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Pressures mount in BowelScreen

Exclusive documents obtained by this newspaper under Freedom of Information legislation have revealed that the National Bowel Screening Programme (BowelScreen) has instigated “short-term screening invitation pauses” and engaged a private contractor in a bid to tackle lengthening waiting times.

Moreover, the issue of waiting times has affected the accreditation status of screening units under the UK Joint Advisory Group on GI Endoscopy (JAG) quality process. As a result, an Ireland-specific JAG accreditation programme has been developed, the Medical Independent (MI) understands.

A draft memorandum of understanding (MoU) between the National Screening Service (NSS) and individual units, dated 2018, refers to an obligation on contracted hospitals to “maintain NHS Joint Advisory Group on Gastroenterology or JAG Ireland accreditation including the completion of twice yearly GRS Ireland Census returns”.

The 14 units participating in BowelScreen were JAG-accredited when contracted to provide endoscopy services for the screening Programme, according to a HSE spokesperson. They added that 12 of the units “are currently JAG-accredited”.  

University Hospital Galway and Mercy University Hospital, Cork lost their accreditation in 2016 because of waiting list issues, the HSE confirmed.

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University Hospital Galway

However, the HSE’s spokesperson commented: “Whilst attending the British Society of Gastroenterology (BSG) in 2016, BowelScreen sought the opinion of their (BSG) screening experts on this matter. They were informed that the BSG had never suspended a JAG-accredited screening unit solely because of a breach in waiting times.  The BowelScreen Clinical Advisory Group took this on board and adopted a similar approach. Both units continue to provide endoscopy services for BowelScreen.”

A spokesperson for the Saolta University Health Care Group said two of the four hospitals in the Group involved in BowelScreen “have had their accreditation suspended because of waiting list issues”, namely University Hospital Galway and Letterkenny University Hospital. Saolta’s spokesperson said it “should be noted that only three hospitals in the country have been able to retain their JAG accreditation for similar reasons. As a consequence JAG have recently announced an Ireland-specific accreditation programme.”

There are plans for provision of an extra endoscopy room at University Hospital Galway and additional sessions. “However, until a new purpose-built endoscopy unit is constructed in Merlin Park, keeping up with demand will be an ongoing issue,” according to the spokesperson.

“Despite the capacity limitations, we are able to schedule urgent procedures within four-to-six weeks in the main. Routine endoscopy wait is on average 12 months. The surveillance endoscopy wait is at least one year.”

Hundreds of cancers detected through BowelScreen

On average, more than 2,500 people are diagnosed with bowel cancer each year and over 1,000 lives lost. However, the screening Programme has meant that the disease is now more preventable and treatable.

BowelScreen was launched in October 2012 with the aim of offering free screening to men and women aged 55-to-74, on a two-yearly cycle.

The first round was carried out over approximately three years from 22 October 2012 to 31 December 2015, starting with men and women aged 60-to-69.

According to screening statistics for the first screening round, BowelScreen invited 488,628 people for screening and 196,238 people took up the invitation, resulting in a screening uptake rate of 40.2 per cent (uptake in females was 44.1 per cent compared to 36.4 per cent for males).

Some 8,062 people attended for a colonoscopy and 521 cancers were detected, giving an overall cancer detection rate of 2.65 per 1,000 people screened.

There were 355 colon cancers, 159 rectal cancers and seven cases of cancer where the site was unconfirmed. Over 71 per cent of all cancers detected were stage I or II, and approximately 13,000 pre-cancerous adenomas were removed.

In April 2018, updated statistics showed the Programme had detected 718 cancers and removed almost 19,000 pre-cancerous growths. However, fewer than 40 per cent of eligible people had availed of BowelScreen in the most recent screening round.

Falling short

At least 90 per cent of BowelScreen clients with a positive faecal immunochemical test (FIT) result should be offered a colonoscopy within a four-week timeframe, according to official policy. However, many units are falling far short of achieving this due to lack of capacity.

A NSS BowelScreen Programme Status Update paper dated September 2017, which was prepared for a meeting with the Department of Health, warned that increasing numbers of patients were “being treated within a six-week wait, or beyond”.

Short-term invite suspension was being used “sparingly”, as it meant “patient screening is delayed and some geographical areas may not be screened in the two-year round”.  However, a positive development was that the NSS now had the ability to move monies around the system to “incentivise units that may be in a position to provide more capacity to the Programme”, following an agreement with the HSE Chief Financial Officer.

A HSE spokesperson told MI that “all screening units are paused at various intervals”, which they described as “normal and necessary for a number of reasons”.

“BowelScreen manages invitations to participate in the Programme at both a macro and micro level. This is to ensure that patient throughput in affiliated endoscopy units is in line with each unit’s capacity,” continued the spokesperson.

