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									1. INTRODUCTION
Performance of the NHS Screening Programmes in London is generally poor, and especially
poor when compared to the rest of England. Although each screening programme has
specific service and quality issues, there are a range of generic areas of particular concern
that are common to most if not all London programmes. Some of the main issues are
outlined below:

Coverage: Cervical screening coverage, for example, is poor in London (73.4% for 2007-08)
and is falling. Programme coverage ranges across London PCTs: in the period 2007-08, four
PCTs had achieved <69.4% coverage and only two are meeting the standard of 80%
coverage of the target age group (25-64 years). For the year 2007-08, the national Newborn
Hearing Screening Programmes found a range of coverage issues, including four PCTs not
achieving the national standard of offering hearing screening to 99% of new mothers. In
addition, fourteen PCTs are not meeting the requirement of 95% of screening tests to be
completed within four weeks of birth, with a performance range of 57%-98%.

Uptake: antenatal screening probably performs best in this area but overall uptake remains
extremely poor across the majority of screening programmes. For example, according to the
2006-07 annual results of the Breast Screening Programme, uptake in 2006-07 across
London was 60.63 % (ages 50-64), a decrease of 1.5% since 2005-06. Nationally, 11 breast
screening units recorded less than 70% uptake, five of these being in London. Uptake across
London remains lower than any other areas in England where uptake ranges between 75%
and 80%. Similarly, screening for HIV, Syphilis and Hepatitis B virus should be offered to all
pregnant women. Uptake rates vary widely across London, both between trusts, and within
trusts for different diseases. For example, uptake for Syphilis screening ranged from 72.5%
(Royal London) to 100% (e.g. North Middlesex, Kingston) in 2007.

Data quality: lack of data and/or quality of data is a significant problem across all screening
programmes. Major problems are also being reported with the Child Health Record
Department (CHRD) system across London. As part of the Connecting for Health project,
many PCTs have changed their supplier for CHR systems however these new systems do not
link with the newborn screening laboratories. London therefore currently relies on manual
data entry in CHR from hard copies of results from the laboratories which is open to human
error. Current problems with CHR systems mean that only six out of 31 CHRD provided data
on coverage to the national programme in 2008.

Programme quality: significant deficits in the quality of many screening programmes. For
example, an audit of national bloodspot standards in 2006-07 highlights how achievement of
standards across London varies from very good (99%) to extremely poor (1.7%). Of the 19
diabetic retinopathy programmes in London, six are currently under the 12,000 minimum
population size thereby compromising screening safety and effectiveness. In addition,
several programmes are detecting lower levels of retinopathy than we would expect to see,
suggesting case finding and identification needs to be improved.

In light of the poor performance of most screening programmes in London and a number of
recent SUIs, NHS London has requested that all PCTs Boards are provided with assurance
that the screening programmes locally are being commissioned in a way that ensures that
they are safe, conform to national standards and are integrated within the overall care
pathway.




                                                                                                1
The purpose of this paper is to provide an overview of current arrangements for
commissioning, delivery, performance management and quality assurance of the National
NHS screening programmes in Haringey.

The National Screening Committee currently recommends the following systematic
population screening programmes:

Programme                       Eligible Population     Provider                  Lead
                                                                                  Commissioner
Cancer Screening
Cervical                        Women aged 25-64        GP/cytology services at   NHS Enfield
                                years                   the acute trusts
Breast                          Women aged 50-70        North London Breast       NHS Enfield
                                years                   Screening Services
Bowel                           Man and women aged      Central Hub (Northwick    NHS Enfield
                                60-70 years             Park Hospital) and
                                                        UCHL
Non-cancer screening
Diabetic Retinal                People aged over 12     North Middlesex           NHS Haringey
                                years diagnosed with    University Hospital
                                diabetes                (NMUH) and
                                                        subcontracted
                                                        optometrists
Newborn bloodspot               All newborn babies      NMUH                      NHS Haringey
Antenatal infectious diseases   All pregnant women      NMUH                      NHS Haringey
                                booked for antenatal
                                screening
Antenatal Fetal Anomaly         All pregnant women      NMUH                      NHS Haringey
(including Downs syndrome)      booked for antenatal
                                screening
Sickle cell and thalassaemia    All pregnant women      NMUH                      NHS Haringey
antenatal and newborn           booked for antenatal
screening                       screening/newborn
                                bloodspot
Newborn hearing                 All newborn babies      Barnet Community          NHS Islington
                                                        Services
Newborn physical examination    Newborn babies at 6-8   Primary Care              NHS Haringey
                                weeks




