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	Partly	NHS England Midlands-East 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 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 20 May 2025 to Nottingham City 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(s), commissioner and external organisations
information collected during pre-review visits from 1 May to 19 May 2025
information shared with SQAS as part of the visit process.

The screening service

The Nottingham City breast screening service is hosted by the Nottingham University Hospitals NHS Trust (NUH). The service has an eligible population of 102,442 (women aged 50-<71) and is commissioned by the NHS East Midlands Public Health commissioning Team.

The breast screening service offers screening at 2 static sites located at the Nottingham Breast Institute (NBI) at City Hospital and the Ropewalk Centre in central Nottingham and from 2 mobile units, one is permanently based at Newark, and the other visits 5 screening locations. 1 assessment clinic is held per week at NBI on a Wednesday morning. Breast pathology is reported at Nottingham City Hospital. Breast surgery is performed at Nottingham City Hospital.

The medical physics provision for the service is provided inhouse by Nottingham University Hospitals NHS Trust (NUH).

The service currently has 244 women registered on the very high risk (VHR) breast screening programme. VHR screening for the Nottingham population is undertaken at Nottingham City Hospital. The service also provides the full high risk screening service for Lincolnshire breast screening service and MRI for North Nottingham breast screening service, with a formal contract in place. MRI biopsies are undertaken at Nottingham City Hospital.

Findings

On the whole, the Nottingham City breast screening service is a dedicated team that wants to provide a good service to the population served. Working relationships between some of the teams within the service are strained and the service has suffered over the past few years with a fluctuating workforce in some areas.

A workforce review is required to ensure a robust service is in place and to address gaps in service provision.

The service has experienced significant round length slippage since January 2024 due to various factors. The service aims to recover by Autumn 2025 but this has been a challenging period for the team.

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.

Issues around workplace culture were raised to the visiting team; these fall outside the scope of SQAS and are not included in this report. The visit chair escalated these issues to the chief executive and medical director.

Immediate concerns

The QA visit team identified 5 immediate concerns. A letter was sent to the chief executive, on 22 May 2025 asking for an action plan to be completed within 7 working days to address the following items:

Develop an accountability structure and governance process for breast screening, with clear details of escalation routes for service performance, risks, needs and costs.
- Share the structure with all staff working within the breast screening programme to ensure staff are aware of their responsibilities and escalation routes.
Ensure the management of screening safety incidents is consistent throughout the screening pathway.
- Provide assurance that all staff working within the breast screening programme are aware of and adhere to the national guidelines for managing safety incidents in NHS screening programmes
Provide assurance that the breast screening programme has adequate employer’s procedures in place as required by IR(ME)R.
- Confirm that all staff know where to locate the employer’s procedures and have read and comply with them
Provide confirmation that all mammographers are up to date with basic life support techniques.
Confirm that technical recalls are being appropriately recorded on the national breast screening system (NBSS) and all relevant staff are aware of their role.

A response was received within 7 working days, and actions were taken to partially mitigate the immediate concerns within the programme.

High priority findings

The QA visit team identified 6 high priority findings as summarised below:

The operational management structure should be reviewed to ensure clearly defined roles and responsibilities.
- This should include a review of the director of breast screening, programme manager and lead mammographer job descriptions.
A workforce plan should be agreed for administration, very high risk, pathology and surgery and a succession plan for nursing to ensure NHS BSP standards are maintained and a robust service is in place.
Develop an equipment replacement and procurement plan.
The management of open episodes should be reviewed to ensure appropriate and timely closure.
A full very high risk (VHR) audit needs to be undertaken to address discrepancies in numbers, appropriate management of pending clients and to ensure completion of referral reasons in BS Select.
The round plan requires a full review to prevent future round length slippage.
- The service should use the national digital round planning tool on BS Select where its functionality supports other methods of round planning.

Examples of practice that can be shared

The QA visit team identified the following areas of practice for sharing:

The use and availability of positioning chairs in every mammography room to ease positioning and mitigate musculoskeletal issues encountered by both staff and service users.
Availability of the wellbeing room, a dedicated space for respite and reflection for mammography staff in the pressured clinical environment.
Close involvement with the charitable trust resulting in improvements in the clinical environment with a modern, welcoming space for patients.
The breast pathology service has an international profile with many consultants involved in various national and international contributions to publications and guidelines development.

Recommendations

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

No.	Recommendation	Pathway theme	Reference	Timescale	Priority	Evidence required
Immediate concerns
01	Develop an accountability structure and governance process for breast screening, with clear details of escalation routes for service performance, risks, needs and costs. Share the structure with all staff working within the breast screening programme to ensure staff are aware of their responsibilities and escalation routes.	Governance and leadership	Breast screening: best practice guidance on leading a breast screening service NHS Breast Screening Programme Service Specification No. 24	7 days 3 months	Immediate	Submission of action plan. Submission of the final governance structure detailing the management, accountability and escalation process. Confirmation that the structure has been shared with all staff working within the breast screening programme.
02	Ensure the management of screening safety incidents is consistent throughout the screening pathway. Provide assurance that all staff working within the breast screening programme are aware of and adhere to the national guidelines for managing safety incidents in NHS screening programmes.	Governance and leadership	Managing safety incidents in NHS screening programmes NHS Breast Screening Programme Service Specification No. 24	7 days 3 months	Immediate	Submission of action plan. Copy of local screening incident reporting work instructions. Confirmation that all staff working within the breast screening programme are aware of and adhere to the work instructions for the management of screening safety incidents.
03	Provide assurance that the breast screening programme has adequate employer’s procedures in place as required by IR(ME)R. Confirm that all staff know where to locate the employer’s procedures and have read and comply with them.	Infrastructure	Guidance on implementation of Ionising Radiation (Medical Exposure) Regulations 2017 The Ionising Radiation (Medical Exposure) (Amendment) Regulations 2024	7 days 3 months	Immediate	Submission of action plan. Copy of employer’s procedures in place. Confirm the employer’s procedures have been reviewed to consider the latest guidance and the IR(ME)R Amendment Regulations 2024. Confirmation that all staff know where to locate the employer’s procedures and have read and comply with them.
04	Provide confirmation that all mammographers are up to date with basic life support techniques.	The screening test – accuracy and quality	Guidance for breast screening mammographers	7 days 3 months	Immediate	Submission of action plan. Confirmation that all mammographers are up to date with basic life support techniques.
05	Confirm that technical recalls are being appropriately recorded on the national breast screening system (NBSS) and all relevant staff are aware of their role.	The screening test – accuracy and quality	Guidance for breast screening mammographers Guidance on collecting, monitoring and reporting technical recall and repeat examinations	7 days 3 months	Immediate	Submission of action plan. Copy of work instruction which includes how to record technical recalls on NBSS. Confirmation that image readers, mammographers and administration team are aware of their role in recording technical recalls. Confirmation of the plan to discuss the data.

