Annual Report 2014 - Reporting on the Quality and Efficiency Support Team

Part 07: Cancer

ABOUT THE PROGRAMME

David Linden
t: 0131 244 3288
e: david.linden@scotland.gsi.gov.uk

drivers

Every year, about 30,000 people in Scotland are diagnosed with cancer and trends predict that the number is likely to rise to almost 35,000 in 2016-2020. The reason for this increase is that there are more elderly people in the population and life expectancy is increasing further.

Over the last 20 years, almost all cancers have shown improvements in survival five years after diagnosis and survival rates from cancer in Scotland are broadly similar to those in England and Wales.

The Cancer Programme focuses on three key areas:

• Sustaining cancer waiting times standards performance
• Cancer Modernisation: further improvements in the effectiveness, efficiency and patient centredness of service delivery
• Detect Cancer Early: contributing to and improving five year survival from cancer for the population of Scotland, through earlier diagnosis and treatment

aims

Over the last few years, cancer services have developed and improved significantly with more doctors, nurses and other healthcare professionals and state of the art equipment in all five cancer centres. The Scottish Cancer Taskforce Cancer Modernisation Programme aims to build upon the progress already made in effective and efficient cancer service delivery, further improving patient experience and patient outcomes, whilst managing the anticipated increase in cancer incidence.

The Detect Cancer Early Programme aims to increase the proportion of people diagnosed and treated in the first stage of breast, colorectal and lung cancer by 25 per cent by 2015.

workstreams

• Cancer waiting times performance support
• Detect Cancer Early Programme
• Acute oncology service delivery, including development of national chemotherapy helpline
• Surgical oncology, including enhanced recovery after surgical treatment
• Radiotherapy, including the capacity and capability for radiotherapy treatment
• Transforming Care After Treatment Programme

achievements 2014

Cancer Waiting Times Standards Performance

• NHSScotland achieved and sustained performance above 95 per cent in all Cancer Performance Support quarters against the 31-day cancer access target throughout 2013.
• During the final quarter, October to December 2013, 94.6 per cent of patients started treatment within 62 days of urgent referral with a suspicion of cancer. Within the same period, 97.9 per cent of patients started treatment within 31 days of decision to treat, irrespective of the route of referral.
• The team continue to maintain scrutiny of cancer waiting times performance and are providing support to those NHS Boards where there are challenges to sustained above standard performance.

Cancer Modernisation

• The development and piloting of the 24-hour cancer treatment helpline.
• The Radiotherapy Programme Board (RTPB) was established in June 2012 to drive forward improvement work across Scotland. The RTPB reports to the Scottish Cancer Taskforce. A cohesive work-plan has been developed and implementation of the RTPB's objectives is supported by the wider Radiotherapy community. RTPB priority areas of work include:
  • Development of national pathways to ensure equity of access to new innovative techniques and technologies
  • Continued development of workforce capacity and capability
  • Development of evidence based consensus treatment protocols and pathways
  • Robust patient engagement to better understand and improve the experience of radiotherapy
  • Development of future models of working that meet the rising incidence of cancer and radiotherapy demand
  • Promotion of clinical trials and research, and the unique opportunities that exist within Scotland
  • Proactive commitment to exploring new technologies and techniques to ensure Scotland's radiotherapy programme is up-to-date and well prepared
  • Collaboration with our NHS colleagues across all UK countries, and Europe, to better understand the cost-benefits of radiotherapy

Transforming Care After Treatment Programme

• The Transforming Care After Treatment (TCAT) Programme was launched in May 2013 and aims to ensure that people diagnosed with cancer are prepared for and supported to live with the consequences of the diagnosis and its treatment.
• To achieve this aim, Macmillan Cancer Support is working in partnership with the Scottish Cancer Taskforce and providing up to £5 million in funding over the next five years, supporting clinical teams and other partners to review, redesign and test new approaches and models of cancer care after treatment.
• The Programme focuses on redesign of current models of cancer follow-up, managing the transition between acute care and home, and enablement and support for effective self-management.
• It builds upon what has already been achieved in Scotland and other parts of the UK and also contributes to the delivery of the Healthcare Quality Strategy. The timing of this development coincides with a growing appetite for greater collaboration and mutuality across the public sector.
• The Scottish Cancer Taskforce will monitor progress of the programme to ensure that there is delivery against focused, evidenced outcomes that will inform ongoing commissioning of services.

