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	No	Information included but not QA’d as part of this visit
Leadership and governance	Yes	Not applicable
Pathway
Cohort identification	Yes	Key functions are provided by or shared with the pan-London administration hub
Invitation and information	Yes	Key functions are provided by or shared with the pan-London administration hub
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 9 February 2023 to West London Breast Screening Service (WoLBSS) which is commissioned by 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 January and February 2023,
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 WoLBSS.

WoLBSS is provided by Imperial College Healthcare NHS Trust, which since July 2022 has been part of NHS Northwest London Integrated Care Board (NWL ICB). NWL ICB cover the London boroughs of Ealing, Hammersmith & Fulham, Hillingdon, Hounslow, Kensington & Chelsea, and Westminster, Brent and Harrow, with a total population of approximately 2,091,086 (ONS, 2020). WoLBSS covers most of the geography and population of the NWL ICB, excepting the boroughs of Brent and Harrow which are covered by the North London Breast Screening Service.

The population of northwest London is ethnically diverse and growing. WoLBSS serves a large proportion of women from Black, Asian and minority ethnic (BAME) backgrounds, there are a range 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 201,173 women, aged 50 to <71, plus a cohort of 352 Very High Risk (VHR) clients.

WoLBSS provides breast screening by digital mammography at 5 static sites. Following screening, further assessment is provided at Charing Cross Hospital, Hammersmith (CXH).

Most screen-positive cases are treated at CXH, Royal Marsden Hospital (RMH –Fulham Road), Hillingdon Hospitals (THH), Ealing & Northwick Park Hospitals (LNWH) 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 WoLBSS was in January 2018 and all of the recommendations were actioned.

Findings

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

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 breast screening 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.

Uptake 50-70	2018-19	2019-20	2020-21
WoLBSS	61.8 %	57.9 %	48.5 %
National	71.1 %	69.1 %	61.8 %

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

Coverage 50-70	2018-19	2019-20	2020-21
WoLBSS	66.9 %	66.0 %	51.3 %
National	74.6 %	74.2 %	64.2 %

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 WOLBSS include increasing capacity and resilience, improving uptake, coverage and roundlength, maximising equity of access, identifying and tackling inequalities, and strengthening leadership and management.

Immediate concerns

None

Urgent recommendations

The following urgent recommendations were made at the visit:

Stop the practice of informing women of the biopsy result before MDT validation.
Stop the practice of sending assessment appointment letters by courier, to minimise anxiety for women.
Ensure that there is sufficient capacity to deal with the pandemic backlog whilst achieving good pathology turnaround times.

High priority findings

The QA visit team identified 20 high priority findings, which included:

The Director of Screening and deputy posts are temporary, there is not a lead surgeon and the sessional allocations for lead surgeon and lead pathologist are not specified.
The programme management and administration roles are over-stretched and require review of roles and responsibilities.
In the next 5 years, some highly experienced people in key staff groups will retire, for example in management, administration and radiography.
The assessment and MDM workloads exceed capacity, and this is impacting biopsy result times and Faster Diagnosis Standard turnaround times.

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

Excellent culture of being open and learning from incidents.
Comprehensive Quality Management System in place.
Disabled access at all sites.
Rapid retrieval of priors from external sites in time for first read.
Reduction in technical repeat rates by introducing peer review checks.
Excellent information available to women going through assessment.
Comprehensive health promotion plan and activities undertaken by the team. The lead nurse (finalist) nominated for Nursing Times Award in 2022.

Recommendations

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

No.	Recommendation	Pathway theme	Reference	Timescale	Priority	Evidence required
Urgent recommendations
1	Stop the practice of using couriers to deliver assessment invitations.	Diagnosis	Breast screening clinical guidelines for screening assessment (2016)	1 month	Urgent	Confirmation from the DoS.
2	Ensure that there is sufficient pathology service capacity to deal with the pandemic backlog whilst achieving good turnaround times.	Diagnosis	Quality assurance guidelines for breast pathology services	3 months	Urgent	Confirmation from the lead pathologist.
3	Stop the practice of informing women of the biopsy result before MDT validation.	Intervention and outcome	Assessment guidance	1 month	Urgent	Confirmation from the DoS.

