Cervical cancer is preventable, but women – particularly those who have not been screened – are still dying from the disease. The annual incidence of cervical cancer in the UK is around 9.7 per 100 000 population.1 The mortality rate for the disease was 3.9 per 100 000 population in 2001.1
Precancerous cervical cells do not cause symptoms. Population screening is therefore necessary to identify women considered to be at sufficiently high risk of developing cervical cancer. In England, the national screening programme covers women aged 25 to 64 years, and in Scotland, those aged 20 to 60 years. Cervical smears should be performed every three to five years to reduce the risk of precancerous cells and invasive cancer being missed. In Scotland, the screening interval is 3 years, while in England the intervals are now determined by age (Table 1, below).2
|Table 1: Intervals for cervical screening in England recommended by the Advisory Committee on Cervical Screening|
|Age group (years)||Frequency of screening|
|65+||Only screen those who have not been screened
since age 50 or have had recent abnormal tests
|Reproduced from the NHS Cancer Screening Programmes website.
The new contract aims to encourage a continued high level of coverage, which in England was 81.2% of those eligible in the 5 years up to 31 March 2003.3 As a result of national screening programmes, there was a marked fall in incidence and mortality during the 1990s. The number of cases of cervical cancer in Scotland dropped by 32% between 1986 and 1999 and deaths fell by 43% between 1986 and 2001.4
However, screening is labour and resource intensive. In the NHS, around 1000 women need to be screened for 35 years to prevent one death.5
The new GMS contract
The new contract transfers the incentive of target payments to income generated through the provision of cervical screening as an additional service representing 1.1% of the global sum.6 It enables practices to opt out of cervical screening if, as a result of workload, workforce, skills or commitment, the service cannot be provided to a satisfactory level.
Opting out of cervical screening will cost a practice £1203 per GP with a list of 1800 patients in 2004-05 and £1221 in 2005-06. In addition, if practices opt out of providing cervical screening they will lose their entitlement to the 22 quality points available for providing the service (Table 2, below) and jeopardise separate holistic and quality practice payments.
Cervical screening 1
The first indicator requires there to be recorded in patients' notes a cervical smear in the past 5 years (standard: 25-80%). While PCOs may provide these data, practices are advised to record absolute exclusions such as 'total' hysterectomies, where the surgeon removes the cervix as well as the corpus uteri, and exceptions, for example women who have opted out of cervical screening or defaulted on three occasions. These patients will be subtracted from the denominator for payment calculations.5 In Scotland, the General Practice Administration System for Scotland (GPASS) and other software suppliers intend to simplify the recording of appropriate codes in a single integrated process.8
In some hysterectomies or when a 'Manchester' repair is performed for a prolapse, the cervix may be preserved. In these cases women should remain on the register and be recalled routinely.
Hysterectomy may have been performed because of cancer or cervical intraepidermal neoplasia.While these women may have been removed from previous screening targets, vaginal vault cytology should be repeated at appropriate intervals.9 This may be primarily a specialist responsibility but GPs should remain vigilant to avoid patients, particularly those newly registered, being lost to follow up.
The appropriate Read codes for the cervical screening indicators can be found on the Department of Health's website (Table 2, below).10
|Table 2: Additional services indicators for cervical screening 6,10|
|Cervical screening indicator||Points||Qualifier||Preferred Read code||Exception reporting and suggested Read code||Payment stages|
|CS1||The percentage of patients aged 25 to 64 years (in Scotland 21-60 years) whose notes record that a cervical smear has been performed||11||In the last 5 years||
(Time criteria ever)
|CS2||The practice has a system to ensure inadequate/abnormal smears are followed up||3|
The practice has a policy on how to identify and follow up cervical smear defaulters
Patients may opt for exclusion from the cervical cytology recall register by completing a written statement which is filed in the patient record (exception reporting)
|CS4||Women who have opted for exclusion from the cervical cytology recall register must be offered the opportunity to change their decision at least every 5 years||2|
|CS5||The practice has a system for informing all women of the results of cervical smears||2|
|CS6||The practice has a policy for auditing its cervical screening service, and performs an audit of inadequate cervical smears in relation to individual smear takers at least every 2 years||2|
Cervical screening indicators CS2-6 require 'yes/no' answers which cannot be automatically extracted from clinical systems by the Quality Management and Analysis System (QMAS), which will be used to calculate payments. Consequently, practices need to enter the data directly into QMAS via a web browser (Internet Explorer 5.5) over NHSnet.11
All evidence, including computer print-outs,routine PCO data and manual records should be available for inspection by assessors on verification visits. However, the first visit will probably be most concerned with systems and procedures at practice level. Practice staff should be able to demonstrate knowledge not only of cervical screening policies but also how protocols are implemented.
Cervical screening 2
Indicator CS2 states that practices need to have effective systems for ensuring that inadequate/abnormal smears are followed up. Although in many areas the recall system will be coordinated outside the practice, as part of a national screening programme, the practice team needs to be aware of how it operates and where responsibility lies.
