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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 | Yes | Partly |
| 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 8 November 2022 to West Yorkshire Screening Service which is commissioned by the NHS England Yorkshire and Humber 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 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
- data and reports from external organisations
- evidence submitted by the provider(s)
- discussion with the commissioner in advance of the visit
- information collected during pre-review visits; familiarisation visit to the West Yorkshire AAA service at Calderdale Royal Hospital on 12 August 2022
- information shared with the North SQAS as part of the visit process.
The screening service
The West Yorkshire AAA programme (the service) is provided by Calderdale and Huddersfield NHS Foundation Trust (CHFT). The service is based at Calderdale Royal Hospital (CRH) and began screening in January 2012.
The service is provided by screening technicians and clinics take place at venues including GP practices, health centres, community outpatient departments and community hospitals.
Men with large aneurysms (greater than or equal to 5.5cm) are referred for assessment at Bradford Royal Infirmary (BRI) or Huddersfield Royal Infirmary (HRI). BRI provide the treatment for screen referred men and offer both open and endovascular aneurysm repair (EVAR). HRI only offer assessment and not treatment. Complex surgery is provided at Leeds General Infirmary if needed.
Men who are in the surveillance pathway and require an appointment with a nurse are offered a face to face appointment at one of the three hospital sites (BRI, CRH or HRI).
The service covers an area with a total population of approximately 1,007,000 and in 2021/22 the service had an eligible cohort of 5727.
The service is commissioned by NHS England Yorkshire and Humber Public Health Programmes team (PHPT).
Levels of deprivation and ethnicity vary by local authority. Bradford is the most deprived local authority within the provider areas and has the greatest ethnic mix with 11.2% of the population from non-white groups. Craven is the least deprived local authority within the provider area and also has the least variation of ethnic mix with 0.4% from non-white groups.
Data for 1 April 2021 to 31 March 2022 demonstrates that the service was below the acceptable standard for coverage at 58.4%. It is recognised that the COVID-19 pandemic and the temporary pause in screening had a significant impact on service delivery. Uptake of cohort men during that period was 73.7% which is just below the acceptable standard of 75%.
Data for 1 April 2021 to March 2022 demonstrates that the service was above the acceptable standard for coverage in respect of both annual and quarterly surveillance.
Findings
This is the second QA visit for the service, the previous visit took place on 10 November 2016. The QA visit team observed a team that were engaged, flexible and were enthusiastic in providing a quality service.
Through the visit process some areas were considered well established and patient centred, such as the provision of assessments following referral at a hospital local to the man, and weekend and evening clinics. The visiting team identified that the service should review their internal image QA assurance processes to align with national guidance and to support the timely identification of issues and possible safety screening incidents. A workforce review to support service development and resilience should also be completed.
Immediate concerns
The QA visit team identified no immediate concerns.
