Guidance

3. Providing a quality colposcopy clinic

Updated 5 January 2023

1. Good working practices

1.1 Quality assurance

Wherever provided, colposcopy should be organised as a quality assured service that adheres to programme standards and guidance.

Implementation of this national guidance should be fully documented in procedures that reflect how the service is run at a local organisational level. This includes documentation covering clinical management, colposcopy clinic operational arrangements and all administrative activities. The service must be run by a team working to the protocols and quality standards outlined in this document and the associated locally approved procedures. Any problems arising in connection with colposcopy practice should be addressed in a confidential and supportive manner.

1.2 Role of lead colposcopist

Each organisation providing a colposcopy service must have a lead colposcopist who holds overall accountability, whose role is reflected in their job description and who has suitable time allocated in their job plan (a minimum of 1 programmed activity (PA)). Time allocation needs to be assessed in terms of the scope and complexity of the services provided. The lead colposcopist role is to ensure that good practice is followed, that protocols are developed and observed, and that the quality standards outlined in this document are met. They must also ensure that the service collects accurate and valid data by which to measure its performance. This will ensure that the requisite information is available to enable the completion of all required and mandated returns and audits. An example job description is provided. A deputy should be nominated to provide cover.

1.3 Role of lead nurse for colposcopy service

Each organisation providing a colposcopy service must have a named lead colposcopy nurse, whose role is reflected in their job description and who has suitable time allocated in their job plan. The lead nurse takes day to day responsibility for running the colposcopy service and will be actively involved in colposcopy clinics. A deputy should be nominated to provide cover.

1.4 Role of the cervical screening provider lead (CSPL)

Having a CSPL is a requirement of the programme. The CSPL has responsibility for ensuring quality standards are met across cervical screening programme activities. They work closely with the local individual cervical screening programme service leads to achieve this. They have the lead role in the audit of invasive cervical cancers. Full details of the role of CSPL are available.

1.5 Audit of invasive cervical cancers

The audit of invasive cervical cancers aims to understand why cervical cancers occur in spite of the existence of the cervical screening programme. The overall purpose of this is to monitor the performance of cervical screening programme. There is an educational element to the audit, since it offers an opportunity to review the original management of each case of invasive cancer and determine whether it was appropriate. Participation in the audit is an essential component of the programme and quality assurance.

The lead colposcopist and CSPL must work together to ensure the colposcopist aspects of the audit are fulfilled. Individuals who have participated in the screening programme but who have subsequently developed invasive cervical cancer must be offered an opportunity to receive the review of their screening history once it is complete. This is carried out according to the principles for disclosure outlined in the Guidance on applying Duty of Candour and disclosing audit results.

1.6 National Health Application and Infrastructure Services (NHAIS)

Decisions made by colposcopists directly influence an individual’s management, including the interval to any follow-up tests. If follow-up tests are managed by the colposcopy service, details of the test results must be added to the individual’s screening record on NHAIS. This ensures that no premature or inappropriate recall invitations are produced by the failsafe system.

If follow-up tests are to be carried out in primary care, colposcopy services need to communicate information on each individual’s screening recall due date to call and recall departments to allow the NHAIS system to produce an automatic invitation at the correct interval. These updates must be communicated electronically in a standard format and must be sent using a secure mechanism for the transfer of information. A method to log sending and receipt of these updates must be in place.

1.7 Colposcopist certification

All colposcopists in the team must be certified through the British Society for Colposcopy and Cervical Pathology(BSCCP)/Royal College of Obstetricians and Gynaecologists (RCOG) scheme.

1.8 Clinic staffing and facilities

Individuals undergoing colposcopy should have access to a level one registered nurse trained in colposcopy to support them and to act as their advocate during the procedure.

A second support nurse trained in colposcopy is needed to assist in making the necessary preparations for cervical sampling, biopsies and treatment, and to support the colposcopist directly during the examination. All colposcopists working in a clinic must receive the same level of nursing staff support. All clinic staff must be familiar with the treatment method(s) used.

The colposcopy service requires adequate clerical and secretarial support to ensure timely communication with patients and their GPs. In addition, administrative support is needed to ensure efficient data collection, effective communication with other agencies, and effective and timely failsafe activities.

Staffing for the service should ensure that there is appropriately trained cover available for planned absences and there is no over-reliance of the service on single individuals.

Having a dedicated, specialist team in the colposcopy unit provides continuity of care and allows individuals to develop confidence in individual members of staff. This in turn helps reduce anxiety and improves both attendance and satisfaction with the service. The extended role of the nurse colposcopist may be of particular benefit here.

