Guidance

[WITHDRAWN] Bowel scope screening: standard operating procedures

Published 20 June 2018

This guidance was withdrawn on 18 January 2021

Bowel scope screening is no longer offered as part of the NHS Bowel Cancer Screening Programme.

1. Implementation

The UK National Screening Committee (UK NSC) recommended the addition of bowel scope screening alongside the existing guaiac faecal occult blood test (gFOBT) following a clinical trial and 11 years of follow-up.

Access to services will inevitably be inequitable until bowel scope screening is fully rolled out nationally. Full national implementation will be achieved when all GP practices have been electronically attached (‘gone live’) and all eligible cohorts are receiving screening invitations. Screening centres can mitigate against inequitable access by clustering together a demographically diverse range of practices for ‘go live’ purposes within a defined geographical area. Practice uptake of FOBT screening also informs the selection of practices to ‘go live’. This results in a mix of live and non-live practices within clinical commissioning groups (CCGs).

NHS England commissions and manages the rollout of bowel scope screening. The Public Health England (PHE) Screening QA Service (SQAS) supports and advises centres on quality and safety. Most centres expand screening capacity by introducing new screening sites. Subsequent sites need an additional approval process, even if they are already FOBT screening sites. SQAS and the national programme team lead this process, which mirrors the original approval process (see appendix 1).

2. Equality and equity

PHE has a statutory duty, under the Health and Social Care Act 2012, to have due regard to the need to reduce health inequalities. Health inequalities are differences in health between people or groups of people that may be considered unfair. Reducing inequalities should mean everyone has the same opportunities to lead a healthy life, no matter where they live or who they are.

Like other public bodies, PHE also has a duty, under the Equality Act 2010, to consider the needs of all individuals in shaping policy and providing services. Guidance on the Equality Act and reducing inequalities in screening can be found on the PHE Screening blog.

Screening providers should:

• address local health inequalities, tailoring and targeting interventions when necessary
• meet the needs of local diverse populations in a culturally sensitive way
• involve service users, reflecting the local community
• exercise high levels of diligence when considering excluding people with protected characteristics from screening, following equality, health inequality and screening guidance
• comply with safeguarding policies
• comply with reasonable adjustments suggested at best interest meetings

Local services can use the NHS England Equality Delivery System and the Department of Health and Social Care Health Assessment Tool to help consider how to improve equality.

2.1 Health promotion

There will be no national campaigns to increase awareness and uptake during the national implementation of bowel scope screening. This is to prevent confusion for anyone who may want to participate but is not registered with a GP practice that is ‘live’.

Screening centres should support local health promotion with individual GP practices that are ‘live’. Wider campaigns can be undertaken in conjunction with commissioners, CCGs and local media in areas where rollout has completed.

Proactive health promotion advice about bowel cancer prevention and bowel cancer screening is part of the role of a screening centre.

3. Bowel scope screening programme

3.1 Population and programme size

64 local screening centres in England provide bowel scope screening alongside FOBT, each covering a minimum 500,000 total population.

Services offer people aged 55 (in their 56th year) a once-only flexible sigmoidoscopy (bowel scope) test. People aged between 55 and their selection date for FOBT can self-refer for bowel scope.

Inclusions

All people aged 55 years are eligible if registered with a GP and resident in England.

People aged between 55 and their selection date for FOBT can self-refer if they are resident in England and registered with a GP practice that has rolled out bowel scope screening.

Exclusions

Individuals are normally excluded from the programme if they:

• are under 55
• have undergone total removal of the large bowel
• are already in an active colonoscopy surveillance programme
• choose to opt out of bowel scope screening
• are clinically unsuitable

People who temporarily opt out will still be invited to undertake FOBt at the age of 60.

Individuals who make an informed decision to permanently opt out from all bowel cancer screening screening, which involves signing a request for no further contact to be made by the NHS bowel cancer screening programme (NHS BCSP) at any time.

3.2 Service delivery

Local bowel scope screening services should be local and convenient to access to encourage people to participate. This supports the care closer to home model of service delivery.

Screening centres should consider potential options for local delivery, including the use of independent treatment centres (ITCs), local community hospitals, mobile screening facilities and local GP health centres, provided these sites:

• are accredited by the Joint Advisory Group on GI Endoscopy (JAG)
• meet all the criteria for bowel scope screening specified within the additional site application form (see appendix 1)

Options may include providing bowel scope screening lists at evenings and weekends as the screening age group will mostly be in employment and may not be able to easily take time off work.

3.3 Screening equipment

The number of endoscopes required to deliver bowel scope depends on the decontamination facilities available to support each list, including concurrent symptomatic lists. Colonoscopes are the likely instrument of choice, given cost considerations and overall versatility within the endoscopy service. The endoscope processor must be able to support the capture of photographic images. The availability of a scope guide is desirable but not essential.

There should be provision of CO₂ for insufflation (the act of blowing something into a body cavity) at all sites where bowel scope screening is provided in accordance with European Guidelines for Quality Assurance of Colorectal Cancer Screening and Diagnosis.

