NHS England » NHS Abdominal Aortic Aneurysm

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
Workforce	Yes
IT and equipment	Yes
Commissioning	Partly	NHS England South East (Surrey and Sussex) Public Health Commissioning Team
Leadership and governance	Yes
Pathway
Cohort identification	Yes
Invitation and information	Yes
Testing	Yes
Results and referral	Yes
Diagnosis	Yes
Intervention / treatment	Yes

Summary

The NHS Abdominal Aortic Aneurysm Screening Programme is available for all men aged 65 and over in England. The programme 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 03 July 2024 to Sussex AAA Screening Service which is commissioned by South East 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 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 shared with the South SQAS as part of the visit process

The screening service

The Sussex AAA screening service (the service) has an eligible population of approximately 10,554 men (2022/23), with an additional 149 men who self-referred¹. The predominant ethnicity for this population is White (97.4%). Crawley has the greatest ethnic mix with 13.7% of the population from non-White groups. Chichester has the least variation, with1.0% from non-White populations². Levels of deprivation vary across the Local Authorities. Hastings is the most deprived local authority within the provider area (ranked 13/317 nationally, where 1 is the most deprived). Mid Sussex is the least deprived local authority within the provider area (ranked 311/317)³.

The service is provided by Sussex Community NHS Foundation Trust (SCFT). NHS England South East Public Health Commissioning Team (PHCT) commission the service to provide all aspects of the screening pathway including programme management, administration, failsafe, and screening. University Hospitals Sussex NHS Foundation Trust (UHSFT) provides specialised vascular services, which is commissioned by specialised commissioning. Clinical leadership is provided by one of the vascular consultants from UHSFT.

The service offers screening to all eligible men in the year they turn 65 in line with national guidance. This is delivered by screening technicians in community settings comprising of GP practices, hospital sites and prisons. Arrangements are in place to offer a re-screen within the community, where the aorta has been difficult to visualise, or at the vascular department in University Hospitals Sussex Foundation Trust.

Men with large aneurysms (equal to or greater than 5.5cm) or rapidly growing aneurysms (growth over more than 1 cm in a year) are referred for treatment at the University Hospitals Sussex Foundation Trust.

Findings

This was the first QA visit to the Sussex AAA screening service since the previous QA visit in 2018 and the interim QA review in 2021. The service achieved the acceptable threshold for 9 out of the 15 national standards and the achievable threshold for 2 in 2022/23. The annual data for 2023/24 was not available at the time of the visit, although Q4 provisional data for 2023/24 is included for reference.

The service has faced challenges following the Covid-19 pandemic and into the 2023/24 cohort year. Staffing and screening clinic capacity issues have impacted on recovery of the service. In particular, during 2022/23 the vascular service at UHSFT did not operate on any screen referred men within the 8-week target.

NHS England South East Specialised Commissioning Team have supported the vascular service and the trust, with initiatives now in place to minimise preventable hospital/inefficiency delays. There has been an improvement in Q4 of 2023/24 with the vascular service operating on three men within eight weeks.

There is particularly good support for the screening service and engagement from senior management of the provider organisation. The service should be recognised for their efforts and dedication during the last 12 months to complete the 2023/24 cohort ahead of the planned trajectory, and the current position of the 2024/25 cohort. There were several areas of good practice identified for shared learning which are listed below.

Immediate concerns

No immediate concerns were identified.

High priority findings

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

there are no regular local AAA screening meetings (clinical director, programme manager, and administrator) to regularly review the service performance, risks, workforce, screening incident assessment forms (SIAFs), mortality reports, audit and promotional activities
screening incidents have not been managed in accordance with national guidance. SIAFs have not been submitted in a timely manner to SQAS and PCHT and UHSFT has not actively involved SQAS and the PHCT in the investigation and management of serious incidents
there is a 2023/24 nurse appointment backlog due to insufficient nurse clinics to meet the waiting time standard
initiatives in UHSFT to optimise use of current theatre capacity and to review/enhance vascular theatre capacity to ensure timely AAA interventions need to be developed further

