Health screening is an important way of identifying potentially life-threatening illnesses at an early stage. Yet the Department of Health & Social Care (the Department), NHS England and Public Health England (the national health bodies) are not doing enough to make sure that everyone who is eligible to take part in screening is doing so, and do not know if everyone who should be invited for screening has been.
We took evidence on the management of four of the 11 health screening programmes operating in England: bowel, breast and cervical cancers and abdominal aortic aneurism.
None of the screening programmes we examined met their targets for ensuring the eligible population was screened in 2017-18.
Performance varies drastically across the country and yet the national health bodies still do not know which specific barriers prevent certain groups from attending meaning they cannot effectively target these groups to encourage them to attend.
The IT used to identify the eligible population for screening has been unfit for purpose for screening programmes since 2011, but still has not been replaced. National health bodies therefore run a constant risk of not knowing if all the people who should have been identified for screening have been.
At the centre of this, the national oversight of screening programmes has failed patients, resulting in thousands of women not being invited for breast and cervical screenings or waiting too long for their cervical screening results.
The national health bodies have been too slow to recognise and respond to the problems caused, including sufficiently holding local screening providers to account for long-term failure.
“The benefits of screening cannot be under-estimated: if found at an early stage, treatment can be significantly more effective. Yet millions of people are not being screened for serious illnesses like bowel, breast and cervical cancer.
“Our inquiry has exposed a health service that is losing its grip on health screening programmes. Many individuals waiting for delayed results will suffer avoidable anxiety, stress and uncertainty. Those delays also stretch far beyond the Department’s target waiting periods.
“The Government’s understanding of variation across the country and the barriers facing different demographics of the population is patchy at best, which constrains their capacity to act.
“Ultimately, this is a question of health equality. The Government has a duty to ensure that everyone has access to health screening.
“We are pressing the Department and NHS England to set out a plan of action to: better hold local screening providers to account, overhaul governance arrangements and develop an IT system that works as intended.”
Conclusions and recommendations
The Department, NHS England and Public Health England are consistently failing to meet their targets for the number of people who should be screened and have no clear plan on how to reduce the alarming health inequalities that exist. Just 71.7% of the eligible population, or 3.2 million women, were screened for cervical cancer in 2017-18, which represents a 21-year low. We are extremely concerned about the massive disparity around the country with some areas in the North East consistently reaching more of their eligible populations than areas of London. On the cervical screening programme just one out of 207 CCG areas succeeded in meeting the target of screening 80% of its eligible population. There is also an overwhelming lack of understanding about local variation: the national health bodies do not know and could not tell us why performance is good in some areas and so poor in others. It is unacceptable that those in charge cannot pinpoint which economic, social or demographic factors prevent specific groups from attending appointments. The wealth of insight and knowledge local authorities hold about the specific barriers that prevent groups within their areas from attending screening appointments seems to have been completely ignored. Without this detailed understanding, the national bodies will not be able to address the health inequalities that exist.
Recommendation: By the summer recess, the Department of Health and Social Care, NHS England and Public Health England needs to set out the specific steps they are going to take to understand why performance is so poor in some areas and then publish a plan, with timeframes for action, that explains how they intend to address these inequalities.
It is unacceptable that NHS England has continually failed to hold local screening providers to account for their poor performance. NHS England is responsible for commissioning local screening providers and then managing their performance against the agreed targets and standards. Women attending cervical screening appointments are being continually failed by screening providers, with just 55% of women receiving their test results within the expected 14-day period. Targets are being set but not met: this delay is unacceptable and the impact of the undue stress and worry for women must be recognised. What is more, the Department told us that the 14-day target is a customer service ambition and not actually based on any essential clinical need. We are therefore concerned that this lack of clinical significance is not being communicated to women waiting for their screening results, especially when they are delayed. NHS England told us that some local providers currently have staff shortages, but as this target has not been met since November 2015, it is clear to us that NHS England is not managing local providers effectively.
Recommendation: By the summer recess, the NHS England must write to the Committee to set out how it is going to hold local screening providers to account against their agreed targets and standards. It should also set out its targets for improving the performance of local providers over the next 12 months.
Recommendation: NHS England has a duty to make the public aware that the 14-day target is not based on clinical need. In the same letter, it should outline to the Committee how it intends to raise awareness.
