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Approaches to improving breast screening uptake: evidence and experience from Tower Hamlets

Approaches to improving breast screening uptake: evidence and experience from Tower Hamlets British Journal of Cancer (2009) 101, S64 – S67 & 2009 Cancer Research UK All rights reserved 0007 – 0920/09 $32.00 www.bjcancer.com Full Paper Approaches to improving breast screening uptake: evidence and experience from Tower Hamlets ,1 2 2 3 3 4 KW Eilbert , K Carroll , J Peach , S Khatoon , I Basnett and N McCulloch 1 2 3 Public Health Directorate, NHS Waltham Forest, 7 Kirkdale House, London E11 1HD, UK; McKinsey & Company, 1 Jermyn Street, London, UK; Public Health Directorate, NHS Tower Hamlets, Aneurin Bevan House, 81 Commercial Road, London, UK; North London Cancer Network, 5th Floor East (UCLH), 250 Euston Road, London, UK This paper reports on an innovative whole-systems approach to improving uptake of breast screening in Tower Hamlets, a deprived borough in the East End of London with a large minority ethnic population. The approach, developed by the public health team at NHS Tower Hamlets, draws on analysis of needs and existing literature about effective interventions to promote breast screening. Social marketing research led to a campaign targeted at Bangladeshi women, together with a range of initiatives to promote breast screening through primary care services and community outreach through local well-known organisations. The breast screening service itself was upgraded and a new service specification is being introduced from April 2009. British Journal of Cancer (2009) 101, S64 – S67. doi:10.1038/sj.bjc.6605393 www.bjcancer.com & 2009 Cancer Research UK Keywords: breast screening; primary care; community intervention Breast screening provides an opportunity to diagnose cancer 61% in London (Health and Social Care Information Centre, before symptoms develop, when the tumour is small and at an 2009). early stage that is likely to be associated with a good outcome. The  Round length (the proportion of eligible women whose first NHS Breast Screening Programme (BSP) was introduced in the late offered appointment is within 36 months of their previous 1980s after publication of randomised clinical trials showing that screening) is 84% nationally, but only 60% in London (Health screening reduces mortality from breast cancer (Breast Screening and Social Care Information Centre, 2007). Frequency Trial Group, 2002). We describe a multifaceted, whole-systems approach devel- Initially, the NHS BSP was targeted at women aged 50–64 years, oped by NHS Tower Hamlets Public Health to improve but since 2004 it has been extended to include women aged 50–70 coverage, uptake and round length of breast screening and years and improved by undertaking two-view mammography at thereby to decrease breast cancer mortality in Tower Hamlets. all visits. The aim is to screen all women at 3-yearly intervals. This paper draws on existing literature about effective Further improvements to the screening programme were an- approaches, presents new analyses undertaken to understand nounced as part of the Cancer Reform Strategy (Department of the specific problems in Tower Hamlets, describes the inter- Health, 2007). ventions that have already been undertaken and further The NHS BSP is regarded as highly successful. Screening is interventions to be carried out in 2009, and presents data on generally considered to have contributed significantly to the screening uptake. overall fall in breast cancer mortality in the United Kingdom over the past 20 years (Breast Screening Frequency Trial Group, 2002). Over the past decade, the number of screen-detected cancers has Factors that may contribute to low coverage doubled from 6900 per year to 14 100 per year (Health and Social Care Information Centre, 2009), and 5-year survival for screen- Deprivation is a significant factor in explaining low breast detected cancers is 96.4% (Health and Social Care Information screening coverage, but only contributes around 13% of the Centre, 2007). However, the efficiency and effectiveness of breast variation in coverage at Primary Care Trust (PCT) level. Some screening varies across the country, with particular problems in PCTs have high coverage despite severe deprivation. Figure 1 London: shows the relationship between deprivation and breast screening coverage at a PCT level. Within PCTs, coverage at a general Overall coverage (the proportion of eligible women who have practitioner (GP) practice level is not linked to deprivation of their been screened at least once in the previous 3 years) is 77% catchment area (based on unpublished Mori poll data for Tower nationally, but only 65% in London (Health and Social Care Hamlets, Newham, City and