Scottish Breast Screening Programme: major review

Breast Screening Workforce

Current workforce and sustainability

An overview of the current SBSP workforce taken from the Service Level Agreements in place (19/20) for the six breast screening centres in Scotland shows a total of 256.44 w.t.e. clinical, administration, and support staff across the programme. This includes staffing for training and education roles (as these are delivered via the West and South East Screening Centres). NSD staffing in support of the SBSP; Medical Physics (Health Facilities Scotland); and Fleet Management (Health Facilities Scotland) are excluded, and separate agreements are in place to cover these functions and specify resource.

The review undertook a survey of current staffing across the breast screening programme in the last quarter of 2020. This was requested to better understand the current picture of staffing by professional group / job type, and to help capture key workforce issues in each staff group. The summary overview from this survey is shown at Appendix 8. The survey showed a total current staffing of 250.81 wte (a small difference of -6 posts overall across the whole screening programme against the SLA wte gross total. Totals from all centres varied slightly from their SLA totals, and this is likely to be a result of reconciling information from local host Board budget establishments against SLA categories, and capturing the exact split of resources across screening and symptomatic services).

As one would expect, radiographic staff are the largest group at circa 147.72 wte (131.88 wte Radiographers: all grades / posts including CD time, and Consultant Radiologists at 15.84 wte, incl. CD time), followed by Administration at 58.74 wte, and Transport officers at 18.64 wte.

A similar survey for the 2012/13 review showed 249.36 SBSP staff net of central (Health Facilities Scotland) staff. Over the period 2012-13 to 2018/19 there has been a 10% increase in the number of women invited for screening. The service has digitised over this period, and an increase in the number of Advanced Practitioners, Consultant Mammographers, mammographers (including trainees), and Assistant Practitioners can be seen.

There is no common, recognised staffing establishment for a breast screening centre. General (PHE) guidance on composing and leading breast screening services are available, as well as a service specification covering service and quality indicators, and guidance for mammography^[13],^[14],^[15]. Few benchmarks are available or utilised (other than mammography, referenced below). As a result, the SLA with each host Health Board in Scotland is based on funding by service function and allows each centre to develop and vary their staffing compliment per local requirements. Staffing levels and issues are discussed at each mid-year and annual review with each screening centre. Vacancies and job evaluation are dealt with at host NHS Board level in line with local and national policies. This overall approach is in line with NHSBSP guidance which states that local staffing levels should take account of factors such as service configuration and local skill mix.

Across Scottish Breast Screening Centres some differences in skill-mix in radiography can be seen with variable proportions of advanced and assistant roles in the team. Within this, there are relatively few Consultant Radiographer posts including in the large centres in Glasgow and Edinburgh (note: The Clinical Director for the South East Service is a Consultant Radiographer, wte captured in the survey against CD rather than Cons. Radiographer).

Resource allocated to support the Clinical Director role is variable however feedback within the review has suggested that SPA time and personal time is also used to cover necessary duties. Leadership, including supporting major developments and change that may arise from service review, require time to work within the wide networks involved. A Clinical Directors' group exists to aid co-ordination and communication, and nominated CDs represent the programme on various governance groups, however there is no Clinical Director lead for the SBSP overall.

Few health promotion posts are funded and commissioned through the direct service, with a reliance on Public Health NHS Board Screening Co-ordinators (with variable resource / job plan time for Breast Screening) and NHS Board Health Promotion departments to support this. Discussion within the review has suggested that where Health Promotion resource exists within centres this greatly assists in targeted efforts to support improvement in engagement and uptake. Breast Screening Centre CDs commonly called for an improvement in Health Promotion in their presentations to the Independent Review Group.

Some centres have described redesign (reduction) of the Administration Team as a result of changed working practices recognised following the introduction of SBSS. Where teams work across screening and symptomatic services this change may not be as straightforward. The relatively large 'other admin' group in the West of Scotland Centre includes Scottish Mammography Education College and training related staff. Should SBSS be developed further (for example to support planning, forecasting of the screening schedule, and allocation of appointments), with a potential shift to dynamic cohort management based on a changed call-recall model, the administration resource may require further redesign.

