Scope of this report
| Topic | Covered by this report? | If ‘no’, where you can find information about this part of the pathway |
| Underpinning functions | ||
| Uptake and coverage | Yes | Not applicable |
| Workforce | Yes | Not applicable |
| IT and equipment | Yes | Not applicable |
| Commissioning | Partly | NHS England London 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 | Cervical Screening Laboratory |
| Referral | Yes | Not applicable |
| Diagnosis | Yes | Not applicable |
| Intervention / treatment | Yes | Not applicable |
Summary
The NHS Cervical Screening Programme (NHSCSP) invites women 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 19 and 20 October 2022 to Chelsea and Westminster NHS Hospital Foundation Trust cervical screening service which is commissioned by the NHS England London 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 NHS England
- evidence submitted by the provider
- information shared with London SQAS as part of the visit process.
The screening service
Chelsea and Westminster Hospital NHS Foundation Trust provides NHS cervical screening services to the population covered by the NHS North West London Integrated Care System (ICS). The service is commissioned by NHS England London.
Chelsea and Westminster NHS Hospital Foundation Trust provides colposcopy for the boroughs of Kensington & Chelsea, Hammersmith and Fulham and Westminster.
The population eligible (women aged 25 – 64) for cervical screening in these London boroughs is; Kensington & Chelsea – 65,200, Hammersmith and Fulham 82,300 and Westminster 94,200 (source Screening and Immunisations Team, NHS Digital, © 2022 NHS Digital).
As of December 2021, across North West London (CCG), 55.21% of women in the 25 to 49 age group and 68.04% in 50 to 64 age group had been screened in the previous 3.5 or 5.5 years respectively. The coverage is below the national standard of 80%.
The cytology and HPV testing service is provided by Cervical Screening Laboratory.
This cervical screening programme comprises:
- call and recall service – administered by Cervical Screening Administration Service (CSAS) along with cervical screening results
- HPV testing and cervical cytology reporting is provided by Cervical Screening Laboratory (CSL)
- the colposcopy service is provided by West Middlesex Hospital and Chelsea and Westminster Hospital
- the histology service is provided by North West London Hospitals (Charing Cross site)
Findings
The last QA visit to Chelsea and Westminster Hospital took place in March 2017.
All recommendations from that visit were completed.
During the COVID-19 pandemic the cervical screening service remained open and continued to see patients. This was a challenging time for the service with the loss of key members of the team as well as managing an increasing workload.
An interim screening quality assurance review (ISQAR) for Chelsea and Westminster Hospital NHS Foundation Trust cervical screening programme took place virtually in May 2021 to support the recovery of the cervical screening programme. 15 recommendations were identified from this review relating to issues with backlog and capacity, the colposcopy IT systems, staffing and resilience and leadership and governance. Progress of these recommendations have been discussed at this QA visit.
Following the ISQAR, a new cervical screening provider lead(CSPL) was appointed in July 2021. This was followed by the appointment of a highly experienced trust lead colposcopist. Together they must be commended for their efforts to lead and harmonise the two colposcopy teams.
There are still many challenges with increasing workload, prioritising and managing workstreams and ensuring sufficient capacity to meet national guidelines. The colposcopy team should be commended for their dedication and hard work.
Immediate concerns
No immediate concerns identified.
Urgent recommendations
The colposcopy guidelines were not updated in 2020 and more recently in September 2021 when there was a change in national guidance. There was one urgent recommendation:
- A review of the colposcopy guidelines to identify deviation from national standards, assess the impact on the management of women and take any necessary remedial actions.
High priority findings
The QA visit team identified 11 high priority findings as summarised below:
- there is insufficient resource for the cervical screening provider lead (CSPL) to manage the current priorities within the cervical screening programme
- there are no formalised organisational structures, reporting and governance pathways for the CSPL role, trust lead colposcopist, colposcopy nurse and colposcopy team
- there are no formal CSPL business meetings and colposcopy operational meetings
- National screening guidance for the management of cervical screening incidents is not being followed
- there is no audit of offer of disclosure for the invasive cervical cancer audit
- insufficient colposcopy administrators’ capacity to meet the requirements of the NHSCSP guidelines and manage the increase in referrals
- there is an increased referrals to the colposcopy services which will lead to increase in waiting times for patients
- there is no image capture for both colposcopy sites
- not all data is being provided to demonstrate adherence to national standards
- there is no formal process in place for collecting evidence of accreditation for all clinicians
- national standards for colposcopy performance and multi-disciplinary team (MDT) meeting attendance have not been met by all colposcopists
Examples of practice that can be shared
The QA visit team identified several areas of practice for sharing particularly around access and communication, including:
- the use language line and interpreters
- good processes and failsafe in place for GP at hand (Digital primary care practice)
- direct referral form collects patient information from primary care
Recommendations
The following recommendations are for the provider to action unless otherwise stated.
