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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 | Descriptive only | Covers Yorkshire and Humber Public Health Programmes 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 | Gateshead Health NHS Foundation Trust |
| Referral | No | Not applicable |
| Diagnosis | Yes | Not applicable |
| Intervention / treatment | No | QA visit to colposcopy York and Scarborough hospitals were undertaken in September 2019 |
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 13 and 14 September 2022 to York and Scarborough Teaching Hospitals NHS Foundation Trust cervical screening service which is commissioned by 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 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 SQAS
- data and reports from external organisations
- information collected during pre-review visits to York and Scarborough Teaching Hospitals NHS Foundation Trust on 5 September 2022
- information shared with the North regional SQAS as part of the visit process.
The screening service
The York and Scarborough Teaching Hospitals NHS Foundation Trust cervical screening service serves the populations of York, Scarborough, Ryedale, and parts of East Riding. The service has colposcopy units at:
- Bridlington Hospital
- Scarborough Hospital
- The York Hospital
Histopathology services are currently provided by Scarborough, Hull, York Pathology Service Network at:
- The York Hospital
- Hull Royal Infirmary Hospital
The Hull laboratory provide histopathology services for Hull Royal Infirmary (Hull University Teaching Hospitals NHS Trust) colposcopy service.
Findings
The Cervical Screening Provider Lead (CSPL) was newly appointed to the role in April 2022. They have undertaken a review and gap analysis of the CSPL role responsibilities and requirements and attended the national training. The CSPL has engaged with the cervical screening service pathway to improve understanding and develop relationships.
The Scarborough, Hull, York, pathology service was formally established on 1 November 2021. It brings together histopathology staff and services from York and Scarborough Hospitals NHS Foundation Trust (YSTH) and Hull University Teaching Hospitals NHS Trust (HUTH). The collaboration of the two cervical screening histopathology services is in its early stages. The Head Biomedical Scientist was appointed in a collaborative role to work across both sites to support cervical specimen processing consistency and align cervical screening histopathology protocols.
The YSTH cervical screening service supports people who are considered vulnerable or underserved but does not have an overarching strategy to systematically identify and reduce inequalities.
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 2022 asking that the following item is addressed:
- Process map the histopathology specimen pathway to identify delays for outsourced cervical specimens from the Hull laboratory and take action to improve the turnaround times
A response including an action plan has been received informing the QA visit team the steps taken to resolve the urgent recommendation.
High priority findings
The QA visit team identified 3 high priority findings as summarised below:
- Leadership and accountability of the NHS Cervical Screening Programme (NHSCSP) histopathology service across both sites
- Inadequate pathologist workforce on both sites in particular the Hull site where all cervical biopsies are sent to an outsourcing provider for reporting
- York laboratory facilities is limited on space with some pathologists sharing office space for reporting and the laboratory booking in environment and processing of NHSCSP samples
Examples of practice that can be shared
The QA visit team identified several areas of practice for sharing, including:
- Experienced Head Biomedical Scientist for cellular pathology working across both sites to support cross-site laboratory technical working and to develop consistent processes
- Cervical screening programme specimen workflow lean and efficient at both sites
Recommendations
The following recommendations are for the provider to action unless otherwise stated.
| No. | Recommendation | Pathway theme | Reference | Timescale | Priority | Evidence required |
| Urgent recommendation | ||||||
| 01 | Process map the histopathology sample pathway to identify delays for outsourced samples from Hull and take action to improve turnaround times | Diagnosis – histology | 5 | 14 days | Urgent | Action plan, improved turnaround times |
| No. | Recommendation | Reference | Timescale | Priority | Evidence required |
| Governance and leadership | |||||
| 02 | Develop an action plan to reduce screening inequalities in underserved and protected population groups in NHS Cervical Screening Programme pathway | 1 | 6 months | Standard | Action plan |
| 03 | Implement a whole trust organisational accountability structure for the cervical screening service, including detail of escalation routes for governance and performance issues | 2 | 6 months | High | Ratified documents outlining accountability arrangements |
| 04 | Make sure the Cervical Screening Provider Lead administrative support role is documented in their job description | 2 | 3 months | High | Job description |
| 05 | Make sure the Cervical Screening Provider Lead has an annual appraisal for the role | 2 | 12 months | Standard | Confirmation of appraisal |
