Guidance

Ceasing and deferring women from the NHS Cervical Screening Programme

Updated 20 September 2019

1. Introduction

This document gives information about the appropriate use of ceasing and deferring in the NHS Cervical Screening Programme.

The programme invites eligible people for cervical screening at standard intervals. The ‘call and recall’ system operated by the screening programme manages the invitation process and ensures that people are invited at the correct time.

People who choose to withdraw from the programme, and those who are no longer eligible, are removed (ceased) from call and recall.

A person who is ceased from call and recall will not receive any further invitations or reminder letters from the screening programme.

A person for whom a screening invitation is temporarily inappropriate should be deferred from call and recall. Deferral is achieved by postponing their screening invitation for a specified period. The call and recall system will re-invite the person for screening after the period of postponement, provided that they remain eligible.

2. Ceasing

2.1 Ceasing as a result of informed personal choice

The NHS offers cervical screening using the principle of informed personal choice. All screening invitations are accompanied by an information leaflet which seeks to provide accurate and balanced information about the possible benefits and risks of screening. This is to help the individual decide whether or not they wish to accept.

If someone decides to decline screening, either temporarily or permanently, programme and primary care staff must respect this decision.

A person may be eligible for screening but have circumstances which affect their ability to consent to the test, or affect the sample taker’s ability to obtain a sample. Special circumstances which require individual consideration are described in section 2.3. In most instances a person should only be ceased from call and recall if they agree to this. They will then be managed in the same way as people who choose to withdraw from screening.

2.2 Voluntary withdrawal

People can choose to withdraw from the cervical screening programme at any time, and do not have to give a reason for their decision.

Every person who wishes to withdraw permanently from the screening programme must be:

• provided with (or signposted to) sufficient information, in an appropriate and accessible format, to support an informed decision
• given the opportunity to discuss their decision with a GP or other suitably qualified health professional (but they do not have to take up this opportunity)
• informed that withdrawing from the programme means they will not receive any future invitations or reminder letters about cervical screening from the programme
• asked to put their withdrawal request in writing, ideally using the standard template ceasing form available from the NHS Cervical Screening Administration Service (CSAS); if this is not possible, a record should be made at the time of the request (call and recall must receive and retain a copy)
• advised that they can return to the programme at any time providing they are still eligible for screening (following the process in the return to recall section below)
• notified in writing when the ceasing has been completed (their name is removed from call and recall)

Ceasing documentation

A person should put their request for permanent withdrawal from cervical screening in writing if possible. This is to ensure there is no misunderstanding and that they are not ceased from call and recall in error. The template ceasing form available from CSAS should be used. This contains the information needed to support a withdrawal request and is the preferred method of communication. The GP practice should arrange for the form to be provided to the individual. A clear and unambiguous written request signed by the individual is also acceptable.

If a person will not or cannot provide a written request, the GP or a suitably qualified healthcare professional should document the request in writing, noting the time, date and content of the conversation.

The withdrawal request is an important part of the person’s screening record. The GP practice must retain a copy of the document within the person’s medical record.

Return to recall

A person who has been ceased from call and recall will not receive screening invitations, but can be screened on request if they are eligible but overdue for a test. This will include anyone whose last routine test was more than 3 or 5 years ago (depending on their age), and people who have never had a test.

As soon the call and recall system receives a new test result, the system will return the person to recall automatically. A ‘next test due date’ (NTDD) is set according to the result of their last test, and an invitation is generated at the appropriate time.

If a person is not due or overdue for a test but wishes to return to recall so that they will receive an invitation when due, they can ask their GP to contact call and recall to cancel their ceasing. A signed form is not required to cancel a ceasing due to informed choice, but can be used if preferred.

2.3 Individual circumstances

Female genital mutilation (FGM)

People who have undergone FGM may not be able to have cervical screening if it is not possible for the sample taker to pass the speculum.

Ideally, a person should be referred to an FGM service to confirm FGM status and assess the possible need for de-infibulation. There are specialist clinics across the country. Alternatively, the GP or sample taker should consider onward referral to specialist gynaecology and/or counselling services.

A person who is not physically capable of being screened should be advised that they can withdraw from the screening programme to prevent any further invitations being sent. The process for voluntary withdrawal described in section 2.2 is applicable in these circumstances. If the person’s circumstances change they can rejoin the programme at any time. People who do not wish to withdraw from call and recall should remain in the programme and continue to receive screening invitations.

