounting for about 16,000 deaths in These figures equate to an estimated life time risk of developing bowel cancer of around 5%, i.e. about 1 in 20 UK citizens are expected to develop it in their life-time, with over 80% of cases occurring in people over the age of 60. Indeed, with an ageing population the health burden from bowel cancer is increasing rather than decreasing. Although in recent years survival from bowel cancer has improved, little more than half of all people diagnosed outside the screening programmes will survive 5 years. It has long been known that bowel cancer detected at an early stage has a much better prognosis than bowel cancer diagnosed at a late stage and several large trials (the largest being performed in Nottingham) have shown that screening for bowel cancer using a faecal occult blood testing (FOBt) on a regular basis can reduce deaths from bowel cancer by 25% in people participating and by about 15% overall 2, 3. Although several other methods of screening for bowel cancer have now been developed, at present only flexible sigmoidoscopy screening has been adequately assessed in randomised trials 4-6. These trials have shown that a single flexible sigmoidosopy can reduce mortality from bowel cancer by 44% in people participating and by about 28% overall 7. The FOBt screening programme invites men and women aged who are registered with an NHS general practice to complete a guaiac based FOB test every two years 8. The testing kit is posted to them at their homes. Across England the process of invitation and kit testing is managed by one of five Hubs as described in more detail on the following page. People found to have abnormal tests are then referred to their local Screening Centre for further assessment with most going on to have a colonoscopy. The Eastern Hub currently refers people with abnormal tests to 14 Screening Centres in the Eastern region and occasionally to Screening Centres covered by other Hubs. People whose FOB test proves to be normal are written to and advised that they will be sent another kit in 2 years provided they are still under the age of 75. The Bowelscope programme invites people aged 55 to attend their local Screening Centre for a flexible sigmoidoscopy which can examine the lower bowel (rectum and sigmoid colon) where 60% of all bowel cancers occur. The aim of the programme is to identify and remove certain bowel polyps (adenomatous polyps) and in so doing prevent bowel cancer developing, in contrast to the FOBt programme which primarily aims to detect early cancer. The Hub s role is to organise the invitations and respond to the helpline enquiries. Both programmes use a national IT system (the Bowel Cancer Screening System or BCSS) without which the programmes could not function. The BCSS holds the screening records for everyone who has been invited to participate or anyone who has opted into the programme and is the unheralded jewel in the crown of the screening programmes. The system is described in more detail on page Cancer Stats Cancer Statistics for the UK 2 Hardcastle JD, Chamberlain JO, Robinson MH, Moss SM, Amar SS, Balfour TW,et al. Randomised controlled trial of faecal-occultblood screening for colorectal cancer. Lancet Nov 30; 348(9040): Hewitson P, Glasziou P, Watson E, Towler B, Irwig L. Cochrane systematic review of colorectal cancer screening using the fecal occult blood test (hemoccult): an update. Am J Gastroenterol Jun; 103(6): Atkin WS, Edwards R, Kralj-Hans I, Wooldrage K, Hart AR, Northover JM,et al. UK Flexible Sigmoidoscopy Trial Investigators. Once-only flexible sigmoidoscopy screening in prevention of colorectal cancer: a multicentre randomised controlled trial. Lancet May Segnan N, Armaroli P, Bonelli L, Risio M, Sciallero S, Zappa M, Senore C et al; SCORE Working Group. Once-only sigmoidoscopy in colorectal cancer screening: follow-up findings of the Italian Randomized Controlled Trial--SCORE. J Natl Cancer Inst Sep 7; 103(17): Schoen RE, Pinsky PF, Weissfeld JL, Yokochi LA, Church T, Laiyemo AO,et al.plco Project Team. Colorectal-cancer incidence and mortality with screening flexible sigmoidoscopy. N Engl J Med Jun 21; 366(25): Brenner H, Stock C, Hoffmeister M Effect of screening sigmoidoscopy and screening colonoscopy on colorectal cancer incidence and mortality: systematic review and meta-analysis of randomised controlled trials and observational studies BMJ 2014;348:g Logan RF, Patnick J, Nickerson C, Coleman L, Rutter MD, von Wagner C; on behalf of the English Bowel Cancer Screening Evaluation Committee. Outcomes of the Bowel Cancer Screening Programme (BCSP) in England after the first 1 million tests. Gut Oct; 61(10):

8 2. Organisation & Hub Services The Programme Hub The Eastern Hub, hosted by the Nottingham University Hospitals NHS Trust (NUHT) and based at the Queens Medical Centre, is one of the five Hubs in the English NHS Bowel Cancer Screening Programme (BCSP). Figure 1 depicts the geographical areas covered by the five Hubs in England, the Eastern Hub covering the East Midlands and East of England. It also displays their respective total populations (millions); this is all ages and not just the screening population. Figure 1: The five England NHS Bowel Cancer Screening Programme Hubs and their 2012/13 Population figures (millions) (Data source: QMAS database /13 data as at end of June QOF) North East 8.2 Midlands & North West Eastern 8.8 London 14.6 Southern Programme Hubs operate a national call and recall system to send out faecal occult blood test kits (FOBt), analyse samples and dispatch results. They then book appointments at screening nurse clinics for those with abnormal test results. They also provide a free telephone helpline for members of the public regarding all aspects of the screening process. Each Hub is responsible for coordinating the programme in their area. The screening pathway 1 is depicted in Figure 2. 1 NHS Bowel Cancer Screening Programme. Guide book for Programme Hubs and Screening Centres Mar 31 8

9 Bowel Cancer Screening Programme, Eastern Hub Biennial Report The Screening Pathway Figure 2: The Screening Pathway 9

10 Hub Services The primary task for each of the 5 Hubs in England is to effectively and efficiently organise and manage the first stage of the programme pathway. The Hub s main responsibilities are: Sending out kits to invited subjects and the subsequent testing of returned kits. Calling and recalling subjects for screening. Providing a free telephone helpline for subjects. Booking appointments for subjects with an abnormal result with a Specialist Screening Practitioner. Sending out result letters to subjects and GPs. Providing reports and data analysis, including performance monitoring data, to Screening Centres, Commissioners, National Office and Quality Assurance Reference Centres. Maintaining a CPA accredited service that meets national standards. Supporting agreed BCSP research and development projects. A more detailed description of the Hub roles and responsibilities is given in the Bowel Cancer Screening Programme Service Specification 26 May Call and Recall In order for the programme to invite a subject the following criteria must be in place: The subject must be registered with a GP in England. The subject must be in the eligible age range. The Screening Centre must be active. After the first (prevalent) round of screening subjects are recalled within +/- 6 weeks of their new screening due date. This date is two years from the date their previous episode closed, or in the case of non responders two years from the date of their previous invitation. Successful reinvitation to subjects previously ceased for Crohns/IBD 100% of Screening Centres are operating smoothly with regards to invitations issued each month. Age Extension As of September 2013, all of the 14 Screening Centres served by the Eastern Hub were age extended, i.e. were inviting subjects aged between years old. The Eastern Hub were the first Hub to achieve full roll out age extension. Full roll out of age extension Bowel Scope (Flexible Sigmoidoscopy) Screening Bowel Scope Screening (BSS) is into its 2 nd National wave of rollout. The Eastern Hub now has 2 live centres, Norwich Bowel Cancer Screening Centre (live May 13 th 2013) and the newly formed Kettering and Northamptonshire Bowel Cancer Screening Centre (formally part of the Leicestershire, Northamptonshire and Rutland Screening Centre - live March 2014). Training for Bowel Scope almost complete Figure 3 shows the screening pathway for bowel scope. 1 Public health functions to be exercised by NHS England. Service specification No.26. Bowel Cancer Screening Programme. March

11 WEEK 2 WEEK 6 Bowel Cancer Screening Programme, Eastern Hub Biennial Report Figure 3: The Bowel Scope Screening Pathway WEEK 4 WEEK 8 Self Referral requests Demand Link GP practices to FS sites Appt re-bookings / cancellations Generate FS Invitations by site (Appt date 8 weeks) Send FS Pre-invites (Appt date 8 weeks) Send FS Invitations Inc. appt details (Appt date 6 weeks) Process FS Response Slips Capacity Set up FS Screening Clinic Lists Handle Suitability Assessment phone calls Process Decline Requests SC activity Hub activity Send Reminder letters (Appt date 4 weeks) Manage Overbooked / Under-booked FS Lists Process escalated suitability assessments Confirm FS Clinic Lists (Appt date 2 weeks) Maintain Maps and directions to FS sites Send FS Confirmation letter (Appt date 2 weeks) Send Bowel Prep (Appt date 2 weeks) Send Non-Response letters (Appt date 2 weeks) Appointment date Add appt details to local PAS (Appt date 2 days) 11

12 Detection rates Index colonoscopies Summary counts Rates Table 1 below shows the summary figures up to the end of 2013, for Norwich Screening Centre who are currently 42.5% rolled out. It is currently too early in the process to collate figures for the Kettering and Northamptonshire Screening Centre. The Hub s Data Analyst also produces a weekly Hub report on Bowel Scope Screening which can be seen in Appendix I. Table 1: Norwich Bowel Cancer Screening Centre Bowel Scope Screening Summary 13/5/13 31/12/13 (Data source: OBIEE 2-July-2014) Norwich Subjects routinely invited 3,349 Response Rate 1, % Uptake 1, % Self-referrals Total subjects Responded 16 3,365 1,954 Rescheduled % Attended % IC's required % IC's attended % Bowel Scopes 1,682 Adenoma's only % Any Polyp % Within the financial year 2014/15 we expect 7 more Screening Centres to go live with Bowelscope. The Hub will have a massive increase in workload, all of which is currently undertaken in house. The work flow is expected to increase significantly (more than double). Provisional dates have been released by the National Office of the NHS Cancer Screening Programmes and detail initial plans for go live dates during wave 2 and wave 3. Nottinghamshire Screening Centre and the University Hospitals of Leicester Screening Centre have both been in contact with the Hub to discuss the arrangements of their rollouts. The other centres have not yet involved the Hub in their draft plans, making future forecasting difficult for the Hub. Electronic GP Communications The Eastern Hub achieved 100% rollout in early 2013 ensuring electronic results were sent to all practices who requested them and who also had the system capabilities to accept them. We are pleased to be the first Hub to have done this successfully. The Hub has 1,386 practices of which 1,373 are all receiving their results electronically and all paper reporting has been switched off. The 13 practices remaining have all opted out of e-communications. Full implementation of GP Electronic reporting across all GP practices Table 2: Eastern Hub GP Practices receiving electronic communications (as of April 2014) GP practices Comments N.o. Practices in April ,386 Practices receiving Electronic results 1, % of practices receiving E comms Switched off hard copy results 1,373 results have paper copies switched off. Practices opted out of electronic results 13 Practices receiving hard copy results only 13 12

13 Bowel Cancer Screening Programme, Eastern Hub Biennial Report Helpline The helpline receives an average of around 400 calls a day. Of these around 6% are abandoned by the caller. Screening Officers are trained to reply to calls and use a Frequently Asked Questions sheet which is regularly reviewed. An escalation system is in place for difficult calls. Some queries, usually of a clinical nature, are referred to the Programme Director or Programme Manager. Installation of call monitoring platform In February 2014 a call monitoring platform was installed. This records and retains calls for a period of one month and enables us to listen back to calls received. This is being used to deal with queries and complaints and to provide feedback to our Screening Officers. An audit of the helpline was recently carried out using this system. Data relating to the helpline is explored on page 25. Mailing Services Currently the Eastern Hub sends out in excess of 3.2 million letters each year. The majority of these letters and associated inserts are printed and packaged by Real Digital International (RDI). The Hub transfers files in a highly secure manner that exceeds the usual security standards required for NHS data transfer. RDI activity is monitored by the Hub on a regular basis at a number of levels including daily checks, two-monthly meetings at RDI offices and an annual audit against a range of standards. We have worked quite intensively, led by the Southern Hub, to reduce our mailing costs. The Hub retains an in-house mailing service for a number of letter types including patient appointments, self referrals and weak positive kit results. Returned Mail A paperless system of returned mail to CCG s has been implemented which saves on postage costs. This is sent electronically to the CCG s each month. When the returned mail has been actioned the mail is retained for a month before being destroyed. Paperless system of returned mail saving on postage costs Stakeholder Communications The Hub interacts with its stakeholders in a variety of ways: Each Screening Centre has a dedicated Hub Screening Officer who liaises with the centre whenever an issue of interest arises, for example reduced clinic availability. The Screening Officer will also proactively contact the Screening Centre on a weekly basis to check that all is well. The Programme Director, Programme Manager, Operational & Quality Manager, Deputy Operational & Quality Manager and Data Analyst are individually assigned to attend various Screening Centre programme board meetings. The Programme Manager, Operational & Quality Manager and Data Analyst attend the Eastern Bowel Hub consortium meeting organised by the lead commissioners. The Programme Director and Programme Manager attend the 4 monthly Directors QA meeting. The Data Analyst produces 3 monthly reports for Screening Centres and Area Teams and also responds to individual data requests. The Programme Director is a member of the BCSP Evaluation group and the BCSP Research Committee. The Data Analyst regularly attends the East Midlands BCSP Specialist Screening Practitioners (SSP)/Data Admin Meeting, and the East Midlands BCSP Endoscopy Meeting. 13

