Paper 18.07
Bowel Screening Wales
Network
Multidisciplinary
Team and National
Referral Centre for
Complex Polyps
Author: Hayley Heard, Head of Programme Bowel Screening Wales
Date: 10 May 2012
Version: 0b
Purpose and Summary of Document:
This document describes the need for a Network Multidisciplinary Team
and National Referral Centre for treatment of complex colorectal polyps in
Wales. It summarises the findings of a recent pilot and recommends the
way forward for consideration by Public Health Wales Trust Board.
Sponsoring Executive Director: Professor Hilary Fielder
Who will present: Professor Hilary Fielder
Documents attached: None
Date of Board meeting: 24 May 2012
Committee/Groups that have received or considered this paper:
None
Please state if the paper is for:
Discussion
Yes
Decision
Yes
Information
Contents
1
PURPOSE ................................................................................ 3
2
INTRODUCTION ...................................................................... 3
3
BACKGROUND ......................................................................... 4
3.1 Benign polyps in Bowel Screening Wales .................................. 4
3.2 Risks and benefits of alternative approaches ............................ 5
3.3 BSW Network MDT and National Referral Centre ....................... 5
4
RECOMMENDATION(S) ........................................................... 6
5
TIMING ................................................................................... 7
6
FINANCIAL IMPLICATIONS ..................................................... 7
6.1 Costs .................................................................................. 7
6.2 Source of funds .................................................................... 8
7
BOARD MEMBERS ARE ASKED TO: ........................................... 9
8
NEXT STEPS ............................................................................ 9
9
APPENDIX 1 .......................................................................... 10
SCREENING DIVISION BUSINESS CASE TEMPLATE ..................... 10
DEVELOPMENT OF AN ALL WALES COMPLEX POLYPECTOMY
TREATMENT SERVICE............................................................ 10
10 REFERENCES ......................................................................... 16
1
Purpose
This document summarises the requirement, development and outcome of
the pilot Bowel Screening Wales network multidisciplinary team and
national referral centre pilot for treatment of complex polyps and includes
recommendations for the way forward.
Public Health Wales Trust Board are asked to consider the document and
to approve continuation of this service in order for participants of the
bowel screening programme to access equitable care.
2
Introduction
Bowel Screening Wales (BSW) is responsible for the care of participants
prior to a diagnosis of cancer. Most participants can be managed within
the normal screening pathway, but a few have complex benign colorectal
polyps which have historically been dealt with in different ways across
Wales. Complex polyps can be removed endoscopically or by surgery.
Endoscopic removal is usually preferable as it is associated with less risk
to the patient (Association for Coloproctology 2011; Massimo et al 2004,
Moss et al 2011) and is more cost effective (Swan et al 2009), but is
dependent on clinical skill. There are currently few colonoscopists in Wales
who are able to undertake complex colonoscopic procedures and this has
resulted in significant variation in referral rates for surgery and the
evolution of an inequitable service.
BSW
have
recently
conducted
a
pilot
to
establish
a
network
multidisciplinary team (NMDT) and a national referral centre (NRC) for
treatment of complex polyps. The pilot has resulted in participants being
Public Health Wales
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offered the choice of endoscopic removal of their lesion at the national
centre in Cardiff or local surgery following expert opinion from the NMDT.
Thirteen meetings of the NMDT were held over the course of the 6 month
pilot and 44 participants discussed. Twelve participants were referred back
to their local assessment centre for colonoscopy with advice from the
expert panel and 9 people were referred for surgery at their local centre
as their lesion was not removable endoscopically. Fourteen
participants
were referred for treatment to the NRC and 7 await further investigations.
Two people are awaiting a local clinician decision prior to a management
plan being agreed. Of the cases referred to the NRC for treatment there
have been no adverse events and excision has been completed when
checked at 3 months in 100% of cases.
