SE Div Health Improvement Strategydot

By Lois Gonzalez,2014-05-14 12:56
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SE Div Health Improvement Strategydot


     Health Department

     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? ?Address4? ?Address5? ?Address6?

     ?Address7? th14 February 2007

    _____ _____



    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.

    Yours sincerely


    Director of Health Improvement


    SE Approved Version 1.1




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. Introduction

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. Background

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.


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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)


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    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

    screening programme.

    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


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    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

    national perspective.

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 Conclusion

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

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