Review of Breast Screening Services Cheshire Warrington & Wirral Final Report

Transcription

1 Review of Breast Screening Services Cheshire Warrington & Wirral Final Report Page 1 of 63

2 Review of Breast Screening Services Cheshire Warrington & Wirral Final Report First published: April 2014 Prepared by Richard Freeman, Dr Helen Lewis-Parmar and Antoinette Doyle Page 2 of 63

3 Table of Contents Executive Summary... 4 Introduction and Background... 7 Purpose of the Review... 8 Methodology... 8 Scope... 9 Constraints... 9 Issues and findings... 9 Coverage and uptake... 9 Uptake by screening round and coverage Breast screening coverage in vulnerable groups Programme size and assessment of potential configurations Age extension in breast screening Horizon scanning Potential reconfiguration options Compliance with Quality Assurance standards and the national service specification.. 24 Staffing Succession planning The breast screening pathway and links to symptomatic services MDT Composition and Links Support services Women s Involvement and Experience Service costs Options to be appraised Benefit criteria Options appraisal Operational Model Conclusions and recommendations Next Steps Acknowledgments Appendix A: Issues vs Investigations Matrix Appendix B: Key to Practice maps Appendix C: Practice population, uptake and coverage Appendix D. Breast Screening Service User Questionnaire Page 3 of 63

4 Executive Summary This final report sets out the result of investigations into issues identified as important in the review of breast screening services for the Cheshire Warrington and Wirral area. An earlier version of this report was shared with stakeholders and we are grateful for their feedback to inform this final version. The review was established due to a QA finding that the Chester Breast Screening Programme (BSP) size was below recommended levels. It was decided that the review should cover all BSPs in Cheshire Warrington and Wirral because other BSPs were also below the nationally specified size. The size of BSPs is important because sufficient size can provide: Economies of scale to make efficient use of NHS resources Robust statistical analysis of programme performance and quality Professional peer support and challenge to clinical practice within a team environment A more attractive recruitment and retention offer to clinical staff Flexibility of service delivery Greater choice to women of service offer It is accepted that there are downsides to increased size as well, for example travel time in working between sites and a risk of less personal service. However, the national service specification is clear that BSPs should serve a population of no less than 500,000 and up to about 1 million; these figures are taken as a necessary end-point for any service changes. The Chester, Crewe and Wirral BSPs are all well below this level and the East Cheshire/Stockport BSP is just below it. Only the Warrington, Halton, St Helens & Knowsley BSP is currently of sufficient size. There is also potential that the Stockport part could be moved in the future to a GM BSP, resulting in the East Cheshire BSP being well below the necessary size. We conclude that the Warrington programme does not require any change but that changes to all other configurations should be considered. We therefore identified potential configuration options that would meet the specified size. We concluded that No Change should not be an option because it does not address the programme size issue and also because of a risk of future staffing difficulties in smaller BSPs. We identified possible criteria against which to evaluate the options and that the following should be used for evaluation: Population served Links to clinical networks Page 4 of 63

5 Support services We recommend that the Wirral and Chester BSPs should be merged as soon as possible. This option provides the necessary population size and links with current clinical networks. In our interim report we recommended that the Crewe and East Cheshire/Stockport BSPs should merge. Following feedback, we now understand that a federated breast service is planned to be established across Mid Cheshire and North Staffordshire. Should this development be confirmed we recommend that the screening service should be aligned with the federated breast service. However, we note that the federated arrangement may require public consultation and agreement with CCGs and NHS England s Specialised Commissioning function. This will leave the East Cheshire & Stockport BSP serving a population of around 475,000 against a nationally specified minimum of 500,000. However, we are aware that work is ongoing to transform services in the GM South Sector, which may affect breast symptomatic services and therefore may have implications for screening services. It would be sensible to await developments before any decisions are taken on this BSP. We identified the following important factors that should be part of the operational model for delivering the reconfigured BSPs: Maintaining access to all existing primary screening and screening assessment sites Maximising population coverage and reducing inequalities, especially for vulnerable and deprived groups Providing accessible screening and assessment services Ensuring a single fully functioning Multi-Disciplinary Team which provides effective clinical decision-making Facilitating development and sustainability of the workforce Meeting and, if possible, exceeding QA standards Providing an excellent patient experience in line with the 6C s Minimising programme costs for the required service provision and quality We considered the procurement and contracting route for merging the programmes and reviewed guidance from Monitor. We concluded that it is important to maintain alignment of symptomatic and screening services to ensure safe, effective and efficient care. We recommend that the merger results in a lead provider model, whereby some elements of the service are sub-contracted to other providers as necessary. We also recommend that the lead provider should be a current provider of symptomatic breast services within the clinical network. Page 5 of 63

