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Agenda Item 08 Enclosure KPCT/08/106 Part 2


PCT Board


Briefing Paper on Breast screening service

FOI Exemption Category


Lead Director:

Judith Hooper Director of Public Health


Jini D’Cruz, Consultant in Dental Public Health

Key Points to Note:

The paper describes the current position of the Pennine Unit, in relation to national targets for the Breast Screening Programme. It looks at the reasons for the slippage and the cost of actions to bring the round length target down to 36 months. The medium to long term implications of the Cancer Reform Strategy and sustainability of the targets may be best served through a local consortium arrangement.

Budget Implications:

There are immediate and long term financial implications for the constituent PCTs which use the Pennine Unit service in order to correct the slippage on round length targets and work to achieving the new demands of the Cancer Reform Strategy. There will be some knock-on effects for symptomatic services as the increased age-range (47-73 years) for screening by 2012, may lead to more referrals for cancer services.

Risk Assessment:

The proposed arrangements seek to minimise the risks to the PCT of commissioning through an individual or lead PCT basis. The achievement of current and new proposed national targets need to be funded at the earliest opportunity. Investment must cover the increased number of women eligible for screening. Ensure targeted health promotion to increase uptake of screening in disadvantaged communities. 1

Legal Implications:

Legally binding SLAs will be in place with the Pennine Unit and associated secondary care symptomatic services in foundation trusts.

The Health Benefits:

The proposed arrangements will strengthen the commissioning of a screening service designed to identify women with breast symptoms at a stage earlier than would happen if the screening didn’t take place, leading to improvements in patient care and reduction in mortality from breast cancers.

Staffing Implications:

The existing staff in commissioning, public health and finance will play into the new arrangements. For the provider there are implications for the recruitment and training of additional staff which includes radiographers, radiologists, and administration staff.

Sub Group/Committee:


No formal committee at present. There are meetings held between the Pennine Unit and the PCT commissioners. The Y&H SCG is to set up a Collaborative Commissioning Group for all screening services. The PCT Board is asked to: Support the financial consequences of reducing and sustaining the 36 months round length targets for screening. Support the proposal to form a consortium of PCTs for the commissioning of breast screening and associated symptomatic services. Agree to receive an update position paper in November 2008.



Briefing Paper on the NHS Breast Screening Service for Kirklees PCT

Executive Summary Breast screening is one of the national screening programmes for women aged between 50 – 70 years, with given standards to be achieved by PCTs. Locally the service is commissioned by a lead commissioner (Calderdale PCT) from the Pennine Breast Screening Unit which is hosted by Bradford Hospitals NHS Foundation Trust This paper sets out the main reasons for a substantial decline or slippage in the Pennine Unit being able to meet the national targets for invitation of 90% of women aged between 50-70 to attend screening, within 3 years of their previous screen. The budget implications for correcting this slippage are also outlined. The recent publication of the Cancer Reform Strategy (Nov 2007) sets out the government’s vision to build on the success of the NHS Cancer Plan of 2000, as overall cancer mortality is falling, more patients are surviving and people’s experience of cancer services is improving. Finally the paper considers the proposal to have collaborative commissioning arrangements through the Yorkshire and Humberside Specialist Commissioning Group to achieve consistency in service specifications for all screening services, with a local consortium to commission services from the Pennine Breast Screening Unit. 1. Introduction The breast screening programme is a national programme for women aged 50-70 years. Calderdale PCT acts as lead commissioner for the PCT and commissions the service from Pennine Breast Screening Unit, which is hosted by the Bradford Hospitals NHS Foundation Trust. The programme is externally quality assured via a regional QA visit every 3 years and the last QA visit was in November 2006. The latest report for the NHS Breast Screening Programme for the North East, Yorkshire and the Humber Region covers the quarterly periods from April 2006 to March 2008 (see Appendix 1). The Pennine Unit is the breast screening service provider for most of West Yorkshire’s PCTs, excluding Leeds and Wakefield, and covering a total population of 137,500eligible women.


