Intensive work to create awareness about the need for cervical smear tests, especially in those practices and groups of women where uptake was lowest, led to an increase in the number of women having the test.
What was involved
The aim of the improvement plan was to increase the cervical screening rate across all Trafford practices in 2015, with a particular focus on those practices and groups of women where uptake was lowest. Cervical screening uptake in Trafford Clinical Commissioning Group (CCG) was 78.7% of eligible women, ranging from 59.3% to 85.8% between practices.
National evidence of effectiveness, local good practice and community insight was used to tailor support for practices with low uptake. The tailored support focused on areas of deprivation and amongst women from Black and Minority Ethnic (BME) groups. Women were also targeted by age, for example, younger women aged under 30 through promotion at Children’s Centres and women over 50 through the Carers Centre.
During primary care training, practitioners were asked to consider reasons why women may not be attending for their screening and to include this in discussions, for example where the patient was experiencing or had experienced domestic abuse and sexual abuse.
The integrated programme was led by Public Health (Trafford Council) and Primary Care Quality Management, (Trafford CCG). A successful partnership was developed with a third sector organisation, Voice of BME-Trafford.
In order to address the declining cervical screening uptake rates in Trafford, 3 types of intervention were implemented from November 2014:
- a population level package of interventions
- an intensive package of interventions for populations with established BME communities and high social inequality
- a focused package of support for targeted practices with a high proportion of women from BME groups and women at risk of social exclusion
At a borough level, a campaign was undertaken to raise awareness of the importance of cervical screening. The branded One Minute campaign included posters and leaflets being disseminated throughout primary care, pharmacies, supermarkets, hairdressers, grocery shops, restaurants, children centres, libraries and other community based areas. Local survivors championed the campaign featuring in articles published on the CCG twitter account and in the local newspaper.
A screening presentation by Trafford Public Health and Public Health England was delivered at a quarterly education session for:
- practice managers
- general practitioners (GPs)
- practice nurses
The session included clinical information but also tips for improving uptake and the impact of wider social issues on uptake for example, domestic abuse. Additionally, the CCG Nurse Educator contacted all practice nurses identified as requiring a training update in order to ensure they enlisted on a refresher course.
Within primary care a stretch target was introduced to practices who achieved over the Quality and Outcomes Framework (QOF) maximum threshold (80%), in order to provide the GP practices with the resource to extend the invitation to women over and above the national target. With the exception of 2 practices, all registered their intent to participate in the stretch target payment scheme and work towards achieving a minimum of 81% cervical screening uptake rate.
Local community insight, the Joint Strategic Needs Assessment and primary care data was used to inform an intensive package of interventions for populations with established BME communities and high social inequality. Engagement took place with partners and providers, including local voluntary organisations working with BME women and the local Learning Disabilities Partnership Board, to promote the One Minute campaign and identify access barriers.
A third sector community group, Voice of BME-Trafford (VBME-T) was commissioned to provide outreach support. VBME-T developed a community appropriate cervical screening leaflet which included sections in Somali, Farsi, Urdu and Arabic and worked alongside health improvement officers to target groups that were typically less inclined to attend for screening. Over 280 people received a group or one-to-one intervention explaining:
- the importance of cervical screening
- how to book an appointment
- symptom awareness
A third level of intervention was provided to 7 practices with low cervical screening uptake with the purpose of reducing health inequalities and improving outcomes. The practice managers generated lists of women who had been invited for a cervical screen but had not attended. These women were directly telephoned by non-clinical staff from Bridgewater Sexual Health Service and VBME-T, working from the practices to adhere to information governance rules.
The women’s concerns were discussed and if appropriate they were booked for a screen at a convenient time and location for them. Standard operating procedure guidance included the appropriate handover of clinical concerns to the GP. In excess of 170 women requiring a cervical screening were telephoned with 135 smear appointments booked as a result.
Extra provision of cervical screening was commissioned from the local sexual health service provider in community clinics, to supplement that available to women registered at these practices.
The impact of the programme was monitored using monthly data obtained via NHS Open Exeter system. Between June 2014 and March 2015, the proportion of eligible women recorded as receiving a cervical screen in the past 5 years increased from 78.02% to 79.9%.
At a CCG level this improvement equates to a total of 47,218 eligible women screened adequately within the previous 5 years. Three of the 4 practices with the lowest uptake rates and the highest BME practice populations saw an improvement in uptake rates since baseline, with percentage increases of 4.0%, 5.6% and 8.6%.
What works well
The programme reinforced that to improve cervical screening uptake all the factors in a woman’s life must be considered. As well as the quality of primary care, community engagement, perception of risk, knowledge of the test and accessibility to appointments are all important when supporting women to be screened.
It is essential to use inside knowledge of the community to work effectively in the community and spread the message. Access to a BME health professional or worker can have a positive effect in understanding needs and respondents feel more reassured and confident in talking to staff of the same cultural heritage.
It is important to target the local community groups and their leaders, as they are more likely to pass the message across to the women who need support and educating about smear test.
What could be better
Workers were phoning women in the day time and many women were at work during that time and calls were ending on voice mails. To combat this, it was suggested that medical practices could send reminder text messages to the women on the contact list to book a test.
Although the original programme was for a 12 month period, activity has continued and in June 2016, Trafford celebrated a cervical screening uptake rate of 80.3%.
The programme is continuing, with learning extended to other screening programmes including Bowel and Breast Screening and the NHS Health Check.
The campaign was awarded a High Commendation prize by Jo’s Cervical Cancer Trust in 2016.