We hope our latest edition of Health Matters – on the subject of “Making cervical screening more accessible”– will help you and other health professionals by compiling key facts, figures and evidence of effective interventions.
Where we can, we’re also committed to answering your questions and taking on your feedback. In this blog we’ve published the answers to a number of Health Matters cervical screening questions we received from professionals across the UK at the recent launch teleconference.
We’d love to hear from you at firstname.lastname@example.org.
Question 1 (Should women have a choice about where to be screened?)
Should women have a choice about where to be screened? Women don’t always want to go to their GPs, and sometimes the GPs can’t facilitate them. If their practice nurse is off sick or on holiday, there’s often quite a backlog. As a cervical cancer outreach nurse, women complain to me that in my area, none of the family planning clinics now offer the service.
The issue of allowing women to be screened in sexual health clinics is complicated by the commissioning arrangements. You may be aware that while local authorities are responsible for commissioning sexual health services, the new service specifications do not actually include cervical screening. Therefore, you have a situation where women being screened in some sexual health clinics don’t actually have a commissioner paying for those services.
In London and in some other regions, cervical screening has been commissioned in sexual health clinics, particularly offering opportunistic screening to women who are overdue. In London in the six months between October and March we had 4,600 women actually being screened. Most of them were actually overdue. We did also have a small number of routine screening appointments. So, while we would agree with you that choice is important, GPs are actually paid for cervical screening.
In the event that a practice can’t actually offer screening, there would need to be a discussion either with NHS England or the CCG responsible, with delegated responsibility for commissioning primary care, to see what arrangements could be made for those women to be screened within general practice, possibly at another practice. Or, with the new federated models of care that are in place in some parts of the country, it is possible for practices to come together and offer services as a collective. But it isn’t a simple issue. But we would agree – women should have options and they should have choice. But the commissioning context makes it difficult.
Question 2 (Should there be a national cervical screening campaign?)
I’d like to ask, over and above whatever else we do to promote cervical screening as flexibly as we can in venues with more choice, is Public Health England planning to have a national media campaign to raise awareness?
We have been talking to the health marketing team from PHE about having a national campaign, but they are more focused at the moment on the big ‘One You’ and the lifestyle campaigns. The fact is by already writing directly to target women the amount of money we’re spending on marketing or raising awareness is already huge. But there are a couple of things that have been happening. Cancer Research UK and the health marketing team from PHE (the people who would do a national campaign) have done a sub-national campaign on bowel cancer screening. We will see what effect it has. Also London is shaping up to do some sort of general awareness campaign on cervical screening. PHE screening will be involved and we will extract as much learning as possible to see if the case for a national campaign can be made.
Question 3 (HPV vaccine and the continuing need for cervical screening)
As a screening and immunisation coordinator, I find that when speaking to younger women who’ve had the HPV vaccine, a lot of them assume that once they’ve had the vaccine they’re actually immune to the disease and don’t need cervical screening. How are we going to change that perception?
When we roll out HPV as a primary screen it’s an opportunity for us to refresh all the information that we’re going to provide. That’s not only the written information, but also other media, such as texting and social media.
We will continue to say that people require cervical screening but we owe it to all of us to model what kind of screening we’re going to need when there is a vaccinated population. It is clear that the overwhelming majority of cases of cervical cancer are caused by HPV and as we get vaccinated groups through, we should see very much less of it. But we’re still going to need to run a screening programme for the foreseeable future.
As Capita gets more involved, we can make the message more effective by changing the wording of the letters locally, subject to PHE’s agreement. Depending on their IT capability and understanding of the groups they’re writing to, we should be able to alter the letter to women of a particular age.
Question 4 (Do the strains of HPV that cause cervical cancer differ across the world?)
Is it correct that the strains of HPV that are causing cervical cancer – the main ones – are different across the world? And as we get a more mixed population, and with increased travelling, people are more likely to come into contact with different strains of HPV. How is that going to affect our programme?
