A National Bowel Screening Programme Mhairi Porteous Manager, Bowel and Prostate Cancer Programmes [Presented at NBSP Regional Meetings held 9 th & 10 th August 2016]

Agenda for today – introduce Ministry team An overview of the National Bowel Screening Programme Timelines, funding and configuration, and the national, regional and local approach, the equity focus, plus the role of primary care. Building and running a high quality programme Ensuring high quality colonoscopy, monitoring quality standards, capacity, workforce, histology and CTC. Wider bowel cancer perspectives The bowel cancer pathway, symptomatic and surveillance services, colonoscopy wait time indicators and the role of the National Bowel Cancer Working Group.

Agenda - continued National Bowel Screening Programme Implementation The detailed information DHBs will need to supply to inform each stage of the roll-out. Design direction for a National Bowel Screening Programme IT system including functions, users and integration with DHB systems What the NBSP IT system needs to do - context and overview. The BSP pilot IT system and the approach for the initial roll-out to Hutt and Wairarapa DHBs. The new NBSP system including: system functionality use of existing health information using NHI, HPI, and NES services integration with DHB applications DHB business users, processes, and system touch points.

The last eighteen years Population Screening for Colorectal Screening, NHC Report of the Colorectal Screening Advisory Group 2008 – Next Steps Towards a Feasibility Study for Colorectal Screening 2010 – Pilot approach announced October 2011 – Pilot commences May 2015 – 2 year extension to the Pilot July 2015 – Minister of Health announces that he will report to Cabinet by December 2015 on a potential national bowel screening programme May 2016 Budget announcement of $39.3 million to set up a bowel screening programme Currently preparing business case for Cabinet

Waitemata Bowel Screening Pilot (BSP) Four year Pilot to 2015 two screening rounds plus two year extension until end of 2017 Age range 50-74, men and women (commenced with approx 136,000 eligible people) Screening test - Faecal immunochemical test for Haemoglobin (iFOBT) - Every two years Acknowledge the hard work, commitment and willingness of the Waitemata Team.

Essentials of a national screening programme A central agency to lead and co ordinate the screening pathway Clinical Governance Infrastructure and systems to manage a screening programme Monitoring and evaluation Quality cycle

Equity is Essential

As at June 2016

NHI database extract BSP register Pre invitation letter Invitation letter, test kit, consent form Sample returned to laboratory Result to register and GP 10 days GP/Endo nurse refers to Colonoscopy 42 days Result letter to participant Recall to screening in 2 years Colonoscopy Recall to screening in 5 years Surveillance Opt off Treatment Opt off NegativePositive

Proposed Configuration Ministry of Health NBSP NBSP IT System (TBC) National Coordination Centre and Laboratory Test Kit Provider Bowel Screening Regional Centres District Health Boards Primary Health Organisations National Quality Improvement

Proposed Roles and Responsibilities Ministry of Health National Coordination Centre Bowel Screening Regional Centres (BSRC) DHBs

Ministry of Health Central leadership and coordination of all aspects of the screening programme Monitoring and evaluating the quality, equity and effectiveness of the programme Clinical leadership and governance Oversight of infrastructure and systems, including national IT system for bowel screening.

National Coordination Centre National coordination and sending of screening invitations. Analysis of all immunochemical faecal occult blood tests (iFOBT). Management of results, including sending letters following a negative result and advising GPs electronically of both positive and negative results. Advising Regional Bowel Screening Centres of those with a positive and negative result. Targeted actions to drive equitable participation.

Bowel Screening Regional Centre Regional coordination of reporting. Clinical leadership, equity and quality management. Funds awareness raising activities. Notifying GPs/eligible participants of positive results and arranging colonoscopy (regional and/or local) Contracts for colonoscopy service provision

DHBs Colonoscopy delivery Colonoscopy histology Local coordination of awareness raising activities and targeted actions for equitable participation.