There is a requirement to record data on FGM as set out in Department of Health and Social Care (DHSC) guidance

Vaginismus

Vaginismus (involuntary tensing of the vaginal muscles) may make cervical screening painful or even impossible. It may be helpful to offer a person who experiences vaginismus an appointment to discuss the screening process, and become familiar with the environment, procedure and instruments used. Some people find deep breathing exercises during the examination may also help.

If someone has repeatedly been unable to tolerate cervical screening previously and no longer wishes to attend, they should be invited to withdraw from the screening programme using the process for voluntary withdrawal described in section 2.2. If the their circumstances change they can rejoin the programme at any time. People who do not wish to withdraw from recall should remain in the programme and continue to receive screening invitations.

Cervical stenosis

It may not be possible to obtain a cervical sample that represents the entire transformation zone from people who have severe cervical stenosis. The GP should refer a person to colposcopy in such circumstances. If advised by the colposcopy team, the person can be invited to withdraw from the screening programme using the process for voluntary withdrawal described in section 2.2. If the person’s circumstances change they can rejoin the programme at any time. People who do not wish to withdraw from recall should remain in the programme and continue to receive screening invitations.

Physical conditions and disabilities

Physical conditions and disabilities are not a valid reason for ceasing women. Screening is usually achievable with adequate support and preparation. It is essential to explore what support and resources can be put in place to ensure people have equitable access to screening.

There are some disabilities and conditions affecting mobility that may prevent a woman from achieving a position where the cervix can be fully seen and a sample taken. The inability to achieve a suitable position may be temporary or permanent dependent upon the condition. In some cases, progress in medications or treatment can improve a person’s situation such that a cervical sample can be obtained when this was not previously possible. A longer appointment for the screening test may be required, or in some cases it may be necessary to refer the person to a colposcopy setting.

People should have the opportunity to consider their own circumstances at each invitation, and decide whether or not they can accept. People should therefore be encouraged to remain in the call and recall system and receive regular invitations. People who do not wish to receive regular invitations, or who feel that they will never be suitable for screening, should be invited to withdraw from the screening programme using the process for voluntary withdrawal described in section 2.2. If a person’s circumstances change, they can rejoin the programme at any time. People who do not wish to withdraw from recall should remain in the programme and continue to receive screening invitations.

Terminal illness

People who have a terminal illness remain eligible for screening, and should be treated in the same way as people without a terminal illness.This includes being invited for cervical screening as long as they are sufficiently well to tolerate the procedure. It is the person’s decision whether to attend or not.

People who do not wish to receive regular invitations, or who feel that they will never benefit from screening, can be invited to withdraw from the screening programme using the process for voluntary withdrawal described in section 2.2. If a persons’s circumstances change, they can rejoin the programme at any time. People who do not wish to withdraw from recall should remain in the programme and continue to receive screening invitations.

Exceptionally (for example a person with cervical cancer), a screening invitation may cause unnecessary distress. In such cases, at the GP’s discretion, it may be appropriate to defer the woman’s screening invitation for a number of months to prevent any correspondence from being sent in the near future. The situation can then be reviewed when the next invitation becomes due. See section 5 for guidance on deferring a screening invitation.

Mental capacity

Issues of mental capacity are subject to the Mental Capacity Act 2005, with guidance laid out in the Code of Practice for the Act.

Advice specifically for healthcare workers is also available.

There are different physical and mental health conditions and learning disabilities which can affect an individual’s mental capacity. It is important to ensure that all people who are eligible for cervical screening have equality of access to the service.

People with learning disabilities can often understand and consent to screening with adequate support and preparation. Learning disability alone is not a valid reason for ceasing.

Guidance for supporting people with learning disabilities to access cervical screening is available.

Individuals must always be presumed to have capacity to make their own decisions unless it is proved otherwise. Some people can, with appropriate support, make their own decisions about attending for screening, declining individual screening invitations while remaining in the programme, or withdrawing permanently from the screening programme. People who do wish to withdraw from the programme may follow the process for voluntary withdrawal described in section 2.2.