                                                                                                  2
2. CANCER SCREENING PROGRAMMES

2.1 Cervical Screening

Programme details
All women aged 25 to 49 are invited 3 yearly and women aged 50 to 64 invited 5 yearly for
screening. The majority of smears are undertaken at the general practices and family
planning clinics occasionally take smears.

The majority of laboratory and the colposcopy services for Haringey women are provided at
the North Middlesex Hospital and the Whittington Hospital.

Commissioning and governance arrangements
The Barnet, Enfield and Haringey (BEH) Cancer Screening Group meet every quarter and is
chaired by the NHS Enfield Director of Public Health, lead commissioning trust. The Board is
attended by all acute trusts that provide cytology and colposcopy services and it addresses
the performance, contracting issues and the overall quality of the Programme. Performance
issues are also discussed at the NHS Haringey Cancer Screening Steering Group and the
Clinical Quality review meetings with the North Middlesex University Hospital. NHS Haringey
Cancer Screening Group reports to both, BEH Cancer Screening Board and NHS Haringey
Commissioning Committee.

All of the providers produce monthly performance reports containing information on the
turnaround times of tests and breach analysis of tests over 14 days. The providers produce
quarterly performance monitoring reports containing more detailed information on
turnaround times, exclusions, non-responders, coverage and colposcopy waits. The acute
trusts also produce annual reports.

Key quality indicators and performance
Vital Sign VSA15: Women should expect to receive their cervical screening test result within
14 days of it being taken by 2010 – refreshed for 2010/11.

  Cervical Cancer Screening Targets    2008/09      2008/09   2008/09   2008/09     2009/10
                                         Q1           Q2         Q3        Q4          Q1
Coverage (>80% eligible women         72%          71.9%      71.2%     72.5%      72.7%
screened within five years
80% turnaround within 4 weeks         86.6%        87%        23%       7%         11%
Current performance against 14 days
turnaround for results
                                      To be introduced from April 2010 and achieved 100% by
                                      December 2010

Cervical screening coverage in Haringey is improving however the national standard is
currently not met.

The North Middlesex University Hospital is experiencing a backlog in the cytology
laboratory due to long-term staff absence and the „Jade Goody‟ effect that is affecting the
14-days turnaround time. However, the PCT was reassured that outstanding backlog will be
cleared and that the 14-days turnaround time target will be met by December 2010. In
addition, the North Central London Cancer Network is in the process of reviewing the
sector cytology services and to reduce the number of laboratories, thereby increasing
sample processing to limited sites to improve quality.




                                                                                               3
There is a great variation in coverage between GP practices (Chart below) and targeted work
to improve performance of practices performing poorly will take place in 2010. At present,
performance data on cervical screening by practices is included in the balance scorecard and
regularly shared with the practices.

                                   Cervical Screening Coverage by GP practices,
                                              NHS Haringey 2008/09

    90

    80

    70

    60

    50

    40

    30

    20

    10

    0




                         Havergal Villas
                                Dr. Dave




                                  Dr. Suri




                              Dr. Singer
                                 Dr. Berk
                          Dr. Greenbury



                  Crouch Hall Surgery




                             Dr. R Singh




                             Dr. Ikuwuke
                              Dr. Hoque
                           Morris House




                               Dr. Ansari

                              Nagarajah
                              Dr. Sardar




                           Dr. Jeyarajah
                              Dr. Prasad
                       The Old Surgery
                          Dr. AUK Raja
                              Dr. Cohen




