Guidance

Topic 3: organisation of the NHS Cervical Screening Programme

Updated 14 September 2023

Applies to England

1. Topic 3 learning objectives

1.1 The trainee

The trainee should know about:

• the core and supporting activities relating to the NHS Cervical Screening Programme (NHSCSP)
• how the cervical screening programme is commissioned
• the role of Public Health England (PHE) Screening
• the role of the cervical screening programme lead (CSPL)
• the role of clinical laboratories and their relationship to other areas of the programme in line with the programme management guidelines for reporting abnormal samples
• the role and rationale of colposcopy in the diagnosis and management of cervical disease including treatment methods for lower genital system neoplasia
• the responsibilities of clinicians who provide cervical screening services in other settings
• the role and responsibilities of the PHE Screening Quality Assurance Service (SQAS)

The trainee should understand:

• their professional responsibilities as a sample taker and medico-legal considerations including:
• definitions of terminology
• consent to cervical screening
• the General Medical Council (GMC) code and Nursing and Midwifery Council (NMC) code in relation to cervical screening
• indemnity and healthcare professional (HCP) responsibility
• the GP contract
• conduct relating to sharing patient information
• the importance of correct patient details
• incident reporting
• healthcare responsibilities around female genital mutiliation (FGM)
• how the call and recall system works
• the responsibilities of GP practices
• how processes in place in their practice or clinic work to minimise errors in the screening pathway (failsafe)
• their local screening procedures based on national guidance (such as obtaining sample taker pin code)

1.2 Guidance for the trainer

Make sure the trainee arranges to visit a cervical screening laboratory (where logistics permit). If providing a virtual tour as an alternative to a visit, this must take place on the theoretical course and supplemented with up to date supporting information from the local cervical screening laboratory.

Supporting information from the laboratory should cover:

• specimen reception (receive samples at the laboratory)
• checking samples
• accepting or rejecting samples (examples of rejected samples)
• transferring vials to virology for high risk human papillomavirus (hrHPV) testing
• receiving virology results
• processing hrHPV detected samples
• the cytology screening and reporting process

Make sure the trainee arranges to visit a local colposcopy service and attend a clinic (we recommend the trainee writes a reflective account of this activity).

Signpost the trainee to further reading and resources on all topics in this section including:

• cervical screening programme professional guidance
• background information and current data about how the cervical screening programme is organised

1.3 Guidance for the mentor

Suggested topics for professional discussion with the trainee include:

• how cervical screening is managed within their service, for example how the prior notification lists are used
• targeted coverage initiatives in their practice or clinic
• communications with the cervical screening laboratory about failsafe enquiries
• local procedures in place for those individuals who fail to attend colposcopy

Teaching resource

Refer to PowerPoint presentation 3 for subject areas in Topic 3.

2. Screening protocols

Each practice or clinic must have access to the national guidance documents for the cervical screening programme. This guidance includes:

• the arrangements for call and recall
• the arrangements for people to be notified of their test results
• the content of standard letters and leaflets
• how to fill in the test request form correctly, recording all data requirements in accordance with the national sample acceptance policy
• the importance of correctly handling and labelling the sample
• how to obtain supplies and which ones are recommended for use
• approximate turnaround times for results from the local laboratory
• failsafe procedures for all test results, that is the number of tests taken have received a result and are acted on accordingly (if something goes wrong, pathway processes are in place to identify what is going wrong, and what action should follow to ensure a safe outcome)
• local arrangements for referral to colposcopy
• that the sample is appropriate and within the recommended screening interval in accordance with the national sample acceptance policy

3. Sample taker professional responsibilities

All healthcare professionals have a duty to work within their professional boundaries. For cervical screening, this ensures that people receive a quality service provided by competent individuals.

