Breast screening modernisation programme: final report

Programme Priorities, Projects and Performance

Priorities for the Modernisation Programme

Clear themes emerged from these exercises, and potential projects were grouped within these. Four key themes identified by the Board were:

• Access – projects to remove barriers for participants, widen choice and make it easier to book and attend appointments.
• Data – projects to streamline and standardise reports and improve access to data for quality and process improvement.
• Equipment – projects to standardise procurement and make best use of capacity.
• Workforce – work to understand the current workforce state and challenges, improve retention and provide greater flexibility.

In October 2023, while reviewing progress within the programme, the Board came to the clear realisation that to ensure success across the four core themes, an additional layer of management across the service nationally was needed. A fifth and final core piece of work was therefore initiated, lasting for the remaining duration of the programme:

• Management model – work to scope a new national management model for the Scottish Breast Screening Service.

The Programme also considered the delivery of a small set of projects which did not fall directly under any of the core themes but still contributed to the Programme vision and outcomes. Over the course of the programme, elements of these ideas have been incorporated into the core projects rather than delivered independently by the programme. These included:

• Call/Recall improvements – considered by the Call/Recall workstream
• National approach to special requirements – included within Data workstream
• 50-53 information and handling (additional letters to participants to make them aware of their first appointment which will take place between age 50 and 53)
• SNRRS / Cross boundary working – Workforce and Management Model workstreams

Additionally, some projects were considered more suitable for development outwith the programme by host boards, or requiring a separate programme of their own owing to their size and complexity. These included:

• Static Sites in the central belt (host boards)
• Co-location of screening and symptomatic services (host boards)
• High risk/targeted screening (own programme).

It was clear that the number of potential projects identified outstripped the resource available to deliver and support change, both within the Modernisation Programme and across the wider Breast Screening Service. The Modernisation Board therefore undertook a prioritisation exercise, from which a high-level programme plan was developed, and the highest priority projects were started. This plan was reviewed in 2023, with the management model being reprioritised alongside the ongoing core projects.

A breakdown of the planned activities and workstreams within the Breast Screening Modernisation Programme is provided below.

Graphic text below:

Breast Screening Modernisation Programme – Activities and workstreams

There are 4 core programme activities that aim to deliver the vision and outcomes:

1. Access

A. Improving access for underserved groups by removing barriers

B. Improving availability of appointments by providing more choice (time, locations etc.)

C. Improving facilities for making and managing appointments, making it easier to book and attend

2. Data

D. Streamlined and standardised reports by using a standard data set and standard reporting

E. Improved access and data links through providing easier access to data for quality/process improvement

3. Equipment

F. Optimising procurement of breast screening equipment by standardising procurement

G. Optimising use of breast screening equipment through making best use of equipment to maximise capacity

4. Workforce

H. Understanding the workforce through revisiting the make-up and skillset of breast screening staff

I. Improving retention, job satisfaction, and role extension through improving processes and exploring opportunities to increase staff satisfaction and retention

J. National workforce approaches (processes and contracts), improving flexibility and reducing variation across the workforce

Additional Candidate Projects comprised:

• Call/Recall improvements
• National approach to Special Requirements
• 50–53 years information and handling
• SNRRS/ Cross-boundary working

Underpinning all of these improvements was work on Models of Delivery:

• Exploring the options for a new commissioning and delivery model

A number of Health Board-dependent initiatives and pilots were also identified, enabling and sharing outcomes from locally generated solutions:

• Development of options for static satellite centres
• Co-locating screening and symptomatic services
• Approaches to high-risk screening

Core Projects and their outcomes

The following sections capture the outputs from each of the workstreams prioritised by the Modernisation Board since 2022, up to the completion of the programme.

The order in which these are presented reflects the suggested order of implementation, with the earlier changes enabling or facilitating the later ones.

Management Model

Background

It became clear as we worked through the Modernisation priorities that the original concept of six separate centres run by six host health boards had become cumbersome, complicated and obstructive. Every process, change or improvement had to be agreed and/or approved via multiple chains of command – the senior management teams for the six host boards, NSD as commissioners and the 14 individual Health Board CPH leads. With each change the centres were diverging in how screening was delivered: we had a “National” Breast Screening programme in name only.

As already indicated, the challenges for SBSP are real. Staffing, recruitment, equipment, premises, mobile van provision and data integrity are all under real pressure leading to downtime, cancelled appointments, increasing slippage and longer waiting times. Each host board has been fire-fighting these issues as they arise and responding with local solutions, meaning that these do not necessarily take account of the impact of these on the wider service. Increasing costs are not all addressed via the SLA arrangements, with some boards able to supply additional funding, and others introducing methods to control costs. Financial arrangements are increasingly opaque, and budgets are historical. It is acknowledged within NSD that re-baselining is badly needed to address this, and that current SLAs are no longer effective with respect to accountability to NSD. Reputational damage to the service is a reality.

Very quickly a clear consensus was reached within the Modernisation Board that fundamental change to the management structure was required, and in October 2023 the programme team was asked to look at options for a new model.

Restructuring the management arrangement away from the current, nationally commissioned six centres was seen as the key to modernising how Breast Screening is delivered equitably. This immediately became the top priority project for the Board, as the way forward for a safe, responsive and effective service and as the fundamental change needed to enable the implementation of all other workstreams within the Modernisation Programme.

