Guidance

Cervical screening: programme specific operating model

Updated 24 August 2021

This document describes the programme specific operating model (PSOM) for quality assurance (QA) of the NHS cervical screening programme (CSP).

This PSOM was developed by a working group led by the national portfolio lead (NPL) for cervical screening along with members of the regional SQAS teams and, where applicable, colleagues from NHS England and Improvement.

The PSOM describes how SQAS works with, supports and quality assures cervical screening services.

SQAS works to implement the PHE screening inequalities strategy by:

• checking that delivery of the NHS CSP contributes to reducing health inequalities
• making sure SQAS processes support the identification of inequalities in the screening pathway to enable screening services and commissioners to address the issues raised

A separate document explains the quality assurance process of the NHS CSP.

Overview of quality assurance activities

Service engagement

A named senior quality assurance advisor (SQAA) or quality assurance advisor (QAA) acts as visit lead and will be linked to each screening service and NHS England/Improvement (NHSEI) Public Health Commissioning Team (PHCT).

• Throughout the remainder of the document the named SQAS visit lead will be referred to as S/QAA.

The S/QAA or deputy will attend screening service steering or programme boards to:

• identify and monitor screening issues
• support the identification of risks and potential incidents
• monitor progress against QA recommendations
• support service improvement including work to reduce screening inequalities
• update screening services on changes in national policy
• share learning

Analysis of data and intelligence

PHE Screening and SQAS will collect and/or review data in specified time periods. See data and intelligence for quality assurance

Services are benchmarked using national screening standards.

SQAS and PCAs (where applicable) annually review data and intelligence at a national, regional or sub regional level. This data and intelligence is used to prioritise SQAS activities.

Further information and intelligence may be obtained from attendance at screening service steering or programme boards and by other means including regular PHE screening reports, published studies, discussions with screening services and national screening programmes.

Visits and reviews

The QA visit process includes all screening services delivering the full screening pathway or part of it. This includes private providers commissioned to deliver NHS screening programmes.

The frequency of QA visits and other QA activity is based on findings from the annual prioritisation exercise. The maximum interval for a full visit for all screening services is 5 years.

SQAS may undertake a focussed visit or assessment of some or all professional areas within the pathway within the 5-year period if needed. Changes in service provision via re-procurement or reconfiguration will be considered as part of the annual prioritisation exercise with the flexibility for in year adjustment if required.

The QA visit and review of screening services will include:

• programme management and governance
• the screening pathway
• referral to relevant diagnostic or treatment services
• public health system leadership and commissioning
• relevant diagnostic or treatment services

NHSEI and screening services are informed of scheduled visits/targeted interventions to give adequate preparation time

Following a QA visit or targeted intervention a report is produced and sent to the screening service and commissioner(s). Where recommendations are made the screening service should develop an action plan with the commissioner.

The QA report executive summary is published on GOV.UK unless consent is withdrawn by either the screening service or commissioners.

The QA visit process is described in detail in the QA visit preparation section.

Support with incidents

The role of SQAS in screening safety incidents is set out in PHE’s guidance Managing safety incidents in NHS screening programmes. The role includes:

• developing guidance and processes for managing and monitoring screening safety incidents and serious incidents
• developing resources and training packages to support the management of screening incidents
• collating and disseminating the learning from incidents at national, regional and local level

SQAS supports patient safety by:

• providing expert advice to screening services and public health commissioning teams so that safety concerns, safety incidents and serious incidents are assessed, investigated and managed effectively.
• accessing specialist clinical and policy advice for specific incidents from PHE Screening’s national programme team and from professional and clinical advisors who work with regionally based SQAS teams
• working with the Public Health Commissioning and Operations team in NHSEI on incidents that require a national response

Networking and support

A variety of approaches to networking are used across SQAS. Feedback from attendees shows these events are valued by both SQAS and screening service representatives.

Network meetings are used by SQAS to share information relating to new screening standards, guidance and national programme developments. They provide an opportunity to share data, discuss support needs, and enable feedback. They help identify quality issues and potential risks which could inform future QA activity.

Meetings allow staff working in screening services to develop networks and share tasks such as development of protocols.

Meetings may have input from external speakers or include sharing of local audit information.

The frequency of meetings will vary by professional group. There will be a minimum of 3 network meetings per year per region. They will involve different staff groups depending on prioritisation and current issues. This is likely to include some or all of:

• cervical screening provider leads
• laboratory
• colposcopy

National cervical QA teams

Two QA teams have been established to undertake cervical QA work that is more effectively run on a single national basis.

