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Scope of this report
| Topic | 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 | Descriptive only | Covers North East and North Cumbria Public Health Programmes 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 2 and 3 November 2022 to Northumbria Healthcare NHS Foundation Trust Cervical Screening Service which is commissioned by North East and North Cumbria 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 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 Northumbria Healthcare NHS Foundation Trust on 25 October 2022
- information shared with the North Region SQAS as part of the visit process.
The screening service
The Northumbria Healthcare NHS Foundation Trust cervical screening service serves the populations of Northumberland and North Tyneside. The service has colposcopy units at:
- Hexham General Hospital
- Wansbeck General Hospital
- North Tyneside General Hospital
Cervical histopathology services are provided by the histopathology laboratory at North Tyneside General Hospital.
Findings
The Cervical Screening Provider Lead and the Lead Colposcopist were newly appointed to their roles in May and June 2022 due to retirement of the post holder. The leads have undertaken a review and gap analysis of the leadership roles, responsibilities, and have a good understanding of service provision and areas for improvement. The service has been struggling with clinic capacity to ensure the patients are treated within the expected NHS CSP timelines. Since the last QA visit in 2016, the Berwick Colposcopy unit has closed. The new Berwick Infirmary Hospital build has commenced, and this is expected to be completed in 2024. The service will be involved with plans to reintroduce a colposcopy unit.
The cervical screening histopathology service is well-led with good working relationships between the consultants, laboratory, and management staff. The department have an extensive annual audit schedule which is focussed on the learning outcomes to support service improvement.
There is a clear focus on reducing screening health inequalities with the updating of the Northumbria Healthcare NHSFT website, patient information and proactive solutions being progressed following the colposcopy did not attend (DNA) project.
Immediate concerns
The QA visit team identified no immediate concerns
High priority findings
The QA visit team identified two high priority finding as summarised below:
- Insufficient capacity in colposcopy for the timely treatment of women
- Risk assess the accommodation and recovery facilities to ensure they meet NHS Cervical Screening Programme requirements
Recommendations
The following recommendations are for the provider to action unless otherwise stated.
| No. | Recommendation | Reference | Timescale | Priority | Evidence required |
| Service provider and population | |||||
| 01 | Document the processes for supporting vulnerable and underserved people to attend colposcopy, cross referencing trust-wide policies | 1 | 6 months | Standard | Ratified protocol |
| Governance and leadership | |||||
| 02 | Make sure the Cervical Screening Provider Lead attends the relevant training for the role | 2 | 6 months | Standard | Attendance at national cervical screening provider lead training |
| 03 | Make sure the Cervical Screening Provider Lead has access to sufficient administrative support to fulfil their role | 2 | 6 months | Standard | Confirmation of administrative support |
| 04 | Make sure the Cervical Screening Provider Lead has an annual appraisal for the role | 2 | 6 months | Standard | Confirmation of appraisal |
| 05 | Document the deputy Cervical Screening Provider Lead role | 2 | 3 months | Standard | Documented confirmation |
| 06 | Put in place terms of referenace for the cervical screening management meetings | 2 | 3 months | Standard | Terms of reference |
| 07 | Complete the invasive cervical cancer audit backlog of cases | 3 | 12 months | Standard | Completion of cases diagnosed up to June 2022 |
| 08 | Implement an annual audit of disclosure for the invasive cervical cancer audit | 4 | 12 months | Standard | Audit schedule, audit |
| 09 | Make sure the annual performance report and 6 monthly update to cover all NHS Cervical Screening Programme services is provided to the trust clinical governance committee | 2 | 6 months | Standard | Annual performance and 6 monthly report with circulation list |
| 10 | Update standard operating procedure for results and referral to reflect the cervical samples taken in the trust outside of colposcopy | 2 | 3 months | Standard | Ratified protocol |
