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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 | Partly | NHS England London Public Health Commissioning 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 | Cervical Screening Laboratory |
| Referral | Yes | Not applicable |
| Diagnosis | Yes | Not applicable |
| Intervention / treatment | Yes | Not applicable |
Summary
The NHS Cervical Screening Programme (NHSCSP) 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 8 September 2022 to Whittington Health NHS Trust cervical screening service which is commissioned by the NHS England London 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 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 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
- evidence submitted by the provider
- information shared with London SQAS as part of the visit process.
The screening service
Whittington Health NHS Trust provides NHS cervical screening services to the population covered by the NHS North Central London Integrated Care System (ICS). The service is commissioned by NHS England London.
Whittington Health NHS Trust provides colposcopy and cervical histology for the boroughs of Haringey and Islington.
The cytology and HPV testing service is provided by Cervical Screening Laboratory.
Findings
The last QA visit to Whittington Health NHS Trust took place on 10 October 2017.
All recommendations from that visit were completed.
COVID-19 pandemic was a challenging time for the NHS. The cervical screening service remained open and continued to see patients. The team have shown a high level of resilience and dedication.
The cervical screening service is well run by a dedicated team. There are 2 highly experienced clinical leads who oversee the service. Trust management are very supportive of the cervical screening service.
There are still challenges with increasing workload. The trust has identified options to ensure the timely management of the referrals.
Immediate concerns
No immediate concerns identified.
Urgent recommendations
No urgent recommendations were identified as this QA visit.
High priority findings
The QA visit team identified 5 high priority findings as summarised below:
- the colposcopy clinic is frequently staffed with only 1 member of the nursing team
- not all histopathologists are achieving the 150 cases per year in accordance with national guidance
- national standards for colposcopy performance and multi-disciplinary team (MDT) meeting attendance have not been met by all colposcopists
- there is a backlog of patients and referrals to the colposcopy service are increasing
- the multiple IT systems may impact on the tracking of patient management
Examples of practice that can be shared
The QA visit team identified several areas of practice for sharing particularly around access and communication, including:
- the use of picture documents, language line and interpreters
- choice of preference for gender of practitioners
- detailed patient satisfaction feedback undertaken annually
- colposcopy patients are provided with a ‘QR’ code to access all national screening leaflets in various languages
- setting up multi-zonal clinics to provide for the more complex patients of the future
Recommendations
The following recommendations are for the provider to action unless otherwise stated.
| No. | Recommendation | Reference | Timescale | Priority | Evidence required |
| Governance and leadership | |||||
| 1 | Ensure commissioners are provided with trust plan on cervical health inequalities initiatives and outcome of health equity audit | 1 | 6 months | Standard | Confirmation of updates at programme boards |
| 2 | Ensure there is a formal Job description for the CSPL role which document their responsibilities and a dedicated administrative support to support the delivery of their duties | 1, 2 | 3 months | Standard | Copy of job description for CSPL role Confirmation of dedicated administrative support |
| 3 | Ensure succession planning is in place for lead roles in light of impending staff retirement | 1 | 6 months | Standard | Copy of timescales for recruitment and planned mentorship for lead roles |
| 4 | Re-establish quarterly cervical business meetings chaired by the Cervical Screening Provider Lead with representation from all cervical screening service leads | 1, 2 | 3 months | Standard | Terms of reference, Meeting schedule Copies of minutes |
| 5 | Present an annual performance report and 6 monthly update to cover all NHS Cervical Screening Programme (CSP) services to the clinical governance committee | 1, 2 | 3 months | Standard | Share a copy of the reports with commissioners and SQAS |
| 6 | Histology department to maintain documentation and audits to demonstrate compliance with UKAS accreditation during transition | 1, 5 | 3 months | Standard | Share with commissioners and SQAS a copy of the transition plan with timescales |
| 7 | Ensure screening incidents are escalated and managed in accordance with “Managing Safety Incidents in NHS Screening Programmes” | 4 | 3 months | Standard | Develop local policy for management of screening incidents ratified at CSPL management meet/ Confirm all staff have reviewed the new policy |
