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1. Introduction

This guidance aims to make sure that reasonable and effective failsafe measures are applied consistently across the NHS Cervical Screening Programme (NHSCSP), whilst avoiding unnecessary duplication of administrative effort.

This version updates and replaces guidance from 2018 to reflect the implementation of the primary human papillomavirus (HPV) screening pathway.

Failsafe is a backup mechanism. This makes sure that if something goes wrong in the screening, pathway processes are in place to identify what is going wrong, and what action should follow to ensure a safe outcome.

The value of a screening programme is diminished if appropriate action is not always taken to make sure that the right people are invited to be screened, or if the right action is not taken to follow up those with abnormal test results. Failsafe processes are designed to prevent or reduce these risks and errors occurring.

The call and recall system, used for the administration of NHSCSP call and recall, has meant that reliable failsafe measures for routine call and recall are in place. However, additional failsafe measures by laboratories and colposcopy clinics are needed for participants whose test results require referral for investigation or treatment in colposcopy.

2. The failsafe process

Failsafe processes make sure that as far as possible the cervical screening programme (CSP) takes the correct action following a cervical screening test, or that a valid reason for not taking that action is known and recorded. The effective monitoring of failsafe requires documentation of:

• the point at which a required screening activity is started
• the point at which it is concluded

This is usually via a failsafe systematic process or an IT system. In addition, providers should have local protocols to ensure that all processes close within an appropriate timescale.

Opening a process

This is a trigger which indicates that a process requiring a failsafe control for an individual has started. For example, an individual attends a cervical screening appointment and a sample is obtained by the sample taker.

Closing a process

This is an event or a stage of the screening pathway which signals the conclusion of a process requiring failsafe control for an individual. An example is the sending of a letter to notify a participant of their screening test result. There may be a number of events that can result in a particular process closing. For example, a process opened as a result of a participant being directly referred to colposcopy for further investigation and possible treatment will be closed by a subsequent appropriate cervical biopsy, a screening sample booked onto the laboratory information system (LIMS) or correspondence sent to cytology from the colposcopy clinic advising the outcome of the appointment.

Making sure the process is closed

This is an additional check, usually on a group of individuals. It identifies any individual for whom a failsafe process remains open beyond a defined timescale. An example is a check by the laboratory to ensure all participants directly referred to colposcopy have a valid outcome.

Most screening pathways will involve multiple failsafe processes at different levels of detail. For example, a failsafe process to make sure that every participant requiring colposcopy receives direct referral can exist within a broader process making sure that call and recall notify every participant of their screening result.

A failsafe overview is given in appendix 1: failsafe overview (primary HPV).

3. The role of the screening commissioner

NHS England (the commissioner of screening services) has responsibility on behalf of the Secretary of State for Health to commission and contract according to national regulations and guidance to ensure a safe, accessible and effective service. Cervical screening requires actions to pass safely and effectively between many different organisations.

The commissioners will seek assurance that all stages of the screening process work well together. Commissioning for cervical screening, alongside other commissioning for screening programmes, has additional professional support from screening and immunisation teams (SITs).

4. Call and recall system

4.1 Cervical screening call and recall administration provider responsibilities

NHS England is responsible for commissioning the call and recall IT system which supports the local delivery of cervical screening and provides data for monitoring programme effectiveness. The call and recall system is provided by the Cervical Screening Administration Service (CSAS). The call and recall system records the screening history for everyone who has participated in the screening programme in England. The system provides a means of:

• identifying individuals who are due for a cervical screening invitation
• sending, receiving and acting on prior notification lists of individuals due for a cervical screening test, which general practitioners (GPs) have updated to ensure individuals are not invited inappropriately
• inviting eligible individuals for cervical screening tests at the routine screening interval
• inviting participants for an early repeat test before the routine screening interval
• sending individuals information to assist them to make an informed choice about whether to participate in screening
• receiving, validating and confirming receipt immediately of screening results sent by the laboratory
• recording screening results
• informing participants in writing of their screening results
• sending reminder letters to individuals if no test result has been entered on the system after the test due date
• providing non-responder notifications to the individual鈥檚 GP if no test result has been entered on the system after the test due date has passed and reminders have been sent
• operating a failsafe system which ensures that eligible individuals are invited for screening again at an appropriate interval even if no other action is recorded on the system
• operating a failsafe system which ensures that individuals referred to colposcopy are invited for a further cervical screening test at 12 months following the referral if no further results or outcome is entered on the system
• receiving, receipting and updating the system with next test due dates or ceasing instructions from discharge lists sent from colposcopy clinics, and querying with colposcopy any dates or instructions not meeting validation criteria

For participants who attend screening, the sequence of notifications issued by the call and recall system is determined by action codes allocated by laboratories to each test result.

