Guidance

Breast screening: best practice guidance on leading a breast screening service

Published 1 November 2018

This guidance is aimed at those who are responsible for making sure breast screening services are managed in a professional and effective way. This involves meeting agreed standards and continually striving to improve performance.

The NHS breast screening programme (BSP) covers the screening pathway from identification of the eligible population to diagnosis of women with breast cancer.

The role of director of breast screening is crucial in providing the leadership and effective organisation of a breast screening service. This guidance aims to help the directors and senior leadership teams of breast screening services appreciate the full range of their responsibilities. It signposts to other guidance to support and inform them.

1. Senior leadership team roles

1.1 Director of breast screening

The director of breast screening has overall accountability for the safe and effective delivery of the local breast screening service. This is from the identification of the eligible screening cohort to the point of diagnosis as commissioned by NHS England.

The director of screening:

• has responsibility for the leadership, management, performance, quality, governance and co-ordination of the service
• provides leadership and is a role model for the delivery of compassionate care within the breast screening service
• has suitable competencies, skills and experience for this leadership role

The director of screening is usually a consultant breast radiologist, consultant practitioner or breast clinician experienced in the full range of triple assessment.

Alternatively, they can be a consultant from within the breast screening service. For example, a breast surgeon or breast histopathologist. In these cases, they also need a lead radiology advisor who is a consultant radiologist, consultant practitioner, or breast clinician experienced in the full range of triple assessment to support the role.

The director is usually appointed following an internal process within the host trust. If appointed by an organisation external to the host trust, it is essential that managerial structures and clear lines of accountability and responsibility are defined between the appointing organisation and the host trust. Directors new to the role must agree with the trust that they receive appropriate support, such as mentoring or pairing with an experienced director. They must quickly develop a good understanding of the BSP at a local level to allow them to fulfil their responsibilities.

The director of breast screening must have a job description that outlines their overall role within the local screening service. This should include clearly defined and documented clinical and management responsibilities with accountability structures within the service and the organisations where the service is hosted.

Management accountability

The director of breast screening:

• makes sure lines of accountability and responsibility within the service are identified and documented and that this is clearly defined if the service refers women for treatment across trust/healthcare boundaries
• is accountable for budgetary planning and management to make sure the service can meet agreed standards
• is accountable for programme management activities
• is responsible to the chief executive of the trust or organisation in which the service is based
• makes sure the service complies with conditions documented in the national breast screening service specification
• provides assurance that disclosure of audit/duty of candour guidance responsibilities are adhered to
• with the host trust, supports the health and wellbeing of staff by making sure relevant legislation, for example, health and safety and radiation protection, national guidance and local policies are correctly implemented
• provides assurance that screening safety incidents and serious untoward incidents (SUI) are reported within the trust and to the screening quality assurance service (SQAS) in line with local trust, NHS BSP and NHS England guidance
• maintains awareness of incidents in symptomatic practice that involve staff or equipment associated with the screening service
• provides assurance that image readers and pathologists reporting images and material participate routinely in external quality assurance (EQA) schemes as indicated in the breast screening service specification
• has an understanding of the local eligible population to help address issues of inequalities of access
• encourages participation in screening research trials and makes sure research undertaken locally has appropriate ethical and national research advisory committee approval
• provides assurance that all staff involved in client diagnostic work are appropriately trained and have relevant competency sign-off to meet NHS BSP standards
• provides assurance that appropriately managed systems are in place to provide all aspects of the service including:
  • staff training
  • facilities and equipment
  • call and recall
  • external provider compliance
  • risk assessment
  • quality management system
  • adherence to NHS BSP standards
  • escalating risks and issues to trust managers where required

The director should also provide assurance that all internal and outsourced or subcontracted services meet NHS BSP guidance and associated quality, safety and performance standards. This covers, for example, medical physics provision, pathology services or administrative letter outsourcing. This requires the lead trust to have internal subcontract monitoring and oversight arrangements in place.

The director must make sure the local commissioning team has approved all subcontracts, which are then listed in the NHS Standard Contract. Commissioners expect trusts that subcontract elements of their service to oversee the quality and performance of that service through standard contractual arrangements.

