House of Commons - Public Accounts

Select Committee on Public Accounts Sixty-Ninth Report

On the need to have clear lines of accountability

(xviii) We are appalled that the local management at Kent and Canterbury Hospital presided over a state of affairs where repeated warnings of understaffing, poor training, and low morale among all groups of staff went unheeded over many years; and where problems in its former screen smear screening services may have contributed to eight deaths and 30 women undergoing hysterectomy operations. They deserve the severest censure for doing nothing about those problems and for bottling them up within the Trust (paragraph 83).

(xix) The NHS Executive must share some part of the responsibility for not ensuring that they had sufficient information to alert them to the need to intervene earlier. Clearly there were weaknesses in the chain of accountability from the NHS Trust to the NHS Executive, but it is the NHS Executive's job to ensure that there are satisfactory arrangements in place to enable them to exercise effective oversight of major national programmes such as this which affect the lives of millions of women each year (paragraph 84).

(xx) We note the improvements the NHS Executive have now made to strengthen the chain of accountability by strengthening monitoring of the laboratory services and the systems as a whole; by insisting that each part of the health service had someone clearly in charge of the call and recall system, of the laboratory services and of the colposcopy services; and by working on guidance which would help people handle incidents in the future. We expect the Executive to monitor the success of these arrangements and to take further action if they are not fully effective (paragraph 85).

(xxi) We also note the proposal to establish a Commission for Health Improvement, which would also have the right to intervene in such cases. The success of such a scheme will depend crucially on the free flow of information at the right time (paragraph 86).

(xxii) We note the proposed strengthening of accountability for the NHS, to be implemented from April 1999. However, until we see those accountabilities work in practice, we shall remain sceptical about their effectiveness (paragraph 87).

THE NEED FOR IMPROVED COVERAGE OF THE SCREENING PROGRAMME TO MINIMISE THE INCIDENCE OF CERVICAL CANCER AND TO ENSURE EQUITY

8. England has one of the highest recorded incidences of cervical cancer in the European Community, and one of the highest mortality rates from cervical cancer in the developed world.[11] The Committee asked the NHS Executive why this was so. They told us that, while their screening service was ahead of most other European counties, there were lifestyle issues - the sexual activity of young people, teenage pregnancy and teenage smoking—which all contributed to this.[12]

9. When the Committee of Public Accounts last looked at cervical screening in 1992, the Committee pointed out that no national target existed for the coverage of the Cervical Screening Programme.[13] In response, in 1993, the NHS Cervical Screening Programme and the Health of the Nation initiative adopted the target that at least 80 per cent of eligible women aged between 25 and 64 should have been screened within the previous five years.[14] By April 1997, almost 85 per cent of eligible women had been screened at least once every five years. Eighty seven health authorities in England met or exceeded the 80 per cent coverage target, of which seven had coverage above 90 per cent.[15]

10. We asked why, when England had one of the worst death rates from cervical cancer, the Executive screened women only every five years, rather than more frequently. They told us that evidence suggested that five yearly screening prevented 84 per cent of cervical cancers and three yearly screening prevented 91 per cent. However, annual screening prevented only 93 per cent and could not be justified.[16]

11. They pointed out that 53 per cent of health authorities and 70 per cent of general practitioners already screened women every three years. However, this was not a national policy and current priorities were to extend coverage and get quality assurance programmes properly under way, and not to increase frequency which would have some effect but also some cost.[17]

12. Thirteen health authorities had failed to meet the 80 per cent coverage target.[18] We asked whether this was a result of bad practice, and what the Executive were doing to target these authorities to ensure they reached the 80 per cent figure. The Executive confirmed that the emphasis was on coverage. Each of the authorities had their own specific programmes, particularly for coverage of the most vulnerable groups in the population. But there were difficulties, particularly in relation to young people living in inner cities, often fairly transient young people who were difficult to track through the system.[19]

13. In terms of targeting these authorities, the Executive told us the answer was to encourage local initiatives rather than have endless national guidelines. They reviewed health authorities' performance and the regional directors of public health followed through on plans to improve coverage.[20] Each authority had incremental targets for one year, and their aim each year was to build on the success of the previous year. Progress had been made (Table 1[21]), but the Executive could not put a date on when each would achieve 80 per cent coverage.[22]

