National Bowel Cancer Screening Program Policy Framework Phase Four (2015-2020)

Objectives

The National Bowel Cancer Screening Program Phase Four framework aims to reduce bowel cancer incidence, illness and mortality by detecting cancers and pre-cancerous lesions early, when treatment is most effective.[1]It guides phased implementation of free biennial screening for eligible people aged 50 to 74, with full biennial coverage intended by 2020.[2][1][3]The programme uses an immunochemical faecal occult blood test as the population screening test and seeks to balance early detection and prevention benefits against potential harms, access barriers and resource requirements.[4][5][6]

• Maximise participation and equitable access, especially for Aboriginal and Torres Strait Islander people, culturally and linguistically diverse communities, rural and remote populations, people on low incomes, people with disability, and groups with low literacy or health literacy.[7][8][3]
• Provide timely, appropriate, safe and high-quality diagnostic assessment after a positive screening result, generally through colonoscopy and associated histopathology.[7][9]
• Maximise benefits and minimise harm through evidence-based screening, quality control, informed choice, confidentiality and respect for participant autonomy.[7][6]
• Maintain cost-effectiveness, accountable management and effective use of available resources while expanding screening and colonoscopy capacity.[7][10][6]
• Collect and analyse data to monitor participation, pathway progression, outcomes, effectiveness, equity and programme performance.[7][11]
• Promote prevention alongside screening by addressing tobacco smoking, obesity, alcohol consumption, red and processed meat consumption, physical inactivity and low dietary fibre intake.[5]

The framework is aligned with the Australian Population Based Screening Framework and relevant National Health and Medical Research Council clinical guidance, including the recommendation for immunochemical faecal occult blood testing every two years for people aged 50 to 74 at average or slightly above-average risk.[2][7][12]Its intended screening pathway covers invitation, testing, pathology analysis, notification, primary care assessment, diagnostic investigation, treatment and surveillance within usual health services.[9][6][13]

Implementation

Phase Four uses a nationally coordinated, population-based delivery model in which the Australian Government leads screening policy, programme governance, contracts and expenditure, while state and territory governments support usual care, public colonoscopy services, workforce and service capacity.[14][15][16]Eligible people are identified principally through Medicare and Department of Veterans’ Affairs data, invited around their eligible birthday, mailed a test kit and reminders, and supported through a Register-based pathway following a positive result.[4][3][13]

• Deliver invitations, test kits, pathology analysis and participant information through contracted register and pathology providers, supported by the Programme Information Line and programme website.[14][17][3]
• Refer participants with a positive result to a general practitioner for assessment and clinically indicated colonoscopy or other investigation, with positive results generally communicated within two weeks.[9][3][13]
• Provide follow-up through state and territory Participant Follow-up Function officers, who contact participants or health professionals where required action after a positive result is not recorded.[18][15]
• Use reminder letters and telephone contact at defined intervals to monitor whether general practitioner assessment and colonoscopy have occurred after a positive result.[9][13]
• Support locally tailored participation initiatives through Primary Health Networks, general practitioners, nurses, communications, translated materials, interpreting services, alternative invitation projects and pilots for priority populations.[19][8]
• Implement the National Indigenous Bowel Screening Pilot with Menzies School of Health Research, enabling participating Indigenous primary health care services to offer kits directly and support follow-up.[8]
• Manage high-temperature risks by adapting kit storage and return instructions, providing hot-weather guidance and scheduling invitations in cooler months in designated hot-zone postcodes.[9][3]

Governance is coordinated by the Department of Health, with high-level policy decisions made by the Australian Government Minister for Health and advice provided by the Clinical Advisory Group and Program Delivery Advisory Group.[14][17]The Standing Committee on Screening reports through the Community Care and Population Health Principal Committee to the Australian Health Ministers’ Advisory Council, and significant framework updates are subject to appropriate endorsement.[2][15][11]Health professionals, including general practitioners, gastroenterologists, colonoscopists, surgeons, nurses and pathologists, provide clinical services and contribute pathway and outcome data to the Register.[15][19]

Quality assurance combines a Quality Framework, audits of contracted service providers, national work on colonoscopy accreditation and clinical standards, proceduralist certification and training, and minimum reporting requirements linked to performance indicators.[14][20][10]Monitoring includes participation, test positivity, diagnostic assessment, time from positive screening to assessment, adenoma and colorectal cancer detection, positive predictive value, interval cancer, adverse events, incidence and mortality.[21]The Australian Institute of Health and Welfare produces annual monitoring reports, while operational reports are provided six-monthly to Health and jurisdictional programme managers where meaningful data are available.[11]Planned five-yearly and ad hoc reviews assess programme elements, emerging technologies, effectiveness, governance and delivery implications.[21][22]

Programme expenditure managed by the Department of Health includes screening tests, pathology analysis, Register services, follow-up support and associated services, while Medicare support applies to relevant consultations and private-sector follow-up.[14][15]The Australian Government committed a further 95.9 million Australian dollars over four years in the 2014–15 Budget to accelerate biennial screening by 2020.[3]

