Health Improvement Strategy Division
St Andrew’s House
Regent Road ?Name? Edinburgh EH1 3DG ?Organisation? ?Address1? Telephone: 0131-244 1826 ?Address2? Fax: 0131-244 2042 ?Address3? Pam.firstname.lastname@example.org ?Address4? http://www.scotland.gov.uk ?Address5? ?Address6?
?Address7? th14 February 2007
CERVICAL CYTOLOGY LABORATORY REVIEW
I am writing to invite you to become a member of a Steering Group, which will undertake a review
of cervical cytology laboratory service delivery in Scotland and its future provision. This review has
been commissioned by the Scottish Executive Health Department, in order to address models of
service delivery, manpower planning and technology changes within the Scottish Cervical Screening
Programme. We have already held discussions with the Scottish Pathology Network (SPAN), who
have produced a short paper outlining the necessity for this review and its potential scope (Annex A).
As the scope of this review crosses Health Board boundaries, it is fundamental to the process that
NHS Board Chief Executives are aware and supportive of its initiation and its eventual outcomes.
The Steering Group will therefore be chaired by John Burns, Chief Executive of NHS Dumfries and
Galloway. We envisage the review will take a year and will involve 3-4 meetings in this time. The
review will report to NHS Chief Executives, SEHD and the Minister for Health and Community
The first meeting of the group will take place in St. Andrew’s House, Edinburgh on 21 May 2007 at
10:30am, followed by another meeting on 10 September 2007 at 10.30am, also at St Andrew’s
House. I would be grateful if you could let me know if you would be willing to participate in the
Steering Group and are available to attend the first meeting.
Director of Health Improvement
SE Approved Version 1.1
CERVICAL CANCER SCREENING – POTENTIAL REVIEW OF CERVICAL
CYTOLOGY LABORATORY PROVISION
Scottish Pathology Network (SPAN)
Scottish Cervical Cytology Laboratory Provision
Potential for Review
Briefing Paper for Discussion
The Scottish Executive Health Department (SEHD) has commissioned a report on the future provision of the laboratory
aspects of cervical cytology. The content of this paper is to outline some of the areas of challenge as identified by SPAN.
It does not define the remit of any review but suggests areas for consideration which may be require addition or
amendment. It also does not define the composition of the review group which clearly requires significant discussion.
SE Approved Version 1.1
1.1 The Scottish Executive Health Department (SEHD) has commissioned through the
Scottish Pathology Network (SPAN) a review of cervical screening laboratory service delivery and its
future provision, taking into account models of service delivery, manpower planning and technology
1.2 This paper is designed to give a short background to the current provision of laboratory based cervical
cytology and highlights areas of strength, weakness and constraints in the delivery of service.
2.0 The Scottish Cervical Screening Programme (SCSP) was introduced to allow early diagnosis of
preinvasive changes which may lead to cervical cancer. As part of the programme women in the 20-60
year age group are invited for a routine cervical smear once every three years. Across Scotland this
equates to 406000 smears per year. The workload is spread across 11 laboratories with varying
workloads from 18500 in Highland through to 76500 in Lothian. The programme has been successful
and there has been a reduction in incidence of cervical cancer by 36% and a decrease in deaths from
199 in 1986 to 100 in 2002
2.1 Liquid Based Cytology (LBC) a new method of preparation was introduced throughout Scotland in
2003/04 after successful piloting. The effect of the introduction of LBC has been to provide a 20-30%
productivity gain in primary screening and has reduced the workload from 489000 in 1997/98 to
406000 in 2004/05 by the reduction in inadequate preparations. There has also been a significant
countrywide improvement in turnaround time of cervical smear reporting dropping from a country
wide mean of 18 days in 00/01 to a mean of 13 days in 04/05
2.2 This required a significant investment in capital equipment and revenue costs across Scotland with the
capital costs of ?2.75m funded centrally and Boards funding the additional revenue costs of
approximately ?1.5m pa
2.3 This technology along with changing skill mix and other emerging newer technologies will further
impact on the organisation and delivery of cytology laboratory services and it is clear that a national
strategic approach is required to guide and help Boards and laboratories in decision making.
3 Scope of the Review
3.1 The full scope of the review requires further discussion between the Review Steering Group but may
include aspects as outlined in the suggested topic areas below.
SE Approved Version 1.1
3.2 Manpower Planning
3.2.1 The cytology laboratory normally consists of 5 groups of staff including medical staff, advanced
practitioners and biomedical scientists, cytoscreeners, medical laboratory assistants and clerical Staff.
Each of these groups is faced with challenges in delivering the future service model for cytology. It is
not within the confines of this paper to describe in detail each of the roles and responsibilities but it
does highlight areas of focus
3.2.2 Recruitment of consultant pathologists into cytology laboratories is a pressure point.
Consultants are opting not to go into cervical cytology because of the effect of some of the drivers for
change outlined below. There is a viewpoint that the service is not sustainable in its current form. The
new consultant contract and specialisation have both led to a reduction in the number of consultant
sessions allocated to cervical cytology
A number of lead cytology consultants are over 50 (4) with few if any trainee pathologists indicating
cervical cytology as a preferred career pathway.
