Scope of this report

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 3 November 2022 to South West London Breast Screening Service (SWLBSS) which is commissioned by the NHS England Public Health Commissioning team, London region.

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 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 administration and clerical, radiography (including image review), radiology (including image review), medical physics, breast care nursing, pathology slide review, surgical case note review, observation of multidisciplinary team meetings and a ‘right results’ walkthrough in October and November 2022
• information shared with the London SQAS as part of the visit process

The screening service

The public health commissioning team at NHS England, London region, commissions this service. The London breast screening model is comprised of a stand-alone pan-London call/recall administration hub, provided by the Royal Free London NHS Foundation Trust, and 6 breast screening services, including SWLBSS.

SWLBSS is provided by St Georges University Hospitals NHS Foundation Trust, which since July 2022 has been part of NHS South West London Integrated Care Board (ICB). The ICB and SWLBSS cover the London boroughs of Wandsworth, Richmond, Sutton, Merton, Kingston and Croydon, with a total population of approximately 935,000 (2020 estimate).

The population of south west London is ethnically diverse and growing. SWLBSS serves a large proportion of women from Black, Asian and minority ethnic (BAME) backgrounds, there are a number of non-English speaking population groups that are particularly deprived and there is a mobile/transient population.

At the time of the QA visit the eligible population for breast screening was 190,416 women, aged 50 to <71, plus a cohort of 475 Very High Risk (VHR) clients.

SWLBSS provides breast screening by digital mammography at 7 static sites. Following screening, further assessment is provided at St. George’s Hospital (SGH).

Most screen-positive cases are treated at SGH, Royal Marsden Hospital (RMH – Sutton & Fulham Road), Kingston Hospital (KH), Croydon University Hospital (CUH) and West Middlesex University Hospital (WMUH).

In March 2020, due to the COVID-19 pandemic, breast screening was paused throughout England for around 4 months, creating a significant backlog. Since then, and whilst managing a backlog recovery programme, both the ability to provide screening and improving the uptake of screening have been negatively impacted.

The last QA visit to SWLBSS was in October 2018. At the time of this visit, 3 recommendations remained open.

Findings

The COVID-19 pandemic has presented and continues to present significant challenges for screening services and the wider NHS. The SWLBSS team should be commended for their admirable dedication to recovering the resulting backlog of screening.

The service is clinically well-led, and all of the staff and professional groups are experienced and committed. The trust is engaged with and supportive of the breast screening service.

In the 3 year period from April 2018 to March 2021 the annual uptake rate for the service showed a declining trend and was below the national standard (≥ 70%). The uptake rate was also below the national average and followed the national trend. Before this period, uptake was also lower than the national average.

In the same period, the annual coverage rate (national standard ≥ 70%) has varied. Coverage was below the national average and followed the national trend.

Since March 2020, the uptake and coverage of all breast screening services in England has been significantly impacted by the pandemic and the subsequent recovery programme.

The main challenges ahead for the breast screening service include maximising equity of access, improving uptake, maintaining and increasing capacity and resilience, and identifying and tackling inequalities.

Immediate concerns

None.

Urgent recommendations

The following urgent recommendations were made at the visit:

• Ensure that every invited client can book an appointment when they first telephone (the Hub).
• Conduct a gap analysis of local processes against the latest VHR guidance, appoint at least one deputy VHR coordinator and establish more rigorous management oversight of the VHR pathway.
• Establish a systematic and rigorous Right Results process for the VHR pathway.
• Ensure that (a) all administration and clinical data entry staff have up-to-date Right Results training and (b) administration staff have access to the NBSS training website.
• Implement desktop integration of the NBSS clinical module with PACS.
• Provide a completed QA visit pathology questionnaire from Royal Marsden Hospital (subsequently provided).
• Provide pathologist cover for the core biopsy section of the Kingston MDM to ensure that the meeting is quorate.

On 24 November 2022, the service shared an action plan to address these recommendations and further updates since then.

High priority findings

The high priority findings included:

• There is a lack of oversight of the programme management function which is split and delegated across a number of individuals who are not all routinely co-located with the programme manager and who sometimes work in silos.
• In the next 5 years, some highly experienced people in key staff groups will retire, for example, management, administration, radiography and nursing.
• Although there are separate budgets for each service, it was not clear how mammography personnel and WTEs are, in practice, allocated and split between the screening service, the symptomatic service and the training centre.
• The pathology consultant workforce at SGH has 3 vacant posts which is not compliant with Royal College of Pathology (RCPath) guidelines on staffing levels.
• There is no facility for the pathologist to check MDM outcomes (treating trusts’ MDMs) when participating online, from both Kingston and Croydon Hospitals.
• The surgical data is incomplete and with some inaccuracies, with complex Hub processes for data collection and validation.

Examples of practice that can be shared

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

• Using the learning from patient experience to improve the service.
• Since the last QA visit, the service has increased disabled access to 4 of the 7 sites.
• Annual audit of the VHR cohort with each referring service.
• Comprehensive health inequalities and health promotion plans.
• Use of QR codes in key documents which staff use, to easily register compliance with radiation protection requirements.
• Comprehensive evaluation of new surgical techniques.

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: References

1. Best Practise Guidelines for Surgeons in Breast Cancer Screening Guidance Platform – Association of Breast Surgery

2. Breast screening care pathway Breast screening care pathway

3. Breast screening 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 pathway requirements specification Breast screening pathway requirements specification

6. Breast Screening: arbitration guidance Breast screening: arbitration guidance

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

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. Guidance for clinical nurse specialists 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. Key Performance Indicators NHS screening programmes Antenatal, newborn, young person and adult 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 England Serious Incident Framework – Supporting learning to prevent recurrence (March 2015) serious-incidnt-framwrk-upd2.pdf

27. NHS Patient Safety Incident Response Framework NHS England » Patient Safety Incident Response Framework

28. NHS population screening standards NHS population screening standards

29. Opting out of breast screening Opting out of breast screening

30. Organising very high risk (VHR) screening Breast screening: organising very high risk (VHR) screening

31. Protocols for the surveillance of women at higher risk of developing breast cancer Breast screening: very high risk women surveillance protocols

32. Quality assurance for medical physics services Breast screening: quality assurance for medical physics services

33. Quality Assurance Guidelines for Breast Cancer Screening Radiology (2nd Edition) Breast screening: quality assurance standards in radiology

34. Quality Assurance Guidelines for Breast Pathology Services Breast screening: quality assurance guidelines for breast pathology services

35. Remote radiographic supervision Breast screening: remote radiographic supervision

36. Reporting, classification and monitoring of interval cancers and cancers following previous assessment Breast screening: interval cancers

37. Retention, storage and disposal of mammograms and screening records Retention, storage and disposal of mammograms and screening records

38. Right results audit & checklist Breast screening: Right Results audit

39. Screening office management guidance Breast screening: screening office management

40. 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