NHS England » Screening Quality Assurance visit report – North Lancashire and South Cumbria

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

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 27 September 2022 to North Lancashire and South Cumbria Screening Service which is commissioned by NHS England – North West. 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, promote continuous improvement in breast screening and support reducing health inequalities. This is to ensure all eligible people have access to a consistent high, effective, equitable and safe 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) and external organisations
discussion with the commissioner in advance of the visit
information collected during pre-review visits to Royal Lancaster Infirmary in May, August and September 2022
information shared with SQAS North as part of the visit process.

The screening service

The North Lancashire and South Cumbria breast screening service is commissioned by NHS England – North West and serves the eligible population based in North Lancashire, South Cumbria, Blackpool, Fylde & Wyre and Greater Preston.

Findings

The QA visit team found that the screening service is providing a good quality of service despite several ongoing challenges. The service has limited accommodation and workstations, is short-staffed in several disciplines – including leadership roles – and has been struggling to clear the backlog caused by the pause in screening during the COVID-19 pandemic.

Several positive findings were noted, including a pilot project for improving access to cancer screening for homeless clients. The learnings from a pathology incident were shared at a regional network meeting in December 2021. The service is trialling split multidisciplinary (MDT) meetings to encourage flexibility and time to focus on screening clients, and there were several examples of good administrative practice.

Immediate concerns

The QA visit team identified no immediate concerns.

High priority findings

The QA visit team identified 11 high priority findings as summarised below:

the Director of breast screening should have oversight of the screening budget and meet regularly with Trust management to review service needs and financial forecasting
ensure all required posts are filled and that succession plans are in place
improve communications between departments delivering the screening pathway
ensure the symptomatic service does not compromise screening service delivery
improve the accommodation (including the mobiles) to ensure that there is sufficient access for service users and staff
Trust should renegotiate the SLA for medical physics services to ensure the provider is able to deliver against the NHSBSP service specification
produce an action plan to address issues impacting on round length. This should lead to a new round plan to restore and maintain the screening round length KPI at ≥90%
ensure there is protected time for film reading and MDT meeting preparation
review assessment capacity to ensure it is sufficient to allow backlog recovery
ensure a clinical nurse specialist is in every assessment clinic
surgical representatives from Blackpool Teaching Hospitals and Lancashire Teaching Hospitals should attend UHMBT MDT meetings.

Examples of practice that can be shared

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

the unit has a member of staff dedicated to health promotion, with a focus on improving uptake
the administrative team maintains internal systems to schedule and keep track of essential reports, self referrals, out of area requests and outsourced letters
the administrative team have shared their knowledge of the NBSS smart clinic algorithm with colleagues
incident management is transparent and comprehensive, with learning shared with the team
involvement with a project to improve access to screening for people who are homeless
medical physics quality control (QC) is logged in a well-maintained database
radiologists note anticipated pathology results for each client discussed in the screening MDT meeting, so unexpected results are flagged quickly.

