Guidance

AAA screening: programme guidance

Updated 23 May 2025

1. Executive summary

NHS England is responsible for delivery and implementation of national screening programmes. This Programme Guidance is designed to inform the delivery of a local screening service within the NHS Abdominal Aortic Aneurysm (AAA) Screening Programme in England and support the achievement of nationally agreed guidance, standards[1] and service specification[2].

NHS England commissions local services to provide individuals eligible for screening with a high quality, reliable, supportive, and effective service. Local services are responsible for providing screening to their local population which meets national standards, guidance and makes sure that the requirements of the service specification are met.

This includes:

• co-ordinating and managing their local service
• setting local operational policies in line with national guidance
• inviting eligible individuals
• providing information, support, and advice for participants
• undertaking and interpreting screening results
• informing men of results
• recording results, scheduling follow-up surveillance scans, and running failsafe systems
• referring for further diagnostic imaging investigations, assessment and potential intervention
• providing appropriate advice to men on surveillance
• recording and monitoring the outcomes of interventions
• reporting on performance against pathway standards

1.1 Background

The NHS AAA Screening Programme aims to reduce AAA related mortality by providing a systematic population-based screening programme for men and individuals assigned male gender at birth during the year, 1 April - 31 March, in which they turn 65 and, on request, for men over 65 years.

An AAA is defined as an aortic diameter of 3cm or greater in the maximum anterior-posterior measurement, measured from the inner wall to inner wall. There is no aneurysm present if the aortic diameter is less than 3cm.

The objectives of the NHS AAA Screening Programme are to:

• identify eligible men and invite them for screening
• provide clear, high-quality information that is accessible to all, enabling men to make an informed choice about taking up the offer of screening
• make sure that ultrasound scans are undertaken on eligible men in accordance with national guidance and standards
• minimise the adverse effects of screening, including anxiety and unnecessary investigations
• identify AAAs accurately
• enable men to make an informed choice about the management of their AAA
• provide appropriate health advice to surveillance men
• make sure that men with AAA of 5.5cm or greater, or an aneurysm that has grown by more than 1cm in 1 year, are referred to appropriate specialised vascular services
• promote audit and research

1.2 The principles of screening for abdominal aortic aneurysms

Screening for AAA refers to measuring the maximum aortic diameter on apparently well men to detect those with AAA’s.  When AAAs are identified the screening process includes onwards referral to specialised vascular services for assessment of fitness for surgery and appropriate treatment.

NHS England is committed to reducing AAA related mortality across England.

The AAA Screening Programme contributes to this through earlier detection of AAA by ensuring the provision of:

• an effective AAA screening programme for men during the year, 1 April - 31 March, in which they turn 65
• screening on request for men over 65 who have not previously been screened
• referral to a specialised vascular service meeting the criteria for potential intervention
• a surveillance programme for men with a screen detected AAA who have not reached the criteria for referral
• referral to specialised vascular services which meet the national service specification set by NHS England and comply with the quality improvement framework set by the Vascular Society of Great Britain and Ireland (VSGBI).

The main guiding principles for the NHS AAA Screening Programme are:

• all individuals should be treated with courtesy, respect, and an understanding of their needs
• all those participating in the NHS AAA Screening Programme should have adequate information on the benefits and risks to allow an informed decision to be made before participating
• the target population should have equitable access to screening
• screening should be effectively integrated across a pathway including the local screening service provider, specialised vascular services, and primary care.

1.3 Vascular networks and specialised vascular services

Screen detected AAAs must be treated in vascular units with a proven track record of excellence in AAA care to reduce the risk of harm. As part of the phased roll out of the NHS AAA Screening Programme between 2009 and full implementation by April 2013, prospective local screening services were required to participate in a pre-implementation quality assurance process.  A range of nationally agreed criterion had to be met and evidenced before the local service could start screening.

The Vascular Society Quality Improvement Framework (VSQIP), originally implemented in 2008, resulted in a reduction in mortality rates following elective AAA repair from 7% to 2.4% by 2013[3].

Vascular units that did not achieve the historical pre-implementation QA criterion, but now wish to treat screen detected AAAs, must demonstrate that their clinical outcomes (based on National Vascular Registry (NVR) data) are within accepted parameters. The accepted parameters are set by the Vascular Society (please refer to most recent version of Provision of Vascular Services for people with vascular disease document)[4] and are required by the NHS England national specialised commissioning service specification for all specialised vascular services. These parameters are documented and specify the minimum requirements for a specialised vascular service. Any proposed changes in vascular units, which impacts on the local AAA screening service referral pathway, must be in accordance with an agreed plan which aims to improve clinical outcomes and quality of the services provided.

When there is planned reconfiguration of vascular services in a region, the specialised commissioners must decide which vascular units can undertake major vascular surgery (including AAA procedures).

This is based on the national service specification and vascular society guidance, including:

• vascular units must be part of a clinical network covering a minimum population size of 800,000
• vascular units must be fully compliant with submitting data to the NVR (as per National Healthcare Quality Improvement Partnership (HQIP))
• the clinical network formed must perform a minimum of 60 AAA procedures per year (averaged over a 3-year period)
• vascular units’ operative outcomes for AAA procedures must be within the expected range based on NVR data

Director/clinical leads and commissioners must work with specialised commissioning to ensure that men referred with a screen detected AAA are only treated in vascular units which already meet all the requirements set out in the national service specification and the vascular society guidance for the provision of specialised vascular services.

There must be clear leadership and reporting mechanisms in place between the director/clinical leads of the local screening service and the specialised vascular service.

Regional Public Health Commissioning teams, in conjunction with the director/clinical lead, should regularly conduct due diligence to ensure that the vascular units within their network continue to meet the Vascular Society & specialised commissioning minimum standards.  This will be achieved by presentation of annual NVR data to programme board for review and escalating any concerns to specialised commissioning. The lead clinician will be responsible for providing the public health commissioning team and specialised commissioners with NVR data related to any requests by prospective new vascular surgical units who wish to receive screen detected AAAs. Specialised vascular service providers are responsible for informing local screening services about AAA ruptures or AAA deaths in men who are part of the screening programme, usually achieved by submission to NVR.

If concerns have arisen about the quality of the vascular service provider in relation to:

• published NVR data
• local incident investigations
• regular routine monitoring of outcomes
• QA visit/recommendations

the regional Public Health Commissioning teams may decide that there is a need to work with commissioners of specialised vascular services to redirect men with screen detected AAAs to other vascular units. Specialised commissioners must be involved in any proposed changes.

Where a vascular unit moves from one site to another but is essentially the same service i.e. retain the same surgeons, radiologists and have the required infrastructure and facilities, this does require additional input from specialised commissioning.

2. The screening programme

2.1 Population and local service size

A local screening service (minimum 800,000 total population) must have suitable vascular units for treating patients with detected AAA’s to receive referrals. The vascular units providing treatment must comply with the requirements set out in the NHS England service specification for specialised vascular services and recommended by the VSGBI for the treatment of AAA’s. Specialised vascular services must provide data for screen referred men on the treatment and outcome of every AAA operation or intervention on to the National Vascular Registry. In 2025 there are 37 local AAA screening services in England.

Men are offered a single scan during the year, 1 April - 31 March, in which they turn 65. In cases where there is doubt over whether the man should be invited or not, they should be sent an invitation. Local screening services must encourage all men in this age group to register with a GP. Long term residents in secure and detained settings and men who are registered as housebound should be offered the opportunity to be screened if they meet the eligibility criteria. A joint decision by the GP and local director/clinical lead that the man would not benefit from screening must be made before the man is excluded. This should be documented clearly within the national Screening Management and Referral Tracking (SMaRT) IT system.

Inclusions:

• all men eligible for NHS care registered with a GP within the commissioned screening service boundaries. Selection is based on year of birth. Men should be offered screening during the year - 1 April to 31 March - in which they turn 65. Men who are resident in England but registered with a GP in Wales are also eligible to be screened by the English programme and will be automatically picked up by SMaRT
• it is acceptable to invite men as soon as they have turned 64, which is the start of their 65th year
• men aged over 65 on request - see self-referral process for further details
• men resident in local secure and detained settings during their 65th year and at the agreement of the regional Public Health Commissioning team and Prison Service - see Appendix C for suggested protocol
• men resident in secure mental health facilities
• men in their 65th year known to have a small/medium AAA <5.5cm. Local services will receive information about these men in the appropriate cohort demographic for that given year. However, they will not be identified in subsequent years as they already have an identified AAA. If men are transferred between local screening services, the first scan within the new screening service should be classed as their initial scan and previous surveillance scan measurements from any local vascular service not referenced. Other healthcare providers such as the GP and the vascular surgeon whose care the man is under should be notified of the screening attendance. It is advised that the man should remain in one local screening service only and not be scanned by two separate services

Exclusions:

Individuals are normally excluded from the programme if:

• they have previously been diagnosed with an AAA that is equal to or greater than 5.5cm
• they have previously undergone surgery for AAA repair
• their GP advises that they should not be screened due to other health concerns
• they have already had a scan through the NHS AAA Screening Programme and the aortic diameter measured less than 3cm indicating there is no aneurysm present

In rare cases a ‘best interest’ decision may need to be completed in line with the principles enshrined in the Mental Capacity Act[5].  Decisions should be made on a case-by-case basis by the local screening service in conjunction with the GP, family, commissioner, and power of attorney.

Men who have asked to be permanently removed from the NHS AAA Screening Programme remain eligible for screening. This will need to be documented on SMaRT and then the man’s contact details removed from SMaRT.

Services should record the reason for exclusion on the man’s record and supporting evidence if available, in the event of a future query.