Entonox pain relief should be available at all sites where bowel scope screening is provided, as the procedure will be performed without sedation, unless a decision was made and documented at a best interest meeting about the appropriateness of performing the test with reasonable adjustments.

3.4 Information technology

The Bowel Cancer Screening System (BCSS) identifies and invites eligible people aged 55 years. It also allows participants aged between 55 and their selection date for FOBT screening to self-refer to the programme, if registered with a GP practice in England that has rolled out bowel scope screening.

Subjects who reach the age of 60 are automatically invited into the bowel cancer screening programme unless they have an open episode from bowel scope screening.

The BCSS IT system is used to create the call or recall invitation plans used within the bowel cancer screening programmes across all hubs and screening centres.

BCSS includes functions for:

• maintaining organisation-related information
• managing invitations and appointments
• identifying participants requiring an enema prior to bowel scope screening
• recording test results
• reporting

BCSS supports all elements of the bowel scope screening pathway. To maintain a secure system screening centres are expected to use the latest edition of Internet Explorer.

All staff working within the bowel scope screening programme need to undertake BCSS training to access the system through NHS Digital.

Endoscopists should still use their trust’s IT system for recording the endoscopy procedure to make sure a comprehensive record of the test is documented.

4. Workforce requirements

4.1 Clinical lead

The clinical lead for the screening centre must be a clinician directly involved in the screening service with designated sessions in their job plan to provide managerial support for the bowel cancer screening programmes.

They:

• are responsible for strategic, professional and operational performance, including quality assurance (QA)
• ensure endoscopists within the programme meet all key performance indicators (KPIs) and any underachievement is acted upon
• participate in root cause analysis of adverse incidents

The clinical leads are accountable for ensuring a high-quality effective bowel scope screening programme on behalf of commissioners, delivered in line with agreed protocols. They are also accountable for monitoring screening outcomes in line with national BCSP standards.

4.2 Programme manager

The addition of bowel scope screening to BCSP means there is a need for a dedicated local programme manager who oversees both the FOBT and bowel scope programmes. They should be of appropriate seniority to be accountable and responsible for the management of both programmes.

Programme managers must undertake bowel cancer screening system (BCSS) training provided by NHS Digital.

4.3 Lead specialist screening practitioner (LSSP)

The lead specialist screening practitioner (LSSP) plays a pivotal role in supporting the bowel screening programmes. They act as the clinical expert and manage and educate the clinical team to make sure they are maintaining the key performance indicators (KPIs) required for the services. They develop protocols, guidelines and work instructions for the BCSP quality management system (QMS).

The LSSPs lead clinical audit and benchmarking to improve clinical effectiveness in the pursuit of reduction in colorectal mortality and morbidity.

4.4 Specialist screening practitioner

At least one specialist screening practitioner (SSP) should be present at all times during bowel scope screening sessions unless the screening list is being run by a screening practitioner or assistant screening practitioner. In these cases, the SSP should be available to provide additional support when requested.

The SSP has overall management of the screening list. SSPs manage the discharge of participants with abnormal findings specific to the screening programme pathways and histology sampling.

Screening centres should consider opportunities for developing new models of delivery using screening practitioners (SPs) and assistant screening practitioners (ASPs) with the support of SSPs.

4.5 Screening practitioner

SPs are registered people who have completed the BCSS training but do not have the same access level to the system as SSPs. They may work in a procedure room, input information into the dataset and give support to the participant during their clinical procedure. They can manage participants with non-adenomatous pathology when advancing episodes in BCSS. However, any adenomatous histology must be referred to the SSP to manage.

4.6 Assistant screening practitioner

The ASP supports the workforce required to deliver bowel scope screening. ASPs do not need to be registered practitioners but do require clinical competence in addition to the function of data entry within the procedure room.

ASPs are expected to be able to interact and support participants along the screening pathway in addition to working closely alongside all members of the team.

4.7 Bowel scope screening endoscopist

The screening centre will need to determine the medical, nursing and non-medical endoscopist workforce required to undertake the bowel scope examinations for the local population in order to recruit and train staff. The number of accredited bowel scope screening endoscopists will be determined by the number of screening lists and sites to be covered, with an allowance for study or annual leave.

Endoscopists working alone for evening or weekend sessions (with no medical cover on site) will need local trust clinical governance protocols to acknowledge autonomous practice.

All accredited screening colonoscopists are automatically accredited for bowel scope screening.

4.8 Lead pathologist

The lead pathologist makes sure pathology support for the screening programme service meets BCSP standards. They also ensure pathology results are available in a timely manner for patients who have had a tissue sample taken at colonoscopy and bowel scope and also develop a special interest in bowel cancer pathology.

The pathology laboratory would need to have nominated consultant histopathologists who participate in the BCSP external quality assurance (EQA) scheme to report BCSP samples from both screening programmes.

4.9 Endoscopy workforce

Endoscopy units should look into supporting weekend and evening bowel scope screening lists as well as those during normal working hours. This could require reconfiguration of working hours and a consultation process to review individual employment contracts.

A minimum of 2 healthcare professionals (HCPs) must be present during the bowel scope screening procedure in addition to the endoscopist, whether that individual is a nurse or not. One of the HCPs must be a registered practitioner and all staff must have demonstrable competencies for the role they are undertaking.

4.10 Programme administration staff

The BCSS is set up to allow for ‘multiple booking’ of bowel scope screening appointments, with subsequent cancellations due to lack of response within the time limit. Services should anticipate a large amount of re-booking of appointments and changes to bowel scope screening lists.

Additionally, there is considerable workload for administrative staff who are required to monitor and manage the booking of bowel scope screening appointments and the bowel scope screening lists locally through BCSS. The administration staff need to be competent in using their local hospital patient administration system (PAS) and adhering to policies to ensure the bowel scope screening participants are added to the pathways.

The administration staff are essential in the efficient running of the bowel scope screening service. Setting up and ensuring efficient management of bowel scope screening lists is a demanding administrative workload. It is essential to have an adequate number of administration and bookings staff for the proficient running of the bowel scope screening service.

4.11 Support services

Providers should consider how bowel scope screening increases the workload in related departments including pathology services, colorectal MDT, colorectal surgical, gastroenterology and decontamination units.

Endoscopy reception and shared waiting areas need appropriate staff to meet and greet bowel scope screening participants, especially if services are extended into evenings and weekends.

Evening and weekend bowel scope screening lists need to allow access for appropriate cleaning services without disruption to participants or lists.

Bowel scope screening lists could generate an increase in the number of medical case notes required and would need appropriate resources.

5. Workforce education and training

5.1 Clinical lead

The clinical lead must be an accredited endoscopist with the Screening Assessment and Accreditation System (SAAS).

5.2 Programme manager

The programme manager must undertake the BCSS training provided by NHS Digital. It is recommended that they should have a management qualification which includes capacity and demand management.

5.3 Lead specialist screening practitioner

The LSSP must be a registered healthcare professional who has completed the formal educational programme for screening practitioners. It is recommended that they should have worked previously within a screening programme.

5.4 Specialist screening practitioner

SSPs are registered healthcare professionals who must commence the formal educational programme within a year of starting in post.

If an SSP fails the formal course they should be given additional support to enable them to reach the required course standards. If, after appropriate support has been provided, they still do not reach the required standard, the screening centre should work with the trust’s human resources department to relocate them or terminate their contract. The educational provider will inform the trust of anyone who fails to successfully complete the course. The programme manager should notify the local SQAS team.

SSPs may consider undertaking training as bowel scope screeners. Training must be undertaken within a JAG accredited programme. Health Education England (HEE) has more information about accelerated clinical endoscopist training.

5.5 Screening practitioner

SPs must be registered healthcare professional. They are not required to undertake any formal training courses other than the BCSS training provided by NHS Digital.

5.6 Assistant screening practitioner

ASPs must have an understanding of relevant anatomy, physiology and pathophysiology.

They must complete the national ASP induction and relevant elements of the competency package before starting independent practice (see appendix 2). ASPs must also complete the BCSS training with NHS Digital.

Additional educational courses available at Level 5 (foundation degree level) are desirable but not essential for an ASP to work within the programme.

5.7 Bowel scope screening endoscopists

Bowel scope screening endoscopists must be registered practitioners with independent practice undertaking flexible sigmoidoscopy procedures. Endoscopists cannot train on bowel scope lists unless they are registered with SAAS and have a date for their accreditation assessment.

All endoscopists must undertake the bowel scope screening accreditation assessment process and meet the minimum standards in order to perform bowel scope screening procedures on the screening population. The 2 elements of the bowel scope screening accreditation are:

• multiple choice questions
• clinical practical assessment

Guidance for the accreditation of bowel scope screening endoscopists or becoming a mentor can be found on SAAS.

Endoscopist training can take 18 months to complete, so planning ahead of rollout is essential. HEE supports an accelerated training programme that can train an endoscopist in approximately 7 months.

6. Governance

PHE is responsible for the essential elements of screening programmes that are done once.

These include:

• developing and piloting, to agreed national service specifications, all extensions to existing screening programmes and new screening programmes
• setting and reviewing pathway standards
• reviewing national service specifications and advising on section 7A agreements
• developing education and training strategies
• providing patient information
• determining data sets and management of data, for example, to ensure KPIs are collected
• setting clear specifications for equipment, IT and data
• procuring and supplying the national IT screening management system
• collecting, collating and quality assuring data for screening programmes
• monitoring and analysing implementation of NHS-commissioned screening services
• providing advice on priorities and outcomes for the NHS England mandate and section 7a agreement and leading on detailed provisions
• working with NHS England to optimise coverage
• quality assurance of screening programmes
• public health expertise and advice on screening
• action to optimise access to screening, for example among disadvantaged groups.

NHS England is responsible for:

• commissioning and rolling out the bowel scope screening programme
• contracts with providers based on the national service specification
• performance management of providers

Screening centres are responsible for:

• following local trust governance
• delivery of the service specification
• maintaining PHE QA standards, KPIs and audits

6.1 Confidentiality and security

Basic principles of information governance:

Information about participants is confidential and should only be entrusted to those with a justified need to know.

Integrity of information must be monitored and maintained to make sure it is of good enough quality to use for the purposes it was collected.

All staff should understand their responsibilities and be routinely assessed. Appropriate education and awareness should be provided.

Risk assessment and overall priority planning of organisational activity should take place to make sure there are appropriate and effective information governance controls.

Basic principles of storage and transfer of person-identifiable data

All person-identifiable information should be stored securely and transferred safely and appropriately.

Non-encrypted devices (such as memory sticks and CD-ROMs) should not be used to store or transfer person-identifiable information including photographs or videos files which contain person-identifiable information.

Files, documents or whole systems (including PCs and laptop) containing person-identifiable information must be restricted, with only appropriate staff members being able to access them. Access must be restricted by unique user names and strong passwords.

Emailing and other electronic transfer of person-identifiable information

The sending and receiving of person-identifiable information should be via an approved mechanism, for example via approved email addresses or approved secure file transfer protocol (sFTP) sites. Data transfer should only be carried out where it is legal to do so, appropriate and necessary.

Any person-identifiable information sent via secure e-mail transfer does not require additional protection but any data sent via an insecure route must be encrypted before it is attached to the email. The password to decrypt the data can be sent via the insecure email route as long as it is sent in a totally separate email to the one containing the encrypted data.

The sending of data to NHS.net is considered secure for file transfer and does not need the content to be encrypted. Any e-mail system outside of the NHS, such as Hotmail or Gmail or any other email address supplied via a non-NHS route is considered insecure. If you are sending to or receiving from such addresses then the data being sent must be encrypted.

See encryption guide for NHSmail.

7. Accommodation

7.1 Clinic endoscopy rooms

You should consider available lighting and patient privacy in any room used for bowel scope screening. Ideally, the room should allow for subdued lighting with good blackout blinds on windows because endoscopic procedures require control over the level of lighting during scoping.

Oxygen and suction equipment must be available in the event of any adverse event. CO₂ insufflation equipment and entonox should be present.

7.2 Screening office

Offices should be secure and large enough to accommodate appropriate staffing levels, office equipment and administrative paperwork. Security is vital as the office will contain patient identifiable data.

8. Screening pathway

The screening procedure is divided into the following stages:

1. Identification.
2. Demand and capacity.
3. Invitation process.
4. Bowel preparation.
5. Consent.
6. Procedure.
7. Histology sampling.
8. Participant discharge.

8.1 Identification

Participants are identified by BCSS from GP practices that are ‘live’ to deliver bowel scope screening. They are selected by birth date (55 years plus 2 months), not gender. Therefore bowel scope screening cannot be delivered on single sex lists.

8.2 Demand and capacity

Screening centres must plan capacity to screen all their eligible population. However, as the response rate is unknown, the number of bowel scope screening lists required is unknown. Modelling should reflect local knowledge of FOBT programme uptake. If this is unknown, centres should model a range of uptakes between 30% and 60% to cover best and worst case scenarios for capacity planning.

The screening centre endoscopy service must be able to provide a flexible service and provide capacity to meet any unexpected increase in demand.

Within the current FOBT programme, screening centres only see individuals who require further investigations (approximately 2%). Bowel scope screening invitations are sent to all individuals in the eligible age range.

The initial estimates of demand for bowel scope screening were based on numbers of people aged 55 years, which equated to 1% of the total population. However, the proportion in some areas could be as high as 1.6%. In addition, opt-in rates for people aged 56 to 59 are unknown.

The national programme office can provide each screening centre with the number of people aged 55 by GP practice over a 2-year period.

Calculating potential numbers

In an area with a population of 500,000 and assuming that 1.6% of those are aged 55 (highest estimate), there will be:

• 8,000 bowel scope screening invitations per year
• 160 bowel scope screening invitations per week

Assuming an uptake rate of 50%, this will require:

• 8 bowel scope screening lists (80 people) per week (10 examinations on a bowel scope screening list)

Up to 5% of people examined are expected to be referred for a BCSP colonoscopy.

You may need additional SSP pre-assessment clinic slots for some of those people. These can be combined with BCSP participants and lists. For a population of 500,000 people there would need to be 4 additional colonoscopy slots per week (1 BCSP list).

All bowel scope screening lists should be planned at least 8 weeks in advance to ensure the invitation timeline can be delivered - see appendix 3. The screening centre administration team must upload the list availability on BCSS.

