Scope of this report
Service* | Provider | Commissioner | Within the scope of this visit |
|---|---|---|---|
|
Sickle cell and thalassaemia screening laboratory services |
Full blood count: Health Services Laboratories (HSL) HPLC: HSL |
Royal Free London NHS Foundation Trust |
No |
|
Infectious diseases screening laboratory services |
HIV: HSL Hepatitis B: HSL Syphilis: HSL |
Royal Free London NHS Foundation Trust |
No |
|
Fetal anomaly screening – combined screening services |
Dating/NT scan: Royal Free London NHS Foundation Trust Screening laboratory: Birmingham Womens Hospital |
NHS England – London region
Royal Free London NHS Foundation Trust |
Yes
No |
|
Fetal anomaly screening – quadruple screening laboratory services |
Dating scan: Royal Free London NHS Foundation Trust Screening laboratory: Birmingham Womens Hospital |
NHS England – London region
Royal Free London NHS Foundation Trust |
No
Yes |
|
Fetal anomaly screening – NIPT screening laboratory services |
HSL
|
NHS England – London region
|
No |
|
Fetal anomaly screening – 20-week screening scans |
Royal Free London NHS Foundation Trust |
NHS England – London region
|
Yes |
|
Diabetic eye screening
|
North Central London Diabetic Eye Screening Programme |
NHS England – London region
|
Yes |
|
Newborn and infant physical examination |
Royal Free London NHS Foundation Trust |
NHS England – London region
|
Yes |
|
Newborn blood spot screening laboratory services |
Great Ormond Street Hospital NHS Foundation Trust |
NHS England – London region
|
No |
|
Newborn hearing screening programme |
Whittington Health NHS Trust North Central London Newborn Hearing Screening Programme (NHSP) service |
NHS England – London region
|
Yes |
|
Child Health Information Service (CHIS) |
North East London Foundation Trust (NELFT) |
NHS England – London region
|
Yes |
Screening laboratories are quality assured by the United Kingdom Accreditation Service (UKAS).
Summary
Quality assurance looks at the antenatal and newborn screening pathways starting with identifying the eligible population of pregnant women and babies. It also includes the relevant screening tests for each programme. For women and babies with screen positive/higher chance results it will also include the pathways for referral, diagnosis and/or treatment.
The findings in this report relate to the quality assurance visit on 4th and 5th June 2024 to Royal Free London NHS Foundation Trust Screening Service which is commissioned by NHS England London Commissioning team. Any commissioning findings are outside the scope of this report and will be followed up directly with the commissioner.
We use the term ‘woman’ or ‘mother’ to encompass all gender identities and is intended for anyone who is pregnant. Similarly, where the term ‘parents’ is used, this encompasses anyone who has main responsibility for caring for the baby.
Quality assurance purpose and approach
Quality assurance (QA) aims to achieve and maintain national standards, promote continuous improvement in antenatal and newborn (ANNB) 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 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 Royal Free London NHS Foundation Trust on 4th and 5th June 2024
- information shared with the London SQAS as part of the visit process
The screening service
Royal Free London NHS Foundation Trust is an acute Trust situated in North Central London.
Maternity and neonatal care is provided at: Barnet Hospital, Royal Free Hospital, Chase Farm Hospital and Edgware Birth Centre. Barnet Hospital is a 19 bedded obstetric led delivery suite and there is a 5 bedded birth centre. From April 2023 to March 2024 there were 5,479 births at Barnet Hospital. The neonatal unit (NNU) is a level 2 and has 30 cots. Royal Free Hospital is an 8 bedded obstetric led delivery suite and there is a 3 bedded alongside birth centre.From April 2023 to March 2024 there were 2,746 births at Royal Free Hospital. The NNU is a level 1. Chase Farm Hospital runs as an outpatient antenatal clinic including ultrasound provision. The Edgware Birth centre supported 23 births in the last year and is run by the continuity of care teams, it also runs as an outpatient antenatal clinic. There is a large community midwifery service running 16 community midwife teams, 3 midwifery continuity of care teams and 2 vulnerable women’s teams. There were 30 home births in the last year.
Sickle cell & Thalassaemia (SCT) screening counselling services are provided by the specialist SCT midwives based at the trust.
The Newborn Hearing Screening Programme (NHSP) is provided by Whittington Health NHS Trust North Central London Newborn Hearing Screening Programme (NHSP) service.
Child Health Information Services (CHIS) are provided by the North East London Foundation Trust (NELFT).
North Central London Integrated Care Board (ICB) commission the maternity services. NHS England London region commission antenatal and newborn screening.
Findings
There is a strong and cohesive team working across the sites with resilient cross cover in place. The team are committed to providing the best care possible to women and babies.
There is an open and collaborative culture with ability to escalate up to the senior teams when required. This is evidenced via their engagement with both the screening quality assurance service and commissioners and their documented escalation processes. . It was evident from the interviews conducted on the visit day that screening is a prioritised by the senior midwifery team.
