Background and governance arrangements
The Breast Screening Standards are a key component in supporting the SBSP approach to quality assurance. Monitoring and improving performance against these standards, at a local and national level, aims to improve the quality of the SBSP.
There are 3 tiers of governance under current arrangements, local, national and UK wide. National Scotland wide arrangements have been the subject of review in 2018 and has resulted in the establishment of the National Screening Oversight Function (NSOF), and National Screening Oversight Board (NSOB), alongside the newly convened National Breast Screening Programme Board.
Locally at centre level QA modality leads continue to monitor and evaluate the programme metrics against National standards. This is currently performed separately for Radiology, Radiographers, and Administration. National Surgical and Pathology QA leads were responsible for monitoring these specialties and organising annual national multimodality QA meetings, however these posts are currently vacant due to recent retirements. As a result of this, and historical lack of data, the previously undertaken annual modality based QA visits have largely been suspended. Concerns have been discussed about the QA process by NSD, CDs' and QA leads over in the last 18 months, mainly around the lack of data since the implementation of SBSS, the lack of external review embedded in the system, and the single modality based visits. As a result, interim arrangements involving these 3 groups had been set up but again were suspended as a result of the Covid pause. This has been recently re-instated and recommendations for future arrangements are under development to be submitted to the Programme Board.
Standards and Quality Assurance Reporting Processes
The current reporting processes, used to report against the HIS Breast Screening Standards, are outlined below:
ASDC: Annual Audit of Screen Detected Cancers. This is an annual meeting to review UK wide data. The data has not been available from Scotland to participate in this process for the last 3 years, and the 2020 meeting was cancelled due to Covid. Scotland has, however, submitted data for the 2021 review.
KC62 publication: Published annually by Public Health Scotland, in line with the same process in the remainder of the UK. Historically this formed the basis of annual QA reports for each centre and the Scottish programme as a whole. The statistics are now reviewed by the newly established Monitoring & Evaluation Group. The group will identify variances in data which require further investigation or management and escalate these to centres and to the Programme Board.
CPG: Clinical and Professional Group: This forum, hosted by Public Health England, is a Radiology advisory group encompassing all of Breast screening England. Representatives from the devolved nations are invited to attend as observers only.
MEG: Monitoring and Evaluation Group: Newly constituted under the redesign of the Breast Screening governance structure, this multimodality committee is supported by Public Health Scotland and NSD. Its role is to monitor all the data generated in relation to the National Screening Programme, to evaluate this in relation to standards, to inform QA activity and provide an early warning system for potential issues within the Programme.
NSD Annual Report: The NSD commissioning model requires that each Breast Screening Centre, and the NSS Physics team, submit an Annual Report (and mid-year report) to NSD. This is then discussed in detail at the centre's Annual Performance Review.
Service Level Agreements: Each Breast Screening Centre, through its host Health Board, has a Service Level Agreement in place with NSD, which spans a 3-year period. This includes a number of performance measures in line with HIS standards, but also incorporates some previous QA standards.
HIS standards: Recently updated in 2019, these sit alongside the QPI's and contain a variety of metrics based on a format adopted by HIS. Some of these are qualitative and general, and some are granular and more related to the QPI's. They also include a number of turnaround time guarantees. In this format they are regarded as unlikely to have an impact on service performance. Although key metrics from the standards are reported in the KC62 report, the standards require to be connected to a wider quality improvement cycle which connects the standards, performance and turnaround times (for example for image reading and access to screening assessment clinics), programme schedule performance, and links to wider breast cancer QPI's. An overview of clinical and management performance for the programme arising from this, and locally owned action plan with an escalation process for support where required would assist (similar to the current cancer QPI's reporting and performance management process).
Annual Multidisciplinary QA days: Until 3 years ago, there would be an annual research, audit and QA meeting organised nationally by either the Surgery or Pathology Screening QA lead. This was a 2-day meeting, the 2nd of which dealt with any QA issues raised from the annual visits. These meetings have not been held due in part, to the well-known acknowledged problems with retrieving meaningful data from SSBS until the last financial year, and in part due to changes in personnel within the key leadership roles. This was an excellent forum for all screening staff which enabled the sharing of good practice, networking and exploration of solutions and also some horizon scanning. There is a general consensus amongst all screening staff that this needs to be re-instated.
