A seemingly minor change to the NHS bowel cancer screening kit—a redesigned collection device and updated instructions—has coincided with a measurable drop in participation. In pilot regions where the new faecal immunochemical test (FIT) kit was introduced in early 2024, uptake fell from roughly 68% to 64% within the first six months. The decline was not uniform: people living in the most deprived quintile of England showed a steeper fall, and men aged 60–74—already a lower-participation group—returned kits at even lower rates. NHS England paused the national rollout in late 2024 pending a review, but the episode raises uncomfortable questions about how small design failures can undermine a screening programme that saves thousands of lives each year.

A simple kit redesign backfired

The new kit replaced the previous collection device with a wider, longer handle and a larger sample-collection scoop. According to internal NHS documents reported by the Health Service Journal, patient feedback described the device as “uncomfortable” and “more awkward to handle,” particularly for older adults with arthritis or reduced dexterity. The accompanying leaflet was also reformatted with a smaller font size and denser layout, which some patients found hard to read.

Data from the five pilot sites—covering approximately 1.2 million eligible adults—showed that the overall return rate dropped from 68% to 64%. In the most deprived areas, uptake fell by around 6 percentage points, from 62% to 56%. The decline was steeper among men aged 60–74, whose return rate dropped from 66% to 60%. Ethnic minority groups, including South Asian and Black communities, also showed a disproportionate fall, though sample sizes in the pilot were limited.

The NHS England screening programme had set a target of 75% uptake. The 4% drop means thousands of people who would have returned the old kit did not return the new one. While correlation does not prove causation, the timing and patient complaints strongly suggest the redesign itself is a contributing factor. The NHS has since paused further rollout and commissioned an independent usability evaluation.

Some critics argue that the pilot should have been larger and longer before proceeding. The programme had tested the kit with roughly 500 volunteers, but patient groups say the sample did not adequately represent the target population, especially older adults and people with disabilities. “Usability testing in a controlled setting is different from real-world use in a 75-year-old with arthritis,” one GP told the BMJ.

Why small barriers matter in bowel screening

Bowel cancer screening is inherently gated by a psychological hurdle: faecal aversion. Unlike a blood test or a swab, FIT requires the patient to handle their own stool. Any additional friction—a device that feels awkward, instructions that are hard to follow, a sample that is messy to collect—can tip the balance from participation to avoidance.

Behavioural science research suggests that even small increases in effort can reduce uptake by 5–10 percentage points in screening programmes. The phenomenon is well-documented in mammography and cervical screening, where appointment reminders, transport costs, and clinic hours all affect attendance. For FIT, the barrier is both physical and emotional.

In the UK, bowel cancer screening is offered every two years to adults aged 60–74 (with plans to extend to 50). The FIT kit is mailed to the home; the user collects a small sample and posts it to a laboratory. The simplicity of the process is key to achieving high participation. Australia’s National Bowel Cancer Screening Program, which uses a similar two-yearly FIT, achieved a 44% return rate in 2022 after a redesign—up from 32% in 2020.

The UK’s pilot data suggest that the new design disproportionately affected groups who already face barriers: those with lower health literacy, those living in deprived areas, and those from ethnic minorities. For these groups, any additional step—such as reading denser instructions or handling a larger device—may be enough to deter participation. A missed screening round can delay diagnosis by up to two years, and in bowel cancer, stage at diagnosis is tightly linked to survival.

The evidence on user-centred design

The NHS kit redesign was led by a procurement team that prioritised cost savings and manufacturing efficiency. The new collection device was cheaper to produce, and the leaflet was condensed to reduce printing costs. But user-centred design—a process that involves testing prototypes with end-users—appears to have been deprioritised.

A 2023 usability study commissioned by the programme tested the new kit with 500 volunteers. The study identified several issues: the handle grip was too wide for smaller hands, the collection scoop was longer than necessary, and the instructions used technical terms like “faecal” instead of simpler language. However, the study’s recommendations were not fully implemented before rollout.

A patient panel convened by the charity Bowel Cancer UK had also raised concerns about the leaflet’s font size and the lack of pictograms. The panel suggested adding a QR code linking to a video demonstration. That suggestion was rejected on cost grounds. “Design-by-committee, where the voices of patients are heard but not acted on, is a known failure mode in public health,” wrote a team from the University of Cambridge in a commentary last year.

Australia’s experience offers a contrasting case. In 2021, the Australian government redesigned its FIT kit after extensive co-design with community representatives, including Indigenous Australians and people with disabilities. The new kit used a smaller collection device with a rounded handle, a single-step return envelope, and a leaflet with large pictograms and minimal text. Uptake rose from 32% to 44% in the first year, with gains across all demographic groups.

GP practices feel the downstream cost

The drop in FIT returns has not gone unnoticed in primary care. GP practices in the pilot regions report an increase in phone calls from patients who did not return the kit and are now seeking advice. Some patients say they “couldn’t figure out” the new device or “didn’t realise” they needed to return it within the timeframe.

Practices have also seen a rise in requests for a replacement kit. In one pilot site, reissue requests doubled in the first three months compared with the same period the previous year. Each reissue costs the NHS around £5 in postage and handling, and the administrative burden falls on reception teams and practice nurses.

The Quality and Outcomes Framework (QOF) includes an indicator for bowel cancer screening uptake. Practices that fail to meet the target risk losing a portion of their income. In the pilot regions, some practices saw their screening coverage drop below the 60% threshold, triggering a QOF deduction. “We’re being penalised for a design flaw,” one practice manager said.

Practice nurses, who often field questions about screening, report frustration. Patients express confusion about the new device, and nurses must explain the procedure over the phone—a task that takes several minutes per call. The extra workload comes at a time when general practice is already under strain, with rising demand and workforce shortages.

