Equality impact assessment: risk stratification in the NHS Cervical Screening Programme

Question 1

Background information about screening

Accepted Answer

Screening is the process of identifying people who are asymptomatic (have no symptoms) but who have an increased risk of developing a disease or condition. NHS screening programmes are an efficient and proven method for early diagnosis while minimising false positive and negative results as much as possible.

Results from screening include the possibility of a false positive or false negative result. This means each individual should be supported to understand what the benefits and risks of screening are and decide for themselves whether to accept or not. This is referred to as making a ‘personal informed choice’.

Early detection for some conditions has real benefits, with individuals identified as being at greater risk of developing a condition being supported to take preventative interventions or treatments to reduce their likelihood of becoming unwell. For those where a condition is detected, individuals can make informed decisions around their treatment. Early detection is likely to make any required treatment more effective and therefore lead to better health outcomes.

The UK National Screening Committee (UK NSC) is a scientific advisory committee that advises ministers across the UK on all aspects of screening, including evidence-based modifications to existing programmes.

Question 2

The NHS Cervical Screening Programme in England

Accepted Answer

The NHS in England offers cervical screening to all women and people with a cervix aged 24 and 6 months to 64 (the first invitation is sent out at age 24 and 6 months to help ensure the first screening appointment can happen by age 25). For this EIA the age range for the NHS CSP is referred to as age 25 to 64.

Anyone with a cervix and within the screening age range is eligible for NHS cervical screening regardless of their gender identity.

The NHS CSP in England provides the opportunity for eligible people aged 25 to 64 to be screened routinely to detect cervical cell abnormalities at an early stage. The aim of the programme is to reduce the number of people who develop invasive cervical cancer and reduce the number of people who die from it.

Cervical screening does not test for cancer; it helps to detect the risk of developing cervical cancer. This is because since December 2019, the primary screening method (the first test carried out on the screening sample) has been to check for high-risk human papillomavirus (hrHPV) which causes nearly all cervical cancers. For the rest of this EIA, the term HPV (human papillomavirus) will be used to refer to hrHPV.

A negative screen for HPV means that the chances of developing cervical cancer within 5 years are very small. It can take decades for HPV infection to develop into cervical cancer. Previously, eligible people were offered cervical screening:

every 3 years at ages 25 to 49
every 5 years at ages 50 to 64

Eligible people who attend for cervical screening on or after their 60th birthday will be automatically removed (ceased) from screening recall if their last test result is normal with routine recall and they have had no recent abnormal results. This is because their next routine test would be due after their 65th birthday.

Anyone aged 65 or older continues to be offered screening if one of their last 3 screening tests was abnormal. Someone aged 65 or older can also have screening if they have not been tested since the age of 50. Anyone who tests positive for HPV is invited for annual screening until they test negative. If they are still HPV positive at their third consecutive test, they are referred to colposcopy.

A person may be eligible for cervical screening but have circumstances which affect their ability to consent to the test, or which affect the sample taker’s ability to obtain a sample. Special circumstances which require individual consideration are described in NHS guidance on ceasing and deferring women from the NHS Cervical Screening Programme.

In most instances a person should only be ceased from call and recall (not receive further screening invitations) if they agree to this. Once ceased, they are then managed in the same way as people who choose to withdraw from screening.

Policy change to the NHS Cervical Screening Programme

In February 2019, UK NSC recommended a modification to the NHS CSP to stratify screening by risk, allowing longer intervals between screens for people without HPV and shorter intervals for those with the virus.

HPV testing is a more accurate and sensitive screening test (than the previously used cytology-only test), which detects the risk of developing cervical cancer before it develops. Therefore, UK NSC recommended screening people based on their individual risk rather than just their age. This means screening people who are HPV negative (and therefore with a very small risk of developing cervical cancer over the next 5 years) less frequently, and screening those who are HPV positive more frequently.

This policy change means:

extending screening intervals from 3 to 5 years for people aged 25 to 49 who have an HPV negative result as part of their routine screening
implementing 12-month surveillance recall for people aged 25 to 49 who are found to be HPV positive and cytology negative (this was implemented in 2019 with primary HPV testing)
implementing a 12-month recall for people who are found to be HPV positive and cytology negative at their final screen aged 64 - people who are still HPV positive at this follow-up appointment are referred to colposcopy (this was implemented in 2019 with primary HPV testing)

It is important to reiterate that people who test positive for HPV are already followed up with yearly testing and referral to colposcopy if HPV is persistent. This is vital to ensure that individuals are monitored for any early signs of cervical abnormalities and provided with any necessary treatment.

This recommendation is based on the outcomes of studies demonstrating that the use of HPV testing as a primary screening test compared with cytology reduced the risk of developing cervical cancer through increased sensitivity for underlying disease.^{[footnote 1]}^{[footnote 2]}

Scotland adopted this approach in March 2020 and Wales in January 2022. The Health Minister in Northern Ireland has approved the approach, but this can only be implemented once their new screening IT call and recall system is in place.

Question 3

Policy objectives

Accepted Answer

For individuals, this policy means the timeframe for inviting people back is based on their risk of developing cervical cancer. It means some people will have the test less often. This reduces potential harms such as unnecessary follow-up tests and treatment, and anxiety that can occur from having cervical screening. Evidence suggests that extending the intervals between cervical screening invitations would also be beneficial in reducing pressure on primary care, by shifting resources to better reflect the balance of risk.

