Scottish Screening Committee minutes: January 2023

Attendees and apologies

Members

• Jann Gardner, Chief Executive, NHS Lanarkshire (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  
• Janette Fraser, Head of Planning, NHS Forth Valley
• Fiona McQuiston, Cancer Research UK 
• Graham Foster,  Director of Public Health, NHS Forth Valley

In attendance

• Tasmin Sommerfield, National Clinical Advisor for Screening, NHS NSO
• Belinda Henshaw-Brunton, Healthcare Improvement Scotland
• Fiona Wardell, Healthcare Improvement Scotland
• Steven Wilson, Healthcare Improvement Scotland
• Sinéad Power, Deputy Director, Population Health Directorate, Scottish Government
• Alexander Cruickshank, Committee Secretariat, Health Protection Division, Scottish Government
• Chloe Kelly, Committee Secretariat, Health Protection Division, Scottish Government

Apologies

• Scott Urquhart, Director Of Finance, NHS Forth Valley
• Bob Steele, Senior Research Fellow, University of Dundee
• Safia Qureshi, Director of Public Health, Healthcare Improvement Scotland
• Christine McLaughlin, Director of Population Health, Scottish Government
• Laura McGlynn, Committee Secretariat, Health Protection Division, Scottish Government 

Items and actions

Welcome and apologies

• Jann Gardner (JG) welcomed the committee and noted apologies from Bob Steele, Scott Urquhart, Christine McLaughlin, Laura McGlynn and Safia Qureshi
• it was also noted that Jane Burns, medical director for NHS Lanarkshire, has now retired and the SSC is currently holding talks with SAMD to find her replacement
• Minutes from the previous meeting were approved and will be published on the Scottish Government website

National Screening Programmes overview and National Screening Oversight (NSO) update

Gareth Brown (GB) provided an update on the screening programmes. Most of the programmes operating largely in line with the previous SSC update.

Bowel screening

• continues to operate in line with pre-COVID performance. Uptake is slightly higher; however, there continue to be challenges further along the pathway with colonoscopy capacity
• progress is being made around recruitment and training of staff to undertake endoscopy and colonoscopy
• it has been reported that changes to the symptomatic pathway are leading to reductions in demand on endoscopy and increase in capacity
• Fiona McQuiston (FM) asked why one board is still using FIT scores. GB advised that this continues to be against Programme Board recommendations. The Programme Board is engaging with the relevant health board to resolve

Diabetic Eye Screening (DES)

• capacity across the programme is improving, although impacted by winter pressures
• challenges remain in terms of clinical space and staff capacity

Breast screening

• continues to be the programme facing the greatest challenge, but there is variation across the country
• all breast screening centres have action plans in place with NSD, particularly those with the greatest challenge, work is underway to reduce the screening round length. The East centre has had additional mobile units deployed with ongoing work to address recruitment challenges
• modelling shows that round length should be back on track later this year
• self-referrals have restarted, though initially this is only for women aged 71 to 74, and those 75 and over with a history of breast cancer. Around 2.8% of all appointments are allocated to self-referrals, which is lower than pre-COVID levels of self-referral

Cervical screening

• challenges remain around the two laboratories that process samples. Turnaround times for cytology are the main concern as these are around seven to eight weeks
• work is ongoing to reduce this back down to the 14-day standard
• routine colposcopy waiting times continue to exceed the target of eight weeks or less for five of the boards
• an adverse event has occurred within the programme in the last month. A relatively small number of samples were not reported to cytology due to an IT issue. This was around 100 samples from various boards, managed by the Lanarkshire lab. All 100 participants needed to be re-called for a repeat sample

National no cervix audit 

• considerable preparatory work has been carried out over the last year to develop sufficient IT and clinical pathways
• the audit is expected to commence soon. It is not possible to say how long the audit will take. It is hoped the review of records will take 12 months, but the duration of the entire process will be determined by the number of individuals found to require clinical follow-up

