Scottish Breast Screening Programme: major review

Executive Summary & List of Recommendations

Overview

Our Breast screening service is in need of reform. We need to improve uptake overall but especially for those women living in our most deprived communities. These are the communities who for many years have had a lower uptake of health services overall and this has been heightened in the context of the recent Covid pandemic. This review was commissioned to allow a comprehensive assessment of the delivery of the Scottish Breast Screening Programme. In addition to addressing the inequalities in uptake the review was asked to take account of current pressures in the breast screening programme, recent incidents affecting the programme, and previous reviews undertaken, and to make recommendations on future service delivery.

Breast screening policy in NHS Scotland (and across the UK) is that all women aged 50-70 years +364 days are invited for breast screening once every three years. Women over the age of 71 can self-refer. Breast screening in Scotland is delivered via six Breast Screening Centres across the country, complimented by the provision of a fleet of 20 mobile breast screening units. The service offers 2-view digital mammographic screening to approximately 750,000 women across Scotland in each three-year screening round. Seven women in every 1,000 women screened are found to have invasive cancer.

The service performs relatively well against clinical service standards, however over the past decade there has been a steady decline in overall uptake of breast screening which, if continued, would threaten the effectiveness of the screening programme. Average performance on overall uptake over the last 10-years is 72%, just above the minimum standard established. We know that once women do participate in breast screening they are more likely to continue in future years; and we know that women from our more deprived areas are less likely to attend for breast screening, currently with under six in ten women (59.5%) from the most deprived communities attending for screening compared with almost eight in ten women (79.7%) living in our least deprived areas, a difference of over twenty percentage points. In this review we geographically mapped uptake across Scotland and whilst we can see that most areas meet or exceed the minimum uptake standard expected (70%), and small areas of under-target performance can be identified across Scotland, the central belt of Scotland has by far the greatest concentration of areas of lower levels of uptake.

Improving access to breast screening is particularly challenging, with screening delivered on a locality basis across Scotland to minimise travel and distance for all, as these are potential barriers to attendance. There is also a clear need to continually focus on improving participation by women in our most deprived communities. The review explored barriers to breast screening uptake with women who do not normally participate in breast screening, and makes recommendations to support improving the uptake of breast screening. Review recommendations also include developments that focus on modernisation of the delivery of the programme across Scotland to support better access.

Key recommendations

The Scottish Breast Screening Programme currently invites women for screening based on the GP practice with which they are registered, and we recommend that a new approach to breast screening call-recall be taken forward which is more person-centred and is based on calling individual woman (rather than the GP Practice they belong to) based on their Next Test Due Date.

There remains a consensus view across the Scottish Breast Screening Programme that in the longer-term screening centres and symptomatic breast services should be further co-located, and there is good progress being made in this regard. Feedback we received from women who don't routinely attend for breast screening included a number of 'environmental factors' relating to the design, location and delivery of breast screening. The review also noted that a significant number of appointments are lost to late cancellation and non-attendance in the current model (a 24% level of non-attendance overall). This has highlighted the need to both improve mobile screening provision where geography and population size require a mobile programme, and to take the opportunity of improving the screening venue in urban and semi-urban areas which have the population base to sustain more static screening provision. The inequalities gap in the level of uptake between our most and least deprived communities, referred to above, is a Scotland-wide issue. The Breast Screening Programme should therefore continue to target action to tackle these inequalities in access, recognising that initiatives may vary across population groups and rural, urban, and semi-urban territories according to need. Given the volume, and concentration of areas of lower levels of uptake, the review recommends in particular the development of a strategy for static satellite screening centre provision in the central belt of Scotland.

Currently, approximately 3000 women per year are being invited to attend for breast screening while they are receiving treatment for breast cancer, or when they are in mammographic follow-up following a diagnosis of breast cancer. Whilst this does ensure that no women are inappropriately excluded from the programme, it can cause confusion and unnecessary distress. This review recommends that IT and PACS systems are developed to safely facilitate the temporary removal from calling to breast screening for women on follow up surveillance programmes. We also noted that by removing these cases from uptake calculations there would be an improvement in uptake overall (ranging from 0.6% to 0.8% improvement in uptake at breast screening centre level in our calculations).

