NHS England » Screening quality assurance visit report – Leeds Teaching Hospitals NHS 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	NHS England North East and Yorkshire 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	Gateshead Health NHS Foundation Trust
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 18 June 2025 to The Leeds Teaching Hospitals NHS Trust (LTHT) Cervical Screening Service which is commissioned by NHS England North East and Yorkshire 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 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 LTHT on 18 June 2025
information shared with the SQAS as part of the visit process.

The screening service

LTHT provides NHS cervical screening services to part of the population covered by the West Yorkshire Integrated Care Board. The service is overseen by NHS England North East and Yorkshire Public Health Commissioning Team with support from the West Yorkshire Public Health Programme team.

LTHT provides colposcopy from the St James’s University Hospital and Wharfedale Hospital, Otley. The cervical histology is provided from St James’s University Hospital. Gateshead Health NHS Foundation Trust provides the human papillomavirus (HPV) testing and cytology service.

Findings

Since the last visit to this service in 2018, there has been a major service change with the implementation of human papillomavirus primary screening and the challenge presented by the COVID-19 pandemic. The service has seen a significant increase in NHS Cervical Screening Programme referrals and the waiting time for patients referred with low grade screening results has not been achieved since the pandemic.

The service does not have sufficient colposcopy clinic capacity to see patients in a timely way. At the time of the QA visit the waiting time for patients referred with low grade screening results is 20 weeks (national standard is 6 weeks) which the Trust accepts is unacceptable and presents a clinical risk. The approach to managing this issue is also increasing health inequalities. Priority action by the Trust to address this and develop sustainable internal capacity sufficient for its referral workload is required. A number of opportunities to support this were identified by the QA Team.

There has been a recent change in some leadership roles and an impending change later in the year. The service needs to be clear on the roles and responsibilities of all key leadership posts and deputies. This is an opportunity to ensure a collaborative, multi-disciplinary and inclusive approach to building the team for the future.

Following a colposcopy administration QA review in 2023, the service has introduced dedicated administration and multi-disciplinary team (MDT) coordinators which is now providing demonstrably improved support to the cervical screening provider lead, colposcopy failsafe processes and MDT meetings and increased service resilience.

Immediate concerns

The QA visit team identified 1 immediate concern. A letter was sent to the chief executive on 23 June 2025 asking that the following item is addressed within 7 working days:

Stop the clinical practice of taking punch biopsies to investigate patients referred with ?glandular neoplasia and borderline changes in endocervical cells screening test results.

A response was received within 7 working days which assured the visiting QA team the identified risk was mitigated and no longer poses an immediate concern.

Urgent recommendations

The QA visit team identified 2 urgent recommendations. These urgent recommendations were included in the letter sent to the chief executive on 23 June 2025 asking that the following items were addressed:

Implement and monitor a plan and trajectory which has colposcopy team ownership to achieve and maintain equitable colposcopy waiting time standards using sustainable internal trust capacity for all NHS Cervical Screening Programme referrals.
Implement clinician validation of the colposcopy discharge report sent to the Cervical Screening Administration Service (CSAS) to update the date of next screening test.

A response including an action plan was received informing the visiting QA team of the steps taken to partially resolve the urgent recommendations.

High priority findings

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

The governance arrangements for the colposcopy service and roles and responsibilities are not in line with national guidance. There is evidence of a disconnect between trust senior management and the clinical team in decision making about the service leading to a lack of collective multi-disciplinary decision making. This puts the service at risk of poorly informed decision making that could have patient safety implications.
There is no cervical screening management meeting in place to oversee the cervical screening pathway. This means not all risks and issues may be identified
There is no succession plan in place for colposcopy trainers for continuity of colposcopy training for trainees. This means training will have to stop if there is no approved trainer available, directly impacting the development of internal capacity
The local guidance on the use of punch biopsy in individuals referred with glandular abnormalities is not in line with national guidance which means patients may have been inappropriately managed
There is limited assurance on the oversight of clinical validation of data and actions taken on performance outside national standards which means issues may not be identified and acted upon in a timely manner
A colposcopy-specific patient survey by clinic site has not been undertaken in the last 5 years meaning that patient feedback is not being used to develop the service
Not all colposcopists routinely achieve the required standard for attendance at the colposcopy multi-disciplinary team meetings so are not fully engaging in the service. There is no audit of case selection which means there is a risk not all cases that need MDT discussion are being included

Examples of practice that can be shared

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

The LTHT website has a designated page about colposcopy and the colposcopy service within the Trust and contains a short video created by the nurse colposcopists welcoming patients to the service with a walk through of the clinic facilities and patient journey
Invasive cervical cancer audit is up to date due to extensive administration support from the colposcopy coordinators in developing effective internal processes for the smooth running of the audit
The colposcopy lead with support from the team has taken a proactive action to reduce inappropriate primary care referrals into colposcopy.

