1QA Director’s Update & NHS reforms Dr Linda GarvicanQA Director, Cancer Screening Programmes,NHS South East CoastNHSCancer Screening Programmes
2Screening and NHS reforms National Screening Programme Teams Public Health EnglandJulietta Patnick, Director of Cancer ScreeningAnne Mackie, Director of UK National Screening Committee [all non-cancer screening programmes, and screening policy]Roles and responsibilitiesQuality assurance and standardsNew programme implementationService specificationsCommissioning Screening ProgrammesEstablished programmes: National Commissioning BoardNew programmes: Public Health EnglandNHSCancer Screening Programmes
3Local Public Health involvement in screening No Regional Director of Public HealthDirector of Public Health in local authority/PHENo longer in NHSHealth and Wellbeing BoardsNeed for some local public health leadershipPractical local implementation issuesSerious incidentsCancer screening QARCFunded by PHE or fully integrated?
4Cervical screening 1 14 day turnaround Sample taking in primary care to result letter posted first class on day 1398% target set out in Improving Outcomes – a Strategy for CancerSustainability in smaller labs…Sussex Pathology Network: centralised hub in Haywards Heath?West Surrey Pathology Network: Merger of ASPH pathology service and Partnership Pathology?Even more laboratory consolidation in Kent and Medway?
7Cervical screening 2 Introduction of HPV Testing Triage of low grade abnormalities, from 2011/12‘Test of cure’ for treated women from 2012/13Several automated technologies, using the LBC sampleSentinel sites used Hybrid Capture 2High volume throughput required for cost effective use of controls
8Implications Triage All borderline or mild Result within 14-day turnaroundHPV +veStraight to colposcopyHPV –veRoutine recall in 3/5 yearsTest of cureCytology 6/12 post treatmentHPV +veStraight back to colposcopyHPV –veRoutine recall in 3 yearsNo annual follow- up for 10 years
10Commissioning HPV testing Announced 15 December 2010 in NHS Operating Framework 2011/12, and in Improving Outcomes: a Strategy for Cancer in January 2011No details on costs or rules of engagement availableStill PCT responsibility to commission screening for 2011/12No new money…Deadline for PCT’s operating plans for 2011/12 in early January Missed the boat for new financial year…ButThere is national funding for 2 years from April 2011:Year 1 - £2 per sample screenedYear 2 - £1 per sample screenedAll within programme samples: GP & community, clinic, hospital, GUM – not just HPV tested ones, not under 25s and not non NHSPro-rata from start dateIncludes costs of testing and additional colposcopy
11NAT COLP QA Workload changes in Colposcopy After HPV Units seeing pts – 2 mild / 3 borderline= 120 extra colp / screenedUnits seeing – 1 mild / 3 borderline= 64 extra colp / screenedTest of cure – expect % HPV +ve at 6/12Extra 12% workload due to cyto –ve/HPV +ve
12Criteria to bid for national funding Laboratory must have a minimum workload of 35000The programme must continue to comply with 14 day turnaroundColposcopy capacity must be sufficient and sustainableHPV testing must be subject to QA and EQAThere must be a Pathway Manager – one lead person for each programme with whom National Office and other parties will liaiseSign off will be by QA and the PCT(s) (not SHA)National Office will contract with each laboratory for HPV testing through an SLA. Labs will be expected to sub- contract for additional services such as colposcopy and virology and pass on the appropriate portion of funding to those services
13National ‘to do’ listEvaluation Report, & Advice to the NHS – from DH in May 2011Implementation GuidePrimary Care PackPatient materials – letters & leafletsRevised NHSCSP guidelines – ABC, Colposcopy & HistopathologyEvaluation of different technologiesNHS Supply Chain Framework Agreement (Procurement must be subject to the European Procurement Tendering Process)
14What we need to do in next few months Formally merge laboratories to reach >35,000…Develop bidsConsider technology platforms (but prices won’t be available until September)Address colposcopy capacity issuesRe-write local protocolsAdopt national template leafletsEducate primary care/sample takersIdentify a Pathway Manager in each laboratoryAmend laboratory systems to cater for new result & action codes
15New DH standard Acute Contract from April 2011- implications for cancer screening Cancer waiting times62 day target for screen detected cancers must be met in 90% of cases, cf 85% for symptomatic 2WW31 day targets forFirst definitive treatment (96%)Second and subsequent treatmentsSurgery (94%) and drugs (98%)Radiotherapy live from 1 January 2011 (94%)Breaches of all cancer waits will incur below target levels will incur fine to Trust of 2% of ‘Actual Outturn Value of service line revenue’Staging data:Mandatory inclusion in dataset sent to Cancer RegistryNeed to ensure recorded at gynae MDM
16Training sample takers New training scheme organised by SECQARCQuality-accredited by Universities of Brighton & SurreyMore course planned for 2011On-line update schemeTakes about 1 hourUpdates on changes to programme and what to tell womenUptake of e-learning high in Kent & Medway but more work needed to raise awareness in Surrey & SussexContent reviewed annually - will now need to include HPV testingBMJ Learning: 6 free CPD modules on cancer screening
17No news on… Revised protocol for invasive cancer audit Audit of experiences of young women (<30) with cervical cancerNext QADs meeting 5 May
18NHSCSP Audit of Invasive Cervical Cancer, National Report, 2007-2010 DRAFT 6,173 cases of cervical cancer and 21,481 controls,90% overlap with cancer registry dataApproximately 80% of all cases within screening age-range (25-64). Peak number in women aged 35-3923% of cases had no stage recorded in audit45% of cases in women aged are diagnosed with FIGO Stage 1A and 73% of these are treated by cone biopsy.60% of women > 65 with cervical cancer are FIGO Stage 2 or worse.About three quarters of cervical cancers are of squamous histology.
19Attempt to classify women’s screening histories 28% of cases with invasive cervical cancer stage 1A and 28% of those with stage 1B or worse occurred despite apparent adherence to screening guidelines (i.e. their screening history is up to date).Much higher proportion of population controls complied with the screening guidelines (60%) than cases (28%). They were also more likely to have been screened (13% of controls had no screening history compared to 17% of cancers stage 1A and 23% of those stage 1B+).
20Colposcopy in ICAColposcopy data ‘particularly challenging to collect and the variability in the quality of the data included in this Audit has made its interpretation challenging’Colposcopy data is of particular interest in women who had a cytology test indicating referral to colposcopy more than 4 months before diagnosis, because it suggests a recurrence of a previously treated cervical abnormality or delay in the diagnostic procedure.While 69% of all cervical cancers in the Audit had cytology with an action code of suspend, only in 21% (1290 cases) of them was the cytology taken more than 4 months before diagnosis. Complete colposcopy data on this subset of cases is essential to evaluate colposcopy management as part of the Audit.
21Trent Cancer Registry / NCIN / NHSCSP publication Incidence has halved and mortality decreased by 2/3 in 20 yearsIncidence reduction has levelled off in recent yearsNorth/south divide in both incidence and mortality by SHA and cancer networkPoorer incidence and mortality associated with deprivation in PCT of residenceSome improvement in survival from mid 1980s82% 86% at 1 yr62-68% at 5 yrs
25Young women 1 year: 96% at 15-39 cf 52% aged >80 Incidence in women aged increased by 77% between and 2008Incidence in women aged increased by 29%...Mortality in these age groups stabilised…Relative survival much worse in older women:1 year: 96% at cf 52% aged >805 year: 86% at cf 27% aged >80