6 We recommend that discussions should be held with current providers of programmes that are due to be merged with the intention of: Maintaining access to current screening and assessment sites, irrespective of lead provider Discussing whether a consensus can be reached on how to merge the programmes Gaining clarity on the staff and infrastructure that could be included in the merged programme and any associated costs Our preferred solution is for a suitable consensus solution to be achieved. However, should a consensus solution not be reached, we recommend that a tender exercise should take place that is restricted to current providers of the programmes. Since it is likely that the unsuccessful bidder will be a sub-contractor it is important that each bidder is transparent about the facilities and staffing that would be open to the successful bidder. This must include ensuring that the costs to be charged for any facilities and staff are the same whether or not the bidder is the lead provider or subcontractor. We also recommend that the tender process should be competitive dialogue, whereby bidders would submit tenders that are evaluated and on which feedback is provided. Bidders would then be able to resubmit their tenders based on the feedback. This could continue for a number of iterations until they are finalised and a decision made. We recommend that the evaluation criteria for agreeing a consensus solution or for a competitive process should be: Ability to deliver a high quality user experience complying with the 6 C s Ability to deliver the national service specification and the operational model Good value for money Achievement of QA standards Ability to mobilise the new service without disruption to patient services Formal sign-off by NHS England Area Directors NHS England will expect of the appointed lead provider that service costs are contained within existing resources. Any one-off set-up costs for merging services should be funded by reducing recurrent costs through service efficiencies. Page 6 of 63

7 Introduction and Background NHS England is responsible for commissioning breast screening services and should work with patients and clinical staff so that women receive high quality, cost-effective, evidence-based services that meet nationally defined service specifications. Breast screening is offered to all women aged 50 to 70 with a randomised trial in operation for women aged 47 to 49 and 71 to 73, whereby a proportion of women are invited for screening and the remainder are not. Women can self-refer in these age groups if they are not invited at the time of their screening round. Within the Cheshire, Warrington and Wirral (CWW) area there are currently five Breast Screening Programmes (BSPs), two of which are cross boundary with neighbouring Area Team areas. The programmes are summarised in the table below: Table 1: Summary of CWW Commissioned Breast Screening Programmes NHS Breast Screening Programme Number of women Age 50 to 70 Partial age extension* Full age extension Age 47 to 73 Chester 26,043 29,687 33,332 Crewe 42,629 48,627 54,626 East Cheshire and Stockport 70,449 80,362 90,275 Warrington, Halton, St Helens 77,134 87,825 98,516 and Knowsley Wirral 51,241 58,173 65,105 *Partial age extension is a 50% randomisation of women aged and The CWW Area Team has identified that current breast screening services do not meet the national specification. The Chester BSP does not meet the minimum size standard as defined by the QA programmes and other programmes, whilst meeting QA required sizes, remain relatively small, are below national service specification minimum sizes and have issues with their future sustainability in respect to the recruitment and retention of staff. The requirement to increase the size of the Chester BSP by merger with another programme was recommended as an urgent action in November 2012 following an External Quality Assurance visit from the regional Breast Screening Quality Assurance team. In order to consider the full range of options concerning the future programme configuration for breast screening services across CWW it was decided it was necessary to review all commissioned programmes to ensure full consideration of the screening pathway including the interface with symptomatic and treatment services. Page 7 of 63

8 Purpose of the Review The main purpose of the project was to commission breast screening services for the eligible population of Cheshire, Warrington and Wirral that meet, and ideally, exceed quality standards, maximise coverage, reduce health inequalities and are good value for money. Methodology The review was conducted by the Public Health section of the CWW Area Team. A project working group was formed including Public Health (PHE), Quality Assurance, Commissioning, the Cheshire and Mersey Cancer Network, Patient Experience Representation, Call/Recall and Finance. The role of the project team was to undertake the review and implement any agreed outcomes. A stakeholder group was formed alongside the project group so that those affected or with an interest in the review s outcome could contribute to the review and be kept informed of progress. Initial information gathering and interviews took place in July and August 2013, followed by a Stakeholder Workshop in September 2013 to feedback initial findings. Participants were asked to identify missing or inaccurate information, to identify requirements for further information and to suggest potential options for appraisal. Following the workshop an Issues vs. Investigations matrix was produced (attached as Appendix A), which formed the basis for the second phase of work. The review consisted of: Meetings with staff at the current programmes Gathering information about current services. Reviewing services against good practice guidelines and specifications. Identifying benefit criteria against which options will be assessed. These could include clinical quality, improving population coverage, patient experience, links to treatment services etc. Identifying options for the future of services Appraisal of the various options using the benefit criteria Identifying the preferred option based on the options appraisal Working through the detailed implications of the preferred option to identify risks and how to mitigate them Developing a project plan for implementation of the preferred option if approved An interim report was produced in November 2013, followed by a second Stakeholder Workshop at which presentations were made concerning the report s findings and initial feedback was received from participants. The workshop also considered how any reconfiguration should be undertaken. Reports have been produced summarising the November workshop and comments on the interim report. These have informed this report. Page 8 of 63

