Screening Quality Assurance visit report – Great Yarmouth and Waveney Breast Screening Service

NHS Breast Cancer Screening Programme
29 November 2022

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 coverageYesNot applicable
WorkforceYesNot applicable
IT and equipmentYesNot applicable
CommissioningPartlyNHS England – East of England public health commissioning team
Leadership and governanceYesNot applicable
Pathway
Cohort identificationYesNot applicable
Invitation and informationYesNot applicable
TestingYesNot applicable
Results and referralYesNot applicable
DiagnosisYesNot applicable
Intervention / treatmentYesNot 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 29 November 2022 to Great Yarmouth & Waveney breast screening service which is commissioned by NHS England East of England Public Health commissioning team. Any commissioning findings are outside the scope of this report and will be followed up directly with the commissioner.

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 the NHS England
  • data and reports from external organisations
  • evidence submitted by the provider(s) and external organisations
  • information collected during pre-review visits to James Paget University Hospitals NHS Foundation Trust and Norfolk and Norwich University Hospital from 10 November to 28 November 2022
  • information shared with the Midlands and East regional SQAS as part of the visit process

The screening service

The Great Yarmouth & Waveney breast screening service is hosted by James Paget University Hospitals NHS Foundation Trust (JPUH) and has an eligible population of 34,784.  The total population of the area served is 242,145.  JPUH provide the programme and it is commissioned by the NHS England (NHSE) East of England Public Health commissioning team.

The breast screening service operates a single static screening service as well as having one mobile unit.  Assessment clinics take place on a Monday in the breast imaging department at JPUH.  All breast histopathology is provided by at Norfolk and Norwich University Hospital and the medical physics service is delivered by the East Anglia Regional Radiation Protection Service (EARRPS), Cambridge University Hospitals NHS Foundation Trust.

A very high risk (VHR) service has been provided since 2014-15 screening year and includes an eligible population of 35 women who have been proven to be at very high risk of breast cancer. Very high risk women are screened at JPUH and all further imaging including ultrasound is completed at the service. MRI reporting is at JPUH with support from Norfolk and Norwich University Hospital (NNUH) if required and MRI guided biopsy referred to Addenbrookes Hospital. All results and management are discussed at JPUH multidisciplinary meetings (MDT). 

The service has worked well to address the backlog of appointments for women impacted by the pause in screening due to the COVID-19 pandemic. The service meets the current definition of recovery. For services to be considered to have sustainably restored, they must:

  • have a total adjusted backlog of less than 5% of total 2019/20 delivered activity, as reported in the demand and capacity tool output
  • have less than 100 women in tier 5, as reported in the recovery dashboard
  • have met the 90% round length measure for 3 consecutive months in combination with delivering the above two metrics

Findings

The visiting QA team found this to be a dedicated service that has recovered well from the Covid pandemic and succeeded in maintaining service delivery despite significant challenges. The service has strong ambitions to develop their workforce and acknowledges that management and governance structures need to be reviewed in addition to a long-term staffing plan for maintaining screening provision.

Overall, the key priorities to be addressed are as detailed below.

Immediate concerns

The QA visit team identified no immediate concerns.

High priority findings

The QA visit team identified five high priority findings as summarised below:

  • provide clarity and stability regarding the leadership and management of the service with roles and responsibilities clearly defined and recruited to substantively
  • review governance process including those for the oversight of screening safety incidents and amend relevant local policies to include reference to “Managing Safety Incidents in NHS Screening Programmes”
  • review the management forums currently in place and address any gaps so that there is clarity regarding operational management of the service
  • provide breast clinical nurse specialist support for all women attending assessment clinics
  • ensure effectiveness is not compromised in multidisciplinary team working due to inadequate videoconferencing facilities

Examples of practice that can be shared

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

  • proactive health promotion work undertaken with travelling & homeless communities with the aim of improving uptake from these underserved communities
  • development of an educational video to support new staff in becoming competent completing the required QC testing and acting on results
  • allocation of patients to a named surgeon prior to multidisciplinary team (MDT) meeting to prime the receiving consultant and aid surgical planning
  • utilisation of the MDT meeting to facilitate the patient selection process for Magtrace so as to identify and avoid its use in patients who may require future MRI breast imaging