Development of a new management model

A Short-Life Working Group (SLWG) was established in January 2024 to progress an approach and explore options. To assist with this task, a wider Reference Group with representation from across the Breast Screening service and (later) national partnership was also set up^[2]. The team also met with BreastCheck Ireland, NHS Assure and SNBTS to understand alternative management models.

Two in-person workshops were held with the Reference Group in June and September 2024. These established a consensus on the issues and the need for change, explored potential models, agreed a set of guiding principles for the change, and began work on a draft Target Operating Model for a new national approach. This draft Target Operating Model was then refined by the Short Life Working Group and presented to the Modernisation Board in March 2025 for ratification.

The drivers for change highlighted by the work included:

• A lack of strategic/clinical leadership at national level, meaning that boards have considerably diverged in how they deliver Breast Screening
• Marked variations in screening round times and waits for assessment, which mean that the centres cannot provide an equitable service for all participants
• Issues with the recruitment and retention of staff, leading to loss of resilience and over-reliance on key individuals
• An increased need for mutual aid but current system creates barriers to enabling this
• A lack of transparency over budgets/finance between centres
• Challenges for the procurement and use of equipment nationally in the absence of a capital replacement plan and funding pressures

Summary of the model

Appendix B.1 below summarises the final Target Operating Model and an associated high level Business Case. This document:

• sets out the case for change, highlighting the consensus on the pressures being faced by the service, the unsuitability of the current model, and the strategic fit with the overall Vision and Outcomes championed by the Modernisation Programme
• presents a suitable Target Operating Model for a sustainable service, capturing the functions required to be delivered at national level, and the organisational structures, governance, staffing, infrastructure and processes to support them
• sets out what the new management model might look like, as well as the key roles and reporting structures required
• develops a proposed route for implementation and transition, along with indicative one-off and recurring costs
• and highlights the benefits that a new management model would bring.

Appendix B.2 below sets out a suggested Communications and Engagement plan covering the development of the model and any future implementation.

The new Target Operating Model for Breast Screening

The Modernisation Programme strongly recommends the creation of a single national service, directly managed and not commissioned, with a dedicated national senior management team under a single national Board similar to the model adopted by SNBTS. This would be the key change which would underpin and enable many of the other changes required to modernise Breast Screening.

An overview of the scope and content of the new Target Operating Model for Breast Screening is given below (see Appendix B.1 for further detail).

Graphic text below:

Target Operating Model for Breast Screening – Overview

The National Breast Screening Service is a single national service directly managed and hosted by a national board, screening participants from the 14 client territorial Boards.

National Leadership Team

• A dedicated senior management team providing national strategic clinical leadership and direction.

Cross cutting functions provided at national level:

• Quality assurance
• Communications and engagement
• Screening management/administration
• Medical physics
• Training

Breast screening pathway – this represents a "once for Scotland", uniform screening pathway with uniform performance standards. Operational delivery of the screening pathway remains unchanged. Pathway comprises:

• Call/Recall
• Image acquisition
• Reading
• Results or Assessment/MDT

Service delivered from regional screening/assessment centres & mobile fleet, under national strategic management. Existing regional centres retained for the foreseeable future.

National strategic management of programme resources including:

• Workforce
• Equipment and IT
• Processes and SOPs
• Full control of the national breast screening budget within the service.

The service, led by a new senior management team under a National Clinical Director, would be supported by and report to a robust clinical leadership structure within the host organisation, ideally with a direct line to the host organisation’s executive board to ensure a strong voice for screening alongside other essential services. The role of the Scottish Director of Screening/Screening Oversight & Assurance Scotland would evolve to include overall accountability for the new national service. A potential organisational structure and reporting lines for the new service and senior management team is outlined below, and a suggested sample Job Description for the National Clinical Director role is attached as Appendix B.3.

Note that these suggested structures are not intended to be prescriptive but are presented as a guide to how the new service might work based on the experience within the team and other screening services, and the similar transition undergone by SNBTS.

Graphic text below:

Suggested organisation structure for the National Breast Screening Service

• The host board clinical leadership/senior management would have overall accountability for the service, via
• the Scottish Director of Screening
  • provides links to external screening governance, comprising UK NSC, SSC, NSOB, BSPB & subgroups (Board Coordination group and QPMG)
  • manages and receives reports from the national management team.
• The national management team for the service comprises the National Clinical Director, National Radiography Lead and the National Service/Operations Manager, with PA / Management Team administrative support
• National Clinical Director
  • links to external screening governance
  • supported by and line manages the National Radiography Lead and the National Service/Operations Manager
• National management team is collectively supported by service leads or functions:
  • National QA leads
  • National Systems/Data Manager
  • Transports/Estates Manager
  • National Comms Manager
  • Training/SABI
  • Medical Physics
• Operational delivery provided by local screening/assessment teams
• The host board manages essential central services – HR, IT and Finance

Benefits

The key benefits of the proposed national approach highlighted in the Business Case would include:

• Improved sustainability and resilience for the service, reducing the risk of failure
• More equitable service provision and waiting times for participants
• Dedicated national strategic and clinical leadership and support
• Enables strategic planning and decision-making across the service
• Greater understanding, control and transparency over the Breast Screening budget
• Improved attractiveness of senior posts, helping to address issues of recruitment and retention in senior roles
• Enables pooling/sharing of skills and expertise nationally
• Enables national approach to procurement and maintenance of imaging equipment on a national basis
• Streamlined accountability and communication within the service
• Potential for making savings and economies of scale in the future
• Easier implementation of upgrades and service improvements within a single organisation
• Coherent national approach to emerging technologies and opportunities including wider changes in the national screening landscape (e.g. advent of lung cancer screening)

Implementation

Implementation of the new model would be dependent on approval and funding by Scottish Government. The Business Case sets out a provisional timetable over a minimum of three years, beginning with the appointment of a programme team, detailed implementation planning, wider communications and engagement with host boards and staff, and initial appointments to the senior management team in the first year. Senior roles in the new organisation would need to be appointed as early as possible to help to define and progress the change programme, as well as providing strong leadership and direction for the service throughout the transition.