                           Queenswood



                         Dukes Avenue
                       Highgate Group




                              Dr. Kundu
                              Dr. Caplan




         Laurels Healthy Living Centre
                         Dr. Henderson




                      Broadwater Farm




                             Dr. Akunjee
                 Dr. D Mukhopadhyay
                            Dr. El Kinani




                           Dr. Ramnani




                      Lawrence House




         Tiverton Surgery (Dr. Ghosh)
                      Allenson Hse MC
                          Morum House




                        Dr. Pelendrides




                   Charlton House MC
                           Dr. Obineche
               The High Road Surgery




                         Dr. Friedmann




                            157 Practice
                       Dr. Sivananthan

                         Rutland House




                         Dr. Das Gupta
                       Dr. Karunaratne




           Dr QM Rahman (Dr. M Pal)




                       The Greens MC
                    Tynemouth RD HC




                   JS Medical Practice
                 The Christchurch Hall




               Dr. Sivasinmyananthan
                     Arcadian Gardens




                     The Vale Practice
              Dr. MK Patel & Partners




                Bounds Green Grp prc




                Somerset Gardens HC




         The Laurels Medical Practice
                          Dr. Woollacott
Key issues of concern
•            Variation in coverage among practices;
•             Overall the cervical screening programme currently does not meet national
             standards;
•            There needs to be a robust action plan in place to meet the 14 days turnaround time
             by December 2010.


Actions for improvement
The priorities for 2010 are to:

         
        Ensure that the action plan for clearing cytology backlog at the North Middlesex
        University Hospital is regularly monitored and performance managed. Lessons could
        be learnt from pilot sites for the 14 days turnaround time at the Northwick Park and
        Barts and London;
     Review the existing SLA with NMUH and clarify the performance management
       arrangements for the acute trusts with the NCL Acute Agency.
For primary care:

            Conduct clinical audit and data cleaning at the practices to improve uptake and
             performance;
            Social Marketing findings are being implemented to promote cervical screening
             services targeting specific areas with lowest uptake in the borough;
            From March 2010, Health Trainers will be engaged with neighbourhood health



                                                                                               4
       centres and third sector to raise awareness on cervical cancer screening targeting
       those communities that are hard to reach;
      An audit of competencies of all staff carrying out cervical sample taking and ensuring
       that cervical screening novice and update training is attended by all smeartakers.

2.2 Breast Screening

Programme details
The North London Breast Screening Service (NLBSS) is one of the largest breast screening
services in the country and one of six breast screening programmes serving the eligible
women in London. The NLBSS is based at Edgware Community Hospital and screens from
two static sites: Edgware Community Hospital and Forest Primary Care Centre in Enfield, as
well as a number of mobile units including St. Ann‟s Hospital, the Whittington Hospital and
North Middlesex Hospital. The service provides a screening and assessment service for
eligible women resident within Barnet, Brent, Enfield, Haringey, Harrow and the southern
half of West Hertfordshire.

Commissioning and Governance arrangements
The service is commissioned by the 6 Primary Care Trusts through a consortium
arrangement with NHS Enfield currently serving as the Lead commissioner. NLBSS
Consortium meets bi-monthly and discusses the overall quality and performance of the
programme, commissioning arrangements and implements Q&A action Plans. In addition to
these meetings, BEH Cancer Screening Group and NHS Haringey Cancer Screening Steering
Group meet quarterly to discuss local uptake, coverage and engagement with primary care.

Key quality indicators and performance
Vital sign VSA09: Percentage of women aged 47-49 and 71-73 invited for breast screening –
refreshed in 2010/11.

NLBSS produces a monthly dashboard of key indicators including uptake, round length,
technical recall rates and screen to assessment timeline.