Sample takers are responsible for:

• only taking samples if they have met the initial training and subsequent 3 yearly national update requirements
• making sure they are on the sample taker database
• identifying any personal training needs
• understanding how the programme operates and their responsibilities within it
• keeping up to date with changes in the programme and current best practice in line with national guidance
• maintaining competency and monitoring their own results
• being accountable for all use of their allocated sample taker code
• making sure the person has been provided with or signposted to the national information leaflet to assist them in making an informed choice about attending screening
• taking the cervical sample in the correct manner
• making sure the person is informed of their test result
• making sure the test result is followed up
• communicating with the individual if their sample is rejected and advising when another sample should be taken (and reflecting on this)
• making sure referrals take place for individuals who require further investigation and treatment
• co-operating with failsafe enquiries in a timely manner
• making sure reasonable adjustments are offered for individuals who need additional support
• making sure adverse events and incidents are recorded, discussed and investigated

4. Commissioning

NHS England and NHS Improvement (NHSEI) works closely with PHE and the Department of Health and Social Care (DHSC) to provide and commission a range of public health services.

The public health functions agreement (section 7A) is an annual agreement between the Secretary of State for Health and NHS England. It sets out the arrangements under which the Secretary of State for Health delegates responsibility to NHS England for certain public health services including cervical screening. The agreement aims to improve public health outcomes and reduce health inequalities and to contribute to a more sustainable public health, health and care system.

Section 7A outlines the arrangements for commissioning the cervical screening programme. The service provided by organisations must be consistent with national guidance from the screening programme (including NHSCSP best practice guidance).

For cervical screening, NHS England ensures that arrangements are in place to:

• verify the appropriateness for the screening of people on call and recall lists
• make sure that eligible people who are not on NHS lists have access to screening
• make sure that local arrangements are made to cover residential institutions, including prisons
• make sure that all equipment used complies with national equipment standards
• make sure that staff working in the programme are trained to meet the required standards of competence and are actively involved in continuing personal and professional development

This includes communicating with laboratories to ensure the provision of:

• sample taker databases
• feedback both by individual sample taker and by general practice or clinic on reporting profiles, workload, and error rates (for example incomplete patient identity details)

5. Call and recall

A fundamental principle of any screening programme is to ensure that all people who are eligible for screening receive invitations to participate in a timely manner. The call and recall function is an administrative process in which:

• ‘call’ is the initial invite to participate in screening for the first time
• ‘recall’ is the invitation to participate in future rounds of screening at appropriate intervals dictated by programme policy

The call and recall system:

• generates lists of people who are due to be invited for cervical screening
• sends invitation letters and reminder letters to people due for screening
• records test results on a person’s screening history
• sends result letters to people to inform them of their test result

See the overview of the call and recall process in the primary HPV screening pathway.

6. General practice

GP practices are responsible for:

• understanding their contractual obligations and responsibilities in relation to cervical screening
• making sure that all members of staff involved in delivery of the cervical screening programme:
  • comply with national guidance and quality standards
  • participate in audit and review to improve the cervical screening service
  • are aware of mechanisms by which they can raise concerns, identify risks and report incidents
  • are trained in accordance to programme guidance
  • attend regular updates
• keeping records to show that the employer has monitored the above
• reporting areas of concern to their local commissioners
• making sure all sample takers provide people with the necessary information and are able to support people to make an informed choice about whether to accept the offer of screening
• making adequate arrangements and reasonable adjustments as required, to enable people to access cervical screening
• making sure the laboratory returns a result for each sample taken
• making sure processes are in place to inform people of their test results
• making sure failsafe is in place so test results are followed up appropriately
• making sure referral processes are in place so people who require further investigation and treatment are managed appropriately
• making sure processes are in place to respond to failsafe enquiries
• working to improve the uptake and coverage of the cervical screening programme

There may be circumstances when a person does not want their test result posting to their home address, or they may not have a correspondence address. The sample taker should agree with the individual an appropriate arrangement for them to collect their test result, and document this on the test request.

