Guidance

NHS Cervical Screening Programme: the role of the cervical screening provider lead

Published 26 March 2018

1. Introduction

All organisations (NHS or private and standalone services) must have a cervical screening provider lead in place (formally called a hospital based programme co-ordinator) if they provide one or more services for:

• cervical cytology and high risk human papillomavirus (hrHPV) testing
• colposcopy
• cervical histopathology

The cervical screening provider lead (CSPL) is a senior member of staff formally appointed within an organisation providing cervical screening services. They have delegated responsibility from the Chief Executive. Their role is to oversee and co-ordinate the quality and effectiveness of the NHS Cervical Screening Programme (NHSCSP) services provided within the organisation. CSPLs also play a vital role in the audit of invasive cervical cancers and in ensuring that the individual elements of local programmes work together to provide the best possible service and outcomes for women.

The delivery of the CSPL role must remain consistent and effective across screening services and organisational boundaries. This document outlines the requirements of the role, accountability and governance within the organisation and working relationships across organisational boundaries.

2. Requirements of the role

The organisation providing cervical screening services is responsible for identifying and employing an individual who is competent to undertake this role. CSPLs must have a thorough knowledge and understanding of the NHSCSP pathways. They should also be of sufficient seniority to be comfortable with discussions at board level, and have appropriate skills to be able to effect change and escalate concern in what can be challenging circumstances.

The CSPL will be employed by the organisation providing services to the NHSCSP. The responsibilities of the role within that organisation are common and not dependent on which individual undertakes the role. Persons likely to be able to fulfil the role include:

• consultant cellular pathologists
• non-training grade experienced senior colposcopists or consultant colposcopists
• laboratory lead biomedical scientists (BMS) or consultant BMS
• senior nurse colposcopists or lead colposcopy nurses

The CSPL role must be included in the individual’s job description, and a job plan produced identifying dedicated time required to fulfil the role. As a minimum this would equate to one programmed activity or one half day per week. The time commitment is the same regardless of who fulfils the role. Time allocation will need to be assessed in terms of the scope and complexity of the services provided. For example, an organisation providing all NHSCSP services across multiple sites, and colposcopy referrals to other trusts, will require additional time for the role. An organisation providing histology and, or colposcopy services only should ensure that there is an appropriate time allocation as the role will require regular communication with off-site screening services providing other elements of the screening pathway.

A named deputy who should satisfy the above requirements should also be nominated to cover periods of annual leave and sickness absence. Tasks that are considered to be administrative by the CSPL may be delegated to appropriate individuals and this must be formally recognised in their job description. Designated administrative or secretarial assistance is required to support the CSPL in carrying out their responsibilities.

3. Accountability

Accountability for the CSPL role is ultimately to the Chief Executive of the NHSCSP provider organisation, but may be through a nominated deputy at board level, independent of the post-holder’s directorate.

The CSPL will be required to communicate with and escalate concerns to appropriate executive level directors responsible for cancer, women’s services, pathology and/or governance. The CSPL should have access to the medical director and appropriate oversight boards or groups such as the organisation’s overall governance committee.

To avoid conflicts of interest, the CSPL must be accountable for this specific role outside of their departmental accountability structure. For example, a consultant BMS undertaking the role could be accountable to the medical director rather than the clinical head of pathology; or the lead colposcopist could be accountable to the medical director rather than the clinical director for gynaecology.

A formal annual appraisal which incorporates the CSPL role must be undertaken by someone in a position to be able to discuss all aspects of the CSPL role covered, for example activities covering both laboratory and colposcopy. If it is necessary for the appraisal for the CSPL role to be performed separately this must feed into the individual’s main appraisal.

4. Working relationships and continuity of services across organisational boundaries

The CSPL is responsible for maintaining close working relationships between all parts of the provider’s cervical screening activities and with NHS England and other stakeholders. The CSPL should also ensure close working relationships are maintained with other CSPLs across the screening pathway to provide continuity across the programme.

The CSPL will have working relationships with:

• divisional boards
• the medical director or chief executive
• leads for gynaecology, colposcopy, cytology, histopathology and virology
• business management
• contracting personnel
• governance and risk personnel
• legal personnel
• the Public Health England (PHE) Screening Quality Assurance Service (SQAS)
• NHS England’s screening and immunisation teams
• community and sexual health clinics
• primary care

Issues arising in an organisation that have, or have the potential to, affect the quality of the programme in another organisation should be discussed between the relevant CSPLs. Actions should be agreed to rectify problems through appropriate departmental leads. Ongoing or serious issues should be reported to SQAS for advice and escalated to provider clinical governance committees.

5. Roles and responsibilities

CSPLs must be employed in organisations with any of the following combinations of cervical screening services:

• cytology and hrHPV testing
• cytology and hrHPV testing, colposcopy and histopathology
• cytology and hrHPV testing and colposcopy
• cytology and hrHPV testing and histology
• colposcopy and histopathology
• colposcopy alone
• histopathology alone

The CSPL role will be defined to some extent by the services provided. The following sections describe the overarching roles and responsibilities that apply to all CSPLs.