Hackney, Waltham Forest, Islington, Information Centre, 2009). Camden PCTs). Uptake (proportion of women invited for whom a screening Ethnicity accounts for around 28% of the variation between result is recorded within 6 months) is 73% nationally, but only PCTs as shown in Figure 2. There are significant differences in uptake between minority ethnic groups within the area covered *Correspondence: Dr KW Eilbert; E-mail: [email protected] by the Central and East London Breast Screening Service Breast screening in Tower Hamlets KW Eilbert et al S65 90 90 60 65 0 5 10 15 20 25 30 35 40 45 50 15 20 25 30 35 40 IMD (Index of Multiple Deprivation 2007) Population turnover (% of population that moved in or out last year) Figure 1 The relationship between deprivation and breast screening Figure 3 The relationship between population turnover and breast coverage at a PCT level (r ¼ 0.13). Source: Office for National Statistics screening coverage at a PCT level (r ¼ 0.04). Source: Bailey and Livingston (2003) and Health and Social Care Information Centre (2007). (2007). Office for National Statistics (2003) and Health and Social Care Information Centre (2007). MATERIALS AND METHODS The whole-systems approach taken by Tower Hamlets includes interventions aimed at targeted outreach work through respected community organisations to the eligible population (women aged 50–70 years), improving the breast screening service and strengthening commissioning. Targeted outreach through respected community organisations Previous studies undertaken in groups of women with low rates of 0 10 20 30 40 50 60 70 Ethnicity (percentage of women who are not white) screening, including Asian/Indian women, have shown the positive effects of knowledge building (Sadler et al, 2001), telephone Figure 2 The relationship between ethnicity and breast screening 2 counselling (Rimer et al, 2002), person-to-person conversations coverage at a PCT level (r ¼ 0.28). Source: Office for National Statistics (Legler et al, 2002), professional encouragement (Legler et al, (2003) and Health and Social Care Information Centre (2007). 2002) and peer support (unpublished work by Straight Talk). Among Bangladeshi women, the belief is that cancer is a death sentence and language barriers may be particular problems (identified in unpublished work by the social marketing company Forster for Change for Tower Hamlets PCT). (CELBSS). Unpublished Dr Foster Intelligence work for CELBSS Building on this, Tower Hamlets PCT worked with Forster for indicated that uptake is 60% in the white population and a similar Change to develop a campaign targeted at both Bangladeshi and figure is seen for the Indian population, whereas uptake is much white women. The team worked with an influential community lower in Pakistani (40%) and Bangladeshi (37%) populations. This group, Social Action for Health, to support Bangladeshi women to may be caused by cultural, linguistic or other factors. In Tower attend screening appointments. This involved calling women who Hamlets, 55% of the population of screening age (50–70 years) are did not attend their appointments, rebooking their appointments white, 1% is Pakistani and 27% are Bangladeshi. To improve for them and, in some cases, providing transport for groups of coverage levels, it is very important to work with all of these women to attend. Of 219 women involved in this pilot, 151 (69%) communities. went on to attend screening. Meanwhile, a local woman was Population turnover in Tower Hamlets is marginally above appointed to lead a campaign for white women, giving positive that for London and 4% higher than that for England (Office messages about attending breast screening as part of taking care of for National Statistics, 2003). High population turnover is their health. A Bosom Buddy pilot is now starting to encourage commonly thought to contribute to low screening coverage, but women who have been screened to recruit a friend or family this is not supported by analysis of coverage and total population member who has not attended, and help them through the turnover at a PCT level (Bailey and Livingston, 2007). However, the appointment. measure of total population turnover may not accurately reflect Measures have also been developed to help women who have changes in the eligible screening population, as most turnovers are low literacy or are unfamiliar with English. Talking invitations in people under 45 years. Population turnover accounts for about were developed for women who cannot read or use a spoken-only 4% of the variation in breast screening coverage as shown in dialect such as Sylheti, and these will be tested from June 2009. Figure 3. A pilot was implemented in two GP practices to call women before The importance of deprivation, ethnicity and population