1.9 Operational meetings

The colposcopy team should hold operational team meetings at least every 3 months to discuss:

• clinic policy
• protocol problems and operational issues
• incidents and risks
• findings of audit and peer review visits
• any areas where the clinic falls short of quality standards

These meetings include colposcopists, colposcopy nursing staff and the administrative team, and are chaired by the lead colposcopist. The colposcopy operational meetings are separate to management meetings convened by the CSPL which cover discussion of the full cervical screening pathway. CSPL meetings are covered in more detail in the CSPL guidance.

1.10 Reducing anxiety for individuals

Information and communication

Effective information and communication are important in reducing anxiety. Counselling must be available as an integral part of colposcopy.

All individuals at their cervical screening consultation should be provided with information about what happens if a colposcopy referral is indicated. Written information is provided both before and after colposcopy and includes:

• an appropriately worded invitation, containing the name of a contact at the clinic, a telephone number for the clinic, and the clinic’s opening times
• information concerning each visit to the clinic and the results of investigations should be communicated to the patient and GP
• biopsy results should be communicated to the individual within 4 weeks of the test (acceptable standard of ≥90%), and 100% must be communicated within 8 weeks (achievable standard)
• locally produced information leaflets tailored to the needs of the local population and reflecting the local colposcopy service should be sent with the colposcopy invitation, given to individuals after procedures or issued with their result, as appropriate; additional copies should be available at each clinic
• colposcopy services must have protocols describing the notification process for future community-based screening
• good practice dictates that patients should have their history taken and be counselled with an independent interpreter if required

Information given to individuals having colposcopy outpatient treatment

Where an individual is considering outpatient treatment, providing relevant information can reduce anxiety and inform and prepare the patient regarding the effects of treatment. All individuals needing treatment must be informed that treatment is required, and their consent (either written or verbal) must be recorded.

Information must be provided to individuals having colposcopy outpatient treatment to advise that:

• they should avoid using tampons for 4 weeks following treatment
• they should not have vaginal intercourse for 4 weeks following treatment
• they should avoid swimming for 2 weeks following treatment
• they may drive following loop excision or local treatment, unless advised otherwise by the examining colposcopist
• they may consume alcohol in moderation after treatment
• other normal activities, including light exercise, may continue
• although there are no known health grounds for avoiding travel following treatment, overseas medical attention for complications arising from the treatment may not be covered by insurance
• there may be a temporary change in their menstrual pattern following loop excision
• there is no clear evidence that ablative or excisional treatment measuring less than 10mm in depth is associated with any increase in the incidence of preterm labour and preterm pre-labour rupture of membrane (see research published in 2006, 2016(a) and 2016(b)
• ablative or excisional treatment is not associated with any increased risk of infertility but may increase the risk of mid-trimester miscarriage
• treatment has to be tailored to individual circumstances and may require excisions more than 10mm in depth

1.11 ‘See and treat’ clinics

Clinics operating a ‘see and treat’ policy must ensure that all individuals offered treatment at their first visit have been sent or given adequate and appropriate information in advance of their appointment.

1.12 History taking

Good practice dictates that patients should have their history taken and be counselled with an independent interpreter if required.

Appropriate and sensitive enquiries regarding sexual history may be made, but only under the auspices of an ethically approved study, or if the patient presents with a specific indication.

1.13 Clinic facilities

The clinic’s facilities must include:

• a private area with changing facilities
• toilet facilities
• a permanently sited specific room for colposcopy
• refreshment facilities
• separate waiting and recovery areas
• access for individuals with disabilities

1.14 Visitors to the clinic

Individuals should be able to have a friend or relative present if they wish. The patient’s consent should be sought prior to colposcopy if anyone not essential for its performance is to be present (for example trainees or undergraduates).

2. Equipping the colposcopy clinic

The clinic environment should be welcoming and protect the patient’s dignity. Patients should be given time to discuss their care both before and after the colposcopy examination and or treatment.

Equipment and protocols in the colposcopy clinic must include:

• a permanent couch and colposcope
• suitable sterile instruments, set up separately for each individual, compliant with national health and safety recommendations
• adequate and immediately accessible resuscitation equipment, and staff involved in the clinical care of patients who are familiar and trained in its use
• suitable IT equipment
• software for the collection of data for submission of the mandatory quarterly and annual KC65 return, clinic and individual screening quality assurance service data returns and audits, BSCCP accreditation requirements and to support local audit programmes.
• daily back up of all data, and disaster recovery arrangements must be in place
• where possible, television monitoring facilities for patients who wish to watch the procedure (image capture is advantageous)

Additionally, if laser, thermal coagulation or diathermy equipment is in use, adequate safety guidelines should be in place, and all staff must be trained in the operation of this equipment. Clearly written and easily accessible emergency guidelines must also be available in each clinic. These must conform with local protocols.