It is unacceptable that the national oversight of screening programmes has failed, with the Department, NHS England and Public Health England all being too slow to recognise and respond to the problems this has caused. The existing arrangements for oversight and monitoring of screening programmes failed to identify that thousands of women had not been invited for breast and cervical screenings. In the case of breast screening, the failure went undetected for more than half a decade. The division of roles and responsibilities between the national bodies, between individual programmes, and between national and local bodies causes us concern, and the national bodies accept that there is “fragmentation” in the system. Public Health England is responsible for quality assuring the screening activities that take place, for example, visiting local providers to make sure they are conducting screening in the way set out in the national guidance, yet it has not got the power to enforce any changes it deems necessary. The national health bodies seem overly complacent in their approach to understanding the specific challenges facing health screening. They are heavily relying on Professor Sir Mike Richards’ review to solve a host of problems, some of which have been evident for some time. It is also worrying that the review is not focused on speaking to people undergoing screening or to local authorities - who would both have clear ideas about what needs to change to deliver the screening services that we all expect.
Recommendation: Professor Sir Mike Richard’s review into screening programmes should scrutinise oversight arrangements, the division of roles and responsibilities and the quality assurance arrangements. It should also include evidence that the conclusions are informed not just by central government bodies, but also by people who actually undergo screening and local authorities.
The woeful inadequacy of the IT supporting breast screening has played a fundamental role in the failure of the screening programme. All of the screening programmes rely on a single IT system, known as NHAIS, to identify the eligible population for screening. Without NHAIS, the individual programmes cannot send invites for screenings. The Department of Health & Social Care accepted that NHAIS was “not fit for purpose” for health screening in 2011. NHS England has now committed to replacing NHAIS during 2020. However, this is three years later than planned, with the delay costing the taxpayer £14 million. NHS England has decided that it can no longer work with Capita, its original partner, on this project, so NHS Digital will take on responsibility for replacing NHAIS. Until NHAIS is replaced, there remains a risk that more people will not be invited for screening when they should be. After those eligible for screening have been identified using NHAIS, each screening programme has its own IT system to send invites, reminders and test results. Public Health England acknowledges that the IT supporting some individual screening programmes is “hopeless”. The IT supporting the breast screening programme causes us particular concern. Public Health England put in place a new, single system in 2016 to replace the 78 separate systems that had previously been propping up the programme. The national health bodies, by not undertaking this reform sooner, undoubtedly contributed to the ambiguity around what women could expect from the breast screening programme; and, ultimately, to the national incident in May 2018 when the then Secretary of State was forced to announce some 450,000 women were affected by a failure in the system that invites women for screening, albeit that the actual number turned out to be closer to 122,000.
Recommendation: Public Health England and NHS England should develop a more integrated approach to its IT systems to make sure that the multiple systems that need to be in place are able to connect and talk to each other to give screening patients the best possible service. This integration should also include a single owner who is responsible for making sure the IT works as intended.
We are extremely doubtful that NHS England will be able to successfully bring the failing IT system that supports the cervical programme back in-house, remove the backlog of samples that are waiting to be tested, and roll-out a new testing regime in just 6 months’ time. NHS England intends to move to HPV testing on the cervical programme in December 2019 but faces an uphill battle to do so. The incident on the cervical programme in November 2018, when 43,220 women did not receive their invite or reminder letters, was a warning signal that the programme was in turmoil. Capita subsequently accepted full responsibility for the failure. NHS England announced at our evidence session that it is terminating Capita’s contract for cervical screening in June 2019. However, our concerns are not alleviated given NHS England’s continued reliance on 360 separate IT systems to function, some of which are 30 years old, creating a high risk and far too complex operating environment. While NHS England has committed to creating a “unified cervical screening system” it cannot give a number for the number of systems it is working towards. NHS England is also working through 98,000 samples that are waiting longer than 14 days to be tested. Despite witnesses assuring us that there is no clinical impact from results being delayed, many women will not know this and will suffer undue stress and anxiety whilst waiting longer than expected for their results.
Recommendation: NHS England should set out a clear plan for how it intends to deliver this inherently risky project on time without making the service provided to women undergoing screening even worse.