Examples of practice that can be shared

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

the service has a business continuity plan which is exemplary in its comprehensiveness and detail
the service has dedicated pages on the trust’s website to provide online information for service users and has produced a promotional video for screening cohort men
the service undertakes annual environmental audits, covering musculo-skeletal, equipment weight and environmental issues
the vascular service has an excellent record of low mortality elective intervention with high volumes of repairs including complex open and endovascular interventions (301 cases, 0% 2020-2023)

Recommendations

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

No.	Recommendation	Reference	Timescale	Priority	Evidence required
Service provider and population served
	No recommendations
Governance and leadership
01	Initiate regular local AAA screening meetings (clinical director, programme manager and administrator) to periodically review the service performance, risks, workforce, SIAFs, mortality reports, audit, and promotional activities	Service specification	3 months	High	Confirmation to programme board
02	Ensure that all incidents are managed in accordance with national guidance; to include active involvement of SQAS and PCHT in the investigation and management process of serious incidents and that SIAFS are submitted in a timely manner	National guidance	3 months	High	Active involvement of SQAS and PCHT in the investigation and management process for future serious incidents and timely submission of SIAFS going forwards
03	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; underserved 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
04	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
05	Develop an annual audit schedule in conjunction with the PHCT, and consider audit training for the wider screening team	Service specification	6 months	Standard	Confirmation to programme board
Infrastructure
06	Develop regular training sessions for the screening technicians	National guidance	6 months	Standard	Summaries of training sessions presented to programme board
Identification of cohort
07	Create a standalone standard operating procedure (SOP) for managing exclusions	National guidance	6 months	Standard	Confirmation to programme board
Invitation, access and uptake
08	Address the 2023/24 nurse appointment backlog and ensure sufficient nurse clinics to meet the waiting time standard	National standards	3 months	High	Achievement of pathway standard 13. Quarterly standards report confirmation to programme board
The screening test – accuracy and quality
09	Explore ways that the CST and QA lead could be released to attend team meetings to improve shared learning	National guidance	6 months	Standard	Confirmation to programme board of CST and QA lead attendance at team meetings
Referral
10	Review and update SOPs to include the following: · the referral process for aneurysms >6.5cm and managing the referral tracker · the local process for managing incidental vascular findings · the process for monitoring the waiting times for non-visualisation referrals	National guidance	6 months	Standard	Confirmation to programme board
Intervention and outcome
11	Create a SOP for management of false positives and ensure they are reported on a SIAF as per National guidance	National guidance	6 months	Standard	Confirmation to programme board
12	Review the process for identification of NAAASP surveillance patients to prevent unnecessary referrals to the vascular service and potential duplication of surveillance	National guidance	6 months	Standard	Confirmation of surveillance process to programme board
13	Further develop initiatives in UHSFT to optimise use of current theatre capacity and to review/enhance vascular theatre capacity to ensure timely AAA interventions	National standards	3 months	High	Reported at programme board and review of quarterly standards report

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.

References

ONS 2022 mid-year LA population estimates Estimates of the population for the UK, England, Wales, Scotland, and Northern Ireland – Office for National Statistics (ons.gov.uk)
Men aged 65 years and over by ethnic group from NOMIS using the 2021 census data Nomis – Official Census and Labour Market Statistics (nomisweb.co.uk)
Indices of deprivation 2019 scores for Local Authorities English indices of deprivation 2019 – GOV.UK (www.gov.uk)
AAA screening standard operating procedures: Essential Elements in providing an AAA screening and surveillance programme AAA screening: standard operating procedures
Managing safety incidents in NHS screening programmes Managing safety incidents in NHS screening programmes
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: Ultrasound Equipment Guidelines Abdominal aortic aneurysm screening: ultrasound equipment guidelines
Abdominal Aortic Aneurysm Screening: Nurse Specialist Guidance AAA screening programme nurse specialist guidelines
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: Standards Abdominal aortic aneurysm screening programme supporting information
Abdominal Aortic Aneurysm Screening: Education and Training Abdominal aortic aneurysm 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: Management of Non-Visualised Aortas AAA screening: management of non-visualised aortas
Abdominal Aortic Aneurysm Screening: waiting times standards AAA screening: waiting times standards
Abdominal Aortic Aneurysm Screening: Protocol for Reporting Deaths AAA screening: protocol for reporting deaths

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