Generally, women with borderline or mildly dyskaryotic smears are reviewed at reduced screening intervals. However, the results of the MRC funded TOMBOLA trial and the English HPV pilots' experience of using testing for high risk types of human papilloma virus as a form of triage may have implications for cytological surveillance in women with mild or borderline dyskaryosis.12
Care should be taken to record patients referred to gynaecology. Computer call/recall systems which continue to send for these women to have further smears cause distress and confusion.
Cervical screening 3
Importantly, most cervical cancer now occurs in unscreened women.13 Practices should have in place a written policy on how to identify and follow up cervical smear defaulters and encourage these women to make best use of the services available. Inevitably, there will be those who ignore reminders.
It is acknowledged that GPs should not be penalised for respecting choice. Patients who have been recorded as refusing to attend on at least three occasions or who have opted for exclusion from the cervical cytology recall register may be exception reported; in the latter case the patient must complete a written statement to that effect which should be filed in the patient record.
Given that the biggest risk factor for cervical cancer is non-attendance at cervical screening,13 GPs need to bear in mind the public health and ethical aspects of exception reporting.
Cervical screening 4
A woman with a cervix should not be permanently excluded from a cervical screening programme regardless of her current or previous sexual experience. If she is within the age parameters she should be offered the opportunity to change her decision at least every 5 years.
Cervical screening 5
Practices should ensure that they have a system for informing women of the results of a smear. Ideally, the results of cervical smears should be issued within 4 weeks of the test being carried out.14
Cervical screening 6
The quality of smears determines the effectiveness of a screening programme. On average 8% (range 5.9- 11.0%) of Pap smear tests are inadequate or unsatisfactory.1
The new contract rewards practices for undertaking 2-yearly audit of their cervical screening service, particularly smear takers' incidence of inadequate smears and their educational needs. Following the Scottish Implementation Study of liquid-based cytology,15 in Lanarkshire alone the unsatisfactory rate has fallen from 7% to 2% across the health board area.15
The new GMS contract remunerates practices for providing an effective and safe cervical screening service that does not exist in isolation, but as part of the continuous holistic care of women in primary care. As such, it should be delivered alongside opportunistic health promotion advice such as smoking cessation to ensure that unnecessary deaths and suffering from cervical cancer are prevented.
I would like to thank Dr Jennifer Darnborough,Public Health Medicine and Julian Hodgson, Alistair MacKenzie Library, NHS Lanarkshire, Dr Ken Harden, GPASS and Carol Colquohoun, National Co-ordinator NHS Scotland for information and advice.
- National Institute for Clinical Excellence. Technology Appraisal Guidance No 69. Guidance on the use of liquid-based cytology for cervical screening. London: NICE, October 2003. www.nice.org.uk
- NHS Cancer Screening Programmes. About the NHS Cervical Screening Programme. www.cancerscreening.nhs.uk/cervical/#eligible
- Department of Health. Statistical Bulletin 2003/24. Cervical Screening Programme, England: 2002-03. October 2003. www.publications.doh.gov.uk/public/sb0324.pdf
- NHS Quality Improvement Scotland. National Overview November 2003.Cervical Screening. NHS Quality Improvement Scotland, 2003. www.nhshealthquality.org/nhsqis/files/cervical_overview.pdf
- Raffle AE, Alden B, Quinn M et al. Outcomes of screening to prevent cancer: analysis of cumulative incidence of cervical abnormality and modelling of cases and deaths prevented. Br Med J 2003; 326: 901-4.
- NHS Confederation, British Medical Association. Investing in General Practice: The New GMS Contract. www.bma.org.uk
- NHS Confederation, British Medical Association. Investing in General Practice: The New GMS Contract. Supplementary documents. Quality and outcomes framework evidence base p.110. www.nhsconfed.org/gms/gms_contract_documentation.asp
- Dr Ken Harden, personal communication.
- Department of Health. New GMS Contract QOF Implementation: Logical Query Indicator Specification. February 2004. http://www.dh.gov.uk/PolicyAndGuidance/OrganisationPolicy/PrimaryCare/Commissioning/CommissioningArticle/fs/en?CONTENT_ID=4078648&chk=nP7W%2Bs
- NHS National Programme for Information Technology. GMS IT QMAS Bulletin.May 2004. http://www.dh.gov.uk/PolicyAndGuidance/OrganisationPolicy/PrimaryCare/Commissioning/CommissioningArticle/fs/en?CONTENT_ID=4084258&chk=7IoW5p
- NHS Cancer Screening Programmes. Cervical cancer incidence, mortality and risk factors. www.cancerscreening.nhs.uk/cervical/risks.html
- Clinical Standards Board for Scotland. Clinical Standards: cervical screening. Edinburgh: CSBS, September 2002 www.nhshealthquality.org
- Scottish Cervical Screening Programme. Steering group report on the feasibility of introducing liquid based cytology. Edinburgh: Scottish Executive Health Department, 2002. www.show.scot.nhs.uk/sehd/publications/ScreeningLiquidCytologyv2.pdf