Introduction
1.1 – Policy Statement
The aim of our cervical screening programme is to reduce the incidence of cervical cancer by promoting its screening. In collaboration with Public Health England (PHE) we provide a reliable system for calling and recalling all women who are eligible for cervical screening based on the NHS Cervical Screening Programme Good Practice Guide No.2 (July 2011).
The % of patients aged from 25 to 64 whose notes record that cervical smears have been performed in the last five years. We should be hitting at least 80% of patients.
Policy and Processes
2.1 – Effective Administration
CQC GP mythbuster 104: Cervical screening advises that effective administration is a key part of the cervical screening pathway, and that every organisation must have a reliable cervical screening system that includes:
- Standard operating procedures and detailed work instructions that follow guidance on the national screening programme
- Routine review of the prior notification list (PNL) to identify who should be invited, and non-responder lists to follow up people who have not attended
- Processes to ensure that:
- All tests are transported safely to the laboratory
- A result is received for each test
- The appropriate action is taken based on the result of the test
- Samples are not repeated within three months to avoid being rejected
- A programme of audit and non-conformance monitoring is in place, including regular review of performance data for individual sample takers
2.2 – Call and Recall Process
The practice cervical screening programme is managed by PHE, who communicate direct with patients. PHE will send the practice a Prior Notification List (PNL) which we will then check and verify that the women listed are indeed eligible for the Cervical Screening Programme. This will then be returned to PHE. The GP or PN must authorise the PNL if a woman is removed from the list for any other reason than moved away.
Each smear taker is responsible for ensuring that the results are back for all the smears they have done and that relevant follow up has been initiated.
The call and recall service must send all PNL lists to GP practices 70 days prior to the individuals’ NTDDs. The programme recommends these are sent electronically to the practices. When the PNLs are returned, the call and recall service should process any requests for an update within five working days.
2.3 – Eligibility and Screening Intervals
NICE advises that cervical screening is available for people with a cervix as follows:
| Age | Type and frequency of screening |
| 24.5 years of age | The first invitation is issued to ensure that the screening test can be completed by their 25th birthday |
| 25 – 49 years | Recall every three years (with invitations issued 34.5 months after the previous test) |
| 50 – 64 years | Recall every five years (with invitations issued 58.5 months after the previous test) |
| 65+ years | Invited if a recent cervical cytology sample is abnormal and/or they have not had a cervical screening test since 50 years of age and they request one |
2.4 – Withdrawing from Screening
Individuals have the option to voluntarily withdraw from the cervical screening programme and detailed information is available in the ceasing guidance. This guidance also includes information on the deferral process.
Patient information is available for those wishing to opt out of NHS screening programmes.
Colposcopists can also cease individuals in the following scenarios:
- Prior radiotherapy to the cervix
- Absence of the cervix
A template letter that can be sent to patients wishing to withdraw from the programme can be found at Annex A and a disclaimer template can be found at Annex B.
2.5 – Transgender (Trans) or Non-Binary people
A trans man or non-binary person registered as female who has a cervix will be automatically included in the screening programme. However, a trans man or non-binary person registered as male who has a cervix will not be invited for screening by the national screening programme. Therefore, screening invitations will need to be made manually by this organisation.
A trans man or non-binary person who wishes to withdraw from cervical screening does not have to mention their trans or non-binary status if they do not wish to (it is not necessary for anyone to provide a reason for withdrawing).
2.6 – Objecting to Data processing
Cervical screening: guidance for call and recall administration best practice states that people have a right to request that their data is no longer processed in the screening programme. However not all data can be removed as per Section 17 of the UK General Data Protection Regulations. Processing personal information is necessary to deliver a safe and effective screening service and is required even if a person has opted out of screening. Historical data held by NHS organisations may need to be retained (for example in case there is an incident and an affected individual needs to be told).
Requests to cease data processing must be sent to PCSE Patient Registrations Department to implement. Once received, the relevant details are notified to the call and recall service to enable the screening history to be deleted.
2.7 – Consent
At this organisation, the decision to attend for cervical screening rests with the person who is invited, and it is important that any decision a person with a cervix makes is informed. Consent must be recorded in the individual’s healthcare record.
