Download Bowel Cancer Screening Locally Commissioned Service Specification

Service Specification No.
Service
Commissioner Lead
Provider Lead
Period
Date of Review
Bowel Cancer Screening Locally
Commissioned Service Specification
Public Health: Jessica Ayeh-Kumi
GP Practices in Camden and Islington
April 2014 – March 2015 in Islington
July 2014 – March 2015 in Camden
January 2015
1. Population Needs
1.1 National/local context
Bowel cancer is the third most common cancer in the UK and is the second most common
cause of cancer death, after lung cancer1. If diagnosed at an early stage (Dukes stage A)
the 5 year relative survival rate is 93.2%. This falls to less than 6.6% at Dukes Stage D2.
The Bowel Cancer Screening Programme has been running in the UK since 2006. It aims to
detect asymptomatic individuals at an early stage, when treatment is more likely to be
effective, and to detect and remove polyps. The programme screens individuals aged 60-74
every 2 years using Faecal Occult Blood testing (FOBt). Evidence from a meta-analysis of 4
randomised controlled trials showed a 15% reduction in bowel cancer specific mortality with
biennial screening3.
However, participation in the Bowel Cancer Screening Programme is low. Uptake of bowel
cancer screening in 2012/13 was 44.4% in Camden and 44.9% in Islington. This was lower
than the London uptake of 47.82% in 2012/13 and lower than the national target of 60%.
1.2 Evidence Base
Evidence suggests GP involvement can increase the uptake of bowel cancer screening.
Specifically the following interventions have been found to have a positive impact on bowel
screening uptake:

1
Endorsement letters – Some evidence has found that letters from GPs to patients
due for screening have been shown to increase uptake by nearly 6% (5.8%, 95%
CI 4.1-7.8%). Letters signed with electronic GP signatures were found to be
more effective than letters sent on behalf of the practice in general.4
Cancer Research UK. Bowel Cancer Statistics. January 2014. [Online]. Available from
th
http://www.cancerresearchuk.org/cancer-info/cancerstats/types/bowel/. [Accessed 17 February
2014).
2
National Cancer Intelligence Network (NCIN). Colorectal Survival by Stage. London: ONS, 2009
3
Hewitson P, Glazsiou P, Towler B, et al. (2011). Screening for colorectal cancer using the faecal
occult blood test: an update. The Cochrane Database of Systematic Reviews. [Online]. Available
from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001216.pub2/pdf [Accessed 17th
February 2014)
4
Hewitson P, Glazsiou P, Towler B, et al. (2011). Screening for colorectal cancer using the faecal
occult blood test: an update. The Cochrane Database of Systematic Reviews. [Online]. Available
from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001216.pub2/pdf [Accessed 17th
February 2014)

Telephone or face-to-face advice – The use of telephone calls and written reminders
to patients about screening, have been found to be more successful than written
reminders alone5,6,7 A recent study in three East London boroughs found significant
increases in uptake following targeted telephone and face-to-face health promotion8.
2. Outcomes
2.1 NHS Outcomes Framework Domains & Indicators
Domain 1
Preventing people from dying prematurely

This LCS will support the following NHS and Public Health Outcomes Framework’s
indicators:
 to reduce under 75 mortality rate from cancer.
2.2 Local defined outcomes
This LCS will also contribute to Camden and Islington’s key health and well-being priorities:

