The purpose of this audit is to initiate conversations about
cervical screening with patients who are not regularly
participating in the cervical screening programme, to identify
the reason(s) why they are not and then, if possible, to try to resolve these issues.
N.B. The term “female” is used in this audit to describe the biological
sex of the patient population who are at risk of cervical cancer.
However, we acknowledge that this may not reflect the identity of
all patients which will include transgender boys or men, intersex
and non-binary individuals.
Cervical cancer is now largely preventable through HPV
vaccination and cervical screening programmes; since
the implementation of these programmes, fewer people
are being diagnosed with and dying from cervical cancer.
However, there are still an average of 171 new diagnoses
(from 2015 – 2020) and 53 deaths (from 2015 – 2018)* caused
by cervical cancer each year. Cervical cancer is the third most
common gynaecological cancer in New Zealand.
*Mortality data are available for 2019, but are preliminary so have not
been included. Mortality data for 2020 are not yet available.
Although the HPV immunisation programme has effectively
reduced the prevalence of HPV infection and the incidence of
cervical cancer, vaccination cannot eliminate cervical cancer
entirely as people may:
- Not have been eligible for vaccination, did not opt to
be vaccinated or did not complete the course (in rare
cases, people may not develop immunity despite being
- Have been exposed to HPV prior to being vaccinated
- Have been infected with a high-risk type of HPV that
was not covered by the vaccine (Gardasil 9 only covers
seven of the 14 high-risk HPV types known to be
associated with cervical cancer)
- Have been infected with a low-risk type of HPV that very
rarely, can cause cervical cancer
- Have a non-HPV associated cervical malignancy
Therefore, all eligible people including those who have been
vaccinated against HPV should undergo regular cervical
screening to detect any pre-cancerous lesions and prevent
progression to invasive cervical cancer.
The National Cervical Screening Programme (NCSP)
currently recommends cervical screening every three years
for “participants with a cervix aged 25 – 69 years† who have
ever been sexually active”. The target is for at least 80% of all
eligible people to have had cervical screening. Those with
abnormal cytology results are either referred directly to a
colposcopy service or recalled for repeat cytology depending
on the type of abnormality detected.
† Prior to 2019, the start age was 20 years; people aged < 25 years who
have already started cervical screening should continue to be recalled
and managed in the same way as those aged 25 – 69 years. People
aged ≥ 70 years who were unscreened or under-screened prior to age
70 years are recommended to have two consecutive normal cytology
samples (taken 12 months apart) before ceasing screening.
Young people who have been sexually active and who have
been immune deficient for more than five years should
start cervical screening before age 25 years. People who are
immune deficient may also require more frequent screening,
e.g. annual, due to evidence of increased risk of persistent
HPV infection and cervical lesions, and because established
lesions may progress more rapidly.
From July, 2023, HPV testing will become the primary cervical
screening test in New Zealand. The screening interval for
participants with normal results will be five years. The new
method of obtaining a sample for HPV testing is with a vaginal
swab taken by either the patient (self-testing) or a healthcare
professional. Patients can, however, still opt for a clinician to
perform a speculum examination and take a liquid-based
cytology sample for HPV testing if they prefer. The option of
self-testing may change the views of some people who have
previously declined cervical screening because they did not
want to have a speculum examination (although a speculum
examination will be required if the patient tests positive for
HPV from a vaginal swab).
The responsibility for notifying patients that they are due for
cervical screening, providing results and placing a recall on
the PMS belongs to the primary care team. The NCSP provides
an important “backstop” to ensure that people who have an
abnormal cervical screening result are informed and that
appropriate follow-up is planned.
If a patient is not undergoing regular cervical screening,
it is important to discuss the reason(s) why (see below)
and the benefits of being screened for cervical cancer if
appropriate. Try to resolve the reason(s) if possible and book
Some patients have appropriate reasons for not participating
in cervical screening, e.g. they have had a hysterectomy (unless
they had a recent history of abnormal cervical cytology), do
not have a cervix, have been treated with radiotherapy for a
gynaecological cancer (can cause abnormal changes to cells
and therefore false positive cytology results), have never been
Other patients may not be participating because they have
missed appointments (e.g. due to COVID-19) or were not
recalled. Some patients may decline to participate in cervical
screening; consider periodic discussion with these patients
about the importance of cervical screening and address any
barriers or misconceptions (see: “Reducing barriers to cervical
**Ensure patients are aware that being sexually active involves any form
of sexual contact, i.e. it is not restricted to sexual intercourse. Patients
should be asked about participating in cervical screening from time-totime
in case their circumstances have changed. Patients who have never
been sexually active can still choose to participate in cervical screening.
