MODULE B – PERFORMANCE REQUIREMENTS – SPECIFICATION, QUALITY AND
PRODUCTIVITY
SECTION 1 – SPECIFICATION
Care Pathway/Service
Breast Familial Mammography service Final
Commissioner Lead
NHS North Lancashire – Lead commissioner
Provider Lead
University Hospitals of Morecambe Bay NHS Foundation Trust(UHMBFT)
Period
Applicability of Module E
(Acute Services Requirements)
1st August 2012 to July 31st 2015
1. Purpose
1.1 Aims
To provide mammography for the breast familial history service
1.2 Evidence Base
2007(DH) The National Cancer Reform Strategy
2008( NW SHA) The North West Cancer Action Plan.
NICE 2004 Familial breast cancer: the classification and care of women at risk of familial breast
cancer in primary, secondary and tertiary care Clinical guideline 14
NICE 2006 Familial breast cancer: the classification and care of women at risk of familial breast
cancer in primary, secondary and tertiary care Clinical Guideline 41 (Partial update of NICE clinical
guideline 14
NHS Breast Screening Programme 2005 Consolidated guidance on standards for the NHS Breast
Screening Programme NHSBSP No 60 (version2)
NHS Breast Screening Programme (2009) Guidelines for managing incidents in the breast screening
programme 3rd Edition NHSBSP No 44
UK National Screening Committee 2010 Managing Serious incidents in the English NHS National
Screening Programmes: Guidance on behalf of the UK National Screening Committee Version 4.0
1.3 General Overview
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The National Cancer Reform Strategy 2007 recommended that the NHS Breast Screening programme
will take responsibility for the management of surveillance for women at high familial risk of breast
cancer. This guidance was reinforced within the North West Cancer Plan of 2008.
Within the North West Cancer Plan it stated that:
Pledge 9: We will review and enhance capacity within our breast services to
ensure that we meet the new standards including the introduction of digital
mammography. Those with a high familial risk of breast cancer will be kept
under surveillance through the breast screening service. We will see greater
integration with the symptomatic breast services. This will be fully implemented
by December 2012.
1.4 Objectives
To transfer the responsibility for the management of surveillance digital mammography for women
of medium familial risk of breast cancer within the local breast screening programme; North
Lancashire and South Cumbria. The service will aim to introduce high risk women once the guidance
is formalised and the national breast screening specification is available in 2013.
The rollout of digital equipment within UHMBFT was completed in April 2012, which now allows the
service to progress.
2. Scope
2.1 Service Description
UHMBFT is to undertake screening mammograms and assessment to NHS BSP standards for those
patients identified as being at raised risk of developing Breast Cancer as a consequence of family
history assessment as agreed Familial Breast Pathway (appendix A).
The provision of services will be in 2 parts:
o
Part A – A cost per case agreement for familial breast surveillance mammograms reported to
NHS BSP standards.
Patients will be referred to the Breast Screening Service at the Royal Lancaster Infirmary,
UHMBFT from the Family History Clinic provided by Blackpool Teaching Hospitals NHS
Foundation Trust, and from women from Central Lancashire(Preston locality).
The breast Screening service will offer patients an appointment for routine breast screening
mammograms within six weeks of the screening commencement date appointment and
subsequently recall patients for annual mammograms or 18 monthly mammograms
alternating with the NHS BSP as specified by the authorised referrer.
On completion of mammogram all positive results to be telephoned through to the referring
breast care nurse and confirmed by fax. The breast care nurse subsequently contacts the
patient with results explaining the recall for investigations.
The breast screening unit will offer patients an appointment for assessment recall
investigations within 3 weeks.
The breast screening unit will contact the breast care nurses following the assessment by
fax/telephone with the outcome of the recall investigations, arranging for discussion of
investigations/biopsies at the Lancaster breast MDT.
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‘Normal’ results which require no further assessment will be issued within 21 days
maximum. Reports to be faxed directly to breast care nurse. Patients will then be offered
annual mammograms annually or 18 monthly alternating with the NHS BSP by the breast
screening service at UHMBFT as per the individual screening schedule.
