NHS England » Screening quality assurance visit report – Bedfordshire Hospitals NHS Foundation Trust

Scope of this report

Service*	Provider	Commissioner	Within the scope of this visit
Sickle cell and thalassaemia screening laboratory services	Full blood count and HPLC: Bedfordshire Hospitals NHS Foundation Trust	NHS England (East of England region)	No – interfaces only
Infectious diseases screening laboratory services	HIV, Hepatitis Syphilis: Bedfordshire Hospitals NHS Foundation Trust	NHS England (East of England region)	No – interfaces only
Fetal anomaly screening – combined screening services	Dating/NT scan: Luton and Dunstable Hospital and Bedford Hospital Screening laboratory: Birmingham Women’s and Childrens FASP screening laboratory	NHS England (East of England region)	Sonography element – yes
Fetal anomaly screening – quadruple screening laboratory services	Dating/NT scan: Luton and Dunstable Hospital and Bedford Hospital Screening laboratory: Birmingham Women’s and Childrens FASP screening laboratory	NHS England (East of England region)	Sonography element – yes
Fetal anomaly screening – NIPT screening laboratory services	TDL Genetics	NHS England	No
Fetal anomaly screening – 20-week screening scans	Bedfordshire Hospitals NHS Foundation Trust	NHS England (East of England region)	Yes
Diabetic eye screening	Bedfordshire Hospitals NHS Foundation Trust	NHS England (East of England region)	Yes
Newborn and infant physical examination	Bedfordshire Hospitals NHS Foundation Trust	NHS England (East of England region)	Yes
Newborn blood spot screening laboratory services	Great Ormond Street Hospital for Children NHS Foundation Trust	NHS England (East of England region)	No
Newborn hearing screening programme	Cambridgeshire Community Services NHS Trust	Bedfordshire Hospitals NHS Foundation Trust	Yes
Child Health Information Service (CHIS)	Hertfordshire Community NHS Trust	NHS England (East of England region)	No – interfaces only

Screening laboratories are quality assured by the United Kingdom Accreditation Service (UKAS).

Summary

Quality assurance looks at the antenatal and newborn screening pathways starting with identifying the eligible population of pregnant women and babies. It also includes the relevant screening tests for each programme. For women and babies with screen positive/higher chance results it will also include the pathways for referral, diagnosis and/or treatment.

The findings in this report relate to the quality assurance visit on 05 and 06 March 2024 to Bedfordshire Hospitals NHS Foundation Trust Screening Service which is commissioned by NHS England (East of England region). Any commissioning findings are outside the scope of this report and will be followed up directly with the commissioner.

We use the term ‘woman’ or ‘mother’ to encompass all gender identities and is intended for anyone who is pregnant. Similarly, where the term ‘parents’ is used, this encompasses anyone who has main responsibility for caring for the baby.

Quality assurance purpose and approach

Quality assurance (QA) aims to achieve and maintain national standards, promote continuous improvement in antenatal and newborn (ANNB) screening and support reducing health inequalities. This is to ensure 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 NHS England.
Data and reports from external organisations.
Evidence submitted by the provider(s) and external organisations.
Discussion with the commissioner in advance of the visit.
Information collected during pre-review visits to Bedfordshire Hospitals NHS Foundation Trust on 5 and 6 March 2024
Information shared with SQAS as part of the visit process

The screening service

Bedfordshire Hospitals NHS Foundation Trust (BHFT) formed as a new entity in April 2020 following a merger between Luton and Dunstable Hospital NHS Foundation Trust and Bedford Hospitals NHS Trust.