Abdominal Aortic Aneurysm (AAA) screening

• the screening part of the pathway is performing as expected, similar to bowel, uptake is higher than pre-COVID. Only two boards are still to catch up with the backlog, and funding has been secured for Quality Assurance and Clinical Lead posts from Scottish Government (SG)
• one current issue relates to the treatment key performance indicator (KPI), for men to be treated within eight weeks of a positive screen. National performance is currently 15%, against the essential performance KPI of 60%
• the programme board asked for this to be escalated to SSC for awareness, however, ultimately the responsibility for addressing waiting times for treatment lies with Chief Executives and vascular services
• GB opened up to comment from the committee. There was further discussion of the treatment protocols, including prioritisation, and the risks around delays. However, TS highlighted that the screening pathway ends at the point of referral of a detected aneurism to vascular. The risk assessment surrounding triage lies with vascular surgeons
• it was agreed that this issue would be escalated and brought to the attention of Board Chief Executives for action locally. JG and GB agreed to discuss how to do this

Pregnancy and newborn screening

• operating as normal in all boards
• some boards are not meeting target timelines for newborn hearing screening referrals to be seen for diagnostic assessment, and there is a national audiology review which is being undertaken that will address this to some extent
• the IT system used to support newborn hearing screening across the boards was discussed at length at the previous SSC meeting. A paper was taken to NHS Board Chief Executives recently, with principal agreement to try to work towards all boards using the same system

Overall, the challenges across screening programmes reflect challenges within the wider NHS, and the performance update is not considerably different to that from the last update. 

Board Screening Coordinators Workshop

• GB added that NSO hosted a workshop with NHS Screening Coordinators in November – this considered issues around governance and roles and responsibilities. As a result of that NSO will establish a short-term programme of work to review roles and responsibilities of Board Screening Coordinators, Programme Boards and Programme Board Chairs, working with colleagues from across the system

Nationally commissioned colonoscopy services for screening

• GB provided an update on work NSO had undertaken following the SSC’s request that the feasibility and desirability of a nationally commissioned screening colonoscopy service in Scotland be scoped. GB advised NSO has produced a paper which he can share with the Committee. In summary, while there is potential for national commissioning of colonoscopy to improve quality assurance and data, any implementation is likely to be expensive, lengthy and disruptive. SG has work underway to increase colonoscopy capacity through training and recruitment, and the development of a new national data system to provide comparable data between boards.  On that basis, the NSO view was that it would best to maintain a watching brief for up to 12 months, to allow the SG endoscopy improvement work to deliver, before deciding to commence upon a potentially significant change. SSC agreed to take no further action on colonoscopy commissioning, and to review the position in 12 months’ time

GB welcomed discussion and questions from the Committee on all the issues raised. 

GB highlighted that a recognised concern around the robustness of information gathering and the processes at Board level to quality assure screening. NSO have a data, escalation and reporting role, but work is needed to ensure what happens at local level is more visible to them. Boards are responsible for assuring activity locally against national standards, but there is no formal mechanism for that activity to be reported to Programme Boards, or to NSO in turn.

TS noted that Healthcare Improvement Scotland (HIS) is beginning work on reviewing screening standards, including new core standards (such as leadership, governance, adverse events). That work will commence shortly, and the standards should be published before the end of the year. The NSO is closely involved with this work. 

Fiona Wardell (FW) from HIS added that leadership and governance will be the first standard included within the new Core Standards, at, but training and education, supporting people to make informed decisions, and tackling inequalities will also be considered. Leadership and governance include a range of different criteria, for example how to ensure that KPI’s are delivered. Some of these are pre-existing and well-established practice. HIS will go out for consultation on the standards and these will link to the work that TS has described, to any emerging work around internal and external quality assurance, and to national policies, for example around duty of candour. This will enable different programmes to pull out what specifically relates to them whilst also having a number of core principles that cover them all. 

FW added that some of the standard’s evidence is work that is already routinely carried out by boards and programmes. One of the purposes of the standards is about national consistency but it’s also about driving improvement, and part of that principle of driving improvement is peer learning and sharing of intelligence. FW will share some further information with the group. 

FM asked whether there would be an interest or space for Cancer Research UK (CRUK) to be part of this work. FW noted there will be a short life working group, but that HIS will also go out for consultation so there are a number of ways in which people can engage. 

JG closed the section as no further questions. 

Standards and Internal Quality Assurance (IQA) of screening programmes

TS advised the SSC that NSO has responsibility for reviewing and driving improvement in the quality of screening programmes. At the SSC meeting in August 2022, it was agreed that NSO would undertake a review of existing internal quality assurance mechanisms across the programmes to identify existing gaps opportunities for improvement. This is separate and distinct from the HIS work on the external quality assurance process. 

All six screening programmes were divided into key components of the screening pathway, from cohort identification through to diagnosis. The processes that are in place to quality assure the programme were then mapped at each level.  
Positive findings show that there were IQA mechanisms embedded throughout the screening pathways of each programme. For four of the six screening programmes that use KPI monitoring, the monitoring and evaluation groups (MEG), which are subgroups of the Programme Boards, offer robust national assurance by scrutinising KPIs and reviewing board level data. This ensures any outlier can be quickly identified and concerns escalated if necessary. It was however noted later in the discussion that there was a need for greater clarity between the MEG and Programme Board on the escalation process.

Other positive examples of good practice include the built-in quality assurance system surrounding images within the AAA screening programme, which takes a random set of images quarterly to the lead screener in each board for QA. 
The breast QA radiologist post has been filled for about a year, this has led to an increase in QA activities across the centres, for example there have been joint visits, peer learning sessions and sessions on image quality.

There are a number of areas with work still to do. HIS create standards for all the screening programmes but there are currently no assurances as to how individual health boards use these. Some board coordinators advise that they are undertaking self-assessment against these standards, but this requires further monitoring and review at agreed frequency by programme boards.  

Failsafe reports are vital in screening. There are a number of failsafe reports built into the IT systems of the screening programmes. NHS Boards state that they run fail safes, but this is something that needs to be evidenced. Within the pregnancy and new-born screening programme, there are also identified issues around the storage of foetal anomaly scans across the country. NSO have had initial discussions to try to baseline what each board is doing and to learn from England. Another major anomaly is lack of nationally commissioned labs for antenatal infectious diseases screening and antenatal haemoglobinopathy screening, meaning there is no national data held on individuals screened, results or follow-up. The lack of national data also makes it difficult to QA how antenatal haemoglobinopathy screening guidance is followed. 

More generally, there is a great deal of inconsistency across the screening programmes, in part because the programmes evolved at different times and because of funding differences, including around QA posts. There is a need to review all of the QA posts that have historically been available and assess whether they still have benefit, or the risks of not having them filled, and identify any resource requirements. 

The role of programme board chairs is currently unfunded but when the programme boards were established, it was the intention that the chairs would hold responsibility for programme QA. As chairs are expected to be consultants in public health they require protected time to focus much more on QA. NSO is looking at identifying funding for these roles to put them on a protected footing.

TS concluded that there is IQA being carried out by each of the programmes, but we need to get better at ensuring the QA is being carried out, and clarity is required on who undertakes the roles and whether dedicated funding is needed. JG welcomed questions or comments from Committee. 

GB commented that there are a number of actions NSO are going to carry forward, with support from NSD, and that they have discussed with SG funding for some of these posts. NSO will develop a programme of work on strengthening IQA and keep the SSC updated. 

JG wondered whether there is a self-assessment or support tool required for boards so that they have a means to step through the questions they have considered when approaching their own boards. 

GB added that feedback from Board Coordinators was that IQA could be challenging and NSO can work to develop a national tool/template to help boards over the next few years, programme by programme. 

BHB added that when the AAA review was conducted, HIS asked all boards to undertake a self-evaluation against all of the standards and it was viewed to be quite resource intensive, so she would advocate for a self-evaluation tool being either risk based, or intelligence led.

Healthcare Improvement Scotland (HIS) presentation - External Quality Assurance (EQA)

BHB along with Stephen Wilson (SW) presented on HIS work to develop external quality assurance (EQA) for screening programmes.