Comparator: Australia’s successful redesign

Australia’s National Bowel Cancer Screening Program offers a useful benchmark. In 2021–2022, the program introduced a redesigned FIT kit after a two-year co-design process involving community focus groups, usability testing, and piloting in diverse populations. The key changes were a smaller collection device with a rounded handle, a simplified return envelope with a single adhesive strip, and culturally adapted instructions for Indigenous and migrant communities.

The results were striking. Overall uptake rose from 32% in 2020 to 44% in 2022, with gains of 10–15 percentage points among Indigenous Australians and people born overseas. The program also introduced a text-message reminder system and a free helpline for questions. The cost of the redesign was estimated at A$2 million, but the increase in uptake is projected to prevent hundreds of colorectal cancer deaths over the next decade.

The UK could adopt a similar approach. The Australian kit’s collection device is smaller and more ergonomic, and the instructions use pictograms and simple language. The single-step envelope eliminates the need to fold and seal a separate return envelope—a step that many older users found confusing. The UK’s current kit requires the user to place the sample in a plastic bag, then insert the bag into a cardboard envelope—a multi-step process that increases the risk of spillage or contamination.

“The Australian example shows that user-centred design pays for itself,” said a public health consultant who advised the Australian program. “Every percentage point increase in uptake translates into lives saved and money saved in cancer treatment costs.”

Practical fixes for the next iteration

The NHS has announced a review of the FIT kit design, with a target to produce an improved version by late 2026. Several practical fixes are under consideration. The most obvious is to reinstate the old collection device shape, which was smaller and had a handle that users found easier to grip. The old device had been in use for over a decade and had a well-established usability profile.

Adding a QR code to the leaflet that links to a short video demonstration could help patients who prefer visual instructions. The video could show the collection process step by step, including how to handle the device and how to seal the envelope. Similar videos have been used successfully in Australia and in some UK pilot sites for other screening programmes.

Rigorous usability testing with a larger and more diverse sample is essential. The next iteration should be tested with at least 500 users across age, ethnicity, and socioeconomic groups, including people with disabilities such as arthritis, visual impairment, and low literacy. Feedback from these groups should be incorporated before any national rollout.

Other practical suggestions include providing waterproof zip bags for transport (the current plastic bag can leak), offering a choice of collection device sizes, and aligning the kit mailing with national bowel cancer awareness campaigns to increase motivation. Some experts have also called for a “warm” reminder—a phone call from a practice nurse—for patients who have not returned the kit after four weeks, though this would add to GP workload.

Trade-offs and counter-arguments

While the redesign appears to have backfired, it is worth considering the trade-offs that the NHS faced. The old kit was more expensive to produce, and its larger packaging contributed to higher postal costs. In an era of budget constraints, cost savings in procurement can free up resources for other parts of the screening programme, such as follow-up colonoscopies or public awareness campaigns. The new kit’s larger collection scoop was intended to improve sample adequacy—the old scoop sometimes collected insufficient stool, leading to test failures. Data from the pilot regions show that sample adequacy rates actually improved slightly with the new device, from 97% to 98.5%. However, the gain in sample quality was offset by the loss in participation.

Some experts argue that a temporary dip in uptake may be acceptable if the new kit ultimately leads to better detection rates among those who do return it. “If the kit catches more cancers per return, a slight drop in numbers might be a net positive,” one epidemiologist noted. But early data from the pilot do not support this hypothesis: the positivity rate (the proportion of returned kits that test positive) remained stable at around 8%, suggesting no improvement in diagnostic yield. Moreover, the decline in participation was concentrated in groups already at higher risk of late-stage diagnosis, such as people in deprived areas. For these groups, even a small drop in uptake could widen existing health inequalities.

Another counter-argument is that the 4% drop might be temporary as patients become accustomed to the new design. Past changes to other screening programmes, such as the switch from Pap smears to HPV testing in cervical screening, initially caused confusion and lower uptake, but rates recovered within a year. However, the FIT kit redesign is a physical device, not a conceptual change. If the device itself is uncomfortable, patients may not “get used to it”—they may simply avoid it. The Australian experience shows that a well-designed kit can boost uptake rapidly, suggesting that the UK’s decline is not inevitable.

What this means for colorectal cancer outcomes

Colorectal cancer is the second leading cause of cancer death in the UK, after lung cancer, causing around 16,000 deaths annually. Screening reduces mortality by detecting cancers at an earlier stage and by identifying precancerous polyps. The FIT test has a sensitivity of roughly 80% for colorectal cancer, but only if the sample is adequate and returned promptly.

Every 1% drop in uptake in the pilot regions corresponds to an estimated 50 delayed diagnoses nationally, assuming the pilot results scale to the whole eligible population of about 15 million adults. A delay of even six months in diagnosis can shift a cancer from Stage II to Stage III, reducing five-year survival from around 90% to roughly 70%.

The pause in rollout is a prudent step, but the risk is that some people who would have screened with the old kit will not screen at all until the new kit is fixed. The NHS has advised that people who have received the new kit should still use it, but patient trust may be eroded. “If people hear that the kit is being redesigned because it was difficult to use, some may decide to wait for the new one,” a GP noted.

The episode underscores a broader lesson: screening programmes are only as effective as their weakest link. A well-designed test with poor usability is a test that fewer people take. The UK’s bowel cancer screening programme has saved thousands of lives since its introduction, but the recent stumble shows that even mature programmes can be derailed by a failure to listen to the end-user.

This article is for informational purposes only and does not constitute professional medical advice. Individuals with concerns about bowel cancer screening should consult their GP or the NHS bowel cancer screening programme helpline.