Ineligible:

• men under the age of 64
• individuals identified as female at birth (unless they undergo gender reassignment (see below)
• previous AAA surgery
• over 65 and on local vascular service surveillance for an AAA

Individuals who undergo male to female gender reassignment retain the male genetic risk of developing an AAA in later life. However, the local screening service will not receive their demographic data if they have registered as a woman. Individuals who self-refer to the programme and have undergone male to female gender reassignment must be screened as per guidance.

Females undergoing gender reassignment will not routinely be invited for screening until they register as a male. At that point, NHS Spine will identify them as being male and identify them along with the rest of the screening cohort.

2.2 Screening service models

The model for the service involves ultrasound scanning being undertaken within community healthcare facilities including hospitals, mobile units, primary care facilities and other locations which meet the needs of the population. Clinic locations are a local responsibility. It is the responsibility of the service to assess the suitability of the clinic by undertaking a risk assessment.

2.3 Clinical management of the programme

The following staffing whole-time equivalents (WTE) were recommendations when the NHS AAA Screening Programme was rolled out. However, local service circumstances may have different requirements.

Director/clinical lead (0.2 WTE per 800,000 total population)

The director/clinical lead oversees the local screening service, ensuring a continuous high-quality service is maintained and takes clinical responsibility including giving support for the co-ordinator/manager, particularly in matters involving patient care. They are also responsible for making clinical decisions related to screening men up to the point where a referral has been made but also ensuring that appropriate care is given following referral.

The key components of the role are to:

• take overall responsibility and accountability for the management, quality assurance and clinical governance of the local screening service
• act as the strategic lead for the local service with responsibility and authority for leading the service, implementing service developments, and involved in relevant funding and resources discussion
• advise on clinical matters concerning the local service
• act upon relevant updates from NHS England and professional organisations such as the VSGBI
• monitor and ensure that diagnostic and treatment services meet the demand and quality requirements of the NHS AAA Screening Programme
• be aware of and accountable for the timely and complete data entry of all outcomes, including final outcomes after referral and post-operative rupture
• take professional responsibility for the local service. The director/clinical lead will remain the responsible clinician for men entered into the screening programme up to the point where a referral is made and accepted by the specialised vascular unit, and ensuring that the referral is acted upon appropriately
• ensure the local service tracks the progress of each referral made to a vascular unit and ensure action is taken to detect and rectify any delays in the man being seen for assessment or subsequent treatment
• provide oversight and/or management of and clinical guidance to the senior screening staff (sonographer, clinical skills trainer and co-ordinator/manager)

Consultants in the specialised vascular units

In specialised vascular units, the consultant responsible for the care of the patient will be classed as the “responsible” consultant once the referral is received. They should:

• notify the co-ordinator/manager of the local screening service of the outcome of initial and further outpatient visits and if indicated, the treatment
• submit data for audit purposes on an ongoing basis to the online VSGBI NVR for all AAA surgery. Failure to do so will mean the vascular consultant is ineligible to participate in taking referrals from the NHS AAA Screening Programme
• provide the local screening service and NHS England with outcome data as required
• report on any subsequent AAA ruptures and AAA related deaths

2.4 Programme screening staff

Internal Quality Assurance (IQA) lead (0.1 WTE per 800,000 total population)

A consultant sonographer/vascular scientist/radiologist is responsible to the director/clinical lead. The internal QA lead has special responsibility for quality assurance of screening technicians and the screening process with responsibility for the screening equipment, screening technicians’ competence assessment and monitoring of clinical performance (including review of scans identified by SMaRT from screening clinics).

Many of these tasks are often delegated to the clinical skills trainer (CST). This is a local decision. Any QA concerns should be brought to the attention of the director/clinical lead. The internal QA lead is involved in the process about which ultrasound equipment should be used within the service (subject to the NHS AAA Screening Programme specifications) and when it needs to be updated or replaced. See QA ultrasound equipment guidance[6]. There should be an induction plan for any newly appointed internal QA lead/s which should include meeting with other internal QA leads and attendance at national network meetings.

Clinical Skills Trainer (CST) (senior sonographer/vascular scientist) (0.1 WTE per 800,000 total population)

A senior sonographer/vascular scientist is responsible to the director/clinical lead. This is an advanced practitioner who holds any of the following:

• Consortium for the Accreditation of Sonographic Education (CASE) accredited qualification
• full College and Society for clinical vascular science (CSVS) accreditation.
• General Medical Council (GMC) registered and practicing clinical radiologist who performs diagnostic vascular or abdominal ultrasound
• completed MSc in clinical science in the specialism of vascular science with NHS Scientist Training Programme

They must also have completed the NHS AAA Screening Programme mandatory training for Clinical Skills Trainers (CSTs) prior to their involvement with the screening programme. The CST must maintain the appropriate registration and Continual Professional Development (CPD) with the appropriate professional organisation. CSTs may be required to evidence their CPD record. CSTs must attend annual NHS AAA Screening Programme study days. There should be an induction plan for any newly appointed CSTs which should include meeting with other CSTs in other regions. See CST and IQA lead training guidance[7].

As the first line supervisor of the screening technicians, the CST is responsible for staff training and regular review of staff for quality assurance in addition to undertaking routine equipment quality assurance assessments and ensuring regular maintenance of the ultrasound equipment. In addition, CSTs can be responsible for routine equipment QA assessments. In those instances where there is a separate CST and internal QA lead, the service must ensure there are mechanisms in place to feedback information from QA reviews to the CST as part of continuous screening technician improvement. CSTs may also run occasional screening clinics to maintain their skills and ensure their full understanding of the use of SMaRT.

It is essential that the time required for the CST role is ring-fenced from other clinical duties. CSTs should have extensive experience of training in the workplace. CSTs must conduct competence assessments of screening technicians. See CST and IQA lead training guidance[8].

NB: In some local services, the internal QA Lead and CST roles may be performed by the same person but need to meet the NHS AAA Screening Programme standard for qualifications.

Screening technicians (3.0 WTE per 800,000 total population)

Screening technicians are expected to hold the Level 3 Health Screener Diploma or completed the former training programme provided by Salford University and prior to that, the AAA screening ultrasound course designed and delivered by the Scott Research Centre based at St. Richard’s Hospital in Chichester during the initial role out of AAA screening.

All screening technicians undertaking scanning must hold one of these qualifications or be working towards the health screener diploma. All screening technicians must undergo an annual competence assessment. See full scope of practice for screening technicians[9].

The screening team should normally consist of pairs of screening technicians. This is to ensure effective throughput in the clinic and reduce risks of repetitive strain injury. Solo clinics can be undertaken only following local risk assessment and agreement with commissioners. The screening team is overseen by the CST who is a senior sonographer/vascular scientist. They are required to undergo regular assessments and an annual competence assessment as per the NHS AAA Screening Programme guidance.

Clinics are held at various locations within the local screening service area and staff are expected to travel to the different locations and move portable screening equipment and supplies.

Screening technicians ensure that men attending clinics have their ID verified accurately and efficiently and are advised of the benefits and risks of AAA screening and give informed consent to the procedures. They will accurately record sonographic measurements of the aortic diameter, collect other subject information and report scan results to men both verbally (negative) and in writing (positive). They may also prepare copies of the results for GPs, transfer clinic data to the screening office and update SMaRT.

Vascular nurse specialist (0.1 WTE per 800,000 total population)

The vascular nurse specialist is responsible to the director/clinical lead and is involved in assessing and counselling men at specific points in the screening pathway and giving advice on changes in lifestyle as appropriate, including signposting to community services.

Further referral on to other specialists should be made following discussion with the director/clinical lead of the local screening programme. Unless the nurse specialist has undertaken the level 3 Health Screening Diploma and passed all the competency requirements of the training, they are not permitted to scan men. See AAA screening: nurse specialist guidance[10].

2.5 Programme management, administration and technical staff

Co-ordinator/manager (1.0 WTE per 800,000 total population)

The co-ordinator/manager is responsible to the director/clinical lead. The primary purpose of the co-ordinator/manager’s role is to direct the day-to-day operational management of the local service. They will also work to identify service improvement initiatives. They oversee the work of the administrator and screening teams, and their duties include to:

• act as the professional lead for the day-to-day management, evaluation, and quality assurance of the screening process, including the provision of information, screening procedures and any onward referral
• act as a single point of contact for the local screening service across multiple professional groups and possible multiple screening facilities within that local service (which might include hospitals, clinics, and other screening locations)
• liaise with appropriate staff to ensure that policies and procedures are adhered to across all agencies and professional groups involved in the local screening service
• ensure that all parties in the local screening service, as well as other appropriate local staff, are kept fully informed of performance and any related issues including changes to guidance and policy
• act as the main point of contact for communications from NHS England
• disseminate communications to local staff as appropriate
• liaise with localities or NHS England regional teams to identify new GP practices within the local AAA screening service area
• locate suitable screening sites and discuss with commissioners
• organise staff rotas
• ensure all invitations to eligible subjects are sent
• reconcile processes at the end of each year to ensure all men in that cohort have been offered a screening appointment
• ensure appropriate referrals are sent for men to vascular surgeons
• arrange appropriate medical imaging scanning following a non-visualised screen
• monitor fail-safe systems
• monitor and report any incidents to commissioners and quality assurance teams in line with National Guidance[11] and taking steps to ensure the safety of staff and patients
• arrange appropriate local QA of images as per national guidance
• ensure that the NHS AAA Screening Programme protocols and procedures are adhered to and meet the NHS AAA Screening Programme pathway standards
• lead the screening team on non-clinical matters
• line manage appropriate members of the screening team, ensuring that regular reviews of screener performance are undertaken, and appropriate personal development plans are written and implemented
• be responsible for the recruitment, retention, and organisation of the training of the screening team in accordance with national and local policies and procedures
• manage all aspects of the screening equipment, ensuring protocols are followed, service and calibration is completed at the required intervals, and equipment is safely and securely stored
• participate in a cross-region induction programme
• undertake patient satisfaction surveys/feedback
• optimise access to the local screening service, such as among underserved population groups, supporting a reduction in health inequalities
• monitor and maintain an audit schedule for quality assurance purposes

Administrator (1.0 WTE per 800,000 total population)

The administrator is responsible for the administration of the local screening service and is often the first point of contact between the screening population and the screening office. The administrator plays a supporting role to the local AAA screening service and can give members of the public factual information about the benefits of the programme.