“Capacity may be impacted by seasonal factors, staff on annual leave, etc, or ad hoc factors, for example, a peak in the number of referrals going to the unit, adverse weather conditions, which may result in a list being cancelled etc. BowelScreen endeavours to manage referrals on a consistent and regular basis and monitors invitation numbers closely to achieve this.”

A revised BowelScreen Programme Status Update paper, from November 2017, outlined that the second screening round of two years commenced on 1 January 2016. As with the first round, which started in late 2012, it targeted men and women aged 60-69.

“As of 31 August 2017, 465,970 people have been invited. At the commencement of round two, a participation target for those invited of 42 per cent was agreed, rising to 45 per cent in 2017. By the end of September 2017, an uptake of 39.7 per cent up to the end of June 2017 was reported. Among those that required a FIT kit, 92.3 per cent took the test and returned the kit. Of those returned tests, 3.6 per cent were classified as not normal, which is in line with modelled expectations regarding demand for screening colonoscopies. The long-term target uptake for the Programme is a minimum greater than or equal to 50 per cent, with an achievable stretch target of 60 per cent.

“From January 2016 to August 2017, the Programme completed 2,791 colonoscopies (2,172 index (post screen) colonoscopies and 619 repeat surveillance colonoscopies), against a forecast based on MoU contracted levels of 2,690 colonoscopies. That means the units have performed 101 colonoscopies year-to-date in excess of the MoU figure.”

But despite significant work being undertaken in units, increasing numbers of patients are facing waits beyond the mandated four-week maximum period. According to the BowelScreen Status Update Paper (November 2017), some 74.53 per cent of patients were scheduled for colonoscopy in 20 working days or less in January 2017, and this declined to 32.76 per cent by August that year.

Moreover, the percentage of patients waiting over 30 working days grew substantially from 9.91 per cent in January 2017 to 40.96 per cent in August 2017.

“It is important to note that all screening colonoscopies are classified as urgent, as agreed with the HSE Acute Hospitals Division,” outlined the report. “Therefore, cases where KPIs are not met for colonoscopies that originate from screening should be included in all reports on compliance with the colonoscopy KPIs more broadly.”

Units ‘worthy of note’

The Status Update paper of September 2017 provided a briefing on units “worthy of note for their particular importance to Programme delivery”.

The unit at Wexford General Hospital had “asked for invitations to be paused, due to insufficient capacity locally”. The NSS had contracted UK company Medinet to carry out procedures over four weekends starting at Wexford in August (2017), and, as a result, all waiting patients had been cleared by the end of that month. The screening Programme had offered the hospital additional sessions with Medinet and “these are being considered locally”. The paper noted that “this conversation has only been supported by the agreement of appropriate and timely financial flows since July 2017”.

All appointments at Sligo University Hospital were fully booked until October and the service was under “significant pressure”, outlined the paper. The screening Programme placed a “temporary hold on their invites for a two-week period, but this will not resolve underlying issues. Given that services are provided by a single clinician, the Programme is engaging with the unit to secure additional capacity.”

At South Tipperary General Hospital (STGH), Clonmel, the situation described was of particular concern. The paper stated that a letter was received notifying of intention to withdraw, citing funding issues. “The unit cited a total of €770,000 that should have been received by the unit from the BowelScreen Programme over a number of years, but has never been invested/used in the local endoscopy unit”.

The Programme team had entered discussions with local management regarding additional lists over and above the MoU requirement. “This has been received positively and follow-up conversations will take place in the coming days.” It was not possible to use an insourced private provider as an alternative source of capacity due to the “environment” and there was no other local service to which patients could be diverted.

On STGH, a spokesperson for the South/South West Hospital Group told MI: “Management at South Tipperary General Hospital can confirm that it has never informed BowelScreen that it was withdrawing from this screening programme. The hospital is managing routine colonoscopies effectively and are performing to targets set out nationally.” The Group spokesperson said it had no comment on the issue of funding allegedly not received by the STGH endoscopy unit.

The service at Ennis Hospital was being provided by a long-term locum, with ongoing efforts to secure “additional sustainable capacity”.

Meanwhile, St Vincent’s University Hospital, Dublin, was not meeting the waiting time standard, but a proposal had been received to increase capacity. “This is supported in principle by the Programme and can be funded only as a result of the agreement of financial flows between the NSS and units.”

Connolly Hospital, Blanchardstown, a strong performer in respect of the BowelScreen waiting target, had the potential to expand capacity, noted the report. The Programme team was “seeking to enter negotiations to procure additional capacity… the Programme is also working to re-allocate patients from the midlands and SJH [St James’s Hospital] to this site.”