Bedfordshire Hospitals NHS Foundation Trust serves around 700,000 people and offers maternity services for women living in South Bedfordshire, Luton and parts of Hertfordshire and Buckinghamshire. There are two main hospital sites, Luton and Dunstable Hospital and Bedford Hospital. Luton and Dunstable share borders with Milton Keynes, East and North Herts (Lister/Stevenage hospital) and West Herts (Watford). Bedford Hospital borders Milton Keynes, Kettering and East and North Herts. There is a level 3 neonatal intensive care unit at the Luton site and a level 1 unit in Bedford. There is a diverse ethnic population, particularly in the Luton area. The trust is designated as high prevalence for sickle cell and thalassaemia screening.

The East of England Child Health Information Service (CHIS), run by Hertfordshire Community Trust provide services to Bedfordshire.

Cambridgeshire Community Services are commissioned by the trust, to provide the newborn hearing screening programme (NHSP) for Bedfordshire.

Findings

This is the first quality assurance visit to BHFT as a merged organisation. Antenatal and newborn (ANNB) screening at BHFT is a patient focused service delivered by a screening team clearly committed to the care of pregnant women and babies.

There are two dedicated and hardworking screening midwives in post, supported by a wider multi-disciplinary team across all programmes. There are skilled and dedicated staff across the screening programmes, including the newborn hearing screening and sonography workforce. There are some identified workforce gaps with a need for greater resilience within the screening teams. There is a good understanding of areas for improvement with some quality improvement plans initiated.

The maternity leadership team are working to develop a whole service approach across the two hospital sites and wider geography of the trust following the 2020 merger. There is a service wide opportunity for shared learning between the sites and a need to unite the different screening services under the maternity management structure. The leadership team is working collaboratively to address limitations within their screening processes with many plans already in place that will support meeting the recommendations.

Positive findings and shared learning:

the development of bespoke Luton site failsafe process for screening
a focus on patient need, for example the development of hip screening leaflet with ability to translate into 100 different languages
driving quality improvement with the implementation of courier service for newborn blood spot screening samples
the service are proactively addressing limitations within their processes. There are many plans already in place that will support meeting the recommendations
implementation of Trust Screening Steering Group for antenatal and newborn (ANNB) screening, with first meeting in place and plan for quarterly meetings
focused on patient need, for example, employing patient experience midwife, social prescriber, close relative midwife, transformation midwives leading quality improvement projects
the integration of Smart4NIPE (S4N) as a single platform across the trust

Immediate concerns

The QA visit team identified one immediate concern. A letter was sent to the chief executive, on 8 March 2024 asking that the following item(s) is addressed within 7 working days:

scanning rooms at Luton Hospital are small and could compromise patient safety in the event of an emergency and could be impacting on sonographer’s wellbeing.

A response was received within 7 working days. The trust has provided an action plan to address the immediate concern. NHS England has requested that the obstetric emergency drills are expedited to provide assurance on the safety on the scanning rooms.

Urgent recommendations

The QA visit team identified four urgent recommendations. A letter was sent to the programme manager on 8 March 2024 asking that the following items were addressed:

make sure that the whole antenatal cohort is identified at Luton and Dunstable Hospital, including transfers in, women presenting unbooked in labour and women not self-referring to the maternity service
implement a process for non-invasive prenatal testing (NIPT) for Down’s syndrome, Edwards’ syndrome and Patau’s syndrome (T21/T18/T13) as part of the R445 genomic test screening pathway (1 April 2024 implementation) to make sure that it does not impact on the delivery of fetal anomaly screening programme (FASP)
audit and evaluate the screening pathway for women with a high chance result from T21/T18/T13 screening and low chance result from NIPT. The visiting team were informed that women with a low chance result from NIPT are offered prenatal diagnosis (PND)
make sure screen positive results for sickle cell and thalassaemia (SCT) screening at Bedford hospital are communicated as soon as available, including interim reports, to make sure that the service can meet SCT-S05/KPI ST4: timely offer of PND to women at risk of having an infant with sickle cell or thalassaemia. Screen positive results are currently communicated from the laboratory to the screening team on a weekly list

An action plan was received within 14 working days which assured the visiting QA team the identified concerns were mitigated.

