• Review commissioned by Public Health England identifies weak governance and corporate memory loss
  • Leaked review reports a serious misunderstanding by senior figures about the programme
  • Estimates of impact and letters to alert women were also based on mistakes, it says
  • Reports conclusions may be contested by other ongoing reviews

Weak governance, loss of “corporate memory”, and a crucial misunderstanding in the national breast screening programme lay behind a major national alert over potential deaths, according to an official review of the incident leaked to HSJ.

The review by management consultants for Public Health England looked into the causes of the problem, which in May saw Jeremy Hunt tell Parliament that some women were likely to have died as a result of missed scans – potentially up to 270.

The PwC report states that a small but significant mistake was made in 2013 in a new specification of who should be screened and when under the programme, and has gone uncorrected for five years. The programme itself continued unchanged.

The PwC paper, completed in June, suggests there has also been ongoing confusion during this year and that the number of women who missed a screening invitation may have been substantially overestimated.

In May, the then health secretary said “latest estimates” showed “between 2009 and the start of 2018 an estimated 450,000 women aged between 68 and 71 were not invited to their final breast screening”. A Daily Mail front page at the time described a “breast screening outrage”.

The report says the subsequent “national patient notification exercise”, which aimed to inform more than 200,000 women that they may have missed a screen, was based on the same misunderstandings.

The consultants said they could not tell how many women were not invited for screening who should have been, based either on how the programme operated or on how the national specification says it should operate, they said. It is not known whether other ongoing reviews will establish this.

In 2012-13, national responsibility for the screening programme was moved out of the Department of Health and Social Care, and regional management moved out of strategic health authorities.

Robust governance

The report says it is unclear exactly how the error was introduced because of “a lack of clear documentation and comprehensive audit trail as to why and how decisions were made”. It was also unclear whether the new, apparently mistaken, specification was approved by the “tripartite” which took over national running of the screening programme under the 2013 Lansley reforms: PHE, NHS England and the DHSC.

Although PHE was put in charge of drawing up the new specifications, PwC said: “There does not appear to have been a robust governance process, across the tripartite, surrounding the approval of the specifications.”

It added: “The priority must be to review the current [screening programme specification] and update it to align with the practical realities of how the system operates.”

The report, entitled Project Crystal Briefing Paper, is part of the agency’s ongoing internal inquiry into how its national screening programme caused a national incident.

The PwC review is expected to contribute to a wider internal review by PHE which is ongoing. The DHSC also commissioned an independent inquiry into it. Both are due to be published in November.

Officials in PHE became increasingly aware of the discrepancy between the 2013 specification and the actual way in which women were being invited for screens last year, coming to light following a change in computer systems. But the report does not comment on how and when it was reported to PHE’s senior management, to NHS England, or to the DHSC.

The report contradicts the initial explanation of what went wrong given by Mr Hunt and PHE.

Mr Hunt told Parliament in May “a number of linked causes” had been identified “including issues with the system’s IT and how age parameters are programmed into it” and regional “variations in how local services send out invitations”. He also pointed to a major trial known as “AgeX”, which was set up in 2009 to test extending screening to age 73, indicating that the trial was central to the problem.

HSJ understands the drafting of PHE’s final internal report is well advanced, and also appears likely to place greater emphasis on the AgeX trial than PwC has done.

Corporate memory

PwC’s report itself indicates the AgeX system was not the primary cause, instead focusing on the misunderstanding surrounding the difference between the national specification, and how the screening programme operates and has long operated.

This relates to when women are meant to be invited for their final screening invitation, and echoes the account of a former lead adviser to government on the programme, who is also involved in AgeX, reported by HSJ in May. 

The PwC report says the screening programme lost “a significant amount of corporate memory” in 2015 when a “longstanding lead for the cancer screening programme left PHE resulting in a lack of detailed understanding of how the [breast screening programme] operates at a granular level”.

“There is a lack of corporate knowledge across the screening team as to how and why historical decisions were made,” the paper added.

The PwC review does, however, state that “PHE staff familiar with the relevant systems” said “the timing between certain processes and impact of AgeX still may have led to circa 30,000 women being incorrectly omitted from screening invitations”.

The consultants were not given access to the data needed to validate this observation. They also make clear they have only spoken to staff in PHE and those working on AgeX, not in the DHSC or NHS England.

PHE has declined to answer specific questions about the PwC report, but its chief executive Duncan Selbie said in a statement: “The independent review set up by the secretary of state will establish the facts and we should not meantime speculate on its findings.”

DHSC and NHS England were approached for comment but had not responded by the time of publication. PwC declined to comment.