14 Screening Centres and the Population Served Table 3 shows the 14 Screening Centres within the Eastern Hub boundary. The Screening Centres provide the colonoscopy services and specialist screening nurse clinics for people receiving an abnormal result. Screening Centres are also responsible for referring those requiring treatment for bowel cancer to their hospital multidisciplinary team (MDT). Table 3: Eastern Hub Screening Centres and their 2012/13 Population figures (Data source: QMAS database /13 data as at end of June QOF) Screening Centre Centre Start Population Age Extension ( /13 74) roll out Bedfordshire Mar ,635 Oct-12 Cambridge Oct ,771 Apr-10 Derbyshire 1 Mar-07 1,021,287 Apr-10 East And North Hertfordshire Mar ,247 Apr-10 Hull And East Yorkshire 2 Feb-07 21,159 Apr-10 Leicestershire, Northamptonshire and Rutland 3 Dec-07 1,787,024 Jun-12 Lincolnshire Dec ,189 Sep-13 North Essex Feb-09 1,094,855 Sep-12 Norwich Jul ,740 Sep-08 Nottinghamshire Mar-08 1,025,735 Jun-13 Peterborough And Hinchingbrooke Jul ,878 Jul-13 South Essex Sep ,105 Nov-10 South Yorkshire And Bassetlaw 4 Feb ,930 Apr-10 West Herts Mar ,319 Oct-10 Eastern Hub Total 10,834,874 1 Derbyshire Screening Centre also covers the East Staffordshire CCG population of 135,146 people. This comes under the remit of the Midlands and North West Hub however. 2 Hull and East Yorkshire may not be shown in individual Screening Centre analyses due to small numbers. This population is for 3 GP practices belonging to Lincolnshire East CCG. 3 Leicestershire, Northamptonshire and Rutland Screening Centre split on the 10 th February 2014 due to its size and became Kettering and Northamptonshire Screening Centre and the University Hospitals of Leicester Screening Centre. 4 As of 28 th February 2014 the population of Bassetlaw normally referred to the South Yorkshire and Bassetlaw Screening Centre but covered by the Eastern Hub became the responsibility of the North East Hub. 14

15 3. FOBt Activity Analysis invites/kits returned Bowel Cancer Screening Programme, Eastern Hub Biennial Report Invitations and Test Kits Figure 4 shows an overview of the Eastern Hub activity since January 2012 until December It shows the number of invitations sent along with the number of kits returned. It also illustrates the considerable weekly variation in Hub activity. The peaks and troughs around the Christmas and New Year period can be seen in the low numbers of kits received at the end of the year, picking up again the beginning of January where high numbers of kits are received. An average of 10,115 kits were received each week in Figure 4: Total number of invitations sent and kits returned by week (Source: OBIEE 25-Mar-2014) 20,000 Invites Kits Returned 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 Managing Kit Returns Table 4 portrays the proportion of each kit result received into the Hub. Although about 93% of first returned kits test as normal, most of the remaining 7% of samples require retesting of some sort and the subject journey time for this part of the algorithm often takes several weeks before a definitive normal or abnormal result is obtained. Table 4: Kit results per 1,000 kits, Jan 2012 Dec 2013 Kit Result % per 1,000 kits Normal 92.90% 961 Strong Positive 0.37% 4 Weak Positive 5.65% 59 Spoilt 1.07% 11 Technical Fail 0.01% 0 15

16 Uptake Positivity Uptake and Positivity Figure 5 shows the population uptake of the screening programme within the Eastern Hub along with the percentage positivity of those subjects who have had a definitive test result, from January 2012 to December It must be noted that the date is based on the subjects invitation to take part in screening date. That is for a subject invited in January and returning a positive FOBt in March, their uptake will be included in the January figures, as would their positivity. Figure 5: Uptake (%) and Positivity (%) by month (Source: OBIEE 26-Mar-2014) 64% Uptake Positivity 2.5% 62% 60% 58% 2.0% 1.5% 56% 54% 52% 1.0% 0.5% 50% 0.0% While uptake and positivity fluctuates month on month this mainly reflects the population being invited at any one time. The decline in uptake towards the end of 2013 is similar to that experienced in 2011 and is further analysed under Uptake according to Prevalence / Incidence round on page 19. This decline also refelcts the same picture seen nationally. 16

17 Positivity Uptake Bowel Cancer Screening Programme, Eastern Hub Biennial Report Uptake and Positivity by Age and Gender Figures 6 and 7 display the percentage uptake and positivity of year olds and year olds from January 2012 to December % Figure 6: Uptake - Eastern BCSP Hub Year Olds and Year Olds Jan Dec 2013 (Source: OBIEE 26-Mar-2014) year olds year olds 65% 60% 55% 50% % Figure 7: Positivity - Eastern BCSP Hub Year Olds and Year Olds Jan Dec 2013 (Source: OBIEE 26-Mar-2014) year olds year olds 3.0% 2.5% 2.0% 1.5% 1.0% 0.5% 0.0% Uptake is similar for the two age groups, but kits returned by year olds are more likely to be positive running at around % compared with % in year olds. 17

18 Uptake To examine trends in uptake and determine whether uptake has increased as the public has become more familiar with the programme, uptake for 60 year olds receiving their first invitation is shown in Figure 8, covering the period January 2012 to December Overall uptake for this age does appear to be decreasing over time. The overall decrease is emphasised by the higher uptake levels experienced during 2011, thought to be a result of the public becoming more familiar with the programme. There is however an 8-11% difference between men and women at this age. 70% Figure 8: Uptake - Eastern BCSP Hub - 60 Year Olds Jan Dec 2013 (Source: OBIEE 26-Mar-2014) 60 Year Olds Total 60 Year Olds MALE 60 Year Olds FEMALE 65% 60% 55% 50% 45% 40% The percentage uptake of screening invites in 2012 and 2013 is analysed in Figure 9 by age range of the eligible screening population invited and gender. As expected uptake is greater in women, but this gender difference decreases as people get older. Figure 9: Uptake of Screening Population (Source: OBIEE 26-Mar-2014) Figure 10: Positivity of Screening Population (Source: OBIEE 26-Mar-2014) 66% 64% 62% 60% 58% 56% 54% 52% 50% 48% Female total Male total 60-64's 65-69's 70-74's 60-64's 65-69's 70-74's 3.0% 2.5% 2.0% 1.5% 1.0% 0.5% 0.0% Female total Male total 60-64's 65-69's 70-74's 60-64's 65-69's 70-74's Female Male Female Male Test kit positivity shown in Figure 10 is higher in men than women as is generally found and it also increases with age. These trends in uptake by age and gender have been examined further as shown in the poster in Appendix N, which has been presented at the BSG and UEGW meetings. 18

19 Bowel Cancer Screening Programme, Eastern Hub Biennial Report Uptake and Positivity by Prevalence/Incidence Round As shown in Figures 5 and 6 there was marked decline in uptake seen towards the end of 2013 from a peak in February of 62% to a nadir of 51.6% in November. The explanation for this is not obvious until uptake is examined according to a subject s previous screening experience. Subjects invited to take part in the screening programme can be classified into different subject groups depending on whether they have previously taken part in the programme or not, and their round of screening. Prevalent Episode 1: where a subject is screened after their first invite to take part in the programme. Prevalent Episode 2: where the subject is screened for the first time after being invited for the second time i.e. has never before been screened adequately within NHSBCSP despite a previous invitation/episode. Prevalent Episode 3+: where the subject is screened for the first time after being invited for the third or subsequent time i.e. has never been screened adequately within NHSBCSP before, regardless of the number of previous invitations/episodes. This includes all the Prevalent Episode 3 subjects PLUS all the Prevalent Episode 4 subjects. Incident Episode 2: where the subject is screened having been adequately screened once within the NHSBCSP, either as the result of an invited or requested episode. Incident Episode 3+: where the subject is screened and has previously been screened adequately at least once within the NHSBCSP, either as the result of an invited or requested episode. This includes all the Incident Episode 3 subjects PLUS all the Incident Episode 4 subjects. A subject may have taken up their 1 st screening episode, missed their 2 nd episode, but then completed their 3 rd episode. Episode 3 and Episode 4 subjects have been grouped together due to small numbers of episode 4 subjects and simplification of graphical presentation. Figure 11 shows the total number of invitations and the uptake for these 5 groups. The decline in overall uptake is explained by the increasing number and proportion of invitations being sent to subjects who previously had not returned a kit despite being called for screening twice previous (Prevalent Episode 3+). Uptake within each group has shown little change. For the incident group uptake remains high with around 90% of subjects previously screened returning a second or third kit. 19

20 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Positivity Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Invite Count Uptake Figure 11: Uptake & Invitation Count - Eastern BCSP Hub by Subject Group Jan Dec 2013 (Source: OBIEE 5-Mar-2014) Prevalent E1 Invitations Prevalent E2 Invitations Prevalent E3+ Invitations Incident E2 Invitations Incident E3+ Invitations Prevalent E1 uptake Prevalent E2 uptake Prevalent E3+ uptake Incident E2 uptake Incident E3+ uptake 50, % 45,000 90% 40,000 80% 35,000 70% 30,000 60% 25,000 50% 20,000 40% 15,000 30% 10,000 20% 5,000 10% 0 0% Figure 12 shows the positivity for these 5 groups. The Prevalent Episode 2 and 3+ groups have a higher positivity rate as expected for these low uptake groups, whilst incident episodes have a reduced positivity rate compared to the Prevalent Episode 1 group. These findings on uptake and positivity mirror the findings from the other Hubs. Figure 12 : Positivity - Eastern BCSP Hub by Subject Group Jan Dec 2013 (Source: OBIEE 5-Mar-2014) Prevalent E1 Positivity Prevalent E2 Positivity Prevalent E3+ Positivity Incident E2 Positivity Incident E3+ Positivity 7% 6% 5% 4% 3% 2% 1% 0% 20

21 Total Female Male Bowel Cancer Screening Programme, Eastern Hub Biennial Report Programme Attrition Programme attrition describes the drop out at each stage of the screening pathway. It has been analysed by gender for the 1 year period January December 2013 in Table 5 below. Table 5: Programme Attrition in 2013 Stage of the Screening Pathway No. Drop-out stage No. % Invitation Count 399,349 Opt out before receiving a kit 7, % Invitation kit count Do not return a test kit 163, % 391,689 Reason for non-participation recorded 6, % Return at least one test kit 221,527 Do not reach a definitive FOBt outcome 1, % Invited to attend SSP appointment 4,938 Did not attend an SSP appointment % Referred for Diagnostic testing 4,454 Declined further investigation 1 0.0% Invited to attend for colonoscopy 4,453 Did not attend colonoscopy % Invitation Count 413,027 Opt out before receiving a kit 10, % Invitation kit count Do not return a test kit 144, % 402,443 Reason for non-participation recorded 7, % Return at least one test kit 250,156 Do not reach a definitive FOBt outcome 1, % Invited to attend SSP appointment 3,697 Did not attend an SSP appointment % Referred for Diagnostic testing 3,273 Declined further investigation 0 0.0% Invited to attend for colonoscopy 3,273 Did not attend colonoscopy 4 0.1% Invitation Count 812,376 Opt out before receiving a kit 18, % Invitation kit count Do not return a test kit 307, % 794,132 Reason for non-participation recorded 14, % Return at least one test kit 471,683 Do not reach a definitive FOBt outcome 2, % Invited to attend SSP appointment 8,635 Did not attend an SSP appointment % Referred for Diagnostic testing 7,727 Declined further investigation 1 0.0% Invited to attend for colonoscopy 7,726 Did not attend colonoscopy % 2.2% of subjects who are invited to take part in the programme opt out after the pre-invite letter, before they are sent a test kit. 38.8% sent a kit do not then complete and return it, with a further 1.9% opting out or being ceased from the programme due to clinical reasons. This is higher in males than females with 41.7% of males not returning a kit compared with 35.9% of females. Only 0.5% of those who complete and return a test kit do not go on to reach a definitive FOBt outcome of normal or abnormal due to not completing their retest kit(s). Of those found to be abnormal who are then invited to attend an SSP clinic appointment, 1.3% did not attend at all. 89% (7,727/8,635) were then referred for diagnostic testing with 99.99% being invited to attend a colonoscopy. Only 0.3% of these go on to not attend, but again this is greater in males than females. 21

