Screening Division, Public Health Services
Strategic Themes, Issues and Developments for Screening
Author: Rhys Blake, Head of Business and Service Development
Dr Rosemary Fox, Acting Director, Screening Division
Date: 30th September 2010 / Version: 0a
Publication/ Distribution:
· Screening Division Executive team
· Public Health Wales Board members
Review Date: N/A
Purpose and Summary of Document:
To describe the current remit of the Screening Division, strategic challenges over the medium term and to horizon scan for the future. The paper is intended to be an informative planning document that can be shared amongst senior management and exec and non exec board members who need a reference point for this service.
Work Plan reference:
Date: 18th October 2010 / Version:0a / Page: 20 of 20
Public Health Wales / Strategic themes: Screening Division
1 Executive Summary
The Screening Division of Public Health Wales has unparalleled expertise in the planning, delivery and evaluation of quality assured population screening programmes. The next five years will require unprecedented change. The Division’s remit and profile are growing rapidly with the addition of new programmes, while major structural and strategic change will affect existing programmes delivered by the Division.
Internal relationships within Public Health Wales are still under review following the formation of the Trust in 2009. External relationships with WAG, Health Boards and WHSSC are progressing, and will be crucial to the Division’s success in meeting the challenges ahead.
This programme of change and development is taking place within the current NHS Wales environment, with funding certain to diminish year on year for the foreseeable future. The financial and service challenges faced by the Division must be managed so as to minimise risk to the Division and to Public Health Wales.
2 Background
2.1 Screening
The UK National Screening Committee (NSC) defines screening as:
‘a public health service in which members of a defined population who do not necessarily perceive themselves to be at risk of, or affected by a disease or its complications are asked a question or offered a test to identify those individuals who are more likely to be helped than harmed by further tests or treatments to reduce the risk of disease or its complications.’
Implicit in this definition are several important concepts:
· Screening programmes operate within defined populations (eg babies born in Wales, women aged 50-70), and screening is proactively offered to all members of that population
· People taking part in screening programmes have not previously thought of themselves as being unhealthy or affected by the disease in question
· Screening can harm as well as help
· Screening is not diagnostic- it aims to reduce, rather than eliminate, risk from disease or complications.
These concepts differentiate screening from the usual healthcare setting where a worried individual approaches a healthcare provider for assistance. While every care must be taken to reduce harm to healthy participants, all screening programmes do harm, from anxiety caused by the wait for screening results, through irradiation of healthy women’s breast tissue in breast screening, to the loss of normal pregnancies following amniocentesis after an abnormal Down syndrome screening test.
Screening programmes are therefore under a particular duty to be able to show that their programme is doing more good than harm on a population level.
2.2 The Screening Division of Public Health Wales
The mission of the Screening Division is ‘To provide and support evidence based population screening programmes which prevent disease occurring and/or improve early detection, giving more chance of successful intervention.
The Division delivers programmes according to Welsh Assembly Government policy. For example, ‘Designed to Tackle Cancer’ sets out the Welsh Assembly Government’s strategy to 2015 for prevention, early detection, access to services and service quality. Designed to Tackle Cancer describes the role screening has in reducing cancer mortality.
The Screening Division is responsible for the management and delivery of four national population based health screening programmes:
· Breast Test Wales (BTW), screening approximately 100,000 women each year
· Cervical Screening Wales (CSW), screening approx 220,000 women each year
· Newborn Hearing Screening Wales (NBHSW), screening approx 30,000 babies each year
· Bowel Screening Wales (BSW) screening started October 08. Estimated activity at full roll out approx 435,000 people each year
In addition, at the request of Welsh Health Specialised Services Committee (WHSSC) the Division is currently planning a screening programme for Abdominal Aortic Aneurysm, and is preparing to take over the management of newborn bloodspot screening to provide a safe and sustainable quality assured national programme.
Public Health Wales carries the legal liability for all programmes delivered by the Division, up to the point of diagnosis of the condition concerned and subsequent referral for intervention. Since screening, by definition, is not a diagnostic service, the Division therefore bears the legal liability for the inevitable false positive and negative results, as well as for genuine failures which are minimised by strong quality management.
The Division also manages Antenatal Screening Wales (ASW), which is tasked with improving the quality of antenatal screening in partnership with Trusts and Local Health Boards currently providing maternity services, but which is not responsible for the delivery or monitoring of the service provided.
In addition to the screening programmes which the Division is required by WAG to manage and deliver, some services have historically been provided ‘at risk’. One example is the provision of mammography to young women at high genetic risk of breast cancer. This service, which is provided in conjunction with the All-Wales Cancer Genetics Service, has never been explicitly funded, although it is regarded throughout the UK as an exemplar.
The Screening Division requires a working relationship with every Health Board and GP practice in Wales. It also has well established and long standing links with the voluntary and community sectors. Wales presents a distinctive policy context for public services, especially since devolution. Of particular relevance to The Screening Division is the considerable and increasing emphasis on:
· The health of the population and, in particular, on inequalities in health
· Preventing ill health
· Empowering individuals and communities to improve their own health and wellbeing and participate in the design of public services
· Approaching the delivery of programmes and services on a ‘whole pathway’ perspective
· Maintaining local delivery and accountability
· Promoting an ethos of cooperation, coordination and partnership between providers and stakeholders, within Wales, UK the worldwide
· Development and use of the evidence base to support the development of existing and introduction of new services
· Benchmarking services to ensure value for money
· Increase in the requirement for delivery of specialist training
· Environmental issues
· Governance and risk management
The Division is led by a Director (currently an Acting Director, Dr Rosemary Fox) who has overall responsibility for all elements of the programmes, including those elements which are provided by other NHS organisations in Wales. All programmes are centrally managed by the Division , though delivered locally through organised managed clinical networks. The Director is accountable through the Executive Director of Public Health Services to the Chief Executive of Public Health Wales. The Director reports to the Welsh Assembly Government, Welsh Health Specialist Services Committee (WHSSC), Local Health Boards and General Practices on the performance of the programmes. The Division also contributes data to UK level evaluations, and supports UK audit and research.
