NHS England » Screening quality assurance visit report – Guy’s and St Thomas’ NHS Foundation Trust

Scope of this report

	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	N/A
Workforce	Yes	N/A
IT and equipment	Yes	N/A
Commissioning	Partly	NHS England London Public Health Commissioning Team
Leadership and governance	Yes	N/A
Pathway
Cohort identification	No	Cervical Screening Administration Service
Invitation and information	No	Cervical Screening Administration Service
Testing and results	No	Cervical Screening Laboratory, London
Referral	Yes	N/A
Diagnosis	Yes	N/A
Intervention/treatment	Yes	N/A

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 13 March 2024 to Guy’s and St Thomas’ NHS Foundation Trust (GSTT) Cervical Screening Service which is commissioned by NHS England London Public Health Commissioning team.

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
evidence submitted by the provider
information collected during pre-review visits to Guy’s and St Thomas’ NHS Foundation Trust on 5 March 2024
information shared with the London SQAS as part of the visit process

The screening service

GSTT provides NHS cervical screening services to the populations covered by the boroughs of Lambeth and Southwark. The service is commissioned by NHS England (NHSE) London Public Health Commissioning Team (PHCT).

The cytology and HPV testing is provided by Cervical Screening Laboratory based at the Halo Building in Euston, London.

Findings

The trust has experienced significant changes in leadership over recent years. The most recent change has been the new appointment to the lead colposcopist role just prior to the QA visit. The trust will need to clarify roles and responsibilities of its lead roles, along with governance and reporting structures.

The cervical screening service continued through the COVID-19 pandemic and all staff involved should be commended for this. Cervical histology turnaround times have been challenged but are now improving.

With the change to HPV primary screening, the colposcopy service has experienced the expected increase in referral activity. At the time of the QA visit there is a significant backlog of referrals suggesting that the workforce is not sufficient for the number of referrals being received. There is a business plan in place to increase colposcopy capacity to manage the backlog of referrals but a broader review of all aspects of the service is needed to identify areas for change to release capacity.

Colposcopy IT is a risk due to unsupported software and trust support will be needed to ensure a suitable system is in place as a matter of priority.

Not all colposcopists are meeting national standards and this requires action.

Immediate concerns

The QA team identified no immediate concerns.

Urgent recommendations

The QA team identified no urgent concerns.

High priority findings

The QA visit team identified 7 high priority findings as summarised below:

roles, responsibilities, and support are not clearly defined for key leadership posts and there is no formally appointed lead colposcopy nurse in post
cervical screening meetings and colposcopy operational meetings do not have the appropriate staffing representation, discuss all relevant items, or have appropriate terms of reference and there is no clear risk management process which means that risks and issues may not be identified and managed
audits of disclosure of cervical cancer case reviews are not taking place
not all national colposcopy standards for individual colposcopists or the service are being met
here is a risk to patient management and the data capture and validation through having an unsupported colposcopy IT system which needs replacing

Examples of practice that can be shared

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

embracing and actively modifying IT in histology to support efficient workflow, including a specimen tracking and alerting process
wall charts highlighting questions that patients may be asked during consultations
QR code in colposcopy, general gynaecology reception and waiting areas to access screening information leaflets
colposcopy nurses “message of the week” feeding back news and updates to the whole team