The SQAS national call and recall team undertakes the QA of the cervical screening call and recall service, which is provided by a single national provider, known as the Cervical Screening Administration Service (CSAS). CSAS is part of the NHS and is run by North of England Commissioning Support Unit. The QA of the call and recall service may include QA visits, QA audits, QA advice to call and recall incidents and facilitative support to the provider and commissioner of call and recall activities.

The SQAS national external quality assessment (EQA) scheme team runs the operational aspects of the 2 published PHE screening cervical screening EQA schemes.

The gynaecological cytopathology EQA scheme is mandatory for all cytology laboratory staff reporting cervical screening tests. This scheme is accredited by the UK Accreditation Service to ISO/IEC: 17043 standards.

The technical EQA scheme is mandatory for all laboratories running a cervical screening service for the NHS. This scheme assesses the quality of laboratory staining of cervical cytology specimens. This scheme aims to apply for ISO/IEC: 17043 accreditation in due course.

Both schemes need to obtain feedback from participants and maximise the educational benefits. This is achieved through various means, including running an annual EQA workshop.

Data and intelligence

Data sources

National health application and infrastructure services

National Health Application and Infrastructure Services (NHAIS) is a population database with details of all eligible women registered with GPs in England. The system is used to:

• invite eligible women at correct intervals
• notify test results to women and GP practices
• record screening histories and ensure these follow women when they move area
• provide a failsafe to ensure appropriate follow up and recall
• record HPV vaccination status as part of the screening record
• provide web-based controlled access to aggregated (KC53 and VSA15) and patient level data held on NHAIS (Open Exeter)

KC53 is run on a quarterly and annual basis by NHS Digital staff approximately 6 weeks after the end of each quarter. The geography level is upper tier local authority (ULA). Measures include number of women screened, invitations and screening test results. This data is sent to SQAS for analysis.

VSA15 is run monthly as an automatic report on the Open Exeter system by SQAS staff on a national basis. The geography level is clinical commissioning group (CCG). VSA15 reports the time from the date of the screening test to the estimated date of the receipt of the result by a woman. This monitors achievement of the national 14-day turnaround time standard. The national cervical QA data and intelligence team produces the monthly VSA15 report for CCGs around 7 working days after the end of the month. It distributes this to regional SQAS teams in a standardised format for onward dissemination.

Laboratory information systems

Cervical screening samples reported by pathology laboratories are recorded on provider organisation data systems. There are multiple laboratory information systems in use across England. All should be able to report the mandatory KC61 return in addition to the monthly, quarterly and annual laboratory data requirements for SQAS.

KC61 is run annually by pathology laboratories. Each regional SQAS is responsible for the collection and initial validation of these local data according to standard validation criteria. The data are then collated and further validated by the national cervical QA data and intelligence team. The data are used for local SQAS quality monitoring as part of the annual QA data review once validated. The nationally collated KC61 data are also sent to NHS Digital by the national cervical QA data and intelligence team for inclusion in the annual national Statistical Bulletin.

SQAS monthly, quarterly and annual laboratory data returns are defined nationally and requested at SQAS regional level according to a nationally defined timetable. Each regional SQAS is responsible for the validation of these local data according to standard validation criteria. The data requested will include KPIs, as defined in service specification no.25 and national guidance. The data collected on a monthly and quarterly basis will be requested at service level only. The annual laboratory data will request more detailed individual level data such as workload and individual staff performance. Quarterly laboratory data will be circulated back to laboratory services so they can assess their performance in relation to other laboratory services.

Laboratory monthly, quarterly and annual data sets will be used to form the QA visit data pack.

Colposcopy data systems

Women with an abnormal screening test result or with a clinically suspicious cervix are seen in colposcopy clinics. Details of referrals, appointments and procedures are recorded on specialist data systems at provider organisations. There are multiple colposcopy data systems in use across England. All systems should be able to produce the mandatory KC65 return and annual QA data requirements.

KC65 reports are run on a quarterly and annual basis by each colposcopy service and reported by individual clinics within the service. Each regional SQAS is responsible for the collection and initial validation of these local data according to standard validation criteria. The data are then collated and further validated by the national cervical QA data and intelligence team. The data are used for local SQAS quality monitoring as part of the annual QA data review once validated. The nationally collated KC65 data are also sent to NHS Digital by the national cervical QA data and intelligence team for inclusion in the annual national statistical bulletin. The quarterly data are circulated back to colposcopy services and commissioners so they can assess their performance in relation to other colposcopy services.