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
Governance and leadership
01	The DoBS should have oversight of the screening budget and meet regularly with Trust management to review service needs and financial forecasting	23 – best practice guidance on leading a breast screening service	3 months	High	Terms of reference and minutes from an appropriate Trust meeting
02	Ensure all required posts are filled and that succession plans are in place	15 – guidance for clinical nurse specialists; 23 – best practice guidance on leading a breast screening service; Service specification 24	3 months	High	Staffing capacity review to include all elements of the screening pathway and succession planning Confirmation of appointments and if substantive or fixed term: · Deputy director of breast screening · lead radiographer (or equivalent) · cover for the PACS lead · very high risk coordinator · lead clinical nurse specialist Job description and job plan for the deputy director post
03	Improve communications between departments delivering the screening pathway	23 – best practice guidance on leading a breast screening service	3 months	High	Terms of reference, minutes and actions from interdepartmental meetings
04	Ensure the symptomatic service does not compromise screening service delivery	Service specification 24	6 months	High	Risk assessment and action plan
05	Complete a health equity audit and prepare a screening inequalities action plan	Service specification 24	12 months	Standard	Audit and action plan
06	Produce an annual audit schedule	Service specification 24	6 months	Standard	Audit schedule
07	Complete all recommendations made in the 2022 right results walkthrough	38 – Right results audit & checklist	6 months	Standard	Summary of completed actions
Infrastructure
08	Improve the accommodation (including the mobiles) to ensure that there is sufficient access for service users and staff	Service specification 24	3 months	High	Estates plan (3 months) to include: · access for wheelchair users and stretcher evacuations · sufficient space for service administration and clinician office space · additional film reading workstations · sufficient clinic space · separate waiting areas for screening clients and symptomatic patients Confirmation of implementation of estates plan – 6 months
09	The Trust should renegotiate the SLA for medical physics services to ensure the provider is able to deliver against the NHSBSP service specification	32: Quality assurance for medical physics services; IPEM National Diagnostic Radiology Workforce Survey 2021	3 months	High	Review of medical physics service provider capacity to deliver against the NHSBSP service specification Approved and signed SLA Audit report and action plan Medical physics service to commence stereotactic accuracy testing Medical physics service to investigate and resolve the variance in mean glandular dose
10	Implement an equipment replacement plan to provide business continuity	Service specification 24	6 months	Standard	Capital replacement plan
11	Update medical physics QC processes	32: Quality assurance for medical physics services	6 months	Standard	Record completion of remedial actions and inform the medical physics service Record post-service QC in the local QC database Update local QC database to include details of escalation routes and remedial and suspension levels for each QC test Audit of compliance
Identification of cohort
12	All assessment MRIs should be recorded onto NBSS, as well as all MDT meeting records	12 – Clinical Guidelines for Breast Cancer Screening Assessment; NBSS website user guide	3 months	Standard	Confirmation of actions completed
13	Improve data validation methods between administration and clinical (pathology and surgery) teams to ensure that data entered on NBSS is correct and complete	13 – Consolidated Guidance on Standards for the NHS Breast Screening Programme	6 months	Standard	Audit of compliance SOP
Invitation, access and uptake
14	Produce an action plan to address issues impacting on round length. This should lead to a new round plan to restore and maintain the screening round length KPI at ≥90%	24 – maintaining and achieving the 36 month round length; Service specification 24; SR050 report	3 months	High	Confirmation of attendance at round planning tool training Action plan Review of baseline capacity at each site New round plan with appropriate smoothing of peaks and troughs
The screening test – accuracy and quality
15	Ensure there is protected time for film reading and MDT meeting preparation	42 – ABS Breast MDTM Toolkit	3 months	High	Updated job plans for film readers
Referral
16	Review assessment capacity to ensure it is sufficient to allow backlog recovery	12 – Clinical Guidelines for Breast Cancer Screening Assessment	3 months	High	Action plan to achieve required capacity Ensure PACS download speed accommodates the fast download of tomosynthesis images Confirmation of recovery
Diagnosis
17	Ensure sentinel lymph nodes are cut at 2 mm during dissection	34 – Quality Assurance Guidelines for Breast Pathology Services	3 months	Standard	SOP update
18	Undertake pathology report reviews on data from 01 April 2020 to 31 March 2021 to examine B3 with and without atypia and lymphovascular invasion statuses	34 – Quality Assurance Guidelines for Breast Pathology Services	6 months	Standard	Summary reports to include: · examine if B3 atypia and LVI statuses are recorded correctly on NBSS · state how many entries were corrected · action plan to ensure B3 atypia and LVI cases are recorded correctly
Intervention and outcome
19	Ensure a clinical nurse specialist is in every assessment clinic	15 – guidance for clinical nurse specialists	6 months	High	Audit of compliance
20	Provide clinical supervision for clinical nurse specialists	15 – guidance for clinical nurse specialists	3 months	Standard	Confirmation of compliance SOP
21	Surgical representatives from Blackpool Teaching Hospitals and Lancashire Teaching Hospitals should attend UHMBT MDT meetings	42 – ABS Breast MDTM Toolkit	3 months	High	Confirmation of compliance
22	Consider opportunities for radiography staff to attend the MDT meeting	42 – ABS Breast MDTM Toolkit	6 months	Standard	MDT meeting attendance records

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 Practise 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
Association of Breast Surgery Breast MDTM Toolkit

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