The review overviewed the current Scottish breast screening workforce to help capture key workforce issues and risks. We recommend the development of an overarching workforce plan for the Scottish Breast Screening Service, focussing in particular on role development and role redesign, training capacity, leadership for major developments which will help to automate aspects of activity, and benchmarked staffing levels.

Technology is a key enabler for modernising and improving the breast screening pathway. Scotland's Digital Strategy for Screening is already taking forward a number of key initiatives to support modernisation and development of the breast screening service, and these are vital to support choice and improved access for women. Artificial Intelligence (AI) in breast screening mammography is a key part of the digital strategy, and the review has supported the development of this programme by developing the outline strategic case for AI with the support of colleagues from across the service and from within the Industrial Centre for Artificial Intelligence Research in Digital Diagnostics iCAIRD. We recommend that the Scottish Breast Screening Programme should progress to prospective evaluation and proof of concept for AI in breast screening, with a view to future adoption in the service subject to positive evaluation and formal approval from the UK National Screening Committee for AI to be used in breast screening.

To help support capacity in screening assessment, the SBSP should consider enabling Digital Breast Tomosynthesis in screening centres across NHS Scotland. The review also recommends that a single, co-ordinated capital replacement programme for screening mammographic x-ray units be developed.

The review heard from many users of the Scottish Breast Screening (IT) System (SBSS) a frustration over the lack of data available to support operational, performance and strategic planning at Breast Screening Centre level. Obtaining and using data was also a significant constraint for the review. New developments such as the new National Screening Digital Service Management Board (NSDSM Board), and the planned Screening Intelligence Platform (SIP) should help to improve this in future. As part of recommendations to improve data, intelligence, and analytical capability the review recommends that funding allocated for SBSS development in the 'Committed Development Resource' should be reviewed with a view to increasing resource to better support users and the service overall.

Breast Screening Standards are key to improving the quality of the SBSP. The review recommends the further progression of work to develop a Quality Management System approach to the development and application of standards, and a streamlining of national and local level reporting where possible.

All recommendations are more fully outlined in the review report, and we are particularly grateful for the support and engagement of the service in this review, which has been responding to Covid-19 throughout and necessarily focussing on adaptation and recovery. We hope that this review will lead to a redesign of service and improve uptake amongst all women living in Scotland.

Heather Knox
Independent Review Group Chair

List of Recommendations

Overarching Theme / Strategic Recommendation

Access: Breast Screening Call / Recall

1. Develop a new approach to call-recall

The Review Group recommends that a new approach to breast screening call-recall be taken forward which is more person-centred and is based on calling individual woman (rather than the GP Practice they belong to) based on their Next Test Due Date. Development of the Scottish Breast Screening System algorithm should also incorporate age, Area of Residence, and screening location to enable identification of women becoming newly eligible for breast screening, and local geographical cohorting of invites.

2. Developments to Scottish Breast Screening System

NSD and DaS should take forward the further specification work necessary to support development of the Scottish Breast Screening System. The Breast Screening Programme Board should advise and support this development, recognising that a person centred focus; incorporation of the new CHI functionality; and the potential to further automate planning, forecasting and allocation are key drivers for change and development.

Access: Central belt screening satellites

3. Static satellite screening centre provision

The Review Group recommends that further work is progressed to develop a Scottish Breast Screening Service strategy for central belt satellite static screening centre provision, including their locations. This should develop an agreed approach, common planning assumptions for the SBSP, service configurations, and further scope and identify potential central belt satellite facilities in liaison with NHS Boards.

Access: Self-Referrals in over 70s

4. Over-70 self-referrals

The Review Group recommends that the Breast Screening Programme continues to support self-referral in the over 70's until the AgeX trial reports in 2026.