For the Pennine Unit, the report shows a continuing decline in meeting the national round length target of 90% eligible women aged 50-64 years, being invited for screening within 36 months of their previous screen. This figure had reached 91% at 38 months for the January to March 2008 period. However, increasing round lengths decrease the effectiveness of screening leading to a rise in interval cancer rates. Slippage would also have an adverse effect on coverage rates. Coverage measures the proportion of eligible women who received a screen in the previous 3 years. The target for coverage rates is a minimum of 70%, however for Kirklees PCT this has been consistently above 80% showing that the Pennine Breast Screening Service has been effective in this field. In view of this, comments are limited to ways of reducing the slippage and getting back on track to achieve the round length target. 2. Background The Pennine Unit data covers the population of women aged 50 – 64 years in Bradford, part of N Yorkshire, Calderdale and Kirklees PCTs. The performance measures for the programme are established as national standards, which are monitored quarterly by the Quality Assurance Reference Centre and through QA visits. The QA visit in November 06 identified that the unit had been under-funded for the expansion of the programme and that commissioners needed to address this in the next financial year. A position paper has been prepared by the Unit to address the continual slippage in the 36 month round length and this has been discussed with the commissioners. In the meantime 2.4 wte radiographers have been recruited but people being recruited now tend to be staff in need of specialist training rather than already trained. This means trained staff are involved in training which also causes short term pressures.

3. Key Issues Contributory factors and actions taken to address slippage The Government announced the introduction of 2-view mammography for all screens and the extension up to age 70 for automatic invitations in the NHS Cancer Plan. Following this, the Pennine Screening Service implemented the 2-view mammography in September 2002 and the age extension in December 2004. Phased funding for both projects was received and new equipment purchased and staff recruited. When 2 views were implemented in 2002 the screening cohort for women between 50 - 64 years was approximately 100,000. The screening interval was 91% within 36 months achieving the NHSBSP target of 90% within 36 months. Age extension was introduced in December 2004 with the cohort increased to 130,000 women between the ages of 50 - 70 years.


The screening interval then slipped to 55% within 36 months and 92% within 38 months. Older women were having an impact on the programme, taking increased time to screen, so throughput was reducing. There is also pressure on the service due to the increasing longevity of the population. It is forecast that the cohort of women in the 50-70 year group will increase by 11% in 5 years, and 21% in 10 years from a baseline of 130,353 in July 2005. Radiology sessions were increased with the appointment of a 5th Radiologist in November 2004. Trainee Assistant Practitioners were recruited in an attempt to address the difficulties all units were experiencing when trying to recruit radiographic qualified staff. Direct Entry Technology This technology was required to run the National upgrade on the BSP software and a requirement of the Quality Assurance Programme. Expenditure has been committed for this year. Medical Physics This had previously been funded by the Regions Quality Assurance Reference Centre, (QARC). This year half was funded by the Programme (8K). Next year the full cost of the program (16k) will be funded by PCTs Equipment Replacement Equipment replacement is not included in the current SLA. The previous major capital had been funded by New Opportunities Funding. This would not be repeated. There is current debate about how this should best be addressed. 4. Impact of the Cancer Reform Strategy (2007) The recent publication of the Cancer Reform Strategy (Nov 2007) sets out the government’s vision to build on the success of the NHS Cancer Plan of 2000, as overall cancer mortality is falling, more patients are surviving and people’s experience of cancer services is improving. In summary the main priorities for action between 2008 to 2012, by PCTs for breast cancer prevention in the Strategy are: •

Investment in breast screening to ensure a three year round length because of increasing numbers of women becoming eligible for breast screening.

Extend breast screening to nine screening rounds between 47 and 73 years, with a guarantee that women will have their first screening before the age of 50, facilitated by the roll out of digital mammography.

All units to have at least one full-field digital mammography


Currently the surveillance of all women identified as being at high risk is managed at a local level to varying protocols. The NHSBSP offers the opportunity to manage such surveillance to national standards; ensuring women receive a consistent and high quality service. A need to ensure that health inequalities are tackled with targeted programmes that increase uptake of screening in poor communities and in BME communities

5. Budget Implication Financial allocation for Kirklees PCT 2008/9 Kirklees PCT accounts for 33% of the annual contract income of the Pennine Breast Screening Unit. The total PCT expected costs of breast screening for 2008 / 09 is expected to be £897,863. This is based on the following: £ 07/08 contract value uplifted


07/08 recurrent pressures outstanding


07/08 non-recurrent pressures outstanding


08/09 recurrent pressures




Overall costs for the Pennine Breast Screening Programme to address slippage, based on QARC data at December 2007 A) To achieve NHS BSP round length target of 100% of eligible women to be invited for screening within 36 months would require £277,763 to cover the costs for additional staff and materials B) To maintain the round length at 100% within 36 months from the years 2008 to 2010 would be a total of £94,461. QARC advise that the programme should aim for a 34 month round length to provide security that the 36 month target will be met. C) The current forecast total is £372,224 for 100% target or £344,461 for 90% round length figures. This does not cover the longer-term implications of the cancer reform strategy or an equipment replacement programme.