they receive their invitations and encourage them to attend their turnover, as well as other factors such as literacy levels and screening appointments, helping those who cannot read to make social integration, is reviewed elsewhere (Sutton et al, 1994; an informed choice about attendance. Support and translation is Champion and Scott, 1997; Box, 1998; Raja-Jones, 1999; Oelke, also provided through the Tower Hamlets PCT health advocates 2002; Chui, 2003). service at the static breast screening unit. & 2009 Cancer Research UK British Journal of Cancer (2009) 101(S2), S64 – S67 Coverage (% of eligible women screened Coverage (% of eligible women screened within 36 months) within 36 months) Coverage (% of eligible women screened within 36 months) Breast screening in Tower Hamlets KW Eilbert et al S66 Primary care services Stronger commissioning Tower Hamlets PCT has instituted a range of interventions, based The CELBSS is commissioned jointly by six PCTs working through on published evidence where available, to promote breast screen- a lead PCT in Tower Hamlets. A new service specification for the ing through primary care services. A Local Enhanced Scheme was breast screening service has been introduced from April 2009. This launched in 2007/2008 to incentivise GPs to increase participation focused on quality measures of patient experience and included in screening. Payment was based on the number of additional a tariff-based payment scheme that incentivises the provider and eligible women screened within the practice. allows for increased capacity. Training was provided to all 20 GP practices that formed the 2007/2008 screening round. Public health teams visited each RESULTS practice three times, accompanied by a representative of the local breast screening service on the first visit. The benefits of screening Tower Hamlets PCT has historically had low participation rates in were explained to staff, as recommended by Gorin et al (2007), and breast screening. Detailed analysis showed that there were multiple the roles of individuals within the practice team in increasing reasons for this. A whole-systems approach, based on evidence of screening uptake were explored, as recommended by Atri et al effective interventions, has been implemented. Preliminary find- (1997). ings indicate significant improvements both in processes and in A Bangladeshi GP screening lead was appointed for the PCT uptake. In 2005, uptake was 44.5%. Three years later, this had risen to raise the profile of all three cancer screening services, to front to 58.1% and in 2008/2009, the figure was 63.4%. These increases the campaign to advise Bangladeshi women to attend breast have not been analysed for statistical significance. screening and to work with Public Health to encourage best practice in primary care for cancer screening in GP practices. After recommendations of a Best Practice Cancer Screening Guide for DISCUSSION Primary Care developed by the Public Health Directorate in NHS Tower Hamlets, each general practice also nominated a cancer A multi-pronged approach through a strong partnership between screening lead (a practice manager or a GP). community organisations, GP practices and public health with To encourage uptake, GP practices set up alerts for eligible targeted promotion, along with attention to the quality of the women to provide opportunistic reminders when they attended the service provided, seems to be effective in increasing breast clinic for other reasons. They also endorsed invitation letters, as screening rates. recommended by Turner et al (1994), established ‘well-women’ There are several potential areas for improvement. Text messa- ging can only be as good as the availability of mobile numbers. In pilots to provide ‘prescriptions’ for breast screening and sent the participating GP practices, only 10% of mobile numbers were reminders through text messages. While the service only available. As text messaging is an effective way of managing overall had mobile phone numbers for 10% of women, 70% of those appointments, GP practices could work to collect mobile numbers who received messages attended their screening appointments for the next screening round. Community outreach worked well (unpublished evaluation of test messaging services by iPLATO in with the Bangladeshi community. There is still need to develop an 2008). appropriate outreach mechanism for the white community. A Bosom Buddy scheme is being piloted to test a mechanism to Breast screening service reach white women. There is still work to do to involve GPs more in the screening process, including understanding the variation As part of the whole-systems approach to improving breast between GP practice rates (range from 79.3% to 35.9%). screening in Tower Hamlets, it was recognised that