Cervical Screening. Bexley Bromley and Greenwich (BBG) Annual Report 2009/10. Dr Angela Bhan Screening Commissioner

Transcription

1 Cervical Screening Bexley Bromley and Greenwich (BBG) Annual Report 2009/10 Dr Angela Bhan Screening Commissioner 1

2 Contents EXECUTIVE SUMMARY 3 1. NHS Cervical Screening Programme 1.1 Local programme Borough and population profile Primary Care and Acute Care Trust arrangements Links with cancer network Epidemiology of cervical cancer 5 2. SERVICE PROFILE 2.1 Overall coverage Coverage at individual practice level Number of samples and Inadequate test rate Reporting times Invasive Cervical Cancer Audit Diagnosis QUALITY ASSURANCE AND SERVICE DEVELOPMENT 3.1 Primary Care Achieving 14 day turn around time London Quality Assurance (QA) Team visits CONCLUSION AND FOCUS OF FUTURE WORK 4.1 Conclusion Focus for future work 15 APPENDICES 1 Cervical Screening Programme Coverage of Target Age 16 Group 25/64 2 Tests from GP and NHS Community Clinics 17 Women aged 25/64 3 Summary Colposcopy Statistics by Colposcopy Clinic 18 2

3 EXECUTIVE SUMMARY This is the seventh annual report of the cervical screening programme across Bexley Bromley and Greenwich. Once again, my thanks go to the entire screening team for the production of the report. The need to ensure optimum co-ordination and commissioning of services during a period of major local organisational change continued. On 1 April, following a period of comprehensive consultation, The Princess Royal University Hospital Bromley, Queen Mary s Hospital Sidcup and Queen Elizabeth Hospital Greenwich merged to form The South London Healthcare NHS Trust with agreement for cytology services to be centralised at The Princess Royal University Hospital. The major organisational and management changes involved had a corresponding negative impact on the ability to retain/ recruit staff in addition to disrupting established pathways related to cytology and colposcopy services. My thanks go to all service providers for maintaining NHS Cancer Screening Programme standards throughout a difficult time. A note of caution is necessary when interpreting some of the information, especially for coverage. This information at practice level is based on local data which does not allow for the inclusion of women who are registered with GPs in BBG, though resident in another borough. In addition, even through 3-year rolling average figures are used for incidence and mortality data, the numbers are small and so may not reflect small trends accurately. Key findings of the report include: 1. The number of samples processed and examined in all three laboratories and the overall number (55,154) was lower compared to last year (58,649) when there was a sudden and unprecedented increase in response to media coverage related to the terminal illness of TV personality Jade Goody. 2. All but a very few of the recommendations made following a visit by the London QA team to all three acute Trusts, Call Recall Service and three PCTS in October/November 2008 have been implemented. 3. Local coverage rates for 2009/10 were marginally increased in Greenwich (74.9%) with a marginal decrease in Bexley (81.9%) and Bromley (81.8%) compared to the previous year. All three boroughs achieved above the average for London (73.9%) with Bexley and Bromley continuing to achieve amongst the highest rates in London. 4. Work continued towards implementation of a government directive that from the date a cervical sample is taken to the date the woman receives the result should be no more than 14 days. The impact of widespread organisational change involved in the formation of the South London Healthcare NHS Trust and subsequent establishment of a single site cytology service had a major adverse effect on progress towards achieving this goal (see section 1.3) However it is anticipated that the new centralised service now in place will facilitate progress in reducing laboratory reporting times. Dr Angela Bhan, Screening Commissioner Bexley Bromley & Greenwich 3