3
Background
3.1
Benign polyps in Bowel Screening Wales
Since the beginning of the bowel screening programme in Wales polyp
detection rates have been higher than expected at around 60% and many
complex lesions have been detected. The aim of polypectomy is to remove
a lesion in its entirety in a safe, timely and cost-effective manner. Methods
of removal include laparoscopic surgery, open surgery or endoscopic
therapeutic techniques such as Endoscopic Mucosal Resection (EMR) or
Endoscopic Submucosal Dissection (ESD), but it may not always be
immediately apparent which option is best.
Although usually preferable, endoscopic removal of complex lesions is
often technically challenging and carries an increased risk of incomplete
excision, recurrence and complications if not undertaken by appropriately
skilled endoscopists. Complete removal of lesions is more likely when EMR
is undertaken by an experienced colonoscopist (Srinivas et al 2009). The
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BSW assessment process for screening colonoscopists does not currently
assess therapeutic skill and some colonoscopists are more experienced
than others in removing complex lesions. Prior to the pilot Health Boards
without appropriate expertise for endoscopic removal of lesions could only
offer participants surgery. This potentially exposed them to unnecessary
risk and resulted in an inequitable service for participants of the bowel
screening programme in Wales.
3.2
Risks and benefits of alternative approaches
As with all surgical interventions, there is a mortality rate associated with
colorectal surgery there have been instances where participants of the
English bowel cancer screening programme have died as a result of
undergoing surgical procedures to remove benign colorectal polyps.
Recent mortality data reveals a 30 day mortality for major colorectal
surgery of 3.4% in England and 4.0% in Wales (Association for
Coloproctology 2011). Mortality from colonoscopy is extremely rare at
around 1 in 10,000 cases.
Colorectal surgery is expensive and involves a lengthy recovery period for
what is largely benign disease. Participants undergoing surgery usually
have part of their bowel removed and a permanent stoma may be
required. Procedures undertaken endoscopically do not involve removal of
bowel or formation of stoma and are usually undertaken on a day case
basis.
3.3
BSW Network MDT and National Referral Centre
The BSW Network MDT and NRC was established as a pilot in October
2011 to address issues of safety, patient choice and equity. Referrals were
taken from Screening Colonoscopists and local MDT’s according to specific,
agreed criteria. The pilot focused on developing an equitable, participant
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focused service aiming to reduce waste, harm and variation of practice.
Formal evaluation is ongoing, but preliminary findings suggest that it has
been successful and confirmed that this approach is feasible within an NHS
programme rather than a purely research setting.
The pilot has created a mechanism for expert opinion on complex polyps
found during screening colonoscopy. It enabled discussion of options and
technical feasibility for removal of complex lesions at MDT level.
Information is then given to participants in order for them to make an
informed decision on management.
Wales is leading the way in management of complex polyps in the UK as
other bowel screening programmes in the country have recently started
planning their approach to this issue. It is likely that other programmes
will use the findings of the Welsh pilot to inform their developments. The
bowel screening programme in Wales is well placed to undertaken such
innovative developments as the QA process is now robust and population
size manageable while significant enough to generate meaningful data.
4
Recommendation(s)
The continued delivery of a safe, sustainable and high quality screening
programme means that patients identified by the programme as requiring
further intervention should be referred to and dealt with by a service that
has the best possible outcomes, is cost effective to deliver and makes the
most efficient use of NHS resources.
Screening programmes must do more good than harm at a population
level. Ensuring optimum care and management for participants identified
with complex polyps is an important mechanism to reduce unnecessary
harm.
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Continuation of the network MDT and NRC is recommended in
order for participants of the bowel screening programme to access
high quality, safe and equitable care.
Continuation of the service
will also provide the opportunity to train
additional Screening Colonoscopists
to undertake complex procedures,
who could then offer the procedures more locally in the future. It is
recommended that the service should be further developed to disperse
expertise throughout Wales. This can be achieved by Expert Advisors
undertaking complex procedures in other units in Wales while training the
local Screening Colonoscopists. This would future proof the service and
enable development of enhanced skills for colonoscopists which would in
turn also benefit the symptomatic service.
Continuous
evaluation
will
report
outcomes
annually
and
include
comparison of completion rates, mortality reduction and costs. Service
delivery will be monitored in line with SLA arrangements and reported
through established lines of communication to the Trust, to Health Boards
and to the Welsh Government.
