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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 | No | NHS England Midlands Public Health Commissioning Team |
| 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 | Yes | Not applicable |
| 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 08 November 2022 to the Staffordshire and South Cheshire screening service which is commissioned by the Midlands 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 NHS England (NHSE)
- data and reports from external organisations
- evidence submitted by the provider and external organisations
- discussion with the commissioners in advance of the visit
- information shared with the Midlands and East SQAS as part of the visit process.
The screening service
The Staffordshire and South Cheshire AAA screening service (the service) has an eligible population of approximately 6,524 (01 April 2021 to 31 March 2022) covered by 157 GP practices. The population is predominantly (98.8%) white. Stoke-on-Trent has the greatest ethnic mix with 2.6% of the population from non-White groups. Staffordshire Moorlands had the least variation, 0.5% from non-White populations2. Levels of deprivation vary across the local authorities. Stoke-on-Trent was the most deprived local authority within the service’s geographical area (ranked 15/317 where 1 is the most deprived). South Staffordshire was the least deprived local authority (ranked 235/317)3.
The Staffordshire and South Cheshire AAA service is provided by University Hospitals of North Midlands (UHNM) Trust. The NHS England Midlands public health commissioning team commission the service to provide all aspects of the screening pathway including programme management, administration, failsafe, screening, internal quality assurance, nurse assessments and clinical leadership.
The service offer 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 89 locations such as hospitals, GP practices and health centres. Arrangements are in place to offer a re-screen where the aorta has been difficult to visualise and nurse assessments are provided to all men with a screen detected aneurysm.
Men requiring a clinical assessment are referred to either Royal Stoke University Hospital (University Hospitals of North Midlands), County Hospital Stafford (University Hospitals of North Midlands), or Leighton Hospital (Mid Cheshire Hospitals NHS Foundation Trust). Men requiring treatment are referred to the Royal Stoke University Hospital which offers a full service for open and endovascular aneurysm repair (EVAR).
Findings
This is the second QA visit to the Staffordshire and South Cheshire AAA service, the previous QA visit took place on 07 June 2016. The QA visit team observed a knowledgeable, enthusiastic, and invested workforce, all of whom demonstrated a commitment to deliver a quality screening service for men, with patient care at the forefront.
The service met 13 of the 15 national quality assurance pathway standards (1 April 2021 to 31 March 2022). Standards for timeliness of internal quality assurance and timeliness of treatment were not met. Achievable levels were met for quarterly and annual surveillance men attending their screening appointment within pathway standard timescales.
The service has a number of initiatives that contribute to reducing health inequalities which have not yet been implemented systematically or as part of an overall Trust AAA screening health inequalities strategy. The service is aware that many of their standard operating procedures require review and that they need to evidence the effective work that is undertaken within the service.
Immediate concernst5
The QA visit team identified no immediate concerns.
High priority findings
The QA visit team identified one high priority finding as summarised below:
- the service is unable to meet the national pathway standard for internal quality assurance of abnormal images on or within 21 days of an initial scan.
Examples of practice that can be shared
The QA visit team identified several areas of practice for sharing, including:
- a collaborative approach to screening promotion and reducing heath inequalities through joint working with other screening colleagues in the Trust
- integrated failsafe processes are embedded within standard operational practice
- quarterly surveillance men are booked their next appointment on attendance to maximise the ability to meet the national pathway standard
- all team members contribute to promotional activities
- all team members are encouraged to observe nurse assessments, non-visualisation scans and aneurysm surgery to develop their wider understanding of the screening pathway.