| 8 | Re-establish quarterly colposcopy operational group meetings for the trust which has attendance from all clinical, nursing, managerial and administration staff | 1, 6 | 3 months | Standard | Copy of Terms of reference and minutes |
| Referral | |||||
| No recommendations made in this section. | |||||
| Sample taker register | |||||
| No recommendations made in this section. | |||||
| Diagnosis – histology | |||||
| 9 | Ensure sufficient technical laboratory staff to undertake cut up within the department which will release consultant time | 1 | 3 months | Standard | Confirmation of measures put in place |
| 10 | All pathologists to participate in the General Pathology External Quality Assessment (EQA) scheme. | 5 | 6 months | Standard | Confirmation of participation in EQA |
| 11 | All pathologists to report the minimum number of 150 programme cervical histopathology samples each year | 5 | 12 months | High | Histology data return |
| 12 | Ensure appropriate equipment is available for the department to improve efficiencies and mitigate any risks | 1 & 6 | 6 months | Standard | Confirmation of actions taken |
| Intervention and outcome – colposcopy | |||||
| 13 | Undertake a risk assessment and establish a process for the triage of direct and non-direct referrals to ensure there is appropriate cover for clinical leave | 1 & 6 | 3 months | Standard | Risk assessment of the current triage pathway Submit SOP |
| 14 | Develop a business plan for the management of clinical capacity and backlog which will include appropriate failsafe | 1 & 6 | 3 months | High | Submit copy of business plan |
| 15 | Ensure appropriate nurse staffing of colposcopy clinics as per NHCSP guidance(or is it a standard?) | 1 & 6 | 6 months | High | Confirmation and update of clinic schedule |
| 16 | Ensure administrators are trained to oversee screening pathway data and correct data entry errors | 1 & 6 | 3 months | Standard | Confirmation of action completed |
| 17 | Risk assess the impact of using multiple patient IT systems on tracking of patients and put mitigations in place to reduce any risks identified | 6, 7 | 6 months | High | Submit outcome of risk assessment and mitigation plan |
| 18 | Ensure all active colposcopists are registered on the colposcopy IT system and recording their own cases | 1,6 | 3 months | Standard | Confirmation of action completed |
| 19 | Document standard operating procedures for the nursing aspects of the colposcopy clinic | 1,7 | 6 months | Standard | SOP including referral triage, failsafe, clinic set up and use of equipment |
| 20 | Update and implement standard operating procedures for the safe use of electrosurgery in colposcopy | 1,6 | 3 months | Standard | SOP to include smoke evacuation and instructions on how to operate and perform safety checks on the equipment |
| 21 | Update the process for results and referral for cervical samples taken in the Trust outside of colposcopy | 1,8 | 3 months | Standard | Updated SOP |
| 22 | Complete audit of the individual clinician data and implement an action plan where breaches are identified | 6 | 3 months | High | Confirmation that an audit has taken place that includes all areas highlighted in the report. Provide information on any action taken and how performance is being monitored |
| 23 | Ensure data is collected to demonstrate compliance with all national standards | 1, 6 | 3 months | Standard | Submit copy of mapped data and of audits including details of actions taken |
| Multidisciplinary team | |||||
| 24 | All colposcopists including locums to attend a minimum of 50% of MDT meetings and all histopathologists a minimum of 3 MDTs per year | 1 | 12 months | High | Confirmation of attendance and adherence to guidance |
| 25 | Identify a deputy for the lead histopathologist to cover MDT meetings in their absence | 1 | 3 months | Standard | Confirmation of deputy. Update staffing structure |
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: Reference List
1. NHS Public Health Functions Agreement Service Specification No. 25, Schedule 2, 2022/23
2: NHS CSP: the role of the cervical screening provider lead. March 2018
3: NHS CSP: Disclosure of cervical screening history review results and applying duty of candour. April 2021 Updated October 2022
4: Managing Safety Incidents in NHS Screening Programmes. March 2015 Updated July 2021
5: NHS CSP Publication No.10: histopathology reporting handbook. November 2019 Updated September 2021
6: NHS CSP: Programme and Colposcopy Management. Guidelines for commissioners, screening providers and programme managers for NHS cervical screening. February 2020 Updated September 2021
7: Cervical screening: cytology reporting failsafe (primary HPV). July 2019
8: SQAS advice document: Management of NHS population screening cervical samples obtained in hospital settings. November 2019
9: NHS CSP 27: Improving the quality of the written information sent to women about cervical screening. December 2006
10: Cervical screening: implementation guide for primary HPV screening. February 2019
11: Cervical screening: quarterly coverage data reports September 2021. Accessed April 2022
12: NHS population screening: inequalities strategy. July 2019