A new report from Healthcare Improvement Scotland has prompted a call for ‘significant changes’ to better deliver a person-centred cervical screening service.

Following 2020-21 audit which identified that two women who had been mistakenly excluded had subsequently developed cervical cancer, the Scottish government commissioned Healthcare Improvement Scotland to review the cervical screening programme. 

These women had a subtotal hysterectomy, wherein some cervical tissue remains and therefore should have been included in the cervical screening programme and invited for their screening.

Now published, the review found that despite a ‘very committed workforce’ in place across the cervical screening programme, there are many issues within the management of exclusions. 

Exclusions from the programme can be temporary or permanent and the invitation process for screen is managed by the Scottish Cervical Call Recall System (SCCRS) which will not contact those who are no longer eligible.

When a cervical screening is deemed inappropriate for a certain timeframe, e.g. pregnancy, a temporary exlusion should be in place to postpone screening invitation.

Permanent exclusion means a person will no longer receive an invitation or reminder and is reserved for if they do not have a cervix, including patients who have undergone a total hysterectomy.

Longstanding weaknesses

The review identified there were a number of instances prior to 2020 where people were incorrectly excluded from the programme and a failure to address the risks associated with this and implement solutions.

A key reccomendation from the review is to inform and consult patients excluded from a screening appointment, meaning they should be made aware and invited to question the decision if they believe that they should not be excluded.

An expert group was convened to carry out the review, with an independent chair external to Healthcare Improvement Scotland.

One of the report’s main findings was that the systems, processes and governance arrangements around the management of exclusions from cervical screening require significant changes, with longstanding weaknesses in the management of exclusions from cervical screening and a ‘failure to fully recognise the risks’ associated with exclusions.

The review’s independent chair, Dr Karin Denton, Consultant in Cellular Pathology with the North Bristol NHS Trust, says these weaknesses must now be addressed:

“We know that the cervical screening programme in Scotland saves lives. It’s important that confidence in the system for calling women to be screened remains high.

“Our review identified a hard-working and committed workforce, but also longstanding weaknesses in the system that need to be addressed to ensure that everyone eligible for a cervical screening test is called.

“We are confident that the recommendations in this report, if implemented, will help to ensure that the system meets the needs of women in Scotland.”

The review team focused on how the system used to invite women to be screened managed exclusions, looking at over 2,000 documents and holding group meetings with those involved in the programme.

From this, their report states that there was ‘little evidence’ of actively engaging women in the design, development and delivery of exclusions in the national cervical screening programme, adding.

Additionally, it states that the impact on women of the decision and process to exclude them was not fully understood or considered at a national level – with permanent exclusions not routinely monitored and no benchmarking in place.

Implementing change

The report calls for a clearly documented process to be implemented, including minimum critera for exclusions, monitoring procedures, failsafes for if something goes wrong in the screening processes, communication of decisions, and governance arrangements.

Additionally, it states that a rolling national training programme for the SCCRS should be developed and delivered for all involved in the cervical screening programme – and regularly reviewed.

The review identified confusion among key organisations delivering cervical screenings – including National Services Scotland, NHS boards and primary care providers – around who is responsible for monitoring and reporting exclusions.

The report states that this responsibility needs to be clarified and procedures surrounding the IT system for recalling patients for cervical screening should be reviewed.

Some of the healthcare professionals spoken to during the process of review felt the recall procedures for patients screening appointments and IT system were confusing and complex.

The team has urged the Scottish government to decide which organisations and governance groups should take forward and implement specific recommendations made in the report.

To do so, they have suggested the government convenes an expert working group to explore specific actions, assign these actions with timelines and to monitor the delivery.

Iona Stoddart, Deputy Head of Information and Engagement with the charity Jo's Cervical Cancer Trust, said:

“This report is very welcome and the recommendations will ensure the programme is more suited to individual patient needs, and is as effective and safe as possible.

“We urge for them to be swiftly implemented. Cervical screening can stop cervical cancer before it starts so it is an incredibly important test. If your test is overdue, I encourage you to book it in or if you have questions our free Helpline is on 0808 802 8000.”

Read more: Microwaves offer less invasive cervical cancer therapy; Cervical cancer unit to treat patients in 30 minutes; Pandemic impact on cancer incidence in Scotland; All cancer patients to access extra support by 2024

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