Breast screening review

Healthcare Improvement Scotland review of the Scottish Breast Screening Programme

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. 

Our findings

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.

More information

Published Date: 21 December 2016