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Cervical Screening Incident

On 17 October 2018, Primary Care Support England (PCSE), delivered by Capita, informed NHS England and Public Health England that between January and October this year a significant number of cervical screening letters were not issued to women when they were due.



The failure was down to human error within Primary Care Services England, which led to letter files not being sent to be printed and posted on a number of occasions over this period.

Capita has issued a full apology in acknowledgement of these unacceptable failures and have implemented changes to their process to ensure this does not happen again. 

A ministerial statement has also been made

The investigation into these incidents has shown that reminder letters were not sent to 43,220 women.

Capita has also identified that 4,508 results letters were not printed and dispatched to patients between January and October. Eight out of ten of these women had normal results.

However, 182 women had a result that required a follow-up test (colposcopy) and 252 women needed an early repeat screening test.

All of these women have now been contacted by Capita with information about the next steps for their care.

Advice for women who have not received a letter

The public health advice from Public Health England is that the risk posed by the delay in sending these letters remains low in the context of the development of cervical cancer, which takes place over many years.

Every woman’s case will be reviewed, but there is no current evidence that this incident has led to harm to the women involved and our priority now is to ensure that anyone affected is contacted and knows how to get checked if they are due a cervical screen or follow up treatment.

Affected women are now being written to unless we know that they have taken action to have a screen or follow up treatment, and the advice to contact their GP if they have any queries or concerns. This letter includes an apology from Capita for the delay.

The investigation so far shows that the vast majority of women who did not receive an invitation have had one of two invitations to attend screening - and a quarter of women have already gone on to have their test.

Action taken

  • An incident panel – including Public Health England screening experts - has been established to complete a thorough investigation into this issue to establish how many women have been affected, in what way and what remedial action is required
  • Contact is being made with women who missed out on correspondence relating to the screening programme where this is appropriate
  • NHS England will also undertake a full audit of screening outcomes for the women affected in nine months
  • Capita has now implemented a series of checks to ensure this does not happen again
  • Since notifying NHS England, PCSE have begun a review of all invitation, reminder and result files to provide NHS England with confirmation as to whether this incident just impacts invites and reminders, or whether results letters have also been affected. This review goes back to June 2016 when the current system was adopted. This review is still ongoing but to date has identified the result letters outlined above that were not sent

The national screening programme:

Cervical screening is a free NHS health test that checks for abnormal cell changes on a women’s cervix caused by high-risk human papillomavirus (HPV). Abnormal cells in the cervix could, if undetected and untreated, develop into cervical cancer.

Cervical screening isn't a test for cancer, it's a test to check the health of the cells of the cervix. Most women's test results show that everything is normal, but for around 1 in 20 women the test shows some abnormal changes in the cells of the cervix.

Most of these changes won't lead to cervical cancer and the cells may go back to normal on their own, but in some cases, the abnormal cells need to be removed before they become cancerous. If screening finds abnormal cells, women are referred for either for further testing or treatment.

In England, a total of 4.45 million women aged 25 to 64 were invited for screening in 2016-1 and 3.18 million women aged 25 to 64 years were tested. It is estimated that the screening programme saves 5,000 lives a year across the UK. A total of 220,000 British women are diagnosed with cervical abnormalities each year and 3,000 cases of cervical cancer are diagnosed annually. Mortality rates have fallen by up to 70% since the introduction of the NHS Cervical Screening Programme in 1988.

The Cervical Cancer Screening call and recall programme is run by Primary Care Services England (PCSE), delivered by Capita. All women between the ages of 24.5 and 64 are regularly invited, by letter, to attend for cervical screening. These letters are issued at different routine intervals depending on a woman’s age:

  • aged 24.5 to 49 – every 3 years
  • aged 50 to 64 – every 5 years
  • over 65 – only women who have recently had abnormal tests

If after 18 weeks a test result is not recorded, a reminder letter is generated. If, after 32 weeks from the first invitation a test result has still not been received, Primary Care Services England (PCSE) notifies the woman’s GP practice and it becomes the responsibility of the GP practice to follow up with the woman concerned.

NHS Digital Cervical Screening Programme, England 2016-17, National Statistics

https://files.digital.nhs.uk/pdf/t/b/cervical_bulletin_report_2016-17_-_final.pdf

Advice for the Public

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