Preventing and managing long term conditions to extend both length and quality of
life and reduce health inequalities, including reducing early death from cancer.
3. Scope
Aims and objectives of service
The overall aim of this LCS is to increase the uptake of the bowel cancer screening
programme and decrease the premature mortality rate from bowel cancer in Camden and
Islington.
Specific objectives are:
- To increase GP and practice staff engagement in bowel cancer screening and to
support the proactive promotion of bowel cancer screening to the eligible population
through general practice.
- To follow up those individuals who did not send back their test kits and encourage
them to complete the test.
- To ensure that practices regularly update bowel screening participation and test
results in their electronic patient records.
Service description
1. The practice will appoint a named lead for the LCS (ideally the existing cancer screening
lead) who will be primarily responsible for the overseeing and implementation of the LES.
5
Telephone Outreach to Increase Colorectal Cancer Screening in an Urban Minority Population.
Basch C, Wolf R.L., Brouse C.H, Shmukler C, Neugut A, DeCarlo L.T, et al. American Journal of
Public Health. 96 (12) 2246-2253 (2006).
6
Myers R.E, Ross E.A., Wolf T.A, et al. Behavioural Interventions to increase adherence in colorectal
screening. Med Care. 1991; 29:1039-1050.
7
Myers R.E., Ross E, Jepson C, et al. Modelling adherence to colorectal screening. Prev Med.
1994; 23: 142-151.
8
Shankleman J, Massat N, Khagram L, Ariyanayagam S, Garner A, Khatoon S, Rangrez S, Colorado
Z, Hu W, Parmar D, Duffy SW Evaluation of services aimed at improving awareness of bowel cancer
screening and increasing uptake Submitted to British Journal of Cancer January 2014
Health Promotion Materials
2. As a minimum practices should display:
- Promotional posters in the waiting area and other appropriate areas e.g. the toilets,
etc.
- Leaflets promoting and explaining the bowel screening programme.
Where a practice has a high number of patients from certain ethnic minority groups,
posters and/or leaflets should also be displayed in the relevant languages (e.g. Sylheti,
Bengali, Turkish and Somali) as well as in English.
Practices may also wish to:
- Use health screens to display bowel screening awareness DVDs, where these are
available
- Set up bowel cancer screening promotion display stands
- Organise an awareness event at the practice and/or conduct an outreach event in
conjunction with local community or religious groups
A list of approved promotional resources can be found in Appendix 2.
Endorsement Letters
3. Every month the London Bowel Cancer Screening Hub will send practices a list of which
patients are due to be invited for bowel cancer screening in the following month (as long as
practices have returned their data sharing agreement), via secure nhs.net email addresses.
- Each month practices should send a letter to all patients who are due to be invited for
bowel cancer screening in the following month.
- The letter should inform patients about the programme and encourage completion of
the test kit. (A template letter can be found in Appendix 3 for practices to use or
adapt.)
- The letter should be addressed to the patient, printed on paper with the practice letter
head and have the GP’s electronic or actual signature.
Follow-up with patients not completing kits
4. If a patient has not returned their kit four weeks after invitation, the London Bowel Cancer
Screening Hub send the patient a reminder letter. The Bowel Screening Hub will also send
practices a list of patients they have sent reminder letters to each month via secure nhs.net
email addresses (as long as practices have returned their data sharing agreement).
- Practices should follow-up these patients and offer advice and further information
about bowel cancer screening.
- Follow-up must be carried out by an appropriately trained member of staff (GP,
practice nurse or health care assistant) and must be either a face to face or
telephone conversation. Follow-up can be either opportunistically when the patient
attends the practice or proactively by telephoning these patients.
- Suggestions on what information to discuss can be found in Appendix 4 and 5.
Bowel Cancer Screening Results
5. Practices must record bowel screening test kit results, within two weeks of the information
being sent to the practice from the hub. This data should be entered into the patient’s record
via the EMIS bowel screening template using the read codes specified (see Appendix 6).
Reporting
Practices should use EMIS WEB Read codes to record when a letter has been sent (9Ow5)
or when health promotion advice has been given through face-to-face or telephone follow-up
consultations (8CAy) (see Appendix 6).
Payment for this activity will be made through routine quarterly extractions from EMIS.
Please see Appendix 1 for the payment schedule.
Population covered
All patients eligible for the bowel cancer screening programme, i.e. patients aged 60 – 74
being invited for screening.
Appendicies
Appendix 1: Payment Schedule
Activity Detail
Payment
Payment Schedule
Source of data
Health Promotion
Displaying health
promotion materials
within the practice
Administration
payment
Entry of bowel screening
results and other
administration
Letters
Sending GP
endorsement letters to
all patients being invited
for Bowel Cancer
Screening
Follow-up
consultations
Follow-up consultations
(either telephone or
face-to-face) with
patients who have not
returned kit after 4
weeks.
£50 per practice
End of LCS
Health promotion
report (appendix
7)
£100 payment proportionate to the average practice list size
End of LCS
Signed
agreement form
£3 per letter
Quarterly
Remote data
extraction of
Read code 9Ow5
£10 per consultation
Quarterly
Remote data
extraction of
Read code 8CAy
Activity Detail
Payment
Payment Schedule
Source of data
Increases in uptake
Practices will be paid for
increases in uptake over
the LCS period
For practices with baseline uptake <48% (13/14):
Increase in uptake < 3%: no additional payment
Increase in uptake of 3-4.9%: £3 per eligible bowel screening
patient in practice that year.
Increase in uptake of 5-6.9%: £4 per eligible bowel screening
patient in practice that year.
Increase in uptake 7-9.9%: £5 per eligible bowel screening
patient in practice that year.
Increase in uptake >10%: £6 per eligible bowel screening
patient in practice that year.
- Increase in uptake >13%: £7 per eligible bowel screening patient
in practice that year.
Approximately 4-5
months after the
end of the LCS
2014/15 Uptake
data from the
Bowel Cancer
Screening Hub
For practices with a baseline uptake of 48% or more (13/14):
Increase in uptake < 2%: no additional payment
Increase in uptake of 2-3.9%: £3 per eligible bowel screening
patient in practice that year.
Increase in uptake of 4-5.9%: £4 per eligible bowel screening
patient in practice that year.
Increase in uptake of 6-8.9%: £5 per eligible bowel screening
patient in practice that year.
Increase in uptake >9%: £6 per eligible bowel screening
patient in practice that year.
- Increase in uptake >12%: £7 per eligible bowel screening patient
in practice that year.
Appendix 2: Approved Promotional Resources
Recourse
Type
Leaflet/
DVD/
CD
Title
Leaflet/
DVD
/CD
Bowel screening
: the facts
NHS
CSP
Leaflet/
DVD/
CD
Bowel cancer
screening: the
colonoscopy
investigation
NHS
CSP
Learning
Disabilitie
s leaflet
An Easy Guide
to having
Colonoscopy
NHS
CSP
Learning
Disabilitie
s leaflet
An Easy Guide
to bowel cancer
screening
NHS
CSP
Leaflet
Understanding
bowel cancer
screening
Macmill
an
cancer
support
Bowel screening
kit instruction
leaflet
Produc
ed by
NHS
CSP
Notes & Links
Languages Available in: Arabic, Bengali.
