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Health Overview & Scrutiny Committee
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Subject |
Update on Cervical Screening and HPV Vaccination in Brighton and Hove
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Date of meeting: |
20 November 2024
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Report of: |
NHS England, NHS Sussex and Director of Public Health
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Contact Officer: |
Morag Armer Consultant in Public Health, Screening and Immunisation Lead (Surrey and Sussex), NHS England
Katy Harker Consultant in Public Health, Brighton and Hove City Council Katy.Harker@Brighton-Hove.gov.uk
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Wards affected: |
All |
1. Purpose of the report and policy context
1.1 The purpose of this paper is to report on coverage and access for NHS Cervical Screening Programme and NHS Human Papillomavirus (HPV) Vaccination Programmes in Brighton and Hove. Data is presented which allows comparison with other areas, informs barriers to uptake and outlines the improvement work that is underway together with plans for the future.
2. Recommendations
2.1 That Committee notes the information provided on the NHS Cervical Screening Programme and NHS Human Papillomavirus (HPV) Vaccination Programmes.
3. Context and background information: Cervical Cancer Screening
3.1 Cervical screening identifies presence of HPV, changes in the cervix, and precancerous changes. Appropriate timely treatment can prevent cancers developing.
3.2 The city supports the World Health Organization aim[1] to eradicate cervical cancer by 2030 via the three key pillars of HPV vaccination, screening, and timely treatment.[2] This report covers the first two pillars.
3.3 Screening refers to the testing of an asymptomatic population to detect disease at a stage when treatment is more effective. Cervical screening is for people with a cervix aged 25 to 64 and saves approximately 4500 lives a year nationally[3]. It is important that GP records reflect eligibility (existence of a cervix) so that all are invited for screening correctly, regardless of gender identity.
3.4 The NHS Cervical Screening Programme coverage standard is for ≥ 80% of the eligible population to have an adequate screen in their last recall period. GPs are the main point of access for cervical screening sample taking with opportunistic cervical screening also commissioned from sexual health clinics in Brighton and Hove to increase accessibility to the programme. Some Primary Care Networks (PCNs) are undertaking delivery across their PCN and the Brighton GP Federation also offers some cervical screening capacity accessible to all practices.
3.5 People with a cervix are invited every three years from 25-49 years and every five years 50-64. After 65, they can request a screen but the data for the over 65s is not included.
3.6 If people have changed their NHS or GP record gender marker to male and are eligible, they will need to contact their practice directly to book a screen or have the screen via Clinic T. Data is currently only collected for ‘females’.
3.7 The most recent cervical cancer data is from 2020 and the age standardised incidence rate of cervical cancer in Brighton and Hove was 13.2 per 100,000 (n=18), higher than East Sussex (9.8), West Sussex (9.0) and England (8.5) [4]
3.8 It is estimated that screening currently prevents 69.7% of cervical cancer deaths nationally. In England 2018-2020 the age standardised mortality rate was 2.5 (n=2,048), in Brighton and Hove, for the same period, the rate is 3.2 higher, n= 12 deaths due to cervical cancer [5]. However, if everyone attended screening regularly 82.9% of deaths could be prevented (i.e. half of deaths currently occurring could be prevented). [6]
3.9 NHS Sussex has a focus on Cancer Health Inequalities and, in collaboration with the local NHS England Public Health Commissioning Team, Surrey & Sussex Cancer Alliance, Berkshire & Surrey Pathology Services (Cervical Screening Laboratory) and Local Authority colleagues, strives to support all Sussex sample taking organisations to achieve the 80% target.
3.10 There has been a downward trend in eligible people aged 25-49 years attending cervical screening since 2010 across the country, region and locally.