| 11 | Develop and implement a whole trust annual audit schedule for cervical screening services | 2 | 12 months | Standard | Annual audit schedule covering colposcopy and histopathology with confirmatory evidence of actions taken |
| 12 | Update the incident reporting standard operating procedure to include local reportingprocesses | 2 | 6 months | Standard | Standard operating procedure, |
| 13 | Formally appoint a Deputy Lead Colposcopy Nurse | 6 | 3 months | Standard | Confirmation of appointment |
| Referral | |||||
| No recommendations made in this section | |||||
| Sample taker register | |||||
| No recommendations made in this section | |||||
| Diagnosis – histology | |||||
| No recommendations made in this section | |||||
| Intervention and outcome – colposcopy | |||||
| 14 | Make sure there is adequate colposcopy administration staff for the service including trained cross cover support | 6 | 6 months | Standard | Colposcopy administration staffing structure |
| 15 | Risk assess the service facilities to ensure that they meet NHS Cervical Screening Programme requirements | 6 | 12 months | High | Action plan for addressing issues with accommodation and recovery area(s) |
| 16 | Make sure that there is enough punch biopsy forceps of sufficient quality to maintain the adequate biopsy rate | 6 | 3 months | Standard | Confirmation of punch biopsy replacement plan |
| 17 | Update colposcopy clinical guidelines that are aligned with current practice and NHS Cervical Screening Programme guidance | 6 | 3 months | Standard | Ratified guidelines with evidence of implementation |
| 18 | Update the administration standard operating procedures to include detail on results management and failsafe processes | 1,6 | 3 months | Standard | Ratified standard operating procedure |
| 19 | Audit the see and treat pathway for high-grade referrals at individual colposcopist level | 6 | 12 months | Standard | Audit and outcome for period April 2022 to March 2023, actions taken |
| 20 | Audit the cervical biopsy rate with histopathology service to make sure that all biopsies are clinically necessary based on colposcopic impression | 6 | 12 months | Standard | Audit and outcomes for period April 2022 to March 2023, actions taken |
| 21 | Ensure all colposcopists are following the NHS Cervical Screening Programme pathways including discharge to primary care for follow-up | 6 | 6 months | Standard | Audit with outcomes for period April 2022 – September 2022, actions taken |
| 22 | Make sure women are offered treatment within 4 weeks of the colposcopy clinic receiving a diagnostic biopsy report | 1, 6 | 12 months | High | Agreed action plan with evidence of regular monitoring |
| 23 | Update the appointment and result letters to make sure they meet NHS Cervical Screening Programme guidance | 6 | 3 months | Standard | Example appointment and result letters |
| 24 | Update patient information leaflets to make sure they meet NHS Cervical Screening Programme guidance | 6 | 6 months | Standard | Patient information leaflets |
| Multidisciplinary team | |||||
| 25 | Update the multidisciplinary team protocol to reflect the process for invasive cervical cancer case discussion | 3 months | Standard | Protocol | |
| 26 | Make sure all colposcopists attend a minimum of 50% of multidisciplinary team meetings | 6 | 12 months | Standard | Multidisciplinary team meeting attendance records 06/2022 to 06/2023 |
| 27 | Make sure there is sufficient administration support for the multidisciplinary team meetings to reduce the administrative burden on clinical staff | 1 | 3 months | Standard | Colposcopy administration staffing, defined responsibilities, standard operating procedures |
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 England. NHS Public Health Functions Agreement: 2022/23 Service Specification No.25 Cervical Screening Service Schedule 2
- NHS Cervical Screening Programme. Cervical screening: role of the cervical screening provider lead; 2018.
- NHS Cervical Screening Programme. Cervical screening: auditing procedures; 2021.
- NHS Cervical Screening Programme. Cervical screening: disclosure of audit results toolkit; 2021.
- NHS Cervical Screening Programme. Cervical screening: histopathology reporting handbook; 2021.
- NHS Cervical Screening Programme. Cervical screening: programme and colposcopy management; 2021.
- NHS Cervical Screening Programme. Cervical screening: cytology reporting failsafe (primary HPV); 2019.
- Ministry of Housing, Communities & Local Government. English indices of deprivation; 2019.
- Official Census and Labour Market Statistics. LC2101EW – Ethnic group by sex by age; 2011
- Official Census and Labour Market Statistics. LC2107EW – Religion by sex by age; 2011
- NHS England. Quarterly Cervical Coverage Report; June 2022.