22 Clinical and Colonoscopic Outcomes In the last 2 years over 17,000 subjects were referred to SSP clinics having had a definitive abnormal result. Over 21,000 diagnostic investigations, including surveillance investigations, took place as shown in Table 6. Table 6: Diagnostic Tests undertaken split by patient gender Jan 2012 Dec 2013 Diagnostic Test Female Male Total Colonoscopy 7, % 12, % 19, % Flexible Sigmoidoscopy % % % Virtual CT Colonoscopy % % % Limited Colonoscopy % % % Abdominal CT Scan % % % Barium Enema % % % Total 8, % 13, % 21, % Table 7 shows the diagnostic test outcome according to the number of kits returned and resulting in an abnormal result. It also shows the outcomes of any surveillance colonoscopies during this time period. Table 7: Diagnostic test outcomes according to the number of kits returned or surveillance attendance Jan 2012 Dec Kit 2 Kits 3 Kits Surveillance episode Grand Total Cancer detected % % % % 1, % High-risk Adenoma % % % % 1, % Intermediate-risk Adenoma % 1, % % % 2, % Low-risk Adenoma % 1, % % 1, % 4, % Other Abnormal finding % 2, % 1, % 1, % 5, % Abnormal, no Histology 8 0.4% % % % % Normal result % 1, % % % 3, % No result % % % % % Total Histology 2, % 8, % 4, % 4, % 19, % *surveillance data included to match with outcomes according to Screening Centre. It should be noted that 32% of cancers (419/1,326) are detected as a result of a straight or strong positive test (5-6 windows positive). A fifth of patients who under go surveillance diagnostic testing are found to have a normal result, with nearly two thirds having an outcome of low-risk adenoma or other abnormal finding. The data presented in Figures 13 and 14 on the following page are the results of (potentially multiple) diagnostic tests (including any surgery), i.e. the definitive outcome of a patient s episode. It uses what is classed as the greatest risk. Figure 13 shows that a higher proportion of cancers are detected in the subject s first episode, with detection of low risk adenomas being higher in the incident rounds. Figure 14 shows the proportion of cancers detected increases with age as might be expected. Other abnormal findings are predominately Diverticulosis and Haemorrhoids. 22

23 Bowel Cancer Screening Programme, Eastern Hub Biennial Report Figure 13: Outcome of Investigation by episode Jan Dec 2013 (Source: OBIEE 26-Mar-2014) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 1.5% 1.7% 1.5% 1.6% 20.2% 19.2% 19.7% 19.5% 0.7% 0.6% 0.4% 0.5% 26.3% 28.5% 27.2% 27.7% 15.7% 21.3% 23.3% 21.2% 16.0% 13.3% 13.0% 13.6% 10.3% 8.9% 8.4% 8.9% 9.2% 6.5% 6.5% 6.9% Episode 1 Episode 2 Episode 3 Total No result Normal result Abnormal, no Histology Other Abnormal finding Low-risk Adenoma Intermediate-risk Adenoma High-risk Adenoma Cancer detected Figure 14: Outcome of Investigation by age range Jan Dec 2013 (Source: OBIEE 26-Mar-2014) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 1.4% 1.4% 1.7% 1.4% 21.6% 19.2% 16.2% 19.6% 0.5% 0.7% 0.5% 0.6% 27.2% 18.3% 27.5% 17.8% 14.0% 15.1% 26.4% 18.8% 15.3% 9.6% 9.6% 11.0% 27.1% 18.2% 14.7% 9.9% 7.4% 8.8% 10.0% 8.4% years old years old years old Total No result Normal result Abnormal, no Histology Other Abnormal finding Low-risk Adenoma Intermediate-risk Adenoma High-risk Adenoma Cancer detected 23

24 Outcomes According to Screening Centre Tables 8 and 9 break down the patient episode outcomes by Screening Centre, for January 2012 December 2013 and from the programme start to December CCG and Area Team level data is shown in Appendix C & D. Table 8: Screening Centre Outcomes, Jan 2012 Dec 2013 (row percentages) Cancer detected High-risk Adenoma Intermediaterisk Adenoma Low-risk Adenoma Other Abnormal finding Abnormal, no Histology Normal result No result Bedfordshire % % % % % 2 0.2% % % 1,024 Cambridge % % % % % 5 0.3% % % 1,639 Derbyshire % % % % % % % % 2,330 East And North Hertfordshire % % % % % 2 0.2% % 9 0.9% 1,028 Leicestershire, Northamptonshire and Rutland % % % % % % % % 2,872 Lincolnshire % % % % % % % % 1,066 North Essex % % % % % % % % 1,888 Norwich % % % % % % % % 2,428 Nottinghamshire % % % % % 8 0.5% % % 1,731 Peterborough And Hinchingbrooke % % % % % 2 0.2% % % 811 South Essex % % % % % 3 0.2% % % 1,314 South Yorkshire And Bassetlaw % % % % % 2 0.7% % 1 0.4% 268 West Herts % % % % % 1 0.1% % % 1,038 Eastern Hub Total 1, % 1, % 2, % 4, % 5, % % 3, % % 19,437 Total Table 9: Screening Centre Outcomes, Programme Start Dec 2013 (row percentages) Cancer detected High-risk Adenoma Intermediaterisk Adenoma Low-risk Adenoma Other Abnormal finding Abnormal, no Histology Normal result No result Bedfordshire % % % % % 3 0.1% % % 2,298 Cambridge % % % % % 9 0.2% % % 4,090 Derbyshire % % % % % % % % 5,999 East And North Hertfordshire % % % % % 5 0.2% % % 2,592 Leicestershire, Northamptonshire and Rutland % % % % % % % % 7,257 Lincolnshire % % % % % % % % 2,414 North Essex % % % % % % % % 4,187 Norwich % % % % % % % % 7,087 Nottinghamshire % % % % % % % % 4,344 Peterborough And Hinchingbrooke % % % % % 8 0.4% % % 1,915 South Essex % % % % % 4 0.1% % % 3,133 South Yorkshire And Bassetlaw % % % % % 2 0.3% % 3 0.4% 694 West Herts % % % % % 6 0.2% % % 2,451 Eastern Hub Total 3, % 4, % 7, % 9, % 10, % % 12, % % 48,461 Total 24

25 Number of calls received Bowel Cancer Screening Programme, Eastern Hub Biennial Report Helpline Calls by week The number of calls received by the helpline each week fluctuates, as indicated in Figure 15. On average 1,711 calls were received each week in The peak number of calls received in January was also seen in 2012, though data for this year is not shown. The chart also portrays the number of helpline calls answered. For % of calls received to the helpline were answered. This excludes any calls received out of hours (between the hours of 5pm and 8am) and on weekends. Approximately 9% of calls are received out of hours. 3,000 Figure 15: Number of helpline calls received and the proportion answered in 2013 (excludes out of hours calls and on weekends) (Source: Avaya Telephone Platform) Helpline Calls (total for week) Helpline Calls Answered Average calls received per week 2,500 2,000 1,500 1,711 1, The categories of calls received during 2013 are shown in Figure 16. As indicated the majority are general enquiries. Figure 16: Categories of Calls during 2013 (Source: Avaya Telephone Platform) Kit use 1% Appointment 3% Other 2% Cease - Clinical 1% Cease - Non Clinical 0% Closed Episode - Clinical 8% General Enquiry 41% Closed Episode - Non Clinical 25% New Kit 11% Self Referral 8% 25

26 4. Data Analysis The Eastern Hub Data Analyst continues to produce various data and reports as part of the monitoring of the effectiveness of the programme, as well as internal processes within the Hub. Quarterly Reporting Quarterly reports, which are distributed to Screening Centre and Area Team stakeholders on how the Screening Centre is performing, have been revised and are now much more user friendly. More recently they have seen the addition of a key highlights front page summary, of which very positive feedback has been received. The data covered within these reports includes information on invites, uptake and positivity, SSP appointments, diagnostic tests, and waiting times. A comparison against the Hub for uptake and positivity is also included which helps when looking at the national trend down in uptake rates. Centres also receive GP level data by CCG shown cumulative since the Screening Centre opened. KPI Reporting Another area of development has been KPI reporting. This has been continuous development throughout 2013 with the introduction of targets, RAG ratings and 8 new indicators, as well as the link to the NHS England BCSP service specification. The indicators have also been separated into quadrants; Process Effectiveness, Programme Effectiveness, Employee Welfare and Employee Development. KPI s are vital to ensure the smooth running and management of the Hub, as well as quality of the Hub activity taking place. It shows the commissioners what is happening by giving an overview of the performance of the Hub. The current KPI s reported quarterly are shown in Appendix E. Work is also currently underway on the production of a balanced scorecard approach to KPI reporting. The financial year 2013/14 saw the implementation of a quarterly key performance indicator report for Screening Centre programme board meetings. This report meets the needs and routine data requirements of the Bowel Cancer Screening Programme service specification and has proven invaluable for Screening Centres. It is a vehicle in which they are able to share their performance with their commissioners; the Area Team Screening & Immunisation Leads and Managers, as well as achieving the need to report these KPI s as per their contract. The template for 2013/14 reporting can be seen in Appendix F. Continuous development of Hub KPI s Implementation of a quarterly key performance indicator report for Screening Centre board meetings Other Regular Reporting Weekly statistics ensure the department has an up to date source of information on Hub activity. Again this is vital to ensure the smooth running and management of the Hub. The FOBt activity report has continued to be produced on a weekly basis, with 2013 seeing the introduction of a weekly Hub report on Bowel Scope Screening (BSS). Appendix G displays a copy of the Eastern Hubs weekly FOBt activity report, with the method of measurement shown in Appendix H. Similarly the BSS weekly report and method of measurement are shown in Appendices I and J. The Hub s Data Analyst continues to produce statistics on Screening Officer positivity reading rates. This analysis is covered under Reader Positivity in the Quality Assurance section, page 35, and is vital to ensure there is some consistency with the reading of kits and to highlight any potential issues in individual reading. The number of adhoc data requests received from Screening Centres and other stakeholders has decreased dramatically with very few now being received. This is as a result of greatly improved regular reporting. The Data Analyst attends various stakeholder meetings including Screening Centre programme boards, the Eastern Bowel Hub consortium meeting organised by the lead commissioners, the East Midlands BCSP Specialist Screening Practitioners (SSP)/Data Admin 26

27 Bowel Cancer Screening Programme, Eastern Hub Biennial Report Meeting, and the East Midlands BCSP Endoscopy Meeting. Attendance at these meetings has allowed the Data Analyst to build excellent working relationships with our wide range of stakeholders, as well as gaining a better insight into their information and data requirements, enabling the production of more comprehensive reports. The Bowel Cancer Screening System (BCSS) The Health & Social Care Information Centre (HSCIC) continues to develop the national Bowel Cancer Screening IT System (BCSS) as the screening programme evolves. Staff members from the Eastern Hub are regularly involved in User Acceptance Testing for system developments which have included Bowel Scope and FIT (Faecal Immunochemical Testing). The reporting aspect of the system, OBIEE (Oracle Business Intelligence Enterprise Edition), also continues to be developed and 2013 has seen the introduction of a Pathology dashboard. This dashboard displays information about polyps and adenomas, cancers found, and information about the pathologists who processed the samples. A Bowel Scope dashboard is also currently under development. Dashboard delivery of reports is the new strategy being implemented by the NHS Cancer Screening Programme (NHS CSP) and HSCIC. In time, current BCSS reports will be replaced with new dashboards and new reports will be developed. NHS CSP will be working with QARCs and clinicians to develop specifications, test and implement new reports. As well as having access to the different dashboards within OBIEE, the Hub Data Analyst continually utilises the Answers tool in creating bespoke queries on the data currently held in the dashboards. 27

28 5. Management Structure & Staff Figure 17 shows the organisational structure of the Eastern Hub at December A list of staff is shown in Appendix K. Over 75% of our staff are Screening Officers, whose duties involve testing kits in the laboratory, answering calls on the helpline, booking clinic appointments and a range of other administration duties. They are supported by Senior Screening Officers who act as team leaders and who take on some more specialised tasks. Laboratory 1 The Office Manager/Programme Administrator is responsible for managing all the Screening Officers and supporting the Senior Management Team. The Laboratory Lead is an HPC registered Biomedical Scientist who oversees all aspects of the laboratory work and is also the Training Officer for the department. Helpline The Project and Service Development Coordinator is a part time post responsible for managing new developments, in terms of new project work and BCSS developments. The Data Analyst and Information Officer provides data and information to the Senior Management Team and our stakeholders across the region. The Operational and Quality Manager manages the technical, administrative and quality aspects of the Hub, supported by the Deputy Operational and Quality Manager. Both these posts are occupied by HPC registered Biomedical Scientists. The Programme Manager is responsible for the overall management of all aspects of the Hub, including finance, people, quality and general management. The current post holder is a Chartered Scientist; HPC registered and has a Masters degree in Business Administration. Administration The Programme Director is responsible for delivering the objectives of the National Programme and directing the strategic development of the programme for Eastern England. The current post holder is medically qualified, a Consultant Gastroenterologist and Emeritus Professor of Clinical Epidemiology with the University of Nottingham. Table 10 outlines the number of whole time equivalents (WTEs) by band working within the Eastern Hub at the end of 2012 and Table 10: Eastern Hub Staffing WTEs Band Medical Total

29 Bowel Cancer Screening Programme, Eastern Hub Biennial Report Figure 17: Eastern Hub Bowel Cancer Screening Management Structure as at Dec 2013 National NHS Screening Director Programme Director Directorate Management Team Lead Biochemist Programme Manager Pathology General Manager Operational & Quality Manager Deputy Operational & Quality Manager Project & Service Development Coordinator Data Analyst and Information Officer Office Manager/ Programme Administrator Specialist BMS Laboratory Lead Senior Screening Officers Screening Officers 29

