NHS England » Screening Quality Assurance visit report – Barnsley Hospital NHS Foundation Trust

	Covered by this report?	If ‘no’, where you can find information about this part of the pathway If ‘yes’ insert ‘not applicable’
Underpinning functions
Uptake and coverage	Yes	Not applicable
Workforce	Yes	Not applicable
IT and equipment	Yes	Not applicable
Commissioning	Partly	NHS England North East and Yorkshire Public Health Commissioning Team
Leadership and governance	Yes	Not applicable
Pathway
Cohort identification	No	Cervical Screening Administration Service
Invitation and information	No	Cervical Screening Administration Service
Testing and results	No	Gateshead Health NHS Foundation Trust
Referral	Yes	Not applicable
Diagnosis	No	The Rotherham NHS Foundation Trust
Intervention / treatment	Yes	Not applicable

Summary

The NHS Cervical Screening Programme invites women and people with a cervix between the ages of 25 and 64 for regular cervical screening. This aims to detect abnormalities within the cervix that could, if undetected and untreated, develop into cervical cancer.

The findings in this report relate to the quality assurance visit on 26 March 2025 to Barnsley Hospital NHS Foundation Trust (BHFT) Cervical Screening Service which is commissioned by NHS England North East and Yorkshire Public Health Commissioning team. Any commissioning findings are outside the scope of this report and will be followed up directly with the commissioner.

Quality assurance purpose and approach

Quality assurance (QA) aims to achieve and maintain national standards, promote continuous improvement in cervical screening and support reducing health inequalities. This is to ensure that all eligible people have access to a consistent, high quality, effective, equitable and safe service wherever they live.

QA visits are carried out by the NHS England Screening Quality Assurance Service (SQAS).

The evidence for this report comes from the following sources:

monitoring of routine data collected by the NHS England
data and reports from external organisations
evidence submitted by the provider and external organisations
discussion with commissioner in advance of the visit
information collected during pre-review visits to BHFT on 18 March 2025
information shared with SQAS as part of the visit process.

The screening service

BHFT provides NHS cervical screening services to part of the population covered by the South Yorkshire Integrated Care Board. The service is overseen by NHS England North East and Yorkshire Public Health Commissioning Team with support from the South Yorkshire Public Health Programme team.

BHFT provides colposcopy from Barnsley Hospital. Gateshead Health NHS Foundation Trust provides the human papillomavirus (HPV) testing and cytology service. The Rotherham NHS Foundation Trust as part of the South Yorkshire pathology network provides the histology service.

Findings

Since the last visit to this service in 2017, there has been a major service change with the implementation of human papillomavirus primary screening and the challenge presented by the COVID-19 pandemic. The colposcopy service has worked hard to improve its waiting times for patients over the last 12 months following issues with capacity. The service recognises the importance of working to reduce inequalities and supports people who are considered vulnerable or underserved.

All leadership roles in the service are in place, however, there is a lack of deputies to support business continuity planning and future succession planning. The management of patients referred to colposcopy with glandular abnormalities following a cervical screening test appeared not to be managed in line with NHS Cervical Screening Programme guidance. The service has a significant backlog of incomplete invasive cervical cancer audit cases. This needs to be addressed without delay to enable timely offer of the audit findings and disclosure to patients.

Immediate concerns

The QA visit team identified one immediate concern. A letter was sent to the chief executive, on 28 March 2025 asking that the following item is addressed within 7 working days:

stop the clinical practice of taking punch biopsies to investigate patients referred with ?invasion, ?glandular neoplasia and borderline changes in endocervical cells screening test results

A response was received within 7 working days which assured the visiting QA team the identified risk was mitigated and no longer poses an immediate concern.

Urgent recommendations

The QA visit team identified 2 urgent recommendations. These urgent recommendations were included in the letter was sent to the chief executive on 28 March 2025 asking that the following items were addressed:

provide an action plan to address the invasive cervical cancer audit and disclosure backlog of cases recorded between 2019 and 2024
implement clinician validation of the colposcopy discharge report sent to the Cervical Screening Administration Service to update the date of next screening test. Provide confirmation of the arrangements in place

An action plan was received which assured the visiting QA team the identified concerns were mitigated.