The QA visit team identified a further two urgent recommendations in relation to the NHSP. A letter was sent to the Chief Executive Officer of Cambridgeshire Community Services NHS Trust on 8 March 2024 asking that the following items were addressed.

identify the movers-in cohort and make sure that newborn hearing screening is offered to all eligible babies. The visiting team was notified that the CHIS stopped sending a movers-in report to the newborn hearing screening service in June 2023
determine the outcome of the babies requiring immediate follow up in audiology following referral from the newborn hearing screening service and the outcomes of babies referred for targeted follow up whose outcomes are outstanding on the newborn hearing screening IT system Smart4Hearing (S4H)

An action plan was received within 14 working days which assured the visiting QA team the identified concerns were mitigated.

High priority findings

The QA visit team identified 13 high priority findings as summarised in themes below.

It is unclear how FASP related issues are escalated up through the Imaging Directorate on both sites or how issues are escalated between the maternity and sonography departments.

There are some identified workforce and training gaps, with a need for greater resilience within the screening teams:

there is no resilience for the absence of key members of staff, including the failsafe officer at Bedford
the role of the screening support sonographer is not formalised (Luton only)
there is no induction pack for the orientation of new and agency sonography staff (Luton only)

There are elements of the ANNB screening pathways that do not comply with the national specification:

the notification of incomplete family origin questionnaire (FOQ) from the laboratory to the screening team so that results are not delayed (Bedford only)
there is no laboratory failsafe to make sure that all SCT screen positive results are notified to the screening team (Luton only)
the infectious diseases in pregnancy (IDPS) request form (paper and electronic) does not comply with the minimum data fields
the IDPS pathway for women who decline screening (Luton only)
the IDPS pathway for unbooked women presenting in labour
the FASP pathway for women with very high chance results following combined or quadruple screening (Bedford only)
the FASP pathway for women who require a referral to fetal medicine following a 20-week screening scan at the weekend (Luton only)

Audiological services are not currently Improving Quality in Physiological Services (IQIPS) accredited and this is not on a risk register.

Recommendations

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

No.	Recommendation	Pathway theme	Reference	Timescale	Priority	Evidence required
Immediate concerns
01	Risk assess the scanning rooms at Luton Hospital against the Royal College of Radiologists (RCR) and Society and College of Radiographers (SCoR) Standards for the provision of an ultrasound service and take action to mitigate the risk	Infrastructure	14	7 days	Immediate	Risk assessment and action plan
Urgent recommendations
02	Cambridgeshire Community Service NHS Trust to identify movers-in to area to make sure that newborn hearing screening is offered to the full eligible cohort	Identification of cohort-newborn	1 and 2 (NHSP)	14 days	Urgent	Action plan to address the recommendation Documented process (that is signed off) for ensuring eligible cohort is identified (to be completed within 3 months of the visit date)
03	Cambridgeshire Community Service NHS Trust to determine the outcome of the babies requiring immediate follow up in audiology following referral from the newborn hearing screening service and the outcomes of babies referred for targeted follow up whose outcomes are outstanding on the newborn hearing screening IT system Smart4Hearing (S4H)	Newborn Hearing Screening	1 and 2 (NHSP)	14 days	Urgent	Action plan to address the recommendation All outcomes to be completed on S4H and a process for ongoing timely completion of S4H (to be completed within 3 months of the visit date)
04	Risk assess the cohort tracking mitigation process at Luton and Dunstable hospital to make sure the whole cohort is identified and tracked, including transfers in, women presenting unbooked in labour and women not self-referred	Identification of cohort – antenatal	1 and 2 (Antenatal)	14 days	Urgent	Action plan to address the recommendation Documented process (that is signed off) for ensuring eligible cohort is identified (to be completed within 3 months of the visit date)
05	Implement a process for non-invasive prenatal testing (NIPT) for Down’s syndrome, Edwards’ syndrome and Patau’s syndrome (T21/T18/T13) as part of the R445 genomic test screening pathway to make sure that it does not impact on the delivery of fetal anomaly screening programme	Fetal anomaly screening	1 (FASP)	14 days	Urgent	Action plan to address the recommendation R445 pathway to be included in trust guideline (that is signed off). (to be completed within 3 months of the visit date)
06	Audit and evaluate the screening pathway for women with a high chance result from T21/T18/T13 screening and low chance result from NIPT to make sure that no further testing is offered	Fetal anomaly screening	1 (FASP)	14 days	Urgent	Action plan to address the recommendation Guideline (that is signed off)
07	Make sure that screen positive results for sickle cell and thalassaemia (SCT) screening at Bedford hospital are communicated as soon as available	Sickle Cell and Thalassaemia screening	1 and 2 (SCT)	14 days	Urgent	Action plan to address the recommendation Documented process (that is signed off) for the immediate reporting of SCT screen positive results as soon as they are available