attention The measure of success for each separate activity was women’s should be given to improving the efficiency and effectiveness of the attendance for their breast screening appointments. This was screening service itself. An investigation in 2004 by Sue Hudson measured by providing a card to each person participating in an had shown that on average 830 calls per day are made to the breast activity that she then turned in if she attended her appointment. screening services in London, and of these, 37% were engaged or As there were a number of interventions run at the same time, it unanswered. This can lead to a significant number of appoint- was not possible to say that any single one caused a woman to ments not being attended as on average 23% of appointments are attend. cancelled or changed by phone. While some interventions were based on evidence from the McKinsey and Company was engaged to work with the CELBSS literature, where there was no evidence, pilots were used to test to address this and other efficiency issues. As a result, CELBSS interventions. As success was measured solely by attendance established a dedicated call centre; the missed call rate dropped without controlling for possible intervening factors, it is not by 38% within 2 weeks. This meant, for example, that women possible to generalise findings to other settings. who called were more likely to be able to change their appointments. Conclusion Interactions with radiographers during a screening appointment can influence a woman’s decision to return. On that basis, Working in a community setting to influence behaviour change customer service training was provided for all staff, including poses challenges to research that may call for practical approaches radiographers and daily team meetings were set up with the where resources may be limited and it would not be possible to superintendent radiographer. A service charter, developed by control for all factors that influence women’s decision making. CELBSS staff, will be put on display at each screening site, setting Combining a systematic approach based on existing evidence with out what women can expect during their appointment in terms of innovative interventions led to useful lessons in Tower Hamlets waiting time, access to interpreters and friendly and respectful that can be applied to improve uptake of this important public staff. health screening programme and thus the health of women of The service now provides second timed appointments for Tower Hamlets. non-attenders (from April 2009), as these have been shown to increase attendance rates in comparison with an open in- vitation to call the service (Stead et al, 1998). Capacity was Conflict of interest increased to ensure that round length targets are achieved (see next section). The authors declare no conflict of interest. British Journal of Cancer (2009) 101(S2), S64 – S67 & 2009 Cancer Research UK Breast screening in Tower Hamlets KW Eilbert et al S67 REFERENCES Atri J, Falshaw M, Gregg R, Robson J, Omar R Z, Dixon S (1997) Improving breastscreening0708/Breast%20Screening%20Programme%20Report%2007- uptake of breast screening in multi-ethnic populations. BMJ 315: 08.pdf (accessed 28 August 2009) 1356– 1359 Legler J, Meissner H, Coyne C, Breen N, Chollette V, Rimer B (2002) The Bailey N, Livingston M (2007) Population Turnover and Area Deprivation. effectiveness of interventions to promote mammography among women The Policy Press: Bristol with historically lower rates of screening. Cancer Epidemiol Biomarkers Box V (1998) Cervical screening; the knowledge and opinions of Prev 11: 59–71 BME women and of health advocates in East London. Health Educ J Oelke N (2002) Cervical and Breast Cancer Screening Literature Review of 57: 3–15 Interventions for Underserved Populations. Alberta Cancer Board: Breast Screening Frequency Trial Group (2002) The frequency of breast Alberta, Canada cancer screening: results from the UKCCCR Randomised Trial. United Office for National Statistics (2003) Census 2001: Key Statistics for Health Kingdom Co-ordinating Committee on Cancer Research. Eur J Cancer Areas in England and Wales. TSO: London 38: 1458–1464 Raja-Jones H (1999) Breast screening among ethnic minority women – a Champion V, Scott C (1997) Reliability and validity of breast cancer screen- literature review. Br J Nurs 8: 1284–1288 ing belief scales in African American Women. Nurs Res 46: 331–337 Rimer B, Halabi S, Skinner C, Lipkus I, Strigo T, Kaplan E, Samsa G (2002) Chui L (2003) Inequalities of Access to Cancer Screening. A Literature Effects of a mammography decision-making intervention at 12 and 24 Review. Cancer Screening Vol. 1: NHS Cancer Screening Programmes: months. Am J Prev Med 22: 247–257 Sheffield Sadler G, Dhanjal S, Shah N, Shah R, Ko C, Anghel