NHS England » Screening Quality Assurance visit report – Cheshire and Stockport Breast Screening Service

Scope of this report

	Covered by this report?	If ‘no’, where you can find information about this part of the pathway
Underpinning functions
Uptake and coverage	Yes	Not applicable
Workforce	Yes	Not applicable
IT and equipment	Yes	Not applicable
Commissioning	Yes	Not applicable
Leadership and governance	Yes	Not applicable
Pathway
Cohort identification	Yes	Not applicable
Invitation and information	Yes	Not applicable
Testing	Yes	Not applicable
Results and referral	Yes	Not applicable
Diagnosis	Yes	Not applicable
Intervention / treatment	Yes	Not applicable

Summary

The NHS Breast Screening Programme aims to reduce mortality from breast cancer by finding signs of the disease at an early stage.

The findings in this report relate to the quality assurance visit on 07 February 2023 to Cheshire and Stockport Breast Screening Service which is commissioned by the North West Public Health Commissioning team.

Quality assurance purpose and approach

Quality assurance (QA) aims to achieve and maintain national standards and promote continuous improvement in breast screening. This is to ensure all eligible people have access to a consistent high quality service wherever they live.

QA visits are carried out by the NHS England Screening Quality Assurance Service (SQAS).

The evidence for this report comes from the following sources:

monitoring of routine data collected by NHS England
data and reports from external organisations
evidence submitted by the provider(s), commissioner and external organisations
information collected during pre-review visits to Macclesfield District General Hospital, Leighton Hospital and the Royal Stoke University Hospital in January 2023
information shared with the North SQAS as part of the visit process.

The screening service

The Cheshire and Stockport breast screening service is commissioned by NHS England – North West and serves the eligible population of Crewe, Macclesfield and Stockport.

Findings

The QA visit team found that the screening service is providing a good quality of service despite several ongoing challenges. The service still operates as 2 separate services and does not have clear governance and oversight across the whole pathway and is short-staffed in several disciplines. The benefits of merging such as resilience, efficiency and shared learning are not being realised.

Several positive findings were noted, including the process for identifying and screening clients who are resident in a local prison, incident reporting and management at a service level, structures for patient feedback and there were several examples of good administrative practice.

Immediate concerns

The QA visit team identified no immediate concerns

High Priority Findings

governance and oversight arrangements are not clear
the service has not integrated and is currently operating as 2 services
staffing levels are below national guidance requirements
pathology consistently does not meet turn around times

Examples of practice that can be shared

The QA visit team identified several areas of practice for sharing, including:

user satisfaction survey (independent analysis, action plan and results poster)
prison screening (including plan and pathway document)
recovery from the Covid 19 pandemic pause despite inadequate staffing levels.

Recommendations

The following recommendations are for the provider to action unless otherwise stated.