Proposed BSRC set up timeline End August 2016: Ministry sends DHBs a BSRC guidance document. During September 2016: Regional meetings to support BSRC development. End October 2016: Each region sends the Ministry: 1.the name of the organisation the region nominates to be the BSRC 2.written support from each DHB CEO in that region for the nominated BSRC organisation. December 2016: BSRC organisations provide information to the Ministry for the business case (e.g. high level implementation plan and operating model, finances and contractual relationships). April 2017: Pending Cabinet approval, commence set up work. January 2018: BSRC ‘go live’.

Quality is Critical Across all elements of the programme incl. national endoscopy quality improvement programme

15 Pilot Monitoring indicators DescriptionOverall participation Evidence This is the % of people with a final iFOBT result (+ve or –ve) out of all those eligible invited by the programme, for the first and subsequent screening round. Target 60% for first screen (Round 1) ValueRound 1: 56.8%Average for Round 2: 54.3%Where Round 2 was first screen  Aged in or moved in: 45.8%  Did not respond or unsuccessful in Round 1: 24.3% Where Round 2 was second screen: 84.0% As at June 2016

DescriptionCoverage Evidence This is the % of eligible people in Waitemata DHB region* who were invited to participate during the first screening round.* Target >95% Value 97.50% DescriptionTime to colonoscopy for Round 2 Evidence This is the % of people whose time between the laboratory receiving a positive iFOBT to having a colonoscopy carried out was within a specified target (excludes persons who decline colonoscopy or those having a colonoscopy performed privately). Target 95% < 11 weeks Value 95% As at June 2016

Description Proportion of individuals with a positive screening test undergoing colonoscopy or CT colonography Evidence This is the % of screened people with a positive iFOBT result who have had a colonoscopy or CT colonography through the programme, or have a date booked for a colonoscopy. Target > 90% undergo colonoscopy or CT colonography Value  Round 1: 88.1% (95.1%)****  Round 2: 85.6% (93.4%)**** ** This includes those that chose to receive a colonoscopy through a private provider As at June 2016

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Building and running a high quality bowel screening programme Part 1 Susan Parry Gastroenterologist, Clinical Director, MOH Bowel Cancer Programme [Presented at NBSP Regional Meetings held 9 th & 10 th August 2016]

Core principles screening National Health Committee The condition is a suitable candidate for screening There is a suitable test There is an effective and accessible treatment or intervention for the condition identified through early detection There is high quality evidence, ideally from randomised controlled trials, that a screening programme is effective in reducing mortality or morbidity The potential benefit from the screening programme should outweigh the potential physical and psychological harm (caused by the test, diagnostic procedures and treatment) The health care system will be capable of supporting all necessary elements of the screening pathway, including diagnosis, follow-up and programme evaluation. There is consideration of social and ethical issues There is consideration of cost-benefit issues.

Major pre- requisites to making a decision for NZ Bowel screening pilot – local data Colonoscopy volumes Information on performed symptomatic colonoscopy volumes and wait times Anticipated screening colonoscopy volumes Workforce implications

Bowel Screening Pilot Results

Round 1 results: Between 1 January 2012 and 31 December 2013: * Over 121,000 eligible people invited to take part in the Pilot Coverage 97.5% (based on census data) The programme participation rate was 55.8% Overall positivity rate was 7.5% 96% of those with a +ve FIT went to colonoscopy CRCs found in 196 (22) people (44.2% TNM Stage 1) * Data pulled August 2015

Positivity in the BSP Round 1 and the first year of Round 2

Bowel Screening Pilot results to Sep 2015 (pulled Feb 2016) Rd 1 Rd 2 CRC detection rate DR/1000 screened 2.8 ( ) 1.4 Advanced adenoma DR Adenoma DR 36.2 ( ) 23.2 PPV CRC % 4.3 ( ) 2.9 PPV Advanced adenoma % PPV adenoma % 56.1 ( ) 47.7 Numbers cancers found(private)192 (22) 92 (10) Those with low risk adenoma returned to screening Remainder with adenoma offered surveillance

