NHS England » Screening Quality Assurance visit report – West Berkshire Breast Screening Service

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 Public Health Commissioning team South East (Thames Valley)
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 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 2 November 2022 to West Berkshire Screening Service which is commissioned by NHS England South East (Thames Valley) Public Health Commissioning team.

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 the 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 Berkshire Hospitals in October and November 2022
information shared with the SQAS South team as part of the visit process

Local screening service

The West Berkshire breast screening service is located at the lower ground floor in a building separate to and opposite the main hospital. The symptomatic service is located at the main hospital building and is entirely separate to the screening programme in terms of staffing, funding, and budget.

The West Berkshire service provides screening for eligible women living in the West Berkshire Clinical Commissioning Group (CCG) area. The screening service offers screening to women aged 50 to <71 years and the eligible population is 75,248 (source NHS Digital).

The service provides screening for women at very high risk (VHR) of breast cancer. The Clinical Nurse Specialist (CNS) is the named VHR co-ordinator and admin assistant is deputy; Magnetic Resonance Imaging (MRI) is provided in house at RBH, and MRI guided biopsies are carried out at Northwick Park Hospital, London.

All screening assessment clinics are held at the screening service. There are four assessment clinics held per week at RBH – Monday (am and pm), Tuesday (am and pm), and occasional Wed pm if bank holiday on a Monday.

Pathology is organised by Berkshire and Surrey Pathology Services; two histology laboratories at RBH/WPH & Royal Surrey County Hospital – RBH covers West Berks/Wexham labs. Breast surgery is carried out at the RBH.

Findings

The West Berkshire breast screening service meets most of the key performance indicators and provides a good clinical quality service to the local population. Since the last QA visit in September 2016, the service has a new service manager, new superintendent radiographer and new office manager. There are good lines of communication between the breast screening service and trust management.

Staff in the service work extremely hard. The service made an early recovery from the COVID-19 pandemic backlog ahead of the national timeline. All staff should be congratulated on this achievement.

Immediate concerns

The QA visit team identified no immediate concerns.

High priority

The QA visit team identified several high priority findings including:

staff shortages, particularly in radiography and pathology, are a risk to the service’s ability to meet breast screening targets and requires resilient workforce planning
all five mammography units are around 10 years old, and a formal written plan is needed for their replacement, along with defined timescales for installation
all women with a diagnosis of breast cancer should receive their results in the presence of a clinician and a clinical nurse specialist in breast care. This is currently not occurring and therefore a review of the results pathway if required to ensure it is in line with guidance.

Shared learning

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

Use of a pre-screening questionnaire assists the service to maintain a high level of patient confidentiality in waiting areas.

Individual performance data is provided to mammographers on a monthly basis, including technical recall and repeats, and there is good peer support to further improve technique and decision-making skills, with evidence that this has resulted in sustained improvements.

Detailed induction packs are provided to all new mammography staff that includes sign off of completion along with 3, 6 and 12 month reviews.

