What is cervical screening?
Women are invited every 3 or 5 years, depending upon their age, for a smear test in the Primary Care Centre.
Women aged:
- 24 ½ years-49 years are recalled every 3 years
- 50-64 years are recalled every 5 years
- Women older than 64 years old can request a smear test
When a woman attends a screening appointment a speculum is inserted into the vagina and a sample of cells are taken with a small brush:
- the sample is first tested for HPV (human papilloma virus) in the GHA laboratory. If this is negative then women do not have the virus and have a very low risk of developing cervical cancer. Most cervical cancer is caused by the HPV virus, and the women then enter into a routine recall time period and should remain in the screening program until the age of 65 years old. This is why we offer HPV vaccines to school age children to prevent cervical cancer in the future.
- If the sample is HPV positive, the laboratory look at the same sample in more detail and the cells under the microscope to see if there are any cell changes. This is called Liquid Based Cytology or LBC. Whilst we have been repatriating this LBC service to the GHA, as a temporary step, if a woman tested HPV positive, we have offered them a colposcopy. The GHA will revert to the usual pathway once the LBC service is up and running and this means that not all women who are HPV + will have a colposcopy in the future. If they are HPV + and their LBC is negative they will be offer another cervical smear test in 12 months check timescale.
- Colposcopy is when a woman is invited to attend as an outpatient and have her cervix examined by a highly trained health professional more closely and if necessary more samples or biopsies are taken. The health professional may be a consultant gynaecologist or a highly trained specialist nurse.
FAQ’s
What do you mean when you use the term a screening program?
Many people use the term ‘screening’ when from a public health perspective there is a very narrow description of what is classified as screening defined by the internationally recognised Wilson and Junger criteria.
The reason that it is important that the terminology is used correctly is because there are a number of criteria that have to be met for a service to be classified as screening.
The impact is that if a screening program is not delivered systematically and correctly there is the potential to cause harm at a large scale by either falsely reassuring people that they are OK or advising them they need further testing that will cause anxiety or potentially physical harm.
The criteria for a screening program include:
- It has to be an important health condition
- There has to be a ‘good enough’ test for the illness
- There has to be an asymptomatic phase for the test to be used to detect the illness
What screening programs do the GHA deliver?
The 12 screening programs that the GHA offers are:
In pregnancy:
- Screening for infectious diseases infectious diseases: HIV, hepatitis B and syphilis
- Screening for congenital anomalies: Downs, Edwards and Patau’s syndromes
- Screening for sickle cell
- Screening to check the physical development of the baby: 20 weeks
Newborn:
- A physical examination: including hips, eyes, heart and testes
- A hearing test
- A blood spot test: in the NHS this is for 9 diseases
Older children and adults:
- Diabetic eye screening: additional screening undertaken during pregnancy
- Cervical screening
- Breast screening
- Bowel screening
- Aortic aneurism
The screening programs provided in Gibraltar may differ slightly from the way that screening programs are delivered in the NHS because we can tailor them to our local population needs, health seeking behaviours and services.
What is cervical screening and what do HPV and LBC mean?
Cervical screening is when a sample of cells from the cervix are tested for a virus, HPV or human papilloma virus.
The majority of cervical cancer is cause by the HPV virus.
In Nov 2020 the GHA moved to a system of testing women when they had a smear for HPV. This means that if you are negative for
HPV you are very unlikely to have cervical cancer because the majority of cervical cancer is caused by the HPV virus
In 2022 the GHA introduced a system of molecular testing for the presence of HPV in the cervix. This technique is extremely sensitive for detecting DNA from the virus which, if found, will automatically mean that cells for the cervix are examined under the microscope to look for pre-cancerous changes that might require treatment. The fundamental purpose of the screening program is to identify these pre-cancerous cells and remove them thus preventing later cervical cancer.
We are confident that women who tested HPV negative do not have cervical cancer because the majority (99.7%) of cervical cancer is caused by the HPV virus.
If a women tests positive for HPV their smear sample is examined in more detail under a microscope. This is called Liquid Based Cytology or LBC.