Table 1: For age group years at various Hb concentration cut-offs * as at May 2015 Advanced adenoma > 10mm, high grade dysplasia, villous component

Colonoscopy Wait time Indicators

National colonoscopy wait time indicators

Wait time indicators Northern region

Wait time indicators Midland region

Wait time indicators Central region

Wait time indicators Southern region

Colonoscopy numbers performed nationally

Colonoscopy - number waiting outside target

The number of colonoscopies performed has increased over the years of collection The number of people waiting has decreased over the last three years, particularly the number waiting over the target time period

Endoscopy workforce initiatives Increased number of gastroenterology trainees Ongoing discussions relevant professional surgical college/societies Nurse endoscopy training course established Colonoscopy model

Workforce implications

Assumes 20% increase in symptomatic referrals over first two years of screening

Who performs colonoscopy in NZ? Main centre colonoscopy performed by Gastroenterologists Regional Centres by Surgeons Approximately 60/40 split Averaged across NZ for the model A FTE general surgeon may perform one colonoscopy list a week. Assume new graduating FTE gastroenterologist from end 2016 perform on average 3 colonoscopy lists ( 5 per list) a week A FTE DHB colonoscopist ( performing endoscopy 5-6 sessions per week (5 cols per list) for 44wks ) could perform = colonoscopies/year Approximately 5% colonoscopy by NE in UK

Medical Specialty Workforce Forecasting Model for the National Bowel Cancer Screening Emmanuel Jo Principal Technical Specialist, Health Workforce New Zealand, Ministry of Health [Presented at NBSP Regional Meetings held 9 th & 10 th August 2016]

* * * TWO Strea ms For Each Specialty

Formulas used in the model

Assumptions in the model Variable exit rates for each age group and specialty have been used for every future year. Variable ratio of Full Time Equivalent(FTE) per Head Count (HC) is used for each age group and specialty to reflect different patterns of working over different parts of the lifespan

More trainees in gastroenterology MOH/ College Gastro Specialist Training Committee/NZSG purposely placed additional 3 gastroenterology trainees per year to prepare the National Bowel Cancer Screening role out from end of Additional 1 end 2015, further 1 end 2016 Expect 9 completing during or end of 2016, 6 finish in 2017, and average 7 from 2018 Gastroenterologists from overseas, but did not use in the model (very conservative measure) Assumed 1 new FTE gastroenterologists performing 660 colonoscopies per year. (in discussion with NZSG)

Gastroenterologists

Gastroenterologists

Gastroenterologists

Gastroenterologists

Gastroenterologists

Gastroenterologists

Gastroenterologists

2015 to 2020 – General Surgeons

2015 to 2020 – Pathologists

2015 to 2020 – Diagnostic & Interventional Radiologists

Building and running a high quality bowel screening programme Part 2 Susan Parry Gastroenterologist, Clinical Director, MOH Bowel Cancer Programme [Presented at NBSP Regional Meetings held 9 th & 10 th August 2016]

Positive predictive value for CRC at colonoscopy – lower limit international experience Positive predictive value adenoma - higher than international experience Colonoscopy requirements not achievable for many years National roll out as per WDHB BSP

National roll out as per WDHB pilot

7 National roll out as per WDHB pilot

National roll out 60-74yrs – adjusted threshold ( similar Ireland / Netherlands)

Estimated National requirement as per DHB responses Endoscopy Nurses: 43 (6.4 per 100,000) Endoscopy health care technicians /assistants 6.5 (1 per 100,000) Endoscopy SMO: 12 (1.8 per 100,000) Nurse endoscopists: 2.5 (0.4 per 100,000) Estimated endoscopy staff FTE requirements for screening /100,000 population- as provided by DHB’s Marked variation between DHB’s