4.2 Early repeat tests

The call and recall system provides a failsafe for participants recommended for an early repeat test. Laboratory failsafe is not required.

Call and recall generates the following notifications if no test result is entered into the system after a defined number of weeks following the invitation. The time periods are:

• 18 weeks after invitation 鈥� a first reminder (early repeat) letter to the participant
• 32 weeks after invitation 鈥� a non-responder notification to the GP
• 12 months after invitation 鈥� a new early repeat invitation letter

The call and recall system also provides validation checks as an additional safeguard for participants who have had a recent abnormal result to prevent an inappropriate immediate return to routine recall (see section 4.3).

4.3 Validation checks

The call and recall system validates all test results entered into the system to ensure that:

• the result and action codes allocated by the laboratory form a valid code combination
• participants who require more than one follow-up test after an abnormal result are not returned to routine recall prematurely

A summary of the result and action codes is included in appendix 2: cervical screening result and action codes (primary HPV) part 1. Valid code combinations are shown in appendix 2: cervical screening result and action codes (primary HPV) part 2.

Some participants will require 2 or more normal tests after an abnormal screening test result before they can be returned to routine recall. A normal test result is any combination of cytology and HPV test results that can validly have a routine recall action.

Under the HPV primary screening protocol, only an HPV negative test result is considered normal. However, there are other results from historic screening protocols that can be considered if they are recorded in a person鈥檚 screening record (see appendix 2: cervical screening result and action codes (primary HPV) part 3). When the rollout of primary HPV screening is complete this will only include the X0A code combination.

Participants who cannot be returned to routine recall at their next normal test are those whose most recent adequate NHS test was one of the following result code combinations.

3R, 8R or 9R
4S, 49S, 4US or 4QS
5S, 59S, 5US or 5QS
6S, 69S, 6US or 6QS
7S, 79S, 7US or 7QS

Colposcopy outcomes are not recorded on the call and recall system. The system will therefore only enforce the minimum requirement for follow-up based on the most favourable possible colposcopy outcome for any given screening test result. In all cases, a maximum of 2 consecutive HPV negative results will be required before a participant can be returned to routine recall. In practice, this means that a routine recall action (code A) can be recorded in conjunction with a participant鈥檚 second normal test result so that their subsequent next test due date will be set at the routine recall interval.

A laboratory must always check that a routine recall recommendation is appropriate with reference to a participant鈥檚 screening history before issuing an A-coded result. It is important to note that the call and recall system cannot be relied upon to identify inappropriate recommendations for routine recall in all cases.

If a participant was referred for colposcopy after a screening result not subject to validation and requires non-routine recall (for example B9S leading to untreated CIN1), the system will accept a routine recall-coded normal result at the next test if one is provided by the laboratory. Similarly, if a participant under follow-up after treatment for CGIN requires 3 or more consecutive normal tests, the system may accept a routine recall-coded normal result at the first or second subsequent test if one is provided by the laboratory, dependent upon the immediately preceding screening test result.

The call and recall system will, in accordance with professional guidance, allow an immediate return to recall when a normal test result is entered for a participant whose most recent abnormal test (regardless of cytological classification) was taken more than 5 years earlier.

The call and recall system will apply the validation rules to all test results including those from participants who are on a non-standard screening pathway (such as participants whose pathway began under a superseded screening protocol or who had a private test which was recorded on the screening system as a non-standard result). This will include participants who had a borderline or low-grade abnormal test result without a referral for colposcopy prior to the implementation of HPV triage and test of cure. Such participants should have at least 3 consecutive cytology negative tests before routine recall unless a follow-up test was normal that included a negative HPV result. The system will no longer prevent a return to routine recall on the second normal result.

If the system rejects a test result because it has failed validation checks then the call and recall department should notify the laboratory immediately in writing and ask for the test result to be reviewed and resent.