|
Period |
Brighton & Hove |
East Sussex |
West Sussex |
South East |
England |
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2010 |
72.4% |
76.3% |
76.4% |
75.8% |
74.1% |
|
2011 |
72.3% |
76.7% |
76.3% |
75.6% |
73.7% |
|
2012 |
72.6% |
76.7% |
75.8% |
75.3% |
73.4% |
|
2013 |
69.7% |
74.4% |
74.2% |
73.3% |
71.5% |
|
2014 |
69.4% |
74.8% |
74.2% |
73.2% |
71.8% |
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2015 |
68.2% |
74.1% |
73.4% |
72.7% |
71.2% |
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2016 |
67.3% |
73.4% |
72.6% |
71.8% |
70.2% |
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2017 |
66.3% |
72.8% |
72.7% |
71.1% |
69.6% |
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2018 |
65.6% |
72.3% |
72.6% |
70.6% |
69.1% |
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2019 |
65.4% |
73.4% |
73.5% |
71.4% |
69.8% |
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2020 |
64.9% |
74.3% |
74.0% |
71.6% |
70.2% |
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2021 |
62.4% |
72.1% |
72.2% |
69.5% |
68.0% |
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2022 |
61.2% |
71.8% |
72.1% |
69.1% |
67.6% |
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2023 |
59.2% |
69.7% |
70.5% |
67.3% |
65.8% |
Table 1: CSP Coverage 25-49 Year Olds[7]
Figure 1: CSP Coverage 25-49 Year Olds2
Figure 2: Brighton & Hove CSP Coverage 25-49 Year Olds
|
Period |
Brighton & Hove |
East Sussex |
West Sussex |
South East |
England |
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2010 |
76.7% |
79.1% |
80.3% |
80.2% |
78.7% |
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2011 |
76.8% |
79.7% |
80.2% |
80.7% |
80.1% |
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2012 |
77.0% |
79.6% |
79.8% |
80.5% |
79.9% |
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2013 |
77.0% |
79.3% |
79.5% |
80.1% |
79.5% |
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2014 |
77.0% |
79.3% |
78.6% |
79.7% |
79.4% |
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2015 |
76.0% |
78.1% |
77.9% |
78.8% |
78.4% |
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2016 |
75.6% |
77.7% |
77.8% |
78.3% |
78.0% |
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2017 |
74.7% |
76.6% |
76.9% |
77.4% |
77.2% |
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2018 |
74.3% |
75.7% |
75.9% |
76.4% |
76.2% |
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2019 |
74.5% |
75.4% |
75.9% |
76.4% |
76.2% |
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2020 |
74.4% |
75.2% |
76.1% |
76.2% |
76.1% |
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2021 |
72.6% |
73.9% |
74.8% |
74.8% |
74.7% |
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2022 |
72.6% |
73.9% |
75.1% |
74.7% |
74.6% |
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2023 |
72.8% |
74.0% |
75.1% |
74.6% |
74.4% |
Table 2: CSP Coverage 50-64 Year Olds
Figure 3: CSP Coverage 50-64 Year Olds[8]
Figure 4: Brighton & Hove CSP Coverage 50-64 Year Olds
3.11 There is a correlation between deprivation and cancer screening coverage; people from more deprived areas are less likely to access screening, the data at GP practice level corroborates this. There are national and local strategies that aim to address these inequalities.[9]
3.12 In October 2019, NHS England published their independent review of the National Adult Screening programmes in England. Recommendations included developing new IT systems for screening programmes, implementing evidence-based initiatives to improve screening uptake, and investing in screening equipment and facilities.[10]
3.13 The COVID-19 pandemic impacted on the delivery of cervical screening and, whilst the system made great progress to recover, there remains much to do to address health inequalities in coverage and uptake of services, (including targeted support for people with protected characteristics)[11],[12],[13]This is important as the pandemic exacerbated preexisting inequalities.
3.14 The Core20Plus5 [14] objectives for early cancer diagnosis are that 75% of cases diagnosed at stage 1 or 2 by 2028. The 2023 Major Conditions Strategy [15] includes emphasis on early diagnosis of cancers and evaluating self-sample cervical screening tests for women who have not attended previous screening appointments.[16]
3.15 As an Essential Service within the Standard General Medical Services Contract[17], cervical screening is a well-established General Practice (GP) service and included in CQC inspections.[18] Practices are able to use the Sussex Integrated Data Set cervical screening dashboards to view segmented data to review gaps in coverage and address within their action plans, demonstrating the importance of continuing with the system wide collaborative work to support the population effectively, as described in this paper.