Table 1

Progress in Health Authorities Achieving less than 80 per cent Coverage

Health Authority 1994-95 1995-96 1996-97

Coventry 79.8 79.2 79.6

Barnet 75.1 77.9 79.4

Liverpool 76.6 77.2 77.8

Merton, Sutton & Wandsworth 76.3 77.0 77.9

Brent & Harrow 74.1 75.9 77.1

Redbridge & Waltham Forest 77.8 77.0 76.3

East London and City 73.5 73.7 74.2

Lambeth, Southwark & Lewisham 70.4 71.2 72.9

Enfield & Haringey 69.4 71.2 72.2

Manchester 72.7 74.7 71.9

Ealing, Hammersmith & Hounslow 67.6 70.2 70.1

Camden & Islington 65.7 68.1 69.2

Kensington, Chelsea & Westminster 62.8 67.1 68.1

14. We noted that nine of the 13 authorities that failed to achieve the national target screened more frequently than once every five years,[23] and asked why the Executive did not encourage these authorities to give priority to coverage. They told us that while it was their priority to increase the coverage, it would be extremely difficult to take away three-yearly screening cycles when people had got used to them. They pointed out that there was no financial constraint or trade-off between frequency and coverage.[24]

15. In his report, the Comptroller and Auditor General drew attention to variations across the country, and between socio-economic groups. For example:

nine of the fourteen regions in 1992 had standardised mortality ratios more than 50 per cent greater than South West Thames;

in women classified as semi and unskilled manual workers, long term unemployed, casual or lowest grade workers, incidence of cervical cancer was more than double that in women classified as higher managerial, administrative or professional; and

research indicated that women from some ethnic minorities, particularly Bangladeshi, Pakistani and India, were underscreened, as a result of a combination of religious and cultural factors.

Part of the reason for women not accepting invitations for screening was that women in lower socio-economic groups held more negative attitudes towards the test procedure and were less likely to believe that they were at risk of cervical cancer.[25]

16. The Committee asked about the reasons for these variations, and how they could be tolerated. The Executive confirmed that one of the main factors in regional variations was socio-economic class, and that poverty was an element.[26] They told us that to reduce inequalities and under-screening in those groups most at risk they were adopting a whole range of different approaches.[27] [28]

17. First, they were seeking to improve the quality of data on the extent of the problem. Ethnicity data were not held on the health authority database, and coverage of particular groups could not be routinely monitored at either national or local level. So the NHS Cervical Screening Programme was looking at the possibility of funding a project which would use the regular survey undertaken by the Office for National Statistics.

18. Second, the Cervical Screening Action Team was considering what action was needed to restore confidence in the screening programme, following recent adverse publicity, and the type of messages that should be used to give women the information they need about screening.

19. Third, the NHS Executive and the NHS Cervical Screening Programme had taken a number of initiatives to promote high coverage in cervical screening, such as:

a handbook including the principal elements of a successful screening programme and good practice in promoting high coverage (1993);

guidance to assist the development of local strategies to raise coverage of the screening programme (1995);

information leaflets for women, explaining and answering common questions. These were subsequently translated into six ethnic minority languages (1996);

guidance on improving the quality of written information sent to women (1997);

a resource pack for use with ethnic minority women to encourage more of them to come forward for screening (1998);

audio tapes in ethnic minority languages (1998).

20. Finally, there were the many local initiatives and all the authorities that had not achieved 80 per cent coverage were actively addressing the causes. For example, translators and link-workers, and female-only screening staff were widely used to encourage more women to come forward. And authorities where coverage was low were trying to identify the wards and general practices where take-up was low and to put in particular incentives there.

21. The Executive also confirmed that the National Coordinator of the Cervical Screening Programme now provided annual reports to the Executive Board of the NHS on the breast and cervical screening programmes.[29]

22. We asked whether it would be useful for the Executive to pull together a national picture of coverage of women in the different ethnic communities. They told us that this information would be useful, but such an exercise would not be possible because the database used for the call and recall programme did not carry data on ethnicity. The NHS Cervical Screening Programme was looking into the possibility of other research-based methods of obtaining this information.[30]

23. Health authorities make payments to general practitioners for smear taking. General practitioners with a coverage of 50 per cent to 79 per cent of eligible women received a standard payment of around £900 a year in 1995-96; and those with a screening coverage of 80 per cent or higher received a standard payment of around £2,600 a year. Both percentages are defined in terms of screening women once at least every five years, and payments are not designed as direct remuneration for the financial costs of smear taking, and do not depend directly on the number of smears taken.[31]

24. We asked the Executive whether the target payment scheme for general practices might be more effective if it took into account the general practice's population profile, in terms of ethnicity, deprivation and mobility. They told us that the objective was to obtain better coverage, and in general terms that was working. But they agreed that one of the most significant areas of inequality was in relation to access to general practices, and they had a study going on which would inform the next round of resource allocation. They hoped to right some of these differences by taking a much clearer account of population need, the historical development of services, age and population mix.[32]

25. We asked why it was that there was an imbalance between the £280 million spent on tens of thousands of people under the HIV AIDS programme and the £132 million spent on cervical screening, which covered 13.8 million people. They told us that some treatment for HIV AIDS was very expensive indeed, while the cervical screening programme was very cost effective.[33]

Conclusions

26. If health authorities screen women every five years, they will prevent 84 per cent of cervical cancers, and screening every three years will prevent 91 per cent. Although some authorities face particular problems with ethnic minorities and transient populations, we are very concerned that 13 health authorities have not yet achieved the target of screening even 80 per cent of women aged 25 to 64 within the previous five years.

27. We recognise that the Executive, the NHS Cervical Screening Programme and health authorities are taking a wide range of national and local actions to improve coverage, and in 1996-97 10 of the 13 authorities improved their coverage over the previous year. But their failure to achieve the 80 per cent coverage target is putting lives at risk, and we urge the Executive to look again at the scope for targeted action, and to set each authority a firm deadline by when they should have achieved 80 per cent coverage.

28. There are considerable variations in the incidence of and deaths from cervical cancer across regions, and research indicates that women in the lower socio-economic groups and ethnic minorities are under-screened. We note the wide range of actions the NHS Executive and others have taken to address these inequalities, but the fact remains that the NHS is failing many of the most vulnerable people in our society.

29. A pre-requisite to tackling inequality amongst ethnic minorities is quality data at local, regional and national levels. Such data do not yet exist although some steps are in hand to obtain this information through other research-based methods. Without such baselines, the Executive cannot set meaningful targets which would lead to action to achieve equitable levels of coverage of women in those groups. We look to the Executive to give priority to improving the data available.

30. One way of improving coverage in the 13 health authorities currently missing the 80 per cent target, and of those women who are currently under-screened, might be to refocus the target payment system for general practitioners. The Executive are studying the question of equality of access to general practitioners, and we look to them to explore ways of refining the incentives scheme to help.

THE NEED TO MINIMISE UNSCHEDULED SMEARS IN ORDER TO FOCUS RESOURCES ON THOSE MOST AT RISK AND AVOID UNNECESSARY CONCERN TO WOMEN

31. The Comptroller and Auditor General reported that in 1996-97 4.4 million smears were taken. Some 454,000 were unscheduled smears taken for reasons outside guidance from the Cervical Screening Programme, and of these, 157,000 were taken from 95,000 women below the age of 20 and 297,000 were taken from 254,000 women without symptoms or special risk factors. In 1996, a study found that 50 per cent of all unscheduled smears were taken in only 18 per cent of general practices.[34]

32. The Comptroller and Auditor General noted that reducing the number of unscheduled smears could save time in general practices, reduce costs in laboratories and colposcopy clinics, and reduce the inconvenience and possible anxiety for a substantial number of women.[35]

33. The Committee asked the NHS Executive why 95,000 women under 20 had a smear taken in 1996-97 in spite of guidance that there was no justification for such smears, and what they were doing to reduce unscheduled smears generally. They told us that the majority of unscheduled smears were taken because, in the past, doctors had been taught to take smears as the opportunity arose, for example when prescribing oral contraception. Some doctors continued to believe that additional smears were appropriate in certain circumstances.[36] The Executive pointed out that general practitioners were dealing with millions of clinical decisions, and what was taking place between the doctor and his patient on a particular day was not something the Executive could control in the conventional definition of the word. It was a matter of changing the minds of some clinicians from their traditional practices, and that would take time.[37]

34. The Executive told us that in December 1997 they had issued more stringent guidance which stated that:

There was no justification for including teenagers in the cervical screening programme;

Recall invitations should be issued no sooner than three years and no later than four and a half years after a previous normal smear;

Providing a woman was in the age group to be screened, and had had a smear within the last three to five years, additional cervical smears were not justified:

When a woman started taking the pill or HRT;

In association with pregnancy or an abortion;

On insertion of an IUCD;

In women with genital warts, an infection, or vaginal discharge;

In women who had had multiple sexual partners;

In women who were heavy smokers.[38]

35. The Executive noted that these guidelines also set out the research evidence supporting the guidance now being given, because doctors changed their behaviour and their pattern of working by looking at the science and at the evidence.[39] The Executive pointed out that as the National Audit Office had found, the number of unscheduled smears had fallen from 684,000 in 1995-96 to 454,000 in 1996-97, and the Executive were confident that the number would continue to fall as the 1997 guidance was implemented.[40]

Conclusions

36. We note that the number of unscheduled smears fell from 684,000 to 454,000 between 1995-96 and 1996-97, and that the NHS Executive are confident that the number will fall further following the more stringent guidance they issued in 1997. We look to the Executive to track progress in reducing unscheduled smears, in order to ensure that costs are not diverted from tackling those most at risk, and that almost half a million women do not suffer unnecessary inconvenience and possible anxiety.

37. In addition to the steps they have already taken, we expect the Executive to consider whether a more targeted approach to general practitioners might help, given that 50 per cent of all unscheduled smears are taken in only 18 per cent of practices.

THE NEED TO ACHIEVE QUALITY STANDARDS THROUGHOUT THE CERVICAL SCREENING PROGRAMME

38. In his report, the Comptroller and Auditor General drew attention to the failure to achieve quality standards at key stages of the cervical screening process:

Smear taking;

Smear screening and reporting by laboratories;

Colposcopy; and

Providing women with information at key stages in the process.[41]

(a) Improving the quality of smear taking

39. The Comptroller and Auditor General noted that in order to screen a smear properly at a laboratory, the sample of cervical cells has to be of the right type, spread at the correct thickness on the slide and not be obscured by blood cells or bacteria. Smears that did not meet these standards were classed as inadequate. He pointed out that inadequate smears caused inconvenience to women and possible anxiety in having to re-attend for a repeat smear, and that in 1996-97, 8.3 per cent of cervical smears were classified as inadequate, compared to a target of seven per cent set by the Cervical Screening Programme. The difference represented 57,000 smears that might have been avoided through better smear taking.[42]

40. Most smears are taken in general practice. To improve quality, the NHS Executive recommend that health authorities should know the extent of inadequate smears for each general practice in their area and follow up those with persistently high rates of inadequate smears in order to set local targets for improvement. However, only around two thirds of health authorities contacted general practices with persistently high rates of inadequate smears and only 40 per cent of general practices received data on individuals' rates of inadequate smears.[43]

41. The Committee asked why one third of health authorities failed to contact general practices with persistently high rates of inadequate smears. The Executive confirmed that good practice was to provide direct feedback to the smear takers at general practices, and told us that their advice over the past four years had been consistently clear on that issue. The key relationship was that between the laboratory and the smear taker, and they were dealing with the issue by increasing training and building that key relationship, and that they had now put in place guidance and systems to improve compliance.[44]

(b) Improving smear screening and reporting by laboratories

42. Laboratories screen smears to assess whether abnormal cells are present and report back the results to the smear taker. Screening involves the interpretation of subtle variations in the shape, size and structure of cervical cells. Accuracy is a vital requirement. In 1996-97, 181 laboratories in NHS hospitals screened 4.4 million cervical smears.[45]

43. There have been a small number of discoveries of cases of quality failings in smear screening in hospital laboratories in England. The most serious case has been at Kent and Canterbury Hospital which has been subject to an independent review. The hospital has reported that the problems in its former smear screening services may have contributed to eight deaths, as well as to 21 women undergoing hysterectomy operations with cancerous changes in the cervix and to nine women undergoing hysterectomy operations with pre-cancerous changes in the cervix. The Chairman of the independent review (Sir William Wells) cited as one of the causes that repeated warnings of understaffing, poor training, low morale and breakdown in relations among all groups of staff went unheeded over many years. He concluded that there had been many individual tragedies, unnecessary suffering and anguish caused to women and their families as a result of the appalling series of events and failures which should never have been allowed to happen.[46]

44. In March 1996, the NHS Cervical Screening Programme launched guidance which aimed to set achievable standards and targets for laboratory practice. The guidance was part of the overall response to the Committee of Public Accounts' report on Cervical and Breast Screening in England[47] and brought together earlier guidelines for laboratories issued between 1990 and 1995. It set out:

Criteria for all laboratories to follow on judging the adequacy of cervical smears, and in judging and reporting on adequate smears;

Acceptable profiles for reporting smear results across laboratories, which should normally be achievable in the majority of the laboratories if they adopted the criteria. The purpose of the profiles was to provide a reporting range to help avoid missing abnormalities, while preventing excessive reporting of possible abnormalities that turned out to be inaccurate and caused anxiety to women;

That individual screeners should screen a minimum of 3,000 smears a year. This was to maintain and improve their recommended standards and skills;

That laboratories should screen at least 15,000 smears a year;

That all laboratories should participate in external quality assessment schemes, and have rapid review systems in place;

That laboratories should become accredited with the Clinical Pathology Accreditation (United Kingdom).[48]

45. The Comptroller and Auditor General noted that screeners achieved 3,000 smears a year at only 38 per cent of laboratories, and eighteen per cent of laboratories did not achieve 15,000 smears a year. In 1996-97, only around half of laboratories in England reported results within the reporting profiles set down in guidance. All laboratories were participating in external quality assessment schemes, and almost all had rapid review systems in place. In 1997, around a third of laboratories undertaking cervical screening were not externally accredited. But in December 1997, the NHS Executive required all laboratories which screen cervical smears to obtain external accreditation and gave laboratories a six month deadline for applications for accreditation to be completed.[49]

46. The Committee asked the Executive when they would be able to assure women that these problems had been dealt with. They told us that laboratories' performance overall against the targets was unacceptable. The data had not been collected before. Now that they were, the Executive aimed to see clear and consistent progress towards the targets. They could not give a date for achievement of the targets by all laboratories, but told us that their objective was to see improvement against them year on year.[50]

47. As regards those laboratories that did not screen sufficient smears each year, the Executive assured us that action was in hand in the eight regions of the country. Six mergers had already taken place, and where the Executive had worries that were not being resolved by reorganising services, they confirmed that they would close laboratories. But they added that at present everyone was being co-operative in trying to make the improvements and developments the Executive wanted.[51]

48. On external accreditation, the Executive told us that all but a handful of laboratories would have applied for the accreditation process by June 1998. Fewer than five laboratories had not applied, and discussions were in hand to resolve outstanding issues. They added that a crucial part of the discipline was the process of self-assessment which preceded accreditation.[52]

49. We asked the Executive how they could be sure that women and their families would never again be victims of the failures that had occurred in Kent and Canterbury Hospital. They told us they had learnt some hard lessons from Kent and Canterbury, and had taken a great deal of action to respond to the failings that happened there. They had ensured that they now had a nationally based quality assurance programme and ways of dealing promptly with problems as they arose; and they had improved accountability for the screening programme.[53]

50. The Executive added that there had not been a system at Kent and Canterbury Hospital to encourage the people providing the service to express their concerns freely with line managers, or beyond their line managers to the management of the Trust. This was a very unhealthy characteristic of a poorly managed organisation, and they assured us that there was clear guidance which encouraged staff if they had concerns, particularly about the safety and effectiveness of care, to speak to someone who would deal with that problem.[54]

51. However, the Executive cautioned that while improvements to quality assurance and accountability should minimise risk, they did not mean that there would not be problems of some sort in the future. The screening process was not always a precise science and errors of human judgement were always possible.[55]

(c) Improving the quality of colposcopy

52. Colposcopy has a central role in the management of pre-malignant disease of the cervix revealed by abnormal smear results. It is a diagnostic technique involving the examination of a woman's cervix using a low powered microscope. Treatment may also be carried out in the colposcopy clinic and at the first attendance. Around 100,000 women were referred for colposcopy for the first time in 1996-97.[56]

53. The Cervical Screening Programme issued guidelines in 1996 aimed at improving the quality of colposcopy services. These guidelines were designed to ensure that women referred for colposcopy receive a high quality service in respect of:

Meeting waiting time targets;

The nature of information about colposcopy and treatment;

Encouraging women to attend a colposcopy clinic if necessary;

Quality, accuracy and timeliness of diagnosis;

Clinic staffing and staff skills;

Appropriate quality of selection for treatment, and treatment itself.[57]

54. The Comptroller and Auditor General reported that colposcopy clinics were largely implementing these guidelines, but not all clinics were fulfilling the requirements set out in those guidelines. In particular:

Achieving waiting time targets was generally poor - for example only 50 per cent of clinics met the target that 90 per cent of women should wait less than eight weeks for assessment;

Some clinics were not meeting targets for provision of clinic staff and maintenance of skills;

Targets related to the number of biopsies and their quality were being missed or could not be monitored by a significant number of clinics.[58]

55. We therefore asked what the Executive were doing to improve colposcopy services. They acknowledged that insufficient attention had been paid in the past to the colposcopy element of cervical screening, and they confirmed that this was a priority area for action in the coming year.[59]

56. As part of regional reviews of the cervical screening programme, regional directors of public health had agreed action plans with health authorities to ensure that the screening programme met national standards. Colposcopy services featured prominently in these action plans with particular emphasis on reducing waiting times and better monitoring. In support, the Executive gave us a note on particular regional issues and examples of initiatives across the country.[60]

57. At the national level, the Executive told us that they would consider the need for additional guidance in the light of the results of an audit of the colposcopy service in 1996 which was about to be published. And they would be considering extending the statistical returns they required to colposcopy.[61]

58. The Executive concluded that it would take time for targets to be met, but they were confident that, given the measures put in place, the targets would be met in the future.[62]

(d) Improving communication with women

59. In April 1997, the NHS Cervical Screening Programme issued guidance to health authorities on improving the quality of written information sent to women about cervical screening. That guidance reported that many women had felt inadequately informed at almost every stage of the screening process, and noted that the main causes of anxiety in women were misconceptions about the purpose of the test and the implications of an abnormality being found, investigated and treated. The guidance therefore focussed on the presentation and content of letters and leaflets so that the initial information which women receive should deal in advance with fears and anxiety to reduce the psychological problems which may be associated with an abnormal smear result.[63]

60. The Comptroller and Auditor General's report highlighted shortcomings in communications at every stage:

In inviting women for screening;

Giving women the results of their smear tests;

Providing women with information about colposcopy;

Providing information on the results of colposcopy quickly;

Providing key information about treatment.[64]

61. We asked the Executive what they were doing to ensure that all women received all the information they needed at the time they needed it. They agreed that there had been problems, and that the approach some people had taken—that no news is good news—was not good enough. They assured us they were committed to ensuring that everyone received proper written information at every stage of the process. They now had very clear guidance in place and were doing a great deal to insist on written responses. One of their regions, North Thames, was leading on this as a priority area, and a group led by the Chief Medical Officer was looking at the whole question of public information.[65]

62. In a note on the time it takes for women to receive the results of smears, the Executive admitted that backlogs were increasing, largely due to growing problems in recruiting cytoscreeners. They were therefore taking initiatives to improve the recruitment and retention of cytoscreeners. However, they admitted that the situation would take some time to resolve.[66]

(e) Review of the cervical screening programme

63. In the light of these continuing concerns about the cervical screening programme, we asked the Executive about the progress being made by the action team which the Chief Medical Officer set up to look into the programme. They told us that the action group had been set up in the wake of the events at Kent and Canterbury, but also in relation to other issues. It would focus on the questions of quality improvement, public confidence, staffing and resources, and public information and communication. It would draw out the lessons from failures and from good practice, and the National Screening Co-ordinating Committee would ensure that that work was properly and professionally carried through. The report was published on 24 August 1998.[67]

Conclusions

64. It is regrettable that one in 12 women must go through the stress of having a repeat smear taken, because of poor smear taking. In 1996-97 the proportion of smears which were inadequate was greater than the target set by the Programme. Had the target been met, 57,000 women would have been spared that experience.

65. We are surprised that as many as a third of all health authorities failed to contact general practices with persistently high rates of inadequate smears. We note the Executive's view that the key relationship is that between the laboratory and the smear taker, and that they were acting to improve the effectiveness of that relationship. But we look to them to take all available measures, including health authorities contacting smear takers, to reduce the unacceptably high number of inadequate smears.

66. It is a vital part of the cervical screening programme that laboratories accurately screen smears, and identify any abnormalities. The significant failings at Kent and Canterbury Hospital demonstrate the appalling consequences if laboratories fail to provide a quality service. And there have been other significant failures elsewhere.

67. The NHS Cervical Screening Programme has taken a number of initiatives since this Committee's report in 1992, and in the light of Kent and Canterbury. But we are disappointed that it was not until March 1996 that they launched comprehensive guidance that aimed to set achievable standards and targets for laboratory practice and performance.

68. In our view, the late development of this guidance and standards is one reason why many laboratories are a long way from achieving key targets, and from providing an effective service to women. This is continuing to put women at risk.

69. We note the Executive's confidence that there will be consistent progress on quality issues. But we are disappointed that they are not prepared to set a target date by when all laboratories should meet the standards expected. We look to the Executive to set firm national and local timetables for achieving the improvements necessary.

70. It is essential that the colposcopy service provides a quality, accurate and timely diagnosis and treatment. We note that continuing progress is being made, but we are concerned that improvements are still needed particularly in waiting times, staffing, and quality. We therefore welcome the programme of national and local action now taken by the NHS Executive and colposcopy clinics.

71. Providing women with clear, timely information at every stage of the screening process is essential if the Programme is to allay women's fears and anxieties. The Executive are committed to ensuring that everyone receives proper written information at every stage of the process. We note their initiatives to improve recruitment and retention of cytoscreeners, and thus to provide women with their results promptly; their insistence that women receive their results in writing; their treatment of information for women as a priority area; and the Chief Medical Officer's examination of the whole question of public information about cervical screening. We look to the Executive to ensure that these initiatives lead to women receiving clear and timely information at every stage of the screening process.

72. The Chief Medical Officer set up a review of the cervical screening programme and the report was published on 24 August 1998. We expect the NHS Executive to let us have their action plan to implement its findings.

PROGRESS IN HANDLING CLAIMS MADE FOR PERSONAL INJURY ARISING FROM EVENTS AT THE KENT AND CANTERBURY HOSPITAL

73. At Kent and Canterbury over 91,000 smears were re-screened, 5,566 women were followed up and 333 women were found to have moderate or severe abnormalities. The Hospital has reported that the problems in its former smear screening services may have contributed to eight deaths, as well as 21 women undergoing hysterectomy operations with cancerous changes to the cervix and nine women undergoing hysterectomy operations with pre-cancerous changes in the cervix.[68]

74. We asked the NHS Executive what they had been able to do for those involved. They told us that:

To date, the Trust had received 88 potential claims for personal injury arising from the mis-reporting of cervical smears;
In 60 cases the Trust or Health Authority had admitted liability. Of these 13 were cases of admission of causation of physical damage; 27 were cases where there was no causation of physical damage; and 20 cases where investigation into causation was still in progress. Of these 60 cases:

In 10 cases a total of £176,000 had been offered in settlement of damages;

In 18 cases an award of damages had been made in full and final settlement. The total figure of full and final damages settlements of these cases was £202,500;

One case had been withdrawn;

In 31 cases it was not yet possible to assess damages;

In six cases, the Trust had made voluntary interim payments totalling £132,500 in cases where the evidence indicated that there would be a substantial damages award. Three of these cases were to families of deceased women and payments ranged from £30,000 to £50,000 in each case;

There were 16 cases where the Trust or Health Authority had denied liability, of which four had been withdrawn and 12 were still in progress;

5 cases had been withdrawn before the defendant's liability had been established; and

7 cases were still in the early stages of claim.

75. Settlement of the first 18 cases averaged 10 months. But the Executive pointed out that clinical negligence claims rarely reach settlement within the first year, and those that did were simple cases. It was usual for settlements to take between one and three years with the complexity of the case inevitably extending the timescale. The Executive told us that the Trust were managing claims as speedily and sympathetically as possible under a protocol drawn up and agreed with the solicitors representing 80 women. But while the Trust wanted to expedite claims, it also recognised its responsibility to ensure that public money was paid only where this could be fully justified.[69]

Conclusions

76. We recognise the effort that Kent and Canterbury Hospital is taking to manage the claims made by those women, and their families, involved in the failure of the screening service there. We are, however, concerned that settlements could take as long as three years and we urge the NHS Executive and the Trust to continue to explore ways of expediting settlements.

