Scope of this report

Summary

The NHS Breast Screening Programme (BSP) 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 February 2024 to North Cumbria Screening Service which is commissioned by North East and North Cumbria 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(s), commissioner and external organisations
• information collected during pre-review visits to Cumberland Infirmary in January and February 2024, and West Cumberland Hospital in November 2023 and February 2024
  • several remote meetings were also held using Microsoft Teams in this period
• information shared with SQAS as part of the visit

The screening service

The Newcastle upon Tyne Hospitals (NUTH) NHS Foundation Trust is commissioned by NHS England – North East and North Cumbria (NENC) to oversee delivery of the North Cumbria breast screening service. Since 2011, this has been undertaken by the development of a comprehensive service-level agreement (SLA) between NUTH and the North Cumbria Integrated Care (NCIC) NHS Foundation Trust.

The North Cumbria breast screening service functions are hosted by the NCIC Trust within the NHS NENC Integrated Care System (ICS), serving the eligible population (51,218) of North and West Cumbria, including the bulk of Cumberland and the northern half of Westmorland and Furness. Screening is provided at two static sites: Cumberland Infirmary in Carlisle and West Cumberland Hospital in Whitehaven.

Findings

North Cumbria breast screening service is a dedicated team; the service is to be commended for their hard work addressing the recovery from the COVID-19 pandemic.

There are workforce challenges across the pathway and a number of disciplines require recruitment to vacant posts.

Governance of the breast screening service requires improvement. The service-level agreement (SLA) between the NUTH and NCIC trusts is out of date, with no evidence of effective monitoring and review since the 2019/20 SLA was signed off.

There is a pressing need to ensure clarity in roles, responsibilities and accountability between the NUTH and NCIC trusts.

The North Cumbria breast screening team are keen to improve the service and repatriate from NUTH to the NCIC Trust. They demonstrated this commitment throughout the visit; the QA team reiterated throughout the visit that this is not the decision or remit of SQAS.

Immediate concerns

No immediate concerns were identified.

High priority findings

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

• NCIC to ensure a service-level agreement is signed with NUTH for the provision of governance and leadership, and with suitable providers for medical physics and pathology services
• ensure the contractual requirements of reducing health inequalities are executed
• create and implement a workforce and succession plan to ensure current and future capacity meets demand for all disciplines
• manage the very high risk screening provision in line with national guidance
• ensure that service users are ceased from the NHS BSP in line with guidance
• comply with the QA clinical nurse specialists in breast screening NHS BSP guidelines
• review surgery schedules to ensure pathology specimens can be processed in a timely fashion.

Examples of practice that can be shared

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

• the administration team uses a colour-coded calendar to monitor the weekly and monthly audits carried out by the service
• medical physics QA includes analysis of the noise power spectrum
• imaging errors such as incorrect laterality or client name are only amended by the picture archive and communication system (PACS) support team with the individual radiographer present to confirm the Audit logs are kept and can be accessed when required
• the service is working closely with the Trust’s learning disabilities team and they are hoping to plan an open day for learning disability clients
• technical recall (TR) appointments are arranged by telephone by the radiographer who performed the initial imaging, to ensure a timely and convenient appointment is made
• having access to a radiological opinion for the interpretation of pathology specimen X-rays is an example of good practice

Recommendations

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

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 A: references

1. Best practice guidelines for surgeons in breast cancer screening Guidance Platform – Association of Breast Surgery
2. Breast screening care pathway Breast screening care pathway
3. 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: guidance for image reading Breast screening: guidance for image reading – GOV.UK (www.gov.uk)
6. Breast screening pathway requirements specification Breast screening pathway requirements specification
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 – GOV.UK (www.gov.uk)
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. Clinical nurse specialists in breast screening 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. Population screening KPIs: purpose and data submission guidance 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 patient safety incident response framework NHS England » Patient Safety Incident Response Framework
27. NHS population screening standards NHS population screening standards
28. Opting out of breast screening Opting out of breast screening
29. Organising very high risk (VHR) screening Breast screening: organising very high risk (VHR) screening
30. Protocols for the surveillance of women at higher risk of developing breast cancer Breast screening: very high risk women surveillance protocols
31. Quality assurance for medical physics services Breast screening: quality assurance for medical physics services
32. Quality assurance guidelines for breast cancer screening radiology (2nd Edition) Breast screening: quality assurance standards in radiology
33. Quality assurance guidelines for breast pathology services Breast screening: quality assurance guidelines for breast pathology services
34. Remote radiographic supervision Breast screening: remote radiographic supervision
35. Reporting, classification and monitoring of interval cancers and cancers following previous assessment Breast screening: interval cancers
36. Retention, storage and disposal of mammograms and screening records Retention, storage and disposal of mammograms and screening records
37. Right results audit & checklist Breast screening: Right Results audit
38. Screening office management guidance Breast screening: screening office management
39. Section 7a service schedules FutureNHS Collaboration Platform – FutureNHS Collaboration Platform
40. Technical guidelines for MRI for the surveillance of women at higher risk of developing breast cancer Breast screening: using MRI with higher risk women
41. Breast screening: reducing inequalities Breast screening: identifying and reducing inequalities – GOV.UK (www.gov.uk)
42. NHS public health functions agreement 2023 to 2024 NHS public health functions agreement 2023 to 2024 – GOV.UK (www.gov.uk)
43. Guidance for radiology and advanced radiographic practice in the NHS Breast Screening Programme Guidance for radiology and advanced radiographic practice in the NHS Breast Screening Programme – GOV.UK (www.gov.uk)
44. 2024/25 NHS standard contract, NHS England
45. Guidance on opting out (cease) from breast screening Guidance on opting out (cease) from breast screening – GOV.UK (www.gov.uk)
46. Achieving and maintaining the 36month round length Achieving and maintaining the 36 month round length – GOV.UK (www.gov.uk)
47. Breast screening: right results audit Breast screening: Right Results audit – UK (www.gov.uk)
48. European society of radiology statement on the renewal of radiological equipment: insights imaging (2014) 5:543-546 Renewal of radiological equipment | Insights into Imaging | Full Text (springeropen.com)
49. Routine quality control tests for full field digital mammography systems – equipment report 1303 nhsbsp-equipment-report-1303.pdf (publishing.service.gov.uk)
50. Institute of Physics and Engineering in Medicine (IPEM) report 89 – The commissioning and routine resting of mammographic X-ray systems Report 89 The Commissioning & Routine Testing of Mammographic X-Ray Systems – IPEM
51. Care Quality Commission IR(ME)R annual report 2022 to 2023 IR(ME)R annual report 2022/23 – Care Quality Commission (cqc.org.uk)
52. National Cancer Action Team – the characteristics of an effective multidisciplinary team (MDT) MDT Development (ncin.org.uk)