Recommendations

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

No.RecommendationReferenceTimescalePriorityEvidence required
Service provider and population served
No recommendations were made in this section
Governance and leadership
01Develop a detailed flow diagram of governance and accountability to include a clear process for identifying and escalating incidents and risks and the management of complaintsService specification No. 24  3 monthsHighSubmit the flow diagram detailing accountability, governance and escalation including individuals in post for each role and how these roles link to the trust. Include details of specific meetings where issues can be raised by the various staff groups and how these are escalated through the system
02Agree roles and responsibilities for the leadership posts, update job descriptions and recruit to vacant postsService specification No. 24  3 monthsHighCopy of revised job description for director of breast screening and programme manager Action plan for the recruitment of a permanent head of breast imaging, programme manager and lead clinical nurse specialist (CNS)
03Update the relevant trust incident policy to include reference to managing screening incidents in accordance with “Managing Safety Incidents in NHS Screening Programmes”Managing Safety Incidents in NHS Screening Programmes3 monthsHighProvide evidence of trust (and service) incident management policy, this should reference the specific requirements of incident management within a screening programme
04For outsourced elements of the screening pathway revise the current service level agreements (SLA) and establish a clear process for regular review to ensure they meet the requirements of the programmeService specification No. 24   Breast screening: guidelines for medical physics services6 monthsStandarda. A copy of updated SLA’s including medical physics, pathology, MRI guided biopsy and MRI reading b. Evidence of process for
regular review of SLA’s
05Establish regular breast screening senior management meetings, with agreed terms of reference (ToR)Service specification No. 246 monthsStandardA copy of minutes and agreed ToR detailing how staff can raise issues for discussion, how risks are identified and recorded, and how outcomes are communicated  
06Have an agreed annual audit schedule to cover the whole screening pathwayService specification No. 24  a. 3 months b. 6 months c. 12 monthsStandarda. proposed timescales for agreement of audit schedule   b. copy of audit schedule for 12-month period and confirmation that the methodologies, objectives and reporting mechanisms had been agreed at a multidisciplinary meeting