Service provider and population served – no recommendations made in this section
Governance and leadership
08	Make sure that there is a Trust Board director with overall responsibility for screening	Leadership roles	1, 2	6 months	Standard	Organisational chart (that is signed off)
09	(Luton FASP only) Strengthen the oversight and accountability of the sonography service, documenting risks and making sure that there is a clear route of escalation through the Imaging Directorate, linked to maternity governance arrangements and to Trust Board	Leadership roles Escalation	1 and 2 (FASP)	3 months	High	Organisation chart (that is signed off) Escalation process (that is signed off) Risk and mitigation plan (that is signed off)
10	Improve the governance structure for antenatal and newborn screening by embedding the Trust Screening Steering Group (TSSG). This should include representation from Diabetic Eye Screening, Child Health Information Service, Newborn Hearing Screening and the newborn haemoglobinopathy nurse specialist	Screening group	1, 2	6 months	Standard	Organisation chart (that is signed off) Escalation process (that is signed off) Risk and mitigation plan (that is signed off) Risks are documented on the organisation risk register Terms of reference for the Trust Screening Steering Group (that is signed off) including review and learning from incidents from all ANNB programmes Minutes of meetings Business continuity plan (that is signed off)
11	Review and update newborn hearing screening service business continuity plan	Risk	1 and 2 (NHSP)	12 months	Standard	Business continuity plan (that is signed off)
12	Put in place a defined contractual arrangement for the NHSP service	Contracts		6 months	Standard	Signed document
13	(Luton only) Make sure the sonography service has joint oversight with the maternity service of Fetal Anomaly Screening Programme (FASP) incidents	Incident management	5, 6	6 months	Standard	Incident management policy (that is signed off) to include process for the sonography service to be consistently notified of FASP related incidents Evidence of shared learning with sonographers participating in FASP Evidence of collaborative incident investigation between the maternity and sonography services
14	The Public Health Commissioning team should work with the Integrated Care Board (ICB) commissioner to make sure that newborn hearing screening referrals are referred into a United Kingdom Accreditation Service / Improving Quality in Physiological Services (UKAS IQIPS) accredited audiology service (add to trust risk register)	Newborn hearning screening	1 and 2 (NHSP)	6 months	High	Risk assessment or action plan
15	Change guidelines to cover the end-to-end pathways and to comply with national policy across all six ANNB programmes	Guidelines	1, 2	12 months	High	Guidelines (that are signed off)
16	Implement a process for the maternity, sonography and newborn hearing screening services to identify areas of the screening pathway for audit within an agreed audit plan, listed on organisation’s audit schedule with timescales for feedback at the screening group and follow-up of actions and shared learning across the directorates and sites	Audit	1 and 2 (FASP and NHSP)	12 months	Standard	Audit plan including timescales Minutes from the screening group and/or programme board
17	(Luton only) Undertake quality improvement audits to improve capacity and quality within the Fetal Anomaly Screening Programme (FASP), including a rescan audit	Audit	1 and 2 (FASP)	12 months	Standard	Audit schedule, completed audit and action plan Evidence of sharing and collaboration with the maternity service
18	Put in place a process to ensure that DQASS findings are understood and acted upon by the team	Leadership roles	1 and 2 (FASP)	12 months	Standard	Documented process for management of DQASS reports
19	Make sure that there is a collaborative process between the maternity and sonography service for undertaking a clinical review when a baby is born unexpectedly with one of the FASP conditions	Clinical review	1 and 2 (FASP)	6 months	Standard	Documented clinical review/minutes of clinical review meeting – using the SQAS clinical review checklist for antenatal and newborn screening Shared learning
20	Make sure that the sonography teams on both sites receive the findings of the National Congenital Anomaly and Rare Disease Registration Service (NCARDRS) report and take action if required	Outcomes	1 and 2 (FASP)	12 months	Standard	Action plan to address improvement actions outlined in the NCARDRS report if required (fetal anomaly detection rate report)