Medical physicist (5 days per year per 800,000 total population)

The purpose of this role is to undertake acceptance of new ultrasound machines and to provide independent, regular quality assessments using sophisticated test objects. This specialist will undertake annual assessments on all the ultrasound machines and probes, assisted by the CST/IQA lead. They will prepare reports for the co-ordinator/manager.

2.6 Governance

The provision of the NHS AAA Screening Programme involves a number of organisations:

• NHS England
• Department of Health and Social Care (DHSC)
• primary care providers
• local screening services
• diagnostic and treatment services
• integrated care boards
• local authorities

2.7 Responsibilities in the programme

NHS England is responsible for implementation of the NHS AAA Screening Programme nationally and commissions local services via regional Public Health Commissioning teams which contract these services based on the nationally agreed service specification. Public Health Commissioning teams are also responsible for the performance management of local services.

NHS England is responsible for the following:

• developing, piloting and roll-out to agreed national service specifications of all extensions to existing screening services and new screening services
• setting and reviewing pathway standards
• reviewing national service specifications and advising on Section 7A agreements (under the direction of DHSC requirements)
• developing education and training strategies
• developing patient information
• determining data sets and management of data, for example to ensure KPIs are collected
• setting clear specifications for equipment, IT, and data
• procuring and supplying the national IT screening management system
• collecting, collating and quality assuring data for screening programmes
• monitoring and analysing implementation of NHS commissioned screening services
• providing advice to DHSC on priorities and outcomes for the NHS England mandate and Section 7A Agreement, and to lead on detailed provisions, in particular the 7A Agreement on screening
• working with NHS England regional teams to optimise coverage
• providing the screening quality assurance service (SQAS) including assessment of the quality of local screening services
• providing public health expertise and advice on screening at all levels of the system
• ensuring action is taken to optimise access to local screening services, such as among underserved population disadvantaged groups, supporting a reduction in health inequalities in conjunction with ICBs
• NHS England regional teams are responsible for commissioning local AAA screening services

General practice

The intention of the screening programme is to keep the primary care workload relating to AAA screening to a minimum.

However, GPs and practice staff should be aware of the programme so they can take advantage of opportunities to raise awareness among men aged 65 and over in their practice, particularly those with risk factors for AAA such as smoking or family history, including those men who did not attend (DNA) their screening invitation. Some people receiving invitations may want to discuss the screening process with their GPs. GPs will also be notified by their local screening service of the screened outcome for men registered with their practice, including the referral of men with large aneurysms and those whose aneurysm has grown by more than 1cm in 1 year.

NHS trusts and screening service providers

The chief executive has overall responsibility for the quality of the local AAA screening service within their organisation. Those organisations contracted to provide screening services have responsibility to ensure that:

• performance against screening standards is assessed as satisfactory by NHS England
• failsafe procedures operate in accordance with national policy
• they comply with the requirements of the NHS Information Governance Toolkit[12]

Those Trusts contracted to provide diagnostic and treatment services have responsibility to ensure that:

• appropriate diagnostic investigation and treatment is offered to men referred from the screening programme according to the timelines in the pathway standards
• appropriate follow-up procedures are undertaken
• failsafe procedures operate in accordance with the agreed policy
• they report on outcomes for screen-referred men including AAA rupture or AAA related death

2.8 Accommodation requirements

Clinic rooms

Rooms with appropriate facilities should be identified within the community, ensuring a height adjustable examination couch. Ideally there should be good wi-fi access and N3 network access (the NHS secure network) in the clinic rooms either via PC or laptop. Consideration should be given to available lighting and patient privacy in any room offered as a clinic room. Ideally the room should allow for subdued lighting with good blackout blinds on windows as ultrasound requires control over the level of lighting during scanning. There should be suitable signage and instructions to enable men to locate clinic rooms. See Appendix A for site survey form.

Screening office

Offices should be secure and large enough to accommodate appropriate staffing levels.

2.9 Information resources

Key elements of information will need to include:

• publicity: NHS England’s regional press office teams can provide support and guidance for publicity in relation to the programme
• leaflets and information: nationally developed and approved information is available to all local AAA screening services from the national print supplier. It is the responsibility of the local service to ensure that information is available to all men and that literature is displayed in appropriate locations. Initial screening leaflets should be ordered from the national print supplier[13].

The national invitation leaflet is designed to ensure that men are informed what screening can and cannot achieve.

This, along with the invitation letter, addresses the need to inform men about the use of personal information for audit, as set out in guidelines developed for the programme by the National Information Board (NIB).

Men should be able to make an informed choice based on an understanding of why they are being offered screening, what happens with a positive result and the risks involved and what happens to their records after being screened. The information will be sent to all men with their invitation for AAA screening.

There are two leaflets for men who require surveillance - one for those with small aneurysms (3 to 4.4cm), who are invited for 12-monthly surveillance appointments, and one for those with medium aneurysms (4.5 to 5.4cm), who are invited for 3-monthly surveillance appointments. These leaflets are QR code only.

There is a leaflet for men identified with large aneurysms (5.5cm or greater), or whose aneurysm has grown by more than 1cm in 1 year who are referred to a vascular consultant. This leaflet is QR code only.

Letter templates are available within NHS England and accessible via SMaRT. All local services must use these. Minimal changes to the template will be permitted with approval from NHS England, however, changes to the core content should not be made.

Online information for professionals about AAA screening can be found on GOV.UK[14]. Information for patients and members of the public can found on NHS.UK[15]. Downloadable pdf and text leaflets are available on GOV.UK – information leaflets[16], including translated and easy read versions of patient information leaflets.

SMS/Text message reminders to men who have a booked appointment must be sent to ensure full utilisation of screening capacity and appointment slots. This is to help increase uptake and reduce barriers in accessing screening to address health inequalities. The expectation is a text message reminder for the initial invitation and at least one reminder for non-attenders.

See further guidance[17].

2.10 Screening equipment

Screening equipment consists of portable ultrasound machines.

Local services must select equipment from the manufacturers listed within the ultrasound equipment QA guidelines (see ref. 7)

Screening technicians should not undertake screening on any machines other than those approved by NHS England. This includes loan or temporary replacement machines. All local services should have procedures for storage and transport of ultrasound machines. Cleaning of machines should comply with local policies for infection prevention and control, and equipment manufacturers’ guidance for cleaning and maintenance.

Equipment set up and optimisation

Ultrasound scanner software and model versions will be updated during the lifetime that a machine is available for purchase, and this can affect the appearance of the image or function of the controls.

For this reason, it is not possible to quote a default setting for a particular scanner as this may only be applicable for a limited time. However, local services should consult the manufactures application specialist for guidance on optimising scanner pre-sets for imaging the abdominal aorta. This can be undertaken in conjunction with the local service CST/IQA Lead.

CSTs can also provide additional advice on pre-set optimisation and support screening technicians in the optimisation of images.

Local services can have different scanning pre-sets on a machine for quick selection, for instance when additional penetration and scanning depth is required. Screening technicians should understand the basic differences between specific pre-sets.

Local services should also consult the NHS AAA Image Quality Guidance[18] that describes optimisation of the ultrasound image.

Safety, compliance, and quality assurance of ultrasound machines

Quality assurance of the performance of ultrasound equipment is essential to ensure safety, correct functioning of equipment, and the accuracy and reproducibility of electronic calliper diameter measurements. Therefore, all local services should undertake regular quality assurance and safety checks of ultrasound equipment. Further information can be found in the ultrasound equipment quality assurance guidance.

Local services must ensure or undertake:

• compliance with local ultrasound equipment policies and directives. All equipment will need to be safety tested and accepted locally following delivery
• ensure that all the components belonging to one piece of equipment are clearly labelled. Local services should colour code each piece of equipment to allow the matching of equipment to each man scanned and easier identification of equipment should problems occur
• electrical safety testing is required as directed by the local organisation
• regular maintenance (as per the manufacturer’s guidelines) and quality assurance testing to specified levels by qualified personnel is required

The following procedures should be implemented:

• in-depth baseline tests on new equipment
• annual routine tests using specialist equipment
• routine monthly tests to be carried out locally by the senior sonographer or medical physics department or a suitable trained screening technician and results reported to the screening office
• the integrity of mains cables, transducer cables and the transducer face should be inspected before every clinic. Defective equipment should be taken out of service and reported

Adequate liability and insurance for equipment loss and damage must be in place and comply with policy of the host organisation.

Equipment review and replacement

Local services should have a formally agreed equipment review and replacement programme in place with their local Trust.

The Board of the Faculty of Clinical Radiology, Royal College of Radiologists, recommends review of ultrasound equipment at four to six-year intervals to evaluate if replacement is required. Regular quality assurance testing will identify deterioration in equipment performance. Documented QA evidence will help to support the case for replacement.

Prevention of musculoskeletal injuries

Services should refer to published documentation relating to ultrasound and the prevention of work-related musculoskeletal injuries. See Society and College of Radiographers guidelines[19].

Local services should make reasonable adjustments to policy and working conditions to reduce the risk of work-related musculoskeletal injuries.

2.11 Continuous training and development

All new staff joining the local screening service must undertake a comprehensive induction programme.