M, Harshburger R Department of Health (2007) Cancer Reform Strategy. NHS: UK (2001) Asian Indian women: knowledge, attitudes and behaviors toward Gorin S, Ashford A, Lantigua R, Desai M, Troxel A, Gemson D (2007) breast cancer early detection. Public Health Nurs 18(5): 357–363 Implementing academic detailing for breast cancer screening in Stead M, Wallis M, Wheaton M (1998) Improving uptake in non-attenders underserved communities. Implement Sci 2: 43 of breast screening: selective use of second appointment Journal of Health and Social Care Information Centre (2007) Breast Screen- Medical Screening. J Med Screen 5: 69–72 ing Programme, England 2006–2007. http://www.ic.nhs.uk/webfiles/ Sutton S, Bickler G, Sancho-Aldridge J, Saidi G (1994) Prospective study publications/breastscreening0607/Breast%20Screening%20Bulletin%20 of predictors of attendance for breast screening in inner London. 2006-07.pdf (accessed 28 August 2009) J Epidemiol Community Health 48: 65–73 Health and Social Care Information Centre (2009) Breast Screening Pro- Turner K, Wilson B, Gilbert F (1994) Improving breast screening uptake: gramme, England 2007–2008. http://www.ic.nhs.uk/webfiles/publications/ persuading initial non-attenders to attend. J Med Screen 1: 199–202 & 2009 Cancer Research UK British Journal of Cancer (2009) 101(S2), S64 – S67 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png British Journal of Cancer Springer Journals

Approaches to improving breast screening uptake: evidence and experience from Tower Hamlets

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Springer Journals
Copyright
Copyright © 2009 by The Author(s)
Subject
Biomedicine; Biomedicine, general; Cancer Research; Epidemiology; Molecular Medicine; Oncology; Drug Resistance
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0007-0920
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1532-1827
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10.1038/sj.bjc.6605393
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British Journal of Cancer (2009) 101, S64 – S67 & 2009 Cancer Research UK All rights reserved 0007 – 0920/09 $32.00 www.bjcancer.com Full Paper Approaches to improving breast screening uptake: evidence and experience from Tower Hamlets ,1 2 2 3 3 4 KW Eilbert , K Carroll , J Peach , S Khatoon , I Basnett and N McCulloch 1 2 3 Public Health Directorate, NHS Waltham Forest, 7 Kirkdale House, London E11 1HD, UK; McKinsey & Company, 1 Jermyn Street, London, UK; Public Health Directorate, NHS Tower Hamlets, Aneurin Bevan House, 81 Commercial Road, London, UK; North London Cancer Network, 5th Floor East (UCLH), 250 Euston Road, London, UK This paper reports on an innovative whole-systems approach to improving uptake of breast screening in Tower Hamlets, a deprived borough in the East End of London with a large minority ethnic population. The approach, developed by the public health team at NHS Tower Hamlets, draws on analysis of needs and existing literature about effective interventions to promote breast screening. Social marketing research led to a campaign targeted at Bangladeshi women, together with a range of initiatives to promote breast screening through primary care services and community outreach through local well-known organisations. The breast screening service itself was upgraded and a new service specification is being introduced from April 2009. British Journal of Cancer (2009) 101, S64 – S67. doi:10.1038/sj.bjc.6605393 www.bjcancer.com & 2009 Cancer Research UK Keywords: breast screening; primary care; community intervention Breast screening provides an opportunity to diagnose cancer 61% in London (Health and Social Care Information Centre, before symptoms develop, when the tumour is small and at an 2009). early stage that is likely to be associated with a good outcome. The  Round length (the proportion of eligible women whose first NHS Breast Screening Programme (BSP) was introduced in the late offered appointment is within 36 months of their previous 1980s after publication of randomised clinical trials showing that screening) is 84% nationally, but only 60% in London (Health screening reduces mortality from breast cancer (Breast Screening and Social Care Information Centre, 2007). Frequency Trial Group, 2002). We describe a multifaceted, whole-systems approach devel- Initially, the NHS BSP was targeted at women aged 50–64 years, oped by NHS Tower Hamlets Public Health to improve but since 2004 it has been extended to include women aged 50–70 coverage, uptake and round length of breast screening and years and improved by undertaking two-view mammography at thereby to decrease breast cancer mortality in Tower Hamlets. all visits. The aim is to screen all women at 3-yearly intervals. This paper draws on existing literature about effective Further