DHBPopulatio n (60-74) Colonoscopy demand - Round 1 Year 1* Cancers – Round 1 Year 1* Colonoscopy demand - Round 1 Year 2* Cancers - Round 1 Year 2* Auckland59, Northland33, Counties Manukau 70,3801,032791,06881 NBSP - Population, Colonoscopy demand and Cancers *These volumes are based on the Bowel Screening Pilot results from Waitemata DHBPopulatio n (60-74) Colonoscopies - Year 1 Cancers – Year 1 Colonoscopies - Year 2 Cancers - Year 2 Waitemata82, # 44 # 839 # 46 # # Waitemata volumes are based on Round 2 results Northern Region

DHBPopulatio n (60-74) Colonoscopy demand - Round 1 Year 1* Cancers – Round 1 Year 1* Colonoscopy demand - Round 1 Year 2* Cancers - Round 1 Year 2* Taranaki19, Waikato62, Tairawhiti7, Lakes17, Bay of Plenty 42, NBSP - Population, Colonoscopy demand and Cancers *These volumes are based on the Bowel Screening Pilot results from Waitemata Midland Region

DHBPopulation (60-74) Colonoscopy demand - Round 1 Year 1* Cancers – Round 1 Year 1* Colonoscopy demand - Round 1 Year 2* Cancers - Round 1 Year 2* Hutt20, Wairarapa8, Cap Coast39, Whanganui11, Hawkes Bay28, Mid-Central28, NBSP - Population, Colonoscopy demand and Cancers *These volumes are based on the Bowel Screening Pilot results from Waitemata Central Region

DHBPopulatio n (60-74) Colonoscopy demand - Round 1 Year 1* Cancers – Round 1 Year 1* Colonoscopy demand - Round 1 Year 2* Cancers - Round 1 Year 2* Canterbury82,6601,212921,25495 Southern50, West Coast6, South Canterbury 11, Nelson Marlborough 30, NBSP - Population, Colonoscopy requirements and Cancers *These volumes are based on the Bowel Screening Pilot results from Waitemata Southern region

Anticipated number of cancers Round 1 Year 1 Northern Region

Anticipated number of cancers Round 1 Year 1 Midland Region

Anticipated number of cancers Round 1 Year 1 Central Region

Anticipated number of cancers Round 1 Year 1 Southern Region

Workload implications Surgery based on current BSP – Mike Hulme- Moir  10% cancers do not require surgery  BSP cancers approx 20% WDHB colorectal cancer  0.6 Surgical FTE Patholog y based on current BSP (3.2 pots per colonoscopy, 224 cancer resections in 3 years) – Nicole Kramer Expected FTEs for the population screened are estimated at:  Specimen services – 2.4 FTE  Chemical pathology – 0.7 FTE with oversight  Anatomic pathology  Administration – 0.2 FTE  Scientist/technicians – 0.7 FTE  Pathologists – FTE ( includes cancer resections, M and M 1 hr/wk per week, Troubleshooting 1-2 hrs/ week. Time allowances more generous than RCP guidelines)

Radiology - David Cranefield Clinical Director WDHB Approx 20% cancers rectal cancers and require MRI as well. 10% background increase in CT volumes year on year for a number of reasons BSP workload just one contributor NRAG developing a detailed assessment of predicted impact

Includes unplanned and planned – majority reported as unplanned.

Oncology Assessment of impact BSP now being addressed 10% of cancers do not require surgery

General Practitioners Essential involvement in the bowel screening programme Encourage appropriate participation Those with a family history of concern /extensive inflammatory bowel disease advised to consult with their GP before participating Manage participants with positive iFOBT results Active follow-up to facilitate equity of participation Going forward National workshops Development National GP education modules

Colonoscopy - changes from clinical practice Colonoscopy pre- assessment by phone Colonoscopy first offered appointment within 42 days Completion simple family history questionaire Inclusion of family history in colonoscopy report Identify those at moderate risk Referral to NZ Familial GI Cancer Service where appropriate Five colonoscopies per list Each polyp in separate pot Histology results are not to individual clinicians Role senior nurse – pre-assessment, data entry, managing histology