According to the HSE, BowelScreen engaged the services of Medinet for 10 weekends in 2017 and for five weekends to-date in 2018. “A number of private providers were appointed to a National Framework Panel of the HSE for the Provision of Contingency Endoscopy Services in support of the BowelScreen Programme in 2014. The services sought under this framework are on an as-required basis only. Service costs are deemed commercially sensitive.”

Despite screening invitation pauses and the contracting of private companies, recent statistics show that demand is continuing to outstrip capacity in many units.

From 1 January to 31 May 2018, just over half of patients (53.18 per cent) were scheduled within 20 working days, with marked variances between units.

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South Tipperary General Hospital

Age expansion

According to the National Cancer Strategy 2017-2026, “efforts will continue to increase [BowelScreen] uptake rates, including addressing the lower uptake rate among men when compared to women. Evidence supports the extension of bowel cancer screening to the full population aged between 55 and 74 years.”

But age expansion is controversial given that a significant investment in endoscopy services is required to meet current demand.

In correspondence seen by MI, the then Head of Screening at the NSS Mr Charles O’Hanlon informed other HSE stakeholders in August 2017 that he had “reminded” the Department of Health about “the need for clarity on the interpretation of the 2021 target for BowelScreen between two views (1) endoscopy capacity must be in place for a 2021 roll-out of age extension or (2) age extension must be rolled out by 2021. They have confirmed they will provide a response. I have reminded them of the unworkable being option (2), so I remain hopeful they will interpret that as (1).”

A Department spokesperson informed MI: “It is envisaged that the age extension to the BowelScreen Programme will commence on a phased basis from 2021.”

BowelScreen colonoscopies and urgent colonoscopies outside the screening programme must be accorded equivalence in respect of urgency, according to HSE policy.

Following a meeting late last year between the Department and HSE, the former was asked to revert with “concrete plans to address the clinical prioritisation issue in respect of colonoscopies coming through the National Screening Service’s BowelScreen Programme”.

Last December, an internal HSE email from an official in the Acute Hospitals Division to the HSE Director of Health and Wellbeing Dr Stephanie O’Keeffe, stated that a review of waiting times across BowelScreen and urgent colonoscopy breaches was conducted and, on review of the available data, it was “not possible to determine if one cohort are prioritised over the other”.

“It was determined that both streams are competing for the same limited resources and this is impacting on waiting times. To address this capacity deficit, the endoscopy programme has conducted a demand capacity exercise, which resulted in an action plan, including costs to address current demands. The demand capacity study has shown that at least 109 additional endoscopy sessions every week are required to maintain current waiting times, keep surveillance or planned procedures up-to-date and allow BowelScreen needs to be met (one session = half day). Currently, 106 sessions are potentially available in endoscopy units, subject to funding being made available. The recurring cost of funding these sessions is approximately €7 million.”

According to this note, an action plan from the National Endoscopy Programme had previously been submitted to and approved by the National Planning Oversight Group (NPOG). It had also been submitted to the Department of Health and was used to inform a briefing paper for a ‘performance meeting’ involving the Department’s Management Board and senior HSE officials in June 2017. “Receipt of sufficient funding will ensure plans can move forward to implementation,” it noted.

According to that briefing paper on the Endoscopy Programme, drawn-up by the Department of Health, in 2016 the National Clinical Lead for Endoscopy invited all adult public units (37) to participate in a short study to capture all procedures carried out in endoscopy units, eg, inpatient activity, private activity, other non-gastrointestinal procedures. This study captured live data on all referrals into each public unit over four one-week periods.

Some 25 of the 37 units returned data within the study timeframe. The study found that 2,500 endoscopy procedures took place each week across 39 hospitals nationally – 37 adult and two paediatric units.

Of the 25 units that returned data within the timeframe, only four units had capacity to meet current demand for endoscopy services.

The findings showed that 109 additional endoscopy sessions per week were required to achieve and maintain compliance with the National Service Plan KPI requirements, keep surveillance or planned procedures up-to-date and allow BowelScreen needs to be met. This equated to a requirement for almost 5,000 sessions across the country per year. Potentially an additional 106 sessions could be provided in existing endoscopy units, but these sessions were not available because of funding constraints.

There were also insufficient numbers of highly skilled endoscopists to perform complex endoscopy, outlined the paper.

Moreover, the funding requirements calculated from the capacity demand analysis were based on full or partial data submitted from 25 of 37 adult endoscopy services and, therefore, the requirements may have been an underestimate, the paper also underlined.

It further noted that the demand capacity report did not address the expected growth in demand.

The briefing paper referred to patient safety as paramount when considering how to address the “challenges” facing endoscopy services.

Arising from the data collected, the Endoscopy Programme developed an action plan outlining a number of funding options for improving the service, ranging from ‘no change to current service provision’ to seeking significant investment to address all workforce and capital issues.

The option of no change to current service provision and training “must be disregarded due to the risk to patient safety and lack of sustainable waiting list management”, the briefing paper stated.

Option B was that a number of actions be implemented on a phased basis over two years, including insourcing surveillance patients within Hospital Groups with unfunded capacity; fund staffing for 109 [sic]vacant sessions currently available throughout the country on a recurring basis; commence demonstrator projects across two Hospital Groups; validate referrals in order to reduce unnecessary referrals to endoscopy services; appoint 0.5 national training lead for endoscopy; ensure strict adherence to the HSE Acute Hospitals Division governance structure for endoscopy to ensure patient safety; plan for sustainable endoscopy service through 2018 estimates process; complete review of capacity and demand; complete external review of endoscopy services to identify quality assurance issues and risks for symptomatic and BowelScreen services; increase number of units with JAG accreditation; and outsource routine, non-urgent patients to private facilities via the National Treatment Purchase Fund (NTPF). Accumulated funding requirements over three years would be €6.8 million. 

Option C would entail capital investment to enable all units to meet international standards and HSE waiting times, including considerable investment in equipment and physical infrastructure. The estimated cost would be significant, being in excess of €16 million over eight years for endoscopy equipment alone.

The Programme’s preferred approach was option B, according to the Department briefing paper.

“The Department is supportive of this recommendation and has been engaging with the Endoscopy Programme to develop a submission for the 2018 Estimates outlining the shorter term funding for staffing and longer term capital expenditure… We note that the Programme has outlined a comprehensive and sustainable approach. Funding of short-term initiatives by the NTPF to target the longest waiters in recent years, while arguable [sic] necessary, and effective in the short-term, has not provided a sustainable solution to the growing endoscopy waiting lists.”

By press time, the HSE had not provided an update on investment and developments in endoscopy services.

Statistics awaited on impact of CervicalCheck controversy

The Scally report recently focussed national attention on CervicalCheck.

MI asked the HSE if BowelScreen had seen any fall-off in participation since the controversy over CervicalCheck. A spokesperson responded that uptake for Quarter 2, 2018 (March – June 2018) will not be available until later this month (October).

This newspaper also queried if the Programme had undertaken any audit in respect of patients who received negative/benign results (either from a stool sample or colonoscopy) and who subsequently developed bowel cancer, and if BowelScreen had any data on false positives/negatives.

A spokesperson said: “As the BowelScreen programme is relatively new, the process for ascertainment of interval cancers for the Programme is not long under development. A certain period of time must elapse to allow for interval cancer development, detection and reporting to the National Screening Service. Any work relating to clinical audits for each of the national screening programmes is currently on hold pending the outcome of the Scally Inquiry. Data in relation to false positives and false negatives is available from materials published by bowel screening programmes in other jurisdictions and can be sourced from international literature.”

Meanwhile, MI asked for information on advancement of quality assurance/safety measures since the patient safety incident at Wexford General Hospital involving screening colonoscopies. An external review of the HSE’s management in regard to 13 probable missed cancer diagnoses (the Steele Report), published earlier this year, found there were “missed early opportunities to identify shortcomings in the performance of the colonoscopist responsibility for the incident”.

A HSE spokesperson told MI: “In conjunction with the implementation of the recommendations of the Steele Report, BowelScreen can provide the following update: CIR [caecal intubation rates] are verified by the clinical lead in each BowelScreen unit. The clinical lead when reporting this data, also conducts a mandatory audit of the photographs within the colonoscopy reports. While CIR rate is an important quality standard, the ADR [adenoma detection rate] is the most important indicator of clinical quality in colorectal screening. The ADR standard was reviewed and increased from 25-35 per cent to 40-50 per cent as at 8 April 2015 and revised upwards again in April 2017 to 45-50 per cent.

“ADR rates are now measured at both unit and individual clinician level. All units and individual clinicians are performing within acceptable standards. The process of ongoing performance review occurs quarterly at both the Clinical Advisory and Quality Assurance Committees. Both committees are represented by external clinicians with specialist knowledge in the clinical areas of histology, surgery, CT and endoscopy.

“Work is continuing between BowelScreen and RCPI, specifically the GI Endoscopy QI Programme, to develop a shared robust statistical approach in order to assist with the identification of outliers. It is planned that BowelScreen cases will be clearly identifiable within NQAIS (National Quality Assurance Intelligence System) – Endoscopy. Thus providing an additional reporting tool for quality assurance purposes and it will also facilitate the analysis of and comparison to national data.”

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