The SQAS annual colposcopy data return is requested at SQAS regional level according to a nationally defined timetable. Each regional SQAS is responsible for the validation of these local data according to standard validation criteria. The data requested will include KPIs as defined in service specification no.25 and national guidance. The annual colposcopy data submission requests more detailed individual level data such as workload and staff performance data.

Colposcopy quarterly and annual data sets will be used to form the QA visit data pack.

Key performance indicators (KPIs)

Screening KPIs define consistent performance measures for a selection of public health priorities, using terminology that is clear and common across all NHS screening programmes, so performance can be understood, assessed and compared. They are a subset of screening standards and relate to a limited range of screening priorities that are not in themselves sufficient to quality assure or performance manage screening services. The KPIs reflect areas where consistency and an understanding of variation across England are important.

KPIs are collated and reported quarterly, unless numbers are small, in which case aggregated data is reported in the public domain annually. Small number KPIs are available for PHE Screening staff for quality assurance purposes. These KPIs are contained within the Section 7a agreements between the Department of Health and Social Care (DHSC) and NHSEI and in the public health outcomes framework (PHOF). Further information about screening standards, screening pathway requirements and screening service specifications is available.

Screening pathway reporting

PHE Screening is committed to publishing data required to support quality assurance of screening standards. Standards are reported annually, apart from when any standard is also a KPI, in which case it is usually reported on quarterly and annual figures are aggregated.

PHE screening co-ordinates an annual collection and analysis of standards data. The submitting organisation is responsible for timely submission of data and making sure that only accurate data is submitted. Good quality data is important for monitoring and improving screening services. Screening providers may want to refer to the guidance for providers on the false or misleading information (FOMI) offence, which sets out the responsibility of providers to supply and publish accurate data.

The current list of outline reports and frequency are:

• VSA15 - monthly
• KC53 - quarterly/annually
• KC61 - annually
• KC65 - quarterly/annually
• HPV testing - monthly/quarterly
• Cytopathology_Quarter - quarterly
• Cytopathology_Annual - annually
• Colposcopy_Annual - annually
• visit pack - at QA visit

Data analysis

SQAS will comply with the set national screening methodologies as these are developed.

Data quality and completeness of data is reviewed using national guidance and other data validation operating procedures (manual and/or automatic).

Data analysis is undertaken by national or regional data analysts and the national data and information team in the case of KPIs and screening standards as required.

Data reporting

Reporting and analysis is done once, nationally where possible. Dissemination of data not already in the public domain to screening services is via SQAS regional teams.

Data sharing

Routine data sharing between PHE screening and NHSEI for all 11 NHS screening programmes is underpinned by the Memorandum of Understanding (MoU) signed by both organisations. This MoU extends to any onward sharing to any third party, for example, PHE centre directors, providers of screening services, local authority, clinical commissioning groups (CCGs), voluntary organisations and other health professionals using screening data to improve and monitor services. This is for the purpose of improving the quality of screening services.

The set of data items covered by the MoU is shared prior to publication and for management purposes only. Data flows, schedules and the list of data items shared are managed by the national data and information team. All data shared under the MoU is also available to PHE screening staff.

Annual KC61 and KC65 data are shared with NHS Digital.

Non routine data requests from commissioners and service providers should be discussed with SQAS regional teams and/or Research Advisory Committees (RACs) who will consider requests in line with data release principles including, but not limited to, asking:

1. Has the data already been shared via the MoU or is it available in the public domain?
2. Is the data likely to support population health improvement?
3. Is the data likely to improve the quality of screening services?
4. What is the level of anonymisation required (open government licence to potentially identifiable and identifiable information)?
5. What are the resources and costs required to extract, collate, quality assure and release the data set?

SQAS regional teams will seek initial advice from the national SQAS cervical QA data and intelligence team in the case of non-routine data requests. Where necessary, further advice will be obtained from national programme managers and the national data and information team. Advice will also be sought from RACs where appropriate. All requests for data not aggregated to the information standards board (ISB) for health and social care anonymisation standard is discussed with the PHE office for data release.

The RAC application process and a detailed flowchart are available.

All data requests and releases will be centrally logged and tracked.