Two strains of HPV, HPV16 and HPV18, cause the majority of cervical cancers all around the world. There are slight differences in the percentage of cancers caused by these main strains in different parts of the world, with several other strains causing more cancers in some parts of the world - including parts of the world where cervical screening has not been widely used, so cervical cancer is more common.
There is some concern that other strains might become more prevalent as vaccination reduces the two main strains (HPV16 and HPV18). This is being monitored and we will have to wait and see, however, the evidence and research that’s available now does not support the case that other strains will become more prevalent in vaccinated populations (including in England).
Question 5 (Delays in getting screening results)
How quickly in 2019 is the new HPV primary screening testing going to be set up? Because although lower numbers of people are having cervical screening, we are having considerable worrying delays on the turnaround times for the people who are going.
As we shift to HPV primary screening, cytologists know in their hearts that they’re going to have very much less work to do, particularly if we extend the intervals and therefore it’s becoming a profession that’s quite hard to recruit and retain people. As a result the time it’s taking to get women’s results back to them is extending in various places. Recently we met with colleagues across the NHS to talk about it and to work out what mitigations we can put in place as soon as possible. We acutely understand that this is a problem and we are on it as much as we can.
Once we implement HPV as a primary screen, activity and volumes will vary and change quite a bit. We are shifting to a test which is much better and we’ll reduce the number of times we may need to have tests. But we have to be honest that in the middle it could be bumpy and make sure that we don’t lose people in the meantime. We produce as many blogs as we can to keep people up to date and you’re welcome to write to the screening helpdesk and ask as often as you like. We will answer what we can and pass you over to the NHS commissioning team who will be closer to the details than we are.
Question 6 (Role of NHS England commissioners)
I work in an NHS England local area office. As we are the commissioners for this service, we are pulling together an incentive programme for GPs and my role will be raising awareness with GPs and with the public. You make recommendations in your Health Matters edition but I can’t see NHS England being mentioned specifically.
The recommended actions that are in the summary slides will require commissioning. One of the things that PHE has done is to write into the service specifications the things we know will work and a whole set of stimulating activities to improve what we know will work. As commissioners you have a variety of responsibilities which cut across the presentation that we’ve just heard, including improving uptake and coverage. One that has already been mentioned is the commissioning of sexual health services. But in the new commissioning landscape, commissioners also have a key role in being a convener with vanguard alliances and sustainability and transformation partnerships (STPs) in making sure that cervical screening is actually prioritised.
Additionally, some regions around the country have done some very good work on improving cervical screening in hard-to-reach groups such as those with learning disabilities. PHE has recently worked with NHS Digital and we’ve got coverage data by GP now on the PHE site and on the NHS digital side. That should be really helpful for you, so you’ll be able to see how you compare with other areas.
But also one of the most striking things is that GP practices in deprived areas have widely varying coverages. So there’s more to be done than simply to say this is about the difficulty of our population. A little while ago we had an inequalities and uptake session. The overwhelming message from the public health professionals who had been commissioning and working locally was just to do something locally. Almost anything, talking to GPs or talking to CCGs does make a difference. So we’d be very interested to hear how your campaign goes because it might form another argument in the suggestion that we have some sort of national campaign about this.
Question 7 (Funding of cervical screening)
Going back to the funding of cervical screening via sexual health services, is NHS England looking to commission sexual health services to increase access to screening? We do some already in my area, but we fund that through the local authority, because we know that there are some women who will go to sexual health services who are hard to reach for any kind of health services. While they are there we will offer screening opportunistically. We can help to map out the situation in our local area using PHE data so that we can identify where it needs to be targeted and who needs to be targeted. But then what? We can’t increase screening that significantly without the commissioner, NHS England, funding it. I’d like NHS England to be doing something as well.
The issue with funding cervical screening and sexual health services is that most public health departments don’t have the funds to actually pay for it. So where a few regions have funded this, it is actually a cost pressure, and in many cases is funded non-recurrently. You are right in saying that we probably do need to have a national discussion about whether there could be a budget line specifically for screening and sexual health services. It is not for local authorities to commission the service, and so where are the levers?
