Scottish Screening Committee minutes: 30 August 2022

Attendees and apologies

Members

• Jann Gardner, Chief Executive, Golden Jubilee Hospital (Chair)
• Gareth Brown, Scottish Director of Screening, NHS National Services Scotland
• Nick Phin, Clinical Director and Director of Health Protection, PHS
• Fraser Tweedie, Public Partner
• Susan Siegel, Public Partner
• Safia Qureshi, Director Of Evidence, Healthcare Improvement Scotland
• Christine McLaughlin, Director of Population Health, Scottish Government   
• Janette Fraser, Head of Planning, NHS Forth Valley
• Fiona McQuiston, Cancer Research UK 
• Jane Burns, Medical Director, NHS Lanarkshire
• Graham Foster,  Director of Public Health, NHS Forth Valley

In attendence

• Belinda Henshaw-Brunton, Healthcare Improvement Scotland
• Sandra McDougall, Healthcare Improvement Scotland
• Fiona Wardell, Healthcare Improvement Scotland
• Jennifer Layden, Healthcare Improvement Scotland
• Tasmin Sommerfield, National Clinical Advisor for Screening, NHS NSS
• Sinéad Power, Head of Health Protection, Population Health Directorate, Scottish Government
• Jo MacLennan, Committee Secretariat, Health Protection Division, Scottish Government
• Chloe Kelly, Committee Secretariat, Health Protection Division, Scottish Government
• Susan Thompson, Committee Secretariat, Health Protection Division, Scottish Government

Apologies

• Scott Urquhart, Director Of Finance, NHS Forth Valley
• Bob Steele, Senior Research Fellow, University of Dundee

Items and actions

Welcome and apologies

• Jann Gardner (JG) welcomed the committee and introduced new members to the committee and visitors
• new members include Nicholas Phin, from PHS; Christine McLaughlin, Director of Population Health in Scottish Government (SG), who has replaced previous Scottish Screening Committee (SSC) member Michael Kellett; and Fiona McQuiston, who represents Cancer Research UK
• JG also introduced Belinda Henshaw-Brunton, Sandra McDougall, Fiona Wardell, and Jennifer Layden from Healthcare Improvement Scotland (HIS), who will be speaking on an agenda item
• Minutes from the previous meeting were approved and will be published on the Scottish Government website

National Screening Programmes overview

Gareth Brown (GB) provided an update on the screening programmes.

Bowel screening

• bowel screening kits are being issued at pre-COVID levels. However, there continues to be significant challenges regarding downstream colonoscopy capacity for those who receive a positive screening result
• bowel Screening Clinical leads within NHS Boards have advised National Screening Oversight (NSO) that in general, screening participants are not waiting unduly, but the data is not available at a national level to evidence this. Work is underway regarding this
• one board continues to use FIT scores to prioritise screening patients, – the Bowel Screening Programme Board is engaging with the health board on the issue

Diabetic Eye Screening (DES)

• there has been progress made within the programme, with some boards now exceeding 100% capacity compared to pre-COVID
• the programme overall is moving towards pre-COVID capacity levels, and hopefully this progress will continue

Breast screening

• some breast screening centres continue to experience radiology and radiography staffing challenges. Work is ongoing with these centres to develop action plans to help address the challenges but this issue is not easily resolved as there is a UK-wide shortage of these staff
• there continues to be substantial interest around self-referrals for women aged 71 and over and these have now recommenced on a phased basis. This may have an impact on screening capacity for the recommended screening population of women aged 50-70

Cervical screening

• there has been a slightly lower number of samples received by the cervical screening labs each week compared to pre-COVID levels, and it is not completely clear why this is –it may be due to challenges in primary care
• some Boards are facing challenges in meeting routine colposcopy waiting times of eight weeks or less

Abdominal Aortic Aneurysm (AAA) screening

• there are currently no significant concerns, however assessment and treatment capacity in local vascular units varies, reflecting wider pressures across the system
• there are ongoing discussions with colleagues in SG for funding for quality assurance leads for the programme

Pregnancy and newborn screening

• the programmes are operating as normal
• there are challenges associated with some newborn hearing referrals which will be discussed in a later agenda item. However, overall there are no significant concerns at presen

Overall, the challenges seen are similar to those observed more widely within NHS.

GB welcomed questions and feedback from the Committee. Colonoscopy waiting times were discussed again and GB advised there are data issues to be worked through. For example, for those who have undergone a colonoscopy, the data can say how long they waited following a positive screening result, but it is not possible to obtain detailed, real-time information on those who are currently waiting. Work is ongoing through SG’s Endoscopy and Urology Diagnostic Programme Board (EUDPB) to develop a national endoscopy data system and there is a recognised gap in national data.

