Analysis: Testing times for NHS screening programmes

Attendance at the UK’s national health screening programmes is down due to the pandemic. As new Covid variants blow through and disrupt the system, what can pharmacy teams do to help reverse this decline in testing and is it a golden opportunity to get more involved in screening themselves?

Learning objectives

After reading this news feature you should be able to appreciate:

• The importance of encouraging the public to participate in the national NHS screening programmes
• The role pharmacy teams can play in encouraging people to take up the offer of in-store health screening
• The core elements to running a successful screening service in pharmacy.

The NHS provides five national screening programmes for adults. These are abdominal aortic aneurysm, diabetic retinopathy, bowel cancer, breast cancer and cervical cancer. They are all aimed at identifying apparently healthy people who may be at increased risk of a disease or condition, enabling earlier treatment or informed decisions about their health.

Not everyone finds it easy to see their GP or other providers for regular screening, and many people avoid going in the first place – with the pandemic adding extra layers of complication to this already challenging situation.

Figures for the national screening programmes show that the number of people being tested is down due to Covid. For example, the latest annual figures on cervical screening show 3.03 million individuals aged 25-64 years of age were tested in 2020-21 – down 5.3 per cent compared to the previous year, when 3.2 million were tested.

Pharmacy screening

While community pharmacies cannot take on this type of screening, initiatives such as the new NHS hypertension case finding service launched in 2021, and private health check services including blood pressure, BMI, cholesterol and type 2 diabetes screening, are a key way in which pharmacies can support customers to protect and improve their health.

With the pandemic changing the way that everyone accesses healthcare, a recent survey by patient-centric online health community TalkHealth found that 65 per cent of respondents use pharmacy services at least once a month, with 62 per cent saying they would be very keen and likely to take up the offer of a free blood pressure check at their local pharmacy.

Badham Pharmacy offers a range of services at each of its 23 branches in and around Gloucester, and superintendent pharmacist and managing director Peter Badham says there are a number of key elements to encouraging people to take up the offer of testing in community pharmacy.

"Covid put pharmacy centre stage as the first provider of healthcare services and the public are beginning to realise pharmacy’s strengths," he says, "so it is the ideal time to make them aware of all the free and paid-for services we offer."

Peter’s advice for pharmacies looking to extend their service offer into screening is firstly to look at the pharmaceutical needs assessment (PNA) and information on demographics in their area to help them choose which services to offer.

"Then look at your competition to see what they are doing or not doing, and if you can do it better. If you can, the core elements to running a successful service are quality of staff, competency and training, and suitable premises."

If there is no material cost in providing the service other than staff members’ time, "you might have more enthusiasm to provide it free in the hope of generating goodwill and bringing people into the pharmacy", Peter adds. However, whether a service is free or private and paid-for, he stresses that it is vital "to maintain the standards people expect from community pharmacy".

'C' for convoluted?

One pharmacy screening service that appears to be struggling to reach the people it is designed to help is the new Hepatitis C Antibody Testing Service, which has been taken up by fewer than one in 10 pharmacies in England.

As part of the NHS goal to eliminate the hepatitis C virus (HCV) by 2025, this advanced service was launched in September 2020 as part of the five-year Community Pharmacy Contractual Framework in England. It is set to run until the end of March this year.

Under the service, contractors in England receive £36 for each point-of-care hepatitis C test administered to people who inject drugs, and who are not currently accessing community drug and alcohol treatment services. Those who test positive for hepatitis C antibodies are referred for appropriate further testing and treatment via the relevant NHS Operational Delivery Network (ODN).

The NHS has been criticised for setting a pricing point that failed to cover contractors' costs in offering the service, and a recent webinar hosted by HCV Action – the hepatitis C professional member organisation run by the Hepatitis C Trust – noted other barriers to community pharmacy involvement and patient take-up.

Speaking at the webinar, Dr Ryan Buchanan, associate professor of hepatology at the University of Southampton, said that although community pharmacies can play a vital role in HCV management because they can hit three key criteria – identifying cases, treating and offering harm reduction – the programme has had little uptake due to its limiting criteria of:

• Being England only
• Available to any community pharmacy with a private room
• Available to persons who inject drugs (PWID) not engaged with drug support services
• Offering antibody testing only
• Including paper referrals to ODN for treatment.