Information governance

PHE acts as the sole or joint data controller for certain data. This includes data within national information communication technology (ICT) systems which is used to deliver the call recall part of the screening pathway. It also includes data which is processed to assure the quality, safety and efficacy of screening. These systems are usually ones that PHE has directly commissioned or has a role in establishing.

PHE holds a responsibility to ensure that any data we control is processed in line with the relevant legal and ethical requirements. Because we process personal confidential data without gaining prior consent from patients, PHE requires permission to set aside the legal duty of confidence (this is the obligation that medical services have to keep information they hold on patients secure and confidential and not share it with third parties, such as PHE).

The legal authority to set aside the duty of confidence comes from approval by the Health Research Authority’s Confidentiality Advisory Group (HRA CAG). This is commonly referred to as Section 251 (S251) support. PHE has approval to process confidential data for a specific set of circumstances required to deliver safe, effective screening. Specifically, PHE has Section 251 support to discharge its duty to oversee the delivery of screening, its quality assurance and its evaluation.

PHE does not have S251 support to undertake research. Researchers cannot claim PHE’s S251 support as their own without an explicit data processing agreement between PHE and the processor and a letter of amendment from the HRA CAG.

QA visit preparation

Objectives

The objectives of the QA visit are to:

• examine the performance of the screening service
• confirm if national screening standards are met
• identify variance from screening standards
• support professionals working in the screening service to maintain and improve performance against screening standards
• identify areas for shared learning and disseminate these to all screening services
• share experiences and understanding of current problems or concerns in NHS cervical screening services and contribute to national development

The QA visit team

The QA visit team is selected by SQAS, led by the visit chair and supported by the:

• SQAA and/or
• QAA/quality assurance facilitator (QAF)

Members of the team may include:

• commissioning
• cytopathology (a)
• biomedical science (b) (cytology)
• HPV virology (b) (depending on local arrangements)
• colposcopy (clinical)
• colposcopy nursing
• histopathology (a)

Roles above marked (a) can be done by the same PCA, and roles marked (b) can be done by the same PCA.

QA visit team members are asked to declare conflicts of interest before the visit. If this raises concerns about the use of a PCA for a visit, SQAS will take advice within PHE.

A maximum of 2 observers may be present at a QA visit, for training and education purposes. The observers are not involved with providing feedback and will not input into the interviews or decision-making processes.

Role of the QA visit chair and QA advisor

For cervical screening, the visit chair is the regional portfolio lead (RPL) or a PCA who has received specific training to perform this role. If the visit chair is also a PCA they are not expected to act in their usual PCA role during the QA visit unless agreed in advance.

The visit chair is responsible for:

• chairing and directing the conduct of the QA visit
• providing considered, consistent feedback on the QA visit findings
• managing sensitively and appropriately any serious issues or concerns raised prior to or on the day of the QA visit
• facilitating the exchange of knowledge and ideas and encouraging productive networking

The S/QAA supporting the visit chair is responsible for adequate preparation before the QA visit including:

• notification of the visit date to the provider organisation chief executive (CE) and commissioner at least 6 months before the visit
• making sure the screening service knows what to prepare for the QA visit
• arranging any preliminary meetings between SQAS and the screening service
• acting as a point of contact for any queries relating to organising and co-ordinating the QA visit
• identifying and managing the QA visit team who are accountable to the QA visit chair up to and including production of the final report and executive summary
• making sure PCAs are contracted appropriately and agreements are signed prior to undertaking QA activity
• making sure all PCAs selected have completed the required training
• making sure the evidence to support the QA visit is submitted via the screening division IT system known as Marvin and any observational pre-visits are completed
• identifying late submission or missing evidence and escalating as appropriate
• reviewing the evidence submitted and identifying areas for discussion
• developing agendas for the pre meeting, QA visit and feedback sessions
• making sure adequate preparatory work is complete
• supporting the visit chair to collate feedback during the QA visit

After the QA visit, the S/QAA is responsible for:

• making sure PCAs provide feedback in a timely manner to allow drafting of the factual accuracy report within the agreed timescales
• making sure an accurate final report of the QA visit is issued within the agreed timescale and sent to provider CE, NHSEI screening and immunisation leads (SIL)
• making sure recommendations are followed up and monitored within the agreed timescale and escalated where progress is not made
• making sure the executive summary is uploaded to GOV.UK in accordance with SQAS guidance

Skills and experience of QA visit team

Members of the QA visit team need skills in:

• report writing
• interview techniques
• an understanding of screening incident identification and management
• analytical skills

They should also:

• have programme specific QA training
• understand public health aspects of screening
• have the opportunity to observe a QA visit

Specialist skills required of the individual PCAs are documented in the cervical screening PCA person specification/role description.