5.1 Quality and performance

The CSPL will:

• monitor the quality and effectiveness of the services provided by the organisation according to NHSCSP standards and guidelines and take appropriate action to address any shortfalls or escalate appropriately
• ensure there is timely collection and submission of data for national mandatory statistical returns and data for routine and ad hoc programme monitoring for NHS England commissioners, SQAS and other organisations
• review data relating to the services provided by the organisation and monitor performance against both nationally and locally agreed standards
• report to the appropriate screening and immunisation team(s) (SITs) and local cervical screening programme boards any aspects of the programme which do not meet nationally and locally agreed standards
• report to clinical governance committees on the performance, achievements and significant issues related to the cervical screening programme within the organisation
• produce an annual performance report and 6 monthly update to cover all NHSCSP services provided for the organisation’s main clinical governance committee (this will also feed into local cervical screening programme boards): the report should relate to the laboratory and, or colposcopy based aspects of the service carried out, as agreed with and required by cervical screening commissioners and SQAS
• ensure all new cases of invasive cervical cancer diagnosed in women referred to the provider for investigation (from any source) are registered and audited in accordance with current NHSCSP guidelines
• play an important role in the SQAS visit process for all aspects of the programme that are provided by the organisation, ensuring that any recommendations are addressed in a timely manner and responding with evidence of achievement to SITs and SQAS
• ensure that operational policies and quality management systems are implemented across the programme (in conjunction with clinical and operational leads)
• oversee effective failsafe systems for all women referred to colposcopy, in line with the requirements set out in NHSCSP guidance
• contribute to the agreement of the cervical screening contract specification with NHS England and ensure implementation
• oversee that effective systems and IT links are in place to feedback colposcopy attendance and histology outcomes to the screening laboratory

5.2 Attendance at meetings

The CSPL will:

• attend local cervical screening programme board meetings chaired by the SIT and feed back to provider colleagues
• attend regional SQAS meetings and feed back to colleagues
• organise and chair a quarterly trust cervical screening management meeting (see section 6.1)

A report must be requested from the associated laboratory service to feed into the quarterly management meeting in organisations where there is no screening laboratory and/or histology laboratory.

5.3 Incident handling

The CSPL will:

• ensure that the provider and its staff are aware of the guidance for managing NHS screening incidents and the process to follow
• implement processes to ensure that screening safety concerns are notified to the CSPL
• ensure all screening safety incidents are notified to SQAS and recorded and investigated according to NHS screening and local organisational policy
• ensure that recommendations are implemented and lessons learned shared
• be a member of any incident panel if a serious incident relating to the cervical screening programme is identified

5.4 General audit and training

The CSPL will:

• be involved with and support the scheduling or programming of relevant cervical screening audits covering clinical and administrative or procedural activities in colposcopy, histopathology and hrHPV testing or cytology as required (depending on which services are provided)
• ensure all staff working in the NHSCSP have access to appropriate and mandatory training and development - this must include information governance training as specified by the NHS and the screening programme’s confidentiality and disclosure policy (organisational systems must be in place to monitor this)
• attend NHSCSP approved CSPL training if they are new to the role or requiring further development to support them in achieving the competencies required

6. Meetings

6.1 Provider cervical screening management meetings

The CSPL is responsible for organising quarterly provider management meetings to discuss:

• routine data submissions to NHS England teams and SQAS
• performance against standards
• patient surveys
• risks and incident reporting
• staffing issues
• new guidance
• audit
• sample taking within the organisation
• service development
• action on recommendations arising from SQAS QA visits and other QA activities

The CSPL within the organisation will chair the meeting and ensure it is appropriately documented. Where applicable (according to local variance), the meeting should include representation from the:

• CSPL (Chair)
• lead cytopathologist and BMS in cervical cytology
• lead virologist or microbiologist if hrHPV testing is provided in this department
• cytology or hrHPV testing service if off site or provided by another organisation
• lead histopathologist
• lead consultant colposcopist
• lead colposcopy nurse
• sexual health clinical lead (if any element of screening service is provided by the organisation)
• directorate managers with responsibility for laboratory, colposcopy and sexual health services (where provided)

The organisation’s cervical screening management committee should have appropriate terms of reference and report into the organisation’s overall clinical governance group.

6.2 Colposcopy multidisciplinary case discussion meeting

The CSPL at the organisation providing the colposcopy service is responsible for ensuring that multidisciplinary case discussion meetings take place according to NHSCSP guidance.

The CSPL will oversee the arrangements for these meetings, in particular that appropriate representation is achieved. This may involve communication with other organisations to enable representatives for cytology or histology to attend in person or by video link, skype or similar.