FIT in Cheshire and Merseyside: Better prioritisation, better care, better outcomes

Faecal Immunochemical Testing (FIT) in Cheshire and Merseyside:
Better Prioritisation, Better Care, Better Outcomes
By Anna Murray, Senior Programme Manager

FIT is a test which detects hidden blood in the stools of patients with symptoms consistent with bowel cancer. A simple test, FIT has been successfully rolled out across Cheshire and Merseyside over the past year to ensure those at the greatest risk of colorectal cancer are given further tests quickly, despite Coronavirus.

Bowel cancer is the third most diagnosed cancer in the UK and is very treatable. However, like all cancers, the earlier it is diagnosed, the easier it is to deal with, and patients with an earlier diagnosis have a much better chance of successful treatment.

However, around 16,000 people die from the disease each year across the UK and it is the second most common cause of cancer death, after lung cancer.

The signs of bowel cancer can include:

• Bleeding from your bottom and/or blood in your poo
• A persistent and unexplained change in bowel habit 
• Unexplained weight loss
• Extreme tiredness for no obvious reason
• A pain or lump in your tummy

Patients who spot these signs and visit their GP may have common conditions other than cancer. However, before the pandemic struck, if GPs suspected bowel cancer – also known as colorectal cancer – they would ask for extra tests to be carried out on the patient, including a colonoscopy.

FIT has been used by the NHS as a bowel screening test for people with no known signs of cancer since December 2018 and the home-testing kits are automatically sent out through the post to people aged 60 to 74 years of age every two years (though people aged over 74 can request one by ringing 0800 707 6060).

The new FIT kit is easier to use than the old check and involves using a tiny brush to collect a small sample of poo that is sent to a laboratory to be analysed to look for microscopic spots of blood. People with an abnormal result or where blood is detected are referred for an investigation to either confirm a diagnosis of bowel cancer or receive the all clear. This could be a colonoscopy.

Since 2018, Cheshire & Merseyside Cancer Alliance (CMCA) has worked with hospitals and national clinical experts to extend the use the FIT beyond the bowel cancer screening programme and use it to test people who present with symptoms that could be bowel cancer. In doing so, we ensure they are put on the correct ‘pathway’ to investigate their risk and help them to get treated sooner if needed.

The test can be used to support triage in primary and secondary care if the patient has low or high-risk symptoms respectively. This means a better patient experience of care and helps to target investigations to those patients who are most clinically urgent. It also supports endoscopy services to reduce waiting lists effectively and ensure earlier treatment.

In early 2020, the first pilot sites for this way of using the test went live – then, in March 2020, the COVID-19 pandemic began.

The risks of COVID-19 infection meant that invasive tests carried out by endoscopy services, such as colonoscopies – which involves inserting a tiny camera on the end of a flexible tube into your rectum to search for signs of cancer – were paused.

CMCA and clinical leaders in Cheshire and Merseyside realised that FIT had to be expanded to cover all areas as soon as possible to help ensure all suspected bowel cancer patients could be assessed for their risk of the disease and prioritised for investigation as soon as it was available again. 

CMCA worked with more than 150 highly collaborative and motivated individuals from 21 organisations, including eight acute hospital trusts across Cheshire and Merseyside to roll this out in just eight weeks. Pathology services also worked together so that laboratories were able to ensure that test results were available within 48 hours. It meant that 1,400 patients awaiting investigation could be assessed and new patients could also receive the test.

In June 2020, FIT went live for suspected cancer patients across seven hospitals and helped to reduce the anxiety of patients concerning their cancer diagnosis at a time of huge uncertainty.

Patients with low risk symptoms can also be tested so only those at high risk of colorectal cancer need to be referred for a suspected bowel cancer and avoid unnecessary investigations and hospital appointments. 

Over the last 12 months, CMCA and hospitals across Cheshire and Merseyside have worked hard to ensure that this project has been implemented. 

Because of the efforts of all involved, more than 2,000 GPs in 400 GP practices across the region now have the ability to order FIT kits for patients showing these signs. This will enable the testing of up to 17,000 two week wait (TWW) lower GI patients a year, and tests on 37,000 patients who are deemed as having low risk of the disease.

As of June 2021, nearly 14,000 FIT kits have been sent to patients within a year, who had either low or high-risk symptoms. CMCA has also now worked with hospitals to ensure that patients who are on surveillance programmes are also being FIT-tested if they are eligible, to ensure they are investigated at the right time.

CMCA, hospitals and pathology services have achieved a lot in the past year to ensure that FIT supports effective clinical prioritisation of patients, targeted use of endoscopy, and enhanced patient reassurance and quality of care:

• A project team was established to oversee and coordinate the programme and trust implementation, driving a shared vision for FIT across the region
• Clinical leadership was established together with FIT and Pathology Steering Groups, ensuring membership from endoscopy, commissioning, colorectal services and pathology
• Guidance and new, agreed cancer ‘pathways’ were developed and agreed across the system
• Trust implementation support packs were developed, including patient communications
• There was a clear governance structure in place with representation across organisations and networks to support the programme, and incorporating the Cheshire & Merseyside Pathology and Endoscopy Network and Endoscopy Operational Recovery Team
• Implementation of pathology tracking dashboard to support patient tracking and monitoring through data sharing between pathology and the acute trusts
• Recruitment of six medical laboratory assistants, Band 6 nurse and five early diagnosis support workers to support FIT and colorectal services.
• Local trust implementation teams were in place to ensure clinical capacity for triage and enhanced support worker capacity to support patients

• 50% reduction in suspended TWWs (1,400) within eight weeks of the first COVID-19 wave
• 58% (3,095) of TWW patients identified as having a 1.1% or less risk of colorectal cancer and able to transfer to a routine pathway
• 5,313 TWW patients prioritised for endoscopy
• Initial pilot site found 28% TWW patients did not require a scope
• 88 colorectal cancers diagnosed (2.6% of tests completed), eight other cancers found
• 62% low risk patients did not require TWW referral, so did not require urgent endoscopy out of 3,179 patients
• 5% of low risk patients were identified with a 30% risk of colorectal cancer and a 50% risk of significant bowel pathology and referred on a TWW (171 patients) so prioritised for investigation
• 18% of low risk patients identified with at least 4.8% risk of colorectal cancer; referred on a TWW (582 patients), so prioritised for investigation

It is testament to the dedication of the many clinicians and health professionals across a number of CCGs and trusts who have made this happen, implementing standardised best practice across the region and collaborating to a high degree – taking their partnership working to another level.

