Guidance

ANNB screening: identifying inequalities

Published 25 August 2021

Applies to England

Identifying and addressing health inequalities is a legal duty for all screening services.

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.

The NHS population screening inequalities strategy sets out how Public Health England (PHE) and its partners aim to tackle screening inequalities.

Equal access to uniform and quality-assured screening must be offered to all eligible pregnant women and parents or carers of newborn babies in England.

This guidance is aimed at antenatal and newborn (ANNB) screening providers, commissioners and other public health specialists. They should refer to it in order to support work to identify inequalities and interventions that can improve access and reduce inequalities. They can also refer to NHS population screening: identifying and reducing inequalities for more guidance and information on tackling screening inequalities.

Health inequalities can exist across a range of characteristics or dimensions, including social deprivation, geography, vulnerable or inclusion health groups and the 9 protected characteristics described in the 2010 Equality Act.

Screening inequalities can happen at any point along the screening pathway. Examples of how inequalities can occur within the antenatal and newborn screening pathways include:

• access to services, including offer of screening, referral, diagnosis and treatment
• timeliness of the offer and provision of services
• information provision, including meeting the communication needs of women and parents or carers to enable personal informed choice
• inability to record protected characteristics or gender identity on IT systems, resulting in an inability to meet an individual’s needs

Evidence of inequalities in ANNB screening

In 2013, UK research using large survey data consolidated evidence that women from ethnic minority groups are more likely to book late for antenatal care, engage less with screening and have fewer antenatal checks and ultrasound scans (1).

An audit undertaken in London in 2015 to 2016 (2) reviewed pre- and post-referral delays in antenatal bookings. The audit found evidence of persistent inequalities in access to timely antenatal care across London, with different groups at risk of late referral, longer waits after referral or both. Those at increased risk of both pre- and post-referral delays included:

• women living in more deprived areas
• ethnic minority communities
• women whose first language was other than English
• women of Jewish religion
• people experiencing maternal unemployment

Evidence indicates that earlier initiation of sickle cell and thalassaemia (SCT) screening in primary care reduces the time to complete the screening process. Possible factors that may impact on early access and personal informed choice in SCT screening include:

• failure to offer screening or screening offered too late in pregnancy
• lack of knowledge about the screening test
• the screening process taking too long
• diagnostic testing offered too late in pregnancy

Newborn screening is not always provided at all institutions where babies may receive treatment, such as specialist children’s hospitals. In addition, the national newborn IT systems are not always used in these settings, so babies cannot be tracked along the screening pathway. This may lead to a delay in screening and/or diagnosis or in some cases missed screening.

Delays in screening may result in some babies not being eligible for some of the newborn screening tests due to their age. For example, the cystic fibrosis screening test is not reliable in babies more than 8 weeks of age and newborn hearing screening is difficult to perform on babies more than 3 months of age.

Health equity audit guidance

ANNB screening providers should use the PHE screening health equity audit (HEA) guidance in conjunction with the generic PHE Health Equity Audit Tool (HEAT) to:

• identify health inequalities for the eligible cohort
• assess health inequalities in relation to the screening service
• identify actions to take to help reduce those inequalities

Data reports

ANNB screening providers collect and report data relating to nationally set standards. This may help providers to identify inequalities in the pathway and where improvements are needed to reduce barriers and address variation. For instance, this could include looking at variation in standards related to the timeliness of the test, reporting of results, attendance for diagnostic testing and laboratory turnaround times.

Providers can also use learning from screening incidents. Evidence following a review of screening incidents highlighted that some eligible women are not offered screening at their booking appointment, potentially limiting their choices. As part of the process of reviewing and learning from incidents, providers should consider any inequality factors which may have contributed to them.

Evidence from screening incidents shows that these inequality factors include women who do not attend appointments and women whose first language is not English. These 2 groups can miss the offer of screening or, where the offer is accepted, screening is not always completed.

Considering these factors will help inform appropriate service improvement work to address any inequalities.

Evaluation

Providers should involve users in the design and evaluation of services.

When planning changes to how a service operates it is important for providers to decide the outcome they hope to achieve and how they would know it had been achieved. They need to consider if the change:

• has any positive or negative impacts that were not expected
• is cost-effective
• is sustainable

Providers also need to consider what factors influenced the achievement or non-achievement of the outcome.

There are many different ways to evaluate changes depending on the type of change. Routine data can be used to measure a change that affects a large number of people.

References

1. Henderson J, Gao H and Redshaw M. 2013. Experiencing maternity care: the care received and perceptions of women from different ethnic groups. BMC Pregnancy and Childbirth, 13, 196. [Accessed online June 2021]

2. McDonald H, Moren C, Scarlett J. Health inequalities in timely antenatal care: audit of pre- and post-referral delays in antenatal bookings in London 2015 to 2016. Journal of Public Health (Oxf) 2020 Nov 23;42(4):801-815.