The Review Group acknowledged however that the Breast Screening Programme is under significant pressure following the Covid pause, and that full capacity has not yet returned. Whilst Covid pressure continues, the Review Group recommended that available screening capacity should be used for the 50-70-year age group, rather than for a group in whom there is currently no conclusive evidence of mortality benefits.

Access: Women currently on treatment or in breast cancer follow-up

5. Managing invitations for women currently on treatment or follow-up for breast cancer

The Review Group recommends that the Breast Screening Programme develops the use of exclusion codes in SBSS to facilitate the temporary removal from calling to breast screening for women on follow up surveillance programmes. The text of the screening invitation letter should also be improved to better explain why the Breast Screening Programme continues to invite women who may have had recent mammograms, are in treatment or follow-up for breast cancer, or have previously had both breasts removed. Record linkage to support cross-referencing of databases should be scoped. The Breast Screening PACS reprovisioning should be used as an opportunity to provide a mechanism for coding follow-up mammograms so that they can be identified. Scoping should be undertaken around the potential to move to more standardised national follow-up guidance across Scotland

Access: Family History Screening

6. Consideration of bringing Family History/High Risk screening within the remit of the national screening programme.

Overall, the review group noted that there were more potential opportunities present now within breast screening than at the time of reporting the previous review of Family History (2009) – in particular a single, standardised IT system (SBSS), and some initial evidence from experience that clinical examination may be removed from the family history pathway acceptably. The review group acknowledged that a larger piece of work would be needed to fully assess the potential advantages, feasibility, benefit, and costs of integrating with screening, or whether key improvements could be made in the family history pathway independently. The group recommended that any further work should be referred for national cancer policy consideration, potentially in the context of supporting greater service integration and co-location.

Uptake: Reduce barriers to Breast Screening

7. Improve the understanding and perceived value of breast screening

Media campaigns will help to communicate both the value of screening and to provide cultural contextualisation by clarifying the prevalence of breast cancer in Scotland and the populations at risk. There are advantages to employing a variety of channels to help convey the importance of breast screening (e.g. television advertising) and its relevance to this audience (through trusted sources using social media channels for example). The value of screening can be emphasised through GP reinforcement, and normalisation within these communities will be helped by encouraging informal conversations (between both peers and health professionals), for example on social media.

8. Increase the convenience of appointments

Greater flexibility of appointment scheduling and availability would enable better access and uptake. Consideration should be given to a range of service elements: reminder texts or telephone calls which can help to retain screening appointments on the radar, an online appointment cancellation and rebooking system to provide a greater sense of individual control and convenience, and evening and weekend appointments for those who find it hard to adjust weekday commitments or rely on support from others. Increased appointment availability in rural and semi-urban locations would provide some flexibility for women in these areas.

9. Improve the acceptability of breast screening

There is a need for better engagement with women to demystify the screening process and provide reassurance. This could take the form of informal social support via social media channels, enabling telephone or online support e.g. live chat, peer conversations, and the sharing of positive stories from women who have been screened. Facilitating easy access to concise, straightforward information and honest description e.g. videos of the process would also be helpful. Engagement and empathy during the appointment is vital in encouraging repeat screening. Mammographer sensitivity and consideration is key, and longer appointment times or (peer) support in the waiting area would enable questions to be asked and reassurance provided. The use of gowns that do not need to be fully removed while the mammogram is being taken would also help in addressing the modesty concerns.

10. Increase the user-friendliness of screening venues

This should be considered at both a practical and an emotional level. Co-location of breast screening services with existing GP or well woman services would facilitate attendance by providing a local, familiar and professional environment, together with more discreet access to the service. At a psychological level, these venues were perceived to be friendlier, with the expectation of a more personalised experience and the opportunity to be accompanied. Larger mobile units with 'warmer' waiting areas can also help to provide a more reassuring environment. Better communication of the adjustments that can be made for women with disabilities is key, ideally though personalised invitations.

