This submission from Bowel Cancer UK to the Health Select Committee's inquiry on health inequalities is based on a recent Bowel Cancer UK report entitled The Bowel Cancer Screening Programme: A progress report on the roll-out of screening in England which was published in November 2007.

  This report evaluated the impact of the screening programme on patient care, and made a number of recommendations concerning equality of access to screening services, diagnostics, treatment and support.

1.  INTRODUCTION

  1.1  Bowel cancer is the third most common cancer in the UK and the second most common cause of cancer death. One in 20 women and one in 18 men will develop the disease during their lifetime. However, it is one of the most treatable of all cancers and is curable if caught in the early stages.

  1.2  The National Bowel Cancer Screening Programme for England was rolled-out in July 2006 and is the first screening programme of its kind for both men and women. It is designed to detect the signs of bowel cancer early in people with no symptoms through the distribution of home test kits by post to people aged 60-69.

  1.3  There is strong evidence that of the 16,000+ deaths in the UK per year from bowel cancer more than 2,500 of these could be reduced through screening.

  1.4  The programme works by distributing test kits to eligible people at home, which needs to be posted back to a laboratory for analysis. Although the kit does not diagnose cancer itself, the result can determine whether a follow-up examination of the bowel is necessary.

  1.5  It is expected that once the screening programme has been fully rolled-out by 2009 there will be over 90 screening centres across England managed by five regional screening hubs.

2.  INEQUALITIES EXIST IN THE ROLL-OUT OF SCREENING ACROSS THE UK

  2.1  Bowel cancer screening is currently being rolled-out in England and is expected to be fully implemented by 2009 for 60-69 year olds. The age range will be extended upwards to include 70-75 year olds after 2010.

  2.2  However, in Scotland, Wales and Northern Ireland, bowel cancer screening is being rolled-out for people aged between 50-74, which will create an inequality in the provision of screening within the UK.

  2.3  While Bowel Cancer UK has welcomed the Government's commitment to raise the age range for screening in England from 2010, we believe the age range should be expanded to include those aged over 50 to bring it fully into line with the devolved nations.

3.  REGIONAL VARIATIONS IN UPTAKE MUST BE TACKLED TO REDUCE INEQUALITY OF ACCESS

  3.1  Evidence from the report (page 12) showed that there were regional variations in the uptake of screening. While some degree of variation may be due in part to differences in the date each screening hub commenced operations, the Department of Health should examine why such disparities exist.

  3.2  Regional differences in the way screening is promoted, and the method by which test kits are dispatched and managed, should be investigated to identify if lessons can be learned from those hubs whose response rates are highest.

  3.3  NHS services should be incentivised to improve levels of uptake to reduce regional variations to minimal levels. A possible mechanism for doing this would be to include screening within the scope of Payment by Results.

  3.4  Patients who receive an abnormal test result are referred for a

bowel examination at a screening centre, usually by way of a colonoscopy. There is currently a significant variation in colonoscopy uptake rates (page 15) and further research must be undertaken to identify the reasons why these vary so widely across the various screening centres.

4.  VARIATIONS BY GENDER AND ETHNICITY

  4.1  Recent evidence shows that uptake of screening was only slightly higher in women compared to men (page 20). However, in a review of the screening pilot programme, evidence showed that the variation was more marked at 56.2% for women and 47.7% for men. It is essential that the screening programme—which is the first to target men—pre-empts any indication that a gap is opening-up in the uptake of bowel cancer screening through regular audits of gender uptake.

  4.2  The review of the screening pilot also identified that uptake in testing was lower among those living in areas with a high proportion of people living from the Indian Sub-continent. People from this ethnic group may warrant targeting in future screening rounds. It will be important to involve external stakeholders in planning this process, such as Bowel Cancer UK.

  4.3  Bowel Cancer UK is committed to raising awareness of screening, and of the disease generally, amongst at risk and hard to reach groups. This includes younger people, who are often believed to be too young to have bowel cancer; people from ethnic minorities; people with mental health issues; and those living in deprived or isolated areas. In 2008, the charity will be undertaking a screening awareness raising initiative amongst ethnic minority groups in the Midlands, sponsored by the Amgen Foundation.

  4.4  The spearhead group of Primary Care Trusts responsible for narrowing gaps in health outcomes in England's most deprived area should also adopt strategies to ensure that bowel cancer screening is used as a tool for addressing health inequalities within their boundaries.

5.  REDUCING INEQUALITIES ACROSS THE PATIENT PATHWAY

  5.1  Effective screening is only the first step towards improving the early detection and treatment of bowel cancer. Once bowel cancer or pre-cancerous symptoms have been identified, a patient will enter into a treatment pathway which will involve a range of health services and health professionals.

  5.2  Charity Cancerbackup's concept of a "Patient Passport" for cancer patients having treatment could be adopted for those who have been identified with bowel cancer through the screening programme. A "Screening Passport" could be introduced which would give these patients a clear idea of what is happening to them and when in terms of their pathway. Implementation of the passport across the UK would ensure equity in the provision of information to patients on their treatment regime.

  5.3  Multidisciplinary teams have been shown to be very effective in managing the treatment pathway for cancer patients. It is crucial that specialist nurses are kept in post to meet the demands of the screening programme on hospital services. Reductions in specialist nurse provision across the UK could open-up gaps in patient support which could widen regional health inequalities.

  5.4  Reduced waiting times and speedy access to surgery and radiotherapy are major factors in effectively treating bowel cancer. As the screening programme identifies more people with cancer and pre-cancerous symptoms, there will be greater pressure on these services. The Department of Health must ensure that proper monitoring of health service capacity is put in place to ensure patients identified with cancer through screening are effectively and equitably treated.

  5.5  After 50 years of just one drug—5FU—being available for bowel cancer patients, there has been a significant increase in the number of new treatments available for bowel cancer, including chemotherapy, oral IV treatments and the biological agents. Unfortunately, current evidence shows that these treatments are often denied to patients in the UK unless they take part in a clinical trial, pay for them privately, or travel abroad to get them. This may be due to a range of factors, including negative or developing NICE guidance, NHS funding shortfalls, perverse incentives in commissioning, or the commissioning policies of different PCTs. Policy makers must take action to ensure health service mechanisms operate in the most effective way possible so that access to the best available treatments can be maximised, including reviewing the methodology for the NICE appraisal system to make it work better for cancer.

Janauary 2008