Guidance

Bowel cancer screening pathway requirements specification

Published 21 June 2021

Applies to England

This document provides an overview of the NHS Bowel Cancer Screening Programme (BCSP), describing what should happen at each stage of the pathway.

It should be read in conjunction with the:

• programme standards
• the programme specific operating model (PSOM)

Local commissioners and providers should also review schedules 2 and 4 of the bowel cancer screening service specification (number 26) held by the NHS England (NHSE) public health commissioning and operations team.

Please also read the general information relevant to all NHS screening programme pathways.

Bowel cancer screening

The NHS offers bowel cancer screening every 2 years to people aged 60 to 74. This age range is being extended, starting from spring 2021 with people aged 56. In future years this will be further extended to different age ranges to meet the commitments of the NHS Long Term Plan.

The purpose of bowel cancer screening is to:

• detect bowel cancer at an early stage when it is easier to treat
• find polyps, which may turn into cancer over time if not removed

The initial test is a kit used at home, sent out by post from regional programme hubs. If the kit result indicates further tests are necessary, people are offered a colonoscopy. Screening colonoscopies are carried out by accredited colonoscopists in local screening centres.

Programme hubs should have United Kingdom Accreditation Service (UKAS) accreditation, and all screening sites undertaking screening colonoscopies should have Joint Advisory Group on GI Endoscopy (JAG) accreditation. New sites should have accreditation in place before starting BCSP lists. Any sites that lose accreditation should be working towards it again to continue screening.

Find out more about bowel cancer screening in the programme overview.

End-to-end pathway

The pathway for bowel cancer screening consists of the following elements.

The dotted boxes and numbered labels show how the different parts of the screening pathway map to the generic pathway themes used in the headings below.

An accessible text-only version of the bowel cancer screening pathway is also available.

1. Before screening test

These requirements relate to making sure that screening is offered to the correct people.

Screening population

Programme hubs must have systems in place to:

• maintain accurate records of the eligible population for screening
• make sure invitations to screening are sent at the right time (every 2 years); this consists of a pre-invitation letter with either a paper copy of or signposting to an online version of the national programme information leaflet
• send out a faecal occult blood test (FOBt) kit 2 weeks after the initial invitation (unless the invitee has contacted the programme to decline screening)
• signpost to or provide information about screening in other formats such as translations or an easy guide, or request information for people in formats such as braille and audio
• signpost to video information about using the FOBt kit with subtitles in other languages and in British Sign Language (BSL)
• use the Bowel Cancer Screening System (BCSS) to maintain clear and accurate records of a person’s screening episode in its entirety

People not eligible for NHS bowel cancer screening include anyone:

• not resident in England
• not registered with a GP practice
• under the eligible age threshold for screening
• who has undergone total removal of the whole bowel

Coverage and uptake

The programme collects data on both coverage and uptake.

Programme hubs should monitor data for:

• coverage standard BCSP-S01
• uptake standard BCSP-SO2 and KPI-4

Coverage

Coverage reports the proportion of eligible people who were screened (adequately participated in FOBt bowel cancer screening) within the reporting period.

Coverage is reported monthly, for a 30-month (2.5 year) period, 6 months in arrears.

Uptake

Uptake reports the proportion of invited people who were screened (adequately participated in FOBt bowel cancer screening).

For standard BCSP-S02, uptake is reported monthly for a 12-month (1-year) period, 6 months in arrears, for all people screened within 6 months of their invitation. For KPI-4, uptake is reported monthly for a 1-month period, 3 months in arrears, for all people screened within the invited screening episode (at time of reporting).

2. Screening test

These requirements relate to the processes of carrying out the screening test (the FOBt kit).

