Health Audit. Norfolk Public Health Improving health and wellbeing Protecting the population Preventing ill health.

Transcription

1 Norfolk Public Health Improving health and wellbeing Protecting the population Preventing ill health Health Audit By: Dr Kadhim Alabady, Principal Epidemiologist Dr Shamsher Diu, Public Health Consultant Date: March

2 Table of Contents TABLE OF CONTENTS... 1 EXECUTIVE SUMMARY... 4 ABBREVIATIONS... 6 KEY FINDINGS:... 7 RECOMMENDATIONS DESCRIPTION OF SCREENING WHAT IS SCREENING? AIMS OF ALL SCREENING PROGRAMMES EXPECTATIONS OF SCREENING SAFE AND EFFECTIVE SCREENING A. Commissioning arrangements that provide: B. Effective governance to ensure: C. Quality assurance to look at the whole of the screening pathway: D. National and/or regional essential supporting aspects: E. Local core activities CERVICAL CYTOLOGY SCREENING CERVICAL CYTOLOGY - WHAT IT DOES CERVICAL CYTOLOGY - WHAT IT INVOLVES CERVICAL CYTOLOGY - HOW IT PERFORMS Current Screening Parameters Screening Pathway Standards and Key Performance Indicators (KPIs) Quality Assurance (QA) AUDIT DEFINITIONS DEFINITIONS AND EXPLANATIONS OF TERMS USED IN THE CERVICAL SCREENING PROGRAMME, NORFOLK AND WAVENEY: Eligibility Page 1 of 123

3 3.1.2 Coverage Uptake Exclusions from the programme Lost to follow-up POPULATION: ALL FEMALE RESIDENTS AGED INCIDENCE OF CERVICAL CANCER (ICD10 C53) RATES AND TRENDS IN THE INCIDENCE OF CERVICAL CANCER INCIDENCE OF CERVICAL CANCER BY ETHNIC AND BLACK MINORITIES ETHNIC GROUPS (BME) Cervical cancer incidence among Black and Minorities Ethnic groups (BME) in National Cancer Intelligence Network (NCIN) report, June Asian ethnic group compared with the White ethnic group Black ethnic group compared with the white ethnic group MORTALITY FROM CERVICAL CANCER (ICD10 C53) HOW MANY WOMEN DIE FROM CERVICAL CANCER? SCREENING POPULATION COVERAGE SCREENING POPULATION COVERAGE BY CLINICAL COMMISSIONING GROUP Great Yarmouth and Waveney CCG North Norfolk CCG Norwich CCG South Norfolk CCG West Norfolk CCG CEASING FROM THE CERVICAL CANCER PROGRAMME EFFICIENCY OF PROGRAMME POPULATION COVERAGE TIMELINESS OF THE SCREENING TEST STATUS OF ELIGIBLE WOMEN AT THE TIME OF INVITATION IN THE PREVIOUS YEAR WOMEN TESTED IN THE REVIEW PERIOD RESPONSE TO THE CALL/RECALL PROGRAMME IN THE REVIEW PERIOD Page 2 of 123

4 9.6 SCREENING TEST RESULTS TIMELINESS OF PRODUCTION OF RESULT CORRESPONDENCE MANAGEMENT SUGGESTED BY THE LABORATORY AS A RESULT OF THE FINDINGS OF THE SCREENING TEST REFERENCES APPENDICES APPENDIX 1: CERVICAL SCREENING HISTORY IN NORFOLK AND WAVENEY APPENDIX 2: GLOSSARY OVERVIEW APPENDIX 3: SOURCES OF DATA APPENDIX 4: SOURCES OF INFORMATION APPENDIX 5: CANCER SCREENING FOR PEOPLE WHO LACK THE MENTAL CAPACITY TO CONSENT APPENDIX 6: CEASING WOMEN FROM THE NHS CERVICAL SCREENING PROGRAMME Page 3 of 123

5 Executive summary This report summarises the findings and recommendations from a Public Health led project to explore the National Cervical Screening Programme in Norfolk and Waveney. Exploration includes the cervical screening programme and its links with cervical cancer incidence, mortality, population coverage, uptake and management in Norfolk and Waveney. Women between the ages of 25 and 64 are invited for regular cervical screening under the National Cervical Screening Programme. The programme aims to detect abnormalities within the cervix that could, if untreated, develop into cancer. National policy is that women are offered screening every three or five years depending on their age. The main purpose of this report to provide Clinical Commissioning Groups (CCGs) and all GP (General Practitioner) surgeries within the Norfolk and Waveney catchment area with details of their cervical screening practice coverage via this report in comparison with other practices in the county measured alongside both regional and national expectations. Additional purposes for this report include the need: for commissioners to review the definitive set of standards within which the service is provided to review performance management systems to ensure that any deviation from the agreed standards is identified, reported and addressed in a timely manner to follow up on the population unscreened or untreated to ensure that that all eligible people are identified and invited for screening to produce performance monitoring statistics to research response and uptake rates to investigate the reasons for compliance and non-compliance Where this is a clear deviation from national standard in terms of uptake, coverage and patients excluded from the cervical screening programme the aim shall be to work with individual GP practices to address these identified differences. The context for this project is provided by the Regional Quality Assurance structure in place for Cervical Screening. The East of England Quality Assurance Reference Centre (ESQA) 1 was previously an NHS organisation and since 1 April 2013 became part of Public Health England. It monitors performance and quality across the screening programmes within the East of England whilst promoting and leading on the continual pursuit of excellence in the screening programmes. ESQA participates in Quality Assurance (QA) visits to all parts of the screening programme (Call/Re-call, Cytology and Colposcopy) every three to four years. Data from statistical returns are considered at 1 Page 4 of 123

6 these visits along with discussion with staff about screening standards. Recommendations are made in a report that is circulated to all clinicians, Trust Management, Commissioners, Cancer Networks and the National Programme Team. Commissioners are encouraged by QA to review programme statistics and strive for and implement improvement; for example how screening coverage/uptake might be increased whilst considering patient inequalities. The Norfolk and Norwich University Hospital Foundation Trusts (NNUHFT) provides the majority of Cytology services for Norfolk and Waveney. NNUHFT received its last QA visit in January The report is still needs to be released but no major issues were reported in the feedback session during the visit. Overall, East Anglia is the second least deprived region in the country according to 2009 Health Profiles published by the Association of Public Health Observatories but there are still pockets of deprivation. Norfolk and Waveney are predominantly rural areas with areas of urban deprivation. The scope of this project includes cervical screening and cervical cancer only. Page 5 of 123

7 Abbreviations ASP Anglia Support Partnership ICD BME Black and Minority Ethnic JPUH C53 CCG Page 6 of 123 Cervical cancer where it has been identified as the primary cause of death Clinical Commissioning Group International Classification of Disease James Paget University Hospitals NHS Foundation Trust QA QEH KPIs Key Performance Indicators QMAS KC 53, 61, 63 Mandatory national Körner statistical returns QOF Quality Assurance Queen Elizabeth Hospital, King s Lynn Quality Management and Analysis System Quality and Outcomes Framework CGIN Cervical Glandular Intraepithelial Neoplasia LA Local Authority SMR Standardised Mortality Ratio CI Confidence Interval LBC Liquid Based Cytology SOA Super Output Area CIN Cervical Intra-epithelial Neoplasia. LL Lower Limit of confidence interval UL Upper Limit of confidence interval CIS Carcinoma In Situ NCC Norfolk County Council WHO World Health Organisation CSU Commissioning Support Unit NCHOD National Centre for Health Outcomes Development WN&W West Norfolk & Wisbech DH Department of Health NCIN National Cancer Intelligence Network WSH West Suffolk Hospital NHS Trust DHA District Health Authority NCRS The National Cancer Registration Service Eastern Office DSR Directly age-standardised Rates NHS National Health Service ECRIC Eastern Cancer Registry and Information Centre NHSCSP NHS Cervical Screening Programme ESQA East of England Quality Assurance National Health Service Information NHSIA Reference Centre Authority EoE East of England NICE National Institute for health and Clinical Excellence ERPHO Eastern Regional Public Health Observatory NNUH FHSA Family Health Services Authority NNUHFT Norfolk & Norwich University Hospital Norfolk and Norwich University Hospital Foundation Trusts FPC Family Planning Clinic NSF National Service Framework GP General Practice NWA North West Anglia GY&W Great Yarmouth & Waveney ONS Office for National Statistics HA Health Authority PCT Primary Care Trust HPV Human Papilloma Virus PHO Public Health Observatory IC Information centre SHA Strategic Health Authority

8 Key findings: Population Currently, almost 248,586 (slightly less than 50%) women aged years are resident in the CCGs area of Norfolk and Waveney nearly 57,092 are resident in the neighbouring area of Great Yarmouth & Waveney, 41,596 in North Norfolk, 53,629 in Norwich, 54,952 in South Norfolk, 41,317 in West Norfolk 2. The district area of King s Lynn and West Norfolk has the highest number of female residents; 37,779 aged years 3. The projected population figures for women aged for the next 16 years estimate a large increase in the number of residents, as follows: Year Norfolk % increase compared to previous year Great Yarmouth and Waveney CCG % increase compared to previous year Number Number ,049 55, , , , , , , , , Source: Based Subnational Population Projections, Population Projections Unit, ONS. The balance in ethnic groups in the area of Norfolk and Waveney in the age range is predominantly white British based on Office for National Statistics (ONS) in 2011 with the main five ethnic groups populated as follows: Around 241,327 (96.7%) white British 1,968 (0.8%) Mixed/multiple ethnic group 4,393 (1.8%) Asian/Asian British 1,302 (0.5%) Black/African/Caribbean/Black British 576 (0.2%) Other ethnic group 249,566 Total number of women aged These figures are based on GP practice registries 2012/13 (Source: Exeter database). 3 This is based on Office for National Statistics (ONS) mid-year 2011 estimates. Page 7 of 123