BHB and SW provided an overview of principles around EQA and the respective roles of local teams, of internal quality assurance at organisation level, and then EQA as the ‘third line’ of defence. BHB then updated the committee on work that had been done to learn from models of EQA in other parts of the UK.

In England, their approach to EQA is prioritised based on level of perceived risk, there is a set of qualitative and quantitative criteria that are regularly reviewed to determine the levels of risk and any required actions. They utilise three levels of escalating QA actions, one is business as usual – where most screening programmes are, two is additional QA activities where intelligence has identified a need for assurance or practical improvement, and three where there is a level of risk where a QA visit is actually undertaken. 

In Wales, governance sits centrally and takes an intelligence led approach, it also aligns to the HIS model, where they use expert groups to undertake commissioned reviews but there is differing approaches for the different programmes. 
BHB advised that HIS is proposing a blended approach for EQA of screening, using the commissioned approach which has always been available, but which is usually retrospective, but also to have a proactive approach of thematic EQA investigations. 

There are a number of principles for thematic EQA. The theme or topic would be identified through intelligence. The methodology that would be used follows a standard HIS approach. There could be a number of levels of thematic review but all responding to data intelligence and utilising an intelligence gathering framework. 

HIS is planning to engage with stakeholders and convene a short life working group to test and develop the process. They have begun the identification of data screening sources that would be the source for intelligence and will look to set triggers and early warnings for signs of concern. They aim to test the EQA process with one or more programmes over, develop an evaluation framework to measure the impact of EQA and plan and from that implement an EQA process for screening in Scotland. This work has an 18-month timeline. 

BHB noted that a conversation around funding and resources will be required. HIS will develop and agree a business case with SG. GB asked when the business case will be ready, and when might this thematic model and subsequent reviews start. BHB advised business case to be undertaken as a matter of urgency, if the SSC is satisfied with what is being proposed. A review should be undertaken towards second half of 2023. SSC agreed.  

Sinéad Power (SP) welcomed future conversations and BHB advised some narrative in terms of the business case will make this clearer, as it is quite complex.

Update on development of Equity Strategy 

TS provided a verbal update on the Equity Strategy but would plan a fuller description of the strategy at the next SSC meeting. There is a great deal of work being done across screening to address inequalities but until now, there has not been a cohesive approach. The aim of the new strategy is to provide this.

TS has been leading on this work with Helen Reed at NSO. They have worked with a range of stakeholders including boards, SG and PHS.

The strategy has identified four key areas for action and improvement; communications and education; accessibility; data and research, and evaluation. The strategy should be ready for publication in April and a formal launch is to be discussed with SG colleagues. TS is hopeful that this will be a very welcome addition to screening activity in Scotland, providing more consistency on how different boards and different organisations are dealing with equity. 

UK National Screening Committee (UK NSC) update

TS advised the UK NSC to have given two new programme recommendations. The first being targeted lung cancer screening for current or ex-smokers aged 55 to 74, with identification through GP IT systems followed by an initial risk assessment, with those meeting the criteria attending for a low dose CT scan.

The UK NSC has formed a four nations lung task group to establish what the screening programme will involve. In England there are a number of lung screening pilots in place covering about 15% of the population, and in Scotland we have one pilot at the moment which is currently about halfway through. The UK NSC task group is building an IT model which provide information to all four nations in order to plan resource requirements, i.e., number of CT scanners, radiologists, radiographers. The downstream impact on the lung cancer pathway must be considered, there are already capacity issues currently with the lung cancer treatment pathway so careful planning is essential. It will take some time to get the planning right before full implementation. SG and NSO will be taking forward a lung cancer screening implementation group which will start looking at some of the data and making projections, updates will be provided to the committee. 

The second recommendation is screening for tyrosinemia. This is a rare genetic metabolic disorder. It is very similar to existing screening for conditions such as Phenylketonuria (PKU), so will be carried out during the newborn blood spot period. The labs already have the equipment needed to screen for tyrosinemia, but there will be a cost of additional reagents and perhaps IT changes, however the business recommendation has only just been made and so is at a very early stage. The UK NSC has established another task group for this, which TS will be on and will be able to feedback on planning for implementation in Scotland. 

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 18 April 2023.