For further information, see: “Cervical cancer – early dedetection and referral”
Ultimately the decision to participate in cervical screening
is made by the patient and not the general practitioner,
therefore it is difficult to audit practice in the usual way; hence
this audit slightly differs from traditional ones. You will not
need to search for and access the patient’s clinical notes to
complete this audit. Instead, it can be completed over time
opportunistically during consultations for other reasons with
eligible patients until the required number of patients has
When an eligible patient presents for any reason during the
period of the audit, check their cervical screening status.
If they are up to date, indicate this in the audit data sheet;
no further action is required. If they are not up to date with
cervical screening, note the general reason(s) why in the data
sheet (avoid any identifiable information) and ensure that this
is also more comprehensively documented in their clinical
record. If appropriate, reinforce the importance of being
screened for cervical cancer and put a plan in place to resolve
the reason(s) why the patient is not up to date. Indicate in the
data sheet whether an appointment has been booked.
Recommended audit standards
All females aged 25 – 69 years who are sexually active are
recommended to undergo regular cervical screening. Ideally
those who do not participate in regular screening should
periodically be encouraged to do so and asked if their
circumstances or views have changed. The purpose of this
audit is to initiate conversations about cervical screening with
patients who are not regularly participating in the cervical
screening programme, to identify the reason(s) why they are
not and then, if possible, to try to resolve these issues.
All females aged 25 – 69 years are eligible for this audit.
This includes people who are biologically female but have a
different identifier in their clinical record.
This is a “working audit” where the data sheet is filled in over
time when you have a consultation for any reason with an
eligible patient until the required number of patients has
For the purposes of this audit, continue until 30 eligible
patients have been identified and included.
Criteria for a positive result
A positive result is achieved by discussing cervical screening
with a patient who is not regularly participating in the cervical
screening programme to identify their reason(s) why, and
then if possible, trying to resolve the reason(s). Ideally, the
outcome is a booked appointment.
Use the sheet provided to record your data. Aim to resolve
reasons for not participating in regular cervical screening for
as many patients as possible.
The first step to improving medical practice is to identify the criteria where gaps exist between expected and actual
performance and then to decide how to change practice.
Once a set of priorities for change have been decided on, an action plan should be developed to implement any changes.
It may be useful to consider the following points when developing a plan for action (RNZCGP 2002).
Problem solving process
- What is the problem or underlying problem(s)?
- Change it to an aim
- What are the solutions or options?
- What are the barriers?
- How can you overcome them?
Overcoming barriers to promote change
- Identifying barriers can provide a basis for change
- What is achievable – find out what the external pressures on the practice are and discuss ways of dealing with them
in the practice setting
- Identify the barriers
- Develop a priority list
- Choose one or two achievable goals
- No single strategy or intervention is more effective than another, and sometimes a variety of methods are needed
to bring about lasting change
- Interventions should be directed at existing barriers or problems, knowledge, skills and attitudes, as well as performance
Monitoring change and progress
It is important to review the action plan developed previously at regular intervals. It may be helpful
to review the following questions:
- Is the process working?
- Are the goals for improvement being achieved?
- Are the goals still appropriate?
- Do you need to develop new tools to achieve the goals you have set?
Following completion of the first cycle, it is recommended that practitioners complete the first part of the Audit of Medical Practice (CQI Activity) summary sheet (Appendix 1).
Undertaking a second cycle
In addition to regular reviews of progress with the practice team, a second audit cycle should be completed in order
to quantify progress on closing the gaps in performance.
It is recommended that the second cycle be completed
within 12 months of completing the first cycle. The second
cycle should begin at the data collection stage. Following
the completion of the second cycle it is recommended that
the remainder of the Audit of Medical Practice (CQI Activity)
summary sheet is completed.
Claiming credits for Te Whanake CPD programme requirements
Practice or clinical audits are useful tools for improving clinical practice and credits can be claimed towards the Patient Outcomes (Improving Patient Care and Health Outcomes) learning category of the Te Whanake CPD programme, on a credit per learning hour basis. A minimum of 12 credits is required in the Patient Outcomes category over a triennium (three years).
Any data driven activity that assesses the outcomes and quality of general practice work can be used to gain credits in the Patient Outcomes learning category. Under the refreshed Te Whanake CPD programme, audits are not compulsory and the RNZCGP also no longer requires that clinical audits are approved prior to use. The college recommends the PDSA format for developing and checking the relevance of a clinical audit.
To claim points go to the RNZCGP website: www.rnzcgp.org.nz
If a clinical audit is completed as part of Te Whanake requirements, the RNZCGP continues to encourage that evidence of participation in the audit be attached to your recorded activity. Evidence can include:
- A summary of the data collected
- An Audit of Medical Practice (CQI) Activity summary sheet (Appendix 1 in this audit or available on the
N.B. Audits can also be completed by other health professionals working in primary care (particularly prescribers), if relevant. Check with your accrediting authority as to documentation requirements.