4 1. NHS Cervical Screening Programme 1.1 Local programme The National Heath Service Cervical Screening Programmes (NHSCSP) is coordinated nationally with standards and targets monitored through a national quality assurance framework. The aim of the programme is to reduce the number of new cases and deaths from cancer. Women between 25 and 49 were invited for screening every 3 years and then every five years up until the age of 64 years 1.2 Borough and population profile Bexley, Bromley and Greenwich are the three outer London boroughs of the South East London Sector and work closely with Lewisham, Southwark and Lambeth (LSL) as the three inner London boroughs of this sector. The data provided in Table 1 illustrates considerable differences in population profiles. Table 1. Borough and population profile - updated Bexley Bromley Greenwich 2009 Total population 1 218, , , Total female population 2 112, , ,569 Index of Multiple Deprivation National Ranking of Index of Multiple Deprivation Age standardised mortality rate for all cancers under yrs % persons from ethnic minorities % 12.0% 33.0% 1&2 GLA 2009 Round Population Projections 3 Department of Communities and Local Government, Indices of Deprivation Compedium of Clinical and Health Outcomes 5 GLA 2008 Round ethnic group population projections PLP low 1.3 Primary Care and Acute Care Trust arrangements Bromley Primary Care Trust (PCT) is the Lead PCT for the cervical screening programme for Bexley Bromley and Greenwich. In this capacity it works closely with Bexley Care Trust (CT) and Greenwich Teaching Primary Care Trust (TPCT) as Associate PCTs. Up to April 2009 cytology services were provided for Bromley, Bexley and Greenwich respectively by The Princess Royal University Hospital, Queen Mary s Hospital and Queen Elizabeth Hospital. In April 2009 these three acute trusts merged to form The South London Healthcare NHS Trust with agreement for a single site cytology service to be based at The Princess Royal University Hospital. The major organisational and management changes involved had a corresponding negative impact on the ability to retain/ recruit staff in addition to disrupting established pathways related to cytology and colposcopy services. Throughout this re-organisational time the Screening Commissioner worked with all organisations to ensure a focus on maintaining NHS Cancer Screening Programme standards and agreeing a revised service specification. 4

5 Table 2 provides details of the key leads for cytology in the former three district general hospitals, and now sites of the newly formed South London Healthcare NHS Trust, which act as acute trust service providers Table 2. Key cytology leads in the Acute Trust providers Consultant Lead Consultant Lead Laboratory for Gynaecology Services Acute Trust Provider Queen Mary s Hospital NHS Trust Bromley Hospitals NHS Trust Queen Elizabeth Hospital NHS Trust Consultant Lead for Genito Urinary Medicine Hospital Based Programme Coordinator Dr Nada Ibrahim Mr Rod Irvine Mr Gary Bradley Dr Rashida Goderya Mr N Hill Dr Caroline Dimian Mr Gary Bradley Dr Thelma Pinto Mr Mahesh Patwardhan Dr Judy Russell Mr Neil Woodward 1.4 Links with cancer network The screening programme links with the SE London Cancer Network and the Cancer Leads in the three PCTs. The Associate Director for Service Improvement of the SE London Cancer Network is a member of the BBG Screening Board. During the report period the main focus of joint work with the SE London Cancer Network was on moving towards a 14 day reporting time from the date a cytology sample is taken to the date women receive their result. Table 3. Cancer Leads for Bromley Bexley & Greenwich Name Role Bexley CT James Westbury Interim Director of Commissioning Bromley PCT Dr Nada Lemic Director of Public Health Greenwich TPCT Dr Karim Jan Mohammed GP and PEC Chair 1.5 Epidemiology of cervical cancer The data shown in Figure 1 illustrates a marginal decrease in the incidence of cervical cancer in Bexley and Bromley and a marginal increase in Greenwich for the last available two year audit period. The data shown in Figure 2 illustrates an increase in the mortality of cervical cancer in all three boroughs for the same period which requires further investigation. 5

6 Figure 1. 3 Year Rolling Average directly standardised incidence rate for cervical cancer all ages Figure 1. 3 Year Rolling Average - directly standardised incidence rate for cervical cancer - all ages Directly Standardised Incidence Rate (European) per 100, Year Bexley Bromley Greenwich Figure 2. 3 Year Rolling Averages directly standardised mortality rate for cervical cancer all ages Figure 2-3 Year Rolling Averages - directly standardised mortality rate for cervical cancer - all ages Directly Standardised Mortality Rate (European) per 100, Year Bexley Bromley Greenwich 6

