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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 | NHS England South East (HIOW) Public Health Commissioning Team |
| Leadership and governance | Yes | Not applicable |
| Pathway | ||
| Cohort identification | Yes | Not applicable |
| Invitation and information | Yes | Not applicable |
| Testing | Yes | Not applicable |
| Results and referral | Yes | Not applicable |
| Diagnosis | Yes | Not applicable |
| Intervention / treatment | Yes | Not applicable |
Summary
The NHS Abdominal Aortic Aneurysm Screening Service is available for all men aged 65 and over in England. The service aims to reduce abdominal aortic aneurysm related mortality among men aged 65 and older. A simple ultrasound test is performed to detect abdominal aortic aneurysms. The scan itself is quick, painless and non-invasive and the results are provided straight away.
The findings in this report relate to the quality assurance visit on 26 April 2023 to Hampshire and Isle of Wight (HIOW) AAA Screening Service which is commissioned by NHS England South East (HIOW) Public Health Commissioning team (PHCT). 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 abdominal aortic aneurysm (AAA) 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 the 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 Hampshire and Isle of Wight on 26 April 2023
- information shared with the South SQAS as part of the visit process
The screening service
The Hampshire and Isle of Wight AAA screening service implemented screening in January 2011 and covers an area with a population of approximately 1.9 million. As of 01 July 2022, The Hampshire and Isle of Wight integrated care boards (ICB) covers the boundary of the screening service. The screening service also covers 12 Local Authorities (LAs) and 129 GP practices. The Hampshire and Isle of Wight service covers a mix of urban and rural areas.
In 2021/22 the service had an eligible cohort of 9,289 with an additional 113 men who self-referred.
The ethnic mix of the LAs within the service boundary area is 98.5% White, 0.84% Asian/Asian British, 0.21% Black/African/Caribbean/Black British, 0.13% other and 0.3% mixed. Southampton has the greatest ethnic mix with 4.3% of the population from non-White groups. Isle of Wight and New Forest LAs have the least variation with 0.6% from non-White populations.
Findings
This was the second QA visit to the Hampshire and Isle of Wight AAA screening service. The service achieved the acceptable level for 10 out of 15 of the national standards for 2021/2022. There are some good areas of practice that are listed below.
The service has faced challenges throughout the Covid 19 pandemic and into the 2022/2023 cohort year. There have been changes to key staff members, and screening clinic availability which has impacted on recovery of the services. Changes to vascular theatre availability, intensive care units (ICU) and high dependency unit (HDU) capacity has resulted in increased waiting times for AAA surgery.
The QA visit team were concerned that staff groups were operating in isolation. There is a lack of regular interaction between the various staff groups within the screening service including technicians, clinical staff, and trust management. The governance arrangements and escalation route to the trust board were not clear.
Immediate concerns
The QA visit team identified no immediate concerns.
High priority findings
The QA visit team identified 8 high priority findings as summarised below:
- staff groups within the service were operating in isolation. Communication between the multidisciplinary team could be improved
- the screening service risk register is not formally escalated within the trust. Therefore, the trust board is not informed of risks associated with workforce or resilience of the service
- workforce allocations are not in line with national guidance
- the roles of QA Lead and Clinical Skills Trainer have recently been combined. Clarity is needed on the amount of time which will be allocated to each role
- standard checks of ultrasound machines are not in line with national guidance
- there was no evidence of a comprehensive induction programme for new Clinical Skills Trainers. This should include information on all aspects of national guidance specific to the role
- men who need their temporarily ineligible status actioned e.g. men who are made inactive for a period of time such as those who have been in the post office return phase are not being managed in a timely manner
- the national standard for timeliness of appointments for men on quarterly surveillance is not being met. These men are most at risk of a AAA related adverse event
Examples of practice that can be shared
The QA visit team identified several areas of practice for sharing, including:
- audit activity is proactive and undertaken by a variety of team members
- there is a good Trust intranet site with an informative video
- there are bi-monthly meetings with the Clinical Skills Trainer and screening technicians that are very well received
- supportive urgent pathways involving the on call vascular consultant
- high volume, excellent outcome AAA interventions
- the Clinical Skills Trainer had a good working relationship with senior colleagues highlighting the advantage of peer support
Recommendations
The following recommendations are for the provider to action unless otherwise stated.
