Enhanced Service
Clinical Lead
Commissioner
Reporting Mechanism/Frequency
Payment Frequency
Payment Contact
Version
Date
Bowel Cancer Screening LES
maggie.luck@nclondon.nhs.uk
Camden
Variable, please see Sec. 4
Variable, please see Sec. 5
Sharon.peppard@nclondon.nhs.uk
1
Jul-12
Local Enhanced Service Specification
Bowel Cancer Screening in Camden
2012/13
Summary
Uptake of the NHS Bowel Cancer Screening Programme in Camden is well below the national
target of 60%. For Quarter 4 of 2011 - 2012 Camden’s uptake was 42.5%, compared to 39.51%
in London and 53% in England. The target population is all adults 60 – 69 years of age.
According to the Bowel Cancer Screening System (BCSS) dataset, uptake for the year 2011 12, was 39.86%, with variation by practice from 7.41%% - 50.99%% (Appendix 1)
The Camden Bowel Cancer Screening Local Enhanced Service (Bowel Cancer LES) aims to
increase uptake of the bowel screening programme across the borough by promoting greater
responsibility for activities that promote bowel cancer screening by Camden general practices.
There is strong evidence that this improves screening uptake.
NB: This LES is not prescriptive in stating which activities should be undertaken by
practices to increase uptake of the screening test. Practices will be rewarded based on
their achievement of an increase in uptake by their practice eligible population regardless
of how this is achieved, using as a baseline uptake at March 2012.
Practices will be provided with information about the literature on barriers to screening, what
activities can improve uptake, and the target age range for bowel cancer screening. This
information will be presented at an education day which all practices signing up will be expected
to attend and in information packs that practices can take away. Practices may wish to consider
this information in designing their activities but that is their choice. Information on these including
a reference guide for promoting bowel cancer screening can be found in Appendices 8 and 9.
The LES will go live on 1 October 2012 and will run until the 30th September 2013.
Practices will be paid:
 A fee of £200 for attending the launch / information event
 A fee per patient screened calculated incrementally according to increase in uptake from
2011 – 2012 baseline figures (BCSS) of 10% (£75 / extra patient screened), 15% (£125) and
20% (£175).
The initial administrative fee will be paid at the beginning of the LES, following attendance at the
launch event and submission of a signed Cancer Screening LES participation agreement.
Payments for additional patients screened will be made 13 weeks after the completion of the
LES based on activity data from the Bowel Cancer Screening Hub and anonymous data
extracted remotely from BCSS.
Further details on payment for the LES are provided in Section 5.
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1. Introduction and background to the LES
Bowel cancer is the third commonest cancer and the second most common cause of cancer
death (after lung cancer) in the UK. Approximately 100 new cases are diagnosed each day1,2. If
bowel cancer is diagnosed at an early stage (Dukes stage A), the 5 year survival rate after
treatment is 85-95%2. This falls to less than 10% at Dukes Stage D. 2
Table 1: Dukes Staging of Colorectal Cancer2,3
Dukes Stage
Explanation
A
Tumour confined to Intestinal Wall
5 year
Rate
85-95%
B
Tumour invading through Intestinal Wall
60-80%
C
Lymph node involvement
30-60%
D
Distant Metastasis
<10%
Survival
Trials have shown a 16% reduction in bowel cancer specific mortality with annual bowel cancer
screening using Faecal Occult Blood testing (FOBT) and a 15% reduction in those trials that
used biennial screening4. A national pilot conducted by the Department of Health demonstrated
the feasibility of the use of FOBT for population based screening in the UK5. Bowel cancer
screening is considered to be a cost effective intervention, with an estimated cost per QALY of
between £2,600 and £6,000, which is well below the minimum cost effectiveness threshold used
by NICE.
Since 2006, a national bowel screening programme has been running across the country. The
programme screens individuals aged 60-69, every 2 years. The aim of the screening is to detect
asymptomatic individuals at an early stage in the disease process, when treatment is more likely
to be effective (refer to Table 1) and to detect and remove polyps2.
Table 2: Cancer Detected at Screening by Stage 2
Stage
Cancer Detected
Unstaged polyp cancers ( presumed stage A)
16.8%
Dukes Stage A
25.2%
Dukes Stage B
26.0%
Dukes Stage C
25.2%
Dukes Stage D
1.5%
Other Unstaged cancers
5.3%
Cancer is the leading cause of premature death (deaths in those under 75 years) in Camden.
Although overall cancer mortality is only slightly higher than the national average (Directly
Standardised Rate 169.57 compared to 169.42 for England), cancer mortality in men is
significantly higher with a DSR of 208.41 compared to 201.48 for England.
