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Scope of this report
| 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 (Kent, Sussex, and Surrey) 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 service 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 October 2022 to West Surrey and North Hampshire Screening Service which is commissioned by the NHS England (Kent, Sussex and Surrey) Public Health Commissioning team (PHCT). 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 pre-review visits to West Surrey and North Hampshire Screening Service on 20 October 2022
- information shared with the South SQAS as part of the visit process
The screening service
The West Surrey and North Hampshire screening service implemented AAA screening in April 2012 and covers a population of approximately 1.3 million. The service boundary covers three Integrated Care Boards (ICBs): NHS Surrey Heartland (co-terminus with the administrative boundary of Surrey County Council), NHS Frimley and part of NHS Hampshire and Isle ofWight. There are also 12 Local Authorities (LAs) and 115 GP practices. The West Surrey and North Hampshire service covers a mix of urban and rural areas.
In 2021/2022 the service had an eligible cohort of 6,797 with an additional 95 men who self-referred.
The ethnic mix of the LAs within the service boundary area is 96.9% white, 2.13% Asian/Asian British, 0.24% black/African/Caribbean/black British. 0.32% other and 0.36% mixed. Rushmoor had the greatest ethnic mix with 8.2% of the population from non-white groups. East Hampshire had the least variation, 0.8% from non-white populations2. Levels of deprivation vary across the LAs. Rushmoor was the most deprived local authority within the provider area (ranked 196/317 where 1 is the most deprived). Hart was the least deprived local authority within the provider area (ranked 317/317)3
Findings
This was the second QA visit to the West Surrey and North Hampshire AAA screening service. The service achieved the acceptable level for 10 of the 15 national standards for 2021/2022. There are some good areas of practice that are listed below.
The service has faced challenges throughout the Covid pandemic with changes to key staff members and a high sickness level. The service has yet to complete the 2021/2022 cohort. This is likely to impact the timely completion of the 2022/2023 cohort.
There is a lack of regular interaction between the various staff groups within the screening service including technicians, clinical staff, and Trust management. The QA visit team were concerned that staff groups were operating in isolation, making service coordination a challenge. This was demonstrated by some staff members meeting for the first time at the QA visit. Subcontracts for key clinical staff have expired.
In addition, completion of the practical element of the Screening Technician accreditation is not timely. This is impacting on screening capacity within the service.
Immediate concerns
There were no immediate concerns identified.
High priority findings
The QA visit team identified four high priority findings as summarised below:
- the service has yet to fully restore following the Covid pandemic. Not all men in the 2021/2022 cohort had been invited for screening.
- lack of joint working between all staff groups and at Trust level
- subcontracts for the vascular team at Frimley Park Health Foundation Trust who support the service have expired
- excessive time taken to provide training to screening technicians
Examples of practice that can be shared
The QA visit team identified several areas of practice for sharing including:
- useful local transport information provided with invitation letter
- monitoring how men who self-refer became aware of the screening service
- social media (Twitter) account to promote the service
- sharing of weekly referral and non-visualisation trackers
- use of Red Cross emergency communication book, for communicating with people that have a wide range of needs
Recommendations
The following recommendations are for the provider to action unless otherwise stated.