This policy change may also contribute to NHS England’s ambition to eliminate cervical cancer by 2040, by releasing resource within primary care to focus on improving screening uptake among people aged 25 to 49, and for those who are more at risk of developing cervical cancer because they are HPV positive.

There could also be an increase in coverage for the programme. Eligible people aged 25 to 49 who are HPV negative would be required to attend screening less often and therefore may be more likely to accept screening when the offer is made. In addition, eligible people who currently do not engage with the cervical screening programme (and who therefore may be at higher risk of developing cervical cancer) may choose to attend screening if appointments are less frequent (every 5 years instead of every 3).

This programme modification means a more consistent approach to cervical screening across Great Britain, considering Scotland and Wales have already implemented this programme change.

Impact on the public

This change affects anyone eligible for cervical screening in the younger cohort - that is, those aged 25 to 49 who test HPV negative. The screening pathway will be changed so that HPV negative individuals will be screened less frequently, with screening intervals extended from 3 to 5 years. Those who test HPV positive in the younger cohort will remain on the current pathway (therefore will not be affected by this programme modification) and will have annual screening and any necessary treatment.

The older eligible cohort for screening (ages 50 to 64) will not be affected by the risk stratification changes to the cervical screening programme because their screening intervals are already every 5 years.

When planning for the implementation of HPV primary screening (the initial testing of screening samples for HPV), NHS England established relationships with the relevant professional bodies and trade unions that support the cervical screening workforce in laboratories. NHS England will utilise professional body relationships and NHS forums for engagements with trade unions, to ensure that the cervical screening workforce are well informed of any potential workforce implications of the change to 5-year intervals prior to implementation.

Impact on NHS staff

The following categories of NHS staff may be affected by the changes.

GP practices

The implementation of extended screening intervals may impact on general practice ability to receive Quality and Outcomes Framework (QOF) payments for cervical screening. Any changes to the cervical screening QOF indicators will need to be agreed as part of the annual amendments to the General Medical Service contract, which are negotiated by NHS England and the British Medical Association’s General Practitioners Committee (GPC). With the reduction in workload for cervical screening, there is an opportunity for better targeting of interventions to understand communities in order to increase uptake of cervical screening in these groups.

The NHS Extended Screening Intervals Implementation Task and Finish Group is in discussion with the NHS England Primary Care Group to co-ordinate internal governance approvals, prior to the commencement of discussions with the National Institute for Health and Care Excellence (NICE) and the GPC to agree any changes which would take effect in 2027 to 2028.

Screening sample takers

Sample takers are health professionals who carry out cervical screening. The modelling of screening activity (the number of cervical screening samples taken) reflects the workload of sample takers.

NHS England’s modelling predicts a decline in screening activity in years 4 and 5 following implementation of increased screening intervals. This is because a high number of people aged 25 to 49 screened in year one of the changes (who would normally be due again in year 4) will not be due again until year 6 if HPV negative. Activity would pick up again in years 6, 7 and 8 before declining again in years 9 and 10. This pattern would repeat, but the decline will lessen over time due to the growing population in England.

Screening laboratories

NHS England awarded 5-year contracts to 8 cervical screening NHS laboratory providers starting on 1 April 2019. Extending screening intervals is unlikely to affect the current contractual arrangements unless these contracts are extended. The workload trend in cervical screening laboratories is already reducing due to HPV primary screening implementation. NHS England anticipates there will be further reductions overall with the revised intervals and variable workloads during implementation.

The Extended Intervals Implementation Task and Finish Group is working with NHS England’s regional public health commissioning teams to consider the impact of this, to determine what commissioning and contractual implications there are and what actions need to take place now and in the future.

Colposcopy services

Colposcopy volumes are expected to follow a similar pattern to sample-taking, but to a slightly lesser extent as they will include an ongoing element of symptomatic referrals throughout.

A review of colposcopy services by NHS England is underway and is focusing on a number of workstreams which aim to maximise capacity by:

sharing best practice in ways of working
improving staff training and retention
supporting appropriate referrals from primary care

In addition, an approach is being developed to appropriately audit and manage a cohort of participants within the surveillance pathway who remained HPV positive at their last cervical screening (at ages 60 to 65 years old). The aim of this is to release capacity in colposcopy services.

Question 4

Evidence

Accepted Answer

Until November 2019, cervical screening was based on cytology. However, the causative role of hrHPV together with the introduction of the HPV prophylactic vaccination programme constitute a powerful rationale for switching to primary HPV screening and reserving cytology for HPV positive samples. This was supported by 4 large European randomised trials, from which a subsequent pooled analysis confirmed that, compared with cytology, HPV screening better reduces the risk of developing cervical cancer. One of these trials, the ARTISTIC trial, was conducted in England.

All of these trials compared cytology with cytology plus HPV testing, with interventions for HPV positive, cytology negative women. In all 4 trials the HPV arms showed a reduction in the detection of CIN2+ in the second screening. This was as a result of greater sensitivity achieved by HPV testing in the first screening. CIN2+ is a cervical intraepithelial neoplasia - a premalignant lesion that can progress to cervical cancer.