Breast Cancer Screening national target/standard
                                                                                2008-09
Uptake of invitation to screen (50-70) – 70% screened in three years              55%
Round length – 90% of women offered an appointment for screening within 46       96.5%
(36 is the national target) months of their last screen
Screen to normal standard – 90% of women sent their normal results within 2       99%
weeks of screening
Screen to assessment standard – 90% of women requiring further assessment         89%
seen within 3 weeks of their last screen
Screen to DOFO assessment – 90% within 3 weeks                                    99%

Following the suspension of the service between December 2006 and May 2007, the national
team advised the service to produce a new Three Year Screening Plan based on a 48 -
month screening interval or “round length” (the NLBSS original plan was to revert back to
the 36 months “round length”, standard by October 2010). The national team also advised
against a backlog catch up exercise as this was seen as potentially putting the service at
risk. The commissioners have worked closely with NLBSS to improve performance and meet
the target.




                                                                                            5
There is a significant variation of uptake by practices and further actions should focus on
proactive engagement with those practices to follow-up women who do not attend
screening.
                                Breast screening coverage by GP practices
                                                2008/2009
80.00

70.00

60.00

50.00

40.00

30.00

20.00

10.00

    0.00




                   Dr. D Mukhopadhyay

           Laurels Healthy Living Centre
                            Dr. Greenbury




                    Crouch Hall Surgery




                             Dr. Jeyarajah
           Tiverton Surgery (Dr. Ghosh)




                 Dr. Sivasinmyananthan
                             Queenswood
                 The High Road Surgery
                                  Dr. Dave



                         The Old Surgery




                         Dr. Sivananthan
                              Dr. El Kinani




                        Lawrence House




                           Havergal Villas
                                Dr. Cohen




                                Dr. Kundu
                                Dr. Caplan




                                Dr. Hoque
                             Dr. Obineche




                                Dr. Prasad




                           Dukes Avenue


                           Dr. Henderson
                         Dr. Karunaratne



                           Rutland House




                                 Dr. Ansari
                               Dr. R Singh


                                   Dr. Suri
                              157 Practice




                             Morris House




                           Dr. Das Gupta
                         Highgate Group




                        Allenson Hse MC




                                Dr. Sardar




                     Charlton House MC



                                Dr. Singer
                      Tynemouth RD HC




                     JS Medical Practice
                          Dr. Pelendrides
                Dr. MK Patel & Partners
                       Arcadian Gardens




                            Dr. AUK Raja




                                Nagarajah
                  Bounds Green Grp prc




                              Dr. Ikuwuke
                   The Christchurch Hall

                             Dr. Ramnani




                       The Vale Practice




                       Broadwater Farm
                         The Greens MC




           The Laurels Medical Practice
                           Dr. Friedmann




                                   Dr. Berk
                            Morum House




                               Dr. Akunjee
                  Somerset Gardens HC
             Dr QM Rahman (Dr. M Pal)




                            Dr. Woollacott
Key issues of concern
•          Low uptake and great variations among practices;
•          Round length directly impacts on the coverage however plans are in place to reduce
           round length to required national standard.

Actions for improvement
NLBSS is the first service in London to become fully digitalised from December 2009. The
programme has made a significant improvement over the last 18 months and it is on target
to reduce round length to 36 months by June 2010.

The cancer reform strategy set out the requirements for two key service
improvements:

•      Family history screening service should be in place and the Regional Quality
       Assurance Centre is considering systematic extension of this service across London;
•      Age extension of the screening programme to women aged 47 – 73 years by Q4 in
       2010
All these improvements require additional funding and the 6 PCTs‟ in NLBSS Consortium are
reviewing current funding and identifying any financial investment required to undergo
review as part of the organisational prioritisation process.

NHS Haringey Social Marketing Project identified specific communities that should be
targeted with health promotion activities and plans are in place to implement Social
Marketing findings and design appropriate interventions in 2010.

NHS London will performance manage the implementation of the recently developed action
plan aimed at improving local uptake. The Plan will be implemented in 2010. Proactive
engagement of primary care may require additional resources.



                                                                                                6
2.3 Bowel Screening

Programme details
The NHS Bowel Cancer Screening Programme is the first national screening programme in
England to be offered to both men and women. The programme is being phased across
England over three years and Haringey started to invite men and women in May 2007. Men
and women aged 60-69, who are registered with a GP will automatically be sent an fecal
occult blood (FOB) test every two years. Those aged 70 and over are able to „opt in‟ to the
programme by contacting the National hotline.