7 2. SERVICE PROFILE 2.1 Overall coverage Coverage is a key indicator associated with the provision of a high quality screening service. Cervical coverage is defined as the percentage of eligible women with an adequate screening test during the last five years, excluding those who have been ceased from the programme for clinical reasons. The national target rate for coverage is 80%. Figure 3 illustrates the annual coverage rates for BBG with more detailed data provided in Appendix 1. For The coverage rate for London showed a marginal increase to 73.9% compared with 73.8% the previous year The coverage rate for Bexley showed a marginal decrease to 81.9% compared with 82.1% the previous year The coverage rate for Bromley showed a marginal decrease to 81.8% compared with 81.9% the previous year The coverage rate for Greenwich showed a marginal increase to 74.9% compared with 74.4% the previous The coverage rates for Bexley and Bromley remain amongst the highest achieved across London. The BBG Screening Team (Screening Commissioner, Screening Co-ordinator, Call/Recall Manager) monitors coverage as part of an overall performance management framework with data provided to PCT Leads, practices and screening groups. Figure 3.Cervical coverage of target age group (25 65) Cervical coverage % Bromley Bexley Greenwich 7

8 2.2 Coverage at individual practice level Figures 4 to 6 show the distribution curves of cervical cytology coverage for all practices in BBG. The bars represent the coverage rate of each practice in rank order. This information at practice level is based on local data which does not allow for the inclusion of women who are registered with GPs in BBG, though resident in another borough. These women are commonly referred to as fringe patients. The figures for 2009/10 show that the proportion of practices not achieving the 80% national target rate remains fairly constant across all three boroughs. There continues to be a need for focussed work on improving coverage in practices with low achievement. For details of specific work with primary care to improve coverage see section 3.1 Primary Care Figure 4. Distribution curve of cervical coverage for GP practices (Bexley) 2009/10 Cervical Coverage per GP Practice (Bexley CT) 2009/ Coverage (%) less than 5 years since last adequate test

9 Figure 5. Distribution curve of cervical coverage for GP practices (Bromley) 2009/10 Cervical Coverage per GP Practice (Bromley PCT) 2009/ Coverage (%) less than 5 years since last adequate test Figure 6. Distribution curve of cervical coverage for GP practices (Greenwich) 2009/10 90 Cervical Coverage per GP Practice (Greenwich TPCT) 2009/10 80 Coverage (%) less than 5 years since last adequate test

10 2.3 Number of samples and inadequate test rate The numbers of samples processed and examined in all three laboratories were lower than last year when there was a sudden and unprecedented increase in response to media coverage related to the terminal illness of TV personality Jade Goody. Tests are reported as inadequate or un-reportable for a variety of reasons associated with technique of taking the test, transportation of the sample or the processing of the slide. Table 4 provides details of the number of tests taken and the inadequate rates with more detailed data provided in Appendix 2. This data shows a marginal increase in inadequate rates in Bexley and Bromley and a 3% increase in Greenwich. At the time of writing this report the inadequate rate for Greenwich had reverted to be within the normal range. Table 4. Inadequate tests 2002 to updated Laboratory Year Total Samples Examined Inadequate All sources/ all ages GP & NHS Community Clinics (20/64) Category 1 % Queen Mary s Sidcup NHS Trust 2009/ / / / / / /04 18,314 19,107 16,484 18, ,762 22,031 15,172 16,103 12,280 15,628 17,955 18,387 19, Princess Royal University Hospital / / / / / /04 Queen Elizabeth Hospital NHS Trust 2009/ / / / / / /04 Source: ONS National Statistics Cervical Screening Programme 2.4 Reporting Time 24,971 26,037 22,972 27,654 27,652 27,834 26,914 20,425 21,373 16,950 19,158 20,348 19,909 18,107 21,793 23,039 20,181 24,037 24,037 23,836 24,772 18,189 19,507 15,306 16,681 17,236 16,055 16,158 Reporting or turnaround time refers to the time between taking of the test to the issuing of the result letter and is monitored by the Screening Commissioning Team (Screening Commissioner, Screening Co-ordinator, Call/Recall Manager) on a quarterly basis for all three boroughs. The national standard is for more than 80% of women to receive their result within 4 weeks of the test being taken and 100% of women to receive their result within 6 weeks

