NHS population screening: identifying and reducing inequalities

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Letter from PHE and NHS Test and Trace to school and college leaders

All eligible people should be able to access NHS population screening programmes and understand the potential benefits and harms of screening tests in ordered to make an informed choice. However, variation in participation exists both within and between national screening programmes.

Barriers can result in some people being unable to maximise the benefits of screening. And people at higher risk of the conditions being screened for are generally less likely to participate.

The NHS England Standard Contract Service Condition 13 (SC13) outlines the contractual requirements for equity of access to services, equality and the avoidance of discrimination.

Under the Equality Act 2010, the Health and Social Care Act 2012 and the Public Services (Social Value) Act 2013, NHS screening providers have a legal duty to make sure screening services are accessible to everyone, including people with one or more protected characteristic.

Health inequalities can occur at any of these points along the screening pathway:

  • cohort identification (invitation)
  • provision of information about screening
  • access to screening services
  • access to treatment and onward referral
  • outcomes

Inequalities strategy

The national PHE Screening inequalities strategy, published in 2018, supports local screening services, commissioners and others involved in the provision of screening to address inequalities.

The strategy emphasises the importance of ensuring equitable access to screening services and supporting people to make an informed choice about participating in screening.

Guidance, resources and shared learning

PHE has published a range of guidance and resources to support providers, commissioners and other partners in reducing screening inequalities.

These include guidance for health and social care professionals and easy read resources for people with learning disabilities.

PHE also shares learning on reducing screening inequalities in PHE Screening blog articles and events such as the national screening inequalities conferences of 2019 and 2021.

Identifying inequalities

The first stage in addressing screening inequalities at local or regional level is to identify the inequalities that exist within the screening pathway. This is essential to know where and how to target action, and to identify interventions to improve access to services and outcomes.

PHE sets standards and guidance to support the quality and performance of the NHS screening programmes.

Review at a local level of performance by population group may indicate inequity in participants entering and completing the screening pathway, or accessing services within optimal timescales.

Services can also use learning from screening incidents which can occur throughout the screening pathway.

Health equity audits (HEAs) examine how health determinants, access to relevant health services and related outcomes are distributed across the population.

Screening providers and commissioners should use the NHS population screening health equity audit (HEA) guide to help:

  • identify groups less likely to participate in screening
  • assess health inequalities related to screening services
  • identify possible actions to help reduce inequalities

The screening HEA guide is designed to be used in conjunction with the wider PHE Health Equity Assessment Tool.

E-learning for the PHE HEAT is also available.

Local screening providers should have procedures in place to identify and support people who are considered vulnerable or underserved, including but not exclusive to:

  • those who are not registered with a GP
  • homeless people and rough sleepers
  • asylum seekers
  • gypsy and traveller groups
  • those in prison
  • those with mental health conditions
  • those with drug or alcohol harm issues
  • people with learning disabilities, physical disabilities or communication difficulties
  • non-English speakers
  • sex workers

Providers should comply with safeguarding policies and good practice recommendations for such people.

Providers should include appropriate cohorts of local armed forces personnel and their dependents who are registered with defence medical centres within their responsible population boundaries.

Reducing inequalities

PHE has developed a range of cross-programme and programme-specific resources to support providers, commissioners and other partners in reducing screening inequalities.

Cross-programme resources include:

Reasonable adjustments

Screening providers have a legal duty to make reasonable adjustments to make sure services are accessible to everyone, including people with disabilities.

Providers must follow the Accessible Information Standard by law. The standard aims to make sure people who have a disability, impairment or sensory loss are provided with information they can easily read or understand with support, so they can communicate effectively with health and social care services.

As part of the Accessible Information Standard, providers should:

  • ask people if they have any information or communication needs, and find out how to meet those needs
  • record those needs clearly and in a set way
  • highlight or flag a person’s file or notes so it is clear they have information or communication needs and how these are met (see more information on the reasonable adjustment flag)
  • share information about people’s information and communication needs with other providers of NHS and adult social care, when they have consent or as permitted by law
  • take steps to ensure people receive information which they can access and understand, and communication support if they need it (PHE provides many information resources nationally to help meet this requirement)

Providers should use appropriate interpreter services for people who have specific communication needs, for example if English is not their first language or if they have a hearing impairment.

Accessible information resources

PHE has published national easy guide versions of screening information leaflets and screening appointment letter templates for people with learning disabilities, people with low levels of literacy and others who find easy read information helpful. Providers should use these national materials when inviting individuals for screening who have been identified as benefiting from information in an easy read format.

People with sight loss can access the digital web page versions of standard information leaflets on GOV.UK using screen reader technology. Providers can also advise people with sight, hearing, motor or cognitive impairments that they can adjust settings on mobile devices to make it easier to read digital publications. Step by step instructions are available on the AbilityNet website.

Providers should direct any individual requests for hard copy Braille versions of PHE Screening leaflets to the screening helpdesk at phe.screeninghelpdesk@nhs.net.

Programme-specific guidance

Abdominal aortic aneurysm (AAA) screening

Read guidance for AAA screening providers, commissioners and other stakeholders on sharing learning and good practice in reducing barriers to attendance

Antenatal and newborn (ANNB) screening

ANNB screening: supporting women with learning disabilities has guidance for supporting women with learning disabilities to access and make an informed personal choice about ANNB screening.

Bowel cancer screening

Bowel cancer screening: helping people with learning disabilities has information for health professionals to support eligible people with learning disabilities to access and understand bowel cancer screening.

Breast screening

Breast screening: supporting women with learning disabilities has information for health professionals to support eligible people with learning disabilities to access and understand breast screening.

Cervical screening

Cervical screening: supporting women with learning disabilities has information for health professionals to support eligible people with learning disabilities to access and understand cervical screening.

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