Cervical Screening Programme, England - 2023-2024 [NS]

The statistics presented in this publication are derived from information that is routinely collected by NHS England to inform policy and to monitor the quality and effectiveness of screening services.

Information is collected on the following NHS England Korner Collection (KC) returns:

• KC53
  Information from the call and recall system, collected for all 153 upper tier local authorities (LAs).
• KC61
  Information on screening samples examined by pathology laboratories, collected from all 8 laboratories carrying out cervical screening in 2023-24. The KC61 includes data from the previous year (2022-23) which arises from the 8 laboratories that reported activity during 2022-23.
• KC65
  Information on referrals to colposcopy, subsequent treatment and outcomes, collected from all 186 clinics providing colposcopy services in 2023-24. 

Individuals between the ages of 25 and 64 are invited for regular cervical screening under the NHS Cervical Screening Programme (the programme).

The cervical screening programme is intended to detect abnormalities within the cervix that could, if undetected and untreated, develop into cervical cancer.

A first invitation for screening is sent to eligible individuals registered as female when they are 24.5 years old.

Subsequent invitations are sent every 3 or 5 years depending on age³.

Those aged 65 or over can still be invited for screening if a recent or previous cervical cytology sample is abnormal. (Additionally, they may also be screened if they have not had a cervical screening test since 60 years of age and they request one.)

Call

A call invitation is an invitation sent to previously unscreened individuals registered as female.

Recall

A recall invitation is an invitation for subsequent screens.

A more detailed overview of the programme is available. 

HPV primary testing began implementation as a pilot in 2013 and full rollout was achieved by December 2019.

HPV is a common virus which, although harmless in most people, is linked to the development of abnormal cervical cells. If left untreated, these abnormal cells can develop into cervical cancer.

Under HPV primary testing, screening samples are sent to pathology laboratories for HPV testing first.

Where the HPV virus is detected (an hrHPV positive result), a cytology screen is then performed.

The results of each test are sent to the national call and recall IT system to generate letters to send to the individual who has had the test.  Results are also sent to the individual’s GP or the sample taker (if not the GP) by the laboratory. Individuals should be notified of their test results in writing within 2 weeks of the sample being taken.

Most individuals receive a normal result and are recalled for another routine test in 3 or 5 years dependent on their age.

Actions following HPV primary testing results are detailed below.

In a small proportion of cases the pathology laboratory is unable to get a valid HPV result or assess the cells on the cytology slide. In such cases, the test is considered an unavailable HPV result or an inadequate cytology result and the individual is asked to return for a repeat test 3 months later.

Prior to the implementation of HPV primary testing, HPV testing as triage (sorting) was used for individuals with borderline and low-grade dyskaryosis results. This was rolled out from March 2012.

With HPV testing as triage, screening samples are sent to pathology laboratories for slide preparation and screening by a cytologist/screener.

Where a test result shows borderline change or low-grade dyskaryosis (abnormal cell changes), the sample is then tested for infection with high-risk HPV (Human Papillomavirus). 

Actions following HPV testing as triage results are detailed below.

Negative cytology

Individual is returned to routine recall screening without an HPV test.
 

Borderline change or low-grade dyskaryosis
(abnormal cell changes)

An HPV test is carried out.

If the result is hrHPV negative the individual is returned to routine recall screening.

If the result is hrHPV positive the individual is referred to colposcopy.
 

High-grade dyskaryosis (moderate or worse)

Individual is referred to colposcopy immediately without an HPV test being carried out.

In a small proportion of cases the pathology laboratory is unable to assess the cells on the cytology slide to give a result and the test is considered inadequate. In such cases individuals are asked to return for a repeat test 3 months later.

Individuals referred for colposcopy⁴ attend a colposcopy clinic where a colposcope (a lighted, low-powered microscope) is used to closely examine the cervix to determine appropriate treatment, if any.

An individual may be referred for a colposcopy following their cervical screening if:

• some of the cells in the screening sample are abnormal
• the HPV test is positive and there is a cytological abnormality or they have had persistent HPV-positive and cytology negative tests (under HPV primary screening)
• the nurse or doctor who carried out the screening test thought the cervix didn't look as healthy as it should
• it wasn't possible to give a clear result after several screening tests
• unable to take a sample in primary care

A colposcopy can also be used to find out the cause of problems such as unusual vaginal bleeding (for example, bleeding after sex).