Workforce

The Breast Screening workforce has struggled to keep up with the demand of the screening workload for a number of years. Staff shortages, an ageing workforce and the longer term effect of the pandemic on service recovery have left the service teetering on the edge of collapse. It was clear from the 2021 Major Review, but also from the testimony of staff themselves, that support was required.

The Workforce workstream began in January 2023, identifying its scope and priorities. The Modernisation Board were clear this project was likely to last the duration of the programme and was vital to ensuring service sustainability into the future. The work was chaired by [Name redacted], Clinical Director of the West of Scotland Breast Screening Centre.

Understanding the workforce

The first phase of the project focussed on developing a better understanding of the workforce. Two surveys, one for staff and one for each senior management team, were developed and sent out across the service to gather information about issues such as the key challenges for the workforce, workforce satisfaction, likelihood of leaving and suggestions for improvement. Statistics were also gathered from the centres to determine staffing numbers (headcount, WTE and SLA-funded WTE per centre) as well as the key recruitment and retention challenges in each area.

The outcomes of the survey were analysed and presented back to the service and the Modernisation Board. They demonstrated the stark reality for the Breast Screening workforce and highlighted the need for a National Workforce Plan for the Scottish Breast Screening Programme.

National Workforce Plan 2024-2029

The need for an overarching national workforce plan for Breast Screening was highlighted as one of the recommendations from the 2021 Major Review. To date, there has not been a fully national workforce plan devised for the service, screening being out of scope when the Diagnostic Imaging Workforce Plan for NHS Scotland^[3] was developed in 2022/2023.

A copy of the National Workforce Plan is attached as Appendix C.1 below.

The plan should be seen as a companion to the Diagnostic Imaging Plan, and was developed following the same Six Step Methodology for Integrated Workforce Planning^[4] (also previously used for the National Workforce Strategy for Health and Social Care in Scotland). The approach is based on the five ‘pillars’ of the workforce journey – Plan, Attract, Train, Employ and Nurture.

Graphic text below:

Six Step Methodology for Integrated Workforce Planning

1 – Defining the plan

This feeds into:

2 – Mapping service change

3 – Defining the required workforce

4 – Understanding workforce availability

These have a 2 way relationship with

5 – Developing an action plan

This feeds into:

6 – Implementing, monitoring and refreshing, which is also supported by 1 – Defining the plan.

Current state of the workforce

Using the information gathered during the initial surveys, the plan documented how the current workforce are utilised across the screening pathway, setting out the steps along the screening pathway and the roles within the service that may be involved at each step:

Graphic text below:

Breast Screening Centre – Workforce Pathway

This diagram shows the pathway of a participant through the Breast Screening Centre system, including key stages and the healthcare roles involved. The pathway moves from left to right and is overseen and supported by the Senior management team, their support, administration and Health Board Services.

1. Call/Recall

• A call recall process invites eligible population to breast screening.
• If participant attends > Screening Appointment.

2. Screening Appointment

• Mammogram is taken
• Staff involved depend on location
  • Mobile Van
  • B6 Mammographer, B4 Assistant Practitioner, B2/B3 Transport Officer
  • Centre or Static Site
  • B7 Advanced Practitioner, B6 Mammographer, B4 Assistant Practitioner
• After screening > Reading Sessions

3. Reading Sessions

• Assessing mammogram and determining whether further investigation is required
• Staff involved:
  • Clinical Director
  • Consultant Radiologist
  • Specialty Doctor
  • B8b Consultant Radiographer
  • B8a Superintendent Radiographer  
  • B7 Advanced Practitioner (if completed Mammographic Image Interpretation qualification)
• Outcomes:
  • If no further investigation required > Return to routine recall
  • If further investigation required > Assessment Clinic

4. Assessment Clinic

• Further images, examination or biopsy may take place
• Staff Involved:
  • Consultant Radiologist
  • Clinical Director
  • Specialty Doctor
  • B8b Consultant Radiographer
  • B7 Advanced Practitioner (often stereo biopsy mandatory; all B7 APs need regular exposure to assessment clinics to maintain clinical practice)
  • B7 Breast Cancer Nurse
  • B6 Mammographer
  • B5 Registered Nurse
  • B4 Assistant Practitioner (non-clinical duties only)
  • B3 Healthcare Support Worker
• If a biopsy or other views are taken:
  • A group of clinicians then meet once results ready as an MDT to go through each case and sign off formal decision. Participant informed at results clinic in person or via telephone.
• MDT can include:
  • Consultant radiologist
  • Consultant radiographer
  • Surgeon
  • Pathology
  • Advanced practitioner
  • Breast cancer nurse
• After Assessment > Results Clinic

5. Results Clinic

• Informing participant of decision
• Staff involved:
  • Consultant Radiologist (often inform malignant cases)
  • Breast Surgeon (often inform malignant cases)
  • Specialty Doctor (often inform malignant cases)
  • B8b Consultant Radiographer (often inform malignant cases)
  • B7 Breast Cancer Nurse (often inform benign cases but can inform malignant cases too)
• Outcomes:
  • If benign > return to routine recall
  • If malignant or further management required > referral to health board services

Host boards, as the employers of the staff in their centres (in line with commissioning agreements with NSD), determine the exact staffing resource they require in their own centre and across the screening pathway. This has resulted in variation across the centres in terms of staff utilisation. While this is not necessarily a negative thing, as co-located services can benefit from sharing staff with the symptomatic service, it does limit the cohesion between commissioned staffing agreements and accurate staffing profiles.