Locations to be visited

The QA visit will assess the screening service and screening pathway(s). If a service has sites located away from the main provider unit it may not be possible to visit all screening sites on the same day. Where needed the S/QAA will arrange visits to other sites before the main provider unit QA visit takes place.

Screening service personnel

Depending on service configuration the QA visit should be attended by:

• cervical screening provider lead (CSPL)
• lead pathologist (cytology)
• lead biomedical scientist
• lead HPV scientist
• lead colposcopist
• lead colposcopy nurse
• lead pathologist (histology)

Evidence considered

The QA team review:

• pre-visit questionnaires completed by the screening service (where applicable)
• commissioning
• supporting evidence and documents submitted to SQAS
• interviews undertaken during the QA visit
• observational visits (where applicable)
• case reviews (where applicable)
• analysis of annual report data and routine data for the preceding 12-month period
• analysis of audit reports
• programme specific inequalities evidence guide to identify inequalities in the screening pathway

Preparation

SQAS will agree the QA visit date with the screening service and commissioners. At least 6 months’ notice is given. The screening service should identify a contact person to co-ordinate arrangements. They are responsible for evidence submission, booking meeting rooms for interviews on the day and providing relevant contact details.

The date of the QA visit will not be changed once it is agreed, except in exceptional circumstances, and only with the agreement of both parties.

SQAS informs the CE(s) of the host trust, stakeholder trusts, providers of any associated services, treatment providers and commissioners of the QA visit. They are required to attend or send a suitable representative to the QA visit feedback session and subsequent discussions as appropriate.

Preliminary meeting

A preliminary meeting between SQAS and the screening service or commissioners may take place. This will vary by programme, for example, SQAS may attend the next scheduled screening service steering or programme board meeting or operational group meeting once the QA visit date is agreed.

If no meeting is scheduled prior to the QA visit SQAS may request a bespoke meeting around 3 months before the QA visit date.

SQAS will use the meeting to inform the screening service about arrangements for the QA visit. This includes arrangements for any observational visits, an outline of the agenda and answering any questions that the screening service and its stakeholders may have.

Information to provide

In preparation for a QA visit the screening service is asked to provide:

• action plans from previous QA recommendations (where not already available to SQAS)
• completed pre-visit questionnaire
• supporting documents and protocols as outlined in the pre-visit questionnaire or documentation
• performance reports as requested
• information on any incidents that have occurred in the last 12 to 24 months
• information on venue organisation, the location of the QA visit including rooms for interviews and feedback sessions
• other relevant information requested by SQAS

This information should be provided to SQAS at least 8 weeks prior to the QA visit date. There is no flexibility to extend the deadline for evidence submission unless it is agreed by the visit chair and S/QAA.

Evidence should be submitted via the screening division IT system known as Marvin. SQAS will provide details of how to upload evidence.

Evidence transfer must conform to information governance rules. No patient identifiable or sensitive information should be transferred to SQAS. SQAS information governance protocols should be followed.

Evidence submitted that is out of date, for example policies or guidelines, is not assessed, but is used to inform decisions about screening service governance.

Where needed the S/QAA leading the QA visit will request clarification of evidence submitted or for further evidence to be provided.

Where evidence is not submitted the S/QAA will escalate within the screening service and with the commissioner/SIL.

Observation of clinical practice and premises

In cases of organisations with multiple colposcopy clinics at different locations, a mutually convenient time will be agreed for the colposcopy nursing PCA to visit each clinic away from the main site. This visit will review the facilities and undertake a ‘patient journey’ walkthrough. It will take place before the main QA visit. The main site colposcopy clinic will be reviewed on the day of the full QA visit. A ‘specimen journey’ walkthrough will take place at each laboratory.

If required based on the evidence review, a PCA may be asked to observe a colposcopy multi-disciplinary team (MDT) meeting. The service is asked to provide a list of MDT meeting dates immediately after the date of the QA visit has been confirmed to enable this to happen if it is required. Any changes to these meeting dates should be notified to SQAS immediately by the service.

