| 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 South West of England Collaborative Commissioning Hub 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 | Severn Pathology, North Bristol NHS Trust |
| Referral | No | Severn Pathology, North Bristol NHS Trust |
| Sample taker register | Yes | Severn Pathology, North Bristol NHS Trust |
| Diagnosis | No | Royal United Hospitals Bath NHS Foundation Trust Histopathology Service |
| 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 12 September 2024 to Royal United Hospitals Bath NHS Foundation Trust (RUHB) Cervical Screening Service which is commissioned by NHS England South West of England Collaborative Commissioning Hub Team.
The Cervical Histopathology Service at RUHB is out of scope for this QA visit but is part of the overall cervical screening service provided. 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 conducted 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 and external organisations
- discussion with commissioner in advance of the visit
- information collected during the pre-visit meeting with the Cervical Screening Programme Lead of RUHB on 20 August 2024
- information shared with the SQAS as part of the visit process
The screening service
RUHB provides NHS cervical screening services to the population covered by the NHS Bath and North East Somerset, Swindon and Wiltshire Integrated Care System.
The service is overseen by NHS England South West with support from the South West of England Vaccinations and Screening Team.
RUHB provides colposcopy and cervical histopathology from the Royal United Hospital in Bath.
Severn Pathology, North Bristol NHS Trust (NBT) provides the human papillomavirus (HPV) testing and cytology service.
Findings
Since the last QA visit to this service in 2019, HPV primary screening has been implemented, the COVID-19 pandemic caused major disruption and there have been changes in the service’s key administration roles.
The service has coped reasonably well with these challenges but has not been able to consistently maintain colposcopy waiting time standards.
Many of the recommendations made within this report are to complete work of standardisation that has already started, for example, appointment of permanent administration staff.
Action is required to ensure there is sufficient clinic support and capacity to meet demand and sustain waiting time performance over the long term.
Restrictions in IT systems have led to manual processes to track patient referrals and inappropriate allocation of results to consultants not involved in the patient’s colposcopy care.
These issues raise the potential that referrals and results may be overlooked resulting in patients not being followed up.
Governance meetings and reporting for cervical screening are in place but do not entirely fulfil all the requirements of national guidance. Colposcopy clinic and individual clinician performance data do not meet the performance requirements of all national standards.
The trust does not have a specific strategy to support reductions in health inequalities but is actively undertaking work in a number of areas that will contribute to reducing inequality and increasing accessibility.
Immediate concerns
The QA visit team identified no immediate concerns.
Urgent recommendations
The QA visit team identified one urgent recommendation. A letter was sent to the cervical screening provider lead on 16 September 2024 asking that the following item(s) is addressed:
- undertake a colposcopy administration pathway process map to reduce reliance on manual processes for referral management and histopathology results
A response including an action plan was received informing the visiting QA team of the steps taken to partially resolve the urgent recommendation(s).
High priority findings
The QA visit team identified 9 high priority findings as summarised below:
- cervical screening management meetings and colposcopy operational meetings do not have appropriate terms of reference, attendance or agenda meaning risks and issues may not be identified
- limited understanding of cervical screening risk management and screening incident reporting
- colposcopy clinics are not always appropriately staffed by at least 2 support nurses
- no evidence of standard operating procedures for colposcopy administrative processes or colposcopy clinic arrangements
- data is not always validated or recorded accurately
- waiting time standards for appointments and treatments and individual clinician standards are not routinely met
Examples of practice that can be shared
The QA visit team identified several areas of practice for sharing, including:
- ‘In house’ colposcopy information videos available via the trust website, including a walkthrough video for people with learning disability, autism, or mental health needs
- clear flowchart showing how to manage the rare situation of a patient who has collapsed in the colposcopy clinic
Recommendations
The following recommendations are for the provider to action unless otherwise stated.