A template to help screening centres plan capacity and demand for bowel scope screening is available. The screening centre should use a demand and capacity plan to inform the roll-out of bowel scope screening. This should identify the order in which each GP practice will ‘go live’. The screening centre is responsible for attaching the GP practices in accordance with the roll-out plan. Before attaching new GP practices, screening centres should gain support from their local SQAS team and NHS England commissioners. Once the GP practice is attached to BCSS, it should not be moved without permission from the NHS England commissioner and SQAS.

Providers should roll out bowel scope screening based on the trajectory agreed with their commissioners.

8.3 Invitation process

Generation

The screening centre creates bowel scope screening lists on BCSS. There must be enough appointments across the lists in the week to appoint all participants due to be invited. This will mean more than one appointment per time slot. Due to the predicted uptake rate (between 30% and 55%) this number will inevitably reduce during the 8 weeks before the appointment as participants decline.

The screening centre administrator will generate invitations for each site on a daily or weekly basis. BCSS appoints participants into each slot automatically. The oldest participant will be appointed first. BCSS selects participants by birth date, not gender, so single sex lists cannot be accommodated.

Screening centres must make sure bowel scope screening lists are always available. It is not appropriate to cancel bowel scope screening appointments that have been offered to individuals. In extreme circumstances where this does occur, centres must complete and submit an AVI to SQAS.

Pre-invitation

BCSS automatically generates the pre-invitation letter 8 weeks before the participant’s appointment date. Letters are produced and printed by the hubs.

Invitation

Six weeks before the appointment the BCSS automatically generates the invitation letter. The hub processes and prints the letter which will contain the time, date and location of the appointment and a response slip. A leaflet is also included to help the individual decide whether to participate in bowel scope screening. If the participant chooses to take part they must either return the provided response slip or ring the hub to confirm their wish to take part.

Text reminders should be used to increase uptake, if it is an acceptable local trust policy.

Screening centres should provide the hub with an up to date map of where the screening will take place. It is also recommended that they should provide information about parking charges and alternative methods of transport to the screening location are provided to encourage participation.

Self-referrals

Individuals aged 55 to 59 years and registered with a GP practice which is currently ‘live’ for bowel scope screening can self-refer (opt in) by contacting the hub for an appointment.

In order to be eligible to self-refer, the individual should:

• not have a bowel scope screening invitation due date
• have no previous bowel scope screening episode within the programme
• not be on surveillance or have further appointments pending from symptomatic endoscopy

The hub which will arrange an appointment no less than 5 days in the future. This is to enable time for the appropriate correspondence to be delivered and the enema to be posted by the enema supplier. A shorter interval is possible. However, the potential participant would have to collect a trust prescribed enema from the endoscopy unit or make arrangements to receive an enema on arrival if the service can accommodate this.

Hubs

Programme hubs will:

• send out pre-invitations, invitation letters, confirmation packs and reminder letters
• manage bowel scope screening appointments booking and re-booking by participants either by post or telephone
• provide a telephone helpline for participants to answer questions and queries related to suitability assessment with SSP support from screening centres
• receive and manage self-referral enquiries

Participant choice

Individuals can choose to have bowel scope screening in another centre that may be more conveniently located for them. This gives individuals greater access to screening and increases uptake rates.

Bowel scope screening is funded on a cost per case basis. The screening centre invoices NHS England for the actual number of procedures delivered, so it is not detrimental to a screening centre to accept a participant from another area.

It is not acceptable to discourage participants from out of area from participating in the programme if they wish to do so and belong to a GP practice that is ‘live’ for bowel scope screening.

Appointments and re-booking

Participants can contact the hub to accept, change, or decline their appointment. Hub staff can offer another appointment for up to 8 weeks in the future. For appointments, more than 8 weeks in advance participants need to contact the hub again nearer the time.

Suitability

All potential participants are presumed suitable for bowel scope screening. A list of contraindications is sent out with the invitation. These include:

• total colectomy or colostomy
• cardiac surgery in the previous 3 months
• exercise tolerance less than 100 yards due to dyspneoa
• active inflammatory bowel disease

Other special considerations may be needed for some participants, for example, due to:

• previous colorectal cancer
• myocardial infarction in previous 6 months
• renal dialysis
• anticoagulant therapy
• having additional care needs

Suitability queries need to be captured on BCSS to progress the patient’s episode. People who cannot consent for themselves will require the screening centre to arrange a best interest meeting, with an Independent Mental Capacity Advocate (IMCA) to ensure the person is supported an their best interest considered and documented. At this time reasonable adjustments should be considered and accommodated if appropriate.

People may contact the hub to question their suitability to participate. The BCSS has a module to help hub staff answer these questions.

If the hub cannot resolve the query they can escalate it to the screening centre. Suitability requests appear on the front page menu of BCSS. The screening centre needs to identify regular time slots within the SSP’s workload to action suitability queries in a timely manner to prevent delays in the patient pathway. The outcomes of the suitability queries need to be captured on BCSS to progress the patient’s episode.

All suitability queries must be resolved before the participant progresses to their appointment. This might mean the appointment has to be rescheduled.