9 Incidence of cervical cancer During North Norfolk had the highest directly age standardised rate per 100,000 women of cervical cancer. The rate was 14 for women aged < 75 years (17 cases), and 13.6 for women of all ages (18 cases). This was worse than East of England (7.5 per 100,000 women) and England (8.6 per 100,000 women) average. This could be related to early detection rather than other risk factors. During the same period of time Norwich had the highest number of new cases of cervical cancer (25 cases among women aged < 75 years and 28 among women of all ages). This could be possibly related to deprivation and to early detection. This data does not distinguish the cancers detected as a result of women presenting symptomatically from those identified through the screening programme and this, too, may influence the figures. Over the years , the directly age standardised rate per 100,000 of cervical incidence for women of all ages in Norfolk on seven occasions (1993, 1995, 2004, 2007, 2008, 2009, and 2010) were higher than East of England and England average. Between 2001 and 2010, there were 419 new cases of cervical cancer in Norfolk, giving an average of 42 new cases per year. It was not possible to distinguish the cervical cancers detected as a result of women presenting symptomatically from those identified through the screening programme. Black and Minority Ethnic (BME) communities Rates for cervical cancer among females <65 years and females of all ages were lower in the Asian ethnic group. On contrast rates for females aged 65 years and over were higher in the Asian and Black minorities ethnic groups. Mortality Mortality trends over time from cervical cancer for women <75 years and for women of all ages vary across Norfolk due to small number of deaths from cervical cancer each year, there is considerably year-on-year variability associated with the estimates so it would be expected that a change would occur simply due to random variation. Page 8 of 123

10 Data since 1993 the rates of deaths from cervical cancer have fallen in Norfolk and better than England. However, data during indicate the trends for cervical cancer deaths may be changing. Screening population coverage Overall for the eligible age range (25-64), North Norfolk CCG and South Norfolk CCG achieved the coverage target for the five reporting years from 2007/8 to 2011/12. In contrast Norwich CCG and West Norfolk CCG have never achieved the target during the five years, while Great Yarmouth and Waveney CCG only failed to achieve the target in the last two financial years 2010/11 and 2011/12. The coverage for the lower age range of women (25-49) Great Yarmouth & Waveney CCG and West Norfolk CCG have failed to achieve the national target of 80% in any year, while North Norfolk CCG and South Norfolk CCG have achieved the target in the five years. Norwich CCG has only achieved the target during two financial years 2009/10 and 2010/11. Coverage for the upper age range (50-64), Norwich CCG has successfully achieved the 80% target during the five years 2007/8-2011/12. South Norfolk CCG missed to achieve the target only once in the last financial year 2011/12. While Great Yarmouth CCG, North Norfolk CCG, and West Norfolk CCG have achieved the target occasionally. Page 9 of 123

11 to target practices with: overall low coverage. low coverage in women aged to identify number of non-attenders by post code. to monitor the cervical cancer incidence and mortality across Norfolk. to take a joint call/recall and GP practices/ccgs plan to follow-up women who are lost to followup. to distinguish the cancers detected as a result of women presenting symptomatically from those identified through the screening programme. to repeat the analysis in two years. Page 10 of 123

12 In 2009, there were 2,747 new registrations of invasive cervical cancer in England. After the NHS Cervical Screening Programme started in the UK in the late 1980s, cervical cancer incidence rates decreased considerably. In Great Britain, the agestandardised incidence rate almost halved (from 16 per 100,000 women in to 8.5 per 100,000 women in ). Cervical cancer is the 11th most common cancer among women in the UK, and the most common cancer in women under 35. Between 2008 and 2009 incidence rates increased by more than 20 per cent in the 25 to 34 age range (22 per cent for women aged and 21 per cent for those aged 30-34). Cervical screening saves approximately 4,500 lives per year in England. Cervical screening prevents up to 3,900 cases of cervical cancer per year in the UK. Page 11 of 123

13 What are the risk factors of cervical cancer 4? The exact cause of cervical cancer is not known. However, it is known that: Some types of Human Papillomavirus, in particular HPV 16 and HPV 18, are found in over 99 per cent of cervical cancers. These are known as 'high risk' types. Other types (e.g. HPV 6 and HPV 11) cause genital warts. Those which cause genital warts do not place a woman at increased risk of developing cervical cancer. Other types of HPV appear to be harmless. The majority of sexually active women will come into contact with high risk HPV types at some time in their life. In most women, their body's own immune system will get rid of the infection without them ever knowing it was there. Only a minority who are positive for high risk HPV types will develop cervical abnormalities i.e. Cervical Intra-epithelial Neoplasia (CIN) which could develop into cervical cancer if left untreated. Women with many sexual partners, or whose partners have had many partners, are more at risk of developing cervical cancer. This is because their behaviour is more likely to expose them to HPV. However, a woman with only one partner could contract HPV if that partner has previously been in contact with the virus. Women who are immunosuppressed (for example, those who are taking immunosuppressive drugs after an organ transplant or women who are HIV positive) may be at increased risk of developing cervical cancer. Women who smoke are about twice as likely to develop cervical cancer as non-smokers. This may be because smoking is associated with high risk health behaviours or because it suppresses the immune system allowing the persistence of high risk HPV infection. Stopping smoking appears to help clinical abnormalities to return to normal. Using a condom offers only very limited protection from transmission of HPV. Long term use of oral contraceptives increases the risk of developing cervical cancer but the benefits of taking oral contraceptives far outweigh the risks for the majority of women. Women with a late first pregnancy have a lower risk of developing cervical cancer than those with an early pregnancy. The risk rises with the number of pregnancies. Despite the risk factors, cervical screening can prevent around 75 per cent of cancer cases in women who attend regularly. Screening is one of the best defences against cervical cancer. Many of those who develop it have never been screened. The biggest risk factor is non-attendance. 4 Page 12 of 123

14 1.0 Description of screening 1.1 What is screening? Screening is a public health service in which members of a defined population who do not necessarily perceive that they are at risk of, or are already affected by a disease or its complications, are asked a question or offered a test, to identify individuals who are more likely to be helped than harmed by further tests or treatment to reduce the risk of a disease or its complications. Screening has an important ethical difference from clinical practice as the screening is targeting apparently healthy people and offering to help individuals to make better informed choices about their health. However, there are risks involved and it is important that people have realistic expectations of what a screening programme can deliver. 1.2 Aims of all screening programmes Page 13 of 123 identify a predefined group of well people who are at risk of a specific disease offer screening to all at risk individuals investigate the site of the specified disease at regular, predefined intervals identify disease at its earliest stage diagnostic phase 1.3 Expectations of screening if a disease is present, the screening programme will detect it once detected, the disease will be successfully treated those recognised as being at continued risk will be monitored on a regular basis 1.4 Safe and effective screening In order to provide a safe and effective screening programme, the following conditions must be clearly set and monitored: A. Commissioning arrangements that provide: a definitive set of standards within which the service is provided a clear service specification, describing how each of the standards will be delivered performance monitoring around predefined measurements management of the provider services through routine review

15 B. Effective governance to ensure: agreed lines of responsibilities and accountabilities at each stage of the pathway demonstrable fail-safe mechanisms at each stage of the pathway performance management systems that ensure that any deviation from the agreed standards is identified, reported and addressed in a timely manner a clinical input to identify, report and review any incident within the pathway C. Quality assurance to look at the whole of the screening pathway: the disease clinical outcomes of the screened population treatment services across the Norfolk and Waveney follow up of the population unscreened or untreated D. National and/or regional essential supporting aspects: researching the evidence devising the strategy setting aims, objectives and policy setting standards for each part of the pathway procuring equipment training staff appraising evidence, assessing health technology, commissioning new and ongoing research planning the workforce organising publicity, information and communications strategy quality assuring every aspect developing and maintaining systems for information management collating the data advising on incidents and serious incidents E. Local core activities setting the multidisciplinary operational policy Page 14 of 123

16 identifying and inviting eligible people taking and reading tests providing an appropriate suggested management recording results, scheduling follow-up and running failsafe systems performing and reading diagnostic investigations carrying out interventions providing information, support and advice for participants producing performance monitoring statistics collecting evidence of adherence to quality recommendations researching response and uptake rates investigating the reasons for compliance and non-compliance ensuring multidisciplinary activities and pathways across the area managing incidents within the programme and ensuring quality standards are fulfilled Those points highlighted in are the key objectives/reasons for undertaking this audit report. Page 15 of 123

17 2.0 Cervical Cytology Screening Cervical Screening is not a diagnostic test for cancer. It is a method of identifying and treating, as appropriate, early abnormalities which, if left untreated, could lead to cancer in a woman s cervix. Cervical screening was first introduced in the 1960 s. From 1 April 2013 Public Health England 5 aims to reduce the number of women who develop invasive cervical cancer (incidence) and the number of people who die from it (mortality). It does this by coordinating the regular screening of all women at risk so that conditions which might otherwise develop into invasive cancer can be identified and treated. NHS Cervical Screening Programme NHSCSP was set up in 1988 with a computerised call / recall system (the National Health Service Information Authority NHSIA database; also known as the Exeter system) introduced to ensure that those with the greatest risk of the disease were targeted. The NHSIA system ensures the identification of the appropriate cohort of the population registered with an NHS GP, the production of all correspondence for invitation and results and for activating the management of the individual s recall, in conjunction with information received from surgeries, clinics and laboratories. The cervical cancer screening programme is a multidisciplinary activity managed variously across primary and secondary care, with cross-border activities according to the location of surgery, laboratory, and acute unit and GP practices. Local context regarding the introduction of cervical screening and developments over the years within Norfolk and Waveney is detailed in Appendix 1 page Cervical Cytology - What it does A cervical cytology sample, when processed (screened) detects abnormalities in the cellular pattern of the cells of the cervix. The identification of cellular irregularities or abnormalities and the early intervention to prevent the abnormalities progressing into a disease which readily leads to cancer of the cervix prevents about 75% of cases of invasive cervical cancer. A screened cervical sample identifies a common virus, human papilloma virus (HPV). A screened cervical sample identifies a common virus, human papilloma virus (HPV), which indicates further management through a triage pathway for surveillance or further investigation (HPV is implicated in almost 100% of cervical cancer cases). 5 Before that NHS Cervical Screening Programme (NHSCSP) were responsible, Page 16 of 123