Tasmin Sommerfield (TS) added that unlike in other parts of UK, Scotland doesn’t have a nationally commissioned colonoscopy programme for bowel screening which makes the monitoring of screening colonoscopies challenging, as each individual board is responsible for colonoscopy and the screening programme has no direct control over this. An SBAR on this topic is currently being produced and will be brought to the next SSC meeting.

Christine McLaughlin (CM) highlighted it would be helpful to her to be clear what the biggest areas are to focus on, and to know where she could add value to the work. It was agreed that she would meet with NSO colleagues to discuss further.

TS updated on the breast screening modernisation work. The first board meeting had recently taken place and had been extremely positive. There was a huge appetite for changes to be made to address service challenges and improve resilience.

Healthcare Improvement Scotland (HIS) presentations - Standards and Quality Assurance (QA)

GB introduced the guests from HIS to update the SSC on work regarding screening standards and quality assurance. 

Jen Layden (JL) provided the update on screening standards.

In March 2022, workshops were held with the screening community following the screening review to further explore the requirement to develop standards. A report from the workshops will be published and distributed to the SSC and screening colleagues. Future work will be done in collaboration with the screening community, and the aim is for a final product that offers consistency across all screening programmes and opportunity for regular review. 

With the screening workshop, the key aims were to agree criteria for prioritisation for standards to be reviewed; how to best utilise colleagues’ time; and how to reduce production time-lines from 12-15 months to nine months, particularly for technical standards. It was agreed at the workshop to develop core governance standards separately that will apply across all programmes.

The proposal is for the HIS Standards and Indicators team to go to each screening programme board and ask them to evaluate current standards against targeted criteria, and to consider if there is new evidence or identified gaps or revisions. They will also be asked to identify staff and organisations that should be involved in the development group. This information will then go as a recommendation to the National Screening Oversight (NSO) board, who will review the submissions and then identify which of the standards should be prioritised for review in the next financial year. It is proposed this could then be ratified by the SSC, following which the HIS standards team will plan the development group recruitment process to allow work to begin.

Progress regarding this work will also be reported to the programme boards, the NSO board and SSC.

Currently, work is focused on updating bowel screening standards, including development of the first set of core standards for the programme. The update of the Bowel Screening standards started in 2020; however this was postponed due to the pandemic. It is proposed to start the development in November 2022 and publish revised bowel screening standards in summer next year.

JL welcomed SSC feedback on this.

GB advised the SSC that the NSO knew that standards for screening needed reviewed. This work will allow standards to be refreshed more regularly and dynamically.  Progress to date has been encouraging.

It was asked how it would be ensured there are no major operational risks, and if the composition of the review team has been predetermined to ensure for example that there is an operational delivery service representative. In addition, it was queried if it has been ensured that there will be early alerts about anything that would be problematic to deliver. This would not be to prevent the right standards being developed, but it would mean standards are developed cognisant of any pressures that they would create for the operational service components.

The committee was advised there will be a full risk register, and actions to mitigate risks, including wide representation on review groups and on-going consultation.

Belinda Henshaw-Brunton (BHB) from HIS provided the Committee with an update on the external quality assurance work.

BHB advised there is a lengthy background to this work. Recent development work has sought to strengthen governance arrangements in screening. HIS have worked to try to fully define the ask of External Quality Assurance (EQA) in screening. However work has been paused due to a number of factors, including the Screening Review; establishment of NSO; and the pandemic.

HIS have been working closely with NSO and other colleagues to work out options for QA. Learning from past experience of EQA has been incorporated, such as from managed incidents within screening.

BHB advised that HIS have undertaken a number of EQA exercises for screening in the past, usually commissioned by SG; these include the ongoing cervical incident following an adverse event, and a review of a breast screening incident in 2016. A Scottish AAA screening programme review was also commissioned by SG, at a time when there was a desire for baseline reviews. Learning from this found that, while recommendations for improvements were made, a baseline review approach was cumbersome and resource intensive for the screening service.

One benefit of having core standards is it would lend itself to potential thematic EQA for screening. HIS propose that a mechanism to identify those themes should be explored, along with how to ensure reviews are data and intelligence-led so that anything undertaken is proportionate and adds value. The intention is to follow a well versed quality assurance system used within HIS, as it has been well used and demonstrable as an approach for producing recommendations for learning. BHB welcomed feedback from the committee.

GB noted for the committee’s awareness that in England and Wales, there is a more developed approach to EQA in screening, such as dedicated funding and EQA teams. Comparisons must be undertaken between Scotland and the rest of the UK to assess the suitability of Scotland’s approach.

BHB clarified that EQA has always been available to screening programmes in Scotland and EQA has been undertaken in the past. Now, however, HIS seek to build on experience of AAA baseline review, across all standards of AAA. Robust internal quality assurance makes EQA much easier, as data and monitoring etc is already there.

TS highlighted there is a need for timely approach as well. Recently commissioned reviews for EQA following incidents are retrospective, rather than looking at current issues with the programmes.