Additional guidance can be found in the Cancer screening: informed consent document.
2.8 – Supporting Patients with Learning Disabilities
Screening uptake is lower in people with learning disabilities compared to the general population and this organisation has a legal duty to make reasonable adjustments for people with learning disabilities. There are a range of resources available for staff to enhance access, including guidance for health professionals on helping patients with learning disabilities to be screened for cancer.
Reception staff play a pivotal role in supporting people with a learning disability to access cervical screening. This guidance can help enhance the patient experience.
2.9 – Supporting Patients with Physical Disabilities
CQC GP mythbuster 104 explains that this organisation has a duty of care to ensure all eligible people have access to cervical screening. People with a disability may find it hard or impossible to attend for cervical screening. This may be because of:
- Lack of wheelchair access
- Problems getting onto the examination couch
- Previous misunderstanding, dismissal and negative experiences of cervical screening.
Should this organisation consider offering cervical screening during home visits, a risk assessment will need to be undertaken for each individual patient. This will ensure that the patient is supported by other services if treatment, follow up or referral is required.
2.10 – Chaperones
The organisation must make sure it provides care and treatment that ensures people’s privacy, dignity and always treats them with respect. It is important for sample takers to check a person’s preferences about their cervical screening. This could include asking if the patient would like a chaperone even if this question has been asked at reception or promoted by posters displayed.
2.11 – Cervical Screening Results
Individuals should expect to receive their results within 14 days from the date of the sample being taken. Results are sent directly to the individual sample taker and this organisation will also be notified of the results. Patients are to be advised that there are four possible results:
| Result | Comment |
| HPV negative | No further tests required |
| HPV positive: no abnormal cells | Patient will be called for screening sooner than usual (full details will be given in the result letter) |
| HPV positive: abnormal cells found | Patient will be referred for colposcopy |
| Inadequate result | Patient will be asked to attend for cervical screening in three months’ time |
2.12 – Recording Results
All results must be recorded in the individual’s healthcare record on the clinical system. For normal results, patients will be recalled in line with the NHS CSP. For abnormal results, patients will be managed as detailed in the cervical screening care pathway.
It is the responsibility of the nominated individual to ensure all results are accurately recorded on the clinical system using the correct SNOMED CT codes.
Failsafe Arrangements
3.1 – Overview
A failsafe arrangement is a means to ensure that, should something go wrong, there are processes in place to identify the issue(s) and timely actions are taken to resolve these thereby ensuring a positive outcome.
The failsafe process for newly registered individuals is that if the individual’s screening history has not been received by call and recall within 21 days of registering in England, a ‘failsafe’ NTDD is set.
To comply with the service specification, this organisation is required to:
- Include appropriate failsafe mechanisms across the whole screening pathway
- Ensure routine staff training on failsafe procedures takes place
- Maintain a record of tests taken
- Check that results are received from the laboratory for every sample
- Ensure individuals whose samples they report will be notified of results (either by the organisation, the colposcopy clinic or the call and recall service)
- Ensure the required colposcopy referrals are made and outcomes recorded
- Ensure that the colposcopy service is responsible for informing the call and recall service regularly of the next test due date by completing the discharge template for all women discharged from colposcopy
- Act on non-responder notifications
- Respond to failsafe enquires from the laboratory
- Report incidents in line with screening incident guidance
Staff Competency, Responsibilities and Training
4.1 – Training
The practice will fully comply with all requested for training and mandatory updates required by the Cervical Screening Programme. All smear takers attend refresher training as routine.
4.2 – Sample Taker Responsibilities
Sample taker responsibilities are outline in the Guidance for acceptance of cervical screening samples in laboratories and pathways, roles and responsibilities document at Section 4.
Audit
5.1 – Requirement
There is a requirement to audit the cervical screening process within this organisation every two years. The audit will include the following information:
- Title
- Reason for the audit
- Criterion or criteria to be measured
- Standard(s) set
- Preparation and planning
- Results
- Description of change(s) implemented
- Reflections
An audit template can be found at Annex C