18 2.2 Cervical Cytology - What it involves million Samples have been examined (25-64) in 2013 compared to 3.54 in ,695 abnormalities have been detected between in A total of 4.24 million women aged 25 to 64 were invited for screening in , a fall of 9.7 per cent from when 4.69 million were invited million Samples were examined by pathology laboratories in This compares with 3.87 million in Of the samples examined in , 3.36 million (94.1 per cent) were submitted by GPs and NHS Community Clinics. A total of 167,394 referrals to colposcopy were reported in , an increase of 13.2 per cent from (147,889 referrals). The large increase in referrals is likely to be partly due to the roll-out of HPV testing. 2.3 Cervical Cytology - How it performs The programme has routine performance monitoring measures to ensure uniformity of activity for eligible age range, conditions for exclusion and the type and frequency of correspondence at each stage of the screening pathways as well as equitable quality assurance measures throughout the screening activities Current Screening Parameters Women are invited (called) at the age of 25 years and should have a first test at that age a development for 2011 is that all women will be invited (called) at the age of 24 years and 6 months so that a first test can be taken, processed and recorded on the population database by the age of 25 years women must not be offered a screening test under the age of 25 years as cancer is rare but abnormalities are common women aged are recalled every 36 months and must not be offered a routine test before 36 months women aged are recalled every 60 months and should not be offered a routine test before 54 months women aged 65+ must not be offered a routine screening test unless they have not been screened since the age of 50 or who have had recent abnormal tests 6 Page 17 of 123

19 Note: in Norfolk, since , any test received and verified by the laboratory as out-of-programme has not been processed) Screening Pathway The following pathway should be in place for the Cervical Screening Programme: women are identified by the agents for the population database (SERCO) as they approach the predefined date for call/recall notifications are sent electronically to the woman s GP to establish the appropriateness of inviting the woman invitations are produced 6 weeks prior to due date and are dispatched to each woman at her registered address with the mandatory national information leaflet and an HPV information sheet woman attends surgery or clinic; appropriateness of the test verified pre-population sample request form electronically downloaded and verified with woman sample taken by trained nurse or GP and packaged with request form in laboratory sample packaging; woman informed that her result will be processed within 14 days and a letter dispatched to her at her registered address samples are collected by van and delivered to the processing laboratory samples processed, read, reported and checked at the laboratory triage for HPV processing identifies samples required to be sent for further tests at Bristol results sent electronically to call/recall results requiring management or further investigation are sent electronically to the appropriate colposcopy unit for direct referral all result letters produced and dispatched to women within 14 days of the sample being taken recall of all women according to the management recommended by the processing laboratory, takes place through SERCO, as appropriate follow-up monitored by laboratory/gp in conjunction with Public Health. women moving in or out of the area are part of the national programme and every woman will be recalled at the recommended interval Standards and Key Performance Indicators (KPIs) Page 18 of 123 coverage: at least 80% of the total eligible population to be adequately screened within the past 60 months

20 laboratory turnaround time: 100% samples received should be read and reported within 14 days waiting times for colposcopy: at least 90% of women with an abnormal result to be seen within 8 weeks of referral communication of colposcopy results: 90% of results within 4 weeks commissioning consortium: a regional commissioning group should oversee activities laboratory size: each laboratory should process at least 35,000 samples per annum liquid based cytology should be implemented at all laboratories Quality Assurance (QA) QA visits for cytology laboratories are undertaken by a regional multidisciplinary QA team on a triennial basis and any recommendations made following the visit become part of the unit s performance action plan. This is monitored by Public Health England since April QA visits for colposcopy clinics are undertaken by a regional multidisciplinary QA team on a triennial basis and any recommendations made following the visit become part of the unit s performance action plan. An annual technical audit of the call/recall database is undertaken and any recommendations are reported and become part of the agent s (Anglia Support Partnership ASP) immediate action plan. The commissioning body undergoes a triennial QA visit by the regional multidisciplinary QA team and any recommendations made following the visit become part of the action plan. Data returns are aggregated regionally and then nationally and any deviations from the expected norm are reported and investigated on an annual basis. Any national, regional or local serious incident is highlighted to give further opportunity to quality assure the programme. 7 Page 19 of 123

21 3.0 Audit Definitions Having provided a brief introduction to screening and cervical screening this chapter now provides a summary of the key definitions and explanation of the key terms used within this report. 3.1 Definitions and explanations of terms used in the Cervical Screening Programme, Norfolk and Waveney: Eligibility describes the group or cohort of the population who will benefit from screening. Women aged between 25 and 64 years are eligible for cervical screening and are invited and recalled at pre-defined, regular intervals under the national Cervical Screening Programme. This is intended to detect abnormalities within the cervix which, if not identified and if untreated, develop into cancer Coverage is defined as the percentage of women in a population eligible for screening at a given time who were screened adequately within a specified period. Coverage is calculated differently for different age groups to reflect the national age and recall interval: Page 20 of 123 Women aged (the lower target age group): coverage is calculated as the number of women in this age group who have had an adequate screening test recorded within the last 3.5 years as a percentage of the eligible population aged Women aged (the upper target age group): coverage is calculated as the number of women in this age group who have had an adequate screening test within the last 5 years as a percentage of the eligible population aged Women aged (the complete target age group): coverage is calculated as the number of women in this age group who have had an adequate screening test within the last 5 years as a percentage of the eligible population aged Uptake is defined as the number or percentage of eligible women who respond to an invitation by accepting a screening test within a specified time following the production of that invitation. Uptake is calculated by the number of test results recorded at three stages of notification:

22 Uptake to first invitation: uptake is calculated as the number of women invited and having a test result recorded within 16 weeks of the production of the notification. Uptake to reminder invitation: uptake is calculated as the number or percentage of women having a test result recorded within 16 weeks of production of the reminder notification, that is, between 16 and 32 weeks after the due date. Uptake at final-non-responder stage: uptake is calculated as the number or percentage of women having a test result recorded within 16 weeks of production of a notification to the woman s GP Exclusions from the programme are defined as the number of women who have been removed either automatically by predefined computer parameters or manually by intervention of a healthcare professional or at the request of the women or her named carer. These exclusions fall into three categories: Woman has no cervix: either born without a cervix or the cervix has been surgically removed normally as a result of a hysterectomy. Woman is over the age of eligibility for the programme and has fulfilled the national requirements for screening. Woman s request (or her carer s request) in writing having been fully informed of the consequences of this action Lost to follow-up is the term used to describe women who have been invited to attend a referral clinic and who have failed to attend that clinic on at least two occasions. Page 21 of 123

23 4.0 Population: all female residents aged In this section we provide information on women aged within Norfolk and Waveney by geographical location, age band and ethnicity in order to contextualise this report. As explained previously, females aged who have a cervix are eligible for cervical screening. It is crucial to understand both Norfolk and Waveney current population estimates, and how these may change in the future, in order to plan for adequate cervical screening services. There are two sources for estimates of the eligible population. These sources show differences in total numbers, in age bands and in resident districts. General Practitioners registers: figures are derived from the capitation records for all residents registered with an NHS GP. These estimates relate to registered population only and exclude all people who remain unregistered for whatever reason. There are areas where residents are registered out of their immediate ward, district or county area. Office for National Statistics (ONS) population estimates: derived from the 2001 Census, updated mid-year (annually) from records of births, deaths and migration. These estimates relate to the total population resident in the area. The Office for National Statistics (ONS) also produces estimated projected population forecasts for births, deaths and migration calculated from the statistical impact arising from new homes, business growth and patterns in demography 8. Tables 1 and 2 show the number of women aged by Clinical Commissioning Group (CCG) using the capitation figures from GP registers in 2012/13. All figures are sub-divided into the cervical screening age bands: There are 248,586 women aged in Norfolk and Waveney, 49.6% of the total population. There are 57,092 women aged in Great Yarmouth and Waveney CCG (of which 25,515 in Great Yarmouth and 31,577 in Waveney). The CCG with the highest number of women aged years is Great Yarmouth and Waveney CCG with 57,092, followed by South Norfolk CCG with 54,952. The CCG with the smallest population in the age range is West Norfolk with 41,317 women. 8 Source: Based Subnational Population Projections, Population Projections Unit, Office for National Statistics (ONS). Page 22 of 123

24 The accuracy of the figures in the above table is imperative for the running of the cervical screening programme. Discrepancies between the actual figures and the recorded figures will be slight due to a number of scenarios: some women will move out of the area and fail to register in the new area so their screening and capitation details will remain upon the original surgery s database until the woman is either re-registered or the surgery chooses to de-register her; conversely, some women move into the area and fail to register with an NHS GP therefore they will not be included in the figures. A small number of women may be held in abeyance at the time the statistical analysis reports are processed. There may also be women who are either removed from the GP s list and awaiting acceptance on another GP s list or who have removed themselves from the care of an NHS GP. Travellers who are not registered with a GP in the area. Women with total private healthcare cover. Any other un-registered women. The entire population serving in Her Majesty s (HM) forces are excluded automatically but the dependants of people employed in HM forces are eligible to choose to register with an NHS GP and may, therefore (but not necessarily) be included. The population held in custody while awaiting Her Majesty s pleasure are excluded automatically after the first period of 24 months in detention has elapsed. Table 1: Number and percentage of females aged by age band, Clinical Commissioning Group (CCG), Norfolk and Waveney GP practice registries 2012/13 Number % of total females population aged CCG GY&W 34,212 22,880 57, North Norfolk 22,783 18,813 41, Norwich 36,850 16,779 53, South Norfolk 33,184 21,768 54, West Norfolk 24,212 17,105 41, Norfolk and Waveney 151,241 97, , Page 23 of 123

