Back in the summer I wrote about an unusual Commons statement made by the then Health Secretary, Jeremy Hunt, that some 450,000 women over a near ten year period had not been properly invited for their final breast screening and this error had potentially led to hundreds having “had their lives shortened” as a result. I was, in case you did not read the earlier post, somewhat incredulous that such a major and shocking process failure had happened at all and gone undetected for so long in what is the largest and longest-running health screening programme in the world, particularly because Hunt stated that the error was due to a “computer algorithm failure”. Naturally, the impact of his announcement attracted much Press comment & criticism and the impact on the affected women and their families, many learning of this bureaucratic failure in the Press or via a standard letter well after the event, might have been life-changing for many families, particularly those who may since have contracted or even died of the disease. This was a major incident and Mr Hunt apologised repeatedly in his statement on behalf of all the DoH agencies involved.
The independent breast screening review Hunt commissioned to look into the incident has duly completed and its report makes for interesting, if somewhat depressing, reading. Basically, it found there was no ‘incident’. There was no major failure of the screening programme, there was nothing wrong with the algorithm and the IT systems were generally doing what they were designed to do. The reasons behind Mr Hunt’s statement were basically due to a huge muddle by those charged with administering the programme or, in the words used in the report, ‘…the Health Secretary’s announcement was made following advice based on an incomplete understanding of what had happened.’ So primarily, it was a spectacular failure of management and governance.
The report’s Executive Summary states:
‘The Secretary of Health was advised that women had not been invited to their final breast screenings between the ages of 70 and 71 because of a problem with a computer algorithm. In fact, the reason that the women were not invited between those ages is that the way the breast screening programme had been run since the late 1980s meant they had already received their final screening three years earlier. The misunderstanding arose because of a Specification document written in November 2013 which stated that women should be invited for screening “within 36 months of their previous screening, until they reach the age of 71”. We believe this document [written by the DoH and NHS England] was based on a misunderstanding of how the programme was being delivered in practice. The vast majority of women who were told earlier this year that they may have missed an invitation to screening were only affected under the definition of this document, and of them some (those eligible for final screening before the Specification was written) should not have had the document applied to them at all.
For many years, from the beginning of the breast screening programme in the late 1980s, the specific age range of women to be invited was not set out in sufficient detail, and there was variability across breast screening units. In the hand-over of responsibilities to the newly-formed Public Health England and NHS England in 2013 we have found no evidence that there was a shared understanding of how the screening programme was being delivered. A new Service Specification was written to provide specific instructions against which the programme could be commissioned and quality assured, but it included a level of specificity which did not align with the IT system then in use, and was not consistently implemented by the breast screening units. We believe this to have been written in error. It appears that no-one in the Department of Health and Social Care, Public Health England or NHS England realised that this was not consistent with past policy or understood that this change then caused a misalignment between policy, delivery, the IT system and the AgeX trial algorithm. This lack of understanding of the root cause of the confusion continued even as the incident was being investigated and announced.’
The report further states: ‘The Review team is surprised that an incident was declared before the full extent of the problem had been understood or uncovered. The impact of this appears to have changed the focus of Public Health England to addressing the problem they thought they had discovered. So, despite the lack of understanding of the issue, work shifted in this period to how to respond operationally to the perceived problem.’
Comments relating to the programme’s failed governance include:
‘There is no strategic oversight to ensure the separate strands of the breast screening programme are functioning as a whole – there is no senior responsible owner. The quarterly section 7A agreement meetings are too large in scope to address individual issues in a robust way.
The November 2013 Service Specification (and its yearly updates) is central to the incident, but none of the tripartite organisations have been able to confirm how it was signed off. What is clear is that it was not implemented properly. This was a failure of governance.
NHS England failed to hold breast screening units to account for delivering against the contracts, which were based on the Service Specifications.’
As to how the ‘incident’ was dealt with, it states:
‘The Review has found that the initial handling of the incident was not sufficiently gripped within Public Health England, which resulted in delays in fully understanding the nature of the incident and ultimately led to a response that did not reflect the precise failings in the service. In particular, we would have expected the most senior management to have been involved in the initial handling to provide overall direction to the response and to ensure those responding to the incident had the necessary resources available to complete a thorough review at pace. We did not find evidence that such an approach was adopted. Public Health England has an excellent track record of responding to public health incidents but the approach adopted for this incident meant that some three months elapsed between the initial realisation that an incident had occurred and the Secretary of State being advised to make a statement to Parliament. Not only is this arguably too long a period of investigation but, worse, the failure to fully understand what had occurred led to the Secretary of State being advised to make a statement that we now know to have lacked the complete evidence and analysis. This was due to assumptions being made that the November 2013 Service Specification amounted to policy, and a lack of understanding of what was being delivered by the breast screening programme in practice.
The Review has also found that there were failings in the handling of the data which resulted in the severity of the incident being exaggerated publicly and in thousands of women being warned unnecessarily that they may have been affected by a failure in the IT system.
The Review believes that the way in which the public was alerted to the incident and the lack of communication with screening units and the devolved administrations placed an avoidable strain on resources. ‘