Clinical accountability

The director of breast screening:

• makes sure clinical policy is maintained through regular multidisciplinary team (MDT) meetings
• makes sure decisions taken about patient management at MDTs are consistent with clinical policy and are documented in one consistent record agreed by all members of the MDT
• deals with concerns about individuals working within the screening service and reporting and escalating performance concerns in accordance with trust processes
• makes sure all performance monitoring and mandatory audits are undertaken according to guidance and all performance data is reported, including:
  • national audits: NHS BSP and Association of Breast Surgery (ABS), interval cancers and others
  • KC62 Department of Health returns
  • KPI and routine monitoring statistics
• examines ad hoc audits for national collation, statistical returns and audits before submission, formally signs them off as appropriate and makes sure any resulting actions to improve performance are undertaken

Other responsibilities

The director of breast screening:

• co-ordinates the running of the service, communicating with the management and clinical leads within the trust(s), with commissioners and with screening and immunisation leads (SILs) within local commissioning teams
• works with the lead radiographer, programme manager and screening office manager to agree appropriate delegation of tasks which must be reflected in job descriptions and be adequately resourced
• takes responsibility for data accuracy, accurate allocation of named individuals on NBSS and the completeness of the NBSS record
• makes sure the service’s working environment is open and transparent, developing a learning culture and avoiding a blame culture
• works with the host trust to maintain adequate numbers of trained, qualified and competent staff to provide a high-quality breast screening service in line with national guidance
• attends regular management meetings within the host trust, programme board meetings and director of breast screening professional network meetings with SQAS (see Appendix 2)
• makes sure there are regular senior leadership team meetings with the lead radiographer, programme and screening office manager (no less than monthly) to discuss operational aspects of the programme

The independent Burns Review in 2008 stated: “The role of Director of Screening at a Breast Screening unit is of critical importance to the success of the national breast screening programme.”

The determination to excel in service quality must firstly emanate from the director of the service. They must be actively involved in the screening programme and possess suitable competencies, capability and experience. They must take overall responsibility for the service and its quality, demonstrating proactive clinical and programme leadership and acting as a role model for both service management and staff.

Transfer from screening to treatment services

Links between screening and treatment responsibility must be seamless. So that women at the end of the screening process are referred to treatment services once diagnosis with breast cancer is made explicit.

The BSP relies on systematic, specified relationships between screening services and stakeholders, which include treatment services, histopathology, laboratories, genetics services, external diagnostic services, primary care representatives and others.

The director of breast screening (or designate) should take the lead in making sure inter-organisational systems are in place to maintain the quality of the whole screening pathway.

This includes, but is not limited to:

• providing coordinated screening across organisations, so all parties are clear about their roles and responsibilities at every stage of the screening pathway, and particularly where responsibility for a patient is transferred from one party to another
• agreeing joint failsafe mechanisms, where required, to ensure safe and timely processes across the whole screening pathway
• contributing to any initiatives led by NHS England or Public Health England to develop the screening pathway in line with NHS BSP expectations
• maintaining electronic links with IT systems, including picture archiving and communication systems (PACS) and relevant organisations across the screening pathway
• agreeing links with primary care, secondary and tertiary care

Budgetary oversight

The director is responsible for screening budget oversight and should develop a working understanding of budget management and the requirements of the service.

They should liaise with management accountants and budget managers to understand the total budget for screening and have an understanding of revenue (if tariff driven) and costs – both pay and non-pay and how to balance the service’s budgets.

The director must work with trust management and commissioners in reviewing service needs and managing the budget.

The director’s budgetary responsibilities include:

• working collaboratively with commissioners in reviewing the service in line with service specifications and needs, for example resulting from SQAS reports
• considering the eligible population, running costs, new programme guidance and new service developmental costs resulting from changes in practice which would require a change in resources or equipment replacement
• meeting regularly with trust management to review service needs and costs

The day-to-day management of the budget will usually be delegated to the programme or screening office manager.

Appraisals and continuous personal development

The director of breast screening must be appraised annually and trusts should allow for input from a second appraiser with experience of breast screening if the appraiser is not the service line manager or lead.

The director of breast screening is responsible for making sure all breast screening staff are appraised annually by their line manager.

The role of medical appraisal and revalidation is directed by the General Medical Council (GMC) for medical workforce.