25 Table 2: Number and percentage of females aged by age band for Great Yarmouth and Waveney Clinical Commissioning Group CCG, GP practice registries 2012/13 Great Yarmouth and Waveney CCG Number % of total females population aged Great Yarmouth 15,660 9,855 25, Waveney 18,552 13,025 31, Great Yarmouth and Waveney 34,212 22,880 57, Table 3 shows the number of women aged by district area using the ONS mid-year estimates, All figures are subdivided into cervical screening age bands. Figures show that there are: 219,502 women in Norfolk (increase of 2,493 over the GP capitation figures) 248,306 women in Norfolk and Waveney (decrease of 280 compared with GP capitation figures) The populations in each of the district areas vary in number by approximately 10,000 women. The area with the highest number of women aged years is King s Lynn & West Norfolk with 37,779, followed by Norwich with 33,782. The area with the smallest population in the age range is Great Yarmouth with 24,673 women. Table 3: Number and percentage of females aged by age band, district, Norfolk and Waveney (2011) Local Authority Number % of total females population aged Breckland 20,031 13,315 33, Broadland 19,402 13,671 33, Great Yarmouth 14,824 9,849 24, King's Lynn and West Norfolk 22,187 15,592 37, North Norfolk 12,376 11,492 23, Norwich 23,581 10,201 33, South Norfolk 19,592 13,389 32, Waveney 16,769 12,035 28, Norfolk 131,993 87, , Norfolk and Waveney 148,762 99, , Page 24 of 123

26 Temporary residents are not estimated in the above table or included in table 1. Temporary residents will include seasonal workers, people on holiday for a period of less than three months and longer-term residents who are outside the remit of the ONS. Table 4 shows the number of women aged years by their ethnic origin for the county of Norfolk and Waveney based on Census estimates in White British women are the dominant group in Norfolk with 213,075 residents in the age range (241,327 in Norfolk and Waveney). Major Black Minorities Ethnic groups (BME) account for 4,095 women from Asian/Asian British origins in Norfolk (4,393 women in Norfolk and Waveney). Table 4: Norfolk and Waveney female aged population shown by ethnic group, Census estimates in 2011 Page 25 of 123 All ages Number % Norfolk White: Total 422, ,262 86, , Mixed/multiple ethnic group: Total 4,954 1, , Asian/Asian British: Total 6,875 3, , Black/African/Caribbean/Black British: Total 2,167 1, , Other ethnic group: Total 1, All categories: Ethnic group 437, ,539 88, , Norfolk and Waveney White: Total 480, ,602 98, , Mixed/multiple ethnic group: Total 5,521 1, , Asian/Asian British: Total 7,361 3, , Black/African/Caribbean/Black British: Total 2,326 1, , Other ethnic group: Total 1, All categories: Ethnic group 496, , , ,

27 5.0 Incidence of cervical cancer (ICD10 C53) 5.1 Rates and trends in the incidence of cervical cancer The national cervical cytology cancer screening programme is a crucial secondary prevention mechanism for the early detection of disease which may readily lead to cancer and, therefore, for the early diagnosis and treatment of cervical cancer. This section focuses upon the incidence of cervical cancer in residents of Norfolk and Waveney. Definition of incidence rate for cancer: Incidence rate for cancer is the rate of the recorded occurrence of new cases of cancer within a given population over a given time period Available data on the incidence of cervical cancer incidence data provides valuable new information on the risk factors for developing cervical cancer and how it changes with treatment. Incidence data provides a powerful means of evaluating the risk at the time of the disease is identified and provides information useful for the aetiology of cervical cancer; that is, by geographical areas, or by a group of women. Data relating to incidence of cervical cancer is shown by local authority district areas. Table 5 and Figure 1 give the directly age-standardised incidence rates of cervical cancer incidence (DSR) of women <75 years and women of all ages per 100,000 European Standard populations shown by Local Authority, East of England (EoE) Strategic Health Authority and England., (pooled). The above table and the graph highlight that women < 75 years of age and all ages in all districts in Norfolk and Waveney have higher cervical cancer incidence than East of England and England average rates. This could be explained either by the effectiveness of the programme to identify women earlier especially those aged years of age or to areas where deprivation is high. Page 26 of 123

28 Table 5: Directly age standardised rate (DSR) of cervical cancer incidence per 100,000 women by district, (pooled) District area females aged <75 per 100,000 population females in all ages per 100,000 population number rate LL UL number rate LL UL Breckland Broadland Great Yarmouth Kings Lynn and West Norfolk North Norfolk Norwich South Norfolk Waveney Norfolk East of England England 6, , Note: Directly Age- (or age- and sex-) standardised mortality (DSR) Death rate calculated to enable fair comparison with another area allowing for the difference in age (or age and sex) composition of the population Page 27 of 123

29 Figure 1: Directly age standardised rate (DSR) of cervical cancer incidence per 100,000 women by district, (pooled) Source: Health & Social care Information centre (hscic) It can be seen that women < 75 years in in North Norfolk have the highest cervical incidence rate in the county which could be related to early detection rather than other risk factors. The most deprived areas such as Great Yarmouth, Norwich, Kings Lynn and West Norfolk, and Waveney has higher cervical cancer incidence rate not statistically significantly difference when compared to East of England and England average rates. Page 28 of 123

30 Factors affecting the elevated incidence of cancers can well be lifestyle related but may also be influenced by the call/recall intervals for cervical screening present at the time prior to diagnosis, the sensitivity of the testing process and the timeliness (or otherwise) of the woman s response to invitation for screening and/or response to the referral unit for Colposcopy. Prior to 2004, national policy was to invite women for screening at intervals of not more than 5 years and there was significant variation in local practice. This changed in 2004 to the current age and interval policies but it has taken five years to be fully implemented nationally. Call and recall intervals are described in Appendix 1 page 103 and can significantly reduce the impact of interval cancers. For example, Waveney had a 36 monthly recall from 1992 for all women and, therefore, cellular changes may have been identified earlier than other areas where the recall period remained at 60 months for women over the age of 35 years. The sensitivity of the Liquid Based Cytology (LBC) process is known to have an influence upon the detection rate of cancers and this may show in the high incidence of cancers in the Norfolk where the LBC process was introduced as a pilot area well in advance of its introduction for the population served by the cytology and pathology laboratories based at the Queen Elizabeth Hospital (Kings Lynn), the James Paget Hospital (Gorleston) and the West Suffolk Hospital (Bury St Edmunds). For the purpose of this study, we are concerned with the incidence of cancer and not with the woman s history of screening as it has not identified the stage in the cycle at which the women responded (or not) to their invitations for screening and/or for colposcopy. Finally, the above table does not distinguish the cancers detected as a result of women presenting symptomatically from those identified through the screening programme and this, too, may influence the figures. Lifestyle factors are known to have a significant influence upon susceptibility to cancer. The high numbers of cancers detected in Great Yarmouth, Norwich, Kings Lynn and West Norfolk, and Waveney correlate to the following known factors: deprivation smoking Page 29 of 123

31 Between , the incidence rates for cervical cancer were highest in Norfolk with this high incidence rate exceeding the EoE and overall England incidence levels. The tables show Norfolk with an incidence elevated above the national average for women <75 years of age and, again, an elevated incidence overall for all women in the eligible screening age range. Table 6: Norfolk with EoE and England compared: females of all ages directly age-standardised registration rates incidence of cervical cancer (DSR) per 100,000 European Standard populations, Year NHS Norfolk area GY&W CCG number Norfolk EoE England NHS Norfolk area DSR per 100,000 population GY&W CCG Norfolk EoE England , , , , , , , , , , , , , , , , , , Source: Health & Social care Information centre (hscic) Page 30 of 123

32 Table 6 shows there are normal fluctuations in the number of women who are invited to attend for screening each year (see Appendix 1 page 103 for the historical outline of the screening call and recall in Norfolk and Great Yarmouth and Waveney). The numbers of women screened will impact upon the numbers of women found to have cervical cancer. However, this will only account for the cancers identified through the call/recall programme and does not apply to the number of symptomatic cases diagnosed. The high numbers and DSR rates identified in the early years of population screening reflect the stages at which screening was introduced by the former District Health Authority s (DHAs), (see Appendix 1 page 103 for the phased introduction of screening across the county and across the eligible age range). The figures from 1998 were standardised nationally and any fluctuations found will reflect actual activity without any variation in the national reporting. Workload in terms of number of samples processed and the number of women invited remain subject to variation (see DHA activities, as above). Boundary changes, coupled with splits and mergers of the former DHAs affect the populations. The sudden increase in incidence of cancer in 2004 as shown in Table 6 (11.1 for NHS Norfolk area, and 11.3 for Norfolk per 100,000) in this population may be due to the peak of workload in that year but, again, this may only be clarified by separating the numbers of women identified as part of the screening process from the women presenting symptomatically. The increase in incidence of cancer in 2010 for Norfolk 13.7 could be likewise. Finally, the introduction of a laboratory pilot for the triage of HPV testing at the pathology laboratory at the NNUH and the implementation of LBC sampling in 1998 also impacts upon the figures as the sensitivity of the testing process became far greater during the period of the pilot and for the surgeries sending samples to the Norfolk and Norwich University Hospital for processing. It is only through a thorough examination of the full individual case studies that it is possible to explain the fluctuations in the reported incidence of cervical cancer. Between 2001 and 2010, there were 419 new cases of cervical cancer in Norfolk, giving an average of 42 new cases per year. Page 31 of 123

33 Figure 2: Norfolk with EoE and England compared: females of all ages directly age-standardised registration rates incidence of cervical cancer (DSR) per 100,000 European Standard populations, Source: Health & Social care Information centre (hscic) Figure 2 gives trends information of incidence of cancer of the cervix during for Norfolk and compared to EoE and England. It can be seen there is fluctuations in rates over time and the rate for Norfolk is higher than EoE and England average rates in Page 32 of 123