No.	Recommendation	Reference	Timescale	Priority	Evidence required
Service provider and population served
	No recommendations made in this section		Choose a timescale	Choose a priority
Governance and leadership
01	Make sure that oversight and governance arrangements for the whole service are clear, and risks are minimised	Breast screening: best practice guidance on leading a breast screening service – GOV.UK (www.gov.uk)	3 months	High	· Minutes that show the DoBS attending financial oversight meetings · Assurance that the DoBS has clinical oversight of the whole screening pathway · accountability structure for the service · A clear escalation procedure for risks and issues affecting the whole screening pathway · Produce communications (and training if required) to all discipline leads about screening incident reporting
02	Fully integrate the screening service to make sure that the benefits of a larger service are realised, work is not duplicated, and learning is shared	Breast screening: best practice guidance on leading a breast screening service – GOV.UK (www.gov.uk) Service Specification No. 24	6 months	High	· Evidence of joint management and discipline specific meetings for all elements of the screening pathway for period 01/03/2023-30/09/2023 · A single QMS for the whole service · Joint SOPs across the screening pathway with clear accountability (including VHR and the right results pathway)
03	Complete a health equity audit and prepare a screening inequalities action plan	Service Spec No. 24	12 months	Standard	Health equity audit and health inequalities action plan presented at an appropriate governance forum
04	Annual user satisfaction surveys should be carried out across the whole screening pathway	Service Specification No. 24	12 months	Standard	Present the survey and associated action plan at an appropriate governance meeting
Infrastructure
05	The service should review screening service staffing levels (including pathology) against national guidance and put in place plans to address shortfalls	Breast screening: best practice guidance on leading a breast screening service – GOV.UK (www.gov.uk) Service Specification No. 24	6 months	High	· Present the review at an appropriate governance forum · Create job descriptions for key staff that accurately reflect activity · Produce a succession plan for key roles
06	Improve the accommodation to ensure that there is sufficient access for service users and staff. This should include consideration of the environmental specification for reporting areas.	Service Specification No. 24	12 months	Standard	Estates plan for both Trusts to include: · access for wheelchair users and stretcher evacuations · sufficient space for service administration and clinician office space · sufficient clinic space · separate waiting areas for screening clients and symptomatic patients
07	The medical physics provider should make remedial and suspension levels for each QC test visible to users	32: QA for medical physics services	6 months	Standard	Share a copy of the document with SQAS
08	Make sure 5MP monitors meet the DICOM maximum luminance requirements		12 months	Standard	Confirmation that monitors meet requirements
09	Implement an equipment replacement plan to provide business continuity	Service Specification No. 24	12 months	Standard	An equipment replacement plan for the merged service to be produced and presented and an appropriate governance forum
10	Make sure all equipment meets user QC requirements	32: QA for medical physics services	12 months	Standard	· Mammography QC should include a failsafe to make sure biopsy needle batches are appropriate lengths · Work with the manufacturer to identify and rectify the orientation of tomographic image slices · Tomographic QC must be performed routinely at both sites
11	Make sure that screening images can be viewed from both Leighton and Macclesfield sites.	Breast screening: best practice guidance on leading a breast screening service	6 months	High	Confirmation that screening staff are able to review images from both sites as required
Identification of cohort
12	Ensure routine NTDD batches include clients from 50 years of age	NHSBSP Guidance-Breast Screening requirements specification	6 months	Standard	Action plan to gradually reduce age parameter down to 50
13	Review breast density review process to improve timeliness of screening results	Service Specification No. 24	6 months	Standard	Breast Density Review SOP Improved VHR screen to routine recall KPI
Invitation, access and uptake
14	Ensure appointments that are rebooked within six months of the date of first offered appointment use client’s original episode to accurately reflect uptake	Service Specification No. 24	6 months	Standard	Reduced self-referral numbers in quarterly KPI submissions
The screening test – accuracy and quality
15	Develop scopes of practice for Advanced Practice and Assistant Practitioners	Breast Screening: Guidance for Breast Screening Mammographers 2020	6 months	Standard	Trust approved scopes of practice The Assistant Practitioner scope should cover any imaging performed outside of guidance
