Scope of this report
Covered by this report? | If ‘no’, where you can find information about this part of the pathway | |
|---|---|---|
|
Underpinning functions | ||
|
Uptake and coverage |
No |
NHS England regions |
|
Workforce |
Yes |
Not applicable |
|
IT and equipment |
Yes |
Not applicable |
|
Commissioning |
No |
NHS England Support Services team |
|
Leadership and governance |
Yes |
Not applicable |
|
Pathway | ||
|
Cohort identification |
Yes |
Not applicable |
|
Invitation and information |
Yes |
Not applicable |
|
Testing and results |
No |
NHS cervical screening laboratories |
|
Referral |
No |
NHS cervical screening laboratories |
|
Sample taker register |
No |
NHS cervical screening laboratories |
|
Diagnosis |
No |
NHS colposcopy and histology services |
|
Intervention / treatment |
No |
NHS colposcopy and histology services |
Summary
The NHS Cervical Screening Programme (CSP) 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 25 March 2025 to Cervical Screening Administration Service (CSAS) which is commissioned by NHS England Support Services Team, part of the Primary Care, Community, Vaccination and Screening Directorate. 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:
- evidence submitted by the provider
- information available to SQAS representatives through routine CSAS meetings
- information shared with SQAS as part of the visit process
The screening service
CSAS administers the call and recall functions for the NHS CSP across England. It is part of the North of England Care System Support (NECS) Commissioning Support Unit that was awarded the contract for the provision of call and recall services for the NHS CSP in 2019.
Findings
CSAS has experienced a significant period of change since taking on the call and recall administration for England in 2019. During this time, CSAS leadership has managed 2 office relocations and the harmonisation of working practices across these offices, worked to significantly reduce CSAS screening incidents and, most recently, provided significant input into the design and implementation of the new Cervical Screening Management System. At the QA visit, CSAS demonstrated a commitment to staff development and positive working culture and its leadership has worked hard to create a positive and supportive working environment.
Previous SQAS QA reviews have highlighted the need for a coherent quality management system (QMS) and associated processes to support consistency, reliability, efficiency and to reduce the potential for risk arising from manual processes which could lead to incidents occurring. Some progress has been made and the building blocks of a QMS are present but the individual elements do not link together and a variety of issues have been found with the documentation used throughout the service. At present, CSAS is not able to demonstrate that the processes and policies it has in place are being followed routinely and consistently.
There is a need for CSAS to take a fresh approach to its QMS to address these issues. The QA visit and discussion with the CSAS team have identified that there are many opportunities to redesign, streamline and more critically assess day to day operations, to enable quality management and quality improvement processes to work coherently together and be embedded at all levels across the team. While this report has been written to provide the CSAS team with sufficient information to support planning and improvements, SQAS will provide CSAS with a detailed assessment of the documentation it has reviewed for this QA visit to support the development of the CSAS QMS action and quality improvement plan.
Immediate concerns
The QA visit team identified no immediate concerns.
Urgent recommendations
The QA visit team identified no urgent recommendations.
High priority findings
The QA visit team identified 2 high priority findings as summarised below:
- the CSAS QMS is not working effectively and there are inconsistencies in documentation compared with approved policies. This means that it is not possible to accurately understand operational issues that may undermine quality and safety and put in place appropriate mitigations or escalations in a timely manner
Recommendations
|
No. |
Recommendation |
Reference |
Timescale |
Priority |
Evidence required |
|
Call and Recall Administration | |||||
|
01 |
Critically review the quality management system (QMS) and develop and implement an action plan to put in place a coherent QMS approach that is fully audited |
1 |
3 months |
High | Action plan to include as a minimum: · Governance arrangements, including development of relevant documentation · Issues, incidents and risk management processes, including SOPs and consolidated issues log · Documentation, including updated document index, updated standard operating procedures (SOPs) and work instructions covering all processes, business continuity plan · Record management and retention, including SOPs · Approach to audit, updated 2025/26 audit plan and SOP which includes methods for audit findings analysis, non-conformity, risk and quality improvement identification and critical appraisal of audit and incident findings · Training on QMS |
|
02 |
Demonstrate successful implementation of QMS action plan |
1 |
12 months |
High |
Provision of documentation as described in action plan |
- Cervical screening: guidance for call and recall administration best practice
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.