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 | Partly | NHS England – East of England public health commissioning team |
| 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 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. | Recommendation | Reference | Timescale | Priority | Evidence required |
| Service provider and population served | |||||
| No recommendations were made in this section | |||||
| Governance and leadership | |||||
| 01 | Develop a detailed flow diagram of governance and accountability to include a clear process for identifying and escalating incidents and risks and the management of complaints | Service specification No. 24 | 3 months | High | Submit 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 |
| 02 | Agree roles and responsibilities for the leadership posts, update job descriptions and recruit to vacant posts | Service specification No. 24 | 3 months | High | Copy 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) |
| 03 | Update 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 Programmes | 3 months | High | Provide evidence of trust (and service) incident management policy, this should reference the specific requirements of incident management within a screening programme |
| 04 | For 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 programme | Service specification No. 24 Breast screening: guidelines for medical physics services | 6 months | Standard | a. 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 |
| 05 | Establish regular breast screening senior management meetings, with agreed terms of reference (ToR) | Service specification No. 24 | 6 months | Standard | A 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 |
| 06 | Have an agreed annual audit schedule to cover the whole screening pathway | Service specification No. 24 | a. 3 months b. 6 months c. 12 months | Standard | a. 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 |
| 07 | Work with the commissioning team to complete a health equity audit and action plan | Service specification No. 24 | 12 months | Standard | A copy of the health equity audit and resulting action plan with clear timeline for implementation |
| Infrastructure | |||||
| 08 | East 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 services | 3 months | Standard | Evidence of performance data and doses to women available on NCCPM database |
| 09 | East Anglia Regional Radiation Protection Service to complete analysis of recent doses to women and issue a writtenreport to the breast screening service | Breast screening: guidelines for medical physics services | 3 months | Standard | Evidence of written report of doses to women and submission to the service |
| 10 | East 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 screening | Breast screening: guidelines for medical physics services | 6 months | Standard | A copy of the workforce plan |
| 11 | East Anglia Radiation Protection Service to perform equipment performance surveys and issue reports within four weeks of the due dates | Breast screening: guidelines for medical physics services | 12 months | Standard | Confirmation that surveys are carried out within four weeks of the due date |
| 12 | Review 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 versions | IR(ME)R17 | 6 months | Standard | Revised IR(ME)R documentation |
| 13 | Evaluate the TORMAM QC images acquired in tomosynthesis mode | NHSBSP 1406 | 3 months | Standard | Confirmation that tomosynthesis TORMAM images are evaluated |
| 14 | Ensure there is adequate cross cover within the team to score TORMAM images | NHSBSP 1303 | 6 months | Standard | Confirmation of named individuals that have been trained |
| 15 | Remedial levels for Signal to Noise Ratio (SNR) and Contrast to Noise Ratio (CNR) to be updated in work instructions to reflect current national guidance | NHSBSP 1303 and 1406 | 3 months | Standard | Revised daily and monthly user QC work instructions |
| 16 | Ensure there is an accurate record of mammography and ultrasound user QC test results | NHSBSP 1303 | 3 months | Standard | Evidence 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 | |||||
| 17 | Ensure that the reason for referral is complete on BS Select for all live very high risk (VHR) clients | Breast screening: guidance for organising a Very High Risk (VHR) screening programme | 3 months | Standard | a. 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 |
| 18 | Ensure 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 months | Standard | Confirmation 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 | |||||
| 19 | Ensure sustainability of the breast screening service by securing additional, substantive breast radiology support | Service specification No. 24 | 3 months | High | A copy of the action plan with timescales |
| 20 | Develop a process to enable individual film readers and the director of screening to review radiology and film reading performance to inform practice | Service specification No. 24 | 6 months | Standard | A copy of the process and timescales for implementation |
| Referral | |||||
| 21 | Review and revise the current assessment process to ensure it meets the NHSBSP quality standards and guidance | Service 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 months | Standard | action 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 | |||||
| 22 | Norfolk and Norwich University Hospital to safeguard service continuity through ensuring there is sufficient trained biomedical scientists in post to report HER2 FISH | Breast screening: quality assurance guidelines for breast pathology services | a. 3 months b. 6 months | High | a. action plan b. confirmation of named individuals in post |
| 23 | Norfolk 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 services | a. 3 months b. 6 months c. 12 months | Standard | Confirmation of the method to audit B3 diagnoses Report on initial findings of audit Final completed audit to be submitted |
| 24 | Norfolk 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 services | a. 6 months b. 12 months | Standard | Review 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 | |||||
| 25 | Ensure adequate videoconferencing facilities for the multidisciplinary team meeting is in place | Service specification No. 24 | 3 months | High | Copy of plan and confirmation of implemented changes |
| 26 | Appoint a nominated lead CNS for breast screening | Breast screening: guidance for clinical nurse specialists | a. 6 months b. 12 months | Standard | a. copy of the job description which reflects the duties detailed in national guidance b. Confirmation that this role is in place |
| 27 | Ensure all breast CNS have access to reflective practice | Breast screening: guidance for clinical nurse specialists | 3 months | Standard | Details of the arrangements put in place |
| 28 | Patient 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 biopsies | NICE guidance 101 | 12 months | Standard | Actions 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
- 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 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 England 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
- 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
- The Ionising Radiation (Medical Exposure) Regulations 2017 The Ionising Radiation (Medical Exposure) Regulations 2017
- The Ionising Radiation Regulations 2017 The Ionising Radiation Regulations 2017