Chinese, English, Farsi, French, Greek.
Gujarati, Hindi, Italian, Kurdish, Polish,
Portuguese, Punjabi, Somali, Spanish,
Turkish, Ukrainian, Urdu, Vietnamese
Also Available in : British sign language DVD,
Audio set DVD, Animated video
Available at:
http://www.cancerscreening.nhs.uk/bowel/publi
cations/kit-instructions.html
Languages Available in: Arabic, Bengali.
Chinese, English, Farsi, French, Greek.
Gujarati, Hindi, Italian, Kurdish, Polish,
Portuguese, Punjabi, Somali, Spanish,
Turkish, Ukrainian, Urdu, Vietnamese
Also available in: large print leaflet, British sign
language DVD, Audio CD set (languages
include English, Arabic, Bengali, Cantonese,
Polish, Punjabi and Urdu). A brail version is
also available.
Available at:
http://www.cancerscreening.nhs.uk/bowel/publi
cations/information-leaflets.html
Languages Available in: Arabic, Bengali.
Chinese, English, Farsi, French, Greek.
Gujarati, Hindi, Italian, Kurdish, Polish,
Portuguese, Punjabi, Somali, Spanish,
Turkish, Ukrainian, Urdu, Vietnamese
Also available in: large print version, British
sign language DVD and Audi CD set
Available at:
http://www.cancerscreening.nhs.uk/bowel/publi
cations/colonoscopy-investigation.html
Available at:
http://www.cancerscreening.nhs.uk/bowel/publi
cations/nhsbcsp-colonoscopy-learningdisabilities-leaflet.html
Available at:
http://www.cancerscreening.nhs.uk/bowel/publi
cations/nhsbcsp-learning-disabilitiesleaflet.html
Available at: http://be.macmillan.org.uk/be/p306-understanding-bowel-cancerscreening.aspx
DVD/
VHS
NHS Bowel
Cancer
Screening: It's
Your Choice
NHS
CSP
DVD
Animated
REME
Medicine: Bowel DICA
Cancer (DVD)
DVD
Bowel
Cancer NHS
Screening
kit CSP
Cartoon
Available in: English, Hindi, Punjabi,
Gujarati, Bengali and Urdu, in addition to a
British Sign Language option. It explains
about receiving your invitation for screening,
the screening process, and what the results
mean
Available at:
http://www.cancerscreening.nhs.uk/bowel/publi
cations/its-your-choice.html
This DVD contains 3D medical animations of
the growth and removal of a polyp via
colonoscopy.
http://www.remedica.com/bowel
This is a short animated film about the bowel
cancer test kit and how it can be used.
DVDs of the cartoon are available from the five
regional NHS BCSP hubs, or from the national
office of the NHS Cancer Screening
Programmes.
http://www.cancerscreening.nhs.uk/bowel/publi
cations/screening-kit-cartoon.html
Email [email protected]
Tel: 0114 271 1060.
DVD
Bowel
Screening: Your
test at home
NHS
CSP
This DVD features a short fictional bollywoodesque story to explain the bowel cancer
screening programme simply. Available in both
Hindi and English. Available at:
http://www.cancerscreening.nhs.uk/bowel/publi
cations/your-test-at-home.html
Video
Spot bowel
cancer early
CR UK
Available at:
http://info.cancerresearchuk.org/spotcancerearl
y/
A4 Poster
Available at:
http://www.cancerscreening.nhs.uk/bowel/publi
cations/poster-test-at-home.html
Posters
We've all done
the test at home
NHS
CSP
Posters
Eat well, keep fit,
use the test kit
NHS
CSP
A3 Portrait
Available at:
http://www.cancerscreening.nhs.uk/bowel/publi
cations/poster-use-test-kit.html
Posters
You can't always
see the signs
NHS
CSP
A3 Portrait
Available at:
http://www.cancerscreening.nhs.uk/bowel/publi
cations/poster-signs.html
Posters
Take a seat
NHS
CSP
A3 Portrait
Links:
http://www.cancerscreening.nhs.uk/bowel/publi
cations/poster-take-a-seat.html
Appendix 3: GP Endorsement Letter
INSERT GP PRACTICE HEADER
Patient Name
Patient Address
Date
Dear [insert patient name],
RE: Important information about the Bowel Cancer Screening Programme
Our records show that you are shortly due to be invited to take part in the Bowel Cancer
Screening Programme. All those invited to take part receive a bowel cancer test kit through
the post. We are writing to tell you about the bowel cancer test kit, which will be arriving in
your post soon.
The bowel cancer test kit is automatically sent to people aged 60-74, every two years.
As you get older, your chance of getting bowel cancer increases. The test kit aims to detect
bowel cancer at an early stage, in people with no symptoms, when treatment is much more
likely to be effective. Bowel cancer is the second most common cause of cancer death in
the UK. However it is also one of the most curable, if detected early.
The test kit is used privately in your own home. A pre-paid envelope is provided for you to
send the completed kit to an NHS laboratory for processing. Results are posted back to you
about 2 weeks later.
Millions of people around the world have completed the test kit and continue to do so as it
helps to save lives. This is why we are encouraging all patients at our GP practice to
complete the test kit that they receive in the post.
If you need further information and advice, please call the freephone helpline on 0800 707
6060 or visit the website www.cancerscreening.nhs.uk
[Practices may also wish to insert a sentence with an alternative contact at the practice for
patients to contact if they have any further questions. For example, “You can also call
Joanna Bloggs, Practice Nurse on 0207 523 4537 if you have any further questions or
queries.”]
Yours sincerely
(INSERT ELECTRONIC SIGNATURE OF GP)
(INSERT PRINTED NAME OF GP)
Appendix 4: Follow-up advice for patients who have not returned kit
If a patient has not returned their kit four weeks after their invitation, the London
Bowel Cancer Screening Hub send the patient a reminder letter. If there is still no
response 13 weeks after the reminder letter is sent the person is counted as a nonresponder and their episode is closed. The practice will then receive notification that
the patient did not respond. The patient will be re-invited for screening two years
later.
As part of the LCS the Bowel Screening Hub will send practices a list of patients they
have sent 4 week reminder letters to in the previous month via secure nhs.net email
addresses.
Steps for following-up with these patients:
i.
An appropriately trained member of staff (GP, practice nurse or health care
assistant) to discuss the bowel cancer screening with the non–responders
either opportunistically when patient attends the practice or proactively by
telephone conversation.
ii.
If they have difficulty communicating in English a consultation with an
interpreter should be offered and arranged.
iii.
Points to cover in consultation
o Check whether the patient has received their test kit.
o If they did not, check that the patient’s address details on your records
are correct.
o Offer to order another test kit for the patient. Practices can order
kits over the phone (using the freephone number 0800 7076060) you will need to supply each patients name, address and NHS Number
when you make the call.
o If the patient did receive the test kit, determine whether they are
planning to complete it and send it back.
o Discuss any practical problems they may have completing the test or
any barriers/ concerns they may have with the test. Use appendix 5.
o If they are willing to complete the test ask if they have an unspoilt test
kit at home. If not, give them details of how to order another or offer to
order it for them.
o If the patient does not want to complete the test, explain that they
should contact their GP with any symptoms of bowel cancer
immediately.
Appendix 5: Promoting bowel screening - a reference guide
Patients often seek advice from their GP and practice nurse when considering undertaking a
screening programme. It is therefore important for healthcare professionals to be aware of
the key messages and benefits of the programme. We have produced the following
reference guide which can be used either when promoting bowel screening or following up
patients that have not returned test kits.
What is Colorectal Cancer?