Detect Cancer Early Programme

• Development and launch of priming, breast, bowel and lung cancer social marketing campaigns.
• Development of systems and processes for data collection to support the Detect Cancer Early HEAT target.
• Development and implementation of nGMS contract element to support the primary care contribution to increasing bowel screening programme participation and improvement.
• An e-health refresh of the GP referral guidelines for suspected cancer and progression of education sessions for primary care professionals.
• Funding to support diagnostic and treatment capacity building.

priorities 2015

• Sustain cancer waiting times standards performance
• Cancer Modernisation
  • Further rollout of cancer treatment helpline
  • Continue to support safe, efficient and patient-centred radiotherapy treatment delivery and Radiotherapy
• Programme Board work-plan
  • Support Transforming Care After Treatment project development and Implementation
• Detect Cancer Early
  • Develop breast screening social marketing campaigns
  • Support further lung, breast and colorectal campaign activity bursts
  • Support NHS Boards to build capacity in diagnostics and work towards HEAT target achievement
  • Continue to support development and implementation of cancer referral guidelines
  • Continue to support national nGMS bowel screening initiative
  • Programme evaluation
  • Explore potential for inclusion of further tumour types to programme

http://www.qihub.scot.nhs.uk/quality-and-efficiency/cancer.aspx

Programme Case Study

Detect Cancer Early - Bowel Cancer

Background and context

The Detect Cancer Early (DCE) programme forms part of the work of QuEST's Cancer Performance Support Team.

The DCE programme was formally launched in February 2012 and aims to improve the overall five year survival rates for people in Scotland diagnosed with cancer.

The incidence of cancer in Scotland has increased over the last 10 years from 26,169 cases (2000) to 29,449 cases (2010) largely due to an ageing population. Individuals living in deprived communities have an increased incidence of cancer and a higher mortality rate.

The DCE programme has an associated HEAT target to increase the proportion of people diagnosed at stage 1 (as a proxy indicator of survival outcome) for the three most common cancers in Scotland - lung, breast and colorectal cancer. If successful, this initiative could save an additional 300 lives a year.

Problem

Bowel cancer is the third most common cancer in Scotland - every year, almost 4,000 people are diagnosed with the disease.

Although bowel cancer is common, it is also highly treatable if detected early - 9 out of 10 people beat bowel cancer when it is found early.

However, one issue that people face is the fact that the early signs of bowel cancer are often hidden - symptoms regularly cannot be seen or felt. The most effective way to detect bowel cancer in its earliest stage is through screening. This helps determine whether there is any presence of blood in stools, which can indicate the presence of cancer cells, long before an individual or their doctor notices them. Figures show that 28.3 per cent of all cancers detected by screening are at the earliest stage, when it is easier to treat and the chance of survival is higher.

All men and women between the ages of 50 and 74 are invited to participate in the national bowel screening programme every year. Those aged over 74 can request a screening kit via the Scottish Bowel Screening Helpline.

Currently, just over half of the approximate 750,000 people who are eligible to participate in screening each year, actually do (54.5 per cent) with 57 per cent of that figure being women and 51 per cent men. Data shows that this figure falls into the thirties for men living in the most deprived areas of Scotland, who are more at risk of bowel cancer.

Aim

The overall objective of the Detect Bowel Cancer Early campaign was to increase uptake in participation in the National Bowel Screening Programme. To do so, social marketing had a key role to play in shifting behaviours by:

• Educating people that the best way to survive bowel cancer is to detect it early, by taking the bowel screening test
• Empowering those eligible for bowel screening to do so

Action taken

Approach

Evidence suggests that the main barrier to completing and returning a kit is the fact that people do not believe they are at risk of bowel cancer. This can be explained by a lack of understanding about the disease i.e. not knowing that your risk increases with age. Embarrassment around the subject matter and nature of the test also creates obstacles for people completing and returning kits.

In order to overcome these barriers and shift behaviours and beliefs surrounding one of Scotland's most common cancers, the social marketing approach had to be carefully considered.

Scale: In order to normalise bowel screening and generate conversations about the subject, in turn releasing the social stigma attached to it, a wide-spread, multi-channelled media campaign was needed.

