Investigating participation in the Australian National Bowel Cancer Screening Program through general practice: a survey on practices, challenges and digital opportunities

Introduction

In 2022, it was predicted that 15,713 Australians would develop bowel cancer, resulting in an estimated 5326 lives lost.^1,2 With more than 39,400 general practitioners (GPs) in the Australian primary healthcare workforce, providers can expect, on average, to diagnose fewer than one patient every 2 years with the disease. This limits the potential for bowel cancer prevention and early detection to be prioritised within the practice setting.³ Bowel cancer screening using an Immunochemical Faecal Occult Blood Test (iFOBT) is a proven effective public health method of early detection and demonstrates high efficacy in reducing population morbidity and mortality.⁴ The Australian National Bowel Cancer Screening Program (NBCSP) is a public health program that involves the distribution of self-administered iFOBT kits every 2 years to adults aged 50–74 years. In July 2024, the Australian Government announced the introduction of a lowered age eligibility, from 50 years to 45 years, through ‘opt-in’ access to the program for younger age cohorts. Despite the widely publicised benefits of participating in the Australian NBCSP uptake remains low, with 40.9% of eligible Australians returning their kit between 2020 and 2021.^5,6

It has been well established within scientific literature that GP endorsement is an effective strategy for increasing uptake in population bowel cancer screening programs.^7–11 Despite the influence GPs have, there remain several barriers that inhibit GP endorsement of the NBCSP as part of routine practice. These include gaps in knowledge and a lack of education/quality improvement resourcing for GP engagement with the NBCSP and competing priorities.^12–14 Previous studies, however, have been limited to the exploration of current practices to promote patient participation in the NBCSP and enablers/opportunities for consistently endorsing patient participation. The National Cancer Screening Register (NCSR) is an interoperable digital platform that holds the contact details, eligibility status and kit delivery and return data for all NBCSP invitees.¹⁵ Integration between GP electronic medical records (EMR) software and the NCSR has been enabled via the NCSR Healthcare Provider Portal, allowing GPs access to their patients’ screening statuses within the NBCSP and providing clinicians with an on-screen prompt to engage those patients overdue for screening in conversation.^16,17

The aim of this study was to gain a comprehensive understanding of current general practice knowledge of the NBCSP and existing health promotion strategies that are encouraging NBCSP participation. This study further sought to understand the barriers and enablers to promoting the NBCSP in general practice and to identify the resources, knowledge and systems required to enable routine endorsement of the NBCSP in general practice through practices such as accessing the NCSR Healthcare Provider Portal.

Methods

This study applied a mixed methods approach via a 52-item online survey (see Supplementary Material) of a cross-section of general practice staff in metropolitan Brisbane, Australia, from May to June 2022. The present study focuses on the analysis of 24 included items. Participants were general practice staff working in the Metro South Hospital and Health Service. Eligibility criteria included (i) being aged 18 years and older, (ii) able to read and understand English, and (iii) being registered and working as a GP, practice nurse or practice manager. Participants received A$50 remuneration as compensation for their time. Invitations to participate were distributed to all practices within the Metro South region (n = 320) via direct email using contact details publicly available online and from the Queensland Health Secure Transfer Service address book, which lists health service providers registered in Queensland. Invitations contained a participant information sheet and a promotional flyer featuring a weblink to the survey tool. This study was approved by the Metro South Human Research Ethics Committee HREC/2021/QMS/77486.

Items were developed and selected through extensive consultation with key government health professionals, GPs and reference to a relevant study on GP endorsement of the NBCSP.¹²

Survey data were analysed and graphed using a combination of Microsoft Excel and IBM’s Statistical Package for Social Sciences (SPSS Statistics 22). Frequencies and proportions of responses were calculated for the sample. Comparisons were made according to the participant’s role in general practice using Pearson Chi-squared analyses with between-column z-tests to identify whether participants in specific roles were significantly more or less likely to endorse a response. Answers to open-ended questions underwent inductive thematic analysis whereby identical and highly similar responses were collapsed into single conceptual codes and summarised.¹⁸

Results

Eighty-eight participants completed the survey. Of these participants, 74 were female, 38 were practice nurses, 26 were GPs and 24 were practice managers (see Table 1). The majority of participants (n = 51) were born in Australia aged between 30 and 50 years and had worked in general practice from 1 to 37 years (mean = 8.32, s.d. = 6.97).