| No. | Recommendation | Reference | Timescale | Priority | Evidence required |
| Governance and leadership | |||||
| 01 | The board should review and clarify its expectations of a patient representative with the possible intention of appointing someone | Service specification | 12 months | Standard | Recruitment of patient representative to the programme board |
| 02 | Develop the governance structure including the internal team meetings and escalation to board level | NHS Abdominal Aortic Aneurysm (AAA) Screening Programme Essential elements in providing an AAA screening and surveillance programme | 3 months | High | Terms of reference for all internal meetings to be submitted at programme board |
| 03 | Update and create Standard Operating Procedures ensuring they follow a standard template | NHS Abdominal Aortic Aneurysm (AAA) Screening Programme Essential elements in providing an AAA screening and surveillance programme | 6 months | Standard | Updated Standard Operating Procedures to be submitted to programme board |
| 04 | Review and update risk register to include but not be limited to; lack of screening technicians, Clinical Skills Trainer being a seconded role | Service Specification | 3 months | High | Updated risk register presented at programme board |
| 05 | Work with the public health commissioning team, and other stakeholders where appropriate, to develop and complete a health equity audit and action plan. To include, but not be limited to; hard to reach populations such as learning disabilities, homeless, transgender and unregistered men | AAA Screening: identifying inequalities NHS standard contract | 12 months | Standard | Summary of audit findings and action plan presented to programme board |
| 06 | Develop a programme of patient engagement events and promotional activity to target areas of identified need. | AAA Screening: identifying inequalities NHS standard contract | 12 months | Standard | Programme of patient engagement events developed and presented to programme board |
| 07 | Review locations and accessibility of clinic venues ensuring these meet service user needs | NHS Abdominal Aortic Aneurysm (AAA) Screening Programme Essential elements in providing an AAA screening and surveillance programme | 6 months | Standard | Clinic venue plan to be submitted to programme board |
| 08 | Review the audit schedule. Undertake regular audits and carry out service improvements based on the outcomes | Service specification Standard operating procedures | 12 months | Standard | Audit schedule presented to programme board and service improvement plans based on outcomes of audits monitored at programme board |
| 09 | Develop and implement user satisfaction surveys to cover all parts of the screening pathway | Service specification | 6 months | Standard | Results of user satisfaction survey presented to programme board for discussion and action plan for service improvement developed based on results |
| 10 | Develop processes for sharing an annual report with relevant stakeholders | Service specification | 12 months | Standard | Annual report to be submitted to programme board and the Trust management team |
| Infrastructure | |||||
| 11 | Develop a comprehensive business continuity plan which includes cover arrangements for staff absence | Service specification | 6 months | Standard | Business continuity plan presented at programme board |
| 12 | Review the current workforce allocation including the Quality Assurance Lead and Clinical Skills Trainer secondment, and WTE screening technicians to ensure all roles are adequately covered going forwards | Service specification | 3 months | High | Evidence of sustainability of combined roles to be presented at programme board |
| 13 | Review the time allocation for the combined Quality Assurance Lead and Clinical Skills Trainer role ensuring enough time is allocated | Service specification | 3 months | High | Evidence of time allocated to the role submitted to programme board |
| 14 | Review the job description for all core roles to ensure they are aligned with national guidance and written in the trust’s format | Service specification | 6 months | Standard | Revised job descriptions to be presented to programme board |
| 15 | Ensure monthly checks of the ultrasound machines are delivered in accordance with national guidance | Ultrasound equipment quality assurance guidelines | 3 months | High | Evidence of monthly reporting submitted to programme board |
| 16 | Ensure annual electrical safety checks are carried out on all ultrasound machines | Ultrasound equipment quality assurance guidelines | 12 months | Standard | Evidence of annual safety checks submitted to programme board |