21	Demonstrate that feedback (including complaints) from service users, including those with protected characteristics or from underserved groups is used to develop and/or improve service delivery for antenatal and newborn screening	User feedback	1, 2	12 months	Standard	User feedback findings action plan discussed at the screening group and/or programme board
Infrastructure
22	Make sure there is resilience in the service to maintain delivery of screening functions when key members of staff are absent from the screening team (including the failsafe officer at Bedford)	Staffing	1, 2	3 months	High	Business continuity plan (that is signed off) Job description, Structure chart/guideline that outlines the functions of the respective role(s) if relevant
23	(Luton only) Put in place an induction pack to support the orientation of new and agency staff that includes FASP e-learning	Staffing	1 and 2 (FASP)	3 months	High	Induction pack
24	(Luton only) Formalise the role of the screening support sonographer	Staffing	1 and 2 (FASP), 7	3 months	High	Rostered time Job description/ structure chart/guideline (that are signed off) that outlines the functions of the role
25	(Luton only) Appoint a deputy screening support sonographer	Staffing	1 and 2 (FASP), 7	6 months	Standard	Job description/ structure chart/guideline (that are signed off) that outlines the functions of the role
26	(Luton only) Complete a demand, capacity and workforce audit to improve the resilience of the sonography service, decrease staffing absence, make sure that the service can meet the requirements of FASP and reduce reliance on agency staff	Staffing	1 and 2 (FASP)	6 months	Standard	Workforce audit and action plan
27	Implement and monitor a process to make sure all ultrasound practitioners delivering the fetal anomaly screening programme complete the required e-Learning resources	Staff training	1 and 2 (FASP), 7	6 months	Standard	Training log / completion of FASP e-Learning resources (with dates) Rostered time for training
28	Make sure that there is equity in access to the fetal medicine service at Luton for all women booked at Bedfordshire Hospitals NHS FT	Health inequalities	1 and 2 (FASP)	6 months	Standard	Audit
29	Make sure new newborn hearing screeners complete the External Competency Assessment (ECA) within three months of starting employment	Staff training	1 and 2 (NHSP), 8	6 months	Standard	Certificate of completion (with dates)
30	Implement and monitor a process to make sure NHSP screeners complete e-learning every year	Staff training	1 and 2 (NHSP), 8	12 months	Standard	Training log / completion of NHSP e-Learning resource (with dates)
31	Make sure new NHSP screeners register for the level 3 diploma within 6 months of starting employment	Staff training	1 and 2 (NHSP), 8	12 months	Standard	Staff registered for diploma within 6 months Documented process (that is signed off) for registering new starters and check diploma is started within 12 months
32	(Bedford only) Appoint a designated NIPE lead midwife/nurse and deputy for day to day oversight of the programme	Staffing	1 and 2 (NIPE)	6 months	Standard	Job description/ structure chart/guideline (that are signed off) that outlines the functions of the respective role(s)
33	Implement and monitor a process to support continuing professional development of practitioners who perform the newborn examination	Staff training	1 and 2 (NIPE), 9	6 months	Standard	Training log/completion of NIPE e-learning resource each year (with dates)
34	Implement and monitor a process for NHSP equipment calibration, maintenance and repair as per the manufacturer’s recommendations	Equipment and facilities	1 and 2 (NHSP), 8	6 months	Standard	Maintenance contract/log Calibration log Confirmation that equipment is replaced
35	Make sure quality assurance checks are performed on NHSP equipment before screening babies	Equipment and facilities	1 and 2 (NHSP), 8	3 months	Standard	Audit from S4H Documented process
Identification of cohort (newborn)
36	Implement a process for notifying key stakeholders about babies who die including updating the baby’s status as deceased on the S4H, S4N and NBSFS national IT system	Babies who die	1 and 2 (Newborn)	6 months	Standard	Guideline (that is signed off) Audit Communication templates (if available)
Invitation and access
	No recommendations made in this section
Sickle cell and thalassaemia screening
37	Implement and monitor a plan to meet the acceptable threshold for standard/key performance indicator SCT-S02/ST2 – the proportion of pregnant women having antenatal sickle cell and thalassaemia screening for whom a screening result is available at less than or equal to 10 weeks + 0 days gestation	KPIs/Standards	1 and 2 (SCT) 4 – Standards 2018 SCT-S02	12 months	Standard	Submission of data for standard/key performance indicator SCT-S02/ST2 ST2 check list and action plan that is agreed and monitored by the screening group and programme board