30 6. Quality Assurance Clinical Pathology Accreditation (CPA) In 2010 the Eastern Bowel Cancer Screening Hub was the first of the five Hubs to be assessed by CPA as an individual stand-alone laboratory. Following full CPA accreditation the Hub underwent a surveillance visit in September Only one minor and non-critical non conformity was identified which was cleared by December At the request of the National Office we have also been assisting a fellow Hub in gaining CPA accreditation. Quality Assurance Reference Centre (QARC) In July 2013 the Eastern Hub was inspected by the East Midlands and East of England QARC teams. The one day inspection consisted of assessing compliance around the standards associated with laboratory management, administration, call and recall and data & information. The department received just 9 recommendations around areas such as succession planning and accommodation. The majority of these recommendations have been cleared and the remainder are in progress. External Quality Assurance (EQA) The laboratory participates in the Birmingham NEQAS for Faecal Occult Blood. Every two months each individual Screening Officer who tests within the laboratory is issued with three sample cards from the scheme, resembling the subject cards received routinely into the Hub. Each Screening Officer is provided with a report from the scheme and a comparison report can be accessed by the Operational and Quality Manager for review. If there is individual non-compliance (reporting of false negative or false positive results) then the Laboratory Lead, Operational and Quality Manager or Deputy Operational and Quality Manager are responsible for completing an EQA exception report. Accepted concentrations are those where there is a result consensus (positive or negative) of all NEQAS participants over 80%. During 2013 the Hub was still consistently detecting haemoglobin levels at 0.2mg Hb/g matrix and above, which is a concentration much lower than the expected positive result of 0.6mg Hb/g matrix as outlined by the test kit manufacturer. Results from the scheme are therefore read with this in consideration. Exceptions Exceptions are recorded and monitored by the Laboratory Lead. An exception by definition is an EQA reading which is contradictory to the national standard limit of reading. During 2013 there was only one exception produced from an EQA report. This was from 1 Screening Officer who reported 0.4mgHb/g as negative when all other SO s recorded the result as positive. The individual Screening Officer was communicated with in regards to the exception and then observed during the next run of Birmingham NEQAS samples. They carried out the second run without any problems or indications that their testing was impaired. They were signed off as competent and allowed to re-enter the routine scheme. It was thought that the wrong radial button when inputting the results on the schemes website was the cause of the error. Hub involvement with the scheme The Hub has been visited by Jane French who is the organiser of the Birmingham NEQAS scheme. She presented findings on different matrices tested for effective EQA material and also asked for feedback from the team. This was a successful visit and the team now understand their report more and feel more involved with the EQA scheme and the benefits it has to offer. 30

31 Bowel Cancer Screening Programme, Eastern Hub Biennial Report Laboratory Practices During 2012 and 2013 the laboratory practices have developed to incorporate some new challenges and changes. The laboratory has now introduced methods of detecting Priority testing and testing re-test FOBt kits. The EAST on the envelope is highlighted pink at the of re-test kits distribution from the Hub stage. This allows the laboratory to identify these pink envelopes when counting the returned kits at the start of the testing day. This process has allowed the majority of appointments to be made by the Hub earlier in the day, reducing the pressure on the admin aspect of the programme later on in the day. Initially only positive test kit results were quality checked within the Hub. As of 2013 all test kits now have a result check carried out before they are sent to storage pre disposal. There was concern that results were being entered incorrectly, though none have been found on the checks. The procedure has added extra assurance to the quality of the results being issued from the Hub. Adverse Incidents Incidents and errors which arise in the programme are recorded as Adverse Incidents (AVI s) or Internal Errors. The categorisation of incidents in the Eastern Hub is that incidents which have no impact on activity beyond the Hub are reported as internal errors, and those of a more serious nature which might affect the population are reported as AVI s. The Eastern Hub has established a set of incident and error logging procedures, which are used in conjunction with the NUH Trust incident reporting procedures and the National Office AVI format. Information from both sets of procedures is collated and trends are investigated. The information is reviewed and acted upon by the Senior Management Team. Incident forms are made available to National Office, NUH Trust, QARC for East Midlands and East of England, Screening and Immunisation Leads, and Programme Commissioners. A total of 6 AVI s were reported in 2012 and 4 in These have been categorised in Table 11 below and are described in more detail in Appendix M. Table 11: AVI s Administration Laboratory Helpline Appointments Outsourcer errors external Outsourcer errors internal BCSS Other Total There were very few errors in 2012 and 2013, a marked decrease from previous years. Internal error reporting was introduced into the department in Internal errors include minor transcription errors such as incorrect dates entered at logging. Internal errors are reported to senior management and are logged for analysis. Trends are reviewed and root cause analysis is performed. Processes are then evaluated and altered if necessary using corrective and preventative measures. In 2012 there were 165 internal errors and in 2013 there were 281. When relating these errors to activity in the Hub the error rates are significantly low; laboratory errors 0.023%, helpline 0.019% and appointment booking 0.069%. 31

32 User Feedback The Hub receives user feedback from 3 sources: Participants who call or write into the Hub. A post clinical investigation questionnaire given to subjects attending the Screening Centre. In-house questionnaires sent from the Hub. Participants Who Call or Write into the Hub We receive suggestions, comments and/or user feedback each year from individuals who take the time to contact us. These suggestions are categorised and discussed at the Senior Management Team every six months. We also receive around 100 calls or letters each year thanking us for the service. A Post Clinical Investigation Questionnaire Given to Patients Of the 5,630 subjects who completed the colonoscopy questionnaire in 2013, 14.3% (806) answered the question Did the helpline give you the information you needed? The breakdown of their response is portrayed in Figure 18 below. Figure 18: Did the helpline give you the information you needed? January - December subjects 3% 605 subjects 75% 175 subjects 22% Disagree/Strongly disagree Neither agree nor disagree Agree/Strongly Agree The 26 who disagreed/strongly disagreed were further investigated to see if there were any improvements which could then be made. 3 of these subjects made comments at the end of the questionnaire. These didn t relate badly to the helpline however stating: The freephone helpline were very helpful. I rang the helpline and asked for a more convenient date, preferably at the Lister hospital (nearer home). Within 24 hours a very efficient staff had answered my request. The third made no comment in relation to the helpline. Individual subject s episode notes were also consulted. Nothing of concern was uncovered within them. Some of the subject s had contacted the Screening Centre and not the Hub, others contacted to rebook their appointment. It has thus been concluded that they had ticked the incorrect box when completing the questionnaire, possibly due to the positioning of the question. 32

33 Bowel Cancer Screening Programme, Eastern Hub Biennial Report In-house Questionnaires Sent From the Hub We have 2 in house questionnaires we periodically send out from the Hub: 1. One regarding the screening process covering aspects of invites, test kit, helpline and results. 2. One to look at feedback from subjects with an abnormal result for whom we book an SSP clinic appointment, at which they are then booked for further investigation, usually a colonoscopy. The Post SSP Appointment Questionnaire was sent at the beginning of We sent this questionnaire to a sample of 500 subjects who attended an SSP appointment in February or March 2013, and were then subsequently booked for endoscopic investigation. We had an excellent response rate of 63% (313 returned questionnaires). The main results are displayed in Figures below. Figure 19: Did receiving your appointment letter cause you concern or anxiety? Extreme Concern, 19, 6% No concern at all, 36, 12% Figure 20: Was your appointment made within a satisfactory time limit for you to be able to attend? % 0.6% Yes A lot, 48, 15% Moderate, 90, 29% Some, 119, 38% % No, my appointment was too soon, I needed more time No, I had to wait too long for my appointment Figure 21: How do you feel about the screening programme so far? Agree/Strongly Agree Neither Agree or Disagree Disagree/Strongly Disagree The test kit was easy to use The helpline has been useful The service so far has been very quick The service so far has been excellent The information supplied was clear and concise The nurse clinic appointment was at a suitable hospital The nurse clinic appointment was convenient for me % 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Any negative responses have again been further investigated, but nothing of concern was discovered. Future Activity A revised version of the questionnaire relating to the screening process is due to be repeated in We also investigated the possibility of using an automated user feedback for subjects who telephone the helpline but due to the implementation cost this was deemed not economic. 33

34 Audits In 2012 and 2013 a total of 75 audits (procedural reviews) of our processes surrounding laboratory and administration activities were carried out. The information regarding these is shown in Appendix L. The audits included 36 surrounding the Quality Management System (QMS), 3 pre-examination (Pre Exam), 13 examination (Exam), 5 post examination (Post Exam), 6 Health and Safety (H & S) and 12 around internal processes (IP). A breakdown of these is shown in Figure 22, with Figure 23 displaying these by their CPA standard. All staff at the Hub now participate in conducting the audits as audit training has been rolled out to all Screening Officers. The staff feel they can participate and be involved in other areas which contribute to the quality of the department. Figure 22: Audits by Category (Jan Dec 2013) Pre Exam 4% IP 16% QMS 48% Exam 17% Post Exam 7% H&S 8% Figure 23: Number of Audits by CPA Standard (Jan Dec 2013) G Std, 5 F Std, 9 E Std, 3 H Std, 7 A Std, 5 D Std, 9 B Std, 10 C Std, 7 34

35 % positive spots Bowel Cancer Screening Programme, Eastern Hub Biennial Report Reader Positivity Due to the subjectivity of the test it is necessary to monitor Screening Officer positivity to minimise the level of variation between readers. Reader positivity is an issue which is monitored closely within the Eastern Hub. Screening Officer variation is not only monitored by the Senior Management of the Hub but also by individual Screening Officers themselves. Figure 24 shows Screening Officer variation from January December Each spot on the chart illustrate the monthly positivity for the individual Screening Officer. Green rectangles show tight reader positivity, with red rectangles showing a broader varied positivity. Figure 24: Screening Officer Spot Positivity Monitoring Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Mean +2 SD -2 SD The blue line shows the average spot positivity for the Eastern Hub in 2011 at 2.02%. Red and green lines show +/- two standard deviations from the mean; that is the range in which you would expect 95% of reader positivity to lie within. Only the spot positivity which lies outside this range are considered to be statistically significant and it is these points which are scrutinised more, along with broad varied positivity. 35

36 Staff Training and Development within the Hub Training within the Eastern Hub has been very successful. Within the past two years there have been numerous different courses which Screening Officers, Senior Screening Officers and members of the Senior Management Team have completed successfully. These included: QCF in Business and Administration Level 2 Introduction to Leadership and Management Level 2 Dealing with distress course QCF in Pathology support Building Essential Leadership Skills Introduction to Leadership and Management in healthcare Science Quality Management in Healthcare Science PRINCE Project Management Certificate of Expert Practice in Quality Management Appraisal Training Skills for Life Internal training has developed over the course of 2013 with the introduction of a more thorough laboratory competency and helpline booklets to help with new starters. There has also been the introduction of internal Quality and Audit training for all staff which underpins the audit schedule within the department. Nottingham University Hospitals NHS Trust has standards of mandatory training for all staff to attend. The Hub has maintained its high level of attendance at running over 90% compliance for the majority of the two year period. 8 members of staff have either completed or are undertaking development courses 36

37 7. Commissioning Bowel Cancer Screening Programme, Eastern Hub Biennial Report Primary Care Trusts, Cancer Registries, Public Health Observatories and the Health Protection Agency ceased to exist after 31 March 2013 and a number of new organisations took over these and other public health functions. Public Health England (PHE) was established on 1 April 2013 and became responsible for providing public health functions for health protection, health promotion, screening, immunisation and public health information & intelligence. PHE operates as an Executive Agency of the Department of Health (DH) with a small national office led by a Chief Executive. The first new organisation to be established under the Health and Social Care Bill was the NHS Commissioning Board Authority. It was established in shadow form as a Special Health Authority and replaced by the NHS Commissioning Board (NHS CB) on 1 October NHS England is the operating name of the NHS CB. Within the NHS England structure there are both statutory and non-statutory organisations that will each have their own geographic footprint. Clinical Commissioning Groups (CCGs) are the only statutory organisations in the NHS England family. Their function is defined by Statute to commission local health services. There are 39 CCGs covered by the Eastern Hub. Area Teams (ATs) support CCG development and assurance, emergency planning and directly commission GP, dental, pharmacy and optical services in England. The Eastern Hub is made up of 6 ATs, shown in Figure 25 along with the populations covered. Figure 25: The six NHS Commissioning Board Area Teams covered by the Eastern NHS Bowel Cancer Screening Programme Hub and their populations (1,000 s) (Data source: QMAS database /13 data as at end of June QOF) 112 2,047 1,823 2,504 2,545 1,803 The service for subjects aged between years is commissioned by the 6 AT s that the Eastern Hub serves. The service for subjects aged between years is currently commissioned by the National Office for NHS Cancer Screening, but will become the responsibility of the AT s from April