Continuous training, development and information are required for the following staff groups (all training is based around a national competency framework):

• CSTs are expected to cascade practical training to other staff and offer support and advice. There is a requirement for these professionals to clinically support the screening technicians during the initial months of their training within the programme
• nurse specialists who undertake screening
• screening technicians
• co-ordinator/managers, who are expected to cascade training to screening and administrative staff

Directors/clinical leads must attend information seminars and update events. Information updates will also be required for:

• internal QA leads
• clinical skills trainers - mandatory study days
• medical physicists
• vascular nurse specialists

It is recommended that all administration personnel, including the co-ordinator/manager, undertake some local IT training to cover the use of Microsoft office products. This would assist with the production and analysis of performance and activity reports. To use and produce performance reports, it is recommended that co-ordinators/managers are proficient in the use of Excel.

Ongoing training for screening technicians involves a combination of e-learning, self-directed study, on-site clinical skills and competency-based training with the local screening service. The service must make arrangements to provide training to staff on the use of SMaRT. This also includes CST/IQA lead and vascular nurse specialist.

See training documents on GOV.UK for further details.

2.12 Confidentiality and security

Basic principles of information governance apply:

• local services must comply with GDPR requirements
• patient information is confidential and should be entrusted only to those with a justified need to know
• integrity of information must be monitored and maintained to ensure that it is of sufficient quality for use within the purposes it was collected
• staff awareness and their understanding of their responsibilities should be routinely assessed, and appropriate education and awareness provided
• risk assessment in conjunction with overall priority planning of organisational activity should be undertaken to determine appropriate, effective and affordable information governance controls are in place

Basic principles of storage and transfer of person-identifiable data apply:

• all person-identifiable information should be encrypted when stored or transferred electronically
• non-encrypted memory sticks should not be used to store patient information or ultrasound image files which contain patient information
• storage or transfer of bulk person-identifiable information should only be completed with the express permission of the Caldicott Guardian who will maintain a register and should be undertaken via a secure service
• all electronic bulk person-identifiable information must be encrypted to an acceptable level (256-bit Advanced Encryption Standard [AES-256] algorithm plus a strong password - 12 or more characters in length)
• files containing person-identifiable information can be encrypted individually or, in the case of laptops, the hard drives can be encrypted
• images and patient information on the ultrasound scanners should be uploaded to the central image storage system on SMaRT as soon as possible following a clinic. Once the local service is assured the images have all successfully been uploaded, they and any residual patient information should be removed from the scanner

Mobile computer media and devices:

The above principles apply to all forms of mobile/portable computer media and devices including laptops, notebook computers, PDAs, solid-state memory cards, memory sticks, pen drives, USB drives, DVDs, CD-ROMs etc.

Emailing and other electronic transfers of person-identifiable information:

• the above principles apply to all forms of electronic transfer of person-identifiable information including email, file transfer protocol, internet submissions and text messaging
• files containing the person-identifiable information must be encrypted during full transit from sender to receiver and must be properly protected as stated above when stored on the sender’s and receiver’s computer devices
• NHS numbers should not be used in emails between local services and/or NEC Software Solutions IT service desk other than using nhs.net email addresses to send and receive. For the Trust email to be considered secure, it must either use an already compliant service, such as NHSmail or have accredited their own service to the DCB1596 secure email standard
• information about it can be found at the secure email standard[20]
• the link above contains a list of accredited organisations, which is maintained and updated as soon as an organisation accredits to the DCB1596 standard. Any uncertainty, the local service should seek advice from their Caldicott Guardian/Senior Information Risk Owner (SIRO). The confidential ID number generated for each subject within the IT system should be utilised in such cases

Information governance incident reporting

Staff should report all information security breaches or near misses via the incident reporting process.

2.13 Information technology

Systematic screening requires call and recall information and the capture and management of ultrasound images. Screening services must use the software developed through and provided by NHS England and ensure that the national minimum dataset is collected.

The following modules make up the functionality within the SMaRT system:

• identification and collation of screening cohort (Screening Subject Population Index SSPI): the purpose of this module is to identify all men in their 65th year, and to collate a screening cohort for each local screening service as well as keeping the demographics of the active cohort up to date. Local screening services are defined by the list of GP practices to which they are responsible for offering screening. Local services together with commissioners, must keep this list up to date and let the NEC Software Solutions helpdesk know of any new GP practices in their area or any other changes to the GP practice list

• Screening management and referral tracking: this module provides the core functionality for the screening programme, including the administration of call/recall for new and surveillance men, management of referrals for those screened positive and collation of audit and performance management data for the programme. Whilst the data for the programme is stored in a single national system (SMaRT), local screening services only have access to the men for whom they are responsible

• Recording of AAA surgery and outcomes: to measure the effectiveness of the screening programme, it is necessary to collate data regarding AAA surgery and outcomes following a positive screen. Assessment information should be entered into SMaRT by the local service. Surgery outcomes can either be collected via the NVR, in which case an NHS number must be used to allow the linking of the surgery to SMaRT, or directly into SMaRT by the local service staff

The call and recall system has been specified by NHS England and is centrally hosted by IT supplier NEC Software Solutions. Local installation is not required but appropriate N3 connections must be available via a suitably fast and resilient link.

As the NHS AAA Screening Programme uses a national call and recall screening management system, it has responsibility for providing local services with regular activity reports as well as key performance indicators (KPIs) and pathway standards reports. The activity reports are to inform the local service and commissioners of monthly activity whilst the KPIs are related to the performance of programmes.

In addition, the following are also required:

• computers and printers
• telephone system with appropriate voicemail
• access to internet via computer at each screening location
• at least one computer which has the “Image Cube” software (provided via SMaRT) installed with an extra Ethernet port to allow the uploading of images
• local network firewall configuration to allow the images to flow to the centralised image storage over the N3 network using secure DICOM

Use of data and consent

AAA SMaRT is a national IT system which processes personal data for the purpose of inviting eligible men for AAA screening, recording screening outcomes and referrals to vascular services; and managing ongoing surveillance. Local screening services access the system to obtain lists of eligible men to be invited for screening. NHS England is responsible as controller under data protection legislation for the processing supported by the SMaRT system.

Following Section 251 approval, the NHS AAA Screening Programme receives details of all men who during the year from 1 April - 31 March, turn 65 years. This information is received from the NHS SPINE via NHS England Live Services. The use of a national screening system has advantages in monitoring the programme and better understanding the progression and clinical management of AAA. It is important that men are informed about the screening programme and how their information is used.

An information leaflet “Abdominal Aortic Aneurysm (AAA) screening, a free test for men aged 65 and over” is issued with all invitations and available on GOV.UK. The leaflet contains a link to “National population screening programmes: the information we use and why, and your options”[21]. This page includes privacy information meeting UK GDPR requirements for all screening programmes.

Every man who attends for screening must be given an opportunity to read the ‘how we use your personal information’ sheet. There is no need to obtain explicit consent for the use and sharing of information for AAA screening. As this is a direct care purpose, consent (for common law purposes) may be taken as implied by the man’s agreement to be screened.

Declined or withdrawn consent

It is important that any man who declines consent for their personal information to be used in this way understands the consequences of their decision.

Often explaining why information is needed and affirming that it will only be used within the NHS as part of the care, evaluation and improvement process, will reassure the man that this use of their personal information is appropriate. However, it is important that only legitimate informed consent is recorded within the system.

Men may decline consent for any or all of the activities listed on the information sheet. However, a man declining consent must not be screened.

If a man asks for his information to be removed, the NHS AAA Screening Programme must comply with this request and the national software supplier asked to delete their details permanently. A record of the request and any screening results (if this is after screening) should be held locally.

The following paragraph must be included in all men’s letters:

Data Protection: We use personal information from your NHS records to invite you for screening at the right time. Read more about how we use and protect your information at www.gov.uk/screening-data. Find out how to opt out of screening at www.gov.uk/screening-opt-out.

Image storage and retrieval

All images taken as part of the screening process (apart from those taken in medical imaging departments for internal QA and non-visualisation scans) must be stored on the central image storage system which forms part of SMaRT. Reports of scans which are undertaken in medical imaging must be provided to the local screening service - see clinical scope of practice.

Local services must make sure that there is a clear process for inputting the correct measurements against each man’s record.

To minimise the risk of data loss, images should be removed from ultrasound machines as soon as possible following image upload.

3. Screening pathway

3.1 The screening process

The screening procedure is divided into the following stages:

• identification
• invitation
• inform
• test
• surveillance
• referral
• treatment/intervention
• outcomes and end point

Identification

Each local service will have access to their entire cohort list approximately five months prior to the start of the screening year to allow for clinic planning. This will come via the national software solution from NEC. There will be a unique identifier for each man in addition to the NHS number.

Clinic booking

It is suggested that morning or afternoon clinics are scheduled for three to four hours. Appointment slots are usually allocated at 5 or 10-minute intervals with a short break mid-session. There are generally two staff to cover each clinic.  If the clinic is run by one screening technician, a risk assessment should be completed in line with the NHS Trust/provider organisation lone working policy. The site survey form at Appendix A includes suitability for single technician clinics. Approximately 15-18 men should be seen over three hours. However, the number can be reduced if:

• there are newly qualified screening technicians who are gaining experience
• more than five surveillance subjects are to be included

Invitation

Eligible men are invited by letter to one of the dedicated screening clinics held in a variety of locations within their community. The invitation will come from the local screening office and not the GP.

If a local screening service receives its cohort ‘early’ i.e. before the year (1 April - 31 March) that the men turn 65, men who are 63 must not be invited. It is acceptable to invite men for screening as soon as they have turned 64, even if the date of screening falls before the start of their cohort year.

If a man is invited for screening when he is still aged 64, his local service should use the following wording if the man subsequently asks why he has been invited:

The NHS AAA Screening Programme invites men for screening during the year, 1 April - 31 March, they turn 65. This is because most AAAs occur in men aged 65 and over. However, some men may be invited for screening shortly before their 65th birthday. Inviting men for screening ‘a few months early’ is not clinically significant.

All call and recall appointments must be organised at, and generated from, the central administrative office within the local screening service. The local screening service will generate and send invitations using the cohort list of men within the IT system.