Reminder letter

All invited people who do not respond are sent a reminder letter by the hub 4 weeks before their bowel scope appointment due date.

Management of lists

From the time that the hub sends out the pre-invitation letters, the administrators in the screening centre will manipulate the bowel scope screening lists to achieve the optimal number of participants attending. This optimal number may vary between services but is usually between 10 and 12 people in a 4-hour clinical session. The administrators will need to rearrange some appointments, remove empty appointments and create new appointments to achieve this. Shorter sessions can be run but should reflect the optimal number of participants for the time of the session, for example, 20 mins per participant.

Confirmation of lists

Two weeks before the appointment date, the screening centre will confirm the bowel scope screening list. Any participants who have not responded to their invitation are automatically cancelled. Documentation for the appointment is produced. Enemas are dispatched by a third party provider.

The hub sends a letter to each participant who agrees to attend confirming the time, date and location of their appointment, a map with the screening centre’s contact details and the participant-specific consent form.

The enema is dispatched from a separate distribution centre following notification of the participant’s name and address by the hub.

Non-respondent participants will receive a letter informing them that their appointment has been cancelled because they did not accept their invitation. Their episode will be closed and their GP informed. If the participant changes their mind they can contact the hub which will provide a new appointment if they are still eligible.

Any unused slots on a bowel scope list 2 weeks before the appointment date can be given back to the symptomatic service to ensure efficiency and capacity is not lost. It is advisable to group all bowel scope participants together to release screening centre staff from the list.

Text messaging

Reminder text messages may be used in accordance with the local trust guidelines. Text messages should only be sent to participants who have accepted their bowel scope screening appointments and provided a mobile telephone number.

8.4 Bowel preparation

Two weeks before the procedure the hub instructs a third party provider to send out an enema in the post for the participant to administer at home. Instructions for administration are included with the enema and participants are advised to use the enema 1 hour before their appointment time.

If on arrival for the procedure, the participant says the enema has been unsuccessful and this is before the endoscopy has been inserted, you must give the participant the option of an additional (second) enema in the endoscopy unit. The enema used in the endoscopy department should be the local trust formulary enema of choice and given in accordance with local patient group directives. This should be administered rectally or if found to be unsatisfactory during the bowel scope procedure, administered via the endoscope.

After the scope has been inserted and the procedure started, the administration of a second enema is a clinical decision by the endoscopist with the consent of the participant.

If the bowel preparation remains poor, no further enemas should be given and the endoscopist should perform as accurate and complete an examination as possible within the boundaries of safety, comfort and time. In these circumstances, if nothing is found, it should be made clear to the participant that ‘as far as was seen, the test was negative to the limit of the examination’. This should be recorded in the episode notes.

Admission administration

The administration team admits the participant on to the hospital PAS to show arrival in the department.

The dataset on BCSS for bowel scope screening is similar to the current screening colonoscopy investigation dataset. The SSP/SP or ASP will record the participant’s attendance for the bowel scope screening procedure and advance the episode to start data collection. The SSP/SP/ASP will complete the investigation dataset for each participant in live time.

8.5 Consent

The information leaflet sent to every participant from the hub has details about the potential benefits and risks of the screening procedure. This enables participants to make an informed choice about whether or not to accept the screening invitation. Participants are also sent a consent form they are asked to bring to their appointment. If they do not remember to bring it along to their appointment another copy can be printed from BCSS.

Consent form 4

If a participant lacks the capacity to make a decision for themselves any decision must be made in their best interest. A best interest meeting should be arranged by the screening centre with an IMCA to ensure that the test is appropriate for the individual and reasonable adjustments considered. A trust consent form 4 should be completed in accordance with local policy.

A participant is unable to make a decision if they cannot do one or more of the following:

• understand the information given to them that is relevant to the decision
• retain that information long enough to be able to make the decision
• use or weigh up the information as part of the decision-making process
• communicate their decision – this could be by talking or using sign language and includes simple muscle movements such as blinking an eye or squeezing a hand

A participant’s capacity to consent may be temporality affected by factors such as confusion, panic, shock, fatigue, pain or medication. However, the existence of such factors should not lead to an automatic assumption that they do not have capacity to consent.

No one is able to give consent to the procedure on behalf of a participant who lacks capacity unless they have been authorised to do so under a medical/healthcare lasting power of attorney.

Declined or withdrawn consent

A participant with capacity is entitled to withdraw consent at any time, including during the procedure. If possible, when a participant objects during the procedure it is good practice for the endoscopist to stop the procedure, establish their concerns and explain the consequences of not completing the procedure. Sometimes the objection may be due to pain, not withdrawal of consent. In these circumstances, appropriate reassurance and the offer of entonox may enable the endoscopist to continue with the participant’s consent.

If the participant continues to withdraw consent the procedure must be stopped immediately. If a participant with capacity makes a voluntary and appropriately informed decision to refuse the procedure their decision must be respected.

8.6 Procedure

The bowel scope procedure is a flexible sigmoidoscopy which examines the rectum and lower sigmoid colon and should not go past the splenic flexure.