Incidence of bowel cancer in Camden is lower than the national average with a DSR (all
persons) of 41.31 compared to 74.18; this trend is the same for males and females. Mortality
rates from bowel cancer are also lower than the national average with a DSR of 91. (England
DSR 100) http://nww.indicators.ic.nhs.uk/webview/
Evidence has shown that premature deaths from cancer can be reduced through screening
programmes6. However, the uptake of all screening programmes in Camden is below that of
national targets (Table 3).
Camden Bowel Cancer Screening LES/ML June 2012
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Table 3: Bowel Screening Uptake in Camden, compared to national targets and London Average
(March 2012)6
National Target
60%
Camden Uptake
39.86%
London Uptake
39.51%
England Uptake
53%
Uptake of bowel cancer screening varies considerably between GP practices in Camden (7.41%
- 50.99%)7. No practice reaches the national target of 60%. In addition, inequalities can be seen
in bowel screening uptake between the different social groups and ethnic minority populations in
Camden.7
2. The Bowel Cancer Screening Programme in London and Camden
Everyone aged 60 - 69 is currently offered screening for bowel cancer via a FOBT. By the end of
2012 the age range for screening will be increased up to 75 years.
In London, all FOBT kits are distributed from the Programme Hub (“the Hub”) located at St
Mark’s Hospital. The Hub obtains a list of patients eligible for screening from the Central
Registration Database. If a patient does not respond they are sent a further FOBT. If they do not
return the kit after 13 weeks of the original kit being sent they are deemed to be a non-responder
and are next invited to participate in screening in two years if they are still between 60-75 years.
The practice receives a letter confirming their non-return of the FOBT.
If a patient returns the kit, the practice receives a letter confirming the result. Patients receive the
result of their test in a letter within two weeks.
If the result is negative the patient will be re-invited in two years
If the result is positive, the patient is referred to the local Screening Centre at UCLH. The Hub
will send the patient an appointment for assessment at a Specialist Screening Practitioner (SSP)
clinic; the standard for providing this is 14 days. The consequences of the positive test result will
be explained and the patient’s fitness for colonoscopy will be assessed. Colonoscopy takes
place within 14 days of the SSP assessment
If a patient has not responded twice and has been “discharged” from that screening round, they
can request a further FOBT kit be sent to them. The practice can request kits from the Hub on
behalf of their patients. Practices cannot supply the kit themselves; this needs to come from the
Hub so that it can be specifically tracked for failsafe purposes.
3. Aims and objectives of the LES
3.1 Aims
The ultimate aim of this LES is to decrease mortality from bowel cancer in Camden. The specific
aim is to produce a step change increase in the uptake of the NHS bowel cancer screening
programme in Camden so that the national target of 60% uptake is met.
3.2 Objectives
i.
To encourage practices to identify and follow up individuals who have not returned test
kits to encourage them to complete the test.
Camden Bowel Cancer Screening LES/ML June 2012
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ii.
To ensure that practices regularly update bowel screening participation and test results in
their electronic patient records.
4. LES Outline
4.1. LES coordination, training and development
The practice will appoint a named lead for the LES (ideally the existing cancer screening lead). It
is assumed that this person will be primarily responsible for overseeing implementation of the
LES including ensuring information is collected and recorded in a way that allows performance
to be assessed. Please see Appendix 2 for a description of key roles and responsibilities within
the practice
Practices wishing to participate in the LES should complete the Bowel Screening LES
participation Agreement Form (LES Forms 1).
The named Bowel Screening LES lead and another member of the practice staff will attend the
LES launch event. Where this is not possible an in-house session will be arranged.
4.2. Receipt of electronic results for bowel cancer screening
All practices wishing to sign up to the LES for bowel cancer screening must receive results from
the Hub via electronic links. To do so practices will need to apply to the Hub to obtain an
electronic link. See LES Forms 2 for the application form for bowel cancer screening electronic
results messaging.
Practices are expected to record bowel screening test kit results, within two weeks of the
information being sent electronically to the practice from the hub. This data should be entered
into the patient’s record using the following READ codes:
i.
Did not respond - 9Ow2
ii.
Adequately screened normal result – 686A
iii.
Adequately screened abnormal result – 686B
iv.
Bowel cancer detected through screening programme - 9Ow1
v.
Spoilt kit - 6867
4.3. Data and monitoring
Baseline data for uptake of bowel cancer screening (BCSS March 2012) will be provided to the
practice at the start of the LES. This data will be used to validate increases in uptake by practice.
At the outset of the LES, the Hub will on receipt of a GP Request Form for Patient Identifiable
Information (LES Forms 3) provide participating practices with a list of all patients who will be
invited for bowel cancer screening during the next month; these lists will be sent on a monthly
basis arriving no later than the 2nd day of each month. Practices should check that this list is
accurate (search on age criteria – dates will be provided) and any inaccuracies should be
updated through GP Links or reported to the Primary Care Registration Team for updating of
registration details and to the Hub to cancel the invitation.
