Reconfiguration of the Cervical Screening Programme in Wales

1. Reconfiguration of the Cervical Screening Programme in Wales Public Health Wales Staff Conference 2010 Wednesday 6th October 2010 Bryan G Rose All Wales Programme Manager Cervical Screening Wales David S Nuttall Head of Laboratory Services Screening Division

2. Cervical Screening Wales was established following publication of the National Service Framework in 1999 fulfilling a defined need and Government policy The Programme objective established within the NSF is: To ensure that cervical screening is delivered in a consistent manner across Wales, to national published standards, and in particular, that all eligible women receive the same level of service and quality of care for the same level of need The National Service Frameworkfor the Cervical Screening Programmein Wales

3. Development of the National Screening Framework • When the NSF was established there was an identifiable disparity in the practice and protocols employed • There was no national approach to screening within the regions, although a good standard of care was provided across Wales • Cervical Screening Wales built on this foundation & sought to establish, maintain, and develop a nationally coordinated screening programme

4. Organisational Scope In implementing the all-Wales programme CSW covers the directservices provided, and defines and is responsible for how the programme is organised and managed. In doing so CSW: • Sets Policy - in accordance with Wales & UK guidance • Sets Standards - for service operation and delivery • Defines Protocols - enabling a uniform approach to screening • Provides Clear accountabilities • Works in partnership with providers (HBs)

5. Managerial Structure Director of Screening Division All-Wales Management Group Chaired by Director Policy group includes Regional Programme Co-ordinators, Senior Managers, & Specialist Advisors Local Management Groups (5) Chaired by Regional Programme Coordinator Policy implementation group with representation from Labs, Colp units, 1ry care, CSADs and CSW senior manager

6. Organisational Responsibility CSW provides a managed clinical network taking responsibility and providing accountability for the whole of the cervical screening programme offered to women resident in Wales; the remit includes: • programme management and coordination (CSW) • call and recall arrangements (CSADs) • smear taking (Primary Care) • cervical cytology services (Pathology) • cervical histology services (Pathology) • colposcopy services/treatment of CIN (Gynaecology)

7. The changing programme • The network provides management, organisation and development, and support of/to the service at the all-Wales level and ensures the effective operation and delivery of the service by Health Boards • Over the past 11 years there has been considerable development and refinement of the service. This has directly impacted on the operation and delivery of the service • Changes have been driven by both NHS &Wales Government organisation and policy leads, and operational and technological changes within the service • Currently CSW is progressing modernisation and networking arrangements in laboratories and administrative services across Wales

8. CSW modernisation and development policyfor cervical screening • Current policy was established following controlled appraisal projects • In full consultation with the service • The decision was influenced by the need to be ready to take advantage of anticipated developments in screening techniques and processes • In parallel with the laboratory screening services, our administration service has been reviewed and reorganisation targets identified.

9. Reconfiguration of Admin Service • In parallel with the laboratory services, CSW administration service has been reviewed and reorganisation targets identified. • CSW was organised on a divisional basis incorporating five screening areas managed through Cervical Screening Administration Departments (CSADs), originally based in Health Authorities • Operational pressures have contrived to precipitate the need for reconfiguration, especially as the Screening Service has evolved to organisation on a three region basis. • Delivery of CSW administration service has been evaluated, through internal assessment, formal process mapping, work pattern evaluation and standard procedure development. • This evaluation has enabled improved links within the organisation and the transfer or consolidation of admin processes (from ‘clinical’ services) within admin departments.

10. Changes in Local Service Management- reconfiguring the CSADs • Major changes associated with NHS reorganisation have impacted on delivery of call and recall services for CSW • Originally five CSW screening divisions in Wales based on HA’s • Service development has resulted in establishment of three regions for the management of the service • Consolidation of services has resulted in reconfiguration of CSADs • Local management groups have been retained to fit with local service delivery requirements North Wales West and Mid Wales Morgannwg Gwent Cardiff Bro Taf

11. Reconfiguration of CSADs • A major reconfiguration of the SE Wales Screening Region has been completed, with the objective of locating an integrated service on a single site • Reconfiguration of the Gwent and Cardiff CSAD (incorporating mid and south Glamorgan), required relocation of offices, effective from 1st September • The office now operates as the SE Wales Region • Changes have been influenced by ‘natural’ development - in particular staff changes at senior level (Programme Coordinators) • This driver has been compounded by other acute factors - accommodation/facilities in particular

