NHS population screening: identifying and reducing inequalities
Guidance and resources to support providers and commissioners in reducing screening inequalities.
Applies to England
Overview
All eligible people should be able to access NHS population screening programmes and understand the potential benefits and harms of screening tests in ordered to make an informed choice. However, variation in participation exists both within and between national screening programmes.
Barriers can result in some people being unable to maximise the benefits of screening. And people at higher risk of the conditions being screened for are generally less likely to participate.
Health inequalities are avoidable and unfair differences in health status between groups of people or communities. They can occur at any of these points along the screening pathway:
- cohort identification (invitation)
- provision of information about screening
- access to screening services
- access to treatment and onward referral
- outcomes
Health inequalities exist across a range of dimensions or characteristics.
There are 4 dimensions of health inequalities:
- the 9 protected equality characteristics described in the Equality Act 2010
- socioeconomic factors, for example, low incomes, high levels of unemployment or living in deprived areas
- socially excluded and vulnerable groups, for example, people not registered with a GP, Gypsy, Roma and Traveller communities, homeless people and sex workers
- geographical variation, for example, variation between urban and rural areas
Each of these dimensions overlap, as shown in the illustration below adapted from the Health Equity Assessment Tool (developed by Public Health England (PHE)), so that individuals experience inequalities because they fit within one or more of the groups.
Screening provider responsibilities
The NHS England Standard Contract Service Condition 13 (SC13) outlines the contractual requirements for equity of access to services, equality and the avoidance of discrimination.
Under the Equality Act 2010, the Health and Social Care Act 2012 and the Public Services (Social Value) Act 2013, NHS screening providers have a legal duty to make sure screening services are accessible to everyone, including people with one or more protected characteristic.
The responsibilities for all providers are set out in the inequalities section of the Population screening: pathway requirements supporting information.
Inequalities strategy
The national screening inequalities strategy supports local screening services, commissioners and others involved in the provision of screening to address inequalities.
The strategy emphasises the importance of ensuring equitable access to screening services and supporting people to make an informed choice about participating in screening.
Guidance, resources and shared learning
Access national guidance and resources to support local providers, commissioners and other partners in reducing screening inequalities.
These publications include guidance for health and social care professionals and easy read resources for people with learning disabilities.
Identifying inequalities
The first stage in addressing screening inequalities at local or regional level is to identify the inequalities that exist within the screening pathway. This is essential to know where and how to target action, and to identify interventions to improve access to services and outcomes.
National standards are agreed and set to support the quality and performance of the NHS screening programmes. Local services can use screening data to identify inequalities in the pathway and where improvements are needed to reduce barriers and address variation.
Review at a local level of performance by population group (see section 2 of Our approach to NHS population screening standards) may indicate inequity in participants entering and completing the screening pathway, or accessing services within optimal timescales.
Health equity audits (HEAs) examine how health determinants, access to relevant health services and related outcomes are distributed across the population.
Screening providers and commissioners should use the NHS population screening health equity audit (HEA) guide to help:
- identify groups less likely to participate in screening
- assess health inequalities related to screening services
- identify possible actions to help reduce inequalities
The screening HEA guide is designed to be used in conjunction with the wider Health Equity Assessment Tool.
E-learning for the PHE Health Equity Assessment Tool (HEAT) is also available.
Local screening providers should have procedures in place to identify and support people who are considered vulnerable or underserved, including but not exclusive to:
- people who are not registered with a GP
- homeless people and rough sleepers
- asylum seekers
- Gypsy and Traveller groups
- people in prison
- people with mental health conditions
- people with drug or alcohol harm issues
- people with learning disabilities, physical disabilities or communication difficulties
- non-English speakers
- sex workers
Providers should comply with safeguarding policies and good practice recommendations for such people.
Providers should include appropriate cohorts of local armed forces personnel and their dependents who are registered with defence medical centres within their responsible population boundaries.
Providers should involve service users in the development and evaluation of services whenever possible. This should include representation from service users reflecting the local community, including those considered vulnerable or underserved.
Reducing inequalities
There is a range of national cross-programme and programme-specific screening information and guidance to support providers, commissioners and other partners in reducing screening inequalities.