4.4 Individuals who move address

An individual retains their next test due date even if they move to a different part of England. If the participant registers with another GP then their address can be updated on PDS so they still receive relevant and timely invitations, reminders and result letters. If the participant has not registered with another GP, correspondence will continue to go to their previous address.

4.5 Participants who request screening results to be sent to an alternative address

When a participant requests that their cervical screening results go to an alternative address the arrangement will only apply to that single screening episode. Future call and recall letters and results letters will then default back to their home address by default.

In some circumstances it may be necessary for the GP (or clinician responsible for requesting the test) to ensure that alternative arrangements are made to give the person their test result, and to ensure that any necessary referral for investigation or treatment is completed. The GP (or responsible clinician) must ensure that the person understands that by requesting no results correspondence to the home address, they take on the responsibility for collecting the test result and for responding to any recommendation for further tests or investigations. The person must also understand that the arrangement is for that single screening episode only.

5. Failsafe in primary care

5.1 GPs providing cervical screening services

GPs that provide cervical screening services in accordance with the are responsible for:

• making sure that the eligible individual is provided with the necessary information and advice to assist them in making an informed choice about whether to participate
• respecting the wishes of individuals who wish to be ceased from screening, supporting them in making their decision, and notifying the call and recall service where necessary
• acting on non-responder notifications for individuals who have not responded to an invitation for a routine test or early repeat test
• inviting eligible individuals who have not responded to their centrally produced invitation and reminder letters (sending a third invitation)
• making sure that individuals no longer eligible for screening (due to absence of cervix or pelvic radiotherapy) are notified to the call and recall service promptly
• reviewing prior notification lists from call and recall services and revising accordingly
• making arrangements for taking an appropriate cervical screening sample in line with programme guidance and according to the participant鈥檚 circumstances
• arranging for a participant to be informed of their test result (1)
• discussing the test result in person with the participant if required for cases of high-grade dyskaryosis/ ?invasive squamous carcinoma or ?glandular neoplasia of endocervical type
• giving a participant their test result in person where an urgent referral is required for ? glandular neoplasia (non-cervical)
• ensuring that arrangements are made for participants who fall outside the call and recall system to receive their test results
• making sure that the test result is known and followed up appropriately
• for intersex individuals with a cervix, female to male transgender (trans) men, and for individuals who identify as male but require cervical screening, the GP should take responsibility for and arrange the screening process, as the call and recall service is not commissioned to send invitations or results to people registered as male 鈥� the GP should also notify the laboratory that the results should be returned to the practice directly
• referring a participant for further investigation and treatment where necessary (for example, a participant needing colposcopy who has moved from another area, or a participant who has been discharged following a previous non-attendance at colposcopy) (2)
• acting on the non-responder notification from the colposcopy clinic for participants who have not attended for colposcopy
• cooperating promptly with failsafe enquiries from the laboratory about a participant who requires further investigation and treatment (3)

(1) Although it remains the responsibility of the GP to make sure participants are informed of their test result, this function is provided automatically by the call and recall service once a valid result is received.

(2) All laboratories operate a direct referral system for colposcopy in conjunction with their local colposcopy clinics. In areas using this system, the GP still has a responsibility to make sure that colposcopy has taken place.

(3) It should be noted that failure by providers to respond to failsafe enquiries should be considered as a clinical governance issue.

5.2 GPs opting out of cervical screening services

Under the , some GPs may choose not to provide cervical screening services for their registered population. NHS England has the responsibility for commissioning cervical screening for this population.

5.3 Other clinicians responsible for requesting a cervical screening test

Cervical screening services may be provided in other settings including community clinics, out-of-hours clinics and genito-urinary medicine (GUM) clinics. Clinicians responsible for requesting cervical screening tests are also responsible for:

• ensuring the individual is provided with the necessary information and advice to assist them in making an informed choice about whether to participate
• making arrangements for taking an appropriate cervical screening sample in line with programme guidance (1)
• arranging for the participant to be informed of their test result
• arranging for the participant鈥檚 GP to be notified of the test result
• ensuring that there is a mechanism in place so that the test result is followed up appropriately (2)
• ensuring the participant receives colposcopy for further investigation and treatment where necessary, where the clinician has responsibility for the participant鈥檚 clinical care for example in a GUM clinic, or where the clinician is providing a cervical screening service because the participant鈥檚 GP has opted out
• co-operating with failsafe enquiries about a participant who requires further investigation and treatment (3)