5
Timing
The pilot has been extended and a decision on the way forward is
requested as soon as possible in order to establish a smooth transition
into service model.
6
Financial Implications
6.1
Costs
Health Boards have not, so far asked Bowel Screening Wales to pay for
surgical procedures, although these participants remain the responsibility
of the screening programme and it is likely that this cost will need to be
covered by BSW in future. A precedent exists where Breast Test Wales
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(BTW) pays for the cost of participants open surgical biopsy when
required.
The average HRG cost for major colorectal surgery is £7,448 per
procedure compared to £3,000 for an endoscopic procedure. Had the 14
cases referred to the NRC undergone local surgery the cost to NHS Wales,
and potentially BSW in the future would have been £104,272. This
relates only to the procedure cost and additional resources for hospital
stay, pathology and follow up procedures need to be factored in. NRC
cases have cost BSW £42,000 which represents total clinical expenditure.
Based on experience during the pilot and taking into consideration the
expansion of eligible age range (undertaken in December 2011) it is
anticipated that the NMDT will refer an average of one case per week and
approximately 45 per annum to the NRC for treatment. Please see
business case for further details (appendix 1)
Total costs for the NMDT and NRC are £160k per annum.
The Network MDT established for the pilot comprised of 8 expert advisors
including surgeons, colonoscopists, pathologists and radiologists. Each
advisor was paid a nominal half session per week to attend NMDT
meetings and advise on management of participants.
6.2
Source of funds
The service can be funded from efficiency savings with within existing
Screening Division funding. No additional funding is required to provide
this service for the age range currently invited. A business case has been
presented to the Public Health Wales Executive Team.
6.3
Sustainability
The pilot has established that around 45 people per year will require
referral to the national centre for complex polypectomy. Bowel Screening
Wales
is currently inviting all people aged 60-74 for bowel screening
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every two years, and invites around 300,000 people per year. Thus the
rate of referral for complex polypectomy is around 1: 6,700 invitations.
The Screening Division is currently in discussion with Welsh Government
regarding options for expanding the age range invited for bowel screening.
The cost of providing complex polypectomy would be included in any plan
for programme expansion.
7
Board Members are asked to:
Approve continuation of service for the network MDT and National Referral
Centre for treatment of complex polyps on a permanent basis within the
remit of Bowel Screening Wales.
8
Next Steps
Continuation
of
NMDT
and
NRC.
Further
development
of
patient
information, standards, QA processes and pathways based on evaluation
of the pilot phase.
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Appendix 1
SCREENING DIVISION BUSINESS CASE TEMPLATE
Development of an all Wales Complex Polypectomy Treatment Service
Authors: Rhys Blake; Hayley Heard
Date: 11th April 2012
Version: 1.0
Purpose and Summary of Document: To set out service development in the bowel
screening programme to ensure a high quality, safe and sustainable service for the
treatment of complex polyps discovered within the screening programme.
Financial Framework approved by Financial Manager:
Signature of Financial Manager:
Name of senior sponsor: Dr Rosemary Fox / Dr Hilary Fielder
Signature of senior sponsor:
Approved by Director:
Signature:
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Executive Summary:
Bowel Screening Wales (BSW) is responsible for the care of bowel screening
participants prior to a diagnosis of cancer. Most participants can be managed within
the normal screening pathway, ie home faecal occult blood testing followed by
colonoscopy and polypectomy where required. A few participants have large
complex polyps. These polyps are within the remit of the programme to manage as
they are mostly benign but may develop into cancers if not removed. These complex
polyps can be removed either by open surgery or endoscopically. Endoscopic
removal is preferable as it is associated with less risk to the participant.
Endoscopic removal of complex polyps is available at only one of the Health Boards
in Wales The Health Boards without appropriate expertise for endoscopic removal of
lesions currently offer these participants surgery. This potentially exposes them to
unnecessary risk and results in an inequitable service for participants of the bowel
screening programme in Wales.