Key workforce risks, and Initiatives taken forward

A descriptive overview of key workforce issues for each Breast Screening Centre is outlined at Appendix 8. Key risks and issues include:

• Clinical Director succession planning – 4 centres currently have either a vacant CD post; known imminent retirement of the CD in post, a CD of retirement age (no planned retirement date as yet), or CD retired and returned and planning to fully retire within 2 years. All also cover senior clinical duties across Radiology, Consultant Radiography, and Breast Clinician roles.
• Vulnerability due to radiology understaffing in both breast symptomatic and screening units (with East of Scotland facing particular issues with long-term absence and further planned retirement)
• Loss of experienced radiographers, including Advanced Practitioners, and the necessity (given recruitment constraints) to replace these with radiographers requiring mammography training, leading to reduced capacity in the service during the training period
• Being at, or close to, the number of Assistant Practitioner roles that can be incorporated into the multidisciplinary team within the current supervision model of service
• Constraints on backfilling posts following the progression / development of Advance Practice posts, due to insufficient training capacity / supervision locally and / or constraints within the SMEC pathway including recent covid related training constraints
• The need for succession planning for the training resource (SMEC trainers) with 3 of 7 trainers at retirement age in the next 5 years
• Limitations in Consultant Pathologist numbers reporting to breast activity
• Very little contingency due to relatively small numbers of screening staff in some centres, and balancing the competing pressures involved in prioritising resource working across symptomatic and screening services where staff/equipment are shared, with an occasional reported pressure to prioritise symptomatic demand.
• Significant over-reliance on locum staff, including a large proportion of image reading undertaken by locums and/or previous 'high-volume readers' who have now left the service (see below).

A number of approaches have supported the service over recent years including:

• Maximising skill mix in Advanced Practice including advanced practice in imaging reading and stereotactic biopsy, supporting both screening and assessment service capacity
• Development and appointment of Consultant Radiographers, further supporting capacity across screening and assessment, clinical leadership, training and research.
• Working across screening and symptomatic services, regardless of the degree of formal service integration in a single managed unit, to allow a wider pool for capacity planning
• Maximising Assistant Practitioners replacing radiographer staff where possible within current guidelines
• Flexible and imaginative recruitment to the Breast Clinician role, drawing from a number of medical disciplines. And enhancing this approach with the further utilisation of Clinical Nurse Specialists.
• Developing the role of Clinical Nurse Specialist in the assessment service and building links to CNS provision in acute services.

Mammography – benchmarking, role development and opportunities

Professional standards for radiographers are specified by the Society and College of Radiographers (SCoR).

Breast Screening was one of the instigators of the four tier structure for role development in radiography. The service uses a 4-tier model of skill-mix originally developed in 2002. The 4 tier model includes:

• Assistant Practitioners – these staff complete routine screening images, with supervision
• Mammographers - complete routine screening views, including work in assessment clinics.
• Advanced Practitioners – have undertaken additional training to undertake additional activities such as film reading, biopsy, or use of ultrasound.
• Consultant Radiographer – with advanced training, skilled in additional activities such as teaching and research.

In its 2019 annual UK-wide diagnostic radiography workforce census, the Society and College of Radiographers reported a vacancy rate in Scotland of 6.3%, this is lower than the UK average of 9.6%, however was a rise from the Scottish figure of 5.7% in 2018^[16]. Vacancies were greatest at band 5 and 6. The survey also noted that 3.7% of respondents' (UK wide) diagnostic radiography workers are due to retire in the next two years, with the largest segment in the most senior roles at band 8b and 8c.

Staffing levels

NHS Breast Screening Programme Guidance for breast screening mammographers provides some guidance on staffing levels for mammography. Guidance on staffing levels quoted per 10,000 eligible population relate to direct delivery of a screening service and are intended for activity in mammography screening and assessment clinics only. They guide the level of wte staffing directly required to deliver mammography screening activity. This does not for example include elements of Advanced Practice activities where mammography is not undertaken, activities such as image reading, biopsy, ultrasound, training roles, or any managerial responsibilities, these are additional.

NHS Breast Screening Programme guidance on mammography staffing levels is based on uptake level and population, as below.

Mammography staffing level guidelines

Uptake Rate % w.t.e. per 10,000 eligible population

65-75 1.3

76-85 1.5

86-90 1.6

A survey of mammography staffing levels, using this guidance, was undertaken with the six Breast Screening Centres in Scotland as part of the review during mid 2020. The results are outlined in Appendix 8. In summary the results indicate an overall deficit of 5.9 wte posts overall. Three centres show a mammography staffing deficit: East of Scotland, South East, and West of Scotland, with other centres balanced or showing a small additional level.

