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GP mythbuster 104: Cervical screening
As we move into COVID-19 recovery, GP practices and services commissioned to take part in the NHS cervical screening programme continue to restore services and build capacity for the programme.
The national cervical screening programme Cervical screening programme tests for high-risk human papillomavirus (HPV) as HPV is the cause of 99.7% of cancers. If a test is positive, the programme checks the sample for changes in the cervix cells. These may lead to cancer in the future.
All eligible women and people with a cervix aged between 25 and 64 should be invited to take part. This is unless they have opted not to. The initial invitation for screening is usually sent in advance for the person to be screened by their 25th birthday.
Sample takers and non-clinical primary care staff play an important role in the cervical screening programme. They ensure eligible women and people with a cervix:
- can make an informed decision about whether to attend screening
- are invited to screening appropriately
Cervical screening can present many complex issues for some women. Everyone has different needs so approaches to the programme need to be made to support those needs.
Public Health England has published cervical screening: professional guidance. It contains standards and information for those working in NHS cervical screening programme. This includes programme management.
Charity Jo’s Cervical Cancer Trust produced cervical screening guidance for healthcare professionals. This includes information and resources practice staff can access:
- good practice for cervical screening
- informed decision making
- improving access for cervical screening
- barriers to screening
- myths and facts
- COVID-19 information
- suggested language to use
- resources for information stands
- general patient information
- suggestions for drop-in clinics
- answers to frequently asked questions.
Improving uptake of cervical screening can be complex. Practices should consider their current screening uptake in comparison to the national target rate. For non-attenders, providers should attach a message to their clinical record and make sure screening is raised at the next appropriate visit. Clinicians should discuss the benefits of screening, including identifying barriers that may prevent attendance.
GP reception staff should have access to appropriate update training. They should be fully informed of any changes to the screening programme.
An understanding of the local patient demographics are needed to understand which patients the practice should be trying to make the test more accessible for. This would include consideration of:
- age ranges
- languages spoken
- cultural needs
- LGBTQ+ communities
- other demographics.
Public Health England has published data on improving access and making cervical screening more accessible.
Improving access to cervical screening can include:
- targeting population groups or communities
- getting involved in cervical cancer prevention
- screening awareness weeks.
Jo’s Cervical Cancer Trust provide a variety of health promotion resources.
When planning to improve coverage, practice staff should remember that taking part in screening is always an individual choice. Practices should link with local screening programme boards. All services are then aware, and prepared, for increased demand for screening.
Effective administration of the call and recall service is a main part of the cervical screening patient pathway. Public Health England has published information on cervical screening recall administration best practice.
Providers must have reliable call and recall systems in place. This includes:
- standard operating procedures and detailed work instructions following national guidance
- clear operational instructions
- a programme of audit and non-conformance monitoring.
Mental capacity and consent
The decision to attend screening is the choice of the invited person.
‘There must always be the presumption that people you provide care or treatment for have capacity to make decisions for themselves’.
A best interest decision can be made on the persons behalf by the appropriate people. For example, the person’s family, carer, and or GP.
The Office of the Public Guardian has published Making decisions: a guide for people who work in health and social care. The guidance covers:
- the five principles of the MCA
- assessing capacity
- best interest decisions
- providing care for people who lack capacity.
Consent is an important aspect of providing care and treatment. It is important that any decision a person with a cervix makes is informed. Information provided should be unbiased and factual. Sample takers must make sure patients:
- understand what screening is and is not
- have access to accessible information
- know what will happen during a test
- can opt out at any time.
Once the sample-taker is confident the person understands the test, consent should be recorded. The practice decides how this is recorded.
Public Health England have published guidance and information on consent and ceasing patients from screening programmes. The NHS Cervical Screening Administration service (CSAS) provides forms to be used for patients withdrawing from the programme.
If the woman or person with a cervix has not understood enough to make their own decision on cervical screening, a best interest decision may need to be made.
Barriers to cervical screening
There are many reasons why women and people with a cervix choose not to attend screening or find cervical screening difficult. Reasons can vary between different groups or communities.