As of October 2024, there were 306 staff working for the Breast Screening Programme across all six centres. This equates to 206 WTE, just over 10 WTE less than accounted for in the individual SLAs between NSD and the six host boards, which provide total funding equivalent to 216.3 WTE staff. The discrepancy is representative of chronic staff shortages and hidden vacancies within the service (e.g. retirals and long-term absence without backfill or proleptic appointment in place). A breakdown of the staffing profiles and actual WTE within these profiles for the entire service is given below:

Graphic text below:

Workforce WTE

Role	WTE
Radiologists	11.69
Radiographers (bands 6 to 8b)	83.35
Administration (bands 2 to 8a)	50.34
Nurses (bands 5 to 7)	6.7
Specialty and other consultant doctors	6.93
Supporting roles (bands 2 to 7)	47

Key challenges for workforce planning

On the basis of the staff and centre management surveys, the Workforce Planning SLWG identified the most critical challenges for staffing across the Breast Screening service. These included issues with the supply and training of qualified staff, the ageing screening workforce, chronic staff shortages, a lack of opportunity for CPD, variations in staffing profiles across services, and difficulties in attracting staff to senior positions with the service. Many of these challenges were also highlighted as part of the work on the new Management Model. See Appendix C.1 below for full details.

Impact of future developments

The Workforce Planning SLWG was conscious that there were a number of potential future developments within Breast Screening which could have an impact on staffing requirements within the next five years. While it was not possible to quantify the impact of any of these changes at this stage, it was clear that the Workforce Plan would need to be reviewed to take account of them should any of them be implemented. The developments in question included:

• Changes to the scope of extended practice for Assistant Practitioners
• Use of hybrid working in management and administrative roles
• Centralised national Call/Recall
• Centralised national image reading
• Electrification of the Breast Screening fleet
• Future use of Artificial Intelligence (AI) to support image reading

See Appendix C.1 below for further details.

Workforce optimisation exercise and modelling

We feel it is essential that the workforce plan is based on optimal staffing levels, with proper allowance made for breaks, annual leave, learning/CPD, research and audit activities. Optimal staffing levels were investigated by five optimisation subgroups which each explored an individual part of the Breast Screening pathway. Between them the subgroups agreed a scalable staffing profile for a notional centre based on an eligible population of 50,000 across one full screening round of three years. Based on this profile, the plan recommends an optimal staffing level of 22.74 WTE for a centre of this size. While this is only indicative, the estimated cost at current salary levels to employ 22.74 WTE starts at £1.4 million.

These figures were then scaled up to accommodate the forecast national eligible population for varying levels of uptake (from 100% down to 70%). See the table below. From these figures it is evident that a large increase from the current 216.3 WTE staff is required across the lifetime of the plan to meet optimal staffing levels. The national eligible population is forecast to reduce slightly over the lifetime of the plan, which will reduce the requirement for staff as the years proceed. However, even allowing for this reduction, when compared with the current staffing complement of 216.3 WTE, an increase in staff will be required across the service for the entire lifetime of the plan to optimally deliver the service.

Uptake %
Eligible Population		100	90	80	75	70
794,288	2024	361.2	325.1	289.0	270.9	252.9
793,258	2025	360.8	324.7	288.6	270.6	252.5
791,371	2026	359.9	323.9	287.9	269.9	251.9
786,319	2027	357.6	321.9	286.1	268.2	250.3
781,490	2028	355.4	319.9	284.3	266.6	248.8
777,613	2029	353.7	318.3	282.9	265.2	247.6
774,482	2030	352.2	317.0	281.8	264.2	246.6

Staffing will have to remain flexible within the centres, particularly those which are co-located or regularly share staff with the symptomatic service. However, the results give an indication of the number of staff nationally required to comfortably meet screening demand, while giving staff the capacity to take regular breaks, benefit from learning and continued professional development, and partake in research and audit activities, which are often not available to them on current staffing levels.

Recommendations

In response to the findings, the workforce plan has developed 28 recommendations to be taken forward by the service, covering the five ‘pillars’ of Plan, Attract, Train, Employ and Nurture. Some of these recommendations align with the wider Diagnostic Imaging Plan for NHS Scotland, some with the steps required to deliver the new management model discussed above, while some are independent of both and can be taken forward immediately. Full details of the recommendations are given in Appendix C.1 below.

Data

Data was identified by the Board as a key theme to be addressed during the lifetime of the Modernisation work. A Data SLWG was established in June 2023, chaired by Dr Gerald Lip, Clinical Director of the North-East Scotland Breast Screening Centre.