Recommendations

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

No.	Recommendation	Reference	Timescale	Priority	Evidence required
Governance and leadership
01	Clarify and document responsibilities and support for the cervical screening provider lead (CSPL) and escalation routes without conflicts of interest for the lead colposcopist role	1,2	3 months	High	Confirmation of CSPL nominated deputy and activities to be undertaken Confirmation of administrative sessional support for CSPL Escalation and governance pathway for lead colposcopist
02	Put in place updated terms of reference with appropriate content, representation and reporting for the quarterly cervical screening management meetings and colposcopy operational meetings	1,2	3 months	Standard	Terms of reference and minutes of all meetings held since the QA visit Updated organogram demonstrating reporting up to trust board
03	Update the trust policy on the invasive cervical cancer audit and disclosure of invasive cervical cancer audit so it demonstrates a cohesive approach	1,2	3 months	Standard	Ratified cancer audit and disclosure policies agreed by the trust governance board Standard operating procedures (SOPs) identifying roles and responsibilities for the management and completion of the invasive cervical cancer audit
04	Complete an audit to demonstrate offer of disclosure of invasive cervical cancer audit	3	6 months	High	Audit report
05	Implement a trust-wide cervical screening audit schedule	1,2	12 months	Standard	2024-2025 audit schedule
06	Ensure colposcopy administrative team has training on screening incident awareness	1,2	3 months	Standard	Confirmation that colposcopy administration team have undertaken appropriate training
07	Ensure all screening issues and risks are being identified and acted upon, including sharing learning outcomes	1,2	12 months	Standard	Audit of incidents and risks discussed at the CSPL and colposcopy meetings
08	Put in place documented risk management processes covering the cervical screening programme pathway	1,2	3 months	High	Document risk management process SOP
09	Ensure there is a trust lead colposcopy nurse for cervical screening who has responsibility for ensuring good practice, compliance with protocols and NHS CSP standards	1,6	3 months	High	Confirmation of named appointment and deputy. Confirmation that colposcopy organisational structure has been updated
Referral – no recommendations
Sample taker register – no recommendations
Diagnosis – histology
10	Document the specimen chain of custody pathway between colposcopy clinics and the histology laboratory	1,5	3 months	Standard	Colposcopy and histology pathways
11	Put in place reporting using a standardised proforma	1,5	3 months	Standard	Confirmation of 2023 audit that all pathologist are using standardised reporting proforma
12	Ensure there is consistent use of SNOMED codes	1,5	3 months	Standard	Audit
13	Assess the impact of the cervical screening workload on the service and take action in an appropriate timescale	1,5	6 months	Standard	Confirmation of process in place
Intervention and outcome – colposcopy
14	Make sure there is sufficient permanent colposcopy administrative staff to meet the requirements of the NHS Cervical Screening Programme	1	6 months	Standard	Confirmation of named appointments and colposcopy time allocation Gap analysis covering all colposcopy administration functions and details of actions taken
15	Ensure the new information technology (IT) systems are implemented according to the planned timetable and that performance and audit data are available during and following migration	1,6	6 months	High	Confirmation of IT process in place Plan for access and migration of legacy data
16	Put in place a “did not attend” (DNA) process which is in line with trust policy	1	3 months	Standard	DNA SOP
17	Document the process for the management of cervical samples taken outside of the colposcopy service	1	3 months	Standard	SOP
18	Document the process for recording cervical screening tests using the EPIC IT system	1	3 months	Standard	SOP
19	Ensure all colposcopists see the required 50 new abnormal cytology patients in the year	1,6	3 months	High	Update colposcopy IT database with active colposcopists Action plan
20	Put in place a holistic plan which demonstrates there is sufficient routine capacity to meet the expected workload and national standards for the service and individual clinicians	1,6	3 months	High	Action plan
21	Put in place action plan for data validation and individual colposcopist performance where national standards are not achieved	1,6	3 months	High	Action plan
22	Streamline and update the content and production of colposcopy and DNA letters	1,6	3 months	Standard	Confirmation that patients have access to the national information leaflet Confirmation that map is sent with appointment letter Updated colposcopy and DNA letters
Multidisciplinary team
23	Update SOP for case selection and local arrangements for the multi-disciplinary team (MDT) meeting	1	6 months	Standard	SOP
24	Document an agreed management approach for patients discussed at MDT for conservative management of CIN2	1	3 months	Standard	SOP
25	Audit MDT case selection and document the continuous audit that MDT outcomes have been completed	1	6 months	Standard	Audit report and MDT outcomes
26	Ensure all colposcopists participate in a minimum of 50% of MDT per year	1	12 months	Standard	Audit of MDT attendance

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

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. NHS Futures dashboard website: Cancer Screening Coverage and Uptake: Bowel, Breast and Cervical Programmes – Vaccinations and Screening – Future NHS Collaboration Platform. Accessed March 2024

12. NHS population screening: inequalities strategy. July 201

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