1.On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department of Health & Social Care (the Department), NHS England and Public Health England (collectively referred to as the national health bodies) about the management of health screening programmes in England.
2.Health screening is an important way of identifying potentially life-threatening illnesses at an early stage. The Department is ultimately responsible for the delivery of health screening in England but has delegated its responsibilities to NHS England under the Health and Social Care Act 2012. NHS England is responsible for commissioning and managing the local providers that deliver screening services to members of the public; it also manages some of the IT that supports delivery of the programmes. Public Health England is responsible for providing the Department and NHS England with information and expert advice; producing and analysing data; managing some of the IT that supports delivery of the programmes and undertaking quality assurance work including visiting screening providers to make sure they are delivering screening services to the expected standards and processes. We focused on four of the 11 health screening programmes operating in England: screening for bowel, breast and cervical cancers and abdominal aortic aneurism. In 2017–18, almost 8 million people were screened for these conditions at a cost of £423 million.
3.The Department measures the success of screening programmes by looking at the proportion of the eligible population that has been screened. Each programme has different targets, but in 2017–18, none of the screening programmes that we took evidence on had met their targets. On the breast and cervical screening programmes, in March 2018 more than a quarter of women who were eligible were not screened (just 72.1% and 71.7% respectively). The breast and cervical screening programmes are considered to be running optimally if they achieve their target of screening 80% of their eligible population. The national health bodies conceded that they were not content with current performance levels and accepted that there were areas in health screening “where we need to do better”. The Department told us that the number of people who were undergoing screening had increased but recognised that it had more to do to make best use of modern screening methods, make screening appointments more accessible and encourage uptake.
4.The number of people going to screening appointments varies greatly by area. We were concerned that the disparity in the number of patients being screened effectively created a postcode lottery. In London for example, performance is consistently below expected levels, whereas some areas, such as areas in Yorkshire, South Derbyshire and Hampshire consistently perform well. The national health bodies asserted that the differences across the country in the number of people attending screening appointments are explained by a combination of socio-economic factors including the age of a population, deprivation levels and ethnicity. NHS England told us that it is the responsibility of its local teams to track uptake of health screening and work on approaches that will tackle these health inequalities. Despite this, NHS England, nor the Department or Public Health England could explain to us what was causing the low take up of screening in specific areas, such as London. None of the national health bodies to date have set personal targets for reducing these health inequalities.
5.We asked the national health bodies how they shared good practice between the best and worst performing areas, and to encourage specific groups who are less likely to attend screening to take part. NHS England told us that it had introduced ‘some fairly straightforward’ activities, such as text reminders and personalised letters from GPs, that it asserted have been shown to increase uptake. However, these approaches are not new and we were concerned that they would not be sufficient to encourage some groups to take part. NHS England also told us it had recently met with its Muslim health network to increase understanding and the acceptability of cervical and breast screening invites because areas with a large Muslim population, such as Leicester and Bradford, have low take up rates.
6.Attendance at cervical screening appointments is at a 21-year low, with just 3.2 million women screened in 2017–18. Only one Clinical Commissioning Group area met its target of screening 80% or more of its eligible population in 2017–18; and in a further 143 out of 207 Clinical Commissioning Group areas at least 25% of the eligible population were not screened in the same period. The national health bodies admitted that they do not understand why so few areas met their targets or why performance is so different across the country. None of the national health bodies had engaged with women to understand why they do not attend cervical screenings; instead they offered generalities including women having “busier lives” as reasons for the decline in attendance. Public Health England launched the first national campaign to encourage women to attend cervical screenings in early 2019. We welcomed this campaign, but we questioned how well it will be able to target specific groups of women and convince them to attend a screening appointment when the national health bodies do not fully understand why women are not attending in the first place.
7.The national health bodies recognised that more needs to be done to make cervical screening less frightening and invasive and more accessible to women. Yet, they fell short of providing us with concrete plans to do this. Public Health England told us about a pilot that is underway to allow women to complete the test at home which we welcome. All of the witnesses were reliant on the review of screening, currently being conducted by Professor Sir Mike Richards, to come up with specific recommendations about how to improve in this area.
8.NHS England is responsible for managing the performance of local screening providers and has delegated this responsibility to its local commissioning teams. We were concerned that local screening providers are supposed to deliver cervical screening results to 98% of women within 14 days of their screening appointment; yet in December 2018, they were delivering this level of service to just 55% of women. Public Health England admitted that the proportion of women who receive their results letter within 14 days varies considerably across the country. In Southern Derbyshire, only 2.1% of women received their results letter within 14 days. NHS England told us that there was no clinical reason why results needed to be sent to women within this timeframe, describing the rationale for setting the target at 14-days as a ‘public service reason’. We were nonetheless concerned that women could endure unnecessary stress and worry if they are forced to wait longer for their results.
9.We asked about the breast screening programme, where in 2017–18, 8% of women were not being invited for a repeat screening within the required 36 months window. NHS England told us that problems, such as a lack of staff in hospitals in the Portsmouth and Brighton areas, had hindered performance across screening programmes. But, it was unable to tell us how it is tackling this poor performance beyond theoretically needing to balance local problems with being “quite hard-nosed” about provider performance. Whilst NHS England’s local teams can apply financial penalties for poor performance, and as a last resort, terminate a contract, NHS England admitted it is difficult to enforce this because of market conditions.
10.We were concerned that the oversight arrangements in place for the breast and cervical screening programmes had failed to identify major issues in the programmes over a number of years. In May 2018, the then Secretary of State for Health and Social Care announced that there was a failure in the system that selects women for breast screening, affecting some 450,000 women. This figure was later revised down to 122,000 when a full analysis was completed but nonetheless raised concerns about the programme. This confusion began when a change was made to the programme’s national specification in 2013 to try to remove ambiguity around the definition of age for breast screening. The national specifications set out who to invite for screening; how often to invite them; and how the screening is to be conducted. The Independent Review of Breast Screening subsequently found that the change was too late and, although not put into practice, was incorrect. The change to the national specification went unnoticed for more than half a decade. It only came to light through a data analysis exercise conducted for another purpose. The independent review also concluded that once the issue was identified, Public Health England was slow to develop a clear understanding of the incident and its causes. A similar incident on the cervical programme in October 2018 was identified by a hospital manager who was concerned that women were not being invited for screening when they should have been. The subsequent review found 43,220 women did not receive invitation or reminder letters for a cervical cancer screening and a further 4,508 were not sent letters containing their results.
11.In light of these incidents, the national health bodies accepted that the division of roles and responsibilities was not working as it should be. The Department accepted that the governance of the screening programmes “looked quite good on paper but did not work as they should do in practice”. NHS England similarly told us that the governance arrangements were overly complex, describing the situation as a “triple fragmentation” between: the national health bodies; the individual screening programmes; and, within the delivery chain. We were concerned that Public Health England is responsible for conducting quality assurance checks on local screening providers, yet it has no power to enforce the changes it deems necessary. Public Health England must rely on local screening providers themselves and NHS England to address its recommendations and take appropriate action. Aside from suggesting that simplification is required, none of the national health bodies were able to tell us what specific actions should be taken to improve the governance arrangements, choosing to rely on Professor Sir Mike Richard’s review to furnish them with answers.
12.Professor Sir Mike Richard’s was commissioned by NHS England to undertake a review of all national cancer screening programmes in November 2018, following the incident in the cervical screening programme. NHS England told us that it expects the review to be completed by Summer 2019. However, we were concerned about the review’s ability to cover the length and breadth of screening, including encouraging people to attend, reducing health inequalities, performance targets, governance arrangements and technology, in such a short timeframe. All of the health bodies deferred to Professor Sir Mike Richard’s review during our questioning. While witnesses recognised a wide range of issues that needed to be addressed, they told us that their response would be dependent on the results of the review. NHS England told us that it expected Professor Sir Mike Richard’s review to result in a “huge shift” in how it worked, which the review would provide a route map for. It told us that this relied on the review providing recommendations that had “built-in proposed phasing and timescales for pragmatically and practically what could get done, so that we could then work off that”. NHS England similarly told us that while it would make a range of changes to health screening programmes over the next 12–24 months, it relied on the review to “practically sequence that for us and to set us a road map that can be delivered, taking account of the staffing constraints and all the rest of it”. Professor Sir Mike Richard’s told us that he had been talking to local authorities, through the Directors of Public Health as part of his review. He committed to speaking to more of this cohort to help inform his review.
1 C&AG’s Report, Investigation into the management of health screening, Session 2018–19, HC 1871, 1 February 2019
2 C&AG’s Report, paras 1, 1.1, 1.3 to 1.6
3 Q 2, C&AG’s Report, para 2.3 and Figure 5
4 Qq 4, 52, C&AG’s Report, para 2.10–2.11
5 Qq 4, 7, 14
6 Qq 6–8
7 Qq 25–27, C&AG’s Report para 1.2, Figure 1
8 Qq 16, 24, 31–34
9 Qq 6–8, 19–22, 32
10 Q 17, C&AG’s Report paras 7, 2.14–2.16
12 Qq 19–22
13 C&AG Report, para 2.12
14 Qq 4–5, 174
15 C&AG’s Report, para 3.4
16 C&AG’s Report, paras 1.9, 3.9–3.10
17 Qq 102–103
18 C&AG’s Report, para 3.9
19 Q 150
20 Qq 150, 156–157
21 Q 173 and C&AG’s Report, para 8
22 Qq 150, 166–167
23 Q 153
24 Qq 2, 14, 65, 157–159, 166–167, 170
25 Qq 167, 191–192
26 Q 161
Published: 10 May 2019