The 4 trials involved over 176,000 women with a median of 6.5 years of follow up. They showed clear evidence of a reduction in the incidence of cancer in the HPV arms of the trial compared with cytology alone.

In the ARTISTIC trial, the cumulative rate of CIN2+ over a mean of 6 years was 1.41% (95% confidence interval (CI) 1.19% to 1.65%) for negative cytology at baseline compared with 0.87% (95% CI 0.70% to 1.06%) over 6 years for negative HPV. The corresponding data for CIN3+ (CIN3+ is cervical intraepithelial neoplasia which if not treated can spread to nearby normal tissue) was 0.63 (95% CI 0.48% to 0.80%) for negative cytology compared with 0.28 (95% CI 0.18% to 0.40%) for a negative hrHPV test.

These studies were therefore able to report that primary HPV screening offered the prospect of greater sensitivity for the detection of underlying disease compared with cytology. The studies also suggested longer protection for those people who test HPV negative.

UK NSC review

To explore the cost effectiveness of extended screening intervals, UK NSC referred to a model commissioned by the NHS CSP. This was undertaken by a team based in Public Health England and the London School of Hygiene and Tropical Medicine. Compared with the modelled primary cytology 3-year protocol (current practice), the modelled primary HPV 5-year interval protocol was expected to:

lead to a 17% decrease in primary screens, while providing a 14% increase in detection of cervical intraepithelial lesions of grade 2 or worse (CIN2+)
lead to a median decrease in cervical cancer incidence of 159 cases per year and reduction in cancer-related deaths of 54 per year
reduce net health-related costs by £35 million per year

A review of international modelling exercises found that these results were in keeping with other models exploring comparable issues.

Following discussion with the cervical screening programmes in the 4 UK countries, UK NSC recommended:

an expanded 5-yearly screening interval for women testing HPV negative
a 12-month surveillance (recall) interval for women testing HPV positive with cytology negative
that people with persistent HPV infection and negative cytology should undergo 2 surveillance tests - if still HPV positive at the second surveillance test they should be referred to colposcopy irrespective of cytology result

UK NSC hosted a 3-month public consultation exercise which closed in January 2019. Comments were requested on the policy proposal, with 21 stakeholder organisations also contacted directly about the consultation. A total of 13 responses were received.

Across the responses there was a broad consensus on the proposal for a 5-year primary screening interval and the proposal for 2 surveillance tests at 12-month intervals for people found to be HPV positive.

Views diverged on the management of women whose results remained HPV positive and cytology negative at the second surveillance test. It was acknowledged that there was a very limited evidence base relating to this point in the pathway, and that the proposed strategy to offer colposcopy to all would be a conservative strategy. However, there was also concern that the positive predictive value of colposcopy would be low, and that cytology triage may be a realistic and equally safe approach. In addition, there was interest in the use of genotyping and other markers to stratify risk at this point in the pathway. Across the responses there was interest in monitoring and evaluating any strategies that were implemented to manage persistent HPV positive and cytology negative results.

HPV primary screening pilot in England

A 2021 study of 1.3 million women from the English HPV primary screening pilot sites found that those aged 25 to 49 were less likely to develop abnormal changes of the cells known as CIN3+, and cervical cancer, 3 years after a negative primary HPV screen compared with a negative primary cytology test. The study suggests that following the introduction of HPV testing for cervical screening, a 5-year interval is at least as safe as the previous 3-year interval.

Question 5

Analysis of impacts

Accepted Answer

Disability (learning and physical)

Guidance on reducing inequalities in screening shows that in general, people with a learning disability, autism or both are less likely to access screening. Research also shows that women with learning disabilities are less likely to participate in cervical screening compared with those without learning disabilities.^{[footnote 3]}

People with severe mental illnesses are 30% more likely to die from cancer than the general population. One reason for this may be low uptake of nationally offered cancer screening tests by people with mental illness.^{[footnote 4]}

A 2018 report by Public Health England on inequalities in screening uptake by people with severe mental illness found that people with severe mental health issues are:

18% less likely to have participated in breast screening
20% less likely to have participated in cervical screening
31% less likely to have participated in bowel screening

Guidance for health professionals to support people with a learning disability or autism to access screening is available, and can be used to help improve uptake in the NHS CSP. This publication includes guidance and resources for local screening providers, commissioners and other partners to help reduce barriers to screening.

A survey of cervical screening for women with physical disabilities by Jo’s Cervical Cancer Trust, answered by 335 women with a physical disability or physically debilitating symptoms as a result of a long-term health condition, found that:

88% said it is harder for women with physical disabilities to attend or access cervical screening
63% said that they have been unable to attend cervical screening because of their disability
49% said that they have chosen not to attend cervical screening in the past for reasons such as previous bad experiences related to their disability or worries about how people might react

Contractually, providers of NHS screening services are required to make reasonable adjustments to ensure that their services are accessible to people with disabilities. If someone requires specialist equipment, providers must ensure that they have access to its use in a safe environment. Guidance on reasonable adjustments to screening programmes sets out how providers may make adjustments for people to help support them to access screening.