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 made in this section | |||||
| Governance and leadership | |||||
| 01 | Schedule monthly operational group meetings for senior team members | National Service Specification | 3 months | Standard | Governance structure, including the regularity and membership of meetings to be provided at programme board |
| 02 | Develop a regular team meeting schedule to include operational and educational agenda items and make sure attendance from all staff groups (when relevant) is facilitated | National Service Specification | 6 months | Standard | Schedule andminutes of teammeetings (to includeattendance) provided to programme board |
| 03 | Produce an annual report | National Service Specification | 6 months | Standard | Annual report signed off by the organisation’s board provided to programme board |
| 04 | Review and update standard operating procedures (SOPs) included within Appendix C | National Service Specification Essential elements in providing an abdominal aortic aneurysm screening and surveillance programme | 6 months | Standard | Updated standard operating procedures provided to programme board |
| 05 | Develop a local incident policy for the recording and management of screening incidents to include the requirement for all staff to undertake the screening incident training module | National Service Specification Managing Safety incidents in NHS Screening programmes | 3 months | Standard | Policy and evidence to show all screening staff have completed the screening incident training module provided to programme board |
| 06 | Undertake a health equity audit and refine current action plan | National Service Specification NHS Screening: a health equity audit guide Guidance for NHS commissioners on equality and health inequalities NHS Accessible Information Standard | 6 months | Standard | Health equity audit and refined action plan provided to programme board |
| 07 | Present schedule, summary results and actions from audits to programme board | National Service Specification | 6 months | Standard | Summary results and actions presented at programme board Audit schedule provided to board to include consideration of additional audits being undertaken by the service such as uptake in those not receiving a text reminder and audits proposed by the vascular nurse |
| 08 | Update the Trust website with the correct link for accessible information, amend the number of results and make sure there is reference to AAAs that grow by 1cm or more within a year | National Service Specification | 3 months | Standard | Confirmation at programme board that website has been amended |
| Infrastructure | |||||
| 09 | Identify and facilitate an individual from the service to undertake the certificate in assessing vocational achievement (CAVA) | National Service Specification AAA screening: education and training | 12 months | Standard | Confirmation that a member of the service has obtained the certificate in assessing vocational achievement (CAVA) |
| 10 | Agree an equipment replacement programme for ultrasound scanners | National Service Specification | 6 months | Standard | Equipment replacement plan developed and shared at programme board |
| Identification of cohort | |||||
| No recommendations made in this section | |||||
| Invitation, access and uptake | |||||
| 11 | Introduce an automated solution for text message reminders | National Service Specification | 12 months | Standard | Confirmation at programme board that an automated solution is in place |
| The screening test – accuracy and quality | |||||
| 12 | Review the organisation of CST/QA Lead(s) resources so that the pathway standard for timeliness of QA of abnormal images can be met | National Service Specification AAA screening programme standards Internal quality assurance framework and resources | 3 months | High | Review of CST/QA leads resources (i.e., rota / schedule reviewed to allow standard to be achieved) Pathway standard to be met and evidenced at programme board |
| 13 | Develop a SOP to make sure screeners receive regular feedback on their performance using national templates and include within the SOP how poor performance would be managed | National Service Specification Clinical guidance and scope of practice Internal quality assurance framework and resources | 6 months | Standard | SOP presented to programme board Anonymised feedback log/tracker presented to programme board with summary of outcomes as part of routine reporting |
| 14 | Develop a local screening policy for the systematic review of AAA controlled documents, including dissemination, change control and ratification | National Service Specification | 6 months | Standard | Policy provided to programme board |
| Referral | |||||
| 15 | Review and improve the referral log to allow internal audit of treatment delay factors for continuous service improvement | National Service Specification | 6 months | Standard | Audit findings presented to programme board |
| 16 | Implement the electronic patient record AAA alert flag at all referral centres | National Service Specification | 6 months | Standard | Alert system implemented and confirmed at programme board |
| Intervention and outcome | |||||
| No recommendations made in this section | |||||
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 B: References
- ONS 2020 midyear LA population estimates: https://www.ons.gov.uk/peoplepopulationandcommunity/
- Men aged 65 years and over by ethnic group from NOMIS using the 2011 census data: https://www.nomisweb.co.uk/
- Indices of deprivation 2019 scores for Local Authorities: https://www.gov.uk/government/statistics/english-indices-of-deprivation-2019
- AAA screening standard operating procedures: Essential Elements in providing an AAA screening and surveillance programme AAA screening: standard operating procedures
- 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: Standards. Abdominal aortic aneurysm screening programme supporting information
- Abdominal Aortic Aneurysm Screening: Protocol for Reporting Deaths. AAA screening: protocol for reporting deaths
- Abdominal Aortic Aneurysm Screening: waiting times standards. AAA screening: waiting times standards
- Abdominal Aortic Aneurysm Screening: Management of Non-Visualised Aortas. AAA screening: management of non-visualised aortas
- 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: Education and Training. Abdominal aortic aneursym 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: Ultrasound Equipment Guidelines. Abdominal aortic aneurysm screening: ultrasound equipment guidelines
- Abdominal Aortic Aneurysm Screening: Nurse Specialist Guidance. AAA screening programme nurse specialist guidelines
- National Vascular Registry 2022 Annual Report https://www.vsqip.org.uk/reports/2022-annual-report/