To maintain participant anonymity, identifying information about each participant’s practice was not collected. It was suggested from a review of the approximate location of IP addresses (which were not linked to response data) that respondents most likely came from approximately 75 different practices. Practice characteristics of the sample are therefore not presented, except to say that practices from which the participants came varied in size ranging from 1 to 22 GPs, 1 to 16 registered nurses and 1 to 20 receptionists. Results are reported below according to the study aims they addressed.

Opportunities to enable routine endorsement of the NBCSP to patients

When presented with a list of potential resources, knowledge and system changes as useful strategies for promoting NBCSP participation in general practice, over 90% of participants reported that improved streamlined integration between the NCSR and general practice EMR (i.e. providing GPs with access to up-to-date NBCSP data for their patients) would be a helpful strategy (see Fig. 1). Over 70% indicated that an automated system that sends an SMS to promote participation in the NBCSP to eligible patients would be beneficial. Quality improvement (QI) and practice incentives programs (PIP) with activity templates, training and automatic production of reports from EMR to identify active eligible patients who have not completed an iFOBT were also identified as helpful strategies.

Fig. 1.

Factors that would enable general practitioners, practice nurses and practice managers to promote the national bowel cancer screening program (NBCSP) to patients. *Significance difference (Pearson’s Chi-square <0.5).

When asked about an integration between the NCSR and EMR, several GPs reiterated that because of the current lack of integration, data had to be entered manually, and this was time-consuming and may lead to inaccuracies; however, others did not see any challenges or issues with the proposed solution. When questioned on automatic production of reports from EMR identifying active eligible patients who have not completed an iFOBT, GPs were mixed in their responses. Some reported seeing no challenges, while others were concerned about time constraints, lack of incentive and the potential inability to filter out colonoscopy results from the records. Some participants reported concerns about using lists to notify patients via SMS as opposed to the list generation itself. In these cases, concerns about patient access to technology and awareness or acceptance of being contacted were issues. Time constraints and lack of training for staff were also cited by many as concerns (Fig. 2).

Fig. 2.

Barriers to promoting the national bowel cancer screening program (NBCSP) in general practice overall, for general practitioners (GPs), practice nurses and practice managers. *Significant difference between respondent groups (Pearson’s Chi-square <0.05).

Finally, participants were asked to provide open-text responses suggesting additional strategies to increase participation in the NBCSP. Suggestions included the need to tailor approaches to priority population groups who experience further barriers to accessing the NBCSP, such as campaigns targeting promotion to patients who are Culturally and Linguistically Diverse (CALD), screening options/pathways for people who are intellectually disabled and/or institutionalised, and bowel cancer screening messaging through men’s health initiatives. Other suggestions included education and improved media coverage including improved public education campaigns, social media advertising and positive messaging highlighting the benefits of screening for bowel cancer. Some participants stated the need for MBS incentives, having test kits available to hand directly to patients (either from the NBCSP or private pathology), improved integration of NCSR and GP software as well as resources, training and information packages to support general practice staff in the facilitation of NBCSP promotion to their patients (Fig. 3).

Fig. 3.

Perceived helpfulness of strategies for supporting general practice to promote the national bowel cancer screening program (NBCSP) to patients. Abbreviations: NCSR, national cancer screening register; GP, general practitioner; EMR, electronic medical record; QI, quality improvement; PIP, practice incentives programs; PHN, primary health network; FOBT, faecal occult bowel test; SMS, short message service.

Discussion

The aim of this study was to gain a comprehensive understanding of current general practice knowledge and existing health promotion strategies encouraging NBCSP participation within the Australian community. This study further sought to understand the barriers and enablers to promoting the NBCSP in general practice and the resources, knowledge and systems required to enable routine endorsement of the NBCSP in general practice. Despite propitious attitudes towards the NBCSP, general practice staff disclosed several barriers inhibiting their ability to promote the NBCSP to patients: lack of time, low patient awareness, absence of an MBS item number to claim reimbursement and the lack of data integration/digital systems to facilitate identification of patients due to complete screening.

NBCSP promotion techniques in place were largely passive, including displaying posters and pamphlets in the waiting room, the effectiveness of which is often limited in terms of influencing behavioural change within patient cohorts.¹⁹ The lack of specific incentives or reimbursement for the GP, together with time constraints and competing priorities, often meant that more proactive forms of NBCSP endorsement were not a priority during regular consultations, with only 2% of participants reporting that NBCSP promotion was routinely imbedded in usual care within their practice. These findings reinforce the importance of providing compensation to general practice for the promotion of the NBCSP. This is supported by existing evidence that emphasises that the allocation of resources and prioritisation in primary healthcare is largely dictated by the financial resources available, meaning acute and chronic care is often prioritised over prevention.²⁰ Encouragingly, incentivisation for general practice endorsement and facilitation of the Australian National Cervical Cancer Screening Program is well embedded into usual care practices through both the MBS and the Practice Incentives Program Quality Improvement Incentive (PIP-QI).^21,22 Similar to the MBS, the PIP-QI provides financial incentivisation to general practices to encourage the prioritisation of patient engagement and quality improvement initiatives to improve patient outcomes.²³ Similar strategies for increasing GP engagement with the NBCSP could increase program uptake.