3.16 As detailed in the Primary Care Network Directed Enhanced Service (PCN DES)[19], PCNs must work with partners to improve screening to support earlier cancer diagnosis and improve health outcomes. There are PCNs in Brighton & Hove where improvement is needed in cervical screening coverage performance:
Figure 5: Brighton & Hove CSP Coverage 25-49 Year Olds by Primary Care Network2
Figure 6: Brighton & Hove CSP Coverage 50-64 Year Olds by Primary Care Network2[20]
4 Support for increasing coverage of cancer screening, cancer awareness and early diagnosis service (Act on Cancer Together)
4.1 In 2022, The Public Health Team at Brighton and Hove City Council and NHS Sussex ICB (Brighton and Hove), jointly commissioned Act on Cancer Together (ACT)[21], a programme to raise awareness of the early signs and symptoms of cancer, support community members to learn about and attend screening appointments and access the support available to them if they receive a diagnosis of cancer.
4.2 ACT is delivered by a partnership between the Trust for Developing Communities (TDC), the Hangleton and Knoll Project (HKP), and the Macmillan Horizon Centre.
During 2022/2023, ACT targeted engagement in neighbourhoods of deprivation and ethnically diverse communities. The focus for 2023/2024 has expanded to include people with learning disabilities and autism, LGBTQIA+, and Gypsy, Roma, and Traveller communities. Communications are tailored to specific audiences to address health inequalities. The ACT publicly available Padlet holds a wide range of differing resources for people to access.
4.3 A campaigns calendar[22] and action plan links to national campaigns and uses these as a hook onto which the team focuses on priority groups and communities using data and information from local insights. In June 2023 in line with cervical screening awareness week, the local campaign was aimed at people eligible for smear tests aged 25 – 64.In June 2024 ACT ran a month-long campaign to raise awareness about cervical cancer and screening. This involved presence at community events, cervical cancer awareness sessions for some community groups, a social media campaign, and with digital and paper posters in Brighton & Hove buses and Metro buses.
4.5 Messaging was targeted and delivered via the partnership’s community development networks, reaching people in deprived communities, and via the ethnically diverse staff members and volunteers, reaching people from ethnically diverse communities with the aid of its communications cascade.
Campaign materials were developed/amended to make them accessible, for example, translating into appropriate languages and ensuring paper resources were available to avoid digital exclusion. Several community events and locations served as venues to disseminate tailored information about cervical cancer and screening.
a. In the first quarter of 2023, ACT commenced the Primary Care Partnership pilot at Portslade Health Centre. This involved a team member (HKP ACT coordinator) seconded to the practice to contact people (by telephone) who had not taken up their offer of cervical cancer screening with the aim of increasing patient engagement with, and uptake of, the cervical screening programme. The objective was to discuss any barriers to screening and offer support to attend screening, where necessary. The support provided included assistance with booking a screening appointment, bespoke arrangements for clients during the screening appointment (for example, provision of chaperone and double appointments), pick-up and drop-off of clients at appointments, and translation support.
Following a successful delivery at Portslade Health Centre, the pilot has been rolled out to the Benfield Valley Branch of Well BN practice, (part of Goldstone PCN), and also with Wellsbourne Healthcare CIC (East and Central PCN). [23]
Barriers to screening identified include:
- Fear of the procedure – either perceived or due to a previous negative experience. such as sexual violence.
- Worries about physical discomfort (pain).
- Feeling overwhelmed due to other physical health issues or personal circumstances.
- Inertia and forgetfulness to book a screening appointment.
- Physical mobility issues.
- Uncertainty about the need for a smear test, especially if not currently sexually active or or previously received HPV vaccine.
- Lack of availability of appointments out of working hours.
- Caring responsibilities, including childcare makes it difficult to find the time to book and attend a screening appointment.
- Mental health issues.
- Some clients had complex needs which required access to advice from medical staff to assess the appropriateness of screening, and at times access to a clinician was limited. e.g. people who had experienced sexual violence and female genital mutilation
- Language barriers – some individuals did not receive accessible or translated information about cervical screening to enable them to make an informed decision about attending screening.
- Lack of knowledge and understanding of screening programme.
- Uncertainty about the need for screening if they have had a full or partial hysterectomy.
b. Summary of findings from Portslade Health Centre were as follows:
- Out of 545 clients on the non-responders list, 195 were reached via phone call, and 30% of these resulted in completed test.
- Following this, text reminders were sent to 241 clients following no response when called, and 8% of these texts resulted in completed test
- Letters/email reminders were sent to 74 clients who did not respond to phone calls or text messages. Letters or emails produced no responses.
