GP mythbuster 104: Cervical screening

Page last updated: 14 July 2022
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Cervical screening is a procedure which tests for high-risk human papillomavirus (HPV) as this is the cause of 99.7% of cancers. If a test is positive for HPV, the sample is checked 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 have the test unless they have opted not to. The initial invitation for screening is usually sent in advance to enable 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. GP practices may need to make changes to meet the needs of their local population and support the national programme.

National guidance Cervical screening: professional guidance includes standards and information for those working in the NHS cervical screening programme. This includes programme management, failsafe responsibilities and guidance on training for cervical sample takers. There is also a cervical screening pathway document, which describes what should happen at each stage of the pathway.

The charity, Jo’s Cervical Cancer Trust, has also produced Information for professionals: Cervical screening. This includes information and resources for practice staff:

  • 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 attendance

Improving attendance for cervical screening can be challenging. Practices should consider their current screening coverage compared with the national target rates to decide if they need to take any action to improve.  Where a practice’s current screening coverage is below national target rates, they should take action to improve uptake

If people do not attend their appointment, a message should be attached to their clinical record and make sure screening is discussed at the next appropriate visit. Clinicians should discuss the benefits of screening and identify barriers that may prevent the person attending. It is important for practice staff to remember that taking part in screening is always an individual choice

Practice reception staff should have access to appropriate up to date training. They should be fully informed of any changes to the screening programme.

To make the test more accessible to more people, it’s important to understand the demographics of the local patient population. This includes considering:

  • age ranges
  • ethnicities
  • languages spoken
  • cultural needs
  • LGBTQ+ groups
  • other demographics.

See the National NHS cervical screening programme (CSP) guidance on improving access to screening and awareness of cervical cancer. Making cervical screening more accessible.

Improving access to cervical screening could include:

  • targeting population groups or communities
  • participating in screening awareness weeks.

Jo’s Cervical Cancer Trust provides a variety of health promotion resources.

When planning to improve coverage, practices should link with local screening programme boards so that all services are aware of and prepared for an increased demand for screening.

Effective administration

Effective administration is a key part of the cervical screening patient pathway. National cervical screening programme information on Cervical screening: cytology reporting failsafe provides information for General Practice. Guidance on the nationally administered call and recall of participants for cervical screening is available.

Each practice must have a reliable cervical screening system that includes:

  • standard operating procedures and detailed work instructions that follow guidance on the national screening programme
  • routine review of prior notification lists (PNLs) to identify who should be invited and non-responder lists to follow up people who have not attended
  • processes to ensure that:
    • all tests taken are transported safely to the laboratory
    • a result is received for each one
    • the appropriate action is taken based on the result
    • samples are not repeated within 3 months to avoid being rejected
    • a programme of audit and non-conformance monitoring is in place, including regular review of performance data for individual sample takers.

Mental capacity and consent

The decision to attend screening is the choice of the person who is invited.

The Mental Capacity Act (MCA) 2005 states:

“There must always be the presumption that people you provide care or treatment for have capacity to make decisions for themselves”.

An appropriate person can make a best interest decision on the person’s behalf, 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 Mental Capacity Act
  • 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. The information provided should be unbiased and factual. Sample-takers must make sure patients:

  • understand what screening is and what it does not include
  • have access to accessible information
  • know what will happen during a test
  • are aware they can opt out at any time.

Once the sample-taker is confident the person understands the test, they should record their consent. The practice decides how this is recorded.

Read the guidance from the National cancer screening programme:

The NHS Cervical Screening Administration service (CSAS) provides forms to use when patients withdraw from the programme.

If the woman or person with a cervix has not understood enough to make their own decision on cervical screening, the practice may need to make a best interest decision on their behalf.

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, for example:

  • embarrassment
  • pain
  • fear
  • physical disabilities
  • fear of judgement or results
  • previous trauma or female genital mutilation (FGM)
  • convenience
  • lack of understanding
  • mental health issues
  • previous traumatic experiences
  • sexual abuse.

The National cervical screening programme Cervical screening: support for people who find it hard to attend is for people who feel anxious attending cervical screening. They can use this information to help people decide whether to attend and can also help them plan for their screening appointment.

Practice staff can also make 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.

Read the guidance from Jo’s Cervical Cancer Trust:

Physical disability

Practices have a duty of care to ensure all eligible people 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.