Quality in colonoscopy Facility standards Colonoscopists pre- requisite quality performance indicators Currently > 250 colonoscopies over 5 years, caecal intubation rate of > 90% average withdrawal greater than 6 minutes. Three monthly feedback on colonoscopy performance 30 day readmissions following colonoscopy reviewed 2 weekly Adverse events classified according to UK Quality Assurance Guidelines and reported in monitoring indicators Local endoscopy lead. Regional/National clinical leads

DescriptionColonoscopy completion rate as at December 2015 Evidence This is the % of completed colonoscopies (reaching the caecum). Target  Acceptable >90%  Desirable > 95% Value  Round 1: approximately 97%  Round 2: approximately 97% Monitoring Indicators – as published on MOH website

Monitoring Indicators DescriptionColonoscopy complication rate for perforation or bleeding Evidence This is the number of people requiring admission to hospital for an intermediate or serious adverse event related to perforation or bleeding occurring within 30 days of colonoscopy, per 1000 of those who had a colonoscopy during the first and subsequent screening round. Target <10 per 1000 colonoscopies*** *** Value 3.4 per 1000 *** This number was calculated on the expected number of adverse event rates reported in the UK Bowel Cancer Screening Programme Quality Assurance Guidelines for Colonoscopy and based on the fact that 7 out of 10 pilot participants proceeding to colonoscopy are identified to have had a lesion.

Monitoring Indicators Description Colonoscopy complication rate for events other than perforation or bleeding Evidence This is the number of people requiring admission to hospital for other intermediate or serious adverse events not related to perforation or bleeding occurring within 30 days of colonoscopy, per 1000 of those who had a colonoscopy during the first and subsequent screening round. Target No agreed international standard Value 0.4 per 1000

Endoscopy Quality Improvement Currently conducting negotiations with Hawkes Bay DHB and Dr Malcolm Arnold for hosting and leading the Endoscopy Quality Improvement Programme (NZGRS) Northern Regional Cancer Network and Dr Russell Walmsley for the hosting and leading Governance of the Endoscopy Governance Group NZ Supported by Joint Advisory Group on Endoscopy (JAG) RCP UK Contracts should be in place, with work commencing, in the next month

Quality standards along the entire screening pathway Ensure timeliness and quality Key performance indicators Readiness assessment Ongoing monitoring/audit

Acknowledgements Emmanuel Jo Jibu Stephens Helen Gower Nalayini Thiagalingham

Wider Bowel Cancer Perspectives Susan Parry Gastroenterologist, Clinical Director, MOH Bowel Cancer Programme [Presented at NBSP Regional Meetings held 9 th & 10 th August 2016]

Wider Bowel Cancer Perspectives National Bowel Cancer Screening programme cannot be developed in isolation Aim to detect bowel cancer at an earlier stage Need to ensure quality treatment nationally to optimise outcomes Need to ensure equitable access to treatment Need to ensure symptomatic pathway not compromised

Endoscopy Quality Improvement Currently conducting negotiations with Hawkes Bay DHB and Dr Malcolm Arnold for hosting and leading the Endoscopy Quality Improvement Programme (NZGRS) Northern Regional Cancer Network and Dr Russell Walmsley for the hosting and leading Governance of the Endoscopy Governance Group NZ Supported by Joint Advisory Group on Endoscopy (JAG) RCP UK Contracts should be in place, with work commencing, in the next month

Wider Bowel Cancer Programme

National Bowel Cancer Working Group

Health Quality and Safety Commission

Bowel Cancer Tumour Standards

Faster Cancer Treatment Indicators

NZ Familial GI Cancer Service

National Bowel Screening Programme (NBSP) Implementation Lara Penman Programme Manager, Bowel and Prostate Cancer Team & Corinne Thompson Senior Contracts Manager, Bowel and Prostate Cancer Team [Presented at NBSP Regional Meetings held 9 th & 10 th August 2016