An invitation pack should include:

• an appointment letter detailing a specific date, time and location. This letter should also ask men with special requirements (such as mobility, hearing or visual) to contact the screening office in order to arrange an appointment at a separate dedicated clinic if applicable (a standard invitation letter is available on SMaRT and should be used)
• the NHS AAA Screening Programme invitation leaflet
• a direction sheet with map (unless the location is the man’s own GP practice)
• an address/phone number/email address to contact the local screening office

It is important that invited men give informed consent to be screened.

For non-English speakers, translations of the NHS AAA Screening Programme patient information leaflets and consent forms are available to download and print out from GOV.UK. Local services should arrange any required interpreter services through their Trust.

Post Office Returns

A ‘Post Office Return’ generally refers to a situation where a letter or package is undeliverable and returned to the sender by the Post Office. When an item is returned by the Post Office, it is often marked as “Post Office Return” or “Return to Sender”.

Within AAA screening, this can happen when the local screening service invites a man who no longer resides at the address held by the screening service and has not informed his GP of any change. The current residents may mark the envelope as ‘Return to sender’ or ‘Not known at this address’ and will repost the letter accordingly. On some occasions, the local screening service may receive a phone call from the current residents to explain that the invitee is no longer at their address. In both of these circumstances, the man can be considered a ‘Post Office Return’.

Local AAA Screening services should manage Post Office (PO) returns for men invited for either an initial screen or surveillance appointment as follows (See Appendix D for process flowchart):

Check address and contact details

Is the address and telephone number on SMaRT the same as that held on the Spine?

• If different, update SMaRT and send invitation to new address
• If same address and telephone number as listed on the Spine, contact GP to check if same address and telephone number is held on the GP record
• If the GP records match details on the Spine, try to contact the man via telephone initially and then other means such as email if available
• If successful, and man wishes to continue to be screened, update SMaRT and send new invite. If man does not wish to be screened after explaining purpose and importance, record the reason on SMaRT and deactivate.  Letter to be sent to GP to advise of man’s decision and that he will be able to return for a screen, should he change his mind
• If unsuccessful, then suspend the man from further contact until new address arrives

Suspending men from further contact until new address arrives

If still unable to identify a new address, record on SMaRT as:

‘PO decision – Await new address’

This will place the man’s record into a suspended state, cancelling any current appointments and prevent further appointments being made until a new address arrives.

SSPI updates continue for 2920 days (8 years) in line with the NHS records retention.

When a new address arrives, the SMaRT system will present the man to the local screening service for reinviting via the SSPI alerts.

Note: the man may still be registered at the GP practice but may have moved house and not registered with a new GP. He may also have moved house but remain in the same catchment area therefore no change in GP.

Patient choice

Screening populations are covered by one local screening service with agreed and commissioned referral pathways to specialised vascular treatment providers. This enables safe management of men across pathways and monitoring of outcomes.

If a man moves outside of his local screening service boundaries, he is advised to register with another local GP.

Once a man registers with a new GP, SMaRT will automatically notify the previous screening service that the man is being transferred out and the new screening service responsible will be notified that the man is being transferred in. The new screening service will then be able to see his full screening history on SMaRT with an alert to ensure he is offered an appointment.

There may be occasions when a man, out of choice, would like to be screened or treated outside of their locally commissioned screening service boundary and remain registered with his current GP. 

Patient choice must be taken into account. The local screening service is responsible for continuity of care and must ensure:

• there is full agreement between the current screening service, the receiving screening service/tertiary referral centre and the GP practice at which the man is registered. If there are any issues in relation to funding, this must be escalated to the local screening commissioners
• men are appropriately transferred on SMaRT. This will need to be done manually and the local service will need to ensure that any automatic transfers are overridden to ensure that the man does not get referred back to the local service associated with his GP
• local screening services routinely audit numbers of external referrals made and received and discuss any funding issues with their local commissioners

Inform

At the clinic

The man will be seen by the screening technicians on arrival at the screening clinic. This will allow further information about screening to be given before the decision to participate is taken.

The screening technicians must verify the identity of the man being screened and is securely established by:

• asking to see the letter of appointment, where possible, and double checking the NHS number against the man’s record both on SMaRT and on the ultrasound machine. If SMaRT is unavailable, the NHS number must be checked against the clinic list and all details entered onto the proforma
• asking the man to state their full name, address, and date of birth rather than asking them to confirm their details as read to the man, and checking that the details match the man’s record
• asking about preferred language and ethnicity

The man should be fully informed about the process and possible outcomes. This information should also include an explanation regarding the use of his data, including for research purposes. His full consent should be obtained prior to screening commencing (see ref.21).

Qualified screening technicians should check demographics with the man. The screening technician undertaking the scan must also verbally check that the man’s demographics match those displayed on the ultrasound machine and those open on SMaRT before commencing the scan. Qualified screening technicians are those who passed the original Abdominal Aortic Aneurysm (AAA) Screening Technicians Ultrasound Course designed and delivered by the Scott Research Centre based at St. Richard’s Hospital in Chichester during the initial role out of AAA screening, those that have successfully completed the Salford Course that replaced the Chichester course and those that have completed the health screener diploma (HSD). In addition, screeners who are undertaking the HSD and have achieved semi-independent scanning status, having passed external assessment, (where they will have been observed taking consent), can also take consent in clinic.

If there are two screening technicians running a clinic, one can enter details on SMaRT and the other can gain consent and scan the man. Staff in clinic should only gain consent if they are fully qualified screening technicians. They can switch roles during the clinic as needed to vary workload and reduce the risk of work-related upper limb disorders.  It is important that the technician scanning, verbally checks with the man that their name and DOB matches that shown on the scanner before applying the probe.  This is to ensure that images are recorded to the correct patient record. The technician scanning does not need to check all the details on SMaRT again if the other technician has already completed this.

Administrative staff can check men into the clinic i.e., check demographics (name, address, DOB, NHS Number, telephone number/s, GP Practice). However, administrative staff cannot gain consent for the scan and use of data. 

Test

Screening technicians take views of the abdominal aorta using ultrasonography:

• two anterior-posterior (AP) measurements of the maximum aortic diameter should be recorded in centimetres to 1 decimal place, measured across the lumen from/to the INSIDE of the ultrasound-detected aortic wall, one with the probe in the longitudinal plane and one with the probe in the transverse plane
• it is recommended that all images should be annotated TS for transverse section and LS for longitudinal section. Alternatively, the body marker pictogram can be used
• details of men are usually loaded from the worklist generated by SMaRT, but if a man needs to be added to the scanner manually it is vital to ensure that the NHS number, subject’s last name and DOB are provided
• screening technicians should also check that the Institution Name and/or Referring Physician fields are completed with the 3-character programme prefix
• the use of coronal imaging planes should be avoided and is not part of the screening protocol. Additionally, screeners should not attempt to use colour or spectral Doppler modes on the scanning equipment. Further details regarding the scan can be found in the clinical guidance document

All men entering the programme should follow the national process and pathway outlined.

The images are assessed at the time of screening to determine whether or not an AAA of 3cm or greater has been detected, and the aortic diameter measurements are recorded. A minimum of two static sonographic images, including no aneurysm, abnormal or non-visualised results, should be recorded and stored to allow recall in cases of serious incidents and for quality assurance purposes. In cases where the aorta cannot be seen, local service staff should refer to the clinical scope of practice)

All screening results should also be recorded in writing on a printed work sheet at each clinic, where they are used. These work sheets are submitted to the local programme co-ordinator/manager who checks them for audit, quality assurance and failsafe purposes. They do not need to be retained once all failsafe and audit checks have been completed.

Result outcomes should be communicated to all men verbally in clinic. For those men who have an aneurysm, this should be communicated verbally in clinic and followed-up in writing using the national standard letter template. The result should be sent as soon as possible to the GP.

If the aortic diameter is less than 3cm, the man is advised that no AAA has been detected and no further follow-up/screening will be arranged.

If the aortic diameter is 3cm or greater, the man is advised that an aneurysm has been detected. The man should be given the QR code to access additional information on AAAs which is available online at GOV. UK. If a man does not have internet access, the local service must supply a hard copy of the information leaflet. Please note, the leaflet is no longer available nationally in printed format and will have to be printed locally.

Men are informed that a further follow-up will be arranged at a future screening clinic at a specified time interval, or at a hospital outpatient clinic. Men must also be given the vascular nurse specialist’s contact details in case the man has concerns prior to receiving the vascular nurse appointment.

If an AAA of ≥5.5cm or an aneurysm that has grown by more than 1cm in 1 year is identified, the screening office must be contacted by telephone from the clinic. Arrangements must be made for referral to a vascular surgeon within one day.

If the aorta cannot be visualised to measure the diameter accurately, the man is invited for one further scan. If the outcome is still non-visualised at a second screening scan, the man must be referred to the vascular lab/medical imaging department. Guidance should be offered recommending minimum food and drink intake in the four-hour period prior to the proposed scan.

The vascular lab/medical imaging department should notify the screening office of the outcome of the scan, and it is the responsibility of the screening office to send the correct information and action accordingly depending on the presence and size of an aneurysm.

Surveillance men should be followed up in the local service’s community screening location, unless this is otherwise advised. If the aorta still cannot be visualised after the imaging scan in the vascular lab/medical imaging department, the individual case must be discussed with the director/clinical lead.

The screening pathway does not include CT/MRI scanning for non-visualisation as routine. This is not considered to be cost effective and has associated clinical risks. This should not be carried out unless considered important by the director/clinical lead, taking into account the wishes and circumstances of the man involved. Commissioning arrangements for additional images outside of the national screening programme must be agreed locally.

All local screening services should ensure that their screening technicians have been appropriately trained and assessed as competent to give verbal feedback at the time of the scan. Screening staff should only scan the aorta and not carry out any additional abdominal scanning during a screening appointment. A local process for incidental findings should be in place.