A biopsy may be taken from the cervix for diagnosis and/or the cervix may be treated.

Individuals who do not require immediate treatment may be kept under surveillance by repeat screening tests, with or without repeat colposcopy, at suitable intervals.

The cervical screening call and recall programme invites eligible individuals for cervical screening at regular intervals.

Individuals are identified as eligible for screening if they are:

• registered with a GP (or otherwise known to the NHS)
• in the screening age range (24.5 to 64 years)
• a woman or person with a cervix
• not ineligible because their recall has been ceased as they do not have a cervix (most commonly due to hysterectomy)

In 2023-24, the cervical screening programme sent invitations to patients who are registered as female or indeterminate.  If a person changed their gender registered on their primary care medical records to male, they will no longer automatically receive invitations from the programme, however, they remain eligible to have screening if they have a cervix. The screening should be organised from the GP practice who would take on the responsibility for inviting for screening at the required screening intervals.

Learn more about the national guidance about who can be screened in the national screening programmes. 

Coverage is defined as the percentage of individuals  in a population who were eligible for screening at a given point in time (31 March 2024 in this instance) and who were screened adequately within a specified period. (See above definition of eligibility in Appendix B)

As the frequency with which individuals are invited for screening is dependent on age, coverage is calculated differently for different age groups.

For the total target age group (25 to 64 years), coverage is presented in this report, which represents the most up to date definition.

This takes into account the frequency with which individuals of different ages are invited for screening.

Individuals aged 25 to 49

Individuals aged 50 to 64

Individuals aged 25 to 64

Coverage statistics in this report are calculated using data from the National Health Application and Infrastructure Services (NHAIS) system via Open Exeter and include all individuals registered as female with an NHS GP practice and those who are not registered with a GP practice but who are otherwise known to the NHS.

The total number of individuals who are not registered with a GP or otherwise known to the NHS is not recorded. It is therefore not possible to estimate how overall coverage rates might be affected by this group.

NHAIS data supports many primary care services including the NHS Cervical Screening Programme’s call and recall system for inviting individuals for screening. NHAIS is the only data source that can identify both the eligible population and those individuals who have been tested in the last 3 or 5 years.

Coverage at LA level is based on the eligible LA resident population. Coverage at Primary Care Organisation (PCO) level, i.e. prior to 2013-14, was based on the eligible PCO responsible population.

For more information on the difference between LA resident and PCO responsible populations see the ‘Impact of NHS reorganisation’ section of the data quality statement.

Standards for laboratory reporting in cervical screening are set for key indicators. See the main report for current data relating to these standards.

Positive predictive value (PPV) is the proportion of individuals referred with high grade abnormalities who have a histological outcome of cervical intraepithelial neoplasia (CIN)2, CIN3, adenocarcinoma in situ/cervical glandular intraepithelial neoplasia (CGIN) or cervical cancer.

PPV is calculated from outcomes of referral for tests with results of high-grade dyskaryosis (moderate) or worse as follows:

(Numerator / Denominator) x 100

Numerator
Number of individuals referred to colposcopy in the previous 12 months with a cytology result of moderate dyskaryosis or worse, whose colposcopic outcome is a histological diagnosis of CIN2, CIN3, adenocarcinoma in situ/CGIN or cervical cancer.

Denominator

Number of individuals referred to colposcopy in the previous 12 months with a cytology result of moderate dyskaryosis or worse, whose colposcopic outcome is no abnormality detected (NAD) or a histological diagnosis of normal, HPV, CIN1 or worse.

CIN1 or worse is defined as: CIN1, CIN2, CIN3 adenocarcinoma-in-situ/CGIN or cervical cancer.

Abnormal predictive value (APV) is the percentage of samples reported as borderline or low grade which lead to a colposcopy referral and where the histological outcome is CIN2, CIN3, adenocarcinoma in situ/CGIN or cervical cancer.

