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Brighton and Sussex Universities NHS Trust
Published date:
November 2020

This project describes the development and implementation of a service implementation concerning the referral of patients with breast symptoms (including those suspicious of breast cancer) from primary to secondary care.

The project had the following focus:

  • To optimise the urgent (where cancer is suspected) referral process with no reduction in cancer diagnosis rates seen.
  • To support primary care in the optimal management of patients with low index of suspicion (where cancer is not suspected) symptoms with cancers diagnosed in these patients remaining below screening rate (approximately 1%) and unchanged compared with 2019, and
  • To enhance the breast symptom patient pathway and its associated outcomes.

The project has relevance to the Suspected Cancer Recognition and Referral process outlined in NG12. It is also relevant to other NICE resources including NICE Pathway Patient experience in adult NHS services overview, Patient Experience in Adult NHS Services CG138, and NICE Implementing Guidelines in the NHS.

Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives


It is further anticipated that achieving this aim will enhance patient outcomes in association with mortality, 1- and 5-year survival, stage at diagnosis and quality of life (NICE QS12).


Primary Objective:

  • To determine the utility of an adapted local breast symptom referral proforma (NG12: 16.7) by quantifying outcomes to secondary objectives below:

Secondary Objectives:

  • To compare and contrast urgent and non-urgent primary care referrals post implementation of service change (NG12: 1.4).
  • To compare and contrast breast pain referrals post implementation of service change (NICE Scenario – breast pain)
  • To compare and contrast cancers diagnosed post implementation of service change (NG12: Introduction).
  • To compare and contrast primary to secondary care referral patterns and impact on unwarranted variation post implementation of service change (NICE Charter:10)

Reasons for implementing your project

The breast assessment service in our large South of England acute NHS Trust currently offers cancer services to a population of approximately 1,000,000 people in our region and the surrounding areas.

In 2018 our service was functioning under considerable strain due to the collective impact of staff shortages (particularly mammographers and radiologists), compromised ability to provide a ‘single visit’ service consistent with NICE Guidance 1, 2, support optimal patient experiences 3, and maintain acceptable performance against national standards CSV file 12.

Rationale for Change

An audit within our Trust reviewing patients with breast symptoms assessed 2013-2018 observed a large volume of referrals for breast pain and that these referrals conveyed to low cancer conversion rates (Lekanidi, currently unpublished, and a further local audit Tse and Preston 2019).

 Additionally, work published with the Association of Breast Surgery (ABS) Year Book 2019 by Nottingham Breast Institute demonstrated a service improvement outlining redesign of their primary care referral form, signposting enhanced primary care support for patients with breast pain, eczema and gynaecomastia (benign increase in size of male breast tissue). This service change resulted in a significant and sustained reduction in low index of suspicion breast symptom referrals and no significant impact on cancer diagnosis rates (Sawers.L, 2018: 92-94). In October 2019, our Brighton and Sussex University Hospitals NHS Trust service lead Mr Charles Zammit requested we consider this approach in our service.

How did you implement the project

We completed NICE NG12 baseline assessment tool and NICE Implementing Guidelines in the NHS tools to better understand the need for improvement in our service. Findings from the NG12 baseline assessment tool included considerable variation in type and quality of referral documentation received and a potential need for enhanced support/collaboration between secondary care and referring primary care colleagues, particularly in relation to non-urgent referrals (attachment 1).

We then completed a project proposal and presented this to our cancer service managers. The proposal recommended one day per week senior nurse support for a period of 20 weeks. Our service managers were supportive of the proposal however there were no service funds available at the time.

We then made an application for funding to Surrey and Sussex Cancer Alliance (SSCA) who supported the project. Surrey and Sussex Cancer Alliance also contributed significant expertise and internal knowledge through support including stakeholder introductions, project management expertise and regional group collaboration; all of which were significantly impactful in terms of project success.

The project was subdivided into 4 phases as shown in Table 1 below. At the time of writing the project had completed Phase 1.

Project challenges and how these were overcome

  • This service change impacted on multiple stakeholders from different settings (primary and secondary care service leads/managers, Cancer Alliance colleagues/partners and commissioning leads). The project impacted upon the referral process for over one hundred busy primary care practices in East and West Sussex and we anticipated (and received) concerns and questions from stakeholders. Challenges raised included clinical concerns: (will cancers be missed? Will patients receive sufficient care/support?), pathway concerns (will this service change result in unintended consequences affecting resource provision and service delivery?), process concerns (how will the referral pathway be supported and will referrals be robustly delivered/received?) and governance concerns (is this service change NICE compliant? How will Cancer Waiting Times be influenced?). Without exception, all acted to positively shape the delivery of the project however, there were occasions when any one of these challenges could also have permanently arrested it. A strong mitigating factor guarding against this latter risk however was shown to be the support of key stakeholders (service lead, admin lead, finance lead, regional cancer alliance lead, primary care and clinical commissioning group leads) which we collaborated extensively to secure in the early part of the project.
  • When initially outlining the requirements for this project, the key elements identified were historical evidence, understanding NICE guidance, service capacity/demand understanding, prospective data collection, collaboration with stakeholders, a key admin team project link and finally me. On reflection, this was a rather myopic view on my part and it quickly became clear to me that I needed to reframe my approach if the project was to be a success. I needed to let go of the idea this project was for me to lead and embrace the concept of ‘co-production’ where the focus is one of sharing ideas, care delivery and – most importantly – ownership. Having realised this, my starting point changed from a linear vision of the project to a more fluid approach throughout collaboration with all stakeholders. This liberated beneficial outcomes I had not envisioned or considered. These included an enhanced understanding and relationship between our services and teams, and specific benefits such as improved patient triage in secondary care and increased safety and speed of appointment provision by administrative (non-clinical) colleagues who receive appointment requests from primary care.
  • The collaboration required for this project - both in terms of planning and delivering the service change, and positively responding to challenges when they arose - also created opportunities for learning and progress which would not have emerged, had this project been conducted less intermutually. For example, by sharing the project with SSCA and collaborating openly and transparently, the project delivered a service change which was far richer and more comprehensive than it would have been. Subsequently, a ‘stand-alone’ piece of work has evolved into a multi-faceted Resource Suite (attachment 2) which other organisations can use to adopt/adapt to greatest benefit in their services.
  • A further challenge related to the outbreak of Coronavirus which palpably impacted clinical services in our region from March 2020. This project began in February 2020 however the clinical impact was to be measured from early April 2020 when new referral documentation was first rolled-out. At the same time, referral numbers were seen to drop by 70% in the wake of Covid-19 related changes in patient choices and service delivery across the primary and secondary care sector. This significantly influenced data liberated in the early weeks and months of the intervention, making initial interpretation of findings, and understanding of the risks and benefits of this service intervention, more challenging.