The comfort of participants during the bowel scope screening procedure is paramount. The endoscopist should only examine the colon as far as their comfort allows.

The bowel scope screening procedure time is expected to be between 5 and 10 minutes.

Repeat examinations are not available within bowel scope screening. This includes instances where the examination is incomplete.

The bowel scope screening procedure is performed unsedated with an option of entonox for pain relief, unless a reasonable adjustment at a best interest meeting has been made. Entonox administration must be available and used in line with local trust policy for safe drug administration. Contraindications and potential side effects should be discussed and suitability assessed before the procedure. Entonox requires prescribing or a specific patient group directive for safe administration.

All endoscopy units where bowel scope screening is undertaken must have CO₂ available. The use of CO₂ insufflation will also improve participant comfort. Comfort scores must be assessed and recorded throughout the procedure and documented following a consensus agreement between the patient, the endoscopy team and the endoscopist.

Recovery space with oxygen and suction must be available in the event of any adverse event.

Participants can be discharged as soon as they feel comfortable by a member of the clinical bowel screening team or the clinical endoscopy team.

8.7 Histology sampling

Patients who have some form of intervention which requires pathology analysis will be informed of the turnaround time for their results and how they will be contacted to deliver the findings and results. Histology sampling in endoscopy should be performed in accordance with local trust policies and protocols. The process of ‘right test, right patient, and right result’ must be part of this policy.

Bowel scope screening requires sufficient pathology capacity. Pathology reporting must be standardised within the trust with clear pathways and protocols for the management of pathology specimens, especially if screening is performed on peripheral sites.

Transportation of specimens must be safely and securely carried out by authorised personnel only and be delivered within a timely manner.

Pathology results must be available within one week of the specimen’s receipt within the laboratory.

Data collection

The SSP/SP/ASP completes the investigation dataset in the procedure room in live time.

At the end of the procedure where no pathology or referral to colonoscopy has occurred, the participant’s discharge letter will be produced. This can be given to the participant along with their endoscopy report by any clinical team member. A right results pathway must be agreed and in place.

Where pathology has been taken, the data will need to be entered on to BCSS when the histology report is received. The SSP can enter all pathology data. The SP can enter all histology but cannot progress the episode to book an SSP appointment for counselling for a screening colonoscopy. This must be undertaken by an SSP. The ASP cannot enter the histology results where the outcome is progression to screening colonoscopy.

8.8 Participant discharge

At the end of the bowel scope screening procedure, it will be clear that some participants might need to return for a full colonoscopy examination. These people must be seen by an SSP who can counsel and discharge them appropriately.

Other participants may need counselling before discharge, for example, if they have had small polyps removed. These participants should also be seen by the SSP before discharge. SPs and ASPs can discharge participants with normal incidental findings, such as haemorrhoids, diverticulitis and hyperplastic polyps.

All participants should have an agreed discharge plan including contact arrangements for any pending results.

Participants who are subject to biopsy or polyp removal, or referred for colonoscopy in the screening programme, should be added to the cancer waiting times database of the local trust. If they are later proven to have cancer, they should receive their first treatment within 62 days of their attendance for a bowel scope screening procedure – day 0 being the date of the bowel scope procedure.

Participants requiring a screening colonoscopy or an SSP appointment should be offered this appointment within 2 weeks of their bowel scope screening procedure.

9. Potential results

Normal result

Participants with normal results are discharged from bowel scope screening with a discharge letter and a copy of their endoscopy report. A copy of their endoscopy report will be sent to their GP with a copy of the BCSS letter.

Participants are sent a FOBT kit at age 60 years to join the bowel cancer screening programme. It is best practice to highlight signs and symptoms that the participant should be aware of. If any are noted, they should be encouraged to see their GP as soon as possible.

Abnormal result at bowel scope

Abnormal results include:

• stricture
• polyp surgical excision
• polyp EMR
• anal lesion
• diverticulitis
• non-neoplastic pathology
• inflammatory bowel disease

Participants with abnormal results such as those above should be referred to the symptomatic service for ongoing management outside the screening programme.

Cancer or suspected cancer detected

Photographs, multiple biopsies and a tattoo of the lesion are recommended if participants are found to have cancer or suspected cancer at bowel scope.

High risk polyp identified

For participants found to have polyps/s ≥10mm in size it is recommended that photographs are taken but the polyps are not removed. Participants should be followed up on surveillance in line with the BSG guidelines.

Participants could still be in bowel scope surveillance at the age of 60 years when they would normally be sent a FOBT kit. However, as they are still in a surveillance programme, it would need to be individually calculated as to when this is offered.

Intermediate risk polyp identified

For participants found to have polyp(s) <10mm in size it is recommended that photographs are taken and polypectomy is performed on these polyps at the bowel scope procedure.

If the endoscopist is confident that a polyp is not an adenoma (for example an unequivocal hyperplastic polyp in the rectum), it need not be removed or biopsied and this can be recorded in the investigation dataset.