Colorectal (bowel) cancer refers to either cancer of your colon (large intestine/bowela part of your digestive tract) or rectum (back passage- where stools are stored
before you pass them).
It is one of the most common cancers in UK.
It is more common in older people - 8 out of 10 people diagnosed with bowel cancer
are over 60.
The National Bowel Cancer Screening Programme









The chances of surviving bowel cancer are much better if it is detected at an early
stage – 9 out of 10 people survive for 5 years or more.
When the cancer first starts to develop, there are typically no symptoms for weeks or
months.
The bowel cancer screening programme has been developed for people aged 60-74,
every 2 years.
The aim of the screening programme is to detect cancer at an early stage where
there is a good chance that treatment will cure cancer.
Regular screening can reduce deaths from bowel cancer by 15%, equivalent to 1 in 6
fewer people dying from bowel cancer.
Screening can also detect polyps (growths) on inner lining of the bowel- these are not
cancers but may develop into cancers over time if left. If detected they can easily be
removed which reduces the chance of cancer developing.
The screening process involves sending people a Faecal Occult Blood test (FOBt) in
the post. The FOBt kit allows small samples of stool to be collected at home and can
then be posted back to the screening centre for testing.
It is quick and easy to perform- there are clear instructions on the kit.
The stool samples are tested to detect small amounts of blood in the stool. It detects
very small amounts of blood that are unnoticeable to yourself but common in people
with bowel cancer.
How to Complete Test Kit
1. Prepare the kit by writing the date on the appropriate flap
2. Collecting the Sample. You could collect the sample on:
- Folded piece of toilet paper
- Hand covered in small plastic bag
- Clean disposable container
- Putting cling film over toilet bowel
You need to take samples from 3 different stool samples on different days. For each of
them:
- Take two samples from different areas of the stool , using the cardboard sticks
provided
- Spread the samples thinly over the first and second window
- Repeat the same steps for the 2nd and 3rd stools that you take samples from
- In total you should have 6 stool samples from 3 different stools.
3. Put the kit in the freepost envelope and post it back
To Request another Kit/ Answer Any Further Queries