Table 1                                           Phase 1

      Preliminary work

·       Close collaboration with Clinical Commissioning Group Lead

·       Close collaboration with Primary Care Lead and Primary Care Teams

·       Internal review of Trust Advice & Guidance process to include specific areas of enquiry relating to:

·       Breast pain

·       Nipple eczema

·       Male breast symptoms 

·       Family history

·       Explanatory letter sent out to all regional referring primary care teams with links and supporting guidance

·       In-service collaboration through regular presentations at Trust Clinical Governance meetings with regular Cancer Alliance review

·       Redesign of current breast symptom referral form to align with NICE guidance, capacity/demand enhancement and improved patient experience

Phase 2

·       Ongoing data collection and Dissemination to partners across Surrey and Sussex Cancer Alliance and other Regional Cancer Alliances across the Country.

Phase 3

·       NICE collaboration and consideration for NICE Shared Learning, Endorsement, and Implementation Teams

Phase 4

·       Dissemination to Cancer Alliance partners throughout NHS and NICE Stakeholders to further enhance patient experience, outcomes and service provision in Suspected Cancer Recognition and Referral (NG12) processes.

Key findings

To most succinctly and credibly interpret evaluation data in the wake of the coronavirus outbreak we chose to therefore crystallise our focus into three main questions in the first 3 months of data collection with subsequent attention to the full aims and objectives of the project to be addressed at the 6 month data collection stage.

The three focus questions were:

1) How has the project influenced cancer diagnosis rates?

2) How many patients are referred with breast pain as their only symptom? and

3) How many patients with breast pain as their only symptom have a subsequent breast cancer diagnosis?

Findings were then compared with those of a 2019 service audit. For the project to be considered a success, cancer diagnosis rates compared with 2019 should not be adversely affected, patients referred with breast pain should be reduced and the number of cancers diagnosed in patients with breast pain as their only symptom should remain below screening rate (approximately 1%) and unchanged compared with 2019.

Initial findings have been consistently promising with no change in cancer diagnosis rates, a significant reduction in referrals for patients with breast pain as their only symptom and no cancers diagnosed in patients referred with breast pain as their only symptom.

By June 2020, referral rates for patients with high index of suspicion symptoms were approaching those of the same month in 2019. This indicated the impact of Covid-19 was normalising in terms of patients referred with urgent breast symptoms and increased the potential significance of findings and their relationship to the service change rather than coronavirus.

Data shown in Table 2 below demonstrates that following the service change, referrals for patients with breast pain as their only symptom had reduced by more than half with no cancers seen before or after the service change in this population. Cancers diagnosed remained at 3% of patients seen for both June 2019 and 2020, indicating no evidence to date that the service change has negatively impacted upon cancer diagnosis rates.


Table 2                   Initial Comparisons Pre and Post Service Improvement

Breast Symptom Referrals

Breast Symptom Referral Data


June 2019


Invasive breast cancers diagnosed June 2019



Breast Pain alone


28% (no cancers identified)

June 2020


Invasive breast cancers diagnosed June 2020



Breast Pain alone


13% (no cancers identified)

Key learning points

1) Secure senior level buy-in at an early stage

  • The degree challenges impacted upon project progress and its ultimate success depended heavily on the support of key stakeholders, secured in the early part of the project.

2) Promote co-production and shared power in project delivery

  • Keeping an open mind throughout collaboration with key stakeholders facilitated improvements that had not been envisioned or considered.

3) Collaborate widely and openly with key stakeholders

  • Collaboration created opportunities for learning and progress which would not have emerged, had this project been conducted less intermutually

4) Be prepared to adapt to the unpredictable – Covid-19

  • Being cognisant of the impact unpredictable external events may have on the project (in this case Covid-19 impacting referral patterns/service delivery) and adapting data gathering approaches contemporaneously, facilitated optimal understanding of project and its outcomes.

Contact details

Mrs Suzanne Halliday
Advanced Nurse Practitioner
Brighton and Sussex Universities NHS Trust

Secondary care
Is the example industry-sponsored in any way?