c. confirmation that audits are in place and the forum at which the findings are shared
07Work with the commissioning team to complete a health equity audit and action planService specification No. 24  12 monthsStandardA copy of the health equity audit and resulting action plan with clear timeline for implementation  
Infrastructure
08East Anglia Regional Radiation Protection Service to upload performance data from physics surveys and doses to women to the database hosted by the National Coordinating Centre for the Physics of Mammography (NCCPM)Breast screening: guidelines for medical physics services3 monthsStandardEvidence of performance data and doses to women available on NCCPM database
09East Anglia Regional Radiation Protection Service to complete analysis of recent doses to women and issue a writtenreport to the breast screening serviceBreast screening: guidelines for medical physics services3 monthsStandardEvidence of written report of doses to women and submission to the service
10East Anglia Regional Radiation Protection Service to develop an action plan to address the significant shortfall in staff members available to carry out medical physics services to breast screeningBreast screening: guidelines for medical physics services6 monthsStandardA copy of the workforce plan
11East Anglia Radiation Protection Service to perform equipment performance surveys and issue reports within four weeks of the due datesBreast screening: guidelines for medical physics services12 monthsStandardConfirmation that surveys are carried out within four weeks of the due date
12Review which staff are entitled to act as IR(ME)R Referrers, Practitioners and Operators in breast screening, ensure this is clearly described in trust and local IR(ME)R procedures and documentation and dispose of old versionsIR(ME)R176 monthsStandardRevised IR(ME)R documentation
13Evaluate the TORMAM QC images acquired in tomosynthesis modeNHSBSP 14063 monthsStandardConfirmation that tomosynthesis TORMAM images are evaluated
14Ensure there is adequate cross cover within the team to score TORMAM imagesNHSBSP 13036 monthsStandardConfirmation of named individuals that have been trained
15Remedial levels for Signal to Noise Ratio (SNR) and Contrast to Noise Ratio (CNR) to be updated in work instructions to reflect current national guidanceNHSBSP 1303 and 14063 monthsStandardRevised daily and monthly user QC work instructions
16Ensure there is an accurate record of mammography and ultrasound user QC test results        NHSBSP 13033 monthsStandardEvidence that user QC records at both the static and mobile sites are accurately recorded on up-to-date versions of spreadsheets in chronological order with no duplication  
Identification of cohort 
17Ensure that the reason for referral is complete on BS Select for all live very high risk (VHR) clientsBreast screening: guidance for organising a Very High Risk (VHR) screening programme3 months  Standarda. Confirmation that all VHR clients have their reason for referral recorded on BS Select   b. Sample audit to be completed demonstrating that all VHR clients have the reason for referral recorded on BS Select and evidence that this has been added to the audit schedule   c. Updated VHR SOP which outlines the requirement for reason for referral to be recorded for all VHR clients  
18Ensure that the imaging, reporting and recording on NBSS of VHR clients is in line with national guidance  Breast screening: guidance for organising a Very High Risk (VHR) screening programme    6 monthsStandardConfirmation that kinetic curve software has been installed and are utilised   Confirmation that density reviews are completed using BIRADS scoring and findings saved on NBSS
Invitation, access and uptake
No recommendations were made in this section
The screening test – accuracy and quality
19Ensure sustainability of the breast screening service by securing additional, substantive breast radiology supportService specification No. 243 monthsHighA copy of the action plan with timescales
20Develop a process to enable individual film readers and the director of screening to review radiology and film reading performance to inform practiceService specification No. 246 monthsStandardA copy of the process and timescales for implementation
Referral
21Review and revise the current assessment process to ensure it meets the NHSBSP quality standards and guidanceService specification no.24   Breast screening: clinical guidelines for screening assessment   Breast screening programme: standards   Breast screening: guidance for clinical nurse specialists   Best practise guidelines for surgeons in breast cancer screening  3 monthsStandardaction plan which outlines how the service will address shortcomings in achieving NHSBSP quality standards action plan for the provision of breast CNS cover in assessment clinics confirmation that all women awaiting a biopsy result receive an appointment date before leaving the clinic confirmation that a review of personnel within assessments has been completed confirmation of the process used to address any dictation discrepancies when typing assessment letters  
Diagnosis
22Norfolk and Norwich University Hospital to safeguard service continuity through ensuring there is sufficient trained biomedical scientists in post to report HER2 FISHBreast screening: quality assurance guidelines for breast pathology services  a. 3 months b. 6 monthsHigha. action plan b. confirmation of named individuals in post
23Norfolk and Norwich University to complete an audit of B3 diagnoses for the most recent 12 month period available, due to the high B3 rate with the BQA data.Breast screening: quality assurance guidelines for breast pathology servicesa. 3 months
b. 6 months
c. 12 months  
StandardConfirmation of the method to audit B3 diagnoses Report on initial findings of audit  Final completed audit to be submitted
24Norfolk and Norwich University to develop processes to ensure that the Lymphovascular invasion (LVI) data on NBSS is accurate    Breast screening: quality assurance guidelines for breast pathology servicesa.  6 months b. 12 monthsStandardReview LVI one year data and confirm there are no data entry errorsIf the data is found to be correct, complete a prospective audit of LVI positivity ratesDevelop a SOP to ensure long term data accuracy
Intervention and outcome             
25Ensure adequate videoconferencing facilities for the multidisciplinary team meeting is in placeService specification No. 24  3 monthsHighCopy of plan and confirmation of implemented changes
26Appoint a nominated lead CNS for breast screeningBreast screening: guidance for clinical nurse specialistsa. 6 months b. 12 monthsStandarda. copy of the job description which reflects the duties detailed in national guidance b. Confirmation that this role is in place
27Ensure all breast CNS have access to reflective practiceBreast screening: guidance for clinical nurse specialists  3 monthsStandardDetails of the arrangements put in place
28Patient centred follow up pathway and decision making should be reviewed and intended evidence based follow up decisions clearly documented at MDT.  This should clearly include the surveillance requirements of women with B3 biopsiesNICE guidance 10112 monthsStandardActions plan for patient centred follow up development

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.

