How this PCN uses a cancer lead

Havering North PCN funds a dedicated cancer lead, Dr Ameesh Patel, to focus on cancer issues in the area. Here, he explains how being a PCN cancer lead was instrumental in the success of a bowel cancer screening initiative.

Historically, cancer screening has been perceived as the responsibility of the NHS screening programmes. However, the advent of accurate coding systems and tracking of non-responders within GP clinical record systems has opened the door to allow practices to coordinate efforts to encourage screening uptake. 

In 2021, Havering North PCN in East London – which comprises 14 GP practices serving approximately 86,000 patients – implemented a PCN-wide intervention that aimed to increase patient uptake in the national screening programme for bowel cancer. The importance and effectiveness of bowel screening as a diagnostic process are clear, with the latest figures from the National Bowel Cancer Audit’s (NBOCA) State of the Nation report for England and Wales showing that 15.75% of all colorectal cancers are picked up by screening alone.

The result of the PCN intervention was a great improvement in screening to almost universal uptake (96%) among the eligible population, which was 60–74-year-olds at that time, from a baseline of 65%.

This was made possible because the PCN had a dedicated cancer lead who could focus on this clinical area. Cancer was highlighted as a priority area by the PCN, and it makes financial remuneration from the PCN budget to my practice to release me from clinical duties on a two-sessional (eight hours) per month basis. 

Having this role at the PCN meant it was possible to concentrate on building relationships with local organisations, work collaboratively with other cancer lead GPs and focus on achieving the early cancer diagnosis PCN Direct Enhanced Service (DES).

Aims

The project aim was to increase uptake of bowel cancer screening among eligible patients. In particular, we wanted to improve uptake amongst South Asian and learning disabled groups to narrow health inequalities within the PCN. To achieve this, we monitored non-responders to the national screening programme and then actively engaged with them. The intervention followed similar protocols developed nationwide.

At the time, as well as being PCN cancer lead, I was also cancer lead for the North East London (NEL) Cancer Alliance, a post that was funded by Cancer Research UK (CRUK) on a short-term basis. This boosted PCN and practice-level confidence in the initiative. It also gave me access to a collaborative working group of other CRUK GPs across the country, where we could debate cancer issues and focus specifically on the PCN DES. 

My colleagues at NEL Cancer Alliance were also a great support. For example, the alliance provided an animation on the practicalities of providing a stool sample for the purposes of bowel cancer screening. The easy-to-follow animation was displayed on GP surgery waiting room monitors and sent to patients via text message. 

As the clinical cancer lead at the PCN, I ran the initiative supported by our PCN management team, including joint clinical directors Dr Jwala Gupta and Dr Gurmeet Singh.

Approach

An educational event was delivered to the GP partners who were practice leads for the initiative in which baseline data was shared, demonstrating very low bowel cancer screening uptake. PHE Fingertips data showed 57% uptake in 19/20, and CEG data showed 61% uptake in those aged 60-74 in 2021.

No additional funding was provided as it was part of a wider requirement to secure PCN DES funds.

The success of the bowel screening project relied on effective team working within and across practices. So, a multidisciplinary team collaborated closely to ensure the smooth implementation and ongoing management of the screening programme. This comprised staff such as social prescribers, admin, and IT support who worked across the PCN and practice-based staff such as nurses and GPs.

Regular PCN meetings were held to discuss progress, address challenges, and share best practices. This collaborative approach fostered a sense of shared ownership and allowed for effective coordination of tasks and resources.

Throughout the implementation process, feedback and suggestions from staff and patients were actively sought and valued. This created a positive, supportive and motivated work environment.

Method

As the PCN cancer lead, I delivered training to GP partners and managers across the PCN on all aspects of the bowel screening programme. This included education on the importance of early detection, the screening process, and the appropriate use of screening tools. 

Clear leadership was crucial. We encouraged each practice to appoint a dedicated member of staff to be project and clinical lead, responsible for overseeing all aspects of the programme. These individuals provided guidance, set objectives, ensured compliance with screening guidelines, and coordinated the efforts of the team. 

Where this was lacking – for example, at very small practices – I would step in to provide support as needed. Usually, this required one practice visit to demonstrate the project methods and rationale.

A major component of encouraging patient uptake involved the use of GP-endorsed messages, both on batch and opportunistic levels, to remind patients to complete the asymptomatic faecal immunochemical test (FIT) sent out as part of the screening programme. To be effective, we needed to know who to target with those messages.

So, from an early stage, all practices used various data sources, such as Ardens and NHS insights, to capture a population of bowel screening non-responders.

We used digital technologies to streamline the screening process, such as implementing an electronic system for sending invitations, reminders, tracking responses, and delivering results. We also utilised PCN dashboards to support low-uptake practices. 

We worked with a secondary care facilitator – a health improvement specialist – who helped with the practice data to identify trends and opportunities. The aim was to support practices in focusing activity on a relatively few patients who had yet to complete the FIT tests.

The PCN intervention also involved reaching out to low-uptake populations, including the South Asian population and learning disabled patients.

We did this by focusing on radio stations popular with South Asian communities to educate them on the practicality and importance of bowel screening. To help boost the number of learning disabled patients, we confirmed carer mobile numbers to ensure screening messages were sent to them to help enhance uptake. We also educated care home managers and encouraged uptake amongst their clients.

Outcomes

PCN data demonstrated clear success. Bowel screening uptake in an eligible population for the five months preceding March 2022 demonstrated vast improvements to almost universal uptake (96%) from a baseline of 65% following the success of our PCN-based interventions.  

As displayed in the table below, screening uptake increased significantly over just one month. This was sustained in the two months following.

As well as boosting overall uptake, we also improved the screening figures for those in the South Asian population and learning disabled group, though this wasn’t formally monitored by the PCN. Nevertheless, it has helped to narrow health inequality within the PCN.

The initiative shows the value of employing a dedicated cancer lead at each PCN. There is a myriad of organisations one must interact with and then disseminate to PCN members. I would also advocate for them to be funded, as I am, to allow them protected time to fulfil the demands of the role especially attendance at local and national meetings.

Future

Ease of use was a clear enabler in achieving the outcomes and staff feedback was positive.

I am proud to say the hugely positive impact of our project has inspired our PCN to continue monitoring and actively engaging with bowel cancer screening non-responders. And we have shared our approach with neighbouring PCNs and practices to effect scalable change across North East London. 

The successful use of technology in this project laid the foundations for adopting an AI-driven tool to case-find those at high risk of prostate cancer and invite them for PSA and MRI screening.

Myself and Havering North PCN were short-listed for the PMA award for outstanding contribution to general practice 2023. We were also recognised locally at the North East London Primary Care Workforce Awards 2023.