Workforce: Workforce planning

11. Development of an overarching workplan for the Scottish Breast Screening Service.

Host NHS Boards should further develop their workforce plans, incorporating areas highlighted in the review. NSD should support development and incorporation into a single, Scottish Breast Screening Programme-wide, workforce plan for the commissioned service. The Breast Screening Programme Board should provide support, overview and endorsement of the plan.

Workforce planning and commissioning of Breast Screening Centres by NSD should have regard to projected population changes by Breast Screening centre, as reported.

Technology & Equipment : Digital Strategy

12. Scotland's Digital Strategy for Screening

The Review Group recommends that a number of key initiatives are taken forward to support modernisation and development of the breast screening service, as part of the Digital Strategy for Screening and a digital roadmap is developed to capture all future developments.

Technology & Equipment : Artificial Intelligence in breast screening mammography

13. Evaluation and Proof of Concept of Artificial Intelligence in breast screening mammography.

The Review Group recommends that the Scottish Breast Screening Programme should progress to prospective evaluation and proof of concept for Artificial Intelligence in breast screening mammography, with a view to future adoption in the service subject to positive evaluation and formal UK NSC approval that AI can be used in the screening programme.

The Review Group approved the outline strategic case for Artificial Intelligence in breast screening mammography, and supported the further business case development process, to be led by DaS, with advice and support from the Breast Screening Programme Board.

Technology & Equipment : Digital Breast Tomosynthesis

13. Use of digital breast tomosynthesis (DBT) in the assessment setting

The Scottish Breast Screening Programme (SBSP) should consider enabling DBT for use in the assessment setting in screening centres across NHS Scotland. A business case should be developed by NSD, in collaboration with host NHS Boards, to realise the benefits and efficiencies identified. Consideration should be given to linking the enabling of DBT with x-ray unit replacement as part of a national managed equipment replacement programme, should this be agreed, and the route is more cost effective.

Technology & Equipment: Mammography equipment replacement

14. Development of a single, co-ordinated capital replacement programme for mammographic x-ray units

The review group recommends that a single, co-ordinated capital replacement programme for mammographic x-ray units in the Scottish Breast Screening Service should be developed, to support the prioritisation of capital with host NHS Boards and inform National Infrastructure planning.

Standards: Standards reporting and development

15. Streamlining of reporting

The Review Group recommends that for national and local level reporting, reporting against breast screening standards and performance be streamlined by NSD in liaison with NHS Boards, where possible, taking into the account differences in the level of detail required for different stakeholders. Defining this should be supported by the Monitoring and Evaluation Group.

16. Development of a Quality Management System

The Review Group recommends that initial work with NHS Healthcare Improvement Scotland to develop a Quality Management System approach to the development and application of standards should be progressed. This should be taken forward through the development of a national screening Quality Management Framework being led by the National Screening Oversight Team. This work also links to wider related work on screening metrics being taken forward for the National Screening Oversight Board.

Data: Improving data, intelligence and analytical capacity

17. Improve data availability, and data reporting across the Scottish Breast Screening Programme.

Funding allocated for SBSS development in the 'Committed Development Resource' should be reviewed by DaS and NHS Boards with input from NSD, with a view to increasing resource to support user development requests prioritised, and SBSS data reporting functionality, including the provision of patient level data extracts routinely to Public Health Scotland.

The review noted that the forthcoming development of the Screening Intelligence Platform (SIP), intended to provide a single point of access to linkable data from all of the National Screening Programmes, may assist in improving analysis and automated dashboard reporting.

Geographical Information System analytical capabilities for the Breast Screening Programme should be developed further by PHS to support tackling inequalities, to assist Breast Screening Centres in planning screening schedules, and for strategic planning of screening delivery locations.

Given the concentration of areas with poorer levels of uptake in the Central Belt of Scotland, associated with inequalities, a specific focus and central belt strategy targeting uptake maximisation, and improving the targeted location of screening delivery should be developed.