9 Scope The following are included within the review: All BSPs operating within the Cheshire Warrington and Wirral area (where Area Teams share BSP provision, e.g. East Cheshire & Stockport, only the CWW element is in scope, although implications to external areas will be considered) Pathways into symptomatic services Ensured provision of core support functions e.g. pathology, call-recall provision The following services are outside the scope of the review: BSPs operating in Wales and areas adjoining CWW Symptomatic service provision Treatment services Constraints The project had the following constraints: National service specification requirements Existing estate for BSP provision Quality Assurance requirements Relevant legislation and policy Organisational structures are new and roles are taking time to clarify Difficulties in obtaining data, especially around inequalities Issues and Findings The sub-sections below identify issues relating to the breast screening programme, together with findings to date on each issue. This is intended to inform identification and appraisal of options, together with how services will be commissioned in the future. Coverage and uptake The proportion of eligible women that attend breast screening within each BSP is measured by the KC62 return for the incident (women with a previous screening episode) and prevalent (first time of invitation). Quality Assurance standards and the national service specification set a 70% minimum and 80% achievable target for both the incident and prevalent attendance. At a population level coverage (proportion of women resident and eligible for screening that have had a mammogram at least once in the last three years) is measured. This is available at CCG and GP practice level. Women ineligible for screening e.g. those with bilateral mastectomy are excluded. Practice level uptake data is also collected by each screening programme within the screening round. High breast screening coverage is important to achieve the best outcomes for women in the reduction of mortality and morbidity from breast cancer. Screening services with high uptake and coverage also need to be cost effective. In order to achieve the best outcomes in screening we will be working with providers to aim to achieve the 80% coverage. In the context of breast screening, key factors include the maintenance of the 36 month round length and provision of screening and screening assessment at accessible locations that meet the needs of women including those in vulnerable groups e.g. women with physical and or learning disabilities, women from low socio-economic Page 9 of 63

10 groups, prisoners disabled and women from minority ethnic groups less likely to access screening. The CWW BSP s each overall meet the minimum 70% target for eligible women attending screening in the prevalent cohort and the 80% achievable target in the incident cohort. However within each programme there is variation at a local GP practice level with lower coverage seen in areas with higher deprivation and with more ethnically diverse populations. Within this report a target 75% overall coverage will be used to reflect the ambition to increase coverage to 80%. Coverage figures for eligible women aged age group was only available for the Wirral BSP. For the other programmes the nationally available dataset of coverage of eligible women aged was chosen in preference to the age age cohort because this was considered to more accurately reflect programme performance, as the age does not allow for the programme round invite time and the impact of partial age extension and would underestimate coverage figures. Map 1: CWW Commissioned BSPs by GP Practice Map1 shows the location of breast screening services for the five breast screening programmes serving the population of Cheshire, Warrington and Wirral and the coloured dots are the GP practices served by each BSP. It can be seen that the BSPs are broadly aligned with CCG or local authority boundaries. The main exceptions are the Wirral BSP providing screening for women from three Western Cheshire practices, close to the Wirral border, and the Warrington Halton, St Helens and Knowsley BSP providing screening for Helsby and Frodsham women Page 10 of 63

11 (screening provided by mobile van in the locality, practices identified on the map but site locations for mobile van not identified). The main screening unit for all programmes are co-located with screening assessment and symptomatic breast services. The Wirral and Warrington Halton, St Helens and Knowsley BSP s have second static digital screening units providing initial mammogram screening for CWW women. Uptake by Screening Round and Coverage The screening round is organised by GP practice on a three year rolling basis. Women are offered screening when their practice population is due for invitation. This should be within the round length time period of 36 months (full screening round). Uptake by screening round is the proportion of women invited from that GP practice that attend for screening. This information is fed back to GP practices after the invite period by the CWW commissioned BSPs. Uptake by screening round differs from coverage because the coverage measure is also dependent upon other factors including round length. Also, uptake by screening round relates to individual programme performance, whereas coverage will include women all registered with a practice independent of which programme they attend, for example practices which are on the border of a BSP may have a number of women that attend another BSP and who are not included in uptake figures but are included in coverage. The sub-sections below review coverage by practice for each BSP. Appendix B provides the key to identify practices on the maps. Appendix C includes practice level data. The purpose of this analysis is to identify any factors that may lead to lower than required screening coverage and, in particular, to check whether programme configuration or operation has affected coverage. Page 11 of 63