Stratifying cervical screening by risk means that anyone eligible for screening who is aged 25 to 49 and tests HPV negative, including those with physical and learning disabilities, mental health issues and autism, will be offered screening every 5 years instead of every 3. Being screened less frequently may benefit some individuals who have anxiety about having screening.

An updated easy-read version of the cervical screening leaflet and invite will be available to communicate the interval changes in the NHS CSP.

Working in partnership with NHS England’s mental health and learning disability teams and ‘expert by experience’ panel, NHS England will seek to directly communicate the change by:

co-developing a range of audio and visual resources, including posters, social media assets, video message and visual display unit (VDU) assets, to clearly communicate the benefits of cervical screening and when to attend (the intervals)
making these assets available to NHS and public health teams on the FutureNHS collaboration platform, Comms Link and the Campaigns Resource Centre, and promoting them through NHS England bulletins and updates (register and log in to the FutureNHS website in order to access material)
sharing relevant assets on NHS.UK and NHS England social media channels, and the experience panel’s own Facebook group
working with stakeholders such as Equally Well UK, National Autistic Society, Mencap and the British Institute of Learning Disabilities to communicate the need for cervical screening and explain the intervals
seeking to run a patient case study piece in disability magazines such as Disability Horizons and Able Magazine
providing information in NHS England’s public-facing bulletin Engage

Alongside this, NHS England will work with their staff Disability and Wellbeing Network (DaWN) to communicate the benefits of cervical screening to people with a wide range of disabilities. In addition to using NHS England’s internal communications structure to convey the message, it will use blogs from people with disabilities to explain the importance of cervical screening and what steps people can take if they are nervous or concerned about it.

To ensure both paid and unpaid carers are aware of the change and supporting information resources, NHS England will:

add notices in the NHS England primary care bulletin, mental health and learning disability and autism bulletin, leader’s update and community bulletin
work with NHS England’s social care team to liaise with stakeholders such as Care England and Carers UK
seek to publish a short notice on the Department of Health and Social Care’s Care Workforce app

Sex

Women and people with a cervix aged 25 to 49 will be affected by this programme modification and will be recalled for screening according to risk. Those who are HPV negative will be screened every 5 years (rather than every 3 years). Those who are HPV positive will continue to have annual screening up to a maximum of a third consecutive HPV positive test, at which point they will be referred to colposcopy for assessment.

Women and people with a cervix aged 50 to 64 are already invited for cervical screening every 5 years and will not be affected by this risk stratification.

People whose sex is assigned as male at birth are not eligible for this screening programme as they do not have a cervix.

Sexual orientation

Lesbian, gay and bisexual people are more likely to have had negative experiences of using healthcare systems^{[footnote 5]} and may be less likely to attend cervical screening.^{[footnote 6]}^{[footnote 7]} The LGBT+ Cervical Screening Study (1,158KB, PDF) published in 2021 shows that 15% of lesbian and bisexual women aged over 25 have never had a cervical screening test compared with 7% of women aged over 25 in general.

This lower uptake is partly due to the misconception that women who only have sex with women do not require cervical screening tests. However, nearly all cases of cervical cancer are associated with HPV. This is passed on by skin-to-skin contact through any type of sexual activity, including activity between women.

Possible reasons for this lower uptake are highlighted in a cervical screening awareness campaign report by the LGBT Foundation (3,834KB, PDF) which found that 37% of lesbian and bisexual women had been told at some point that they did not need cervical screening because of their sexual orientation. In some instances, this information had come from healthcare professionals. The study found 14% had been actively refused or discouraged from having cervical screening by a healthcare professional as a result of their sexual orientation.

NHS England plans to develop a communications campaign with targeted information for GP practices and other cervical screening providers, sample takers, laboratories and colposcopy clinics which will support the overall aim of improving access and uptake to cervical screening for eligible transgender (trans) and non-binary people.

NHS England is also planning a national communications campaign to follow the introduction of the new Cervical Screening Management System (CSMS) which is due to replace the existing call and recall system currently delivered through the Open Exeter and National Health Application and Infrastructure Services (NHAIS) system. NHAIS is the current platform used in the NHS in England, Wales and the Isle of Man to manage primary care registration and administration of cervical screening. This communications campaign will inform both people eligible for screening (women, people with a cervix who identify as male (including transgender men) and non-binary individuals with a cervix) and healthcare professionals across the screening pathway that there is an opt-in function. It will be used as a ‘call to action’ to encourage individuals to attend their GP practice to discuss opt-in with a healthcare professional. The opt-in solution was well received and supported by the British Medical Association (BMA) General Practitioners Committee in September 2023.