Observation of administration practices

If required based on the evidence review, the S/QAA or other appropriate member of SQAS staff will arrange to visit the screening service in advance of the visit to examine colposcopy administrative practice. This will take place before the QA visit and SQAS will liaise with the screening service regarding when and where this visit will take place.

Review of evidence to inform the QA visit

The evidence is reviewed by the visit chair, lead S/QAA and PCAs

The lead S/QAA completes the context grid (summary document) and reviews the evidence with the visit chair (where applicable) to determine initial key lines of enquiry (KLOE). The final KLOE are agreed with the PCAs following the evidence review meeting.

The standing QA team

SQAS regional teams work with a defined group of PCAs who provide expert advice for cervical screening. These PCAs are known as the standing QA team. They support regional QA professional networking opportunities and form the QA visit team in addition to providing ongoing advice as required. Where necessary, PCAs are expected to join other regional teams undertaking QA visits.

Information for the QA visit team

The information pack includes:

• contact details of visiting PCAs
• list of screening service personnel
• agenda for the QA visit day (including details of venue and rooms booked)
• overview of the screening service (context grid where applicable)
• copy of last QA visit report and progress against action plan (where applicable)
• all documents submitted by the screening service, relevant to the PCAs professional area
• outcome of the observation of clinical practice and premises (where applicable)
• outcome of the observation of administration practice (where applicable)
• data relating to performance of the screening service
• results of annual prioritisation exercise
• QA visit report template
• SQAS evidence summary table

The information pack is available at least 4 weeks before the QA visit.

The SQAS evidence review summary document will be provided to the visit chair, PCAs and portfolio lead (where they are not the visit chair) 2 weeks before the QA visit.

Briefing for visit chair, PCAs and S/QAA

The QA visit team meets either before or on the day of the QA visit and will:

• introduce the members of the QA visit team
• give PCAs an accurate overview of the main elements of the screening service
• initiate discussions and highlight potential areas of concern
• triangulate initial findings from pre-visit evidence review such as KLOEs generated by the PCAs and SQAS
• make sure the visiting QA team are aware of their roles and responsibilities

The laboratory ‘specimen journey’ and ‘colposcopy clinic walkthrough’ at the main hospital site will take place on the day of the QA visit and will form part of the QA assessment of these areas. These will be arranged prior to the QA team meeting at the beginning of the day or during the professional discussion session as appropriate.

QA visit day

Presentation from the screening service

The cervical screening provider lead (CSPL) or designated representative is asked to give a short 10 to 15-minute presentation which outlines the service, including:

• changes since the last QA visit
• activity
• achievements
• any challenges or particular issues

Individual interviews

Each PCA ideally meets their professional counterpart(s) in the screening service. The PCA uses the interview to help determine whether national screening standards are met. They may also assess the relationships within the screening service.

The PCA summarises the discussion, feeds back the main issues and checks for mutual understanding at the end of the interview.

Preparation for feedback sessions

The QA visit team meets to discuss and triangulate the findings from interviews. They focus on areas of risk, recommendations and shared learning. Findings are summarised and fed back to the screening service.

Feedback sessions

Feedback on the day may be given in 2 sessions.

The visit chair and S/QAA meet with the provider CE(s) and NHSEI PHCT representative, for example SIL, to give a verbal summary of risks, high level findings and recommendations. This session may be used to raise concerns regarding performance of an individual or concerns for patient safety which would not be appropriate to raise in a wider audience.

This session usually, but not always, takes place before the main feedback session and is likely to last no longer than 15 minutes.

All interviewees are invited to the main feedback session where the visit chair gives a summary of the main findings and recommendations. All screening service staff and invited stakeholders are welcome to attend.

Senior management representatives of the provider trust/organisation(s), CE (s), CCG representatives (where applicable), NHSEI PHCT representatives and other stakeholders identified by the screening service are also invited to attend this session. Directors of public health (DoPH) or their nominated representative can be invited to attend by the PHCT.

The feedback session highlights:

• areas for shared learning
• risks
• high level recommendations
• the intention to publish the executive summary of the QA visit report on GOV.UK

This feedback session usually lasts no longer than 30 minutes.

Where immediate safety concerns are raised the S/QAA informs the RPL. Within 2 working days the RPL writes to the CE of the screening service and the lead commissioner outlining the main concerns and required actions. The letter is copied to the regional head of QA (RHQA) and to the national lead SQAS. PHE screening division director and national programme manager may also be informed. The provider is asked to send a written response with 7 working days.