THE NEED TO HAVE CLEAR LINES OF ACCOUNTABILITY

77. The Chairman of the independent review of the failings at Kent and Canterbury Hospital concluded that there was a lack of clear line of accountability on both management and quality assurance for the national programme through the NHS Executive and Health Authority to the Trust. The Chairman recommended that the Executive overhaul the lines of accountability, including local accountability within trusts and health authorities, for the national programme.[70]

78. The Committee asked the NHS Executive when they became aware of the problems at Kent and Canterbury Hospital. They told us that they had only become aware of the detail at a point when it was too late.[71]

79. We asked whether there had been managerial negligence and who had taken the can for the failings. The Executive told us that one of the crucial problems was that local management had identified the problems that existed but were not doing anything about them. The management of the Trust should have properly addressed the failings. They added that the Chairman and Chief Executive had since resigned and were no longer working in the Health Service, and two of the medical staff were no longer carrying out the duties they were at the time.[72]

80. On accountability, the Executive confirmed that accountability should have worked from the Trust to the Health Authority to the South Thames Regional Office of the NHS Executive. But the problems had been bottled up at the Trust and the relationship between the Trust and the Health Authority were not good enough.[73] There was not a hierarchical arrangement in place at that time, but they assured us that the relationships and regional links now existed which should obviate these sorts of problems in future.[74]

81. They added that although there had been powers of intervention into a trust by the Secretary of State, there was nothing resembling a line management system. That had now been recreated around the quality assurance process in this specific area. Changes now in place meant that the Executive had the capacity to intervene in a much more swift and efficient manner in the activities of individual trusts. In addition, the Government proposed a Commission for Health Improvement that would be independent of Government and would have powers on behalf of the Secretary of State to intervene when things were going wrong or were thought to be going wrong.[75]

82. As regards accountability for the national screening programme, the Executive added that they had moved away from the rather devolved approach that existed at the time of the Kent and Canterbury problems to a much tighter approach which had accountability direct to the regional directors of public health. They had strengthened monitoring of the laboratory services and the systems as a whole. At an operational level they were insisting that each part of the health service had someone clearly in charge of the call and recall system, of the laboratory services and the colposcopy services; and they were working on guidance which would help people handle incidents in the future.[76]

83. In a note, the NHS Executive set out the current accountability for the NHS and the proposals for change which would operate, subject to legislation, from April 1999. The proposed changes include a new national framework for assessing NHS performance, new clinical governance arrangements and the establishment of the Commission for Health Improvement, which would have the capacity to intervene and address concerns about clinical quality.[77]

Conclusions

84. We are appalled that the local management at Kent and Canterbury Hospital presided over a state of affairs where repeated warnings of understaffing, poor training, and low morale among all groups of staff went unheeded over many years; and where problems in its former screen smear screening services may have contributed to eight deaths and 30 women undergoing hysterectomy operations. They deserve the severest censure for doing nothing about those problems and for bottling them up within the Trust.

85. The NHS Executive must share some part of the responsibility for not ensuring that they had sufficient information to alert them to the need to intervene earlier. Clearly there were weaknesses in the chain of accountability from the NHS Trust to the NHS Executive, but it is the NHS Executive's job to ensure that there are satisfactory arrangements in place to enable them to exercise effective oversight of major national programmes such as this which affect the lives of millions of women each year.

86. We note the improvements the NHS Executive have now made to strengthen the chain of accountability by strengthening monitoring of the laboratory services and the systems as a whole; by insisting that each part of the health service had someone clearly in charge of the call and recall system, of the laboratory services and of the colposcopy services; and by working on guidance which would help people handle incidents in the future. We expect the Executive to monitor the success of these arrangements and to take further action if they are not fully effective.

87. We also note the proposal to establish a Commission for Health Improvement, which would also have the right to intervene in such cases. The success of such a scheme will depend crucially on the free flow of information at the right time.

88. We note the proposed strengthening of accountability for the NHS, to be implemented from April 1999. However, until we see those accountabilities work in practice, we shall remain sceptical about their effectiveness.

11 C&AG's Report (HC 678 of 1997-98), Appendix 3, para 3 Back

12 Qs 14, 36-37 Back

13 Second Report from the Committee of Public Accounts, 1992-93: Cervical and Breast Screening in England (HC(92-93)58) Back

14 C&AG's Report (HC 678 of 1997-98), para 2.1 Back

15 ibid, para 2.8 Back

16 Evidence, Appendix 1, pp 21-31 Back

17 Qs 26-29 Back

18 C&AG's Report (HC 678 of 1997-98), para 2.8 Back

19 Qs 14-15, 42-45 Back

20 Qs 14-15 Back

21 Evidence, Appendix 1, pp 21-31 Back

22 Qs 72-82 Back