efficiency review of the breastcheck screening programme · health, hse south (cork & kerry),...
TRANSCRIPT
Authors:
Professor Ivan J. Perry, Department of Epidemiology & Public Health, University College Cork, College Road, Cork.
Professor Charles Normand, Centre of Health Policy and Management, University of Dublin, Trinity College, College Green, Dublin 2.
Dr Orla Healy, Specialist in Public Health Medicine, Department of Public Health, HSE South (Cork & Kerry), St. Finbarr’s Hospital, Douglas Road, Cork.
Dr Sheena Mc Hugh, Department of Epidemiology & Public Health, University College Cork, College Road, Cork.
Ms. Ella Tyrell, Centre of Health Policy and Management, University of Dublin, Trinity College, College Green, Dublin 2.
Ms. Bridget Johnston, Centre of Health Policy and Management, University of Dublin, Trinity College, College Green, Dublin 2.
Ms Deirdre Ryan, Department of Epidemiology & Public Health, University College Cork, College Road, Cork.
Efficiency Review of the
BreastCheck
Screening Programme November, 2012
Report commissioned by the Department of Health, Ireland
1
Preface Breast cancer is the largest cause of cancer mortality among Irish women, after lung cancer.
Breast cancer places a heavy physical, psychological and social burden on the individual
and has significant cost implications for the health system. Similar to other European
countries, there is a national breast cancer screening service in Ireland known as
BreastCheck. BreastCheck provides screening free of charge to women aged 50 to 64 years
every two years.
This review on the efficiency of the BreastCheck screening programme was commissioned
by the Department of Health. The review was led by Professor Ivan Perry, Department of
Epidemiology & Public Health, University College Cork and Professor Charles Normand,
Centre for Health Policy & Management, Trinity College Dublin.
Research Team
Principal Investigators:
Professor Ivan J Perry, Department of Epidemiology & Public Health, University College Cork, College Road, Cork.
Professor Charles Normand, Centre of Health Policy and Management, University of Dublin, Trinity College, College Green, Dublin 2.
Dr Orla Healy, Specialist in Public Health Medicine, Department of Public Health, HSE South (Cork & Kerry), St. Finbarr’s Hospital, Douglas Road, Cork.
Research Team:
Dr Sheena Mc Hugh, Department of Epidemiology & Public Health, University College Cork, College Road, Cork.
Ms. Ella Tyrell, Centre of Health Policy and Management, University of Dublin, Trinity College, College Green, Dublin 2.
Ms. Bridget Johnston, Centre of Health Policy and Management, University of Dublin, Trinity College, College Green, Dublin 2.
Ms Deirdre Ryan, Department of Epidemiology & Public Health, University College Cork, College Road, Cork.
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Contents Preface........................................................................................................................................ 1
Research Team ........................................................................................................................... 1
Acknowledgements .................................................................................................................... 5
Executive Summary ................................................................................................................... 6
List of Tables ....................................................................................................................... 27
List of Figures ...................................................................................................................... 29
List of Abbreviations ........................................................................................................... 31
Glossary ............................................................................................................................... 32
1. Background ...................................................................................................................... 34
1.1. Breast Cancer in Ireland ............................................................................................ 34
1.1.1. Breast Cancer Incidence .................................................................................... 34
1.1.2. Breast Cancer Mortality ..................................................................................... 34
1.1.3. Breast Cancer Survival ...................................................................................... 34
1.2. Screening ................................................................................................................... 35
1.2.1. Breast Cancer Screening .................................................................................... 36
1.3. Evidence of Effectiveness Debate ............................................................................. 36
1.4. Background to the review ......................................................................................... 37
1.5. Scope of the report .................................................................................................... 37
2. Aims & Objectives ........................................................................................................... 38
3. Methods............................................................................................................................ 39
3.1. Evaluation Framework .............................................................................................. 39
3.2. Literature Review ...................................................................................................... 39
3.3. Stakeholder Interviews .............................................................................................. 40
3.4. Data Collection .......................................................................................................... 40
3.5. Economic analysis methods ...................................................................................... 41
3.6. Review Process ......................................................................................................... 42
4. Structure ........................................................................................................................... 43
4.1. Governance................................................................................................................ 43
4.2. Infrastructure & Organisation ................................................................................... 45
4.3. Comparison with Organisation of Screening Models Internationally ....................... 45
4.3.1. Screening & Assessment.................................................................................... 48
4.3.2. Cost of Screening & Assessment ....................................................................... 49
4.3.3. International Comparison of Screening Costs ................................................... 51
4.4. Synergies between the NCSS and the NCCP ............................................................ 53
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4.4.1. Staff Levels ........................................................................................................ 53
4.4.2. Head Office Costs .............................................................................................. 56
5. Processes .......................................................................................................................... 59
5.1. Consent & Invitation Process .................................................................................... 59
5.2. Scheduling ................................................................................................................. 61
5.3. Uptake of Screening at National and International Level ......................................... 62
5.3.1. Screening Uptake Rates ..................................................................................... 62
5.3.2. Mechanisms to Optimise Utilisation & Uptake ................................................. 64
5.4. Screening Process ...................................................................................................... 67
6. Programme Outputs ......................................................................................................... 69
6.1. Programme Activity: ................................................................................................. 69
6.1.1. Invitation, Screening & Uptake ......................................................................... 69
6.1.2. Screening Activity ............................................................................................. 70
6.2. Monthly Breakdown of Activity ............................................................................... 73
6.2.1. Southern Unit ..................................................................................................... 73
6.2.2. Eccles Unit ......................................................................................................... 75
6.2.3. Merrion Unit ...................................................................................................... 77
6.2.4. Western Unit ...................................................................................................... 79
6.3. Screening at Mobile and Static Units ........................................................................ 82
6.3.1. Reasons for Variation in Utilisation Rate .......................................................... 85
6.4. Radiographer workload model .................................................................................. 86
6.5. Programme Productivity ........................................................................................... 88
6.5.1. Alternative Work Practices ................................................................................ 91
6.6. Assessment & Surgery .............................................................................................. 97
6.6.1. Assessment Clinics: Structure & Process .......................................................... 97
6.6.2. Assessment Activity........................................................................................... 98
6.6.3. Links with the Symptomatic Service ................................................................. 99
7. Achieving current screening targets & planning for the age extension ......................... 102
7.1. Current & Anticipated Workload ............................................................................ 102
7.2. Staffing for the Age Expansion ............................................................................... 104
7.3. Clearing the Screening Backlog .............................................................................. 105
7.4. Equipment Capacity to provide current and expanded service ............................... 106
7.4.1. Machine capacity for current eligible population & age expansion ................ 108
7.5. Additional screening sessions ................................................................................. 111
7.6. BreastCheck Financial Results Review................................................................... 112
7.6.1. Pay Costs .......................................................................................................... 114
7.6.2. Non-Pay Costs ................................................................................................. 114
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7.6.3. Potential Savings - Non-Pay Cost .................................................................... 115
7.6.4. Summary .......................................................................................................... 119
7.6.5. Age Expansion Budget .................................................................................... 120
8. Conclusions & Recommendations ................................................................................. 123
9. Appendices ..................................................................................................................... 126
Appendix 1: Literature Search Strategy ............................................................................. 126
10. References ................................................................................................................... 131
5
Acknowledgements
The principal investigators and the research team gratefully acknowledge the management
and staff of the National Cancer Screening Service and the BreastCheck programme who
provided information for this review. In particular, we would like to thank the staff of the
Programme Evaluation Unit, the HR and Finance Division of the National Cancer Screening
Service and Ms Joanne Hammond, National Radiography Manager. We are also grateful to
the Unit Managers in each region who collated data for the review, and to all of the
stakeholders who participated in interviews.
6
Executive Summary
Breast cancer is the most commonly diagnosed cancer in Ireland and accounted for 32.3%
of total cancer diagnoses in women from 2007-2009, according to the National Cancer
Registry Ireland. Breast cancer is also the largest cause of cancer mortality among Irish
women, after lung cancer. In 2008, Ireland had the fourth highest mortality rate for breast
cancer in Europe. However, survival for those diagnosed with breast cancer has improved
significantly over time in Ireland. This improvement has been linked to early detection
combined with advanced and improved treatment options.
Most countries in the developed world have established organised screening programmes
for the early detection of breast cancer. In Ireland the national breast cancer screening
programme, known as BreastCheck, provides biennial screening to women aged 50 to 64
years. Screening is delivered at four regional centres (static units) and at sixteen mobile
units located at specific sites across the country. The BreastCheck service also covers all
follow-up procedures, up to and including primary surgery for a detected cancer.
In 2009, HIQA highlighted the potential for increased efficiencies and productivity within the
service, following an evaluation of cancer screening programmes and associated services in
Ireland. While limited to analysing activity over a one-month period, the review found an
average utilisation rate of 63% across mobile screening units. Furthermore, the unit cost of
screening in Ireland appeared to be high compared to other European countries. Based on
these findings, HIQA recommended further analysis of utilisation and the drivers of the unit
cost, suggesting that consideration be given to whether improvements in productivity could
provide additional capacity to facilitate the proposed extension of screening services to
women aged 65 to 69 years. The most recent BreastCheck report, published in 2011,
highlighted a number of challenges facing the service including staff shortages and
difficulties meeting key performance indicators for the current eligible population.
This review concentrates on the issues identified by HIQA in 2009; utilisation, capacity and
cost. The focus is on the operational and technical efficiency of the service, and includes an
analysis of the structure, process and outputs (utilisation, productivity, unit costs). The
analysis of programme efficiency was undertaken in the context of significant resource
constraints facing the service and its staff. The review was conducted in light of existing
proposals to extend the screening service, taking into consideration the current challenges in
meeting targets for those known to or within the programme.
7
Project aims and objectives
The overall aim of the project was to review the operational efficiency of the national breast
cancer screening programme, BreastCheck. The terms of reference, set by the Department
of Health were to examine:
Methods
The inherent approach taken in this review is based on the stated aims and operational
objectives of BreastCheck, with benchmarking of activity (whether defined in terms of
utilisation, productivity or operational efficiency) against these aims and objectives. Thus, the
modelling contained in the report is not extraneous to the service but based on existing work
practices and current levels of operational efficiency achieved within the service.
The time frame for conducting the review was four months. The Donabedian Framework of
structure, process and outputs, was adopted as the evaluative framework for this review.
The review comprised of a number of interconnected work packages
Literature review of national and international breast screening programmes
Qualitative interviews with key stakeholders involved in the governance,
management, delivery and receipt of screening.
Quantitative analysis of data on screening activity and programme costs
Economic modelling of the operational efficiency within the service.
A review of the literature was conducted to examine international models of breast cancer
screening and to identify similarities and differences with the BreastCheck screening model.
Relevant literature was identified through the use of electronic databases including PubMed,
Medline and Science Direct, hand-searching of relevant reference lists and surveying
websites of official government health departments, cancer research organisations, and
breast-screening programmes. Papers from electronic databases were searched using
MeSH terms and considered if published after 1990 and available in English. The primary
dimensions on which international models were compared included; programme
1. How the utilisation of the screening units and mechanisms used to optimise
utilisation (in particular attendance) at screening units vary across the country, how it
compares with a selection of other countries, and what potential changes could help
to optimise utilisation
2. How the unit cost of breast screening in Ireland compares with a selection of other
countries, and what are the drivers of observed differences.
3. What efficiencies have been made and what are the potential programme efficiencies
or savings from the subsuming of the NCSS into the National Cancer Control
Programme?
4. Based on the conclusions of the Evaluation, to identify whether savings/efficiencies
be made so that (a) and (b) could be achieved?
a. Achieve optimum targets for number of women screened aged 50-64
years;
b. Expand BreastCheck to women from 65-69 years.
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organisation, screening interval, frequency, screening modality (digital versus analogue) and
uptake. Preliminary searching highlighted the lack of detailed information at international
level, on the processes involved in the delivery of breast screening (e.g. scheduling,
development of screening plans etc) and the unit cost.
In-depth interviews were conducted with key stakeholders involved in the BreastCheck screening service. In total, twenty interviews were carried out with stakeholders including:
BreastCheck staff: Clinical Directors/Consultant Radiologists, Senior Radiographers,
Radiography Service Managers, Unit Managers, Clinical Nurse Managers, Surgeons.
Representatives from the National Cancer Screening Service
Representatives from the National Cancer Control Programme
Representatives from the Department of Health
Representatives from EuropaDonna Ireland, the patient advocacy group
Service users who received screening, assessment and treatment through the
BreastCheck service.
A semi-structured topic guide was used to explore the processes and practices involved in
the delivery of BreastCheck, perceived efficiencies and inefficiencies in the current model,
barriers to optimal utilisation and potential changes to optimise utilisation. Stakeholders were
also asked for their views on the proposed expansion of the screening service. Interviews
were digitally recorded with the participants consent and transcribed. Transcripts were
analysed using thematic analysis.
Quantitative data were utilised in the review to describe the current level of service and to
model potential workload and resource requirements to:
Achieve current screening targets
Clear the screening backlog
Expand the screening service.
A list of data and documentation was requested from and collated by the NCSS Financial
and HR divisions, the Programme Evaluation Unit and the individual regional screening
units. The sources and types of data used in the review included financial data, programme
activity data, regional activity data for mobile and static units, staffing levels and screening
plans. Where further information or clarification was required during the course of the
evaluation, this was requested from stakeholders. In particular, data for modelling were
based on information from the 2012 Screening Plan and HR data provided by the NCSS.
This review employed a workload model, based on existing levels of efficiency within the
service, to model potential capacity and resource requirements to deliver screening. Overall,
workload depends on the number of women eligible for screening in the current and
extended age cohort, the expected uptake of screening and the proportion who need further
assessment and treatment. Screening capacity was modelled on the current BreastCheck
quality assurance guideline for achieving the screening round, which suggests that each
radiographer can perform an average of 20 high quality screens per day (1). The analysis
also takes into account the required time for training and other duties such as assessment
clinics. Allowances were also made within the model for travel and the reduction in workload
in remote rural locations. Capacity was examined at varying levels of efficiency (70%, 80%,
90%). Modelling in this way reduces the number of sessions that a radiographer would be
9
available for screening rather than lowering productivity during any given screening session.
Estimates were based on the efficiency levels currently achieved in the service and more
ambitious targets, some of which have already been achieved in parts of the service.
Machine capacity was assessed on the basis of current operating hours. The cost of
equipment was estimated based on capital costs (converted into equivalent annual cost),
costs of maintenance and repairs. Other costs were estimated from the budget figures
provided by the NCSS.
Using this modelling, three workload phases are considered in the report: the work practices
and staffing levels required to screen the current eligible cohort, the requirements to clear
the screening backlog and finally the resource requirements to expand the screening service
to those aged 65 to 69 years. In all instances, estimates are based on the current efficiency
levels within the service and more ambitious but achievable targets, some of which have
already been achieved in parts of the service.
Main Findings
Comparison with International Models of Breast Cancer Screening
There is broad similarity between the fundamentals of the Irish screening model and
international counterparts in terms of the frequency of screening, the use of fixed and mobile
units, and the issuing of appointments with a pre-specified time and location. However, there
are a number of unique features in the Irish model including the complete use of digital
mammography and coverage of screening, assessment and initial treatment for detected
cancers within the BreastCheck programme. These features of the service model make
international cost comparisons difficult. According to estimates provided by the NCSS, 65%
of net expenditure in BreastCheck can be attributed to screening activity, with the remaining
35% attributable to assessment activity. In 2008, the cost per woman screened was €121.42
compared to €90.32 per woman screened in 2011. Overall, there was a 26% reduction in the
unit cost of screening activity between 2008 and 2011. It should be noted, however, that the
figures for the earlier period may be partly due to the early developmental stages of the
programme. In 2011, 4.2% of women were recalled for assessment (n=5,202). While the
cost per woman has fallen with respect to screening activity, the unit cost per woman
assessed increased by 4% from €1,115.38 in 2009 to €1,164.43 in 2011.
In summary, in 2011;
The cost per woman screened was €90.32
The cost per woman assessed was €1,461.29
The unit cost per woman screened was estimated to be €55.77 in England, €97.08
in Scotland and 56.65 in the Netherlands. However, as there are several
fundamental differences in the screening models, direct comparisons should not
be made exclusively on the basis of cost.
10
Uptake
The uptake rate in BreastCheck compares favourably to rates recorded by the UK screening
programmes. According to data provided by the Programme Evaluation Unit, the uptake rate
in 2010 was approximately 73% in 2010 (n=121,730) and 2011 (n=124,788). In the first six
months of 2012, the uptake rate was 73.8% (n=62,892 women). The most recent figures
from the UK indicate an uptake rate of 73% in England and 75% in Scotland and Wales.
Overall, the number of women invited and screened by BreastCheck increased between
2010 and 2011. There was a 3.2% increase in the number of invites issued in 2011 and a
corresponding increase of 2.8% in the number of women screened. There was a 5.9% drop
in the overall number of assessments from 2010 (n=5,533) to 2011 (n=5,202), probably
reflective of the changes in the population screened and the increasing extent of subsequent
screening as the programme becomes more established.
Screening Activity
Screening days refer to the number of days spent screening in a unit. There was a 10.9%
increase in the number of screening days in 2011 (n=2662) and a 7.3% increase in the
number of women screened (n=91212) (based on data provided by 3 units). Data provided
by the PEU and individual screening units allowed us to examine the average number of
women screened per day in the BreastCheck service. There was an increase in the average
number of women screened per day from 35.46 women screened per day in 2010 to 37.96
screened per day in 2012 (based on 6 months data).
A number of activities take place in the static unit in addition to screening including
assessment clinics, results clinics and multidisciplinary team meetings. There are four x-ray
machines for screening in the Eccles Unit and three machines in each of the other units.
Examining the number of screens per machine within the static unit, there were on average
14 screens per machine per day in a static unit in 2010 and 13.2 screens per machine per
day in 2011 (Table 1). Analysing the use of each screening machines in the mobile units, in
2010 each mobile unit in the service operated for an average of 12 days per month. This
number increased to 14 days in 2011 and dropped back to 13 days during the first half of
2012.
In summary,
There was a 73% uptake of breast cancer screening among women aged 50 to 64
in 2011, comparable with uptake rates internationally and above the European
target of 70%.
There was an overall increase in the number of women invited and screened
within the programme between 2010 and 2011.
11
Table 1 Screens per machine at the static unit
2010 2011
Total Number Screen
ed
Total Screening Days
Screens per day in static unit
Average
screens Per
Machine
Total Number Screene
d
Total Screening Days
Screens per day in static
unit
Average screens
per machin
e
Eccles 13,021 241 54.0 13.5 10,419 243 42.9 10.7
Southern 9,482 177.8 53.3 17.8 11,672 187 62.4 20.8
Western 6,140 194 31.6 10.5 5,611 201 27.9 9.3
Total 28,643 612.8 46.7 14.0 27,702 631 43.9 13.2
In BreastCheck, a higher proportion of women are screened in mobile units given the variety
of additional activity which takes place in the static unit. According to the BreastCheck
Quality Assurance Guidelines, “each radiographer will be able to perform an average of 20
high quality screens per day” (1). Each mobile unit is operated by 2 radiographers. Hence, it
was possible to calculate the number of women screened per day in each mobile unit and
benchmark this figure against the operational guideline of 20 screens per radiographer per
day. In 2011, utilisation of screening slots in the mobile units was equal to or above 70% in
each of the three units for which data were available.
There are a number of reasons for variation in screening activity and the utilisation of
screening slots. There is a distinction between the factors influencing the number of
screening days in a unit (time) and the factors influencing the number of women screened
per day and the subsequent utilisation rate of a unit (volume). The main determinants of the
number of screening days per unit include the number of radiographers available to operate
the mobile unit or screening machine in the static unit, servicing time and moving mobiles.
The primary determinant of utilisation of screening slots (i.e. the number of screening slots
used per day) is uptake (proportion of women screened out of those invited). The number of
women invited is a process factor and therefore changeable within the programme. The
results suggest more scope for over-inviting based on the number of women screened per
day. However, not all women who are invited to attend will do so therefore under-utilisation is
inevitable to a certain extent. The units have introduced changes in the invitation process to
try to minimise the impact of non-attendance including the re-bulking process and utilising
lists of self-registered women to fill late cancellations.
12
Workload Model
Currently, the invitation and screening rates described in the BreastCheck 2012 Screening
Plan are based on a ratio to population model of 2.25 whole time equivalent (WTE)
radiographers per 10,000 eligible population. Current performance levels achieved within the
service demonstrate that an alternative approach to planning the delivery of services is
possible. This review applies a workload model to examine the potential capacity and
operational efficiency within the service.
Currently, the average WTE radiographer’s weekly schedule includes 3.5 screening days (7
screening sessions), 1 assessment day and a half day spent on additional duties such as
quality assurance activity and multi-disciplinary meetings. Based on this model of 3.5
screening days, it would be anticipated that each WTE radiographer would typically carry out
7 screening sessions per week (70% of time available), based on 2 sessions being held
each day (morning and afternoon). Based on the programme’s quality assurance guidelines,
a radiographer can perform an average of 20 high quality mammograms per day. Therefore,
a radiographer can complete an average of 10 screens per session, equating to a total of 70
screens per week.
The workload model presented in this report used levels of activity currently achieved in the
service to model potential capacity at various levels of operational efficiency, using the figure
of 70 screens per week per radiographer, as a ceiling. In order to calculate the monthly and
yearly optimum screening levels, available days at the various efficiency levels are multiplied
by 0.7 as this is the proportion of time spent screening. Within this model, the number of
sessions that a radiographer could spend screening is reduced, rather than lowering the
level of productivity during any given screening session. At 100% operational efficiency
within the current service model, each WTE radiographer would perform screening for 37
sessions each month. This figure reduces to 33, 29 and 26 at 90%, 80% and 70%
operational efficiency, respectively. This model assumes that a WTE radiographer works on
average 220 days per year and takes into account nine Bank Holidays & thirty-two days
Annual Leave.
In summary,
There was an increase in the average number of women screened per day from
35.46 women screened per day in 2010 to 37.96 screened per day in 2012.
There were on average 14 screens per machine per day in a static unit in 2010
and 13.2 screens per machine per day in 2011.
In 2010, each mobile unit operated for an average of 12 days per month. This
number increased to 14 days in 2011 and dropped back to 13 days during the first
half of 2012.
In 2011, utilisation of screening slots in the mobile units was equal to or above
70% in each of the three units for which data were available, above the 63%
utilisation rate previously identified by HIQA.
There a number of reasons for variation in utilisation including lack of staff to
operate screening machines, mobile servicing, invitation rates and uptake.
13
As seen in Figure 1, the number of screens per WTE radiographer will vary depending on
the number of screening sessions they can carry out. With maximum operational efficiency,
257 screens could be performed per WTE radiographer each month. This figure is reduced
to 231 screens at 90% operational efficiency, 205 screens at 80% and 180 screens at 70%
operational efficiency.
Figure 1 Number of screens per radiographer per month
Based on the parameters outlined above, we analysed the number of screens a
radiographer could perform per year, at varying degrees of operational efficiency from 70%
to 100%. Figure 2 illustrates the marked difference between the number of screens
performed at 70% operational efficiency (2,156 screens per year) and at 100% operational
efficiency (3,080 screens per year).
Figure 2 Number of screens per radiographer per year
180
205
231
257
0
50
100
150
200
250
300
Monthly
Nu
mb
er
of
scre
en
s
70% 80% 90% 100%
2156
2464
2772
3080
0
500
1000
1500
2000
2500
3000
3500
Yearly
Nu
mb
er
of
scre
en
s
70% 80% 90% 100%
14
We understand the need for adjustments to be made for women with special needs who may
require longer time to complete the examination. However, at present it would appear from
stakeholder feedback that the current model operates under the quality assurance guidance
of 20 screens per day while incorporating women with special needs at specific time slots of
30 minutes. We also appreciate the difficulty determining the exact participation rate when
inviting women. Therefore, on some days radiographers will screen more or less than 20
women, depending on the attendance. Taking into consideration the requirement for training
and professional development, for every additional session that is required for training
(beyond the 3 sessions per week already incorporated into the workload model for additional
activities), there would be a reduction of approximately 0.5 of 1% in the maximum number of
screens achievable. For example, at 100% operational efficiency, one day of additional
training would reduce the number of screens achievable from 3080 to 3060 screens per
year.
Productivity
As illustrated in Figure 1 above, 100% operational efficiency equates to 257 screens per
month under the workload model. Table 2 shows that performance levels over 90% (231
screens) were achieved by the service throughout the first half of 2012. The average number
of screens per radiographer per month across the four units was 246, greatly exceeding the
205 screens per available WTE radiographer planned for by the service in the 2012
screening plan. The figures ranged from the lowest level of average productivity of 182
screens to a high of 337 screens per month. At unit level, each unit exceeded the anticipated
screens every month for the first six months of 2012, with the exception of the Merrion Unit
which only dropped below the anticipated screening figure in April, 2012. The number of
screens anticipated in the screening plan took into account the available WTE radiographers
each month (employed plus agency minus long-term sick leave and maternity leave).
Table 2 Number of screens per radiographer per month by regional unit
Jan Feb Mar Apr May Jun Average
Eccles 228 317 238 198 304 237 254
Merrion 275 260 253 194 263 251 249
South 240 263 337 182 254 204 247
West 233 225 183 185 316 260 234
Average 244 266 253 190 284 238 246
15
In summary,
Based on the programme’s quality assurance guidelines and current service
delivery model, a radiographer can complete an average of 10 screens per
session (2 sessions per day), equating to a total of 70 screens per week (7
screening sessions per week).
Extending these parameters, it would be anticipated that each WTE radiographer
would perform frontline screening for 37 sessions each month at 100% operation
efficiency. This figure reduces to 33, 29 and 26 sessions each month at 90%, 80%
and 70% operational efficiency, respectively.
With maximum operational efficiency, 257 screens could be performed per WTE
radiographer each month. This figure reduces to 231 screens at 90% operational
efficiency, 205 screens at 80% and 180 screens at 70%.
Analysis of the 2012 Screening Plan indicated that performance levels over 90%
(231 screens per month) were achieved by the service throughout the first half of
2012.
The average number of screens per radiographer per month across the four units
was 246, greatly exceeding the 205 screens per available WTE radiographer
anticipated by the service in the 2012 Screening Plan.
16
Achieving current screening targets & planning for the age extension
From the perspective of stakeholders involved in the governance and delivery BreastCheck, the proposed age extension is not feasible without substantial additional resources, particularly in terms of radiography and administrative staff. The first priority of the programme is to return to full screening capacity and achieve targets for the current eligible cohort of women aged 50 to 64 years. Three workload phases are modelled within the report:
Potential work practices and staffing levels required to screen the current eligible
population in the first instance,
Resource requirements to clear the screening backlog within the service
Resource requirements and work practices to expand the screening service.
Current & Anticipated Workload
Current Population
Using 2011 Census data, the number of eligible women aged 50-64 would be 184,484. As previously mentioned, the actual number of women to be screened is calculated from the 2011 BreastCheck Programme Report which states that the ‘eligible women acceptance rate’ (including women who opted not to consent) was 73.9% in 2010/2011. Therefore, at 74% uptake the total number of women to be screened is 136, 518 (Figure 3).
Figure 3 Current population aged 50-64 & projected uptake
Age Extension Population
Using the 2011 Census figures, the number of women eligible in the 65-69 age group would be 87,340. Extending eligibility to women between the age of 65 and 69 in the BreastCheck programme would lead to an additional 43,670 invitations per year. Uptake among women attending for subsequent screening is higher than initial women. Furthermore, a higher uptake rate would be expected among the older age group. Figure 4 illustrates the increase in the current workload based on an uptake rate of 90% among the eligible age extension population.
Current Population Per Year Current Population @ 74%
uptake
Eligible Women 184,484 136,518
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
180,000
200,000
Nu
mb
er
of
Elig
ible
Wo
men
17
Figure 4 Increase in workload with age extension (65-69) at 90% uptake Current + Age Extension Population
Extending the age limit to 69 years would bring the estimated total number of women eligible per year to 228,254. With an uptake rate of 90% for the newly eligible women (65-69) and 74% for the current population (50-64), approximately 175,821 women would be screened (Figure 5).
Figure 5 Workload associated with screening current eligible population & age extension
Age Extension per year Age Extension 90% uptake
Eligible Population 43670 39303
37000
38000
39000
40000
41000
42000
43000
44000 P
op
ula
tio
n
Current Population + Age Expansion
Current Population @ 74% uptake + Age Expansion @
90% uptake
Population 228,254 175,821
0
50,000
100,000
150,000
200,000
250,000
Nu
mb
er
of
Elig
ible
Wo
men
18
Staffing for the Age Expansion
Based on the level of anticipated maternity leave of 10% and the HSE targeted sick leave
rate of 3.5%, the total number of additional WTE radiographers required for the age
expansion workload would be 18.1 WTE, at 80% operational efficiency. This number would
reduce to 16.1 WTE at 90% operational efficiency (Figure 6).
Figure 6 Additional WTE Radiography Staff required for the age extension Overall, the total number of radiography staff required to provide screening for the current
population and age extension population (n=175,821 women) is 79.6 WTE at 80%
operational efficiency and 70.7 WTE at 90% efficiency (Figure 7).
Figure 7 WTE Radiography staff required to screen current population & age extension
70% 80% 90% 100%
WTE Required 18.2 16.0 14.2 12.8
WTE Required with 3.5% sick leave & 5% maternity leave
19.8 17.3 15.4 13.8
WTE Required with 3.5% sick leave & 10% maternity leave
20.7 18.1 16.1 14.5
WTE Required with 3.5% sick leave & 15% maternity leave
21.6 18.9 16.8 15.1
0.0
5.0
10.0
15.0
20.0
25.0 N
um
ber
of
WT
E r
eq
uir
ed
70% 80% 90% 100%
WTE Required 80.1 70.1 62.3 56.1
WTE Required with 3.5% sick leave & 5% maternity leave
86.9 76.1 67.6 60.8
WTE Required with 3.5% sick leave & 10% maternity leave
90.9 79.6 70.7 63.6
WTE Required with 3.5% sick leave & 15% maternity leave
94.9 83.1 73.8 66.4
0
10
20
30
40
50
60
70
80
90
100
Nu
mb
er
of
WT
E r
eq
uir
ed
19
Clearing the Screening Backlog
Due to the recruitment moratorium in the Public Service, BreastCheck has been unable to
hire new staff such as radiographers and administrative support, which has resulted in
difficulties maintaining charter commitments to screen women every 24 months to 27
months. Currently, there are 18,386 women waiting more than 24 months to be invited to
screening. The cost of outsourcing the screening backlog was compared to the cost of
providing the service within BreastCheck using financial data for 2011. The data indicated
that €179,000 was spent outsourcing screening to Nuffield who screened 2,552 women over
4 months. This would equate to a unit cost of approximately €70 per screen. Based on this
unit cost, it would be anticipated that with 18,386 women invited at 74% uptake rate, 13,605
women would be screened at a cost of €954,269. Comparing this to the cost of providing the
service within BreastCheck (assuming 80% operational efficiency were achieved), it would
take 6.3 WTE radiographers (maternity leave of 10% & sick leave of 3.5%) 12 months to
screen 13,605 women, at a cost of €401,656 (Figure 8).
Figure 8 No. of WTE Radiographers required to clear screening backlog in 12 months
70% 80% 90% 100%
WTE Required 6.3 5.5 4.9 4.4
WTE Required with 3.5% sick leave & 5% maternity leave
6.8 6.0 5.3 4.8
WTE Required with 3.5% sick leave & 10% maternity leave
7.2 6.3 5.6 5.0
WTE Required with 3.5% sick leave & 15% maternity leave
7.5 6.5 5.8 5.2
0
1
2
3
4
5
6
7
8
9
10
WT
E R
ad
iog
rap
hers
Req
uir
ed
In summary:
Extending the age limit to 69 years would bring the estimated total number of women
eligible for screening to 228,254 per year. With an uptake rate of 90% for the newly
eligible women (65-69) and 74% for the current population (50-64), approximately
175,821 women attend for screened.
At 80% operational efficiency, 79.6 WTE radiography staff would be required to
provide screening for the current population and age extension population (n=
175,821 women), allowing for 3.5% sick leave and 10% maternity leave within the
staffing complement.
Z
20
Equipment Capacity to provide current and expanded service
Potential screening days are the number of days it would be anticipated that machines are
available for screening. As assessment clinics are also held in the static units, the number of
potential screening sessions per week is less than the number that can be offered in the
mobile units. The figures presented below are based on 248 potential working days per year
taking into account bank holidays, allowing for a 5% loss of availability of machine time in the
static units due to maintenance (Table 3). This has been increased to 10% for machines in
the mobile units to allow for the re-location of the units throughout the year.
Table 3 Machine Capacity Parameters - per machine
Number of potential screening sessions
per week
Total Monthly Yearly
Static Units
Mobile Units
7
10
Potential Screening Days
Static Units
Mobile Units
14
18.6
165
223
Number of screenings per session
Static Units
Mobile Units
20
20
Maximum Potential Screening Capacity
Static Units
Mobile Units
550
744
6597
8928
At present, the number of screens performed in each session is estimated to be 20 per
machine, irrespective of location. The maximum potential screening capacity assumes that 2
screening sessions are held on each of the screening days with 20 screens being
performed. Figure 9 shows the potential number of screens that could be achieved at
various levels of usage per machine in the static and mobile unit, on an annual basis.
In summary:
Clearing the screening backlog and achieving charter commitments for the current
eligible population is the first priority of the BreastCheck programme.
It is more cost effective to screen the backlog of women within the BreastCheck
service, rather than outsourcing the work to an independent provider. Furthermore,
outsourcing the backlog to an independent provider is limited to the taking of
mammograms and does not include mammogram reading, assessment or any other
activity.
Hence, we would envisage that the recruitment of radiographers and other staff into
the BreastCheck service would begin as soon as possible to deal with the backlog as
phase one of the expansion.
To avoid an unbalance between screening and assessment workload, an
appropriately balanced increase in capacity throughout the BreastCheck service
would be required as part of the expansion.
21
Figure 9 Potential machine capacity per year
Machine capacity for current eligible population & age expansion
The overall potential screening capacity available, using existing x-ray equipment at various
levels of efficiency, is shown in Figure 10. This estimate is based on the 29 machines
currently available across the BreastCheck programme; 13 in the static units and 16 in the
mobile units. If maximum machine utilisation were achieved, more than 228,600 women
could be screened on an annual basis. This number is significantly higher than would be
required within the current service delivery model. If 80% of available machine capacity was
utilised, it would be anticipated that approximately 182,885 women could be screened on an
annual basis. This is more than sufficient to screen the eligible population of approximately
136,518 women, in addition to accommodating approximately 39,303 additional women
eligible under the age expansion, at a 90% uptake rate.
Figure 10 Yearly machine capacity for BreastCheck digital x-ray machines
Static Mobile
70% 4618 6250
80% 5277 7142
90% 5937 8035
100% 6597 8928
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000 N
um
ber
of
Wo
men
70% 160024
80% 182885
90% 205746
100% 228606
0
50,000
100,000
150,000
200,000
250,000
Nu
mb
er
of
Wo
men
22
The utilisation model assumes that a digital x-ray machine would have a maximum annual
capacity of 7,883 screens (based on 100% usage of 228,606 screens across 29 machines).
At present there is significant unused capacity in the current x-ray infrastructure due to
radiography staff shortages (Table 4). If 124,000 women are screened before the end of
2012, this would represent 54% utilisation of the maximum machine capacity.
Table 4 Current Machine Capacity Utilisation
Estimated Number To be screened in 2012 124,000 women
Screening Capacity per machine 4,276 screens per machine
Machine usage as % of total capacity
(7883 screens per machine)
54%
Assuming a maximum machine capacity of 7,883 screens per year, if 80% of available machine capacity was utilised, 21 machines would be required throughout the BreastCheck service to provide screening services for the current population of just over 136,518 eligible women. Table 5 Machine requirement for current population
Current Population Levels of Efficiency
Machine Capacity 70% 80% 90% 100%
Screens per machine 5,518 6,306 7,095 7,883
Machines Required 24 21 19 17
Extending eligibility to women aged between 65 and 69 would bring the number of women
screened annually to approximately 175,821; representing an increase of 29% in the current
anticipated workload. With 80% machine utilisation, the number of machines required would
rise to 27 (Table 6).
In 2011, 86,825 women were screened in mobile units. This represents a utilisation rate of
61% of total annual machine capacity for the 16 mobile units (8,928 screens per machine,
combined maximum screening capacity of 142,848 screens across the 16 units). If the entire
age extension population of 39,303 women were screened only in the mobile units, the
machine utilisation rate would increase to 88% of total capacity for the 16 machines.
However, it would be anticipated that patterns in the numbers currently attending for
screening within the various regions will not change significantly as a result of the age
extension.
Table 6 Machine requirement for current population & age extension
Current Population + Age Extension Levels of Efficiency
Machine Capacity 70% 80% 90% 100%
Screens per year 5,518 6,306 7,095 7,883
Machines Required 31 27 24 22
23
The estimate of 27 machines does not take into consideration the backlog of 18,386 women
(as of 1st August 2012) currently waiting longer than 24 months to be invited for a screening.
With an uptake rate of 74%, approximately 13,605 women would be screened. Again, if
increased machine utilisation were to be achieved, there would be adequate capacity within
the service to comfortably accommodate the current population and simultaneously address
the backlog, whilst preparing to extend the age limit (Table 7).
Table 7 Machine requirement for current population & backlog
Current Population + Backlog Levels of Efficiency
Machine Capacity 70% 80% 90% 100%
Screens per year 5,518 6,306 7,095 7,883
Machines Required 27 23 21 19
Likewise, there is sufficient machine capacity to continue with the current practice of keeping
screening and assessment clinics completely separate. However, it should be noted that this
model could potentially leave three machines unused during these assessment clinics.
Should greater capacity in the static units be needed, consideration might be given to finding
alternative methods of providing the service that would allow for simultaneous assessment
and screening work. More than likely, this would require some level of investment in the
reconfiguration of the static unit buildings.
Investment in additional mobile units
If, for any reason, increased utilisation rates are not feasible, it may be necessary to invest in
additional machinery. Using accounting data provided by the NCSS, the equivalent annual
cost (EAC) of investing in new mobile digital mammography equipment and relevant
maintenance was calculated (Table 8). Assuming a 10 year lifespan and applying a discount
rate of 3%, the EAC would be approximately €133,211. The cost per additional woman
screened as a result of the age extension ranges from €14.92 to 18.65, depending on the
level of machine utilisation achievable.
Table 8 Equivalent annual cost (EAC) of new equipment & maintenance
Mobile Unit Investment
Investment Cost €612,000.00 €612,000.00
Expected lifetime 10 10
Annual maintenance €61,466 €61,466
Discount rate 3% 5%
EAC €133,211.33 €140,723.06
24
Conclusions and Recommendations
The report outlines the structures, processes and outputs from the BreastCheck screening
service. This review, conducted over four months, comprised of a number of interconnected
work packages; literature review of national and international breast screening programmes,
qualitative interviews with key stakeholders involved in the governance, management
delivery of screening, quantitative analysis of data on screening activity and programme
costs, and finally modelling workload practices within the service to screen the current
eligible population, address the accumulated screening backlog and expand the service to
women aged 65-69 in Ireland. The approach inherent in this review process is based on the
aims and operational objectives of BreastCheck. The review examines the screening service
as it currently operates, including current levels of operational efficiency and volumes of
work completed, taking into account that some parts of the service have been in a
developmental phase in recent years. The analysis models future staffing levels and
resource requirements, based on expected workloads, given plausible estimates of the
numbers of people eligible to be screened using data from the 2011 Census. The following
recommendations are based on in-depth quantitative and qualitative analysis of the current
service model.
Administrative & Management Systems
Given the maturity of the BreastCheck programme, we would suggest re-examining the
management processes within the current model and the operating systems needed to
support the service. The service is at risk of becoming unbalanced due to difficulties
recruiting and retaining staff, and incentivised retirement schemes within the public
service. We recommend investment in management personnel, with appropriate staff
training and development, to support the delivery of the screening service.
Furthermore, there is a need for increases in the administrative staffing levels and
radiography staffing levels within the BreastCheck service. We see this as a priority, as
building capacity in this area will allow for more efficient use of time, machine capacity
and professional personnel. We have been able to show the potential advantages of the
optimal utilisation of clinical and administrative resources and facilities. Therefore, a
failure to realise this potential through a lack of adequate management and
administrative processes, or staffing levels, would be fundamentally inefficient.
In this context, there is potential to enhance the efficiency of the service through
operational research and related methods such as constraints modelling. These methods
have been applied elsewhere in the HSE, in areas such as the scheduling of theatre time
and radiology services.
Workload Models & Resource Requirements
We recommend that clearing the screening backlog should be the initial priority for the
service. In this review the back-log is treated as a separate issue to be managed in the
first instance, rather than a long-term problem. The backlog would be most efficiently
managed within the BreastCheck service, as opposed to outsourcing the additional
workload, as part of the first phase of expanding capacity to cope with the proposed age
extension. We recognise that this will require a balanced increase in capacity in all areas
of the service, not just in the provision of frontline screening.
25
Screening activity has been examined in significant detail based on anticipated activity
levels for radiographers, outlined in the BreastCheck Screening Plan. It was not possible
to determine desirable workload levels in the assessment and treatment phase given the
lack of national and international workload norms for other staff categories such as
radiologists, pathologists and BreastCheck nurses. Instead, the analysis is adjusted for
the additional workload in assessment and treatment as a result of the age extension by
modelling a pro rata increase of the existing complement of staff (taking all vacancies
into account). While it has been possible to scrutinise the screening process in a great
deal of detail and make recommendations regarding required radiography staffing levels,
we would recommend critical analysis of the assessment and treatment phase to ensure
not only safe and effective, but also best value of services.
Maximising utilisation of equipment
The findings suggest that ambitious targets for the use of equipment and efficiency of
service delivery may be feasible within the current service delivery model. We have
modelled on a number of different levels of machine capacity and operational efficiency,
with reasonable allowances for training, maternity leave and sick leave. The models
suggest that it is feasible to accommodate the expanded population within the current x-
ray machine infrastructure. We recognise that in order to operate at these higher levels,
investment in upgraded equipment and skilled staff is required. As mentioned previously,
we are very much supportive of investment in the service that would see the machine
capacity used to the optimal level.
Given the staffing flexibility required to deliver the service, we recommend that
BreastCheck be allowed to manage its own Whole Time Equivalent requirements, while
remaining cognisant of employment ceilings within the HSE.
We recognise that it has not been possible for the programme to use equipment to full
capacity due to staff shortages. If the machinery is being used more intensely with
appropriate staffing, it may be necessary to move the mobile units more frequently.
Should it be considered infeasible to increase current machine capacity for any reason,
the equivalent annual cost (EAC) of investing in mobile equipment would be
approximately €133,211 euro.
One of the anticipated advantages of extending the age limit for screening eligibility
would be a shift in some of the current workload from the symptomatic service to the
BreastCheck assessment service. In relation to capacity to accommodate the increased
assessment workload resulting from a higher cancer incidence amongst women aged
65-69, figures provided by the NCSS project the need for a 50% increase in consultant
WTE staffing levels. We have presented a budget for the age extension based on a 20%
increase in workload. However, data from the UK screening service suggests an
increase of 25% in the current workload based on an approximately 3% recall rate for
women aged between 65-69 years. Therefore the pay costs associated with a 30%
increase in workload have also been calculated.
Consideration should be given in the medium term to reviewing the skill mix and
workforce models within the BreastCheck service, particularly given the challenges
26
recruiting and retaining radiography staff within the service. This is based on experience
in the UK where changes in skill mix emerged in response to similar challenges in that
service including a proposed age expansion, a national shortage of radiographers and
difficulties achieving programme targets.
In summary, our role has been to examine how greater efficiency can be achieved within the
BreastCheck service. We are not suggesting changes to the fundamental features of the
current service delivery model which includes the delivery of biennial screening, and the
coverage of assessment and primary treatment for detected cancers under the BreastCheck
programme. We have conducted a series of interviews and meetings with management, staff
and service users to understand the challenges facing the current service. We have used
expected activity levels to model optimal machine utilisation and various levels of operational
efficiency. Based on these models, we believe that the existing equipment should be used
more intensively rather than investing in new digital x-ray machinery. The need for additional
radiographer staff should be seen in the context of achievable levels of efficiency. It is our
view that capacity of the service should be increased in preparation for the age extension but
this should be used in the first instance to address the screening backlog. With respect to
follow-up assessment and treatment workload, we do not have complete information on
which to model other staffing requirements and therefore have modelled a pro rata increase
of existing staff levels to adjust for any additional workload. We recognise that it is not
feasible to achieve optimal utilisation of x-ray equipment and professional staff within the
BreastCheck service without investment in suitable operational systems and administrative
staff to support the management of the service.
27
List of Tables Table 1 Screens per machine at the static unit .................................................................... 11 Table 2 Number of screens per radiographer per month by regional unit ............................ 14 Table 3 Machine Capacity Parameters - per machine ......................................................... 20 Table 4 Current Machine Capacity Utilisation ...................................................................... 22 Table 5 Machine requirement for current population ........................................................... 22 Table 6 Machine requirement for current population & age extension ................................. 22 Table 7 Machine requirement for current population & backlog ........................................... 23 Table 8 Equivalent annual cost (EAC) of new equipment & maintenance ........................... 23 Table 9 Documentation & Data Review ............................................................................... 41 Table 10 Organisation & Delivery of screening across countries (21) .................................. 47 Table 11 Unit Cost per woman screened & assessed (2008-2011) ..................................... 49 Table 12 Cost per woman screened & assessed at regional level (2008-2011)................... 50 Table 13 Recall Rate for Assessment (2008-2011) ............................................................. 50 Table 14 Unit Cost of Digital Mammography across Countries ............................................ 51 Table 15 Central Administrative Staff Employed (NCSS) .................................................... 53 Table 16 Radiology, surgical & histopathology staff employed in BreastCheck (HR 2012) .. 54 Table 17 Senior Radiography Staff employed in BreastCheck (HR 2012) ........................... 55 Table 18 Administrative, nursing, science and health care assistant staff employed ........... 55 Table 19 Head Office Costs 2008-2011 (as a percentage of BreastCheck Expenditure) ..... 56 Table 20 Head Office Pay Costs (2010 vs. 2011) ................................................................ 57 Table 21 Head Office Financial Costs (2011) ...................................................................... 58 Table 22 Uptake Rate by Type of Invite .............................................................................. 60 Table 23 Attendance Rates across Countries ..................................................................... 63 Table 24 Static Unit Activity................................................................................................. 67 Table 25 Average number of screens per days 2010, 2011, 2012....................................... 72 Table 26 Southern Unit WTE Radiography staff employed & available ............................... 74 Table 27 Eccles Unit: WTE Radiography staff employed & available .................................. 75 Table 28 Merrion Unit: WTE Radiography staff employed & available ................................. 77 Table 29 Western Unit: WTE Radiography staff employed & available ............................... 79 Table 30 Travel to mobile units in County Donegal ............................................................. 81 Table 31 Potential efficiency due to travel to Donegal Unit. ................................................. 81 Table 32: Number of women screened across static and mobile unit in each region ........... 82 Table 33 Screens per machine at a static unit ..................................................................... 83 Table 34 Average daily activity per screening machine in mobile unit ................................. 84 Table 35 Utilisation of Screening Slots in Mobile Units 2010-2011 ...................................... 84 Table 36 Radiographer Workload Parameters .................................................................... 86 Table 37 Number of screens per unit (January-June 2012) ................................................. 88 Table 38 Number of screens per radiographer per month by regional unit .......................... 89 Table 39 Radiography Maternity Leave within BreastCheck (2012) .................................... 92 Table 40 Non-Radiography Staff Maternity Leave (2012) .................................................... 93 Table 41 Total Maternity Leave (2012) ................................................................................ 93 Table 42 Sick Leave Estimates January-August 2012......................................................... 94 Table 43 Structure of Assessment Clinics ........................................................................... 97 Table 44 Number of Women Recalled to Assessment ........................................................ 98 Table 45 Cost of Clearing Backlog .................................................................................... 105 Table 46 Machine Capacity Parameters- per machine ...................................................... 106 Table 47 Current & Potential Machine Capacity at regional level ...................................... 107 Table 48 Current Machine Capacity Utilisation .................................................................. 108 Table 49 Machine requirement for current population ....................................................... 109 Table 50 Machine requirement for current population plus age extension ......................... 109 Table 51 Machine requirement for current population plus backlog ................................... 109 Table 52 Equivalent annual cost (EAC) of new equipment & maintenance ....................... 110 Table 53 BreastCheck Financial Results ........................................................................... 113
28
Table 54 Medical & Surgical Supply spend by regional unit (2011) ................................... 116 Table 55 Supplies & Contracts spend by regional unit (2011) ........................................... 116 Table 56 X-Ray & Imaging spend by regional unit (2011) ................................................. 117 Table 57 Laboratory Costs by regional unit ....................................................................... 117 Table 58 Cleaning, Washing & Waste Costs by regional unit ............................................ 117 Table 59 Maintenance Costs by regional unit .................................................................... 118 Table 60 Transport & Travel Costs by regional unit ........................................................... 118 Table 61 Office Expenses by regional unit ........................................................................ 119 Table 62 Budget for age expansion based on efficiencies within the system ..................... 122 Table 63 RCTs included in review ..................................................................................... 127 Table 64 Systematic Reviews included in the review ........................................................ 129
29
List of Figures Figure 1 Number of screens per radiographer per month .................................................... 13 Figure 2 Number of screens per radiographer per year ....................................................... 13 Figure 3 Current population aged 50-64 & projected uptake ............................................... 16 Figure 4 Increase in workload with age extension (65-69) at 90% uptake ........................... 17 Figure 5 Workload associated with screening current eligible population & age extension .. 17 Figure 6 Additional WTE Radiography Staff required for the age extension ........................ 18 Figure 7 WTE Radiography staff required to screen current population & age extension .... 18 Figure 8 No. of WTE Radiographers required to clear screening backlog in 12 months ...... 19 Figure 9 Potential machine capacity per year ...................................................................... 21 Figure 10 Yearly machine capacity for BreastCheck digital x-ray machines ........................ 21 Figure 11 Organisational Structure of BreastCheck ............................................................ 44 Figure 12 Type of invitation as a proportion of the total invites in 2011 ............................... 60 Figure 13 number of women invited & screened & uptake rate 2008-2011 .......................... 62 Figure 14 Structure of Week for Radiographers in Static Unit as estimated by the NCSS ... 68 Figure 15: Programme Activity based on data from the PEU, 2010 ..................................... 69 Figure 16: Programme activity based on data from the PEU, 2011 ..................................... 70 Figure 17 Total Screening Days (static & mobile units combined) for 3 regions, 2010-2011 70 Figure 18 Number of women screened & utilisation rate, across 3 units (2010-2011) ......... 71 Figure 19 Southern Unit: Monthly utilisation for 2010-2012 ................................................. 73 Figure 20 Southern Unit: Anticipated vs. Actual screens, Jan-Jun 2012. ............................. 74 Figure 21 Southern Unit: Percentage difference in anticipated vs. actual screens ............... 74 Figure 22 Eccles Unit: Monthly utilisation, 2010-2012 ......................................................... 75 Figure 23 Eccles Unit: Anticipated vs. Actual screens, Jan-June 2012 ................................ 76 Figure 24 Eccles Unit: Percentage difference in anticipated vs. actual screens................... 76 Figure 25 Merrion Unit: Monthly utilisation Jan-June 2012 .................................................. 77 Figure 26 Merrion Unit: Anticipated vs. Actual screens, Jan-June 2012 .............................. 78 Figure 27 Merrion Unit: Percentage difference in anticipated vs. actual screens ................. 78 Figure 28 Western Unit: Monthly Utilisation 2010-2012 ....................................................... 79 Figure 29 Western Unit: Anticipated vs. Actual screens, Jan-June 2012 ............................. 80 Figure 30 Western Unit: Percentage difference in anticipated vs. actual screens ................ 80 Figure 31 Annual screening days and average per month, at the static unit in each region . 82 Figure 32 Number of screens per radiographer per month at varying levels of efficiency .... 87 Figure 33 Number of screens per radiographer per year at varying levels of efficiency ....... 88 Figure 34 Number of women screened per month per unit (January-June, 2012) ............... 89 Figure 35 Number of women screened per month per unit (January-June, 2012) ............... 90 Figure 36 Monthly activity based on screening guidelines of 20 & 22 screens per day ........ 91 Figure 37 Yearly activity based on guidelines of 20 & 22 screens per day .......................... 92 Figure 38 WTE requirement to screen current eligible population (target of 20 screens per day) ..................................................................................................................................... 95 Figure 39 WTE requirement to screen current eligible population (target of 22 screens per day) ..................................................................................................................................... 96 Figure 40: Assessment & Results Clinic Process ................................................................ 97 Figure 41: Treatment Pathway for Clients ........................................................................... 98 Figure 42: Care Pathway in Symptomatic & Screening Services ....................................... 100 Figure 43 Nursing Workload & Client Contact ................................................................... 101 Figure 44 Current population aged 50-64 & projected uptake ........................................... 102 Figure 45 Increase in workload with age extension (65-69) at 90% uptake ....................... 103 Figure 46 Workload associated with screening current eligible population & age extension ......................................................................................................................................... 103 Figure 47 Additional WTE Radiography Staff required for the age extension .................... 104 Figure 48 WTE Radiography staff required to screen current population & age extension 104 Figure 49 Potential machine capacity per month ............................................................... 106 Figure 50 Potential machine capacity per year .................................................................. 107
30
Figure 51 Yearly machine screening capacity for BreastCheck Digital x-ray equipment .... 108 Figure 52 Screening activity based on changes to number of screening sessions per week (using all available X-ray equipment) ................................................................................ 111 Figure 53 Proportion of resource use in the non-pay cost categories (2011) ..................... 114
31
List of Abbreviations DNA ‘Did Not Attend’
EAC Equivalent Annual Cost
GMS General Medical Scheme
HIQA Health Information and Quality Authority
HR Human Resources
HSE Health Service Executive
IARC International Agency for Research on Cancer (IARC).
ICT Information and Communication Technology
ISCN International Cancer Screening Network
MeSH Medical Subject Heading
NCCP National Cancer Control Programme
NCSS National Cancer Screening Service
NHS BPS National Health Service Breast Screening Programme
PACS Picture Archiving and Communication Systems
PEU Programme Evaluation Unit
PNA Previous Non-Attender
PYLL Potential Years of Life Lost
QA Quality Assurance
UK United Kingdom
US United States
WTE Whole Time Equivalent
32
Glossary Assessment Further investigation of a mammographic abnormality or symptom reported at screening. BreastCheck offers a triple assessment approach which is a combination of a clinical examination, additional imagery (mammography or ultrasound) and cytology. Biopsy The removal of a sample of tissue or cells for examination under a microscope. Biopsy is used to aid diagnosis. Detection Rate Number of cancer cases identified divided by the number of people tested. Digital Mammography Special form of mammography which uses digital receptors and computers instead of x-ray film to help examine breast tissue for breast cancer Efficiency The extent to which WTE radiographer time is used for the purpose of conducting frontline screening services during the seven sessions available throughout the working week. Eligible women The known target population less those women excluded or suspended by the programme based on certain eligibility criteria. Excluded women Women in follow-up care for breast cancer, not contactable by post, some women who have a physical/mental incapacity which may preclude screening, terminal illness or other. Histopathologist Medical specialist who analyses human tissue to diagnose disease. Initial screening A woman’s first visit to a breast screening unit e.g. Ireland’s BreastCheck unit. Moratorium Suspension of activity Previous non-attenders Women who did not attend their screening appointment when previously invited. Productivity The level of screening activity carried out at either the unit level or per radiographer. Radiologist A doctor with specialist training in the use of diagnostic imaging. Screening mammogram Breast x-ray used to look for signs of disease such as cancer in women who are symptom free. Used to detect a breast cancer at an earlier stage than would otherwise be the case. Subsequent screening A woman’s visit to a screening unit when she has attended a previous screening appointment.
33
Unit Cost The cost incurred by a company to produce, store and sell one unit of a particular product Uptake/Attendance Rate Number of women screened divided by the number of women invited to be screened Mobile Unit Utilisation Rate
According to the BreastCheck Quality Assurance guidelines, each radiographer will be able
to perform an average of 20 high quality screens per day (1). Each mobile unit is operated
by 2 radiographers, hence it is possible to calculate the number of women screened per day
in each mobile unit and benchmark this figure against the operational guidelines of 20
screens per radiographer per day (which equates to a maximum potential output of 40
screens per mobile unit).
34
1. Background
1.1. Breast Cancer in Ireland
1.1.1. Breast Cancer Incidence
In Ireland, women have a one in eleven chance of being diagnosed with breast cancer in
their lifetime (2). Breast cancer is the most commonly diagnosed cancer in Ireland; it
accounted for 32.3% of total cancer diagnoses in women from 2007-2009. In 2009, 2740
women were diagnosed with breast cancer (3). In 2008, Ireland featured fourth highest in the
European Union (ninth in the world) for incidence of breast cancer, just below Belgium,
France and the Netherlands (3). Between 1994 and 2009, there was an average annual
increase of 1.9% in the incidence of breast cancer in Ireland (4).
The incidence of breast cancer is higher in older women in Ireland. In 2009, the age-specific
cancer incidence rate was 191.13 cases per 100,000 women aged 45-49 years, 308.76
cases per 100,000 women aged 50-55 years and 385.66 cases per 100,000 women aged
60-64 year olds (5). Incidence is significantly higher in the highest socioeconomic group in
this country, with 119 cases per 100,000 women compared to 103 cases per 100,000
women in the lowest socioeconomic group (3). Between 2000 and 2002, there was an
increase in incidence in the eastern region, which coincided with the initiation of breast
cancer screening in that area. In 2007, there was a nationwide increase in incidence, which
coincided with BreastCheck being rolled out across the country (6).
1.1.2. Breast Cancer Mortality
Breast cancer comes second only to lung cancer as a cause of cancer mortality among Irish
women (611 deaths compared to 647 in 2007) (3). In 2008, Ireland had the fourth highest
mortality rate for breast cancer in Europe, with 28 deaths per 100,000. This was just below
figures for Belgium, Denmark and the Netherlands. Potential Years of Life Lost (PYLL) due
to breast cancer have increased, with 11,214 lost in 1996 compared to 12,976 PYLL in 2006
(3). Despite a steady increase in incidence of breast cancer, mortality from breast cancer
gradually decreased by an average of 2% each year from 1994 to 2007 (3). Reduced
mortality from breast cancer is believed to be related to improved treatment and
management of the disease, particularly stage one and two cancers (3).
1.1.3. Breast Cancer Survival
Cancer survival for those diagnosed with breast cancer is generally quite high, particularly
when compared with other common cancers such as lung cancer or colorectal cancer. Data
from the most recent report by the National Cancer Registry, Ireland suggest that survival of
women with breast cancer diagnosis has improved significantly over time in Ireland. In the
time period 1994-1997, the five-year relative survival rate was 70% compared to 83% in the
time period 2003-2007 (3). This improvement in survival can be linked to early screening
interventions, combined with advanced and improved treatment methods (3).
35
1.2. Screening
Screening is defined as the systematic application of a test or enquiry to identify individuals
at sufficient risk of a specific disorder to benefit from further investigation or direct
preventative action, among people who have not sought medical attention due to symptoms
of that disorder (7). The aim of screening is to reduce the burden of disease by ensuring
early detection, often before signs and symptoms occur, in order to allow for early treatment
intervention (8). Screening can be performed using a variety of approaches (9).
Opportunistic screening is offered, often by a General Practitioner, to one person within a
routine health service, without any attempt to apply an organised approach (e.g. a prostate
examination). In contrast, targeted screening is conducted systematically among a selected
sub-group of the population based on prior knowledge of their risk (e.g. blood pressure in
elderly) (10).
Specific criteria, which were outlined by Wilson and Junger in 1968 (11), are used to justify
the provision of a screening programme. Criteria are specified for the condition, screening
test and follow-on treatment:
Condition The condition should be a significant health problem
Risk factors should be detectable and there should be a latent and
symptomatic phase
Test A standardised, cost-effective, safe and reliable test should be available-
it should minimise false-positives and maximise true-positives.
There should be an agreed policy on the further diagnostic investigation
of individuals with a positive test result and on the choices available to
those individuals.
Treatment A proven effective treatment for early detection of the disease should be
available to all those who are diagnosed through screening. Evidence of
early treatment leading to better outcomes than late treatment should be
known.
Most countries in Europe have developed organised screening programmes for a number of
diseases and conditions such as breast cancer, bowel cancer and diabetic retinopathy. In
Ireland, there are organised neonatal screening programmes including the commonly known
‘heel prick test’ which screens for conditions such as cystic fibrosis and galactosaemia, and
the newly introduced Newborn Hearing Screening Programme. There are currently two
national cancer screening programmes operating nationwide, BreastCheck for the early
detection of breast cancer in women aged 50-64, and CervicalCheck for the early detection
of cervical cancer in women aged 25-60. The National Cancer Screening Service (NCSS) is
also preparing for the introduction of two more screening programmes; the national
colorectal screening programme and the national diabetic retinopathy screening programme.
36
1.2.1. Breast Cancer Screening
The aim of breast cancer screening is to detect breast cancer at an early stage in order to
reduce morbidity and mortality from the disease. In Ireland, the national breast cancer
screening programme, known as BreastCheck, provides free mammograms to women aged
between 50 and 64, every two years. Screening is provided in four regional static units
(Eccles, Merrion, Southern (Cork) and Western (Galway)) and sixteen mobile units, which
travel to various locations around the country.
The programme was established in 1998 and screening first became available to women in
the Eastern Region in 2000 (12). Approval was granted by the Department of Health for
expansion of the programme in 2005 to the Southern and Western regions (13). This
expansion was completed in 2008 and BreastCheck has been in operation nationwide since
then. BreastCheck falls under the auspices of the National Cancer Screening Service, which
was originally set up in 2007 as an independent agency to replace the National Breast
Screening Board. In April 2010, the NCSS joined the National Cancer Control Programme
(NCCP) within the Health Service Executive (HSE), with the aim of eliminating duplication in
areas such as recruitment, procurement, payroll and Information and Communications
Technology (ICT). The NCSS is also responsible for Cervical Check, the new colorectal
screening programme and the national diabetic retinopathy screening programme.
In BreastCheck, breast cancer screening is performed by specially trained radiographers,
using digital mammography. The process involves double imaging; taking a side image and
frontal image of each breast, which increases the detection rate (14). Mammograms are
read independently by two radiologists for increased quality assurance. In BreastCheck, all
follow-up procedures up to and including surgery for a detected cancer are covered within
the programme. Women with abnormal results are re-called for further assessment by a
multi-disciplinary team, which takes place in the static unit. A triple assessment is carried
out, which includes a repeat mammogram, an ultrasound, and if necessary, a biopsy. Tissue
from the biopsy is examined by a histopathologist for cancerous cells and based on the
results either surgery, chemotherapy and/or radiotherapy is provided (8).
BreastCheck has an established Women’s Charter, which outlines the commitments to
women invited to attend the service. It also informs women of what to expect from the
programme. For example, once known to the programme women will be invited for
screening every two years while aged 50 to 64; those who require further assessment will be
offered an appointment for an assessment clinic within two weeks of being notified of an
abnormal result and those women will receive their results from the assessment clinic within
one week. The programme regularly monitors its performance against the standards outlined
in the Charter and the annual performance is outlined in the BreastCheck report.
1.3. Evidence of Effectiveness Debate
The effectiveness of breast cancer screening in reducing the burden of the disease has been
widely debated. In response, Cancer Research UK and the National Cancer Director for
England established an independent review panel chaired by Sir Michael Marmot, to assess
the benefits and harms associated with population screening for breast cancer. The review
concentrated on the UK where women aged 50 to 70 years are offered screening every
three years. The findings of the review were published in October 2012 (15), concluding that
37
screening reduces breast cancer mortality but some over-diagnosis occurs. The results of a
series of meta-analyses indicated that for every 10,000 UK women aged 50 invited for
screening over the next 20 years, 43 deaths from breast cancer would be prevented and 129
cases of breast cancer would be over diagnosed. This equates to one breast cancer death
for approximately three over diagnosed cases identified and treated.
1.4. Background to the review
This review focuses on the efficiency of the screening programme rather than the
effectiveness of the intervention. A report by the Health Information Quality Authority (HIQA)
in 2009 examined the utilisation of mobile screening units and the unit cost of breast cancer
screening in Ireland. The results indicated an average utilisation rate of mobile screening
units of 63%. The unit cost of screening was estimated to be €97 and the unit cost of further
assessment was €921. Based on the findings, HIQA identified two areas for potential
increased efficiency: mechanisms to optimise utilisation and drivers of unit costs. However,
due to time restrictions the HIQA analysis of BreastCheck was limited in its focus on mobile
screening units during one month of the year (March 2009) (16). HIQA recommended further
analysis of mobile unit utilisation and suggested that consideration given to whether
improvements in productivity could provide additional capacity to facilitate the extension of
screening services to women aged 65 to 69 in Ireland.
1.5. Scope of the report
This review concentrates on the issues identified by HIQA in 2009; utilisation, capacity and
cost. The focus is on the operational efficiency of the service, and includes an analysis of the
structure, process and outputs (utilisation, screening efficiency, productivity, unit costs). The
analysis of programme efficiency was undertaken in the context of significant resource
constraints facing the service and its staff. The review was conducted in view of existing
proposals to extend the screening service to women aged 65 to 69 years. Given the current
challenges to meeting targets for those within the programme, there is a need to examine
the efficiency of the screening process and the capacity to expand the service.
38
2. Aims & Objectives
The following terms of reference were set by the Department of Health.
1. How does the utilisation of the screening units and mechanisms used to optimise
utilisation (in particular attendance) at screening units vary across the country, how
does it compare with a selection of other countries, and what potential changes could
help to optimise utilisation?
2. How does the unit cost of breast screening in Ireland compare with a selection of
other countries, and what are the drivers of observed differences?
3. What efficiencies have been made and what are the potential programme efficiencies
or savings from the subsuming of the NCSS into the National Cancer Control
Programme?
4. Based on the conclusions of the evaluation, can savings/efficiencies be identified so
that (a) and (b) could be achieved?
a. Achieve optimum targets for number of women screened aged 50-64 years;
b. Expand BreastCheck to women aged between 65-69 years.
To address these research questions, a series of interlinked analyses were conducted using
quantitative and qualitative methodology, these are organised in sections as follows:
Section 3 Outline of review methodology
Section 4 Structure of Programme:
Overview of the organisation and governance of BreastCheck and
comparison with international screening models.
Analysis of the unit cost of screening and assessment and central
administrative costs.
Section 5 Processes
Description of the consent, invitation and scheduling processes in
BreastCheck.
Review of screening uptake in Ireland compared to other countries
Review of mechanisms to optimise uptake
Section 6 Outputs
Description of previous programme activity including invitation,
screening and assessment.
Monthly analysis of screening activity at unit level and within static and
mobile units.
Outline of potential workload approach to modelling screening activity
Section 7 Scope to achieve current screening targets and plan for age extension
Description of current and anticipated workload
Model of radiography staff requirements and machine capacity
Outline of age extension budget
Section 8 Conclusions & Recommendations
39
3. Methods
3.1. Evaluation Framework
The inherent approach taken in this review is based on the stated aims and operational
objectives of BreastCheck, with benchmarking of activity (whether defined in terms of
utilisation, productivity or operational efficiency) against these aims and objectives. Thus, the
modelling contained in the report is not extraneous to the service but based on existing work
practices and current levels of operational efficiency achieved within the service.
The Donabedian Framework (17) was adopted as the evaluative framework for this review
as the terms of reference called for examination of the structure, processes and outputs of
the programme. Each of the levels was used to build an overall picture of the operational
efficiency within the screening service. The results are based on a number of interconnected
work packages; literature review, qualitative interviews and analysis, collation, analysis of
quantitative data on activity and operations, economic modelling of capacity and resource
requirements.
3.2. Literature Review A review of the literature was conducted to examine international models of breast cancer
screening and to identify similarities and differences with the BreastCheck screening
programme.
The review concentrated on models of breast cancer screening in the EU as well as the US,
Canada and Australia. Relevant literature including review articles, programme evaluations
and annual reports were used to profile national screening programmes. Information was
identified through the use of:
- Electronic databases including Medline, Embase, Science Direct and the Cochrane
Library
- Search of reference lists of appropriate papers
- Websites of official government health departments and cancer research
organisations such as the International Cancer Screening Network (ICSN) and the
International Agency for Research on Cancer (IARC).
- Individual websites for the national screening programme (http://www.breastcheck.ie)
and international counterparts.
Literature considering the cost of breast cancer screening programmes was examined, as
well articles on the organisation and delivery of services. MeSH (Medical Subject Headings)
terms used included ‘breast neoplasms’, ‘cancer screening- early detection of cancer AND
mass screening’, ‘mobile units- mobile health units’, ‘health care costs’, and ‘delivery of
services’. Papers from 1990 to June 2012 were included in the review. Paper titles were
scanned, duplicates omitted, and relevant abstracts read. All full texts of pertinence were
obtained. Translation, using Google’s inbuilt package, was used for some European breast
screening programme websites such as Spain, Portugal, France and Slovenia. National
screening programmes in other countries were contacted to verify the most up-to-date
performance data or where performance data could not be sourced online.
40
The primary dimensions on which international models were compared included; programme
organisation, screening interval, frequency, screening modality (digital versus analogue) and
uptake. Preliminary searching highlighted the lack of detailed information at an international
level, on the processes involved in the delivery of breast screening (e.g. scheduling,
development of screening plans etc) and the unit cost. Therefore, there was limited scope for
comparison between countries on these dimensions.
3.3. Stakeholder Interviews In order to gain a broad understanding of the screening model used by BreastCheck, a
series of in-depth interviews were carried out with key stakeholders involved in the
governance, organisation, delivery and receipt of BreastCheck services. In total, twenty
interviews were conducted with the following stakeholder groups:
BreastCheck staff across four units: Clinical Directors/Consultant Radiologists (N=3),
Senior Radiographers (N=3), Radiography Service Managers (N=2), Unit Managers
(N=4), Clinical Nurse Managers (N=2), Surgeon (N=1).
Representatives from the National Cancer Screening Service (N=3)
Representatives from the National Cancer Control Programme (N=1)
Representatives from the Department of Health (N=3)
Representatives from EuropaDonna Ireland, patient advocacy group (N=2).
Service users who received screening, assessment and treatment through the
BreastCheck service (N=3).
Individual interviews were conducted with the majority of stakeholders. However two
radiographers were interviewed together and stakeholders from the Department of Health
were interviewed with representatives from EuropaDonna as both groups were involved in
commissioning the review. EuropeDonna also assisted with the recruitment of service users
for interview. The Irish Cancer Society was contacted and invited to nominate a service-user
from the society however there were no volunteers available at that time.
Interviews were typically held within the BreastCheck screening units or at locations
convenient to participants. A semi-structured topic guide was used to explore the current
processes and practices involved in the delivery of BreastCheck, perceived efficiencies and
inefficiencies in the current model, barriers to optimal utilisation and potential changes to
help optimise utilisation. Stakeholders were also asked for their views on the proposed
expansion of the screening services. Interviews were digitally recorded with the participants
consent and transcribed verbatim. Transcripts were analysed using NVIVO, a computer
software package for qualitative analysis. Thematic analysis was applied to the data to
identify the main efficiencies and inefficiencies of the current screening model including
potential mechanisms for improving utilisation.
3.4. Data Collection Quantitative data were utilised in the review to describe the current level of service and to
model workload and resource requirements within the service. A list of data and documents
was requested from a number of sources to inform the review. The primary sources of
information included the National Cancer Screening Service, particularly the Programme
Evaluation Unit and the Human Resources Department, and the individual regional units.
The sources and types of data used in the review are outlined in Table 9. Where further
41
information or clarification was required during the course of the evaluation, this was
requested from stakeholders.
Table 9 Documentation & Data Review
Information Detail
Current BreastCheck
Services
Annual BreastCheck Reports
Staffing Levels Human Resources: broken down by grade and Whole Time
Equivalent (WTE)
Financial Information Financial Manager: Financial Results for 2008-2011, head
office costs, estimate of the cost of screening & assessment,
earlier costing of age extension
Programme Activity Programme Evaluation Unit: included data on number of
invites, type of invites, number screened, number assessed
per region, from 2008-2011
Regional Activity data for
all static and mobile units
Individual Units/Unit Managers: activity data included the
number of screening days per unit per month and the
numbers invited and screened per unit per month. Data
available for 3 regions for 2010-2011. Data from 4 units
available for the first 6 months of 2012.
2012 Screening Plan Outlines the anticipated and actual numbers invited and
screened based on the radiography WTE available in each
unit.
Screening Time
Questionnaire
Questions on the average working hours, screening
sessions per week, allowances for travel time, radiography
requirements for assessment clinics
Staff Survey Census of staff levels to provide snapshot/description of
current human resource levels, issued to each unit in August
2012. Questions related to current staff available at each
level, number on sick leave/maternity leave, vacancies within
each unit.
3.5. Economic analysis methods
While there are legitimate technical arguments about the best methods for screening and
follow-up of breast cancer, the economic analysis in this report is based on the screening
and further management model (assessment and treatment) adopted by Ireland. In Ireland,
the screening service extends to assessment and primary treatment for women with
mammograms that require further investigation.
The economic analysis was based on a workload model, using information on existing levels
of efficiency within the service. This approach was used to model potential capacity and
resource requirements to deliver screening. Overall, workload depends on the number of
women eligible for screening in the current and extended age cohort, the expected uptake of
screening and the proportion who need further assessment and treatment. Screening
capacity was modelled on the current BreastCheck quality assurance guideline for achieving
the screening round, which suggests that each radiographer can perform an average of 20
42
high quality screens per day (1). The analysis also considered the required time for training
and other duties such as assessment clinics. Allowances were also made within the model
for travel and the reduction in workload in remote rural locations. Capacity was examined at
varying levels of efficiency (70%, 80%, 90%). Modelling in this way reduced the number of
sessions that a radiographer would be available for screening, rather than lowering
productivity during any given screening session. Estimates were based on the efficiency
levels currently achieved in the service and more ambitious targets, some of which have
already been achieved in parts of the service. Machine capacity was assessed on the basis
of current operating hours. The cost of equipment was estimated based on capital costs
(converted into equivalent annual cost), costs of maintenance and repairs. Other costs were
estimated from the budget figures provided by the NCSS for 2011.
Using this model, three workload phases are considered in the report: the work practices
and staffing levels required to screen the current eligible cohort, the requirements to clear
the screening backlog and finally the resource requirements to expand the screening service
to those aged 65 to 69 years. In all instances, estimates are based on the current efficiency
levels within the service and more ambitious but achievable targets, some of which have
already been achieved in parts of the service.
3.6. Review Process
The review was conducted from the 25th of June until the 9th of November 2012. Regular
update meetings were held between the Department of Health and the research consortium.
Interim findings were circulated to stakeholders of the study on the 24th of October 2012
(Figure) for review and comments were invited on matters of fact or accuracy. A lengthy
submission was received from stakeholders on the 31st of October and the final report was
reviewed in light of this commentary. The final report was approved by the consortium on 9th
November 2012 and submitted to the Department of Health and Children.
Note: Data Sources
Data on screening activity in 2010, 2011 were received from three regional units. The
purpose of these data was to highlight previous screening activity at regional level; the data
are not used for modelling workload or resource requirements. Data from all four units were
received for the first six months of 2012 and this information was also used to describe
screening activity within the service.
Modelling was based on information contained within the 2012 Screening Plan prepared by
the NCSS which outlined the anticipated and actual numbers invited and screened according
to the number of radiographers employed and available within the service. Data on 2012
staffing levels provided by the NCSS HR division also informed the models. This information
was also used to estimate the efficiency and productivity of the service. The data source
used in each section of analysis is highlighted throughout.
43
4. Structure
This section provides an overview of the structure of the BreastCheck programme. The
section begins with an overview of the governance and organisation of BreastCheck,
followed by a comparison with international screening models. It is important to note that few
countries publish detailed descriptions of the structure, organisation and processes involved
in the delivery of national breast screening programmes. The international literature
describes programme fundamentals such as frequency and age intervals, and focuses on
key performance indicators such as those published annually by BreastCheck, rather than
the scheduling and work practices which underpin the service. Comparisons are mainly
drawn with the UK and Netherlands which have published information on the structure and
processes involved in breast cancer screening.
This section includes an analysis of the unit cost of screening and assessment at national
level and regional level in Ireland. International cost comparisons are complicated by a
number of differences in the organisation and governance of screening including the
invitation process, detection methods used, reading and interpreting mammograms, recall
and follow-up processes and the different health systems within which these programmes
operate (18). Finally this section examines the synergies between the National Cancer
Screening Service (NCSS) and the National Cancer Control Programme (NCCP), sets out
the current staffing levels in the BreastCheck service and includes analysis of central
administrative costs.
4.1. Governance
Since 2007, BreastCheck has been governed by the National Cancer Screening Service
(NCSS). The NCSS was established as an independent agency to replace the National
Breast Screening Board, as recommended within the national cancer control strategy (19).
Figure 11 outlines the organisational structure of the BreastCheck Programme at national
and regional level. The NCSS is currently led by an Acting Director with responsibility for all
four of the screening programmes which are at different stages of development and
implementation; BreastCheck, CervicalCheck, Colorectal Screening, Diabetic Retinopathy
Screening.
BreastCheck is supported by a number of executive functions within the NCSS including HR,
Finance, Communications and the Programme Evaluation Unit which is responsible for
producing the annual BreastCheck report. BreastCheck is led by an Executive Lead Clinical
Director. The National Radiography Manager oversees the quality assurance of radiography
and mammography services within the programme, using the guidelines produced by the
BreastCheck Quality Assurance Committee (1). Each screening unit is led by a Clinical
Director (Consultant Radiologist) who works with a Unit Manager and Radiography Services
Manager to coordinate screening at a regional level.
44
Figure 11 Organisational Structure of BreastCheck
DOHC
NCCP
NCSS
Acting Director
Executive Management Team x4
Breast Check
Lead Clinical Director
4 centres
4 Clinical Directors
Screening Promotion Officers
Senior Physicist
Unit Manager
Admin/Clerical
Health Care Assistants
Radiography Service
Manager
Mammographers/Radiographers
Consultant Radiologist
Surgeons/ Histopathologist/
Anaesthetist
CNM/ BreastCheck
Nurses Senior Medical
Scientist
Cervical Check
Colorectal Cancer
Diabetic Retinopathy Screening
Clerical Officers Research Officers
HR Manager Head of ICT Head of Communications Director of PEU Finance Manager Specialist in Public Health Medicine Planning & Risk Manager Screening Promotion Manager National Radiography Manager Chief Physicist
45
4.2. Infrastructure & Organisation
In Ireland, screening is provided to women aged 50 to 64 years, every two years. Screening
is delivered in static (four units) and mobile units (sixteen units) across the country. The
static units are on the grounds of or adjacent to an acute hospital/symptomatic cancer
service, with the exception of the Southern BreastCheck Unit. The Southern Unit in Cork is
adjacent to the South Infirmary Hospital however cancer services have since been
centralised to Cork University Hospital.
Screening and assessment take place within the static units while the mobile units are used
for screening only. Three static units have three x-ray machines each while one static unit
(Eccles unit) has four x-ray machines. Each mobile unit contains one x-ray machine for
screening and is staffed by two radiographers. Mobile site selection is based on a number of
client, technical and operational criteria including car parking facilities, transport links,
wheelchair accessibility, ISDN lines and availability for an entire screening round (20). The
objective is to select a location with the greatest potential to serve the most eligible women.
The majority of mobile sites are on the grounds of public hospitals or other medical facilities
such as primary care centres. In some instances BreastCheck would invest “to make a site
suitable”, for example installing a concrete plinth to hold the mobile unit. The plan would be
to revisit this site and maintain it for future screening. Mobile units “are more static than their
name suggests” as they typically revisit certain sites. In some areas mobile sites are
practically permanent due to the size of the population (e.g. Donegal, Tallaght). The site
selection process may be refined depending on feedback from women attending the service,
changes in population density and the balance of technical and operational requirements.
After each mobile move a physicist is sent to the site to conduct quality assurance on the
unit before screening.
4.3. Comparison with Organisation of Screening Models Internationally
The delivery of screening across fixed and mobile units is similar to the organisation of
screening in other European countries such as the UK, France, Germany and the
Netherlands. In addition to the organisation of screening, there are a number of similarities
between the screening model in Ireland and international models, namely the frequency and
age ranges screened. Table 10 outlines the main features of screening programmes
internationally, largely based on information from 2007-2008 published by the International
Cancer Screening Network (ICSN) (21).
During the late 1980s and 1990s many countries began to develop national, regional or pilot
population-based breast cancer screening programmes. In 1995, the International Breast
Cancer Screening Network (ICSN) conducted a review of breast cancer screening
programmes which found that most countries provided screening every two years, using
dedicated centres for film mammography which was the most common detection method
(18). Relatively fewer programmes were using mobile screening units. At that time there was
also variation in the age intervals for screening, particularly the upper age limit.
46
In 2012, there appears to be greater uniformity across international screening programmes.
Most countries invite women for screening every two years; the UK screening programmes
are a notable exception with a three-year screening interval. Most countries provide
screening to women from the age of 50 to 69 years. Ireland is one of a handful of countries
currently screening to age 64. The national screening programme in the Netherlands
extended screening services to the 70-75 age group between 1998 and 2000 (22). The NHS
breast screening programmes (NHSBPS) across the UK completed the expansion to women
aged 70 in 2004. This expansion equated to a 40% increase in workload over three years
and was cited as the main cause of round length slippage in the programme (23). A number
of countries are also piloting screening among younger (40-49) and older women (70-74)
e.g. Sweden (24), UK (25).
While some countries operate national centralised screening programmes, more often
aspects of service delivery and organisation are decentralised and implementation is
determined regionally within an overarching national policy (21). The distinction between
national programmes (N) and national screening policy with state/provincial/regional
screening program implementation (NS) is not straight forward. For example, Belgium is
classified as a national screening policy with state/provincial/regional screening program
implementation (NS). Eleven screening centres are responsible for identifying the target
group, sending invitations, second reading, data recording and reporting results to the
referring doctor (26). This is similar to the way the BreastCheck model operates as each unit
coordinates the invitation process, mammography reading and reporting of results, however,
it is classified by the ICSN as having a national screening policy with national program
implementation (N).
47
Table 10 Organisation & Delivery of screening across countries (21)
Country
Year est. Programme Type* (21)
Age range Interval Model of Delivery Detection Method† (21)
Austria 2007 (pilot) NS 40-69 1 (2) years Fixed centres -
Belgium 2001 NS 50-69 2 years Fixed screening centres MM, DM
Cyprus (27) 2006 N 50-69 2 years - -
Czech Rep(28, 29) 2002 N 45-69 2 years Fixed units MM, DM, CBE
Denmark(30) 1991 S 50-69 2 years Fixed & mobile units MM, DM
Finland 1986 N 50-69 2 years Fixed centres MM, DM
France (31) 2003 N 50-74 2 years Fixed & mobile units MM, CBE
Germany (32) 2005 NS 50-69 2 years Fixed & mobile units MM, DM
Greece (26) 2004 Sub-national/NGO 40-69
Hungary (33, 34) 2002 N 45-65 2 years Fixed & mobile units MM
Ireland(12) 2000 N 50-64 2 years Fixed & mobile units DM
Italy (35) 1991 (pilot) NS 50-69 2 years Fixed & mobile units MM, DM
Latvia (36) 2009 - 50-69 2 years Fixed & mobile units
Lithuania (37) 2005 - 50-68 2 years Fixed & mobile units
Luxemburg(38) 1992 N 50-64 2 years Fixed & mobile units MM
Malta 2007 - 50-60 2 years Single central fixed unit
Netherlands(22, 39) 1989 N 50-74 2 years Fixed & mobile units MM, DM
Norway (40, 41) 2005 NS 50-69 2 years Fixed & mobile units
Poland (42) 2007 Opportunistic 50-69 2 years Fixed & mobile units
Portugal (43, 44) 1990 S 45-69 2 years Fixed & mobile units DM
Romania 2009 - 59-69 2 years Fixed & mobile unit
Slovenia 2008 - 50-69 2 years Fixed & mobile units
Spain 1990 S 50-(65)69 2 years Fixed & mobile units MM
Sweden (24, 45) 1986 NS (50-69 (Pilot 40-74)
2 years Fixed & mobile units MM, DM
UK [1] 1988 N 50-70 (Pilot 47-73)
3 years Fixed & mobile units MM, DM
Australia (46) 1991 NS 50-69 2 years Fixed & mobile units MM, DM
New Zealand 1998 N 45-69 2 years MM, DM
Canada (47) 1988 NS 50-69 2 years Fixed & mobile units MM, DM, CBE
United States (48, 49)
- O 50-74 2 years Fixed & mobile units General radiology dept.
MM, DM, CBE
48
Programme Types: N (National screening policy with national program implementation) NS (National screening policy with state/provincial/regional screening program implementation) S (State/Provincial/Regional screening and program implementation) P (pilot program) O (Other) †Detection Methods: MM (screen-film mammography), DM (digital mammography), CBE (clinical breast exam)
Based on US Task Force Recommendations (ref)
4.3.1. Screening & Assessment
As illustrated in Table 10 above, the overall BreastCheck model is similar to other European
countries in its use of mobile units and two-yearly screening cycle. However, there are
certain differences between the Irish model of breast screening and international
counterparts, which make direct cost comparisons difficult. Firstly, in the Irish model
screening, assessment and primary surgery are covered as part of the BreastCheck
programme. This is in contrast to the UK where clients are referred to a surgeon in the
symptomatic service for treatment following assessment if necessary. Following screening
and assessment in Australia, women diagnosed with breast cancer have the option of
referral to a clinic specialising in the treatment of breast cancer or returning to their doctor for
referral (50).
Furthermore, BreastCheck is a consultant-delivered service and has a higher proportion of
consultant-led services and consultant-level staff than in England for instance, due to the
coverage of assessment and primary treatment. The Irish programme is based on a salary
model as opposed to a fee-for-service model hence the majority of health care professionals,
including surgeons and consultant radiologists, are contracted to BreastCheck and paid a
salary by the programme. In contrast, a number of screening programmes in the United
States and Canada operate on a fee-for-service basis whereby radiologists and
radiographers are private providers who hold contracts with the Ministry of Health or State
Agency to provide a certain volume of screening at an agreed cost per mammogram.
There are a number of other skill-mix differences between screening models in Ireland and
the UK. The NHS BSP have extended the scope of radiographic practice and introduced
new staff grades such as assistant and advanced practitioners, as part of a four-tier service
delivery model. This model was developed in response plans to expand the service (51). At
that time the programme was facing a number of challenges similar to the Irish screening
service; achievement of targets for waiting times for diagnosis and treatment and the
international shortage of radiography staff. Evidence from the literature appears to support
the idea of changes to skills mix with adequate training and supervision (52-54).
49
4.3.2. Cost of Screening & Assessment
According to estimates provided by the NCSS, 65% of net expenditure in BreastCheck can
be attributed to screening activity, with the remaining 35% attributable to assessment. The
unit cost per woman screened in the BreastCheck programme between 2008 and 2011 is
presented in Table 11.
In 2008, the cost per woman screened was €121.42. In 2009, the number of women
screened increased by almost 32% in 2009, with a 21% reduction in the cost per screen to
€95.74 that year. There was almost no change in the number of women screened in 2010
and the unit cost of €95.57 was only marginally lower than the previous year. In 2011, there
was a 3% increase in the number of women screened. This change in the level of screening
activity, in conjunction with a reduction in net expenditure, brought the unit cost down by a
further 5% to €90.32. Overall, there was a 26% reduction in the unit cost of screening activity
between 2008 and 2011. It should be noted, however, that the figures for the earlier period
may have been partly driven by the developmental stages of the programme.
While the cost per woman screened has fallen with respect to screening activity, the unit
cost per woman assessed increased by 4% from €1,115.38 to €1,164.43 between 2009 and
2011. Although this represents on overall reduction of 20% from the unit cost for assessment
in 2008, further analysis of this trend may be beneficial given the possibility of small savings
being made available to the BreastCheck service.
Table 11 Unit Cost per woman screened & assessed (2008-2011)
2008 2009 2010 2011
Number of women attending for Screening
92,061 121,160 120,730 124,551
Total Pay & Non- Pay Expenditure
€17,197,344 €17,846,155 €17,751,836 €17,306,771
Total Cost per Woman Screened €186.80 €147.29 €147.04 €138.95
Number of women recalled for Assessment
4,119 5,600 5,504 5,202
Estimated Costs*
Screening €11,178,274 €11,600,001 €11,538,693 €11,249,401
Assessment €6,019,070 €6,246,154 €6,213,143 €6,057,370
Cost per Woman
Screening (65% of costs)
€121.42 €95.74 €95.57 €90.32
Assessment (35% of costs)
€1,461.29 €1,115.38 €1,128.84 €1,164.43
Regional Unit Cost
A similar breakdown of screening and assessment costs at the regional level is presented in
Table 12. The relatively high cost of €196 per woman screened in the Southern and Western
Units in 2008 is more than likely reflective of the implementation phase of the programme in
those regions. When the number of women screened increased by 95% in 2009, the unit
cost was reduced to by more than 50% to €116.70. Currently, the cost per woman screened
in the Western and Southern units is €95.74, €10 more than in the Eastern units where the
unit cost per woman screened is €85.45. However, the cost per screening is likely to remain
higher in these units which have more dispersed populations.
50
Table 12 Cost per woman screened & assessed at regional level (2008-2011)
2008 2009 2010 2011
No. of women attending for Screening 92,061 121,160 120,730 124,551
East 66,346 70,923 72,708 67,815
South & West 26,329 51,312 48,662 56,973
Total Pay/Non-Pay Expenditure
East 9,259,514 8,634,038 8,657,118 8,914,939
South & West 7,937,830 9,212,117 9,094,719 8,391,832
Total Cost per Woman
East €139.56 €121.74 €119.07 €131.46
South & West €301.49 €179.53 €186.90 €147.29
ESTIMATED COSTS
No. of women recalled for Assessment
4,119 5,600 5,504 5,202
East 2,393 2,750 2,624 2,576
South & West 1,757 2,902 2,909 2,626
Total Expenditure
Screening - East €6,018,684 €5,612,125 €5,627,126 €5,794,710
Assessment - East €3,240,830 €3,021,913 €3,029,991 €3,120,228
Screening - South & West €5,159,590 5,987,876 5,911,567 5,454,691
Assessment - South & West €2,778,241 3,224,241 3,183,151 2,937,141
Cost per Woman
Screening East €90.72 €79.13 €77.39 €85.45
Assessment East €1,354.30 €1,098.88 €1,154.72 €1,211.27
Screening South & West €195.97 €116.70 €121.48 €95.74
Assessment South & West €1,581.24 €1,111.04 €1,094.24 €1,118.48
Cost of Assessment
The cost per woman assessed in the Western and Southern units fell from €1,581 to €1,118
between 2008 and 2011, an overall reduction of more than 29%. In the Eastern units, the
cost per woman assessed decreased between 2008 and 2011 by more than 11%, from
€1,354 to €1,211. Currently, the cost per woman assessed in the Western or Southern units
is €93 less than the Eastern units. There was a higher recall rate for assessment in Southern
and Western Units compared to the Eastern units (Table 13), however this may be due to
the larger proportion of initial screening (as opposed to subsequent screening) which takes
place in the newer units.
Table 13 Recall Rate for Assessment (2008-2011)
Eastern Unit 2008 2009 2010 2011
Screened 66,346 70,923 72,708 67,815
Assessment 2,393 2,750 2,624 2,576
Recall Rate 3.6% 3.9% 3.6% 3.8%
Western & Southern Unit
Screened 26,329 51,312 48,662 56,973
Assessment 1,757 2,902 2,909 2,626
Recall Rate 6.7% 5.7% 6.0% 4.6%
51
4.3.3. International Comparison of Screening Costs
The unit cost of screening varies significantly across countries (Table 14), ranging from
approximately €31.75 in the United States (55) to upwards of €138 in Switzerland (56).
However, as there are several factors which may account for at least some of the differences
observed, direct comparisons should not be made exclusively on the basis of the cost per
woman screened.
Table 14 Unit Cost of Digital Mammography across Countries
Country Year Cost per Woman Screened
Euro Equivalent*
Australia 2006-2007 $152 AUD €121.82
England 2009 £45.50 €56.77
Ireland 2011 €90.32 €90.32
The Netherlands 2009 €56.65 €56.65
Scotland 2009 £77.80 €97.08
Switzerland 2008 €138 €138
United States 2005; 2006 $41 - $135.29 USD €31.75 - €104.76
*2012 exchange rates
In the first instance, screening programmes in countries such as England, Wales, Scotland
and the Netherlands have been in operation significantly longer than the BreastCheck
service. Therefore, it would be anticipated that the unit costs in these countries are reflective
of a higher level of efficiency being achieved than would be possible in the development
phase of a screening service.
Another important factor is the differences in service delivery models across these countries,
some of which have been previously outlined. Although the unit cost is highest in
Switzerland, organised population-based screening accounts for only 25% of all screening
activity (56). In the United States, where a national screening programme has not been
implemented, there is significant variation in the unit cost between various service providers
(€31.75-€104.76) (55, 57). The highest figure is based on Medicare reimbursement rates for
2006. However, this is a flat rate and may not necessarily reflect actual costs to the provider.
The lower cost estimates of €31.75 ($41) and €79.24 ($102) per woman screened at a
stationary unit or digital mobile unit in 2006 were obtained directly from hospital accounting
data (55).
52
Since 2008, BreastCheck has been providing a fully digital mammography service. This
technology is currently being implementing in the NHS breast screening programmes
(NHSBPS). According to the latest update from the NHSBSP, 85% of breast screening units
had at least one digital mammography set as of July 2011 (58). Digital mammography
screening is estimated to have a higher unit cost per woman screened than film
mammography (57, 59, 60). For example, the cost per woman screened in Australia in 2006-
2007 was €113.66 ($141 ASD) (60). As these costs would have included a relatively low
amount of mammograms performed utilising digital x-ray equipment, a separate unit cost of
€121.82 ($152 ASD) for digital mammography was estimated. Similarly, Medicare
reimburses $50 more per digital mammogram than per film mammogram (57). The cost per
woman screened in The Netherlands in 2009 was approximately €56.65. However, only 42%
of women underwent digital mammography screening as digital X-ray equipment was not
available in all screening units during this period (61). The unit cost may have been higher
had a larger proportion of women been screened using digital x-ray equipment.
Finally, the delivery of screening services to women within the community using mobile units
has an impact on the overall unit cost. In the United States, the cost per woman screened in
a digital mammography mobile unit was estimated to be almost 2.5 times higher than the
cost per screen within a static unit (55). Similarly, data obtained from the Scottish Breast
Screening Programme estimated the cost of a mammogram to be £77.80 (€97.08) in 2009
(62), approximately 71% higher than the unit cost in England and Wales. The higher unit
cost may, in part, be related to the need for frequent movement of mobile units to provide
screening services to a highly dispersed population.
In Ireland, pay costs are one of the primary drivers of cost in the BreastCheck model. Based
on accounting data provided by the NCSS, we would estimate pay costs to account for 74%
of the unit cost in Ireland. While details on specific cost drivers were not available in the
literature examined, a report by the NHS found that approximately 66% of the unit cost per
screen in England and Wales was attributable to staffing costs (59). Similarly, it was reported
that approximately 63% of the unit cost per woman screened in Australia is related to staff
pay (60).
53
4.4. Synergies between the NCSS and the NCCP
As mentioned previously, the NCSS was subsumed into the National Cancer Control
Programme (NCCP), part of the Health Service Executive (HSE), in 2010. The aim of this
merger was to eliminate duplication in areas such as recruitment and ICT. The NCCP has
benefited from having the NCSS subsumed into its programme as the NCSS is providing
and supporting a number of central administrative functions including IT, HR and
communications. The same NCSS management structure is also supporting the additional
screening programmes, consequently there is greater administrative workload being taken
on at unit level.
The synergies are limited to executive functions such as HR and IT support; the subsuming
of the NCSS into the NCCP did not result in changes to service delivery at unit level.
However, becoming part of the wider HSE structure has had an impact on efficiency of
certain functions particularly recruitment and procurement which influence the delivery of
screening at unit level. A number of stakeholders commented on difficulties with the HSE
recruitment process including time taken to obtain approval to fill posts, the delay recruiting
and filling posts, and the lack of flexibility in the posts being sanctioned given that the
screening service often utilises part-time staff to adapt to changes in the screening schedule.
This is a separate issue to the wider challenge of the moratorium in the health sector.
4.4.1. Staff Levels
Central administrative staff in the NCSS support the running of the NCPP and provide
central to three other screening programmes. Table 15 outlines the current staff available
based on data for 2012 provided by HR (please note HR do not take parental leave into
account in the information provided).
Table 15 Central Administrative Staff Employed (NCSS)
Type & Grade Number Mat Leave Sick Leave Vacancies
Clerical Officer Grade III 5 1
Clerical Officer Grade IV 6
Clerical Officer Grade V 1
Clerical Officer Grade VI 4 1
Clerical Officer Grade VII 15 1 1
Clerical Officer Grade VIII 3
HR Manager 1
Head of ICT 1
Finance manager 1
Head of Communications 1
Planning and Risk Manager 1
Consultant Epidemiologist 1
Specialist in Public Health Medicine
1
Director/ Acting Director 1
54
Tables 16, 17 and 18 outline the number of staff available in each unit based on data for
2012 provided by HR. Vacancies, maternity leave and sick leave are also included. Each
unit has a Unit Manager however in the Merrion Unit this post is shared between two part-
time agency managers. A number of units also have acting Radiography Services Managers
who are responsible management and scheduling as well as screening.
Table 16 Radiology, surgical & histopathology staff employed in BreastCheck (HR 2012)
Eccles Merrion Southern Western
Consultant Radiologists
Number (WTE) Number (WTE) Number (WTE) Number (WTE)
Consultants in post
4 (2.17) 4 (2.35) 3 (1.8) 3 (1.8)
Specialist Registrar
1 (1.0) 1 (1.0) 0
Sessions per week
26 26 20
Vacancies 0 0 0 1(1.0) (Registrar)
Leave 1 (0.5) 1 (0.5)(Maternity) 1 (Maternity) -
Surgeons
Consultants in post
2(1.0) 2 (1.0) 2 (1.0) 1 (0.5)
Specialist Registrar
1(1.0) 1 (1.0) 1 (1.0) 1 (1.0)
Sessions per week
- 18 12 -
Leave 1 (Parental) - - -
Histopathologists
Consultant 1 (0.5) 1 (0.5) 1 (0.5) 1 (0.5)
Specialist Registrar
1 (1.0) 1 (1.0) 1 (1.0) 1 (1.0)
Anaesthetists
Consultants in post
1 (0.5) 1 (0.36) 1 (0.5) 1 (0.5)
Medical Scientist
In post 1 (0.9) 3 (3.0) 1 (1.0) 2 (2.0)
Vacancies 1 (1.1) - - -
Leave - - 1 (1.0) (Maternity)
-
Physicist
In post 2 (2.0) (Chief & Snr)
- 1 (1.0) 1 (1.0)
55
Table 17 Senior Radiography Staff employed in BreastCheck (HR 2012)
Merrion Eccles Southern Western
No.
WTE No. WTE No WTE No. WTE
Available 19 12.7 incl. RSM
20 15.2 15 12.5 14 12.5 incl RSM
Vacancies - 4.5 2 1.8 incl RSM
6.5 incl RSM
3 3.0
Leave
Maternity - - 2 1.3 4 1.6 1 1.0
Parental - - - - - -
Sick (LT) 1 0.6(LT) - - - -
RSMs in post 1 1.0 0 0 (2 acting) 0 0 (1 acting) 1 1.0
Table 18 Administrative, nursing, science and health care assistant staff employed
Merrion Eccles Southern Western
No. WTE No. WTE No. WTE No. WTE
Administration/Clerical
Available 9 8.3 10 10 14 14 13 13.0
Vacancies 2 2 (incl Unit Mgmt)
0 - 3 3.0 2 2.0
Leave Maternity - - 2 1.8 - - 3 3.0
Sick 1 1 - - - - - -
BreastCheck Nurses (Clinical Nurse Manager Level)
Available 3 3 3 2.5 2 1.9 2
2.0
Vacancies - - 1 0.5 - -
Leave Maternity 1 1.0 - - 2 1.9 1 1.0
Sick - - - - - - - -
Health Care Assistants
Available 1 0.4 1 1.0 1 1.0 1 1.0
Vacancies 1 0.6 1 1.0 1 1.0 - -
Leave Maternity - - - - - - - -
Sick - - - - - - - -
Physicist
Available - - 2 (Chief/Snr)
2.0 1 1.0 1 1.0
*Parental leave was not recorded in the data provided by HR for 2012
56
4.4.2. Head Office Costs
Accounting data provided by the NCSS indicates that central overhead spending reduced
considerably between 2010 and 2011 (Table 20). Prior to subsuming, head office costs were
€7.9 million, with the administration of BreastCheck accounting for approximately 45% of
total expenditure (€3.58 million). Based on stakeholder accounts, head office costs are
equally apportioned across the four screening programmes administered through the NCSS.
Consequently, BreastCheck now represented one-quarter of the overall NCSS budget of €5
million, or approximately €1.2 million in 2011.
Table 19 Head Office Costs 2008-2011 (as a percentage of BreastCheck Expenditure)
2008 2009 2010 2011
Head Office Costs €8,498,859 €6,615,533 €7,959,383 €5,051,727
Allocated to BreastCheck €3,824,487 €2,976,990 €3,581,722 €1,262,932
BreastCheck Expenditure €16,608,233 €17,221,455 €16,501,985 €18,358,181
% of BreastCheck Expenditure 23% 17% 22% 7%
Data provided by NCSS
57
BreastCheck Expenditure
Currently, head office costs account for approximately 7% of BreastCheck expenditure. This
represents a reduction in resources spent between 2010 and 2011 from 22% to 7% (Table
21). Again, it would be anticipated that some of that the figures for the earlier period may
have been partly driven by the early developmental phase of the programme.
Due to the moratorium, there was a reduction of more than 1.6 million in pay costs between
2010 and 2011 (Table 21). According to feedback from the NCSS, many of the figures
represent reallocation of costs between screen programmes and one-off exit scheme costs
and are not reflective of pay savings. It is important to highlight that the significant reduction
in certain staff categories, through incentivized retirement and the recruitment moratorium,
will potentially lead to an inappropriate balance of staff to manage and deliver the service.
Feedback from stakeholders suggests that this has already occurred. This will ultimately
undermine the operational efficiency of the programme.
Table 20 Head Office Pay Costs (2010 vs. 2011)
Pay by Category Difference on 2010 figures
Management/Admin -€896,710
Medical/Dental (Consultants) €506
Paramedical -€362,247
Pensioners -€2,010
S/Ann Refunds/Lump Sums -€96,934
Pay Other Costs -€251,089
Total Pay Savings €1,608,484
Overall, we would expect that areas where potential reductions in head office costs could be
made, are relatively small and the amounts saved within these would be quite low (Table
22). The majority of costs for the BreastCheck Service are directly linked to service delivery
and staffing requirements within the units.
58
Table 21 Head Office Financial Costs (2011)
IT Finance HR Comms PEU GM Central
Total
PAY BY CATEGORY
Management & Admin
485,280 362,707 299,318 595,631 313,723 610,129 2,666,789
Medical/Dental (Cons)
0 0 0 0 77,549 0 77,549
TOTAL PAY 485,280 362,707 299,318 595,631 391,272 610,129 2,744,337
NON-PAY BY CATEGORY
Laboratory 0 0 0 0 0 1,694 1,694
Catering 84 0 38 1,229 0 8,278 9,628
Heat, Power & Light 0 0 0 0 0 39,970 39,970
Cleaning, Washing & Waste
0 0 0 0 0 20,846 20,846
Furniture, Crockery & Hardware
250 0 0 9 0 21,635 21,894
Maintenance 0 0 0 0 0 23,630 23,630
Transport & Travel 658 357 2,081 37,088 136 15,432 55,752
Bank Charges 0 551 0 7 0 59 617
Insurance 1,356 0 0 0 0 0 1,356
Audit & Accountancy
0 -3,696 0 0 0 0 -3,696
Legal 0 0 0 0 0 605 605
Office Expenses 29,892 496 850 707,694 501 461,532 1,200,966
Computer 893,922 12,308 0 484 19,435 4,743 930,892
Professional Services
375 -25,418 5,000 6,516 1,579 2,825 -9,123
Training 362 1,139 675 1,637 2,050 17,270 23,132
Miscellaneous 0 338 195 999 944 -337 2,140
TOTAL NON-PAY 926,899 -13,925 8,839 755,663 24,646 618,182 2,320,304
INCOME BY CATEGORY
Other Income 0 -2,598 -750 -3,319 0 -6,248 -12,915
0 -2,598 -750 -3,319 0 -6,248 -12,915
TOTAL EXPENDITURE
1,412,180 346,183 307,407 1,347,976 415,917 1,222,664 5,051,726
59
5. Processes
This section provides a detailed description of the processes involved in the delivery of
BreastCheck including the consent, invitation and screening process. As mentioned
previously, there is a dearth of information on the scheduling and work practices which
underpin international screening models, however, comparisons are drawn with other
countries where available. This section outlines the most recent data available on uptake
rates across a number of countries and examines mechanisms to optimise utilisation.
5.1. Consent & Invitation Process A register of women eligible for screening had been built and maintained by the BreastCheck
screening service. The Head Office of the NCSS maintains the register of eligible women
from details supplied by the Department of Social Protection, General Medical Services
(GMS), private health insurers and women who self-register with BreastCheck. This register
is used to identify the target population for screening. Data is uploaded on a monthly basis
from each of the providers. An external agency carries out a de-duplication process every
month (63). Due to the lack of universal patient registration and unique patient identifier in
Ireland, there is potential for duplication and gaps in the register system. Registration
systems in other countries are more dynamic due to the IT infrastructure and identification
systems in place. For example, in Sweden, the booking system is connected online to the
daily updated regional population register, facilitated by the unique identification number
assigned to each individual in the country (45).
In Ireland, each woman is initially sent an information leaflet and a letter seeking her consent
to invite her for screening. This consent process is coordinated through Head Office in the
NCSS. The onus is then on the woman to inform the programme in writing within three
weeks if she does not wish to receive an invitation. Women who do not respond are then
issued a letter of invitation from BreastCheck to attend screening, which includes an
appointed time, date and location. Issuing invitations with a pre-specified appointment is
similar to the invitation process in most other countries such as Sweden (45) and the
Netherlands (64). Each regional unit issues invitations for their area, scheduling
appointments for both the static and mobile units.
First & Second Invitation Letter
The BreastCheck Charter states that women will receive at least seven days’ notice of their
appointment. However, women often receive their appointments a number of weeks in
advance. In 2010, 93.6% of women received seven days’ notice of their appointment (65).
The client is not required to respond to this letter to confirm attendance but is advised to
inform the unit if she is unable to attend. She can contact the unit and reschedule the
appointment if necessary. If a woman does not attend the first appointment (DNA) she will
be issued a second invitation before the end of the screening round. Research conducted by
the Programme Evaluation Unit (PEU) using the BreastCheck clinical database, found that
between 2000 and 2010 the second invitation letter accounted for an additional uptake of
30% and a further 1,550 cancers detected (35%) (66). Following the initial invitation 54.8%
of women attended which increased to 84.7% following the second invitation. There was no
significant difference between women who attended following the initial or second invitation
60
letter in terms of cancer detection rates. The most recent annual report from BreastCheck
indicated an uptake rate of 74%, above the European target rate of 70% (67).
Some women are deemed ineligible following the first invitation including those who de-
consent, women in follow-up breast cancer care, those non-contactable by post, and those
being treated for a terminal illness. These women are not sent a second invitation. Previous-
non-attenders (women who did not attend any screening appointment during previous
screening rounds) are not offered a second invitation in a given screening round (66).
Type of Invitation- Initial, Subsequent & Previous-Non-Attenders (PNAs)
Data provided by the PEU show that each unit invited a similar proportion of initial women,
subsequent women and PNA/DNA women to attend screening in 2011 (Figure 12). The
newer units (Southern and Western units) have a higher proportion of initial women to invite
whereas the more established units (Eccles and Merrion units) have a higher proportion of
subsequent women to screen.
Figure 12 Type of invitation as a proportion of the total invites in 2011
Influence of Uptake Rate on the Invitation Process
The number of invitations issued to initial women, subsequent women and those who had
previously not attended (PNA) varies according to expected attendance rates, which differ
substantially (Table 22). In 2011, the uptake rate among previous non-attenders (PNAs) was
15%, compared to an 87% uptake among those attending for subsequent screening. The
balance of invitations between subsequent and initial women also impacts on the workload
at the assessment and surgery stage as there is a higher cancer detection rate from initial
screens. The number of invites issued for the static unit is typically higher as there is more
space to accommodate women while they wait; space in the mobile unit is very confined.
Table 22 Uptake Rate by Type of Invite
22.9% 23.8%
33.9%
52.3%
11.4% 9.4% 7.2% 9.9%
65.8% 66.9%
58.8%
37.8%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Eccles Merrion Southern Western
initial % of total PNA % of total Sub % of total
61
Invited Screened Uptake Rate
Initial Subs PNA Initial Subs PNA Initial Subs PNA
2008 52,793 57,545 9,898 38,808 52,401 1,466 74% 91% 15%
2009 88,051 63,550 11,935 64,409 56,092 1,734 73% 88% 15%
2010 64,379 84,655 17,778 44,242 74,659 2,469 69% 88% 14%
2011 55,123 100,555 16,437 34,820 87,554 2,424 63% 87% 15%
Data provided by PEU
5.2. Scheduling
In addition to previous uptake rates, there are a number of other factors taken into
consideration when planning the screening schedule which was described by stakeholders
as a “balancing act”:
Charter commitments in an area
Number of radiographers available
Previous uptake in an area
Initial vs. subsequent invitation
Number of DNA/PNA women in an area
While there is a standard approach to scheduling within the programme, each unit may vary
slightly in its approach to invitations and screening plans. Units schedule screening between
two and six weeks in advance of screening. Typically women due for subsequent screening
are invited first as this allows the consent period for initial women to pass (women have
three weeks to de-consent from the programme). However, who gets invited first (initial
women or subsequent women), may also depend on charter commitments in an area. Two
radiographers are needed to deliver screening in each mobile unit and all radiographers are
required to rotate between the mobile and static units. Two or three clients are scheduled for
every fifteen minute screening slot, depending on whether it is an initial or subsequent visit
(seven minutes per screen). Longer screening slots are allocated for those with special
needs.
Scheduling Previous Non-Attenders
Previous non-attenders (PNAs) are one of the main barriers to the optimal utilisation of
screening slots. Given the poor and unpredictable uptake rate, high numbers of PNA/DNA
women are invited to screening (e.g. 140- 150 invited a day). One approach to scheduling
this group adopted by a number of units, involves inviting PNA’s throughout the normal
screening day, as opposed to having a set day dedicated to this cohort of women. In the
static unit a number of PNA/DNA women are scheduled every day in the 12.30pm slot.
Re-bulking- mechanism to optimise utilisation of screening slots
In an effort to fill cancellations, stakeholders described a “re-bulking” process whereby reuse
cancelled slots within the schedule are reused. The computer system recognises vacant or
cancelled appointments for a day so the bulk schedule can be put through the system again
and new invitations can be issued for those vacant slots. Scheduling up to six weeks in
advance allows the unit to utilise cancelled slots in this way. It is difficult to reuse
62
appointments that are cancelled at short notice, however units try to refill slots up to the day
before screening by ‘re-bulking’ and utilising lists of self-registered women. The balance of
initial versus subsequent invites needs to be taken into consideration in this re-bulking
process as subsequent women are more likely to attend. Filling slots with subsequent
women that were originally cancelled by initial women, can lead to over-booking and heavy
screening days.
5.3. Uptake of Screening at National and International Level
Optimising the utilisation of screening units involves increasing uptake and maximising the
use of available screening slots. This section will deal with the former, uptake rates, as there
is a dearth of information from international screening programmes on other aspects of
utilisation such as scheduling processes and the organisation and timing of screening slots.
5.3.1. Screening Uptake Rates
Uptake by a substantial proportion of the eligible population is required for a population-
based screening programme to be effective (68). According to data provided for this review
by the Programme Evaluation Unit (PEU), the uptake rate was approximately 73% in 2010
(n=121,370 women) and 2011 (n=124,788 women) (Figure 13). In the first six months of
2012, the uptake rate was 73.8% (n=62,892 women).
Figure 13 number of women invited & screened & uptake rate 2008-20111
1 Data provided by programme Evaluation Unit: The BreastCheck database is constantly being updated therefore the numbers in this report may vary slightly from previous BreastCheck annual reports which are based on a snapshot of the database in a given year.
78.5% 74.8%
72.8% 72.5%
73.8%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
0
20000
40000
60000
80000
100000
120000
140000
160000
180000
200000
2008 2009 2010 2011 2012 (Jan-June)
Invited Screened Uptake rate among eligible women
63
The uptake rate is higher in the Netherlands than that reported by BreastCheck (82% in
2009) (61). BreastCheck compares favourably to uptake rates recorded by the UK screening
programmes, and is substantially higher than attendance in Germany, and Australia (Table
24). Given the variation in the quality and reporting period of data, the comparison was
restricted to countries with national screening programmes (excluding pilot programmes)
which had complete data on uptake within the last five years (2007-2012).
Table 23 Attendance Rates across Countries
Country (data year)
Year
Age range
No. women
invited
Number screened
Uptake rate
Recall Rate
England(69)† 2010/2011 45+ 50-70
2.4 million 2.3 million
1.88 million 1.73 million
73.4% uptake
In women aged 45+: 7.7% initial 2.8% subsequent
Scotland (70) 2010/2011 50-70 228,657 170,664 74.6% 9.6% Initial 3.8% Subsequent
Wales× (71) 2010/2011 50-70 334,108 249,168 74.6% 9% Initial
3.9% Subsequent
Northern Ireland (72)
2009/2010 50-70 71,773 53,454 74% 3.7%
Ireland 2010/2011 50-64 167,088 120,730 73.9% 4.6%
Slovenia 2011 50-69 26,781 19,504 72.8% 3.8%
Czech Rep. (28, 29)
2008 45-69 ** 453,514 * 12,426
Sweden (45) 2008 Stockholm County
40-69
154,270
110,586
71.7%
3%
Latvia (36) 2009/2010 50-69 286,785 57,340 20% *
Lithuania (37, 73)
2006 50-68 29,700 * * *
Netherlands (61, 64, 74)
2009
50-75
1,121,185
911,441
82%
17,413 referred (1.9%)
Canada(47) 2006 50-69 * 823,182 43.9% *
Australia (8) 2007/2008 50-69 2,307,802
1,273,403 54.9% 9.5% Initial 4.1% Subsequent
Germany (75)
β
(32)
2009 50-69 4,525,530 (systematic invites) 4,800,975 (includes self-invites)
2,350,643 2,608,406
51.9% 54.3%
6.1% Initial 3.0% Subsequent
France(31, 76)
2011 50-74 4,554,000 2,400,00 52.7% 8% initial
Luxembourg (38, 77, 78)
2006-10 50-69 121,950 75,121 61.5% average
7.5%
Table Legend: *Information not available. ** No invitation system. Invited through the screening
programme †Screening policy changed in 2001. In 2010 a further extension of the breast screening
programme was phased in to cover women aged 47-73. Nearly a half of the 81 breast screening units
had started implementing the age extension by the end of 2010-11 collection year, but in many cases
this was in the last quarter of the year.(69) ×3 year review period of screening in Wales
β Personal Communication
64
5.3.2. Mechanisms to Optimise Utilisation & Uptake
The following section outlines the type of reminder systems used to increase uptake in
screenings services and the evidence of effectiveness. There are many reasons for missed
appointments including practical issues such as work obligations or transportation difficulties
as well as psychological or emotional issues such as anxiety about the process and results,
or the pain and discomfort of the procedure. Service-users of BreastCheck, interviewed as
part of the review, reiterated these factors as potential reasons for non-attendance.
Unintentionally missed appointments are believed to be the main contributing factor for non-
attendance (79-82). As a result, a number of studies have assessed the impact of reminder
systems on attendance at healthcare appointments.
Research has been carried out on a variety of strategies to increase attendance including
the benefit of sending traditional reminder letters, GP signed letters, providing home visits,
telephone counselling and peer education (83-85). Some interventions used combined
techniques, for example sending a letter endorsed by a GP plus a reminder telephone call to
increase attendance (86). More recently, the use of text messaging or short message
service (SMS) reminders has been examined as a cost-effective use of modern technology
for reminding patients of appointments (79, 81, 82, 87-89).
The search strategy and methodology for this section is outlined in Appendix 1. The search
was limited to systematic reviews and randomised controlled trials of client-focused
strategies to improve uptake. Five systematic reviews and nine RCTs met the inclusion
criteria. The detailed results of the systematic reviews are outlined below. The results from
recent RCTs are included in the Appendix section (see Appendix 1).
Systematic Reviews of Reminder Systems
Looking at interventions to improve attendance at health care appointments generally, Car et
al (2012) assessed the impact of mobile phone messaging reminders on attendance (81).
This review identified four eligible randomised control trials (RCT’s), three of which were of
moderate quality and one trial of low quality. SMS reminders had a positive impact on the
rate of attendance when compared to no reminders. The study graded as low quality found a
positive effect in favour of SMS reminders when compared to postal reminders. Two of the
studies which compared text message reminders to telephone call reminders detected
similar effects. However, mobile phone messaging was found to be more cost effective. Guy
(2011) also examined the effectiveness of SMS reminders at increasing the uptake of
appointments in health care services. The review included 8 RCTs and 10 controlled
observation trials which compared appointment attendance rates between patients who did
and did not receive SMS reminders. The median effect of SMS reminders showed enhanced
attendance [OR 1.48 (95% CI: 123-1.72)] The review concluded that SMS reminders
substantially increase likelihood of attendance of appointments, compared with no
appointment reminder (88).
A recently published systematic review by Hasvold & Wootton (2011) examined the impact
of telephone reminders (manual or automated voice/ SMS) on attendance at hospital
appointments (90). Twenty-nine studies were included, twenty-eight of which found that
reminders had a positive effect on the non-attendance rate. Manual phone calls were found
to be more effective than automated voice calls or SMS reminders while the timing of the
65
reminder (one day or one week in advance) did not appear to have an impact on the DNA
rate. Overall, 14 of the total 26 studies included a cost analysis. Converting the costs to
euro, the results suggested that the mean cost of a telephone reminder was €0.90 and the
mean cost of an SMS reminder equated to €0.14 per person (90).
Looking specifically at attendance for breast cancer screening, Vernon et al (2012)
conducted a systematic review and meta-analysis to evaluate the impact of reminder-only
interventions and more intensive interventions i.e. counselling and education (91). The
results suggested that both simple and intensive interventions significantly increased uptake
of repeat screening. However of the two, the reminder-only intervention strategy was much
more effective than the intensive strategies in increasing uptake. Bonfill Cosp et al (2009)
carried out a review of randomised trials to assess the effectiveness of different strategies to
enhance participation in breast screening such as invitation letters, mailed educational
material, direct reminders, home visits and sending letters plus a phone call (92). The results
from twelve studies indicated that the combinations of strategies were effective individually
or in combination. However the most costly intervention, a home visit, was not effective.
Implementation in International Screening Services
Evidence of the effectiveness of SMS reminders has been used to inform the improvement
of national screening programmes. For example, in 2008 the NHS piloted an SMS system
for reminding patients about their appointment for breast screening in Tower Hamlets
Primary Care Trust. This study was aimed at increasing attendance among minority ethnic
women who had poorer uptake rates. Of the women who received the SMS reminder, 70%
went forward for their appointment (93). NHS Greater Manchester, NHS Tower Hamlets &
NHS West Midlands Screening programmes are some of the Trusts which now offer this
SMS reminder service (80, 93, 94). In contrast, in Sweden, reminders are no longer sent to
those who don’t attend appointments without prior cancellation, known within the programme
as ‘passive non-participants’. A decrease in attendance was noted following the
discontinuation of these reminders in 1999 (45).
The Australian Government have evaluated the potential of various reminder systems to
improve uptake of the National Breast Screening programme. Public opinion on text
message reminders for breast screening appointments was split as some felt it would be an
added memory aid while others felt it unnecessary to be reminded, or didn’t use text
messaging. The conclusion drawn was that SMS reminders would boost uptake, but not
among those who do not intend to participate in screening (95). Despite the opinion that
SMS reminders may not change the minds of those who have no intention of being
screened, populations of high risk women or those hard to reach, including minority groups
or various nationalities and cultures, could benefit from specialised SMS/automated
reminders (80, 93).
66
Attitudes to Mechanisms to optimise utilisation in BreastCheck
As part of the review stakeholders were asked for their opinions on ways to increase the
utilisation of screening slots and maximise uptake in the BreastCheck programme.
Stakeholders suggested that the message needs to be communicated to women more
effectively that if they cannot attend or do not wish to be invited to screening they should
contact the BreastCheck unit. This would allow the service to reuse cancelled screening
slots and may also save invitations being issued to women who do not want to be part of the
programme.
In the Netherlands, there is an online appointment change option indicated, and also a cancellation form is included with the initial invitation letter. Women can select from the following opt-out options on the cancellation form:
opt out of this invitation (but will be sent a reminder within the next three months)
opt out of this screening round (and will be invited again in two years
Opt out of the programme.
Women can also indicate their reasons for dropping out. A reminder is issued after two to
three months to women who fail to respond (39, 64). Stakeholders expressed concern
regarding an opt-out system as women may feel they could not re-enter the programme.
Therefore, the message would need to be communicated carefully.
Requiring women to confirm their attendance prior to their appointment would maximise the
utilisation of the screening slots and optimise scheduling as cancelled slots could be reused
however stakeholders flagged the increased administrative support that would be required to
take calls and deal with queries. While stakeholders, including staff and service users, were
largely in favour of sending reminders to clients to attend screening, there are a number of
factors which would need to be considered. Car et al highlighted that incomplete coverage of
the target population’s mobile numbers would automatically exclude some clients from
reminders and updates (81). In BreastCheck, mobile numbers are only recorded and
available for those who self-register or who have already attended the service (subsequent
women), therefore there are no contact numbers available for initial women or previous non-
attenders. Other factors which need to be considered are the decreased use of mobile
phones with increasing age (81), difficulties associated with visual impairment (96), and the
technology necessary to implement and integrate such a system in the Irish system.
While there are evidence-based mechanisms for increasing the utilisation of the screening
service, consideration needs to be given to the administrative support required to manage
these systems and the additional cost of implementation, particularly in light of the current
administrative pressures within BreastCheck.
67
5.4. Screening Process
As mentioned previously two radiographers are needed to deliver screening in each mobile
unit and all radiographers are required to rotate between the mobile and static units. Two or
three clients are scheduled for each fifteen minute screening slot depending on whether it is
an initial or subsequent visit (seven minutes per screen depending on the individual).
According to the BreastCheck Quality Assurance guidelines, each radiographer will be able
to perform an average of 20 high quality screens per day (1).
Mobile Units
Screening at mobile units “would be most women’s experience of a screening programme”.
Appointments run from 9.30am until 4pm at the mobile unit and radiographers are required
to be on the mobile unit up to one hour in advance of screening to carry out quality
assurance and equipment testing. There are also additional end-of-day duties including
downloading and checking images and documentation for transfer to the static unit,
equipment shutdown and preparation for the next day. Each mobile has one x-ray room and
the unit is operated by two radiographers; while one radiographer is screening the second
radiographer is booking in women and doing the administrative work typically done by
administrative staff in the static unit (e.g. reception, client listings, checking stock). The
suggestion to add an administrative staff member to the mobile unit instead of having two
radiographers was not considered viable by stakeholders as the maximum screening
capacity for a radiographer is twenty screens per day. Therefore, having a mobile unit
manned by a radiographer and an administrator would only produce twenty screens per day
as opposed to the current potential output of forty screens per mobile unit based on two
radiographers screening.
Static Units
Screening in the static unit runs from 9am until 4pm. Screening only take places in a static
unit when there are no assessment clinics, results clinics or multidisciplinary team meetings
taking place. Table 25 outlines the timing of clinics across each of the units. Typically five to
six radiographers provide screening in the static unit; however this depends on the number
of radiographers available. Each static unit has three machines for screening, with the
exception of the Eccles Unit which has four. As these machines are used for screening and
assessment, if a morning assessment clinic runs over time it can limit the amount of
screening which can take place in the afternoon.
Table 24 Static Unit Activity
Eccles Merrion Southern Western
Number of Assessment Clinics
2 Clinics- Monday & Wednesday Screening in afternoon
1 Clinic Screening in afternoon
1 Clinic- Monday Screening in afternoon
1 Clinic Wednesday & 1 every 2
nd Monday
Screening in afternoon
Number of Results Clinics
2-4 Clinics Usually Mon & Tues afternoon (Depending on surgeons)
Screening Capacity
4 machines 3 machines 3 machines 3 machines
68
All radiography staff are required to rotate between the mobile and static unit where they
provide screening and work in the assessment clinics (Figure 14). Additional duties include
multidisciplinary team meetings, managing PACs, uploading and checking images from
mobiles, quality assurance (QA), quality control tests and assisting with wire localisation
prior to surgery. While all radiographers engage in quality assurance there is also a
designated QA radiographer to oversee the process and take charge of tasks such as fault
reporting and clinical recall.
Figure 14 Structure of Week for Radiographers in Static Unit as estimated by the NCSS
0.5 Day
Additional Duties
1 day Assessment
3.5 screening days
69
6. Programme Outputs
This section of the report sets out the main outputs of the BreastCheck during 2010, 2011
and the first six months of 2012 including the number of women invited and screened within
the service. Activity is described at programme-level, regional level and static/mobile unit
level.
The analysis of screening activity is based on data for 2010, 2011 and 2012. The analysis of
productivity is based on data from the 2012 Screening Plan developed by the NCSS. The
average number of screens per day and per machine is calculated for static and mobile
units. The utilisation of screening slots in the mobile units is calculated based on the average
number of screens per day as a proportion of the BreastCheck guideline (1) that each
radiographer can complete an average of 20 screens per day (2 radiographers per mobile
unit). It was not possible to calculate the utilisation rate for the static unit given the variety of
activity which takes place there and the variation in the number of radiographers screening
within the static unit.
6.1. Programme Activity:
6.1.1. Invitation, Screening & Uptake
The number of women invited and screened by BreastCheck increased in 2010 and 2011,
while the uptake rate remained at approximately 73% (Figure 15 and 16). There was a 3.2%
increase in the number of invites issued in 2011 and a corresponding increase (2.8%) in the
number of women screened. However, there was a 5.9% drop in the overall number of
assessments from 2010 (n=5,533) to 2011 (n=5,202). At unit level, in 2011 there was an
increase in the number of women invited to screening in the Western (29%) and Southern
Unit (+8% on 2010 invitation figures). Similarly, there was an increase in the number of
women in the Western (23% increase on 2010 figures) and Southern Unit (12% increase on
2010 figures).
Figure 15: Programme Activity based on data from the PEU, 2010
166812
53127 47395
37712 28578
121370
36980 35728 27542
21120
5533 1506 1118 1826 1083
72.7% 69.6%
75.4% 73.0% 73.9%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
20000
40000
60000
80000
100000
120000
140000
160000
180000
Programme Total
Eccles Merrion Southern Western
Invited Screened Assessed Uptake Rate
70
Figure 16: Programme activity based on data from the PEU, 2011
6.1.2. Screening Activity
Screening days refer to the number of days units spent screening each year, as estimated
by the individual units (i.e. excluding time spent on other activities such as assessment and
results clinics). Total screening days reflect the total number of days for the static and mobile
units combined. The Eccles Unit had the largest number of screening days in 2010 and
2011, reflective of the radiography staff available in that unit. As illustrated in Figure 17, in
each unit there was an increase in the number of days spent screening in 2011. There was a
substantial increase in the number of screening days (28%, +205 days) in the Western Unit
in 2011.
Figure 17 Total Screening Days (static & mobile units combined) for 3 regions, 2010-2011
172115
47856 46661 40776 36822
124788
33648 34167 30885 26088
5202 1211 1365 1309 1317
72.5% 70.3% 73.2% 75.7%
70.8%
0%
20%
40%
60%
80%
100%
0
50000
100000
150000
200000
Programme Total
Eccles Merrion Southern Western
Invited Screened Assessed Uptake Rate
930
730
739
937
935
754
1000 800 600 400 200 0 200 400 600 800 1000
Eccles
Western Unit
Southern Unit
2010 2011
71
In 2010, there were 85,032 women screened over 2,398 operational days across three units
for which data were available. In 2010, the average number of women screened per day was
35.46 compared to 34.27 women per day in 2011. There was a 10.9% increase in the
number of days spent screening in 2011 (n=2662) and a 7.3% increase in the number of
women screened (n=91212) (based on data available for 3 units) (Table 25). Data for 2012,
based on activity across the 4 units from January to June of that year, indicates that on
average 37.96 women were screened per day during the first six months of the year.
Figure 18 illustrates the total and average number of women screened in during the first six
months of 2012. The Southern Unit had the highest number of screens per day in 2012 (42
screens per day) based on 12,360 women screened over 296 screening days. Similarly the
average in the Eccles Unit was 40 screens per day while the average in the Merrion Unit
was 38 per day. The average number of screens in the Western Unit was 31.3 during the
first six months of 2012.
Figure 18 Number of women screened & utilisation rate, across 3 units (2010-2011)
40.20 38.40
31.30
41.80
0
5
10
15
20
25
30
35
40
45
0
10,000
20,000
30,000
Eccles Merrion Western Southern
Number of women screened Screens per Day
72
Table 25 Average number of screens per days 2010, 2011, 2012
2010 2011 2012
Total
Number
Screened
Screening
Days
Women per
day
Total
Number
Screened
Screening
Days
Women per
day
Total
Number
Screened
Screening
Days
Women per
day
Eccles 36837 930 39.61 33679 973 34.61 20882 519.5 40.2
Southern 27584 738.8 37.34 30962 754 41.1 12360 295.6 41.8
Western 20611 729.5 28.25 26571 934.5 28.43 11902 380 31.3
Merrion - - - - - - 17798 463 38.4
Total 85032 2398.3 35.46 91212 2661.5 34.27 62942 1658.1 37.96
73
6.2. Monthly Breakdown of Activity
Some variation in screening activity is due to unit-specific circumstances, which are
highlighted in the monthly breakdown of activity for each unit. The regional breakdown
outlined below also presents the anticipated versus actual screening activity in each unit
over six months, based on the 2012 Screening Plan (January-June). The anticipated
screening target takes into account the available WTE radiographers each month (employed
plus agency minus long term sick leave and maternity leave). Each unit exceeded the
anticipated screens every month for the first six months of 2012, with the exception of the
Merrion Unit which only dropped below the anticipated screening figure in April 2012,
possibly due to the public holidays associated with Easter.
6.2.1. Southern Unit
Screening Activity
During the first six months of 2012, the average number of screens per day was 41.8 in the
Southern Unit (Figure 19). In 2011, there was an average of 41.06 screens per day
compared to 37.25 screens per day in 2010. During 4 months of 2011 (Jan/Feb, Nov/Dec) a
fifth mobile unit was in use, commissioned by BreastCheck from Nuffield Health in the UK. In
October and November 2011, the Southern Unit also delivered screening on a Saturday.
During the second quarter of 2010, screening was scaled back in the unit due to assessment
and surgery waiting lists, as a result of the bed shortage in CUH at that time.
Figure 19 Southern Unit: Monthly utilisation for 2010-2012 (*Data for 2012 based on January-June)
Productivity
0
10
20
30
40
50
60
Jan Feb March April May June July Aug Sept Oct Nov Dec Total
2010 2011 2012*
74
Actual screening activity exceeded the expected activity each month in the first half of 2012
illustrated in Figure 20. The percentage difference between anticipated and actual screening
activity ranged from 9% in April to 101% in March shown in Figure 21. The current
configuration of screening and symptomatic services on separate sites may be the source of
some inefficiency because due to the staff travel involved. However, this was part of the
reorganisation of cancer services in Ireland and has led to improvements in all cancer
services in the South.
Table 26 Southern Unit WTE Radiography staff employed & available
Southern Unit Jan Feb March April May June
Employed Radiographer WTE 10.64 10.64 11.64 11.04 11.04 11.04
Available Radiographers 9.44 8.44 8.94 9.44 8.54 8.14
Employed radiographer WTE
available
89% 79% 77% 86% 77% 74%
Figure 20 Southern Unit: Anticipated vs. Actual screens, Jan-Jun 2012.
Figure 21 Southern Unit: Percentage difference in anticipated vs. actual screens
0 500 1000 1500 2000 2500
Jan
Feb
Mar
Apr
May
Jun
Actual Screens Anticpated based on % WTE
44%
57%
101%
9%
51%
22%
0%
20%
40%
60%
80%
100%
120%
Jan Feb Mar Apr May Jun
Southern Unit
75
6.2.2. Eccles Unit
Utilisation
During the first six months of 2012, the average number of screens per day was 40.2 in the
Eccles Unit. This is an increase from 34.61 screens per day in 2011 and 39.6 screens per
day in 2010 (Figure 22).
Figure 22 Eccles Unit: Monthly utilisation, 2010-2012 (*Data for 2012 based on January-June)
Productivity
Actual screening activity exceeded the expected activity each month in the first half of 2012,
demonstrated in Figure 23. The percentage difference between anticipated and actual
screening activity ranged from 5% in April to 68% in February show in Figure 24.
Table 27 Eccles Unit: WTE Radiography staff employed & available Eccles Unit Jan Feb March April May June
Employed Radiographer WTE 15.3 13.8 13.8 13.8 13.8 14.8
Available Radiographers 15.2 13.5 13.4 13.5 13.5 13.3
Employed radiographer WTE available
99% 98% 97% 98% 98% 90%
0
10
20
30
40
50
60
Jan Feb March April May June July Aug Sept Oct Nov Dec Total
2010 2012 2011
76
Figure 23 Eccles Unit: Anticipated vs. Actual screens, Jan-June 2012
Figure 24 Eccles Unit: Percentage difference in anticipated vs. actual screens
Jan
Feb
Mar
Apr
May
Jun
0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000
Actual Screens Anticpated based on % WTE
21%
68%
26%
5%
61%
26%
0%
20%
40%
60%
80%
100%
Jan Feb Mar Apr May Jun
Eccles Unit
77
6.2.3. Merrion Unit
Productivity
During the first six months of 2012, the average utilisation rate in the Merrion Unit was 96%, based on an average of 38.4 screens per day (Figure 25). Data on screening activity were not available for 2010 and 2011.
Figure 25 Merrion Unit: Monthly utilisation Jan-June 2012
Actual screening activity exceeded the expected activity each month in the first half of 2012,
with the exception of April (possibly due to Easter bank holidays) (Figure 26). The
percentage difference between anticipated and actual screening activity ranged from -6% in
April to 34% in January (Figure 27).
Table 28 Merrion Unit: WTE Radiography staff employed & available Merrion Unit Jan Feb March April May June
Employed Radiographer WTE 13.8 12.8 12.8 13.5 13.5 13.3
Available Radiographers 12.5 11 11 12.7 12.3 12.1
Employed radiographer WTE available 91% 86% 86% 94% 91% 91%
0
5
10
15
20
25
30
35
40
45
50
Jan Feb March April May June Total
2012
78
Figure 26 Merrion Unit: Anticipated vs. Actual screens, Jan-June 2012
Figure 27 Merrion Unit: Percentage difference in anticipated vs. actual screens
0 500 1000 1500 2000 2500 3000 3500 4000
Jan
Feb
Mar
Apr
May
Jun
Actual Screens Anticpated based on % WTE
34% 26%
23%
-6%
28%
22%
-20%
0%
20%
40%
60%
80%
100%
Jan Feb Mar Apr May Jun
Merrion unit
79
6.2.4. Western Unit
Utilisation
During the first six months of 2012, the average number of screens per day was 31.3 in the
Western Unit. This is an increase from an average of 28.43 screens per day in 2011. As
illustrated in Figure 28, there was a substantial increase in activity per month during the first
half of 2012. In 2011, the Western Unit had to scale back screening due to the shortage of
radiological staff to carry out assessment.
Figure 28 Western Unit: Monthly Utilisation 2010-2012 (*Data for 2012 based on January-June)
Productivity
Actual screening activity exceeded the expected activity each month in the first half of 2012
(Figure 29). The percentage difference between anticipated and actual screening activity
ranged from 11% in March to 91% in May (Figure 30).
Table 29 Western Unit: WTE Radiography staff employed & available
Western Unit Jan Feb March April May June
Employed Radiographer WTE 12.5 11.5 11.5 11.5 11.5 11.5
Available Radiographers 8.0 7.0 6.5 9.5 9.0 9.5
Employed radiographer WTE
available
64% 61% 57% 83% 78% 83%
0
10
20
30
40
50
60
Jan Feb March April May June July Aug Sept Oct Nov Dec Total
2010 2011 2012*
80
Figure 29 Western Unit: Anticipated vs. Actual screens, Jan-June 2012
Figure 30 Western Unit: Percentage difference in anticipated vs. actual screens
Loss of efficiency due to travel
Allowances are made within the screening programme for the mobile unit located in Co.
Donegal (Western Unit), given the distances to be travelled by the radiographers. In the
Donegal mobile unit screening starts in the afternoon (2pm) on the first screening weekday
and finishes at 12pm on the last screening weekday to allow radiographers to travel. On
these days invites and screening targets are halved approximately (10 screens per
radiographer). Therefore, allowances should be made for this mobile unit in terms of
efficiency.
0 500 1000 1500 2000 2500 3000
Jan
Feb
Mar
Apr
May
Jun
Actual Screens Anticpated based on % WTE
41% 36%
11% 12%
91%
57%
0%
20%
40%
60%
80%
100%
Jan Feb Mar Apr May Jun
Western Unit
81
Based on a 10-session screening model for a mobile unit (2 sessions per day for 5 days), it
would be anticipated that 2 sessions would be lost due to travel time between the static unit
and the mobile location. Consequently, 2 radiographers would be able to perform a
maximum of 200 screenings during the 5 day week versus the maximum 240 screens if
allowances for travel were not necessary. Although this is equivalent to approximately 40
potential screens lost for every 5-day block in the Donegal mobile unit, it may be the most
practical solution given the remoteness of these locations relative to the static unit.
Table 30 Travel to mobile units in County Donegal
Location Distance from
Static Unit (km)
Sessions
Lost
Women Screened
Equivalent
Operational
Efficiency
Buncrana 285 2 40 80%
Donegal 243 2 40 80%
Letterkenny 250 2 40 80%
In 2011, approximately 21% of the screening activity within the Western unit was carried out
in mobile units located in County Donegal. It would be anticipated that only 80% of maximum
screening efficiency could be achieved in these locations. As shown in Table 31, screening
in the Donegal mobile unit accounted for 21% of the total screening carried out in the
Western unit in 2011. This would have resulted in 4% loss of efficiency, reducing the
maximum screens achievable in this unit to 53,282.
Table 31 Potential efficiency due to travel to Donegal Unit.
Location Number of
women screened
Proportion of
Screening Activity
Potential
Efficiency
Static 5,393 21% 100%
Donegal mobile units 5,476 21% 80%
All other mobile locations 15,008 58% 100%
Total screened: 25,887 Potential Efficiency: 96%
Based on information from stakeholders, it has been noted that the operational guideline for
all other mobile locations remains at 20 screens per radiographer per day. It would be
anticipated that there are no further efficiency losses due to travel to mobile locations in the
current service delivery model. The assignment of radiographers to other mobile units is
based on their location within the region as far as possible, in order to minimise travel time
and expenses (e.g. radiographer living in Cavan sent to North Leinster sites such as
Monaghan and Louth). However, this is not always possible and all radiographers are
required to travel to the static unit for other duties. In addition, expanding machine capacity
to deal with the age expansion may require new models of rostering that would have to take
some additional travel into account.
With regard to further recruitment, it would be ideal to continue with current practice where
feasible and source radiographers from remote locations as a means for reducing the losses
associated with travel to mobile units. We recognise, however, that there may be difficulty
recruiting suitably trained candidates for such positions.
82
6.3. Screening at Mobile and Static Units
In 2011, the proportion of screening taking place at each of the static units ranged from 21%
in the Western Unit to 38% in Southern Unit (Table 32). The aim of the service is to keep a
steady flow of clients through the static and mobile units. As mentioned previously, planning
the balance of screening between the static and mobile units is influenced by a number on
constraints including staff available and charter commitments in an area.
Table 32: Number of women screened across static and mobile unit in each region
2010 2011
Static Mobile Total Static Mobile Total
Eccles 13021(35%) 23816 (65%) 36837 10419 (31%) 23260 (69%) 33679
Merrion* 10268(29%) 25475 (71%) 35743 10829 (32%) 23305 (68%) 34134
Southern 9842 (34%) 18102 (66%) 27584 11672 (38%) 19290 (62%) 30962
Western 6140 (29%) 14471 (71%) 20611 5601 (21%) 20970 (79%) 26571
*Based on data provided by the PEU
Screening at the Static Unit
A higher proportion of women are screened in mobile units given the variety of additional
activity which takes place in the static unit such as assessment clinics and results clinics.
The programme estimates that screening is provided 3.5 days per week (7 screening
sessions per week) in the static unit which is approximately 15 days per month. All of the
units were providing screening on at least 15 days per month (Figure 31).
Figure 31 Annual screening days and average per month, at the static unit in each region
241 243
177.8 201 194 187
20.1 20.25
14.8 16.8 16.2 15.6
0
5
10
15
20
25
0
200
400
2010 2011 2010 2011 2010 2011
Eccles Southern Western
Days per Year Average per Month
83
There are 4 x-ray machines available for screening in the Eccles Unit and 3 machines in
each of the other static units. Examining the screens per machine within the static unit, there
were on average 14 screens per machine per day in a static unit in 2010 and 13.2 screens
per machine per day in 2011 (Table 33). As mentioned previously the Southern Unit had the
highest proportion of screening taking place in the static unit (38%) compared to the Eccles
(31%) and Western Unit (21%).
Table 33 Screens per machine at a static unit
2010 2011
Number Screened
Days Screens per day in static
unit
Average screens
Per machine per day
Number Screened
Days Screens per day in static
unit
Average screens
per machine per day
Eccles 13,021 241 54.0 13.5 10,419 243 42.9 10.7
Southern 9,482 177.8 53.3 17.8 11,672 187 62.4 20.8
Western 6,140 194 31.6 10.5 5,611 201 27.9 9.3
Total 28,643 612.8 46.7 14.0 27,702 631 43.9 13.2
Screening at the Mobile Unit
The daily activity rate per mobile unit machine is outlined in Table 34. Each region has 4
mobile units and each mobile represents 1 screening machine. Calculations for 2010-2011
are based on 3 units (12 mobile units) as data were not available for the Merrion Unit for that
time period. Calculations for 2012 are based on data from all 4 regions (16 mobile units) for
the first six months of the year. In 2010, each mobile unit in the programme screened for an
average of 12 days per month, which increased to 14 days in 2011 and dropped back to 13
days during the first half of 2012.
The average utilisation of screening slots within the mobile is outlined in Table 35. According
to the BreastCheck Quality Assurance guidelines, each radiographer will be able to perform
an average of 20 high quality screens per day (1). Each mobile unit is operated by 2
radiographers hence it was possible to calculate the number of women screened per day in
each mobile unit and benchmark this figure against the operational guidelines of 20 screens
per radiographer per day (which equates to a maximum potential output of 40 screens per
mobile unit).
Table 25 presents the average number of women screened per day at each mobile unit and
the utilisation rate for in three regions for which data were available. Utilisation of screening
slots was equal to or above 70% in each unit. There was a 2% increase in utilisation of
available screening slots in the Western Unit from 68% in 2010 to 70% in 2011. Utilisation of
mobile unit slots also increased in the Southern Unit from 81% in 2010 to 87% in 2011.
There was a decrease in the Eccles Unit from 86% in 2010 to 80% in 2011.
84
Table 34 Average daily activity per screening machine in mobile unit
Unit 2010* 2011* 2012†
Screening Days in
2010
Screening Days per
month
Average Days per machine
per month
Screening Days in
2011
Screening Days per
month
Average Days per machine
per month
Screening Days in
2012
Screening Days per
month
Average Days per machine
per month
Eccles 689 57.4 14.4 730 60.8 15.2 416 69.3 17.3
Southern 561 46.8 11.7 553 46.1 11.5 201 33.5 8.4
Western 535.2 44.6 11.2 747.5 62.3 15.6 285 47.5 11.9
Merrion - - - - - - 359 59.8 15.0
Total 1,785.2 148.8 12.4 2,030.5 169.2 14.1 1261 210.2 13.2
*Calculations are based on 12 mobile units (three regions) †2012 Calculations are based on 16 mobile units over 6 months (4 regions). Table 35 Utilisation of Screening Slots in Mobile Units 2010-2011
Unit 2010 2011
Number Screened
Days Screens per day
Utilisation Rate
Number Screened
Days Screens per day
Utilisation Rate
Eccles Mobile 1 5,681 162 35.07 87.7% 6,529 199 32.81 82.0%
Mobile 2 6,429 199 32.31 80.8% 5,707 188 30.36 75.9%
Mobile 3 5,405 140 38.61 96.5% 4,885 155 31.52 78.8%
Mobile 4 6,301 188 33.52 83.8% 6,139 188 32.65 81.6%
Total 23,816 689 34.57 86.4% 23,260 730 31.86 79.7%
Southern Mobile 1 3,044 100 30.44 76.1% 4,342 132 32.89 82.2%
Mobile 2 4,208 142 29.63 74.1% 3,362 105 32.02 80.0%
Mobile 3 4,584 151 30.36 75.9% 3,983 121 32.92 82.3%
Mobile 4 5,225 149 35.07 87.7% 5,081 144 35.28 88.2%
Mobile5* 1,041 19 54.79 137.0% 2,522 51 49.45 123.6%
Total 18,102 561 32.27 80.7% 19,290 553 34.88 87.2%
Western Mobile 1 4,646 180 25.81 64.5% 5,880 217 27.10 67.7%
Mobile 2 3,604 142.5 25.29 63.2% 4,444 156 28.49 71.2%
Mobile 3 3,346 121 27.65 69.1% 5,059 178 28.42 71.1%
Mobile 4 2,875 92 31.25 78.1% 5,587 196.5 28.43 71.1%
Total 14,471 535.5 27.02 67.6% 20,970 747.5 28.05 70.0%
85
6.3.1. Reasons for Variation in Utilisation Rate
There are a number of reasons for variation in the utilisation of screening slots. There is a
distinction between the factors influencing the number of screening days in a unit (time) and
the factors influencing the number of women screened per day and the subsequent
utilisation rate of a unit (volume).
The determinants of the number of screening days per unit include:
Number of radiographers available to operate the mobile unit or screening machine
in the static unit.
Due to the lack of radiographers it is often not possible to operate all of the available mobile
units, reducing the possible screening days for that unit. The staff shortages are particularly
challenging on days when assessment clinics are being held in the static unit as five to six
radiographers are required in the static unit. In some instances screening at a given unit may
need to be scaled back in order to meet screening targets (‘stay in charter’) in another area.
Servicing time and moving mobiles
Servicing of mobile units usually takes place during the summer months when the mobile is
sent to the UK. Overall it is estimated that servicing accounts for approximately one and half
weeks per mobile or the loss of one month of mobile screening per unit. This down time
would be coordinated with moving the mobiles between locations and/or staff holidays.
The primary determinant of utilisation of screening slots (i.e. the number of screening slots
used) is uptake (proportion of women screened out of those invited).
Invitation rate
The number of women invited is a process factor and therefore changeable within the
programme. The results suggest more scope for over-inviting based on the number of
women screened per day (thirty-four on average across the programme in 2011).
Attendance rate
Not all women who are invited to attend will do so. Therefore, under-utilisation is inevitable to
a certain extent. The number of women who attend or do not attend is influenced by
personal or demographic factors outside the influence of the programme, including work
commitments, cost of travel, socioeconomic status, a woman’s knowledge and awareness of
breast cancer and screening services, and anxiety towards screening. As mentioned
previously, the units have introduced changes in the invitation process to try to minimise the
impact of non-attendance including the re-bulking process and utilising lists of self-registered
women to fill late cancellations.
86
6.4. Radiographer workload model Results presented in the previous section are based on the current work practices and
operational guidelines employed by BreastCheck (1). The current model is based on 3.5
screening days per radiographer per week (7 screening sessions) and an operational
guideline of an average of 20 screens per radiographer per day (1). This section analyses
and models potential radiographer workload, in order to achieve optimum screening targets
for the BreastCheck service. Our approach will demonstrate that WTE radiographer staffing
levels can be determined by using potential workload, rather than a specific number linked to
the size of the eligible population (currently using ratio to population model of 2.25 whole
time equivalent radiographers per 10,000 women). This will allow improvements in
operational efficiency and optimal targets, which will also enhance future capacity and
planning for the BreastCheck service.
The current average WTE radiographer’s weekly schedule includes 3.5 screening days (7
sessions), 1 assessment day and a half day spent on additional duties linked to multi-
disciplinary meetings and quality control tests. Extending from this model, it would be
anticipated that each WTE radiographer would complete 7 screening sessions per week,
based on 2 sessions being held each day; morning and afternoon. Based on information
supplied by BreastCheck for their quality assurance guidelines a radiographer can perform
an average of 20 high quality mammograms per day. Therefore the number of screens
completed per radiographer in each session is assumed to be on average 10 screens with a
total of 70 screens per week (Table 36).
The workload model presented in here uses levels of activity currently achieved in the
service to model potential capacity at various levels of operational efficiency, using the figure
of 70 screens per week per radiographer, as a ceiling. In order to calculate the monthly and
yearly optimum screening levels, available days at the various efficiency levels are multiplied
by 0.7 as this is the proportion of time spent screening. Within this model, the number of
sessions that a radiographer could spend screening is reduced, rather than lowering the
level of productivity during any given screening session. At 100% operational efficiency
within the current service delivery model, each WTE radiographer would perform frontline
screening for 37 sessions each month. This figure reduces to 33, 29 and 26 at 90%, 80%
and 70% operational efficiency, respectively. This model assumes that a WTE radiographer
works on average 220 days per year and takes into account nine Bank Holidays & thirty-two
days Annual Leave.
Table 36 Radiographer Workload Parameters
Radiographer Workload Parameters
Screenings Per Session 10
Screenings per day 20
Current Assessment Sessions per week 2
Current MDM & Quality Control sessions per week 1
Current Screening Sessions per week 7
Total Screenings per week 70
87
Monthly workload
Figure 32 illustrates the number of screens a radiographer could perform per month at
varying levels of operational efficiency, from 70% to 100%, based on the parameters
discussed above. At 70% efficiency a radiographer can perform 180 screens per month,
rising to 257 screens at 100% efficiency. Maintaining higher efficiency levels, therefore, can
have a significant effect on potential workload and optimising output in order to maintain the
screening round length of two years for women aged between 50 and 64 years.
Figure 32 Number of screens per radiographer per month at varying levels of efficiency
Yearly Workload
Figure 33 depicts the number of screens that could be performed per year at varying levels
of efficiency from 70% to 100%, based on the parameters discussed above. There is a
marked difference between the number of screens performed at 70% efficiency (2,156
screens) and at 100% efficiency (3,080 screens per year). We understand the need for
adjustments to be made for women with special needs who may require longer time to
complete the examination. However, at present it would appear from stakeholder accounts
that radiographers work with the guideline of 20 screens per day, whilst incorporating women
with special needs at specific time slots of 30 minutes. We also appreciate the difficulty
anticipating uptake rates when inviting women. Therefore, on some days radiographers will
screen more or less than 20 women, depending on the attendance. Taking into
consideration the requirement for training and professional development, for every additional
session that is required for training, (beyond the 3 sessions per week already incorporated
into the workload model for additional activities), there would be a reduction of approximately
0.5 of 1% in the maximum number of screens achievable. For example, at 100% operational
efficiency, one day of additional training would reduce the number of screens achievable
from 3080 to 3060.
180
205
231
257
0
50
100
150
200
250
300
Monthly
Nu
mb
er
of
scre
en
s
70% 80% 90% 100%
88
Figure 33 Number of screens per radiographer per year at varying levels of efficiency
6.5. Programme Productivity
The following analysis is based on data from the 2012 Screening Plan made available by the
NCSS. The screening plan, developed by the NCSS, calculated the anticipated number of
screens which could be conducted given the number of WTE radiographers available in
each unit, and the actual screening activity which took place. A breakdown of total number of
screens performed in each of the 4 units is presented in Table 37. The average number
screened per month in 2012 was 2,621 women. The average number of screens per month
in the Eccles Unit was higher than the other units, which may reflect the staffing levels and
machine capacity in that unit. Overall, the number of screens performed each month ranged
between 1,639 and 4,286 screens.
Table 37 Number of screens per unit (January-June 2012)
Jan Feb Mar Apr May Jun Average
Eccles 3,473 4,286 3,190 2,672 4,107 3,154 3,480
Merrion 3,436 2,855 2,779 2,461 3,235 3,032 2,966
South 1,923 1,838 2,191 1,733 2,282 1,935 1,984
West 2,204 1,902 1,639 1,751 2,698 2,116 2,052
Average 2,759 2,720 2,450 2,154 3,081 2,559 2,621
Figure 34 demonstrates that with the exception of the Western unit, the month with the
lowest level of productivity was April, probably due to the number of bank and public
holidays associated with the Easter break.
2156
2464
2772
3080
0
500
1000
1500
2000
2500
3000
3500
Yearly
Nu
mn
ber
of
scre
en
s
70% 80% 90% 100%
89
Figure 34 Number of women screened per month per unit (January-June, 2012)
As previously illustrated in Figure 32, 100% operational efficiency equates to 257 screens
per month under the workload model. Table 38 demonstrates that performance levels over
90% (231 screens) were achieved throughout the first half of the year in 2012 (average
96%). The figures ranged from the lowest level of average productivity of 182 screens to a
high of 337 screens per month. The average number of screens per radiographer per month
across the 4 regional units was 246, greatly exceeding the 205 screens per available WTE
radiographer anticipated by the service in the 2012 Screening Plan. This demonstrates the
potential to achieve higher targets than those set under the WTE to population model which
underpins the current service model (2.25 whole time equivalent (WTE) radiographers per
10,000 eligible population).
Table 38 Number of screens per radiographer per month by regional unit
Jan Feb Mar Apr May Jun Average
Eccles 228 317 238 198 304 237 254
Merrion 275 260 253 194 263 251 249
South 240 263 337 182 254 204 247
West 233 225 183 185 316 260 234
Average 244 266 253 190 284 238 246
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
Jan Feb Mar Apr May Jun
Eccles
Merrion
South
West
90
Figure 35 Number of women screened per month per unit (January-June, 2012)
While the data show that the average productivity was 246 screens per month per
radiographer in the first six months of 2012, because of the likely disruption both in terms of
the number of radiographers available for work and the number of women attending for
screening, a sensible interpretation would be that the overall level of productivity for the year
will be significantly less than the six-month average of 96%.
In summary, although the invitation and screening targets described in the BreastCheck
2012 screening plan are based on a ratio to population model, current performance levels
demonstrate that an alternative approach to planning the delivery of services is possible.
The workload model presented in this report of operational efficiency of 70% and upwards, is
based on existing levels of productivity within the service.
Jan Feb Mar Apr May Jun
0
50
100
150
200
250
300
350
400
Eccles
Merrion
South
West
91
6.5.1. Alternative Work Practices
This section examines the impact of international work practice guidelines on potential
workload and staffing requirements. The latest edition of the European Guidelines for Quality
Assurance in Breast Cancer Screening and Diagnosis (2006) (67) suggest that “each
radiographer should be able to perform approximately twenty-two good quality sets of
mammograms during a six-hour screening day”, taking into account that working practices
should not place undue pressure on the individual radiographer, which may adversely affect
quality. The guideline recommends the two-view mammography model, preferably using
digital equipment.
Monthly Workload
Applying this guideline of 22 screens per day would result in a 10% increase in the number
of women screened. Figure 36 shows the implications for the potential number of women
screened per month, per WTE radiographer. For example, at 80% efficiency the number of
women screened would increase from 205 to 226 women per month. Similarly, at 90%
efficiency the number of women screened increases from 257 to 282 per month.
Figure 36 Monthly activity based on screening guidelines of 20 & 22 screens per day
70% 80% 90% 100%
20 Screens 180 205 231 257
22 Screens 198 226 254 282
0
50
100
150
200
250
300
Nu
mb
er
of
scre
en
s
92
Yearly Workload
Figure 37 depicts potential yearly activity, at varying degrees of operational efficiency from
70% to 100%. Again, there is an increase in the potential number of screens that each WTE
radiographer could perform per year. For example, at 80% efficiency there is an increase of
246 screens and at 90% there is an increase of 277 screens per year.
Figure 37 Yearly activity based on guidelines of 20 & 22 screens per day
Staffing Levels Required
This section presents the radiography staffing levels required, depending on the screening
target applied within the service, at varying levels of operational efficiency. The percentage
of maternity leave is calculated in order to determine sufficient staff levels for the
BreastCheck service, using data on the 2012 staffing levels provided by the HR division of
the NCSS. Maternity leave for radiographers was calculated at 7.7% separately from other
staff to examine whether there was a higher percentage which would impact screening
targets (Table 39).
Table 39 Radiography Maternity Leave within BreastCheck (2012)
Regional Unit WTE
Galway 1
Cork 1.6
Merrion 0
Eccles 1.3
Total 3.9
Employed 50.6
Overall Maternity Leave 7.7%
Based on data provided by HR for 2012
70% 80% 90% 100%
20 Screens 2156 2464 2772 3080
22 Screens 2372 2710 3049 3388
0
500
1000
1500
2000
2500
3000
3500
4000
Nu
mb
er
of
scre
en
s
93
The level of maternity leave for non-radiographer staff was higher at 8% (Table 40) than
radiography staff (7.7%). The overall level of maternity leave for the BreastCheck service in
2012 was 7.9% as illustrated in Table 41.
Table 40 Non-Radiography Staff Maternity Leave (2012)
Regional Unit WTE
Galway 4
Cork 2.7
Merrion 0
Eccles 1.3
Total 8
Employed 100.8
% Maternity Leave 8%
Table 41 Total Maternity Leave (2012)
WTE
Total maternity leave 11.9
Total WTE employed 151.5
Overall % Maternity Leave 7.9
While data supplied by the service shows that maternity leave is currently 7.7% for
radiographers, a slightly higher rate of 10% was used when modeling capacity, to
accommodate any fluctuations in these levels. Although the maternity rate will ultimately vary
across the service, we would anticipate that it would fall within this 5-15% range.
In relation to sick leave, Table 42 illustrates the percentage sick leave estimates for
radiography staff employed in the BreastCheck service. The percentage of sick leave is
calculated by subtracting the WTE maternity leave of 3.9 radiographers (provided by HR
2012 data) to find the difference in the number of WTE employed by the service versus the
total available for work. Overall, sick leave between January and August 2012 ranged from
3.1% to 12.1%.
As BreastCheck is now part of the HSE we would anticipate that the HSE target sick leave
rate of 3.5% would apply. Therefore, we have also calculated the difference between actual
sick leave and the HSE target of 3.5%. The cost of a senior radiographer’s annual salary
was divided by twelve in order to obtain a monthly figure, which was then applied to the
number of WTE on sick leave above the HSE target. The potential savings as a result of
achieving the HSE sick leave target of 3.5% is estimated to be €71,839 (based on 8 months
of data provided January 2012 to August 2012) (Table 42).
94
Table 42 Sick Leave Estimates January-August 2012
Sick Leave Estimates Jan Feb Mar Apr May Jun Jul Aug
Full Total employed WTE (Excluding RSM. Excluding agency)
52.24 48.74 49.74 49.84 49.84 50.64 50.64 51.64
Total Available WTE Radiographers (including agency, minus maternity leave)
48.34 44.84 45.84 45.94 45.94 46.74 46.74 47.74
WTE unavailable for work (excluding maternity leave)
3.2 4.9 6 0.8 2.6 3.7 3.8 1.6
WTE unavailable (at HSE Sick leave target of 3.5%) 1.7 1.6 1.6 1.6 1.6 1.6 1.6 1.7
Difference Target and Actual 1.5 3.3 4.4 -0.8 1.0 2.1 2.2 -0.1
Total Percentage Sick leave 6.6% 10.9% 13.1% 1.7% 5.7% 7.9% 8.1% 3.4%
% difference in actual sick leave versus HSE targets 89% 212% 274% -50% 62% 126% 132% -4%
Monthly WTE 1.5 3.3 4.4 -0.8 1.0 2.1 2.2 -0.1
Potential savings €7,980 €17,624 €23,260 -€4,275 €5,250 €10,923 €11,452 -€375
Total Savings €71,839
95
Workload Model Staffing Requirements (taking into account maternity and sick leave)
Figure 38 and 39 outline the number of WTE radiographers required to screen the current
population, based on various levels of efficiency, taking into account maternity leave and the
3.5% HSE sick leave target. The population figures of eligible women aged 50-64 have been
updated from the 2006 Census figure of 361,979 women to the new 2011 Census figure of
368,967 women, representing an increase of 6,988 eligible women or 1.9%. Therefore, the
total number of current eligible women for invitation is 184,484 per year. The actual number
of women to be screened is calculated using the 2011 BreastCheck Programme Report
which states that the eligible women acceptance rate (including women who opted not to
consent) was 73.9% in 2010/2011. Therefore at 74% uptake the total number of women to
be screened is 136, 518.
Figure 38 illustrates the number of WTE radiographers required within the current service
model of 20 screens per day, at various levels of maternity leave. If 80% operational
efficiency was achieved, the number of WTE radiographers required would be 62.9 at 10%
maternity leave. If the rate of maternity leave were slightly lower at 5%, 60.1 WTEs would be
required, while a higher maternity rate of 15% would result in 65.7 WTE radiographers
required.
Figure 38 WTE requirement to screen current eligible population (target of 20 screens per day) Figure 39 demonstrates the number of WTE radiographers required at the alternative
international target of 22 screens per day, at various levels of efficiency and maternity leave.
There is a considerable difference in the WTE required at 22 screens per day (11 screens
per session) compared with 20 screens per day model. For example, at 80% efficiency and
10% maternity leave 62.9 WTE radiographers would be required at 20 screens per day
compared to 57.2 WTE required at 22 screens per day
70% 80% 90% 100%
WTE Required 63.3 55.4 49.2 44.3
WTE Required with 3.5% sick leave & 5% maternity leave
68.7 60.1 53.4 48.1
WTE Required with 3.5% sick leave & 10% maternity leave
71.9 62.9 55.9 50.3
WTE Required with 3.5% sick leave & 15% maternity leave
75.0 65.7 58.4 52.5
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
WT
E R
eq
uir
ed
96
Figure 39 WTE requirement to screen current eligible population (target of 22 screens per day)
70% 80% 90% 100%
WTE Required 57.6 50.4 44.8 40.3
WTE Required with 3.5% sick leave & 5% maternity leave
62.5 54.6 48.6 43.7
WTE Required with 3.5% sick leave & 10% maternity leave
65.3 57.2 50.8 45.7
WTE Required with 3.5% sick leave & 15% maternity leave
68.2 59.7 53.1 47.7
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
WT
E R
eq
uir
ed
97
6.6. Assessment & Surgery
6.6.1. Assessment Clinics: Structure & Process
In BreastCheck, any women with abnormalities detected during screening are invited to an
assessment clinic. The Charter target is that all women will be offered an appointment for an
assessment clinic within two weeks of notification of an abnormal result. Assessment
secretaries coordinate the invitation to and scheduling of assessment clinics. The number of
women invited to assessment depends on the number of radiologists available to run the
clinic. However, it typically ranges from 25-35, as estimated by stakeholders (Table 43).
Assessment clinics are run in each unit once or twice a week depending on the number of
clients requiring assessment. Clinics take place in the morning with screening in the
afternoon in the static unit.
Table 43 Structure of Assessment Clinics
Eccles Merrion Southern Western
Clinics per week 2 1 1-2 1-2
No. of women booked 25 30-35 28 30-35
The professional mix at each assessment clinic includes BreastCheck Nurses,
Radiographers, Radiologists, Surgeons, Health Care Assistants, Assessment Secretaries
and Administrative staff. In some units there are additional nurse-led assessment clinics in
which women can have additional views, ultrasound and biopsy carried out by the
radiographer and radiologist. However as these clinics take place on the same day as
surgery, the women return to the following week’s assessment clinic to meet the surgeon.
Five or six radiographers are required for assessment clinics, depending on the number of x-
ray machines in the static unit which are used for carrying out additional views and
stereotactic core biopsy procedures (Figure 40). After assessment, clients are called back to
a results clinic the following week.
Figure 40: Assessment & Results Clinic Process
The number of results clinics per unit ranges from two to four per week. The clinics involve
giving results from the previous assessment clinic and results from previous surgery.
According to its Charter, BreastCheck aims to provide women with their results from the
assessment clinic within one week. Women attend the BreastCheck unit prior to surgery for
breast localisation (insertion of a wire with the aid of x-ray or ultrasound) to delineate the site
Additional Views
•Conducted by Radiographer
Ultrasound
•Consultant Radiologist
•Nurse
•Some women discharged at this point.
Biopsy
•Consultant Radiologist
•Radiographers
•Nurse
Clinical Exam
&Consult
•All ladies who have a biopsy are seen by the Surgeon & Nurse
•Women are booked in to the results clinic the following week
Results Clinic
• Surgeon & Nurse
• Results of biopsy
• Exam • Psych.
Support
98
for surgery which is then carried out in the host hospital linked to the BreastCheck static unit
(Figure 41). Unlike models of breast screening in other countries, BreastCheck employs
surgeons to provide primary treatment to women diagnosed through screening. BreastCheck
surgery is typically a day case, for example in the Western Unit a number of surgeries are
carried out in a special day-bed unit. Some cases such as women having a mastectomy
require over-night or three/four day stay beds. The allocation of beds and theatre depends
on the hospital; it is typically coordinated through the surgeons.
The reduction in available beds for surgery and the provision of theatre time was a barrier to
efficiency raised by stakeholders. As a result of this a number of women have fallen outside
of the Charter parameters. The most recent annual report from BreastCheck indicated that in
2010, 74% of women were offered hospital admission for treatment within three weeks of
diagnosis of breast cancer, below the Charter target of 90% (97).
Figure 41: Treatment Pathway for Clients
6.6.2. Assessment Activity
Approximately 5% of women screened are recalled for assessment. Based on data provided
by the PEU, 5,533 women were recalled for assessment in 2010 (4.56% recall rate). This
number dropped to 5,202 women in 2011 (4.17% recall rate) (Table 44). The current
numbers are considered manageable by stakeholders due to the fact that screening is not
operating to full capacity.
Table 44 Number of Women Recalled to Assessment
Eccles Merrion Southern Western Total
2010 1,506 1,118 1,826 1,083 5,533 (4.56%)
2011 1,211 1,365 1,309 1,317 5,202 (4.17%)
We recognise that increased targets of efficiency for screening such as those outlined in the
previous section, can only be achieved if the correct resources and staff are available for
assessment, further diagnostic procedures, and the treatment of women for whom the
screening examination yields abnormal results.
Breast Localisation
Pre-Op Care Surgery Post-Op Care
BreastCheck Nurse
BreastCheck Nurse-coordinates bed allocations with hospital
Surgeon Carried out in host hospital (n=4 sites)
Consultant Radiologist Radiographer
99
6.6.3. Links with the Symptomatic Service
As mentioned previously, the BreastCheck model is unique in its coverage of screening,
assessment and primary treatment for detected cancers. In other countries such as the UK
and the Netherlands, women are referred to symptomatic services following diagnostic
assessment.
The BreastCheck static units are located on the grounds of acute hospitals, three of which
are symptomatic cancer centres hence BreastCheck utilises hospital services such as
security arrangements, maintenance and cleaning. The Southern Unit is in a unique position
as it is not located on the site of the symptomatic service and therefore is required to
manage and maintain its own facilities. This leads to a certain level of inefficiency within the
service due to travel between the two sites. However, this was part of the reorganisation of
all cancer services in Ireland and has led to improvements in all cancer services in the
South.
There is potential for inefficiency in the communication of information between settings as
there is no facility to share patient information between settings. For example, if a client
presents for assessment or surgery BreastCheck must manually request access to medical
history or previous mammograms conducted in the symptomatic service.
There are a number of members of staff within BreastCheck who are also contracted to the
symptomatic or acute services including surgeons, pathologists and radiologists. The
potential for increased sharing or streamlining between the symptomatic and screening
service, given the improvements in the symptomatic service in recent years, was addressed
during discussions with stakeholders. However, the two services are viewed as completely
separate, with separate care pathways and separate cohorts, and this should be maintained
according to stakeholders (Figure 42). The main difference identified between the pathways
of the two cohorts of patients is the input of the BreastCheck nurse which is consistent from
assessment through to post-operative care for women screened by BreastCheck. Any
proposals to increase the overlap between the settings would first have to identify and
quantify the spare capacity within both services, requiring an analysis of work practices and
workload within both settings.
100
Figure 42: Care Pathway in Symptomatic & Screening Services
Role of the BreastCheck Nurse & the Transfer to the symptomatic service
The point at which a woman becomes part of the symptomatic service is not clear or well-
defined within the service and the point of transfer is typically dependent on the individual
case and the working patterns in each unit. Figure 43 outlines the workload/care pathway
coordinated by the BreastCheck nurse based on documentary analysis and input from
stakeholders. The BreastCheck nurse arranges a follow-up appointment in the out-
patient/symptomatic clinic and the first annual mammogram in the symptomatic service.
Some stakeholders voiced concern about follow-up and the risk that clients will “fall between
two stools” because they have come from the screening service into the symptomatic
service. There is scope to develop clearer protocols for the transfer of care to the
symptomatic services taking into consideration the different needs of the client depending on
the diagnosis, treatment and recovery.
Surgery
Symptomatic Service
8 Hospital Centres
GP
Women with symptoms
Treatment if necessary Radiation & Oncology as needed
MDM Symptomatic BreastCheck
BreastCheck 4 static units
16 mobile units
4 linked with static BC Units
Surgeons exclusive to either service or sessions with both
Women without symptoms
Assessment
Surgery
101
Figure 43 Nursing Workload & Client Contact
Assist with ultrasound, biospy, psychological
support, education
Assessment
Clinic
Results Clinic
1 wk later
(with surgeon)
Pre-Op care
Surgery
Further Surgery Post-Op Care
Education, Drainage, Prosthesis
fitting
Post-op Results
(1 wk later)
Tranfser to Symptomatic
Neoadjuvant group
3-4 mnths after surgery
Uncomplicated Surgery
3 mnths after surgery
Reconstruction
6-12 mnths after surgery
Arrange Follow-Up & Annual Mammogram
Benign surgery
Prepare Surgery Packs
Patient Notes, Pathology Report, Radiology
Reports, Letters from surgeon etc
Arrange surgery beds (based on
allocation) & contact women
Psychological support
Outline care plan, Education
102
7. Achieving current screening targets & planning for the age extension From the perspective of stakeholders involved in the governance and delivery of breast
cancer screening, the proposed age extension would require substantial additional
resources particularly in terms of radiography and administrative staff. The first priority of the
programme is to return to full screening capacity and achieve targets for the current eligible
cohort of women aged 50 to 64 years. This section outlines the potential work practices and
staffing levels required to
Screen the current eligible population
Clear the screening backlog within the service
Expand the screening service to those aged between 65 and 69 years.
7.1. Current & Anticipated Workload
Current Population
Under the current service model, women between the ages of 50 and 65 are eligible for
screening on a biennial basis. Using 2011 Census data, the number of eligible women aged
50-64 would be 184,484. As previously mentioned, the actual number of women to be
screened is calculated from the 2011 BreastCheck Programme Report which states that the
‘eligible women acceptance rate’ (including women who opted not to consent) was 73.9% in
2010/2011. Therefore at 74% uptake the total number of women to be screened is 136, 518
(Figure 44).
Figure 44 Current population aged 50-64 & projected uptake
Current Population Per Year Current Population @ 74%
uptake
Eligible Women 184,484 136,518
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
180,000
200,000
Nu
mb
er
of
Elig
ible
Wo
men
103
Age Extension Population
The age extension population was previously estimated to be 84,837, based on 2006
Census. Using the 2011 Census figures for women aged 65-69, this number increases by
2.95% to 87,340, an increase of 2503 women. Extending eligibility to women between the
ages of 65 and 69 in the BreastCheck programme would lead to an additional 43,670
invitations per year. As previously mentioned, the uptake among women attending for
subsequent screening is higher than initial women. The uptake rate for subsequent women
from 2008-2011 ranged between 87% and 91%. Figure 45 illustrates the increase in the
current workload based on an uptake rate of 90%, taking into account the expected higher
uptake rate among the older age expansion population.
Figure 45 Increase in workload with age extension (65-69) at 90% uptake
Current + Age Extension Population
Extending the age limit to 69 would bring the estimated total number of women eligible per
year to 228,254. With an uptake rate of 90% for the newly eligible women (65-69) and 74%
uptake among the current population (50-64), approximately 175,821 women would be
screened (Figure 46).
Figure 46 Workload associated with screening current eligible population & age extension
Age Extension per year Age Extension 90% uptake
Eligible Population 43670 39303
37000
38000
39000
40000
41000
42000
43000
44000
Po
pu
lati
on
Current Population + Age Expansion
Current Population @ 74% uptake + Age Expansion @
90% uptake
Population 228,254 175,821
0
50,000
100,000
150,000
200,000
250,000
Nu
mb
er
of
Elig
ible
Wo
men
104
7.2. Staffing for the Age Expansion
Based on the level of anticipated maternity leave in the steady state of 10% and the HSE
targeted sick leave rate of 3.5%, the total number of additional WTE radiographers required
for the age expansion workload would be 18.1 WTE at 80% radiographer efficiency, and
16.1 at 90% WTE radiographer efficiency (Figure 47).
Figure 47 Additional WTE Radiography Staff required for the age extension
The total number of radiography staff required for the current population and age extension
population of 175,821 women is 79.6 WTE at 80% radiographer efficiency and 70.7 WTE at
90% efficiency (Figure 48).
Figure 48 WTE Radiography staff required to screen current population & age extension
70% 80% 90% 100%
WTE Required 18.2 16.0 14.2 12.8
WTE Required with 3.5% sick leave & 5% maternity leave
19.8 17.3 15.4 13.8
WTE Required with 3.5% sick leave & 10% maternity leave
20.7 18.1 16.1 14.5
WTE Required with 3.5% sick leave & 15% maternity leave
21.6 18.9 16.8 15.1
0.0
5.0
10.0
15.0
20.0
25.0 W
TE
Req
uir
ed
70% 80% 90% 100%
WTE Required 80.1 70.1 62.3 56.1
WTE Required with 3.5% sick leave & 5% maternity leave
86.9 76.1 67.6 60.8
WTE Required with 3.5% sick leave & 10% maternity leave
90.9 79.6 70.7 63.6
WTE Required with 3.5% sick leave & 15% maternity leave
94.9 83.1 73.8 66.4
0
10
20
30
40
50
60
70
80
90
100
WT
E R
eq
uir
ed
105
7.3. Clearing the Screening Backlog
As mentioned previously, the Government introduced a moratorium on appointments and
promotions in the Public Service with effect from the 27th March 2009. Hence, BreastCheck
has been unable to hire new staff such as radiographers and administrative support, which
has resulted in difficulties maintaining targets to screen women every 24 months to 27
months. Currently, there are 18,386 women who are now waiting more than 24 months to be
invited to screening. Clearing this backlog by providing screening to the current eligible
cohort of women (aged 50-64) and maintaining subsequent screening round targets is the
first priority of the BreastCheck programme, before the introduction of the age extension for
women of 65-69 years. Hence, we would envisage that the recruitment of radiographers and
other staff into the BreastCheck service would begin as soon as possible. This would ensure
women in the backlog are screened as a first priority.
Cost of Outsourcing the Backlog
Although it would be more favourable to begin the recruitment of staff to the BreastCheck
service, the cost of outsourcing the screening backlog to Nuffield or another similar service
was examined. The current shortage of appropriately trained radiographers in Ireland may
lead to delays in the recruitment of the required personnel. In particular, radiographers may
need to attend further training in mammography before taking up employment with
BreastCheck, which could result in further delay for women waiting to be screened.
Financial data for 2011 provided by the NCSS indicated that €179,000 was spent
outsourcing screening to Nuffield who screened 2,552 women over 4 months (based on
information supplied by the PEU). This would equate to a unit cost of approximately €70 per
screen. Extending from this unit cost, it would be anticipated that with 18,386 women invited
at 74% uptake rate 13,605 women would be screened at a cost of €954,269. A contracted
service like Nuffield pays unnecessarily for equipment that is already available within the
existing screening programme.
Comparing this figure to the cost of providing the service within BreastCheck based on 80%
radiographer efficiency level at 20 screens per day, it would take 6.3 WTE radiographers
(maternity leave of 10% & sick leave of 3.5%) 12 months to screen 13,605 women, at a cost
of €401,656. Hence, it is more cost effective to screen the backlog of women within the
BreastCheck service, than outsourcing the work to an independent provider (Table 45). It
should be noted that outsourcing the backlog to a service such as Nuffield is limited to the
taking of mammograms. It does not include the reading of the mammograms, assessment or
any other activity. To avoid any potential unbalance between screening and assessment
workload, clearing the backlog as phase 1 of the expansion service would require an
appropriately balanced increase in capacity throughout the service.
Table 45 Cost of Clearing Backlog
BreastCheck Nuffield
Number to be Invited 18,386 18,386
Number to be Screened (based on 74% uptake)
13,605 13,605
Unit cost per screen €70
Cost €401,656 €954,269
106
7.4. Equipment Capacity to provide current and expanded service Potential screening days are the number of days it would be anticipated that machines are
available for screening. As assessment clinics are held in the static units, the number of
potential screening sessions per week will be less than the number that can be offered in the
mobile units. The figures presented below are based on 248 potential working days per year
taking into account bank holidays, allowing for a 5% loss of availability of machine time in the
static units due to maintenance (Table 46). This has been increased to 10% for machines in
the mobile units to allow for the re-location of the units throughout the year.
Table 46 Machine Capacity Parameters- per machine
Number of potential screening sessions
per week
Total Monthly Yearly
Static Units
Mobile Units
7
10
Potential Screening Days
Static Units
Mobile Units
14
18.6
165
223
Number of screenings per session
Static Units
Mobile Units
20
20
Maximum Potential Screening Capacity
Static Units
Mobile Units
550
744
6597
8928
At present, the number of screens performed in each session is estimated to be 20 per
machine, irrespective of location. The maximum potential screening capacity assumes that 2
screening sessions are held on each of the screening days with 20 screens being
performed. Figures 49 and 50 show the potential number of screens that could be achieved
with various levels of machine usage in the static and mobile units on a monthly and annual
basis.
Figure 49 Potential machine capacity per month
Static Mobile
70% 385 521
80% 440 595
90% 495 670
100% 550 744
0
100
200
300
400
500
600
700
800
Nu
mb
er
of
wo
men
107
Figure 50 Potential machine capacity per year
Regional Equipment Capacity
As mentioned previously the three regional units – Merrion, Southern and Western Units –
have three digital x-ray machines in the static unit and four mobile units (each equipped with
one machine). The fourth regional unit – Eccles – has four digital x-ray machines and four
mobile units. Table 47 outlines the number of screens that could be performed monthly and
annually, based on the present configuration of machinery within the various regional units
and with additional capacity in the static unit. Given the additional activities conducted in the
static unit (assessment, results clinic etc), x-ray equipment in the static units cannot be
utilised for screening with the same intensity as those placed in mobile units. If 80% of
machine capacity were achieved, 44,402 women could be screened annually in the regional
units with 3 machines in the static centre. It would be anticipated that having 4 digital x-ray
machines in the static unit would result in a 12% increase, bringing the total amount to
49,679 screens per machine.
Table 47 Current & Potential Machine Capacity at regional level
Machine Capacity Month Year
3 Static Machines + 4 Mobile Units
100% 4,625 55,502
90% 4,163 49,952
80% 3,700 44,402
70% 3,238 38,852
4 Static Machines + 4 Mobile Units
100% 5,175 62,099
90% 4,657 55,889
80% 4,140 49,679
70% 3,622 43,469
Static Mobile
70% 4618 6250
80% 5277 7142
90% 5937 8035
100% 6597 8928
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000 N
um
ber
of
Wo
men
108
7.4.1. Machine capacity for current eligible population & age expansion
The overall potential screening capacity available, using existing x-ray equipment at various
levels of efficiency, is shown in Figure 51. This estimate is based on the 29 machines
currently available across the BreastCheck programme; 13 in the static units and 16 in the
mobile units. If maximum machine utilisation were achieved, more than 228,600 women
could be screened on an annual basis. This amount is significantly higher than would be
required within the current service delivery model.
Figure 51 Yearly machine screening capacity for BreastCheck Digital x-ray equipment
It would be anticipated that approximately 182,885 women could be screened on an annual
basis if 80% of available machine capacity was utilised. This is more than sufficient to screen
the eligible population of approximately 136,518 women, in addition to accommodating
approximately 39,303 additional women who would be screened annually upon extension of
the upper age limit, at a 90% uptake rate.
As shown in Table 48, there is significant unused capacity in the current X-ray machine
infrastructure. If 124,000 women are screened before the end of 2012, this would represent
a 54% utilisation of the maximum machine capacity.
Table 48 Current Machine Capacity Utilisation
Number To be screened 124,000
Capacity per machine 4,276
Machine usage as % of capacity 54%
70% 160024
80% 182885
90% 205746
100% 228606
0
50,000
100,000
150,000
200,000
250,000
Nu
mb
er
of
Wo
men
109
The utilisation model assumes that a digital x-ray machine would have a maximum annual
capacity of 7,883 screens (Table 49). If 80% of available machine capacity was utilised, 21
machines would be needed to provide screening services for the current population of just
over 136,518 eligible women.
Table 49 Machine requirement for current population
Current Population
Machine Capacity 70% 80% 90% 100%
Screens per machine 5,518 6,306 7,095 7,883
Machines Required 24 21 19 17
Extending eligibility to women between the ages of 65 and 69 would bring the number of
women screened annually to approximately 175,821; representing an increase of 29% in the
current anticipated workload. With 80% machine capacity utilisation, the number of
machines required would rise to 27 (Table 50). In 2011, 86,825 women were screened in
mobile units. This represents a utilisation rate of 61% of total machine capacity for the 16
mobile units (142,848). If the entire age extension population of 39,303 women were
screened only in the mobile units, this would increase utilisation to 88% of total capacity for
the 16 machines. However, it would be anticipated that patterns in the numbers currently
attending for screening within the various regions will not change significantly as a result of
the age extension.
Table 50 Machine requirement for current population plus age extension
Current Population + Age Extension
Machine Capacity 70% 80% 90% 100%
Screens per year 5,518 6,306 7,095 7,883
Machines Required 31 27 24 22
This figure does not, however, take into consideration the backlog of 18,386 women (as of
1st August 2012) who have been waiting longer than 24 months to be invited for a
mammogram through the BreastCheck service. With an uptake rate of 74%, approximately
13,605 women would be screened. Again, if increased machine utilisation were to be
achieved, there would be adequate capacity within the service to comfortably accommodate
the current population and simultaneously address the backlog, whilst preparing to extend
the age limit (Table 51).
Table 51 Machine requirement for current population plus backlog
Current Population + Backlog
Machine Capacity 70% 80% 90% 100%
Screens per year 5,518 6,306 7,095 7,883
Machines Required 27 23 21 19
110
There is sufficient machine capacity to continue with the current practice of keeping
screening and assessment clinics completely separate. However, it should be noted that this
model could potentially leave three machines unused during these assessment clinics.
Should greater capacity in the static units be needed, consideration might be given to finding
alternative methods of providing the service that would allow for simultaneous assessment
and screening work. More than likely, this may require some level of investment in the
reconfiguration of the static unit buildings.
Investment in additional mobile units
If, for any reason, increased utilisation rates are not feasible, it may be necessary to invest in
additional machinery. Using accounting data provided by the service, the equivalent annual
cost (EAC) of investing in new mobile digital mammography equipment and relevant
maintenance was calculated (Table 52). Assuming a 10 year lifespan and applying a
discount rate of 3%, the EAC would be approximately €133,211. Applying a higher discount
rate of 5% had relatively little impact on the findings.
Table 52 Equivalent annual cost (EAC) of new equipment & maintenance
Mobile Unit Investment
Investment Cost €612,000.00 €612,000.00
Expected lifetime 10 10
Annual maintenance €61,466 €61,466
Discount rate 3% 5%
EAC €133,211.33 €140,723.06
111
7.5. Additional screening sessions
While there is sufficient capacity within the existing infrastructure to continue with the current
service delivery model, the implications of providing additional screening sessions during the
week was examined. Additional screening sessions could be catered for by offering
extended evening hours on Thursday & Friday along with Saturday appointments, or a
combination of these two alternatives. The number of potential screens that could be offered
in these 2 scenarios and how these figures compare with the current service delivery model
of 10 screening sessions is illustrated in Figure 52. Overall, extending the 10 session model
to allow for 12 and 14 screening sessions during the week would result in an increase in
maximum machine capacity to 283,590 screens and 331,275 screens, respectively.
However, consideration should be given to ensuring that access to IT & database support
along with administration support is in place before offering extended screening sessions.
Figure 52 Screening activity based on changes to number of screening sessions per week (using all available X-ray equipment)
Summary
As mentioned above, the current machine utilisation in 2012 is currently at 54% of potential
capacity. Results from stakeholder interviews indicated that due to the lack of radiographers
it is often not possible to open all of the available mobile units. This leads to an inefficient
use of the current X-ray machines. Therefore, we recognise that in order to achieve optimum
machine utilisation, adequate staffing is required. Furthermore in order to achieve the best
possible machine utilisation the servicing and moving of mobile units between locations
should continue to be co-ordinated with staff holidays. Overall there is sufficient unused
capacity available in the current X-ray machines in the static and mobile units to comfortably
accommodate the age extension population.
10 Screening Sessions 228,606
12 Screening Sessions 283,950
14 Screening Sessions 331,275
0
50,000
100,000
150,000
200,000
250,000
300,000
350,000
Nu
mb
er
of
Wo
men
112
7.6. BreastCheck Financial Results Review The following section analyses the financial budget for BreastCheck in 2011 (Table 53).
Successive budgets were not analysed as with the move to the HSE Chart of Accounts there
is large variation in accounting practices, limiting scope for high level scrutiny of
performance.
113
Table 53 BreastCheck Financial Results
Eccles Merrion Galway Cork NTC Prog Mgmt
Total
PAY BY CATEGORY
Management and Admin
551,197 496,085 432,202 458,298 35,703 422,363 2,395,848
Medical/Dental (NCHD)
381,258 139,929 220,409 201,834 0 0 943,430
Medical/Dental (Cons)
1,524,605 1,700,437 1,283,174 1,236,007 0 0 5,744,223
Nursing 225,820 188,332 117,915 202,575 0 0 734,642
Paramedical 1,046,009 1,213,031 994,304 794,040 90,301 384,652 4,522,337
Support Services
36,333 41,495 34,531 35,743 0 0 148,102
TOTAL PAY 3,765,222 3,779,310 3,082,535 2,928,496 126,004 807,015 14,488,582
NON-PAY BY CATEGORY
Drugs & Medicines
0 9,418 1,419 731 0 0 11,568
Medical Gases 0 0 0 198 0 0 198
Medical & Surgical Supplies
65,352 111,479 75,410 84,253 0 0 336,494
Other Medical Equipment
3,733 0 3,570 1,589 0 11,834 20,726
Supplies & Contracts
11,818 25,742 29,159 9,040 0 0 75,759
X-Ray/Imaging 387,374 330,676 314,188 494,283 0 0 1,526,522
Laboratory 1,773 3,951 146,200 74,924 0 0 226,848
Catering 4,898 2,471 3,619 2,320 35 438 13,781
Heat, Power & Lighting
15,278 33,926 64,219 34,276 3,820 0 151,519
Cleaning, Washing & Waste
26,704 40,425 32,079 58,154 3,432 0 160,794
Furniture, Crockery & Hardware
11,411 2,376 49 7,383 0 0 21,219
Bedding & Clothing
2,573 3,277 1,527 2,189 0 0 9,566
Maintenance 129,893 53,113 101,827 107,832 0 91 392,755
Transport & Travel
142,593 119,644 165,662 137,353 5,068 21,848 592,168
Bank Charges 0 10 191 0 0 9 210
Legal 0 7 0 0 0 0 7
Office Expenses
216,106 213,063 144,883 191,428 5,994 33,291 804,764
Computer 16,679 18,327 44,709 45,206 0 49,712 174,633
Professional Services
21,601 43,814 600 89 0 1,623 67,727
Training 27,001 26,260 25,663 3,504 0 1,761 84,190
Miscellaneous 4,452 4,694 2,628 160 140 803 12,876
TOTAL NON-PAY
1,089,238 1,042,672 1,157,603 1,254,913 18,489 121,409 4,684,324
INCOME BY CATEGORY
Consultant Salary Recharges
-660,453 -101,052 0 -31,714 0 0 -793,219
Other Income -2,973 -248 -13,425 -4,859 0 0 -21,505
Total Income -663,426 -101,300 -13,425 -36,573 0 0 -814,724
114
7.6.1. Pay Costs
Pay costs represent 74% of the overall BreastCheck budget (excluding head office costs),
while non-pay costs account for 26% of the budget. Hence, as previously mentioned the
main driver of cost in the BreastCheck budget is pay costs for the service. Radiographer pay
costs were analysed in the previous section on WTE, which is the single largest item of
expenditure after consultant pay. It was not possible to analyse in detail the staffing
requirements for other staff categories, particularly in relation to the assessment and follow
up workload, due to the lack of information on national and international workload practices
and workload norms.
7.6.2. Non-Pay Costs
The proportion of resource use in the non-pay cost categories for 2011 is represented in
Figure 53. The largest cost driver was X-Ray & Imaging at 33% of the non-pay budget,
followed by office expenses at 17% and the other cost categories at 17%.
Figure 53 Proportion of resource use in the non-pay cost categories (2011)
The following categories of expenditure illustrate the variation in resource use for Drugs &
Medicines and Other Medical Equipment between the 4 BreastCheck units. However, it is
not possible to draw any solid conclusion on potential savings as there was not sufficient
information on the accounting or clinical practice variation between the units. As many of the
budgets for these categories are below the €50,000 tender limit applied in the HSE, the units
would identified suppliers and typically obtained three quotes from different companies.
Because contracts are continually assessed within the NCSS as a normal part of annual
activity, there may be some scope to achieve the best value for money for the BreastCheck
budget. However, it should be noted that any savings represent a small proportion of the
overall BreastCheck budget. Without complete data it is not possible to assess what savings
can be made in the following categories. The objective of this analysis is to highlight the
inconsistencies in the level of expenditure between units, based on practice and related to
the agreements between units and host hospitals, not accounting systems. There may be
scope for savings, but we cannot be certain given that we do not have enough information
33%
17%
7%
8%
5%
13%
17% XRay/Imaging
Office Expenses
Medical/Surgical Supplies
Maintenance
Laboratory
Transport & Travel
Other
115
related to such practices or agreements. We also realise that within each year there are
typically “one-off” or particular spends that are not part of normal activity.
Drugs & Medicines
Based on information supplied by the NCSS, the drugs and medicines category typically
relate to local anaesthetic compounds for taking of biopsies.. It does not include drugs that
would be administered by the hospital for treatment & surgery. It should be noted that such
drugs are not the responsibility of the screening programme and the programme is not
funded for these items. The Merrion unit spent €1628 in 2011 compared to the Eccles unit
which did not purchase any drugs and medicines in 2011 according to budgetary
information. The Southern Unit spent €731 whilst the Western Unit spent €1,419 on drugs
and medicines in 2011.
A possible explanation for the variation between units could be a difference in accounting
practices or the clinical practice of administering drugs at biopsy. Another possible reason
for this difference may be that the Eccles Unit sources medicines from its host hospital, The
Mater Misericordiae Hospital, free of charge. Therefore we cannot draw any strong
conclusions on potential savings for this category without further analysis of accounting
practices in different units.
Other Medical Equipment
The other medical equipment category is a very low expenditure category. However there is
a variation between units; Eccles (€3,733), Western (€3,570) and Southern (€1,589)
compared to the Merrion Unit which did not appear to spend any resources on medical
equipment. Again, it this may be explained by HSE Chart of Accounts or host hospitals
supplying consumable in the case of the Merrion Unit. It is not possible to draw conclusive
potential savings from this category without further information.
7.6.3. Potential Savings - Non-Pay Cost
The following section provides analysis of potential savings that could be achieved if the
practices of the unit with the lowest cost could be adopted in the other three BreastCheck
units. The lowest cost is calculated differently in each category depending on whether the
cost is related to the volume of women invited, screened, assessed or if it is linked to a
specific difference in resource use.
Medical/Surgical Supplies
Based on information supplied by the NCSS, the medical/surgical supplies include
consumable items used at assessment clinics such as bandages, needles, and syringes.
There is a large variation between the four BreastCheck units with each unit using the
following amount of resources; Eccles (€65,352), Merrion (€119, 269), Western (€75,410)
and Southern (€84,253). This difference may be related to the change over to the HSE Chart
of Accounts in 2011 and different ways of accounting for supplies.
Nevertheless the cost per woman assessed is for medical/surgical supplies for each unit was
calculated in order to examine the potential savings of applying the lowest cost across all
units. The Eccles Unit cost per woman assessed is the lowest in terms of medical and
surgical supplies at €54, compared to the highest in Merrion at €88. Hence, Table 54
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outlines a budget for medical and surgical supplies, in which the lowest cost per screen is
applied to the number of women assessed in each unit in 2011. If all units had the lowest
cost per screen of €54, the potential savings that could be achieved is €63,556 for this
category of the financial budget.
Table 54 Medical & Surgical Supply spend by regional unit (2011)
Unit Eccles Merrion Western South Total
Medical/Surgical Supplies €65,352 €119269 €75,410 €84,253 €336,494
Cost per woman assessed €54 €88 €57 €64
Applying Lowest cost per screen
€65,352 €73663 €71,072 €70,641 €280,728
Potential Savings €0 €45606 €4,338 €13,612 €63,556
Supplies & Contracts
Based on information supplied by the NCSS, this category has changed with the HSE Chart
of Accounts; what would have been considered part of medical/surgical supplies in 2010, is
now considered part of supplies & contracts in 2011. Although this is one of the lower
categories of expenditure there is still some variation between units. In 2011, the following
units spend on supplies and contracts was; Eccles (€11,818), Merrion (€25,742), Western
(€29,159) and Southern (€9,040). The unit cost of supplies and contracts per woman
assessed in each unit was calculated. Table 55 illustrates that the Southern unit had the
lowest cost per woman assessed at €7 in terms of supplies and contracts. The Western unit
has the highest cost per woman assessed of €22. If all units were to spend the lowest cost of
€7 on supplies and contracts per woman screened, in each unit €39,835 savings could be
achieved in this category.
Table 55 Supplies & Contracts spend by regional unit (2011)
Unit Eccles Merrion Western South Total
Supplies & Contracts €11,818 €25,742 €29,159 €9,040 €75,759
Cost per woman assessed €10 €19 €22 €7
Applying the Lowest Cost €8,363 €9,427 €9,095 €9,040 €35,925
Potential Savings €3,455 €16,316 €20,064 €0 €39,835
X-Ray and Imaging
This category includes costs associated with the purchase and upkeep of digital X-ray
equipment. Approximately 94% of expenditure (€1,261,782) was for equipment maintenance
contracts in 2011. X-Ray film, equipment repairs and other miscellaneous costs accounted
for the remaining 6% of total spending in 2011.
Data supplied by the NCSS indicate that the payments made to Nuffield for outsourced
screening services were also included in the overall amount spent on x-ray and imaging
services. However, as BreastCheck imaging equipment was not used in the screening of the
women, these costs were omitted from the analysis. The higher level of total expenditure for
the Eccles unit may be attributable to the additional machine in the static unit. Overall, the
cost per machine was lowest in the Western unit at €44,884 (Table 56). This is almost 8%
lower than in the Eccles unit where the cost per machine was approximately €48,422. If the
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lowest cost per machine were applied to each of the other three regional units, this could
potentially lead to overall savings of €45,885.
Table 56 X-Ray & Imaging spend by regional unit (2011)
Unit Eccles Merrion Western South Total
X-Ray/Imaging €387,374 €330,676 €314,188 €315,283 €1,347,522
Cost per machine €48,422 €47,239 €44,884 €45,040
Applying the Lowest Cost €359,072 €314,188 €314,188 €314,188 €1,301,637
Potential Savings €28,302 €16,488 €0 €1,095 €45,885
Laboratory Costs
This category of expenditure includes laboratory costs paid to host hospitals for pathology
services provided to BreastCheck. The following units spend on laboratory costs in 2011
was; Eccles (€1,773), Merrion (€3,951), Western (€146,200) and Southern (€79,924). The
Western Unit spent the largest amount on laboratory costs representing almost 65% of the
overall budget for this category. If the lowest cost per woman assessed (achieved in Eccles
of €1.46) could be achieved in the other units, savings of €219,231 could be realised (Table
57). Also as BreastCheck is now part of the HSE, this cost could be transferred to the host
hospitals altogether which would result in savings of €226,848.
Table 57 Laboratory Costs by regional unit
Unit Eccles Merrion Western South Total
Laboratory €1,773 €3,951 €146,200 €74,924 €226,848
Cost per woman assessed €1.46 €2.89 €111.01 €57.24
At Lowest Cost €1,773 €1,999 €1,928 €1,917 €7,617
Potential Savings €0 €1,952 €144,272 €73,007 €219,231
Cleaning, Washing & Waste
This category of expenditure includes items such as contract cleaning, clinical waste and
household waste. Table 59 outlines the units spend the following amount of resources;
Eccles (€26,704), Merrion (€13,721), Western (€5,375), and Southern (€31,450). Based on
information supplied by the NCSS, variation in costs for washing and waster is related to the
agreement in place with its host hospitals. For example, the Mater hospital, which is the host
hospital for the Eccles unit, provides contract cleaners at a lower cost than would be
possible if the Eccles unit was to source a contract cleaning company independently. If all
units were to achieve the lowest cost for this category, (i.e. the same as Eccles), there would
potential savings of €50,546 to be achieved in this category. However, as the Southern Unit
is not on the same site as the host hospital and coordinates its own contracts for cleaning
services it may be harder to achieve all of the potential savings mentioned.
Table 58 Cleaning, Washing & Waste Costs by regional unit
Unit Eccles Merrion Western South Total
Cleaning & Washing & Waste (2011) €26,704 €40,425 €32,079 €58,154 €157,361
At Lowest Cost €26,704 €26,704 €26,704 €26,704 €106,815
Potential Savings €0 €13,721 €5,375 €31,450 €50,546
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Maintenance
According to information supplied by the NCSS, these costs are related to the maintenance
of buildings and mobile units. In 2011, approximately €240,000 (61%) was spent on
maintenance and haulage of the mobile units, while the remaining proportion was allocated
for maintenance carried out within the static units. The following table shows that there was
significant variation in the total spend per unit, ranging from €53,000 in the Merrion unit to
upwards of almost €130,000 for Eccles. If cheaper maintenance contracts could be secured,
to the same level as that achieved in the Merrion Unit, this could generate savings of
€180,213 for the BreastCheck service.
Table 59 Maintenance Costs by regional unit
Unit Eccles Merrion Western South Total
Maintenance (2011) €129,893 €53,113 €101,827 €107,832 €392,664
At Lowest Cost €53,113 €53,113 €53,113 €53,113 €212,451
Potential Savings €76,780 €0 €48,714 €54,719 €180,213
Transport and Travel
Reimbursement for transport and accommodation costs, incurred by radiographers when
travelling to mobile units, amounted to slightly more than €565,000 in 2011 (Table 60). The
cost per screen was calculated based on the number of women screened in the mobile units.
The lowest cost per screen was €5.13 for the Merrion unit, while the highest cost was €7.90
in the Western unit, possible due to the geographically dispersed nature of the population
served by the Western. If the cost per woman screened was equal across the four units, this
would reduce expenditure in this category by €199,508.
Table 60 Transport & Travel Costs by regional unit
Unit Eccles Merrion Western South Total
Transport & Travel (2011) €142,593 €119,644 €165,662 €137,353 €565,252
Cost per woman screened (Mobile)
€6.13 €5.13 €7.90 €7.12
At Lowest Cost €119,413 €119,644 €107,656 €99,031 €445,744
Potential Savings €23,180 €0 €58,006 €38,321 €119,508
Office Expenses
This category of expenditure includes items such as postage, phone and office
consumables. The postage cost is quite high for the BreastCheck service as all women are
invited to screening by letter every year. Screening results are also posted to women and
their GP. Hence, much of the spending in this category is related to volume of work and
phone costs for customer service etc. In order to quantify potential savings for this item of
expenditure the total spend for each unit on office expenses was divided by the number of
women invited in that unit in 2011 to generate a unit cost. Table 61 outlines the units’ spend;
Eccles (€126,106), Merrion (€213,063), Western (€144,883) and Southern (€191,428). The
lowest cost per invited woman was in the Western unit of €3.55. If all units could achieve a
similar cost for office expenses there could be significant potential savings of €269,902.
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Table 61 Office Expenses by regional unit
Unit Eccles Merrion Western South Total
Office Expenses (2011) €216,106 €213,063 €144,883 €191,428 €765,480
Cost per woman invited €4.52 €4.57 €3.55 €5.20
At lowest cost €119,556 €121,400 €144,883 €109,739 €495,577
Potential Savings €96,550 €91,663 €0 €81,690 €269,902
7.6.4. Summary
In summary, it has been illustrated that there is scope for modest savings to be made in the
larger expenditure items in the non-pay categories. However the most substantial driver of
costs is staff time for the BreastCheck service. We don’t know for certain which differences
in resource use between units are related to agreements between units and host hospitals,
and which may be attributable to accounting practice, but by calculating the lowest cost per
unit, we get a general idea of the potential savings within the non-pay expenditure. If all of
the savings mentioned above could be achieved there may be potential savings of €980,886
to be realised. Further sharing of consumables & contracts between host hospitals and the
BreastCheck units would generate additional savings. Although BreastCheck must source
several consumables from HSE suppliers, this relates only to certain items such as office
supplies. Hence if further purchasing power could be harnessed with other suppliers and
contracts through the HSE or through units such as the Western & Southern unit joining
together to achieve better pricing, this could produce modest savings for BreastCheck.
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7.6.5. Age Expansion Budget
A new budget for the proposed expansion of the service to women aged 65-69 is displayed
in Table 62, based on a 20% increase in workload given the information provided by the
service. The resources requested in the initial age expansion budget, provided by the NCSS,
were used as a basis for evaluating the new budget. As we can see from the new age
expansion budget above, the new funding, highlighted in red, ranges from €2,882,734 at
70% €2,432,050 at 80% and €1,657,191 at 90% according to the level of efficiency
compared with the original proposed age expansion budget of approximately €7,372,568.
In relation to staffing costs the number of WTE radiographers required for the age
expansion, as previously discussed, is based on a workload model with efficiency levels
ranging from 70% to 90%. Any surplus between the funding currently available for 66 WTE
and the current population WTE radiographer staffing requirements previously modelled at
70%, 80% and 90% (71.9, 62.9 and 55.9 respectively) has been applied to the number of
WTE radiographers needed under the age expansion in order to determine the additional
funding required.
It was not possible to analyse in as much detail, the desirable workload levels in the
assessment and treatment processes for other categories of staff as there is a lack of
information nationally and internationally on the recommended workload and practices for
other staff categories in a breast screening service. However, data provided by BreastCheck
suggests that there is a 20% additional assessment workload (including biopsies and multi-
disciplinary meetings) anticipated with the age expansion, which was used for calculating the
new WTE requirements.
The analysis also takes into consideration the total approved WTE posts for each staff
category. At present there is 9.26 WTE Consultant Radiologist approved posts. An additional
20% increase in assessment workload due to the age expansion would equate to the need
for an extra 1.85 WTE Consultant Radiologist’s. At present there is 1.65 WTE Consultant
Histopathologist approved posts. An additional 20% increase in the assessment workload
due to the age expansion would equate to the need for an addition 0.33 WTE Histopathology
post. The WTE requirements for the following staff categories were not analysed or changed
due to the lack of data; Grade III (Customer Service), Grade IV (Assessment/Histo Sec)
Health Care Assistant, CNM2 and Senior Medical Scientist.
In relation to the non-pay costs the following categories were not altered from the original
proposed budget provided by the NCSS; Medical/Surgical supplies,
Cleaning/Washing/Waste, Office Expenses and Computer. There was insufficient
information on which to make projections about the proportionate increase in resource use
for these categories. Overall, €13,500 has been allocated to each WTE radiographer above
the current funding available for 66 WTE for Transport & Travel, as this was the original
figure used for the age expansion budget. Similarly training costs have been reduced as they
are only required for radiographer staff above the 66 WTE, as the NCSS have funding for
these associated costs.
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As recruitment costs are now borne by the HSE this cost has been removed from the
budget. The capital cost of new mobile screening units has also been removed from the
budget based on previous modelling outlined in the previous section, which demonstrated
that there is sufficient capacity within the existing mobile unit infrastructure to accommodate
the age expansion population. X-Ray & Imaging have also been removed from the age
expansion budget as the NCSS confirmed that these costs are not volume-related and are
associated with the five new mobile units originally proposed in the budget. In addition site
costs are no longer necessary as there are no new mobile unit sites to be set up.
Note:
Data from the NHSBSP indicates that approximately 3.3% of women between the ages of 65
and 69 were recalled for assessment after being screened. Assuming that a similar number
were recalled for assessment in the BreastCheck programme, this would represent a 25%
increase in the current workload. We have modelled for a workload increase of 30% in
assessment and treatment and estimate the additional staff costs to be €237,300. All other
non-pay costs would remain the same.
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Table 62 Budget for age expansion based on efficiencies within the system
Operational Efficiency 70% 80% 90% Grade WTE
WTE Senior Radiographer Required 20.7 18.1 16.1
Minus funding available for 66 WTE 3.1 10.9
Senior Radiographer 20.7 15 5.2
Consultant Radiologist (Type B) 1.85 1.85 1.85 1.85
Consultant Histopathologist (Type B) 0.33 0.33 0.33 0.33
Grade III (Customer Service) 4 4 4 4
Grade IV (Assessment/Histo Sec) 4 4 4 4
Health Care Assistant 2 2 2 2
CNM2 4 4 4 4
Senior Medical Scientist 2 2 2 2
Total WTE staff required 38.9 33.2 23.4
Pay
Senior Radiographer 1,319,729 956,325 331,526
Consultant Radiologist (Type B) 1.85 422,068 422,068 422,068
Consultant Histopathologist (Type B) 0.33 75,287 75,287 75,287
Grade III (Customer Service) 4 126,813 126,813 126,813
Grade IV (Assessment/Histo Sec) 4 150,137 150,137 150,137
Health Care Assistant 2 67,677 67,677 67,677
CNM2 (BCN) 4 225,372 225,372 225,372
Senior Medical Scientist 2 124,532 124,532 124,532
Total Pay Cost of WTE 2,511,615 2,148,211 1,523,412
Non-Pay
Medical/Surgical Supplies 10,000 10,000 10,000
Transport & Travel 279,450 202,500 70,200
Training 103,500 75,000 26,000
Cleaning/Washing/Waste 43,750 43,750 43,750
Office Expenses 50,000 50,000 50,000
Computer 10,000 10,000 10,000
Total Non-Pay Cost 496,700 391,250 209,950
Income - Pension contributions -125,581 -107,411 -76,171
Capital Cost - Mobile Units Required 0 0 0
Overall Total Funding Required 2,882,734 2,432,050 1,657,191
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8. Conclusions & Recommendations The report outlines the structures, processes and outputs from the BreastCheck screening
service. This review, conducted over four months, comprised of a number of interconnected
work packages; literature review of national and international breast screening programmes,
qualitative interviews with key stakeholders involved in the governance, management
delivery of screening, quantitative analysis of data on screening activity and programme
costs, and finally modelling workload practices within the service to screen the current
eligible population, address the accumulated screening backlog and expand the service to
women aged 65-69 in Ireland. The approach inherent in this review process is based on the
aims and operational objectives of BreastCheck. The review examines the screening service
as it currently operates, including current levels of operational efficiency and volumes of
work completed, taking into account that some parts of the service have been in a
developmental phase in recent years. The analysis models future staffing levels and
resource requirements, based on expected workloads, given plausible estimates of the
numbers of people eligible to be screened using data from the 2011 Census.
The following recommendations are based on in-depth quantitative and qualitative analysis
of the current service model.
Administrative & Management Systems
Given the maturity of the BreastCheck programme, we would suggest re-examining the
management processes within the current model and the operating systems needed to
support the service. The service is at risk of becoming unbalanced due to difficulties
recruiting and retaining staff, and incentivised retirement schemes within the public
service. We recommend investment in management personnel, with appropriate staff
training and development, to support the delivery of the screening service.
Furthermore, there is a need for increases in the administrative staffing levels and
radiography staffing levels within the BreastCheck service. We see this as a priority, as
building capacity in this area will allow for more efficient use of time, machine capacity
and professional personnel. We have been able to show the potential advantages of the
optimal utilisation of clinical and administrative resources and facilities. Therefore, a
failure to realise this potential through a lack of adequate management and
administrative processes, or staffing levels, would be fundamentally inefficient.
In this context, there is potential to enhance the efficiency of the service through
operational research and related methods such as constraints modelling. These methods
have been applied elsewhere in the HSE, in areas such as the scheduling of theatre time
and radiology services.
Workload Models & Resource Requirements
We recommend that clearing the screening backlog should be the initial priority for the
service. In this review the back-log is treated as a separate issue to be managed in the
first instance, rather than a long-term problem. The backlog would be most efficiently
managed within the BreastCheck service, as opposed to outsourcing the additional
workload, as part of the first phase of expanding capacity to cope with the proposed age
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extension. We recognise that this will require a balanced increase in capacity in all areas
of the service, not just in the provision of frontline screening.
Screening activity has been examined in significant detail based on anticipated activity
levels for radiographers, outlined in the BreastCheck Screening Plan. It was not possible
to determine desirable workload levels in the assessment and treatment phase given the
lack of national and international workload norms for other staff categories such as
radiologists, pathologists and BreastCheck nurses. Instead, the analysis is adjusted for
the additional workload in assessment and treatment as a result of the age extension by
modelling a pro rata increase of the existing complement of staff (taking all vacancies
into account). While it has been possible to scrutinise the screening process in a great
deal of detail and make recommendations regarding required radiography staffing levels,
we would recommend critical analysis of the assessment and treatment phase to ensure
not only safe and effective, but also best value of services.
Maximising utilisation of equipment
The findings suggest that ambitious targets for the use of equipment and efficiency of
service delivery may be feasible within the current service delivery model. We have
modelled on a number of different levels of machine capacity and operational efficiency,
with reasonable allowances for training, maternity leave, and sick leave. The models
suggest that it is feasible to accommodate the expanded population within the current x-
ray machine infrastructure. We recognise that in order to operate at these higher levels,
investment in upgraded equipment and skilled staff is required. As mentioned previously,
we are very much supportive of investment in the service that would see the machine
capacity used to the optimal level.
Given the staffing flexibility required to deliver the service, we recommend that
BreastCheck be allowed to manage its own Whole Time Equivalent requirements, while
remaining cognisant of employment ceilings within the HSE.
We recognise that it has not been possible for the programme to use equipment to full
capacity due to staff shortages. If the machinery is being used more intensely with
appropriate staffing, it may be necessary to move the mobile units more frequently.
Should it be considered infeasible to increase current machine capacity for any reason,
the equivalent annual cost (EAC) of investing in mobile equipment would be
approximately €133,211.
One of the anticipated advantages of extending the age limit for screening eligibility
would be a shift in some of the current workload from the symptomatic service to the
BreastCheck assessment service. In relation to capacity to accommodate the increased
assessment workload resulting from a higher cancer incidence amongst women aged
65-69, we have presented a budget for the age extension based on a 20% increase in
workload. However, data from the UK screening service suggests an increase of 25% in
the current workload based on an approximately 3% recall rate for women aged between
65-69 years. Therefore the pay costs associated with a 30% increase in workload have
also been calculated.
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Consideration should be given in the medium term to reviewing the skill mix and
workforce models within the BreastCheck service, particularly given the challenges
recruiting and retaining radiography staff within the service. This is based on experience
in the UK where changes in skill mix emerged in response to similar challenges in that
service including a proposed age expansion, a national shortage of radiographers and
difficulties achieving programme targets.
In summary, our role has been to examine how greater efficiency can be achieved within the
BreastCheck service. We are not suggesting changes to the fundamental features of the
current service delivery model which includes the delivery of biennial screening, and the
coverage of assessment and primary treatment for detected cancers under the BreastCheck
programme. We have conducted a series of interviews and meetings with management, staff
and service users to understand the challenges facing the current service. We have used
expected activity levels to model optimal machine utilisation and various levels of operational
efficiency. Based on these models, we believe that the existing equipment should be used
more intensively rather than investing in new digital x-ray machinery. The need for additional
radiographer staff should be seen in the context of achievable levels of efficiency. It is our
view that capacity of the service should be increased in preparation for the age extension but
this should be used in the first instance to address the screening backlog. With respect to
follow-up assessment and treatment workload, we do not have complete information on
which to model other staffing requirements and therefore have modelled a pro rata increase
of existing staff levels to adjust for any additional workload. We recognise that it is not
feasible to achieve optimal utilisation of x-ray equipment and professional staff within the
BreastCheck service without investment in suitable operational systems and administrative
staff to support the management of the service.
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9. Appendices
Appendix 1: Literature Search Strategy
A literature search was conducted on reminders for increasing attendance at breast
screening appointments. Both systematic reviews and Randomised Control Trials (RCTs)
published after 1990 were included. Literature searches were performed in PubMed,
MedLine, Science Direct, EMBASE, Cochrane Library and NHS EED/CRD using the
following MeSH terms:
((("Breast Neoplasms"[Mesh]) AND "Mass Screening"[Mesh]) AND) AND "Reminder Systems"[Mesh] Further information on reminders was retrieved from systematic searches of international breast screening programme web pages. Google translate was used information was not available in English.
Search of electronic databases: PubMed, Science Direct, MedLine, Cochrane Library, EMBASE.
Review of 83 titles
Rejection of 54 titles: Duplicates, Rejection of paper
based on relevance to research question:
Review of 32 abstracts Rejection of 18 abstracts:
Full text obtained for: 14 articles
Inclusion of 6 articles in the review after data extraction
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Table 63 RCTs included in review
Author/Year Design Type Intervention Outcome Effect
Hegenscheid 2011 Prospective RCT
Breast Screening
Control-Letter reminder Intervention- letter reminder + telephone counselling
Telephone counselling increases non-attenders uptake of breast screening
Control- 21.6% uptake Intervention- 29% uptake.
Lakkis, 2011
RCT Breast screening
Simple SMS v Detailed SMS Brief SMS is as effective as detailed SMS in increasing uptake
30.7% uptake for simple SMS 31.6% uptake for detailed SMS.
De Frank, 2009
RCT Breast screening
Mail v telephone reminder Overall, 74.5% of women adhered to repeat screening, compared to 56.7% pervious to intervention.
Repeat screening rates were 71.8% for enhanced usual care reminder, 74.5% for enhanced letter reminder and 76.3% for automated telephone reminder Mail- (AOR 1.19 [95% CI= 0.96- 1.48]) Phone- (AOR 1.32 [95% CI= 1.06-1.64])
Chen, 2007
RCT Health promotion centre
SMS v phone reminder Both effective for increasing uptake, SMS more cost-effective than phone reminder, though phone reminder statistically more effective than SMS reminder.
SMS- (O.R. 1.698 [95% CI= 1.22-2.31]) Phone- (OR 1.829 [95% CI= 1.33-2.51])
Chaudhry, 2007
RCT
Breast Screening
Intervention- 2 monthly letters sent 3 months before first appointment plus follow up telephone call to non-responders. Email reminder to further subgroup.
Intervention significantly increased uptake of screening.
Control- 55.3% Intervention- 64.3% Uptake in Employee sub group: Control- 57.5%, US mail- 68.1% Email- 72.2%
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Vogt, 2003
RCT
Breast & Cervical Screening
-usual care -letter + letter - letter + phone call - phone call + phone call
Letter + phone call intervention most effective at improving attendance for breast screening. Letter + letter- least effective.
Screened in 12 weeks following intervention Controls-9% Letter-letter- 21% Letter-phone- 34% Phone-phone- 36%
Richards, 2001
RCT
Breast screening
GP letter v flag*
Both increased attendance Letter more cost effective
GP letter OR 1.31 Flag OR 1.43
Bankhead, 2001
RCT
Breast screening
GP letter v flag*
Letter more effective than flag. Also, letter most cost effective
GP letter- OR 1.51 Flag OR 1.39 Additional £35 per letter, and £65 per flag
Bodiya, 1999
RCT
Breast Screening
No intervention Reminder letter Reminder letter + follow up telephone call for non-responders.
Reminder letters had minor effect on increased uptake compared to no intervention. Reminder letter + phone call significantly increased uptake.
Control- 33% Letter- 37% Letter + follow-up telephone call- 57% Additional cost of $9 for reminder letter + telephone call.
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Table 64 Systematic Reviews included in the review
Author/ Date
Type Intervention Methodology Analysis & Results
Conclusions
Car 2012
Systematic Review
Mobile phone messaging reminders for attendance at healthcare appointments
Lit search Medline Embase, PsycInfo, CINAHL, LILACS African Health Anthology, Cochrane Collaboration published 1993-2008. Grey lit search. Bias assessment of each study.
4 RCTs met inclusion criteria. Bias assessment- 3 RCTs of moderate quality, one of low quality. SMS vs. no reminder- RR=1.10 SMS vs. postal reminder- RR 1.10. Text and phone reminders similar effects on attendance- RR 0.99, 95% CI 0.95- 1.03)
SMS reminders increase healthcare appointment rates, when compared with no reminders or postal reminders. SMS reminders are as effective as telephone reminders, but are more cost effective than telephone reminders.
Guy 2012
Systematic review and meta-analysis
Short message reminders to increase clinic attendance
Medline & Embase and Cochrane Controlled Trials Register- prior to June 2010 Two authors- separate reviewing.
Odds ratio- primary effect measure. 18 papers included. Variety of countries Mainly outpatient clinics. Median effect of SMS on attendance- OR 1.48 (95% CI: 123-1.72) no significant change with each setting, message timing or age group used.
Combined evidence shows SMS reminders substantially increases attendance at clinics. SMS reminders are a simple and effective option for improved service delivery.
Hasvold & Wootton 2011
Systematic Review
Use of telephone and SMS reminders to improve attendance at hospital appointments.
Search PubMed for papers published in 2000 or later. Reference lists searched. Independent reviewing by two authors. Absolute and relative change in DNA- main result sought. ITT analysis.
29 studies included. 33 estimates- 18 manual and 15 automated reminders. 9 studies were RCTs- median quality score of 7. Median DNA before intervention- 23% After- 13%. A cost analysis was included in 14/27 studies, mean cost telephone- €0.90 SMS- €0.14
All studies except 1 found sending reminders improved DNA rates. Manual reminders more effective than automatic- pooled median results 39% and 29% reduction in DNA rate respectively. Automated reminders cost-effective.
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Vernon 2010
Systematic Review & meta-analysis
Interventions to promote repeat breast cancer screening
Electronic search Medline, CINAHL, PsycInfo & Academic search premier from start through to Aug 2009. 2 authors independently reviewed papers. Studies had to report estimate repeat mammography use for at least 1 intervention and 1 comparison group.
25 articles included 23 RCTs, 2 comparative studies. Significant increase in repeat screening for all interventions vs. controls (OR 1.39, 95%CI 1.27-1.52). Reminder only studies- most effective (OR 1.79, 95% CI 1.41-2.29) Counseling ( OR 1.28, 95% CI 1.15-1.43)
Reminder-only and more intensive counseling and motivational/ education strategies are effective in increasing uptake. High effect of reminder only, over intensive strategies, however high heterogeneity between studies.
Bonfill Cosp 2001
Systematic review
Strategies for increasing participation of women in community breast cancer screening
Lit search Embase Medline Central 1966-1999. 16 studies included. (2 further excluded) Outcome measure- attendance in response to Mammogram invitation
Letter of invitation- OR 1.66, mailed educational material- OR 2.81, letter plus phone call- OR 1.94, and training activities + direct reminders- OR 2.46. Home visits not beneficial- OR 1.06
Various interventions either solo or combined are effective strategies. Home visits not effective. Further reviews that include cost-effectiveness of known effective strategies should be conducted.
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27 November 2012 Ms Mary Jackson Principal Officer Cancer Policy Unit Department of Health Hawkins House Hawkins Street Dublin 2 RE: EFFICIENCY REVIEW OF THE BREASTCHECK SCREENING
PROGRAMME Dear Mary Thank you for the copy of the final report following the review commissioned by the DOH. The Review Team had permitted the NCSS to view a draft of the report and we provided comment in advance of the final report being issued to the DOH. The BreastCheck Executive Management Team has reviewed the final report and I would comment as follows. COMPARISONS WITH OTHER PROGRAMMES The Report correctly cautions against comparing the BreastCheck programme against other international programmes due to many fundamental differences. These differences also include such aspects as longevity of programme, skill mix of staffing remit of programmes, age and type of equipment used, and delivery models eg static v mobile.. PLANNING USING UPTAKE RATE V ELIGIBLE POPULATION The NCSS would caution against using an uptake rate as the basis for resource planning rather than the eligible population. Uptake rates are subject to change. For example the CervicalCheck programme saw a spike in the uptake rate following a high profile cervical cancer case in the UK. As a call, recall programme, this spike was not just once-off phenomenon, but has been repeated in subsequent rounds of the programme. If resource planning is tailored to a particular uptake rate, there is little opportunity to respond to such an event. It also does not allow for a growth in the uptake rate. MACHINE UTILIZATION The Report focuses on machine utilization and concludes that, with some provisos, there is sufficient equipment, including mobile units, currently within the programme to support the extension of age range. Theoretically, this may be correct, however, in terms of practicality there are a number of other significant considerations. Lack of additional mobile units for the extended age range renders the additional radiography staffing pretty much ineffective: there can only be two radiographers on
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a mobile unit on any given day. Likewise there are only two radiographers required for each mammography room in the static unit. It is not clear from the Report as to where the additional radiographers would be based. Additional radiographers without additional equipment is of little value . For all equipment additional throughput results in more repairs, more frequent breakdowns and shorter lifespans of equipment, with little opportunity to adhere to targets in such circumstances. Mammography equipment in the static units is used to provide additional views and biopsies during assessment clinics; which means the equipment is not available for screening during those times. In addition, the static units were designed to support a particular throughput of clients in any given day. If would be difficult to increase the throughput without reconfiguring the space available. A higher throughout would require an extended working day; additional administrative and other staff would be required for this which has not been considered nor costed. Radiographers can carry out about 20 mammograms per day. In excess of this increases the chances of repetitive strain injury and other conditions. Therefore to utilize the equipment more, would require additional radiography staff, thus adding to the cost. RADIOGRAPHER WORKLOAD MODEL The workload modelling appears to take into account travel time to mobiles only when based in Donegal. However, the majority of mobile units require some travel time. This travel time naturally eats into the working day and thus reduces the amount of time available for screening. While every effort is made to assign radiographers to mobile units as close to their homes as possible to keep travel time to a minimum, there are a number of service considerations. Radiographers must spend some time in the static as well as mobile units. It is important that radiographers work with a variety of their colleagues. Every static unit is responsible for a wide geographical area which must be serviced appropriately. It is also important, whether at a static unit, or on a mobile unit, that the radiographer has time to deal with anxious or difficult clients. It is not just a matter of being able to get through a set number of clients in a set time. The extra few minutes spent with an anxious client could make the difference between that client having a good experience and returning at her next appointment, and it is the repeat nature of the test that makes screening worthwhile initiative and results in reduction in mortality. Therefore it would appear that the workload modelling does not take into account the reality of the service delivery model in Ireland. ALTERNATIVE WORK PRACTICES Page 91 of the report refers to the 2006 edition of the European Guidelines for Quality Assurance in Breast Cancer Screening and Diagnosis citing “each radiographer should be able to perform approximately twenty-two good quality sets of mammograms during a six-hour screening day”. The Report then applies this guideline to the monthly workload and extrapolates a possible 10% increase in the number of women screened, and goes on the use this further in the report.
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This guideline is not applicable to the situation in Ireland as the majority of women in Ireland are screened on mobile units. Radiographers working on mobile units are responsible for all reception and administration tasks unlike their colleagues at the static unit. These extra tasks reduce the time available for screening. HSE TARGET OF 3.5% SICK LEAVE The Report states (page 93) that “As BreastCheck is now part of the HSE we would anticipate that the HSE target sick leave rate of 3.5% would apply.” It is correct that the HSE “target” is 3.5%, however, it is unwise to assume that this will be the rate of sick leave experienced. The Report appears to have applied this rate in resource planning for the extension of the age range. I also note that the costs applied to savings as a result of achieving a 3.5% sick leave rate are calculated on an incorrect basis (table 42) as there are a number of different payments attached to sick leave dependent on circumstances. ADDITIONAL SCREENING SESSIONS The Report suggests that additional screening sessions (Pg 111) could be considered and re-iterates that there is sufficient equipment for this. However, the report does not include additional staffing that would be required for this endeavour, nor associated costs. Nor does it address how the increased time required for reading and reporting of mammograms, assessment and results clinics might affect the screening targets, nor does it address how the additional numbers might be managed in terms of surgery and theatre. BREASTCHECK FINANCIAL RESULTS REVIEW Section 7.6 reviews BreastCheck costs. This section resulted in much comment and clarification by the NCSS for differences in costs across units on review of the draft report. While some comments were taken on board by the Review Team, a number do not appear to have been considered. For information I have included an extract below from previous correspondence with the Review team. Medical and Surgical Supplies The Merrion Unit figure of €111k is distorted by a purchase of biopsy consumables in December 2011 of €21K. While these were purchased in 2011 they were used throughout 2012. The report rightly suggests that differences in spend may be attributed to purchasing or supply of consumables from individual host hospitals. This is done for reasons of speed, adjacency and has the added advantage of reducing administration time on ordering, delivery and accounting. Such contracts are under the remit of the host hospital. The volume in any contract purchased by the host hospital would typically affect the cost which is passed on to the programme. The programme does not control the cost of these items. It is therefore incorrect to draw a conclusion that the lowest spend is valid for each unit and therefore a saving could be made of €55K. Supplies and Contracts Geographical differences, including proximity and relationship with host hospital affect the day to day management and some costs for each of the units. Such contracts are under the remit of the host hospital. The volume in any contract purchased by the host hospital would typically affect the cost which is passed on to the programme. The programme does not control the cost of these items.
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It is therefore incorrect to draw a conclusion that the lowest spend is valid for each unit and therefore a saving could be made of €39K. X-ray and imaging The report omitted to note that there is a mix of x-ray equipment from different suppliers, eg GE, Sectra, across the units. This decision was based on clinical reasons. Different suppliers attract different maintenance costs. It is therefore incorrect to draw a conclusion that the lowest spend is valid for each unit and therefore a saving could be made of €45K. Laboratory The report omitted to take into account that there are unique arrangements for laboratory services across the units, dependent on location and relationship with host hospital which leads to different spends. Since the reviewers did not raise the question of the arrangements or differences in spend during the review we are happy to clarify the reasons. Historically, when the Merrion and Eccles units were established the relevant host hospital bore the main costs for laboratory services. When the Southern and Western Units were established a different arrangement was required and the programme bears the majority of laboratory costs. It is therefore not appropriate to draw a conclusion that the lowest spend is valid for each unit and therefore a saving could be made of €219K. On a separate note, it is also unclear as to the value to the health service of the recommendation of transferring laboratory costs to the host hospitals. Transferring costs does not equate with reduction or elimination of costs. Cleaning, Washing and Waste Geographical differences, including proximity and relationship with host hospital affect the day to day management and some costs for each of the units. Such contracts are under the remit of the host hospital. The volume in any contract purchased by the host hospital would typically affect the cost which is passed on to the programme. The programme does not control the cost of these items. It is therefore incorrect to draw a conclusion that the lowest spend is valid for each unit and therefore a saving could be made of €50K. Maintenance Within each year there are often “one-off” or particular spends that are not part of normal activity. In the year under review this included €61K in Eccles, €39K in Galway and €30 in Cork. Geographical differences, including proximity and relationship with host hospital affect the day to day management and some costs for each of the units. The volume in any contract purchased by the host hospital would typically affect the cost which is passed on to the programme. The programme does not control the cost of these items. It is therefore incorrect to draw a conclusion that the lowest spend is valid for each unit and therefore a saving could be made of €180K. Transport and Travel The report suggests that “if alternative travel arrangements were to result in a reduction of associated costs throughout the service, the potential savings would be €119K.” This warrants elaboration by the reviewers on possible alternative models for travel.
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Office Expenses Geographical differences, including proximity and relationship with host hospital affect the day to day management and some costs for each of the units. The volume in any contract purchased by the host hospital would typically affect the cost which is passed on to the programme. The programme does not control the cost of these items. It is therefore incorrect to draw a conclusion that the lowest spend is valid for each unit and therefore a saving could be made of €269K. AGE EXPANSION BUDGET The population for the age extension is under-calculated (Figure 44). It is based on the 2011 census, which is correct, but did not appear to use 2013 as the base year. Therefore instead of 184,474 it should read 193,200 for the current population (50-64). The 65-59 population should be 48,800 and not 43,670 (Figure 45). Because of this all following calculations for resource planning appear to be underestimated. 48,800 is an increase of 25% and not 20% which is the figure used for resource planning. In any case, should the age extension begin any year after 2013, the population would have to be recalculated from the appropriate base year. In terms of additional consultant staffing the Report incrementally increases the WTE by 20%. Notwithstanding the fact that the percentage is incorrect, the Report does not take into account the geographical spread (4 static units) required for consultant staff, nor the challenge of acquiring the additional consultant staffing at four different sites, with four different host hospitals. (All BreastCheck consultants have joint appointments). The Report suggests that additional work for consultant radiologists is confined only to assessment. This is an underestimation of the workload as radiologists also read and report on mammograms. SUMMARY
The report provides a theoretical view and basis for planning for the elimination of the current backlog and age extension.
We agree with the Report in that the clearing of the backlog is the immediate
and first priority for the Programme.
It is also our view that it would be of great benefit should the NCSS be in a position to manage its WTE and associated recruitment as it is staff shortages and slow recruitment processes that have primarily led to the backlog.
We welcome the Report’s suggestion of investment in management
personnel to support the delivery of the service and increases in staffing levels. The reduction in staffing over the last number of years due to the exit schemes and the moratorium has without doubt undermined the great work done to establish the screening programme, and if not addressed will lead to a reduction in quality and effectiveness of the programme.
A number of different aspects of the screening programme have been
analyzed. However, each aspect appears to have been considered in
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isolation and not considered as an equal and linked step in the programme right through from consent to surgery. This separation has led to a number of assumptions which when taken in the context of the screening programme result in conclusions or recommendations that appear to be inconsistent with the delivery of the screening programme in its entirety.
We would caution the use of uptake rate rather than eligible population as a
basis for resource planning.
The extension of the age range cannot be undertaken without additional mobile units. Only two radiographers can be assigned to a mobile unit at any time therefore additional radiographers without additional equipment does not allow for additional service delivery.
The majority of the service is delivered through mobile units, therefore travel
time is a standard feature of the service, and must be included in planning.
Any target for sick leave is simply a target. It should not be assumed in planning that actual sick leave will reflect the target.
Screening programmes are designed to manage a regular throughput.
Therefore when additional sessions are suggested as a solution, all impacts must be thoroughly considered and included in planning.
As the four static units are connected with four host hospitals and are
geographically spread, some costs will naturally be different in each location. It is incorrect to draw conclusions that the lowest cost can be achieved in each location.
The calculation of the age range for the extension is incorrect and
underestimated and as a result the resource planning and costing is also underestimated.
The NCSS is committed to extension of the age range to 69 years, but recognises that there are a number of challenges to be overcome. It is the intention of the NCSS to establish a working group in the New Year to identify the issues to be addressed, steps to be taken, and timeline estimated to achieve the objective of extending the age range by the end of 2014. Dr Ann O’Doherty, Executive Lead Clinical Director and I would be happy to discuss the report in further detail should you wish. Kind regards
Majella Byrne ACTING DIRECTOR CC Dr Ann O’Doherty, Executive Lead Clinical Director, BreastCheck Dr Susan O’Reilly, Director, National Cancer Control Programme