Scottish Screening Committee minutes: March 2024

Attendees and apologies

• Jann Gardner, Chief Executive, NHS Lanarkshire (Chair)
• Gareth Brown, Scottish Director of Screening, NHS National Services Scotland
• Fraser Tweedie, Public Partner
• Susan Siegel, Public Partner
• Scott Urquhart, Director Of Finance, NHS Forth Valley
• Emilia Crighton, Director of Public Health, NHS Greater Glasgow and Clyde
• Janette Fraser, Head of Planning, NHS Forth Valley
• Fiona McQuiston, Cancer Research UK
• Tasmin Sommerfield, National Clinical Advisor for Screening, NHS NSO
• Fiona Wardell, Healthcare Improvement Scotland    
• Esther Aspinall, Director of Public Health, NHS Ayrshire and Arran
• Simon Cuthbert-Kerr, Deputy Director, Public Health Capabilities Division, Scottish Government
• Laura McGlynn, Committee Secretariat, Public Health Capabilities Division, Scottish Government
• Alexander Cruickshank, Committee Secretariat, Public Health Capabilities Division, Scottish Government
• Chloe Kelly, Committee Secretariat, Public Health Capabilities Division, Scottish Government

Apologies

• Safia Qureshi, Director of Evidence, Healthcare Improvement Scotland
• Christine McLaughlin, Director of Population Health, Scottish Government   
• Lynne McNiven, Director of Public Health, NHS Ayrshire and Arran
• Nick Phin, Clinical Director and Director of Health Protection, PHS

Items and actions

Welcome and apologies

Jann Gardner (JG) welcomed the committee and noted apologies from Safia Qureshi, Christine McLaughlin, Nick Phin and Lynne McNiven.

Simon Cuthbert-Kerr (SC) introduced himself as Liz Sadler’s replacement as Deputy Director of Public Health Capabilities within Scottish Government.

National Screening Programmes overview

Gareth Brown (GB) provided an update on each of the screening programmes.

Bowel Screening

Continues to operate in line with pre-COVID performance. Uptake is slightly higher than reported at previous meetings; however, there continue to be challenges with colonoscopy capacity. A new national clinical lead has been appointed, replacing Prof. Bob Steele who has retired. Healthcare Improvement Scotland (HIS) published updated national standards for bowel screening late last year, with updated standards for the other screening programmes to come over the next few years. There has been a significant rise in postage costs for the programme, Scottish Government and NSD colleagues are in discussion over how to address the financial pressure going forward.

Breast screening

Overall performance of the programme is good; attendance is high and the average screening interval is now moving closer to the target of 36 months however there is variation between centres for appointment waiting times. Replacement mobile units are being commissioned for implementation into the current fleet. Self-referral appointments were extended to include all those over the age of 71 from 1st December 2023, this is going well with no real impact on service. Modernisation board continues to operate looking at workforce, data, call/recall and future sustainability of models of delivery.

Cervical screening

Both laboratories that process samples are currently operating at higher than expected levels. Turnaround times for cytology (following a HPV positive result) are currently around 11 weeks – work is ongoing to reduce this to the 14 day standard. There are also increasing numbers of colposcopy referrals and turnaround times for results are increased as a result. Five health boards currently have a waiting time higher than the national key performance indicator (KPI) of eight weeks for a routine referral for colposcopy. NSO continue to engage with health boards to reduce these waiting times and chief executives are also aware.

HIS published a report in August 2023 reviewing historical exclusions within cervical screening with a number of recommendations that NSO and Scottish Government are carrying forward.

Diabetic Eye Screening (DES) 

Capacity across the programme is improving since COVID. Challenges remain in terms of clinical space and staff capacity. Monthly appointment numbers have reduced compared with pre-COVID following the introduction of the lower-risk pathway. There are still challenges around waiting times for referrals for treatment to ophthalmology services across the country. NSD have commenced a review of the DES collaborative and any recommendations will be implemented later this year. This will be brought to the SSC for discussion.

Abdominal Aortic Aneurysm (AAA) Screening 

The programme is operating as normal in all Boards but there are still challenges downstream with vascular services as reported at previous SSC meetings. NSO wrote to chief executives about this in 2023, anecdotally performance seems to be improving but there is a lag time between the official data and updates from clinical leads. This continues to be monitored.

Pregnancy and newborn screening 

Operating as normal in all boards, largely in line with pre-COVID. Some boards are not meeting target timelines for newborn hearing screening referrals to be seen for diagnostic assessment, and there is work to be taken forward as part of the national audiology review that will address this to some extent. NSO established a short life working group to take forward work on a single national IT system for newborn hearing screening, NSO is investigating the procurement approach and potential costs for doing so which will be sent to board chief executives and directors of finance for approval. There was a recommendation from the national audiology review to evaluate the two screening models used in Scotland for newborn hearing screening; if funding comes from the audiology review then this work will progress. Scotland continues to participate in the UK work looking at the requirements to implement the UK National Screening Committee (UK NSC) recommendation to expand the newborn bloodspot programme to include screening for Tyrosinemia. In April this year, the first publication of antenatal trisomy screening statistics will be published by Public Health Scotland (PHS).

In summary, all programmes are continuing to operate and performance within screening is largely in line with that pre-COVID. Downstream capacity with colonoscopy, vascular services and colposcopy have a knock-on effect on performance of the screening programme in general.

GB welcomed discussion and questions from the Committee.

JG asked if there have been any specific requests for feedback on how the screening programmes will be sustained within the financial plan of 2024/25 so that NSO have oversight. TS added that NSO had not been made aware that screening was included in Health Boards annual delivery plans (ADPs).

Scott Urquhart (SU) noted that it would be helpful to conduct a risk assessment exercise surrounding screening as Boards are looking at their finances with a lot more scrutiny. There could be a risk to screening as boards look to make savings and also deliver on their ADPs.

JG agreed that this would be helpful and asked if this could be flagged to Directors of Finance and/or chief executives as the financial plans are being laid out, and shared with SSC in terms of potential impact to boards.

JG closed the section as no further questions.

Update of NSO/NSD restructuring

A paper was circulated to SSC earlier this year outlining that the NSO and NSD will be merging into a single screening team within NSS in 2024/25. Commissioning of certain elements of screening will remain with NSD. The restructuring will create a single team at the national level dedicated to oversight and assurance of screening. This will reduce duplication and create capacity.

GB advised that as part of this work, other governance improvements had been delivered including, new methodology for screening standards by HIS and new Terms of Reference (ToRs) for Programme Boards. All NHS Board consultant in public health leads will now attend programme boards to provide assurance on local activity and strengthen internal Quality Assurance (IQA) and audit trails. Programme board chair roles will now be funded, new chairs have been recruited for four of the programmes and will start from 1st April. NSO has also developed a new approach to Monitoring and Evaluation Groups (MEG) – subgroups of Programme Boards that look at data, identify outliers and escalate issues – to improve efficiency, effectiveness of scrutiny of performance and quality at a national level.

Many of these changes will come into effect at the beginning of the new financial year so there will be a period of transition. But it is hoped that the new arrangements  bring about greater capacity, a better focus on quality and greater support to boards.

JG welcomed comments from Committee members.

Emilia Crighton (EC) noted that while it is expected that board coordinators attend the programme boards, it should be ensured that there is not duplication of previous meetings.

GB advised that meetings have been changed so that there are not as many and that they are less frequent to free up time. He also noted that this is very much a transition period and NSO is keen to obtain feedback.

Tasmin Sommerfield (TS) advised that Programme Board meetings will be very strategic in nature and different to the board coordinator meetings, but it is still important that each board has their consultant in public health present for the strategic discussions.

SSC members noted their agreement to this approach.

Lung cancer screening

The UK NSC recommended the implementation of a targeted lung cancer screening programme in 2022 and GB provided an update on Scotland’s work towards this.

A Scottish Expert Advisory Group was established and met for the first time last Autumn, focusing on the range of questions and issues that need to be considered in order to move towards the development of a business case that would go to Scottish Government and Ministers for approval.

A further three meetings have been scheduled around some of the key workstreams such as modelling, identification of the eligible cohort and commissioning models.

This work has been absorbed by existing resource within NSO thus far. It will take at least 12 months to develop an outline business case due to the complexity around implementing a new screening programme. GB highlighted that for AAA, the most recently introduced screening programme, it took around six years from the recommendation to full implementation and so expectations continue to be managed around how quickly this will be done.

Screening prioritisation update

GB gave an update on the exercise undertaken by the NSO Board (NSOB) to prioritise identified pressures within the screening system over the next three to five years. A detailed workshop of the NSOB was held in November 2023, which sought to prioritise three different types of pressures:

• pressures related to ensuring sustainable and safe delivery of existing programmes
• pressures related to major changes to existing programmes
• pressures related to new programmes/new activity

The NSOB agreed on some guiding principles namely funding to support delivery of existing programmes should be prioritised over new programmes, and activities which bring benefit to two or more screening programmes should be prioritised. The NSO were also to review the outputs against costs, affordability and benefit, and recognised that it may not be possible to deliver activities strictly sequentially in the order they are listed in the prioritisation output.

This was the first time that prioritisation was carried out and GB noted that going forward, this will be reviewed annually as part of the NSOB.

GB presented outputs, there are around 10 recognised pressures within the existing screening programmes including that breast and bowel screening as commissioned services require re-baselining. Improvements are needed to the cervical screening programme IT system, and there is a real need to improve quality assurance across all the screening programmes.