| No. | Recommendation | Pathway theme | Reference | Timescale | Priority | Evidence required |
| Urgent recommendation | ||||||
| 01 | Review of the colposcopy guidelines to identify deviation from national standards, assess the impact on the management of women and take any necessary remedial actions | Intervention and outcome – colposcopy | 6 | 14 days | Urgent | Confirmation of audits to be carried out |
| No. | Recommendation | Reference | Timescale | Priority | Evidence required |
| Governance and leadership | |||||
| 02 | Develop an action plan, in collaboration with commissioners, to reduce screening inequalities in underserved and protected population groups | 1 | 6 months | Standard | Action plans Equity audit Confirmation of updates at programme boards |
| 03 | Document lines of accountability for the cervical screening provider lead role | 1, 2 | 3 months | High | Copy of accountability and escalation pathway for CSPL for the trust |
| 04 | Establish formal quarterly cervical business meetings chaired by the cervical screening provider lead with representation from all cervical screening service leads | 1, 2 | 3 months | High | Terms of reference, Meeting schedule Copies of minutes |
| 05 | Annual report to reflect performance and 6 monthly update to cover all NHS Cervical Screening Programme (CSP) services to the clinical governance committee | 1, 2 | 12 months | Standard | Copies of the reports with a circulation list and minutes of meetings where they were discussed |
| 06 | Ensure the national invasive cancer audit data collection is up to date for both sites | 1, 2 | 3 months | High | Confirmation that cases to be audited were identified Updated protocol for completion of the invasive cervical cancer audit |
| 07 | Ensure disclosure of cancer audit result across both sites is offered by the lead clinician to patients and audit is undertaken | 3 | 3 months | High | Updated policy for the offer of disclosure of invasive cervical cancer audit. Lead clinicians to provide evidence of completed mandatory cervical screening disclosure training |
| 08 | Complete a cross site audit to demonstrate offer of disclosure of invasive cervical cancer audit | 1, 2 | 12 months | High | Submit copy of audit |
| 09 | Ensure CSPL has adequate time in her job plan to manage the additional cancer audit backlog and identify adequate administrative support for the CSPL role | 1, 2 | 3 months | High | Identify deputy for CSPL role with clear job description and sessional commitment Identify administrative support to be documented in the CSPL job description |
| 10 | Ensure screening incidents are escalated and managed in accordance with “Managing Safety Incidents in NHS Screening Programmes” | 4 | 3 months | High | Develop local policy for management of screening incidents ratified at CSPL management meet/ Confirmation that all staff have reviewed the new policy |
| 11 | Establish a cross site local risk register for the management and escalation of risks and incidents identified within the screening programme | 1, 2 | 3 months | Standard | Confirmation of local risk register and discussion of identified risks at programme boards and trust governance meetings |
| 12 | Document the governance arrangements for colposcopy including accountability and escalation route for areas of concern | 1, 2 | 3 months | High | Submit accountability arrangements for lead colposcopist, the deputies, the lead colposcopy nurse and the colposcopy administrators for both sites |
| 13 | Appoint a trust lead colposcopy nurse for cervical screening with responsibility for ensuring good practice, compliance with protocols and NHS CSP standards. | 1, 2 | 3 months | High | Confirmation of job description, job plan with dedicated professional activity allocation Formalised accountability and governance chart |
| 14 | Put in place quarterly cross site colposcopy operational meetings | 1, 2 | 3 months | High | Submit terms of reference, agenda and copies of minutes of first meeting |
| 15 | Expand and formalise a cross site audit schedule and ensure annual data e.g. individual colposcopist data is audited and breach reasons provided | 1, 2 | 6 months | Standard | Submit copy of revised audit schedule Submit annual data for 2021-22 with outcome of audit and mitigations provided for breaches. |
| 16 | Carry out an inequalities impact assessment for relocation of colposcopy service | 1,2 | 6 months | Standard | Submit copy of impact assessment and relocation plan |
| Referral – no recommendations | |||||
| No recommendations made in this section. | |||||
| Sample taker register – no recommendations | |||||
| No recommendations made in this section. | |||||
| Intervention and outcome – colposcopy | |||||
| 17 | The Lead Colposcopist to establish a process for collecting evidence of accreditation for all clinicians | 1, 2 | 3 months | High | Lead colposcopist to confirm process is in place |