To help improve uptake of cervical screening NHS England has:

developed clearer messaging about who is eligible for cervical screening, and will ensure this is included in leaflets and invitation letters for cervical screening
ensured NHS England and NHS.UK social media channels continue to share patient case studies to emphasis why cervical screening is for everyone with a cervix; this included Anne, a woman in a long-term lesbian marriage, who recently attended cervical screening and was found to have HPV with associated cervical cell changes

To help communicate the change to cervical screening intervals, and any future changes to support people to register for cervical screening, NHS England will:

work with charities to co-develop a patient-centred editorial for use on social media and in the press, and share messaging
work with NHS England’s LGBTQ+ staff network and organisations such as LGBT Foundation to share messaging around the importance and frequency of cervical screening
share stories across NHS England and NHS.UK social media channels and share relevant materials with the NHS.UK website
co-develop a suite of resources (posters, social media assets, email footers, VDUs) that NHS and public health teams can use to promote cervical screening to everyone with a cervix - including people who do not identify as female, and people in same sex or bisexual relationships or not in a sexual relationship
add relevant content to the FutureNHS collaboration platform, Comms Link and Campaigns Resource Centre
use the Pride movement to raise awareness of the need for cervical screening
share links to the materials on NHS England communication channels such as the primary care bulletin, NHS leaders bulletin, integrated care board (ICB) bulletin, community bulletin and the public-facing bulletin Engage

Race

There are known barriers to accessing healthcare for certain racial groups. Women from Black, Asian and minority ethnic backgrounds are less likely to attend cervical screening than White British women.^{[footnote 8]} Black women are less likely to be diagnosed via screening for cervical and breast cancer, and are most likely to be diagnosed through emergency presentation for ovarian and cervical cancer compared with other ethnicities.^{[footnote 9]} Research has indicated that that Gypsy, Roma and Traveller populations across Europe experience significantly worse health outcomes when compared with majority populations.^{[footnote 10]}

While this policy change of moving from 3 to 5 year screening intervals will not have a direct positive or negative impact on these groups of women, overall mitigations should be considered to increase uptake for cervical screening in these groups.

To improve uptake of cervical screening among ethnic groups, NHS England has or plans to:

broadcast an interview across Asian and Black radio stations on cervical screening during cervical cancer awareness week in 17 to 23 January 2024, including clear lines on eligibility and how to access screening
publish editorials in Asian, Black and Polish UK-based media with clear lines on eligibility and how to access screening
use NHS England and NHS.UK social media channels to share patient case studies to emphasis why cervical screening is for everyone (with a cervix and within the eligible age range)
use diverse patient-led stories and imaging across all of its cervical screening resources and editorial, working closely with charities
provide access to translated cervical screening invites

To help communicate the change to screening intervals NHS England will:

provide translations of the updated cervical screening information leaflet and invitation letter in 30 common languages, based on data from the 2021 Census
work with NHS England’s Muslim, Christian and Jewish staff networks and important stakeholders such as the National Association of Boat Owners, Friends, Families and Travellers charity, British Islamic Medical Association, Kashmir Development Foundation, Caribbean & African Health Network, Cancer Black Care and faith organisations to share messaging around the importance and frequency of cervical screening
share stories across NHS England and NHS.UK social media channels and share relevant materials with NHS.UK
co-develop a suite of resources including translations (posters, social media assets, email footers, VDU assets) that NHS and public health teams can use to promote cervical screening to everyone with a cervix including people who do not have a GP or NHS number
add new assets to FutureNHS collaboration platform, Comms Link and the Campaign Resources Centre
use South Asian Health Heritage month, Black History Month and Cervical Screening Awareness week to raise awareness of the need for cervical screening
share links to the materials in the primary care bulletin, NHS leader’s bulletin, community bulletin and the public-facing bulletin Engage
create a toolkit to help the NHS, public health professionals and Home Office and Voluntary, Community and Social Enterprises (VCSEs) to promote cervical screening to people who are experiencing homelessness, or are refugees, asylum seekers or trafficked people

People who have emigrated to the UK from abroad may not have registered with a GP and may therefore be unaware of services they are entitled to. This could create an obstacle to their uptake of screening services. In addition, groups who do not speak English as their first language are also less able to access health services due to language barriers. Research looking at language as a barrier to healthcare found that people who do not speak English report greater barriers in accessing primary care than those who do, have a poorer patient experience and are more likely to be in poor health.

Language barriers may impact people’s ability to make an informed choice about having screening, and some people may have difficulties understanding why the interval between cervical screening tests has changed.

To help people to make an informed choice in the current NHS screening programmes, information leaflets, invitation letters and videos are available on other languages, and will be updated when risk stratification to the cervical screening programme is implemented. The NHS cervical screening leaflet information is available on GOV.UK, and the number of languages this information is translated into will increase to 30.

Ethnicity data

NHS England has identified collecting ethnicity data and mapping it against Index of Multiple Deprivation data as a priority for all cancer screening programmes. The introduction of the new CSMS will provide an opportunity in this regard. It is important to raise awareness about the importance of recording ethnicity, disability or other reasons meaning an individual may require additional support with any service change, including extending intervals. The rollout of CSMS will allow ethnicity data to be collected and published and will enable local regions to understand which sub-groups of the population to focus on to improve uptake rates.

Age

UK NSC recommended that a 5-year screening interval should be implemented for people aged 25 to 49 years who test HPV negative at their routine screening appointment.  Women under the age of 25 are not eligible for cervical screening and therefore will not be affected.

Uptake of cervical screening in the younger age cohort (ages 25 to 49) is generally lower than that of the older age cohort (ages 50 to 64). In 2022 to 2023, national coverage for individuals registered as female aged 25 to 64 was 68.7% compared with 74.4% for women aged 50 to 64.^{[footnote 11]}

Stratifying screening by risk will mean anyone aged 25 to 49 who screens HPV negative will be re-screened every 5 years instead of every 3. Being screened less frequently may benefit some individuals who have anxiety regarding the screening process.