- physical disabilities
- fear of judgement or results
- previous trauma or female genital mutilation (FGM)
- lack of understanding.
Public Health England has developed guidance to support individuals who find attending cervical screening difficult, due to:
- mental health issues
- previous traumatic experiences
- sexual abuse.
This information talks about support for people who feel anxious attending cervical screening. They can use this information to help decide whether to attend. It can help them plan for their screening appointment.
Practice staff can share suggestions to help patients during the screening procedure. These could include:
- bringing a friend
- listening to music or a podcast
- wearing a skirt or loose clothing.
Practices have a duty of care to ensure all individuals have access to cervical screening. People with a physical disability may find it hard or impossible to attend for cervical screening. This may be because of:
- lack of wheelchair access
- problems getting onto the examination couch
- previous misunderstanding, dismissal and negative experiences of cervical screening.
The Equality Act 2010 states it is a legal duty to make reasonable adjustments for disabled people. This includes people with a learning disability and autistic people. The Accessible Information Standard should be met.
Practices could consider investing in equipment. For example, a hoist or adjustable couch. Practices could refer patients to the colposcopy department at a local hospital. They could also refer patients to another surgery.
If practices consider offering cervical screening on home visits, a risk assessment should be carried out. Risk assessments should be done on an individual basis. This is so the individual can be supported by other services if they need treatment, follow up, or referral to hospital.
All women and people with a cervix aged 24.5 to 64 years, whether they are sexually active or not, are entitled to cervical screening.
People with a learning disability and autistic people are almost four times less likely to go for cervical cancer screening. The reasons given for ceasing and/or not screening suggest that simply being coded as having a learning disability is not the only reason. Sample takers should be aware of the appropriate reasons not to screen and providing screening for women with learning disabilities.
Barriers may include:
- lack of routine
- lack of easy-read invitations
- difficulties using appointment systems
- time pressures
- mobility issues
- communication difficulties.
Public Health England has published guidance on supporting women with learning disabilities to access cervical screening. This includes resources and guidance for health professionals, social care staff, and family members, to help someone with learning disabilities to attend their cervical screening appointment.
Communication is important for the success of the cervical screening experience. Carers may need to be consulted to understand how the person communicates. The person may need an interpreter or signer at the screening appointment. They may want to use Makaton rather than British Sign Language.
Practice staff may also consider offering longer appointment times and pre-appointment visits. These can help to familiarise patients with the practice and staff.
Public Health England’s easy guide to cervical screening helps people with learning disability decide if they want to attend. People without a learning disability may also prefer this easy guide format.
Sample takers can also direct people who cannot read or do not like written words to the Beyond Words cervical screening picture story. This includes a suggested storyline for family members, carers or health professionals to refer to.
An editable, easy read version of the cervical screening invitation letter is available for use as a template. It can be used invite people who have a learning disability. If requested, the easy read invitation letter should be sent with the easy guide instead of the standard letter and leaflet.
Jo’s Cervical Cancer Trust has produced a smear test film. This is designed and made by women with a learning disability. It provides information about smear tests and their role in preventing cervical cancer. The video helps women decide whether to attend their smear test invitation.
Cervical screening for women from Black and minority ethnic communities
There is a lower take-up of cervical screening by women from Black and minority ethnic communities. This may be because of barriers such as:
- lack of good quality information on the importance of screening
- some misconceptions about risk
- cultural or translated information may not be available for those whose preferred language is not English.
Public Health England has published information about making cervical screening more accessible. They have also published leaflets on cervical screening: helping you decide in various different languages.
Cervical screening for lesbians and bisexual women
Cervical screening is for all women and anyone with a cervix aged 25-64. This includes lesbians and bisexual women. Women who do not have sex with men can get cervical cancer and need cervical screening. Health workers have sometimes advised lesbian women that they don’t need to have cervical screening because they do not have sex with men. Some lesbians also share this misconception. Cervical screening uptake is lower for lesbians and bisexual women. They may also not attend screening because of negative experiences of health services.
Public Health England has produced guidance on cervical screening for lesbian and bisexual women.
