Consultant surgeon co-authors breast surgery services report
Consultant oncoplastic breast surgeon Tracey Irvine has co-authored a national report into breast surgery services, which aims to improve care and outcomes for thousands of patients across England.
Miss Irvine is one of the authors of the recently published Getting It Right First Time (GIRFT) national report into breast surgery, which makes a series of national, regional and trust-level recommendations for improving the service.
Highlighted to coincide with Breast Cancer Awareness Month in October, the report’s measures aim to protect patients and allow clinicians to focus on those with the greatest need, helping the NHS to restore safe and efficient care post-pandemic.
Covid-19 has had an impact on the delivery of breast surgery services, with new patient referrals rising since the easing of restrictions and a backlog of operations for those with lower risk cancer or requiring reconstructive surgery whose surgery was deferred. The GIRFT report looks to harness the response of teams across the country in rapidly adapting to change during the peaks of the pandemic, outlining measures which will enable them to deliver the safest and most efficient care possible.
The report is co-authored with Fiona MacNeill, a consultant breast surgeon at the Royal Marsden NHS Foundation Trust. In particular, it addresses the need to reduce unnecessary visits to hospital, minimise unnecessary interventions and improve data collection to inform future improvements in a post-Covid system.
Miss Irvine said: “Throughout our review of services, we were humbled by how hard every member of every breast diagnostic and surgery team is working to provide patient-centred care, despite all the challenges facing the NHS, not least Covid-19.
“We have seen numerous examples of outstanding practice: of innovation, of patients benefiting from real choice and being given thoughtful, caring support through what is an incredibly difficult experience for them. We hope our recommendations can build on that, offering the opportunity to improve services for the benefit of everyone and empowering patients to have more control over their own treatment.”
The GIRFT report is the most complete picture of breast surgery activity there has ever been: the first time data about all breast operations in England has been brought together, whether carried out as plastic surgery, breast surgery, general surgery or another specialty. It focuses on surgery related to breast cancer (the majority of surgery on the breast) but also looks at surgery for non-cancer reasons.
Following meetings with clinicians and managers in 129 breast surgery units it became clear that the need to meet the ‘two week wait (2WW)’ access standard (requiring teams to see all patients referred by a GP for a breast symptom within 14 calendar days) is the biggest challenge facing breast surgery teams.
There are more than 500,000 new outpatient referrals every year in England and the number is increasing, but cancer detection rates have stayed the same. This is because referrals are rising for younger women, especially those under 40 who are least likely to have cancer, with a smaller increase in referrals among the over-60s, who are more at risk.
One of GIRFT’s core recommendations aims to make referrals more flexible and to standardise assessments, giving patients more control and choice over their tests and treatment while still ensuring services can meet the new 28 Day Faster Diagnosis Standard (FDS).
The ability to manage new referrals is more crucial than ever as services work to maintain the capacity for early diagnosis in a post-COVID system. The pandemic has demonstrated the need for a more nuanced approach which can target those at greater and lesser risk of cancer in different ways and support appropriate breast assessments as efficiently and safely as possible. Innovations which could help to achieve this include:
- Better breast health awareness information for all women and men, especially those with lower risk of cancer, and more targeted breast cancer awareness information for those in higher-risk groups, who can be harder to reach;
- Alternative pathways for people with non-cancer breast symptoms, such as pain or breast enlargement, to prevent the anxiety of being referred on a ‘cancer’ pathway;
- Piloting new assessment pathways such as ‘straight to mammogram’ for women over 40 who have concerns about breast changes;
- Piloting open access clinics so that patients can choose when to attend.
It is hoped such innovations will enable clinicians to spend more time treating cancer patients.
GIRFT’s data shows around 102,000 breast operations are carried out every year in the NHS in England – 85% performed by breast or general surgeons and 15% by plastic surgeons. More than 60% of admissions are directly related to primary breast cancer treatment.
Recommendations in the report aim to ensure that any woman with breast cancer can make a balanced and informed choice on her treatment, unrestricted by resources. This includes having full access to the latest oncoplastic surgery techniques, supporting safe cancer surgery and breast appearance after breast conservation or mastectomy. Careful selection of procedures can help to ensure patients do not undergo more surgery than they need and reduce planned and unplanned readmissions, making more effective use of resources for essential care.
GIRFT strongly recommends that oncoplastic multidisciplinary teams (MDTs) are established in all units, both to support more oncoplastic conservation and, for women who opt for mastectomy, to provide access to the full range of reconstruction techniques most appropriate for her needs. MDTs should utilise the skills of specialist nurses and care assistants, as well as breast and plastic surgeons, radiologists, oncologists and pathologists.
The report also stresses that clinical coding and data capture must be improved – including the routine collection of patient reported outcome measures (PROMS) – to provide quality evidence to help understand progress, track the impact of Covid-19 and better plan future care.
Getting It Right First Time (GIRFT) is a national programme designed to improve the treatment and care of patients through in-depth review of services, benchmarking, and presenting a data-driven evidence base to support change. It is part of an aligned set of programmes within NHS England and NHS Improvement.
The GIRFT breast surgery report is available for everyone working in the specialty to download, even if you do not have an NHS email address. Click the link to register for access to the site. (You will need to register for access to this site, but permission is usually granted quickly.)