| 18 | To carry out a demand and capacity exercise in light of the increased referrals due to HPV testing | 1, 6 | 3 months | High | Confirmation of demand and capacity plan is in place |
| 19 | Make sure there are enough colposcopy administrative staff to meet the requirements of the NHS CSP for West Middlesex Hospital and Chelsea and Westminster Hospital | 1, 6 | 3 months | High | Colposcopy staffing structure, defined responsibilities and absence cover arrangements |
| 20 | Ensure replacement programme for old equipment | 1, 2 | 3 months | Standard | Replacement of colposcopy couch and colposcope |
| 21 | Put in place a solution for both image capture and data entry onto Evolve/Cerner | 1,2 | 3 months | High | Confirmation that image capture has been implemented Confirmation of data collection and entry for all national standards |
| 22 | Ensure all colposcopy staff have access to Open Exeter | 1,6 | 3 months | Standard | Confirmation that all staff have access to Open Exeter |
| 23 | Ensure cross site colposcopy guidance is up to date | 6 | 3 months | Urgent | Lead colposcopist to confirm guidance is updated Submit copy of audits where a deviation from national standards was identified |
| 24 | The administrators working with the colposcopy nurses to develop and implement cross site standard operating procedures for colposcopy administrative processes | 1 | 6 months | Standard | SOP including triage, audit and failsafe of all referrals, failsafe for patients treated under general anaesthetic, production and validation of the discharge list the production and validation of KC65 data returns |
| 25 | The colposcopy nurses to develop standard operating procedures for the nursing aspects of the colposcopy clinic | 1,7 | 6 months | Standard | SOP including referral triage, failsafe, clinic set up and use of equipment to include smoke evacuation and instructions on how to operate and perform safety checks on the equipment |
| 26 | Update the process for results and referral for cervical samples taken in the trust but outside of colposcopy | 1,8 | 3 months | Standard | Updated Standard Operating Procedure |
| 27 | Ensure all colposcopists at Chelsea and Westminster Hospital see the required 50 new abnormal cytology patients in the year | 1,6 | 12 months | Standard | Lead colposcopist to put plan in place to ensure all colposcopist meet the national standard Review at next submission of annual individual colposcopy data |
| 28 | Complete audit of the individual clinician data and implement an action plan where breaches are identified | 1,6 | 3 months | High | Confirmation that all individual clinician data requirements have been mapped and can be collected. Provide audit where breaches have been identified and details of actions taken and how performance is being monitored |
| 29 | Complete a patient satisfaction survey that can analyse responses by clinic site and produce a combined outcome and an action plan | 1 | 12 months | Standard | Outcome of survey by clinic and overall service including actions taken |
| Multidisciplinary team | |||||
| 30 | Assess the effectiveness and frequency of MDTs across both sites ensuring support and engagement from CSL and pathology and agree a way forward in collaboration with commissioners | 1,6 | 3 months | High | Confirmation of agreed frequency of MDT meetings Copy of updated cross site MDT policy Confirmation of administrative support for MDTs documented within the MDT policy |
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: Reference List
1. NHS Public Health Functions Agreement Service Specification No. 25, Schedule 2, 2022/23
2: NHS CSP: the role of the cervical screening provider lead. March 2018
3: NHS CSP: Disclosure of cervical screening history review results and applying duty of candour. April 2021 Updated October 2021
4: Managing Safety Incidents in NHS Screening Programmes. March 2015 Updated July 2021
5: NHS CSP Publication No.10: histopathology reporting handbook. November 2019 Updated September 2021
6: NHS CSP: Programme and Colposcopy Management. Guidelines for commissioners, screening providers and programme managers for NHS cervical screening. February 2020 Updated September 2021
7: Cervical screening: cytology reporting failsafe (primary HPV). July 2019
8: SQAS advice document: Management of NHS population screening cervical samples obtained in hospital settings. November 2019
9: NHS CSP 27: Improving the quality of the written information sent to women about cervical screening. December 2006
10: Cervical screening: implementation guide for primary HPV screening. February 2019
11: Cervical screening: quarterly coverage data reports September 2021. Accessed April 2022
12: NHS population screening: inequalities strategy. July 2019