- Results showed that speaking directly with the client was the most effective method of engaging with clients and improving screening uptake, while texts had some, albeit limited, positive impact on engagement.
c. Next steps for ACT
· Continue learning and refining this delivery model at Well BN practice and Wellsbourne Healthcare CIC practices in Brighton & Hove.
· Continued development of the support to be offered to clients facing barriers to screening, for example transport, translated materials, chaperone, 1:1 pre-appointment to discuss fears and questions.
· Develop initiatives to reduce fear/embarrassment among young women
· Collaborative work with specialist services, carers, support staff, and family members when dealing with individuals in groups experiencing high levels of health inequalities.eg inclusion health groups.
4.6 Recommendations for primary care and wider system:
· Work with Brighton & Hove Federation to explore extending access to cervical screening appointments, for example out of working hours and weekend clinics. Including consideration of other venues for screening – other than the GP practice.
· Translation of screening invitation letters and texts in most common languages.
· More information about the screening procedure and why it is important and still needed.
· Practices to send regular reminders to book a screening after the initial letter. ACT research indicates that an email or text rather than printed materials is more effective and needs to include self-bookable links for clients due cervical screening.
· Review and implement strategies to address DNA issues.
· Work with ACT team to facilitate wider uptake of this work.
5 Key actions to increase uptake of cancer screening for all partners
5.1 All partners – ACT, NHS Sussex ICB, the NHS England Surrey and Sussex Screening and Immunisation Team, Cancer Alliance, Cancer Research UK, Local Authorities through the place-based Cancer Action Group and community networks to take direct action to improve access, uptake and coverage especially in seldom heard groups and those living in areas of deprivation.
5.2 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.
· Co-production of screening videos for use by individuals with Learning Disabilities (LD), carers and health care workers to better understand the processes, what will happen and what is required. These have been widely distributed, can be shared via text messaging from General Practice, are available via the ICS Website. They have also been used to facilitate education for residential and day care staff groups. Support for people with a learning disability - Sussex Health & Care (ics.nhs.uk)
· Co-production of a Mental Capacity Act (MCA) video which is directly aimed at clinical teams and now used within MCA training across Sussex especially where people with LD are to be opted out of cancer screening.
· Building greater understanding of Transgender, Non-Binary and Intersex (TNBI) issues. There are two main aspect to this; working with general practice to improve coding and developing TNBI welcoming clinics. Additionally working with the community to raise awareness about eligibility and how to access screening. Initiatives already completed;
· 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)
· Production of a whole-life screening graphic for TNBI in 2024 to increase health literacy and awareness of routes to access cancer screening when current call and recall systems rely solely on current recorded gender for call and recall. NHS population screening: Information for trans and non-binary people - Sussex Health & Care (ics.nhs.uk)
· 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. Shared widely to inform practice. (specifically Brighton & Hove place)
· Participation in the Gypsy, Roma and Traveller Health Promotion event Stoneywish 2023 and the subsequent co-production of screening videos de-mystifying and debunking myths for this community group.
· Co-Produce Cancer awareness leaflets and videos for cancer and cancer screening.
- Healthy Lifestyles: How to reduce the risk of cancer for Gypsies and Travellers
- Men’s Health: FFT Gypsy and Traveller Health Leaflet
- Cervical screening: FFT Screening resources for Gypsies and Travellers
- Breast screening: FFT: Breast Cancer Information for Gypsies and Travellers
https://www.youtube.com/@FriendsFamiliesandTravellers
- Cross county working to disseminate learning and implement learning from others such as the Eastbourne cultural diversity and cancer screening work which was used in Brighton and Hove to link with the Chinese communities about Bowel and Cervical screening.
5.3 Further work underway with communities and populations
· Develop further the work with relevant VCSE groups to tailor appropriate awareness raising with the Black and Racially Minoritised communities of the importance of cervical screening.
· Develop further work with the Violence Against Women and Girls (VAWG) commissioner and related services to gain understanding of the most appropriate way to promote cervical screening and how best to offer/deliver the screening.
· Investigate the proposed development of an NHS-branded Trauma Card, based on a Healthwatch Essex initiative for affected women to bring to appointments.