APV is calculated from outcomes of referral for tests with results of borderline or low grade dyskaryosis as follows:

(Numerator / Denominator) x 100

Numerator
Number of individuals referred to colposcopy in the previous 12 months with a cytology result of borderline or low grade dyskaryosis whose colposcopic outcome is CIN2, CIN3, adenocarcinoma in situ/CGIN or cervical cancer.

Denominator

The number of individuals referred to colposcopy in the previous 12 months with cytology result of borderline or low grade dyskaryosis whose colposcopic outcome is colposcopy NAD or a histological diagnosis of normal, HPV, CIN1 or worse.

Referral Value (RV) is defined as the number of individuals referred to colposcopy (excluding inadequate referrals) per detection of 1 CIN2 or worse lesion.

This is no longer a programme standard but the figures are still calculated and included in the report.

Definition is as follows:

(Numerator / Denominator)

Numerator
Number of individuals referred with all results except inadequate with outcome of referral: cervical cancer, adenocarcinoma in situ / CGIN, CIN3, CIN2, CIN1, HPV only, no CIN/HPV, seen but no abnormality detected/no biopsy taken.

Denominator

Number of tests as per numerator, but only including outcome of referral: cervical cancer, adenocarcinoma in situ/CGIN, CIN3 or CIN2.

From April 2013, RV excludes individuals referred to gynaecology following a test result of ?glandular neoplasia (non-cervical).

Individuals with negative cytology but who test positive for HPV and are referred to colposcopy are not currently included in the calculation of referral value.

Percentiles are no longer calculated in this report for inadequate sample rates as there are now only 8 laboratories reporting the data.

A percentile is the value of a variable below which a certain percent of observations fall.

For example, the 10th percentile is the value (or score) below which 10 percent of the observations may be found.

Definitions of clinical terminology used in this report are provided below - click on a letter to see all terms beginning with that letter.

For definitions of further medical terminology not covered below please visit the Cancer Screening pages on Gov.uk.

HPV result

• Negative (result code 0)
  This indicates that high risk HPV was not found.
   
• Positive (result code 9)
  This indicates that high risk HPV was found.
   
• Unavailable (result code U)
  This indicates no result was able to be obtained from the sample.
   

Cytology result

• Negative
  This indicates that no cell abnormalities were found.
   
• Borderline change (in squamous or endocervical cells)
  These are small changes found in the cells of the cervix which often return to normal by themselves.
  The term ‘borderline change in squamous cells’ describes morphological alterations to squamous cells that fall short of low-grade dyskaryosis.
  Borderline change in endocervical cells describes atypical endocervical cells where dyskaryosis cannot be excluded. Since February 2020, this result is managed as a high grade screening result (along with results showing moderate dyskaryosis or worse) with referral to colposcopy within 2 weeks.

• Low-grade dyskaryosis
  Dyskaryosis is the name given to small changes that are found in the cells of the cervix (the neck of the womb). Low-grade dyskaryosis is associated with CIN1 (see Appendix E).
  These changes are not cancer, and in most cases do not lead to cancer in the future.
   
• High-grade dyskaryosis (moderate) or high-grade dyskaryosis (severe)
  These areas of changed cells are associated with CIN grades 2 and 3 respectively (see Appendix E).
   
• High-grade dyskaryosis/?invasive squamous carcinoma
  This indicates probable CIN3 with additional features suggesting the possibility of invasive cancer.
  ?invasive squamous carcinoma is shown as ?invasive carcinoma in the tables and commentary for ease of reporting.
   
• ?Glandular neoplasia of endocervical type
  This shows cytological features suggestive of cervical glandular intra-epithelial neoplasia (CGIN) or endocervical adenocarcinoma.
   
• ?Glandular neoplasia (non-cervical)
  This category is used where no cervical cell abnormalities were found but the sample contained features suggesting a diagnosis of endometrial, ovarian or metastatic lesions from beyond the genital tract.

The terms ‘potential cervical cancer’, ‘abnormal’, ‘negative’ and ‘inadequate’ are used within the report to represent groupings of the result categories detailed above.