As screening data is used by numerous stakeholders across the health service, it is crucial that data is quality assured and accessible to the right people and addresses the data requirements of all stakeholders. To address this, in addition to Breast Screening staff, all relevant stakeholder groups were also involved in this work, including Public Health Scotland, Primary Care, NSD, SOAS and the six Breast Screening host boards.

The scale and complexity of data within the SBSP presents a challenging landscape but also offers real opportunities for harmonising and streamlining processes to avoid duplication of outputs or activity. The work was undertaken in close collaboration with the service via the SBSS National User Group (NUG) and NSS Digital and Security (DaS) strategic activity. In particular, the group aligned with the project team delivering the Screening Intelligence Platform (ScIP) to ensure there was no crossover or duplication and enhance collaboration.

The Data SLWG focussed on two main priority areas in need of review:

• Streamlining & standardising data reporting
• Data Strategy: Improve data integrity, access and data linkage across the service, including work to better capture inequalities data.

The group also looked at data visualisation tools to allow stakeholders to visualise breast screening data in a meaningful way. The use of Tableau was explored with DaS, and requirements were scoped; however, due to technical constraints and the challenges of accessing live data this solution was not progressed.

Streamlined and standardised reporting

The Scottish Breast Screening Service currently generates a vast number of reports, for internal and external use. Report generation is time consuming, demands a great deal of manual intervention, and requires a combination of technical, clinical and legacy system knowledge to make sense of and utilise the information available.

The SLWG undertook a comprehensive audit across all the reports generated by SBSS and BOXI. Each centre was provided with a report auditing template to complete. Due to severe capacity restraints within the service across the lifetime of the Data workstream, there were challenges in getting completed returns of this audit. On the back of the responses received, a development day was held – attended by all six centre managers – to discuss report rationalisation, identify duplicates, and flag reports for retention, archiving or further investigation by the NUG.

A paper summarising the outputs of this activity will be taken to the NUG in May 2025, seeking commitment to continue work to streamline the remaining reports. It also asks the group to provide governance, training and QA support for the longer-term development, maintenance and usage of reports within Breast Screening. See Appendix D.1 for details.

Identifying Inequalities: Scottish Breast Screening Programme

The SLWG also identified that there were particular challenges around the collection of Inequalities data which have made it difficult to monitor and address inequalities in Breast Screening.

An additional piece of work was undertaken to review available inequalities data for breast screening and understand the use of data on clients’ special requirements across the service.

A report entitled “Identifying Inequalities: Scottish Breast Screening Programme” was developed which made recommendations to improve health inequalities data and inform interventions to address any inequalities. See Appendix D.2 for details

The recommendations made in the paper are incorporated into the overarching Data Strategy.

Data Strategy

The Data SLWG also identified the need for a longer-term vision and strategy for the capture and use of data in Breast Screening.

Aligned to the Modernisation Programme’s vision, the strategy sets out to identify the steps to make better use of data to improve the efficiency and effectiveness of the programme and improve the benefits for participants.

To develop the strategy, the SLWG:

• identified the key challenges facing the service regarding ownership, integrity, technology, reporting, education and training and completeness of data
• set out what the future might look like via a clear vision and agreed outcomes developed a focused action plan to concentrate future effort and resource with a set of short-term, medium-term, and long-term actions

The current challenges and desired future state are summarised below.

Graphic text below:

Challenges and desired future state for breast screening data

Ownership

• Clear ownership rules for Breast Screening data identified, with clearly defined roles and responsibilities

Integrity

• All data is independently quality assured and audited on a national basis

Technology

• Work with Digital modernisation (SOAS) and the NUG to support future contract negotiations and improve processes to drive SBSS developments

Reporting

• Continue to audit key reports and have a clear understanding of all stakeholder reporting requirements

Education and training

• SBSS training for staff, including training materials to develop their knowledge and skills

Incomplete data

• Include SIMD data on SBSS to help target lower uptake areas.
• Review special requirements codes in SBSS to ensure consistency

See Appendix D.3 for the full Data Strategy.

Call / Recall

A review of the Call/Recall system was recommended by the 2021 Review. The current practice is for participants to be called for screening according to the GP practice where they are registered. Over the years this has led to several issues for screening, and a high-level options appraisal conducted for the review concluded that some combination of postcode and date of last screen / next due date should be considered in its place. This had been an exploratory appraisal only and the proposed changes were never scoped or costed.

The Modernisation Board considered the recommendation and agreed (in November 2022) to establish a SLWG to examine the issue, focussing specifically on the current challenges with the Call/Recall system and any potential improvements. The work was chaired by Marion Inglis, Business Manager for the West of Scotland Breast Screening Centre, and Sarah Philip, Breast Services Manager for the North East Scotland Breast Screening Centre.

It was noted that a number of improvements had already been made to SBSS since the publication of the Review which had helped to address some of the concerns in the original analysis.

Challenges and recommendations

Initial discussions highlighted several issues with the current system and scheduling process including a lack of support for individual participant round length management, the increasing impact of GP moves and practice mergers, and the need for extensive manual processes and workarounds to compensate for these deficiencies.

Key recommendations identified by the SLWG and the Modernisation Board included:

• Improving flexibility of scheduling within SBSS (e.g. by location across multiple GP practices) to improve adherence to the target 36-month interval between screens, ease some of the pressures on the system and staff and reduce the need for manual workarounds.
• Improvements to the management of special requirements (e.g., recording, detecting and planning around them, national SOPs for consistency).
• Access to better population data and forecasting tools to help with capacity planning and siting of vans.
• Identifying opportunities for clients to manage changes to their appointments, allowing time for admin staff to perform duties other than answering phones or outbound calling.
• In the longer term, scoping and developing options for a potential move from practice-based calling towards Call/Recall based on individual screening round times.