· Scoping a pilot scheme for a DIY HPV Sample kit as is currently under trial by Kings College, London and NHSE[24]. This helps address concerns about time the screening takes and potential embarrassment.
· As part of all cervical screening campaigns, promote awareness that an abnormal result does not necessarily mean cancer.
· The Public Health funded Healthy Communities programme uses community development approaches to co design very local neighbourhood health initiatives, an example includes work with GP practices and a PCN to support people to their cervical screens.
· Cancer awareness training for staff of other VCS organisations domiciled in Community Base.
· Cancer screening awareness training to be promoted and made available to other key workers eg Housing teams.
· Outlook Foundation Cancer Awareness training session delivered by ACT project coordinator and volunteer for a group of people with learning disabilities and their carers at residential setting.
· The Cancer Communications Network meeting is now led by ACT with a focus on galvanising city-wide action to increase awareness of cancer and uptake of screening.
· Work with the Healthy Lifestyles team colleagues to engage their presence at ACT community health events , as appropriate, discuss screening with their clients.
5.4 Ongoing initiatives with practices
· All relevant partners to 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.
· 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) and recorded ethnicity through the Sussex Integrated Data set (SID) this linked to the preparation of a Cancer Screening deep dive by the ICS in 2023 which has in turn led to more actions to support the Brighton and Hove GP Federation to establish a cervical screening hub.
· Developing a cancer screening educational offer to all practice staff comprising of the Cancer Alliance community of practice, NHS Sussex education hub and co-development and learning for practices on cancer screening led by the Bowel Hub but covering all three programmes.
· Working with NHS England 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 and the need for a repeat sample (incl. Brighton & Hove place.
· Proactive feedback and learning from the analysis of the reasons for rejected cervical samples to practices and where practical implementing system wide changes or support offers, such as the purchase and distribution of label printers to reduce vial labelling errors.
· Promoting the recently updated good practice guide for practice staff, especially the sample takers.
6 Human Papillomavirus (HPV) Vaccination
Background
6.1 For the purposes of this paper, the focus is on HPV vaccination and its role in preventing cervical cancer.
6.2There are 100+ types of human papillomavirus (HPV) 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.[25]
6.3 This is important to note as oral cancer in particular is showing worse outcomes with oral cancer incidence for B&H (20.2 per 100,000), higher than England (15.4 per 100,000) and mortality rate (7.1 per 100,000) compared to England (4.7 per 100,000).[26]
6.4 The HPV vaccination programme is offered as a universal programme for adolescents and as a programme for gay, bisexual and other men who have sex with men (GBMSM) up to and including 45 years of age.
6.5 The adolescent programme is delivered in schools (including state, independent and special schools) and community clinics by the Sussex school-age immunisation service (SAIS). GPs are contracted to offer catch-up to 14-to-24 year olds that missed their vaccination through the schools programme.
6.6 The GBMSM programme is delivered through sexual health and HIV clinics. Non-GBMSM individuals with a similar risk profile and attending these clinics are also eligible.
6.7 From 1 September 2023, the HPV vaccination schedule changed from 2 doses to 1 dose for the routine adolescent programme and GBMSM aged under 25 years. GBMSM aged 25 to 45 years remain on a 2-dose schedule. Eligible individuals who are known to be immunosuppressed at the time of vaccination and those who are living with HIV should continue to be offered 3 doses.
6.8 In the adolescent programme, the single HPV dose is given in year 8 (children aged 12 to 13). The evidence indicates that to give the best protection, the vaccine should be given before people become sexually active. If children miss their vaccine there are opportunities to catch up in school and community clinics, or via their GP.
6.9 Children that were eligible for the HPV vaccination programme before 1 September 2023 and have already received one dose of the vaccine are considered fully vaccinated. All other cohorts who require catch-up via their SAIS provider or GP moved to a 1 dose schedule from 1 September 2023, and remain eligible until their 25th birthday.
6.10 The adolescent HPV vaccination programme was introduced for girls in 2008 and there has since been a big decline in HPV infections and in the number of young people with genital warts. The programme for boys was introduced in 2019.
6.11 The only HPV vaccine now used in the national programme is Gardasil®9, a 9-valent vaccine which was introduced to replace the previously used Gardasil® (quadrivalent) vaccine and prevents against 5 additional cancer-causing HPV types. The vaccine will prevent up to 90% of cervical cancer cases, but women and people with a cervix should still attend for cervical screening when invited to do so.