They are defined as follows in terms of the categories used on the cytology report form HMR 101/5:

Potential cervical cancer
HMR 101/5 cat. 5 (high-grade dyskaryosis/?invasive squamous carcinoma) or cat. 6 (?glandular neoplasia of endocervical type); Those who have such test results should be referred urgently for further investigation.

Abnormal
HMR 101/5 cat. 8 (borderline change in squamous cells), cat. 9 (borderline change in endocervical cells), cat. 3 (low-grade dyskaryosis), cat. 7 (high-grade dyskaryosis (moderate)), cat. 4 (high-grade dyskaryosis (severe)), cat. 5 & 6 (see potential cancer above).

Negative
HMR 101/5 cat. 2 (negative); women with a negative test result will usually be returned to the screening programme to be called again at the normal interval (3 or 5 years).

Shorter recall intervals may be appropriate for women under surveillance or follow-up after treatment.

Inadequate
HMR 101/5 cat. 1 (inadequate); inadequate means it was not possible to obtain a valid result from the sample.

Individuals with inadequate samples will be recalled for a repeat test. Those with 3 consecutive inadequate results should be referred to colposcopy for further investigation. Under HPV primary screening, individuals are referred for colposcopy after 2 consecutive tests with any combination of HPV unavailable or cytology inadequate.

The NHS Cervical Screening Programme uses the following categories to record the results for individuals who are referred for gynaecological investigation at colposcopy clinics:

Cervical cancer
The outcome of investigation shows cervical cancer.

CIN (cervical intra-epithelial neoplasia)
CIN is an indicator of the depth of abnormal cells within the surface layer of the cervix, and is divided into 3 grades.

The higher the number/grade the more severe the condition:

• CIN1
  One third of the thickness of the surface layer of the cervix is affected.
• CIN2
  Two thirds of the thickness of the surface layer of the cervix is affected.
• CIN3
  Full thickness of the surface layer of the cervix is affected (also known as carcinoma in situ)

Adenocarcinoma in Situ
A localised growth of abnormal glandular tissue that may become malignant.

HPV only
Biopsies which were diagnosed as showing features consistent with HPV infection only. See Appendix B for more information on HPV.

No CIN/No HPV
Biopsies where no evidence of cervical disease or HPV infection can be identified and is to be used for specimens of normal tissue only.

Seen in colposcopy - result n/k
Individuals who have had a biopsy taken but the result is not yet known or available.

Inadequate biopsy
Biopsies which are known to be inadequate or unrepresentative due to deficiencies in the sampling process.

Colposcopy – no abnormality detected
Individuals with an adequate colposcopy result showing a normal result for cervical neoplasia or HPV infection without a biopsy being required.

For 2023-24, data submissions have been made for all LAs. In all LA data tables Isles of Scilly have been combined with Cornwall, and City of London with Hackney, to ensure the data are non-disclosive. 

All 8 laboratories submitted data for 2023-24 and for 2022-23 (KC61 part C2).

Data was submitted from 186 colposcopy clinics for 2023-24.

NHS England’s Screening Quality Assurance Service (SQAS) (previously part of Public Health England until 1 October 2021) collects and quality assures the data collections. Validation undertaken by SQAS covers:

• checks on data completeness
• identification of any unusual figures which are then followed up individually
• comparisons with previous years’ data to ensure that any unusual trends are identified and explained
• consistency checks between different parts of the returns
• checks that totals equal the sums of parts
• checks on the calculations of statistics

Data validation and quality assurance checks are also carried out by NHS England as part of the publication process. Validation checks undertaken by NHS England include:

• comparisons with previous years’ data to ensure that any unusual trends are identified and explained
• consistency checks between different parts of the returns
• checks that totals equal the sums of parts
• checks on the calculation of statistics
• checking for outliers (figures that are particularly low or high compared to other areas)

Part of NHS England’s quality assurance procedure includes returning data tables to the SQAS for verification prior to publication.

The sections below describe the issues/areas identified for further investigation through NHS England's validation processes and the outcomes of follow-ups with the SQAS this year.

Some queries were raised with NHS England where the totals of one part did not match another, or an individual below the age of 60 had been categorised as ‘ceased for age reasons’.