The appraisal process must include NHS BSP professional measures and standards and the service must regularly review the appraisal process.

Image reader appraisal should compare performance against national programme standards and outcomes such as film reader quality assurance (FRQA) from the breast screening information system (BSIS). Same site previous assessment and interval cancer reviews should also be included in the discussion.

Identified continuing professional development (CPD) needs should be recorded in the appraisee’s personal development plan (PDP). CPD needs may be identified:

• during participation in EQA training
• as a result of new technologies or changes to working practices
• from a performance review (for example from BSIS or assessment and interval cancer reviews)

CPD processes should follow the appropriate professional guidance where available.

The director of breast screening should develop similar processes for staff who are appraised by another organisation, for example staff who hold honorary contracts, locum staff or staff in hub and spoke models.

Time commitment for role

The trust must provide the director with adequate time to carry out their role effectively. They must have a minimum of one ring-fenced programme activity (PA/SPA) to undertake the role, depending on the size of the screening service.

Larger services with eligible screening populations over 100,000 women must appoint a deputy director of breast screening. Directors of larger screening services will need additional PAs due to the number of staff and clinics and the amount of data they manage.

The local service model and configuration need to be taken into account. Services with multiple sites or with hub and spoke models are likely to be more complicated to manage.

A service with an eligible population over 150,000 is likely to require 1.5 sessions and a population of 200,000 is likely to need 2 sessions. This increases at the rate of 0.5 sessions per subsequent 50,000 population thereafter.

1.2 Deputy director of breast screening

A deputy director is required to share the clinical and managerial roles in screening services where the eligible population is more than 100,000 women. The deputy may also manage certain aspects of the programme independently.

Time for this should be reflected in job plans and 0.5 supporting professional activities (SPAs or equivalent) should be allocated for the deputy director of breast screening role. The deputy director works together with the director of breast screening to:

• provide joint responsibility for the performance of the service
• make sure there is continuity of the service’s leadership in the director’s absence
• ensure effective and safe delivery of the service, working with the director to apply new guidance and report any safety incidents or serious incidents
• represent the director at relevant meetings with the service managers and local commissioning teams when required
• attend programme board meetings with the director at least twice a year
• attend the director of breast screening professional network meetings with SQAS screening director’s meeting with SQAS when the director is absent

1.3 Lead radiology advisor

This role provides clinical advice and support where the director is not a consultant breast radiologist, consultant practitioner or breast clinician experienced in the full range of triple assessment.

The lead radiology advisor makes sure clinical processes and performance is adhered to. Time for this should be reflected in job plans and 0.5 supporting professional activities (SPAs or equivalent) should be allocated.

The lead radiology advisor:

• makes sure clinical protocols and pathways are defined in the service following national guidance
• understands the statistical information for the FRQA and provides image readers in the service with feedback and support
• oversees the radiological aspect of the KC62 report and advises the director to address any issues that arise
• supports the director of breast screening in local and regional meetings when required
• provides advice on emerging technologies within radiology relevant to the BSP

• supports the director with the regular radiology audits required in the screening programme, interpreting:

  • interval cancers
  • previously assessed cancer audits
  • single image reader detected cancers
  • wire localisation
  • benign excision biopsy audits

1.4 Programme manager

The programme manager is responsible for running all the non-clinical aspects of the local breast screening service. This role can be undertaken by the lead radiographer or screening office manager. Sometimes the responsibilities can be shared between several posts or individuals. The programme manager works closely with the director of breast screening and may be the first point of contact for the NHS BSP, SQAS and local commissioning teams.

In larger services of more than 100,000 eligible women population, the service may have a programme manager, screening office manager and lead radiographer. In such cases, the programme manager and lead radiographer have joint responsibility for the operational running of all aspects of the local breast screening service.

The screening director is ultimately accountable for many areas such as budget and workforce planning. However, these activities may be delegated to the programme manager. The programme manager may also support, direct and guide the screening office manager. It must be clear who is responsible for which tasks and functions with clear lines of accountability.

The programme manager is an important member of the service’s senior leadership team. They have wide-ranging responsibilities including people leadership, problem solving, developing and maintaining relationships, developing a learning culture, demonstrating and supporting resilience, developing a caring culture, acting as a professional role model and providing mentorship and coaching. This list is not exhaustive.