16	Improve departmental and personal CPD and peer review activities.	Breast Screening: Guidance for Breast Screening Mammographers 2020	6 months	Standard	Proof of activities to include: · regular review and oversight of the image quality · audit and review at minimum 20 sets of mammograms every 2 month · trends identified and feedback to staff · action plans if appropriate
17	Partial Mammography leaflet to be provided to clients as detailed in the guidance, including where no images were taken	NHS Breast Screening Programme Guidance on collecting, monitoring and reporting technical recall and repeat examinations	3 months	Standard	Standard operating procedure
18	Perform annual partial mammography audit covering the whole service	Annual audit of partial mammography across the service to ensure appropriate recording of partial mammography.	12 months	Standard	Audit and create associated action plans. Provide evidence this has been shared with the team for learning and information
19	Make sure all image readers achieve the minimum number of 4000 per year	Breast screening: guidance for image reading	12 months	Standard	Monitorable action plan for increasing numbers where necessary Present evidence at an appropriate internal governance forum
20	Develop a process to manage and monitor interval cancers across the whole screening service	Breast screening: interval cancers	12 months	Standard	Trust approved interval cancer process
Referral
21	Review assessment capacity to ensure it is sufficient	12 – Clinical Guidelines for Breast Cancer Screening Assessment	3 months	Standard	Action plan to achieve sufficient assessment capacity to meet assessment KPIs with regular demand capacity planning to maintain a steady state
Diagnosis
22	Reduce risks in clinical data entry		6 months	Standard	Risk Assessment and risk mitigation plan of data entry for: · Assessment clinics · VHR MRI · image marking
23	MRI software to allow creation of curves when reporting breast MRI to be made available on PACS reporting workstations at Macclesfield DGH	Breast Screening: guidance for organising a Very High Risk (VHR) screening programme	12 months	Standard	Confirmation software is in place and that the first 10 cases have been reported with access to the software
24	Ensure all assessment clients who do not have a biopsy receive a second review prior to final sign off	NHS Breast Screening Programme – Clinical guidance for breast cancer screening assessment NHBSP publication 49	3 months	High	Standard operating procedure and audit of compliance
25	Improve pathology turnaround times	Breast Screening: Quality assurance guidelines for breast pathology services September 2020	6 months	High	Action Plan Improved turnaround times
26	Improve compliance, in pathology, with National Breast Screening guidance	Breast Screening: Quality assurance guidelines for breast pathology services September 2020 NHSBSP Guidance – Issuing provisional or verbal pathology reports July 2020	6 months	Standard	Confirmation provisional reports are no longer being used Implement synoptic reports including RCPath and NHSBSP pathology data set items Ensure there is processes of accountability for external providers for assurance they are working to NHSBSP guidance
27	Radiology and Pathology to undertake B1/B2 audit from 01 April 2020 to 31 March 2021. Undertake pathology report reviews on data from 01 April 2020 to 31 March 2021 to examine B3 with and without atypia	National Breast Pathology Audit 2018-21	12 months	Standard	Summary reports to include: · Learning points · examine if B3 atypia is correctly entered on NBSS · state how many entries were corrected · action plan including if appropriate to ensure B3 atypia cases are recorded correctly
28	Undertake an audit of grading of invasive cancers and lymphovascular invasion status for 2019-2020	National Breast Screening Pathology Audit 2018-21	12 months	Standard	Summary reports to include: · Learning points · examine if grade and LVI statuses are recorded correctly on NBSS · state how many entries were corrected · action plan including if appropriate to ensure LVI cases are recorded correctly
Intervention and outcome
29	Provide an equitable clinical nurse specialist service, to all clients of the breast service, which meets national guidance and the service specification	15 Guidance for clinical nurse specialists	6 months	High	Confirmation that there are Clinical Nurse Specialists in all assessment clinics
30	Review the capacity of the surgical workforce across the whole service to make sure that all surgeons have an appropriate case load and that there is sufficient time for MDT preparation	Association of Breast Surgeons: Best practice guidelines for surgeons in Breast Cancer Screening	6 months	Standard	Capacity review and action plan
31	Perform a prospective audit on immediate breast reconstruction and salvage procedures and outcomes (across the whole service) over the next 12 months	Association of Breast Surgeons: Best practice guidelines for surgeons in Breast Cancer Screening	12 months	Standard	Audit submission
32	Audit blue dye and magtrace technique results with dual technique standards for sensitivity and specificity	Association of Breast Surgeons: Best practice guidelines for surgeons in Breast Cancer Screening	12 months	Standard	Audit submission