11 The major organisational and management changes involved with the formation of The South London Healthcare NHS Trust and establishment of a single site cytology service had a major impact on laboratory reporting and turn around times. Table 5. Turnaround times for cervical screening Laboratory Within 4 weeks Within 6 weeks Queen Mary s Sidcup NHS Trust 99.20% 99.90% Princess Royal University Hospital 79.30% 85.00% Queen Elizabeth Hospital NHS Trust 95.00% 99.70% 2.5 Invasive Cervical Cancer Audit Princess Royal University Hospital The department continued to audit cervical cancers and transmit the data to the London QARC by NHS Mail in line with NHSCSP Publication No 28 Audit of Invasive Cervical Cancers A total of 9 cervical cancers were audited and discussed at the colposcopy multidisciplinary team meetings and the Regional Cancer Centre. There were 4 screen detected and 5 symptomatic cases. No cases required external review by the London QARC Queen Elizabeth Hospital The department has been auditing invasive cervical cancers from January 1997 and continued to transfer the data to include cytology, histology and colposcopy review to the London QARC using the IT programme installed on the Hospital Based Hospital Coordinator s terminal. All data was transmitted via NHS Mail. There were 17 cervical cancers reported with 9 screen-detected and 8 symptomatic cases. All cases were presented at the multi-disciplinary team. No cases required external review by the London QARC Queen Mary s Hospital Sidcup The department has been auditing invasive cervical cancer from January 1997 and continued to transfer invasive cervical cancer date to the London QARC using the IT programme installed on the Hospital Based Hospital Coordinator s terminal. Seven cases of cervical cancer were audited and discussed at the colposcopy multi-disciplinary team and the Regional Cancer Centre with 6 screen-detected and I symptomatic. No cases required external review by the London QARC 11

12 2.6 Diagnosis In order to be effective the screening programme must ensure that women identified as needing further investigation are referred for colposcopy within the recommended timeframe. Current national guidance is for: At least 90% of women with an abnormal test result to be seen in a colposcopy clinic within eight weeks of referral At least 90% of women with a moderate or severe test result to be seen in a colposcopy clinic within four weeks of referral. The figures provided in Appendix 3 Summary Colposcopy Statistics by Colposcopy Clinic illustrate Queen Mary s Hospital Sidcup (99.3%) and Princess Royal University Hospital (92.8%) as exceeding the 4 week 90% target. The 4 week target for Queen Elizabeth Hospital (61.8%) was disappointingly low. The figure for the Princess Royal University Hospital reflects the great improvement in the service and quality of data since implementation of several quality improvement initiatives during 2008 to 2010 as set out in last year s annual report. The appointment of a new Coloposcopy Coordinator and full time administrator in March 2009 allowed for direct referral to colposcopy to be implemented in October 2009 following an awareness raising excercise in primary care. Implementation of direct referral to colposcopy is a QA recommended quality initiative with the proven effect of reducing waiting times. A final report on options for future commissioning and service provision for colposcopy across Bexley Bromley and Greenwich was completed and informed discussions with agreement in principle for a move to a single management colposcopy service. It is anticipated that this single service will be implemented during 2010/2011. At the time of writing this report a Colposcopy Co-ordinator and Lead Consultant across all three sites have been appointed. 3. QUALITY ASSURANCE AND SERVICE DEVELOPMENT 3.1 Primary Care There were a range of quality assurance and service development activity in primary care. a. The Screening Commissioning Team monitored coverage as part of an overall performance management framework. As part of this framework anonymised annual coverage data was provided to all practices to inform their performance reporting and to act as a benchmark with other practices. b. As set out in last year s annual report the focus on improving coverage during 2009/10 was on increasing awareness and attendance in the 25 to 49 year age range. Quarterly reporting to Greenwich PCT included breakdown of age ranges 29/49 and 50/64 was implemented with plans to roll out to Bexley and Bromley. 12

