NHS England » Screening quality assurance visit report – North Yorkshire and Humber/Hull University Teaching Hospital NHS 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	Not applicable
Workforce	Yes	Not applicable
IT and equipment	Yes	Not applicable
Commissioning	Partly	Not applicable
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	No	Covered as part of intervention/treatment
Intervention/treatment	Yes	Not applicable

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 20 March 2024 to North Yorkshire and Humber Abdominal Aortic Aneurysm Screening Service which is commissioned by NHS England Yorkshire and Humber 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 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 a familiarisation visit on 6 February 2024
information shared with SQAS as part of the visit process

The screening service

The North Yorkshire and Humber AAA service is provided by Hull University Teaching Hospitals NHS Trust. 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 who provide screening in 42 locations such as hospitals, GP practices and health centres. There are three prisons within the area (excluding young offender institutions).

The service covers 174 GP practices and spans the area from Scarborough to North East Lincolnshire. One integrated care board (ICB) is within the service boundary, NHS Humber and North Yorkshire.

In 2022/23 the service had an eligible cohort of 9,990 with an additional 43 men who self-referred.

The ethnic mix of the Local Authorities (LAs) within the service boundary area is 99.0% White; 0.5% Asian, Asian British or Asian Welsh; 0.1% Black, Black British, Black Welsh, Caribbean or African; 0.2% other ethnic group and 0.2%, mixed or multiple ethnic groups. Kingston upon Hull has the greatest ethnic mix with 1.8% of the population from non-White groups. Ryedale has the least variation, 0.3% from non-White populations.

Levels of deprivation vary across the LAs. Kingston upon Hull is the most deprived local authority within the provider area (ranked 9/309, where 1 is the most deprived). Harrogate is the least deprived local authority within the provider area (ranked 278/309).

Men with large (equal to or greater than 5.5cm) aneurysms or whose aneurysm has grown by more than 1cm in a year (rapid growth) are referred for treatment at the York Hospital (York and Scarborough Teaching Hospitals NHS Foundation Trust) or Hull Royal Infirmary (Hull University Teaching Hospitals NHS Trust).

Findings

This is the second QA visit to the North Yorkshire and Humber AAA service, the previous visit took place on 7 July 2016.

The QA visit team observed a knowledgeable, committed and enthusiastic workforce. The service has faced several challenges within the workforce with changes to key staff members and a high sickness level. The screening technician allocation does not align with recommended national guidance and there is no permanent vascular nurse specialist role.

The service met eight of the 15 national pathway standards that they are assessed against for the period 1 April 2022 to 31 March 2023. Several of those that were not met were due to delays in completing restoration of the previous year’s cohort following the COVID-19 pandemic. The service is continuing to screen the 2023/24 cohort and insufficient assurance was provided to demonstrate the timescales for when the cohort would be fully screened.

Standards for timeliness of nurse assessments and timeliness of treatment were also not met. Acceptable levels were met for quarterly and annual surveillance men attending their screening appointment within pathway standard timescales.

Immediate concerns

The QA visit team identified no immediate concerns.

High priority findings

The QA visit team identified 2 high priority findings as summarised below:

Workforce capacity, including the screening technician and vascular nurse specialist, does not align with national guidance
At the time of the visit, the service has a backlog of 2,806 men from the 2023/24 cohort year and there was limited evidence of a formal recovery plan

Examples of practice that can be shared

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

Screening technicians have completed a smoking cessation advice course and provide advice at screening appointments
Training and CPD for staff has been maintained during a period of significant challenge
The service has several trackers they use to monitor the men due to be invited, self-referrals and those under surveillance
The service has a comprehensive handbook for screening technicians.

Recommendations

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

No.	Recommendation	Reference	Timescale	Priority	Evidence required
Governance and leadership
01	A formal strategic plan is to be developed and approved by the appropriate Trust governance process to which the service is accountable. The plan should include recovery, trajectories and escalation trigger points for non-completion of the 2023/24 cohort.	National Service Specification	3 months	High	Operational plan to support recovery. 1-3 year strategic plan to be shared with SQAS and commissioners.
02	Provide assurance regarding the governance process for the development, review and approval of new and existing SOP’s and policies. Suggested polices and SOP’s to be reviewed are referenced in Annex C.	National Service Specification Essential elements in providing an AAA screening and surveillance programme	12 months	Standard	Updated standard operating procedures. Quality manual, index, or library of SOPs to be shared with SQAS and commissioners.
03	Produce an annual report and share through internal governance processes and ensure all staff working in the screening programme have access.	National Service Specification	12 months	Standard	Annual report to be submitted to SQAS, commissioners and the Trust management team.
04	Undertake a health equity audit and develop a local action plan.	National Service Specification NHS Screening: a health equity audit guide Guidance for NHS commissioners on equality and health inequalities	12 months	Standard	Summary of audit findings and action plan to be shared with SQAS and commissioners.
05	Audit schedule to be developed and agreed with commissioners.	National Service Specification	6 months	Standard	Audit schedule, results and summary actions from audits to be shared with SQAS and commissioners.
06	User satisfaction survey should be carried out with consideration to include evaluation of text messages and nurse assessments.	National Service Specification	6 months	Standard	Results of user satisfaction survey and action plan for service improvement developed based on results to be shared with SQAS and commissioners.
Infrastructure
07	Workforce review to be completed reviewing the following against national guidance: recommended staffing levels, job descriptions (clinical director, CST, vascular specialist nurse) and nurse assessment model.	National Service Specification Essential elements in providing an AAA screening and surveillance programme	3 months	High	Outcome of review and any agreed actions or business case to be shared with SQAS and commissioners including mitigations for identified risks as required.
08	Ensure that annual checks on ultrasound equipment are being carried out in line with national guidance.	Guidance for AAA screening: ultrasound equipment quality assurance guidelines	3 months	High	Evidence of annual checks shared with SQAS and commissioners.
Identification of cohort – no recommendations
Invitation, access and uptake – no recommendations
The screening test – accuracy and quality – no recommendations
Referral – no recommendations
Intervention and outcome
09	To support achievement of the national timeliness target for treatment in 8 weeks, review the information flows to both vascular centres including active referrals, provision of performance and breaches to support pathway and case review.	Essential elements in providing an AAA screening and surveillance programme AAA screening: monitoring waiting times to surgery	6 months	Standard	Confirmation information is being shared with both vascular centres including quarterly pathway standards and breach information. Summary of lessons learned following case review of referrals breaching the 8 week pathway standard for the last 12 months.

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.

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