NHS England » Screening Quality Assurance visit report

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	No
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 Cancer 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 26 June 2025 to Kettering Breast Screening Service which is commissioned by East Midlands 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 the NHS England.
Data and reports from external organisations.
Evidence submitted by the provider, commissioner and external organisations.
Information collected during pre-review visits to Kettering Breast Screening Service in June 2025.
information shared with SQAS as part of the visit process.

The screening service

Kettering General Hospital (KGH) is commissioned by NHS England – East Midlands to deliver the Kettering Breast Screening Programme (BSP) to the population of North Northamptonshire.

The Kettering BSP functions within the integrated care system (ICS): NHS Northamptonshire, serving the eligible population of 51,227 women aged from 50 up to their 71st birthday.

Screening is provided by 2 mobile units and a static site used for screening clients with additional needs. One mobile is permanently based at KGH and the other visits three community locations (Corby, Wellingborough and Irthlingborough). Assessment clinics are provided twice weekly at KGH. Surgery is undertaken at KGH.

Pathology services are provided by KGH. All oestrogen receptor (ER) and Human epidermal growth factor receptor 2 (HER2) immunohistochemistry testing is done in-house. Fluorescence in-situ hybridisation (FISH) is outsourced to Source Bioscience.

Medical physics provision is provided by Northampton General Hospital (NGH).

The very high risk (VHR) screening pathway is delivered in-house by KGH with the exception of magnetic resonance imaging (MRI) guided biopsy which is provided by MDT referral to other providers predominantly the University Hospitals of Leicester. In 2023/24 the provider had a VHR cohort of 96 clients.

Findings

Staff working in the service are to be commended on their open and honest approach towards the QA visit process, allowing for the service and SQAS to work together to identify areas for improvement.

The Kettering breast screening service is a dedicated team that provides a good service to the population served. The service performs well achieving acceptable or achievable against most key performance indicators and standards.

There are several workforce issues throughout the screening pathway impacting on service delivery and creating additional pressure on staff. The current director of breast screening (DoBS) is interim with no substantive DoBS in place since October 2023 despite attempts to recruit. The service has also been unable to recruit into the vacant consultant radiologist post. The breast screening pathologists are all on temporary locum contracts and there are vacancies in admin and radiography.

There is a lack of breast screening budget oversight causing a lack of clarity regarding screening and symptomatic provision resulting in competing priorities between screening and symptomatic work. This is highlighted in job descriptions which lack clear screening roles and responsibilities or protected screening sessions.

The University Hospitals of Northamptonshire (UHN) Group brings together Kettering General Hospital (KGH) and Northampton General Hospital (NGH). While the breast screening units remain commissioned separately, there have been changes in directorate and governance pathways. Due to clinical commitments and gaps in staffing many discipline specific and screening meetings have been reduced in frequency, cancelled or stopped. Combined these have resulted in a lack of clarity around escalation and communication routes.

Health inequalities and health promotion work has been supported for key initiatives funded by NHS England. However, due to lack of staff availability the service has been unable to undertake planned new initiatives to support ongoing quality improvements.

The provider is currently transferring all policy and work process documents to a new quality management system (QMS). This should be used as an opportunity to review, test and streamline processes.

Audit, image reviews and service evaluation should be embedded throughout the breast screening pathway to ensure a safe and timely service that strives for continuous improvement. While some evidence of this was seen across the service there were a significant number of mandatory and identified audits and reviews not being undertaken at present.

The provider reviews and maintains a risk register and has a serious incident policy. However, there is no screening safety incident policy in place resulting in only serious incidents being escalated to commissioners and SQAS. Whilst several screening incidents were identified that should have been escalated in this way, they had been appropriately managed internally.

Due to pressure from the symptomatic workload, the clinical nurse specialists (CNSs) have only been able to attend 50% of assessment clinics. This results in women not being seen at the start of assessment or post-biopsy, as mandated in guidance, and impacts on the CNSs’ ability to advocate for clients in the multidisciplinary meeting.