The estimates derived from this survey are a snapshot in time, and rely on centres own determination, in a standardised way, of the proportion of wte mammography staffing available for screening mammography activity. Eligible population forecasts undertaken within the review show a relatively static picture of demand over the next decade and beyond, with only the South East centre eligible population rising. Subject to further discussion with centres to agree the treatment of skill mix in the team (advanced and assistant practitioners) survey results should be used to guide staffing levels agreed required and funded in Service Level Agreement with centres.

Role Development, and Opportunities for further improvement

As part of the survey centres were asked to identify further role development, improvement opportunities, and training requirements in mammography.

Role developments suggested included:

• Training and appointing more Consultant Radiographers to support the shortfall in radiology
• Developing the role and scope of Assistant Practitioners in line with Society of Radiography guidance around scope of practice, supervision, and governance requirements
• Further sharing of roles and development opportunities jointly with breast symptomatic services

Improvement opportunities suggested included:

• Potentially (and keeping within emerging policy and guidance) working towards 2 Assistant Practitioners working independently on mobile units
• Working in partnership with symptomatic services / merging to create a centre of excellence
• Moving to more online working with SBSS data and PACS image transfer capabilities realised nationally.

Training requirements were noted as:

• Further Assistant Practitioner Certificate in Mammography training, and further mammography training for new recruits
• Advance Practitioner training including consultant level training
• National training days / staff development days as a means to encourage all centres to learn together, help standardise working practices, and promote staff development and training
• Future proofing of the SMEC training team to prevent a drop in service level nationally
• Expanding the potential of the SMEC training team – with potential to be expanded, and generate more revenue (currently fee paying students may have to be declined to accommodate (non-paying) breast screening students.

Image reading capacity (reader survey)

As reported in the Strategic Case for Artificial Intelligence in Mammography developed by the review, to help consider the image reading workforce capacity the review conducted a survey of image reading undertaken in 2018/19 and 2019/20. The results showed that a significant proportion of the reader workload was covered either by staff who have now retired from the service, locum staff, or staff who have returned from retirement. In one center two-thirds of the reads in the 2-year period surveyed were delivered by staff now retired or left the service. In 2 centers, approximately a third of reads were delivered by staff now retired or locums. In 3 centers, approximately a fifth of reads were delivered by staff now retired or locums. This highlights the not only the ongoing risk associated with historical reliance on relatively few 'high volume readers', reliance on locum cover, and the impact on delivering screening results from the service within 2 weeks of an adequate screen, but the need for advanced radiographers in image reading, cross-border image reading developments, and subject to proof-of-concept and UK NSC policy endorsement an AI solution to add significant capacity into image reading.

Developing workforce capacity

Developing a more sustainable service –

The review of Breast Screening undertaken in 2012 considered the sustainability of staffing, future workforce requirements for breast screening, and synergies with symptomatic breast services as evidence suggested that a significant number of staff were approaching retirement age. The review noted that:

• Following recruitment policy change for trained radiographic staff, new graduates could be employed within the programme for the first time (previously, a minimum of two years' experience was required)
• First-stage screening mammography could now be undertaken by assistant practitioners, supervised by a radiographer
• That these initiatives have eased (the then current) recruitment issues, provided greater flexibility for the future, and supported more experienced staff in extending their roles to take on additional duties, easing pressure on radiological staffing.
• That the above alleviated the immediate threat to the programme in the majority of areas.
• However, no workforce plan existed for all of the centres combined, that retirals of more experienced staff may still prove an issue, and whilst the changes in recruitment policy provide some flexibility to help manage risk - a sustainable workforce plan must remain an objective for SBSP.
• Closer working with symptomatic services would provide better resilience throughout breast services potentially leading to a more sustainable service with a more flexible, expanded and stable workforce pool.

As previously noted, newly qualified staff are now commonly recruited (however with a training period impact in the service), Assistant Practitioners often appointed to replace radiographer staff where possible, and much Advanced Practice skill mix has been developed in the multidisciplinary team, including the development of a number of Consultant Radiographers. Alongside this, the service has developed the Breast Clinician role and Clinical Nurse Specialist role to further support the assessment service. A significant number of joint posts are in place with symptomatic services, alongside integrated capacity planning to support sustainability.