12 Chester BSP Coverage Map 2: Chester BSP GP Practice Locations The Chester BSP invites women for screening from GP practices that are all within Western Cheshire CCG. Women registered with Western Cheshire practices are also invited to the Crewe, Warrington and Wirral BSP s dependent on their geographical location. Coverage figures for Western Cheshire GP practices will therefore reflect the uptake performance within the related BSPs. Uptake by screening round was greater than 70% for all practices for screening rounds 6 and 7 except for one practice with a 66% uptake in Round 6 and subsequent improvement to 73% in Round 7. All practices in the Chester BSP have screening coverage (eligible women with a mammogram in the last three years aged years) above 70%, two practices have coverage less than 75% (Map identifiers 15 and 82) and 14 have coverage at 80% of higher. Both practices with lower coverage service populations with the highest levels of socio-economic deprivation in Western Cheshire. In addition to the practices identified on the map there is one practice that services the homeless population, this practice has very small number of eligible women and has achieved a 60% coverage in this hard to reach group. Page 12 of 63

13 Crewe BSP Map 3: Crewe BSP GP Practice Locations The Crewe BSP invites women for screening from three Western Cheshire CCG practices, 12 Vale Royal CCG practices, 18 South Cheshire CCG Practices and one East Cheshire CCG practice. All practices have coverage (eligible women with a mammogram in the last three years aged years) above 70%, five practices (Map identifiers 120, 91, 86, 109,137) have coverage between 70% and 75%. The lower coverage practices include two in central Crewe, one in Middlewich, one in Northwich and one in Alsager. There are isolated pockets of higher social deprivation and the Crewe area has a more mixed ethnicity with a higher proportion of the population from Polish ethnic groups, these factors may impact upon the coverage in these practices. Whilst the Alsager practice is potentially closer to cross-boundary services in Stoke-on- Trent the other practices in this area have higher coverage. Page 13 of 63

14 East Cheshire and Stockport BSP Coverage Map 4: East Cheshire and Stockport BSP CWW Commissioned GP Practices The East Cheshire and Stockport BSP invites women for screening from 21 practices from East Cheshire CCG. One East Cheshire CCG practices is linked to the Crewe BSP. All CWW commissioned GP practices have coverage (eligible women with a mammogram in the last three years aged years) higher than 70%, four practices are less than 75% (Map identifiers 134, 133, 123, 132). Five practices have coverage above 80%. One lower coverage practice is in Macclesfield close to the screening unit, the remainder are in the Wilmslow/Handforth areas that are geographically further from the screening unit. Warrington, Halton, St Helens and Knowsley BSP Coverage The Warrington, Halton, St Helens and Knowsley BSP invites women from all Warrington CCG practices and three Western Cheshire practices. Women from the three Western Cheshire practices are invited to screening in a mobile screening van that is located at sites in Frodsham and Helsby. The majority of practices have coverage above 70% (eligible women with a mammogram in the last three years aged years) with seven practices less than 75% (Map identifiers 156, 155, 141, 143, 165, 161, 152), two of which are below 70% (155, 156). These practices are located close to Warrington town centre and screening is geographically accessible within the two static screening sites. Populations registered with these practices are from the more deprived population quintiles. Lower cancer screening coverage has been identified as a key priority within the Warrington MBC Joint Strategic Needs Assessment and community based awareness raising in partnership with the Cheshire and Merseyside Cancer Network is being undertaken. Page 14 of 63

15 Map 5: Warrington, Halton, St Helens and Knowsley BSP CWW Commissioned GP Practice Locations Wirral BSP Coverage Map 6: Wirral BSP GP Practice Locations The Wirral BSP invites women for screening from all Wirral CCG practices and three Western Cheshire practices that are geographically close to the Wirral Breast Centre Clatterbridge site. Practice level coverage shows a wider variation that that seen within the other BSPs and this reflects local population factors such as socio-economic deprivation. Using coverage from the eligible population aged years, six practices have coverage less than 65% and 19 between 65-75% and 18 at 80% and over. Page 15 of 63