38	(Bedford only) Implement and monitor a plan to meet the acceptable threshold for standard/key performance indicator SCT-S03/ST3 – the proportion of antenatal SCT samples submitted to the laboratory accompanied by a completed family origin questionnaire	KPIs/Standards	1 and 2 (SCT) 4 – Standards 2018 SCT-S03	12 months	Standard	Submission of data for standard /key performance indicator SCT-S03/ST3 Action plan that is agreed and monitored by the screening group and programme board
39	(Bedford only) Implement a timely process for the laboratory to notify the screening midwives of an incomplete FOQ so that results are not delayed	Laboratory	1 and 2 (SCT)	3 months	High	Guideline (that is signed off)
40	(Luton only) Implement a laboratory failsafe to make sure that all SCT screen positive results are notified to the screening team	Laboratory	1 and 2 (SCT)	3 months	High	Guideline (that is signed off)
41	Send an sickle cell and thalassaemia alert card to notify the relevant newborn screening laboratory of the woman’s or couple’s ‘at risk’ screening result	Outcomes	1 and 2 (SCT and NBS)	6 months	Standard	Guideline (that is signed off) Feedback at programme board Add requirement to SCT tracker
42	Make sure that the screening midwives are informed of the screen positives from newborn blood spot screening for SCT	Outcomes	1 and 2 (SCT)	6 months	Standard	Guideline (that is signed off) Access to the Newborn Outcomes Solution
Infectious diseases in pregnancy screening
43	Change the infectious diseases request form (paper and electronic) to comply with the minimum data fields	Laboratory	1 and 2 (IDPS), 10	3 months	High	Revised request forms (paper and electronic)
44	(Luton only) Make sure each woman who declines the initial offer of IDPS screening (HIV, hepatitis B and/or syphilis) is identified, tracked and re-offered screening by 20 weeks of pregnancy or within 2 weeks if greater than or equal to 24 weeks gestation	Declines	1 and 2 (IDPS), 10	3 months	High	Guideline (that is signed off) Tracking system Documentation of decline in maternity notes Audit of declines
45	Implement and monitor a process for requesting urgent infectious diseases screening tests for unbooked women or women with no screening results presenting in labour	Unbooked women	1 and 2 (IDPS), 10	3 months	High	Guideline (that is signed off) Audit
46	Implement and monitor a plan to meet the acceptable threshold for standard IDPS-S05 – timely communication of confirmed screen-positive or known positive (HIV and hepatitis B) results for S05a (HIV), S05b (hepatitis B) and S05c (syphilis) at Luton and S05c (syphilis) at Bedford	KPIs/Standards	1 and 2 (IDPS) 4 – Standards 2018 IDPS-S05	12 months	Standard	Submission of data for standard IDPS-S05 Action plan that is agreed and monitored by the screening group and programme board
47	(Bedford only) Implement a multidisciplinary team IDPS meeting to discuss screen positive cases and formulate birth plans	Clinical review	1 and 2 (IDPS)	6 months	Standard	Terms of reference Agenda
48	(Bedford only) Make sure that there is a consistent process for paediatric alerts from antenatal screening, to ensure the completion of the screening pathway and referral into clinical services / vaccination for babies identified as at risk following maternal IDPS screening	Clinical review	1 and 2 (IDPS)	6 months	Standard	Guideline (that is signed off)
49	(Bedford only) Implement and monitor a plan to meet the acceptable threshold for standard IDPS S07a- the proportion of babies born to women with hepatitis B receiving first dose of vaccination at less than or equal to 24 hours of birth	KPIs/Standards	1 and 2 (IDPS), 15 4 – Standards 2018 IDPS-S07a	12 months	Standard	Submission of data for standard IDPS-S07a Action plan that is agreed and monitored by the screening group and programme board
Fetal anomaly screening
50	Implement and monitor a process to make sure women with very high chance results for trisomy screening are given consistent information to make an informed choice about further testing	Screening information	1 and 2 (FASP)	3 months	High	Guideline (that is signed off)
51	(Luton only) Make sure there is adequate provision for counselling of women and tracking through the referral pathway for women where a suspected fetal anomaly is detected at the weekend	Screening information	1 and 2 (FASP)	3 months	High	Guideline (that is signed off)