| 06 | Develop cervical screening management meetings terms of reference | 2 | 3 months | Standard | Terms of reference |
| 07 | Ratify trust-wide protocol for the completion of the invasive cervical cancer audit | 2 | 6 months | Standard | Ratified protocol |
| 08 | Ratify trust-wide policy for the offer of disclosure of invasive cervical cancer audit | 2 | 6 months | Standard | Ratified policy |
| 09 | Make sure all people diagnosed with cervical cancer have been offered the results of theinvasive cervical cancer audit | 2 | 3 months | High | Completion of offer of disclosure for cases diagnosed |
| 10 | Implement an annual audit of disclosurefor the invasive cervical cancer audit | 2 | 12 months | Standard | Audit schedule, audit |
| 11 | Make sure the annual performance report and 6 monthly update to cover all NHSCSP services is provided to the trust clinical governance committee | 2 | 6 months | Standard | Annual performance and 6 monthly report with circulation list |
| 12 | Develop and implement a whole trust annual audit schedule for cervical screening services | 2 | 12 months | Standard | Annual audit schedule covering colposcopy and histopathology with confirmatory evidence of actions taken |
| 13 | Document the process for results and referral for cervical samples taken in the trust outside of colposcopy | 2 | 6 months | Standard | Ratified protocol |
| 14 | Amend trust-wide incident policy to accurately document reporting incidents to Screening Quality Assurance Service | 2 | 6 months | Standard | Ratified protocol |
| 15 | Appoint a Lead NHSCSP Histopathologist across the pathology network with responsibility for ensuring good practice, compliance with protocols and standards are met | 5 | 3 months | High | Job description, job plan with dedicated professional activity allocation |
| Diagnosis – histology | |||||
| 16 | Ensure that the Lead NHSCSP Histopathologist has overall responsibility for all outsourced specimens | 5 | 3 months | High | Confirmation of oversight and responsibility |
| 17 | Make sure that all NHSCSP reporting pathologists have completed e-learning | 5 | 6 months | Standard | Confirmation of completion |
| 18 | Develop a workforce plan to sustainably meet turnaround times for reporting NHS Cervical Screening Programme histopathology | 1 | 12 months | High | Workforce plan |
| 19 | Risk assessment of York site accommodation, including the impact of shared pathologists’ office space for safe reporting, and the booking in environment for NHSCSP samples | 5 | 6 months | High | Risk assessment |
| 20 | Ensure York histopathology staff have access to Open Exeter | 5 | 6 months | Standard | Confirmation |
| 21 | Implement trust-wide standard operating procedures for processing and reporting of NHS Cervical Screening Programme specimens | 5 | 6 months | High | Ratified standard operating procedures |
| 22 | Put in place a process to ensure that the Lead Histopathologist for NHSCSP can monitor histopathology performance data | 5 | 6 months | Standard | Protocol |
| 23 | Document sample selection criteria for p16 staining | 5 | 3 months | Standard | Standard operating procedure |
| 24 | Develop a standard operating procedure for the reporting of NHSCSP incidents to include the escalation process to cervical screening provider lead | 5 | 6 months | Standard | Standard operating procedure |
| 25 | Make sure that all NHSCSP reporting pathologists meet the minimum number of cervical screening specimen reporting | 5 | 12 months | Standard | Individual histopathologist workload data |
| 26 | Make sure that proforma forms for reporting cervical histopathology are used for all NHS Cervical Screening Programme specimens | 5 | 6 months | Standard | Proforma form, re- audit of individual pathologist compliance |
| Multidisciplinary team | |||||
| 27 | Make sure that all NHSCSP reporting pathologists meet the minimum requirement NHSCSP MDT attendance criteria | 5 | 12 months | Standard | Evidence of multidisciplinary team meeting attendance |
| 28 | Document the second review by a pathologist different from the original reporter for histology cases for colposcopy multidisciplinary team meetings | 5 | 3 months | Standard | Ratified standard operating procedure |
| 29 | Make sure there are appropriate arrangements for histopathology representation at Hull MDT for holiday/sickness absence | 5 | 3 months | Standard | Confirmation |
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 England. NHS Public Health Functions Agreement: 2022/23 Service Specification No.25 Cervical Screening Service Schedule 2
- NHS Cervical Screening Programme. Cervical screening: role of the cervical screening provider Lead;
- NHS Cervical Screening Programme. Cervical screening: auditing procedures; 2021.
- NHS Cervical Screening Programme. Cervical screening: disclosure of audit results toolkit; 2021.
- NHS Cervical Screening Programme. Cervical screening: histopathology reporting handbook; 2021.
- Ministry of Housing, Communities & Local Government. English indices of deprivation; 2019.
- Official Census and Labour Market Statistics. LC2101EW – Ethnic group by sex by age; 2011
- Official Census and Labour Market Statistics. LC2107EW – Religion by sex by age; 2011
- NHS England. Quarterly Cervical Coverage Report; March 2022.