Empowerment: While positioning bowel screening as the best way to detect the disease early, a person's decision to take part is a personal one. This had to be mirrored across all materials in order for the target audience to feel more engaged and informed about the issue.

Messaging: The campaign's core key messages had to be crafted to educate and empower the target audience about bowel cancer and the test i.e. 'bowel cancer is the third most common cancer in Scotland', 'bowel screening is the best way to detect bowel cancer early'.

Male skew: To overcome the embarrassment surrounding the subject matter, and appeal to the male-skewed audience, a touch of humour was carefully peppered in the creative brief.

Campaign

The Scottish Government's first bowel cancer campaign launched in February 2013 for six weeks. This was followed by an additional two phases of activity in September 2013 and March 2014 that both ran for one month.

Central to the campaign was a bold TV advert, featuring the voice of Scottish actor, Ford Kiernan. The advert used some humour and was based on the concept that Ford Kiernan was an invisible man, informing a regular guy on the toilet about the facts he didn't know about bowel cancer i.e. 'the early signs are often hidden'.

This was not the only time humour was used throughout the campaign to appeal to the male-skewed target audience. A 'poo song' was specially penned and orchestrated to increase talkability around the subject and encourage the campaign's key messages to be shared amongst the target audience and their influencers.

For the print creative, multiple executions were developed all carrying one of the core campaign messages:

• The early signs of bowel cancer are often hidden
• Nine out of 10 people survive bowel cancer when it is detected early
• The best way to find bowel cancer early is to do your home screening test

The channel being used determined the execution adopted. However, regardless of the execution, the call to action was clear and consistent - 'Bowel Cancer. Don't Take a Chance. Take the Test.' This was accompanied by the Scottish Bowel Screening Centre Helpline number and the campaign URL - www.bowelscreeningtest.org - that directed people to the screening zone on NHS Inform if they wanted/needed any more information about bowel cancer or the national screening programme.

A partnership engagement programme was also put in place, in order to reach more men with our campaign messages. Football clubs across Scotland were engaged and asked to publicly support the campaign and encourage their followers and fans to do the test when invited.

See example of press ad below.

Channels

Our target audience are big consumers of commercial TV and trust the channel to deliver health messages. So, we used this medium to generate widespread awareness and create maximum impact, while landing more detailed campaign information. A 40-second-advert was broadcast alongside a 20-second version that featured a more detailed call to action, including details on who is eligible for the test and the phone number of the bowel screening helpline.

Press advertising was the main support to TV - a crucial channel in reaching the core DE male audience, while supporting a good spread of key messages to women. As well as ads running across key national titles, helping maintain momentum and mass awareness, opportunities to further target men were explored where possible for example, placing an insert in the Racing Post or a campaign advert in the Scottish Cup Final programme.

Three different radio executions were developed - two carrying generic campaign messages from the TV advert while the third promoted a stronger, in-depth call to action. The same voice-over artists were however used to ensure the link between the two were made. These were aired across Scotland's key stations, weighted to peak listening times such as morning and drive-time shows when our target audience are more likely to be listening.

A targeted approach was taken to outdoor - small formats were used to upweight areas of high deprivation and low screening uptake, including:

• Lenticular posters (a message is hidden then revealed): Over 800 appeared in washrooms in bars and clubs as well as in Rangers and Celtic football club stadiums.
• Toilet cubicles: 500 panels appeared in target areas.
• Bus headliners: Over 2,000 were placed in buses covering routes in Glasgow, Edinburgh, Forth Valley and Lanarkshire where screening is lowest.

Following the initial launch in February, we knew that in order to shift attitudes and foster social norming, regular bursts were needed. Two lower weight phases therefore followed - the first included TV while the second saw TV, radio, outdoor, press and digital rolled out.

Underpinning all campaign spikes was PPC activity, directing anyone searching for more information on bowel cancer to www.bowelscreeningtest.org.

All this activity was supported by field and PR. One-to-one engagement through field events took place in 60 locations across Scotland, with an emphasis on the East and West regions, where a high percentage of the population live in deprived areas, and are at higher risk of bowel cancer. Event staff also visited high attendance football matches where we were able to directly target and engage with large numbers of men.

