Subject: Cervical and Breast screening and human papillomavirus (HPV) vaccination
Date of meeting: 23rd November 2022
Report of: NHS England, NHS Sussex and Director of Public Health
Contact Officer: Name: Sarah Morgan, Consultant in Public Health
Screening and Immunisation Lead (Surrey and Sussex), sarah.morgan26@nhs.net
Wendy Young, Programme Director – Planned Care and Cancer, NHS Sussex, wendy.young5@nhs.net
Nicola Rosenberg, Consultant in Public Health, Brighton and Hove City Council, Nicola.rosenberg@brighton-hove.gov.uk
Ward(s) affected: All
1. Purpose of the report and policy context
1.1 The purpose of this report is to provide an overview of the data regarding uptake and access to breast and cervical screening and human papillomavirus (HPV) vaccination, consider how rates compare with other areas, look at barriers to uptake and the work that is underway to address this and plans for the future.
2. Recommendations
2.1 That Committee notes the information provided on breast and cervical screening and HPV vaccinations.
3. Context and background information: Cervical and breast screening
3.1 Screening refers to the testing of an asymptomatic population in order to detect disease at a stage when treatment is more effective. Two of the three cancer programmes in the UK are breast and cervical. Breast screening is for eligible people with breast tissue aged 50 to 71 and saves approximately 1400 lives nationally per year and cervical screening is for eligible people with a cervix aged 25 to 64 and saves approximately 4500 lives a year nationally[1]. For people who are trans it is important that to ensure GP records are up to date so that they are invited for screening correctly.
Brighton & Hove has lower coverage rates for both programmes compared with the South East and England. It also has lower rates than other Surrey & Sussex areas, with the exception of breast cancer screening.
3.2 There is a link between deprivation and cancer screening uptake. Patients from the most deprived GP Practice areas are least likely to access screening. In addition, this difference in uptake is at every point of the screening pathway and there are national and local programmes that aim to address these inequalities.[2]
3.3 In October 2019, NHS England published their independent review of the National Cancer Screening programmes in England, and recommendations including developing new IT systems for screening programmes, implementing evidence-based initiatives to improve screening uptake, and investing in screening equipment and facilities were taken forward as part of the implementation of the NHS Long Term Plan.
3.4 The COVID-19 pandemic has impacted on the delivery of the NHS Long Term Plan and has been a key concern both nationally and locally with delayed and decreased diagnosis, tests and treatment. The system has been engaged in restoration and recovery of this position, with a key focus on continued joint system working and targeted actions to address health inequalities in coverage and uptake of services, (including targeted support for people with protected characteristics).
3.5 The above mentioned work is underpinned by the ambitions of the NHS Long Term Plan, undertaken in accordance with the NHS Planning and Operating Guidance (2022/23), and is closely aligned with the Core20Plus5 objectives for early cancer diagnosis, with 75% of cases diagnosed at stage 1 or 2 by 2028.
4. Breast Screening
4.1 The national programme for breast screening invites eligible people for a mammogram from the age of 50 up to their 71st birthdayevery three years. People are invited before their 53rd birthday. Coverage data is for the 53 – 70 year old age group. Eligible people over 71 years are not routinely invited but can request a mammography screening. The target is 70%.
4.2 Brighton & Hove experienced an upward trend in breast screening coverage in 2020, but this dipped in 2021 due to the impact on services from the COVID-19 pandemic. At 61.7% of eligible people aged 53-70 in 2021 with a test recorded in the last 3 years, this was lower than the South East or England average. Although 2020 had seen an upward trend, there were a lower proportion of eligible people aged 53-70 in Brighton & Hove (69.5%) with a screen recorded in the last 3 years than many other areas in the South East and lower than England. This is shown in the below graph:
Figure 2: 2020/21 Breast Screening Coverage at PCN level
4.3 Three of the five PCNs in Brighton and Hove have breast screening levels below the England average (61%) as demonstrated by above chart. Data at PCN level is from a different time frame to annual figures above, so percentages vary slightly
4.4 Breast Cancer incidence rates for Brighton & Hove at 91.6 are higher than the England average (90.3) and lower than East (96.6) and West Sussex (101.5) in 2019.[3] Over 80% breast cancers are diagnosed early at stages 1&2.[4]
4.5 In a 2021 England-wide case-control study, mammography screening plays an important role in lowering the risk of dying from breast cancer by 38%. Women aged 65 or over see a stronger and longer lasting benefit of screening compared to younger women.[5] [6]
4.6 When looking at annual data it should be noted that breast screening is operated on a 36 month round, unlike cervical screening which is based on next test due date. Screening round length is the interval between the date of a person’s previous screening mammogram and the date of their next first offered appointment. Brighton & East Sussex Breast Screening provider (UHSX) delivers screening using three mobile screening units and one static site. The mobile units move from one location to another offering screening to GP practice registered populations once every 36 months. When reviewing performance data the position in the current round may negatively identify localities where screening has not yet begun.