Depending on the organisation of the service, their specific responsibilities can include:

• the production of the 3-year screening round plan, which may be completed in liaison with the director of breast screening, lead radiographer or screening office manager
• making sure there is a local right results (patient pathway) procedure in place, which is audited annually, and that all staff are aware of their responsibilities
• making sure there is a safe and effective management of the call and recall system, including the running of failsafe batches to ensure all eligible women are invited for screening
• day-to-day management of the service budget
• monitoring and authorising expenditure against a controlled budget
• making sure systems are in place to maintain and accurately monitor expenditure
• advising of any budgetary problems and providing forecasts of expenditure throughout the year, alerting the director if the service is at risk of breaching its targets
• participating in the agreement of the service specification with local commissioning teams
• making sure a workforce plan is in place to maintain a sustainable service, taking account of changes in the eligible population and/or where there are difficulties in the recruitment of appropriately qualified healthcare staff
• making sure governance structures are in place
• making sure a risk register is maintained that fully covers the screening patient pathway and risks are escalated in line with local trust processes
• making sure processes are in place for women recalled to assessment who fail to attend
• making sure IT systems are updated as necessary and changes communicated
• effective communication with the MDT co-ordinator to make sure breast screening data is provided for discussion
• developing a knowledge and understanding of the consolidated standards (national standards) for breast screening
• discussing and resolving any issues with other breast screening services, such as boundary issues
• responsibility for the Quality Management System (QMS) through the production of work instructions, policies and procedures, periodically reviewed in line with national guidance
• making sure all staff are involved in the production of QMS and the annual audit process
• leading the screening service in routine quality assurance visits that will include making sure all required staff and facilities are available
• attending regional role specific meetings facilitated by SQAS to make sure best practice is cascaded to the service
• participating in local management meetings, such as programme board, programme management and service staff meetings
• responsibility for undertaking an annual consumer/client satisfaction survey
• undertaking audits required by SQAS such as the ceased women audit which are presented at programme board meetings
• writing an annual report to be presented at local programme board meeting
• hosting trust board meetings
• participating in health promotion activities as and when required to meet service demands
• participating in the investigation of complaints and incidents relating to the service, if necessary reporting to SQAS according to screening guidance and implement identified corrective procedures
• organising regular meetings with the screening office manager (SOM) and lead radiographer to make sure screening round length and waiting times standards are met
• liaising with the director of breast screening on matters raised by stakeholders, including screening commissioners, SQAS or the trust management team
• undertaking appraisals and overseeing staff personal development

The programme manager should make sure the maintenance of facilities and equipment is fit for purpose and meets NHS BSP standards, including mobile screening services and at all stakeholding trusts in the screening pathway. This includes:

• establishing new mobile sites when required
• the installation and annual service of electrical and water connections
• facilities for staff

The programme manager, in liaison with the screening office manager, has overall responsibility for:

• the collection and distribution of performance data
• the collection and distribution of statistical information on current workload and screening activity
• forecasts of future workload and screening activity for the planning and development of the service
• the production and validation of the central data set KC62, KC63 and the annual NHS BSP and ABS audit of screen detected cancers

1.5 Screening office manager

The screening office manager (SOM) is responsible for the screening office which provides the administrative functions for the service.

Some breast screening services share a single screening office. This is called the administrative hub model. The screening office is responsible for sending invitation letters to women eligible for screening, based on lists derived from the BS Select system. It is also responsible for making sure all women receive the appropriate right result following their screening episode.