Meanwhile, the PR team worked closely with key stakeholder, Bowel Cancer UK, to ensure that there was a drumbeat of bowel cancer media coverage landing throughout the campaign spikes and beyond. This included piggybacking on any reactive opportunities possible, for example organising a photocall with the Birds of a Feather cast when they were in town, to appeal to older women.

Results

Overall, independent quantitative research shows positive shifts in behaviour amongst our target audience (45+ C1C2DE), for example:

• Almost half (48 per cent) strongly agree that 'the best way to detect bowel cancer early is to use the home screening kit'. This is compared to just 31 per cent prior to the campaign going live.
• Almost three quarters (72 per cent) say they are very likely to do the test the next time they receive it, compared to 63 per cent before the campaign.

Alongside this:

• The number of helpline calls per 1,000 invitations saw a huge increase, compared to previous years, immediately following the first campaign spike (Feb 2013), with highs of a rate of 89 per 1,000.
• Data shows noticeable increases in replacement kit requests across 2013, with October seeing the biggest increase, compared with previous years, as a result of the second phase of activity (Sep 2013).
• Latest validated statistics from ISD show an increase in bowel screening uptake of 1.2 percentage points (56.1 per cent from 54.9 per cent) for the period November 2011 to October 2013.
• Uptake for females was 58.8 per cent and for males was 53.3 per cent.
• Uptake has increased across all deprivation quintiles with the highest increase in men in the most deprived communities (2.1 per cent increase)
• Uptake for females in the two least deprived quintiles exceeded the 60 per cent standard at 68.0 per cent and 64.8 per cent, respectively. Uptake for males living in the least deprived quintile was at 61.5 per cent. For males living in the most deprived quintile the uptake was 41.7 per cent.
• More than half of screen detected cancers (57.8 per cent) were diagnosed at Dukes' stage A and B. The earlier a cancer is detected, the greater the chances are of successful treatment.
• The 'poo song' received 74,316 views on YouTube.
• The 'how to do the bowel cancer test' film received 3,629 views.
• PR activity generated 274 pieces of coverage with a value of £952,924 and over 30 million opportunities to see or hear about the campaign.
• An array of famous faces backed the campaign - ten Scottish football clubs, Dorothy Paul, Janey Godley and the cast of Birds of a Feather.
• During the face-to-face engagement events, around 20,500 in-depth engagements took place.
• The Detect Cancer Early page on NHS Inform (under 'Cancer Zone') received 5,379 visits during the three campaign periods while the bowel screening page (under 'Screening Scotland') had 8,385. The graphs below demonstrate the increase in traffic around campaign times - the red circles mark the start of each campaign while the dots on the graph represent the 1st of each month.

Sustainability

To support earlier detection of bowel cancers a new two year GMS contract initiative was introduced in 2013 focusing on bowel screening uptake through shared decision making in primary care. The DCE programme has enabled new IT solutions between the national bowel screening centre and GP practices enabling information on individual patient's uptake of screening and subsequent results to be loaded direct into GP systems, this will support primary care to raise the issue of bowel screening with their eligible practice population.

Next steps

While independent tracking research shows positive shifts in attitudes towards the value of bowel screening and the hidden nature of its symptoms, more work needs to be done to make taking the test the 'social norm'.

The same creative has been running since February 2013 and while campaign recognition has maintained across this time, there is a real risk that it could become wallpaper, resulting in people switching off from its messaging.

Also, another point to note is the fact that while the Scottish National Bowel Screening Centre, has noticed a remarkably sharp rise in the number of people requesting a replacement kit, similar numbers aren't being noticed in the volume of returned tests. We therefore need to review how/if social marketing can support in filling this gap and encourage those who request a kit to do the test and return it. This could well mean tweaking our messaging or up-weighting the role of influencers.

As with all tumour types, fear is a barrier that prevents people from engaging with national screening programmes or presenting to their GP with potential symptoms. This behaviour will be addressed as part of a new strand of activity that falls under the DCE umbrella. The 'wee c' aims to reduce the fear surrounding cancer (regardless of the tumour type), helping shrink the 'big c' to the 'wee c'. This is a long-term task so a more consistent strand of communication, focused on increasing early detection rates in Scotland, will be introduced early next year.