52	(Luton only) Track the screen positive cohort for the fetal anomaly screening programme	Failsafe	1 and 2 (FASP)	3 months	High	Tracking process Guideline (that is signed off)
53	(Luton only) Implement and monitor a plan to meet the acceptable threshold for standard FASP-S08a – timely referral (local) when an anomaly is suspected or confirmed at the 20-week screening scan, including a process to meet the standard when scanning is completed at weekends	KPIs/Standards	1 and 2 (FASP) 4 – Standards 2022 FASP-S08a	12 months	Standard	Submission of data for standard FASP-S08a Action plan that is agreed and monitored by the screening group and programme board
54	(Bedford only) Implement and monitor a plan to meet the acceptable threshold for standard FASP-S08b – timely referral (tertiary) when an anomaly is suspected or confirmed at the 20-week screening scan	KPIs/Standards	1 and 2 (FASP) 4 – Standards 2022 FASP-S08b	12 months	Standard	Submission of data for standard FASP-S08b Action plan that is agreed and monitored by the screening group and programme board
Diabetic eye screening in pregnancy
55	Make sure there is a written guideline for diabetic eye screening in pregnant women that is agreed with the local diabetic eye screening programme (DESP)	DES	1 and 2 (DES)	6 months	Standard	Guideline (that is signed off) agreed with local DESP
56	Implement and monitor a process to identify and track eligible women – pregnant women with existing type 1 and type 2 diabetes	DES	1 and 2 (DES)	6 months	Standard	Guideline (that is signed off) Tracking process
57	Implement and monitor a process to inform the local diabetic eye screening programme (DESP) of pregnant women with existing type 1 and type 2 diabetes when they book for maternity care	DES	1 and 2 (DES)	6 months	Standard	Guideline (that is signed off) agreed with local DESP Referral letter (if available) Tracking process
Newborn hearing screening
	No recommendations made in this section
Newborn and infant physical examination
58	(Bedford only) Track the screen positive cohort for the newborn and infant physical examination and make sure that there is timely escalation in place before babies breach the referral timeframes	Failsafe	1 and 2 (NIPE)	6 months	Standard	Tracking process Guideline (that is signed off)
59	Implement and monitor a plan to meet the acceptable threshold for standard NIPE-S02 – the proportion of babies with a screen positive eye result on newborn physical examination who attend for clinical assessment by an ophthalmology specialist ≤ 2 weeks of the examination	KPIs/Standards	1 and 2 (NIPE) 4 – Standards 2021 NIPE-S02	12 months	Standard	Submission of data for standard NIPE-S02 Action plan that is agreed and monitored by the screening group and programme board
60	Implement and monitor a plan to meet the acceptable threshold for standard/key performance indicator NIPE-S03/NP3 – the proportion of babies with a screen positive newborn hip result who attend for ultrasound scan of the hips within the designated timescale	KPIs/Standards	1 and 2 (NIPE) 4 – Standards 2021 NIPE-S03/NP3	12 months	Standard	Submission of data for standard/key performance indicator NIPE-S03/NP3 Action plan that is agreed and monitored by the screening group and programme board
61	Implement and monitor a plan to meet the acceptable threshold for standard NIPE-S05 – the proportion of babies identified with bilateral undescended testes detected on newborn physical examination and seen by a consultant paediatrician/ associate specialist within 24 hours of the newborn examination	KPIs/Standards	1 and 2 (NIPE) 4 – Standards 2021 NIPE-S05	12 months	Standard	Submission of data for standard NIPE-S05 Action plan that is agreed and monitored by the screening group and programme board
Newborn blood spot screening
62	(Luton only) Implement and monitor a plan to meet the acceptable threshold for standard NBS-S04 – the proportion of first blood spot samples taken on day 5	KPIs/Standards	1 and 2 (NBS) 4 – Standards 2021 NBS-S04	12 months	Standard	Submission of data for standard NBS-S04 Action plan that is agreed and monitored by the screening group and programme board
63	(Luton only) Implement and monitor a plan to meet the acceptable threshold for standard /key performance indicator NBS-S06/NB2 – the proportion of first blood spot samples that require repeating due to an avoidable failure in the sampling process	KPIs/Standards	1 and 2 (NBS) 4 – Standards 2021 NBS-S06/NB2	12 months	Standard	Submission of data for standard /key performance indicator NBS-S06/NB2 NB2 check list and action plan that is agreed and monitored by the screening group and programme board