Going forward there should be a focus on:

• Further development and recruitment to Consultant Radiographer roles to support the assessment service capacity and clinical leadership
• Maximising new opportunities that may be available in extending the scope of the Assistant Practitioner role (the SCoR has approved arrangements for assistant practitioners working on mobile facilities with remote supervision, and PHE has now published implementation guidance^[17])
• Developing the training resource and curriculum to ensure adequate capacity to support training and development needs at all levels of radiography
• Leading on innovation in Artificial Intelligence in mammography to take the opportunity it offers to reduce (by half) the screening image reading demand on human readers
• Reassessing core mammography staffing levels available to screening and assessment clinics
• Building on work undertaken in the Scottish Government Access Collaborative programme on advanced practice role development in symptomatic services, by adapting the Advanced Practice framework developed for symptomatic roles to apply to Breast Screening

Development of an overarching Scottish Breast Screening Programme workforce plan:

It is still the case that no overarching workforce plan is in place for the Scottish Breast Screening Service. Elements of this, alongside breast symptomatic services, should be in place in the workforce plans of the six NHS Boards which host breast screening services in Scotland. It is recommended that NHS Boards further develop these, and that NSD and the Breast Screening Programme Board supports overview, and integration of these into a single programme wide plan. To assist, it would be beneficial if comprehensive data on staffing levels were kept up to date and available, to support forward workforce planning.

Developing training capacity – Scottish Mammography Education Centre (SMEC)

The Scottish Mammography Education Centre (SMEC) is commissioned by NSD to provide mammography training primarily for the Scottish Breast Screening Programme.

Activity agreed per year is:-

• 2 post-graduate mammography courses
• 1 HE Certificate course
• 1 Image Interpretation module
• 1 Breast Biopsy course

Additionally, update training when required by centres is provided to approximately 25 staff members per year. As part of these arrangements at least one national mammography study day should be held.

Training needs associated with the further development of role extension in the SBSP:

Advanced Practice

Advanced practice roles in mammographic image interpretation, x-ray guided interventional procedures & clinical training are well established within breast screening and the training courses provided by SMEC in these areas remain popular.

The breast consultant radiographer (CR) role is less well established in Scotland. This role would generally work in collaboration between the breast screening and symptomatic services. It is a current focus of discussion within the Scottish Access Collaborative and the Scottish Radiology Transformation Programme, primarily with reference to the breast symptomatic service.

The SCoR (2017) document: "Consultant Radiographer – Guidance for the Support of New and Established Roles" states that it is expected that a CR in Breast Imaging will have completed a relevant MSc to include postgraduate modules representing skills in Image Interpretation and Reporting, Ultrasound of the Breast, Clinical Examination and Client Communication, and Interventional Breast Procedures^[18].

Training Developments Required:

• To accommodate the requirements for a CR in breast imaging SMEC should add breast ultrasound training to their portfolio of courses. Initial exploratory work has been started on this with Queen Margaret University. The current MSc Mammography is due to be revalidated by September 2021. As part of the revalidation process work should take place to explore the credits allocated to the courses delivered and production of a clear pathway structure related to advanced practice and breast consultant roles.

• Breast Clinical Examination & Client Communication are also mentioned in the SCoR requirements. Communication is covered within current SMEC courses, however the inclusion of named modules should be considered in future planning of the MSc Mammography Programme.

Developing training capacity

Currently, in addition to SBSP trainees, SMEC attracts students from throughout the UK & Ireland. These fee paying students generate significant income for SMEC. The Post Graduate Certificate in Mammography course is particularly popular, this runs twice yearly and has waiting lists. There are two constraints on increasing numbers on courses:-

1. Physical teaching space for academic input. This has been circumvented to a certain extent recently by the use of online teaching. Longer term consideration should be given to the premises available to SMEC. Income generation may be increased with capacity to accommodate more students.

2. Number of clinical trainers funded for clinical training duties.

Clinical trainers working with SMEC also work as members of staff in their departments. An increase in training duties affects capacity to be part of the workforce that is taken into consideration for workload planning. In addition, three of the seven trainers will be reaching retirement age in the next 5 years. Succession planning is required.

Strategic recommendation – workforce planning

The Review Group recommends the development of an overarching workforce plan for the Scottish Breast Screening Service. Host NHS Boards should further develop their 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.