However, it could also have the opposite effect. It could signal to younger women that HPV screening is not as important as it is now only being offered every 5 years. This, coupled with the fact that women who have received the HPV vaccine may (mistakenly) believe they do not need to be screened, could actually lead to lower uptake than before. Communication around the change will need to be carefully crafted to ensure that the continued importance of screening is clearly conveyed.

Current communications should focus on the importance of having both the HPV vaccine and cervical screening when offered, as part of the overall ambition to eliminate cervical cancer by 2040. This NHS England ambition can only be achieved if people come forward for their HPV vaccine and their cervical screening when invited. While the change in intervals as a result of improved testing means people who test HPV negative are at very low risk of getting cervical cancer over the next 5 years, it is still vital that they come forward at those 5-yearly intervals as their HPV status may have changed during that period (due to changes in sexual activity, sexual partner and so on).

A communications plan has been developed by NHS England and activity will focus on reassuring the public about the rationale for the changes. This will involve working with partners (Department of Health and Social Care (DHSC), UK NSC and the UK Health Security Agency (UK HSA)), external stakeholders (Macmillan, Cancer Research UK (CRUK) and royal colleges) and NHS England’s operational teams and providers (GP practices and sexual health services). Messaging will focus on reassurance around the reasons for the change in screening intervals and will be developed using insight with tactical communications activity aimed at:

the public: working with partners to ensure the public, particularly people who are eligible or about to be eligible for cervical screening, are aware and reassured about the reasons for this change, and working with the media and using social media to ensure the narrative around the change is on message (taking on the learning from the Welsh experience)
the system: preparing and supporting commissioners and providers to enact the interval change consistently and effectively, including ensuring they have supporting communication materials
stakeholders: using expert and trusted voices to support and amplify the reasons for the changes

In the future there may be further stratification of the cervical screening programme. In England there is a universal HPV immunisation offer for all children aged between 12 and 13 years (born after 1 September 2006). UK NSC has commissioned a modelling exercise to consider the long term future of the NHS CSP. This focuses on whether screening for cervical cancer remains a useful intervention in the presence of an HPV vaccination programme in terms of disease reduction and cost effectiveness.

Opportunities to promote the sensitivity and effectiveness of HPV testing in cervical screening are already being used. NHS England has used this messaging within communications activity for various awareness days, and will continue to do so to lay the foundations for explaining the rationale behind the change in intervals.

Messaging will continue to focus on:

the reasons for the change - why it has already been introduced in other countries and is the screening interval for people aged 50 to 64 in England
why the same number of cancers will be prevented with fewer screens where people test negative for HPV

The latest insight work will be used to develop communications messages by NHS England. There are opportunities to work with The Lowdown (a research platform for women’s health), and with social media influencers to improve understanding around HPV and the cervical screening offer.

Cervical screening prevents cervical cancer because it can find and remove abnormal cells before they have a chance to turn cancerous. Cervical cancer usually develops very slowly. It is estimated that it takes between 10 and 20 years for HPV infection to develop into abnormal cervical cells, and then on into cervical cancer. As cervical cancer develops so slowly, it is highly unlikely that women aged over 64 who have been regularly screened will go on to develop the disease.

If someone’s final 3 screening tests in the 15 years running up to turning 65 have had normal results (HPV negative), they will not receive any further invitations past the age of 64. Anyone who has had an abnormal screening result (HPV positive) in that time will continue to be invited for screening until they either have 3 tests showing no abnormal cells or have a clear (negative) HPV test.

If a woman or person with a cervix aged over 64 has never had cervical screening, or has not had screening since the age of 50, they are entitled to be screened. They can make an appointment with their local GP practice.

Women under 25 are not routinely offered cervical screening. Evidence shows that cervical cancer is rare in women younger than 25. Changes in the cells of the cervix can, however, be common in this age group, with the changes often returning to normal and being less likely to develop into cancer. Evidence shows that screening people under the age of 25 leads to unnecessary treatment and worry. In addition, since 2008 the HPV vaccination programme has been underway for teenagers, which will greatly reduce the risk of cervical cancer in women and people with a cervix when they are older.

Gender reassignment (including transgender)

Every person who has a cervix and is within the screening age range of 25 to 64 is eligible for NHS cervical screening regardless of their gender identity.

Transgender men and non-binary people assigned female at birth who are registered with a GP and who still have a cervix are recommended to have cervical screening to help prevent cervical cancer. Transgender men and non-binary people assigned female at birth who have had a total hysterectomy (including removal of the cervix) do not need cervical screening.

Transgender men still registered as a female on GP records and who have a cervix are automatically included in the screening programme and will be invited for screening at appropriate intervals unless they choose to opt out of the programme.

However, a transgender man who is registered as male with their GP will be taken off the screening programme call and recall system. They will need to ask their GP to be added back in to receive regular invitations.

Transgender women or non-binary people assigned male at birth do not need cervical screening as they do not have a cervix.