16 Socio-economic deprivation factors impact upon coverage and there is wide variation in deprivation across Wirral. Population dense areas such as Birkenhead and Tranmere are amongst the most deprived wards nationally in contrast to Heswall, which is in the 10% least deprived. It has been recognised that access to breast screening was an important factor in attendance and a second static digital mammography screening site has been opened at the St Catherine s Hospital site in Birkenhead which is close to and has good public transport links to the most deprived areas with the lowest coverage. The impact of this new screening site will not yet show in available coverage figures. It is understood that the service intends to consolidate a higher proportion of initial screening on this site. The impact of screening for women from areas closer to the Wirral Breast Centre Clatterbridge site will need to be monitored to ensure that this does not significantly impact upon future coverage. This may be particularly relevant to the three Western Cheshire CCG practices. Breast Screening Coverage in Vulnerable Groups It was not possible within the scope of this review to investigate breast screening coverage for vulnerable groups such as women with physical and learning difficulties as they are not readily identifiable within routinely available data. Within the recent local council completion of the Joint Health and Social Care Self- Assessment Framework for the PHE Learning Disabilities Observatory by the local available information from primary care systems reporting screening coverage for women with learning disability was included. Initial results from the Warrington area found low levels of breast screening coverage in this vulnerable group (89 eligible, 25 screened in last three years). Whilst it is accepted that these data are problematic with the possible under-reporting of both numerator and denominator, it seems that LD women are significantly less likely to access breast screening. This is likely to be the same across all BSPs and work is needed to identify any appropriate methods to increase breast screening in this group. A proportion of women with physical disability will be unable to access facilities within mobile screening units. The majority of screening in CWW is undertaken within static units with the exception of the mobile provision for the Helsby and Frodsham population provided by the Warrington, Halton, St Helens and Knowsley BSP. Women can choose to attend any of the screening sites within the programme so women unable to access the mobile provision can attend the static site at Halton. The Stockport component of the East Cheshire and Stockport BSP is delivered in mobile vans. There is an arrangement in place for women unable to access the mobile facility to be screened at the symptomatic service site at Stockport. Practice location has been used as a proxy for women from socio-economic deprived areas and areas with a greater proportion of women from minority ethnic groups has been considered and is included in the narrative above. Breast screening for women in HMP Styal is provided by the East Cheshire and Stockport BSP. Coverage figures are not available for this transient population. Uptake figures for women prisoners screened by the East Cheshire and Stockport BSP have Page 16 of 63

17 not been collated previously but it is planned that they will be collated prospectively. However, we are not aware of any difficulties in accessing screening. Conclusions Uptake and coverage across all five CWW AT commissioned programmes is generally good with the vast majority of practices above the 70% target and many above 80% At the GP practice level there is variation in coverage and we aim to reduce this variation and work towards achieving the 80% achievable target across the programmes as a whole and at practice level. Where there is low coverage at a practice level this seems to be related to population factors such as deprivation and ethnicity rather than screening site location or pathway. Low coverage in deprived areas in the Wirral population around Birkenhead has already been identified and should be addressed by the new screening site at St Catherine s Hospital. Actions to address low coverage is planned, and NHS England will be working with providers and partners such as the CCGs and local government to improve uptake of breast screening to improve outcomes for women. Further work is required to identify and implement methods to increase coverage for women with Learning Difficulties Overall this analysis has not identified any coverage based rationale for any specific future breast screening programme configuration. Page 17 of 63

18 Programme Size and Assessment of Potential Configurations The national service specification for the NHS Breast Screening Programme (Service Specification 24: NHS Breast Screening Programme April 2013) states that an individual programme within the NHSBSP should serve a population of no less than 500,000 and up to about 1 million. This recommended range of programme size is in line with the historic evidence based within the Forrest Report in 1986 which recommended that a basic screening unit should serve a population of 471,000 to give an eligible population of 41,150 women aged 50 to 64 years. Assuming that 70% of women invited accept the invitation, and including an allowance for repeat invites and for self-referrals, this gives an estimated total number of screening attendances of 12,000 per year. Forrest estimated that this would result in 696 referrals for assessment per year. It is accepted that substantial changes have been made to the programme since the Forrest report was published. However, it is clear that sufficient programme size is essential in the commissioning of the NHS Breast Screening Programme because it allows: An economy of scale to ensure the most effective use of NHS resources o Prevents duplication of tasks and roles o Reduces average costs within a programme o Offers opportunity for potential rationalisation of screening facilities e.g. mobile units and the number of screening assessment sites (needs to be balanced against impact on coverage and uptake) Robust statistical analysis of programme key performance indicators and as a marker of service quality and the quantification of outcomes for women. o Small sample sizes lead to wide confidence intervals making the interpretation of results problematic o Sub-analysis within larger programmes can still identify poor performance at an individual practitioner level, but this generally requires analysis of data collected over a longer period Prevention of professional isolation with peer support and the benefits of challenge within a team about individual clinical practice o Smaller centres may not have sufficient staff to allow for appropriate clinical provision o Allows early peer recognition of poor practice which would not be possible for services with lone clinicians Capacity and flexibility of service delivery o Larger programmes have more staff and are less reliant on one individual which puts the delivery of the programme at risk if they are not available. o More staff allows a wider scope to increase capacity where and when it is needed Page 18 of 63

