National Cervical Screening Programme Incident

Steve Brine Excerpts

Thursday 15th November 2018 Written Statements

[The Parliamentary Under-Secretary of State for Health and Social Care (Steve Brine)]

I am today informing the House of a serious incident relating to the ‘call and recall’ process administered by Primary Care Support England (PCSE), a service provided by Capita on behalf of NHS England as part of the national cervical cancer screening programme.

The NHS cervical cancer screening programme saves an estimated 5,000 lives a year by detecting abnormalities of the cervix early and referring women for effective treatment. It is offered to women aged 25 to 49 every three years and those aged 50 to 64 every five years.

On 17 October, NHS England and Public Health England were informed by Capita that a number of cervical screening invitation and reminder letters had not been sent to women inviting them to make a routine cervical screening appointment. Following further urgent investigation of this incident since then, I can now confirm that between January and June 2018, 43,220 women did not receive one or other of these letters and, in a very small minority of cases, neither the invitation nor reminder. In addition, Capita has also informed us that, between January and October 2018, a further 4,508 women were not sent letters informing them of the result of their cervical screening.

In light of this, NHS England declared this as a serious incident and set up a clinically-led multiagency incident panel including PCSE, Public Health England and NHS Digital on 23 October 2018 to assess any risk or harm to the women affected. The panel has put in place actions to assess and mitigate any risk as well as care and support where needed. Daily audits are now in place to ensure all women’s files are accounted for, and the panel is looking closely with Capita at how parts of the process could be automated to reduce errors.

Capita has confirmed that this incident was caused by files from their call and recall operations team not being correctly sent and uploaded to Capita’s print and despatch service between January and October 2018. Capita has accepted full responsibility for this incident and has apologised for it.

For the majority of the 4,508 women who did not receive their result letter, their result was normal. However, 182 women had a result that required a follow-up test (colposcopy) and 252 women needed an early repeat screening test. In most instances, where the screening result requires further tests or treatments, the laboratory will usually refer the woman directly to a colposcopy clinic independently of the woman receiving her result letter from Capita. For women needing early repeat testing, their GP routinely follows up these tests. However, to make sure all women needing a colposcopy or an early repeat test are being managed correctly, every woman’s screening record is being checked to ensure they have been referred appropriately. No harm has been identified to date.

Capita has made a public apology and has written to all the women who did not receive invitation or reminder letters and to those who did not get their normal result letter. Letters and apologies are being sent to all women who have not been referred for colposcopy or who have not had the required follow up screening test. In addition, the GPs of women affected have been informed so they can offer support to their patients.

The results of the screening and further tests on all women affected by this incident will be monitored over time to ensure any impact is followed up.

In addition to reviewing the checks in place around file transfer and checking the number of files processed, sent, printed and dispatched, Capita has produced a briefing for staff and proposed additional automation to the process to remove manual steps that may have contributed to this incident.

Our priority is patient safety and we will be assembling a clinical board that will provide oversight for the cervical screening call and recall service. This will ensure that every part of the process has an in-depth review.

NHS England is also undertaking an independent expert review of its screening programmes.

The Government continue to closely monitor the performance of all our suppliers and to implement improvement plans where necessary. Officials are working with Capita to ensure that the process recommendations and lessons learned from this issue are applied to similar services across Capita's public sector contracts.

Incidents of this type not only are unacceptable in terms of the impact they have on the women affected, but undermine public confidence in our screening programmes as a whole.

[HCWS1086]