Depending on service organisation, the SOM’s responsibilities will include:

• the ongoing maintenance of the 3-year screening round plan, monitoring circumstances so there are no delays to the 36-month recall standard
• production of regular breast screening population estimates from BS Select to help produce and maintain the screening round plan
• being the named contact point for the local management of the national breast screening system (NBSS), having a designated deputy for this role so there is system access and maintenance at all times
• issuing all user logins and passwords as appropriate
• making sure software updates are installed as necessary on IT systems, identifying and rectifying faults and issuing communications to all relevant members of staff
• working with local trust IT so that remote access to the NBSS system is available to authorised users, including NBSS Support, SQAS and the screening histories information manager (SHIM)
• developing a knowledge and understanding of the consolidated standards (national standards) for breast screening
• managing the collection of statistical information on current workload and screening activity
• managing the production of the KC62, KC63 and the annual NHSBSP and ABS audit of screen detected cancers
• managing administrative staff, their recruitment, induction, training and competency
• undertaking appraisals and overseeing staff personal development
• attending regional role specific meetings facilitated by SQAS and reviewing and making recommendations relating to NHSBSP guidelines and computer issues through the regional forum
• participating in local management meetings, such as programme board, senior leadership team and service staff meetings
• participating in the agreement of the service level specification with local commissioning teams
• participating in health promotion activities as and when required to meet service demands
• participating in investigation of complaints and incidents relating to the service and, where necessary, reporting to SQAS according to screening guidance and implementing identified corrective procedures

The SOM is responsible for day-to-day management of the call and recall system in BS Select, making sure appropriate measures are taken to invite all eligible women.

This includes:

• running monthly failsafe data batches and making sure the correct results are sent to the right women
• participating in the annual external review of BS Select undertaken by NHS Digital and the completion of recommendations

The SOM manages the processes for women recalled to assessment who fail to attend. This includes issuing of a second appointment letter. If a woman fails to attend a second time, there should be processes for contacting the woman and her primary care team to agree on appropriate further management.

The SOM is also responsible for ensuring accurate data entry on NBSS in a timely manner by all staff. This includes:

• the collection and input of pathology data for all women referred for diagnostic biopsies
• women diagnosed with breast cancer who have surgical treatment

The SOM manages the collection and distribution of NHS BSP performance data and sends information as appropriate to:

• GPs
• SQAS
• commissioners
• internal service personnel
• host trust

The SOM takes part in routine quality assurance visits which will include:

• completion of visit questionnaires and associated evidence
• helping SQAS with the organisation of the visit day

This is not an exhaustive list of responsibilities. Further good practice guidance to support the screening office manager role will be published in due course.

1.6 Lead radiographer

The lead radiographer is a member of the service’s senior leadership team. They combine clinical and management responsibilities with staff training and development functions outlined in Guidance for breast screening mammographers.

If the programme manager does not have a radiographic background, a lead radiographer must be employed. In some services the lead radiographer also undertakes the role of programme manager (see above).

The lead radiographer’s main responsibilities are to:

• lead and manage both the mammographic team and the radiographic aspects of the service, so that all examinations are of the appropriate diagnostic quality and delivered in a caring and compassionate manner
• make sure all staff work effectively within their scope of practice
• make sure all quality control checks on equipment are properly undertaken and results recorded to maximise patient safety
• maintain close links with the programme manager and SOM so that the service can meet demand and capacity requirements
• undertake audits required by SQAS, such as technical recall/technical repeat audit
• ensure a safe and efficient transition where there are changes to equipment or supplies, communicating clear timelines to staff and providing appropriate training
• manage the maintenance of mammography equipment by ensuring:
  • that timely and appropriate replacement and procurement of equipment takes place
  • a biannual medical physics survey takes place
  • equipment is maintained according to the maintenance schedule for all equipment under their control

The lead radiographer achieves the above by ensuring:

• the service complies with Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) and radiation protection guidelines to maximise patient and user safety
• regular monitoring of mammographers’ performance through peer review, image assessment and technical recall/repeat analysis
• mammography team members undertake training relevant to their scope of practice and have the opportunity to participate in CPD
• the maintenance of the balance of required skill sets within the team
• implementation of national guidelines relevant to radiographic practice at local level through the development of procedural documents and changes to practice and communication to the mammography team
• equipment quality control tests, limiting and suspension values exist and that required action is taken
• equipment faults are reported to the national database and monitored to identify trends
• local infection control and health and safety protocols are implemented and appropriate risk assessments are undertaken
• immediate reporting of radiography related incidents to the trust, SQAS, NHS BSP, national co-ordinating centre for the physics of mammography (NCCPM) and, if appropriate, the medicines and healthcare products regulatory agency (MHRA)
• any incident is promptly investigated and an action or improvement plan developed and shared appropriately
• radiographic elements of the quality management system (QMS) are maintained

The lead radiographer should attend SQAS biannual professional network meetings and regular staff meetings

2. Core management skills for the senior leadership team

2.1 Leading the team

The leadership role must be about establishing a culture where people and teams are motivated to be constructively self-critical in the pursuit of improved standards of service and outcomes for patients. The director retains accountability for the leadership of the service, but effective leadership skills are crucial throughout the service’s senior leadership team.