Uptake reports (unvalidated) will be provided to participating practices on a monthly basis.
These reports will contain unvalidated uptake and a list of patients who have to date not returned
a completed test kit.
Each quarter, a validated report will be sent identifying uptake for the quarter, uptake amongst
patients on whom a further kit has been requested (‘self referrals’) and DNA patients.
Thirteen weeks after the completion of the LES a final report on performance throughout the
year will be supplied to each practice
Patient level data will be supplied by the Hub on a monthly basis to practices participating in the
LES.
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NHS Camden will not receive any patient level data; anonymised data for practice uptake will be
downloaded from the BCSS dataset on a monthly basis and quarterly performance reports will
be received from the Programme Hub.
A full explanation on data and monitoring processes can be found in Appendix 3.
4.4. Promotional activities to raise awareness of bowel cancer screening
Follow up of non-responders through direct contact and requesting of test kits has been proven
to improve uptake for bowel cancer screening in a number of London boroughs. NHS Camden
has commissioned Enhanced Healthcare Services (EHS) to support the LES by contacting
patients and requesting test kits on behalf of practices signing up to the LES. Practices who wish
to delegate such a responsibility will need to complete a data sharing agreement (LES Form 4);
this will enable data sharing between the bowel cancer screening Hub and the practice to
identify true non-responders.
This LES is not prescriptive in stating activities which should be undertaken to increase uptake.
Information on the target age range for bowel cancer screening, barriers to screening and
activities to improve uptake, which the practice may wish to consider, are shown in Appendix 4.
A reference guide for promoting bowel cancer screening can be found in Appendix 5.
Endorsement of the screening programme by a patient’s registered GP/practice has been
proven to improve uptake, particularly amongst rising 60s who are due to receive their first
invitation. A sample endorsement letter is shown in Appendix 6.
5.0 LES Payments
5.1 Overview of payments
Table 5 below summarises the payments attached to each element of the LES, the
data/information that practices are required to submit in order to receive payment and timescales
for these submissions/payments. Note that “per additional patient screened above baseline”
means that practices will be paid at the relevant rate for all patients above the baseline
according to the uptake target met, i.e. not at different rates as uptake improves to higher rates
of payment.
Activity Detail
a. Participation in the
LES
b. Attendance at the
launch event*
c. Providing end of
LES report
a. Increase in uptake
of > 10%
b. Increase in uptake
of > 15%
c.
Increase in uptake
of > 20%
Payment
Administration fee
£200
Increasing Uptake
a. £75 per additional
patient screened above
baseline
b. £125 per additional
patient screened above
baseline
c. £175 per additional
patient screened above
baseline
Payment Schedule
Source of Data
Beginning of LES
LES participation
agreement form signed
and returned and
attendance register at
LES launch event.
One quarter following
the end of LES
Practice-level
uptake
figures obtained from
bowel screening hub.
* Where attendance at the launch event is not possible, a local or in-house session will be
arranged
6. Key contacts
6.1 Public Health
Camden Bowel Cancer Screening LES/ML June 2012
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Maggie luck
Public health Screening Coordinator
Matthew Cruice
Screening Manager – Cancer
For Health Promotion advice and support
Lance Saker
Consultant in Public Health Medicine
GP, Hampstead Group Practice
6.2 Screening Programme Hub
Mark Stewart
Programme Hub Manager
For requesting test kits
Fax
6.3 Registration Team
Vince Divine
NCL Registrations Manager
Fax
020 3317 3667
maggie.luck@nclondon.nhs.uk
020 3317 3828
matthew.cruice@nclondon.nhs.uk
020 3317 3711
lance.saker@nclondon.nhs.uk
020 8869 5268
mark.stewart2@nhs.net
0800 707 6060
020 8869 5281
020 7685 6589
vince.divine@nhs.net
020 7813 8738
References
1 Cancer Research UK. Large Bowel Cancer – UK. June 2006.
2 The NHS Bowel Screening Programme.
Information for Primary Care. {Online}. Available from
http://www.cancerscreening.nhs.uk/bowel/bowel-ipc-booklet.pdf. [Accessed 13th August 2011].
3 Patient.co.uk. Screening and Early Detection of Colorectal Cancer. [Online]
http://www.patient.co.uk/doctor/Early-Detection-Of-Colorectal-Cancer.htm. [ Accessed 30th August 2011].
4 Hewitson P, Glazsiou P, Towler B, et al. Screening for colorectal cancer using the faecal occult blood
test: an update. The Cochrane Database of Systematic Reviews.
5 UK Colorectal Cancer Screening Pilot Group. Results of the first round of a demonstration pilot of
screening for colorectal cancer in the United Kingdom. British Medical Journal, 2004, 329: 133.
6 Public Health Intelligence. North London Cancer Network Profile LEAD1: Colorectal Cancer. Second
edition. June 2011.
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