13 c. Greenwich PCT commissioned an extensive piece of work with all practices invited to take part in a Catch-up Pilot with a focus on women aged years. Practices achieving the coverage target rate were incentivised to continue and those which did not were supported to identify woman whose cervical test was over-due and offer them a screening appointment. d. Information packs were distributed to all practices and community groups as part of Cervical Cancer Week in June. e. As part of the local education and training programme the Screening Commissioning Team held lunchtime training session on all three cancer screening programmes for practice staff across all three boroughs. The training sessions incorporated how practices can improve coverage and work towards helping achieve an overall 14 day turn around time. f. Quarterly Screening Newsletters were distributed to all practices. The newsletters incorporated how practices can improve coverage work towards helping achieve an overall 14 day turn around time. g. The Call/Recall team continued to support the introduction and use of electronic assess by practices to Prior Notification Lists (PNLs) which are established in all but a handful of practices which have declined access 3.2 Achieving 14 day turn-around time Work continued towards implementation of a government directive that from the date a cervical sample is taken to the date the woman receives the result should be no more than 14 days. This reporting period is known as the 14 day turn-around time. The impact of widespread change across all organisations involved in the formation of the South London Healthcare NHS Trust and subsequent establishment of a single site cytology service had a major adverse effect on progress towards achieving this goal (see section 1.3) However it is anticipated that the new centralised service now in place will facilitate progress in reducing laboratory reporting times. At a local level the Screening Commissioning Team monitored progress on a local action plan through the local Cytology Screening Commissioning Groups with all three acute Trusts and Call/Recall service supported by the following action: Key staff in all organisations attended a training day in June 2009 on the recommended LEAN methodology which was subsequently employed at all stages of the reporting pathway As part of a sector approach to implementation, led by SE London Cancer Network (SELCN), key staff in all organisations worked closely with SELCN and Lewisham, Southwark and Lambeth (LSL) PCTs. This joint working incorporated submission of agreed monthly data to SELCN, active part in walk-through of LSL pathway with comparison to local pathway and sharing best practice with LSL 13

14 Workforce problems associated with major organisational changes were supported with overtime of in-house and use of bank laboratory staff. Quarterly newsletters and lunchtime training sessions alerted practices on how to ensure prompt transportation of adequate and clearly labelled samples to respective reception laboratories. Providers accessed Open Exeter computer system and tracked monthly progress as monitored by the NHS Connecting for Health Vital Signs programme The Call /Recall service identified resources to move towards use of first class postage for all except result letters except those notifying an abnormal result. First class post was initiated in September The Call/Recall Service supported and encouraged practices to print off cytology request forms (HMR101 forms) using Open Exeter computer programme which is now operational in all but a couple of practices in Bromley. Use of these prepopulated forms with women s demographic details and cytology screening history facilitate laboratory processing and reporting. The Call /Recall Service worked towards establishing a robust system to transmit and receive laboratory results to and from a single laboratory site, rather than all three, by March London Quality Assurance (QA) Team visits The action plan developed in response to the recommendations of the London QA team visit to all three acute Trusts, Call Recall Service and three PCTS in October /November was updated and outstanding recommendations prioritised. At the time of writing this report only a handful of recommendations are outstanding. Issues around the appointment of A Hospital Based Programme Coordinator (HBPC) at Queen Elizabeth Hospital were resolved by the appointment of an overall HBPC for South London Healthcare NHS Trust 4. CONCLUSIONS AND FOCUS OF FUTURE WORK 4.1 Conclusion Once again the Cervical Screening Programme across Bexley Bromley and Greenwich continued to be of a good standard with all recommendations for future work set out in the last annual report 2008/09 progressed. 14

15 4.2 Focus for future work 1. The focus of work for 2010/11 will on achieving a 14 day turn around time and a move towards a single colposcopy service prioritised. 2. A substantive review of the Cervical Cytology Practical Guide for General Practices and Community Clinic in, Bexley Bromley and Greenwich will be completed and new copies will be distributed.. 3. Quarterly reporting to Greenwich PCT including breakdown of age ranges 29/49 and 50/64 will be consolidated and rolled out to Bexley and Bromley 15