Progress and outcomes

Given the pressures on the system and the limited capacity within the service to support change, the group focussed on developing proposals to improve the flexibility of scheduling within SBSS to improve the management of screening intervals and ease staff pressures.

A scoping session was held with key stakeholders to define the required changes. An SBAR outlining a set of improvements to the booking process and functionality within SBSS – principally a form of location-based calling – was reviewed by NSD Senior Management Group in December 2022 and approved by both the Breast Screening Programme Board (January 2023) and the Breast Screening NUG (February 2023). The changes were then prioritised by the NUG and submitted to the supplier for costing and development.

An initial date was scheduled for development to take place in 2024, but work did not proceed owing to limited resource and the need for the supplier to prioritise changes required by other national developments.

Current position

Since that time and given the lack of progress with the initial changes proposed, the SLWG has reconsidered the position, and a decision has been made (proposed by the Breast Screening NUG and supported by the Modernisation Board at its meeting in October 2024) to re-examine the feasibility of moving to postcode-based calling. This had initially been considered a major challenge, but conversations with the IT supplier (Atos), the programme team and centre managers had reassured the SLWG that it would be possible and worth exploring further given the potential benefits.

A proposal is now being progressed by the service via the Breast Screening Programme Board, highlighting the changes required and the key risks and benefits (see Appendix E.1 for further details). The main risk identified was that the change could impact the service for the next two screening rounds (up to six years) as the new processes were embedded and any issues with postcodes matching to locations were resolved. Intervention from the service and additional reports might be required to ensure that women were not offered additional screening appointments as a result. The benefits focus on reduction in the severe burdens that GP practice mergers are imposing on the service currently, an improvement in adherence to the 36-month target interval (once the changes were fully bedded in), and better support for participants to be screened at locations convenient to them.

It is recommended that a dedicated project and testing team is allocated for this initiative as the complexity and demands of the work would mean that it could not be absorbed within the workloads of existing teams.

Equipment

Ownership of Breast Screening equipment sits in historical and complex arrangements between the six host Boards and NSD, with replacement increasingly proving to be a challenge for the Breast Screening service.

The equipment workstream was established to address the following longstanding issues:

• Host Board owned equipment - Ownership of screening equipment, mammography, ultrasound but also IT infrastructure, viewing stations and computers within the centres sits with the Host Boards in which they are located. The replacement and some of the maintenance for this equipment is the responsibility of the host board. Capital funding for equipment is top sliced from all boards and provided to the host boards to run the screening service. With financial pressures on all health boards, the reality is there are competing needs for capital in which screening is often not seen as a priority.
• NSD owned equipment - Ownership of the mobile unit fleet and onboard mammography equipment belongs to NSD. They are responsible for the procurement, installation and maintenance of the fleet and equipment across the entire service. Ageing equipment, alongside unreliable mobiles, means it has become more difficult to operate the mobile service, with increasing outages leading to reduced capacity and increased screening intervals. Downtime on one mammogram machine or single mobile equates to 50 lost client appointments per day.
• Fallow equipment - There is a recognition that a significant number of mammography machines sited within health facilities, across the country, lie fallow for periods of time across a given week. These machines are typically used by the local symptomatic services. It is generally accepted that these machines could provide extra capacity for the screening service. This would need some minor adjustments, medical physics oversight and access to SBSS, but the potential exists to use this fallow time to support additional capacity for screening. This spare capacity could reasonably be used to cover peaks and troughs in demand, slippage within the programme or as part time static satellite screening sites.
• Consumables - There is no centralised procurement system for the consumables required by the service. This includes items like needles and surgical equipment for assessment clinics. Without centralised procurement, each centre is exposed to different costs for these items given quantities utilised across their NHS Board, meaning some centres are paying more than others for the same things.

Exploratory conversations with National Procurement and NSD took place to determine first steps in addressing these issues. It became apparent that the issues facing the Breast Screening service are widespread across Scotland, with demand for capital replacement across the NHS exceeding the available funding.

The advice provided by National Procurement was to integrate capital replacement requirements for the screening service with wider needs across NHS Scotland. All Health Boards and NSS have now developed five-year capital replacement plans which form a “Whole System Infrastructure Plan”. For those Health Boards who are commissioned to provide a breast screening service, the centre equipment will be included within the board’s plan. However, each health board has competing demands and breast screening equipment may not be identified as requiring replacement within the next five-year plan.

Medical Physics

One of the strengths for Breast Screening equipment is the Scottish Breast Screening Medical Physics team. This small expert team within NSS is commissioned to provide a service to the SBSP and are responsible for QA, commissioning and testing of all Breast Screening modalities, with the mammography units currently covered by a fully comprehensive maintenance contract. The Physics team also undertakes important research in the field of screening technology and equipment. This service functions at a high level but is under increasing pressure with testing, checks and upgrades to failing equipment. Discussions with the Medical Physics team particularly highlighted the downtime associated with the ageing mobile fleet and the downstream impact on capacity that this produces.

Equipment conversations and developments to whole system plans are ongoing with timely replacement plans critical to minimise current issues with the mobile fleet and mammographic units.