There is evidence of multi-disciplinary working shown by the work with the Equality, Diversity and Inclusion (EDI) team and links between services and the maternity service is focused on reducing health inequalities.
The trust provide a high quality ANNB screening service with excellent oversight via their trust screening steering group (TSSG). There is a culture of regular audit and quality improvement.
There are plans for future integration with North Middlesex Hospital but configuration and timelines are not yet confirmed.
From the outset and on review of the evidence submitted for the visit there are many areas for shared learning identified.
Immediate concerns
The QA visit team identified no immediate concerns.
Urgent recommendations
The QA visit team identified no urgent recommendations.
High priority findings
The QA visit team identified three high priority findings as summarised below:
The sonographers currently do not have sight of the National Congenital Anomaly and Rare Disease Registration Service (NCARDRS) report and therefore do not have a process in place to review with completion of due diligence and duty of candour as required.
There can be insufficient newborn hearing screener (NHSP) capacity at the RFH site. This is impacted by the current honorary contract process and a lack of access to electronic patient record (EPR) for NHSP screeners.
There is insufficient workforce capacity for the sustainable delivery of the fetal anomaly screening programme (FASP) (including dedicated time for image audit and review) with the implementation of Saving Babies Lives Care Bundle III
Examples of practice that can be shared
The QA visit team identified several areas of practice for sharing, including:
- Examples of Equality, Diversity and Inclusion work across the trust:
- Muslim Mama cards and deaf awareness cards introduced to hand held notes
- tailored parent education classes for black women and birthing people
- work around digital exclusion for Jewish women
- pathway to support autistic women and birthing people being developed
- Cross site working and collaboration including with neonatal unit
- Shared learning from audits and incidents within monthly dedicated screening newsletter
- Hip scan information stickers with contact email if no hip scan within two weeks also available in other languages
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 | |||||
|
|
|
|
|
|
|
|
Governance and leadership | |||||
01 |
Update the Terms of reference for the Trust screening steering group (TSSG) to include membership from all representatives across the screening pathway and include diabetic eye screening in pregnant women, health inequalities and NCARDRS report as standing agenda items. |
Section 7a screening service schedule 2 no: 15, 16, 17, 18, 19, 20, 21, 22 M2024 – 2025
Antenatal and newborn screening pathway requirements specifications 2021 |
3 months |
Standard |
Terms of reference signed off by the Royal Free London NHS TSSG and evidence of updated screening group agenda
|
|
|
|
|
|
|
|
02 |
Make sure all that all ANNB screening processes are documented and that guidelines are kept up to date regularly. |
Section 7a screening service schedule 2 no: 15, 16, 17, 18, 19, 20, 21, 22 2024 – 2025
|
12 months |
Standard |
Updated ratified guidelines including documented processes for quad, did not attend policy, late booking/unbooked in labour, failsafe processes in NIPE, NBS screening for transfers in/out. Schedule for update and confirmation of trust ratification process. |
03 |
Ratify and implement the updated draft newborn hearing screening programme (NHSP) policy (linked to North Middlesex QA visit recommendation) |
Section 7a screening service schedule 2 no: 20 2024 – 2025
|
6 months |
Standard |
Written confirmation of implementation of ratified policy. |
04 |
Demonstrate that feedback (including complaints) from service users, including those with protected characteristics or from underserved groups is used to develop and/or improve service delivery for antenatal and newborn screening |
Section 7a screening service schedule 2 no: 15, 16, 17, 18, 19, 20, 21, 22] 2024 – 2025 |
12 months |
Standard |
Action plan monitored by trust screening steering group |
|
Infrastructure | |||||
05 |
Implement and monitor a process to support continuing professional development for practitioners who perform the newborn examination
|
Section 7a screening service schedule 2 no: 21 2024 – 2025
|
12 months |
Standard |
Completed appointment of NIPE lead midwife Completion of training needs analysis.
Evidence of CPD monitoring process for NIPE practitioners |
06 |
Make sure there is sufficient NHSP screening capacity for the timely completion of screening at the Royal Free Hospital (RFH) site |
Section 7a screening service schedule 2 no: 20 2024 – 2025 |
6 months |
High |
Written evidence of an expediated process for honorary contracts for NHSP staff with access to electronic patient records (EPR) |
07 |
Make sure that all NHSP staff have completed the mandatory screening specific training as outlined in national guidance. |
Section 7a screening service schedule 2 no: 20 2024 – 2025
|
12 months |
Standard |
Confirmation of completion of external competency assessment (ECA) by NHS manager and that screeners are registered for the diploma within 6 months and
|
08 |
Document the functions of the screening support sonographer and deputy screening support sonographer role. |
Section 7a screening service schedule 2 no: 16 2024 – 2025
|
6 months |
Standard |
Job descriptions/structure chart/guidelines (that are signed off) outling the functions of the respective roles.