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	Lead pathologist and lead surgeon for breast screening to provide confirmation to the director of breast screening that annual appraisals of pathologists and surgeons working in breast screening include consideration of NHSBSP professional measures and standards	Best practice guidance on leading a breast screening service 2018	3 months	Standard	Written confirmation
02	The service should set up regular business meetings to increase staff engagement and to disseminate information	Best practice guidance on leading a breast screening service 2018	6 months	Standard	Copy of meeting agenda
03	Service to ensure that all breast screening incidents on the trust Datix report are supplied to SQAS and SIT in line with national guidance	Managing safety incidents in NHS screening programmes Updated July 2021	3 months	Standard	Submission of Screening Incident Assessment Forms (SIAFs) to SQAS and SIT
04	Service to work with commissioners and other stakeholders to undertake a health equity audit and associated action plan to identify and reduce screening inequalities and improve uptake	NHS public health functions agreement 2019-2 (england.nhs.uk) Guidance for NHS Commissioners on equality and health inequality duties NHS Accessible Information Standard and Specification Service Specification No. 24 (2022)	12 months	Standard	Copy of audit and action plan
05	Develop closer ties between the screening service and the trust Learning Disability Liaison Nursing team to ensure good support of vulnerable clients	Breast screening: reducing inequalities – GOV.UK (www.gov.uk)	3 months	Standard	Written confirmation
06	Investigate the suggested adjustments documented in the right results walkthrough checklist	Right_Results_checklist	6 months	Standard	Written confirmation
Infrastructure
07	Service to develop a workforce plan covering the whole screening pathway, including actions to address current staffing shortages in radiography, radiology and pathology, and to ensure the service can provide adequate numbers of appropriately trained staff in the event of retirements	Service Specification No. 24 (2022)	6 months	Standard	Workforce plan to be monitored through the programme board
08	The trust should provide a formal written plan for replacement of the five mammography X-ray units, with defined timescales for installation	Service Specification No. 24 (2022)	3 months	High	Copy of plan for replacement of aging equipment
09	(a) Local mammography and Ionising Radiation (Medical Exposures) Regulations (IR(ME)R) procedures to be updated to include the following points: • the Employer’s Procedures to include names of all Medical Physics Experts (MPEs) from the Northampton medical physics department that are available to the breast screening service, along with a brief description of the scope of their MPE role (for example equipment quality control, patient dose audit, assistance with IRMER procedures); • relevant IRMER procedure to be amended to state that carers and comforters are not permitted to remain outside the protective screen during the exposure, and the requirement for 0.25 mm lead coats to be removed; • clinical protocol for performing X-ray mammography to include details of mode in which Siemens Inspiration units should normally be used (for example OPDOSE), along with details of when the operator may deviate from using this mode; • protocol for performing X-ray mammography on women with implants to include the manual exposure settings chart. (b) The latest version of the AxREM (Radiation Controlled Area and Equipment Handover Form) should be used (available online)	Guidance to the Ionising Radiation (Medical Exposure) Regulations 2017	3 months	Standard	Copy of updated Employers Procedures, (IR(ME)R) procedures and other relevant updated clinical protocols
10	The pass/fail criteria for the stereotactic needle accuracy test to be added to the QC instructions	Routine quality control tests for full field digital mammography systems Equipment report 1303: fourth edition October 2013	3 months	Standard	Copy of updated QC instructions
Identification of cohort
11	Admin team to establish regular checks of NBSS reports: summary in SMSTA on a daily basis to monitor unprinted letters SASP 4 report to monitor missing results	Breast Screening Office management – Good practice Service Specification No. 24 (2022)	6 months	Standard	Written confirmation
12	Review GP pack in line with guidance, to be more informative and include proforma and list of staff contact details	Breast screening: GP pre-screening pack July 2021	3 months	Standard	Copy of updated GP pack
Invitation, access and uptake
	No recommendations made in this section
The screening test – accuracy and quality
13	Undertake an annual client satisfaction survey of the assessment pathway	Breast screening: best practice guidance on leading a breast screening service November 2018 Breast screening: reducing inequalities Updated June 2022	6 months	Standard	Copy of audit
14	Use of i-passport to collate the departmental work instructions, to ensure they continue to be detailed and provide accurate guidance for the breast screening team, and that they only have access and ability to review those relevant to own departmental practice	Breast screening: best practice guidance on leading a breast screening service November 2018	12 months	Standard	Ongoing audit and review and development as implementation identifies revision
15	Review of VHR work instructions to ensure all roles are clear and to ensure that an appropriate member of the clinical team reviews referrals as per guidelines	Breast Screening: Guidance for organising a very high risk programme	3 months	High	Copy of work instruction