Provisional NBSP tranches – who starts when? Tranche 1 = DHBs starting July 2017 Tranche 2 = DHBs starting during 2018 NBSP IT system National Coordination Centre (NCC) Bowel Screening Regional Centres (BSRC) Tranche 3 = DHBs starting during 2019

NBSP business cases for Cabinet approval Business case type PurposeDHB roleDHB information due ProgrammeApproval of the NBSPQuestionnairesJune 2016 (complete) Tranche 1Approve implementation and release of funding for Tranche 1 Tranche 1 DHBs provide information July 2016 (complete) Tranche 2Approve implementation and release of funding for Tranche 2 Tranche 2 DHBs provide information November 2016 Tranche 3Approve implementation and release of funding for Tranche 3 Tranche 3 DHBs provide information September 2017

DHB information required for the business cases Answers key questions for the Minister and DHB stakeholders: 1.Why is bowel screening a good thing for this DHB in the current DHB context? 2.What are the costs for this DHB and how will they be funded? 3.How is this DHB going to successfully deliver bowel screening?

Proposed Tranche 2 DHB set up timeline August 2016: DHBs nominate a bowel screening project lead. September 2016: Regional business case meetings with the DHB bowel screening project leads, IT lead and finance leads to outline what information is required. End November 2016: DHBs submit completed business case template to the Ministry. Confirm planned month during 2018 that the DHB will commence bowel screening. Jan / Feb 2017: Review business case once IT, NCC and BSRC confirmed. April 2017: Pending Cabinet approval, commence set up work. During 2018: Rollout of bowel screening in Tranche 2 DHBs.

Next steps -August: the Ministry with the nominated bowel screening project lead for your DHB (Tranche 2 DHBs) -August: BSRC guidance document to DHBs -September: Regional BSRC meetings -September: Regional business case meetings -Questions and feedback?

Proposed Design Direction for a NBSP IT System Jasmin Wilkins IT Analyst & Martin Hunter Solution Architect [Presented at NBSP Regional Meetings held 9 th & 10 th August 2016]

Agenda Business Context Guiding Design Principles Solution Overview Approach to Delivery Ministry’s IT Engagement Approach Open discussion

Business Context

Guiding IT Design Principles Information Quality Focus Data Captured Once – at Source Single “Version of the Truth” Information Managed as an Asset Ability to Manage Change Services Oriented – Reuse Common Services & Integration Patterns Standards-Based Integration (HL7, SNOMED, FHIR, OAuth2, SAML) Shared Infrastructure Platforms Continuous Delivery

Guiding IT Design Principles Health Strategy Alignment People Centric Smart Systems Cost Awareness Total Cost of Ownership “TCO” Focus Awareness of Technical Debts

What is the proposed National Bowel Screening Programme “NBSP” IT System? Systems Integration – a “System of Integrated Components” Bowel Programme: “Core” Components e.g. Pathway, User Interfaces, Register Database External (e.g. DHBs): Endoscopy & Histopathology Common Components: Several Existing & New “Common Services” e.g. NHI, NES, HPI Common Data Analytics & Data Warehouse

System Context Solution Overview

How are we getting there? BSP Pilot BSP+Proposed NBSP IT System Tranches / DHB onboarding Systems Integration Incremental Approach Aligning with DHB onboarding in Programme Tranches BSP+ required to meet timeframes for Tranche 1 We will carry over what we can from BSP+ into NBSP – but NBSP is a different thing Early stages – details yet to come! We are here

IT Team Engagement Delivery will be founded on strong cross- team collaboration and engagement Ministry’s NS&I delivery approach: People – “Collective Delivery” Process – Continuous Delivery (“DevOps”) Information – Open Source in Health Sector & Government (system code, delivery code, Infrastructure-as-Code) Technology – Shared & Shareable “Cloud” Delivery Infrastructure & Services

Pilot - Business Context

Tranche 2 – Business Context

Operational Overview

Contact us For any questions about the content in this presentation or the assumptions behind the data presented please contact us.