3.2.3 The traditional role of the consultant pathologist in this specialty has been changing and
has initiated role extension and the introduction of the advanced practitioner in cytology. These
generally have been experienced biomedical scientists who have been trained and examined in
reporting abnormal cervical smears. To date, there have been 4 appointments in Scotland. The current
role of Advanced Practitioners is clearly defined through professional guidance and an HDL but their
potential future role in the development of the service needs discussion.
3.2.4 Biomedical Scientists have been identified as having recruitment and retention issues highlighted in
HDL (2004) 28 and the Biomedical Scientist Modernisation Board has helped in the development and
funding of integrated degrees. It should be within the remit of the review group to report on the
manpower planning and development of this group within cervical cytology taking account of UK wide
direction as appropriate.
3.2.5 The number of cytology screeners has remained relatively static with only a small reduction in
numbers post liquid based cytology implementation. Within this group as with Medical Laboratory
Assistants there has been little opportunity to develop beyond this grade. With Agenda for Change and
within this the Knowledge and Skills framework, and the development of assistant and associate
practitioners across the healthcare professions how could future educational direction facilitate change
within this group.
3.2.6 Clerically there will be significant change in relationship to the introduction of SCCRS (Scottish
Cervical Call Recall System.)
3.3 Technology Changes
3.3.1 Liquid Based Cytology
LBC has produced a number of significant effects including the reduction of the inadequate sample rate
which has reduced the number of repeat smears. It has also produced a 20-30% productivity gain
through the screening of a much smaller slide area by the biomedical scientists and cytoscreeners and
the clarity of the final preparation.
This efficiency gain has driven other healthcare systems to review the cytology provision and initiate
greater centralisation of services and the introduction of various models of delivery including hub and
spoke. (Particularly in England)
SE Approved Version 1.1
In Scotland the decision was made (at the time of introducing LBC) to retain the current services across
11 laboratories with 10 of the laboratories utilising Cytyc’s T3000 processor which has the capacity to
prepare between 60 and 80k preparations per year
3.3.2 Cervical Cytology Imager
As a further development of technology Cytyc has introduced electronic imaging of the LBC
preparations which reduces the manual screening input by the cytoscreener and has been shown to
provide improvements in standardisation of screening. It is now used in over 250 labs worldwide and
has attained full American FDA approval for diagnostic use.
Its method of operation is to analyse the LBC preparation and detect the most abnormal fields by
assessing DNA content stoichiometrically. The fields are electronically marked and made available at a
review station microscope for the screener to view. This reduces the number of fields to be viewed by
the screener from a mean of 120 fields of view to 22 fields
Cytyc have indicated their willingness to take part in a feasibility study of their new imaging system in
Scotland and may be willing to fund part of a study to ascertain its effectiveness within the Scottish
As part of the review it would be important to determine the potential impact of this technology both in
financial and service delivery terms. Also if it was felt appropriate to trial the technology, what format
that trial should take and any determination of exit strategy and costs.
3.3.3 Scottish Cervical Call Recall System (SCCRS)
The introduction in 2006 of the national call recall system will standardise requesting and reporting
across the country. This will enable the electronic requesting of cervical screening and will remove a
number of the labour intensive checks which are done within the current system. This will impact
working practices for clerical staff, screening staff, and medical laboratory assistants
3.3.4 Human Papilloma Virus Vaccination
Decisions on the use of HPV vaccination are on the horizon after recent publications and developments
in relationship to clinical trials on vaccine use in the prevention of cervical cancer. It would be difficult
in this short briefing paper to go into the detail of the effect if vaccination is rolled out. The likely
effect if the decision was made to vaccinate adolescent females for example would be an annual
reduction of cervical smears requested by a cumulative 10000 per annum. Horizon scanning would
indicate that this is unlikely to affect the level of requesting until 2015 at the earliest. The impact,
ethics and potential of this is under consideration by a wider group.
3.3.5 HPV Testing
There is recognition that HPV testing may be introduced in some form to screening within the next 5
years. This may be for triage of women with minor changes, for follow up of women with a treated
abnormality and/or as an exit strategy for women aged 50 or some other variable.
3.4 Service Delivery
3.4.1 The review may consider whether the current model of delivery is the most effective in delivering
cervical cytology in the medium to long term based on the outcomes of the analysis of technology and
manpower planning issues. The current 11 centre acute hospital based model has evolved taking into
SE Approved Version 1.1
account individual Health board input and the impact of the national roll out of LBC. With more than
three years experience and outcomes from LBC, this may be an opportune moment to consider the
3.4.2 The service delivery cannot be considered in isolation and must take into account changing practices in
Primary Care, Colposcopy and other stakeholders in the service
4 Review Group Structure and Reporting Mechanism
4.1 It is anticipated that the review group will be led by a current Chief Executive within the NHS in
Scotland and will comprise representatives from SPAN, NAG, Service Users, Partnership
Representatives, RCPath, IBMS, Lay and National Education Scotland. This representation can be
expanded as required.
The scope of the review crosses Health Board boundaries and it is fundamental to the process that
Chief Executives are aware and supportive of its initiation. Through the Chief Executives Group they
will be made aware of the progress and outcomes of the review.
5.1 An opportunity has arisen to review the future provision of the laboratory aspects of cervical cytology
The content of this paper is to outline some of the areas of challenge as identified by SPAN. It does not
define the remit of any review but suggests areas for consideration which may be require addition or
amendment. It also does not define who the review group will be which clearly requires significant
SE Approved Version 1.1