Guidance

Population screening KPIs: purpose and data submission guidance

Updated 20 February 2024

Applies to England

1. Purpose

Key performance indicators (KPIs) define consistent performance measures for a selection of public health priorities.

They use terminology that is clear and common across all screening programmes, so performance can be understood, assessed and compared.

KPIs are a subset of screening standards and give a high-level overview of the quality of screening programmes at important points on the screening pathway.

They contribute to the quality assurance of screening programmes but are not, in themselves, sufficient to quality assure or performance manage screening services.

See our approach to NHS population screening standards for further information on the format of our indicators, the pathway themes, performance thresholds and the relationship between standards and KPIs.

The KPIs reflect areas where consistency and an understanding of variation across England are important.

Screening KPIs are contained within the Section 7a agreements between the Department of Health and Social Care (DHSC), and NHS England and NHS Improvement, and in the Public Health Outcomes Framework (PHOF). Further information about screening standards and service specifications are available for each programme.

To see the list of KPI indicators, please see the KPI index. The list is also available as a spreadsheet where the indicators can be filtered by national programme and pathway theme.

2. Submitting KPI data

National programme data managers collate and submit directly to the national screening data and information team the data for:

• abdominal aortic aneurysm screening
• diabetic eye screening
• newborn hearing screening
• bowel cancer screening
• breast screening
• cervical screening

You should follow national guidance for submission of KPI data for the AAA, DES, antenatal and newborn blood spot screening programmes.

3. Roles and responsibilities

We strongly recommend that screening data collections and submissions are supported by screening providers’ information and/or performance analyst(s). Submission of KPI data should follow screening providers’ assurance processes.

Data must be complete and valid. Where screening services are unable to return complete and valid data they should submit a blank return and have an action plan in place to enable them to report in the future.

Screening services must have failsafe processes to identify where things are going wrong and take corrective action before harm occurs. The KPI process is not in itself a means of providing failsafe due to the delay in reporting.

3.1 Generic

PHE Screening

PHE Screening is responsible for reviewing data following submission, assessing completeness of returns and performance against KPI thresholds, publication of data and summary factsheets.

The data is shared with the screening quality assurance service (SQAS) and NHS England screening commissioners in accordance with locally agreed arrangements.

NHS England

NHS England responsibilities are outlined in the service specifications.

3.2 Antenatal and newborn screening programmes

Head of midwifery (HoM)

The HoM is accountable and responsible for providing timely collation of accurate data. The data must be signed off by HoM and submitted on the KPI submission template to phe.screeningdata@nhs.net.

Antenatal and newborn screening co-ordinator/provider information team

This team is responsible for collating, checking and submitting accurate data to the HoM.

Child health information service manager

The child health information service manager is accountable and responsible for the timely collation of accurate data. The data must be submitted on the KPI submission template to phe.screeningdata@nhs.net.

Local NIPE lead

The NIPE lead is accountable and responsible for timely collation of accurate and reliable data. Providers must use the NIPE screening management and reporting tool SMaRT4NIPE (S4N) IT system to manage the local screening process. The data is extracted from S4N by the national programme and submitted directly to the screening data and information team.

For screening providers to sign off their quarterly reports, the national programme will publish on S4N the KPI data reports for NP1 and NP2 before the quarter end. Each NHS trust should sign off their reports within 2 weeks of uploading to S4N. If reports are not signed off, they will be taken to be accurate.

NHSP local manager/NHSP team leader

The NHSP local manager/NHSP team leader is accountable and responsible for timely entry of accurate data into the national IT system for newborn hearing screening SMaRT4Hearing (S4H).

The data is extracted from S4H by the national programme and submitted directly to the screening data and information team.

For screening providers to sign off their quarterly reports, the national programme will publish on S4H the KPI data reports for NH1 and NH2 before the quarter end. Each NHSP site should sign off their reports within 2 weeks of uploading to S4H. If reports are not signed off, they will be taken to be accurate.

3.3 Diabetic eye screening programme

Local DES service clinical lead/manager

The clinical lead or manager is accountable and responsible for timely collation of accurate and reliable data.

National DES programme team

The national team is responsible for:

• informing local DES services when they should submit their performance reports
• calculating the KPIs from the submitted reports
• checking data provided is accurate and complete
• submitting to the national screening data and information team

3.4 Abdominal aortic aneurysm screening programme

Local AAA service manager/coordinator

The local manager is accountable and responsible for timely collation of accurate and reliable data.

National AAA screening programme team

The national team collates the KPI data from the screening management and reporting tracker (SMaRT) IT system and sends it to local screening service managers/coordinator for review and sign-off.

Once finalised, the data and information manager submits the data for all screening services to the national screening data and information team.

3.5 Bowel cancer screening programme (BCSP)

The national system produces the data in real time as a by-product of operational delivery.

The national BCSP team downloads the KPI data from the national system and submits the data for all screening services to the national screening data and information team.

3.6 Breast screening programme (BSP)

The national BSP team validates and collates the KPI data from SQAS (regions). Once finalised, the data for all screening services is submitted to the national screening data and information team.

3.7 Cervical screening programme (CSP)

The national CSP team collates the KPI data and checks it is complete. Once finalised, the data for all screening services is submitted to the national screening data and information team.

4. Information governance

It is the responsibility of all staff to make sure they are aware of their obligations regarding compliance with their organisation’s information governance policies. They should be aware of:

• the reasons for adhering to information governance when collecting and validating data and information
• accepted standards regarding data and information such as sources, control files, validity, reliability, completeness, terminology, acronyms, purpose and conventions
• data sharing protocols
• local assurance arrangements regarding board level sign-off

The submitting organisation is responsible for making sure only accurate data is submitted. Good quality data is extremely important for monitoring and improving screening service providers.

Screening providers may want to refer to guidance on the false or misleading information (FOMI) offence from The Care Act 2014, which sets out the responsibility of providers to supply and publish accurate data.

Data is not usually published if the numerator or denominator is less than 5 for an individual quarter. In such cases, the data will be aggregated and published annually where possible.

5. Timescales

Q1 (1 April to 30 June)

Time for sense checking and return: 1 September to 30 September.

Q2 (1 July to 30 September)

Time for sense checking and return: 1 December to 31 December.

Q3 (1 October to 31 December)

Time for sense checking and return: 1 March to 31 March.

Q4 (1 January to 31 March)

Time for sense checking and return: 1 June to 30 June.

We publish screening KPI data each quarter. We share the KPI data with NHS England before publication.

Publication dates for KPI data are:

• Q1 April to June data: published by the end of November
• Q2 July to September data: published by the end of February
• Q3 October to December data: published by the end of May
• Q4 January to March: published by the end of August

Data for some KPIs is collected later than others. Data publications are updated as data becomes available.

We pilot KPIs following an agreed process before they are introduced. New KPIs are not published in the first year of data collection.

This time is used to improve the data quality and completeness, by revising the definition, and adding clarity as required. After this time, we review the data with the aim of publishing it from the following year.