38 The move from PCT s to AT s saw the Derbyshire & Nottinghamshire Area Team take on the role of lead commissioner. This was previously held by the team at the former NHS Nottinghamshire County Teaching PCT, many of which are now employed by the AT, so their knowledge and experience has been retained within the newly formed team. They have continued to take on the responsibility for the Heads of Agreement contract between the Chief Executives of the Lead AT and our Host Trust, NUHT, as well as a contract between each AT and the Lead AT. They also continue to take on the role of co-ordinating and chairing a meeting held every quarter at which representatives from the commissioning AT s, the Hub and the two QARC s attend. This meeting has proved very useful as a single point of reference in terms of discussion and decision making. Invoices are raised for each AT on a monthly basis. The current formula operates on a rate per head of total population of 49p and the population figures are taken from agreed validated Office of National Statistics (ONS) population data. 38

39 8. Research & Evaluation Bowel Cancer Screening Programme, Eastern Hub Biennial Report Presentation at National/International Body events Two pieces of analysis were accepted and presented in the form of posters at the British Society of Gastroenterology Annual Meeting in June 2013, in Glasgow and at the United European Gastroenterology Week 2013, in Berlin. A third poster was presented at UEGW only. They covered the following: 1. Uptake of the BCSP in the Eastern region of England - trends by age and gender. 2. How often is bowel cancer detected from a positive 3rd kit in the English BCSP? 3. Risk of bowel cancer increases with the number of windows positive on guaiac faecal occult blood testing. The poster How often is bowel cancer detected from a positive 3 rd kit in the English BCSP? received a rosette in recognition for being a Poster of Excellence at UEGW. These 3 posters can be seen in Appendices N P. Poster of Excellence award ASCEND The ASCEND project in which the Eastern Hub along with our four fellow Hubs were involved in has now been completed and papers are being prepared for publication. The project involved a series of randomised trials designed to test the effectiveness of four separate interventions aimed at reducing the social gradient in uptake of the screening programme. The interventions tested were: 1) a GIST information leaflet, 2) a Narrative information leaflet, 3) a GP endorsement of screening printed as a banner at the top of the invitation letter, 4) an enhanced S10 reminder letter sent to people not returning kits within 28 days. Neither of the 2 leaflet interventions had any impact on uptake but the other 2 interventions did produce some small increase in uptake particularly when they were combined. 39

40 9. Going Forward Immunochemical Testing A 6 month pilot study of using a faecal immunochemical occult blood test (FIT) started in April 2013 in the Southern and Midland and NW hubs. There is currently a provisional date of January 2016 when FIT will be rolled out nationally. It is planned for all subjects to be switched from gfobt to FIT in one go. For example invitations on 31/12/2015 will be for gfobt, then 01/01/2016 will be for FIT. There is a tender process being undertaken for the analyser that will be used nationally. This is not expected to be announced until after the pilot has been completed. Hard to Reach Groups: Prisons/Military Screening A recent new approach has been developed by the North East Hub in order to create a screening process that is more robust than previous attempts at this cohort. This process will be trialled in the NE Hub region first and then piloted on the other Hubs. The new procedure will require the help and assistance from the Area Teams, to help gain a dummy GP code for each prison healthcare department. A recent workshop day held in Nottingham by the Derbyshire and Nottinghamshire Area Team was arranged specifically to address prisoner screening. This workshop gave us the opportunity to sound out some of the expectations surrounding the new processes and gain some feedback from various stakeholders. Prisoner screening will commence in the Eastern Hub as soon as the new process has been proven to be successful in the NE Hub. It is estimated this will be started in Summer The Health & Social Care Information Centre (HSCIC) have agreed to help assist the Hub with any military requests that we have in the future. 40

41 Appendices Bowel Cancer Screening Programme, Eastern Hub Biennial Report Appendix A: Glossary Abnormal test result An abnormal test result is one which triggers a referral to an SSP clinic. This can occur because of either a strong (or straight) positive FOB test result (5-6 windows positive) or following 2 weak positive (unclear, 1-4 windows positive) FOB test results. The term abnormal is always be used when talking or writing to participants. Adequately FOBt Screened Reaching definitive FOBt outcome of either Normal or Abnormal. Adverse Incident (AVI) An adverse incident can be defined as "an event or circumstance that could have or did lead to unintended or unexpected harm, loss or damage. Area Teams Area Teams work with CCG s and providers of NHS services to commission primary care and public health services, along with specialised services and health and justice services. BCSP The NHS Bowel Cancer Screening Programme. BCSS The Bowel Cancer Screening System, the national IT system for administering call and recall for the BCSP. Bowel Scope Screening (BSS) Bowel scope screening is an examination called flexible sigmoidoscopy'' which looks inside the lower bowel. Call The process of inviting an individual to participate in the BCSP for the first time. Clinical Commissioning Group (CCG) A clinical commissioning group is a new NHS organisation set up by the Health and Social Care Act 2012 to organise the delivery of NHS services in England. They bring together local GPs and experienced health professionals to take on commissioning responsibilities for local health services. Clinical Pathology Accreditation (CPA) CPA provides a means to accredit Clinical Pathology Services and External Quality Assessment Schemes (EQA). It involves an external audit of the ability to provide a service of high quality by declaring a defined standard of practice, which is confirmed by peer review. Colonoscopy An endoscopic examination of the whole colon (large intestine). Department of Health (DH) The Department of Health provides strategic leadership for public health, the NHS and social care in England. Did Not Attend (DNA) A patient who does not attend for an appointment made by the screening programme. Faecal occult blood (FOB) test (or FOBt) A biochemical test to determine the presence of blood in a sample of faeces. Now usually used to refer to a guaiac based FOBt. Flexible sigmoidoscopy (FSIG) An endoscopic examination of the lower part of the colon (rectum and sigmoid colon). Hb/g The measure of haemoglobin per gram of faeces. Health & Social Care Information Centre (HSCIC) The Health & Social Care Information Centre (HSCIC) is an executive non-departmental public body. They are the national provider of information, data and IT systems for health and social care. Health Professions Council (HPC) The HPC regulate health and care professionals in the UK and were set up to protect the public. They only register professionals who meet their standards for their training, professional skills and 41

42 behaviour. They can take action against health professionals who fall below these standards. They can also prosecute those who pretend to be registered. Helpline The telephone service provided by the Programme Hub that offers advice and support to screening participants. Immunochemical Faecal Occult Blood Test (FIT) Immunochemical faecal occult blood tests use antibodies raised against human haemoglobin (Hb) to detect human blood present in faeces. They are more sensitive and specific than the current guaiac-based faecal occult blood test and can be automated. Incident Round Where a subject is invited or attends for screening having previously been adequately screened at least once within the NHSBCSP, either as the result of an invited or requested episode. Invitation letter The initial letter (S1 letter) to an individual inviting them to participate in the BCSP. Key Performance Indicator (KPI) A key performance indicator is a type of performance measurement. KPI s are commonly used by an organisation to evaluate its success or the success of a particular activity in which it is engaged. Multidisciplinary team (MDT) Multi-disciplinary teams (MDT s) are made up of a variety of expert health care professionals who have specialised knowledge and training in specific cancers. The teams meet regularly to discuss individual cases and to plan the best course of treatment for the patient. MDTs improve communication and decision making, waiting times and patient care. Negative FOB test result A test result that shows no indication of the presence of blood in any of the samples. The term normal is always be used when talking to or writing to participants. NHS CSP The NHS Cancer Screening Programme (NHS CSP). NHS England NHS England is an executive non-departmental public body of the Department of Health. NHS England oversees the budget, planning, delivery and day-to-day operation of the NHS in England as set out in the Health and Social Care Act Normal test result A negative FOB test result. The term normal is always be used when talking to or writing to participants. Opt-in A subject can opt-in to the programme where they have previously opted-out or been ceased. Positivity Of the subjects who were adequately screened, what proportion (%) had a definitive FOBt abnormal outcome. Primary Care Trust (PCT) An NHS Primary Care Trust (PCT) was a type of NHS trust, part of the National Health Service in England. PCTs were largely administrative bodies, responsible for commissioning primary, community and secondary health services from providers. Primary Care Trusts were abolished on 31 March 2013 as part of the Health and Social Care Act 2012, with their work taken over by Clinical Commissioning Groups. Prevalent Episode Where the subject is screened for the first time i.e. has never been screened adequately within the NHSBCSP, regardless of the number of previous invitations/episodes. Public Health England (PHE) Public Health England is an executive agency of the Department of Health in the United Kingdom that began operating on 1 April Its formation came as a result of reorganisation of the National Health Service (NHS) in England outlined in the Health and Social Care Act

43 Bowel Cancer Screening Programme, Eastern Hub Biennial Report Quality Assurance Reference Centre (QARC) The Quality Assurance Reference Centres (QARC s) collect and collate data about the performance and outcomes of the Bowel Cancer Screening Programme, organise quality assurance visits, and provide support for the regional director of quality assurance and the professional coordinators. The reference centre is the first point of contact for information about the Bowel Cancer Screening Programme in the region. Recall The process of inviting an individual to participate in the BCSP for the second or subsequent time. Recall is determined when a next screening due date is set during the previous screening episode. Response Rate Percentage of screening subjects who positively respond to the screening invitation (numerator), out of those who were routinely invited to participate in bowel scope screening (denominator). Screening Centre The point of delivery for follow up of patients with abnormal FOB test results. Screening Centres are based on existing endoscopy units. Screening subject The term used in the BCSS for an individual who has been invited or who is currently taking part in the Bowel Cancer Screening Programme. Self-referral This refers to individuals over the age of 75 who ask to be included in the programme. Specialist Screening Practitioner (SSP) If colonoscopy has been advised, an appointment is made for the individual to see a Specialist Screening Practitioner (usually a nurse). The SSPs are based in the Screening Centres where they operate clinics for subjects referred with abnormal test results. SSP clinic Clinic run by a Screening Nurse for patients with an abnormal test result. These may be held in Screening Centres or other suitable accommodation. Strategic Health Authority (SHA) NHS Strategic Health Authorities (SHA s) were part of the structure of the National Health Service in England. Each SHA was responsible for enacting the directives and implementing fiscal policy as dictated by the Department of Health at a regional level. In turn each SHA area contained various NHS trusts which take responsibility for running or commissioning local NHS services. The SHA was responsible for strategic supervision of these services. Strong positive test result An FOB test result which indicates the presence of blood in five or six of the samples, sometimes also referred to as a straight positive result. The term abnormal is always used when talking to or writing to participants. See also weak positive test result. Unclear test result A weak positive FOB test result. The term unclear is always used when talking to or writing to participants. Uptake Bowel Scope Screening Percentage of screening subjects who adequately attend for bowel scope screening (numerator), out of those who were routinely invited to participate in bowel scope screening (denominator). Uptake - FOBt Of the subjects who were sent the standard S1 invitation letter, (that is to say, excluding those who are over age self-referrals), and excluding the late responders, what proportion (%) were adequately FOBt screened. Weak positive FOB test result An FOB test result which indicates the presence of blood in one to four of the samples. The term unclear is always used when talking to or writing to participants. See also strong positive test result. Whole Time Equivalent (WTE) Whole Time Equivalent (WTE) is the standard method for defining the amount of work of an employee or in a position. Contracted WTE is calculated by dividing Contracted Hours or Contracted Sessions by the Standard Hours (or Sessions) for the Grade. For example: if the standard hours for a nurse are 37.5 and an individual Staff Nurse contracts to work 22 hours per week, then that employee's WTE is 22 divided by 37.5 = 0.59 WTE. 43

44 Appendix B: Eastern Hub Summary Activity, Jan 2012 Dec 2013 Invitations and Test Kits All Rounds Prev 1 (%) Prev 2 (%) Prev 3+ (%) Inc 2 (%) Inc 3+ (%) Invitations sent 1,566, % 16.6% 14.0% 23.8% 27.4% Self-referrals/opt-ins 18,757 / % 12.6% 7.2% 38.6% 17.7% Total Kits Sent 1,671, % 16.1% 12.7% 25.2% 27.6% Total Kits Returned 1,034, % 6.5% 2.6% 36.6% 37.5% Total Definitive Normals 927, % 6.3% 2.4% 36.9% 37.7% Total Definitive Abnormals 17, % 10.1% 4.4% 33.4% 34.0% Uptake & Positivity All Rounds Prev 1 (%) Prev 2 (%) Prev 3+ (%) Inc 2 (%) Inc 3+ (%) Uptake 59.24% 53.69% 19.98% 10.63% 87.83% 86.81% Positivity 1.82% 1.88% 2.91% 3.29% 1.63% 1.71% SSP Positive Assessment appointment attendance All Rounds % Booked 21,398 Attended 16, % DNA'd 1, % Cancelled 3, % Referred for an SSP appointment 17,055 Within 14 day wait target 17, % Diagnostic test attendance All Rounds % Booked 21,956 Attended 21, % DNA'd % Cancelled % Referred for a diagnostic test 15,234 Within 14 day wait target 14, % Diagnostic tests carried out All Rounds % Colonoscopy 19, % Flexible Sigmoidoscopy % Virtual CT Colonoscopy % Limited Colonoscopy % Abdominal CT Scan % Barium Enema % Total 21, % Patient Episode Outcomes All Rounds Prev 1 (%) Prev 2 (%) Prev 3+ (%) Inc 2 (%) Inc 3+ (%) Cancer detected 1,323 (100%) 20.2% 10.7% 4.5% 32.9% 31.7% High-risk Adenoma 1,720 (100%) 17.4% 11.1% 3.3% 34.4% 33.8% Intermediate-risk Adenoma 2,643 (100%) 17.6% 9.3% 3.7% 35.1% 34.3% Low-risk Adenoma 4,178 (100%) 10.9% 6.4% 2.2% 38.3% 42.1% Abnormal finding 5,336 (100%) 14.3% 7.3% 2.6% 39.9% 35.9% Abnormal, no Histology 99 (100%) 21.2% 9.1% 1.0% 40.4% 28.3% Normal result 3,820 (100%) 15.3% 7.2% 2.5% 37.4% 37.5% No result 300 (100%) 14.7% 10.3% 6.0% 39.0% 30.0% 44