Bowel Screening Wales is currently piloting a national service for complex
polypectomy. The pilot is being evaluated and results are expected in May 2012.
This case makes the request for £160,000 recurring in order to offer endoscopic
management as an alternative to open surgery to BSW participants.
The programme will refer participants to Cardiff and Vale University Health Board for
endoscopic intervention. Referral will be managed by an all Wales MDT consisting
of surgeons, colonoscopists, pathologists and radiologists. The MDT will receive
cases identified as having large polyps and assess for suitability of referral assessed
against agreed criteria to ensure equity of access.
Need:
Define the need
Current arrangements see screening participants identified
with these particular types of polyps referred for colo-rectal
surgery. There is a mortality rate associated with open
colorectal surgery. NBOCAP Audit data 2010 published:
Post-operative mortality
Mortality within the first 30 days after major surgery was 4.0
per cent for patients with colon cancer, 3.7 per cent for
patients with rectosigmoid cancer, and 2.7 per cent for
patients with rectal cancer.
In England, 3.4 per cent of the patients undergoing major
surgery died within 30 days of surgery. This figure was 4.0 per
cent in Wales
Colorectal surgery is expensive and involves a long recovery
time for what is largely benign disease. Participants
undergoing surgery usually have a large part of their bowel
removed and a permanent stoma may be required. Procedures
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undertaken endoscopically do not involved removal of bowel
or formation of stoma.
(Health Boards have not, so far asked Bowel Screening Wales
to pay for surgical procedures, although the participants are
the responsibility of BSW, and a precedent exists where
Breast Test Wales (BTW) pays for the cost of open surgical
biopsy in BTW participants where required)
Strategic context
Local /
context
The continued delivery of a safe, sustainable and high quality
screening programme means that patients identified by the
programme as requiring further intervention should be referred
to and dealt with by a service that has the best possible
outcomes, is cost effective to deliver and makes the most
efficient use of scarce NHS resources.
Screening programmes must do more good than harm at a
population level and ensuring best practice for participants
identified with a polyp is an important method to reducing
unnecessary harm.
To ensure equity across Wales . participants must be given
the choice of endoscopic removal of their lesion at a national
centre or local surgery
Referred for open colo-rectal surgery with associated risks
service and outcomes in Health Boards without appropriate expertise.
Complex polypectomy is only currently available in Cardiff and
Vale University Health Board.
Dr Rosemary Fox & Dr Hilary Fielder
Case sponsor
Options:
List of options
Option 1: Do nothing
Option 2: Introduce complex polypectomy service
Selection criteria
Clinical Outcomes
Equity of access
Workforce development
Impact on treatment services (surgery)
Cost:
Option 1 ‘Do nothing’:
No improvement to clinical outcomes.
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As the programme
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continues it can reasonably expect to detect increasing
numbers of complex / difficult cases not always picked up
symptomatically.
This option would result in an inequitable provision of services
within the national bowel screening programme: participants
living in the Cardiff & Vale Health board area would be able to
access endoscopic resection while those in other areas would
require open surgery.
There would be no opportunity for development
colonoscopic expertise to more colonoscopists.
of
Local surgical services would continue to be referred patients
who could be offered minimally invasive treatment elsewhere,
and who would take up operating theatre and surgical
capacity.
Although Health Boards have not to date charged Public
Health Wales for open surgery for these participants, there is
a risk that in future open surgery costs for these procedures
are billed to the programme. The HRG spread of costs for
these ranges between £5,000 and £10,000. The cost for a
procedure to be done endoscopically is in the order of £3,000
Option 2: ‘Introduce complex polypectomy service’:
This would ensure all participants receive an equitable and
high quality service, with optimal clinical outcomes (Increased
numbers seen as day case procedures. Lower risk of
colostomy and other associated risks from open surgery)
The provision of the service would provide the opportunity for
training additional colonoscopists in these procedures, who
could then offer the procedures locally.
Would reduce pressure on theatre capacity
Undertaking endoscopic removal of complex polyps costs
£2,950. Based on experience during the pilot the programme
will see an average of one case per week and approximately
45 per annum.