19 Sustainable services that are more resilient o Smaller centres find it more difficult to attract and retain clinical staff o Smaller centres are less resilient should staff leave or are absent Larger services can offer more choice for women with respect to screening, screening assessment and treatment o Greater flexibility to attend any of the screening sites offered within the programme o More flexible use of assets such as mobile vans across the geography There are also some disadvantages of moving to a larger programme size including: Resource implications of potential procurement and implementation of new ways of working Costs and time taken for staff to travel between different sites Costs of more staff attending longer MDT meetings Staff dissatisfaction with proposed changes and potential impact on retention of current staffing particularly those close to retirement Risk of less personal service Age Extension in Breast Screening The calculation of the eligible population for the screening programmes in age extension included consideration of the shifting population age demographic. The phased introduction of age extension within the NHS Breast Screening Programme was announced by the Department of Health as part of Improving Outcomes: A Strategy for Cancer (January 2011). A phased introduction of a 50% randomisation of women aged and has been implemented. This partial age extension has subsequently been extended until at least 2016 for the programmes in the first phase of implementation. Available data on programme size and related practice based populations to be used in this analysis: Table 2 contains information on partial and full age extension based upon the predicted changing population demographic. These figures will be used for the consideration of all potential programme configurations that include mergers of whole programmes. Eligible and registered population numbers at the GP practice based level (Appendix C). These represent absolute values from the time period reported. They underestimate future eligible population size and do not include age extension population numbers. Use of registered populations excludes resident and non-registered women in programme size configurations. The eligible population figures underestimate partial age extension between 20-35%. Page 19 of 63

20 Table 2: Estimated Populations for Current Programme Configurations NHS Breast Screening Programme Number of women Age 50 to 70 Partial age extension* Estimated population* Chester 26,043 29, ,473 Crewe 42,629 48, ,540 East Cheshire and Stockport 1 70,449 80, ,930 Warrington, Halton, St Helens 77,134 87, ,143 and Knowsley 2 Wirral 51,241 58, , Based registered population for East Cheshire plus Mid-2011 CCG population estimate (ONS Census) for Stockport CCG 2- Based on registered population for Warrington plus Mid-2011 CCG population estimates (ONS Census) for Halton, St Helens and 50% of the Knowsley population. Although there are recognised limitations within the methodology for the calculation of the population served by each of the CWW commissioned BSP, it can be seen that the Chester, Crewe and Wirral programmes all fall significantly short of the recommended programme size of 500,000 to 1 million within the national service specification. The reported registered population size is greater than the ONS CCG population estimate. Given that the programmes are so far below the minimum recommended programme size it highly unlikely that any potential under-reporting would change this conclusion. At the time of the last round of Quality Assurance external visits for the programmes, only the Chester programme was identified as being too small compared to the Forrest recommendations. Benchmarking against the current recommended size range within the national service specification would identify Chester, Crewe and Wirral as programmes serving a population smaller than the recommended limit and the East Cheshire and Stockport Programme as being of borderline size. Only the Warrington, Halton, St Helens and Knowsley programme is currently of sufficient size based on population estimates. Horizon Scanning The 2010 Greater Manchester Breast Screening Review recommended the alignment of screening and symptomatic services across Greater Manchester. This was because there are a number of both small and large symptomatic units in Greater Manchester that are not co-located with the screening sites. This review led to discussions concerning the repatriation of the Stockport element of the BSP into a GM provider, although this has not progressed. If Stockport were repatriated to GM without any other changes, the remaining East Cheshire element would be well below an acceptable size. In addition, the GM South Sector review has recently been established to transform services on a collaborative basis and East Cheshire and Stockport are included within its scope. This, combined with the 2010 review, may result in changes to where symptomatic services are located and to possible implications for the Breast Screening Programme. Current service changes at the Mid Cheshire Hospitals Trust (provider base for the Crewe BSP) see an increasing relationship developing with the North Staffordshire Page 20 of 63

21 University Hospitals Trust (provider base for the North Staffordshire BSP). Discussions are underway between these providers to identify service changes that involve symptomatic and treatment pathways. Conclusions There is no rationale around programme size to alter the current configuration of the Warrington, Halton, St Helens and Knowsley BSP. The Wirral, Chester and Crewe BSP s each need to be part of bigger programme configurations. The East Cheshire and Stockport programme is just below the lowest recommended population size and its future sustainability could benefit from being part of a larger programme. There are potential changes to clinical pathways in both Greater Manchester and Mid Cheshire that may affect any reconfiguration. Potential Reconfiguration Options There clearly needs to be a significant change in programme configuration in order to achieve even lowest recommended programme size. The potential reconfiguration options based upon population size are: Chester, Crewe and Wirral BSPs into one programme Chester and Wirral BSPs as one programme, with Crewe and East Cheshire and Stockport BSPs as one programme Chester and Wirral BSPs as one programme with Crewe BSP as one programme with North Staffordshire BSP, no change to East Cheshire and Stockport BSP Chester and Crewe BSPs as one programme, with no change to the Wirral BSP and East Cheshire and Stockport BSP Split of the Chester BSP between the Wirral and Crewe BSPs with/without merger of East Cheshire BSP with new footprint Crewe BSP Increase in size of the Chester BSP with the removal in of border populations from the Wirral, Warrington and Crewe BSPs. Population and eligible population estimates for proposed options are shown below. Page 21 of 63