Appendix C: References

  1. Guidance Platform – Association of Breast Surgery
  2. Breast screening care pathway Breast screening care pathway
  3. Breast screening guidance for breast screening mammographers Breast screening: guidance for breast screening mammographers
  4. Breast screening guidance on collecting recording and reporting repeat examinations Breast screening: repeat mammograms
  5. Breast screening pathway requirements specification Breast screening pathway requirements specification
  6. Breast Screening: arbitration guidance Breast screening: arbitration guidance
  7. Breast Screening: digital breast tomosynthesis Breast screening: digital breast tomosynthesis
  8. Breast screening: identifying and reducing inequalities Breast screening: identifying and reducing inequalities
  9. Breast screening: issuing provisional or verbal pathology reports Breast screening: issuing provisional or verbal pathology reports
  10. Breast screening: programme specific operating model Breast screening: programme specific operating model
  11. Breast screening: transferring specimens between laboratories Breast screening: transferring specimens between laboratories
  12. Clinical Guidelines for Breast Cancer Screening Assessment (4th Edition) Breast screening: clinical guidelines for screening assessment
  13. Consolidated Guidance on Standards for the NHS Breast Screening Programme Breast screening programme: standards
  14. Failsafe Batches Breast screening: failsafe batches
  15. Guidance for clinical nurse specialists Breast screening: guidance for clinical nurse specialists
  16. Guidance for NHS commissioners on equality and health inequalities legal duties hlth-inqual-guid-comms-dec15.pdf
  17. Guidance on applying duty of candour and disclosing audit results NHS screening programmes: duty of candour
  18. Guidance on partial or incomplete screening mammography Breast screening: guidance on partial or incomplete screening mammography
  19. Guidance on reporting breast images from home Breast screening: reporting breast images from home
  20. Guidelines for Non-operative Diagnostic Procedures and Reporting in Breast Cancer Screening (RCPath) Cancer datasets and tissue pathways
  21. Implementing remote image reading in the NHS BSP Breast screening: implementing remote image reading
  22. Key Performance Indicators NHS screening programmes Antenatal, newborn, young person and adult NHS population screening: reporting data definitions
  23. Leading a breast screening service Breast screening: leading a service
  24. Maintaining and achieving the 36 month round length Breast screening: set and maintain round length
  25. Managing Safety Incidents in NHS Screening Programmes Managing safety incidents in NHS screening programmes
  26. NHS England Serious Incident Framework – Supporting learning to prevent recurrence (March 2015) serious-incidnt-framwrk-upd2.pdf
  27. NHS Patient Safety Incident Response Framework NHS England » Patient Safety Incident Response Framework
  28. NHS population screening standards
  29. Opting out of breast screening Opting out of breast screening
  30. Organising very high risk (VHR) screening Breast screening: organising very high risk (VHR) screening
  31. Protocols for the surveillance of women at higher risk of developing breast cancer Breast screening: very high risk women surveillance protocols
  32. Quality assurance for medical physics services Breast screening: quality assurance for medical physics services
  33. Quality Assurance Guidelines for Breast Cancer Screening Radiology (2nd Edition) Breast screening: quality assurance standards in radiology
  34. Quality Assurance Guidelines for Breast Pathology Services Breast screening: quality assurance guidelines for breast pathology services
  35. Remote radiographic supervision Breast screening: remote radiographic supervision
  36. Reporting, classification and monitoring of interval cancers and cancers following previous assessment Breast screening: interval cancers
  37. Retention, storage and disposal of mammograms and screening records Retention, storage and disposal of mammograms and screening records
  38. Right results audit & checklist Breast screening: Right Results audit
  39. Screening office management guidance Breast screening: screening office management
  40. Section 7a service schedules FutureNHS Collaboration Platform – FutureNHS Collaboration Platform
  41. Technical guidelines for MRI for the surveillance of women at higher risk of developing breast cancer Breast screening: using MRI with higher risk women
  42. The Ionising Radiation (Medical Exposure) Regulations 2017 The Ionising Radiation (Medical Exposure) Regulations 2017
  43. The Ionising Radiation Regulations 2017 The Ionising Radiation Regulations 2017