Designing Complete Services

England’s Cervical Screening Program

by Rochelle Gold & Shirley Sarker

Transforming Ageing Technology

Each year, over 10 million people in England are screened as part of the national screening programmes, saving thousands of lives through early diagnosis and preventive treatment.

Some of these screening services are running on technology built in the 1980s. For example, the cervical screening programme is run on the National Health Application and Infrastructure Services (NHAIS), which is an ageing distributed system consisting of more than 80 data hubs covering different geographic areas of England. Users must spend months learning hundreds of different codes in order to perform laborious data management tasks.

The nature of how NHAIS was built prevents us from adding efficiencies. For example, we are unable to integrate new data streams or design new services for participants to manage their own data.

The task to update a live screening service is a grand endeavour. We have to migrate over 27 million screening participants’ data and build a new call-recall system (i.e. the service that invites over 4 million eligible people a year, saves their screening results and sets the recall date) — and all the while making sure it’s future proof. We also have to make sure the new system meets the business needs of the various organisations involved in running the end-to-end service, such as the forms used by clinicians or the letters sent to screening participants.

Since there is currently no single service owner, this makes digital transformation complex and challenging.

NHSX has been created to give people and staff the technology they need. One of its first priorities is the transformation of the technology that supports cervical screening services.

For the first time, a multidisciplinary team of specialists from NHSX, Public Health England, NHS Digital, NHS England and NHS Improvement are working together to improve the whole service using an agile and user-centric approach.

Holistic Research

As a national technology provider to the NHS, NHS Digital’s role is to explore how we can safely migrate from a legacy system to a robust future proof screening platform.

Our journey began by looking at the existing system. We examined previous research undertaken on the number of participants invited and screened, reviewed other NHS screening services (e.g. breast and bowel screening), as well as screening solutions in use around the world, including such other home countries and in the Netherlands and New Zealand. Finally, we looked at existing technology such as products and APIs built by NHS Digital.

We then explored the current state. We visited various clinical teams who deliver the cervical screening programme, which was a challenging task since these teams are employed by separate organisations, are commissioned by separate contracts, are responsible for their own processes, have their own workarounds, and use various non-interoperable computer systems.

We learned from participants who have been through their own screening journey: they told us that paper-based invitations were not enough to solely encourage participation, that limited access to screening locations was causing participants to miss their screening appointment; and that many users had issues with the physical examination itself.

We are also exploring the future. As discussed in Professor Sir Mike Richards’s Independent Review of Adult Screening programs in England we are exploring areas for future development such as self-sampling and AI. Alongside this we are also considering future NHS Digital product availability such as NHS.UK and the NHS App as well as APIs from third party systems.

By looking at these issues from the past, present and future, we now have a much greater understanding of what is possible and what contingencies we need to build for the future.

Designing a Complete Service

Our approach is focused on collaborative design. We will be conducting participatory design sessions with users and stakeholders to make sure we design a system that will allow service providers to deliver a safe and effective service in the most efficient way.

We are continuously engaging with the various government agencies to make sure we don’t design in silos. Our aim at the moment is to design and build the new technology that will run the cervical screening service in an iterative fashion. We will be sharing and re-using our methodology, our technology, and service patterns to enhance the other screening programmes.

Once we start to build an updated cervical screening system, we will be exploring another pressing issue. The NHS Cervical Screening Programme saves an estimated 5,000 lives a year but the number of women attending cervical screening in England is falling, with over one in four women not attending when invited. It is therefore imperative that the systems supporting programme delivery are able to respond effectively to future changes to the service, including national drives to increase Cervical Screening uptake and future policy decisions.

In design and research for health and social care, meeting people’s needs is always our focus. Our aim is to enable care for patients and ultimately save lives. By working on the whole service with all those involved, we are able to find more ways to improve outcomes and enhance user experiences for both patients and staff.

We’re showing how combining user research and design methods with cross-organisational collaboration can help build a safe and efficient system of healthcare for now and the future.

Shirley Sarker is a Lead Service Design contractor at NHS Digital. Previously, she led service design on integrating pharmacy into the wider healthcare system.

Rochelle Gold is Head of User Research at NHS Digital. She has been working in research for 17 years with experience in health, social care, criminal justice and academia.