Where urgent recommendations are made, the RPL writes to the programme manager and commissioner within 2 working days outlining the main concerns and required actions. The provider is asked to send a written response within 14 working days with an action plan to resolve the urgent recommendation within 3 months or sooner.

Post QA visit

Feedback questionnaire

Screening services are asked to complete online feedback questionnaires to evaluate the QA visit process and provide feedback for SQAS to help improve processes.

QA visit report

The QA visit team submits a summary of their findings to the lead S/QAA within 1 week of the QA visit (or earlier as agreed). The lead S/QAA produces a draft report for factual accuracy checking by the screening service and commissioners within 30 working days of the QA visit. Day 1 is the first working day after the QA visit takes place.

The final report is completed within 10 weeks of the QA visit.

The QA visit report is completed using the agreed report template, written in plain English and conforms to the PHE style guide. It includes:

• summary descriptions of screening service organisation and leadership arrangements
• comments on the adequacy of resource, accommodation, and equipment to meet national screening standards
• areas of shared learning
• variance from national screening standards
• strengths and weaknesses within the screening service
• recommendations to address issues identified and improve quality

Circulation of the final report

A copy of the report is sent via email (copying in the CSPL) to:

• provider CE(s)
• NHSEI PHCT representative, for example SIL and the head of public health commissioning (HoPHC)

The CE and SIL are asked to share the report with relevant colleagues including those in the local health economy and public health centres who have a responsibility for screening services. Details of where the executive summary will be published is shared.

Unless consent is withdrawn, the executive summary of the QA visit report is published on the GOV.UK website 8 weeks after the final report is issued (18 weeks after the QA visit).

Where consent is not given SQAS will publish an acknowledgement that a QA visit took place to the named provider however consent to publish the executive summary was declined. A similar note is placed on GOV.UK if NHSEI commissioners decline publication.

The full report can be requested by a member of the public using a Freedom of Information request and may be released by PHE if requested.

Action plan

SQAS supports the screening service and commissioner through the action planning process.

SQAS specifies the evidence used to check whether screening services have met nationally agreed screening standards and any statutory or national guidance or guidelines that apply at the time of the visit.

Recommendations are written so that action plans can be developed. They include the evidence needed to show the action is complete and the criteria for closure.

Timescales for recommendations should be specific, with clear completion dates.

It is the responsibility of the NHSEI PHCT SIL (the commissioner) to make sure the recommendations made in the QA visit report are implemented. It is the responsibility of the screening service to develop an action plan to address the recommendations made.

The action plan is agreed with the SIL or HoPHC within 4 weeks of receipt of the final report. It is good practice for this to be submitted to the next screening service programme board or equivalent governance structure within 3 months of the QA visit.

The SIL makes sure progress against the action plan is maintained using relevant commissioner oversight mechanisms and levers. SQAS should be kept informed via screening service programme boards and direct contact with the providers and commissioners.

SQAS works with commissioners to monitor activity and progress in response to the recommendations for 12 months from receipt of the final report. This enables enough time for at least one response to all recommendations. SQAS sends a letter to the provider CE and commissioners summarising progress made and asking for their direct intervention to address any remaining issues.

Escalation process

SQAS escalates if progress against recommendations is not made. Initially this is through the screening service programme boards or equivalent governance structure and NHSEI PHCT including to the HoPHC where necessary.

Training and development

All staff taking part in QA activity have training related to the role. SQAS staff and PCAs should have the skills and knowledge needed to address inequalities. The training requirements for professional and clinical advisors are set out in the relevant role outlines which are available from SQAS.

Continuous improvement

SQAS is committed to improving processes and measuring the impact of QA. SQAS therefore requests feedback from screening services and commissioners on the QA process and QA visit. Feedback will be requested within 2 weeks via an online Select Survey following the QA visit. Feedback received is shared in relevant forums, or individually where applicable, to improve the QA process.

Purpose and scope

The PSOM outlines the agreed QA process for the NHS CSP. SQAS staff and any professional and clinical advisors (PCAs) supporting the SQAS team must follow the PSOM to make sure the approach to QA is consistent across all screening services.

Cervical screening QA begins with the identification of eligible women and includes sample taking, human papilloma virus (HPV) testing, 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.

A sub-set of high-level standards for the cervical screening programme were published in 2018. SQAS also collects information to monitor the standards and guidelines covered by national programme guidance documents.