GP mythbuster 104: Cervical screening

Page last updated: 23 November 2023

Improving attendance

Improving attendance for cervical screening can be challenging. Practices should compare their current screening coverage with the national target rates. If the current screening coverage is below the national standard, the practice should take action to improve uptake.

If a person does not attend their appointment, a message should be attached to their clinical record as a prompt to discuss screening at the next appropriate visit. Clinicians should discuss the benefits of screening and identify barriers that may prevent the person from 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 also 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, 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 5 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 makes is properly 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 person 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.

Cervical screening: support for people who find it hard to attend from the National Cervical Screening Programme is designed for people who feel anxious attending cervical screening. This information is to help them decide whether to attend and can also help them plan for their screening appointment.

Practice staff can also make suggestions to help people during the screening procedure. These could include:

bringing a friend
listening to music or a podcast
wearing a skirt or loose clothing.

Also read the guidance from Jo’s Cervical Cancer Trust:

Overcoming barriers to cervical screening
Myths and facts about cervical screening.

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 autistic people and people with a learning disability. 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, it will need to carry out a risk assessment for each individual patient. This is so the person can be supported by other services if they need treatment, follow-up, or referral to hospital.

Autistic people and people with a learning disability

Autistic people and people with a learning disability are almost 4 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.

Guidance from the National Cervical Screening Programme 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 cervical screening (smear tests) and their role in preventing cervical cancer. The video helps women decide whether to attend their screening invitation.

Cervical screening for women from ethnic minority groups

There is a lower uptake of cervical screening by women in ethnic minority 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 lesbian and bisexual women

Cervical screening is for all women and anyone with a cervix aged between 25 and 64. This includes lesbian 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 lesbian women also share this misconception. Cervical screening attendance is lower for lesbian and bisexual women. They may also not attend screening because of negative experiences of health services.

See the National Screening Programme’s guidance on cervical screening for lesbian and bisexual women.

Cervical screening for trans or non-binary people

Screening invitation 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 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:

Guidance on training for new cervical sample takers, including education pathways and eligibility
Training and continuing professional development for people working in the NHS cervical screening programme in England, including information on different types of training, for example e-learning, and on training venues for sample takers.

Data

Reviewing data on the practice’s performance in cervical screening is an important part of our inspections.

When looking at the clinical effectiveness of a practice’s cervical screening programme, we use national data collected as part of the NHS Cervical Screening Programme which is published each quarter by NHS England. Practices should use these data sources as part of their practice governance and quality assurance programmes.

The NHS Cervical Screening programme aims to encourage and incentivise practices to promote age appropriate cervical screening in line with the recommendations of the NHS Screening Programme by collecting and publishing data measuring the number of eligible persons screened, and whether they had their screening test at the appropriate time.

When we inspect

When we inspect how GP practices manage the national programme, we will look at evidence of how the practice:

manages and monitors the programme, and how it compares with other services
ensures access to screening, support for patients and consent from patients
ensures people’s privacy and dignity.
addresses any barriers that prevent people attending for screening

We will also check:

the number of patients screened on time as a percentage of those who were eligible
whether staff have the skills, knowledge, and experience to deliver effective care, support and treatment
how the practice manage and learn from any significant events/clinical incidents relating to or arising from the screening programme
whether the practice is following failsafe responsibilities as specified in the contract
governance processes.

This is to check whether the practice is meeting:

Further information and resources

For coverage at GP practice, integrated care systems and/or local authority levels: