The breast screening programme in London includes the Administration Hub (the Hub) and six clinical services. South West London Breast Screening Service (SWLBSS), hosted by St George’s University Hospital NHS Foundation Trust, provides screening at seven static sites, including a base unit co-located with the breast symptomatic services in The Rose Centre.

The population of women in South West London eligible for three-yearly screening between their 50th and 71st birthdays is 190,000. Routine screening is by a timed invitation, using a SMART algorithm that considers the non-attendance probability and significantly overbooks clinics, especially in areas with low uptake.

The Covid-19 infection caused by the novel coronavirus (SARS-CoV-2) severely affected the delivering breast screening services across the UK¹. The early crisis timeline included the following events:

• 30 January – NHS internally declared a level-four incident². 

• 11 March – World Health Organization declared the global pandemic³. 

• 13 March – English local elections postponed for a year⁴. Royal College of Surgeons cancelled courses and events requiring travel⁵.

• 16 March – SWLBSS reported first staff member with suspected Covid-19.

• 17 March – Sir Simon Stevens wrote to trust chief executives announcing the cancellation of elective procedures⁶.

• 23 March – the first national lockdown instructed UK citizens to stay at home except for exceptional reasons⁷.

Non-essential face-to-face meetings were cancelled and the London breast screening study day organised by the regional Screening Quality Assurance Service was postponed. The trust issued detailed bulletins on the fast-evolving crisis, including guidance and operational changes. South West London pathology was identified as a Covid-19 pathology hub and face-to-face attendance at multidisciplinary meetings (MDM) was reduced to one member of each speciality. 

Frequent and intense discussions with national and regional teams escalated the issues experienced at the local level. The Wandsworth Times reported 15 deaths of patients who tested positive for Covid-19 by 23 March, the joint highest number in the country. The same newspaper also reported that the hospital had four wards with Covid-19 patients^8,9.

Clinic uptake dropped to 50% in March 2020 – down from an average 58% over January and February, and 62% over the last three months in 2019 – due to appointment cancellations and non-attendances, especially at the base unit. Sites co-located with general practice reduced face-to-face attendance and screening clinics had to be cancelled at one site. All London services reported increased staff anxiety and unplanned absences, and trusts were taking measures to reduce non-emergency footfall through hospitals.

Ensuring staff safety and wellbeing in the workplace was essential, particularly given the intimate nature of the mammogram examination and the proximity to large numbers of users. Staff were looking to employers and government leaders for guidance and services looked to trusts, NHS England and NHS Improvement (NHSEI) and Public Health England (PHE) to address their concerns.

Addressing these concerns promptly would go a long way to maintain staff engagement in the acute emergency and the subsequent service restoration¹⁰. Vulnerable staff and those with vulnerable household members sought adjustments in working and trusts expanded flexible work arrangements to allow more staff to work remotely.

Regular trust communications and updates informed and helped staff with the fast-developing acute situation. The service reviewed and tightened referral criteria to the symptomatic pathway, in line with published guidelines¹¹. Trusts introduced risk assessments for vulnerable staff, with recommendations to shield¹². Teams were reorganised and resources reallocated to address the increasing acute workload.

Specialist breast radiographers and radiologists were given training to support the acute radiology services, but symptomatic clinics were maintained with significant adjustments. Clinical nurse specialists (CNS) were redeployed to help a family-liaison service for families with relatives in intensive care but they also continued to support breast services. 

The administrative teams were retained in breast services with considerable adjustments in the office, including remote working. This was enabled by using software that allowed secure instant messaging, direct audio and video calls, and virtual meeting capabilities to support remote and mobile working¹³. The trust invested in new IT infrastructure to support virtual MDM to facilitate remote meetings.

On 23 March 2020, breast screening was paused in London (and across England). SWLBSS completed screening outcomes, including assessment, for women who had a screening mammogram before the pause, prioritising interventions for vulnerable users. Some non-urgent priority 4 interventions (such as vacuum-assisted excision procedures for indeterminate B3 lesions) were delayed in line with the guide produced by the Federation of Surgical Speciality Associations (FSSA)¹⁴.

The trust requested risk assessments of all areas and adherence to regional and local Infection Protection and Control (IPC) guidance, including triaging for Covid-19, personal protective equipment (PPE) and social distancing. Risk assessments for vulnerable users and patients were performed before attendance and those considered vulnerable were advised to shield whenever possible. Enhanced IPC measures to reduce infection risk were adhered to for those requiring further assessment.

There was collaboration across the region to allow provision of urgent breast cancer referral and treatment. Breast biopsy site markers were inserted in all indeterminate, suspicious and highly suspicious lesions to facilitate the prioritisation and adjustments in treatment pathways.

Screening women at very high risk of breast cancer resumed after securing breast magnetic resonance imaging (MRI) provision in the independent sector. Other surveillance for women at an increased risk and those with a previous cancer diagnosis resumed at the same time.