45 Bowel Cancer Screening Programme, Eastern Hub Biennial Report Local Area Team Derbyshire And Nottinghamshire Area Team Appendix C: Outcomes According to CCG and Area Team, Jan 2012 Dec 2013 (row percentages) Cancer detected High-risk Adenoma Intermediaterisk Adenoma Low-risk Adenoma Other Abnormal Abnormal, no Histology Clinical Commissioning No result Total Group finding NHS Erewash CCG % % % % % 0 0.0% % 0 0.0% 220 NHS Hardwick CCG % % % % % 1 0.4% % 3 1.1% 268 NHS Mansfield And Ashfield CCG % % % % % 4 1.1% % 3 0.8% 370 NHS Newark & Sherwood CCG % % % % % 1 0.4% % 7 2.9% 240 NHS North Derbyshire CCG % % % % % 3 0.4% % % 722 NHS Nottingham City CCG % % % % % 0 0.0% % % 390 NHS Nottingham North And East CCG % % % % % 0 0.0% % % 279 NHS Nottingham West CCG % % % % % 1 0.5% % % 184 NHS Rushcliffe CCG % % % % % 1 0.5% % 9 4.1% 219 NHS Southern Derbyshire CCG % % % % % % % % 1,156 Derbyshire And Nottinghamshire Area Team Total % % % % % % % % 4,048 NHS Cambridgeshire And Peterborough CCG % % % % % 3 0.2% % % 1,242 NHS Great Yarmouth And Waveney CCG % % % % % 4 0.6% % 8 1.3% 618 NHS Ipswich And East Suffolk East Anglia Area Team CCG % % % % % 4 0.6% % 4 0.6% 717 NHS North Norfolk CCG % % % % % 1 0.2% % 6 1.2% 488 NHS Norwich CCG % % % % % 1 0.3% % 0 0.0% 363 NHS South Norfolk CCG % % % % % 3 0.5% % 5 0.9% 564 NHS West Norfolk CCG % % % % % 0 0.0% % 2 0.5% 383 NHS West Suffolk CCG % % % % % 0 0.0% % 8 1.3% 595 East Anglia Area Team Total % % % % % % % % 4,970 NHS Basildon And Brentwood CCG % % % % % 1 0.2% % 9 2.1% 432 NHS Castle Point And Rochford CCG % % % % % 0 0.0% % 8 2.2% 371 Essex Area Team NHS Mid Essex CCG % % % % % 5 0.9% % 8 1.4% 555 NHS North East Essex CCG % % % % % % % 5 0.8% 659 NHS Southend CCG % % % % % 0 0.0% % 5 1.8% 276 NHS Thurrock CCG % % % % % 2 0.9% % 2 0.9% 228 NHS West Essex CCG % % % % % 0 0.0% % 5 1.0% 478 Essex Area Team Total % % % % % % % % 2,999 NHS Bedfordshire CCG % % % % % 2 0.3% % 5 0.7% 715 NHS Corby CCG 6 5.4% 9 8.0% % % % 2 1.8% % 2 1.8% 112 Hertfordshire And The South Midlands Area NHS East And North Hertfordshire CCG % % % % % 2 0.2% % % 983 Team NHS Herts Valleys CCG % % % % % 1 0.1% % % 1,043 NHS Luton CCG % % % % % 0 0.0% % 6 1.9% 319 NHS Nene CCG % % % % % 7 0.7% % % 1,029 Hertfordshire And The South Midlands Area Team % % % % % % % % 4,201 NHS East Leicestershire And Rutland CCG % % % % % 4 0.7% % 6 1.0% 592 NHS Leicester City CCG % % % % % 5 1.0% % 6 1.2% 492 NHS Lincolnshire East CCG % % % % % 6 1.4% % 8 1.9% 417 Leicestershire And NHS Lincolnshire West CCG % % % % % 1 0.3% % 7 2.1% 340 Lincolnshire Area Team NHS South Lincolnshire CCG % % % % % 4 1.6% % 7 2.7% 258 NHS South West Lincolnshire CCG % % % % % 4 1.8% % % 218 NHS West Leicestershire CCG % % % % % 2 0.3% % 7 1.1% 640 Leicestershire And Lincolnshire Area Team Total % % % % % % % % 2,957 South Yorkshire And Bassetlaw Area Team NHS Bassetlaw CCG % % % % % 2 0.8% % 1 0.4% 262 South Yorkshire And Bassetlaw Area Team Total % % % % % 2 0.8% % 1 0.4% 262 Grand Total % % % % % % % % 19,437 Normal result 45

46 Local Area Team Appendix D: Outcomes According to CCG and Area Team, Programme Start Dec 2013 (row percentages) Cancer detected High-risk Adenoma Intermediaterisk Adenoma Low-risk Adenoma Other Abnormal Abnormal, no Histology Clinical Commissioning No result Total Group finding NHS Erewash CCG % % % % % 5 0.9% % 7 1.2% 585 NHS Hardwick CCG % % % % % 2 0.3% % 6 0.8% 712 NHS Mansfield And Ashfield CCG % % % % % 8 1.0% % 6 0.7% 813 NHS Newark & Sherwood CCG % % % % % 4 0.7% % 7 1.2% 587 Derbyshire And NHS North Derbyshire CCG % % % % % 8 0.4% % % 1,884 Nottinghamshire Area NHS Nottingham City CCG % % % % % 2 0.2% % % 1,022 Team NHS Nottingham North And East CCG % % % % % 1 0.1% % % 729 NHS Nottingham West CCG % % % % % 2 0.4% % % 479 NHS Rushcliffe CCG % % % % % 5 0.8% % % 614 NHS Southern Derbyshire CCG % % % % % % % % 2,889 Derbyshire And Nottinghamshire Area Team Total % % % % % % % % 10,314 NHS Cambridgeshire And Peterborough CCG % % % % % 9 0.3% % % 3,223 NHS Great Yarmouth And Waveney CCG % % % % % 6 0.4% % % 1,692 NHS Ipswich And East Suffolk East Anglia Area Team CCG % % % % % 5 0.3% % % 1,462 NHS North Norfolk CCG % % % % % 1 0.1% % % 1,398 NHS Norwich CCG % % % % % 2 0.2% % 2 0.2% 1,132 NHS South Norfolk CCG % % % % % 5 0.3% % 8 0.5% 1,688 NHS West Norfolk CCG % % % % % 0 0.0% % 7 0.6% 1,163 NHS West Suffolk CCG % % % % % 2 0.1% % % 1,546 East Anglia Area Team Total % % % % % % % % 13,304 NHS Basildon And Brentwood CCG % % % % % 2 0.2% % % 1,099 NHS Castle Point And Rochford CCG % % % % % 0 0.0% % % 830 Essex Area Team NHS Mid Essex CCG % % % % % % % % 1,353 NHS North East Essex CCG % % % % % % % % 1,465 NHS Southend CCG % % % % % 0 0.0% % % 632 NHS Thurrock CCG % % % % % 2 0.4% % 3 0.5% 564 NHS West Essex CCG % % % % % 1 0.1% % 9 1.0% 903 Essex Area Team Total % % % % % % % % 6,846 NHS Bedfordshire CCG % % % % % 3 0.2% % 8 0.5% 1,657 NHS Corby CCG % % % % % 2 0.8% % 3 1.2% 245 Hertfordshire And The South Midlands Area NHS East And North Hertfordshire CCG % % % % % 5 0.2% % % 2,518 Team NHS Herts Valleys CCG % % % % % 6 0.2% % % 2,467 NHS Luton CCG % % % % % 0 0.0% % % 663 NHS Nene CCG % % % % % % % % 2,509 Hertfordshire And The South Midlands Area Team % % % % % % % % 10,059 NHS East Leicestershire And Rutland CCG % % % % % 5 0.3% % % 1,514 NHS Leicester City CCG % % % % % 8 0.6% % % 1,246 NHS Lincolnshire East CCG % % % % % % % % 954 Leicestershire And NHS Lincolnshire West CCG % % % % % % % % 763 Lincolnshire Area Team NHS South Lincolnshire CCG % % % % % 9 1.5% % % 605 NHS South West Lincolnshire CCG % % % % % 9 1.9% % % 476 NHS West Leicestershire CCG % % % % % 4 0.2% % % 1,698 Leicestershire And Lincolnshire Area Team Total % % % % % % % % 7,256 South Yorkshire And Bassetlaw Area Team NHS Bassetlaw CCG % % % % % 2 0.3% % 3 0.4% 682 South Yorkshire And Bassetlaw Area Team Total % % % % % 2 0.3% % 3 0.4% 682 Grand Total % % % % % % % % 48,461 Normal result 46

47 Bowel Cancer Screening Programme, Eastern Hub Biennial Report Appendix E: Key Performance Indicators Eastern Hub Bowel Cancer Screening Quality Indicators - Method of Measurement BCS-PR:85 January 2014 Version 3 Quadrant KPI Method of measurement Data Source OBIEE Answers Total number of kits reported within 2 working days/total number of - DateDiff Process Kits to be tested and reported within 2 working days of 1 kits logged in the laboratory * 100. Month is determined by test kit Logged-Read Effectiveness receipt in the laboratory. logged date. patient level report Process Effectiveness Process Effectiveness 2 3 Test kit results to be sent to participants within 7 days of the result being available Primary clinic bookings to be offered by the Hub to positive participants within 14 days of the positive FOBT test result. Total number of S2 (Normal), S56 (2nd normal, Weak+) and A183 (SSP clinic booking) letter codes sent up to and including 7 days after the test kit read date/total number of S2, S56 and A183 letters sent * 100. Date determined by test kit read date. SQL report using BCSS downloaded data Calculates the number of days between receipt of referral (the date OBIEE the booking is made - Booked date is the date a patient was added Dashboard - to the A183 letter batch (FOBt+ Practitioner Clinic 1st Appointment SSP Waits Letter Batch )) and the first offered FOBt positive assessment Process Effectiveness Process Effectiveness Process Effectiveness 4 5 Abnormal result sent out within 1 working day of becoming available Screening centre reports to be issued within 15 working days from the end of the quarter being reported upon. 6 % Helpline Calls Answered Total number of SSP clinic appointment bookings made within 1 day/total number of SSP clinic appointment bookings made * 100. Date determined by test kit read date. Date reports sent - Date of the end of the quarter being reported Taken from the Nortel Symposium Crosstab Application Performance Report. Calls Answered/Calls received in hours OBIEE Answers - DateDiff Read- Appt booked patient level report Data Analyst Nortel Programme Effectiveness Programme Effectiveness Programme Effectiveness Programme Effectiveness Programme Effectiveness Employee Welfare Employee Welfare Employee Welfare Employee Welfare Employee Development Employee Development Employee Development 7 Uptake of screening population for eligible population to be recorded and monitored. 8 % Positivity % of eligible population who receive an invitation letter who are then sent a test kit The number of calls to the telephone helpline to be recorded and monitored. The number of self referrals received to be recorded and reported. Of the subjects who were sent the standard S1 invitation letter, (that is to say, excluding those who are over age self-referrals), and excluding the late responders, what proportion (%) were adequately FOBt screened (reaching definitive FOBt outcome of either Normal or Abnormal ). 3 months behind. Of the subjects who were adequately screened, what proportion (%) had a definitive FOBt abnormal outcome. 3 months behind. Total number of invitations sent - those not sent a test kit (invitation kit count = 0)/Total number of invitations sent * 100. Month is determined by invite date. Taken from the Nortel Symposium Crosstab Application Performance Report, with the number of out of hours calls removed from July onwards Total number of S83 - Invitation & Test Kit (Self-referral) letters sent. Date determined by S83 letter sent date. Employee Related Indicators Staff sick leave to be recorded and monitored - sickness in Total number of staff sickness days/total possible working days * 12 month 100 Total number of staff sickness days in last 12 months/total possible 13 Sickness Rate rolling 12 months working days in last 12 months * 100 OBIEE Dashboard - Uptake & Positivity OBIEE Dashboard - Uptake & Positivity OBIEE Answers Nortel BCSS Count of Communication s report Office Manager Office Manager 14 Staff Turnover Rate - in month Total number of WTE Leavers in month/total WTE in month * 100 Office Manager 15 Turnover Rate rolling 12 months Total number of WTE Leavers in last 12 months/total WTE in last 12 months * 100 Office Manager 16 Staff appraisal to be recorded and monitored From Training Officer - taken from PDR records Training Officer 17 Staff attendance at mandatory training sessions to be recorded and monitored From Training Officer - taken from training records Training Officer 18 Number of staff studying for a professional qualification From Training Officer Training Officer 47