If a ceasing decision has to be made on behalf of a person who lacks capacity, the person who makes the decision is known as the decision-maker. This will usually be a healthcare professional such as the person’s GP, or other responsible clinician if there is no GP. The decision-maker may only act if the person cannot make their own decision even with support and assistance. The decision-maker is legally accountable for any decision made which affects the person now or in the future.

The decision-maker is required to consider all the relevant factors which affect the ceasing decision, and consult with all relevant patient representatives at ‘best interest meetings’. The team must always act in the person’s best interests, and make objective decisions without imposing their own views. Any decision should usually be the least restrictive of all options unless a restrictive option (such as withholding all future screening invitations) is in the person’s best interests. The decision should be reviewed regularly by the decision-maker to ensure that it remains appropriate, since a person’s best interests may change over time.

Decision-makers are required to document the decision-making process and retain an auditable record of this.

Ceasing from cervical screening recall in a person’s best interests is likely to be appropriate only where the individual would never be suitable for screening or for further investigations and/or treatment in the event of a positive screening result. In most cases the least restrictive alternative is for the person to remain in recall and receive screening invitations at routine intervals.

The main requirements for ceasing under a ‘best interests’ decision are that:

• efforts to support the person to make their own decision must be exhausted, and the their lack of capacity must be formally acknowledged by the decision-maker
• the case must be considered individually, including a case conference with an appropriate family member or other personal representative of the person concerned
• the decision and all supporting evidence must be fully documented and stored with the person’s medical record
• a template ceasing form signed by the decision-maker and patient representative must be sent to the call and recall service and the GP (if applicable)
• call and recall must send a letter to confirm the ceasing to the person’s registered address so that it can be kept with their personal records, copied to the GP (if applicable); the letter should also explain how to rejoin the programme if this is appropriate
• the person’s representatives must confirm that the situation will be reconsidered if the individual’s circumstances change

3. Ceasing due to non-eligibility

3.1 Ceasing due to age

The following people are eligible to receive a screening invitation while under the age of 25:

• women, or people with a cervix (and registered as female with their GP), who are within 6 months of their 25th birthday and who have been identified as due for their first test
• people who have been previously screened elsewhere in the UK and who are subject to routine or non-routine recall as a result of their previous test
• people who have been previously screened privately and who require a follow up non-routine recall as a result of their previous test where the screening programme has been notified of the result of a previous test

People should not be ceased from call and recall due to age while under the age of 25, however, other clinical reasons for ceasing may apply.

Automatic ceasing at age 60 and over

A person who attends for routine cervical screening on or after their 60th birthday will be automatically ceased from recall if their last test result is normal with routine recall and they have had no recent abnormal results. This is because their next routine test would be due after their 65th birthday.

People who have previously had abnormal cervical cells are only automatically ceased from recall when they have completed the relevant follow up. Those who have not completed relevant follow up continue to be invited for non-routine cervical screening after the age of 65 if necessary.

All people who are ceased automatically due to age after attendance are sent a result letter which includes an explanation that they will not be invited for further tests because of their age.

People are also automatically ceased from recall if they fail to respond to a routine invitation which was sent on or after their 60th birthday. This is because their next routine invitation would be due after their 65th birthday. People who have been ceased automatically due to age after non-attendance can request a final routine test at any time regardless of age. If the result of the final routine test is normal, the person is ceased from recall again automatically. If the result of the final routine test is abnormal the person is returned to recall until all necessary follow-up tests have been completed.

Ceasing at age 65 and over

People aged 65 or over who have had a previous cervical abnormality remain in recall until they have completed follow up, even if they have not responded to their most recent screening invitations. This may include people who have had a positive HPV test but no abnormal cytology. People who remain eligible for non-routine screening are not ceased automatically due to age.

GPs can request ceasing of persistent non-attenders and/or low-risk people who have passed their 65th birthday if they feel that further invitations would be of no benefit to the person; for example, because they are highly unlikely ever to attend. Requests for ceasing due to age may be made using the template ceasing form available from CSAS, in writing or by email to call and recall, or via the Prior Notification List (PNL) process.

GPs should not request ceasing due to age if a woman is over 65 but is awaiting a recall invitation where her last test recommended early recall or colposcopy attendance.