It is a legal duty under the Equality Act 2010 to make reasonable adjustments for disabled people. This includes people with a learning disability and autistic people. Practices must also meet The Accessible Information Standard.

To do this, practices could consider:

  • investing in equipment for the practice, for example a hoist or adjustable couch
  • referring patients to the colposcopy department at a local hospital
  • referring patients to another surgery.

If a practice considers offering cervical screening on home visits, they will need to carry out a risk assessment for each individual patient. This is so the individual can be supported by other services if they need treatment, follow up, or referral to hospital.

People with a learning disability

People with a learning disability and autistic people are almost four times less likely to go for cervical cancer screening. Simply being coded as having a learning disability is not the only reason for ceasing or not wanting to be screened. Sample takers should be aware of the reasons why a person has chosen not to have the test when providing screening for women with a learning disability.

Reasons may include:

  • change to a routine
  • lack of invitations in an accessible or easy-to-read format
  • difficulty using appointment systems
  • mobility issues
  • communication difficulties.

The national cervical screening programme guidance on supporting women with a learning disability to access cervical screening includes making reasonable adjustments. The guidance includes other resources for healthcare professionals, social care staff, and family members, to help someone with a learning disability to attend their cervical screening appointment.

Communication is important for the success of the cervical screening experience. The practice may need to consult a person’s carers to understand how they prefer to communicate. The person may need an interpreter or signer at the screening appointment. They may want to use Makaton or British Sign Language to help with communication.

Practice staff may also consider offering longer appointment times and pre-appointment visits. These can help to familiarise patients with the practice and staff.

The national cervical screening programme’s easy guide to cervical screening helps people with a learning disability decide if they want to attend. Other people 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.

Practices can also use a template letter in an easy to read format to invite people with a learning disability for cervical screening. If requested, they can send the easy read invitation letter 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 groups. This may be because of barriers such as:

  • lack of good quality information on the importance of screening
  • some misconceptions about risk
  • availability of cultural or translated information for people who do not speak English as their first language.

See information from the national cervical screening programme about making cervical screening more accessible. There is also a leaflet in different languages Cervical screening: leaflet for women considering screening.

Cervical screening for lesbians and bisexual women

Cervical screening is for all women and anyone with a cervix aged between 25 and 64. This includes lesbians and bisexual women. Women who do not have sex with men can get cervical cancer and still need cervical screening. Health workers have sometimes mis-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 attendance is lower for lesbians and bisexual women. They may also not attend screening because of negative experiences of health services.

See the national screening programme 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 is recorded for a person 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 who is still registered with the GP as a female (or non-binary), and who has a cervix, will automatically be included in the national screening programme. However, a trans man who is registered as a male, and who has a cervix, will not be invited for screening by the national programme.

The GP practice or healthcare team that manages the gender affirming surgeries should ensure screening invitations are sent.

For further information on improving accessibility to screening for trans and non-binary people see:

Chaperones and other considerations

GP practices must provide care and treatment that ensures people's privacy and dignity, and that always treats them with respect. It is important for sample takers to check a person’s preferences about their cervical screening. This could include confirming whether they would like a chaperone even if they were asked this question at reception and where the person has been able to see posters about chaperones.

See our guidance on chaperones.

Staff competence

All registered nurses, midwives and physician and nursing associates who carry out cervical screening should have access to training programmes so they can do this safely. Training includes r ongoing continuous professional development.

The Royal College of Nursing and UK National Screening Committee has recommended that sample takers:

  • familiarise themselves with local polices
  • understand the national screening programme.

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 that staff are competent to undertake all aspects of their role.

The national cervical screening programme provides information on:

When we inspect

When we inspect how GP practices manage the national cervical screening programme, we will look at evidence to show:

  • how the programme is managed and monitored, and how it compares with other services
  • access, support and consent for patients
  • the number of women screened on time as a percentage of women who were eligible
  • whether staff have 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
  • whether the provider is following failsafe responsibilities as specified in the contract
  • governance processes
  • how the provider ensures people’s privacy and dignity.

We look at:

Further information and resources

For coverage at GP practice, clinical commissioning group and/or local authority levels:

 

GP mythbusters:

Clearing up some common myths about our inspections of GP and out-of-hours services and sharing agreed guidance to best practice.

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