Cross-programme screening inequalities guidance and information includes:
- summary of systematic review evidence of interventions aimed at improving screening participation in underserved groups
- guidance on the effective use of text message reminders
- Population screening: supporting people with learning disabilities
- guidance on improving access to screening for people with severe mental illness
- screening information for trans and non-binary people
- Population screening: reducing inequalities in secure settings
- NHS population screening: support for carers
Screening incidents can occur throughout the screening pathway. Providers should review and learn from incidents to identify actions required to improve services and reduce inequalities.
The NHS Equality and Health Inequalities Hub is designed to provide support to the NHS, and beyond, in promoting equality and tackling health inequalities for all patients, communities and the NHS workforce. It brings together equality and health inequalities resources and provides useful links and information for the sharing of good practice.
Inclusion health: applying All Our Health summarises the principles of inclusion health and social inclusion. It includes guidance for health professionals on action they can take to make sure socially excluded people can access and benefit from the services they need.
Health inequalities: reducing ethnic inequalities has guidance on action to reduce health inequalities related to ethnicity.
Local action on health inequalities: improving health literacy explains how health literacy contributes to health inequalities because population groups most at risk of low health literacy are also known to have the poorest health outcomes. It includes action local healthcare providers and other stakeholders can take to improve health literacy and reduce health inequalities.
Reasonable adjustments
Screening providers have a legal duty to make reasonable adjustments to make sure services are accessible to everyone, including people with disabilities.
Providers must follow the Accessible Information Standard by law. The standard aims to make sure people who have a disability, impairment or sensory loss are provided with information they can easily read or understand with support, so they can communicate effectively with health and social care services.
As part of the Accessible Information Standard, providers should:
- ask people if they have any information or communication needs, and find out how to meet those needs
- record those needs clearly and in a set way
- highlight or flag a person’s file or notes so it is clear they have information or communication needs and how these are met (see more information on the reasonable adjustment flag)
- share information about people’s information and communication needs with other providers of NHS and adult social care, when they have consent or as permitted by law
- take steps to ensure people receive information which they can access and understand, and communication support if they need it (see national resources on screening access to help meet this requirement)
Providers should use appropriate interpreter services for people who have specific communication needs, for example if English is not their first language or if they have a hearing impairment.
Accessible information
There are national easy guide versions of screening information leaflets (listed as part of the screening access for all resource) and screening appointment letter templates for people with learning disabilities, people with low levels of literacy and others who find easy read information helpful. Providers should use these national materials when inviting individuals for screening who have been identified as benefiting from information in an easy read format.
People with sight loss can access the digital web page versions of standard information leaflets on GOV.UK using screen reader technology. Providers can also advise people with sight, hearing, motor or cognitive impairments that they can adjust settings on mobile devices to make it easier to read digital publications. Step by step instructions are available on the AbilityNet website.
Providers should direct any individual requests for hard copy Braille versions of national screening leaflets to the screening helpdesk.
Programme-specific guidance
Abdominal aortic aneurysm (AAA) screening
Read guidance for AAA screening providers, commissioners and other stakeholders on sharing learning and good practice in reducing barriers to attendance
Antenatal and newborn (ANNB) screening
Antenatal and newborn screening: identifying and reducing inequalities has guidance to support ANNB screening providers and commissioners in addressing inequalities throughout the screening pathway.
Bowel cancer screening
Bowel cancer screening: helping people with learning disabilities has information for health professionals to support eligible people with learning disabilities to access and understand bowel cancer screening.
Breast screening
Breast screening: identifying and reducing inequalities has guidance and shared practice for breast screening providers, commissioners and other stakeholders on addressing inequalities throughout the screening pathway.
Cervical screening
Cervical screening: supporting women with learning disabilities has information for health professionals to support eligible people with learning disabilities to access and understand cervical screening.
Cervical screening: support for people who find it hard to attend has guidance for people who find it hard to attend cervical screening due to having a mental health condition, or having experienced trauma or abuse.
Cervical screening: ideas for improving access and uptake has guidance to help primary care, commissioners and local authorities plan and evaluate initiatives around cervical screening coverage in their area.
Last updated 24 February 2022 + show all updates
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Addition of link to Cervical screening: ideas for improving access and uptake in Programme-specific guidance section
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Addition of link to summary of systematic review evidence on interventions to improve screening participation in underserved groups.
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Added link to pathway requirements publication and a diagram of overlapping dimensions of health inequalities.
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Added link to Breast screening: identifying and reducing inequalities guidance.
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Added link to 'Antenatal and newborn screening: identifying and reducing inequalities' and 'Cervical screening: support for people who find it hard to attend'.
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First published.