Research into attitudes of transgender men and non-binary people to cervical screening showed that these groups have lower uptake of cervical screening. According to a report compiled by Stonewall (referred to in a 2021 CRUK blog post), 1 in 4 (25%) of LGBT people have faced a lack of understanding for their specific health needs by healthcare staff. The number rises dramatically to more than 3 in 5 (60%) for trans people. And 1 in 6 (16 %) trans people said they have been refused a healthcare service because of being LGBT.

Screening invitation IT systems currently rely on the sex an individual is registered as in their GP record and cannot routinely identify if a person’s gender is different to the biological sex they were assigned at birth. The current system means that trans men registered with a GP as male will not receive automatic invitations and will need to proactively request cervical screening from their GP. The new CSMS will enable individuals to opt in and be more easily identified to ensure that eligible individuals are offered the correct screening at the right time (so trans men with a cervix, registered as male with their GP, can be routinely invited for cervical screening).

There is no reason to believe that the screening interval change from 3 to 5 years for those aged 25 to 49 will have any direct positive or negative impact on the experience of transgender people other than what is already described above.

NHS screening information for trans and non-binary people is available on GOV.UK. Further information on cervical screening for trans men is available on NHS.UK.

As outlined above, NHS England is planning a national awareness campaign delivering targeted communications to this specific cohort to support them to receive screening and provide reassurance for a positive experience, following the delivery and implementation of the CSMS.

To improve uptake of cervical screening, NHS England has:

developed clearer messaging about who is eligible for cervical screening and will ensure this is included in leaflets and invite letters for cervical screening
worked with NHS.UK social media channels to share patient case studies to emphasis why cervical screening is for everyone with a cervix

To help communicate the change in intervals, and any future changes to allow people to register for cervical screening, NHS England plans to:

work with its LGBTQ staff network and organisations such as LGBT Foundation to share messaging around the importance and frequency of cervical screening
share stories across NHS England and NHS.UK social media channels and share relevant materials with NHS.UK
co-develop a suite of resources (posters, social media assets, email footers, VDU assets) that NHS and public health teams can use to promote cervical screening to everyone with a cervix, including people who do not identify as female, and people in same sex or bisexual relationships or not in a sexual relationship
use the Pride movement to raise awareness of the need for cervical cancer screening
share links to materials in the primary care bulletin, NHS leader’s bulletin, ICB bulletin, community bulletin and the public facing bulletin Engage

Religion or belief

Analysis of NHS data for England showed that areas with the largest Muslim populations had, on average, a 12% lower uptake of cervical screening in the year leading up to July 2022 compared with areas with the smallest Muslim population.^{[footnote 12]}

There is also evidence that uptake of cervical screening is low among immigrant women, particularly Muslim women, because of barriers related to religious values, beliefs and fatalism.^{[footnote 13]}

NHS England has stated that faith and religion can have a huge impact on people’s willingness to take up cervical screening, HPV vaccination and on them accessing support if they are found to have HPV. Identified issues included:

shame and embarrassment regarding the actual screening process
the view that screening was unnecessary if married
shame around sexual relationships outside marriage
shame relating to HPV infection

These are themes that NHS England plans to tackle in public facing editorials and social media.

NHS England plans to work with organisations such as the British Islamic Medical Association and Kashmir Development Foundation to raise awareness about cancer screening programmes including cervical screening. For example, to help Muslim women to feel more welcome and able to access cervical screening, the NHS in Bolton worked with local mosques to provide cervical screening information and appointments.

For more information, see also the section on ethnicity above.

Pregnancy and maternity

Women who are pregnant are not eligible for cervical screening. They become eligible for screening again usually 12 weeks after the pregnancy has ended. This is because pregnancy can make it harder to get clear results from the cervical screening test. In some cases, where a woman has had a previous abnormal result from a cervical screening test, they may need to be screened while pregnant and this will be under the guidance of their maternity care team.

Women aged 25 to 49 with children may find it difficult to attend cervical screening appointments due to childcare responsibilities or arrangements. However, extending the screening interval from 3 to 5 years may help improve uptake as having to arrange a screening appointment around childcare would be less frequent.

Marriage and civil partnership

There is no evidence to suggest that people who are married or in civil partnerships are disproportionately affected by this programme modification.

Other identified groups

People in inclusion health groups such as sex workers or those with drug or alcohol dependence are less likely to attend cervical screening and therefore are at higher risk of presenting to the health system with symptomatic cervical cancer. Understanding the risk for those individuals by healthcare professionals, particularly in primary care, is very important. This can be mitigated by healthcare professional training and having healthcare communications specifically targeted to these groups.