In units offering an exclusively diagnostic service, there must be automatic referral to a unit where treatment is available if needed

3. Adjunctive tests in colposcopy

Adjunctive tests are available and have been evaluated by the National Institute for Health and Care Excellence (NICE).

4. Non-attenders

For patient non-attendance:

• there must be written protocols for the management of non-attenders
• audit should include analysis of the records of non-attenders to discern any patterns that could be addressed to reduce the non-attendance rate
• the non-attendance rate per clinic should be less than 10% for new referrals and individuals returning for treatment and less than 15% for follow-up appointments

5. Multidisciplinary working

5.1 Working with other units

Effective working between units is an essential component of high quality integrated patient care. This means that:

• colposcopy clinics within sexual reproductive health clinics must have established protocols for working with gynaecological services
• colposcopy clinics within gynaecology services should have established protocols for working with sexual reproductive health clinic services
• all colposcopy clinics should have established protocols for working with cervical screening and histology laboratories and the call and recall service
• all multidisciplinary audits must be an integral part of the service
• there should be well established clinical and computer links with cervical screening and histological laboratory services to support multidisciplinary working
• all colposcopy clinics must have protocols describing failsafe mechanisms
• all colposcopy clinics must have protocols describing the notification procedure for future community based cervical screening recall

5.2 The colposcopy multidisciplinary team (MDT) meeting

The primary purpose of the meeting is to plan the management of patients with discordant histology, cytology and colposcopic findings.

All meetings must be attended by at least 1 colposcopist, and representatives to present and discuss the histology, HPV and cytology from the relevant laboratories. Histology and cytology attendance can be in person or via video link (clinical and computer links must be in place to support this). In addition:

• all colposcopists must attend at least half the meetings
• lead cytopathologists and lead histopathologists should attend some of the meetings
• attendance at meetings must be recorded
• monthly meetings as a minimum are required (at least 12 per year)

All histopathology must be reviewed prior to the meeting, and be reviewed and presented at the meeting by a consultant histopathologist or appropriately qualified biomedical scientist who undertakes the reporting of histology arising from the colposcopy service.

Histopathology and cytology reviews must be performed by a second individual different to the original reporter. If discordant results arise or potential bias is identified, a third opinion must be obtained.

Cytology must be reviewed prior to the meeting and is reviewed and presented during the meeting by a consultant biomedical scientist or consultant pathologist who reports cervical cytology routinely.

Cases to be discussed must be documented in a clear local protocol. These may include (but are not limited to):

• all cases where high grade cytology including ?invasion has not been confirmed on colposcopy and or histology
• borderline change in endocervical cells, with minor abnormalities or less on colposcopy and or histology
• any case where colposcopists wish to ask for an ‘off protocol’ genotyping HPV test
• all cases of invasive cervical cancer identified from the screening programme
• all cases of ?glandular neoplasia of endocervical type, CGIN/SMILE
• all conservatively managed CIN2 cases
• further management of individuals who have had 2 previous treatments

There must be allowance for colposcopy, histology and cytology to add any cases to the list where they have concerns they wish to discuss.

The outcome of MDT discussion must be recorded in the patient notes and reported to the managing clinician in writing. Outcomes should be recorded on the cytology and colposcopy computer system or other systems allowing access to cytology/histology in the future.

Note that the laboratory does not reissue cytology reports as a result of an MDT review.

Regular audit of MDT case selection and outcomes is recommended. All cases of cervical cancer must be reviewed by a gynaecological cancer centre MDT.

6. Training and certification of colposcopists

6.1 Training requirements

All practising colposcopists must be able to demonstrate that they have received an adequate training as described by the joint BSCCP/RCOG training programme.

6.2 Maintenance of clinical skill and continued medical education (CME)

Colposcopists practising within the cervical screening programme must see at least 50 new referrals a year arising from the programme. Possession of a current BSCCP certificate does not exempt a colposcopist from achieving this standard.

All colposcopists must undergo the recertification process every 3 years in order to maintain levels of expertise. To achieve recertification, a colposcopist must pursue continued medical education (CME) to ensure that they are abreast of developments in scientific knowledge and clinical practice. Suitable CME opportunities include attendance at BSCCP accredited regional educational meetings arranged by the SQAS, advanced colposcopy courses, and the BSCCP annual meeting.

Continued practice should be quality assured, with continuing personal development and regular audit. Discussion of practice should be included in colposcopists’ annual general appraisals.