NHS England » Screening Quality Assurance visit report – Gateshead Health NHS Foundation Trust

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	Yes	Not applicable
Workforce	Yes	Not applicable
IT and equipment	Yes	Not applicable
Commissioning	Partly	Covers North East and North Cumbria Public Health Programmes 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	Yes	Not applicable
Referral	Yes	Not applicable
Diagnosis	Yes	Not applicable
Intervention / treatment	Yes	Not applicable

Summary

The NHS Cervical Screening Programme 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 25 January 2023 to Gateshead Heath NHS Foundation Trust Cervical Screening Service which is commissioned by North East and North Cumbria Public Health Programmes 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 Gateshead Health NHS Foundation Trust on 11 January 2023
information shared with the North Region SQAS as part of the visit process.

The screening service

The Gateshead Health NHS Foundation Trust cervical screening service serves the population of Gateshead. The service has:

The cervical screening laboratory for HPV testing and cytology at the Queen Elizabeth Hospital and they provide the service for North East, Yorkshire, and Humber region. In addition, the laboratory tests cervical screening samples for Jersey.

There are colposcopy and cervical histopathology services located at the Queen Elizabeth Hospital.

Findings

This is the first visit to the North East and Yorkshire cervical screening laboratory since the service was awarded the contract for the centralised laboratory for primary Human Papilloma Virus (HPV) screening. The service has successfully mobilised the other six regional laboratories into one large cervical screening laboratory during September 2019 to March 2020. The service has encountered workforce and logistical challenges developing the primary HPV screening service across the region. They have managed to overcome these with the training of new cytoscreeners, succession planning for cytopathologists, supporting primary and secondary care locations with the implementation of electronic requesting for cervical samples. At the time of the visit, the service had recently achieved the cervical sample reporting turnaround times for the 14 day key performance indicator. NEY cervical screening laboratory have been working with Roche to plan a number of promotional events in November 2022 to support improving cervical screening coverage.

The colposcopy service has seen a leadership change due to the retirement of the experienced lead colposcopist. The reduced number of accredited colposcopists in 2021 to 2022 impacted clinic capacity which resulted in a back log of patient appointments. The service has worked hard with the employment of locums and increased clinics to reduce the backlog to come back within NHS Cervical Screening Programme (NHSCSP) standards. The clinic accommodation does not fully meet the NHSCSP requirements. There is a seven year plan to address this, however, the service is looking to make some short term improvements. The Lead Nurse Colposcopist supports the cervical screening awareness weeks in the area with media campaigns by posting information on the Gateshead Health Facebook and Twitter accounts plus posters and information stands in public areas.

The cervical histopathology service has good team working which is fully staffed with good laboratory accommodation.

Immediate concerns

The QA visit team identified no immediate concerns

Urgent recommendation

The QA visit team identified one urgent recommendation. A letter was sent to the programme manager on 26 January 2023 asking that the following item is addressed:

Implement a formal quality monitoring step before releasing human papilloma virus (HPV) results.

The actions to address the recommendation was received within 14 working days which provided assurance that action had been taken.

High priority findings

The QA visit team identified 6 high priority findings as summarised below:

Lack of an overarching annual audit schedule for all cervical screening services provided by the trust
The HPV laboratory does not complete environmental viral swabbing
There is no internal quality assessment for selective retesting of Human Papilloma Virus samples
There is no long term sustainable plan for colposcopy staffing and leadership
Colposcopy induction not in place for new and locum colposcopists
Colposcopy clinic accommodation outside of NHSCSP requirements with no short term risk assessment in place whilst longer term accommodation plan is progressed Examples of practice that can be shared.

The QA visit team identified several areas of practice for sharing, including:

Laboratory provides an annual newsletter to primary care sample takers
All histopathologists are participating in the National Gynae External Quality Assessments (EQA)
The colposcopy team have a section on the Trust website with ‘Day in the life of a Colposcopy lead and nurse specialist’ along with clinic walkthrough team video.

Recommendations

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

No.	Recommendation	Pathway theme	Reference	Timescale	Priority	Evidence required
Urgent recommendations
01	Implement a formal quality monitoring step before releasing human papilloma virus (HPV) results	HPV testing	5	14 days	Urgent	Quality process, standard operating procedure (SOP)