Summary

A range of improvements and innovations have been brought in to improve uptake across the whole NHS CSP. In some primary care network areas, cervical screening appointments can now be made:

in any primary care setting, rather than just at the person’s own GP practice where they are registered
during evenings and on weekends
through integrated sexual health clinics

Other initiatives from NHS England to improve uptake and reduce inequalities include:

increasing access by expanding delivery through new delivery settings, including women’s health hubs and community diagnostic centres
strengthening the workforce capacity through the wider use of digital histopathology, digital cytopathology and remote cytology reporting
upskilling and retraining the screening and cytology workforce in primary care and secondary care settings to meet medium to longer-term demand and improve uptake
ongoing awareness-raising covering a systematic review of public information materials to ensure materials are impactful and informative, working with partners on communications campaigns aligned to programme changes and other related opportunities and the development of a cancer elimination communications toolkit
improved digital capabilities including implementation of the CSMS, integrated IT systems, national SMS (text) reminders and potential digitisation of letters and leaflets
CSMS opt-in for trans men and non-binary people
rollout of the HPV self-sampling in-service evaluation
revised screening letter templates based on insight work
continued delivery of local outreach activities

Question 6

Engagement and involvement

Accepted Answer

UK NSC consulted in January 2019 on the proposal to extend the screening intervals from 3 to 5 years for women with HPV negative screening results - 21 organisations were contacted directly. These were:

The British Association for Cancer Research
British Association for Cytopathology
British Association of Surgical Oncology
The British Society for Colposcopy and Cervical Pathology
Cancer Research UK
Faculty of Public Health
Jo’s Cervical Cancer Trust
Macmillan
Northern Ireland Cancer Network
Royal College of General Practitioners
Royal College of Nursing
Royal College of Nursing - Women’s Health Forum
Royal College of Pathologists
Royal College of Physicians
Royal College of Physicians and Surgeons of Glasgow
Royal College of Physicians of Edinburgh
Royal College of Radiologists
Royal College of Surgeons
Royal College of Surgeons of Edinburgh
Society and College of Radiographers
Cervical Screening Programme Advisory Group

Public Health England commissioned King’s College London to undertake 2 research studies into the public’s acceptability of extending screening intervals. These studies were published in December 2020.^{[footnote 14]} The main finding was that an increase in screening intervals was supported when the reasons behind it were explained.

Considerable engagement activity was undertaken by UK NSC in their work to make the recommendation for extended screening intervals. NHS England has not repeated this activity but has engaged with stakeholders when operationalising this policy change.

Stakeholder engagement

A ‘lessons learned’ workshop was held between DHSC and NHS England with Scotland and Wales on their experience of announcing the extension to intervals from 3 to 5 years in the cervical screening programme.

Main stakeholders including Cancer Research UK and the Royal College of Obstetricians and Gynaecologists were engaged with the development of this policy change and are supportive of the changes. These organisations have previously provided reassurance on the rationale and safety of the changes when they were implemented in Wales and Scotland. They have also advised that currently, it is difficult to provide reassurance on safety of the extension to intervals due to the difference in the cervical screening programmes between England, Scotland and Wales. The implementation of the programme modification in England will address this inconsistency.

Question 7

Summary of analysis

Accepted Answer

The policy change will only impact women and people with a cervix age 25 to 49. The impact is that some of this cohort will be screened less frequently. While there is a small risk that this policy change could cause initial anxiety (due to not understanding the rationale for the change), the experience in Scotland has been that when the policy is explained clearly, including the clinical reasons for the change, people are reassured that it is a positive change. There is no indication that people with any protected characteristic will benefit or suffer more than any other from this change.

Overall impact

There is very little overall impact from this change other than potentially a positive one with people needing to attend an invasive screening test less frequently.

Addressing the impact on equalities

We do not believe that this change will have a major impact on equalities. However, DHSC works closely with NHS England to address the wider issues of health disparities within screening programmes.

Monitoring and evaluation

Screening programmes are a Secretary of State delegated function under section 7A of the NHS Act 2006 as amended by the Health and Social Care Act 2012. Quarterly meetings between DHSC and NHS England are used to monitor the delivery of the programme against key performance indicators (KPIs). Work is ongoing to develop new KPIs for the NHS CSP with one of these to focus on inequalities.

Equality impact assessment: risk stratification in the NHS Cervical Screening Programme

Applies to England

Background information about screening

The NHS Cervical Screening Programme in England

Policy change to the NHS Cervical Screening Programme

Policy objectives

Impact on the public

Impact on NHS staff

GP practices

Screening sample takers

Screening laboratories

Colposcopy services

Evidence

UK NSC review

HPV primary screening pilot in England

Analysis of impacts

Disability (learning and physical)

Sex

Sexual orientation

Race

Ethnicity data

Age

Gender reassignment (including transgender)

Religion or belief

Pregnancy and maternity

Marriage and civil partnership

Other identified groups

Summary

Engagement and involvement

Stakeholder engagement

Summary of analysis

Overall impact

Addressing the impact on equalities

Monitoring and evaluation

Is this page useful?

Help us improve GOV.UK

Help us improve GOV.UK

Cookies on GOV.UK

Applies to England

Background information about screening

The NHS Cervical Screening Programme in England

Policy change to the NHS Cervical Screening Programme

Policy objectives

Impact on the public

Impact on NHS staff

GP practices

Screening sample takers

Screening laboratories

Colposcopy services

Evidence

UK NSC review

HPV primary screening pilot in England

Analysis of impacts

Disability (learning and physical)

Sex

Sexual orientation

Race

Ethnicity data

Age

Gender reassignment (including transgender)

Religion or belief

Pregnancy and maternity

Marriage and civil partnership

Other identified groups

Summary

Engagement and involvement

Stakeholder engagement

Summary of analysis

Overall impact

Addressing the impact on equalities

Monitoring and evaluation

Is this page useful?

Help us improve GOV.UK

Help us improve GOV.UK