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Make sure your Cytology income is maintained

Having teetered on the edge of the 80 per cent target for smears for five years, Rachel Stark's practice conducted a one-off campaign that raised the level to 85 per cent

Having teetered on the edge of the 80 per cent target for smears for five years, Rachel Stark's practice conducted a one-off campaign that raised the level to 85 per cent

Cytology remains an important part of preventive health care for women and also an important source of practice income. But under GMS2 it attracts a lower income than before, so this makes it even more important for practices to protect their earnings.

In GMS2, practices receive a nominal amount in their global sum for the administration of the cytology service. In addition to this, 22 points are available in the QOF for undertaking a cervical smear programme for women between the ages of 25 and 64 and ensuring that:

  • ·the practice has a system to ensure inadequate/abnormal smears are followed up
  • the practice has a policy on identifying and following up cervical smear defaulters
  • women who have opted for exclusion from the cervical cytology recall register are offered the opportunity to change their decision at least every five years
  • the practice has a system for informing all women of the results of cervical smears
  • 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 two years.

In the light of new evidence, the NHS cervical screening programme is also now implementing screening at different intervals depending on age. For example, women between 25 and 50 will now have a cervical smear every three years. This may have a potential negative impact on uptake so practices should review their uptake and identify and address any risks now.

At the practice where I work we traditionally managed the 80 per cent cytology target comfortably, with an uptake averaging 86 per cent. But this uptake began to decline after 2000, and when our uptake fell to just over 81 per cent in March we decided in our quarterly multi-disciplinary significant event meeting to identify reasons for the decline and devise ways to increase uptake.

If practices are at risk of falling below the 80 per cent target, or are already below target and wish to reach it, there are three things they can do to increase uptake:

  • ensure all women who have had a hysterectomy and who no longer need cervical smears are coded correctly to ensure they are excluded from the targets
  • ensure a procedure is in place for coding discharge summaries for new hysterectomies
  • ensure all cytology history is extracted from the notes and coded on the practice clinical system.

A practice may also benefit from reviewing its approach to women whose cervical smear is overdue. Many practices use a central recall system. These systems do not cater for a special targeted approach for patients who may need extra encouragement. We decided to introduce a new approach for women who were six months or more overdue.

As well as sending the usual invitations from the central recall system, we decided to write to these patients monthly, over a period of three months, until they came for their cervical smear.

We devised a new letter to send to these patients that focused on the benefits for health protection in guarding against cancer but that also acknowledged the anxiety many patients feel about having the smear. We felt it was important that the letter had a sensitive and reassuring tone and that it should come from the patient's own GP. The letter had to have a strong message about the importance of the test but also a reassuring tone, making it clear that we understood the patient's anxiety and would make the test as pleasant as possible.

We also felt that some women who did not have the smear test might be anxious about other areas of their sexual health. At the surgery we have been keen to set up routine chlamydia screening for some time and we felt that we could pilot screening for this group of women. This would enable us to evaluate the pilot on a small scale and also use it as an added incentive for coming in for a cervical smear. The patient would be saved the embarrassment of having to come in twice or remaining anxious about whether they had a chlamydia infection.

In the letter we therefore explained the increasing risk of infection with chlamydia and its long-term consequences. We invited the women to have a chlamydia test if they wanted one.

This initial letter was then sent to all women in the practice who were six months or more overdue for their smear test. Within a week many of the women had contacted us to make an appointment. After a month a modified letter was sent to those in the original group who had not had a smear test since the last letter and who did not have an appointment booked.

After another month a third letter was sent to the original groups who had not had their smear test or booked an appointment. This letter was much less detailed, focusing on the risks of not having the test and urging the patient to make an appointment.

In March, 169 women were overdue their cervical smear text for six months or more.

In May, 96 of these women had had their smear test and a further 22 had appointments booked within the next month. We therefore achieved a 70 per cent success rate in three months, increasing our practice uptake from 81 per cent in March to 84 per cent in May. This will increase further as the women with appointments do have their cervical smear test.

Eight of the women who attended had a chlamydia swab and all of these were negative. We are planning to extend this pilot in the practice over a wider age group.

Practices are now using liquid-based cytology. This will mean more accurate results and far fewer inadequate samples. Many women who have frequent inadequate samples get despondent about coming in for their smear so often. Practices should tell patients about this change in technology and should point out that, from now on, it is less likely that women will have to come back repeatedly for tests.

The whole campaign should be supported by a commitment in the practice to encourage women to have their smear. This should include all clinicians opportunistically reminding patients who are overdue. The clinical computer system reminder facility for the QOF will highlight those patients who need a cervical smear. In such a delicate aspect of health care, a personal and encouraging approach can make women who have avoided their smear test feel comfortable enough to have it.

As part of our campaign, we also considered patients who actively refused to have a cervical smear.

Like many practices, we have an established procedure to send disclaimers to patients who do not attend for their smear test. In signing and returning the disclaimer, the patient agrees to be taken off the register for a period of three to five years. This is coded on to their medical record and the patient is then excluded from the target group and so will not negatively impact on QOF performance.

We did include a disclaimer in the third letter sent out in this campaign (and many would have had them as part of the usual procedure as they had not attended) and a number were returned. However, our main purpose for this exercise was to encourage women to attend for their cervical smear as it is important to their health rather than solely for QOF performance.

Rachel Stark is practice manager of New East Quay Medical Centre, Bridgwater, Somerset

Conclusion

  • Ensure all women who no longer need cervical smears are coded correctly to ensure they are excluded from the targets
  • Ensure a procedure is in place for coding discharge summaries for new hysterectomies
  • Ensure all cytology history is extracted from the notes and coded on the practice clinical system
  • Review your approach to women whose cervical smear is overdue ­ consider a specially targeted approach
  • An individual and carefully phrased letter to defaulters can work wonders
  • Invite women to have a chlamydia test
  • Mention improvements in cytology technology

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