The symptomatic FIT project interim evaluation report, from St Helens & Knowsley Teaching Hospitals NHS Trust, states that the mobilisation of FIT was achieved by “collaborative working with colleagues across CCG and Acute Hospital Teams supported by clear, embedded standard operating procedures ensured the implementation was achieved on time”.

The relationships and partnerships created were transformational and can translate to heightened collaboration in other areas of healthcare and the patient journey for cancer. Such approaches are used by CMCA across our programme for optimal cancer pathway projects, for example.

All stakeholders shared the vision that patients should only undergo endoscopic investigation if absolutely required and the urgency should be according to their colorectal cancer risk, thus improving patient experience.

Dr Jamie Barfield, Wirral CCG GP Lead for Cancer, pictured right, who was involved with the initiative, said: “The project has been vast and needed significant organisation and coordination to be able to achieve the goals.

“This has included fortnightly project working group meetings with the CCG, primary care, the acute trust and CMCA as well as separate discussions with other teams in the region who were at different stages of their implementation of FIT.

“CMCA has provided us with the crucial financial forecasting information that has enabled recurrent funding for the FIT devices to be agreed with the CCG, as well as templates for information that have been disseminated to all GP practices to aid the implementation of the project.

“Importantly, CMCA has helped to drive the project forward when there have been roadblocks to enable us to launch the service as soon as possible.”

Dr Debbie Harvey, Macmillan GP, South Sefton CCG and Primary Care Lead at CMCA, pictured below, said: “The main reason for the success of the FIT rollout across Cheshire and Merseyside was the huge amount of close collaboration between organisations, including CMCA, key people in the secondary care trusts and in our CCGs.

“Supportive and directive project management and people working together towards a common goal for our patients, in the midst of a pandemic, was a great example of what can be achieved by multidisciplinary professionals.

“Significant work included negotiating how the mobilisation was to be achieved and the formulation of pathways going back and forth between cancer leads, managers and providers.

“CMCA produced generic tools for primary care cancer leads which could then be modified for local use to support discussions with Local Medical Committees along with education and information across Primary Care Networks.”

Cheshire and Merseyside receives in excess of 21,000 TWW Lower GI referrals each year and this is increasing. Demand on endoscopy and colorectal services means it is increasingly important to utilise less invasive tests that can rule out cancer, improve early detection, patient experience and outcomes as well as enabling targeted use of limited diagnostic capacity.

Therefore, in November 2020, FIT was also identified as a key diagnostic test to clinically prioritise patients on the endoscopy symptomatic and surveillance backlog, the size of which was significant because of the pandemic.

In April 2021, this went live in six trusts following mobilisation in January 2021 and collaboration between all parties working on the FIT rollout.

This makes the best use of resources, including more effective use of endoscopy capacity, by supporting systems to avoid unnecessary colonoscopies and other investigations, potentially reducing number of endoscopies needed.

National modelling cites the potential for 25% reduction in endoscopies in Cheshire and Merseyside now the pathway has been implemented, enabling cost avoidance of an estimated £3.5m per year, due to a single FIT costing approximately £15 compared to the cost of £513 per colonoscopy.

Dr Ash Bassi, Consultant Gastroenterologist, at St Helens & Knowsley Teaching Hospitals NHS Trust, pictured right, said: “FIT tests are a sensitive and easy to do test which helps to detect blood in the stool samples and can be an early indicator of bowel cancer.

“FIT affords the opportunity to identify the most appropriate patients in whom urgent colonoscopy can be justified to target and detect cancer earlier. It also allows identifying patients in the low risk group in whom any endoscopy was avoided due to the excellent negative predictive value of this test.

“FIT for symptomatic patients was successfully piloted in St Helens, Knowsley, Warrington and Halton in collaboration with CMCA to allow the test to be done before referring for assessment for colorectal cancer in adults in low-risk (DG30) and high-risk (NG12) cases with lower GI symptoms. 

“As the COVID crisis hit, this was then rolled out across Cheshire and Merseyside at breakneck speed. The test was used as a triaging tool to potentially rule out cancer and avoid colonoscopy in 75% of symptomatic patients.

“This clinically and cost effective strategy for triaging helped to shorten the diagnostic pathway,  detect cancer earlier, increased endoscopy capacity and avoided unnecessary invasive tests.

“The FIT programme has since been expanded to provide safety netting for patients on the backlog for colonoscopy surveillance.”

The approach to implementation of the project can be readily replicated, and has been within Cheshire and Merseyside to support implementation of optimal timed cancer pathways and rapid diagnostic services.

The project to roll out FIT as a diagnostic tool across Cheshire and Merseyside has shown that utilising leadership and partnership working across multiple organisations and networks can have a demonstrable impact in a short time period.

By working together, we can achieve and overcome challenges in incredibly testing times.

You can find out more about NHS Bowel Screening and FIT at this website: https://www.nhs.uk/conditions/bowel-cancer-screening/