34 5.2 Incidence of cervical cancer by Ethnic and Black Minorities Ethnic groups (BME) Cervical cancer incidence among Black and Minorities Ethnic groups (BME) in National Cancer Intelligence Network (NCIN) report, June There is limited information available to demonstrate the incidence of cervical cancer among black and BME communities in Norfolk and Great Yarmouth & Waveney. However, in June 2009 the National Cancer Intelligence Network (NCIN) published a report highlighting cancer incidence and survival by major ethnic groups for England ( ). A key finding was: Due to the very low incidence of cervical cancer among women from ethnic minorities groups, only women from Asian and Black minority ethnic groups have been compared with the white population Asian ethnic group compared with the White ethnic group Incidence rates for cervical cancer among females <65 years and females of all ages were lower in the Asian ethnic group with statistically significant results for all three assumptions 10 regarding the distribution of cases with unknown ethnicity. Incidence rates for females aged 65 years and over were higher in the Asian ethnic group with statistically significant results for all three assumptions regarding the distribution of cases with unknown ethnicity Black ethnic group compared with the white ethnic group Rates for females aged 65 years and over were higher in the Black ethnic with statistically significant results for all three assumptions regarding distribution of cases with unknown ethnicity. Results were inconclusive for females under 65 years and of all ages in the black ethnic group Due to the large number of patients with unknown ethnicity, three different methods of assigning an ethnic group to these patients have been used to give an estimate of the possible variation in age-standardised rates and rate ratios. Page 33 of 123

35 Age-standardised cervical incidence rates for the white ethnic group ranged from 8.2 to 8.7 per 100,000 for all ages. Rates for the Asian ethnic group were significantly lower than the White ethnic group for all ages, ranging from 3.6 to 6.5 per 100,000. Rates for the Black ethnic group ranged from 6.3 to 11.2 per 100,000 for all ages These ranges are not confidence intervals but reflect a combination of both statistical uncertainty and uncertainty concerning the distribution of cases with unknown ethnicity. Page 34 of 123

36 6.0 Mortality from cervical cancer (ICD10 C53) This section analyses the mortality figures for cervical cancer where it has been identified as the primary cause of death (C53). Figures are shown at county and local authority level using figures from the Office for National Statistics (ONS) for deaths recorded in the years 2008 to 2010 for women aged <75 years and for women of all ages. This section describes the trend rates in deaths from cervical cancer from 1993 to As there are small numbers of deaths recorded, trends are not shown at the lower level (local authority area). As recorded in chapter 5, North Norfolk shows the highest levels of new cases of cervical cancer. Tables 7a-7b demonstrate that mortality figures from cervical cancer for women <75 years and for women of all ages vary across Norfolk trends over time due to small number of deaths from cervical cancer each year, there is considerably year-on-year variability associated with the estimates so it would be expected that a change would occur simply due to random variation. Mortality from cervical cancer overall is higher for Norfolk compared with EoE and equal to England. How many women die from cervical cancer 12? In 2008, 759 women died from cervical cancer in England. Mortality rates generally increase with age with the highest number of deaths occurring in the age group. Only about 7 per cent of cervical cancer deaths occur in women under 35. Cervical cancer mortality rates in 2008 (2.4 per 100,000 females) are nearly 70 per cent lower than they were 30 years earlier (7.1 per 100,000 females in 1979). The latest relative survival figures for England show that around 67 per cent of women diagnosed with cervical cancer between 2005 and 2009 were alive five years later Page 35 of 123

37 Table 7a: < 75 Directly age-standardised mortality rates of cervical cancer (DSR) per 100,000 European Standard populations by district, (pooled) number rate LL UL number rate LL UL number rate LL UL Breckland <5 Broadland Great Yarmouth <5 <5 <5 Kings Lynn and West <5 Norfolk <5 <5 North Norfolk < Norwich <5 < South Norfolk <5 <5 <5 Waveney < Norfolk East of England England 1, , , Source: Health & Social care Information centre (hscic) Note: Due to confidentiality issue, cells with number of deaths below 5 were suppressed. Page 36 of 123

38 Table 7b: All ages Directly age-standardised mortality rates of cervical cancer (DSR) per 100,000 European Standard populations by district, (pooled) number rate LL UL number rate LL UL number rate LL UL Breckland Broadland Great Yarmouth <5 <5 <5 Kings Lynn and West Norfolk North Norfolk Norwich South Norfolk <5 <5 <5 Waveney Norfolk East of England England 2, , , Source: Health & Social care Information centre (hscic) Note: Due to confidentiality issue, cells with number of deaths below 5 were suppressed. Page 37 of 123

39 Table 8 and Figure 3 demonstrate the directly age standardized mortality trend rates for cervical cancer from among women of all ages. Key findings include: Overall mortality from cervical cancer is declining in EoE and England. The figure for Norfolk in 2014 is slightly higher than East of England and England. The number of deaths is small and, therefore, small variations in the number of deaths show significant changes in the trends of deaths during the period 1993 to The lowest annual mortality rate in Norfolk is seen in 2002 and this is lower than EoE and England. The mortality trend rate is near to 1 in 100,000 in 2002, rising to 2.4 in every 100,000 women in Mortality rates for Great Yarmouth & Waveney CCG are not shown because in many years the number of deaths from cervical cancer is below 5 cases and the figures are, therefore, too small to present. Page 38 of 123

40 Table 8: Norfolk with EoE and England compared - all ages directly age-standardised mortality rates of cervical cancer (DSR) per 100,000 European Standard populations, 1993 to 2012 Year NHS Norfolk area number % Norfolk EoE England NHS Norfolk area Norfolk EoE England , , , , , , , , NA NA NA NA Source: Health & Social care Information centre (hscic) Note: Great Yarmouth & Waveney CCG was excluded from the analysis because the number of cases recorded in most years was less than five and would, therefore, be insufficient to show a meaningful trend Page 39 of 123

41 Figure 3: Norfolk with EoE and England compared - all ages directly age-standardised mortality rates of cervical cancer (DSR) per 100,000 European Standard populations, 1993 to 2012 Source: Health & Social care Information centre (hscic) Page 40 of 123

42 7.0 Screening population coverage Currently, the national minimum target for the population coverage of the eligible population for cervical screening is 80%. This is measured as the percentage of women aged who are resident, registered and eligible for screening with at least one adequate result recorded on the NHSIA population database within the previous 60 months at the time of the running of the national statistical returns. Currently coverage is still monitored by PCT. It may be possible to access practice level data which could then be aggregated at CCG level for current financial years (during the past 5 years it was possible to do this). The national target for the population is that 100% of the entire eligible population are to be invited at the nationally defined intervals. Women enter the screening programme as they approach the age of 25 and are identified and invited for screening. However, many will not have had one test result recorded at the time of the running of the statistics. This is to be addressed nationally and women will soon be invited for screening at the age of 24 years and 6 months in order to give adequate time to be screened before the age of 25 years. Women who are resident but unregistered are eligible for screening but will not form part of the analysis. Women who have been removed from the programme for other reasons are not routinely invited for screening and the responsibility for re-assessing their needs remains with the surgeries. They remain eligible for screening and are included in the calculations. Women who have been automatically removed from the programme at the upper age limit are removed only if they fulfil the requirements of having had a test recorded within the specified period and, therefore, they will already have had a test result within the calculation. For the PCT area, a minimum population coverage target of 80% applies for each of the GP practice areas. Overall, an area is able to achieve coverage of 80% but there can be wide variations of practice population coverage within this overall figure. Table 9 and Figure 4 provide information on population coverage for cervical screening (numbers and percentages) by age ranges for NHS Norfolk area and Great Yarmouth & Waveney CCG, EoE and England for the years 2007/8 till 2012/ Cervical Screening Programme England, Health & Social care Information Centre, Date of Publication: October 24, 2013, Page 41 of 123

43 Table 9: Population coverage for cervical screening (numbers and percentages) by age range for NHS Norfolk area, Great Yarmouth & Waveney CCG, EoE and England for the years 2007/8-2012/13. Year Area Number (000s) - Eligible population (%) - Eligible population ages ages ages ages ages ages /08 NHS Norfolk area GY&W CCG EoE England /09 NHS Norfolk area GY&W CCG EoE England /10 NHS Norfolk area GY&W CCG EoE 1, , England 9, , , /11 NHS Norfolk area GY&W CCG EoE 1, , England 9, , , /12 NHS Norfolk area GY&W CCG EoE 1, , England 9, , , /13 NHS Norfolk area GY&W CCG EoE 1, , England 9, , , Source: Cervical Screening Programme England, Health & Social care Information Centre, Date of Publication: October 24, 2013, top Page 42 of 123

44 Figure 4: Population coverage for cervical screening (percentages) by age range for NHS Norfolk area, GY&W CCG, EoE and England for the years 2007/8-2012/13. Page 43 of 123

45 Overall, Norfolk (NHS Norfolk area and Great Yarmouth and Waveney CCG) has achieved the coverage target 2 times out of for the 6 reporting years 2007/ /13 for the target group of women aged but failed to achieve the target for the lower age group (The overall coverage for East of England and England was not achieved in each year for the 25-49). Norfolk (North Norfolk, Norwich, South Norfolk and West Norfolk CCGs) For the eligible age range, 25-64, Norfolk shows a marginal improvement in coverage in the first three financial years 2007/ /12 from 80.6% to 80.9%. This is likely to reflect the changes in national recall interval whereby the lower age range of women became eligible for recall every 36 months instead of the pre-2005 recall of 54 months and the upper age range already enjoyed a recall of under 60 months, facilitating an enhanced coverage figure. Then the coverage rate starts to decline and could not achieve the required target except in 2011/12 and 2012/13 which was just under the required target. The coverage for the lower age range of women (25-49) improved slightly from 70.8% in 2007/8 to 75.4% in 2011/12 year for Norfolk and this is likely to be because of the more favorable recall interval (see above). However, in this age range the PCT failed to achieve the national target of 80%. It should be noted that coverage is higher in most years compared with GY&W, EOE and England averages. Coverage for the upper age range, 50-64, has fallen over the six years. Although the PCT had previously profited from a more favourable recall interval for the purposes of calculating coverage, this may have ceased to be of benefit. The fall in coverage from 81.7% in 2007/8 to 77.2% in 2012/13 and this has taken the overall coverage in this age range to below the national target. Great Yarmouth & Waveney CCG For the eligible age range, Great Yarmouth & Waveney shows a marginal decline in coverage from 80% in 2007/8 to 79.3% in 2012/13. As with Norfolk, this is most likely to be because of the introduction of the changes in the national call/recall age and intervals in 2005 whereby the Waveney area of Great Yarmouth & Waveney PCT saw their recall interval extend from 36 months to 60 months for all women over the age of 35 years. Coverage for the population in the lower age range (24-49) increased to 71.7% from 73.1% over the six financial years. Again, this may reflect the conditions applying to the change of recall interval. Page 44 of 123