12. Reconfiguration of CSADs • This was a difficult undertaking that has been managed with professional commitment and with considerable tolerance by all staff involved • The process is now complete and a fully functional integrated service is located at Cathedral Road • The Gwent CSAD has been closed and the majority of staff transferred to Cardiff • Some challenges remain, particularly in the area of staff vacancies and recruitment, which are being addressed • An improved and more efficient service can now be offered to the eligible population

13. Reconfiguration of CSADs • A degree of integrated working has been achieved in West Wales between the Bro Morgannwg and Dyfed Powys divisions • CSADs now function under the direction of one Regional Programme Coordinator • Further integration is possible in the future • The N Wales CSAD was consolidated on a single site on the establishment of CSW, but boundary changes may require the redirection of specific functions to the Region (eg Nurse Coordination)

14. Changes in Local Management- reconfiguring the CSADs • Three screening regions now firmly established but service consolidation required reconfiguration CSADs • A fully integrated service is in place in SE Wales, following amalgamation on a single site • Partnership working is established in W Wales; further consolidation is under consideration • Single site long established in N Wales, but some Mid Wales boundary adjustment may be considered North Wales CSAD West and Mid Wales CSAD ----------- Morgannwg CSAD Integrated working strategy S E Wales Regional CSAD Fully reconfigured

15. Effecting change • Never an easy process • Requires transparency, involvement and consultation with staff • Changes based on needs of service and ‘external’ influencing factors • Opportunity to further standardise processes and improve the service • Comprehensive assessment is a prerequisite, including: • process Mapping • internal assessment/staff engagement • work pattern and resource evaluation • standard procedure development.

16. Pathology modernisation – key drivers Modernisation aims to deliver • A more rationalised and efficient approach to the provision of cervical pathology • The opportunity to redesign service to suit organisational requirements and future needs • Enables workload management & redistribution making best use of capacity and resources • Development and adaptation to accommodate further anticipated changes in the delivery of screening

17. Pathology modernisation – key drivers A key aspect is consolidation of sample processing on two sites in Wales • This will enable the introduction of new developments and changes to the screening programme, including • HPV testing • Automation • Adjunct/Reflex assessment of samples (‘Molecular Pap’) • A more efficient service should result from these changes as the new tests are ‘mass critical’ • Parallel developments including HPV vaccination and screening policy will significantly and irretrievably alter the screening profile of the eligible population in Wales

18. Developments are drivenby current service needs • Service specific and operational developments, as well as national initiatives influence future service delivery • NHS/Service reorganisation is a major driver • Staff/Workforce pressures • Current financial pressure • National development initiatives are driving change across pathology. Three key government development policies influenced developing strategies for CSW: • Informing Healthcare • Pathology modernisation programme • Designed for Life

19. Cervical ScreeningA changing service • The changing face of Pathology in England and Wales is influenced by: • Carter Report • ScHARR report1 • Welsh Assembly Government initiatives3,4 Getting Results: A Strategy for Diagnostic Services in Wales, 2004 The Future Delivery of Pathology Services in Wales, 2007 • Service Pressures • High Public Profile • HPV Vaccination • 14 day TAT2 1. Option appraisal: Assessment of a seven-day turn-around for the reporting of cervical smear results. School of Health and Related Research, University of Sheffield. Jan 2006 2. NHS CSP: Achieving a 14 day turnaround for results by 2010. Advice to the NHS. April 2008. 3. Welsh Assembly Government. Getting Results: A Strategy for Diagnostic Services in Wales, 2004. 4. Diagnostic Services Programme: The Future Delivery of Pathology Services in Wales, 2007

20. Networking - extending the principleto local working practice Developing the networking principle In 2006 CSW initiated a process of consultation with the service on future developments, following the ‘three regions’ approach: • SE Wales • Mid and West Wales • North Wales

21. First Steps – N Wales Initial progress focussed on N Wales, set up in consultation with N Wales Trusts, now operating a single processing lab based at Wrexham Maelor Hospital • CSW provided development and management resources - CSW Network Manager • A screening network was established utilising shared processing facilities in a managed network (3 into 1) • Project developed the process of integrated workload management across the three laboratory sites • This has now developed into a fully integrated operational service, following the foundation of BCuHB • This model was proposed as a template for reconfiguration