Where another health care provider rather than the individual鈥檚 GP provides cervical screening, the provider should have clearly documented and agreed roles and responsibilities in place to ensure that:

• participants are followed up appropriately
• a record of the participant鈥檚 screening history is maintained
• adequate failsafe provision is in place

5.4 Further responsibilities of sample takers

In addition to the responsibilities outlined in the sections above, sample takers are responsible for:

• maintaining a register of tests taken
• checking that a test result has been received from the laboratory for every sample taken, within an appropriate timeframe (the practice must have a procedure in place to investigate any sample result not returned)
• making sure all samples are repeated or taken at the correct interval
• making sure the screening history of all newly registered individuals at the GP practice is reviewed prior to taking a sample, to ensure samples are taken appropriately
• making sure that when a test sample has been rejected by a laboratory (see Guidance for acceptance of cervical screening samples in laboratories) the participant is informed and advised regarding repeat testing where appropriate

6. Laboratory failsafe

6.1 Role of the laboratory

Laboratories are responsible for:

• transferring test results and recommendations for management to the call and recall system using standard result and action codes
• notifying the sample taker and GP (or responsible clinician) of test results and recommendations for management
• operating a direct referral system for participants who need a referral to colposcopy 鈥� this will include daily communication with each colposcopy clinic
• informing GPs and responsible clinicians about participants who require referral for colposcopy
• making sure that histology results are collated with cytology results

Laboratories must set up and operate a failsafe system for participants who require referral for colposcopy and are directly referred from the laboratory.

The guidance for laboratories providing HPV testing and cytology services provides information on test results which require referral for colposcopy.

The guidance applies to samples from both primary care and gynaecology clinics. All test results which are subject to laboratory failsafe have an action code S (鈥榮uspend from recall鈥�). Laboratory failsafe procedures should operate during the period of suspension from recall (a maximum of 12 months). The call and recall system provides a final failsafe by returning the participant to recall after a maximum period of 12 months from the date that the test result is recorded.

6.2 Laboratory failsafe system

The lead pathologist for the service is responsible for making sure that a laboratory failsafe system is in place.

The cytology laboratory must:

• keep a record of all test results which are subject to laboratory failsafe
• ensure that the participant鈥檚 GP (or responsible clinician) is notified of test results which require urgent referral
• send the GP (or responsible clinician) sufficient and timely information to respond to queries from participants about their urgent referrals (this may be covered by existing result notification in which case the laboratory is not required to phone the GP)
• record colposcopy attendance and outcome (as defined in the KC61), such as histology results following tests which are subject to laboratory failsafe
• initiate failsafe enquiries to the participant鈥檚 GP (or responsible clinician) if no colposcopy attendance or outcome is notified to the laboratory
• keep a record of all failsafe enquiries (including letters, phone calls, emails)
• send the GP (or responsible clinician) a closure letter when laboratory failsafe enquiries have been made and actions are closed
• keep records of communications from the call and recall service confirming receipt of laboratory test results, and make enquiries of the call and recall service if no receipt is received so that prompt action can be taken as needed
• act immediately in response to call and recall queries on test results
• audit the laboratory failsafe procedures on an annual basis

6.3 Direct referral

The laboratory must have an internal audit system in place to ensure that all direct referrals have been made in a timely fashion to the appropriate colposcopy unit.

The laboratory must have a system to make sure that the appropriate colposcopy units have received all referrals. The colposcopy unit must confirm to the laboratory that they have received the referrals. This also includes both parties confirming if there were no referrals sent or received on a particular day.

The referral arrangements for participants needing investigation following a cytology result of non-cervical glandular neoplasia are not within the remit of the cervical screening programme. It is important that a system is in place for the safe handover of these participants to the appropriate service. It is also good practice to ensure that an outcome is received from these referrals to support cervical cytology staff education and training and to make sure there were no histological findings that involved the cervix.

These participants also require early repeat screening or a referral to colposcopy for their hrHPV positive result, according to the primary HPV screening protocol for participants who test hrHPV positive with negative cytology.

If local direct referral policies exclude urgent referral of non-cervical glandular neoplasia, there is still a requirement for individual notification of these results to the GP.

6.4 Laboratory failsafe enquiries

Access to histology and ideally, to colposcopy databases at all providers where biopsies are reported is crucial for a centralised laboratory referring participants to several different colposcopy clinics. This will reduce the number of failsafe enquiries the cytology laboratory has to perform for those:

• who have not attended
• who have attended but not had a biopsy

6.4.1 Laboratory failsafe enquiries for participants urgently referred with results of high-grade dyskaryosis/?invasive squamous carcinoma or ?glandular neoplasia of endocervical type

If the laboratory has no information about the colposcopy or histological outcome after 6 weeks, failsafe enquiries should be made to the multi-disciplinary team (MDT) or colposcopy clinic and the histology laboratory, then the GP (or responsible clinician) depending on the response. Enquiries are made in writing and a record kept of these and the responses. Example template letters are provided in appendix 3: example failsafe enquiry letter - colposcopy (primary HPV) and appendix 4: example failsafe enquiry letter - GP (primary HPV).

6.4.2 Laboratory failsafe enquiries for non-urgent referrals and participants referred with results of high-grade dyskaryosis (moderate or severe)

This section describes failsafe arrangements for all screening referrals not included in 6.4.1 above.

If the laboratory has no information about the colposcopy or histological outcome after an agreed interval (normally 3 months from the date of the test result, but this may depend on local colposcopy waiting times), failsafe enquiries should be made to the colposcopy clinic and the histology laboratory, then the GP (or responsible clinician) depending on the response. Enquiries are made in writing and a record kept of these and the responses. Example template letters are provided in appendix 3: example failsafe enquiry letter - colposcopy (primary HPV) and appendix 4: example failsafe enquiry letter - GP (primary HPV).

A single enquiry in writing is sufficient. If there is no response, the laboratory should check that the enquiry has been received. Failure to respond to a failsafe enquiry is a clinical governance issue which the laboratory should raise with the provider and relevant SIT.

6.5 Closure of laboratory failsafe

If the participant has attended colposcopy or is removed from call and recall, the laboratory failsafe can be closed. Otherwise, the laboratory should keep failsafe enquiries open for those participants who do not attend colposcopy for at least 6 months (or 12 months if the person is known to be pregnant) after the date of the test result.

If the person does not attend, responsibility for taking any further action rests with the GP (or responsible clinician) who is managing the care of the individual. The laboratory should inform the GP (or responsible clinician) that no further failsafe action will be taken by the laboratory (failsafe closure letter).

If a participant is known to have moved address or is no longer registered with the GP, the laboratory can identify the new GP from the call and recall system and forward the failsafe enquiry.

6.6 Cases where follow-up cannot be established

As part of the annual audit of the laboratory failsafe system, laboratories should keep a record of all participants for whom colposcopy attendance and outcome (as per KC61) could not be established.

The laboratory should provide a quarterly summary report to the SIT, who commission and performance manage the programme, and the cervical screening provider lead(s) (CSPL) linked to the cytology laboratory. The report should detail the findings of failsafe actions for all participants referred to colposcopy. No patient identifiable data (PID) information is required in this report.

The purpose of the report is to assure public health commissioning teams that all appropriate failsafe actions have been taken. Commissioners can also use this information to monitor the performance of the local service and identify practices, geographical areas or groups of participants in order to target screening initiatives.

The summary report should include:

• the number of participants subject to failsafe in the time period covered by the report, for each colposcopy clinic in each provider
• the number of participants who attended their colposcopy appointment, for each colposcopy clinic

• the outcome of failsafe enquiries for those participants who did not attend 鈥� for each colposcopy clinic include reasons such as:

  • pregnancy
  • temporarily moved away
  • permanently moved away
  • undergoing treatment for a condition where colposcopy would be clinically inappropriate
  • no longer registered with a GP
  • death
  • participant has declined further investigation
  • reason not known
  • number of instances of no response to a failsafe enquiry by GP or colposcopy clinic

7. Colposcopy clinics

7.1 Referrals for colposcopy

Responsibility for making sure a participant has been referred for colposcopy rests with the GP (or responsible clinician), irrespective of direct referral arrangements that are in place. Following direct referral, the responsibility for failsafe moves to the colposcopy unit. If the participant attends for colposcopy, the colposcopist to whom they are referred becomes responsible for their treatment, arranging any further follow-up and informing the laboratory and the GP (or responsible clinician) of the outcome.