48 Colonoscopy Hub Testing Appendix F: Quarterly KPI Report for Screening Centres for the financial year Bowel Cancer Screening Centre Commissioning Quarterly data KPI ID Measure Target/ Standard Number of population offered Screening Number Adequately Screened H1 Uptake of Screening 60% Total Definitive Abnormals H3 Positivity rate 2% H2 Response to invite within 30 days National levels Q1 Apr - Jun Q2 Jul - Sept Q3 Oct - Dec Q4 Jan - Mar Fiscal Year running total Comments Invites sent 3 months behind C1 RDR RDR Time from +ve result to 1st +ve clinic No of patients attending positive assessment clinic No of DNAs to positive assessment clinic 100% within 14 days C2 C3 C4 C5 Time from 1st +ve positive clinic to date of 1st offered colonoscopy date Time of 1st positive Clinic to actual colonoscopy procedure < 2/52 2<4/52 4< 6/52 6< 8/52 8< 10/52 10 < 12/52 12< 14/52 14< 16/52 16< 20/ weeks 100% within 14 days % Suitability Rate of abnormal results to Colonoscopy 90% Uptake % of abnormal results to colonoscopy 85% Closed pre clinic Declined following +ve assessment clinic Includes those patients who never attend an SSP colonoscopy fitness assessment. RDR RDR No of Colonoscopies undertaken Colonoscopies performed No of Pts DNA colonoscopy Standard 150 per annum Consultant C7 Colonoscopy Completion Rate 90% Completion evidence with Standard: 90% C8 photo of IC valve/appendix Target: 97% 48

49 Episode Outcome Staging Other Tests Bowel Cancer Screening Programme, Eastern Hub Biennial Report Quarterly KPI Report cont d RDR No of other tests undertaken Site A Site B Radiology CT Colons Site A Site B Others Site A Site B Flexi Sig and limited colonoscopy PPV FOBt Colonoscopy C6 All endoscopy perforations <1 per 1000 Post Polypectomy Perforations <1 per 500 No defined Non Polypectomy perforations standard Post Polypectomy Bleeds Post polypectomy bleeding requiring transfusion < 1 per 100 S1 Dukes' staging 100% Number of blanks S2 TNM staging 100% Number of blanks S3 Haggits/Kikuchi staging 100% P4 Adenoma detection rate 43% P2 High Risk Adenoma detection rate 9% Site A Site B P1 Cancer detection rate 8% P3 Complications Site A Site B Advanced Adenoma or Cancer 25% major, intermmediate, per 100 endoscopies per 100 endoscopies Pathological dukes staging Final pre-treat T and N category Index Colonoscopies only D4 D2 D1 D3 D5 Adenoma detection rate High Risk Adenoma detection rate Cancer detection rate Cancer or High Risk Adenoma Cancer or any-risk adenoma >8 per 1,000 screened >1 per 1,000 screened >1 per 1,000 screened >3 per 1,000 screened >10 per 1,000 screened 3 months behind All Colonoscopies - not just index Numbers are per 1000 screened RDR: Routine Data Requirement 49

50 Week Ending Invitation letters Test Kits Sent (excluding opt ins) Test Kits Sent - Late Responders Test Kits Sent - Over Age Self Referrals Test Kits Returned Result Letters Sent Normal Results % Normals Total Number Weak Positive Strong Positive Ist Clinic Booking in Week Retests (spoilt) Retests Kits Sent (total) Reminder Letters Informed Dissent (programme) Helpline Calls (total for week exc Out of Hours) Helpline Calls Answered % Helpline Calls Answered Weekly Positivity Running Positivity for Last 6 Months Appendix G: Eastern Hub Weekly Activity Report NOTTINGHAM EASTERN HUB--ACTIVITY REPORT BCS-PR:31 Version 5. November /10/ ,857 15, ,499 7,803 7, % ,035 8, ,997 1, /10/ ,362 15, ,421 9,898 9, % ,279 8, ,768 1, /10/ ,035 15, ,148 8,379 8, % ,137 8, ,840 1, /10/ ,739 15, ,158 9,377 9, % ,106 8, ,642 1, /11/ ,533 15, ,175 9,787 9, % ,314 8, ,840 1, /11/ ,902 15, ,106 9,611 9, % ,278 8, ,792 1, /11/ ,585 15, ,557 9,498 9, % ,251 9, ,901 1, /11/ ,062 15, ,020 7,644 7, % ,017 7, ,700 1, /12/ ,594 15, ,801 9,779 9, % ,105 8, ,790 1, /12/ ,316 15, ,724 7,050 6, % , ,508 1, /12/ ,306 14, ,284 7,647 7, % ,045 9, ,776 1, /12/ ,486 15, ,318 6,585 6, % , ,557 1, /12/ ,289 15, ,930 6,317 6, % , /01/ ,981 12, ,180 2,735 2, % , ,728 1, /01/ ,212 17, ,611 8,280 8, % ,217 7, ,651 2, /01/ ,537 14, ,001 14,740 14, % ,344 12, ,199 2, /01/ ,109 15, ,119 13,442 13, % ,496 5, ,033 1, /02/ ,815 14, ,573 10,522 10, % ,291 11, ,794 1, /02/ ,397 14, ,127 9,232 9, % ,117 7, ,895 1, /02/ ,919 14, ,171 11,013 10, % ,201 7, ,673 1, /02/ ,598 15, ,563 9,193 8, % , ,747 1, /03/ ,301 14, ,856 9,746 9, % ,231 7, ,716 1, /03/ ,139 15, ,901 11,007 10, % ,230 7, ,872 1, /03/ ,734 15, ,679 12,369 12, % ,352 7, ,696 1, /03/ ,930 16, ,483 10,840 10, % ,297 6, ,012 1, /03/2014 Totals 391, , , , , % , ,831 42, Running Total 4,464,798 4,344,175 3,160 14,888 2,884,581 2,731,708 2,568, % 90,395 11,931 56,579 79, ,151 1,816, , , ,

51 Bowel Cancer Screening Programme, Eastern Hub Biennial Report Appendix H: Eastern Hub Weekly Activity Report Method of Measurement NOTTINGHAM EASTERN HUB--ACTIVITY REPORT BCS-PR:31 Version 5. November 2012 Description Invitation letters Test Kits Sent (excluding opt ins) Test Kits Sent - Late Responders Test Kits Sent - Over Age Self Referrals Test Kits Returned Result Letters Sent Normal Results % Normals Total Number Weak Positive Strong Positive Ist Clinic Booking in Week Retests (spoilt) Retests Kits Sent (total) Reminder Letters Informed Dissent (programme) Helpline Calls (total for week exc Out of Hours) Helpline Calls Answered % Helpline Calls Answered Weekly Positivity Running Positivity for Last 6 Months Method of measurement This is the pre-invitation letters sent from the hub S1 s These are invitations and test kits sent from the hub S9 s These are the invitations and new test kits sent for late responder subjects. Late responders are identified following any request to continue a closed episode provided the request comes 6 months (182 days) or more after the invitation date. These are the invitations and test kits sent from the hub for over age self refer subjects. All the test kits returned, including normals, abnormals, weak positives, spoils etc. Based on Kit logged date These are all the test kits returned to the hub to be tested: A183 Practitioner Clinic Letters 1st Practitioner Clinic Appt S56 Result Letters Subject Result (2nd Normal; Weak +) S2 Result Letters Subject Result (Normal) All results found to be normal. Patient result letters S56 and S2 This is the percentage of normal results to test kits returned (Normal results/test kits returned) x 100 Number of Weak Positive Test Kit results read in the hub Number of Abnormal Test Kit results read in the hub This is the number of Practitioner Clinic 1st Appt letters sent out A183 This is all the spoils received during the week S3, N112, U66 This is the sum of all retests for the week. This is the sum of all reminders sent out by the hub S10, S84 Number of subjects opting out of the programme Number of helpline calls offered within helpline hours Number of helpline calls answered (all will be within helpline hours) This is the percentage of helpline calls answered to those offered Helpline Calls Answered/Helpline Calls Offered x 100 This is the overall positivity rate for the week: 1st clinic bookings (A183) /(test kits returned-retests) x 100 This is a percentage of positives found that have resulted in a clinic appointment over that last 6 months. Using the totals for the last 6 months: 1st clinic bookings/(test kits returned-retests) x

52 Week Ending Pre-Invitation letters (8 weeks prior to appt) Invitation & Appointment Sent (6 weeks prior to appt) Invitation & Appointment Sent - Self Referrals Subject Not Suitable for FS Screening Notification to subject of Returned/Undelivered mail Reminder Letters (4 weeks prior to appt) DNA Appointment letters Appointment Confirmation letters (2 weeks prior to appt) No of FS undertaken Non Response letters (2 weeks prior to appt) Appointment Rebooks Helpline Calls (total for week exc Out of Hours) Helpline Calls Answered % Helpline Calls Answered Weekly uptake rate Running Uptake Rate Appendix I: Eastern Hub Bowel Scope Activity Report NOTTINGHAM EASTERN HUB--BOWEL SCOPE ACTIVITY REPORT BCS-PR: 160 Version 4. December /11/ % 48.7% 24/11/ % 48.4% 01/12/ % 48.5% 08/12/ % 48.5% 15/12/ % 48.5% 22/12/ % 48.8% 29/12/ % 49.1% 05/01/ #DIV/0! 49.1% 12/01/ % 50.5% 19/01/ % 52.1% 26/01/ % 53.6% 02/02/ % 55.1% 09/02/ % 56.4% 16/02/ % 57.7% 23/02/ % 59.0% 02/03/ % 60.5% 09/03/ % 61.8% 16/03/ % 62.8% 23/03/ % 63.9% 30/03/ /04/ /04/ /04/ /04/ /05/ /05/2014 Totals 2,220 2, , ,252 1, ,618 1, n/a n/a Running Total 4,609 4, , ,281 1,797 1, ,893 2, n/a n/a 52

53 Bowel Cancer Screening Programme, Eastern Hub Biennial Report Appendix J: Eastern Hub Bowel Scope Activity Report Method of Measurement NOTTINGHAM EASTERN HUB--BOWEL SCOPE ACTIVITY REPORT BCS-PR: 160 Version 4. December 2013 Description Pre-Invitation letters Invitation & Appointment Sent Invitation & Appointment Sent - Self Referrals Subject Not Suitable for FS Screening Notification to subject of Returned/Undelivered mail Reminder Letters DNA Appointment letters Appointment Confirmation letters No of FS Undertaken Non Response letters Appointment Rebooks Helpline Calls (total for week exc Out of Hours) Helpline Calls Answered % Helpline Calls Answered Weekly uptake rate Running Uptake Rate Method of measurement This is the pre-invitation letters sent from the hub F2 s These are Invitation & Appointment sent from the hub F9 s These are the invitations and appointments sent from the hub for self refer subjects - F84's. These are the Subject Not Suitable for FS Screening letters - F95's These are the Notification to subject of Returned/Undelivered mail letters - F93's This is the sum of all reminders sent out by the hub F11's This is the sum of all DNA FS Screening Appointment letters - F172 FS Screening Appointment Confirmation Letters - F33 From Norwich Screening Centre report FS Screening non response letters - F40 From the helpline calls spreadsheet Type of Call column Number of helpline calls offered within helpline hours Number of helpline calls answered (all will be within helpline hours) This is the percentage of helpline calls answered to those offered Helpline Calls Answered/Helpline Calls Offered x 100 This is the overall uptake rate for the week: No of FS Undertaken/Invitation & Appointment letters sent 6 weeks prior x 100 This is the running total uptake rate: Total No of FS Undertaken/Total Invitation & Appointment letters (excluding those sent in the last 6 weeks) x

54 Appendix K: Staff List Name Senior Management Team Professor Richard Logan Mike Vogler Fiona McLeod Melanie Boulter Patrick McCormack Sharon Wilson Lucy Peck Andrew Field Senior Screening Officers Nicola Wilson Emma Fogg Chloe Reeves Nicola Kemp Jillian Bourgeois Dave Vernon Screening Officers Asrah Bashir Damien O'Connor Fee Moran Joanne Gorey Linzi Betts Michael Philip Salma Suleman Sylwia Badowska (on secondment) Veronica Carridice (on secondment) Dawn Smart Dawn Rhoades Sharon Gunn Kim Oscroft Julie Hill Sinead Barker Nina Mistry Daniel Wilson Wayne Miller Katie Dale Abby Duffin Laura Geraghty Matthew Goodwin Lisa Hall Zoe Shipman Amy Wratten Ellen Bates Hollie Curgenven Job Title Programme Director Programme Manager Operational & Quality Manager Deputy Operational & Quality Manager Specialist BMS Laboratory Lead Office Manager/ Programme Administrator Project & Service Development Coordinator Data Analyst & Information Officer Senior Screening Officer Senior Screening Officer Senior Screening Officer Senior Screening Officer Senior Screening Officer Senior Screening Officer Screening Officer Screening Officer Screening Officer Screening Officer Screening Officer Screening Officer Screening Officer Screening Officer Screening Officer Screening Officer Screening Officer Screening Officer Screening Officer Screening Officer Screening Officer Screening Officer Screening Officer Screening Officer Screening Officer Screening Officer Screening Officer Screening Officer Screening Officer Screening Officer Screening Officer Screening Officer Screening Officer 54