Any aortic anomalous findings should be marked for QA image review and discussed with the director/clinical lead and documented as per local process.

Screening results should be entered directly onto SMaRT and, as soon as possible if there is no access to SMaRT in clinics.

After the clinic

• images are uploaded to SMaRT whilst in clinic and checked against the clinic list of scanned men. Where it has not been possible to do this, images must be uploaded on return to the office and completed as soon as possible
• result letters are sent to men with aneurysms requiring surveillance and for those requiring a referral. Letters are not sent to men where no aneurysm has been detected. Standard result letters are available on SMaRT
• men identified with aneurysms will also be advised in writing that he will be contacted and offered an appointment to see the vascular nurse specialist who will answer any questions he may have and provide him with some advice, should he want it. This appointment must be offered and the man seen within 12 weeks of the screen positive scan
• results are sent to GPs within one week for all men, regardless of the result
• data from the clinic is reviewed to ensure that information has been fully and correctly recorded
• if the aorta cannot be visualised at the screening clinic, a further scan should be arranged at a later screening clinic or local hospital vascular lab/medical imaging department
• the co-ordinator/manager should make appropriate referrals to a vascular surgeon for those men who have an AAA ≥5.5cm or an aneurysm that has grown by more than 1cm in 1 year and inform the GP within one working day of the clinic
• further invitations (at least one) should be sent to those not attending their first appointment without notification to the local service. Local policy should include details of how non-responders are checked and managed such as checking contact details with the GP
• screening services are able to contact men after the 1st DNA to identify if there are any barriers to their attendance

Surveillance

If the AAA measures:

• 3-4.4cm, a follow-up will be arranged in one year
• 4.5–5.4cm, a follow-up will be arranged in three months

Pre-surveillance appointment checks

Details should be checked, and any changes made to the IT system.

Checks should include:

• men are not deceased
• their address has not changed
• the GP has not indicated that the man is unsuitable for surveillance
• that wherever possible, the man should be invited to the venue which is most suitable for him
• making sure that if men request a delay or change in the appointment, or if a further appointment is declined or deemed inappropriate, SMaRT should be updated accordingly. The updated clinic list is then available to staff on the day of the clinic

Screening clinics should, ideally, include a mixture of surveillance men and those attending their first screening appointment to ensure that staff regularly have the opportunity to scan men with AAAs. This ensures that they maintain their skills and adds interest to the clinics.

At the surveillance clinic

• results should be communicated to all men verbally at the clinic and in writing using the national standard letter template
• results should be entered directly onto SMaRT and as soon as possible if there is no access to SMaRT
• If an AAA ≥5.5 cm or an aneurysm that has grown by more than 1 cm in 1 year is identified:
  • the screening office must be contacted urgently by telephone from the clinic for a referral to a vascular surgeon without delay
  • the screening technicians should inform the man that he should contact the Driver and Vehicle Licensing Agency (DVLA)
  • bus, coach and lorry drivers will have their license suspended – it will be reinstated once the aneurysm has been successfully treated
  • car drivers must inform the DVLA once the aneurysm reaches 6cm, and the license will be suspended once the aneurysm reaches 6.5cm – it will be reinstated once the aneurysm has been successfully treated
• it is essential that GPs are contacted via telephone with letter/email follow-up regarding the non-attendance and the actions taken, including any reason for the non-attendance recorded in case of future rupture of the aneurysm
• screening results and completed clinic lists are returned to the office
• if a man on quarterly surveillance measures below 4.5cm and confirmed with internal quality assurance (IQA), he should remain on quarterly surveillance. This is on the basis that the difference could be blood pressure related or a different screening technician scanning and that the man may cross the 4.5cm threshold again

After the clinic

• result letters are sent to men providing information on the size of the AAA
• results are sent to GPs
• data from the clinic is reviewed by the co-ordinator/manager to ensure information has been fully and correctly recorded
• if the aorta could not be visualised at the screening clinic, a further scan should be arranged either at a subsequent screening session or at a local hospital vascular lab/medical imaging department
• the co-ordinator/manager makes appropriate referrals to a vascular surgeon for men who have an AAA of ≥5.5cm or an aneurysm that has grown by more than 1cm in 1 year and informs the GP within one working day of the clinic
• it is essential that GPs are contacted via telephone with letter/email follow-up regarding repeat non-attendance of a surveillance man and the actions taken; including any reason for the non-attendance recorded in case of future rupture of the aneurysm
• standard result letters must be used
• those men who DNA should continue to receive their respective timely invites for surveillance and must not be removed from the programme
• screening services are able to contact surveillance men to identify if there are any barriers to their attendance

Informed withdrawal

Men with small or medium abdominal aortic aneurysms who indicate that they do not wish to be re-screened should be encouraged to remain in the surveillance recall system and decline their next regular invitation rather than withdraw permanently. However, any man who indicates that he is certain of his decision should have this decision respected.

Men in surveillance that DNA will always be re-invited unless they have confirmed removal from surveillance by the opt out slip on the standard DNA letter.

Annual Surveillance  

Men who DNA their first invitation, should be offered a further appointment to take place within 6 weeks of that DNA date. They will have the opportunity of completing an opt out slip, should they wish to.

Men who DNA their second invitation, will move onto their next scheduled surveillance appointment the following year (annual surveillance). Again, they will have the opportunity of completing an opt out slip.

Quarterly Surveillance

Men who DNA their first invitation, should be offered a further appointment to take place within 4 weeks of that DNA date. They will have the opportunity of completing an opt out slip, should they wish to.

Men who DNA their second invitation, will move onto their next scheduled surveillance appointment (quarterly surveillance). Again, they will have the opportunity of completing an opt out slip.

Informed Choice

Men must be provided with sufficient information to enable an informed decision to be made about withdrawing from the screening programme. This must be in a format which is accessible, and men must be informed that withdrawing from the programme will prevent them from receiving any future invitations or reminders about screening.   

It must, however, be made clear that they may return to the programme at any time at their own request.

Additionally, men must be capable of making and communicating an informed decision. Under the Mental Capacity Act 2005, individuals must be presumed to have capacity to make their own decisions unless it is proved otherwise. Ceasing decisions for people who lack mental capacity may be made by a legally accountable decision maker only where the individual cannot make his own decision even with support and assistance and must always be in the individual’s best interests. This is likely to be appropriate only where the man would never be suitable for further investigations or treatment should his aneurysm increase in size. Decision makers are required to document the decision-making process and retain an auditable record of this.

Wherever possible, a specifically written instruction should be signed by the man or his representative to confirm his informed withdrawal from surveillance recall. Each screening office must have fully defined and documented protocols for ceasing, and these must be available to all staff who deal with queries from men and stakeholders.

Men who have confirmed their wish to be removed from the screening programme should receive no further correspondence relating to any screening episode.

Unless the man has specifically requested otherwise, the screening office must write to him to confirm that recall has ceased and to give instructions on how to re-join the programme if required.

GP

Following a positive screen with the aorta measuring 3cm to 5.4cm, the GP will be sent a letter giving the following information:

• result of scan, including the size of the aneurysm
• an outline of the interval for the next scan
• information that the vascular nurse specialist will contact the man to invite him to an appointment for support, reassurance, and lifestyle advice

Vascular nurse specialist/health promotion clinics

Men will be offered a face-to-face appointment to see a vascular nurse specialist within 12 weeks of the screen positive scan and an opportunity to see the nurse again if they move from annual surveillance to three-monthly surveillance (see ref.10).

Following a positive screen with the aorta measuring 3cm to 5.4cm, the man will be given appropriate surveillance information. The aim is to put the diagnosis in context, support the man to reduce his risk of cardiovascular disease and risk of AAA growth whilst on surveillance, in additional to dealing with their concerns and expectations.

Appointment details

The appointment will be a one-off unless:

• contact from the man is made to the co-ordinator/manager expressing anxiety or concern
• the man is moving from 12-month surveillance to three-month surveillance

The appointment letter should state that the appointment is being offered and that if attending, the man should bring details of any prescribed medication with him.

During the appointment the vascular nurse specialist should:

• measure and record weight
• calculate and record Body Mass Index (BMI) using National Institute for Health and Clinical Excellence (NICE) guidelines
• determine current smoking status:
  • never smoked
  • previously smoked
  • currently smoking
• provide smoking cessation advice if necessary, and offer onward referral to local smoking cessation service
• measure and record blood pressure (more than once)
• ask whether the man is currently taking statins. If so, which?
• ask whether the man is currently taking antiplatelet medication e.g. aspirin, clopidogrel or anticoagulants
• determine and record any concerns of the man
• recommend any interventions such as seeing GP
• provide lifestyle advice as per NICE guidelines and record
• provide reassurance regarding size and presence of AAA
• ensure all measurements and recommendations are recorded and transferred to the screening office for input into the SMaRT system
• send letter to GP within one week outlining outcome of appointment
• send letter to man outlining recommendations

Referral

If the AAA measures 5.5cm or greater or an aneurysm that has grown by more than 1cm in 1 year:

• the man should be informed verbally at the clinic of the need to be referred to a vascular consultant in a hospital outpatient department, and the reasons for this referral explained. This verbal confirmation should be followed up with written confirmation. He should also be given the appropriate referral QR code/information leaflet run off by the local service. If a man declines a referral, confirmation of this should be sent to him and the GP indicating that he is free to change his mind at any time. It is important that this is done in case of later rupture
• the man should be informed that he should contact the DVLA regarding his aneurysm if the AAA measures 6cm or more (see section above)
• the screening clinic should contact the local co-ordinator/manager to inform them of the need for a referral
• the referral should then be made by the local co-ordinator/manager, within one working day of the clinic, to the appropriate vascular unit (see below)
• a letter should be sent to the man and the GP along with a summary of previous screening results
• the letter should be sent in line with the specialised vascular service policy. Local process should determine the quickest and most effective way of making this referral
• the local co-ordinator/manager should verify the referral has been received and acted upon

At the same time, the GP practice should be informed in writing, to ensure the practice is aware of the referral.