Discussions with representatives from modality suppliers were also held. Suppliers are well aware of the financial pressures and are exploring new and different finance options around procurement to help spread the capital costs for the NHS e.g. personalised managed services for equipment. Further discussions regarding these options could be fruitful.

The new management model for the SBSP would facilitate a more co-ordinated and coherent capital replacement programme. However, capital funding arrangements would require to be reviewed in order to allow the service to set priorities against a budget rather than relying on NHS Boards. As a next step it would be helpful to extract information from NHS Board plans to develop an interim whole system infrastructure plan specifically for breast screening modalities to oversee full replacement and resource requirements.

Additional candidate projects

The Modernisation Board also identified a set of potential projects which did not fall directly under any one theme, but which nevertheless contributed to achieving the Programme Vision and Outcomes or addressed specific recommendations from the Review. Others were identified as being principally the responsibility of Host Boards to progress. These ideas for candidate projects included:

• Use of static ‘satellite’ centres to supplement and support mobile provision
• Improving engagement with Primary Care on the promotion and support for Breast Screening
• High risk / family history screening
• Over-70 age group self-referrals
• Co-location of symptomatic and screening services
• Risk stratification / targeted screening
• Call/Recall improvements
• Developing a national approach to how participants with special requirements are accommodated
• Improving information and handling for participants as they become eligible for screening
• Improving opportunities for cross-boundary working

The Modernisation Board was unable to progress some of these directly owing to capacity constraints, or because it was judged that the issues were best handled by the local host NHS Boards.

Static sites

The South East Scotland Breast Screening Centre (SESBSC) proposed to the review team in 2019/20 that screening could be delivered in static satellite centres throughout the region and that many of the issues faced with the use of the mobile units could be overcome. The move to more static locations could also meet many of the recommendations of the review and break down some of the barriers to screening. It is thought that static sites could be of considerable benefit to the staff, the service and the eligible screening population. See Appendix F.1 for further details.

Following discussions with colleagues in NHS Fife some scoping took place with a view to setting up the pilot satellite site within Queen Margaret Hospital in Fife. Further discussions and a site visit took place within the hospital and a suitable space was identified. Since then, a business case has been developed and has subsequently been approved by both NHS Lothian and NSS National Services Division.

It is possible that the use of a mixture of static and mobile screening units will provide a choice of venue and flexibility to meet the demands of the modern cohort of the eligible population. It has also been shown within the business case that the introduction of static sites can reduce the carbon footprint of the service and bring revenue savings, both of which are benefits to the wider NHS and environment.

While the continuation of this work and implementation of the business case will be supported by the business as usual screening service, the Modernisation Board formally endorses this direction of travel and believes an increase in static sites across the central belt will drastically improve the sustainability and resilience of the service.

Primary Care engagement

The Modernisation Board asked the programme team to explore how engagement with primary care services has evolved across Scotland and whether this meets the current needs of Primary Care Teams.

Initially, a small group of GPs was surveyed to get a picture of their current engagement with Breast Screening services and how this reflected their needs. As more interest in the conversations developed, two informal networking and knowledge sharing sessions were arranged across 2023-2024, bringing together wider representatives from across Breast Screening and wider primary care.

It became clear that while there is a level of engagement between the two sectors, more specific engagement could be undertaken to support professionals and participants. Further information can be found in Appendix G.1; however key findings and associated recommendations from the exercise include:

• There are excellent screening educational resources available to NHS staff in Scotland

There is a need for these to be widely disseminated, better promoted, and activity encouraged and audited.

• There is significant variation in screening promotional activity across Scotland, with much being lost because of changing practice within primary care during Covid. There are excellent local initiatives and a willingness to share these via the Equity in Screening Network but no organisation is truly coordinating or sharing these at present.

There is a need for clear sharing protocols, which could be done via the CPH Leads Board Coordination group.

• There is a genuine need for coordination and oversight, but CPH Leads are over-stretched.

CPH Leads need a forum to articulate what they need for this role. There seemed to be some support for CPH Leads Board Coordination group to do this, potentially through a standing agenda item for their meeting.

• Role of Equity in Screening Network, reviewing data and good practice.

More information from this group to the Screening community would be helpful and should be included in their outputs, with consideration of a standing update item for CPH leads.

• Sharing good practice/network opportunities

There is enthusiasm for the suggestion of an annual meeting between CPH Leads and interested parties in Primary Care. This could be developed as a successor to the current SLWG. Primary care will be invited to attend equity network learning events online.

• Data needs for Primary Care were discussed.

The data received by primary care from screening needs reviewed and updated so that the information coming out reflects the needs of primary care and their patients. A focused SLWG should be considered to support primary care data needs and engagement if a move to postcode-based calling takes place.

High risk / family history screening

Consideration of the incorporation of high risk and family history screening within the mainstream Breast Screening programme was identified as one of the recommendations from the 2021 Major Review.

Unlike in the English programme, this client group is not included in SBSP but is provided for on a dispersed basis within the symptomatic breast clinic network in individual health boards. The frequency of screening and definitions are determined by UKNSC, but the delivery of the service varies greatly between and within Health Boards. How clients are identified, called, reported and assessed are all controlled by the local symptomatic service. As a result, the current provision is not subject to the same formal quality assurance standards and programmes as the age-based population screening undertaken between 50-71 yrs by SBSP.