No.	Recommendation	Reference	Timescale	Priority	Evidence required
Service provider and population served
No recommendations
Governance and leadership
06	Ensure an annual report is produced and submitted to both the provider board and local screening governance system.	Service specification No. 24	12 months	Standard	Copy of the annual report and minutes of the meeting of where it was presented.
07	Ensure a robust operational management structure is in place.	Breast screening: best practice guidance on leading a breast screening service Service specification No. 24	3 months	High	Review and clarify the roles and responsibilities within the current management structure to ensure clearly defined roles and responsibilities. Review and amend the director of breast screening, programme manager and lead mammographer job descriptions. Copy of job description for the director of breast screening. Copy of job description and job plan for the programme manager and lead mammographer.
08	Ensure the requirements of reducing health inequalities are delivered.	Service specification No. 24	6 months	Standard	Completed health equity audit and inequalities action plan. Confirmation that ethnicity data is collected and populated on the national breast screening system (NBSS).
09	Maintain, comply with, and regularly audit the local quality management system (QMS) and accompanying documentation.	Service specification No. 24	6 months	Standard	Confirmation that the QMS review process includes a full audit with documented changes. Confirmation that all forms are version controlled. Copy of the QMS audit schedule.
10	Develop and maintain a non-conformance log.	Service specification No. 24 Breast screening: Right results checklist	6 months	Standard	Copy of non-conformance log and copy of work instructions.
11	Agree a service wide audit plan covering all parts of the programme.	Service specification No. 24	6 months	Standard	Agreed audit plan/schedule
Infrastructure
12	Agree a workforce plan for administration, very high risk, pathology and surgery and a succession plan for nursing to ensure NHS BSP standards are maintained and a robust service is in place.	Service specification No. 24 Breast screening: leading a service	6 months	High	Copy of workforce and succession plan(s).
13	Ensure a written service level agreement (SLA) is in place for medical physics services.	Breast screening: guidelines for medical physics services	3 months	Standard	Copy of the agreed SLA.
14	Develop an equipment replacement and procurement plan.	Service specification No. 24 Breast screening: acquisition and testing of ultrasound scanners	3 months 6 months 12 months	High	Copy of a breast screening equipment replacement and procurement plan. Confirm that ultrasound equipment has been procured appropriately. Confirm that the 4 oldest mammography units and the oldest ultrasound unit have been replaced. Confirm consideration of implementing remote image transfer on the mobile units as soon as it is approved by the trust.
15	Standardise dose and image quality settings across all mammography units.	Service specification No. 24	6 months	Standard	Confirmation that all units are set to enhanced dose mode and e-contrast setting and tomosynthesis plane spacing is standardised on all units.
16	Undertake an assessment of clinical dose for the 2 new mobile mammography equipment.	Breast screening: guidelines for medical physics services	3 months	Standard	Completed dose survey on a sample of women.
17	Ensure a robust user quality control (QC) testing programme is in place which complies with national guidance.	Commissioning and testing of full field digital mammography systems guidance Breast screening: Testing biopsy systems guidance Routine quality control tests for full field digital mammography systems and Breast screening: routine tomosynthesis quality control	6 months	Standard	Confirmation of the updated physics user QC programme in place and tests being undertaken, to include testing of automatic exposure control in biopsy modes, electronic calliper calibration and acquisition workstation monitors. Confirmation of the plan for implementing testing of modulation transfer function. Copy of updated procedures, test frequencies, spreadsheets and tolerances in place for biopsy testing. Confirmation that monthly assessment of Contrast to Noise Ratio and monthly testing of acquisition and reporting workstation monitors have been implemented.
18	Ensure sufficient user QC radiographers are appointed to provide resilience for undertaking user QC.	Guidance for breast screening mammographers	3 months	Standard	Confirmation of staff in place to undertake user QC and deputise for the QC radiographer when required.
19	Ensure there is a written procedure indicating how out of tolerance results are managed and escalated.	Guidance for breast screening mammographers	3 months	Standard	Copy of procedure in place indicating how out of tolerance results are managed and escalated and highlighting when equipment might be suspended from use and by whom.
Identification of cohort
20	Ensure open episodes are managed appropriately and with timely closure.	Service specification No. 24	3 months	High	Copy of reviewed work instruction and confirmation that historic open episodes and holding clinics have been managed and closed appropriately.
21	Review and update the ceasing procedures and work instructions.	Guidance on opting out (cease) from breast screening	6 months	Standard	Updated procedure/work instruction(s).
22	Ensure there is a disaster recovery plan in place in the event of a major IT incident.	Breast screening: screening office management	3 months	Standard	Confirmation of the plan in place.
23	Perform a full very high risk (VHR) audit to address discrepancies, pending clients and completion of referral reasons in BS Select.	Service specification No. 24 Breast screening: organising very high-risk (VHR) screening	3 months	High	Feedback on audit covering discrepancies. Confirm pending clients are being managed correctly. Confirm all referral reasons have been entered onto BS Select.
Invitation, access and uptake
24	Ensure that printed ‘Your guide to NHS breast screening’ leaflets are enclosed with prevalent screening invitations until a service user attends for screening.	Service specification No. 24	3 months	Standard	Confirmation that printed leaflets are enclosed with all prevalent invitations.
25	Review the round plan and use the national digital round length planning tool to support round planning and prevent future slippage.	Service specification No. 24	6 months	High	Copy of the 3 year round plan. Confirm the round planning tool is in use.
The screening test – accuracy and quality
26	Establish regular radiography and radiology staff meetings with an educational element.	Service specification No. 24	3 months	Standard	Copy of Terms of Reference and standing agenda. Schedule of dates of meetings for the next 12 months.
27	Develop a process for undertaking regular image reviews.	Guidance for breast screening mammographers	6 months	Standard	Confirmation of the agreed process.
28	Introduce a formal review process for interval cancers and previously assessed cancers, in line with national guidance.	Breast screening: reporting, classification and monitoring of interval cancers and cancers following previous assessment	6 months	Standard	Confirmation that a formal review process for shared learning for interval cancers and previously assessed cancers is in place.
Referral
No recommendations
Diagnosis
29	Provide clinical nurse specialist (CNS) support at assessment clinics as per guidelines.	Guidance for Clinical nurse specialists in breast screening	6 months	Standard	Copy of the revised letters and leaflets sent to women who are recalled and women who are returned from assessment to show they clearly state how they can contact a CNS for further information and support Confirm women are met at the start of the assessment process by a CNS. Confirm women who have a biopsy are seen by a CNS post biopsy. Copy of the protocol for giving benign results.
30	Evaluate the level of patient satisfaction of nursing in the assessment clinic.	Guidance for Clinical nurse specialists in breast screening	12 months	Standard	Copy of questionnaire and audit results
Intervention and outcome
31	Appoint a lead clinical nurse specialist (CNS) for breast screening	Guidance for Clinical nurse specialists in breast screening	6 months	Standard	Confirmation of identified lead CNS. Confirm plan to attend programme board and wider operational management meetings.
32	Ensure that the multidisciplinary team (MDT) meetings operate in line with the service specification.	Service specification No. 24	6 months	Standard	Confirmation that the MDT record is a single record and is validated in real time by all attendees including virtual attendees. Confirm the MDT record is immediately available to the team in clinical areas. Confirmation that equipment is available for viewing pathology slides in MDT.

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 and 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
NICE Early and locally advanced breast cancer: diagnosis and management Overview | Early and locally advanced breast cancer: diagnosis and management | Guidance | NICE
Association of Breast Surgery Guidance for the commissioning of oncoplastic breast surgery Guidance for the Commissioning of Oncoplastic Breast Surgery | Association of Breast Surgery

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