| No. | Recommendation | Pathway theme | Reference | Timescale | Priority | Evidence required |
| Urgent recommendations | ||||||
| 01 | Undertake a colposcopy administration pathway process map to reduce reliance on manual processes. | Intervention and outcome – colposcopy | 1 | 28 days | Urgent | Action plan including how risks will be minimised for referral management and histopathology results issued with timelines for resolution within 3 months |
| No. | Recommendation | Reference | Timescale | Priority | Evidence required |
| Governance and leadership | |||||
| 02 | Develop an action plan, in collaboration with commissioners, to reduce screening inequalities in underserved and protected population groups | 1,2,3 | 12 months | Standard | Action plan |
| 03 | Ensure the trust wide cervical screening provider lead job description includes accountability to the chief executive officer, dedicated time, and administrative support | 1, 4 | 3 months | Standard | Job description with accountability, dedicated professional activity allocation and administrative support |
| 04 | Present an annual performance report and 6 monthly update to cover all NHSCSP services including health inequalities, presented to the Trust clinical governance committee | 1, 4 | 12 months | Standard | Annual and 6 monthly performance report with meeting minutes |
| 05 | Formalise existing quarterly cervical business meetings chaired by the Cervical Screening Provider Lead | 1, 4 | 3 months | High | Terms of reference including representation, agenda, meeting schedule and minutes of most recent meeting |
| 06 | Develop and implement a Trust wide annual audit schedule for cervical screening services | 1 | 6 months | Standard | Approved annual audit schedule covering colposcopy and histopathology, to include audit of conservative management of cervical intraepithelial neoplasia (CIN) grade 2 |
| 07 | Update relevant local policies to include reference to managing screening incidents in accordance with “Managing Safety Incidents in NHS Screening Programmes” | 5 | 6 months | Standard | Ratified policy |
| 08 | Manage all screening incidents in accordance with “Managing Safety Incidents in NHS Screening Programmes” | 5 | 3 months | High | All staff trained in incident reporting e-learning module to be completed by all relevant staffIncident outcomes presented to programme board |
| 09 | Put in place a cervical screening risk management process | 5 | 3 months | High | Confirmation of process |
| 10 | Nominate a trust wide deputy lead colposcopy nurse for cervical screening | 7 | 6 months | Standard | Confirmation of nomination |
| 11 | Establish quarterly cervical operational meetings chaired by the lead colposcopist | 7 | 6 months | High | Terms of reference including colposcopy staff representation, meeting schedule and escalation routes, and minutes of meetings |
| 12 | Update existing invasive cervical cancer standard operating procedure (SOP) to reflect colposcopy review process | 6 | 6 months | Standard | Updated SOP |
| Referral – no recommendations | |||||
| Intervention and outcome – colposcopy | |||||
| 13 | Ensure that all colposcopists see a minimum of 50 new NHSCSP referrals a year | 7 | 12 months | Standard | Data submission showing number of new NHSCSP referrals for each colposcopist in the period April 2024 to March 2025 |
| 14 | Ensure that all colposcopy clinics are staffed by at least 2 nurses of which one is registered | 7 | 6 months | High | Confirmation of nurse staffing and absence cover arrangements |
| 15 | Put in place an action plan to demonstrate sustainable achievement of waiting time standards for appointments and treatments | 7 | 3 months | High | Action plan |
| 16 | Ensure colposcopy IT system can produce reliable data for KC65 submission and key performance indicators and is regularly backed up as outlined in National Service Specification 25 | 1,7 | 6 months | Standard | Submission of accurate, validated KC65 and key performance indicators data and SOP for back up of the colposcopy database and SOP covering process of recording first offered appointments |
| 17 | Update the local Trust colposcopy clinical guidelines to reflect current NHS Cervical Screening Programme guidance | 7 | 6 months | Standard | Ratified guidelines with evidence of implementation to include processes for conservative management of cervical intraepithelial neoplasia (CIN) grade 2 |
| 18 | Put in place a procedure for cervical sample taking across the Trust | 7 | 6 months | Standard | SOP |
| 19 | Implement a SOP for the production, validation, and discussion of actions for internal performance monitoring data | 1,7 | 6 months | High | SOP |
| 20 | Implement SOPs for colposcopy nursing and administrative processes and colposcopy clinic arrangements | 7 | 3 months | High | SOPs |
| 21 | Audit individual colposcopy performance data where national standards are not met | 1,7 | 3 months | High | Audits and actions taken |
| 22 | Update trust colposcopy patient letters so they represent up to date clinical management and use current screening programme terminology | 7 | 6 months | Standard | Updated copies of standard result letters |
| Multidisciplinary team | |||||
| 23 | Develop and implement a SOP for case selection for the MDT meetings | 1,7 | 6 months | Standard | SOP including rolling failsafe process |
| 24 | Ensure all colposcopists attend a minimum of 50% of MDT meetings | 1,7 | 12 months | Standard | MDT attendance records 01 October 2024 to 30 September 2025 |
| 25 | Implement annual audit of MDT case selection and outcomes | 1,7 | 6 months | Standard | Evidence of annual audit of MDT case selection and actions taken |
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 2023-24 Service Specification No. 25, NHS Cervical Screening Programme
- Guidance for NHS Commissioners on Equality and Health Inequality Duties 2015
- NHS Accessible Information standard and specification
- NHS Cervical Screening Programme: the role of the cervical screening provider lead
- Managing safety incidents in NHS screening programmes
- National invasive cervical cancer audit
- Cervical screening: programme and colposcopy management