improvements to the screening programme were an- approaches, presents new analyses undertaken to understand nounced as part of the Cancer Reform Strategy (Department of the specific problems in Tower Hamlets, describes the inter- Health, 2007). ventions that have already been undertaken and further The NHS BSP is regarded as highly successful. Screening is interventions to be carried out in 2009, and presents data on generally considered to have contributed significantly to the screening uptake. overall fall in breast cancer mortality in the United Kingdom over the past 20 years (Breast Screening Frequency Trial Group, 2002). Over the past decade, the number of screen-detected cancers has Factors that may contribute to low coverage doubled from 6900 per year to 14 100 per year (Health and Social Care Information Centre, 2009), and 5-year survival for screen- Deprivation is a significant factor in explaining low breast detected cancers is 96.4% (Health and Social Care Information screening coverage, but only contributes around 13% of the Centre, 2007). However, the efficiency and effectiveness of breast variation in coverage at Primary Care Trust (PCT) level. Some screening varies across the country, with particular problems in PCTs have high coverage despite severe deprivation. Figure 1 London: shows the relationship between deprivation and breast screening coverage at a PCT level. Within PCTs, coverage at a general Overall coverage (the proportion of eligible women who have practitioner (GP) practice level is not linked to deprivation of their been screened at least once in the previous 3 years) is 77% catchment area (based on unpublished Mori poll data for Tower nationally, but only 65% in London (Health and Social Care Hamlets, Newham, City and Hackney, Waltham Forest, Islington, Information Centre, 2009). Camden PCTs). Uptake (proportion of women invited for whom a screening Ethnicity accounts for around 28% of the variation between result is recorded within 6 months) is 73% nationally, but only PCTs as shown in Figure 2. There are significant differences in uptake between minority ethnic groups within the area covered *Correspondence: Dr KW Eilbert; E-mail: [email protected] by the Central and East London Breast Screening Service Breast screening in Tower Hamlets KW Eilbert et al S65 90 90 60 65 0 5 10 15 20 25 30 35 40 45 50 15 20 25 30 35 40 IMD (Index of Multiple Deprivation 2007) Population turnover (% of population that moved in or out last year) Figure 1 The relationship between deprivation and breast screening Figure 3 The relationship between population turnover and breast coverage at a PCT level (r ¼ 0.13). Source: Office for National Statistics screening coverage at a PCT level (r ¼ 0.04). Source: Bailey and Livingston (2003) and Health and Social Care Information Centre (2007). (2007). Office for National Statistics (2003) and Health and Social Care Information Centre (2007). MATERIALS AND METHODS The whole-systems approach taken by Tower Hamlets includes interventions aimed at targeted outreach work through respected community organisations to the eligible population (women aged 50–70 years), improving the breast screening service and strengthening commissioning. Targeted outreach through respected community organisations Previous studies undertaken in groups of women with low rates of 0 10 20 30 40 50 60 70 Ethnicity (percentage of women who are not white) screening, including Asian/Indian women, have shown the positive effects of knowledge building (Sadler et al, 2001), telephone Figure 2 The relationship between ethnicity and breast screening 2 counselling (Rimer et al, 2002), person-to-person conversations coverage at a PCT level (r ¼ 0.28). Source: Office for National Statistics (Legler et al, 2002), professional encouragement (Legler et al, (2003) and Health and Social Care Information Centre (2007). 2002) and peer support (unpublished work by Straight Talk). Among Bangladeshi women, the belief is that cancer is a death sentence and language barriers may be particular problems (identified in unpublished work by the social marketing company Forster for Change for Tower Hamlets PCT). (CELBSS). Unpublished Dr Foster Intelligence work for CELBSS Building on this, Tower Hamlets PCT worked with Forster for indicated that uptake is 60% in the white population and a similar Change to develop a campaign targeted at both Bangladeshi and figure is seen for the Indian population, whereas uptake is much white women. The team worked with an influential community lower in Pakistani (40%) and Bangladeshi (37%) populations. This group, Social Action for Health, to support Bangladeshi women to may be caused by cultural, linguistic or other factors. In Tower attend screening appointments. This involved calling women who Hamlets, 