Expert MDT panel is established as part of the process panel.
A nominal half session a week payment is made to 8 expert
advisers which include surgeons, colonoscopists, pathologists
and radiologists.
Preferred Option
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To introduce all Wales polypectomy service
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Cost benefit
Recurring revenue There are currently 4 screening slots on a standard list for
costs
colonoscopy. Undertaking endoscopic removal of complex
polyps takes up 4 screening slots and costs £2,950. Based
on experience during the pilot the programme will see an
average of one case per week and approximately 45 per
annum.
Expert MDT panel is established as part of the process panel.
A nominal half session a week payment is made to 8 expert
advisers which include surgeons, colonoscopists, pathologists
and radiologists.
There is a risk that open surgery costs for these procedures
are billed to the programme. The HRG spread of costs for
these ranges between £5,000 and £10,000. The cost for a
procedure to be done endoscopically is in the order of £3,000
Non-recurring
revenue costs
N/A
Capital costs
£100,000*
*provided by Cardiff and Vale discretionary capital*
Expenditure
profile
£160k per annum. (assumes continuation of pilot plus
formalisation of service in 12/13)
Source of funds
The funding of this service development is dependant on the
release of costs elsewhere within screening:
As a result of ongoing reconfiguration the following changes to
LTA’s are to be reinvested to fund this development
Colposcopy Benchmarking exercise:
Benefits
Date: 11.5.12
£308,000.
Reduction in mortality and morbidity from open colorectal
surgery
Improved patient outcomes and quality of life
Equity of access across Wales to services
Reduced pressure on theatre and critical care/recover beds.
Usually day case, or one night inpatient procedure
Potential saving if Health bards were to charge for open
surgery
Ability to spread good practice throughout Wales by using the
service as a training setting.
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Continuous evaluation will report outcomes annually to include
comparison of completion rates, mortality reduction and cost
and length of stay amongst criteria to be monitored and
evaluated.
Service delivery in terms of waiting times, results and case
numbers will form part of the evaluation of delivery via existing
LTA arrangements.
These will be reported through existing established lines of
communication through the Trust, to Health Boards, Welsh
Government and the public as part of the continuous
programme statistical reporting process.
Implementation
Implementation leads: Mrs Hayley Heard, Programme Lead
Dr Sunil Dolwani, QA colonoscopist, Bowel Screening Wales
Plan
Risk analysis
Date: 11.5.12
If case is not approved there will be inequitable provision of
treatment for screened participants, exposing significant
numbers to unnecessary risk Open surgery is more costly
than removal endoscopically and if screening covered these
costs then this would be financial risk for programme cost..
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References
Massimo Conio, Alessandro Repici, Jean-Francois Demarquay, Sabrina
Blanchi, Remy Dumas, Rosangela Filiberti: EMR of large colorectal polyps.
Gastrointestinal Endoscopy 2004 Volume 60:No2
Moss A, Bourke MJ, Williams SJ, Hourigan LF, Brown G, Tam W, Singh R,
Zanati S, Chen RY, Byth K: Endoscopic mucosal resection outcomes and
prediction of submucosal cancer from advanced colonic mucosal neoplasia.
Gastroenterology 2011
Association for Coloproctology of Great Britain and Ireland, The Royal
College of Surgeons of England & The NHS Information Centre for Health
and Social Care (2011) The National Bowel Cancer Audit Annual Report
2011; www.ic.nhs.uk/bowelreports
Srinivas R.P, Yasuo K, Takuji G, Daphne A, Yutaka S, Mainor RA: Metaanalysis
resection.
and
Systematic
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colorectal
Gastroenterology
endoscopic
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mucosal
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14,
15(34):4273-4277
Swan MP, Bourke MJ, Alexander S, Moss A, Williams SJ: Large refractory
colonic polyps: Is it time to change our practice? A prospective study of
the clinical and economic impact of a tertiary referral colonic mucosal
resection
and
polypectomy
service
(with
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Gastrointestinal
Endoscopy 2009;70:1128-1136.
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