A decision was taken to repatriate and bring the Liquid Based Cytology service back into the GHA.
The GHA has recruited a new biomedical scientist, purchased new equipment and have recruited a new gynaecological histopathologist to ensure that we have robust and reliable service.
As an interim fail safe measure the GHA did 2 things to the pathway:
Firstly, for women who newly tested positive for HPV in 2025, we offered them directly a colposcopy rather than LBC until this has been brought in house to the GHA.
Secondly, the women who tested HPV positive before 2025 we invited them either for a re-screen to determine if they had cleared the virus or offered colposcopy based upon clinical need.
The final group of ~250 women who previously tested positive for HPV in 2024 are going to be the first group of women invited for a re-screen as part of this recall exercise
This was only an interim measure while we brought the LBC service in house to the GHA. This has now happened therefore women who are HPV + will now not proceed straight to colposcopy unless abnormal cells are detected on LBC.
As part of the initial review meeting in August 2023 the GHA identified that due to a computer recall error some women had never been invited for a screen. They will also all be invited to be screened if they have not already been offered an appointment.
How can you have a negative cervical cancer screen and then develop cancer?
There are a couple of main reasons why someone may have a negative screening test and then actually have cancer. This is why you should never ignore the symptoms of cancer and further information is available on the GHA-Public Health website describing this and the Vague Symptoms pathway.
The main reason is that a screening test is not a gold standard diagnostic test but a screening test that gives an indication that there may be something happening that requires more investigation. This means that there will always be a small number of false positive and false negative results. This is why there is usually a secondary test after you have had a positive screening test to confirm or exclude a diagnosis. Such as a colonoscopy after a positive bowel screening test or a colposcopy after a positive LBC cervical screening test.
The other main reason is the potential to develop an interval cancer. This is when a new cancer develops in between a routine screening time period and is an aggressive quick growing cancer. There is a balance between inviting people too frequently for screening, which leads to generally reducing levels of uptake, against not inviting people frequently enough. The time interval that the GHA offers is the same as the NHS for cervical screening.
If I have tested negative for HPV do I need to attend for cervical screening in the future?
Yes you should still attend either on a 3 or 5 year recall cycle depending upon your age.
This is because you can develop a HPV infection after you have been screened.
The HPV vaccine provides protection against most of the strains of the HPV virus that cause cervical cancer but not all. This is why it is important to still attend for screening.
What happened with the cervical screening progam?
What went ‘wrong’ with the cervical screening program?
In August 2023 the Director of Public Health chaired a meeting that reviewed the whole patient pathway from the call/recall computer system, smear taking, laboratory testing for both HPV virus and cytology and referral into gynaecology.
Areas for improvement were identified across the whole pathway.
As a consequence of this initial meeting a working group was established to explore the concerns in more depth and make recommendations to improve the services provided.
Was cervical screening safe before 2023?
We do not know because the whole pathway was not reviewed prior to the meeting chaired by the DPH in August 2023.
If you knew the screening program was ‘not safe’ why did you not stop the program?
Many discussions were held in the working group to explore the pros and cons of continuing or pausing the program.
A decision was reached to continue with the program because we are confident that for the women who had a negative HPV test that their result is ok meaning they do not have cancer. This is the majority of women who have been screened and this is why we continued with the screening program.
We commenced an interim ‘fail safe’ step of inviting women who were HPV + to colposcopy until the Liquid Based Cytology service was developed in house at the GHA.
The final group of ~250 women who were HPV positive in 2024 are the first group of women who are being offered re-screening as part of this lookback exercise.
We had to develop plans to be able to expand capacity for all of the women who had never been screened to be offered an appointment and for those women who may not have responded and waited too long since their last screening test. The publicity this announcement will develop we anticipate will increase demand for cervical screening and the GHA had to make plans to be able to deal with this.
Why were women not invited for screening who were eligible?
A computer call/recall error was identified that did not consistently identify women who had either arrived in Gibraltar after their 25th birthday or had spent time out of Gibraltar to attend university in the UK for example.
This has now been rectified.
