What Professor Sir Mike Richards’ Cancer Screening Review recommends for bowel cancer screening in England
In November 2018, NHS England announced that Professor Sir Mike Richards, who was the first NHS Cancer Director, would lead on a major overhaul of cancer screening programmes as part of the NHS Long Term Plan’s renewed drive to improve care and save lives. As part of this review, we submitted evidence highlighting the current issues with the Bowel Cancer Screening Programme (BCSP) and made recommendations for immediate and future improvements. With the review published in October, this blog looks at its much needed recommendations for bowel cancer screening in England.
What we called for in our submission
We highlighted the urgent need to address the shortages in NHS workforce capacity, which is holding back implementation of an optimal bowel cancer screening programme (OBCSP), committed to by the Government in 2018 to improve survival rates for bowel cancer. An OBCSP involves:
- Using the simpler, more accurate, quantitative faecal immunochemical test (FIT) at a high sensitivity level in order to prevent more bowel cancers from developing or to diagnose bowel cancer earlier when it is more easily treated.
- Reducing screening age from 60 to 50 in line with Scotland and international best practice.
Additionally, we called for progress to be made on providing targeted screening for people at higher risk of bowel cancer, such as those with Lynch syndrome - a genetic condition that increases the lifetime risk of developing bowel cancer to up to 80% - and for measures to be put in place to ensure the uptake of screening by deprived and minority groups.
We also stressed the need to review the governance of the screening programme and working arrangements between NHS England, Public Health England and the Department of Health and Social Care; as well as the need to make changes to the way screening centres are funded in order to better incentivise uptake in screening, especially in minority groups and those living in deprived areas.
What the review recommends for bowel cancer screening
We are extremely pleased that Professor Sir Mike Richards’ review aligns with aspects of our submission and makes much-needed recommendations to improve the BCSP. This includes:
NHS staff shortages to be addressed in order to make vital improvements to the BCSP
The report acknowledges that workforce issues must be addressed in order to deliver vital improvements to cancer screening programmes in England. These improvements include the NHSE Long Term Plan’s ambition to diagnose 75% of cancers early by 2028, lowering the screening age for bowel cancer from 60 to 50, and increasing the sensitivity of the new, easier to use, faecal immunochemical test (FIT).
Bowel cancer screening is resource intensive, and there is a need for a highly trained workforce particularly in endoscopy and pathology services. These services are under unprecedented pressure because there simply are not enough staff to deal with increasing demand. This is directly impacting patients: nearly 60% more people each month were waiting more than the waiting time target of six weeks for endoscopy tests at their hospital in 2018 compared to 2017. Around 700,000 colonoscopies are currently undertaken in England each year, and it is estimated that at least a million more procedures a year will need to be undertaken by 2020.
Professor Sir Mike Richards’ calls for national guidance to be developed for commissioners and for providers to plan for the required changes in colonoscopy, as well as the training of screening colonoscopists to be given high priority, are very welcome. Additionally, we look forward to seeing Sir Mike’s workforce recommendations as part of his forthcoming diagnostics pathway report later this year.
Targeted screening, including screening (regular check-up) colonoscopies for people with Lynch syndrome to be funded nationally by NHS England
We have been calling for a clear mechanism for ensuring that people at the highest risk of developing bowel cancer, such as people with Lynch syndrome, receive the targeted screening they require. Lynch syndrome can increase your chance of bowel cancer to as much as 80%. Research shows that regular colonoscopy can mitigate this, reducing the risk of dying from bowel cancer by 72% through detecting the disease early, when it is more treatable. The review recommends targeted screening of those at high-risk to be funded nationally by NHS England. This will create a consistent service with nationally agreed standards and service specifications and is a crucial step in the right direction to reducing variation in access to this important screening.
NHS England to become the single body responsible for funding and delivery of screening services
A key focus of this review was to consider the allocation of responsibilities between NHS England (NHSE), Public Health England (PHE) and the Department of Health and Social Care (DHSC), and how effectively they translate screening policy into implementation of cancer screening programmes. This is because it is currently unclear who is ultimately responsible for governance, with DHSC the overall steward of the programme; PHE leading on quality assurance, patient information, and the commissioning of IT systems for screening; and NHSE responsible for the commissioning of screening services and implementation. This matrix management has led to delays to screening improvements.
The review recommends the formation of a new single advisory body that should cover both population and targeted screening. Additionally, it recommends that NHSE should assume sole responsibility for the delivery of screening programmes, including the commissioning and quality assurance of the programmes. Taking forward this recommendation is vital to ensuring clarity over leadership for the BCSP and will prevent future delays to screening improvements.
An increase in the uptake of bowel cancer screening, especially for minority groups and those living in deprived areas
For cancer screening to be effective, it is important that a significant proportion of those invited for screening do take up the invitation to participate. This is known as screening ‘uptake’. The review calls for evidence-based initiatives to increase uptake, including the use of text reminders, social media campaigns, increasing awareness, and the consideration of financial incentives for providers to promote out of hours and weekend appointments.
As it stands, payment mechanisms for bowel cancer screening centres are based on population size, and as such do not take into account variations between high and low uptake within an area. This means that screening centres with the same size populations of 60-74 year olds get paid the same, regardless of whether one area has far more people sending in their bowel cancer screening tests. This provides limited financial incentive to providers to actively improve uptake. We are pleased the review echoes our calls on NHS England to urgently consider how best to use financial incentives to increase uptake of cancer screening services. This might include the introduction of payment by activity, targeted payments for enhanced services or enhancements to GP payment systems at either practice or primary care network level.
What needs to happen now?
It is vital that this important work is now taken forward by the DHSC, working closely with NHS England and Public Health England. In particular, the forthcoming NHS Improvement People Plan provides a crucial opportunity to provide the recommended national guidance for workforce, and must be fully-funded by the Government.
Professor Sir Mike Richards’ review presents an important opportunity for the health sector to work collaboratively to ensure these improvements are made and the best outcomes for people with cancer are achieved. Bowel Cancer UK will be working with the DHSC, PHE and NHSE to ensure bowel cancer can be prevented, or diagnosed at the earliest opportunity when treatment can be more successful.