The director must work with the senior leadership team to establish systematic, collective, multidisciplinary appraisal of clinical performance within the service. The quality of clinical leadership is of fundamental importance to the quality of care offered by the service. The director must keep up to date with programme guidance and show commitment and engagement with external and partner organisations.

Some of the Harvard Business Review skills of a director are as relevant to the role of director of breast screening (and all other leadership roles in this guidance) as they are within the business sector. These include an ability to:

• inspire and motivate others
• display high integrity and honesty
• solve problems and analyse issues
• communicate powerfully
• collaborate and promote teamwork
• build relationships
• display professional expertise
• display a strategic perspective
• develop themselves and others
• take the initiative, innovate, and champion change

2.2 Communicating with the team

Ineffective communication is a leading cause of error and it is crucial that the senior leadership team communicates effectively to make sure the service achieves its goals. Effective communication will help to foster good working relationships between the director, the senior leadership team and across the service.

When planning communications with stakeholders, the senior leadership team should consider:

• setting a clear direction for the service to create a shared vision that helps all staff understand
• communicating to all staff why their role is important in achieving good service delivery
• communicating important messages to staff on a regular basis because reinforcement leads to action
• a variety of communication methods, including face-to-face contact that allows you to check the understanding of staff and spread knowledge and expertise
• being effective listeners and actively engaging staff, asking for suggestions and feedback
• being clear when issuing messages and directions so staff understand what action is required from them and when

3. Organisation of screening services

3.1 Important elements of a breast screening service

Each breast screening service should have:

• named director of breast screening, along with a deputy for larger services
• a named individual for the breast screening programme manager role
• named individual(s) for the SOM role
• MDT members to support service delivery, for example nursing, pathology, radiology, radiography and surgery
• digital mammography screening within accessible static and mobile screening units suitable for the eligible population, for example women with physical or learning disabilities
• screening assessment sites with appropriate access to staffing, equipment and resources to provide further imaging, clinical examination and needle biopsy (sites may or may not be co-located with symptomatic breast services)
• aligned PACS to allow image transfer and reading of images between different sites

Each service should have a QMS to support all processes. Where services are multi-organisational, protocols should be standardised. There should be screening MDT meetings for all women with a biopsy, with a minimum of one MDT meeting per week supported by teleconferencing facilities to reduce travel times where appropriate. The MDT meetings should include:

• attendance by the screening assessment team
• provision of images with lead screening radiologist providing links
• pathology, surgical and nursing representation

Unless these conditions are met, separate assessment centres must be regarded as separate services for QA and performance monitoring purposes.

3.2 Size of service

The breast screening service specification states that an individual service within the NHS BSP should serve an overall general population of between 500,000 and one million people.

In 2018, the eligible populations of breast screening services in England varied from around 25,000 to more than 254,000 with a national median population size of around 93,000 women.

Recruitment and retention of qualified staff can have a greater impact on smaller services because there may be less capacity and resilience to manage staffing shortages.

Benefits of a larger service include:

• increased staff capacity when needed
• less reliance on individuals, which can put service delivery at risk if they are unavailable
• reduced costs due to economies of scale
• more effective use of resources
• prevention of duplication of tasks and roles
• peer support to help prevent professional isolation
• prompt peer recognition of poor practice which might be more difficult for services with a lone clinician
• opportunities for rationalisation of screening facilities, such as mobile units and the number of screening assessment sites, although this must be balanced against the impact on coverage and uptake
• more choice for women for screening assessment and treatment with greater flexibility of screening sites offered within the programme, and more flexible use of assets such as mobile vans across the service
• robust statistical analysis of key performance indicators (KPIs), to monitor service performance and delivery

Smaller service size can lead to statistical instability, making the interpretation of performance data problematic.