The proposed time frame for this work was queried. BHB advised it is hoped that there will be a proposal that can be brought to the SSC towards the end of the financial year. There will likely be a resource implication which needs to be established. There have been discussions with SG regarding this.

Confirmation was sought that SG are aware of risks that are being run while there is an absence of EQA and IQA in case an incident happens.

Sinéad Power (SP) (Scottish Government) noted it had been a very helpful discussion, and that it should form part of the wider consideration around where SG can add value.  She also noted that there needed to be a balance of risk considered around the timescale for a decision on this work.

BHB advised that updates will be brought to the SSC. There are milestones throughout the process and there are discussions with SG particularly around resources and undertaking a pilot as quickly as possible to test the thematic element. The expectation is that this will be set out to committee.

It was noted that a pressing issue was robust Internal Quality Assurance (IQA). EQA should be the third line of defence - issues should be identified internally rather than externally.

GB advised that IQA has been a focus for NSO, and that a paper will be brought to the November SSC meeting so that options for strengthening existing IQA can be considered.

GB also reassured the SSC that there is IQA across all of the screening programmes but that a broader conversation regarding funding and sustainability of elements of existing IQA is now welcomed.

JG concluded this agenda item by advising that the issue would be worked on and moved forward, and there will be a more robust overview and update at the next meeting.

IT support for newborn hearing screening

The SBAR report for IT support for the management of the Newborn Hearing Screening Programme was presented and summarised.

TS advised the SSC that while the SBR system was effective when first implemented there was no longer any ongoing development to the system. The audiology incident in Lothian, which has repercussions for the screening programme, demonstrates how important having a robust screening IT system is, rather just a clinical management system.

Comments and questions were welcomed from the SSC.

It was highlighted that there is currently an exceptionally challenging financial situation. Health Boards are not allowed by law to spend money that they do not have and there are a number of clinical risks to balance. This led to a discussion regarding making a recommendation to Board Chief Executives, and making them aware of the risks of not making any changes to the current system. TS also highlighted that in the absence of systems, there is an increased staffing cost implication due to manual processes – therefore the system would bring greater efficiency. Adverse event management also results in very substantial costs.

There was agreement that the SSC should make the recommendation based on what it believes is the most appropriate and proportionate way forward for screening.  Health Boards should then make the decision on how to proceed.

JG summarised that the SSC are supportive of the proposal to move to a single IT system. She noted that there is enormous financial pressure, and while £80,000 is a small amount, every health board is considering all expenditure now. She highlighted that it should be noted that the decision to recommend implementing the system was made while considering context, and the SSC are aware of the present challenges, but also that this is a relatively small amount given the risks and benefits.

A further discussion took place as to why health boards had not made the decision to take on the system already. GB advised that finance will have been a significant issue, but equally there has been no clear ownership of the issue which has created further challenges. The role of the NSO is to provide leadership and assurance across screening, and NSO has picked up this issue in the absence of progress otherwise.

The group recognised that consideration to the quality and delivery of screening programmes is paramount and this requires a robust and well governed framework.

Update on cervical screening incident - audit

TS provided an update on the work regarding the incorrect exclusions incident within the cervical screening programme. The first phase of the audit is completed for those who were at highest risk of having been incorrectly excluded. All of those individuals were called back, and currently the report is being finalised and is to be signed off. Planning is continuing for phase 2 of the audit, which requires reviewing the records of approximately 150,000 individuals. It is a two stage approach – primary care have been provided with additional funding for admin staff to carry out the audit; and also work is ongoing regarding developing a bespoke data base with ATOS, which should be ready for testing in October. After this, each health board will work to determine whether individuals have been excluded appropriately.

TS highlighted this is significant piece of work. The Minister for Public Health, Women’s Health and Sport has confirmed this audit should go ahead and has approved funding to support it. Due to the significant funding attached to the audit, this has implications for wider screening budgets for this year. An SBAR is being developed to understand the challenges this will create. Once it starts, it is estimated the audit will take a year to complete. A letter is to go out from CMO to Board Chief Executives about the audit, as well as a letter to SGPC to individual GP practices regarding the expectations of them.

SP advised that SG are subject to financial restraints, like health boards, but SG will work to examine other funding opportunities for screening.

UK National Screening Committee (UK NSC) update

TS advised the SSC that the UK NSC Remit has expanded to include targeted screening as well as population screening. The UK NSC met for first time with the new chair Sir Prof Mike Richards in June. The committee is now situated within the UK Department of Health as Public Health England has disbanded.

The main agenda item for this meeting was targeted lung screening. The final minutes for this meeting have not yet been published. TS advised the committee there are multiple lung screening pilots in England, and one pilot in Scotland, within Lothian and Fife. The formal recommendation is still to be made, however this is anticipated later this year.

Any other business and next meeting

There was no other business raised.

JG thanked the committee for attending and noted the next meeting is due to be held on 24 January 2023.