NSO drew conclusions which were presented to Scottish Government being that over the next 1-3 years, the priority should be ensuring the sustainability of the existing screening programmes, including re-baselining the commissioned activity, cervical screening modernisation activity, and work to improve quality assurance across the programmes. There was a view that the breast modernisation programme work should continue and that the Screening Intelligence Platform should continue to be developed given its potential to bring benefits across the programmes. Likewise the Equity Strategy was recognised as an important cross-cutting piece of work that should continue to be prioritised.

SU asked if there is a clear understanding of capital requirements going forward, i.e. the lifecycle and replacement of medical equipment. GB advised that breast screening has a range of capital requirements which is currently funded mostly by local boards.

Laura McGlynn (LM) added a thanks from Scottish Government to both NSO and GB. Scottish Government is considering the outputs from the exercise, with bowel screening costs being prioritised. Within the coming months, they will be looking at what can be done with the available budget.

UK NSC update

TS provided a verbal update on the UK NSC. Tyrosinemia was recommended last year, this is a new programme but the costs are relatively small compared to other items discussed as part of the prioritisation exercise; the equipment required is already in place and so any costs are associated with reagents and training for midwives. Scoping work has commenced in Scotland with the hope that it is implemented by the beginning of 2025 at the latest.

A recommendation is expected to come later this year that HPV self-sampling can be used within the cervical screening programme but only in non-responders (individuals who have not attended for their last two tests). There is not enough evidence to show that using self-sampling as a primary test is as good as a clinician-taken sample. The UK NSC is conducting a large scale in-service evaluation (ISE) to examine if the benefits of increasing uptake from self-sampling cancel out the reduction in sensitivity. Implementing self-sampling has significant costs due to the changes that will be necessary to the IT system and the expense of kits but there is a large political appetite for this development.

Another large scale ISE taking place is screening for spinal muscular atrophy (SMA) in newborns as the UK NSC feels there is currently insufficient evidence to be able to recommend screening given the rare nature of the disease, however there are new treatments that can be given if the condition is detected early enough.

Other notable up and coming pieces of work are cervical screening intervals in the vaccinated population, an evidence review on risk stratification in breast cancer screening, and an ongoing study on the use of artificial intelligence (AI) in breast screening which Scotland is participating in.

Cervical Exclusion Audit update

TS provided an update on the National Cervical Exclusion Audit. The audit is progressing and should be complete within the next 12 months.

There has been significant media reporting recently, much of which has struggled to grasp the complexities of the situation. 59% of records have been reviewed so far and of these, 89% were found to be appropriately excluded.

Governance evolution

LM sought committee members thoughts on the current arrangements of the SSC, if members feel that they are shaping the screening strategy and getting the opportunity to share their expertise. She asked if there could be a different model that would be more effective, for example, the NSOB also meets quarterly and perhaps there was some overlap to streamline governance further. LM invited discussion from members.

TS stated that when the SSC was initially formed, its original purpose was for representatives of directors of finance, board chief executives and directors of planning to be involved in discussions around the recommendations from the UK NSC. As there was no central point of oversight before the creation of the NSO, the SSC also picked up a lot of performance activity. This is now managed through NSOB.

JG noted that there is a new national planning and delivery board where key elements and decisions are being made around prioritisation from a new prioritisation framework. JG advised that she will raise with the chair of that group, and confirm how prioritisation will be given to screening work within boards.

SU added that the focus of the SSC is primarily around screening uptake and delivery of the programmes, and there is a good mechanism for that in place. A different focus on outcomes to understand the relative patient value of each of the screening programmes could be of benefit.

EC added that those elements are also considered further down at the Programme Boards and NSOB. The SSC is more for looking at high cost initiatives. There is the option of looking at the NSOB as the core governance committee.

LM summarised that Scottish Government will consider some of the issues discussed and provide options in the context of  the wider landscape that Scottish Government thinks the NSOB can fit into. This can be circulated to members for comment.

TS advised that, ultimately, for the majority of screening activity in Scotland, it is the board chief executives who are accountable for delivery, so it must be ensured that they are kept abreast of developments. There needs to be a mechanism of direct contact to escalate concerns.

GB noted that it would be helpful if any consideration of options reflects on the functions that are not being delivered in other ways. The NSOB will be meeting quarterly and so NSO can be responsible for the majority of operational performance management and can communicate directly with chief executives. The SSC in its current format is arguably not adding considerable value, but the one thing it does do well is including patient representation - this should be maintained going forward.

LM added that the profile of screening needs to be raised, not just within quarterly meetings but in a sustained and focused way. Also, moving forward, screening prioritisation should be a main focus, at least annually.

JG closed the discussion and noted that a paper will be circulated to SSC members for consideration

Any other business

There was no other business raised.