Breast Cancer QPIs: The QPIs were developed collaboratively with the three Regional Cancer Networks, ISD, and Healthcare Improvement Scotland. There are no screening specific indicators, but there is a recognition that Radiology underpins some of the QPI's. NHS Boards are required to report against QPIs as part of a mandatory national cancer quality programme. Public Health Scotland supports NHS Boards in improving the quality of local data collection and reporting through the production of data validation specifications, and measurability criteria for QPIs.
Health Board Public Health Reporting: These reports are submitted to every Health Board by the Public Health Screening Programme lead, based on the screened population for that Board and is not limited to host Health Boards or centres. In some cases the NSD Annual Report can be provided as part of this in an effort to prevent duplication. More regular Health Board monitoring may also be in place. Some centres have a close working relationship with their local board Public Health departments and have regular meetings to monitor activity and issues, but this is very variable across Scotland, and job plan time allocated for Board screening co-ordinators is also variable. It is of substantial benefit where a good relationship exists.
Monthly and Annual Performance Reports: monthly and annual performance reports are presented to the NSD SMT. Periodic reports also go to the National Screening Oversight Board for update. If there are any performance issues noted these are raised with the Breast Screening Centre, and an action plan sought.
QA groups: As part of the Breast Screening Programme, there are modality based Quality Assurance Groups that monitor data with a modality QA lead at every centre. Previously these groups have met regularly under the Modality National Lead. Annual modality specific site visits were arranged through this process. Any local issues are raised within these groups and escalated to the CDs/NSD as appropriate.
Rationalising the reporting process and gaining oversight of performance and improvement
The Review offered an opportunity to re-assess the QA and governance implications for Breast Screening, in the light of new structures and the ability to now get meaningful data from SBSS. It should be noted that the PHE revamp of the English QA processes, with data review sessions, fewer but multidisciplinary site visits and external review, has much to recommend it. One of the key issues the service reports for the whole Governance/QA process for Breast Screening is the number of different reports and formats required for different agencies which all contain essentially the same information and data. The review would recommend that there is streamlining of data reporting where possible, acknowledging that the detail of information required varies significantly between recipients (Public Health, Health Boards, National Services Division, Scottish Screening Committee, National Screening Oversight Function/Board, Scottish Government).
Within the HIS standards, all criteria are considered 'essential' or 'required' in order to demonstrate the standard has been met. NHS boards are responsible for implementing the breast screening standards to assess quality and support improvement in breast screening services. The detailed implementation of these standards is for local determination.
The Review Team discussed the current Breast Screening Standards with Healthcare Improvement Scotland (HIS) and acknowledged that these were recently reviewed in 2019, as part of a regular review cycle. The Review Team discussed the potential to improve the use of the standards to support improvement (i.e. supporting the wider quality improvement cycle referred to above), rather than once again review and seek to change the standards. Subsequently, HIS outlined initial thinking around the applicability of a conceptual Quality Management System framework approach to the breast screening programme and the associated standards. This is shown at appendix 12. The process for how screening programme standards are developed is being further considered by Healthcare Improvement Scotland (HIS), and will be reported via the National Screening Oversight Function. This new approach to the development of standards will be incorporated into the work being established by the National Screening Oversight Function to develop a national screening quality management system (QMS). The aim of this QMS will be to both support individual screening programmes, and to provide a system-wide approach to quality to enhance cross-programme activities and identify opportunities where a 'Once for Scotland' approach could be adopted.
The further development of breast screening standards will be taken into account when translating the HIS QMS into a national system for screening:
In the context of the breast screening programme, a QMS can provide a roadmap toward better quality. It has the potential to provide a simple framework to guide quality activity including support for self-evaluation and internal assurance. Additionally, where change is required, a QMS is a helpful tool to support services to plot the evolution of different improvement approaches and implement successful change. Continual refinement of the breast screening programme using the QMS would enable the programme to pursue excellence at every level.
4.1 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.
4.2 The Review Group recommends that initial work with HIS 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 QMS being led by the National Screening Oversight Function. This work also links to wider related work on screening metrics being taken forward for the National Screening Oversight Board.
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