Programme hubs must have systems in place to:

• send out FOBt kits to the invited population at the appropriate time interval
• send out FOBt kits to people who self-refer for screening, or to people who need a replacement or additional test kit
• issue a reminder invitation to people who fail to return a completed test kit after 4 weeks
• provide advice to the public on bowel cancer screening and using the FOBt kit via the free programme helpline on 0800 707 60 60
• process returned kits in accordance with ISO 15189:2012, UKAS accreditation and hub protocols in order to meet test standard BCSP-03: FOBt kit turnaround time
• provide results letters to screening participants within 2 weeks of receiving the kit
• return individuals with a test result of ‘no further tests needed at this time’ to routine recall if they will still be within the eligible age range at the time of next invitation
• refer individuals with a test result of ‘further tests needed’ for a specialist screening practitioner (SSP) clinic appointment, to discuss their test kit result and the need for a diagnostic test (such as colonoscopy)
• make sure the BCSS is updated in an accurate and timely manner to reflect test results and outcomes

3. After screening test (diagnosis)

These requirements relate to the process of following-up screen positive results to get a confirmed result.

A diagnostic test (colonoscopy) is required for people who have a FOBt kit result of ‘further tests needed’ (blood is detected in the sample at a level on or above the screening threshold). Anyone unsuitable for colonoscopy may be offered computed tomographic colonography (CTC).

Programme hubs must have systems in place to monitor data for referral standard BCSP-S06: SSP clinic appointment waiting time

Screening centres must have systems in place to:

• monitor data for:
  • referral standard BCSP-S07: diagnostic procedure waiting time
  • diagnosis/intervention standard BCSP-S08: time to attendance at diagnostic procedure
  • diagnosis/intervention standard BCSP-S11: diagnostic procedure uptake rate
• provide clinic appointments with SSPs who are trained in accordance with SSP education and training requirements to assess fitness for colonoscopy (or other diagnostic test) and discuss the procedure
• make sure individuals offered colonoscopy are fully aware of what the procedure entails (including possible benefits and risks), and accurately document their consent
• dispense bowel preparation medicine and provide advice on usage and dietary requirements ahead of the procedure
• undertake screening colonoscopies in line with programme guidelines on colonoscopy, using screening accredited colonoscopists (guidance on accreditation is available from the Bowel Cancer Screening Accreditation (BCSA) website
• offer computed tomographic colonography (CTC) where an individual is medically unsuitable for colonoscopy
• monitor and validate data for diagnosis/intervention standard BCSP-S05: CTC as a diagnostic procedure
• update the BCSS at the time of colonoscopy or when the CTC report is received
• contact patients the day after colonoscopy to check there are no complications following the procedure and to confirm when to expect results
• manage surveillance of patients who have had significant polyps removed, in accordance with British Society of Gastroenterology guidelines
• make sure pathologists handling specimens from screening colonoscopies follow BCSP guidance on reporting lesions
• monitor data for referral standard BCSP-S09: pathology turnaround time
• make sure all BCSS records are complete and all data is up-to-date, to ensure accurate system reporting of:
  • intervention/treatment standard BCSP-S12: adenoma detection rate (FOBt)
  • intervention/treatment standard BCSP-S13: caecal intubation rate
  • intervention/treatment standard BCSP-14: scope withdrawal time
  • intervention/treatment standard BCSP-15: polyp retrieval rate
• contact every person to offer a face-to-face appointment for their diagnostic test results once histology results have been received (they may opt for a telephone call instead)

4. After screening test (intervention)

These requirements relate to the process of following-up people with a confirmed diagnosis and maximising the overall benefits from screening in terms of the final outcome to the person being screened.

Screening centres must have systems in place to:

• make sure all BCSS records are complete and updated with colonoscopy or other test outcomes, including all diagnostic test details, pathology data and cancer datasets
• refer patients for additional endoscopic tests and or treatment if polyps were unable to be removed at the first screening colonoscopy
• refer individuals with confirmed colorectal cancer to the local multi-disciplinary team (MDT) as quickly as possible
• refer individuals as appropriate who require further investigation and/or treatment for incidental findings
• manage surveillance of patients who have had polyps or bowel cancer removed, in accordance with British Society of Gastroenterology guidelines

Treatment

Treatment of people diagnosed with bowel cancer as a result of screening is managed by local NHS symptomatic services and is not part of the screening pathway. Patients may be referred for further tests and/or treatment for bowel cancer or for other pathology or findings.

Pathway outcome

Programme hubs and screening centres must have systems in place to ensure all BCSS records are complete and up to date, including completing episodes and pathways to ensure the correct recall interval for screening is calculated.