In a survey covering 20 ODNs, Dr Buchanan said 95 per cent had pharmacies that registered an interest, of which four ODNs provided training to pharmacies. Of these, three implemented pharmacy testing as part of the new service. While needle exchange and opiate substitution therapy (OST) in pharmacies will continue and there is potential for pharmacy-based treatment of HCV, the new service needs to be adapted, he said.

Community pharmacy successes

Although aimed at pharmacy contractors who provide a needle and syringe programme, Carters Chemist in South Shields is an example of a pharmacy that has successfully engaged in HCV testing. It used the launch of the Hepatitis C Antibody Testing Service to work locally with Gateshead and South Tyneside LPC, the ODN based at the Freeman Hospital in Newcastle upon Tyne, and other stakeholders, to successfully test a high number of patients.

Pharmacist Hassan Malik used in-house posters and leaflets and digital advertising to promote the service to patients. "We provided the service over a three-month period but had a really focused effort for one month and heavily promoted the service to eligible patients," he says.

"We had set clinic times for provision of the service, as well as providing a walk-in option when possible. The clinic approach optimised the logistics of the service and made it easier to undertake the necessary Covid-related safety precautions, such as cleaning the consultation room between patients."

The three-month clinic saw six positive tests from 67 people tested, who were all referred back to the Freeman Hospital for a confirmatory test and appropriate treatment. "The Freeman was delighted with our results as the cost to the NHS of a patient having to be treated further down the line when the virus has caused greater damage is significantly more than the cost of treatment if patients are found early and provided with antivirals," says Hassan.

"I am also happy that our work with local stakeholders has paid off, as about three-quarters of the patients were not actually our regular patients." His advice for other community pharmacy contractors planning to provide the service is to:

• Use the clinic model to provide the appropriate time to patients, as well as being able to provide a walk-in option for added convenience
• Invest in stakeholder engagement – contact your ODN, speak to the other pharmacies and national screening programme sites in your area to let them know you are providing the service and encourage them to talk to their patients about the service
• Make it a whole team approach, so that anyone in the team can explain the benefits of the service and then refer patients who want more information or a test to the pharmacist or pharmacy technician
• Use local advertising, posters, digital screens and leaflets attached to needle and syringe packs to get the message out there about the service
• Consider focusing on providing the service for a set period of time to maximise provision and impact.

Choice, not chance

Whatever the condition being screened for – and whatever the clinical setting – people are free to make their own decisions about whether to be screened or not. However, the dip in screening uptake highlights the concern that many people continue to turn down their appointment or are not aware of the screening offers that are available to them, as well as the recognition that there will always be some degree of variation between different groups in their acceptance of a national screening programme.

With prime positions within their communities, pharmacies have the opportunity to engage with people who are reticent or unaware of the NHS screening programmes through targeted community awareness initiatives as well as the provision of individual support and advice.

"The key to this is making sure people understand the value of getting an early diagnosis, whether that’s for high blood pressure, diabetes, or potentially cancer," says Satyan Kotecha, independent community pharmacist at Belgrave Pharmacy in Leicester. "It is about articulating without scaremongering that the earlier we intervene the better."

However, screening is a pathway, not just a test, and offering or recommending a test comes with an obligation to make sure that the person is cared for and supported throughout their screening journey with the appropriate advice and interventions.

"This wrap-round advice is where pharmacy can really step up," says Satyan. "Successful screening has to be about more than just giving people results and information; it has to include guidance about how patients can navigate what these all mean. As highly trained individuals we can make sense of these for patients, and this is where the skills of community pharmacists really come into their own."

NHS screening: facts & figures

Every year across the UK around:

• 5,000 deaths are prevented by cervical screening
• 2,400 bowel cancer deaths are avoided through screening
• Breast screening prevents 1,300 women dying of breast cancer
• 7,000 people with sight-threatening diabetic retinopathy are referred to hospital eye services for urgent treatment
• 2,500 men have a potentially life-threatening aneurysm detected
• 1,000 babies who may otherwise have been born with HIV are born free of the condition
• 1,100 babies with hearing problems are helped to reach full educational and social potential through early diagnosis and treatment.

Source: gov.uk/government/publications/nhs-population-screening-inequalities-strategy/phe-screening-inequalities-strategy