6.12 National research has determined that women who are vaccinated against 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 vaccination programme has successfully almost eliminated cervical cancer in vaccinated women born since Sept 1, 1995[27].
6.13 In November 2023, the NHS set out its ambitionto eliminate cervical cancer by 2040 by ensuring as many people as possible are being vaccinated against HPV, while also coming forward for cervical screening.
7 HPV vaccine coverage data – adolescent programme
7.1 The COVID-19 pandemic and resulting closure of schools led to some disruption of school-based HPV vaccination programme delivery and the impact varied by region and local authority. HPV vaccine coverage has improved significantly in the last 3 years from the low levels reported for the 2019 to 2020 academic year but is still not back up to pre-pandemic levels.
HPV vaccine coverage data for the adolescent programme is published annually for the previous academic year by local authority.
The published[28] coverage data for school year 2022/23 for Brighton and Hove is as follows:
|
|
Denominator |
Vaccinated with at least 1 dose |
% coverage |
Vaccinated with 2 doses |
% coverage |
|
Year 8 Female |
1569 |
1089 |
69.4 |
Figure suppressed due to small numbers |
Figure suppressed due to small numbers |
|
Year 8 Male |
1522 |
907 |
59.6 |
Figure suppressed due to small numbers |
Figure suppressed due to small numbers |
|
Year 9 Female |
1545 |
1155 |
74.8 |
990 |
64.1 |
|
Year 9 Male |
1396 |
954 |
68.3 |
778 |
55.7 |
HPV vaccine coverage across England in the 2022/23 academic year is shown below:
|
|
Coverage – 1 dose |
Coverage – 2 doses |
|
Year 8 Female |
71.3% |
- |
|
Year 8 Male |
65.2% |
- |
|
Year 9 Female |
75.7% |
62.9% |
|
Year 9 Male |
69.7% |
56.1% |
Compared to national figures in 2022/23, Brighton and Hove coverage was lower for 1 dose in females and males in year 8 and year 9 and for 2 doses in males in year 9 but higher for females with 2 doses in year 9[29]. Compared to the South East Region, Brighton and Hove had lower coverage across all these groups in 2022/23.
This comparison shows no change from the 2020/21 data presented in the previous iteration of this report.
Coverage data for the 2023/24 academic year will be published in January 2025.
Please note that there is no equivalent coverage report for the GBMSM programme – activity data is submitted monthly by providers to the NHS England commissioning team for management purposes.
8. HPV and Colposcopy
8.1. 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).
8.2. HPV primary screening has increased referrals into Colposcopy services for a more thorough examination of the cervix, potential biopsy and treatment to prevent cervical cancer.
8.3. This increase in referrals coincided with COVID recovery and the financial arrangements attached. This meant that there was not sufficient substantial colposcopy capacity to manage the increase demand and ‘low grade squamous intraepithelial lesion’ referrals could not be seen within the waiting time standard of 6 weeks.
8.4. NHS England and University Hospitals Sussex NHS Foundation Trust continue to work very closely to address capacity pressures and ensure the service has access to required resources, workforce and estates to meet the demands of the service within the NHS Cervical Screening Programme colposcopy standards[30] on a substantive basis.
9. HPV vaccination delivery and actions for improvements
9.1. NHS England, the Surrey and Sussex Cancer Alliance (SSCA) and system stakeholders, including the school-age immunisation teams, have agreed a plan for improving HPV vaccination delivery in 2024/25, with emphasis on raising awareness and improving communication, improving data sharing to identify and act on areas of low uptake, and identifying and acting on barriers to vaccination. Progress on agreed actions will be monitored via the Surrey and Sussex Cancer Alliance Primary Care Advisory Group.
9.2. The Sussex school-age Immunisation Service (SAIS) delivered by Sussex Community Foundation Trust is commissioned to offer HPV vaccination to the eligible cohort, predominantly delivered within schools.
9.3. Locally, this is offered in Year 8 through all schools including SEN and Prep schools. Home educated and those that are not in school are contacted and offered the vaccine via a clinic or in some instances a home visiting service. Catch up for missed vaccinations is available from SAIS for those young people that are under 20 years of age.