All test kits are sent to eligible NHS Haringey population from the London Hub (St Marks)
and those with abnormal FOBt results are offered an initial appointment with a screening
nurse practitioner, followed by a colonoscopy at their local screening centre (UCLH) if
required.

Commissioning and Governance arrangements
The NHS Bowel Cancer Screening Programme has been commissioned centrally by the
Department of Health on behalf of all PCTs. From April 2010, funding and responsibilities for
commissioning local screening programme will transfer to PCTs. The 5 hubs will be
commissioned through specialist commissioning. This will also coincide with the age
extension. North Central London sector is currently agreeing commissioning arrangements.
Performance management of this programme is locally managed via BEH Cancer Screening
Board.

Key quality indicators and performance
VSA10: Extension of NHS Bowel Cancer Screening Programme to men and women aged 70
up to 75th birthday – refreshed for 2010/11.
The uptake of bowel screening in Haringey appears to be in line with London overall uptake
however significantly lower than national uptake and below the national standard.


Bowel Cancer     Period         Haringey       London          National       Target/Standard
Screening

Uptake           2008/09        38%            39%             51%            60%

QA standards across the screening programme are being developed.

Key issues of concern
•        Low uptake
•        Uncertainty around commissioning arrangements and funding allocations for
         2010/11.
Actions for improvement
NC London Sector has funded a Social Marketing Project for Bowel Cancer Screening that will
be implemented by July 2010. This work will include intervention activities targeted at
improving uptake and coverage.

Funding arrangements are currently being discussed together with a service specification
that will allow for age extension.




                                                                                              7
3. NON-CANCER SCREENING PROGRAMMES

3.1 Diabetic Retinopathy Screening

Programme details
Enfield and Haringey Diabetic Retinopathy Screening service is based at the North Middlesex
University Hospital and the SLA for this service is part of the main SLA with the Trust. NMUH
acts as the hub accommodating the main grading and administration centre. Screening is
offered at the North Middlesex University Hospital using digital photography; four satellite
sites in the community and at five local optometrists. Following eye screening, patients with
referable retinopathy are referred to the North Middlesex University Hospital, Moorfields or
the Whittington Hospital NHS Trust.

Commissioning and Governance arrangements
NHS Haringey is lead commissioner for this Programme. Enfield and Haringey Diabetic
Retinopathy Screening Board, chaired by Public Health Consultant, meets quarterly and
monitors performance. The Board reports to respective Clinical Executive Committees at
both PCTs.

Key quality indicators and performance

Diabetic retinopathy screening national
standards                                  PCT            2008/09        2009/10      2009/10
                                                                           Q1           Q2
Invite all eligible persons with known     NHS
diabetes to attend diabetic retinopathy    Haringey        98.5%         98.3%         98.4%
screening – 100%
Uptake in the last 12 months – 80%         NHS             53.4%         53.2%         53.2%
                                           Haringey

Key issues of concern
•       The External Quality and Assurance visit in 2008 highlighted a number of areas for
        improvement, most of which have been addressed;
•       Recently conducted Health Equity Audit highlighted inequitable access to screening
        services that need to be addressed;
•       Low uptake;
•       Accuracy of diabetes registers at GP practices that are used for call/recall process at
        NMUH.

Actions for improvement
An Action Plan to improve the uptake has been endorsed by NHS Haringey GRIP and the
Enfield and Haringey Diabetic Retinopathy Screening Board and is being implemented. The
Health Equity Audit is informing targeted initiatives aimed at improving access to screening
in the community, improvement of data collection and interface between primary care and
NMUH.