4.7 In Brighton & Hove breast screening services were in a state of covid recovery since April 2020 and fully recovered by September 2022. 2020/21 data represents a period when there was significant round length slippage (all women not invited ≤36 months of their previous screen) which will have adversely impacted on coverage data. It will also invalidate many performance measures which are based on a 36-month screening round length. The provider, University Hospital Sussex - East is currently doing well and achieving 95% within 36 month round length. The national target is 90%.
4.8 It is expected that a continued emphasis on joint work and the further development of Primary Care Networks, will enable screening providers to meet the 70% by 2024.
4.9 The uptake rates for breast and cervical screening programmes is increasing but there remains a clear link in terms of areas of deprivation demonstrating lower screening uptake rates. Deprivation has an impact in terms of access and uptake of screening and the data for uptake across GP practice correlates with this. The screening uptake results are dependent upon the timing of the three year round length which operates per practice.
4.10 Whilst there are some opportunities through incentivisation within the Primary Care Network Directed Enhanced Service (PCN DES) (to support earlier cancer diagnosis through improving cervical screening uptake), with respect to breast screening uptake, there is no direct role for GP practices to deliver the service. GP practices do deliver cervical screening. The segmentation of data demonstrating gaps in uptake and impact of deprivation is considered and demonstrates the importance of continuing with the system wide collaborative work to support the population effectively, as described in this paper.
5 Cervical screening
5.1 The national programme has a target for cervical screening coverage of 80% of the eligible population and is managed by General Practice and not by a separate provider. Some Primary Care Networks (PCNs) are undertaking delivery across their PCN and others are supported by the activity taking place within commissioned sexual health clinics.
5.2 There has been a downward trend in eligible people aged 25-49 years attending cervical screening since 2010 across the country, region and locally. In 2021 the proportion of eligible people adequately screened in Brighton & Hove (62.4%)[7] was lower than England (68%), the South East (69.5%) and East & West Sussex (72%).
5.3 Data at PCN level is from a different time frame to above, so percentages vary slightly. In 2020/21 West Hove PCN had a higher proportion of females aged 25-49 attending for cervical screening (75%) than England and the South East.
Figure 3 Cervical screening, attendance, PCNs
5.4 In 2019 the incidence of cervical cancer in Brighton and Hove was 9.9 (n=15), higher than East Sussex (8.6) and England (9.8) but lower than West Sussex (11.4).[8] Of those cancers with identified stages all cases bar one were at stage one.
5.5 It is estimated that screening currently prevents 69.7% of cervical cancer deaths nationally. In 2017-2019 the mortality rate of 2.4 (n=681), in Brighton and Hove, for the same period, the rate is 3.0 higher, n=11 deaths due to cervical cancer[9]. However, if everyone attended screening regularly 82.9% of deaths could be prevented (i.e. half of deaths currently occurring could be prevented), although the data for this evidence is from 2016 this emphasizes the importance of cervical screening and the more recent evidence would be affected by the impact of the Covid19 pandemic.[10]
5.6 The NHS Sussex Cancer Health Inequalities Workplan is focused on supporting achievement of the 80% target for all Sussex PCNs by 2024.
6 Support for increasing uptake of cancer screening, cancer awareness and early diagnosis service
6.1 Public Health and NHS Sussex jointly commissioned a service to raise awareness of cancer, giving people the confidence and tools they need to attend screening appointments, recognise the signs and symptoms of cancer and to overcome barriers to getting help when it is needed. It targets engagement in deprived communities and communications are tailored to specific audiences to address health inequalities.