In exceptional cases where it is evident that the participant has many adenomatous polyps, a colonoscopy should be offered within 2 weeks to perform removal.

Low risk polyp identified

Participants who are found to have 1 or 2 adenomas less than 10mm are classified as low risk and therefore may be discharged from bowel scope screening and enter the FOBT programme at age 60 years. BCSS will close this episode and identify the outcome as an abnormal result.

9.1 Outcomes and surveillance

Cancer or suspected cancer detection

Participants with cancer or suspected cancer detection at bowel scope should be referred to the colorectal cancer multiple disciplinary team meeting in the symptomatic service.

High risk polyp identification

Participants found to be in the high risk category will require one-year colonoscopy surveillance as per the BSG guidelines.

Participants could still be in bowel scope surveillance at the age of 60 years when they would normally be sent a FOBT kit. However, as they are still in a surveillance programme, it would need to be individually calculated as to when this is offered.

Intermediate risk polyp identification

The index bowel scope procedure findings should be added to the colonoscopy dataset to give a cumulative polyp count and size. This may dictate a change in the surveillance pathway to high risk.

Participants could still be in bowel scope surveillance at the age of 60 years when they would normally be sent as FOBt kit. However, as they are still in a surveillance programme, it would need to be individually calculated as to when this is offered.

Low risk polyp identification at bowel scope

The following patients should be referred for colonoscopy:

• any patient with a polyp ≥10mm
• any patient with a histological report showing:
  • 3 or more adenomas
  • an adenoma with villous or tubulovillous component
  • an adenoma with high-grade neoplasia (dysplasia)

• patients with 20 or more polyps, which are ≥3mm, hyperplastic in appearance and above the distal rectum

• any patient with suspected adenomas, which fit the criteria for removal, but where this may not be appropriate at the initial flexible sigmoidoscopy screening procedure, such as those:
  • taking warfarin anti-coagulant or antiplatelet therapy (lesions, such as cancers may be biopsied but polyps should not)
  • taking direct oral anticoagulant (DOACs) - biopsies should not be taken
  • intolerant of the procedure or experiencing discomfort
  • with multiple (>6) suspected adenomas
  • at risk of Variant Creutzfeldt-Jakob disease (vCJD)
  • with a polyp which is technically difficult to remove, for example, due to poor access, in an unstable position, or recurrence in a previous polypectomy scar

Adenomas will be combined from all endoscopy examinations to determine appropriate surveillance interval.

Any polyp not retrieved is assumed to be an adenoma.

Hyperplastic-looking polyps < 5mm in rectoigmoid area need not be removed if the endoscopist is confident they are safe to leave in situ.

9.2 Endpoint of programme

Active inclusion in the bowel scope screening programme ends when a participant is discharged or handed over to symptomatic service for ongoing management.

10. Pathway standards, risk management and quality assurance

All screening programme services must monitor performance against the pathway standards for the bowel cancer screening programme. All bowel scope endoscopists must achieve an adenoma detection rate of 6.8% to meet the minimum standard. SQAS works with screening centres to support endoscopists who are not reaching the minimum standard so they find more adenomas and increase their ADR.

SQAS uses a variety of approaches to raise individual ADRs, including:

• regular monitoring of ADR data and sharing this information with screening centre clinical directors
• requesting action plans from screening centre clinical directors for endoscopists who are not reaching the minimum standard
• workshops that help endoscopists understand how to improve their ADR (tips include taking longer to examine the bowel and withdraw the scope)

Successful interventions in action plans to improve ADRs include:

• regular sharing and discussion of endoscopists’ key performance indicators with comparisons to other endoscopists’ data
• mentors or clinical directors observing endoscopists’ bowel scope procedure lists so they can pass on advice and support
• bowel scope endoscopists observing screening colonoscopy lists (within the BCSP) to appreciate the lengths colonoscopists go to in order to find adenomas and polyps
• further training for particular elements of practice such as polypectomy (the technique used to remove polyps)

Following action plans and interventions, most endoscopists performed above the minimum ADR standard, with many performing above the national average.

To continue this improvement, we expect screening centre clinical directors to monitor the ADR performance of bowel scope screening endoscopists regularly. SQAS will continue to support this process.

Action plans should be agreed and submitted to SQAS for individuals whose ADR is below the minimum standard. These plans should detail the interventions to improve the clinician’s performance.

10.1 Quality assurance

Quality assurance (QA) is in accordance with the programme specific operating model (PSOM) for QA of the NHS bowel cancer screening programmes. This should be read in conjunction with the ‘Operating Model for PHE Screening Quality Assurance Service: 2015/16 to 2017/18’ and the relevant SQAS generic standard operating procedure documents.

The provider must ensure the ADR is monitored and made available for review by commissioners and SQAS.

10.2 Managing incidents

Incidents should be managed as per national guidelines.

Managing safety and serious incidents

Safety and serious incidents should be managed as per national guidelines.