Call freephone line on 0800 707 60 60.
Alternatively GP practice can order a kit from the hub via email provided it is via nhs.
net email account - you will need to supply each patients name, address and NHS
Number
Being Bowel Aware (adapted from NHS choices)
Report any of the following:




blood in poo or bleeding from your back passage.
a change to normal bowel habits that persists for more than three weeks, such as
diarrhoea, constipation or passing stools more frequently than usual
abdominal pain
unexplained weight loss
As bowel cancer progresses, it can sometimes cause bleeding inside the bowel. Eventually,
this can lead to the body not having enough red blood cells. This is known as anaemia.
Symptoms of anaemia include:


fatigue, tiredness
breathlessness
In some cases, bowel cancer can cause an obstruction in the bowel. Symptoms of a bowel
obstruction include:




a feeling of bloating, usually around the belly button
abdominal pain
constipation
vomiting
Appendix 6: Bowel cancer screening EMIS template
A bowel cancer screening EMIS template and appropriate READ codes will need to be used
when recording activity relating to bowel screening LCS and the results of the screening test
kits. These are outlined below.
Read code 5-byte
9Ow
Abbreviation
bow scrn admin
Description
Bowel cancer screening programme
administration
9Ow5
bow scrn letter
Endorsement letter sent
686A
FOB NEGATIVE
686B
FOB POSITIVE
68W2
6867
2 yr follow up
FOB SPOILT
686C
FOB INCOMPLETE
9Ow2
dna bowel screen
8CAy
advise after dna
8IA3
9Ow3
BOW SCR OPTOUT
not elig bow scn
Bowel cancer screening programme
faecal occult blood test normal
Bowel cancer screening programme
faecal occult blood test abnormal
Bowel cancer screening programme
Bowel Cancer screening programme:
faecal occult blood testing kit spoilt
Bowel cancer screening programme
faecal occult blood testing incomplete
participation
No response to bowel cancer
screening programme invitation
Advice given about bowel cancer
screening programme
Bowel cancer screening declined
Not eligible for bowel cancer screening
programme
Appendix 7: Template for reporting bowel screening health promotion activities
Practice Name:
Practice Cancer Screening Lead:
Email:
Telephone:
Date:
1. What bowel screening health promotion activity(ies) did you undertake between April 2014
and March 2015? Please provide a brief description in the box below
2. Why did you choose this activity?
3. When did the activity take place?
4. What resources did you use?
5. What worked well?
6. What worked less well?
7.
Comments/ suggestions for future bowel cancer screening promotional activity.
Please send the completed form by no later than Friday 3rd April 2015 to Public Health at
[email protected] or Public Health Cancer Lead, Public Health, 222 Upper Street
(Third Floor), London N1 1XR.