Cervical screening for trans or non-binary people
Screening invite systems rely on the gender that an individual is registered as in their GP records. Every person who has a cervix and is within the screening age range is eligible for NHS cervical screening. This is regardless of their gender identity. A trans man still registered as a female (or non-binary) who has a cervix will automatically be included in the screening programme. However, a trans man registered as a male who has a cervix will not be invited for screening by the national programme. Screening invitations should be made by the GP practice or healthcare team managing the gender affirming surgeries.
Cancer Research UK has published patient information on cervical screening for trans or non-binary people.
Jo’s Cervical Cancer Trust has produced information on barriers to cervical screening for transmen and/or non-binary people.
Public Health England has published a screening leaflet NHS population screening: information for transgender people which aims to improve accessibility to screening for trans and non-binary individuals.
Chaperones and other considerations
Providers must make sure they provide care and treatment that ensures people's privacy, dignity and always treats them with respect. It is important for sample takers to check a person’s preferences about their cervical screening. This could include, asking if the patient would like a chaperone. Even if this question has been asked at reception or promoted by posters displayed. We have published a GP mythbuster on chaperones.
All registered nurses and midwives who undertake cervical screening should have access to training programmes. This equips them to undertake safe cervical screening. Training includes ongoing continuous professional development opportunities.
The Royal College of Nursing (RCN) and UK National Screening Committee (UK NSC) recommended sample takers:
- familiarise themselves with local polices
- understand all national screening programmes.
Sample taking for the cervical screening programme is not part of pre-registration training for nurses. Sample takers must only perform cervical screening after completing a recognised training programme. Registered providers have a duty to ensure staff are competent to undertake all aspects of their role.
Public Health England has produced guidance on:
- Training and continuing professional development (CPD) for people working in the NHS cervical screening programme (CSP) in England. This includes information on different training types. For example, e-learning and sample takers training venues.
- Guidance on the training of new cervical sample takers. This includes information on the education pathways and eligibility.
When we inspect
When we inspect management of the national cervical screening programme, we look at:
- how the programme is managed
- access and support for patients
- the number of women screened on time as a percentage of women who were eligible
- if staff had the skills, knowledge and experience to deliver effective care, support and treatment
- how the provider is addressing any barriers that prevent women attending for screening
- if the provider is following failsafe responsibilities as specified in the contract.
We use Regulations:
- Regulation 10: Dignity and respect
- Regulation 11: Need for consent
- Regulation 17: Good governance
- Regulation 18: Staffing
- E2 Monitoring and comparing with similar services
- E3 Staff skills and knowledge
- E6 Consent to care and treatment
- C3 Privacy and dignity
- R1 Person centred care
- WL4 Governance and management
Further information and resources
- NHS Population Screening: Information for Trans and non-binary people (Gov.uk)
- Reducing cervical screening inequalities for trans people (Public Health England screening blog)
- Cervical screening information leaflets (Public Health England)
- Cervical screening: an easy guide (Public Health England)
- Cervical screening for lesbian and bisexual women (Public Health England)
- Cervical screening: support for individuals who find it hard to attend (Public Health England)
- Cervical screening blog: pioneering picture stories can help reduce barriers to NHS cancer screening (Public Health England)
- Fake news putting 50,000 lesbian, gay and bisexual women at risk of cancer (NHS England)
For coverage at GP practice, clinical commissioning group and/or local authority levels:
- NHS cervical screening (CSP) programme: detailed information (Gov.uk)
- Cervical screening data and research (Gov.uk)
- Cervical screening coverage (Gov.uk)
- Cervical Screening Programme - Coverage Statistics (Management Information) (NHS Digital)
- Cervical screening programme Annual Report 2019/20 (NHS Digital)
- NHS Cervical Screening Programme leaflet (Public Health England)
- Anatomy, physiology, and taking cervical samples (Public Health England)
- Guidance on cervical screening (NICE)
- Mental Capacity Act Code of Practice: Code of practice giving guidance for decisions made under the Mental Capacity Act 2005
- Last updated:
- 30 July 2021