High priority findings
The QA visit team identified 3 high priority findings as summarised below:
- the service should complete a service staffing review to support service development and resilience
- the quality assurance of ultrasound equipment should be reviewed in line with national guidance including training, frequency and outcomes of checks, and audit
- quality assurance processes relating to image upload should be reviewed in line with national guidance
Examples of practice that can be shared
The QA visit team identified several areas of practice for sharing, including:
- weekend and late evening clinics have been introduced to support access and restoration of the service
- the vascular reconfiguration process has been used to streamline and improve the pre-operative investigation pathway for men with aneurysms whilst maintaining local availability up to the point of surgical admission
- in the event screening technicians are required to wear masks they have access to clear visors that can be used to support lip reading
- prior to COVID-19 the specialist nurse was involved in information evenings where people diagnosed with a AAA were invited to attend and meet with members of the vascular teams
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 | Implement a process for the development, control, approval and revision of standard operating procedures, including a review against national guidance. This review should include non-visualised aortas, incidental findings, management of exclusions, sending of images for QA, failsafe process document, self-referrals, clinic planning. | National Service Specification Essential elements in providing an abdominal aortic aneurysm screening and surveillance programme | 12 months | Standard | Updated standard operating procedures. Quality manual, index, or library of SOPs. Gap analysis of current SOPs and development timeline to be provided to SQAS and commissioners as part of recommendations action plan. |
| 02 | Complete a service staffing review to support service delivery and resilience. This should include screening technician capacity, roles and responsibilities of administration and coordinator in line with job descriptions, identification of training requirements to enhance local knowledge and usage of the SMaRT system. | National Service Specification Essential elements in providing an abdominal aortic aneurysm screening and surveillance programme | 12 months | High | Workforce review completed with action plan to address gaps. Submit to SQAS and commissioners as part of recommendations action plan. Revised organisational structure. Documented feedback on any learning from peer support or from SMaRT. |
| 03 | Develop a meeting schedule to include operational and team meetings. Agendas to include educational and feedback for screening technicians. | National Service Specification | 6 months | Standard | Schedule of meetings and minutes shared with SQAS and commissioners as part of recommendations action plan. |
| 04 | Undertake a health equity audit and develop a local 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 action plan shared with SQAS and commissioners as part of recommendations action plan. |
| 05 | Develop an audit schedule which includes did not attend, non-visualised scans, exclusions, incidental findings, 30 day post operative deaths, uptake and AAA interventions recorded on NVR. | National Service Specification | 6 months | Standard | Audit schedule provided to SQAS and commissioners. Results and summary actions from audits to be shared with SQAS and commissioners as part of recommendations action plan. |
| 06 | Introduce text message reminders and documented supporting process. | National Service Specification | 6 months | Standard | Confirmation provided to SQAS and commissioners that an automated solution is in place. |
| 07 | Complete an annual user satisfaction survey and results are presented in a timely manner. | National Service Specification | 12 months | Standard | Annual patient satisfaction survey shared with SQAS and commissioners as part of recommendations action plan. |
| Infrastructure | |||||
| 08 | Site survey checks to resume in line with national guidance. | Essential elements in providing an abdominal aortic aneurysm screening and surveillance programme | 12 months | Standard | Risk assessment and schedule shared with SQAS and commissioners as part of recommendations action plan. |
| 09 | Quality assurance of ultrasound equipment to be reviewed in line with national guidance including training, frequency and outcomes of checks, and audit. Associated SOPs to be updated. | Guidance for AAA screening: ultrasound equipment quality assurance guidelines | 3 months | High | Training log regarding ultrasound equipment checks. Evidence of completed clinic checklists and that any issues identified are being managed appropriately. Updated SOPs to be shared with SQAS and commissioners. |
| Identification of cohort | |||||
| No recommendations made in this section | |||||
| Invitation, access and uptake | |||||
| No recommendations made in this section | |||||
| The screening test – accuracy and quality | |||||
| 10 | Quality assurance processes relating to image upload to be reviewed in line with national guidance. To include incident identification and reporting, image storage, QA timeliness and screening technician feedback, and centrally saved clinic lists. | Guidance: Internal quality assurance framework and resources Essential elements in providing an abdominal aortic aneurysm screening and surveillance programme | 3 months | High | Review of laptop and IT infrastructure has taken place. Updated SOPs to be shared with SQAS and commissioners. |
| 11 | Review current procedure of double scanning in the surveillance pathway and audit any value of this approach. | Clinical guidance and scope of practice for professionals involved in the provision of the ultrasound scan within AAA screening Essential elements in providing an abdominal aortic aneurysm screening and surveillance programme | 3 months | Standard | Audit to be shared with SQAS and commissioners as part of recommendations action plan. |
| Referral | |||||
| No recommendations made in this section | |||||
| 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: References
- ONS 2020 midyear LA population estimates. ONS 2020 midyear LA population estimates
- Men aged 65 years and over by ethnic group from NOMIS using the 2011 census data NOMIS 2011 census data
- Indices of deprivation 2019 scores for Local Authorities. 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