4. ANTENATAL SCREENING PROGRAMMES

Commissioning and Governance arrangements
Antenatal screening programmes are generally commissioned locally by each PCT through
the maternity services contract. The diagnostic arm of the screening programme is



                                                                                                  8
commissioned via specialist commissioning and North Middlesex University Hospital will be
joining the consortium in 2010/11. The National Screening Committee (NSC) recommends
that each maternity Trust has a dedicated screening coordinator in place and both, NMUH
and the Whittington have screening-coordinators in place. All Trusts that provide antenatal
screening for Haringey women are commissioned by the Acute Agency however NHS
Haringey public health plays a role in monitoring performance against national standards.

4.1 Down’s Syndrome and fetal anomaly ultrasound screening

Programme details
All women are offered a minimum of two scans, dating scan (routinely offered at 11-14
weeks of gestation) and a second trimester fetal anomaly scan, as per national guidelines.

In 2003 the Department of Health recommended that all women should be offered combined
test for Down‟s syndrome screening in their first trimester. The test includes nuchal scan and
biochemistry markers. NMUH has introduced combined testing for high-risk women in August
2007 and started offering combined testing to all women in January 2008. Down‟s syndrome
screening is meeting national standards.

Key quality indicators and performance

  No of       No of     No of high risk        No of          No of     Uptake of    Uptake of      *Total        No. of
 Booking    combined     results from       secondary       high risk    Down‟s       prenatal     number     terminations
    s       screening      primary           screening       results    syndrome     diagnosis    of babies         of
 1/04/08      tests     screening test          test          from      screening   for Down‟s   born with     pregnancy
    -                                     i.e. screening   secondary                 syndrome      Down‟s      for Down‟s
31/03/09                                      for late     screening                             syndrome       syndrome
                                              bookers         tests                                   in
                                                                                                 timeframe
 4096         2172           86               729             39          2901         67            1             3
                                                                        (70.8%)      (78%)



North Middlesex University Hospital has made significant progress on the implementation of
combined testing. Over 70% of women have screening for Downs Syndrome. Of those who
are at raised risk defined by the National Programme, 78% go on to have a diagnostic tests
(75% is the standard).

Key issues of concern
•          Since the transfer from the PAS system to PROTOS, it is proving difficult to obtain
           complete data on gestational age at booking. This issue has been raised at the
           NMUH Antenatal Screening Committee Meeting and it is being addressed.
•          Late referrals are still significant (women who book after 12 weeks and are therefore
           not eligible for combined test).

Actions for improvement
•           Training of staff to use PROTOS;
•           Improved performance management arrangements in line with all the maternity
             performance;
•          The PCT has recently funded mobile ultrasound machine that will be used in health
           centres across east of the borough to promote access to early antenatal screening.




                                                                                                                        9
4.2 Infectious Disease Screening

Programme details
All women are offered screening for HIV, Hepatitis B, rubella and syphilis, as per national
standards. Bloods are requested by GPs or, more often by midwife at booking.

Key quality indicators and performance

Indicator                        Period         NMUH Performance                  % of
                                                                          positive/susceptible
                                                                                 women

Hepatitis B Screening – 100%    2008/09                100%                      2.5%
test offered

Uptake for HIV Screening –      2008/09                97.3%                      1%
90%

Uptake for rubella screening    2008/09                100%                      10%
– 100%

Uptake for syphilis screening   2008/09                100%                      1.1%
– 100%


Uptake of screening for infectious diseases is excellent.

Key issues of concern
•       Immunisation coverage of infants at risk of perinatal Hepatitis B. NMUH has high
         prevalence of hepatitis B infection and it is therefore vital to ensure that newborn
         babies are vaccinated and followed-up to receive full course of immunisation.
•       Data record on immunisation is currently incomplete and therefore it is challenging to
         track babies from infected mothers.
Actions for improvement
       The Acute Agency has procured new personal child health record booklets (red
        books) that would have a clear space for recording Hepatitis B immunisation. The
        books will be available at all the acute trusts in North Central London by April 2010
        for all newborn.
       A clear pathway on Hepatitis B immunisation should be developed and implemented
        in partnership between NMUH, Child Community Services and local GPs.

4.3 Sickle cell and thalassaemia screening

Programme details
All women are offered screening for sickle-cell and thalassaemia at 10 weeks of gestation.
The challenge locally is to meet national standards of 50% women screened between 8 and
10 weeks of gestation.