9.4. For all school sessions the SAIS 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 SAIS
- Verbal consent obtained in advance by phoning parents (as required) for those with no consents received
- Gillick[31] 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
- SAIS 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.
9.5. For those not in School or hard to reach SAIS 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
9.6. 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 sent via schools to whole year group with consent link informing them they can still consent with the clinic booking link
· Community clinics in Brighton & Hove are held at Brighton General Hospital, Whitehawk Roundabout Children’s Centre, Withdean Stadium and Hove Polyclinic. 89 Community Clinics in Brighton & Hove were held between 01/09/2023 – 31/08/2024. There is the option to book on to any available clinic in Sussex.
9.7. Annually, each July, the SAIS provide the following:
· Clinic booking information email sent to all who remain unvaccinated but consented
· Those who have 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 SAIS
· Verbal consent obtained in advance by phoning parents (as required) for those with no consents received
· Gillick 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
· SAIS 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
9.8. The Sussex school-age Immunisation Service has undertaken a variety of measures to improve uptake.
· Measures to improve consent completion: a small team of assistants calling parents who have not submitted consent forms (year 8 and above) and offering information and support in completing a consent, extra staff being sent to sessions to complete verbal consents, letters with information for parents being sent out via schools and QR codes to help access the e-consent platform, where we have email information that has been supplied by schools with their roll lists we email reminders to complete consents to pre and post school sessions.
· Measures to assist schools: monthly Q and A drop-in, on Teams, for schools with upcoming sessions for support and feedback, sharing U-tube and other links to NHS HPV information to share with the children in advance of sessions, exploring links in schools to work collaboratively to coordinate the delivery of HPV PHSE lessons before the vaccination session. SEN schools are offered an on-site delivery of this, which also provides the opportunity to assist parents with the consent process.
· Measures to improve opportunities to access vaccination: increased the variety of venues across the area, using the help of local authority teams, booked additional larger venues for holiday catch up, reintroducing trial drop-in clinics in some areas offering greater flexibility for families (these were stopped during the pandemic due to restrictions).
· The SAIS team is sending a hard copy of the NHS HPV leaflet to every year 8 student via schools later this term with the econsent QR code on the front for easy access to our consent system. This process will also be discussed with the LA Home Educated link to send out to parents directly (or via LA).
· These measures apply to the current year 8 cohort and all the catch-up cohorts.
9.9. Local actions to improve uptake include:
· Public Health team have worked with the PHSE lead in a school to develop a lesson plan on HPV and this was shared with all schools.
· Distributed HPV materials to all schools
· Shared information on HPV with the Sussex Interpreting Service for them to upload onto their Language specific pages
· Publicised catch up and anxiety clinics in schools.
· Created the Vaccine Uptake Inequality Forum, which will focus on school age immunisations as part of a rota. Members include BHCC, NHSE, VCSE, Primary care.
9.10. 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
· SAIS to promote in a parent letter and via schools the functionality of viewing the e-consent in the language their phone is set to.
· SAIS to promote access to leaflets in other languages for HPV.
· Link with other areas on best practice ideas to increase uptake including the provision of vaccinations through Primary Care for specific Cohorts such as LD 19-25 year old people and other identifiable target groups.
· Work with the Cancer Alliance to identify target groups and implement catch up clinics for those aged 19-25.
· Consider how to link the TNBI coding at GP Practice level to the vaccination of gay, bisexual, and other men who have sex with men (GBMSM) who are eligible up to the age of 45.
· Preparing for the Integrated Community Teams (ICT) development by supporting the development of Data Packs highlighting cancer screening.
· Continue to support the annual student Freshers week materials (national) encouraging catchup HPV vaccinations.
10. Analysis and consideration of alternative options
10.1. Not applicable for this report to note.
11. Community engagement and consultation
11.1. Not applicable for this report to note.
12. Conclusion
12.1. Members are asked to note information presented.
13. Financial implications
13.1. 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
14.1. No legal implications have been identified for this report, which is for noting only.
Sandra O’Brien, Senior Lawyer, BHCC 27.10.2022
15.1. Equalities implications are addressed throughout the report.
16. Sustainability implications
16.1. Plans for improving action on sustainability and climate change are included in NHS Sussex, NHSE and BHCC commissioning plans.
Supporting Documentation
None