NICAN BREAST REGIONAL GROUP
ACCESS TO SYMPTOMATIC BREAST SERVICES
Background
1. In November 2005, the Department asked Chief Executives of HSS
Boards to develop an integrated approach to addressing timely access to
symptomatic breast clinics across Northern Ireland.
2. A subsequent response from Stuart MacDonnell on behalf of the four
Board Chief Executives recommended that this work be taken forward
within a number of “Strands”, which would focus on modernising the
symptomatic service.
3. Approval to proceed with Strand 1 was given in January 2006 and the
report of the Strand 1 Group Report “Ensuring Timely Access to Breast
Cancer Clinics” was presented to the Department in October.
4. Simultaneously, a review of access times for urgent assessment at
symptomatic breast clinics across the region was conducted by the
Department last month. This review indicated that of the GP referrals
received, there were around 250 women who were considered by a
specialist breast consultant to require an urgent assessment and who
were waiting more than 2 weeks for their appointment. The vast majority
of these women were waiting for assessment at Antrim Area and Belfast
City hospitals.
5. In Northern Ireland, breast services are working to deliver a target that
urgent assessments should take place within 2 weeks of referral.
6. The Department met with the Northern Board and United Hospitals Trust
on 13 October and again on 31 October to discuss the measures that
could immediately be put in place to improve access to the specialist clinic
at Antrim Area Hospital and to consider what might be done to sustain the
service from this point forward. Representatives from Altnagelvin, Belfast
City Hospital, Craigavon Area Hospital, the Ulster Hospital and the
Northern Ireland Cancer Network (NICaN) also attended to provide a
regional perspective.
Access to Symptomatic Breast Services
7. There is a consensus that the key constraint on the number of diagnostic
breast clinics is the availability of consultant radiologist staff specialising in
breast work. This shortage is apparent in Northern Ireland and elsewhere
in the UK. Here, there are currently 8 specialist radiologists working in
support of breast services at five centres across Northern Ireland,
delivering both screening and symptomatic breast services, as well as
general radiology input to a range of other specialties.
8. The breast radiologists met with the Chief Medical Officer on 18 October
and gave their agreement, in principle, to the adjustment of individual job
plans so that more clinical time would be made available to symptomatic
breast services. That agreement recognised that to be of real value,
adjustments to job plans should be for a period of up to 12 months in order
to provide greater stability for this service in the medium term. As we look
towards 2007 and beyond, the situation will be improved by a number of
staff returning from maternity and other absence and in due course by the
appointment of additional specialist radiologist staff.
9. On foot of the agreement with CMO, the Department asked Trusts to set
out their plans for improving access to symptomatic breast services and
an outline of those plans is set out below.
Antrim Area Hospital
10. At Antrim Area Hospital, the Trust has introduced additional week-end
breast clinics to clear the list of women who required an urgent
assessment and who had been waiting more than 2 weeks. The first of
these was held on 4 November and the Trust has confirmed that around
90 women will have been seen at these clinics by 18 November.
11. The Trust will also increase its weekly throughput as a recently appointed
radiologist is now fully accredited.
12. From January, an additional weekly session will be introduced. This has
been made possible by the agreement of a consultant normally based at
Belfast City Hospital to give up one of his general radiology sessions and
to replace that with an additional symptomatic clinic at Antrim.
Craigavon Area Hospital
13. At Craigavon Area Hospital, no woman requiring an urgent assessment
waits more than 2 weeks for her appointment. Consultant radiology staff
there have indicated that they would be willing to do additional sessions at
other locations to assist those localities to manage pressures or backlogs.
The Department will be advising Chief Executives of this potential
resource.
Altnagelvin Hospital
14. The symptomatic breast service at Altnagelvin is being redesigned to
facilitate patients with a range of risks for breast cancer.

All patients are referred to the service by a pro forma from GPs.

All patients are triaged by consultant surgeons

Patients are triaged into high-risk, lower-risk and family history
groups.

Post-surgery follow-up of breast cancer is being redesigned to be
led by specialist breast nurses trained in examination technique.
15. This latter development will free up two additional clinics each week for
patients in the lower-risk group. Between now and January 2007, 20 such
clinics will be held enabling the Trust to ensure the 2 week target for
urgent assessment is maintained and also to ensure that around 400
women considered to be in the lower-risk group will be seen.
Belfast City Hospital
16. In October, around 119 women were waiting more than 2 weeks for a
triple assessment at Belfast City Hospital. The Trust has confirmed that
during October - December 2006, seven additional symptomatic clinics will
be run. This additional capacity will enable 175 women to be seen,
tackling the Trust’s backlog of urgent assessments. In addition, the Trust
will interview candidates for a vacant consultant breast radiologist position
on 23 November and if a successful appointment is made will introduce
additional clinics each week increasing the Trust’s throughput.
The Ulster Hospital
17. The service at the Ulster Hospital is currently affected by the absence of a
consultant radiologist on maternity leave. That individual is expected to
return in December. The Trust operates 2 symptomatic breast clinics
seeing around 70 women in total each week. It would appear that this rate
of throughput is sufficient to sustain delivery of a 2 week access target for
women requiring urgent referral but there is the risk that this service will
too be under pressure.
Monitoring Arrangements
18. Access to breast clinics has to this point been monitored by the
Department’s Hospital Information Branch on a quarterly basis. The
Department now intends to commence, with effect from 20 November
2006, weekly monitoring of referrals to symptomatic breast clinics and the
timeliness of access for women requiring an urgent assessment. The
monitoring template to be used is provided for information.
19. Monitoring the flow of referrals from this point forward will help us prepare
for the monitoring of time from diagnosis to first treatment referral to first
treatment as envisaged in the cancer access standards now being taken
forward by NICaN and the Department’s Service Delivery Unit. Trust
Chief Executives are being advised of the new monitoring arrangements.
The NICaN Regional Breast Group
20. During the Department’s discussions with consultant staff and Trusts, a
number of issues that need to be addressed on a regional basis arose.
Several of these issues are also apparent in the Strand 1 Group paper.
21. There is clearly a need for consensus amongst breast specialists around:

the management of referrals to the breast service, the provision of referral
guidance to GPs including the need to standardise referral pro-formas or
letters

the standards to be applied to clinician-led triage of those referrals

considering how the patient care pathway should be developed taking into
account the potential impact of service redesign such as that under way at
Altnagelvin i.e assessment of lower-risk referrals, family history clinics and
the arrangements for post surgery reviews.
22. The Department would also anticipate that the NICaN Regional Breast
Group will, in time and in conjunction with commissioners and service
provider organisations, make recommendations more fundamental to the
structure of the breast service.
23. There is a need to examine current patterns of service delivery to assess
whether the vulnerability of these services would be reduced through the
creation of stronger multiprofessional / multidisciplinary teams at a
reduced number of localities, or whether there are other solutions to the
difficulties the service faces that may deliver more sustainable services in
the longer time.
ACTION
24. The Group is asked to ensure that its terms of reference and composition
are appropriate to pursue the issues outlined above and to develop a
workplan for consideration of the issues raised above.
David Galloway
Deputy Director
Secondary Care
DHSSPS
9 November 2006