Monitoring & Evaluation

The National Bowel Cancer Screening Program uses a comprehensive monitoring and quality-improvement system spanning participation, test performance, diagnostic assessment, clinical outcomes, service quality, data completeness and programme governance. It is designed to support continuous improvement as biennial screening is expanded for eligible people aged 50 to 74.[1][11][21]

• Monitor performance indicators covering participation, screening positivity, diagnostic assessment, time from a positive result to assessment, adenoma detection, positive predictive value, colorectal cancer detection, interval cancer, pathological stage, adverse-event hospital admissions, bowel cancer incidence and mortality.[21]
• Track the expected immunochemical faecal occult blood test positivity range of 4 to 10 per cent, with the Australian Institute of Health and Welfare and Department of Health using the relevant performance indicator and piloting statistical process control to identify material changes requiring investigation.[4]
• Record screening results, referrals, non-referrals, colonoscopy outcomes, diagnoses, participant pathway status and outcomes in the National Cancer Screening Register, subject to applicable state and territory privacy requirements.[15][19][13]
• Follow up participants with positive results when required clinical action is not recorded, using Participant Follow-up Function officers, Register letters and telephone contact.[18][15][13]
• Report agreed performance indicators annually through Australian Institute of Health and Welfare monitoring reports, provide six-monthly operational reports to Health and jurisdictional programme managers, and publish programme monitoring and evaluation reports on the programme website.[14][11]
• Address data gaps caused by voluntary or manual reporting and incomplete clinician participation by improving Register reporting functions and linking performance monitoring to the Quality Framework.[11]
• Maintain a Quality Framework that supports regular monitoring, review, evaluation, continuous quality improvement and audits of contracted service providers.[14]
• Apply accreditation, certification, training, minimum reporting and clinical performance indicators to strengthen colonoscopy quality, while using Medical Benefits Scheme items 32088 and 32089 to monitor follow-up colonoscopy activity and related characteristics.[10]
• Review the programme regularly under the Australian Population Based Screening Framework, with a Program Review Plan intended to support preferably independent five-yearly reviews and additional reviews when significant issues arise.[11][22]
• Undertake a planned 2017–18 evaluation of effectiveness, cost-effectiveness, governance and the biennial-screening model, using bowel cancer mortality among relevant outcome measures.[23]
• Recognise pathological stage distribution and adverse-event hospital admissions as aspirational indicators because relevant data was not yet available, with reporting intended when data becomes available.[21]
• Maintain accountability through Department of Health management of governance, policy, implementation, contracts and expenditure, with governance reporting progressing from the Standing Committee on Screening to the Community Care and Population Health Principal Committee and Australian Health Ministers’ Advisory Council.[14][15]
• Protect Register data under the Privacy Act 2008, Australian Privacy Principles and National Cancer Screening Register Act 2016, including data-breach notification and controlled research access arrangements.[18]

Costing & Financing

Funding combines Australian Government support for national programme administration, screening and follow-up functions with state and territory responsibility for public-sector diagnostic and treatment services. Although several commitments and economic estimates are identified, the material does not provide a consolidated programme budget, recurrent cost profile, funding gap or resource-mobilisation plan.[14][15][24]

• Fund programme expenditure through the Department of Health for immunochemical faecal occult blood test screening, pathology analysis, Register services, associated support services, participant follow-up support and relevant Medicare Benefits Schedule assistance.[14]
• Provide direct funding to states and territories for the Participant Follow-up Function through a multilateral National Partnership Agreement under the Federal Financial Relations Framework.[18]
• Support Medicare-funded consultations, private-sector colonoscopies, histopathology and other private-sector follow-up, while fund public-hospital colonoscopy services through relevant Australian Government and jurisdictional arrangements.[15]
• Require privately treated participants to meet provider gap payments despite receiving the applicable Medicare rebate, while public colonoscopy and histopathology are managed through state and territory hospital systems.[9]
• Commit a further 95.9 million Australian dollars over four years in the 2014–15 Budget to accelerate biennial screening for people aged 50 to 74 by 2020.[3]
• Identify Phase Four funding for guideline revision, colonoscopy re-certification and training, and development of a national safety and quality model, without specifying allocations.[10]
• Fund Menzies School of Health Research to develop and implement the National Indigenous Bowel Screening Pilot, while making further access initiatives for under-screened communities conditional on available resources.[8]
• Estimate that advanced bowel cancer costs the health system more than 100,000 Australian dollars per case.[24]
• Estimate gross costs of 150 million Australian dollars for full biennial screening of people aged 50 to 74, with projected mortality reduction of 15 to 20 per cent and an undiscounted cost of 25,000 to 41,667 Australian dollars per life-year gained compared with no screening.[24]
• Identify cost-effectiveness as a criterion for programme design, review and evaluation, including consideration of costs associated with phased implementation of age cohorts.[21][23][6]
• Record participant-paid prices for some non-government screening kits and Commonwealth funding of 2.5 million Australian dollars to the Jodi Lee Foundation over 2012–13 to 2014–15 for awareness and participation activities.[25][26]