55% of the population of screening age (50–70 years) are did not attend their appointments, rebooking their appointments white, 1% is Pakistani and 27% are Bangladeshi. To improve for them and, in some cases, providing transport for groups of coverage levels, it is very important to work with all of these women to attend. Of 219 women involved in this pilot, 151 (69%) communities. went on to attend screening. Meanwhile, a local woman was Population turnover in Tower Hamlets is marginally above appointed to lead a campaign for white women, giving positive that for London and 4% higher than that for England (Office messages about attending breast screening as part of taking care of for National Statistics, 2003). High population turnover is their health. A Bosom Buddy pilot is now starting to encourage commonly thought to contribute to low screening coverage, but women who have been screened to recruit a friend or family this is not supported by analysis of coverage and total population member who has not attended, and help them through the turnover at a PCT level (Bailey and Livingston, 2007). However, the appointment. measure of total population turnover may not accurately reflect Measures have also been developed to help women who have changes in the eligible screening population, as most turnovers are low literacy or are unfamiliar with English. Talking invitations in people under 45 years. Population turnover accounts for about were developed for women who cannot read or use a spoken-only 4% of the variation in breast screening coverage as shown in dialect such as Sylheti, and these will be tested from June 2009. Figure 3. A pilot was implemented in two GP practices to call women before The importance of deprivation, ethnicity and population they receive their invitations and encourage them to attend their turnover, as well as other factors such as literacy levels and screening appointments, helping those who cannot read to make social integration, is reviewed elsewhere (Sutton et al, 1994; an informed choice about attendance. Support and translation is Champion and Scott, 1997; Box, 1998; Raja-Jones, 1999; Oelke, also provided through the Tower Hamlets PCT health advocates 2002; Chui, 2003). service at the static breast screening unit. & 2009 Cancer Research UK British Journal of Cancer (2009) 101(S2), S64 – S67 Coverage (% of eligible women screened Coverage (% of eligible women screened within 36 months) within 36 months) Coverage (% of eligible women screened within 36 months) Breast screening in Tower Hamlets KW Eilbert et al S66 Primary care services Stronger commissioning Tower Hamlets PCT has instituted a range of interventions, based The CELBSS is commissioned jointly by six PCTs working through on published evidence where available, to promote breast screen- a lead PCT in Tower Hamlets. A new service specification for the ing through primary care services. A Local Enhanced Scheme was breast screening service has been introduced from April 2009. This launched in 2007/2008 to incentivise GPs to increase participation focused on quality measures of patient experience and included in screening. Payment was based on the number of additional a tariff-based payment scheme that incentivises the provider and eligible women screened within the practice. allows for increased capacity. Training was provided to all 20 GP practices that formed the 2007/2008 screening round. Public health teams visited each RESULTS practice three times, accompanied by a representative of the local breast screening service on the first visit. The benefits of screening Tower Hamlets PCT has historically had low participation rates in were explained to staff, as recommended by Gorin et al (2007), and breast screening. Detailed analysis showed that there were multiple the roles of individuals within the practice team in increasing reasons for this. A whole-systems approach, based on evidence of screening uptake were explored, as recommended by Atri et al effective interventions, has been implemented. Preliminary find- (1997). ings indicate significant improvements both in processes and in A Bangladeshi GP screening lead was appointed for the PCT uptake. In 2005, uptake was 44.5%. Three years later, this had risen to raise the profile of all three cancer screening services, to front to 58.1% and in 2008/2009, the figure was 63.4%. These increases the campaign to advise Bangladeshi women to attend breast have not been analysed for statistical significance. screening and to work with Public Health to encourage best practice in primary care for cancer screening in GP practices. After recommendations of a Best Practice Cancer Screening Guide for DISCUSSION Primary Care developed by the Public Health Directorate in NHS Tower Hamlets, each general practice