Immediate concerns

No immediate concerns were identified.

High priority findings

The QA visit team identified 7 high priority findings as summarised below:

The director of breast screening (DoBS) is an interim post and there is no breast screening radiologist in post.
The DoBS does not have oversight of the breast screening budget resulting in a lack of clarity or protection of screening funded hours.
Lead and specialist job roles do not have clear screening responsibilities or specific screening allocated hours documented in job descriptions.
There is no screening safety incident policy in place, leading to commissioners and SQAS not being informed of incidents.
Due to connectivity issues ethnicity in not recorded in NBSS for all clients when attending their screening appointment however an interim workaround is in place,
There is a lack of clarity regarding reading VHR MRIs due to lack of consultant radiologist.
The clinical nurse specialist (CNS) does not see all women at the start of assessment clinic and after a biopsy.

Examples of practice that can be shared

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

Clients can change appointment by phone or by using an electronic request form on the website.
Face-to-face interpretation services are available for assessment clinics where needs are identified at initial screening appointment.
Oncologists are present in the multi-disciplinary meeting for the discussion of screening cases ensuring guidance on adjuvant and neoadjuvant treatments is available for screening patients.

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
Governance and leadership
01	Put in place appropriate service level agreements and work instructions for outsourced services	Service specification no. 24 NHS breast screening programme	6 months	Standard	SLA work instructions
02	Recruit a substantive Director of Breast screening (DoBs) and a lead breast screening Radiologist	Service specification no. 24 NHS breast screening programme Breast screening: best practice guidance on leading a breast screening service	3 months	High	Confirmation of start date adequate protected breast screening sessions job description with clear roles and responsibilities
03	The DoBs must have oversight of the breast screening budget ensuring screening funded hours are clearly defined and protected.	Breast screening: best practice guidance on leading a breast screening service	6 months	High	Confirmation of oversight regular financial governance meetings
04	Review lead and specialist job descriptions to ensure clarity regarding screening responsibilities and appropriate number of protected sessions allocated to undertake the role.	Breast screening: best practice guidance on leading a breast screening service Breast screening: professional guidance	6 months	Standard	Job descriptions including: roles and responsibilities as per guidance protected screening hours dedicated protected time for audit protected MDT attendance and preparation time
05	Undertake a workforce and skill mix review, ensuring allocated screening hours, resilience and succession planning, creating an action plan to address identified gaps.	Breast screening: professional guidance PHE GW-735 Best Practise Guidelines for Surgeons in Breast Cancer Screening 2018 (section 6.1a) Guidance for Breast Screening Mammographers Breast screening: identifying and reducing inequalities	6 months	Standard	work force summary for each discipline and action plan medical Physics Radiation workforce national calculator outcome skill mix review and training needs assessment summary for each discipline and action plan clarity of screening and symptomatic hours identify staff to support inequalities work with protected time allocated dedicated protected time for audit and image review pathologist sustainability plan including meeting minimum number of 50 resections per year surgery review using Association of Breast Surgery (ABS) job planning guidance
06	Undertake a review of internal governance meetings including individual discipline, operational and senior level meetings	Service specification no. 24 NHS breast screening programme Breast screening: best practice guidance on leading a breast screening service	3 months	Standard	flow diagram of structures including feedback invite SQAS and PHPT to operational meetings confirmation of: meeting frequency TOR standard agenda
07	Implement a screening incident policy inline with managing safety incidents in NHS screening programmes.	Managing safety incidents in NHS screening programmes Service specification no. 24 NHS breast screening programme	3 months	High	policy confirmation shared with staff and in use
08	Record ethnicity in NBSS for all clients attending their screening appointment and audit compliance.	Service specification no. 24 NHS breast screening programme	3 months	High	confirm date commenced undertake audit of compliance
