Healthcare Improvement Scotland review of the Scottish Breast
Healthcare Improvement Scotland carried out a
review of the Scottish Breast Screening Programme (SBSP) between
June and December 2016. The request follows an initial
investigation by National Services Scotland (NSD) which identified
that 3,831 women across Scotland had not received breast screening
invitations in line with standard timescales.
The review was carried out by a
multidisciplinary team including cancer, screening and IT
specialists and supported by Healthcare Improvement Scotland staff.
The review team looked at key documents and data and met with
screening providers, NSD as the commissioning body and key staff
involved in the delivery of breast screening. The review team also
visited two breast screening centres.
The report reviews the management of adverse
events, which included the identification of 3,831 women who had
not been sent a routine invitation to be screened. The report
states that it was unclear who was responsible for the handling of
the issue and that clearer leadership is needed from NSD to ensure
the appropriate management of adverse events.
The report concludes that the new IT system
which is now in place will help to address a number of issues, but
it will require ongoing monitoring to ensure that any future risks
are appropriately dealt with.
All women identified as not being called for
their routine appointment at their local breast screening centre
have been contacted and offered the chance to make an appointment.
By November 2016, 41% of women had still to take up that offer.
This is a significantly lower uptake than would be expected for
breast screening in Scotland.
The report makes five recommendations for NSD
and SBSP and covers the following areas:
- an adverse event management
team should be established to urgently review whether every
practical step has been taken to offer the women identified the
opportunity to attend a breast screening appointment within a
reasonable time frame
- the need for effective
governance arrangements to ensure roles, responsibilities and lines
of accountability are clear
- a clear and structured
adverse event management process with supporting guidance should be
put in place
- a mechanism should be
established to manage ongoing IT issues
- improvements should be made to
the current risk management arrangements.
Healthcare Improvement Scotland will monitor
the implementation of these recommendations.
Published Date: 21 December 2016