Cynulliad Cenedlaethol Cymru	National Assembly for Wales
Y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon	Health, Social Care and Sport Committee
Ymchwiliad i wasanaethau Endosgopi	Inquiry into Endoscopy Services
HSCS(5) E07
Ymateb gan Iechyd Cyhoeddus Cymru	Evidence from Public Health Wales

On behalf of Bowel Screening Wales, Public Health Wales (xxxx, Head of Programme, Bowel Screening Wales)

This submission is in response to three of the terms of reference provided. The remaining two terms of reference relate to areas outside the remit of Bowel Screening Wales and have therefore not been included in this submission.

Earlier diagnosis, specifically the introduction of the Faecal Immunochemical Test (FIT) into the bowel screening programme and the recently announced change to age range

People diagnosed with bowel cancer as a result of participating in the screening programme have their tumours diagnosed at an earlier stage than those presenting through the symptomatic service. Around 37% of people with screen detected cancers are diagnosed with stage 1 disease and 8% at stage 4, compared with 18% at stage 1 in the symptomatic service and 22% at stage 4 (CRUK 2018). Around 9 out of 10 people with stage 1 bowel cancer will survive at least 5 years, compared to around 12% with stage 4 disease (CRUK 2018). In order to improve outcomes for bowel cancer patients it is therefore essential that the bowel screening programme is optimised to reduce the burden of bowel cancer disease in our population.

Currently Bowel Screening Wales offers screening to men and women aged 60 to 74 years and sends them a faecal occult blood test kit to complete every two years. If the test result is positive then they are offered a colonoscopy.

Bowel Screening Wales (BSW) has been asked by Welsh Government to introduce the first line faecal immunochemical test (FIT) as the screening test and this is planned to be introduce from January 2019. This is in line with UK National Screening Committee recommendations. The new test is more sensitive, specific and as it is easier to use than the current test an improvement in uptake is expected.  

Welsh Government has also asked Bowel Screening Wales (BSW) to plan to optimise the screening programme by April 2023 by inviting people aged between of 50 and 74 years as recommended by the UK National Screening Committee.

This will challenge Health Boards by increasing demand on already pressurised diagnostic and treatment services. Health Boards have been asked to develop sustainable capacity to accommodate optimisation of the bowel screening programme and this will require investment and resource that has not currently been identified.

As the FIT test is quantitative there is flexibility to adjust the cut off level in order to maximize cancer and adenoma detection. The initial cut off level (of 150ug/g) to be used in Wales is a pragmatic starting point which will marginally increase demand for diagnostic and treatment services, while delivering some improvement on the current test and allowing Health Boards time to develop additional capacity. A detailed optimisation plan has been developed and will be submitted to the Wales Screening Committee for approval. It incorporates age expansion and improvement in FIT threshold to maximise public health benefit with priority being given to age expansion.

The BSW FIT implementation project is on target to begin the phased implementation in January 2019 with national rollout planned from June 2019. Analysers have been procured and installed into the laboratory and staff training has begun. I.T. system development is ongoing and Public and Health Professional information is being developed. All work streams are on target to deliver on time despite a significant delay in procurement due to a legal challenge.

Diagnostic service capacity and waiting times, including the extent to which capacity constraints are driving the recommendation to set the FIT threshold for its introduction to the bowel screening programme at a relatively insensitive level.

Colonoscopy capacity has dictated the rate at which the bowel screening programme can be optimised. Bowel Screening Wales undertakes around 3,300 lower GI endoscopy procedures per year which accounts for 8- 10% of the total lower GI endoscopy demand. All Health Boards are currently funded for more screening activity than they deliver and yet they struggle to achieve the 28 day waiting time standard (from contact following positive screening test result). In July 2018 only 45% of participants were seen within timeliness standards. There are different issues in various units, but pressure on the symptomatic service is largely the issue as cancelled lists are often replaced with symptomatic cases.