16	Ensure that the service meets and maintains the screen to assessment key performance indicator (KPI)	NHS Breast screening programme screening standards valid for data collected from 1 April 2021	3 months	High	KPI data
Diagnosis
17	Review the assessment work instructions to ensure that the assessment process is clear and reflects local circumstances, and there is uniform practice. This should include mammographic views, which should reflect guidance and practice	NHS Breast Screening Programme Clinical guidance for breast cancer screening assessment	3 months	High	Copy of updated work instruction
18	Second review processes should be reviewed, and the service should consider how this might be modified to reflect guidance	NHS Breast Screening Programme Clinical guidance for breast cancer screening assessment	3 months	Standard	Copy of updated work instruction
19	Cease the use of FNA for breast lesions in line with guidance	NHS Breast Screening Programme Clinical guidance for breast cancer screening assessment	3 months	High	Copy of updated work instruction
20	Monitor SDR and small cancer detection at 6 months	NHS Breast screening programme screening standards valid for data collected from 1 April 2021	6 months	Standard	Copy of KPI data
21	Monitor waiting time for results for very high-risk screening once the work instruction and very high-risk process is reviewed	Breast screening: guidance for organising a Very High Risk (VHR) screening programme Updated November 2021 NHS Breast screening programme screening standards valid for data collected from 1 April 2021	6 months	High	Copy of KPI data
22	Commissioners and managers from Royal Berkshire Hospital/Berkshire and Surrey Pathology Services to review risks in pathology staffing levels. To agree actions to ensure there is sufficient capacity in breast screening pathology reporting and to maintain weekly consultant pathologist attendance to the breast MDT meeting to facilitate full discussion	Service Specification No. 24 (2022) Breast screening: best practice guidance on leading a breast screening service Published November 2018	3 months	High	Written confirmation, copy of action plan, copy of MDT attendance sheets
23	Improve reporting turnaround times (TAT) for breast excision specimens at Royal Berkshire Hospital, to meet national pathology guidelines	Breast screening: quality assurance guidelines for breast pathology services Updated September 2020 RCPath G148_BreastDataset-hires-Jun16.pdf	3 months	High	Written confirmation and audit data
24	Undertake initial prospective 12 month audits of screen detected breast cancer cases relating to each of the following: • histological grading • B3 core biopsy • tumour size	NHS Breast Screening Programme Audit – Association of Breast Surgery National breast screening pathology audit Updated September 2021	12 months	Standard	Copy of audit
Intervention and outcome
25	Benign results to be given in quiet dedicated time, and the option for women to choose whether to receive results that are expected to be benign by telephone or in person, should be explored to make better use of clinician and patient travel time	Clinical nurse specialists in breast screening Updated December 2019 – Section 2.5 Extended roles ‘Giving benign results face to face or by telephone’	3 months	High	Written confirmation
26	Ensure the Clinical Nurse Specialists (CNS) are able to facilitate all the requirements of the CNS role. To include: meeting all women at the start of the assessment process and evaluating each woman’s level of anxiety at an early stage; offering appropriate support to all those attending assessment; training provided as to how information can be uploaded and shared with colleagues along the patient’s pathway allow access to effective reflective practice or clinical supervision, as well as psychological and peer support	Clinical nurse specialists in breast screening Updated December 2019	6 months	Standard	Written confirmation, evidence of training
27	Review the results pathway to ensure all women with a diagnosis of breast cancer receive their results in the presence of a clinician and a clinical nurse specialist in breast care clinic, and the CNS is then able to provide ongoing support and information that the woman needs	Clinical nurse specialists in breast screening Updated December 2019 NHS Breast Screening Programme Clinical guidance for breast cancer screening assessment NHSBSP publication number 49 (Fourth edition November 2016)	3 months	High	Written confirmation and removal of CNS from ‘Protocol for Nurse Led Results Clinic’ work instruction F6.4
28	The local policy for disclosure of audit should reference the trust’s ‘Duty of Candour’ policy and there should be a pathway in place for formal assessment of harm	Interval cancers and applying duty of candour Updated February 2021	6 months	Standard	Copy of work instruction
29	Audit the number of cases of DCIS treated by breast conservation having a sentinel node biopsy for the next screening year 2021-22	NHS Breast Screening Programme Audit – Association of Breast Surgery	6 months	Standard	Copy of audit
30	Audit the margin re-excision rates for the year 2020-21 to see if there are common reasons for the relatively high rate	NHS Breast Screening Programme Audit – Association of Breast Surgery	6 months	Standard	Copy of audit

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

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

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