All images will be archived within the breast screening unit at the University Hospitals of
Morecambe Bay NHS Foundation Trust.
In this part of the agreement, UHMBFT agrees to undertake a number of investigations for
appropriately recalled patients and where clinically appropriate coordinate the
investigations for digital mammograms/guided biopsy.
On completion of mammogram all positive results to be telephoned through to the referring
breast care nurse and confirmed by fax. The breast care nurse subsequently contacts the
patient with results explaining the recall for investigations.
UHMBFT will offer patients an appointment for assessment recall investigations within 3
weeks.
UHMBFT contact the breast care nurses following the assessment by fax/telephone with the
outcome of the recall investigations, arranging for discussion of investigations/biopsies at
the Lancaster breast MDT.
‘Normal’ results which require no further assessment will be issued within 21 days
maximum. Reports to be faxed directly to breast care nurse. Patients will then be offered
annual mammograms annually or 18 monthly alternating with the NHS BSP by UHMBFT as
per the individual screening schedule.
All images will be archived within UHMBFT PACs system.
2.2 Accessibility/acceptability
All women within the breast familial history service within North Lancashire, South Cumbria,
Blackpool and Central Lancashire ( TBC which elements) will access mammography at the breast
screening unit at the RLI.
2.3 Whole System Relationships
University Hospitals of Morecambe Bay NHS Foundation Trust
PCT commissioners: - NHs North Lancashire, NHS Cumbria, NHS Blackpool, NHS
Central Lancashire
North West Breast Screening QA
2.4 Interdependencies
As in point 2.3
2.5 Relevant networks and screening programmes
Lancashire and South Cumbria Cancer Network
NW Breast Screening QA
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3. Service Delivery
3.1 Service model
Patient will be referred directly from the Breast Familial service at BFWFT following an
assessment with the breast care nurses.
Patient will be referred directly from the Breast Familial service at Central Lancashire
following an assessment with the breast care nurses.
3.2 Care Pathway(s)
4. Referral, Access and Acceptance Criteria
4.1 Geographic coverage/boundaries
Women residing in North Lancashire, South Cumbria, Blackpool and Central Lancashire
4.2 Location(s) of Service Delivery
The breast screening unit at the Royal Lancaster Infirmary, Lancaster.
4.3 Days/Hours of operation
Monday- Friday 8:30am-5pm
4.4 Referral criteria & sources
All referrals will be received from the Breast Familial History nurse assessment service at
Blackpool Fylde and Wyre Foundation Hospitals Trust.
All referrals will be received from the Breast Familial History nurse assessment service for
Central Lancashire.
4.5 Referral route
All referrals will be received via fax.
Fax- 01524 583588
All cards then forwarded in the post to Family History Service Breast unit RLI
4.6 Exclusion criteria
Patients who are part of the Breast screening Programme
Patients with Breast symptoms
4.7 Response time & detail and prioritisation
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Patient’s will be seen in the month the mammogram is required.
All images will be reported within 10 working days
5. Discharge Criteria and Planning
On completion of mammogram all positive results to be telephoned through to the referring
breast care nurse and confirmed by fax. The breast care nurse subsequently contacts the
patient with results explaining the recall for investigations.
UHMBFT will offer patients an appointment for assessment recall investigations within 3
weeks.
UHMBFT contact the breast care nurses following the assessment by fax/telephone with the
outcome of the recall investigations, arranging for discussion of investigations/biopsies at
the Lancaster breast MDT.
‘Normal’ results which require no further assessment will be issued within 21 days
maximum. Reports to be faxed directly to breast care nurse at BFWFT and at Central
Lancashire. Patients will then be offered annual mammograms or 18 monthly alternating
with the NHS BSP by UHMBFT as per the individual screening schedule.
All images will be archived within UHMBFT PACs system.