46 In the upper age range, coverage again fell from 80.4% to 77.1%; meaning that the national target was not achieved - this may again be because of the change in recall interval. Overall, there are apparent anomalies in the reporting: the tables relate to the numbers of women resident and registered at the beginning of the year. With a split recall interval, it is possible to have a low coverage in one age range yet still achieve overall high population coverage. This is because the overall age range is measured on an interval of one adequate test within 60 months. However, the lower age range are invited and tested every 36 months and this impacts more favourably upon the response rates in the years up to and including 53 years and adversely for the ages of 53 years and above. Tables show the screening coverage for each Clinical commissioning Group (CCG) for five financial years from 2007/8 to 2011/12. The figures are shown for the full eligible age range and also the break-down into the lower and upper age ranges. In 2011/12 coverage in CCGs varies from For the age range from 77.2% in West Norfolk to 81.8% in North Norfolk. For the age range from 75.7% in Great Yarmouth and Waveney to 84.1% in North Norfolk. For the age range from 74.7% in West Norfolk to 83% in Norwich. Over five years April 2007 March 2012, across Norfolk and Waveney, South Norfolk CCG and North Norfolk CCG achieved the national minimum target for the population coverage of the eligible population for cervical screening is 80% for the three age groups (25-64, 25-49, and 50-64) with few exceptions once for South Norfolk for the age group in 20011/12, and three times for North Norfolk all for the same age group in years 2009/10, 2010/11, and 2011/12. In contrast, West Norfolk CCG during the same period of time has not achieved the national minimum target for the population coverage of the eligible population for cervical screening is 80% for the three age groups only once and that was 80.3 for age group in 2007/8. Between 2007/8 and 2011/12, Norwich CCG was successful in achieving achieved the national minimum target for the population coverage of the eligible population for cervical screening is 80% for women aged years during the five years, while could not manage to achieve the total target for women aged in any year. It seems that younger women in Norwich are not keen to be involved in the cervical screening programme as much as older women. It can be seen that during the five years women aged in Norwich managed to achieve the 80% target only twice during 2009/10 and 2010/11. Page 45 of 123

47 For Great Yarmouth and Waveney CCG, the 80% target was never achieved for the younger women age group over the five years April 2007 March 2012, was achieved twice for the older age group during 2007/8 and 2009/10, and three times for the total age group during 2007/8, 2008/9, and 2009/10. Table 10: Clinical commissioning Group (CCG) population - number of women aged (25-49) (50-64) (25-64) screened within the last 60 months by CCG, 2007/8-2011/12 CCG /8 2008/9 2009/ / / /8 2008/9 2009/ / / /8 2008/9 2009/ / /12 GY&W 26,738 27,039 27, ,903 14,904 14, ,641 41,943 41, North 18,870 18,965 18,918 18,790 18,641 12,817 12,781 12,630 12,674 12,548 31,687 31,746 31,548 31,464 31,189 Norwich 25,948 26,655 27,813 28,000 28,312 10,744 10,826 11,209 11,363 11,331 36,692 37,481 39,022 39,363 39,643 South 27,235 27,847 28,366 28,025 28,276 14,916 15,175 15,111 14,938 14,915 42,151 43,022 43,477 42,963 43,191 West 18,493 18,587 18,719 18,297 18,391 10,424 10,388 10,263 10,051 10,084 28,917 28,975 28,982 28,348 28,475 Table 11: Clinical commissioning Group (CCG) population percentage of women aged (25-49) (50-64) (25-64) screened within the last 60 months by CCG, 2007/8-2011/12 CCG /8 2008/9 2009/ / / /8 2008/9 2009/ / / /8 2008/9 2009/ / /12 GY&W North Norwich South West Page 46 of 123

48 7.1 Screening population coverage by Clinical Commissioning Group This section reviews the achieved national minimum target for the Screening population coverage of the eligible population for cervical screening is 80% by GP practices (among each Clinical commissioning Group CCG) for the three age groups (25-64, 25-49, and 50-64) over five years April 2007 March The practices are all practices primarily responsible to Norfolk and Waveney areas. Page 47 of 123

49 7.1.1 Great Yarmouth and Waveney CCG Tables 12a-12b and Figures 6a-6c show the cervical screening coverage (number and percentage coverage) for women aged 25-49, 50-64, and by GP practice within Great Yarmouth and Waveney CCG [27 GP practices of which 13 (48%) in Great Yarmouth and 14 (52%) in Waveney], for five years April 2007/8-2010/11. The entire eligible age range 25-64: 8 practices have not reached target in any of the 5 years periods for the entire eligible age range. These practices are divided equally between Great Yarmouth and Waveney and they are (D82055, D82613, Y00164, and Y02662) in Great Yarmouth, and (D83002, D83023, D83030, and D83071) in Waveney. In 2011/12 16 (59%) practices achieved the national minimum target for the population coverage of the eligible population for cervical screening is 80%. The lower age range 25-49: 7 practices have not reached target in any of the 5 years periods for the lower age range 25-49, four in Great Yarmouth (D82003, D82067, D82081, and D82102), and three in Waveney (D83002, D83011, and D83071). 7 (26%) practices out of 27 managed to achieve the 80% target each year and these are (D82019, D82098, D82600) in Great Yarmouth, and (D83009, D83016, D83047, and D83619) in Waveney. In 2011/12 17 (63%) practices achieved the national minimum target for the population coverage of the eligible population for cervical screening which is 80%. The upper age range 50-64: 9 (33%) practices failed to achieve the 80% or more target in any of the five financial years. In 2011/12 2 (11%) practices achieved the national minimum target for the population coverage of the eligible population for cervical screening is 80%. During 2011/12 4 practices failed to achieve target in coverage compared to 2010/11 results. Page 48 of 123

50 Figure 5: Great Yarmouth and Waveney CCG percentage of women aged (25-49) (50-64) screened within the last 60 months by CCG, 2007/8-2011/12 Page 49 of 123

51 Table 12a: Great Yarmouth and Waveney CCG, GP practice population - number of women aged (25-49) (50-64) (25-64) screened within the last 60 months, 2007/8-2011/12. GP DQ /8 2008/9 2009/ / / /8 2008/9 2009/ / / /8 2008/9 2009/ / /12 D ,814 1,833 1, ,795 2,800 2, D ,426 1,397 1, ,180 2,152 2, D ,121 1,172 1, ,729 1,802 1, D D ,892 1,939 1, ,324 1,329 1, ,216 3,268 3, D ,090 1,161 1, ,602 1,682 1, D ,452 1,458 1, D ,107 1,129 1, D ,004 1, D D ,014 1, D ,788 1,832 1, ,577 2,623 2, D ,389 2,381 2, ,449 1,429 1, ,838 3,810 3, D ,195 1,217 1, D ,241 1,244 1, ,000 1,997 1, D ,136 1,131 1, ,816 1,802 1, D D ,236 1,232 1, ,982 1,941 1, D D ,243 1,244 1, ,999 1,989 1, D ,089 1,083 1, ,919 1,917 1, D ,549 1,555 1, ,276 2,292 2, D D ,037 1,058 1, D Y Y GY&W 26,738 27,039 27, ,903 14,904 14, ,641 41,943 41, Page 50 of 123

52 Table 12b: Great Yarmouth and Waveney CCG, GP practice population - percentage of women aged (25-49) (50-64) (25-64) screened within the last 60 months, 2007/8-2011/12. GP DQ /8 2008/9 2009/ / / /8 2008/9 2009/ / / /8 2008/9 2009/ / /12 D D D D D D D D D D D D D D D D D D D D D D D D D Y Y NA NA NA NA NA NA GY&W Page 51 of 123

53 Figure 6a: Great Yarmouth and Waveney CCG, GP practice population - Percentage of women aged (25-49) screened within the last 60 months sorted by deprivation quintile, 2011/12. Note: Multiple Deprivation 2010 (IMD) score of the practice patients and grouped into local deprivation quintiles, the figure given in brackets beside each GP practice code represents the local deprivation quintile for that GP practice (1 being the most deprived quintile and 5 being the least deprived quintile). Page 52 of 123

54 Figure 6b: Great Yarmouth and Waveney CCG, GP practice population - Percentage of women aged (50-64) screened within the last 60 months sorted by deprivation quintile, 2011/12. Note: Multiple Deprivation 2010 (IMD) score of the practice patients and grouped into local deprivation quintiles, the figure given in brackets beside each GP practice code represents the local deprivation quintile for that GP practice (1 being the most deprived quintile and 5 being the least deprived quintile). Page 53 of 123

55 Figure 6c: Great Yarmouth and Waveney CCG, GP practice population - Percentage of women aged (25-64) screened within the last 60 months sorted by deprivation quintile, 2011/12. Note: Multiple Deprivation 2010 (IMD) score of the practice patients and grouped into local deprivation quintiles, the figure given in brackets beside each GP practice code represents the local deprivation quintile for that GP practice (1 being the most deprived quintile and 5 being the least deprived quintile). Page 54 of 123