Digital systems for identifying and notifying general practice patients eligible and due for bowel cancer screening through the NBCSP are a key priority for The Royal Australian College of General Practitioners.²⁴ In the current study, these systems were generally welcomed but not often used. Although records of patients’ screening status are available through the NCSR Healthcare Provider Portal, there is currently no readily available mechanism in place to automatically integrate this data into patient medical records, and to complete this manually would be an insurmountable task for most practices. This issue was echoed in a recent systematic review demonstrating the lack of digital interventions available for promoting cancer screening in general practice settings.²⁵ Digital interventions that have been piloted have been met with success.^16,17 For example, the delivery of an NBCSP GP endorsement SMS was recently shown to increase screening uptake by 16.5%, a substantial increase in comparison to many other intervention techniques.²⁶ Implementing and sustaining such an intervention as part of routine practice will require streamlined systems for identifying and notifying patients due for screening.

Similar to previous studies, data highlighted the difficulties caused by high workloads, competing priorities and lack of resources to endorse participation in the NBCSP to patients.¹³ Given the current pressure on general practice caused by the ongoing burden of COVID-19, time-related barriers affecting healthcare providers’ opportunity to engage in the endorsement of the NBCSP are further compromised and require alternative ways to be discovered to prioritise screening. Practice managers and nurses expressed a desire for further education and resources and were more likely to suggest a lack of knowledge, awareness and resources as barriers, while GPs more often cited lack of incentive or time as factors impacting NBCSP endorsement. It is recommended that future quality improvement initiatives focus on supporting general practices through the adoption of strategies that harness NCSR integration with clinical software and remuneration as a support mechanism to successfully guide patients to participate in the NBCSP. Clinical decision support systems (e.g. Topbar) are one potential avenue for facilitating GP cancer screening prompts during consultations. These systems are designed to assist GPs and other healthcare professionals at the point of care. Integrating medical software systems, they provide real-time on-screen alerts about gaps in patient records and suggest opportunities for care improvement. Software integration is made possible because of the Australian NCSR; however, the translation of findings into practice on a global scale will largely be influenced by the mode of screening delivery and the current involvement of general practice across the patient pathway. Although all members of the population should be encouraged to participate in the NBCSP, extending the success of the NBCSP to priority populations currently under-represented in participation rates is paramount.

These findings contribute new evidence regarding the resources, preferences and system-level requirements to support routine GP endorsement of the NBCSP. Findings provide useful preliminary data to inform research and intervention development in the future; however, they cannot be interpreted as generalisable to all practices. This is especially true for practices providing services to priority groups where they are likely to have additional barriers to and challenges engaging in preventative health messaging with their patient cohorts.

Although GPs were involved in the design of the survey, the interpretation of findings may have benefitted from input from a GP co-investigator; this is a key consideration for future research on the topic. Another limitation relates to the low survey response rate, which may limit the generalisability of study findings across general practice in Australia. Similarly, response bias may have been present whereby important _characteristics of the responding sample may have differed from those of non-responders. For example, in 2023 females accounted for 49.6% of the GP workforce in Australia, whereas our sample was made up of 84.1% females.²⁷

Conclusion

Although strongly supported by the evidence, routine involvement of general practice in population-based bowel cancer screening programs is challenging, and adaptions to existing systems are required. Our study findings confirm the willingness of GPs and other practice staff to become involved in providing the additional support required to increase NBCSP participation. GPs referenced the need for incentivisation as the key motivator to conceptualise this idea. Further quality improvement initiatives and research opportunities may improve non-adherence to NBCSP participation through the use of clinical audits and software integration in primary care facilities. Despite the willingness of GPs and other practice staff to prescribe and endorse the NBCSP to eligible patients, there is a clear need for incentivisation and system-level improvements to facilitate the easy identification of patients due to complete screening (e.g. integration of clinical audits and software integration). Quality improvement initiatives and research aimed at co-designing and trialling such systems could lead to significant improvement in NBCSP participation in Australia.

Supplementary material

Supplementary material is available online.