|
09 |
Undertake a capacity review for the antenatal screening service for the delivery of the Fetal Anomaly Screening Programme (FASP) that includes dedicated time for image audit and review |
Section 7a screening service schedule 2 no: 16 2024 – 2025 |
12 months |
Standard |
Completed workforce review that is presented at the Trust screening steering group (TSSG) |
10 |
Implement and monitor a process to make sure all ultrasound practitioners delivering the fetal anomaly screening programme complete the e-Learning resources in the specified timescales |
Section 7a screening service schedule 2 no: 16, 17 2024 – 2025 |
6 months |
Standard |
Completed training needs analysis Streamlined process between sites. Training log for completion of e-learning
|
11 |
Improve quality and completeness of the data submitted to NCARDRS. |
Section 7a screening service schedule 2 no: 16, 17 2024 – 2025 |
12 months |
Standard |
Implement direct access to NCARDRS following implementation of Viewpoint 6 – evidence of timeline and action plan |
|
Identification of cohort (antenatal) | |||||
|
|
|
|
|
|
|
|
Identification of cohort (newborn) | |||||
12 |
Document the step by step process for the failsafe of the newborn cohort |
Section 7a screening service schedule 2 no: 15, 16, 17, 18, 19, 20, 21 2024 – 2025
|
12 months |
Standard |
Ratified SOP including documented process for the management of babies transferred to units without S4N and failsafe oversight at weekends.
|
13 |
Implement a process for notifying key stakeholders about babies who die including updating the baby’s status as deceased on the national newborn IT failsafe systems
|
Section 7a screening service schedule 2 no: 19, 20, 21 2024 – 2025 |
12 months |
Standard |
Ratified SOP Confirmation that bereavement guidelines are updated to include reference to ANNB screening Screening team added to communication check list |
|
Invitation and access | |||||
|
|
|
|
|
|
|
|
Sickle cell and thalassaemia screening | |||||
|
|
|
|
|
|
|
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Infectious diseases in pregnancy screening | |||||
14 |
Make sure processes are streamlined for the screening pathways for the laboratory reporting of all three conditions screened for in infectious disases in pregnancy |
Section 7a screening service schedule 2 no: 15 2024 – 2025
|
12 months |
Standard |
Ratified revised documented process. |
|
Fetal anomaly screening | |||||
15 |
Address inequality in service provision by standardising the processes between sites for ‘Children in attendance at scan’, ‘twice on the couch’ and image review |
Section 7a screening service schedule 2 no: 16, 17 2024 – 2025 |
12 months |
Standard |
Documented ratified process |
16 |
Make sure that sonographers have sight of the NCARDRS report and implement a process for review with completion of due diligence and duty of candour as required |
Section 7a screening service schedule 2 no: 16, 17 2024 – 2025
|
12 months |
Standard |
Feedback at programme board |
|
Diabetic eye screening in pregnancy | |||||
|
|
|
|
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|
Newborn hearing screening | |||||
|
|
|
|
|
|
|
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Newborn and infant physical examination | |||||
|
|
|
|
|
|
|
|
Newborn blood spot screening | |||||
17 |
Continue to monitor the plan to meet the acceptable threshold for standard /key performance indicator NBS-S06/NB2 – the proportion of first blood spot samples that require repeating due to an avoidable failure in the sampling process |
Section 7a screening service schedule 2 no: 19 2024 – 2025 |
12 months |
Standard |
Submission of data for standard /key performance indicator NBS-S06/NB2
NB2 check list and action plan that is agreed and monitored by the trust screening steering group (TSSG) and North Central London (NCL) Integrated Care Board (ICB) 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 G: References
- NHS Section 7a screening service schedules 2 and 4 2024-25
- NHS population screening: pathway requirements specifications and learning from screening incidents
- NHS population screening standards
- NHS population screening: reporting data definitions for key performance indicators
- NHS Managing Safety Incidents in NHS Screening Programmes (last updated 2024)
- NHS England (2022) Patient Safety Incident Response Framework
- NHS Sickle cell and thalassaemia screening programme handbooks (last updated 2022)
- NHS Infectious diseases in pregnancy screening programme clinical guidance (last updated 2023)
- NHS Fetal anomaly screening programme handbook (last updated 2024)
- NHS Newborn hearing screening programme operational guidance (last updated 2024)
- NHS Newborn and infant physical examination: programme handbook (last updated 2024)
- NHS Newborn blood spot screening guidance (last updated 2023)
- NHS England population screening: pathway requirements specification Diabetic eye screening pathway requirements specification
- NHS Screening inequalities strategy
- Department of Health and Social Care Public Health Profiles
- The Society and College of Radiographers and The Royal Collage of Radiologists (2017) Standards for the provision of an ultrasound service
- UK Health Security Agency Immunisation against infectious disease (last updated 2024)
- Hinton et al (2023). A qualitative study of the dynamics of access to remote antenatal care through the lens of candidacy
- Hinton et al (2022) Quality framework for remote antenatal care
There is more detailed information on individual screening programmes that can be accessed via Population screening programmes: detailed information