Why has it taken so long to offer a re-screen since the DPH identified concerns in August 2023?
After the initial meeting in August 2023 the GHA established a working group to explore the issues across the whole pathway that had been identified.
Some issues were straight forward to address such as ensuring nursing staff had received up to date accredited training to undertake smears and the call and recall computer error.
Some issues took longer to resolve for example the development of an in house service for repatriation of the Liquid Based Cytology Service. This included the purchase of new laboratory equipment, recruitment and training of staff and calibration and testing of equipment. This all had to be in place with confidence that it was working properly before a recall announcement could be made.
Has anyone died as a result of this screening failure?
A review of all cervical cancer diagnoses since 2021 has been undertaken.
There have been 15 women diagnosed with cervical cancer and sadly of these 5 have died.
All of their notes were reviewed to determine if they had participated in the cervical screening program and whether any errors in the way that the cervical screening program may have contributed to their diagnosis or death.
The GHA has concluded that of the 15 cases 2 were false negatives. This means that they had a PAP smear reported negative and they had cervical cancer.
PAP smears are estimated to correctly identify 70-80% of high grade cancers and were the best tests that were available at this time.
HPV testing was found to be more accurate and this is why the GHA commenced using primary HPV testing in November 2020.
Has anyone developed cancer as a result of this screening failure?
Of the 5 deaths from cervical cancer;
1 was beyond the age of screening programme – no failure
1 was a recurrence of previous cervical cancer – no failure
1 was not screening compliant – no failure
There were 2 false negative pap smears where screening was undertaken, reported as negative and the woman subsequently developed cervical cancer. To note that like many countries we no longer use the pap smears having moved to HPV testing in 2020 because pap smears were not accurate enough.
False negatives and false positives happen in screening programs. This is why fail safe audits are undertaken to continually review the quality and standards of screening being offered.
Are you now confident that the program is safe?
The cervical screening program is a safe program.
The working group that was established to look at the whole pathway will evolve to become the formal cervical screening coordination group.
The in house GHA service for the Liquid Based Cytology component of the screening program has engaged and will participate in the technical and clinical external quality assurance programs currently used in the UK NHS Cervical Screening Program
The working group will continue to review the entire pathway and undertake regular reviews of standards and audits to provide assurance to the Director of Public Health and the public that the cervical screening service is being delivered to a high standard.
What about all the other screening programs. Are you confident that these are safe?
An independent review of all GHA screening programs was undertaken in the autumn of 2024 upon the recommendation of the Director of Public Health.
A number of recommendations were made both regarding individual screening programs and for improving the GHA wide approach to screening.
There is a proposal for the GHA to establish a screening oversight board that the Director of Public Health will chair. This will have clinical representatives from all screening programs and it will be this forum that ensures that all screening programs are delivering a safe pathway.
What have been the findings of the independent screening review?
The detailed report is being discussed by the GHA Executive Team and in due course the GHA Board.
Recommendations have been made at both organisational level (e.g. the GHA establishes an oversight assurance board that the DPH chairs to cover all of the screening programs)and at individual program level (e.g. a single clinical lead is identified for every screening program, with a job description developed for them)
Will the screening review be published?
The independent screening report requires discussion by the GHA Board ahead of a decision regarding publication.
How will I be invited for re-screening?
We are sending a text message to:
- women who tested positive for HPV in 2024
- women who we have a record of as having not been screened
- or women, based upon our records, where too long has passed since their last screening test.Please click on the link in the message to opt in to opt out of the invitation.We will be sending the text messages out in waves to enable us to book women into clinics over the next coming months.The GHA will be sending out ~12,000 text messages to women.We cannot send all the messages out at once because we want to have the ability to book women into clinics for re-screening based upon those with potentially the greatest clinical risk first.Groups will be contacted in the following order:
- women who tested HPV positive in 2024
- women aged > 66 years old
- women aged 24.5 years old-30 years old
- women aged 31-64 years old
This may mean that you may not have been included in the first wave of messaging and therefore not received a text message as yet.
