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Investigation into the management of health screening

The National Audit Office (NAO) has found that the proportion of eligible adults receiving health screening is inconsistent across different areas in England and that services are not operating to the ‘agreed standards’.

All the screening programmes investigated1 failed to meet the ’standard’ target for the percentage of eligible people attending screening appointments in 2017-18.  However, the bowel screening programme nearly achieved the target with coverage2 of 59.6% against a standard target of 60%.  For the first time in 2017-18, the Department also set a ‘lower threshold’ target3, which all, except for the cervical programme, met.  The cervical programme achieved coverage of 72% against a standard target of 80% and a lower threshold of 75%.

There is considerable variation in the percentage of people screened between different local areas. For example, in 2017-18, of those eligible for bowel screening, 60% were screened nationally, but in eight Clinical Commissioning Groups4 screening providers screened 30%-44% of eligible people. The NAO’s analysis shows that levels of coverage across the four screening programmes are inconsistent, with much of the lowest performance in London.

Two recent incidents with breast5 and cervical screening6 have raised concerns about oversight of screening programmes7.  The Department of Health & Social Care’s governance arrangements assume that all those eligible have been invited for screening. However, NHS England admits that omissions on the scale of the breast screening and cervical screening events are unlikely to be identified through the national level performance data that is used to monitor the programmes.

NHS England has concluded that the cervical screening incident has raised questions about the effectiveness of governance arrangements in place to prevent such issues. NHS England has delegated responsibility for managing the performance of screening providers to its regional and local teams, and where providers fail to perform they can, as a last resort, terminate a contract.

All of the screening programmes the NAO looked at rely on a national database of GP registrations to identify those who are eligible for screening, which the Department considers is not fit for that purpose and increases the risk that some people may not receive invitations for screening. The Department intended to replace the old system, known as National Health Application and Infrastructure Services (NHAIS), in 2017 but this has been delayed. It is estimated it will cost £13.9 million to maintain NHAIS until 2020-21.

Once individuals are identified as eligible for screening, each screening programme relies on its own IT systems to send invites, process tests and send results, with the number and age of the systems varying by programme. For example, the cervical screening programme relies on a large number of different IT systems, with some bodies estimating there are some 350 different systems supporting the various stages of the screening process. Breast screening operates with 78 versions of the same system in place across England and the Independent Breast Screening Review concluded that this IT is ‘dated and unwieldy’. Around 5,000 women were not invited for their breast screening because of errors in using “two separate and complicated systems, despite the best efforts of staff”.

Many patients are also experiencing delays in getting their results after screening. With cervical screening, the Department expects 98% of women to receive test results within 14 days.  This target has not been achieved at a national level since November 2015. In March 2018 a third of women (33%) received their results on time. Performance improved in December 2018 to just over half (55%) of women getting their test results within 14 days.  In October last year, the number of samples waiting to be tested stood at 97,628. A change in the way tests are carried out, which was announced in 2016 and is not expected to be completed until December 2019, is partly responsible.

NHS England and Public Health England has succeeded in implementing a new bowel scope screening, with 64 out of 65 screening centres operational at the end of 2016-17.  However, fewer people than expected were receiving this screening because only 3,162 out of 7,649 GP practices8 were linked to a screening centre that was delivering this service.  By September 2018, only 33% of those entitled to bowel scope screening were invited to an appointment.

Notes for Editors

  1. There are currently 11 national screening programmes in operation in England. The NAO investigated the four health screening programmes that offer screening based on a person’s age rather than because they have a particular condition or are pregnant: abdominal aortic aneurysm screening (AAA screening), bowel cancer screening, breast cancer screening, and cervical screening. In 2017-18 NHS England spent £423 million on these health screening programmes and over 7.9 million people were screened by the programme covered in this investigation.
  2. Coverage is defined as the percentage of people in the total eligible population who have received an adequate screening.
  3. The Department for Health & Social Care has set two performance levels for each screening programme: a ‘lower threshold’ which is the lowest level of performance that programmes are expected to attain, and an ‘agreed standard’ which is the level at which the programme is likely to be running optimally.
  4. Clinical commissioning groups are clinically-led statutory NHS bodies responsible for the planning and commissioning of health care services for their local area. There are now 195 CCGs in England.
  5. In May 2018, the Secretary of State for Health and Social Care informed members of Parliament of a "serious failure" in the breast screening programme. He explained there had been a failure in a computer algorithm that selects women to be invited for breast screening and that, between 2009 and early 2018, an estimated 450,000 women aged between 68 and 71 had not been invited for their final breast screening. In June 2018, the estimated number of women affected was revised to 174,000, which was later revised to 122,000. In December 2018, the Independent Breast Screening Review, concluded there was ambiguity about the age women should stop being invited for screening and noted that it was unacceptable for there to be confusion about what women should expect from the breast screening programme.
  6. In November 2018, the Parliamentary-Under-Secretary of State for Public Health and Primary Care, revealed that between January and June 2018, some 43,220 women had not been invited for a cervical screening; and a further 4,508 women were not sent their results letters. Of these women, 182 needed some form of follow up treatment. Further investigatory work by NHS England and Public Health England has concluded that a serious incident has occurred.
  7. The Department of Health & Social Care is responsible for health screening in England but has delegated statutory responsibility to NHS England. NHS England is responsible for commissioning screening services and managing the contracts of local providers. Public Health England provides expert advice and information at a national and local level to the Department and NHS England, in addition to managing the IT for screening programmes, except for cervical which is the responsibility of NHS England.
  8. There were 7,649 GP practices in July 2017 (the time of the performance). The current number of GP practices is 7,007.
  9. Press notices and reports are available from the date of publication on the NAO website. Hard copies can be obtained by using the relevant links on our website.
  10. The National Audit Office scrutinises public spending for Parliament and is independent of government. The Comptroller and Auditor General (C&AG), Sir Amyas Morse KCB, is an Officer of the House of Commons and leads the NAO, which employs some 785 people. The C&AG certifies the accounts of all government departments and many other public sector bodies. He has statutory authority to examine and report to Parliament on whether departments and the bodies they fund have used their resources efficiently, effectively, and with economy. Our studies evaluate the value for money of public spending, nationally and locally. Our recommendations and reports on good practice help government improve public services. Our work led to audited savings of £741 million in 2017.

Contact

NAO Press Office
+44 (0)20 7798 7400 or email pressoffice@nao.org.uk

PN: 09/19