6.2 In 2017-2018 the provider (Albion in the Community) undertook research to gather insight from people with a cervix living in Brighton and Hove who were or would be, eligible for participation in the cervical screening programme, to determine the barriers to screening, local attitudes and measures that would help more local people to benefit from screening. They conducted a questionnaire for any eligible person living in Brighton and Hove and carried out community engagement - asking people about their experience of cervical screening whilst carrying out outreach work. 272 questionnaires were completed.
6.3 Barriers to Screening were found to be:
· Belief that vaccination against HPV removes the need for screening.
· Belief that people who are not currently sexually active do not need to be screened.
· Worrying about the time it takes for results to come back.
· Concern about pain during the test.
· Anxiety over believing that it is a test for cancer.
· Previous abuse/sexual violence.
· Embarrassment
· Forgetting to book an appointment after receiving the reminder letter.
· Patients not prioritising their own health in busy lives – booking the screening appointment slips down the “to-do” list!
· Trying to fit in screening appointments around work commitments and the menstrual cycle.
· Body dysmorphia and lack of confidence to take part in an intimate examination.
· Perception of need for more trans-friendly health staff who have been educated about trans people and issues.
· Worrying about being asked about lifestyle risk factors or sexual behaviour/orientation whilst attending screening.
· Lack of understanding of what happens if abnormal cells are found and lack of confidence in secondary care and communication of results.
6.4 Summary results from the questionnaires were as follows:
· Overall, 1 in 5 gave ‘worrying about pain and discomfort and forgetting to make an appointment’ as the reasons for not attending their last cervical screening appointment with 1 in 8 too embarrassed to attend.
· More than half of respondents would like more flexible arrangements at their GP practice to allow for appointments at times to suit them and over a third would like to have the option to have their screening somewhere other than the GP practice. More information about the screening procedure and why it is needed was requested by 1 in 5 of the respondents.
6.5 Suggested improvements:
· Having a DIY kit to save embarrassment and time.
· More awareness that an abnormal result does not necessarily mean cancer.
· Regular reminders to book a screening after the initial letter. There is a strong trend towards this being delivered as an email or text rather than printed materials.
· More understanding of trans issues and trans friendly clinics.
· More understanding of sexual violence issues and a separate screening clinic for people who have suffered this.
· Raising awareness of steps to be taken to reduce fear/embarrassment among young women.
· The introduction of steps to create a relaxing space for screening including people bringing in music or a meditation with them.
· A short questionnaire at the screening appointment enabling discrete information about past sexual trauma or other concerns which potentially make the screening more difficult.
· Raising awareness in BAME communities of the importance of cervical screening.
· Raising awareness amongst young women alongside immunisations and then later.
7 Key actions to support improvement to increase uptake of cancer screening
7.1 Members of the NHS Sussex team work closely with the Surrey and Sussex Screening and Immunisation Team, as well as other system partners such as Cancer Research UK, Local Authorities through the place-based Cancer Action Group, and Community Networks to take direct action to improve access and uptake, especially in seldom heard groups and those living in areas of deprivation.
7.2 With a continued emphasis on joint working and the further development of PCNs, it is expected that this will enable the screening providers to close the gap toward meeting the 70% breast target by 2024. NHSE (formerly PHE) as commissioners are working across both Breast Provider Services in Sussex to drive improvement in the screening provision with more access and better siting of mobile units. The ICS has mapped inequalities of access to units and is supporting the Providers to devise location plans.
7.3 The team also continue to work collaboratively to support PCNs to deliver improvements in cervical screening, which are remunerated to practices via the Quality Outcomes Framework and PCN Directed Enhanced Services (DES) elements for improving cancer screening uptake.
7.4 A population health management approach is being taken to the ‘segmentation’ of data to produce a cancer screening dashboard that is able to effectively target activities to local super output area (LSOA) level.
7.5 Examples of actions taken at local level include:
· A task and finish group set up with commissioning colleagues for Learning Disability and Autism to enable a focus on improving all cancer screening uptake to these groups (incl. Brighton & Hove place).