On 29 April 2020, NHSEI wrote to all NHS systems and providers, setting out the second phase response. It outlined that local NHS providers and organisations were to step up the provision of non-Covid-19 services, including screening, as soon as possible¹⁵. Internal conversations about resuming breast screening identified that this required the reorganisation of teams and reallocation of resources.

Trust, regional and national IPC guidelines and policies were developed to support a safe work environment, including social distancing in waiting areas, robust cleaning regimes, PPE and reducing risk for vulnerable users¹⁶. Risk assessments were updated for all screening sites as part of a restart plan required for approval through the trust’s governance and regional commissioning teams. 

Regular communications, updates and meetings with the regional NHSEI were provided to help support teams. The service maintained and increased internal communications and meetings to help staff as we navigated through these changes and planned to restart screening.

Various policy and operational decisions and changes were suggested nationally, regionally and locally, aimed at ensuring the best use of the limited capacity and resources, and ensuring users with the longest wait were screened first. To maximise capacity for screening women aged 50 to 71, the age extension (AgeX) trial investigators decided to cease further randomisation into the trial permanently due to the expected substantial and prolonged overload when services resumed screening¹⁷. Screening self-referred women aged over 71 was suspended in April 2020 but resumed shortly after¹.

IPC and social distancing guidance eliminated overbooking, severely reducing clinic capacity at a time when services needed it most. Maximising attendance for every screening appointment was critical and open invitations (OIs), whereby women received a letter inviting them to contact services to book an appointment, were recommended from September 2020. 

The OIs increased the likelihood of attendance when the user responded by calling the service to make an appointment, maximising utilisation¹⁸. This recommendation proved challenging to implement, given the configuration in London, including the Hub and the size of the six clinical services, which are some of the largest in the country.

Compared with timed appointments, OIs may lead to a significant decrease in uptake and SWLBSS collaborated closely with the West London Cancer Alliance, RM Partners, to contact women who did not respond to the OI¹⁸. Timed appointments were kept for women with learning disabilities and those at very high risk. 

A local decision was made to invite women according to their next test due date or birth date instead of general practitioner (GP) area postcode, so those waiting longest could be offered an invitation first¹⁹. SWLBSS also worked towards recovering the 36-month screening interval (round length) at all sites simultaneously.

Locally, the teams worked extremely hard to increase capacity, maintain and improve on the other key performance indicators not dependent on round length and uptake, such as results letters within two weeks of screening²⁰.

Screening and assessment clinics resumed over the summer of 2020, taking into consideration IPC and social distancing policies at each site, ensuring collaboration with other service providers and providing adequate levels of PPE. Appointment times were longer than previously with only one client scheduled per slot. Some sites initially limited access to one user every 30 minutes and staff had to escort users individually into and out of the building. This had adverse consequences on the available capacity and its utilisation during restoration and recovery¹. Covid-19 pre-attendance checks, introduced for routine screening, were performed by the Hub and the CNS team phoned all women recalled for further tests to confirm attendance.

Enhanced IPC measures included careful cleaning of all surfaces following each attendance, ventilation and air circulation, social distancing and wearing at least a surgical face mask, plastic apron and gloves during routine examinations. For interventional procedures, such as core biopsies and vacuum-assisted procedures, wearing a face shield was also mandatory.

Covid-19 anxiety and fatigue affected the health and wellbeing of staff²¹. The service faced significant workforce challenges over restoration and recovery due to Covid-19-related absences and shielding, retirement, maternity or reduction in working hours.

There was a 100% turnover of trainee mammography radiographers in 2020/21 and recruitment to fill vacancies became exceedingly difficult due to the national shortages. The team made significant efforts to recruit into vacancies and to support the National Breast Education and Training Centre to increase throughput. 

Although the service was successful in securing funding for fixed-term and agency positions, helped by the NHSEI breast screening recovery workforce workstream, employing into these posts proved nearly impossible and recovery was delayed. Staff went above and beyond, providing extra clinics on shifts in addition to their contractual hours, increasing the risk of repetitive strain injury, a known issue in breast screening²².

Delays in the delivery of postgraduate mammography education at universities caused a reduction in the number of newly trained mammography staff available. However, introducing mammography associate apprenticeship training courses, offered by St George’s National Breast Education Centre in partnership with South Thames College, London proved positive.

Over 2021 and 2022, the service recruited four trainees, two externally and two internally (the latter two having been previously employed as an administrator and a healthcare assistant). In 2023, the service is looking to employ another trainee for the apprenticeship.

In 2019, the trust had scheduled a digital mammography equipment replacement project to start at the beginning of 2020 to replace 11 units. Plans were affected by the pandemic and there was disruption to service delivery due to ageing equipment faults. IT and network failures and restrictions led to clinic cancellations at short notice because of over-stretched support services and limited ability for onsite attendance. Limited access to screening sites co-located with GP or other health services continued well into 2022. Global supply chain challenges affected vacuum-assisted biopsy consumables and local anaesthetics. 

The phased rollout of OIs was difficult both for the Hub and the clinical services. In the absence of an adequate round-planning tool, SWLBSS introduced weekly internal meetings to look at the backlog of women due for screening and direct the available screening capacity to sites with the longest wait and largest cohort. Significant shifts in user demands and behaviours meant capacity and utilisation were very difficult to predict and plan for¹.

There was also a marked increase in monitoring and reporting at the trust, regional and national NHSEI levels, which became easier when NHSEI introduced automated reports.

SWLBSS collaborated with regional stakeholders to address health inequalities and to improve access and uptake. It increased access to wheelchair users at one site during the equipment replacement and refurbishment works.

Further refurbishment completed at the base unit allowed for an additional ultrasound room equipped with a PACS workstation, and the re-benching of breast radiology offices and reporting rooms allowed for more PACS workstations. The main screening administrative office was recently fitted with new desks, which increased working space and created a more open-plan layout. 

The CNS team introduced SWLBSS profiles on multiple social media platforms, which proved to be a success.

The past three years brought multiple adjustments, but the main priorities were recovering the delayed screening backlog and 36-month screening interval. However, the service discussed future goals of maintaining round length, addressing health inequalities and increasing uptake to over 70%.

The aim is a sustainable workforce to match desired uptake, building further on the four-tier model in mammography to ensure the health and wellbeing of all screening staff is a priority. There are plans to support more education and clinical training opportunities and succession in senior roles to ensure staff retention, secure organisational intellectual capacity and provide continuity.

The service reached 94% round length over the third quarter of 2022, shifting the focus on to improving uptake, moved to timed appointments, and is working on a steadier rate of invitations per month. The new NHS national round length planning tool, developed to support services to plan the screening round length, will hopefully help maintain the 36-month interval²³.

There are multiple considerations for the future and work is under way to facilitate more paperlite processes, which should improve efficiency and enable remote image reading. The service has also increased participation in research that will affect future work and outcomes, including in artificial intelligence²⁴.

The experience of pausing breast screening due to the acute Covid-19 crisis and the subsequent restoration of service and recovery of backlog have highlighted several important lessons.

Forward planning and monitoring, especially in round-planning, was important to ensure that the number of invitations matched the capacity and available resources. When these were not aligned, there was a significant strain on services caused by high volumes of women unable to make an appointment due to unavailable capacity. OIs helped to improve the use and efficiency of clinics but negatively affected uptake and provided additional significant challenges for the Hub. Published data suggests that OIs adversely affected early diagnosis¹⁸. 

There is a close link between capacity and uptake, where interventions to improve uptake had to be minimised at times because capacity did not match the demand. Users also appear to appreciate and want more choice in the methods of booking appointments and accessing screening. 

Online booking proved popular with OIs and more women are contacting the service via email. The positive response to the CNS calling to confirm an assessment appointment and to the telephone interventions to improve uptake may also suggest that some users prefer more personal communication, rather than a letter in the post.

The value of leadership and collaborative working at different levels – locally, regionally and nationally – was paramount to successfully working through the backlog caused by the pause. This supported the sharing of learning from incidents, good practices and the timely effective escalation of risks and issues. 

The Covid-19 pandemic and the pressures of recovery have highlighted a fragile workforce and a lack of preparedness and sustainability. These challenges have focused attention on the importance of increasing education and training opportunities to attract, retain and support new staff for the programme. Staff retention, health and wellbeing are paramount to service delivery. Disruption presented an opportunity to approach situations differently and we successfully embraced the use of video conferencing, which aided remote working and education and has encouraged the team to engage more in research and service improvement.

Elizabeth Muscat is a Consultant Practitioner Radiographer and Director of Breast Screening at the South West London Breast Screening Service Rose Centre, St George’s University Hospitals NHS Foundation Trust.

References

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15. NHS. Second phase of NHS response to Covid-19. 29 April 2020. Available at https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/04/second-phase-of-nhs-response-to-covid-19-letter-to-chief-execs-29-april-2020.pdf. Accessed January 2023.

16. NHS Cancer Programme website. Cancer Services Recovery Plan. 14 December 2020. Available at https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/12/C0821-Covid-19-Cancer-services-recovery-plan-14-December-2020.pdf. Accessed January 2023. 

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24. St George’s University Hospitals NHS Foundation Trust. AI breast cancer screening project wins government funding for NHS trial. News and events. 16 June 2021. Available at https://www.stgeorges.nhs.uk/newsitem/ai-breast-cancer-screening-project-wins-government-funding-for-nhs-trial/. Accessed January 2023.