Where applicable these explanations are provided within the publication and data tables as footnotes.

Comparisons to previous year’s submissions were performed and notable differences were reviewed. All were confirmed to be acceptable and no resubmissions were necessary.

There were no data quality issues with 2023-24 data. 

No data quality issues were highlighted through the quality assurance and validation procedures.

No data quality issues were highlighted through the quality assurance and validation procedures for 2023-24 data. 

No data quality issues were highlighted through the quality assurance and validation procedures.

Almost all issues that were highlighted through NHS Digital’s validation processes for follow-up with SQAS were resolved satisfactorily. Any remaining mismatches were small and are thought to have minimal impact on the overall of the statistics.

Where data issues were outstanding, footnotes have been placed against the relevant tables as described above.

This section details known users of the report and the purposes for which they use the statistics. All these users have found the information in the report useful for the purposes set out.

Department of Health and Social Care (DHSC) and the Office of Health Disparities (OHID)

Use the statistics from this publication to inform policy. The statistics are also used by DHSC to respond to public and parliamentary business.

NHS England

Use the statistics from this publication to monitor the performance and quality of screening services commissioned against key performance indicators set out in the Section 7a agreement with DHSC. The statistics are used for performance management purposes, comparing local statistics with regional and national figures.
 

The statistics are used to review and develop national screening standards and guidance for programme development.

SQAS teams use the bulletin as a reference document to assess the quality and effectiveness of the cervical screening programme.

Local Authorities (LAs)

LAs and NHS Clinical Commissioning Groups (CCGs) are required to prepare Joint Strategic Needs Assessments of Health and Wellbeing (JSNAs), which inform local commissioning of health and wellbeing services. Indicators from the publication form part of the Local Government Association’s Joint Strategic Needs Assessment: Data Inventory (via the Compendium of Population Health Indicators).

Compendium of Population Health Indicators

Indicators from the publication are included in the Compendium of Population Health Indicators which is widely used within the NHS as well as outside it.

Cancer Research UK

Cancer Research UK use the report for planning and evaluating their work. The statistics are used to inform a wide range of work including the charity’s policy positions and public communications about screening. For example, they are able to inform people potentially taking part in screening about the frequency of abnormal results and all the possible outcomes of screening.

Media

The data are used to underpin articles in newspapers, journals, etc. on matters of public interest.

The cervical screening publication is free to access via the NHS Digital website and therefore the majority of users will access the report without being known to NHS Digital.

It is important to put mechanisms in place to try to understand how these additional users are using the statistics and also to gain feedback on how we can make the data more useful to them.

Feedback on this publication can be sent to the following e-mail address: [email protected]  

Feedback on the following themes would be particularly useful:

• How useful did you find the content in this publication?
• How did you find out about this publication?
• What type of organisation do you work for?
• What did you use the report for?
• What information was the most useful?
• Were you happy with the data quality?
• To help us improve our publications, what changes would you like to see (for instance content or timing)?
• Would you like to take part in future consultations on our publications?

All feedback is passed to the team responsible for the report to consider.

NHS Digital publishes around 90 series of official statistics and National Statistics each year. Use of health and care statistics helps those involved to manage the system more effectively, commission better services, understand public health trends in more detail, develop new treatments and monitor the safety and effectiveness of care providers.

Our strategy for 2015-2020 sets out that over the next few years we are committed to analysing and making openly available data, statistical information and insights about the health and social care sector in ways which better meet our users’ needs.

However, these changes come at a time when spending on central services is being squeezed, and we must better prioritise our current services.

In our 2016 consultation on changes to statistics produced by NHS Digital, we proposed a series of changes over the next 3 years which will help us to better prioritise resources from our stretched budget while developing our statistical products to better meet the needs of our users. 

To date changes to the main publication include greater use of visuals, such as infographics, and simplifying the content and layout of documents for users.

The responses also highlighted the desire to retain the annual data tables as these are regarded as crucial for performance monitoring, benchmarking and trend analysis, as well as contributing to JSNA updates.

Some responses highlighted a requirement to publish timely data at a more granular level, i.e. CCG/GP practice level, in addition to LA, as this will support the needs of commissioners. Since June 2017, interactive dashboards with quarterly coverage data at GP, CCG and LA level have been accessible through our website.