55 Bowel Cancer Screening Programme, Eastern Hub Biennial Report Appendix L: Audits carried out January 2012 to December 2013 Area CPA Identifier Audit Title Date Audited std BCSS 75 Health and Safety quiz 30/01/2012 H & S C5 BCSS 88 Yorkshire External Quality Assurance Scheme Jan-12 QMS H5 BCSS 90 The Telephoned Report Jan-12 Post Exam G3 BCSS 91 Ceasing Audit 20/01/2012 IP BCSS 92 Wreck Monitoring 15/03/2012 QMS BCSS 93 Staff Competency and Training Records Mar-12 QMS B9 BCSS 94 Information Governance 29/03/2012 QMS D2 BCSS 95 Staff Records Jan-12 QMS B6 BCSS 96 Transcription of test kit results and dates Apr-12 Exam F3 BCSS 97 Returned Mail 12/04/2012 IP BCSS 98 Specimen Reception Audit Feb-12 Pre Exam E3 BCSS 99 Audit of Meeting Minutes 15 th May 2012 QMS H1 BCSS 100 Document Control 11/06/2012 QMS A8 BCSS 101 Reporting of Results 21/05/2012 Post Exam G2 BCSS 102 Vertical Audit of a Sample 07/06/2012 Exam F2 BCSS 103 Quality Quiz 17/07/2012 QMS A4 BCSS 104 Procurement and Management of Equipment 11/06/2012 IP D1 BCSS 105 Performance of Audits 20/07/2012 QMS H3 BCSS 106 Health and Safety Audit 06/08/2012 H & S C5 BCSS 107 Control of Non Conformities 07/08/2012 QMS H7 BCSS 108 Turnaround times of test kits received 08/08/2012 Exam BCSS 109 Audit of non-conformity - contents of Quality Manual 55 17/08/2012 QMS A6 BCSS 110 Audit of non-conformity - job descriptions 17/08/2012 QMS B5 BCSS 111 Evaluation and Management of Materials, Reagents, Calibration and Control 17/08/2012 QMS D3 BCSS 112 Room Temperature Monitoring for Storage of Bulk Reagents 10/08/2012 IP BCSS 113 Assess procedures relating to Clinical Waste 25/07/2012 H & S C5 BCSS 114 Training and Education 29/08/2012 QMS B9 BCSS 115 Office Feedback letters(including TATs) 28/08/2012 QMS BCSS 116 PDRS - Reference to Job Description and Business plan 28/08/2012 QMS B5 BCSS 117 Assuring Quality of Examinations 28/08/2012 Exam F3 BCSS 118 Daily Positive Checks 11/09/2012 Exam F3 BCSS 119 Audit of Ceasing Process 10/09/2012 IP BCSS 120 Answerphone messages 23/10/2012 IP BCSS 121 Management of Data and Information 29/11/2012 QMS D2 BCSS 122 Telephoned Record 05/12/2012 Post Exam G3 BCSS 123 Ceasing Audit 19/12/2012 IP

56 Area CPA Identifier Audit Title Date Audited std BCSS 125 Information Governance Audit 25/09/2012 QMS D2 BCSS 124 Staff Registration Records 02/01/2013 QMS B6 BCSS 126 Management of Materials Jan-13 QMS D3 BCSS 127 TAT audit 28/01/2013 Exam BCSS 128 Specimen Reception 26/03/2013 Pre Exam E3 BCSS 129 Staff Health and Wellbeing 01/04/2013 H & S C5 BCSS 130 Turnaround Times for Office Feedback 26/03/2013 QMS BCSS 131 Staff Orientation and Induction 16/04/2013 QMS B4 BCSS 132 Procurement and management of equipment 01/05/2013 QMS D1 BCSS 133 External Quality Assurance Scheme 03/07/2013 QMS H5 BCSS 134 Audit of the Audit Process 20/05/2013 QMS H3 BCSS 135 Audit of Process and Quality Records 24/05/2013 QMS A8 BCSS 136 Facilities and Storage 01/05/2013 QMS C4 BCSS 137 Information Governance 23/05/2013 QMS D2 BCSS 138 Training and Education - Competency Audit 12/06/2013 QMS B9 BCSS 139 Ceasing Audit 10/06/2013 IP BCSS 140 RDI transfer Audit 28/06/2013 IP BCSS 141 Self-Referrals Audit 02/07/2013 IP BCSS 142 Vertical Audit of a Sample 26/07/2013 Exam F2 BCSS 143 Reporting of Results 25/07/2013 Post Exam G2 BCSS 144 Out of hours helpline calls audit 09/09/2013 Exam BCSS 145 Transcription audit 03/09/2013 Exam F3 BCSS 146 Transcription audit 27/09/2013 Exam F3 BCSS 146a Document Control 01/09/2013 QMS A8 BCSS 147 Returned Mail 01/10/2013 IP BCSS 148 Health and Safety 03/10/2013 H & S C5 BCSS 149 Staff Registration Records 04/11/2013 QMS B6 BCSS 150 Specimen collection - assisted kits 16/10/2013 Pre Exam E3 BCSS 151 Temperature Monitoring 01/11/2013 QMS BCSS 152 Control of clinical waste including storage 15/11/2013 H & S C5 BCSS 153 Screening Centre Feedback 01/11/2013 QMS H2 BCSS 154 Result Transcription Audit 11/12/2013 Exam F3 BCSS 155 Stop Watch Timer Audit 12/12/2013 Exam BCSS 156 Assuring the Quality of examinations 17/12/2013 QMS F3 BCSS 157 Ceasing Audit 17/12/2013 IP BCSS 158 Alert Monitoring 15/11/2013 Exam BCSS 159 Audit of staff records 18/12/2013 QMS B6 BCSS 160 Maintenance Records of Equipment 18/12/2013 QMS D3 BCSS 164 Clinical Advice and Interpretation 11/11/2013 QMS G5 56

57 Bowel Cancer Screening Programme, Eastern Hub Biennial Report Appendix M: BCSP Incidents as reported on the electronic Datix system Date Details Area Action Taken 23/04/ /04/ /06/ /09/ /07/ /09/ /01/2013 Screening Officer developed puffy eyes whilst working in the lab. Subject called the helpline after being called 3 yearly instead of 2 yearly. The subject had undergone a colonoscopy with the programme in 2009 and received a letter informing him that he would be called in 2 years for FOBt. The BCSS system failed to reset correctly to 2 yearly recall and instead called the gentleman 3 years later. A subject received a letter addressed to themselves along with another letter for a different subject. The SO had used a template and had copied the details over the details off another, without changing the address. An incorrect result was entered onto the system and not communicated appropriately in the Hub, which meant an incorrect test reading result was sent to RD, and consequently, the subject. A subject was offered an appointment but declined after having a bad experience at that particular SC. She requested to go to a SC across a PCT boundary to the one in which she was offered. The Hub issued the incorrect information and directed her back to her GP instead of contacting the SC to see if she could be accommodated. Real Digital International (RDI) issued 2,700 letters with missing postcodes. RDI had altered some details on the address label and then did not test it on 'test' data but tested it on live data. A batch of appointments were duplex printed which meant that two patients appointment details were on the reverse side of one letter. The Senior Screening Officer (SSO) had noticed 'missing' letters but reprinted the appointments rather than undertaking an investigation and escalating investigate the problem. Laboratory BCSS/OE Admin Laboratory Helpline Outsourcer - FOBt Adminappointments 1) First aider followed procedure for allergic reaction 2) SO went to pharmacy and took anti-histamine 3) SO referred to Occupational Health 4) SO returned to lab and was closely monitored 1) The screening centre was contacted to establish more facts about when the subject attended the colonoscopy. It was verified that the correct action had taken place. 2) Connecting for Health were contacted and investigated the error. The BCSS had failed to reset the subject to the correct point. CfH carried out a full system check to ensure there were no other subjects involved. CfH introduced a failsafe on the system to ensure this did not happen again. 1) A second check has been introduced so details are matched against the system 2) Letters are now typed as 'individual letters' on BCSS 3) Staff informed of the new process and not to use template letters. 1) Called the subject and apologised for the error and sent an amended result. 2) Reiterated to the team of the correct procedures to follow when entering or detecting an incorrect result, outlining who needs to be informed so the error can be appropriately rectified. 1) staff reminded of correct procedure to follow in this case 2) SOP updated to provide more clarity 3) Frequently asked Questions updated to provide guidance when receiving calls of this nature 1) The appropriate letters were reissued 2) RDI agreed that is they make changes, they will not test it on the live system and will inform the Hubs before hand 1) Held a meeting/huddle to ensure that SSOs were aware of their responsibilities towards escalating errors/concerns. 2) Reminded SSOs of 'Right Patient Right Result' Policy 3) Reminded whole team that if a discrepancy is identified during a quality, the process must be halted 4) Data analyst ensured that the printers were not on the 'duplex' setting as a default setting. Improvement to Service 1) Seniors would be more aware of the escalation process when the quality processes fail. 2) All staff up to date on the importance of 'Right Result Right Patient' for future processes. 3) Duplex printing would not be a default setting so this would greatly reduce this error reoccurring. 57

58 Date Details Area Action Taken 05/03/ /04/ /06/2013 Lab Lead cut hand on file when re-arranging shelf. Misc. First aid administered and wound covered. Screening officer, whilst sat next to the Neopost letter folder 1) Moved Neopost machine slightly away machine, bent down and when from the seat. 2) Removed stock from standing up, banged their head underneath the Neopost to prevent the on the machine. Admin occurrence of any future incidents. Whilst testing a Faecal Occult Blood Test (FOBt), a piece of faeces came out of the kit and went in the screening officer s eye. Laboratory 1) Copious amounts of water was used to wash the eye. 2) Screening officer was sent to Occupational Health. 3) The team were informed that safety glasses are available to use whilst testing but as an alternative, point the kit away from you, whilst removing the testing strip. Improvement to Service Safer working environment. Safer working environment. 07/06/2013 When binding up some FOBt kits, the screening officer cut finger on the corner of the kits. Laboratory Washed hands and encouraged wound to bleed. Covered the cut with a plaster. 27/06/2013 Whilst enveloping letters, a screening officer cut finger on the envelope. Admin Applied pressure and covered with a plaster. 07/08/213 A batch of enemas failed to be sent out from the outsourcer. Outsourcer - Bowel Scope A full investigation was undertaken by the company. The company have tightened up their process for enemas distribution. The changes include additional quality checks, increased management presence and increased cover for planned or unexpected absences of staff. A more efficient and robust service for the distribution of enemas. The Hub has more confidence in the service. 26/09/2013 A subject received their kit along with someone else's. The kit had been issued by the outsourcer. Outsourcer - FOBt A full investigation was undertaken by the outsourcer. The error occurred because the operator did not follow the procedure for handling kit rejections. The company have held retraining sessions. 04/10/2013 A subject called the Eastern Hub who was from the London area, to request an appointment change. The screening officer failed to recognise that the subject was from outside the area and rebooked them into a local screening centre as that is the first one alphabetically on the system. Helpline 1) The screening officer was informed of the error. 2) All staff were informed to be vigilant if a subject is calling from outside of the area, as the system defaults to the first screening centre alphabetically.3) A change to the system has been submitted to National Office to request an alert box when booking an appointment outside an area. Staff will be more aware if this occurrence happens again. If the issue notification is agreed, it will prevent further occurrence as it will bring the screening officers attention to it. 06/12/2013 A screening officer walked out of admin and straight into a postal trolley. Misc. The trolley had been left close to the door so could have obscured the view when exiting the room. The team were told to ensure that the trolley is kept a distance from the door so as not to obscure the view when leaving the room. Safer working environment. 12/12/2013 Whilst hanging a coat up in the helpline office, another screening officer entered the office and knocked the screening officer into the coat rail. Misc. The coat rail has been moved away from behind the door and screening officers have been informed to hang their coats up at the other end which is visible to anyone entering the room. Safer working environment. 58

59 Bowel Cancer Screening Programme, Eastern Hub Biennial Report Appendix N: Uptake of the BCSP in the Eastern region of England - trends by age and gender. 59

60 Appendix O: How often is bowel cancer detected from a positive 3rd kit in the English BCSP? 60

61 Bowel Cancer Screening Programme, Eastern Hub Biennial Report Appendix P: Poster - Risk of bowel cancer increases with the number of windows positive on guaiac faecal occult blood testing 61

62 Nottingham University Hospitals NHS Trust Bowel Cancer Screening Programme, Eastern Hub Queen s Medical Centre Campus Derby Road Nottingham NG7 2UH Tel: Ext: Fax: National Freephone Helpline: The NHS Bowel Cancer Screening Programme - Detecting bowel cancer at an early stage (in people with no symptoms), when treatment is more likely to be effective.