A change to this delivery was considered as part of the Modernisation Programme, with a presentation from Fiona Rowan to the Modernisation Board highlighting some of the benefits of including this in the national screening programme. The Board acknowledged that were we introducing a Breast Screening programme de novo, it would include high risk and family history clients. However, while it was generally agreed that it would be beneficial to include high risk and family history screening within the mainstream Breast Screening Programme, this would require a policy decision from Scottish Government supported by major investment to deliver the required changes to IT infrastructure, processes, pathways and communications, which were not within the scope of the Modernisation Programme.

Over 70 age group self-referrals

At the time of the 2021 Major Review, self-referrals for this age group had been suspended as capacity was still constrained following the Covid pandemic. The Review had recommended that the programme should continue to support self-referrals until the outcome of the AgeX Trial in 2026, but that while capactity continued to be constrained following the Covid pause it was not yet appropriate to reinstate this option. The Board supported this recommendation and agreed early on that this issue was more appropriately dealt with under BAU.

Background: Over 70’s age group self-referrals

Mortality reduction – the ultimate goal of screening – lessens with increasing age, and from the outset of the programme there has been an upper age limit of 71 years for routine screening. Clients above this age have been able to remain part of the screening cohort by self-referring for mammography every three years.

There are some issues arising from this policy:

• This group comprises approximately 7-8% of the overall workload and as such, represents a significant additional unfunded workload. This cohort tends to be disproportionately from higher socio-economic backgrounds which works against stated aims of equity in screening.
• During Covid recovery, because of lost capacity and high slippage, the decision was made to suspend self-referral for screening by clients over 71. This was seen a necessary step to recovery for the target population but was unpopular in the media and amongst clients.

Some of these issues will be addressed by the age extension trial, AgeX, currently running in the UK and due to report early results in 2026. This study is likely to influence future decisions about upper and lower age limits for Breast Screening in the UK and hence for SBSP. Until such time that this study reports, self-referral remains unchanged as part of SBSP and was fully re-instated in a phased manner from 2021.

Co-location of Screening and Symptomatic Breast Services

The potential co-location of Breast Screening with symptomatic breast services, preferably in stand-alone premises, has been an aspiration for SBSP for some time.

It offers many advantages, particularly with respect to funding and convenience for any shared staff, and for clients and patients. It has widespread support amongst clinical staff, surgeons and radiologists, and with wider staff groups. Co-located centres have been implemented in many health boards in England with great success, and are widely considered to be the ideal model. Within the SBSP it has been possible for this to be partially implemented in the smaller units (Highland, Tayside and Grampian, and more recently in Ayrshire and Arran), but there has been no appetite to make the change in the two largest Health Boards owing to historical models and legacy symptomatic services in central Scotland.

However, it remains an aspiration for the future SBSP and has been considered in other workstreams rather than in a separate project. We anticipate that exploring this change will become the responsibility of the proposed national service but recognise that to make this a reality in the central belt, it needs to be owned and sponsored by individual health boards.

In practice, this aspiration may be facilitated by some of the Modernisation Board recommendations particularly the new management model. It would require the local symptomatic breast teams to articulate the need and to drive the change if it is felt to be beneficial. Close collaboration with SBSP would be needed, and transition and upfront costs would need to be agreed.

Risk stratification/targeted screening

The Board discussed risk stratification and targeted screening as one of the recommendations from the 2021 Major Review. Currently only breast density sits within this bracket as an independent risk factor. The UK NSC plans to undertake an evidence review around risk stratification based on breast density over the course of the next twelve months. It will be some time before a formal recommendation will be made.

The Modernisation Board gave significant thought to this recommendation, but it was not prioritised as one of the main workstreams because of the cost and complexity of the undertaking that would be required. To take forward, Scottish Government would need to commission this as a separate scoping exercise.

2021 Major Review of Screening – Recommendations

As part of programme closure, the programme team reviewed the 17 recommendations from the 2021 Major Review of the Scottish Breast Screening Programme to assess their relevance to the Modernisation Programme, their current status and the extent to which they have been addressed within the Breast Screening Modernisation Programme and/or Business as Usual (BAU).

As discussed above a number of the recommendations had already been addressed or were no longer relevant given the passage of time between the completion of the Major Review and the start of the Modernisation Programme. Others were picked up by the Breast Screening Programme itself as part of BAU changes and improvements.

The below presents a summary of the outcome for each of the recommendations.

• Category / Outcome

Recommendations addressed or partially addressed by the Modernisation Programme

2021 Major Review Recommendations

1. Develop a new approach to call-recall

7. Improve the understanding and perceived value of Breast Screening

8. Increase the convenience of appointments

9. Improve the acceptability of Breast Screening

10. Increase the user-friendliness of screening venues

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

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

15. Streamlining of reporting

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

• Category / Outcome

Recommendations being progressed as part of BAU or by Host Boards

2021 Major Review Recommendations

2. Developments to Scottish Breast Screening System

3. Static satellite screening centre provision

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

• Category / Outcome

Recommendations already completed as part of BAU

2021 Major Review Recommendations

4. Over 70 self-referrals

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

• Category / Outcome

Recommendations which were superseded, out of scope for the programme, or external dependencies

2021 Major Review Recommendations

6. Family History/High Risk screening

12. Scotland’s Digital Strategy for Screening

13(a). Scotland’s Digital Strategy for Screening

16. Development of a Quality Management System

A full analysis of the status and outcomes for each recommendation is shown in Appendix H.1.