22. South Wales Redevelopment • Complexity of the ‘patch’ demanded a more detailed approach • Focussed on consolidation of processing on a single site serving the M4(+) corridor • Covers lab processing from Gwent across to Pembroke. • CSW developed a new site to handle the considerable volume of processing required • Based on a ‘green field site’ utilising vacant units adjacent to the Bowel Screening Centre in Llantrisant

23. The Cytology Reconfiguration Project • Remit • To recommend and implement a solution for the sustainable delivery of a Cytology Service for Wales • Project Initiation (PRINCE) • Project Board • Project Team • Project Structure • Screening Services members • External Advisors • Stakeholder engagement • Options Appraisal • Processing Centers • Screening Centers • Stakeholder Communication • Outline proposals presented for consultation • Staff engagement

24. The outcome • A newly commissioned purpose designed laboratory • Designed from the outset to embrace ‘LEAN’ • Design and fit-out: good planning essential • Staff input included all laboratories that would be serviced by the processing lab • LEAN processes in screening room • Proect delivered on time and in budget

25. Processing Laboratory

26. South Wales RedevelopmentEstablishment of a Screening Site On site screening is a fundamental operational requirement for the Llantrisant site. Relocation of screening staff from Royal Glamorgan Hospital has been arranged to achieve this • Agreed with Cwm Taf HB for transfer of their screening staff to the new facility. To begin with they will remain CT/HB employees located ‘offsite’ • Agreement reached for TUPE transfer of RGM staff to CSW by April 2011 • A symbiotic relationship will establish as staff will provide the initial core support team for the processing lab

27. Screening Laboratory

28. Phase 2Llandough Hospital Transfer • A similar arrangement for direct staff employment is under negotiation at the request of C&V, for the relocation of the Llandough screening laboratory but the physical transfer is not scheduled until 2011 • Presents specific challenges, in particular – staffing • Staff integration: avoiding the ‘us and them’ scenario • Requires a managed Approach • Staff visits and short term exchanges • Good communication • Meetings and newsletters • Engagement and empowerment

29. Reconfiguration – Further Redevelopment • Redevelopment of screening, has further objectives to fulfil • Plan to assume direct responsibility for screening services as part of this development, in association with HBs • provided for facilities in the new laboratory for screening to be completed on site • Centre will serve as a base for development of screening tests (HPV test, molecular tests) • Has potential for extension to associated tests (eg chlamydia ‘screening’ on ‘same sample’)

30. Further Service Reconfiguration 1. CSW is now actively arranging an integration agreement for the screening service in West Wales • This will require partnership working across two Health Boards and is seen to be a paradigm for future development in the area ABM/HD 2. The Gwent screening laboratory has sufficient workload to remain operationally independent, however, we are seeking arrangements for a broad network approach for the SE region to ensure that workload management is optimised. This may be dependant on the implementation of TrakCare (LIMS) • Probable therefore that ‘hybrid’ arrangements will need to be established for these services.

31. Current Progress on Service Development • Four ‘Screening Centres’ envisaged/developing • Two processing centres • Reduced from eleven cytology laboratories • Some Centres will Incorporate laboratory networks • NC & NE Wales – N Wales HB • West and Mid Wales • Morgannwg Path Services • Cwm Taf NHS Trust • Cardiff and Vale • Gwent Processing Centre 1 1* Histology only Cytology Cross border outflow work 2 4 3 6 5

32. Future proofing the service The service reconfiguration process allows CSW to plan for managing future anticipated radical changes in the design and delivery of the cervical screening service to the eligible population in Wales • Design and configuration of service • Changes to target population • policy amendment • Test type profile • HPV genotyping • viral load assessment • Molecular Pap • Self testing • Change in disease & population presentation • effect of vaccine • Changes in treatment and management protocols

33. Acknowledgements • The success of the reconfiguration projects for both CSW Administration Services and CSW laboratory Services is entirely due to the hard work and dedication of all staff involved in the process. I would like to particularly note the input of the lead staff involved • Mrs Alison Dorras • Head of Administration, Screening Division, PHW • Mr Rhys Blake • Head of Business and Planning, Screening Division, PHW • Mr David Nuttall • Head of Laboratory Services, Screening Division, PHW

34. Final thought Experience is something you don't get until just after you need it ! Stephen Wright