· Presented to the learning disability and supported living forums to engage staff and raise awareness of the Learning Disabilities Mortality Review (LeDeR) programme and their complementary role in improving screening awareness.
· Transgender webinar held with primary care colleagues and FAQs document produced to ‘debunk’ common assumptions and address key areas of need. (incl. Brighton & Hove place)
· Deep dive by Community Researchers (Community Participation in Action Research in 2021-2022 by the Hangleton and Knoll Project focusing on cervical screening uptake, undertaking critical path analysis and identifying case studies. (specifically Brighton & Hove place)
· Working with Screening and Immunisations Team to address errors in cervical screening and investigating/addressing areas of commonality – supported by the production of a Standard Operating Procedure to support practices to avoid common errors, resulting in significant improvement in the sample rejection rate. (incl. Brighton & Hove place)
· Working with the Screening and Immunisations Team to address the recommendations of the ‘Healthwatch insight into Breast Screening services in West Sussex’ within the Brighton and East service.
7.6 The new partnership for the cancer awareness and early diagnosis programme comprises of three local organisations: Trust for Developing Communities (TDC) as lead partner, The Hangleton and Knoll Project (HKP) and the Horizon Centre. They began their contract on September 1st 2022 and the contract runs for 3 years with the option of extending for 2 years. In response to the Equalities Impact Assessment, the service specification was amended to link some key performance indicators (KPIs) to engagement with specific target groups.
7.7 To achieve outcomes they will:
· Take a citywide approach: outreaching to all who would benefit from cancer awareness guided by data and local intelligence.
· For priority neighbourhoods: develop community-led cancer action plans.
· Establish a Steering Group of strategic stakeholders.
· Employ ‘peer-advocates’ building on: TDC’s successful peer-educator model that increased BAME vaccine uptake and HKP’s pilot cancer awareness project with Macmillan
· Recruit a team comprising: new Health Equalities Manager, Co-ordinators, Peer Advocates, Volunteers and Communications Manager.
· Work with Macmillan to develop bespoke training and campaigns materials.
7.8 A campaigns calendar and action plan has been developed by the partnership. The campaigns calendar links with national campaigns and the Partnership plan is to use these as a hook onto which the team will focus on priority groups and communities using data and information from local insight reports. The Partnership will work at a strategic level to address issues such as transport; where possible guide on community venues for screenings; enhance buddying support through social prescribing and provide training to voluntary sector partners. A specific action planned to address the barrier of transport for some is to translate materials into appropriate languages and arrange peer-led minibus trips for groups to attend either screenings (where opportunities exist) or information sessions together.
8 Human Papilloma Virus (HPV) Vaccination
Background
8.1 There are 100+ types of HPV human papilloma virus which sits on and in the skin; the vast majority are harmless and most HPV infections do not cause any symptoms and clear up on their own. Some do not clear up and can lead to oral-genital cancers, whilst others cause genital warts.
8.2 The first HPV vaccination is given in year 8, (age 12/13), and the second one 6 to 12 months later, mostly in year 9 (age 13/14). The evidence indicates that to give the best protection, the vaccine should be given before people become sexually active.
8.3 The HPV vaccination programme has been running for 10 years in the UK and over that time there has been a big decline in HPV infections and in the number of young people with genital warts. Young women have been vaccinated from 2012 and in young men were offered the vaccination from 2019.
8.4 The current vaccine is given in two doses, but there are plans for combining the vaccination into one dose. The vaccine will prevent up to 90% of cervical cancer cases, but women should still attend for cervical screening when invited to do so.
8.5 National research has determined that women who are vaccinated against the human papillomavirus (HPV) have a much lower risk of developing cervical cancer than those who are not vaccinated, and that the effect is even greater for women at a young age. In 2021 research was published in the Lancet indicating that the HPV immunisation programme has successfully almost eliminated cervical cancer in vaccinated women born since Sept 1, 1995[11].
HPV uptake
8.6 In September 2020, schools across the UK reopened for general in-person attendance. During the 2020 to 2021 academic year, students were required to stay at home and learn remotely if they tested positive, or if they were a contact of a confirmed COVID19 case. In England, as part of a wider national lockdown in January 2021, schools were closed to all, except children of keyworkers and vulnerable children. From early March 2021, primary schools reopened, with a phased reopening of secondary schools. All of this led to some disruption of school-based immunisation programme delivery and the impact varied by region and local authority. HPV vaccine coverage in 2020 to 2021 has improved significantly from the low levels reported for the 2019 to 2020 academic year but is still not back up to pre-pandemic levels.
8.7 The published[12] uptake data for school year 2020/21 for Brighton and Hove is as follows:
|
Denominator |
Vaccinated with at least 1 dose |
% uptake |
Vaccinated with 2 doses |
% uptake |
|
|
Year 8 Female |
1465 |
1068 |
72.9 |
30 |
2 |
|
Year 8 Male |
1468 |
956 |
65.1 |
40 |
2.7 |
|
Year 9 Female |
1511 |
1184 |
78.4 |
1053 |
69.7 |
|
Year 9 Male |
1530 |
1111 |
72.6 |
936 |
61.2 |
Across England in the 2020 to 2021 academic year HPV vaccine coverage was 76.7% for dose 1 in year 8 females, 81.8% for dose 1 in year 9 females, 60.6% for dose 2 in year 9 females, 71.0% for dose 1 in year 8 males , 77.3% for dose 1 in year 9 males, 54.7% for dose 2 in year 9 males.
Compared to national figures in 2020/21 Brighton and Hove coverage was lower for one dose in males and females aged 12/13 years but better for coverage for females with 2 doses aged 13/14 years [14]. Compared to the South East Region Brighton and Hove had lower coverage across all these groups in 2020/21.
HPV and Colposcopy
8.8 Collaborative work between NHS Sussex and Brighton and Hove City Council has enabled links to be made between the HPV vaccination programme with communications and education work on prevention of cervical cancer (recognising the impact of the pandemic on vaccination rates in schools).
8.9 However, it should be noted that there has been a direct impact on the increased need for colposcopy procedures, as a result of implementation of HPV primary screening. This is because HPV primary screening is a test to identify the presence of HPV which leads to more people being referred for Colposcopy, including those with no abnormal cells (which was the prior test in the screening programme).
8.10 This has resulted in an increased demand on Colposcopy services to support patients to prevent cervical cancer with and increased waiting time (from 6 weeks to 16 weeks currently) for Colposcopy appointments, predominantly affecting patients with a ‘low grade squamous intraepithelial lesion’ usually caused by an HPV infection.
8.11 The provider (University Hospitals Sussex NHS Foundation Trust) has advised that some additional capacity has been secured to provide an additional colposcopy clinic one weekend per month in order to recover the backlog of patients and bring waiting times back into line with the commissioned service, however further capacity to clear the backlog is needed.
8.12 It is recognised that workforce development is required and this has been escalated to the national Operational Delivery Team, with agreement to commence a focused review. The regional Screening and Immunisations team will conduct a local review of training requirements in support of this.
HPV vaccination delivery and actions for improvements
8.13 The Sussex Immunisation Service (SIS) delivered by Sussex Community Foundation Trust is commissioned to offer HPV vaccination to the eligible cohort, predominantly delivered within schools.
8.14 Locally, dose 1 is offered in Yr 8 & dose 2 offered in Yr 9, local SEN and Prep schools are offered both doses in Yr 8. Home educated and those that are not in school are contacted and offered the vaccine via a clinic or in some instances home visiting service. Catch up for missed vaccinations is available from SIS for those young people that are under 20 years of age.
8.15 Since the start of the Covid pandemic there has been a decline in uptake of all vaccinations at a national level and this has been reflected in the local uptake of HPV due the following:
· From March – July 2020, SIS was unable to access schools due to lockdown
· From Sept 2021, SIS experienced difficulty accessing some schools due to covid testing within schools
· Increased cancellations of booked sessions, due to school staff absence.
· In 20/21 the introduction of the flu programme and Covid vaccination for children aged 12 plus has impacted on uptake of other school based vaccination programmes as fewer consent forms for HPV were received.