22 Option 1: Combined BSP across Chester, Crewe and Wirral CWW BSP s Total Population Eligible population Chester, Crewe and Wirral BSP 836, ,365 East Cheshire and Stockport BSP 474,930 94,104 Warrington, Halton, St Helens and Knowsley BSP 607,143 88,250 This option would leave the East Cheshire and Stockport BSP at just below the minimum 500,000 size and vulnerable should Stockport be repatriated to Greater Manchester, but would achieve recommended programme sizes for the other areas. Option 2: Combined BSP across Chester and Wirral, with Combined BSP across Crewe and East Cheshire and Stockport CWW BSP s Total Eligible Population population Chester and Wirral BSP 541,902 86,815 Crewe and East Cheshire and Stockport BSP 769, , ,143 88,250 Warrington, Halton, St Helens and Knowsley BSP This option would achieve the recommended minimum programme size for all areas but would create a large programme serving the Crewe, East Cheshire and Stockport populations. If screening for the Stockport population was repatriated back into Greater Manchester this would leave a combined East Cheshire and Crewe programme with an estimated total population 485,000. Option 3: Combined BSP across Chester and Wirral with Combined BSP Crewe and North Staffs CWW BSP s Total Eligible population Population Chester and Wirral BSP 541,902 86,815 Crewe and North Staffs ,700 East Cheshire and Stockport BSP 474,930 94,104 Warrington, Halton, St Helens and Knowsley BSP 607,143 88,250 This option would achieve the recommended minimum programme size for all populations but would leave East Cheshire at just below the recommended minimum programme size and vulnerable should Stockport be repatriated to a Greater Manchester provider. Page 22 of 63

23 Option 4: Combined BSP across Chester and Crewe CWW BSP s Total Population Eligible population Chester and Crewe BSP 485,013 78,668 Wirral BSP 351,429 57,697 East Cheshire and Stockport BSP 474,930 94,104 Warrington, Halton, St Helens and Knowsley BSP 607,143 88,250 This option would create a BSP for Crewe and Chester that would remain just below the minimum programme size based on population and leave the East Cheshire and Stockport Programme and Wirral BSP s at below the minimum programme size. Option 5: Split of Chester BSP between Crewe and Wirral BSPs CWW BSP s Total Population Eligible population Wirral BSP with Ellesmere Port practices 415,907 68,560 Crewe BSP with Chester practices 418,037 67,793 East Cheshire and Stockport BSP 474,930 94,104 Warrington, Halton, St Helens and Knowsley BSP 607,143 88,250 This option has split the total and eligible populations served by the Chester BSP, with Ellesmere Port GP practices included within the Wirral BSP and Chester area GP practices included within the Crewe BSP. This would create two BSPs serving populations smaller than the 500,000 minimum population size and leave the East Chester and Stockport BSP also just below minimum size. It would require women from Chester to travel to the Crewe BSP for screening, whilst Ellesmere Port women would be invited to Wirral BSP screening sites. Option 6: Increase Chester BSP by removal in of border populations from the Wirral, Warrington and Crewe BSPs. Increased Chester BSP 249,705 39,697 East Cheshire and Stockport BSP 474,930 94,104 Warrington, Halton, St Helens and 580,863 84,559 Knowsley BSP revised Crewe revised 281,897 47,364 Wirral revised 331,120 53,644 Practices selected for inclusion: From Warrington BSP Frodsham Medical Practice The Knoll Surgery Helsby Health Centre From Crewe BSP Tarporley Health Centre Page 23 of 63

24 Bunbury Medical Practice From Wirral BSP The Willaston Surgery Neston Medical Centre Neston Surgery This option does not increase the Chester BSP sufficiently. It would require a switch in screening programme provision for women in four BSPs requiring consultation. Only the Warrington BSP would be above the minimum programme size. Crewe BSP would be even smaller. Compliance with Quality Assurance Standards and the National Service Specification The eventual solution for BSPs in CWW must ensure that programmes meet, and ideally exceed if possible, QA standards. Three year KC62 compliance against the minimum and achievable quality assurance standards are summarised within Table 3. The three year average figure is used to allow for variation due to small sample size. This reinforces the requirement for larger programme size to allow a suitable sample size to assess against the quality assurance standards. Overall attendance meets the achievable standard for prevalent and the minimal attendance for incident cohorts. All programmes have areas RAG rated RED against the QA standards. Compliance against these standards is vital in assuring the quality of the breast screening programme. For example, low in-situ carcinoma detection rates may indicate that cases may be being missed (although this may be the result of small population sample size). A high proportion of women being referred to assessment may mean that they are being unnecessarily referred with resultant anxiety and additional testing. A high benign biopsy rate indicates that more women are having unnecessary biopsies than would be expected. We recommend that historical performance against these standards should not form part of the criteria to be used in the decision concerning future programme configuration, but we argue that it supports the need to increase programme size. We will be working with the Quality Assurance programme and all commissioned BSPs to support the achievement of these standards within the new programme configurations. All CWW commissioned BSPs are currently working towards full compliance against the national service specification. The main areas outstanding are: Split between screening and symptomatic budgets and resource (staffing, equipment) Compliant radiographic staffing levels (Chester compliant) Second timed appointment (Wirral compliant) Arrangements for the screening of high risk women The 2014/15 national service specification is now available and the future configuration BSPs will be expected to be compliant. Page 24 of 63