The decision to merge or reconfigure screening services needs to be a tripartite agreement between commissioners, SQAS and the NHS BSP national programme team.

There must be full justification for any service redesign or reconfiguration which must be fully costed to include all relevant IT developments. There must be:

• an experienced project manager to oversee the entire process
• expertise in project management, IT and information governance (IG) to ensure the success of complex service delivery changes

Cancer screening programmes rely heavily on IT systems for safe and effective operation. Changes with the potential to disrupt or destabilise these systems must consider the risks and benefits and ensure the necessary governance oversight is in place.

Benefits and disbenefits of reconfiguration must be balanced to make sure disruption to operational delivery is minimised. There must be a clear advantage to undertaking any reconfiguration.

3.3 Service models

There are a variety of service models ranging from single trust/provider to multi- organisational hub and spoke models (see appendix 3). These include:

• a single provider or trust that provides all functions from screening to treatment
• multi-provider, multi-site models where image reading and onward functions take place at more than one site or provider
• multi-provider, multi-site models where assessment and everything afterwards takes place at more than one site or provider
• multi-provider, multi-site model where functions after assessment take place at more than one site or provider (for example pathology, surgery, nursing)

A number of services in larger communities have streamlined their organisation by using a single administrative hub for the call and recall function feeding a range of screening centres. This can be a complex arrangement with a number of questions to be considered. These include:

• where does the governance responsibility for the administrative hub lie?
• who is the director of breast screening for the administrative hub and how do they communicate with the screening units?
• how do the screening services communicate routine recall and recall to assessment results back to the administrative hub?
• how are complaints managed if the fault lies in the administrative hub that may belong to a different trust to the screening service and vice versa?
• how are the right results processes quality assured and checked if the call and recall system lies outside of the screening service?

These issues may be resolved through:

• collaborative planning with services
• formalised data sharing arrangements and service level agreements
• a mixture of agreed central and local responsibilities
• management of incidents or near misses by joint reporting and escalation via the same route

3.4 Governance structure

The screening service must have a documented governance structure that shows how activities happen and the whole time equivalent (WTE) allocation for each function. This includes:

• day-to-day operational working
• line management
• clinical accountability
• reporting and escalation of issues, risks and incidents

The documented governance structure must clarify the divisions between functions delivered for the screening service and for allied services provided by the trust or provider. This is particularly important where functions overlap, for example with:

• symptomatic breast service
• pathology services
• imaging service
• treatment services

The structure must take into account functions delivered from multiple sites, particularly where multiple trusts or providers are involved.

3.5 Stakeholders

Partnership working and communications are important for the provision of a successful screening programme. It is important to identify your stakeholders, including:

• senior management within the trust or screening organisation
• commissioners
• screening and immunisation teams within NHS England local commissioning teams
• SQAS
• national NHS BSP team
• local treatment centres
• the breast screening service team
• all disciplines within the diagnostic pathway
• other screening services

3.6 Defining responsibility for screening and treatment

If screening, assessment and treatment is not co-located, it is important to have good communication between the different organisations providing elements of the screening pathway. Surgical biopsies, elements of treatment work-up, pathology reporting and high-risk screening may all be done by organisations outside the host screening service.

The director of breast screening must make sure that all parties are clear about their roles and responsibilities at every stage of the screening pathway. There must be a seamless pathway between screening responsibility and treatment responsibility.

The director is responsible for the provision of the screening pathway commissioned by NHS England. This responsibility includes:

• cohort identification and invitation
• initial mammographic detection of abnormality
• assessment and MDT process to diagnose or exclude malignancy (including pathology outcomes)
• surgical biopsy

The treatment service is responsible for providing support for therapeutic procedures (such as the insertion of wires and procedures to support therapeutic surgery pre-operatively). All parties must be clear about their roles and responsibilities at every stage of the screening pathway, particularly where responsibility for a patient is transferred from one party to another.

The treatment pathway is the responsibility of the host trust providing care which is commissioned by local clinical commissioning groups (CCGs). This covers:

• therapeutic surgery
• adjuvant and neo-adjuvant hormonal and chemotherapy
• radiotherapy

The NHS England local commissioning teams are responsible for making sure services contracted to provide a breast screening service have adequate staff, equipment and training resources and that appropriate clinical governance arrangements are in place.