If a participant declines their appointment and chooses to attend a different colposcopy unit (NHS or private) the colposcopy unit that received the initial referral should document this to ensure they are able to respond to failsafe enquiries. Some colposcopy units will pass on the referral to the alternative provider. The GP is responsible for making sure that the referral has been made.

7.2 Outcomes of colposcopy

Colposcopy clinics must have a system for notifying laboratories of colposcopy attendance and the results (such as histology results). This includes the results from colposcopy procedures carried out under general anaesthetic. They must also notify the GP (or responsible clinician).

7.3 Colposcopy discharge processes

Comprehensive failsafe processes are in place to manage the follow up of individuals in colposcopy and their discharge to primary care. This ensures that individuals are invited for their next screening test at the appropriate interval in the appropriate care setting.

This guidance is to assist colposcopy services (including those where screening samples are taken) to complete the discharge template with the next test due dates for all individuals discharged from the colposcopy service. The subsequent list is then sent to both the call and recall provider and cervical screening testing laboratory. Management of individuals should be agreed before entering them on the discharge list (cervical screening care pathway). The guidance also assists the call and recall provider to perform the appropriate actions based on the information provided by the colposcopy service.

For individuals who need to be ceased from cervical screening, details can be found in ceasing and deferring individuals from cervical screening.

Roles and responsibilities for colposcopy discharge processes

Flowcharts (and accompanying text version) have been developed to describe the colposcopy discharge process (Appendix 5).聽 The process is complex and involves a number of organisations. Clear and comprehensive communication throughout this pathway is essential so that individuals participating in screening are not invited at the incorrect intervals.

Each arm of the flowcharts describes a different referral scenario.

Flowchart 1

Individuals who are eligible for cervical screening and referred to colposcopy due to an abnormal screening test or cervical abnormalities detected following non-screening referral 鈥� this flow covers the majority of individuals seen in colposcopy and describes how to manage the colposcopy discharge list depending on whether a colposcopy assessment, diagnostic biopsy or treatment was undertaken as required (1a), or a follow up screening test taken in colposcopy (1b). The majority of individuals will be discharged to primary care for follow up.

Flowchart 2

Individuals referred to colposcopy for non-screening reasons where no abnormality is detected 鈥� these individuals must not be included on the colposcopy discharge list as no changes are necessary to their next screening test date.

Flowchart 3

Individuals who are eligible for cervical screening and referred to colposcopy where the screening test cannot be taken in primary care, for either routine (3a) or early recall (3b) 鈥� it is essential to be clear on the sample request form that this screening test is being taken on behalf of the GP/primary care sample taker. Where this information is provided, the laboratory should apply the recall status as if the test had been taken in primary care to avoid unnecessary use of the 鈥淪鈥� code status.

鈥淪鈥� code status indicates that the individual is suspended from national call and recall for 12 months whilst referral and investigations take place. It acts as a failsafe and will ensure the call and recall system reinvites the individual for screening unless a test result is received within the 12 month period that has an 鈥淎鈥� (routine recall) or 鈥淩鈥� (early recall) code status, or the colposcopy service has advised a different next test due date following the outcome of investigations.

Flowchart 4

Individuals having an early recall test taken in colposcopy with a hrHPV negative result leading to a return to routine recall.

Flowchart 5

Individuals who are not eligible for call recall for cervical screening and are referred to colposcopy. These individuals must be managed within the colposcopy service. Do not include these individuals on the colposcopy discharge list as no changes are necessary to their next screening test date. For those who are eligible and wish to opt back into cervical screening follow the flows for eligible individuals.

Colposcopy

Cervical sample takers in colposcopy must specify the reason the screening test is being taken on the sample request form and include details of the original reason for referral and previous history. This ensures the laboratory has clear information on why the test was taken and what management is likely to be appropriate. For example, referral for routine screening test, referral for surveillance/follow up screening test, follow up from treatment for CIN3/CGIN, follow up for CIN1, conservative management of CIN2.

Produce a clinician-validated list (template included in appendix 6) of all individuals discharged from colposcopy (as indicated on the flowcharts) on a minimum of a monthly basis and send to the call and recall provider. A record of lists sent, and confirmation of receipt must be maintained by colposcopy. Individuals who are discharged for non-attendance should not be included on the discharge lists.