Programme co-ordination •

A strategic approach is required to the commissioning of the breast screening service in order to enable service delivery models to be reviewed and for issues such as accessibility of the service i.e. location, timings, physical access to be considered and inequitable take up to be addressed.




Lead commissioning arrangements have in the past led to minimal involvement of PCTs such as Kirklees who do not have lead commissioning responsibilities. Therefore, regular communication with the lead commissioner is required and governance arrangements need to be established.


Governance arrangements also require consolidation within Kirklees PCT so that available data is received and utilised in service planning, contract arrangements are monitored and a forum is created to address issues raised. Current responsibilities are blurred between Public Health and Commissioning roles for breast screening and the associated symptomatic services in secondary and tertiary care. Proposals for collaborative commissioning and consortium arrangements

Collaborative Commissioning of National Screening Programmes. This best practice guidance was issued in December 2007 (Gateway Ref: 8829). It recommends that collaborative commissioning arrangements for screening programmes should be integrated with the commissioning arrangements for specialised services. The Yorkshire and the Humber (North) Specialised Commissioning Group (SCG) comprising of 10 PCTs recently agreed to establish a collaborative to coordinate the commissioning of all screening services. A lead PCT (North Yorkshire and York PCT) has been identified to host, manage and facilitate this process. There is agreement across the SCG that there is benefit in working collaboratively to improve screening services. In line with collaborative commissioning principles, the Collaborative for Screening will coordinate the strategy and service planning of specific screening programmes of their member PCTs and work with the SHA to ensure consistent high quality screening services for the region. The SCG will procure specialised aspects of screening programmes within its remit for commissioning all specialised services from April 2009. When secondary providers are to be commissioned to provide screening services this will be procured through the existing contracting consortia. Where local commissioning is desirable, especially in relation to local community services including Primary Care, PCTs will continue to be the lead commissioners. Local PCTs Consortium to commission Breast Screening Services. Following on from above, it has been suggested that there should be in place a local consortium for PCTs commissioning breast screening from the Pennine Unit.

The consortium could be based on the following model principles:7


The consortium is intended to bring an advantage through the PCTs working together. No control or accountability is ceded to a third party. All participating PCTs are entitled to have a close and clear understanding of their component of the contract and performance against that contract, and will accept the financial consequences of that performance.


The consortium contracting arrangements provide a vehicle for the PCTs to express in contract terms commissioning arrangements that they have made independently.


The legally binding contract with each of the Trusts is based on the ‘multi commissioner – individual purchase agreement’. This contract structure provides for multiple PCT’s in a ‘consortium’, and supported by a ‘coordinating’ PCT, to express their individual contractual relationships with the provider in the form of a single contract.


Within the individual purchase model each commissioner has its own contract activity and resources shown by a separate schedule and has separate rights and payment obligations and signs the contract. All commissioners can pursue contractual remedies such as the issuing of performance notices or the disputes procedures without references to any other party. Each PCT can separately suspend all or part of the services or terminate the services as a whole. However, to obtain maximum benefit from the consortium arrangements coordination of these actions is expected to be the norm.


Decisions relating to clinical activity volumes, baselines, capacity controls, cost per case and other arrangements that may have cost implications for the PCT will remain the responsibility of the individual participating PCT. The PCTs continue to receive activity and cost performance information, including that related to waiting times on an individual PCT basis


Recommendations 1 The PCTs respond and commit to the Pennine Unit business plan quantifying the capacity needed to respond to the increase in demand and to achieve the 36 month round time. 3 The lead commissioner is asked to convene a meeting to review Pennine’s business plan, to lead the development of a breast screening strategy to incorporate the recommendations of the cancer reform strategy and to agree governance arrangements. 4 The PCT clarifies communication and collaboration within the PCT and establishes a clear governance mechanism to ensure the breast-screening programme is responsive to the needs of women in Kirklees.

5. The PCT supports the principle for collaborative commissioning through the Y&H SCG and to make 8

arrangements for a local consortium approach to commissioning breast screening services. 6.

To receive an update report in November 2008

Jini D’Cruz Consultant in Dental Public Health / PH Lead for Cervical and Breast Screening.


Appendix 1 – To show round length data for the Pennine Unit from April ’06 to March ’08.