the need for a more proactive approach
In October 2019, the Independent Review of Adult Screening Programmes in England released its full report, praising the NHS’s adult screening programmes, but noting that uptake of screening services is falling or stagnating in many cases. Chloe Kent looks into the report’s recommendations for organisational reshuffling and improved digitisation.
ollectively, screening programmes currently cost over £660m each year to deliver. Through these programmes, patients are able to understand more about their current state of health and check themselves for serious illnesses, with screenings often helping detect cancers and other conditions in their early stages when they’re more treatable.
However, uptake for many screening services is poor in England – only around half of eligible patients are undergoing the bowel procedures they’re invited to, while breast and cervical screening rates are stagnating.
The final report of a review into adult screening programmes by the NHS’ first cancer director and former Care Quality Commission chief inspector of hospitals Professor Sir Mike Richards was published in October 2019. Originally intended to look solely at cancer screening, the review ended up expanding to consider all adult screening programmes in England, as part of a new NHS drive for earlier diagnosis and improved cancer survival.
The programmes reviewed were for abdominal aortic aneurysm, bowel cancer, breast cancer, cervical screening and diabetic eye conditions.
Initial publicity upon publication of the report focused heavily on proposals to increase the flexibility of screening appointments.
Bluecrest Health Screening managing director Peter Blencowe says: “If you’ve got something that is easy to access, that is nearby, that you can slot into your diary without having to take time off work, you're far more likely to take it up than if you have to take time out of your day or travel a long distance.”
However, it’s the suggested changes to the governance of the programmes that could have the most fundamental change in the way they operate.
Currently, the UK National Screening Committee makes recommendations on national population screening programmes – such as those for bowel, breast and cervical cancer – while the National Institute of Health and Care Excellence (NICE) makes recommendations on targeted screening for people at elevated risk of serious conditions.
Richards has advised combining the responsibilities of these bodies into one centralised agency. Said body would make recommendations to ministers in all four countries in the UK. English funding decisions regarding targeted screening would be made by ministers and supported by the chief medical officer and chief scientific adviser, rather than relying on local commissioning.
Furthermore, oversight of delivery of all aspects of screening would fall solely to NHS England, should the recommendations of the report be followed. Currently, this responsibility is split between NHS England and Public Health England, creating a divide between organisational and quality assurance teams and hampering close working between the two.
In order to maintain the independence of quality assurance teams in reporting any issues, Richards has also recommended that quality assurance reports on local services should routinely be published and should be made available to the local CQC.
In the report, Richards said: “I have repeatedly been asked: who is in charge of screening? Who is accountable for improving uptake for maintaining IT systems, for preventing and addressing incidents and undertaking quality assurance? What are the benefits of having multiple organisations responsible for these different aspects?
“The answer is often not obvious, and the result has been that changes to programmes which would have led to more lives being saved have been slow to be implemented.”
Weak digital infrastructure
Another major call to action in the Richards report concerns the challenges posed by the NHS’ IT systems, which he describes as “woefully out of date”.
High-profile administrative failures recently saw almost half a million women fail to be invited to their final appointment of a breast screening programme and failure to provide nearly 50,000 women with information about cervical screening. Screening programmes rely heavily on being able to identify eligible individuals quickly and efficiently, as well as being able to manage their follow-up appointments if any anomalies are detected, and Richards has welcomed the recent decision for NHSX to take overall responsibility for replacing these systems.
Blencowe says: “When we set up Bluecrest, we looked at what IT systems we could use ourselves. In actual fact, there wasn't anything off-the-shelf. Screening is such a complicated area. We had to build something bespoke from scratch.
“I can only imagine what it must be like in an organisation such as the NHS, you must have lots of different legacy systems and if you've got lots of different systems all operating separately it can be hard to join them all together in the same way that that we have aimed to.”
As the digital health infrastructure is improved, the report has also endorsed the digitisation of the invitation and reminder process. Patients’ mobile phone numbers are now held by almost all general practice (GP) services.
When healthtech company iPLATO was commissioned to participate in a text message reminder project across London in an attempt to boost cervical screening attendance, updates increased by 6% in women aged 50 to 64 and by 5% in women aged 25 to 49. NHS London now plans to extend this to women due for breast screening.
Richards said: “If this can be done in London, there is no logical reason why this should not be extended to the whole country and other screening programmes.”
Urgent change is needed
The report also flags how vital social media can be in improving awareness of screening services. A social media campaign in Stoke on Trent increased the uptake of breast screening by 13% when North Midlands Breast Screening Service promoted their Facebook page on local community groups frequented by women over 50.
Meanwhile, Middlesbrough’s ‘No Fear’ campaign for cervical cancer – which targeted groups with low uptake for smear tests such as women aged 25 to 34, black, Asian and minority ethnic (BAME) women and women from deprived communities – was able to boost uptake between 0.6% to 6% in all participating practices.
Richard recommends further pilots of social media campaigns are prioritised, with formal evaluation and rollout of wider initiatives if successful.
The review proposes significant changes to the core way NHS screening operates, in a bid to improve efficiency and save lives. It is essential, therefore, for sufficient resources to be deployed in implementing these changes as new commissioning arrangements come into effect.
As the report reads: “Urgent change is needed to ensure screening programmes can be readied and resourced to maximise the opportunities they bring.”
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