The director of breast screening’s responsibility ends at the point of diagnosis. Therapeutic surgery, surgical pathology (including stage and receptor status) and imaging equipment of therapeutic specimens are outside the remit of the screening programme.

An exception to this rule is where pre-operative procedures (including wire localisations) for impalpable lesions are undertaken to identify the abnormality at surgical biopsy. Otherwise, responsibility for the care of women in the treatment pathway lies with NHS England. Annual national audit data is collected by NHS BSP and shared with the ABS.

Directors of breast screening must report audit data and KPIs to include any information on outlier performance across the diagnostic and treatment pathway. This data should be reported directly to responsible service leads. This ensures that internal or treatment services can examine and audit performance so that corrective action is taken as appropriate. The director cannot be held accountable for performance beyond the scope of screening.

4. Breast screening service workforce

4.1 Training

The director has overall accountability for making sure all service staff are appropriately trained to meet their job descriptions. Training and development for all staff is an important consideration to maintain an effective and safe service.

All staff should follow local and national NHS BSP guidance and professional guidance where applicable.

The national training centres have a continuing role in supporting ongoing education and development of staff working within the breast screening service.

Their role includes:

• training new entrants into the speciality
• organising refresher courses
• providing individual tuition for radiologists with a development requirement
• reacting to the training needs identified by the various professional QA groups

Training centres should be registered for Continuing Medical Education (CME) points or equivalent for activities that are relevant to breast screening radiology .

4.2 Recruitment

Recruitment of staff in a breast screening service is a joint responsibility between the director of the service and the local trust.

Recruitment of locums

A medical practitioner in locum tenens is someone temporarily covering a vacancy in an established post. Any locum appointment must:

• be made with the same care as a substantive appointment
• meet the entry criteria for the post
• meet patient safety requirements that all medical appointments must be properly trained and qualified for their role
• not be employed until all necessary employment checks have been conducted satisfactorily by the employing organisation, including communication skills
• offer appropriate induction for their role and appropriate supervision and mentorship, including induction into local clinical protocols, with examples including:
  • health and safety training
  • equality and diversity awareness
  • an introduction to patient safety
  • orientation of department and all IT systems

On successful completion of an agreed probationary period and evidence of induction and feedback from the mentor, the locum can start an independent clinical role within the NHS BSP.

See NHS Employers’Guidance on the appointment and employment of NHS locum doctors.

Recruitment from abroad

It can be difficult to evaluate the training and experience of candidates recruited from abroad. It can help to consider the following questions:

1. Have they worked in screening in a previous role?
2. Have they trained in a dedicated breast unit (how many cancers)?
3. Have they been part of an MDT?
4. Are they experienced in ultrasound and stereotactic biopsy?
5. Has there been an assessment of communication skills?

The service must make sure there is appropriate supervision for recruits and that they are on a probationary contract. A specific training programme will include:

• an in-depth understanding of breast disease and the nature of breast cancer development
• a clear understanding of the role of imaging in the early diagnosis of breast cancer
• development of clinical and management skills to enable radiologists to play an integral role in the MDT in screening and symptomatic settings

Training must take place in a team with access to full clinical service for breast imaging and diagnosis.

Where a service needs to recruit staff from abroad a number of areas have to be considered including pre-employment checks to verify that individuals meet the preconditions of the role they are applying for. The NHS Employment Check Standards outline the employment checks employers must carry out for the appointment and ongoing employment of all NHS staff in England.

It is the responsibility of employers to make sure prospective employees have adequate language and communication skills to perform their role.

Advice for trusts considering employing doctors from abroad can be found on the Royal College of Radiologists website. This contains information specifically for radiology but is relevant across a range of disciplines.

The RCR Global Fellows – Earn, learn and return scheme helps organisations recruit and support radiologists from abroad.

5. Acknowledgements

Many thanks to the working group for their invaluable contribution to the development of this guidance. The working group consisted of Claire Borrelli, Anna Follows, Alysa Page, Caroline Dobson, Dr Alison Duncan, Donna Garment, Sheena Hilton, Jacquie Jenkins, Emma O’Sullivan, Dr William Teh, Dr Alexandra Valencia and Phil Walker.