No.	Recommendation	Reference	Timescale	Priority	Evidence required
Service provider and population served
	No recommendations made in this section.
Governance and leadership
4	Appoint permanently to the DoS and deputy DoS roles with appropriate sessional allocation.	Breast screening: leading a service (2018)	3 months	High	Confirmation from the DoS.
5	Streamline existing meetings for DoS and PM, ensure representation of all teams, to achieve better oversight of the whole pathway.	Breast screening: leading a service (2018)	3 months	High	Review outcomes and completed action plan.
6	Review the Breast Imaging & Screening Manager role with a view to separating the individual roles and strengthening them, whilst maintaining strong collaboration between them.	Breast screening: leading a service (2018)	3 months	High	Review outcomes and completed action plan.
7	Establish professional leads meetings to improve communications and oversight and better integrate radiography and nursing leadership into the screening service’s senior management team.	Breast screening: leading a service (2018)	3 months	High	Review outcomes and completed action plan.
8	Appoint a lead breast surgeon and ensure that there is sufficient time allocation for all screening professional lead roles (including pathology, surgery) with clear job descriptions.	Breast screening: leading a service (2018); Best Practise Guidelines for Surgeons in Breast Cancer Screening (section 6.1e)	3 months	High	Confirmation from the DoS.
Infrastructure
9	Put a resilience and succession plan in place due to the ageing workforce for all key service functions and roles (including management, administration and radiography).	National Service Specification No. 24	6 months	High	Workforce review completed and action plan in place.
10	Review the roles and responsibilities of the Administration and Data manager role to ensure a manageable workload.	National Service Specification	6 months	Standard	Review outcomes and completed action plan.
11	Ensure that the office space and IT (desks and remote working functionality) allow staff to carry out their duties comfortably and efficiently.	National Service Specification	6 months	Standard	Review outcomes and completed action plan.
Identification of cohort
12	Ensure that open episodes are routinely closed within 6 months and any exceptions are actively investigated and swiftly closed.	National Service Specification	6 months	Standard	All episodes over 6 months have been accounted for.
13	Establish a log for recording all received VHR referrals to be used for annual audits, and follow national guidance on incorrect referrals.	Breast Screening- organising very high risk (VHR) screening – 2021	3 months	Standard	Confirmation that a log has been established. Updated SOPs.
Invitation, access and uptake
14	Allocate sufficient resource to build the round plan on BS-Select and ensure that the longest waiters are prioritised.	BS-Select and Round Planning Tool guidance	3 months	Standard	Confirmation on resourcing and longest waiters. Up to date roundplan.
The screening test – accuracy and quality
15	Review the ID checking SOP to ensure that all mammographic trained staff can ID check clients	The Ionising Radiation (Medical Exposure) regulations (2017)/ Breast Screening: Guidance for Breast Screening mammographers (2020)	3 months	Standard	Revised SOP.
16	Review and audit departmental partial mammography rates in line with national guidance.	Breast Screening: Guidance for Breast Screening mammographers (2020)	6 months	Standard	Review and audit completed.
Referral
17	Review suitability of reading room for reading without disturbance, and plan for updating facility.	Breast screening quality assurance standards in radiology (updated Dec 2018)	6 months	High	Report on suitability of film reading room, and plan for change as required.
Diagnosis
18	Review assessment clinic capacity against anticipated activity over next 5 years to ensure sufficient capacity is available for all women to have all tests at first visit.	Breast screening clinical guidelines for screening assessment (2016)	6 months	High	Copy of review paper on anticipated activity and how assessment capacity will be delivered, such that all women have biopsies at first visit.
19	Carry out an audit of biopsy times and results and produce a plan if required to meet targets.	Breast screening clinical guidelines for screening assessment (2016)	3 months	High	Audit to include: · whether biopsy is performed at 1st or subsequent visit. · date of biopsy, · date of MDM and · date of results given to women. If target timeframes are not met, produce and share a plan to meet targets.
20	Review documentation of assessment including: PACS annotation; sharing information with assessment team; issuing results to women; and suitability of information available to treating team and introduce improvements as required.	Breast screening clinical guidelines for screening assessment (2016)	3 months	High	Confirmation of action completed.