7. Other clinicians who provide cervical screening services

Clinicians who provide cervical screening services in other settings such as integrated sexual health (ISH) clinics or genito-urinary medicine (GUM) clinics are responsible for:

• making sure people are provided with information and advice to enable them to make an informed choice about whether to accept the offer of screening
• making arrangements for taking cervical samples
• referring people for further investigation if necessary
• cooperating with laboratory failsafe enquiries

In circumstances where a person does not wish the test result to be posted to their home address or notified to their GP, the sample taker should agree with the individual an appropriate arrangement for them to collect the test result and appointment details for any necessary follow-up. The sample taker should document the details on the test request.

8. Cervical screening laboratories

Cervical screening laboratories that participate in the NHSCSP:

• perform HPV testing on samples which are accompanied by an identified and completed vial and test request form or electronic request
• generate a cytology slide for samples testing HPV positive
• allocate a result code and recommendation for management depending on the degree of abnormality seen
• notify test results and recommendations for management to the call and recall system using standard action and result codes
• inform the GP or clinician responsible for requesting the test if a person requires referral for colposcopy
• set up and operate a laboratory failsafe system for people who require further investigation or treatment
• host laboratory visits for trainee sample takers (a virtual tour is an acceptable alternative) to include an overview of:
• specimen reception
• rejected samples
• HPV testing
• cytology slide preparation and staining
• cytology screening
• administration area (data entry and transfer of results)
• provide trainers using the service with supporting information for their theoretical course (laboratory presentation)
• arrangements for direct referral for colposcopy

9. Colposcopy clinics

Colposcopy clinics that participate in the NHSCSP:

• investigate and treat people with abnormal test results
• provide follow up after treatment or discharge people back to routine recall
• co-operate with laboratory failsafe enquiries
• may take cervical samples from people referred because their cervix is difficult to visualise
• schedule visits for trainees to attend a clinic, and host a tour to include:
  • locating the colposcopy department (information for patients)
  • colposcopy facilities and the equipment used
  • communication and counselling services
  • an overview of direct referral and practice referral including 2 week wait
  • witnessing patient experiences during clinic
• refer an individual for colposcopy without waiting for their test result if:
  • an abnormality of the cervix is identified when the cervix is visualised
  • they have symptoms which are suspicious of abnormality

Refer to guidance on colposcopy and programme management for further information.

10. Cervical screening provider lead (CSPL)

The NHSCSP requires a CSPL based in a cytology or histology laboratory or in a colposcopy clinic. The CSPL is responsible for:

• making sure systems are in place for transferring test results from the laboratory to the call and recall system
• collating histology results with cytology test results
• making sure laboratory failsafe measures are initiated if necessary
• taking a lead role in the audit of invasive cervical cancers

11. Quality assurance

Quality assurance (QA) of screening programmes in England became the responsibility of PHE in April 2013. The SQAS is part of the screening division within the PHE Health and Wellbeing directorate, and works alongside NHS screening programme teams.

Cervical screening QA covers the identification of eligible people, sample taking, cytology, colposcopy and histopathology. It ends with the diagnosis of cancer, completion of the screening programme at 65 years of age, or the ending of a surveillance period, whichever is later.

Refer to the cervical screening programme specific operating model for further information.

The SQAS is responsible for:

• evaluating the quality of local cervical screening programmes
• supporting quality improvement activities
• arranging QA visits to laboratories and colposcopy clinics
• monitoring primary care elements of local cervical screening programmes
• advising on incident management, and sharing the lessons learnt and recommendations with the programme

12. National co-ordination

PHE provides expert advice and guidance on screening to the NHS. NHS England is responsible for delivering the NHS Cervical Screening Programme, which is 1 of 11 population screening programmes. PHE is responsible for:

• improving the overall performance of the programme
• producing guidance and developing standards designed to assure a high quality of cervical screening
• supporting individuals to make an informed decision about attending for screening, through the provision of national leaflets, online content, and letter templates