High priority findings

The QA visit team identified 3 high priority findings as summarised below:

there is a joint cervical screening management meeting and colposcopy operational meeting rather than 2 separate meetings as required by national guidance. This means the joint meeting does not have the appropriate staffing representation, reporting arrangements or discusses all relevant items. As a result, there is a possibility that not all risks and issues may be identified
there is no service wide strategic workforce plan in place which leaves the colposcopy service vulnerable to lack of staff with direct implications for patients being seen in a timely way
the colposcopy clinical guidelines are lacking in detail and do not clearly reflect up to date national guidance meaning that clinical practice may not be up to date or could be inconsistent, and essential processes may not be in place

Examples of practice that can be shared

The QA visit team identified an area of practice for sharing, including:

trust-wide approach to supporting patients with learning disabilities and autism with agreed pathways developed for individual services, including colposcopy, and access to a designated learning disability liaison nurse who can facilitate attendance and provide support within the colposcopy clinic as required

Recommendations

No.	Recommendation	Pathway theme	Reference	Timescale	Priority	Evidence required
Immediate concerns
01	Stop the clinical practice of taking punch biopsies to investigate patients referred with ?invasion, ?glandular neoplasia and borderline changes in endocervical cells screening test results	Intervention and outcome – colposcopy	3	7 days	Immediate	Confirmation that all colposcopists are aware of the national guidance
Urgent recommendations
02	Provide an action plan to address the invasive cervical cancer audit and disclosure backlog of cases recorded between 2019 and 2024	Governance and leadership	4,5	14 days	Urgent	Action plan
03	Implement clinician validation of the colposcopy discharge report sent to the Cervical Screening Administration Service to update the date of next screening test	Intervention and outcome – colposcopy	3	14 days	Urgent	Provide confirmation of the arrangements in place

The following recommendations are for the provider to action unless otherwise stated.

No.	Recommendation	Reference	Timescale	Priority	Evidence required
Governance and leadership
04	Update governance arrangements for the cervical screening programme in line with national guidance	1,2	6 months	High	Accountability structure for cervical screening within the trust. Updated cervical screening provider lead (CSPL) and lead colposcopy nurse role job descriptions and nomination of a deputy for each of the lead roles Evidence of designated administration support for the CSPL Updated terms of reference for cervical screening management meeting Evidence of separate colposcopy operational meetings, including terms of reference, escalation and reporting routes and copies of minutes Evidence of the 6 monthly performance report to clinical governance meeting
05	Update the Invasive Cervical Cancer Audit Protocol	3	6 months	Standard	Updated protocol, to include the use of the national patient information leaflet and reporting of potential screening incidents
06	Ensure all staff are aware of the process for reporting potential screening incidents	2	3 months	Standard	Completion of eLearning
Intervention and outcome – colposcopy
07	Put in place an agreed workforce and succession plan for key colposcopy roles	1,2	6 months	High	Workforce plan
08	Update the clinical colposcopy guidelines to ensure they are aligned with NHS Cervical Screening Programme guidance and terminology	2	3 months	High	Updated clinical guidelines
09	Develop a specific colposcopy protocol for the safe use of diathermy equipment	2	3 months	Standard	Protocol
10	Establish ratified colposcopy nursing guidelines	2	6 months	Standard	Guidelines
11	Update administration standard operating procedures (SOPs) to include the correct terminology, health inequalities processes and develop an SOP for the recording and management for treatment under general anesthetic	2	6 months	Standard	SOPs
12	Put in place a formal validation and oversight process for routine colposcopy data at clinic and individual clinician level	2	3 months	Standard	SOP
13	Audit the standards for time to treatment and treated people with cervical intraepithelial neoplasia or cancer within 12 months of colposcopy procedure	1,2	6 months	Standard	Audit outcomes and action plan
14	Put in place a colposcopy clinical audit schedule	2	6 months	Standard	Clinical audit schedule
15	Update all patient literature to reflect HPV primary screening and put in place a local colposcopy patient information leaflet and standardised outcome communication	2	6 months	Standard	Local treatment leaflet Local colposcopy patient information leaflet Updated copies of patient appointment and result letters
16	Develop action plan for patient satisfaction survey findings	2	3 months	Standard	Action plan and outcomes
Multidisciplinary team
17	Demonstrate audit of multi-disciplinary team meeting case selection and rolling audit of outcomes to ensure appropriate cases are discussed and that patients receive the agreed management plan	2	3 months	Standard	Copy of audit and actions taken

Next steps

The screening service provider is responsible for developing an action plan in collaboration with the commissioners to complete the recommendations contained within this report.

SQAS will work with commissioners to monitor activity and progress of the recommendations for 12 months after the report is published. After this point SQAS will send a letter to the provider and commissioners summarising the progress made and will outline any further action(s) needed.

Appendix B: References

NHS Public Health Functions Agreement 2024-25 Service Specification No. 25, NHS Cervical Screening Programme
NHSCSP: Programme and Colposcopy Management. Updated January 2023
NHSCSP: the role of the cervical screening provider lead. March 2018
NHSCSP: National invasive cervical cancer audit. December 2006 Updated September 2021

NHSCSP: Disclosure of cervical screening history review results and applying duty of candour. April 2021 Updated October 202

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