Calculate the next test due date from the date the individual was last seen in colposcopy prior to discharge. If the individual is to be returned to routine recall (5 years) and is aged 60 or over at the date of their last attendance in colposcopy, indicate that the individual can be ceased from recall for age (ceasing and deferring individuals from cervical screening).

Colposcopy services must check the status of the individual using the Cervical Screening Management System to check whether the individual is already ceased.

Colposcopy services must check with the cervical screening laboratory if there is a query over the correct management.

Colposcopy services are responsible for responding promptly to queries raised by the call and recall provider about the discharge lists.

Screening laboratory

Apply the appropriate action code for the circumstances based on the information provided by the colposcopy clinician and available history. Where the individual鈥檚 history suggests that an early or routine recall is the appropriate action, an 鈥淩鈥� code and appropriate months or an 鈥淎鈥� code, based on the laboratory guidance should be used. The 鈥淪鈥� action code may be used by the laboratory when it is not clear that the individual is likely to be discharged as a result of the test.

Laboratories should highlight to the colposcopy service if sample request forms do not contain the necessary information so that quality improvements can be made.

Call and recall provider

The call and recall provider is not responsible for making any clinical decisions on future management. The call and recall provider is responsible for querying with the colposcopy service where information is unclear or appears to be outside national guidance.

When the call and recall provider send a query to the colposcopy service in line with the flowchart action, the call and recall provider will implement what the colposcopy service advises as colposcopy takes responsibility for determining the next test due date.

After taking a routine screening test on behalf of the GP, the colposcopy service can request an individual to be ceased due to age where the individual is aged 60 or over and their next test due date would be in 5 years. If the corresponding screening test result has an 鈥淪鈥� action code, the call and recall provider will contact the laboratory to check the individual鈥檚 history and where appropriate resend the test result with the 鈥淎鈥� action code. This enables the individual to be appropriately ceased for age.

The call and recall provider is responsible for promptly confirming receipt of colposcopy discharge lists to the colposcopy service.

The call and recall provider must check that colposcopy services are providing discharge lists chronologically with no date gaps between lists and contact colposcopy services should queries arise. The call and recall provider will contact colposcopy services, commissioners and SQAS when discharge lists have not been received for a 3 month period as an additional failsafe to reduce the risk of incidents arising.

7.4 Responsibilities for failsafe

The lead colposcopist for the service has responsibility for ensuring that a colposcopy failsafe system is in place.

Colposcopy clinics must:

• confirm receipt of all referrals sent by the laboratory on a daily basis (or confirm no referrals received)
• have an auditable system to ensure an appointment is allocated to all referrals received
• send invitation letters or appointments to participants directly referred for colposcopy
• have a system to make sure participants can have their appointment rebooked for a more suitable time
• send a letter to all participants who do not attend for their appointment advising how they can be re-referred to colposcopy
• send a non-responder notification to the GP (or responsible clinician) and the laboratory if a participant does not attend a first appointment for colposcopy
• send a non-responder notification to the GP (or responsible clinician) and the laboratory if a participant does not attend a follow-up appointment for colposcopy
• have systems in place to make sure a result is received for all cervical screening or histology specimens taken in colposcopy
• send a clinician-validated template of the next test due dates and ceasing requests for all participants discharged from the colposcopy clinic to the call and recall service and the laboratory
• keep records of communications from the call and recall service confirming receipt of the discharge template and make enquiries of the call and recall service if no receipt is received so that prompt action can be taken as needed
• inform the participant and their GP (or responsible clinician) of the future management plan for all participants, make the appropriate arrangements for further colposcopy appointments where indicated (including MDT discussion and agreed outcome) or onward referral, and make sure the GP is aware that they will be responsible for future follow-up for participants who are being discharged
• respond to failsafe enquiries by laboratories
• have a system in place to make sure participants deferring appointments are re-invited at the correct interval
• perform a continuous audit (and produce audit reports) of referrals received against outcome to make sure all participants are accounted for

The CSPL should address any failure to respond to laboratory failsafe enquiries as a clinical governance issue.

8. Cervical screening provider leads

CSPLs may be based in any discipline within the organisation that provides a service to the NHSCSP. They are responsible for ensuring that documented failsafe arrangements (as indicated in this guidance) are in place, and audited regularly, for the cervical screening programme activities carried out by the provider or organisation.