8.16 For all school sessions the SIS offer:
- School Pack with session information sent by email to schools
- Material to promote the upcoming vaccinations on school websites and school electronic info boards
- Information leaflet and online consent information, including FAQs, sent via schools to parents
- Parent consent reminders sent via school two weeks prior to vaccination date
- For those parents that need a paper consent, this is provided once schools provide the info to SIS
- Verbal consent obtained in advance by phoning parents (as required) for those with no consents received
- Gillick[15] consent of young person taken on the day, if appropriate
- Low uptake schools an extra member of staff (staffing levels permitting) to spend the session phoning for verbal consent, using details provided by school
- Outstanding positive consents in years 10 upward are offered to catch up at each school visit
- SIS staff member to assist parents with completing consent forms where indicated by schools
- Additional visits to Alternative Provision and SEN schools, as appropriate. Clinics in these settings are adapted to address the needs of the students
8.17 For those not in School or hard to reach SIS offer:
• Home Educated: links are sent by BHCC, including consent information, for each programme to all eligible young people that are on home education roll
• Traveller site visits by link nurses several times per term
• For Looked After Children - link nurses in each team promote uptake and immunisation status is noted at Initial Health Assessment and catch up will form part of the health care plan
• Dedicated clinics with longer appointments for anxious children
• Community mop-up clinics available and promoted for those that cannot access school service
• Home visits offered when required
Post School Session SIS offer includes the following:
• Mop up session for those with a high DNA (Did not attend) numbers
• Email sent to all who DNA with clinic link and SIS contact information
• Email via schools to whole year groups with consent link informing them they can still consent with clinic booking link
• Community clinics held at Brighton General Hospital & Hove Polyclinic, additionally children can book on to any available clinic in Sussex. There were 187 catch-up clinics held between 01/04/20 and 31/08/22
Annually each July the SIS provide the following:
• Clinic booking information email sent to all who remain unvaccinated but consented
• Those who have consented for one type of vaccination and not another, emails sent informing them of other available vaccines for their child and consent links included
• ‘Missed Vaccinations’ information flyer sent to years 8-11 via schools, containing vaccination and clinic information.
• ‘Missed Vaccinations’ information flyer sent to all venues we use, health visitor and school nurse teams and other relevant contacts, to be displayed during the year
• ‘Missed Vaccinations’ information flyer sent to Brighton and Hove City Council (BHCC) link for sharing with Children and Family Centres and Libraries etc.
• ‘Missed Vaccinations’ information flyer sent to UKHSA for sharing.
• ‘Missed Vaccinations’ flyer’ sent via schools to all students in year 12.
• Share a top tips document to support improving uptake in schools
Potential next steps and future actions include:
• To send reminder clinic emails immediately following DNA, now that the system is in place to do this.
• To send invites to non-attenders in areas of the city with lower uptake for catch up clinics
• To share communications in local area magazines to promote Missing Vaccines poster
• Use banners at venues to improve visibility of the immunisation team at sites
• HPV vaccination leaflets to be shared in different languages with communities
• SIS to promote in a parent letter and via schools the functionality of viewing the e-consent in the language their phone is set to.
• SIS to promote access to leaflets in other languages for HPV.
• Link with other areas on best practice ideas to increase uptake
9 Analysis and consideration of alternative options
9.1 Not applicable for this report to note.
10 Community engagement and consultation
10.1 Not applicable for this report to note.
11 Conclusion
11.1 Members are asked to note information presented.
12 Financial implications
12.1 The cancer awareness and early diagnosis programme is joint funded by Health and the ring-fenced Public Health grant (Health & Adult Social Care directorate). The budget for financial year 2022/23 is £0.077m funded by the Public Health grant and £0.023m from NHS Sussex.
No financial implications have been identified for this report.
Sophie Warburton, Principal Accountant, BHCC 28.10.2022
13 Legal implications
13.1 No legal implications have been identified for this report, which is for noting only.
Sandra O’Brien, Senior Lawyer, BHCC 27.10.2022
14 Equalities implications
Equalities implications are addressed throughout the report.
15 Sustainability implications
Plans for improving action on sustainability and climate change are included in NHS Sussex, NHSE and BHCC commissioning plans.
Supporting Documentation
None