As the referral is based on the ultrasound measurement alone, the GP may want to provide additional information to the surgeon. The man and/or GP may choose to alter the referral location (within three working days of contact with the practice).

All referrals should be seen in the vascular outpatient department within two weeks of the scan. If the AAA has a diameter on ultrasound of over 7cm, an urgent referral should be made with every attempt to see the man at the next available outpatient clinic. Local services should have a standard operating procedure in place for AAAs greater than or equal to 7cm.

On referral to the vascular unit:

• should a repeat imaging test show the AAA to be less than 5.5cm in diameter or confirmed as not grown by more than 1cm in 1 year, or the man is unfit for surgery, continued follow-up should be arranged under the care of the vascular surgeon (not the screening programme). This referral cannot be reversed within SMaRT
• once a man has been under the care of the vascular surgeon due to a referral or for surveillance, they must not be referred back to the local screening service for them to monitor
• any inappropriate referrals must not return to the local screening service. Decisions of care must be made by the director/clinical lead. This referral cannot be reversed within SMaRT
• the screening office should be advised by letter of the outcome and results of each consultation

Treatment/intervention

The vascular unit undertaking surgical treatment should take into account the guidelines of the VSGBI. The vascular unit is responsible for setting up mechanisms with the local screening service to inform the screening office of the decisions concerning surgery and the outcome of surgery.

Men should be made aware that if they are referred for surgery, they may be invited to share their data with the NVR. The NVR collects data on AAA surgery to monitor and improve clinical care across the country.  It is run by the Health Quality Improvement Partnership and will be explained to them at the time of surgery. At that time, the man will be asked for their consent to record this data.

If a man chooses to participate in the NVR, the NVR will be provided with their screening results. Men do not need to take any actions and whether they decide to participate or not, it will not affect their care.

Details of all AAA surgery performed by the vascular unit should be entered on to the NVR by the vascular surgeon using the man’s NHS number and made available to the screening office though the interface across SMaRT (the NHS number must be entered to allow the records to be linked automatically).

Outcomes and end point

Active inclusion in the screening programme ends when:

• the scan is found to be within normal limits (aorta less than 3cm diameter (inner to inner) on AP measurement in both longitudinal and transverse view, at initial scan)
• the AAA reaches 5.5cm diameter or an aneurysm that has grown by more than 1cm in 1 year on ultrasound on either of the AP measurements and the man has been referred to the vascular unit. It is the responsibility of the local screening service to ensure the referral has successfully reached the vascular unit and been acted upon
• the director/clinical lead of the local screening service or the GP decides referral for treatment should be considered if the AAA is <5.5cm, based on other factors (for example, symptoms or co-morbidities)
• after three consecutive scans showing an aortic diameter less than 3cm on ultrasound where the initial scan was 3cm or greater. In this case the man should be discharged from the screening programme and both the man and GP informed by letter
• if the man declines to be in the screening programme, fails to attend two initial invitations, moves out of the area and becomes the responsibility of another local screening service, or dies
• if a man under surveillance moves out of the area, the co-ordinator/manager should alert the local screening service responsible for the GP practice to which the man is then registered

Men who have had AAA identified through routes outside the local screening service must not be referred to the local screening service for surveillance except for inclusions listed in this document (see section 2.1). These men must stay within the care of the vascular service.

Self-referral

Men aged over 65 who have not been screened previously may contact their local screening service asking for a screening appointment. These men are known as self-referrals. Men should only be accepted as a self-referral by the local screening service if they are registered with a GP practice covered by that service.

An NHS number will be required for all men who enter the screening programme, and it is likely some men will not know their individual number. A local process must be established which enables the local screening service to access this important piece of information. The self-referral proforma (Appendix B) can be used for this purpose.

Screening flowcharts

The NHS AAA Screening programme has developed a care pathway which is available at: GOV.UK.

4. Failsafe

4.1 What is failsafe

Screening should be offered to the eligible population in a timely manner; and those who are screened should receive their results (whether positive or negative) with sufficient information to understand them and have them acted on within timescales set out in national standards. The value of a screening programme will be diminished if appropriate action is not always taken to ensure that the right people are invited for screening or if the right action is not taken to follow up those with positive test results.

Most risks and errors in a screening pathway can be predicted. They often arise from a systems failure along the screening pathway, as opposed to individual error. A failsafe is a mechanism to ‘design out’ or reduce these risks.

It is a back-up mechanism, in addition to usual care, to ensure that any errors in the screening pathway are identified and corrected before harm occurs.

All screening programmes have failsafe processes in place.

This section sets out the failsafe processes that all local AAA screening services should have in place to:

• identify anything that is going wrong
• determine what action to take to correct errors before any harm occurs

Failsafe should be a ‘closed loop’ process. The points at which a required activity is started and finished must be noted for failsafe to be effective. This is usually through a systematic process and an IT system.

A system also needs to be in place to make sure all opened loops are closed within an appropriate timescale.

Opening the loop

A loop is opened by a trigger that indicates a process requiring a failsafe control for an individual has started. For example, a man in his 65th year or a self-referral triggers the offer of an AAA screening test.

Closing the loop

A loop is closed by an event or a stage of the screening pathway that denotes the conclusion of a process requiring failsafe control for an individual. For example, a man whose aorta measures less than 3cm would close a loop.

Ensuring the loop has been closed

This is an additional check, usually on a group of individuals, to identify any individual for whom a failsafe loop has been opened but not closed within a defined timescale. For example, incomplete screening records.

Most screening pathways involve multiple failsafe loops at different levels of detail. Loops can exist within other loops. For example, a failsafe loop to make sure every screen-positive man is offered further surveillance or assessment can exist within a broader loop.

Failsafe descriptions are set out below and Appendix E provides a failsafe flowchart.

5. Failsafe Descriptions

5.1 AAA2: Identification of eligible population and invite for screening

• Opening the loop: Population identified, eligibility established, verified by the service, and invited. (men and individuals assigned male gender at birth during the year, 1 April - 31 March, in which they turn 65 and, on request, for men over 65 years).
• Closing the loop: All eligible men in the cohort are offered screening. All eligible men who self-refer are offered screening. NHS England provides guidance on offering screening to men identified through other sources such as secure and detained settings.
• Ensuring the loop has closed: Invitation/appointment issued to latest known address. NHSE monitors the use of inappropriate screening outcomes via SMaRT. Local providers adhere to national guidelines for screening men identified through other sources.
• Local AAA programme task: Check summary page in the ‘subjects’ tab on SMaRT and quarterly pathway standards reports (for example expect approximately 25% of cohort invited each quarter). Check alerts for temporary ineligible population. Update records from SSPI notifications or when informed from other sources.

5.2 AAA3: Follow-up of those who move out of or do not complete the pathway

• Opening the loop: GP notified if screening not completed. Where non-completion is due to physical move out of the area to another address in England, the record is transferred to new local screening service in SMaRT (upon re-registering with new GP).
• Closing the loop: Local screening service makes sure all subjects who are pending a final ‘did not attend’ (DNA) decision are offered a further appointment. Further scan declined by man. Reasons noted on SMaRT and GP informed.
• Ensuring the loop is closed: Following a DNA, SMaRT produces letters to be sent to the man and his GP. After first DNA, subject is offered a new appointment. After second DNA, man is informed they will not be offered an appointment unless they contact the local service. Regular demographic updates are received from Personal Demographics Service (PDS) to minimise postal returns and maintain accurate records. Telephone numbers are available so the local service can contact men if they DNA. SMaRT has a system alert for men requiring appointments following a DNA. Records are made on SMaRT of attempts to contact men for further investigation.
• Local AAA programme task: Addresses of men who DNA are checked against PDS to make sure there have been no changes since the initial invitation was generated. If a change of address is found, this is amended, and a new appointment issued. Daily checks of SSPI updates for demographic changes.

5.3 AAA4: Screen those who accept the offer of screening

• Opening the loop: Screeners obtain verbal consent or decline and record in SMaRT. Screener carries out screening test.
• Closing the loop: Attendance recorded on SMaRT, or paper clinic lists, where in use, at clinic.
• Ensuring the loop has closed: Screener checks SMaRT or clinic lists at end of clinic to make sure outcome is recorded (DNA or screening test).
• Local AAA programme task: Review alerts daily and clear incomplete records.

5.4 AAA5a, AAA11, AAA12, AAA13: All screening results received and recorded

• Opening the loop: Screener enters individual screening test results into SMaRT. Service enters any paper-based results into SMaRT when required.
• Closing the loop: Screener records screening outcomes in SMaRT and checks measurement against image. Screener must record 2 measurements per man – in the longitudinal and transverse planes. Note: SMaRT determines screening outcome based on results.
• Ensuring the loop is closed: All images and results are stored as per national guidance. SMaRT system alert for appointments in the past with no outcomes recorded is checked daily.
• Local AAA programme task: Check alerts daily. Images uploaded and checked against results.

5.5 AAA5b: Follow-up of men whose aorta is non-visualised at screening appointment

• Opening the loop: Screeners record non-visualised screening outcome on SMaRT system. Letters sent to GP advising of non-visualisation.
• Closing the loop: Local screening service arranges further scan. Further non-visualisation: refer to vascular lab or medical imaging. If subsequent scan is still non visualisation, discuss with director/clinical lead and note reasons on SMaRT. If further scan declined, note reasons on SMaRT and inform GP.
• Ensuring the loop is closed: SMaRT allows a decision to recall for screening non-visualised subjects or to refer them to medical imaging. SMaRT has alerts for: subjects awaiting a non-visualised decision, and subjects referred to vascular lab/medical imaging with no outcome recorded. Search available on SMaRT for subjects in state of ‘Requires Appointment – Re-screened’.
• Local AAA programme task: Check alerts daily and action.