| No. | Recommendation | Reference | Timescale | Priority | Evidence required |
| Governance and leadership | |||||
| 01 | Review and approve contracts for the clinical staff | NHS standard contract | 3 months | High | Confirmation of contracts to be submitted at programme board |
| 02 | Develop the governance structure including the internal team meetings’ arrangements, with terms of reference, including quoracy | NHS Abdominal Aortic Aneurysm (AAA) Screening Programme Essential elements in providing an AAA screening and surveillance programme | 3 months | High | Terms of reference for all internal meetings to be submitted at programme board |
| 03 | Update Standard Operating Procedure action plan specifying input from different staff groups | NHS Abdominal Aortic Aneurysm (AAA) Screening Programme Essential elements in providing an AAA screening and surveillance programme | 6 months | Standard | Revised action plan to be submitted to programme board |
| 04 | Identify and record screening service risks in accordance with Trust risk management processes | Service Specification | 6 months | Standard | Updated risk register presented at programme board |
| 05 | Work with the public health commissioning team, and other stakeholders where appropriate, to develop and complete a health equity audit | AAA Screening: identifying inequalities NHS standard contract | 12 months | Standard | Summary of audit findings presented to programme board |
| 06 | Develop and implement an action plan to identify and reduce screening inequalities. | AAA Screening: identifying inequalities NHS standard contract | 12 months | Standard | Action plan presented to programme board |
| 07 | Develop a schedule of audits, in consultation with commissioners, for inclusion in the NHS standard contract | NHS standard contract | 6 months | Standard | Schedule of audits to be presented to programme board |
| 08 | Develop and implement processes to involve service users across all pathways, including those with protected characteristics or underserved groups, in the development and evaluation of the service | AAA Screening: identifying inequalities | 12 months | Standard | Action plan to be submitted to programme board |
| 09 | Develop processes for producing annual report and establish the links for sharing with relevant stakeholders | Service specification | 12 months | Standard | Annual report to be submitted to programme board |
| 10 | Develop text messaging appointment reminders | National standards | 12 months | Standard | Feedback to programme board on implementation |
| Infrastructure | |||||
| 11 | Make sure there is a business continuity plan which includes cover arrangements for staff absence | Service specification | 6 months | Standard | Business continuity plan presented at programme board |
| 12 | Develop a written training strategy for Screening Technicians to expedite practical training | AAA screening: competence assessment and logbook | 3 months | High | Training strategy to be submitted to programme board |
| 13 | Develop continual professional development strategy for Screening Technicians | NHS Abdominal Aortic Aneurysm (AAA) Screening Programme Essential elements in providing an AAA screening and surveillance programme | 12 months | Standard | Continued professional development strategy submitted to programme board |
| 14 | Develop subcontract performance monitoring processes that include, but are not limited to, the review of service delivery against service needs | Service specification | 3 months | Standard | Confirmation of monitoring arrangements to be submitted at programme board |
| 15 | Make sure Screening Technicians are trained to undertake equipment quality assurance in accordance with national guidance | NHS Abdominal Aortic Aneurysm (AAA) Screening Programme Essential elements in providing an AAA screening and surveillance programme | 6 months | Standard | Confirmation of training submitted to programme board |
| Identification of cohort | |||||
| No recommendations made in this section | |||||
| Invitation, access and uptake | |||||
| 16 | Update invitation letter to conform to national templates. | Service specification | 3 months | Standard | Feedback at programme board that this has been completed. |
| 17 | Develop the nurse standard operating procedures to include the function of offering face to face appointments | AAA Nurse guidelines | 6 months | Standard | Submit nurse standard operating procedure to programme board. |
| 18 | Make sure non-visualisation rates are recorded and monitored in accordance with national guidance | Non-Visualised aortas guidance AAA Screening standard operating procedures Service specification | 12 months | Standard | Non-visualisation audit presented to programme board with action plans |
| 19 | Use uptake data and performance activity to support capacity planning and service improvements | Service specification | 3 months | High | Capacity plan submitted to programme board |
| The screening test – accuracy and quality | |||||
| 20 | Develop internal quality assurance processes for feedback to Screening Technicians in line with national guidance including oversight of performance by the Quality Assurance Lead and Clinical Skills Trainer. | Internal quality assurance framework and resources | 6 months | Standard | Submit revised quality assurance standard operating procedure to programme board |
| 21 | Revise the incidental findings standard operating procedure to ensure GPs are notified of all incidental findings | Standard operating procedures | 6 months | Standard | Submit incidental findings standard operating procedure to programme board |
| Referral | |||||
| 22 | Develop a standard operating procedure for the referral of men to St George’s Hospital NHS Foundation Trust | Standard operating procedures | 6 months | Standard | Submit standard operating procedure to programme board |
| Intervention and outcome | |||||
| 23 | Review the rate of men declining surgery to determine if there are any trends in turndown | Service specification | 12 months | Standard | Report results of the review to the 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: References
- ONS 2020 midyear LA population estimates: https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/datasets/populationestimatesforukenglandandwalesscotlandandnorthernireland
- 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 aneurysm 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