The Director is supported in the management of The Screening Division by the following all-Wales functions:
· Nursing & Screening Promotion
· General and business management
· Human Resources
· IM&T
· Finance
· Administration
These functions work seamlessly across all programmes ensuring consistency of management in terms of finances, planning, procurement, IT development, information reporting and statistical analysis.
Screening as part of the Public Health Services Division of Public Health Wales has a role to play in sharing best practice, particularly on national organisation of clinical and diagnostic services (imaging and pathology) and in developing a collaborative approach to service delivery within Public Health Wales.
3 Policy
3.1 Background and Introduction
Policy for the various screening programmes in Wales is determined by WAG, based on advice from a number of sources including the NSC. UK Health Departments take individual decisions regarding implementation on the basis of this advice. Thus there are differences in the screening programmes delivered within each home country. For example, Wales starts cervical screening at age 20 whereas in England this programme does not invite women until age 25.
3.2 Strategic Issues:
Screening policy is a WAG responsibility. Careful communication and joint working between the Screening Division and WAG is required in order to ensure that public health principles are consistently adhered to, and decisions regarding new and existing programmes are made in a timely manner. Such communication can be difficult to maintain as policy has often been split across different individuals and departments within WAG.
At the time of writing, the funding and planning route from WAG to Screening from 2011 onwards remain unclear, as does the role of WHSSC. Should responsibility for funding screening sit with WHSSC in the future, there is the possibility that financial pressures and symptomatic service tensions will result in discord between policy requirements, planning expectations and service deliverables. It is not yet clear how the WAG policy lead for Screening will interface with WHSSC.
4 Development
The development of the Screening Division as a national service provider of population screening in Wales falls into four main themes:
1. Introduction of new programmes
2. Modifications or changes to existing programmes (including the impact of new technologies)
3. The Division’s role in NHS wide initiatives
4. Current screening programmes not being delivered by Screening
4.1 Introduction of new programmes
The NSC reviews the evidence for proposed new screening programmes. Most programmes proposed are not supported by the NSC. If the NSC does approve the introduction of a new programme, WAG must decide whether or not to accept that advice and implement the programme in question.
The Screening Division is currently planning the introduction of a new screening programme for AAA, offering screening to all men living in Wales at age 65. The test is delivered via ultrasound and aims to detect men with abdominal aneurysms who will either enter a surveillance programme or be considered for elective intervention, depending on the size of the aneurysm detected.
The Division has also recently been asked to establish a sustainable and safe newborn bloodspot screening programme for Wales. This programme must be capable of remedying governance issues identified by the 2006 WAG review of the existing programme and must continue to screen babies for phenylketonuria, cystic fibrosis and congenital hypothyroidism. Screening for two additional conditions (sickle cell disease and medium chain acyl co-A dehydrogenase deficiency) is to be implemented and the role of screening for Duchenne muscular dystrophy is to be reviewed.
The two new programmes will require a step change in the capacity of the small central management team which has previously remained unaltered since the introduction of Newborn Hearing Screening in 2003. The funding for this step change will provide the Division with the capacity to plan further new programmes as requested by WAG.
4.1.1 Programme planning
In order to assist WAG in decision making around the introduction of new programmes, the Division is required to produce detailed planning documentation to WAG, including indicative financial plans for new programmes.
This process takes place before the programme is formally commissioned and therefore carries risks for the Division. Costs submitted are often taken as definitive, although in establishing any new programme costs cannot be finalised until detailed project work and procurements are complete. While WAG must set indicative budgets in advance using a planning figures, if the actual running cost of the programme is higher, there is uncertainty as to where the liability rests in terms of making up any shortfall. For example, costs for AAA screening were submitted some years before project work commenced, and are unlikely to resemble anything like current service requirement. This exposes the Division and Public Health Wales to financial and reputational risk should actual costs of delivering the programme prove higher than estimated.
The Division believes that a more integrated approach to policy and commissioning for screening would allow improved forecasting of costs of establishing new programmes.
4.1.2 Potential future screening programmes
Potential screening programmes that WAG may require support in developing include prostate and ovarian cancer as well as developing existing Down syndrome screening.
4.2 Modifications to existing programmes
In addition to planning new programmes, the Division’s existing programmes continue to evolve, with major ongoing and potential change in all three cancer screening programmes (Table 1). While many of these changes are likely to result in improved service effectiveness and efficiency in the long term, they have a significant impact on current central capacity within the Division, creating the risk of failing to deliver on one or more aspects of the expanding agenda.
Date: 18th October 2010 / Version:0a / Page: 20 of 20Public Health Wales / Strategic themes: Screening Division
Table 1. Modifications to existing programmes
Programme & change / Implication / ConsequenceCervical Screening
Centralising sample processing into two centres in Wales. / Reduced cost of processing equipment, with some increased transport cost. / Already underway. A facility has been built to house CSW’s operations in SE Wales. Processing of samples in N Wales will take place in Wrexham
Centralising cytoscreening in fewer sites throughout Wales. Where appropriate, direct employment of cytoscreeners by CSW / Increased control over recruitment and workforce planning for cytoscreeners. Ability to direct work and introduce lean working in CSW / Partially implemented. Cytoscreeners currently employed by Cwm Taf HB are already working in the new CSW lab in Llantrisant. They will be joined by staff from Cardiff & Vale, and their employment will TUPE to PHW in 2011.