Implementing and improving FIT and expanding the screening age range will be extremely challenging for Health Boards who are under pressure to reduce symptomatic service waiting times. Some progress is being made to reduce symptomatic waiting times across Wales, but this has been largely due to costly waiting list initiatives.

Individual Health Board teams are working very hard to address timeliness issues, but although some Health Boards have developed plans to improve sustainable capacity for endoscopy, others are yet to identify how this will be achieved. Of those that have developed plans a shortfall in capacity has been identified and significant improvement is needed to accommodate optimisation of the bowel screening programme.

Health Boards who have developed plans to increase sustainable capacity will need to undertake a variety of improvements including amending job plans for colonoscopists, recruiting more colonoscopists and nursing staff and some will need to develop additional endoscopy rooms. It is difficult to see how this will be possible within the current service model.

Efforts being taken to increase uptake of the bowel screening programme.

The standard for uptake of the Bowel Screening Programme has been set at 60% of invited participants who return a used test within six months of invitation. However, this has not been reached consistently since the start of the programme, although it has shown improvement in recent years. The latest published figures are for the period April 2016 to March 2017 and show an uptake of 53.4% across Wales. The next annual report is due to publish in January 2019 and is expected to demonstrate a small improvement in uptake, but not achieving the 60% target. Uptake is higher in women (54.7%) compared to men (52.0%). There is also a strong correlation with deprivation quintile with uptake in the most deprived areas being 43.6% compared to least deprived areas at 60.6%.

Improving uptake has been a continual focus for the programme and several initiatives have been evaluated and taken forward. These include development and dissemination of consistent key messages based on every contact counts methodology. Also pre-invitation letters were piloted and following evaluation, sent to men prior to their first invitation to improve uptake and reduce the gender inequality gap.

Current work that is underway to improve uptake includes:

a. Routinely sharing information with GPs about their patients who fail to respond to invitations for bowel screening. Bowel Screening Wales have worked with Cancer Research UK to develop a toolkit to increase knowledge of bowel screening among primary care staff in order to encourage them to implement interventions to improve uptake. Initiatives with GP Clusters and Health Boards to help capitalise on this opportunity are ongoing

b. The ‘Be Clear on Cancer’ campaign that was run with Cancer Research UK in February and March 2018 yielded a significant increase in returned test kits  which was maintained for several months.  The quantitative analysis of the effectiveness of the campaign is due to be completed in the next month and a meeting has been arranged with CRUK to discuss the findings and consider the implications in terms of future interventions

c. Discussion with public health colleagues in Cwm Taf Health Board with a view to piloting additional interventions in primary care which if successful could be rolled out nationally

d. Plans to review current letters and literature will also be undertaken with PHW behavioural insights team with a view to developing culturally and literacy sensitive material in accessible formats for different groups of the population

e. Research into the barriers to participation particularly in the younger age range

Bowel Screening Wales is celebrating its 10 year anniversary and the programme is using this to further engage with the public and stakeholders. This has included programme representation at sport events including Cardiff 10K run and a ‘walk with me event’. The Welsh Association of Gastroenterology and Endoscopy (WAGE) conference had a focus on the Bowel Screening Programme. Also during October Bowel Screening is going on a tour around Wales to raise awareness with focus on low uptake and seldom-heard groups. The emphasis is on capturing conversations with participants and the pubic to help us to understand awareness of the programme, barriers to participation and to develop insight as to how community led posts could support the work of BSW. In addition there has been media coverage across various channels including TV, local press and social media using participant stories to deliver a person-centred message around the importance of participating in screening. This has been undertaken with Macmillan, Cancer Research UK and Bowel Cancer UK.

Following on from this community engagement work the BSW team are collaborating with a small group of charity workers and Health Care Professionals to explore the possibility of developing joint work plans for community workers employed by Bowel Cancer UK to work within BSW. Informed by data gathered at the anniversary events, work plans could be developed to include locally led initiatives and support for primary care to encourage engagement with the programme.

References

Cancer Research UK 2018. Bowel Cancer Statistics. Cancerresearchuk.org