Next steps

The screening service 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 progress made and will outline any further action(s) needed.

Appendix A: references

Section 7a screening service schedules 2. All Service Schedules / Specifications – Vaccinations and Screening – FutureNHS Collaboration Platform
NHS England population screening: pathway requirements specifications and learning from screening incidents Population screening: pathway requirements specifications
NHS England population screening standards NHS population screening standards
Key Performance Indicators NHS screening programmes Antenatal, newborn, young person and adult NHS population screening: reporting data definitions
Managing Safety Incidents in NHS Screening Programmes Managing safety incidents in NHS screening programmes
NHS England (2022) Patient Safety Incident Response Framework
NHS Fetal anomaly screening programme handbook (last updated 2024)
NHS Newborn hearing screening programme (NHSP) operational guidance (last updated 2024)
NHS Newborn and infant physical examination: programme handbook (published 2016, last updated 2024)
NHS Infectious diseases in pregnancy screening programme: laboratory handbook (2022)
NHS England population screening: pathway requirements specification Diabetic eye screening pathway requirements specification
NHS England Screening inequalities strategy PHE Screening inequalities strategy
Public Health Profiles Public health profiles
The Society and College of Radiographers and The Royal Collage of Radiologists (2017) Standards for the provision of an ultrasound service
UK Health Security Agency (published 2013, last updated 2020) Immunisation against infectious disease

There is more detailed information on individual screening programmes, including handbooks and operational guidance, that can be access via Population screening programmes: detailed information

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