People who have not attended for a test since their 60th birthday may request their final test at any time, even after they have been ceased due to age. They are returned to recall after this test only if the result is abnormal, and they will remain in recall only until they have completed any relevant follow up or are re-ceased for a new reason.

3.2 Ceasing due to absence of cervix

People who do not have a cervix are not eligible for cervical screening and should be ceased from recall permanently.

A ceasing notification not made through the electronic PNL should use the template ceasing form available from CSAS.

All people who are ceased from call and recall due to absence of cervix are informed by letter that they will receive no further invitations for screening. Where the person is registered with a GP practice, call and recall must notify the practice that the ceasing process has been completed.

People assigned female at birth who were born without a cervix do not require screening and should be ceased from recall.

Hysterectomy

People who have undergone a sub-total hysterectomy (where the cervix is not removed) remain eligible for recall and should continue to be offered screening.

People who have undergone a total hysterectomy (including removal of the cervix) no longer require screening and should be ceased from recall.

The NHSCSP publication ‘Colposcopy and Programme Management’ explains when vaginal vault testing is appropriate in the management of people after total hysterectomy. Vault tests fall outside of the screening programme and so the results of such tests cannot be entered onto the call and recall system. This means that a result letter is not produced or issued, and the individual will not be subject to failsafe recall in the event of an abnormal test result. Sample takers are responsible for notifying the person of their result and ensuring appropriate follow up.

Trachelectomy

People who have undergone a radical trachelectomy (removal of the uterine cervix) for cervical cancer no longer require screening and should be ceased from recall. Clinical follow up may be appropriate and will be managed by the relevant clinician outside of the screening programme.

3.3 Transgender (trans) people

Anyone who has a cervix and who falls within the screening age range is eligible for screening.

A trans woman who is registered as female does not require screening and should be ceased from recall.

People registered as male (including trans men) do not receive cervical screening invitations. However, the GP practice should arrange screening for individuals (with a cervix) who would like to have it.

Trans men who are registered as female automatically receive invitations for screening. A trans man who wishes to withdraw from cervical screening does not have to mention he is trans if he does not wish to (it is not necessary for anyone to provide a reason for withdrawing). Anyone wishing to withdraw from the programme should follow the process for voluntary withdrawal described in section 2.2.

Further information about screening for transgender people is available.

3.4 Ceasing due to radiotherapy

It is difficult to accurately report samples from people who have undergone radiotherapy for cervical, bladder, rectal and other pelvic cancers. All cases should be considered individually, and people who are unsuitable for screening should be ceased from recall. People who require gynaecological follow-up are managed outside the screening programme.

A ceasing notification not made through the electronic PNL should use the template ceasing form available from CSAS

Ceasing due to radiotherapy is a sensitive issue. There is no requirement to notify people in writing that they will receive no further screening invitations. However where the person is registered with a GP practice the practice must be notified when the ceasing process is complete.

4. Ceasing instructions

4.1 Authority to request ceasing

Most ceasing requests are communicated to call and recall directly from a person’s GP practice, either by ad hoc request or via the PNL process. Occasionally ceasing requests are made directly to call and recall by the individual or by other stakeholders using the online CSAS contact form.

Some ceasing requests can be actioned immediately, but in some cases further verification or confirmation is required. The information below summarises the individuals or groups which may make a ceasing request and the additional actions required (if any).

Where a person requests ceasing directly due to:

• informed choice (voluntary withdrawal): call and recall to ensure that formal confirmation is received
• a best interests decision under the Mental Capacity Act: not applicable (no action)
• age (over 65): Not applicable (no action)
• absence cervix: call and recall to seek confirmation from GP practice that ceasing is appropriate (if registered)
• radiotherapy: call and recall to seek confirmation from GP practice that ceasing is appropriate (if registered)

Where a GP practice requests a person is ceased due to:

• informed choice: the practice can provide the link to the online CSAS contact form or print out the withdrawal form for the individual to complete
• a best interests decision under the Mental Capacity Act: not applicable (no action)
• age (over 65): no additional verification required
• absence of cervix: no additional verification required
• radiotherapy: no additional verification required

Where a contraceptive and sexual health (CASH) clinic requests a person is ceased due to:

• informed choice: the clinic can provide the link to the online CSAS contact form or print out the withdrawal form for the individual to complete
• a best interests decision under the Mental Capacity Act; not applicable (no action)
• age (over 65): call and recall to seek confirmation from GP practice that ceasing is appropriate (if registered)
• absence of cervix: call and recall to seek confirmation from GP practice that ceasing is appropriate (if registered)
• radiotherapy: Call and recall to seek confirmation from GP practice that ceasing is appropriate (if registered)

Where a colposcopy or gynaecology clinic requests a person is ceased due to:

• informed choice: the clinic can provide the link to the online CSAS contact form or print out the withdrawal form for the individual to complete
• a best interests decision under the Mental Capacity Act: not applicable (no action)
• age (over 65): not applicable (no action)
• absence of cervix: no additional verification required
• radiotherapy: No additional verification required

Where a GP and/or responsible health professional in conjunction with patient carer and/or patient representative requests a person is ceased due to:

• informed choice: not applicable (no action)
• a best interests decision under the Mental Capacity Act: call and recall to confirm that the ceasing form reflects section 2.3 (mental capacity)
• age (over 65): not applicable (no action)
• absence of cervix: not applicable (no action)
• radiotherapy: not applicable (no action)

People who are not registered with a GP require a responsible clinician to confirm their medical details.

In all cases, call and recall is required to retain a copy of the ceasing request in a secure and accessible location. They may scan paper documents and store them electronically if preferred. The originator of each document or file should retain a copy of the submission for their own records. In all cases, call and recall should send confirmation of ceasing, and the reason, to the registered GP.

Note that screening laboratories do not have authority to cease a woman or to request that a withdrawal form is sent to a woman for completion.

4.2 Ceasing audits

Call and recall are required to audit annually the records of people who are ceased from recall. This is to ensure that all people who are ceased have been managed correctly. All documentation related to individual ceasing requests must therefore be retained in a secure and accessible location.

Ceased people whose screening status cannot be verified must be returned to recall as a failsafe measure.

As part of the audit, GP practices are asked to verify the status of any individuals registered as a women with the practice whose date of ceasing falls within the timeframe of the audit. This can include people who were ceased before they were registered at the current practice. Practice staff should verify the records of individual people in a timely manner to ensure that no-one is returned to recall inappropriately.

The Screening QA Service determines the audit requirements annually in collaboration with NHS England as the service commissioner. Call and recall must provide a report to the Screening QA Service which includes the number of cases reviewed and the number of people by category and by area returned to recall. This data is used to address local issues with inappropriate ceasing.

5. Deferral

5.1 Deferral notifications

All people who are included within the call and recall system are invited for screening based on their NTDD. This is set when they enter the programme, after every invitation and/or attendance cycle, and by colposcopy clinics once a referral episode is complete. The NTDD is the date on which a test is due if the person attends in accordance with the recommended schedule for screening. Call and recall sends invitations to people approximately 6 weeks in advance of their NTDD so that they have the opportunity to make an appointment by the due date.

Call and recall issues each GP practice a PNL at regular intervals. This details the people registered as women with the practice whose NTDDs indicate they are due to be invited for screening. Practice staff must check the details of each person. They must use the PNL response system to notify call and recall of people whose screening invitations should be deferred, by postponing their NTDD for a fixed number of months up to a maximum of 18 months. The practice must give at least one valid reason and specify the NTDD for every deferral.

People referred to colposcopy as a result of a screening test will have a NTDD set 12 months after the date of their last screening test as a failsafe measure. This NTDD can be reset after discharge from colposcopy to allow the woman to be recalled at the appropriate time. This may be earlier or later than the default 12 month period. Call and recall manages this process in the same way as deferrals for other reasons.

Rarely, and individual or GP may make an ad hoc request for deferral. This may be to prevent an invitation or reminder letter arriving at an inappropriate time. The person must submit the request to call and recall by letter or email to a secure address provided by the screening service. The request must specify the exact NTDD, which must not be more than 18 months after the current NTDD.

5.2 Reasons for deferral

Recent test

People may sometimes attend for screening just before they are due to be invited again by the screening programme. If a person has recently attended for screening but call and recall have not received their result, they can appear on a PNL based on their last-known NTDD. In such cases the practice should defer the person’s next test for a period of 3 months to allow processing of the recent sample and addition of the result to their screening record. When the result is recorded, the person’s NTDD will be updated accordingly so they are recalled for screening at the appropriate time.