No.	Recommendation	Reference	Timescale	Priority	Evidence required
Service provider and population
02	Document health inequalities for supporting vulnerable and underserved people in the colposcopy clinical guidelines	1	6 months	Standard	Updated guidelines
Governance and leadership
03	Complete the invasive cervical cancer audit backlog of cases	3	12 months	Standard	Completion of cases diagnosed up to December 2022
04	Make sure the annual audit of disclosure for the invasive cervical cancer audit is undertaken	4	12 months	Standard	Audit schedule, audit
05	Make sure the invasive audit disclosure leaflet is ratified and implemented	4	3 months	Standard	Disclosure leaflet
06	Develop and implement a whole trust annual audit schedule for cervical screening services	2	12 months	High	Annual audit schedule covering colposcopy and histopathology with confirmatory evidence of actions taken
07	Make sure that HPV testing is included within the main job description for the Consultant Virologist with capacity for greater engagement with NHSCSP service	5	3 months	Standard	Job description, meeting minutes
08	Formally appoint a deputy virologist for NHSCSP	5	3 months	Standard	Appointment
09	Put in place a long term sustainable plan for colposcopy staffing and leadership including formal appointment of a lead colposcopist and deputy	7	6 months	High	Plan
10	Revise the governance arrangements for the colposcopy service to make sure that there is better linkage with gynaecology and gynae-oncology including a forum for escalation	7	6 months	Standard	Document outlining the governance arrangements
HPV testing
11	Implement environmental viral swabbing of the laboratory areas	5	3 months	High	Confirmation, SOP
12	Implement selective retesting of a proportion of Human Papilloma Virus (HPV) samples	5	6 months	High	Implemented process and standard operating procedure
13	Update the standard operating procedures with the correct NHSCSP references for Human Papilloma Virus (HPV) and cytology	5	6 months	Standard	Updated standard operating procedure
14	Put in place a NHSCSP Human Papilloma Virus (HPV) testing and cytology business continuity plan	5	6 months	Standard	Plan
Cytology
15	Update the documentation outlining that the presence of endocervical cells is checked and reported for glandular abnormalities (CGIN) appropriately	5	3 months	Standard	Updated standard operating procedure
16	Update the cervical screening booking in standard operating procedure to ensure there is a clear manual process for recording Retroviral Infection	5	3 months	Standard	Standard operating procedure
17	Update the locum induction policy to include cytology screening staff	5	3 months	Standard	Updated policy
18	Ensure all screeners meet the annual throughput requirements for 3000 slides per annum	5	12 months	Standard	Data submission showing individual screeners workload for the period April 2023 to March 2024
19	Implement an annual audit of cytology rapid review	5	6 months	Standard	Audit
20	Reduce the risk from manual data entry by automating data transfer to produce validated KC61 data	5	6 months	Standard	Process
21	Implement the quarterly failsafe feedback to Cervical Screening Provider Lead and Public Health Programme Teams	5	12 months	Standard	Implementation of process
Referral
	No recommendations made in this section
Sample taker register
22	Provide annual performance reports to sample takers	5	12 months	Standard	Copy of performance report
Diagnosis – histology
23	Update SOPs and policies in line with current practice and national guidance	6	6 months	Standard	Updated standard operating procedures
24	Make sure that there is adequate space for multi-headed microscope training sessions	6	6 months	Standard	Confirmation
25	Make sure that results are compliant with the minimum reporting data set required for the NHSCSP	6	6 months	Standard	Proforma report
26	Ensure clinical audits are undertaken to include review of inadequate reporting and recommended proforma dataset	6	12 months	Standard	Audits
Intervention and outcome – colposcopy
27	Put in place a colposcopy induction process including assessment of suitability to work in the NHSCSP for new and locum consultants	7	3 months	High	Induction protocol
28	Update the colposcopy guidelines to include more detail for immunocompromised women and management of glandular non- cervical abnormalities	7	6 months	Standard	Ratified guidelines
29	Risk assess the current clinic facilities and implement interim changes in line with NHS Cervical Screening Programme guidance	7	12 months	High	Risk assessment and outcomes
30	Ensure that all colposcopists see a minimum of 50 new NHS Cervical Screening Programme referrals per annum	7	12 months	Standard	Data submission showing number of new NHSCSP referrals for each colposcopist in the period April 2023 -March 2024
31	Assess the potential benefit for managing colposcopy capacity from the introduction of ablative treatment options	7	12 months	Standard	Outcome of assessment
32	Update the administration standard operating procedures onto the trust/service templates	7	3 months	Standard	Ratified standard operating procedures
33	Undertake an audit of high inadequate biopsy rate in colposcopy data in conjunction with histopathology	6,7	12 months	Standard	Audit and outcomes
34	Undertake an audit of conservative management of Cervical Intraepithelial Neoplasia (CIN) 2	7	12 months	Standard	Audit and outcomes
35	Update the aftercare colposcopy leaflets in line with national guidance	7	6 months	Standard	Ratified leaflets
36	Ensure patient information leaflets are accessible for all people including those from vulnerable groups, and that leaflets are presented in different languages, tailored to the local population	7	12 months	Standard	Leaflets
Multidisciplinary team
37	Ensure all colposcopists attend a minimum of 50% of MDT meetings	7	12 months	Standard	MDT attendance records January 2023 – December 2023
38	Make sure all histopathologists reporting cervical screening attend 3 of the MDT meetings	6	12 months	Standard	MDT attendance records January 2023 – December 2023
39	Introduce a process to make sure that a second review of cytology and histopathology are by a different reporter	7	6 months	Standard	Confirmation of implemented process

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 A: References

NHS England. NHS Public Health Functions Agreement: 2022/23 Service Specification No.25 Cervical Screening Service Schedule 2
NHS Cervical Screening Programme. Cervical screening: role of the cervical screening provider lead; 2018.
NHS Cervical Screening Programme. Cervical screening: auditing procedures; 2021.
NHS Cervical Screening Programme. Cervical screening: disclosure of audit results toolkit; 2021.
NHS Cervical Screening Programme. Laboratories providing HPV testing and cytology

NHS Cervical Screening Programme. Cervical screening: histopathology reporting handbook; 2021.
NHS Cervical Screening Programme. Cervical screening: programme and colposcopy management; 2021.
NHS Cervical Screening Programme. Cervical screening: cytology reporting failsafe (primary HPV); 2019.
Ministry of Housing, Communities & Local Government. English indices of deprivation; 2019.
NHS England. Quarterly Cervical Coverage Report; September 2022.
The British Association of Gynaecological Pathologists. BAGP guidance documents

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