Clinical Radiology (1990) 41, 1-2

Editorial Starting from Scratch

Some Problems with Forrest

The rapid introduction of a nationwide breast-screening programme could hardly be expected to be free of difficulties. It was rather surprising, therefore, at the recent meeting in Cambridge (March 28-30, 1989), held under the auspices of the Marie Curie Foundation, that the generally acceptable initial results from some of the first screening units (with most of the Pritchard criteria being met by the majority of units at six months) gave little mention of problems over implementation. Perhaps this was because initial results only were requested, but difficulties there certainly have been; a brief account of those experienced at our uni,t should be helpful to others setting up a 'Forrest' breast-screening unit. Should a screening unit be separate from the existing X-ray facilities? Initially, these ladies are 'clients' rather than 'patients', so ~recalls should be undertaken away from a busy general X-ray department. Since an essential o f screening is close co-operation between radiologists, surgeons and cytologists, and since screen film reading requires uninterrupted attention, there is a very strong case for quite separate facilities. This requires capital which, although mentioned in Table 9.4 of the Forrest Report (1986), is not specified in the final capital allowance; however, it is accepted that this extra capital cost may be negotiated from the revenue allocation, although this implies that the opening will be delayed on account of diminished revenue. Some health districts have been fortunate, as we were, with an empty area available on the hospital site, but this will n o t be the case at other units. Although capital is pr6vided for a mobile screening unit and X-ray set, we would have been unable to keep within the capital provision without the assistance of the Wessex Cancer Trust (a local registered charity), who provided the trailer unit. Furthermore, the cost of electrical supply for each site for the mobile (£500 per site) was not identified in the capital provided, and, although the Regional Health Authority eventually were able to fund much of this, for other sites the money was provided by local charities. Nor did the capital cover the purchase of computer equipment, and, finally, no allowance was made for VAT. Since Southampton and Salisbury Health Authorities combined are slightly larger than one Forrest unit, £163 500 capital was provided (1986 estimates); the actual purchase cost of the items listed by Forrest was £ 1987/8, with VAT £27000 in addition. The computer costs were a further £22 500. There are hidden costs, which include, for instance, the identification of suitable sites by the manager, negotiation over any service supply for the mobile, and the important pre-screening information visits to the practices to be screened. Radiologists should normally manage these screen units, since well over 90% of the programme is radiological, and the quality of mammography, u p o n which everything depends, is more likely to be high when trained radiographers work with trained radiologists. Additionally, radiologists and radiographers are more likely to be familiar with the running of what is essentially a radiological service. Two radiologists should be involved in the screening/assessment process to ensure that this can continue during periods of leave or sickness. The unit will

only perform satisfactorily if there are good relations at all levels within the team, especially between specialities. The initial centres have been able to use existing mammographically experienced radiologists, but in future there will be fewer of these available, and great reliance will have to be placed on the training provided at Guildford, MancheSter, Nottingham and Kings College Hospital. There are also difficulties in recruiting experienced radiographers, which are likely to increase rather than decrease due to the fall in numbers available for training. The two most senior radiographers at our unit were trained before we commenced screening: they are supported by three part-time radiographers, to increase flexibility and to provide cover for absences for sickness, etc. However, in spite of repeated attempts to obtain training, this has only just been achieved after almost one year of operation, and none of these three part-time staff has yet been certificated by the College of Radiographers, although we feel obliged to use them in order to approach the output expected by the Forrest Report. These staffing levels are adequate to cover a compliance rate of 70%, but it has been hard work to cope with the local compliance of 75%, and were it to rise to over 80%, the number invited for screening might have to be reduced, thereby elongating the screen cycle. No provision has been made by Forrest for doublereading. However, in the Pritchard report (p. 20) it is stated that double-reading increased confidence, and recently the European Group for Breast Cancer supported double-reading (personal communications f r o m Professor J. L. Price and Dr A. K. Tucker), as did the Scottish Advisory Committee on the Forrest Report (personal communication from Dr A. Kirkpatrick). At a maximum output of 70 screened patients daily, doublereading would require almost two additional radiologist sessions weekly. Believing it to be important, we have instituted double-reading, but at the cost of extending our working day by 1.5 hours. The result has been the detection of three additional cancers in the first nine months. The five consultant radiologist sessions identified by Forrest for each screening unit cover the basic reading (two sessions) and the resulting assessments (up to 10% allowed by Forrest= 30 patients per week= 10 patients on each of three assessment sessions). This leaves no time available for stereostatic biopsy, pre-operative localisation, and administration, which therefore have to be taken from existing NHS hours to the detriment of the general radiological service. In discussion at the Cambridge Meeting, it was stated that Sweden has approximately 700 radiologists for a population of 8 million, with Holland having the same number of radiologists for a population of approximately 15 million; in comparison, the U K has 1042 radiologists (1987 figures--RCR Newsletter, Spring 1989) for a population of approximately 54 million. In Holland the recommendations are for 40 radiologists and 250 radiographers for their breast screening programme, which is similar to the numbers projected by the Forrest Report for the whole U K Breast Screening Programme (p. 70). There have been other difficulties. Learning to use the computers took time and would have been more pro-



longed had not our office staff all been computerexperienced. The Family Practitioner Committee (FPC) had intermittent problems providing G P lists due to staff shortages, and up to 20% of patients' data on F P C lists is erroneous; it takes each G P practice up to 80 hours to check and correct these errors and this time is unfunded. The desire for quality assurance which demands statistics over and above those given in the Pritchard Report, means greater secretarial help in the screening office. There have also been problems in providing facilities for an optimum level of surgical c a r e - - f o r example, initial difficulty in obtaining anaesthetic cover, problems with the organisation of extra lists, and last (but by no means least), the workload engendered by the existence of breast screening and the need to treat all patients requiring biopsy as a matter of urgency. Only much hard work and a great deal of enthusiasm have helped give results that can be regarded as a satisfactory start to a complex programme, Just over one-

third of centres are 'up and running', and there is a long ' way to go; it is to be hoped that this dedication and enthusiasm will continue, and will also be found in units starting up. However, there can be no doubt that significantly improved funding is essential if this satisfactory start is to be maintained. REFERENCES

Pritchard J (1987). Guidelines on the Establishment of a Quality Assurance System for the Radiological Aspects of Mammography used for Breast Screening, p. 1. Report of a Sub-Committeeof the

Radiological Advisory Committee of the Chief Medical Officer at the Department of Health and Social Security. Forrest P (1986). Breast Cancer Screening. HMSO, London. Royal College of Radiologists (1989). Newsletter No. 22, p. 5. P. B. G U Y E R Southampton and Salisbury Breast Screening Unit R S H Hospital Southampton

Starting from scratch--some problems with Forrest.

Clinical Radiology (1990) 41, 1-2 Editorial Starting from Scratch Some Problems with Forrest The rapid introduction of a nationwide breast-screenin...
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