We continue to work with colleagues at NHS England to ensure publications remain relevant and explore potential future improvements.

HPV primary screening

Human Papilloma Virus (HPV) primary screening was fully implemented in December 2019¹. With HPV primary screening, a sample is first tested for hrHPV and where the test result is positive, a cytology assessment is then performed on the sample.  If the test is HPV negative then no cytology assessment is carried out.

Prior to full implementation, laboratory providers experienced difficulty retaining and recruiting staff to continue the existing cytology screening services. This severely impacted on the turnaround times of cervical screening samples between 2016-17 and 2018-19, leading to increases in time to receipt of results. Following this, turnaround times improved from 2020-21 onwards.

2023-24 is the fourth year that all data collected is based on HPV primary screening. Following implementation of HPV primary screening, it is expected that there will be an increase in 12 month repeat invitations and additional referrals to colposcopy. This should be considered when interpreting changes in activity over recent years. (See Appendix A for full details on HPV primary screening and HPV triage.)

Further information on HPV Primary screening can be found here.

Disruption from the coronavirus pandemic had minimal effect on the data collection during 2020-21 and 2021-22, most screening services continued to submit data returns and data continued to be available directly from the call and recall IT system.

Due to COVID-19 measures, attendance for screening was less than usual in the early part of 2020-21. Screening and referral of those individuals considered to be at highest risk of a significant cervical abnormality was prioritised during this period and continued to take place.  From the summer of 2020, the NHS cervical screening programme began restoring and higher than normal levels of screening tests were seen. Increases in activity in 2021-22 may include catch-up activity following COVID-19 disruption.

See Appendix F for details of data quality issues and laboratory and clinic changes in 2020-21 and 2021-22.

For the latest information for the cervical screening programme, please see this link.

Sasieni, P, Adams, J, Cuzick, J. 2003, ‘Benefit of cervical screening at different ages: evidence from the UK audit of screening histories’, British Journal of Cancer, 89(1), pp.88-93. 

Lancucki, L, Sasieni, P, Patnick, J, Day TJ, Vessey MP (2012), ‘The impact of Jade Goody's diagnosis and death on the NHS Cervical Screening Programme’, Journal of Medical Screening, 19(2), pp. 89-93.

Solomon D, Nayar R. 2004, ‘The Bethesda System for Reporting Cervical Cytology’, New York, Springer-Verlag’.

Moss, S, Kelly, R, Legood, R, Sadique, Z, Canfell, K, Bin Lew J, Smith, M, Walker, R. 2011, ‘Evaluation of sentinel sites for HPV triage and test of cure: report to the NHS Cancer Screening Programmes’. and https://www.bsccp.org.uk/colposcopy-resources/evaluation-of-sentinel-sites-for-hpv-triage-and-test-of-cure-1/

Poole, J, Patnick, J. 2012, ‘Profile of Cervical Cancer in England: Incidence, Mortality and Survival’, Trent Cancer Registry.

1. PHOF outcome figures may show small variances year-on-year as updates are made to historic figures after the data are published.
2. See http://www.phoutcomes.info/ and https://www.gov.uk/government/publications/healthy-lives-healthy-people-improving-outcomes-and-supporting-transparency for more information.
3. https://cks.nice.org.uk/cervical-screening#!scenario
4. Where HPV primary screening is being piloted, women are first tested for HPV. If the sample is found to be positive, it is then examined by the cytologist for any abnormal cells.
5. https://www.nhs.uk/conditions/colposcopy/
6. See http://www.phoutcomes.info/ and https://www.gov.uk/government/publications/healthy-lives-healthy-people-improving-outcomes-and-supporting-transparency for more information.
7. For more information see: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/436753/nhscsp01.pdf

8. ‘Exeter’ system (NHAIS), Cancer Screening Statistics VSA15 (time from screening to receipt of results) and PHOF (coverage) Reports

9. PHE Screening: https://phescreening.blog.gov.uk/2017/12/18/new-guidance-to-help-cervical-screening-providers-reduce-cytology-backlogs/