16 Cervical Screening Programme Coverage of Target Age Group 25/64 APPENDIX 1 Eligible Population Coverage % (less than 5 years since last (000's) adequate test) Number of Women Screened (000's) England 2009/10 13, , /09 13, , /08 13, /07 13, , /06 13, , /05 12, /04 12, London 2009/10 2, /09 2, /08 2, /07 2, /06 2, /05 2, /04 2, Bexley 2009/ / / / / / / Bromley 2009/ / / / / / / Greenwich 2009/ / / / / / / Source: ONS National Statistics Cervical Screening Programme Tables 9/10, 2003/04, 2004/05, 2005/06, 2007/08, 2008/09 and 2009/10 Tables 12/13 16

17 Tests from GP and NHS Community Clinics Women aged 25/64 APPENDIX 2 Laboratory Year Total Tests Examined Inadequate Cat 1 Total Adequate Tests Result as a percentage of Total Adequate All sources/all ages GP & NHS CC (20/64) % Negative % Cat 2 Borderline % Cat 8 Mild % Cat 3 Moderate % Cat 7 Queen Mary's Hospital (Sidcup) 2009/10 18,314 15, , Queen Mary's Hospital (Sidcup) 2008/09 19,107 16, , Queen Mary's Hospital (Sidcup) 2007/ , , Queen Mary's Hospital (Sidcup) 2006/07 18,766 15, , Queen Mary's Hospital (Sidcup) 2005/06 21,341 17, , Queen Mary's Hospital (Sidcup) 2004/05 22,762 18, , Queen Mary's Hospital (Sidcup) 2003/04 22,031 19, , Severe % Cats 5,6&7 Princess Royal University Hospital 2009/10 24,971 21, , Princess Royal University Hospital 2008/09 26,037 23, , Princess Royal University Hospital 2007/08 22,972 20, , Princess Royal University Hospital 2006/07 27,654 24, Princess Royal University Hospital 2005/06 27,652 24, , Princess Royal University Hospital 2004/05 27,834 23, , Princess Royal University Hospital 2003/04 26,914 24, , Queen Elizabeth Hospital (Greenwich) 2009/10 20,425 18, , Queen Elizabeth Hospital (Greenwich) 2008/09 21,373 19, , Queen Elizabeth Hospital (Greenwich) 2207/08 16,950 15, , Queen Elizabeth Hospital (Greenwich) 2006/07 19,158 16, , Queen Elizabeth Hospital (Greenwich) 2005/06 20,348 17, , Queen Elizabeth Hospital (Greenwich) 2004/05 19,909 16, , Queen Elizabeth Hospital (Greenwich) 2003/04 18,107 16, , London N/K 2009/10 711, , , London N/K 2008/09 733, , , London N/K 2007/08 626, , , London / 24 Laboratories 2006/07 647, , , London / 24 Laboratories 2005/06 665, , , London / 24 Laboratories 2004/05 656, , , London / 24 Laboratories 2003/04 659, , , Source: ONS National Statistics Cervical Screening Programme, 2002/03 Table 16, 2003/04, 2004/05, 2005/06, 2006/07, 2007/08, 2008/09 and 2009/10 Table 19 17

18 18 APPENDIX 3 Summary Colposcopy Statistics by Colposcopy Clinic Total number referred Clinical Indication Less than 4 Weeks wait Informed within 8 Weeks % % % England 2009/10 155, /09 133, /08 122, /07 123, /06 129, /05 124, /04 128, London 2009/10 31, /09 25, /08 23, /07 23, /06 24, /05 24, /04 24, Queen Mary's Hospital (Sidcup) 2009/ / / / / / / Princess Royal University Hospital 2009/ / / / / / / Queen Elizabeth Hospital (Greenwich) 2009/ / / / / / / Source: ONS National Statistics Cervical Screening Programme 2003/04, 2004/05 Table 26, 2005/06, 2006/07, 2007/08, 2008/09 and 2009/10 Table 26a & 26b`