6 Baseline Performance Targets – Quality, Performance & Productivity
Mammography and assessment
All mammography and assessment / recall investigations will be undertaken in
accordance with the appropriate quality requirements of the NHS Breast Screening
Programme as outlined in the Breast Screening specification for the North
Lancashire and South Cumbria Breast Screening Programme.
All mammograms will be read and reported in accordance with best practice NHS
BSP standards (NICE 2004/2006, NHSBSP 2005)
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7. Activity
7.1 Activity
Activity Performance
Indicators
Method of
measurement
Baseline
Target
Threshold
Frequency
Monitoring
of
7.2 Capacity Review
The expected activity for Blackpool, North Lancashire and South Cumbria patients is up to 250
referrals per annum.
For Central Lancashire population up to 50 referrals per annum.
Capacity will be reviewed on an annual basis.
8. Currency and Prices
8.1 Currency and Price
The Charges for the Services to be provided are as follows:
Service
Mammogram
Specialist mammography (per breast)
Ultrasound bilateral or unilateral
Fine needle aspiration
Core biopsy
Cyst aspiration
Tariff
£70.00
£50.00
£130.00
£200.00
£200.00
£150.00
The level of activity is not expected to exceed 300 cases per annum
The level of activity for is not expected to exceed 5% non-technical recall of total patients screened
per annum.
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10 Incident reporting
Please refer to Breast Screening Specification for guidance.
Incidents
An incident or failure of the familial breast screening service which puts women at
risk of inadequate screening, assessment or treatment or in the event that the
provider cannot be confident that cancer has been definitely diagnosed or exclude
or managed appropriately are reported, investigated and managed in accordance
with NHS Breast Screening Programme and UK National Screening Committee best
practice guidelines (NHSBSP 2009, NSC2010).
11. Escalation Policy
Reasons for Escalation
Significant Issues
a) Staffing issues impacting on service delivery
b) Cancellation of screening sessions
c) Equipment failure
d) Notice periods for invitations fall outside of the 6 weeks band
It is accepted that any of these pressures can occur at any time throughout the year, and as
such, the Escalation plan will be activated whenever indicated by analysis of activity.
If the following issues arise then the problems should be escalated to the appropriate
person:


Capacity problems - the service is unable to deliver the desired activity due to lack
of capacity
Staffing – staffing levels are not at the required level
Population changes by PCT level
General principles of escalation are:a) The earlier the better.
b) Try everything you know to resolve the problem.
c) Recognise that you cannot solve all of the problems – but by passing it on you
will give others a chance to.
d) Clearly record and pass on the steps you have taken.
e) Take action in a timely manner – be clear of the timescale of escalation.
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Escalation timetable
In the event of the breast screening service being unable to maintain the service to the
agreed requirements the following actions should be taken. Issues to be raised to the
following team members.
Familial Breast Screening Service Contacts;
PCT leads will be contacted as appropriate.
Contact
1
2
3
4
5
6
Person Responsible
Superintendent Radiographer
Royal Lancaster Infirmary
Nurse Consultant Breast Care
BTHT
Consultant Radiologist UHMBT/
Contact no
01524 583050
(UHMBT)
24 hours
Assistant Directorate Manager
BTHT
Directorate Manager BTHT
01253 303816
24 hours
01253 300000 bleep
166
01524 62345
01524 519236
48 hours
01253 651200
48 hours
01768 245317
48 hours
01772 644400
48 hours
Clinical Director UHMBFT
Commissioning Lead NHS North
Lancashire
Commissioning / Public Health
Lead NHS Blackpool
Commissioning Lead NHS
Cumbria (South Cumbria
population)
Commissioning / Public Health
Lead NHS Cumbria (Central
Lancashire population)
Timescale for Escalation
24 hours
24 hours
48 hours
48 hours
In the event that a resolution cannot be reached within 24 hours the Breast Screening
Manager escalates to the Directorate Manager
If there is a risk of serious or imminent underperformance and normal channels have been
either tried without success or were ineffective then the PCT commissioners will be
informed by the Directorate Manager who calls an emergency meeting of the relevant team
members to discuss and agree action.
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