also nominated a cancer A multi-pronged approach through a strong partnership between screening lead (a practice manager or a GP). community organisations, GP practices and public health with To encourage uptake, GP practices set up alerts for eligible targeted promotion, along with attention to the quality of the women to provide opportunistic reminders when they attended the service provided, seems to be effective in increasing breast clinic for other reasons. They also endorsed invitation letters, as screening rates. recommended by Turner et al (1994), established ‘well-women’ There are several potential areas for improvement. Text messa- ging can only be as good as the availability of mobile numbers. In pilots to provide ‘prescriptions’ for breast screening and sent the participating GP practices, only 10% of mobile numbers were reminders through text messages. While the service only available. As text messaging is an effective way of managing overall had mobile phone numbers for 10% of women, 70% of those appointments, GP practices could work to collect mobile numbers who received messages attended their screening appointments for the next screening round. Community outreach worked well (unpublished evaluation of test messaging services by iPLATO in with the Bangladeshi community. There is still need to develop an 2008). appropriate outreach mechanism for the white community. A Bosom Buddy scheme is being piloted to test a mechanism to Breast screening service reach white women. There is still work to do to involve GPs more in the screening process, including understanding the variation As part of the whole-systems approach to improving breast between GP practice rates (range from 79.3% to 35.9%). screening in Tower Hamlets, it was recognised that attention The measure of success for each separate activity was women’s should be given to improving the efficiency and effectiveness of the attendance for their breast screening appointments. This was screening service itself. An investigation in 2004 by Sue Hudson measured by providing a card to each person participating in an had shown that on average 830 calls per day are made to the breast activity that she then turned in if she attended her appointment. screening services in London, and of these, 37% were engaged or As there were a number of interventions run at the same time, it unanswered. This can lead to a significant number of appoint- was not possible to say that any single one caused a woman to ments not being attended as on average 23% of appointments are attend. cancelled or changed by phone. While some interventions were based on evidence from the McKinsey and Company was engaged to work with the CELBSS literature, where there was no evidence, pilots were used to test to address this and other efficiency issues. As a result, CELBSS interventions. As success was measured solely by attendance established a dedicated call centre; the missed call rate dropped without controlling for possible intervening factors, it is not by 38% within 2 weeks. This meant, for example, that women possible to generalise findings to other settings. who called were more likely to be able to change their appointments. Conclusion Interactions with radiographers during a screening appointment can influence a woman’s decision to return. On that basis, Working in a community setting to influence behaviour change customer service training was provided for all staff, including poses challenges to research that may call for practical approaches radiographers and daily team meetings were set up with the where resources may be limited and it would not be possible to superintendent radiographer. A service charter, developed by control for all factors that influence women’s decision making. CELBSS staff, will be put on display at each screening site, setting Combining a systematic approach based on existing evidence with out what women can expect during their appointment in terms of innovative interventions led to useful lessons in Tower Hamlets waiting time, access to interpreters and friendly and respectful that can be applied to improve uptake of this important public staff. health screening programme and thus the health of women of The service now provides second timed appointments for Tower Hamlets. non-attenders (from April 2009), as these have been shown to increase attendance rates in comparison with an open in- vitation to call the service (Stead et al, 1998). Capacity was Conflict of interest increased to ensure that round length targets are achieved (see next section). The authors declare no conflict of interest. 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Journal

British Journal of Cancer – Springer Journals

Published: Dec 3, 2009

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