Next steps

The screening service is responsible for developing an action plan in collaboration with the commissioners to complete the recommendations contained within this report.

SQAS will work with commissioners to monitor activity and progress of the recommendations for 12 months after the report is published. After this point SQAS will send a letter to the provider and commissioners summarising progress made and will outline any further action(s) needed.

References

Best Practice Guidelines for Surgeons in Breast Cancer Screening Guidance Platform – Association of Breast Surgery
Breast screening care pathway Breast screening care pathway
Breast screening guidance for breast screening mammographers Breast screening: guidance for breast screening mammographers
Breast screening guidance on collecting recording and reporting repeat examinations Breast screening: repeat mammograms
Breast screening pathway requirements specification Breast screening pathway requirements specification
Breast Screening: arbitration guidance Breast screening: arbitration guidance
Breast Screening: digital breast tomosynthesis Breast screening: digital breast tomosynthesis
Breast screening: identifying and reducing inequalities Breast screening: identifying and reducing inequalities
Breast screening: issuing provisional or verbal pathology reports Breast screening: issuing provisional or verbal pathology reports
Breast screening: programme specific operating model http://www.gov.uk/government/publications/breast-screening-programme-specific-operating-model
Breast screening: transferring specimens between laboratories Breast screening: transferring specimens between laboratories

Clinical Guidelines for Breast Cancer Screening Assessment (4th Edition) Breast screening: clinical guidelines for screening assessment
Consolidated Guidance on Standards for the NHS Breast Screening Programme Breast screening programme: standards
Failsafe Batches Breast screening: failsafe batches
Guidance for clinical nurse specialists Breast screening: guidance for clinical nurse specialists
Guidance for NHS commissioners on equality and health inequalities legal duties hlth-inqual-guid-comms-dec15.pdf
Guidance on applying duty of candour and disclosing audit results NHS screening programmes: duty of candour
Guidance on partial or incomplete screening mammography Breast screening: guidance on partial or incomplete screening mammography
Guidance on reporting breast images from home Breast screening: reporting breast images from home
Guidelines for Non-operative Diagnostic Procedures and Reporting in Breast Cancer Screening (RCPath) Cancer datasets and tissue pathways
Implementing remote image reading in the NHS BSP Breast screening: implementing remote image reading
Key Performance Indicators NHS screening programmes Antenatal, newborn, young person and adult NHS population screening: reporting data definitions
Leading a breast screening service Breast screening: leading a service
Maintaining and achieving the 36 month round length Breast screening: set and maintain round length
Managing Safety Incidents in NHS Screening Programmes Managing safety incidents in NHS screening programmes
NHS Englad Serious Incident Framework – Supporting learning to prevent recurrence (March 2015) serious-incidnt-framwrk-upd2.pdf
NHS Patient Safety Incident Response Framework NHS England » Patient Safety Incident Response Framework
NHS population screening standards NHS population screening standards
Opting out of breast screening Opting out of breast screening
Organising very high risk (VHR) screening Breast screening: organising very high risk (VHR) screening
Protocols for the surveillance of women at higher risk of developing breast cancer Breast screening: very high risk women surveillance protocols
Quality assurance for medical physics services Breast screening: quality assurance for medical physics services
Quality Assurance Guidelines for Breast Cancer Screening Radiology (2nd Edition) Breast screening: quality assurance standards in radiology
Quality Assurance Guidelines for Breast Pathology Services Breast screening: quality assurance guidelines for breast pathology services
Remote radiographic supervision Breast screening: remote radiographic supervision
Reporting, classification and monitoring of interval cancers and cancers following previous assessment Breast screening: interval cancers
Retention, storage and disposal of mammograms and screening records Retention, storage and disposal of mammograms and screening records
Right results audit & checklist Breast screening: Right Results audit
Screening office management guidance Breast screening: screening office management
Section 7a service schedules FutureNHS Collaboration Platform – FutureNHS Collaboration Platform
Technical guidelines for MRI for the surveillance of women at higher risk of developing breast cancer Breast screening: using MRI with higher risk women

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