56 7.1.2 North Norfolk CCG Tables 13a-I3b and Figures 8a-8c provide information on the cervical screening coverage (number and percentage) for women aged 25-49, 50-64, and by GP practice within North Norfolk CCG (20 GP practices), between 2007/8 and 2010/11. The entire eligible age range 25-64: 3 (15%) practices have not reached the target in any of the 5 years periods for the entire eligible age range. In 2011/12, 12 (60%) practices achieved the national minimum target for the population coverage of the eligible population for cervical screening which is 80%, and 5 (25%) practices who were successful in achieving the targets in any year during 2007/8-2010/11 has shown drop in 2011/12 and these are (D82001, D82028, D82054, D82038, and D82066). 11 (55%) practices were successful to achieve the targets each year. The lower age range 25-49: In 2011/12 18 (90%) practices achieved the national minimum target 80%, while the remaining 2 (10%) practices have never reached the target in any of the 5 years periods and these are (D82004, and D82038). 13 (65%) practices managed to achieve the 80% target each year and these are (D82001, D82054, D82032, D82628, D82053, D82025, D82030, D82104, D82059, D82029, D82062, D82080, and D82103). The upper age range 50-64: 7 (35%) practices achieved the 80% in 20011/12 and the same practices were also successful in achieving the target in any of the five financial years and these are (D82032, D82059, D82104, D82062, D82029, D82080, and D82103). Over the five financial years 7 (35%) practices failed to achieve the 80% target in any year and these are (D82028, D82004, D82053, D82001, D82009, D82054, and D82005). Page 55 of 123

57 Figure 7: North Norfolk CCG percentage of women aged (25-49) (50-64) screened within the last 60 months by CCG, 2007/8-2011/12 Page 56 of 123

58 Table 13a: North Norfolk CCG, GP practice population - number of women aged (25-49) (50-64) (25-64) screened within the last 60 months, 2007/8-2011/12. GP DQ /8 2008/9 2009/ / / /8 2008/9 2009/ / / /8 2008/9 2009/ / /12 D ,398 1,423 1,391 1,377 1,325 1,057 1,045 1,080 1,077 1,053 2,455 2,468 2,471 2,454 2,378 D ,152 1,178 1,168 1,187 1, ,119 2,127 2,069 2,080 2,124 D ,642 1,618 1,581 1,558 1,499 D ,401 1,383 1,378 1,376 1,352 D ,503 1,513 1,518 1,515 1,540 D ,610 1,616 1,554 1,534 1,480 D D ,708 1,730 1,748 1,731 1, ,011 2,696 2,708 2,706 2,718 2,726 D ,154 1,152 1,158 1,161 1, ,908 1,908 1,903 1,923 1,890 D ,003 1, ,625 1,639 1,618 1,606 1,576 D D D ,693 1,666 1,637 1,638 1,622 1,064 1,067 1,038 1,044 1,031 2,757 2,733 2,675 2,682 2,653 D ,316 1,341 1,319 1,273 1, ,048 2,100 2,087 2,067 2,091 D ,015 1,009 1,050 1,072 1, ,605 1,637 1,667 1,692 1,721 D ,411 1,420 1,402 1,383 1,363 D ,137 1,147 1,176 1,192 1,195 D D ,174 1,183 1,186 1,163 1, ,892 1,908 1,917 1,893 1,855 D North 18,870 18,965 18,918 18,790 18,641 12,817 12,781 12,630 12,674 12,548 31,687 31,746 31,548 31,464 31,189 Page 57 of 123

59 Table 13b: North Norfolk CCG, GP practice population - percentage of women aged (25-49) (50-64) (25-64) screened within the last 60 months, 2007/8-2011/12. GP DQ /8 2008/9 2009/ / / /8 2008/9 2009/ / / /8 2008/9 2009/ / /12 D D D D D D D D D D D D D D D D D D D D North Page 58 of 123

60 Figure 8a: North Norfolk CCG, GP practice population - Percentage of women aged (25-49) screened within the last 60 months sorted by deprivation quintile, 2011/12. Note: Multiple Deprivation 2010 (IMD) score of the practice patients and grouped into local deprivation quintiles, the figure given in brackets beside each GP practice code represents the local deprivation quintile for that GP practice (1 being the most deprived quintile and 5 being the least deprived quintile). Page 59 of 123

61 Figure 8b: North Norfolk CCG, GP practice population - Percentage of women aged (50-64) screened within the last 60 months sorted by deprivation quintile, 2011/12. Note: Multiple Deprivation 2010 (IMD) score of the practice patients and grouped into local deprivation quintiles, the figure given in brackets beside each GP practice code represents the local deprivation quintile for that GP practice (1 being the most deprived quintile and 5 being the least deprived quintile). Page 60 of 123

62 Figure 8c: North Norfolk CCG, GP practice population - Percentage of women aged (25-64) screened within the last 60 months sorted by deprivation quintile, 2011/12. Note: Multiple Deprivation 2010 (IMD) score of the practice patients and grouped into local deprivation quintiles, the figure given in brackets beside each GP practice code represents the local deprivation quintile for that GP practice (1 being the most deprived quintile and 5 being the least deprived quintile). Page 61 of 123

63 7.1.3 Norwich CCG Tables 14a-I4b and Figures 10a-10c give the cervical screening coverage uptake (number and percentage) for women aged 25-49, 50-64, and by GP practice within Norwich CCG (23 practices), Over five years April 2007 March The entire eligible age range 25-64: 9 (39%) practices have not reached the target in any of the 5 years periods for the entire eligible age range. In 2011/12, 11 (47.8%) practices achieved the national minimum target for the population coverage of the eligible population for cervical screening, and 10 (43.5%) practices were successful in achieving the targets in every year and these are (D82018, D82013, D82048, D82060, D82106, D82069, D82076, D82008, D82071, and D82024). The lower age range 25-49: In 2011/12 12 (52%) practices achieved the 80% national minimum target, of which 8 (34.8%) practices achieved the target in every year and these are (D82013, D82048, D82076, D82008, D82106, D82060, D82071, and D82024) 7 (30%) practices have not reached the target in any of the 5 years periods and these are (D82088, Y02751, D82040, D82026, D82620, D82073, and D82017). The upper age range 50-64: 8 (34.8%) practices achieved the 80% target in 20011/12 and the same practices were successful in reaching the target in every year and these are (D82011, D82106, D82076, D82096, D82071, D82008, D82024, and D82069). Over the five financial years 7 (30.4%) practices failed to reach the 80% target in any year and these are (D82040, D82073, D82088, D82012, D82026, D82013, and D82087). 7 (30.4%) practices achieved the target in 2009/10 or 2010/11 but could not manage to do so in 2011/12 and these are (D82017, D82018, D82048, D82060, D82620, D82632, and Y02751). Page 62 of 123

64 Figure 9: Norwich CCG percentage of women aged (25-49) (50-64) screened within the last 60 months by CCG, 2007/8-2011/12 Page 63 of 123

65 Table 14a: Norwich CCG, GP practice population - number of women aged (25-49) (50-64) (25-64) screened within the last 60 months, 2007/8-2011/12. GP DQ /8 2008/9 2009/ / / /8 2008/9 2009/ / / /8 2008/9 2009/ / /12 D ,899 1,985 2,033 2,051 2, ,617 2,710 2,770 2,830 2,783 D ,184 2,283 2,268 2,232 2,234 1,010 1,020 1,008 1,063 1,029 3,194 3,303 3,276 3,295 3,263 D ,701 1,809 1,811 1,783 1, ,489 2,572 2,560 2,551 2,574 D ,124 1,143 1,168 1,160 1, ,606 1,652 1,685 1,682 1,653 D ,427 1,442 1,445 1,418 1, ,047 2,077 2,079 2,040 2,071 D ,211 1,237 1,203 1,192 1, ,891 1,908 1,870 1,859 1,818 D ,941 1,937 1,972 1,942 1, ,729 2,744 2,772 2,757 2,706 D ,098 1,133 1,133 1,126 1, ,600 1,636 1,631 1,613 1,619 D ,465 1,435 1,471 1,459 1, ,959 1,928 1,967 1,938 1,934 D ,153 1,166 1,165 1,125 1, ,653 1,667 1,660 1,589 1,555 D ,920 1,990 2,067 2,073 2, ,777 2,873 2,968 2,962 2,947 D D ,242 1,244 1,246 1,253 1,279 D ,376 1,380 2,126 2,092 2, ,081 1,123 1,125 2,093 2,100 3,207 3,215 3,206 D ,142 1,186 1,148 1,104 1, ,538 1,605 1,567 1,513 1,463 D ,353 1,325 1,336 1,339 1,340 D ,023 1,069 1,105 1,127 D ,119 1,161 1,222 1,288 1, ,190 1,234 1,307 1,384 1,413 D ,117 1,170 1,190 1,232 1,261 D D D Y NA NA NA NA NA NA Norwich 25,948 26,655 27,813 28,000 28,312 10,744 10,826 11,209 11,363 11,331 36,692 37,481 39,022 39,363 39,643 Page 64 of 123

66 Table 14b: Norwich CCG, GP practice population - percentage of women aged (25-49) (50-64) (25-64) screened within the last 60 months, 2007/8-2011/12. GP DQ /8 2008/9 2009/ / / /8 2008/9 2009/ / / /8 2008/9 2009/ / /12 D D D D D D D D D D D D D D D D D D D D D D Y NA NA NA NA NA NA Norwich Page 65 of 123

67 Figure 10a: Norwich CCG, GP practice population - Percentage of women aged (25-49) screened within the last 60 months sorted by deprivation quintile, 2011/12. Note: Multiple Deprivation 2010 (IMD) score of the practice patients and grouped into local deprivation quintiles, the figure given in brackets beside each GP practice code represents the local deprivation quintile for that GP practice (1 being the most deprived quintile and 5 being the least deprived quintile). Page 66 of 123

68 Figure 10b: Norwich CCG, GP practice population - Percentage of women aged (50-64) screened within the last 60 months sorted by deprivation quintile, 2011/12. Note: Multiple Deprivation 2010 (IMD) score of the practice patients and grouped into local deprivation quintiles, the figure given in brackets beside each GP practice code represents the local deprivation quintile for that GP practice (1 being the most deprived quintile and 5 being the least deprived quintile). Page 67 of 123