Deferrals due to recent test must never exceed 3 months. This is in case the recent sample was inadequate, unsuitable for testing or rejected by the laboratory.

Ad hoc requests outside the PNL process for deferrals due to recent test are not required.

Pregnancy

There are very limited circumstances when screening is appropriate for pregnant women. Guidance is outlined in NHSCSP Publication no 20 ‘Colposcopy and Programme Management’.

All pregnant women who are due to be invited for routine screening and most pregnant women who are due to be invited for non-routine screening should be deferred from screening until 12 weeks after delivery. The women’s NTDDs should be postponed for the appropriate number of months up to a maximum of 12.

Ad hoc requests outside the PNL process for deferrals due to pregnancy are not required.

Under care of colposcopy

People referred to colposcopy following a screening test are automatically recalled for a follow-up screening test 12 months after the date of their previous test as a failsafe measure. People who are discharged from colposcopy following assessment and/or treatment have their NTDD set appropriately by the colposcopy service. People discharged from colposcopy due to non-attendance will be invited for the failsafe test.

People who appear on a PNL who are not yet discharged from colposcopy should be deferred from screening for a further 12 months to continue the failsafe system. Practices are advised to verify the person’s discharge status from colposcopy if a second or subsequent 12 month deferral is considered for this reason.

Ad hoc requests outside the PNL process for deferrals due to colposcopy are not required.

Under treatment

People undergoing medical treatment which does not affect the sample-taking process are invited for screening when their test is due.

People undergoing treatment which will affect the sample-taking process should be deferred from screening for an appropriate period. Examples of treatment affecting screening include in vitro fertilisation, pelvic radiotherapy, imminent total hysterectomy, active or palliative treatment for cervical cancer. People’s NTDDs may be postponed for a maximum of 12 months, although the deferral process can be repeated at the next PNL if the woman is still undergoing treatment.

Ad hoc requests outside the PNL process for deferrals due to treatment are not required.

Discharge from colposcopy

Colposcopy clinics must notify call and recall when people are discharged after attendance, giving a new NTDD for every person who is eligible for recall in primary care. Clinics may not alter the NTDDs of people who have not yet been discharged, or of people who have been discharged due to non-attendance at colposcopy.

People who were referred after a negative, inadequate, borderline or low-grade abnormality can be returned to routine recall if the colposcopy examination was adequate and normal; and so their NTDDs may be postponed for up to 36 or 60 months depending on their age.

People who were referred after a cytology result of moderate dyskaryosis or worse are not eligible for routine recall until they have completed all recommended investigations and/or follow-up tests. Deferral periods for these people will depend upon the outcome of colposcopy. In general, untreated individuals may have their NTDDs postponed for up to 12 months from date of last adequate colposcopy. Treated individuals will usually have their NTDD set at 6 months from the date of treatment.

Colposcopy clinics should use a standard template for discharge notifications. This makes sure that the minimum dataset is provided, prevents inappropriate medical information from being passed to call and recall, and allows call and recall to check that all discharge notifications have been received. A nationally-approved template is given at Appendix F in ‘NHS cervical screening call and recall: guide to administrative good practice’.

GP practices should not routinely defer people due to discharge from colposcopy unless it is required to correct an error.

Personal choice

People may notify call and recall, either directly or via their GP practice, that they are unable or unwilling to attend for screening at their NTDD. They can request that an invitation be sent at a later specified date.

Ad hoc requests for deferrals due to individual choice may be sent to call and recall outside the PNL process using the online CSAS contact form.

5.3 Deferral documentation

The majority of deferral requests are managed automatically by the electronic PNL process. The call and recall system maintains an audit file and retains details of all deferrals. The system records all relevant details including, as appropriate, the individual or organisation which requested the deferral and the system user who authorised or actioned it.

Discharge notifications provided by colposcopy clinics, and any ad hoc deferral requests, must be retained by call and recall in a secure and accessible location to support QA and audit activities. Paper documents may be scanned and stored electronically if preferred. The originator of each document or file should retain a copy of the submission for their own records.

6. Specific responsibilities

Different organisations within the screening programme have a number of specific responsibilities.