We recognise that not all of the 12,000 women still live in Gibraltar but their GHA records have not been updated by patients. This is why we would encourage patients to check their registration status and update their details either through eGov or emailing registration@gha.gi
I have been screened in the private sector do I need to attend for screening at the GHA?
We would advise everyone invited for screening to attend the GHA for their screening appointment
We are aware that some women, who have been screened in the private sector and/or in Spain, will not have been offered a HPV test. We would strongly advise women to take up the offer from the GHA of having a smear test that includes a HPV test as well as LBC.
I have not been contacted and invited for a re-screen why?
There may be a number of reasons why you have not received a text message as yet inviting you to book a repeat screening appointment including:
- you are HPV negative and do not require a re-screen at this time. Please attend your routine future appointment in 3 or 5 years depending upon your age. If you are not sure of your HPV status please call us and we and confirm this for you
- we have an incorrect mobile number for you. Please update your mobile number on eGov or email registration@gha.gi to update your details if your GHA card has expired. Please contact registration to renew your card or renew online on eGov or email
- We cannot screen everyone at the same time hence are inviting women in phases. We hope to progress through the different waves of text messaging and booking clinics rapidly. If you have not received a text message by September 2025 please contact the GHA to determine if you are being invited for re-screening.
- A dedicated appointment helpline has been established for this recall exercise: please call 20050666.This telephone helpline will initially be open every day from 1st April 2025 from 4-6.30pm weekdays and from 9am-12pm during weekends.If the line is closed there is an answerphone message advising you of the opening times. The GHA will be monitoring call wait times. If demand exceeds the ability to answer calls during the opening hours then the opening hours will be increased. Additional administration staff have been trained to answer your questions and check your results.From the 3rd April we anticipate that demand for the helpline will reduce and it will be open on Tues/Thurs/Sat hours as above.Every time the GHA sends out a new batch of text messages we will increase the frequency of opening of the telephone helpline to daily from 4-6.30 pm and weekends from 9am-12pm. If demand exceeds capacity of this we will increase the opening hours.
Where can I find more information?
Where can I go for further advice?
More advice is being provided on the GHA-public health website
There is also information provided by the NHS:
You can also discuss this with your GP or in the well person clinic.
If you think you are due a smear or have previously tested positive for HPV please call the helpline and they will be able to check this for you and provide you with advice.
If you are bewteen the ages of 14 and 25 and never received a HPV vaccine, you can request a vaccine by sending an email to hpvvaccine@gha.gi
Should I be concerned?
Most women will not have cervical cancer especially if you have been vaccinated with the HPV vaccine previously.
If you have symptoms of cervical cancer please do not wait to be called for a screening appointment. Please book an urgent appointment with a GP to be clinically assessed and do not wait for a screening appointment.
Signs of cervical cancer include:
- Unusual pain, bleeding or discharge
- Pain during sexual intercourse or bleeding after intercourse
- Difficulty passing urine
Blood in your urine
Why is the HPV vaccine that is offered in schools important?
The HPV vaccine prevents the vast majority of cervical cancer.
This is the main focus of global eradication of cervical cancer by the World Health Organisation
A 2021 study showed that cervical cancer rates were reduced by nearly 90% in women in their 20s who were offered the vaccine at age 12-13 years old in England.
If you are under 25 years old and have not received a HPV vaccine please email HPVvaccine@gha.gi and the team will contact you to arrange. Please note that only patients entitled to GHA treatment will be able to receive the vaccine.
If you are a woman between the ages of 25 and 45 and never been sexually active OR immunocompromised or a Man up to the age of 45 years who has sex with men you may also be eligible for the vaccine and will be considered on a case by case basis. Please book an appointment with your GP or the Well person Unit to discuss this further if applicable.
HPV vaccination in Gibraltar started in girls in 2012 and boys in 2018.
How do I make a complaint?
I want to make a complaint how do I do this?
You can contact the Patient advocacy and liaison service. The details of this are on the GHA website
Patient advocacy & liaison service
Or 20072266 ext 2790 or 2791
Alternatively you can complain to the Ministry for Health on
complaints@gha.gi