                                                                                              10
Key quality indicators and performance

   No of       No of      No of       No of        No      No of „at    No of „at   No of „at   No women
  bookings    women      women       partners   partners     risk‟        risk‟        risk‟      choosing
  1/04/08    screened   screened     offered    screened   couples      couples      couples    termination
     -                    by 10     screening                                         opting         of
  31/03/0                weeks                             Previously   Diagnosed       for      pregnancy
     9                                                       known        in this   prenatal
                                                                        pregnancy   diagnosis
  4096       4096       1109        309         152        83           23          14          1

All women who book at the NMUH are screened for haemoglobinopathies although it is
challenging to achieve timeline of 10 weeks. On average, most women are screened by 13
weeks of gestation.

Actions for improvement
        Strengthen performance management arrangements for a specialist nurse in the
         community and improve data collection and reporting;
        Strengthen and improve pre-conception care and early screening for sickle cell and
         thalassaemia in general practice;
        Mechanisms need to be put in place to ensure regular reporting on performance to
         NHS Haringey.


5. NEWBORN SCREENING

5.1 Newborn bloodspot screening

Programme details
All babies should be offered screening for 5 congenital diseases at 5 to 8 days after birth.
This is a complex screening pathway involving a range of organisations. The new
standards for this programme were introduced in 2008 and NHS Haringey Newborn
Boodspot Screening Policy is being revised to include the new standards.

The newborn bloodspot screening programme now includes tests for: Phenylketonuria
(PKU); Congenital hypothyroidism; Sickle cell disorders (expanded across London in 2003);
Cystic Fibrosis (implemented July 2007); medium-chain acyl-CoA dehydrogenase deficiency
(MCADD) that was implemented September 2008.

Key quality indicators and performance
The UK Newborn Screening Programme Centre (UKNSPC) produced process standards in
2005 that underpin the quality assurance of newborn blood spot screening; these standards
were revised in August 2008. The standards are set at two levels – core and developmental.

  UKNSPC standard                  Core standard definition                 NHS Haringey 2008/09


  Standard 2 Enhanced               95% of blood spot cards received                   81.8%
  tracking abilities                by laboratory include the baby‟s
                                    NHS number - mandatory from
                                    April 2010
  Standard 3 Timely sample         95% of first samples taken by 5-8                   91.3%
  collection                       days after birth


  Standard 4 Timely sample         100% samples received by lab                        95.6%


                                                                                                          11
           dispatched                     within 4 working days of sample
100%                                      collection
           Standard 5 Timely              The avoidable repeat rate is less              0.45%
           identification                 than or equal to 2%
           Standard 7 Timely receipt      100% of positive screening results    All positive cases into a
           of repeat/second blood         available and clinical referral      clinical pathway within 3
           samples                        initiated within 4 working days             working days
           Standard 8 Timely              100% of untested babies identified
           identification of babies for   by 17 days of age                     NHS Haringey is having
           whom the CHRD has not                                               difficulties with obtaining
           received specimen                                                   this data due to problems
                                                                                with electronic records.

       Key issues of concern
       •        Problems with Child Health Record Department (CHRD) e.g., there is no link with the
                newborn screening laboratories meaning electronic transfer of screening results to
                CHRD systems cannot be done and data on coverage is incomplete;
       •        Haringey is currently not meeting Core Standards 2, 3, 4 and 8.

       Actions for improvement
               RIO system has been introduced in Haringey recently and it is hoped that this
                electronic record keeping will improve the Standards greatly.
               Revised NHS Haringey Bloodspot Screening Policy implementation will also enable
                improvements in newborn bloodspot screening programme;


       5.2 Newborn Hearing Screening

       Programme details
       The Newborn Hearing Screening Service across the sector is provided by Barnet Provider
       Services for Barnet, Enfield and Haringey and by Islington Provider Services for Camden and
       Islington. The Barnet service is hospital based and the Islington service is community based.
       The majority of Haringey babies are born at North Middlesex Hospital (NMUH) and
       Whittington Hospital.