21	Ensure women get their results within 7 days of their biopsy to meet both the screening guidance for assessment and the 28-day FDS standard. This should include review of alternative options for scheduling of patients with benign results and the option of repatriation of cancer results appointments to external Trusts.	Breast screening clinical guidelines for screening assessment (2016)	3 months	High	Completed action plan and evidence of achievement.
22	Review the pathway from specimen receipt to reporting and then MDT and identify and address any problems that may hinder achieving target TAT.	Breast screening: quality assurance guidelines for breast pathology services 2.8 Laboratory quality assurance (TAT: 90% of non-operative specimens should be available within 5 working days and 90% of surgical specimen diagnostic reports should be available within 10 working days)	3 months	High	Confirmation from the lead pathologist.
23	Increase use of additional site biopsies at first assessment visit for radiologically malignant multifocal lesions.	NHSBSP Clinical guidelines for breast screening assessment 2016	6 months	High	Confirm implementation and audit use of additional biopsies at first assessment.
24	Audit of B3 cases to address high outlier status for the team.	National breast screening pathology audit and Royal College of Pathologists AND Guidelines for Nonoperative diagnostic procedures and reporting of breast cancer screening	12 months	Standard	Audit report.
25	Review LIMS system handling of addendum reports and audit that they all appear to the clinical team.	Service specification No. 24 NHS Breast Screening Programme	3 months	High	Audit report.
26	At least annual attendance at regional QA meeting, for Royal Marsden pathologists.	Pathologists Guidelines for Nonoperative diagnostic procedures and reporting of breast cancer screening 3.3 Regional pathology meetings	12 months	Standard	Monitoring and confirmation of attendance.
27	Pathology screening service audit at NWLP and Royal Marsden to address low outlier status in small invasive cancers (10-15mm and 15-20mm).	National breast screening pathology audit and Royal College of Pathologists AND Guidelines for Nonoperative diagnostic procedures and reporting of breast cancer screening	6 months	Standard	Copy of the audit.
Intervention and outcome
28	The CNS acting as lead for the breast screening service must obtain a specialist qualification in breast care nursing at degree level in the next 12 months.	Nursing guidance Section 2.5	12 months	High	Certificate of qualification.
29	A minimum of 2 experienced members of the breast care nursing team should complete the duty of candour/interval cancer training via eLearning4Health in the next 12 months.	Nursing guidance Appendix 3	12 months	High	Certificate of completion.
30	Carry out audits of a client satisfaction survey of the CNS involvement in assessment and receiving benign results by phone.	Nursing guidance Section 2.5	12 months	Standard	Audit reports.
31	Introduce a second (catch-up) screening MDM to resolve pathway delays due to results not being ready.	NHSBSP Clinical guidance for breast screening assessment 2016	3 months	High	Establishment of second catch up MDM confirmed.
32	Review consultant surgeon workforce at CXH and consider alternative workforce for one stop delivery, freeing up surgical sessions for complex work.	NHSBSP Clinical guidelines for breast screening assessment 2016	6 months	High	Summary of review.
33	Annotate images prior to referral to assist in lesion identification for external treating trusts and ensure that when multiple biopsies are performed lesions are clipped, clip placement is documented, and marker views supplied.	NHSBSP Clinical guidelines for breast screening assessment 2016	3 months	High	Confirmation that action has been implemented.
34	Lead surgeon to liaise with each treatment unit to audit outcome of sentinel node biopsy for all B5a conservation cases then consider if review of local protocol is indicated.	Best Practise Guidelines for Surgeons in Breast Cancer Screening (section 6.1)	12 months	Standard	Audit summary as described. Minutes of protocol meeting discussion (if indicated).
35	All treating surgeons to copy clinical letters (including post-op letters containing adjuvant treatment information) to the Hub for upload to NBSS.	Best Practise Guidelines for Surgeons in Breast Cancer Screening (section 6.1e)	3 months	High	Copy of communication from lead surgeon (or DoS if appointment delayed) to all treating surgeons. Audit of surgical letters imported to NBSS including for external treating trusts.

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

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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