We recently had a conversation with a director of public health in London. She has got a person in her team who works for the private sector rental sector, and he had managed to book out a room which was available and had got all sorts of external organisations to come and talk to the tenants. And some of that would have been about health, some of that would have been about exercise and lifestyle, all sorts of things. But, there are opportunities to raise awareness about health, to improve health literacy, to have a conversation with women while you are doing cooking lessons about whether these cancers affect them, even though they have had babies, or even if it is possible to organise it so that it is acceptable for Asian women.
So, there are all sorts of things that can be done. They may not be directly about screening; that might be too detailed, but they would be about cancer, about how it is worth getting it early and not being fatalistic about it. This is something that local authorities can actually do, which will overcome quite a few of the barriers. We appreciate they are not going to fix the services, and that is a real difficulty. But they will help an awful lot of the other things about women knowing that it is okay, that it is not as bad as it sounds, that it is worth finding early, that will make a huge difference.
In the case studies section of the Health Matters there is a great example featured in the Health matters webpage This example was from Trafford where they worked collaboratively with the CCG, local authority and voluntary sector and used a number of initiatives across the patch to address coverage with some very successful results.
Question 8 (Role of primary care)
I’m a GP and a colposcopist and I’m also representing the RCGP. I take on board comments that have been made about GPs and funding for primary care for doing all of this. In defence of primary care at the moment, as you know, we are under huge amounts of pressure. Cervical screening was covered in core funding, but one of the issues with reduced access to sexual health clinics is it is now assumed that we in primary care have the capacity to take on the extra screening.
So, in my area, we know that as the contraception and sexual health (CASH) clinics, the sexual and reproductive health (SRH) clinics, have reduced in number, access has gone down. And so those women who were due to go to the contraception clinic now, if they are going to go, they are going to go to GPs, but that is extra work for GPs, because they weren’t doing that work before, and I think we have to acknowledge that primary care doesn’t have the capacity at the moment to take on much extra work, because we are already taking on extra contraception work because of this issue. I do think there will be opportunities under federated practices and primary care homes, but it will be a while before they kick in. So it is really about working together rather than this, ‘primary care can take this on’.
Thanks for explaining the point of view of primary care. We did some work about the amount of screening that the CASH clinics were doing, and nationally, it is about 1%. It is really small, actually. So it’s back to our earlier response which is that it is worth looking to see just how big a problem it is for you locally, and if a small area is using the CASH clinic, then going to knock on the commissioners’ doors, and working out a scheme by which they can help.
The other thing is that we are trying really hard to reduce the burden on primary care. We mentioned Capita earlier on, and we should be able to work with them to do more inviting and reminding, which might take some pressure off primary care. And the other thing to say is that after we get HPV vaccination in, the whole problem will get much less frequent. In addition, once we get HPV as a primary screening we should be able to extend the intervals and reduce the number of times that women get screened. You are absolutely right that we need primary care around the table in local circumstances to plan what’s the best way of getting people through the door to have the test. It’s all very well meeting with the national view but we can see that it’s extremely variable in some areas struggling in a way that others aren’t. So it’s good pushback, and if the RCGP wants to let us know how we can do that between us that would be really helpful.
Question 9 (Is cervical screening on the NHS risk register?)
As a public health manager what I understand from this discussion is that raising awareness may be a local authority responsibility, but the responsibility for commissioning the service lies with NHS England and therefore needs funding. So we need a national discussion about whether this is on the risk register for NHS England, and nationally they need to raise a discussion about their commissioning responsibilities and how to pay for that, because that would help local authorities to understand where that would be paid for and the population served.
You can be assured it’s on the risk register. The funding works through the Section 7a specifications. This is a pot of money given by PHE to the NHS to commission this on our behalf and that needs to reflect the actions that we need to do, both to shift to primary HPV screening but also to improve awareness and to increase uptake. The advent of HPV as a primary screen just on its own and the extended intervals will take a huge amount of resource out of this. And so, we are helping the system by reducing the amount of women who’ve got the condition and reducing the amount of money we spend on it. That is all in NHS England’s plans. So we all have to work at national and local level to do what we can to fix the problem. But you can be sure that at national level we’re on it pretty tightly.
Question 10 (Women not attending for cervical screening)
My question is specifically related to the non-attenders groups that you’ve identified with reference to ethnic minorities. I’m just wondering whether you have any more intelligence in which specific population groups are you referring to? Because when we talk to some of the primary care colleagues there is some intelligence that the Eastern European do not attend for their appointments, but actually they’re going back home to have their screening done. So I just wondered what is known about some of the Eastern European communities. When we talk to them, they actually they say that, yes, they do go home. But we don’t know the quality of standards in terms of the assurance of the programme back home, in comparison to the UK screening programmes.
The cervical screening programme doesn’t collect ethnicity, so our best estimates come from general practice-level data, where we do proxies for these things. We do know that those areas with high deprivation and large groups of black and minority ethnic groups have a lower uptake. Clearly there are many reasons for that and cultural ones play quite highly. We have heard that Eastern European women are screened annually in their country of origin so there may well be reasons locally why your coverage numbers are different.
We are hoping that with the advent of the Capita system we will start to get a better handle on the populations. As we get better data in general practice, we should understand who is not having screening, and we hope to be able to give you much more detailed information than we currently have. Most of the information we have comes from ad hoc or research studies, which say that some women are less likely to have heard of it or less likely to want to have the test done because of anxieties about cancer or embarrassment or pain.
There’s clearly a small group of women who have thought about the test and have made a positive choice not to have it. We can produce data to help, but in the end it will be local conversations with your GPs and with your local authority and screening colleagues that will help you understand whether you’ve got a particular population who are perfectly okay and they don’t need to be screened or much more likely are not taking up the service when they could benefit from it.
Question 11 (Return on investment)
Is there a return on investment tool that picks up the return on investment of cervical screening for the wider economy?
We have done a cost effectiveness analysis of introducing the HPV test which shows that it is highly cost effective. We try our very best to do the societal costs and benefits but, to be honest, we usually end up doing QALYs, because that is what people do and publish, and then there's the comparison with NICE to be had. We are very interested in understanding how local authorities can engage in this conversation, and what sorts of products, eg data reports and information for health and wellbeing boards or politicians, would be useful. So do please let us know what would be useful to you when presenting to your local authority members or to the health and wellbeing board or scrutiny committee. Maybe that's something we could work on together. If you've got an ROI which has worked locally send it in and we will see whether we can do one for cervical screening.
Question 12 (The role of the voluntary sector)
I work in community and volunteer services. We are medically trained, and until recently we had some funding from the NHS to enable us to go out to community groups and deliver some education around topics such as different screening programmes and also cancer signs and symptoms and things like that. I just wanted to make the point really of what a good position the volunteer sector is in to be able to deliver things like that. My colleague speaks Gujarati and Urdu and with South Asian women was able to get the message over really well and in really simple terms.
That's fantastic. You're absolutely right and we know that Jo's Cervical Cancer Trust has done some really good work on raising awareness and understanding the needs of particular groups too. When we're talking about looking at a local area and seeing what the needs are, whether they're particularly geographically-based or particularly in a community, it's incredibly important that we use all the intelligence that we've got, including from organisations like yours. If you've got people really embedded and knowing the communities then that's gold dust and we should make sure that they are used as part of the awareness raising or helping people understand that it's not a bad thing to do. Unfortunately austerity means that these things are increasingly difficult, but it's important that you share the good practice. Other people might be able to pick it up and do it in other areas, or as things shift and if the coverage continues to struggle in some other areas then this sort of information will be incredibly helpful.
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