The National Audit Office (NAO) has found that the proportion of eligible adults receiving health screening is inconsistent across different areas in England and that services are not operating to the ‘agreed standards’.
All the screening programmes investigated failed to meet the ’standard’ target for the percentage of eligible people attending screening appointments in 2017-18. However, the bowel screening programme nearly achieved the target with coverage of 59.6% against a standard target of 60%. For the first time in 2017-18, the Department also set a ‘lower threshold’ target, which all, except for the cervical programme, met. The cervical programme achieved coverage of 72% against a standard target of 80% and a lower threshold of 75%.
There is considerable variation in the percentage of people screened between different local areas. For example, in 2017-18, of those eligible for bowel screening, 60% were screened nationally, but in eight Clinical Commissioning Groups screening providers screened 30%-44% of eligible people. The NAO’s analysis shows that levels of coverage across the four screening programmes are inconsistent, with much of the lowest performance in London.
Two recent incidents with breast and cervical screening have raised concerns about oversight of screening programmes. The Department of Health & Social Care’s governance arrangements assume that all those eligible have been invited for screening. However, NHS England admits that omissions on the scale of the breast screening and cervical screening events are unlikely to be identified through the national level performance data that is used to monitor the programmes.
NHS England has concluded that the cervical screening incident has raised questions about the effectiveness of governance arrangements in place to prevent such issues. NHS England has delegated responsibility for managing the performance of screening providers to its regional and local teams, and where providers fail to perform they can, as a last resort, terminate a contract.
All of the screening programmes the NAO looked at rely on a national database of GP registrations to identify those who are eligible for screening, which the Department considers is not fit for that purpose and increases the risk that some people may not receive invitations for screening. The Department intended to replace the old system, known as National Health Application and Infrastructure Services (NHAIS), in 2017 but this has been delayed. It is estimated it will cost £13.9 million to maintain NHAIS until 2020-21.
Once individuals are identified as eligible for screening, each screening programme relies on its own IT systems to send invites, process tests and send results, with the number and age of the systems varying by programme. For example, the cervical screening programme relies on a large number of different IT systems, with some bodies estimating there are some 350 different systems supporting the various stages of the screening process. Breast screening operates with 78 versions of the same system in place across England and the Independent Breast Screening Review concluded that this IT is ‘dated and unwieldy’. Around 5,000 women were not invited for their breast screening because of errors in using “two separate and complicated systems, despite the best efforts of staff”.
Many patients are also experiencing delays in getting their results after screening. With cervical screening, the Department expects 98% of women to receive test results within 14 days. This target has not been achieved at a national level since November 2015. In March 2018 a third of women (33%) received their results on time. Performance improved in December 2018 to just over half (55%) of women getting their test results within 14 days. In October last year, the number of samples waiting to be tested stood at 97,628. A change in the way tests are carried out, which was announced in 2016 and is not expected to be completed until December 2019, is partly responsible.
NHS England and Public Health England has succeeded in implementing a new bowel scope screening, with 64 out of 65 screening centres operational at the end of 2016-17. However, fewer people than expected were receiving this screening because only 3,162 out of 7,649 GP practices were linked to a screening centre that was delivering this service. By September 2018, only 33% of those entitled to bowel scope screening were invited to an appointment.