       At NMUH, the majority of the screening is carried out at the bedside prior to discharge from
       hospital by Barnet Provider Services. Haringey babies born at the Whittington are not
       screened by Islington Provider Services and appointments are made for them to be screened
       by Barnet. This delay has contributed towards not meeting the completed screens within 4
       weeks target.




                                                                                                             12
Key quality indicators and performance

                                                   Rate (%)
                               07/08              08/09                Q3 09/10

Screen complete by 4
weeks (95%)
                Haringey        41.1                46.7                  68.7
                 London         74.7                78.5                  85.7
                National        86.1                88.4                  91.9

Screen complete by 3
months (99%)
                Haringey        83.5                93.3                  94.8
                 London         90.4                92.6                  96.2
                National        95.2                96.4                  97.7

Screen incomplete
                Haringey        15.7                6.1                    2.1
                 London         8.7                 6.6                    2.8
                National        4.2                 2.9                    1.6


There have been year on year improvement for screens completed within 4 weeks (from
07/08 41.4% to Q3 09/10 68.7%); a reduction in screen incomplete rates (from 07/08
15.7% to Q3 09/10 2.1%) and improvement in screens completed by 3 months after birth
(07/08 83.5% to Q3 09/10 94.8%).

Key issues of concern
      The disadvantages of having two different service models servicing Haringey as well
       as across the sector are recognised. The change in service model is a significant one
       and work is underway to achieve the shift early in 2010.

      Despite the marked improvements and a closing of the gap between Haringey and
       London and nationally, the Haringey rates are still far from meeting the key target
       (95% of screen completed within 4 weeks). Progress is impeded by the dual service
       model and the delay in following up babies transferred into the borough unscreened
       and difficulties encountered by Barnet Provider in staff recruitment and retention (in
       part brought on by the uncertainties facing the service).

Actions for improvement
      The tendering of the service to create a single service model aims to bring about a
       step change in performance. There have also been 2 Quality Assurance visits (2007
       and 2008) from the National QA Team. Both visits had identified recruitment, training
       and coordination and administration concerns relating to Barnet Provider Services.
       Local action plans responding to the QA recommendations are in place and
       monitored.




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5.3 Newborn and Infant Physical Examination


All babies should have a newborn examination at the hospital followed by a 6-8 week
examination in the community. National standards and competencies were published in
March 2008.

There is currently a lack of standardised or robust systems across the country to effectively
monitor this programme. The National Screening Committee is taking this forward. As a
result there are no data to feedback for this report.


6. CONCLUSION

The population based screening programmes in Haringey are different in their structure and
the arrangements for commissioning and quality performance vary considerably.

While there are some examples of good performance such as antenatal screening at the
NMUH, NHS Haringey has recognised that there are a number of concerns around the
performance of the screening programmes overall. However action plans and governance
arrangements are in place to improve the quality, increase uptake and coverage and ensure
equal access to the screening services locally. Clinical governance systems are in place to
address serious untoward incidents and reduce risk and learning is regularly shared across
all agencies involved.

At the same time, NHS London has acknowledged that London‟s performance against the
national screening programme standards is not satisfactory. There is clear evidence that
screening programmes across the capital are underperforming, they are commissioned in a
fragmented way and are failing to secure good patient outcomes. In a response to poor
performance, the London PCT Chief Executives agreed to set up a Screening Improvement
Programme Board that is accountable to the London Specialised Commissioning Group in
February 2009. The Board has been focusing on reviewing commissioning arrangements for
Breast Cancer Screening and Newborn Hearing Screening however there are discussions to
expand its remit to cover all NHS Screening Programmes.

NHS Haringey Board is asked to note recent developments at the Strategic Health Authority
in regards to commissioning arrangements for the NHS Screening Programmes and to be
assured that improvement plans are in place to increase coverage and uptake.



Tamara Djuretic
NHS Haringey Screening Lead

Jin Lim
Associate Director of Public Health
Children and Young People

January 2010




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