25 Table 3: KC62 Performance Summary Standard % eligible women who attend for screening Overall % eligible women who attend for screening Prevalent % eligible women who attend for screening Incident Rate of invasive cancers - Prevalent Screen Rate of invasive cancers - Incident Screen Rate of in situ carcinoma detected - Prevalent Screen Rate of in situ carcinoma detected - Incident Screen Standardised Detection Ratio - Prevalent Screen Standardised Detection Ratio - Incident Screen Rate of invasive cancers <15mm diameter - Prevalent Screen Rate of invasive cancers <15mm diameter - Incident Screen % women referred for assessment - Prevalent Screen % women referred for assessment - Incident Screen % women on short term recall % women who have a non-operative diagnosis Rate of benign biopsies -Prevalent Screen Rate of benign biopsies - Incident Screen Regional (NW) Chester Crewe East Cheshire Warrington Wirral Min Ach stand Page 25 of 63

26 Staffing The recruitment and retention of staff is an issue across all NHS Breast Screening Programmes but the impact of a failure to recruit impacts differentially on smaller breast screening programmes because there is less capacity within the service to manage staffing absence pressures. Smaller breast screening programmes can also find it harder to recruit new staff. All CWW commissioned breast screening programmes were asked to provide detail on current staffing complement and staffing vacancies. Staffing in breast screening services often work within symptomatic services as well as in screening and BSPs have not historically mapped staffing individually from a screening perspective. All five BSPs have an identified Programme Director; this is a Consultant Radiologist in all programmes with the exception of Chester, where a Consultant Pathologist is the Programme Director. Within the QA standards only the dedicated screening radiology staffing level is quantified with a minimum level of staffing based upon the eligible population and uptake within the programme. Three of the five BSP s have identified shortfalls in screening dedicated radiographic staffing as outlined in the table below: Table 4: Shortfall against QA Recommended Radiography Staffing Levels by Programme East Cheshire Warrington Chester Wirral Crewe & Stockport 1.6 wte Nil identified Nil identified 2.3 wte 2.0wte Although other staffing requirements are not quantified within the QA standards, the QA process reviews the overall screening pathway and identifies where the current staffing arrangements are not able to fully support the programme. Dedicated Programme Manager activity sessions (these can be within administration or managerial roles) are essential, and whilst these have not been formally quantified within the QA standards, a minimum of five dedicated sessions is thought to be required by programme dependent on previous experience and programme size. The table below shows programme management sessions by BSP. Table 5: Dedicated Programme Manager Activity Sessions (Admin/Managerial) East Cheshire Warrington Chester Wirral Crewe & Stockport Currently only the Warrington programme has identified more than five dedicated programme manager sessions, with other programmes at five or less sessions. Since Warrington is the largest programme this would have to be investigated to determine if this is sufficient. The provision of dedicated programme manager sessions is expected to be highlighted within the forthcoming QA visiting round. Page 26 of 63

27 There are reported vacancies at East Cheshire & Stockport and Chester BSPs for clerical support, Wirral BSP for Pathology and support worker, and Crewe BSP for Assistant Practitioner. Only Warrington reported no current vacancies, although an interim arrangement is currently in place following the retirement of the Superintendent Radiographer. Succession Planning Succession planning is a key issue within the BSP s and whilst the programmes may currently have staff in post, many key staff are approaching retirement age, which could impact on the future sustainability of the programmes. Table 6 summarises our understanding of possible future retirements. Table 6: Summary of Reported Current Expectation of Future Retirement East Cheshire & Stockport Retirement of Programme Manager/ Superintendent Radiographer. 0.6 WTE radiographer retiring March Associate Specialist leaving in November 2013 Warrington Chester Wirral Crewe Flexible retirement plans in place Nil Two pathologists expected retirement 2014 Retirement 0.4 Radiographer 2014 All programmes with the exception of the Chester BSP have reported that senior members of staff may wish to retire in the near future. Given the existing issues with recruitment and the timeline for staff training this is a considerable issue for the programmes. A possible benefit from merging BSPs is the flexibility to utilise staff across different sites. This can reduce the need for locum staff and ensure that clinical sessions are covered. However, this requires reasonably easy travel between sites and compatible clinical systems. Travel times (taken from Google Maps) are summarised in the table below, but exclude any allowance for parking, which can be an issue on busy hospital sites. Page 27 of 63