5.6 AAA15: All men with screen-detected AAA measuring 3 to 5.4cm enter next stage of pathway

• Opening the loop: Screeners record AAA measurement in SMaRT. Outcomes are also sent to men and their GP within one week. Men are offered an appointment with the local screening service’s vascular nurse specialist within 12 weeks.
• Closing the loop: Follow-up appointments offered at regular intervals – annually for 3 to 4.4cm aneurysms and 3-monthly for 4.5 to 5.4cm aneurysms. If further scan is declined, then reasons should be noted on SMaRT, and the GP/vascular nurse specialist informed. Written instruction should be signed by the man or his representative to confirm his informed withdrawal from surveillance recall.
• Ensuring the loop is closed: Surveillance scans completed at appropriate time and results entered on to SMaRT. Co-ordinator acts upon SMaRT alert for surveillance due dates. Note: SMaRT determines screening outcome based on results unless the screener overrides the automatically generated outcome. Co-ordinator/Manager acts upon SMaRT alert for outstanding nurse appointments.
• Local AAA programme task: Check alerts daily for surveillance appointments due, and outstanding nurse appointments.

5.7 AAA18: All men with screen-detected AAA>=5.5cm or whose aneurysm has grown more than 1cm within the previous 12 months referred to vascular services.

• Opening the loop: Screening outcomes are given to men verbally by the screener at the time of test. Outcomes are also sent in writing to the men and their GP. GPs should be informed within one working day. Local screening service makes referral to vascular services within 1 working day.
• Closing the loop: Acknowledgement of referral recorded on SMaRT within 2 working days.
• Ensuring the loop is closed: SMaRT has a system alert for ‘subjects with vascular service referral sent but no receipt or action taken’.
• Local AAA programme task: Monitor alerts for referrals required and action.

5.8 AAA21: Monitor and track referrals in line with referral pathways.

• Opening the loop: Confirmation of vascular assessment received for men.
• Closing the loop: Final vascular treatment outcome completed and entered into SMaRT.
• Ensuring the loop is closed: Screening co-ordinator/Manager: Checks that the time from referral date to initial assessment is within 2 weeks as per pathway standards. Checks that the time from referral date to treatment is within 8 weeks as per pathway standards. The progress of each referral made to a provider of vascular services should be tracked. Delay reasons should be recorded within the referral alerts in line with waiting time guidance. The local service should be aware of all final outcomes for each man referred.
• Local AAA programme task: Timeliness of assessments and outcomes is managed in referrals tracking module within SMaRT with alerts for those who have breached the waiting times.

6. Pathway standards, incident management and internal quality  assurance

All local screening services are required to monitor performance against the pathway standards for the NHS AAA Screening Programme. All surgeons treating men identified through the NHS AAA Screening Programme will be expected to submit data to the NVR.

The NHS AAA Screening Programme pathway standards are a core set of objectives, criteria, minimum standards, and targets that have been developed to measure the processes or intervention of AAA screening.

Both quality assurance between units and quality control within a unit are important. Involvement of radiologists, sonographers, screening technicians and medical physicists is required.

6.1 National pathway standards

The NHS AAA Screening Programme pathway standards (see ref.1)

6.2 Incidents in national screening programmes

Guidance on reporting and managing incidents in national screening programmes can be found on GOV.UK. This guidance is currently under review following publication of NHS England of Patient Safety Incident Response Framework, July 2022.

6.3 Internal Quality Assurance (IQA)

Local service quality assurance

An internal quality assurance framework has been developed as part of education and training. Details of the quality assurance requirements for screening technicians can be found at: Abdominal aortic aneurysm screening: internal quality assurance - GOV.UK (www.gov.uk).  

A QA module has been developed as part of the SMaRT system and is used to generate men’s details in line with the QA process.

Local QA should be performed by the appropriately qualified IQA lead or the nominated CST.

As part of the QA process, if the screener fails to meet any of the standards in three or more assessments, then remedial action should be taken such as:

• close mentoring and supervision
• retraining
• continuing review of images from random clinic selection
• review of past images and possible recall of men. Local services should work with QA and local commissioners and notify NHS England if a recall is required and should work with them to plan the process
• suspension from screening in the situation of a serious incident, pending investigation as per local trust policy

Ultrasound equipment

Information regarding quality assurance of ultrasound machines can be found on GOV.UK.

Referral to vascular unit

Monitor time from referral to outpatient consultation (see failsafe for limits).

Vascular unit assessment

Monitor time from referral to surgery.

7. Audits

7.1 Aim

This section aims to provide guidance for AAA local screening services, their Public Health Commissioners and SQAS on the completion of audit activities within AAA screening services. This information will help to support services to implement an audit schedule.

Some of the information provided is based on mandatory requirements outlined within this document, other NHS AAA Screening Programme guidance and the NHS AAA Screening Programme service specification.

Other information is based on best practice drawn from the experiential learning from incidents, QA visits and recommendations, as well as QA support for AAA screening services. It is recognised that commissioners or local services may complete additional ad-hoc audits that are not covered here.

7.2 Background

The AAA Service Specification[22] sets out that each service:

• has audit and service evaluation embedded in the service
• takes part in national QA processes including audits as requested by commissioners
• demonstrates that they have audited procedures, policies and protocols in place to ensure best practice is consistently applied for all elements of the screening programme.
• ensures that mechanisms are in place to regularly audit implementation of risk reduction measures

7.3 Audit and Research in Screening

It is essential that any reviews of screening data are of high quality and protect the safety of patients and the public. The NHS England AAA Research Innovation and Development Advisory Committee (RIDAC) has been established to review research and audit activity which may have national implications within the NHS AAA Screening Programme, to ensure that it is undertaken in line with current legislation and guidance - Abdominal Aortic Aneurysm Screening: submitting research proposals[23].

The main function of the RIDAC is to consider proposals for new research and to regulate access requests to national screening programme data.

Most of this will concern research and data queries from outside the screening programme. The RIDAC also have an internal responsibility to:

• review research, evaluation, and audit proposals to consider the impact on uptake, acceptability and delivery of the programme
• ensure that proposals meet ethics requirements, where appropriate

Many factors covered in the NHS AAA Screening Programme guidance have the potential to invite further scrutiny and analysis. This information can signify performance levels, reveal issues to be addressed and provide the foundation for better understanding of what is being done so that it can be refined and improved. A number of these factors are measured as part of formal assurance reporting:

• the NHS AAA Screening Programme has designed AAA screening pathway standards that assess the screening process and allow for continuous improvement. These are intended to enable local services and commissioners to identify where improvements are needed across the pathway
• the NHS AAA Screening Programme key peRrformance indicators (KPIs) are recorded as a subset of the pathway standards
• structural contextual factors are described in the national service specification and are considered during commissioning and reviewed where relevant, as part of QA visits

Audit and research activities should ideally stand outside the areas already covered by assurance reporting processes to avoid duplication of efforts. Information generated as part of formal assurance reporting can still be incorporated into or be deepened by further investigation through audit activities.

7.4 Failsafe checks in AAA screening

Failsafe processes minimise risks of anything going wrong in the screening pathway. Failsafe checks have been designed to ensure that these risks can be monitored and addressed before harm occurs. See failsafe section 4.

These failsafe monitoring checks have been incorporated into SMaRT and as a result, these are part of alert queues with the expectation that they are checked daily with appropriate actions undertaken.

This document highlights where failsafe checks overlap with areas of service performance that local services may wish to review in order to understand how well processes are working. This reflection can inform interventions for service improvement.

7.5 Disclosure of audit results

The men who have their cases audited should be offered the result. Where an audit identifies an anomaly in the screening history, the host provider’s Duty of Candour Guidance must be followed.

7.6 Definitions

The RIDAC apply the NHS Health Research Authority (HRA) definitions to understand what level of ethical scrutiny is appropriate for each proposal. The RIDAC definitions, are useful to understand the differences between activities and for consistency are applied here:

• checks: confirmatory recording to verify that tasks and processes have been completed in a timely, appropriately sequenced manner
• audits and assurance reporting: providing a summary of process outcomes and performance. Answering the question: Does X process meet Y predetermined standard?
• service evaluation: reviews of data to reveal where a service performs strongly or could improve. Answering the question: What standard does X process achieve?
• research: generating and reviewing data to discover new insights
• new research activities require ethical review. The RIDAC consider all new proposals submitted. Checks, audits, and service evaluations are unlikely to need ethical review, but SQAS and the RIDAC will be able to provide feedback where it is not clear

The NHS AAA Screening Programme encourages the use of audit activity to support associated evaluation and learning activities to identify challenges, risks and issues. Services can then develop solutions and make changes to practice that seek to improve the efficiency, effectiveness and safety of services and fundamentally improve outcomes for all service users.

Interventions based on the learning from audits can be reviewed and developed using the same processes. Services can apply monitoring, evaluation and learning processes to support continuous service improvement.

See tables in Appendix F which provides further expansion on these definitions.

7.7 Audit Schedule

Audit schedules are documents ordinarily provided as part of Programme Board papers.

The Programme Board is generally the primary audience for audit outputs and summaries. Audit schedules are regularly recommended to screening services following QA visits as a tool to employ as part of monitoring, evaluation and learning processes that support service improvement. Where Programme Boards no longer take place on a regular basis, local services should agree the reporting mechanisms with their commissioners.

An audit schedule can take a number of formats but always includes as a minimum:

• information on which audits will take place and frequency within a given period (usually 12 months)
• summary of the audit criteria
• when they will be reported on
• who the audit will be reported from/to
• how the summary learning will be followed up with actions

Appendix F provides information on types of checks and audits.

Appendix G provides the list of checks, audits, and service evaluations.