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 14 March 2023 to West Essex breast screening service, which is commissioned by NHS England – East of England Public Health Commissioning team. As the date of the visit coincided with a day of industrial action the visiting QA team worked with The Princess Alexandra Hospital NHS Trust to modify the format of the visit to align with the measures put in place to mitigate for identified risks. The service was extremely accommodating of the swift changes required to ensure the visit continued on the date originally planned.

The service is highly dedicated with a strong commitment to high standards of patient care. The service provides a good quality service to the population served. Innovative practice was witnessed during the QA visit which should be shared with other breast screening services, notably the paperfree approach to breast screening.

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 consistently 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 meetings and pre-visits from 23 February 2023 to 13 April 2023
• information shared with the Midlands and East SQAS as part of the visit process

The screening service

The West Essex breast screening service is hosted by The Princess Alexandra Hospital NHS Trust (PAHT) and has an eligible population of 51,398. The total population of the area served is 393,385. The service is commissioned by the NHS England – East of England Public Health commissioning team.

The breast screening service operates from a single static site located at St Margaret’s Hospital in Epping and a mobile unit which covers ten screening locations. Assessment clinics are held at St Margaret’s Hospital on a Tuesday and Thursday where up to ten women are booked into each clinic. All breast pathology is reported at the Princess Alexandra Hospital in Harlow, except for discordant and complex cases which are outsourced to Health Services Laboratories Advanced Diagnostics (HSLAD). Breast surgery is also performed at the Princess Alexandra Hospital, except for breast reconstruction surgery which is outsourced to Broomfield Hospital in Chelmsford.

The medical physics service for mammography equipment, specimen cabinets and image displays are delivered by the Royal Free London NHS Foundation Trust. The medical physics service for ultrasound and the specimen cabinet located in theatres is delivered by the East and North Hertfordshire NHS Trust who also acts as the Radiation Protection Advisor for mammography.

A very high risk (VHR) screening programme is provided by the service and includes an eligible population of 114 service users. Very high risk service users receive their mammogram at St Margaret’s Hospital and MRI, when required, is carried out at Princess Alexandra Hospital. MRI guided biopsies are referred to the London North West University Healthcare NHS Trust to be performed at Northwick Park Hospital. All results are discussed at the West Essex breast screening service multidisciplinary team (MDT) meetings.

The service has worked well to address the backlog of appointments for women impacted by the pause in screening due to the Covid-19 pandemic. The service does not meet the current definition of recovery, however, the national NHS England team agreed with NHS England – East of England, in January 2023 that the service had effectively recovered. For services to be considered to have sustainably restored, they must:

• have a total adjusted backlog of less than 5% of total 2019/20 delivered activity, as reported in the demand and capacity tool output
• have less than 100 women in tier 5, as reported in the recovery dashboard
• have met the 90% round length measure for three consecutive months in combination with delivering the above two metrics

The service has met the first two requirements, but round length has not met the 90% target for three consecutive months due to regaining service users from another breast screening service part way through their three-year screening interval. There is a planned recovery in place for this cohort of women and the service continues to work hard to recover the round length.

Findings

The West Essex breast screening service is a dedicated, cohesive team that provides a high quality service to the population served. The service displays a strong commitment to high standards of patient care. The service is to be commended on its paperfree pathway and the support offered to other breast screening services aspiring to do the same. 

Overall, the key priorities to be addresses are as detailed below.

Immediate concerns

The QA visit team identified no immediate concerns.

High priority findings

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

• review governance processes to ensure clarity regarding the responsibilities of key service staff and the arrangements for the management and oversight of the screening budget, incidents, risks, and subcontracted services
• produce and maintain a comprehensive communication plan for the service which clearly documents the channels of communication and allows for key information to be promptly and effectively disseminated, collected, and reported back
• conduct a health equity audit and produce a screening inequalities action plan with the support of the commissioners
• devise a comprehensive succession plan to ensure all staffing gaps are addressed and a robust service is in place
• develop a detailed plan which addresses how the service will investigate the possible influencing factors for the reducing small (<15mm) cancer detection rate

Examples of practice that can be shared

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

• innovative paperfree approach to breast screening which aims to reduce administrative processes and allows services users to seamlessly move through the screening pathway
• Royal Free London NHS Foundation Trust has developed and is currently testing an online User Quality Control application which will remove the use of Excel spreadsheets and allows for seamless reporting and automated escalation
• the dedicated very high risk nurse telephones all service users referred onto the very high risk breast screening programme, including those rejected and those who are not of eligible age to ensure they understand the screening process or the reason for rejection

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 C: 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 – 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. 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
41. Technical guidelines for MRI for the surveillance of women at higher risk of developing breast cancer Breast screening: using MRI with higher risk women
42. Guidance on implementation of Ionising Radiation (Medical Exposure) Regulations Breast screening: guidance on implementation of Ionising Radiation (Medical Exposure) Regulations (2017) – GOV.UK (www.gov.uk)
43. Image reading guidance Breast screening: guidance for image reading – GOV.UK (www.gov.uk)
44. Routine quality control tests for full field digital mammography systems. Equipment report 1303: fourth edition Breast screening: routine quality control tests for FFDM – GOV.UK (www.gov.uk)