09	Complete transfer to new QMS system ensuring all documents are reviewed, streamlined and new ways of working implemented where appropriate, with ongoing audit to ensure compliance.	Breast screening: professional guidance	12 months	Standard	confirmation completed ongoing compliance audit schedule confirmation SOP review completed including but not limited to: medical physics when to contact assessment clinic second opinion pathology dissection benign biopsy results
10	Develop and implement a service wide annual audit schedule including action plan development and appropriate sharing mechanisms.	Schedule 4 – Local Quality Requirements NHS Breast Screening Programme	6 months	Standard	audit schedule sharing mechanisms
Infrastructure
11	Review and formalise arrangements for MRI medical physics support	NHE Technical guidelines for MRI for the surveillance of women at higher risk of developing breast cancer	12 months	Standard	Confirmation completed
12	Review and update IRMER Employer’s Procedures	IR(ME)R 2017 Breast screening: quality assurance for medical physics services	6 months	Standard	policy confirmation shared with staff and in use
13	Put in place quality control testing procedures for MRI	NHE Technical guidelines for MRI for the surveillance of women at higher risk of developing breast cancer	12 months	Standard	policy confirmation of start date
14	Ensure identified PAC technical and image issues are resolved	Guidance for Breast Screening Mammographers	3 months	Standard	Resolution of: smaller images display of parameters unretrievable tomo images stacked images archived images
Identification of cohort
15	Put in place a policy for reading VHR MRI’s ensuring staff allocated to review MRI’s meet the minimum requirements.	Breast screening: organising very high risk (VHR) screening Technical guidelines for MRI for the surveillance of women at higher risk of developing breast cancer	3 months	High	policy confirmation of start date
16	Undertake an audit of the VHR cohort including a RRW and review of recall rates.	Breast screening: organising very high risk (VHR) screening	6 months	Standard	VHR RRW results and action plan Audit recall rates April 25 – Sept 25
Invitation, access and uptake
17	Review appointment site allocation process for clients identified via failsafe batches to ensure equality of access.	Breast screening: identifying and reducing inequalities Guidance for NHS commissioners on equality and health inequalities legal duties	6 months	Standard	outcome of review action plan
The screening test – accuracy and quality
	No recommendations
Referral
	No recommendations
Diagnosis, intervention and outcome
18	Ensure a CNS sees all women at the start of assessment clinic and after a biopsy.	Clinical nurse specialists in breast screening Appendix 1: Breast screening clinical nurse specialist mandatory requirements	3 months	High	confirmation audit of compliance (1 month) confirmation of ongoing audit
19	Undertake a review of assessment and results clinics considering working practices and information provided to women to ensure compliance with guidance.	NHS Breast Screening Programme Clinical guidance for breast cancer screening assessment Breast screening: professional guidance	6 months	Standard	outcome of review action plan confirmation new processes commenced review benign results giving policy review allocation process
20	Ensure all CNS complete the minimum required training.	Clinical nurse specialists in breast screening	12 months	Standard	gap analysis of outstanding requirements confirmation commenced completion dates
21	Review slide reporting processes including the use of slide review prior to MDT combined with double reporting, and the processes for second opinions.	Breast screening: quality assurance guidelines for breast pathology services Implementing remote image reading in the NHS Breast Screening Programme	12 months	Standard	outcome of review action plan confirmation new processes commenced
22	Undertake an audit of B3 diagnoses with respect to the B3 with atypia group	Breast screening: professional guidance	12 months	Standard	audit from April 25 – Sept 25 outcome and action plan
23	Ensure all disciplines have deputy arrangements in place for attendance at MDT, including preparation time.	Breast screening: professional guidance Improving the Efficiency of Breast Multidisciplinary Team Meetings	6 months	Standard	confirmation
24	Audit mastectomy and immediate reconstruction rates including decision making.	Best Practice Guidelines for Surgeons in Breast Cancer Screening 2018 (section 6.1 – Assessment of surgical performance in the BSP)	12 months	Standard	audit from April 25 – Sept 25 outcome and action plan

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

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 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 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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