| 17 | Ensure the newly engaged Clinical Skills Trainer has an appropriate induction programme which includes access to all relevant national guidance documents. | AAA screening: professional guidance | 3 months | High | Confirmation with Quality Assurance and Public Health Commissioning Teams |
| Identification of cohort | |||||
| 18 | Increase the timeframe for unregistered men to be in temporarily ineligible status from six months to 14 months | Service specification | 6 months | Standard | Confirmation of change to be submitted to programme board |
| 19 | Ensure all temporarily ineligible men are actioned in a timely manner when actioned date is due | Service specification | 3 months | High | Submit standard operating procedure to programme board |
| Invitation, access and uptake | |||||
| 20 | Review the clinic locations for vascular nurse appointments, ensuring an equitable service for all men | AAA screening programme nurse specialist guidelines | 12 months | Standard | Review of findings to be submitted to programme board |
| 21 | Ensure the vascular nurse has access to the national IT system AAA SMaRT and can input data | AAA screening programme nurse specialist guidelines | 6 months | Standard | Submit standard operating procedure to programme board |
| The screening test – accuracy and quality | |||||
| 22 | Ensure the lone working policy is updated and uses a standardised format | Service specification | 12 months | Standard | Submit standard operating procedure to programme board |
| 23 | Ensure quarterly assessments of the screening technicians are being undertaken within the correct timeframe | Internal quality assurance framework and resources | 3 months | High | Submit evidence of quarterly assessment outcomes at programme board |
| 24 | Ensure the internal quality assurance meets the national standard requirement, including a standard operating procedure to reflect this practice | Abdominal aortic aneurysm screening: internal quality assurance | 6 months | Standard | Submit standard operating procedure to programme board |
| Referral | |||||
| 25 | Review and create a standard operating procedure for the management of incidental findings including iliac and focal aneurysms | Standard operating procedures | 6 months | Standard | Submit standard operating procedure to programme board |
| 26 | Review and update the standard operating procedure for the non-visualisation process | Standard operating procedures | 6 months | Standard | Submit standard operating procedure to programme board |
| Intervention and outcome | |||||
| 27 | Review the capacity restraints in the hybrid theatre to ensure delays to intervention are minimised | Service specification | 6 months | Standard | Review of outcome submitted to programme board |
| 28 | Develop a process for sharing of information on ruptures/deaths with the programme manager | Service specification | 12 months | Standard | Submit process to 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: References
- AAA screening standard operating procedures: Essential Elements in providing an AAA screening and surveillance programme AAA screening: standard operating procedures
- Abdominal Aortic Aneurysm Screening Pathway Requirements Specification
Abdominal aortic aneurysm screening pathway requirements specification - Abdominal Aortic Aneurysm Screening: Reducing Inequalities
Abdominal aortic aneurysm screening: reducing inequalities - Abdominal Aortic Aneurysm Screening: Standards
Abdominal aortic aneurysm screening programme supporting information - Abdominal Aortic Aneurysm Screening: Protocol for Reporting Deaths
AAA screening: protocol for reporting deaths - Abdominal Aortic Aneurysm Screening: waiting times standards.
AAA screening: waiting times standards - Abdominal Aortic Aneurysm Screening: Management of Non-Visualised Aortas
AAA screening: management of non-visualised aortas - Abdominal Aortic Aneurysm Screening: Clinical Guidance and Scope of Practice for Professionals involved in the provision of the ultrasound scan.
PHE standard publication template - Abdominal Aortic Aneurysm Screening: Education and Training
Abdominal aortic aneursym screening: education and training - Abdominal Aortic Aneurysm Screening: Clinical Skills Trainer Guide
AAA screening: professional guidance - Abdominal Aortic Aneurysm Screening: Internal Quality Assurance
Abdominal aortic aneurysm screening: internal quality assurance - Abdominal Aortic Aneurysm Screening: Ultrasound Equipment Guidelines
Abdominal aortic aneurysm screening: ultrasound equipment guidelines - Abdominal Aortic Aneurysm Screening: Nurse Specialist Guidance
AAA screening programme nurse specialist guidelines