69 Figure 10c: Norwich CCG, GP practice population - Percentage of women aged (25-64) screened within the last 60 months sorted by deprivation quintile, 2011/12. Note: Multiple Deprivation 2010 (IMD) score of the practice patients and grouped into local deprivation quintiles, the figure given in brackets beside each GP practice code represents the local deprivation quintile for that GP practice (1 being the most deprived quintile and 5 being the least deprived quintile). Page 68 of 123

70 7.1.4 South Norfolk CCG Tables 15a-I5b and Figures 12a-12c illustrate the cervical screening coverage uptake (number and percentage) for women aged 25-49, 50-64, and by GP practice within South Norfolk CCG (26 practices), From April 2007 to March The entire eligible age range 25-64: In 2011/12, 20 (76.9%) practices achieved the national minimum target for the population coverage of the eligible population for cervical screening, of which 19 (73%) practices were successful in achieving the targets in every year. 2 (7.7%) practices have not reached the target in any of the 5 years periods for the entire eligible age range and these are (D82041, and Y01690). The lower age range 25-49: In 2011/12 22 (84.6%) practices achieved the 80% national minimum target, of which 19 (73.1%) practices achieved the target in every year. 3 (11.5%) practices have not reached the target in any of the 5 years periods and these are (D82041, D82063, and Y01690). The upper age range 50-64: 13 (50%) practices achieved the 80% target in 20011/12 and 12 (46.2%) practices were successful in reaching the target in every year. Over the five years 2 (7.7%) practices failed to reach the 80% target in any year and these are (D82041, and Y01690). Page 69 of 123

71 Figure 11: South Norfolk CCG percentage of women aged (25-49) (50-64) screened within the last 60 months by CCG, 2007/8-2011/12 Page 70 of 123

72 Table 15a: South Norfolk CCG, GP practice population - number of women aged (25-49) (50-64) (25-64) screened within the last 60 months, 2007/8-2011/12. GP DQ /8 2008/9 2009/ / / /8 2008/9 2009/ / / /8 2008/9 2009/ / /12 D ,652 1,621 1,680 1,604 1, ,371 2,348 2,421 2,328 2,328 D ,607 1,589 1,602 1,564 1,575 D ,280 1,311 1,338 1,313 1, ,856 1,907 1,958 1,934 1,947 D ,357 1,337 1,331 1,199 1,203 D ,102 1,249 1,325 1,499 1, ,647 1,811 1,888 2,099 2,344 D ,383 1,403 1,414 1,293 1,301 D ,200 2,170 2,221 2,202 2,138 1,057 1,075 1,054 1,069 1,097 3,257 3,245 3,275 3,271 3,235 D ,536 1,525 1,531 1,518 1,521 D ,229 1,217 1,272 1,276 1, ,829 1,816 1,864 1,906 1,886 D ,627 1,640 1,656 1,622 1,609 D ,297 1,292 1,330 1,336 1, ,864 1,867 1,903 1,908 1,931 D ,426 1,460 1,455 1,445 1,428 D ,430 2,485 2,453 2,456 2,415 1,251 1,245 1,236 1,244 1,254 3,681 3,730 3,689 3,700 3,669 D D ,190 1,184 1,195 1,169 1, ,832 1,792 1,801 1,771 1,790 D ,048 1,033 1,029 1,037 1, ,745 1,736 1,716 1,732 1,751 D ,305 1,310 1,372 1,408 1, ,136 2,145 2,202 2,232 2,162 D ,189 2,274 2,368 2,361 2,384 1,267 1,275 1,276 1,286 1,287 3,456 3,549 3,644 3,647 3,671 D ,097 1,103 1,111 1,096 1, ,687 1,697 1,722 1,727 1,743 D ,068 1, ,329 1,798 1,790 1,458 1,424 D D D D D Y South 27,235 27,847 28,366 28,025 28,276 14,916 15,175 15,111 14,938 14,915 42,151 43,022 43,477 42,963 43,191 Page 71 of 123

73 Table 15b: South Norfolk CCG, GP practice population - percentage of women aged (25-49) (50-64) (25-64) screened within the last 60 months, 2007/8-2011/12. GP DQ /8 2008/9 2009/ / / /8 2008/9 2009/ / / /8 2008/9 2009/ / /12 D D D D D D D D D D D D D D D D D D D D D D D D D Y South Page 72 of 123

74 Figure 12a: South Norfolk CCG, GP practice population - Percentage of women aged (25-49) screened within the last 60 months sorted by deprivation quintile, 2011/12. Note: Multiple Deprivation 2010 (IMD) score of the practice patients and grouped into local deprivation quintiles, the figure given in brackets beside each GP practice code represents the local deprivation quintile for that GP practice (1 being the most deprived quintile and 5 being the least deprived quintile). Page 73 of 123

75 Figure 12b: South Norfolk CCG, GP practice population - Percentage of women aged (50-64) screened within the last 60 months sorted by deprivation quintile, 2011/12. Note: Multiple Deprivation 2010 (IMD) score of the practice patients and grouped into local deprivation quintiles, the figure given in brackets beside each GP practice code represents the local deprivation quintile for that GP practice (1 being the most deprived quintile and 5 being the least deprived quintile). Page 74 of 123

76 Figure 12c: South Norfolk CCG, GP practice population - Percentage of women aged (25-64) screened within the last 60 months sorted by deprivation quintile, 2011/12. Note: Multiple Deprivation 2010 (IMD) score of the practice patients and grouped into local deprivation quintiles, the figure given in brackets beside each GP practice code represents the local deprivation quintile for that GP practice (1 being the most deprived quintile and 5 being the least deprived quintile). Page 75 of 123

77 7.1.5 West Norfolk CCG Tables 16a-I6b and Figures 14a-14c illustrate the cervical screening coverage uptake (number and percentage) for women aged 25-49, 50-64, and by GP practice within West Norfolk CCG (23 practices), Over five years April 2007 March The entire eligible age range 25-64: In 2011/12, 8 (34.8%) practices achieved the national minimum target for the population coverage of the eligible population for cervical screening, of which 6 (26%) practices were successful in achieving the targets in every year and these are (D82021, D82070, D82010, D82049, D82621, and D82618). 6 (26%) practices have not reached the target in any of the 5 years periods for the entire eligible age range and these are (D82051, D82086, D82044, D82099, D82604, and D82065). The lower age range 25-49: In 2011/12 16 (69.6%) practices achieved the 80% national minimum target, of which 11 (47.8%) practices achieved the target in every year. 4 (17.4%) practices have not reached the target in any of the 5 years periods and these are (D82051, D82086, D82099, and D82044). The upper age range 50-64: 3 (13%) practices achieved the 80% target in 20011/12 and 2 (8.7%) practices were successful in reaching the target in every year and these are D82618, and D Over the five years 4 (17.4%) practices failed to reach the 80% target in any year and these are (D82044, D82051, D82072, and D82086). In the last two financial years 2010/11 and 2011/12 20 (87%) practices failed to achieve the 80% target. Page 76 of 123

78 Figure 13: West Norfolk CCG percentage of women aged (25-49) (50-64) screened within the last 60 months by CCG, 2007/8-2011/12 Page 77 of 123

79 Table 16a: West Norfolk CCG, GP practice population - number of women aged (25-49) (50-64) (25-64) screened within the last 60 months, 2007/8-2011/12. GP DQ /8 2008/9 2009/ / / /8 2008/9 2009/ / / /8 2008/9 2009/ / /12 D D ,473 1,477 1,497 1,479 1,421 D D ,377 1,354 1,354 1,302 1,293 D ,166 1,161 1, ,736 1,749 1,751 1,314 1,347 D ,131 1,144 1,147 1,126 1,148 D ,386 2,379 2,406 2,373 2,381 1,318 1,302 1,283 1,286 1,216 3,704 3,681 3,689 3,659 3,597 D D ,803 1,815 1,838 1,802 1, ,696 2,681 2,696 2,655 2,620 D ,070 1,052 1,010 1,002 1,030 D ,038 1,037 1,063 1,088 1,079 D ,304 1,309 1,294 1,290 1,293 D ,055 1,055 1,064 1,064 1,087 D D D D ,558 1,622 1,745 1,835 1, ,025 2,114 2,263 2,401 2,559 D D D ,202 1,235 1,214 1,233 1,224 D ,071 1,043 1,034 1,009 1,009 Y Y ,281 1,275 1,225 1,034 1,016 West 18,493 18,587 18,719 18,297 18,391 10,424 10,388 10,263 10,051 10,084 28,917 28,975 28,982 28,348 28,475 Page 78 of 123

80 Table 16b: West Norfolk CCG, GP practice population - percentage of women aged (25-49) (50-64) (25-64) screened within the last 60 months, 2007/8-2011/12. GP DQ /8 2008/9 2009/ / / /8 2008/9 2009/ / / /8 2008/9 2009/ / /12 D D D D D D D D D D D D D D D D D D D D D Y Y West Page 79 of 123

81 Figure 14a: West Norfolk CCG, GP practice population - Percentage of women aged (25-49) screened within the last 60 months sorted by deprivation quintile, 2011/12. Note: Multiple Deprivation 2010 (IMD) score of the practice patients and grouped into local deprivation quintiles, the figure given in brackets beside each GP practice code represents the local deprivation quintile for that GP practice (1 being the most deprived quintile and 5 being the least deprived quintile). Page 80 of 123

82 Figure 14b: West Norfolk CCG, GP practice population - Percentage of women aged (50-64) screened within the last 60 months sorted by deprivation quintile, 2011/12. Note: Multiple Deprivation 2010 (IMD) score of the practice patients and grouped into local deprivation quintiles, the figure given in brackets beside each GP practice code represents the local deprivation quintile for that GP practice (1 being the most deprived quintile and 5 being the least deprived quintile). Page 81 of 123

83 Figure 14c: West Norfolk CCG, GP practice population - Percentage of women aged (25-64) screened within the last 60 months sorted by deprivation quintile, 2011/12. Note: Multiple Deprivation 2010 (IMD) score of the practice patients and grouped into local deprivation quintiles, the figure given in brackets beside each GP practice code represents the local deprivation quintile for that GP practice (1 being the most deprived quintile and 5 being the least deprived quintile). Page 82 of 123