6.1 GP practice

The GP practices:

• check PNLs and send updates to call and recall within the requested timescales
• monitor repeated consecutive deferrals for the same person to ensure these are necessary
• notify call and recall outside the PNL process if a person needs to be ceased or sent a withdrawal form
• respond to queries from call and recall where a ceasing request has been made by another organisation
• provide advice and support on request to people who want to make an informed choice to withdraw from recall
• help physically and mentally disabled people to access screening services to avoid unnecessary ceasing
• support and input into best interest meetings regarding individuals who may not have capacity to consent to screening or to withdraw from screening themselves
• cooperate and fulfil ceasing audit requirements in a timely manner

6.2 Call and recall service

Call and recall:

• ensures that documentation/forms and processes (including verification processes) meet minimum programme requirements
• provides withdrawal forms to people if instructed to do so by an authorised individual or organisation
• acts promptly when ceasing or deferral requests are made
• confirms to people when they have been ceased from the screening programme (all cases other than radiotherapy)
• retains ceasing and deferral documentation in a secure and accessible location
• ensures that all people ceased due to age are over 60 (including those whose dates of birth have been changed on the system)
• ensures that all people ceased by the GP due to age when over 65 are persistent non-attenders and in particular are not awaiting an invitation for a follow-up test
• carries out routine ceasing audits at least annually to the extent advised by the PHE Screening QA Service
• ensures that people who cannot be confirmed as being ceased appropriately following a ceasing audit are returned to call and recall immediately, and are sent an invitation for screening if one is due or overdue as a result of the ceasing

6.3 Colposcopy clinic

Colposcopy clincs:

• provide complete and accurate discharge lists for attenders to call and recall at regular intervals
• notify call and recall when they determine that a person should be ceased due to non-eligibility using the template ceasing form
• notify call and recall if a person asks to withdraw from recall so that a withdrawal form can be provided

6.4 NHS England

NHS England:

• commissions a high quality call and recall service which follows national guidance
• retains an overview of ceasing and deferral processes and the ceasing audit
• identify or respond to any problem in the operation of the system and take action as appropriate

6.5 PHE Screening QA Service

PHE Screening QA:

• provides advice to call and recall on the provision of a high-quality call and recall service
• collates data on routine ceasing audits from call and recall and provide summarised feedback to stakeholders, including screening and immunisation teams where local action is required

7. Operational considerations

7.1 Retention of documents

Paper documents or electronic files which relate to ceasing must be kept in a secure and accessible location for as long as they affect a person’s recall, or for as long as they may need to be referenced in the event of litigation.

In practice this means that ceasing records should be kept indefinitely.

7.2 Changing the reason for ceasing

If a person has been ceased from the screening programme there is no requirement to change to another reason for ceasing should her circumstances change. It is important to note that changing the reason for ceasing will result in a letter being generated.

7.3 Ceasing after hysterectomy or trachelectomy

Colposcopy or gynaecology clinics may identify people who have had a total hysterectomy or trachelectomy following referral, as part of routine failsafe activities. Call and recall can accept notifications from these organisations and no further verification is required.

Colposcopy or gynaecology clinics should not include people who have had a total hysterectomy or trachelectomy on a routine discharge report. Discharge reports specify recall dates for women who are returning to recall in primary care.

7.4 Identification of errors

If call and recall receives a screening result for a person who is currently ceased from screening due to ‘no cervix’ or ‘radiotherapy’, they must ask the laboratory to confirm that this is a valid screening result and not a vault sample. If the laboratory confirms the screening result, this indicates that the ceasing was carried out in error. Call and recall should seek advice from the Screening QA Service on whether the national incident guidance should be followed. The person must be unceased on the call and recall system so that the new result can be recorded and so that a NTDD can be set as appropriate.

Vault smears are not valid screening results and should not be recorded on the system or lead to further screening invitations.

Where a person is ceased from screening for any reason but the necessary documentation or confirmation cannot be obtained during a ceasing audit, this will be considered an error. Call and recall should review the case immediately to confirm that the person should be returned to recall. Advice should be sought from the Screening QA Service on whether the national incident guidance should be followed. An invitation for screening should be sent if one is due or overdue as a result of the ceasing.

If there is evidence or concerns that systematic errors are being made in relation to ceasing at call and recall or in general practice, advice should be sought from the Screening QA Service. Please refer to Managing safety incidents in NHS screening programmes.