Recommendations

No.	Recommendation	Pathway theme	Reference	Timescale	Priority	Evidence required
Immediate concerns
01	Stop the clinical practice of taking punch biopsies to investigate patients referred with ?glandular neoplasia and borderline changes in endocervical cells screening test results	Intervention and outcome – colposcopy	2	7 days	Immediate	Confirmation that all colposcopists are aware of the national guidance
Urgent recommendations
02	Implement and monitor a plan and trajectory which has colposcopy team ownership to achieve and maintain equitable colposcopy waiting time standards using sustainable internal trust capacity for all NHS Cervical Screening Programme (CSP) referrals	Intervention and outcome – colposcopy	1,2	14 days	Urgent	Action plan, trajectory
03	Implement clinician validation of the colposcopy discharge report sent to the Cervical Screening Administration Service to update the date of next screening test	Intervention and outcome – colposcopy	2	14 days	Urgent	Provide confirmation of the arrangements in place

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

No.	Recommendation	Reference	Timescale	Priority	Evidence required
Service provider and population
04	Develop an action plan, in collaboration with commissioners, to reduce screening inequalities in underserved and protected populations	1	12 months	Standard	Action plan
Governance and leadership
05	Update governance arrangements for the cervical screening programme in line with national guidance	1,2,3	3 months	High	Formal appointment of cervical screening provider lead, new lead colposcopist and lead colposcopy nurse roles, with job descriptions, time allocation, administrative support and induction arrangements, and nomination of a deputy for each of the lead roles Updated terms of reference for cervical screening management meeting and separate colposcopy operational meetings including escalation and reporting routes Cervical screening trust wide audit schedule covering colposcopy and histology Trust representation at commissioner-led cervical screening programme boards
06	Provide an annual NHS CSP performance report for 2024/25 and 6 monthly report	1,3	12 months	Standard	Annual performance report and 6 monthly report with evidence of presentation at the overarching Trust clinical governance meeting
07	Document the process for results and referral for cervical samples taken in the Trust outside of colposcopy	2	6 months	Standard	Standard operating procedure (SOP)
08	Ensure all staff are aware of the process for reporting potential screening incidents	2,3	3 months	High	Completion of eLearning
09	Update the Trust incident policy to include the reference to managing screening incidents in accordance with Managing Safety Incidents in NHS Screening Programmes	3	6 months	Standard	Policy
Intervention and outcome – colposcopy
10	Put in place a succession plan for the training of colposcopists	3	3 months	High	Succession plan
11	Document the colposcopy induction process for clinical and non-clinical staff	3	6 months	Standard	SOP
12	Update the clinical colposcopy guidelines to ensure they are aligned with NHS CSP guidance and terminology (Appendix C)	3	3 months	High	Guidance
13	Establish colposcopy nursing guidelines	3	6 months	Standard	Guidelines
14	Ratify all administration SOPs and develop a SOP for the recording and management for treatment under general anaesthetic and for the clinician validation of the discharge list	3	6 months	Standard	SOPs
15	Undertake a did not attend audit to identify actions to support attendance, including from vulnerable and hard-to-reach groups within the eligible population	1,3	6 months	Standard	Audit
16	Undertake an audit on the management and follow up of multi-disciplinary team (MDT) confirmed borderline endocervical cases from the last 5 years and cervical intraepithelial neoplasia grade 2 conservative management cases	3	3 months	High	Audit and outcomes
17	Demonstrate that the service and clinicians adhere to national workload and quality standards	1,3	12 months	High	Individual Colposcopy performance data 2025/26
18	Put in place routine clinical validation of data and a process for taking action on performance outside national standards	1,3	3 months	High	SOP
19	Update all patient literature and communications to reflect HPV primary screening and standardised outcome communications, ensuring literature is accessible for all people including those from vulnerable groups, and that leaflets are presented in different languages, tailored to the local population	1,3	6 months	Standard	Local treatment leaflet Local colposcopy patient information leaflet Updated copies of patient appointment and result letters
20	Re-commence the annual patient satisfaction survey	3	12 months	Standard	Report
Multidisciplinary team
21	Demonstrate that colposcopists routinely meet the NHS CSP standard for colposcopy MDT attendance	1,3	3 months	High	Audit
22	Audit MDT case selection criteria	1,3,4	12 months	High	Audit

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 B: References

NHS Public Health Functions Agreement 2024-25 Service Specification No. 25, NHS Cervical Screening Programme
NHS CSP: Programme and Colposcopy Management. Updated September 2024
NHS CSP: the role of the cervical screening provider lead. March 2018
NHS CSP: National invasive cervical cancer audit. December 2006 Updated September 2021
NHS CSP: Disclosure of cervical screening history review results and applying duty of candour. April 2021 Updated October 2021

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