Breast Surgery

Ensure that new breast patient referral and assessment pathways are timely and centred around the individual with the aim of providing the best outcomes and experience. a) Provide primary care support and guidance to allow best use of the access pathway. b) Ensure that access and assessment pathways are evidence-based, risk-adapted and standardised to support safety and cost efficiency. c) Redesign and pilot breast clinic access (referral) and assessment pathways to further reduce barriers to early diagnosis, support the Faster Diagnosis Standard and allow patient choice. Ensure new ways of working are audited. d) GIRFT to work with specialty associations and Cancer Alliances to identify the workforce requirements associated with pathway redesign. e) Ensure that breast MDTs have a link to a plastic surgeon.

Support better self-management through public health messaging at both national and local levels which emphasises breast health and targets breast cancer awareness messages at those at greatest risk. a) Ensure that public health messaging focuses on groups underserved by existing initiatives (e.g. older age, BAME) in regard to breast health and awareness to encourage early healthcare engagement for any breast issues. b) Support and promote breast health awareness in the younger age groups. c) Align and collaborate with other health education initiatives aimed at supporting better understanding of women's and men's health. d) Develop educational tools and materials to support public health messaging as outlined in the NHS Long Term Plan.

Reduce unnecessary outpatient attendances for follow-up. a) Trusts to complete or implement the introduction of personalised stratified follow-up. b) All trusts to have robust, up-to-date and highly digital Remote Monitoring Systems for patients on a personalised stratified follow-up pathway with 'call and recall' and 'right-results' systems or capabilities.

Ensure that no breast surgery patients stay in hospital longer than is medically necessary. a) Increase day surgery rates for key index procedures to meet or exceed BADS target of 95% for simple breast excision and 75% for both oncoplastic excisions and mastectomy. b) Reduce median* and long length of inpatient stay for breast reconstruction by, for example, introducing enhanced recovery programmes with the aim of enabling patients to return home sooner. *In regard to implant-based reconstruction, the GIRFT benchmark is a median of two days, with less than 20% of patients at three days or more. In regard to free flap reconstruction, the GIRFT benchmark median is six days, with less than 20% of patients staying seven or more days. c) Trusts to consider day case surgery for selected patients undergoing mastectomy and implant-based reconstruction, if deemed appropriate for the patient.

Ensure equity of access to: oncoplastic surgery to support safe breast conservation; and breast reconstruction, with the aim of reducing variations in immediate reconstruction rates and variable access to free flap reconstruction techniques. (Breast MDTs should have a link to a plastic surgeon). a) Establish oncoplastic MDTs in every breast and plastic surgery unit (virtual/real). b) MDTs to support breast conservation regardless of age whenever safe and desirable. They could for example consider using: primary systemic therapies to support conservation when clinically indicated; oncoplastic breast conservation when appropriate. Where access is not available on site, alternative providers must be offered through oncoplastic networks. c) Trusts to provide access to all index methods of reconstruction, (following NICE guideline NG101) and outsourcing reconstruction where necessary. d) ICS/STPs to work with oncoplastic MDTs to examine facilitators and barriers to immediate reconstruction and free flap reconstruction. e) ICS/STPs to conduct needs assessments and plan capacity between breast and local plastic surgery units with the aim of: achieving an immediate breast reconstruction rate of 25% (GIRFT national rate), whether performed onsite and/or outsourced; ensuring at least 30% (GIRFT national rate) of immediate breast reconstructions are free flap.

Reduce unplanned readmissions and returns to theatre. a) Oncoplastic surgery teams to ensure 30- and 90-day unplanned admissions and return to theatres rates are within the median quartile (GIRFT national benchmark). b) Oncoplastic surgery teams to ensure unplanned implant removal rates at 1 year are 7.5% or below (GIRFT national benchmark). (The target is 5% or less in accordance with the oncoplastic guidelines.) c) Plastic surgery teams to reduce unplanned free flap return to theatres to UKNFR rates of 7%.

Incorporate PROMs for all oncoplastic, reconstructive and related surgery as well as for aesthetic breast surgery. a) Trusts to consider the adoption of the BreastQ questionnaire, or similar, as a standardised means of gathering PROM data.

Ensure that no patients undergo more surgery than is necessary. a) Reduce excisional surgery rates for benign/normal conditions to 25% or less of total excisional surgery (GIRFT national rate) by following ABS guidelines and GIRFT best practice exemplars. b) Reduce repeat surgery after wide excision for cancer, aiming towards repeat surgery rates of 10% or less (as recommended by the American Society of Breast Surgeons). c) Minimise adjustment and revision surgery, following ABS, BAPRAS and Breast Cancer Now 'Guidance for the Commissioning of Oncoplastic Breast Surgery'. d) Limit bilateral mastectomy for unilateral cancer to when clinically indicated and ensure ABS guidelines and NICE guideline CG164 Familial breast cancer are followed. There must be clear documentation regarding the rationale and benefits (e.g. symmetry) and more specially: all trusts must provide clear information to patients with unilateral breast cancer to support shared decision making regarding the benefits and risks of bilateral mastectomy +/-reconstruction; all requests or recommendations for bilateral mastectomy (for unilateral cancer) and immediate breast reconstruction must undergo MDT review.

Reduce admissions/surgery for mastitis to 1% or less of admissions captured under the OPCS codes for excisional breast surgery. a) MDTs to develop a plan to reduce their admissions for non-surgery related breast infections and breast interventions. b) MDTs to work with local healthcare providers, A&E departments and on call surgery teams to reduce the need for emergency hospital admissions for non life-threatening breast infections. c) Specialty associations to develop a best practice pathway for the management of non-surgical breast infections which reflects the NICE guideline CG37 Postnatal care up to 8 weeks after birth.

Reduce inequity in access to aesthetic breast surgery for congenital, developmental and acquired anomalies. a) Commissioning criteria for aesthetic breast surgery for congenital, developmental and acquired anomalies to be consistent, and applied consistently.

Full addressee: Commissioners

Improve the consistency and accuracy of data capture in HES. a) Trusts to capture at least 95% of admissions for (oncoplastic) breast surgery using TFC 103 or TFC160. b) Trusts to capture at least 95% of breast excision procedures under the appropriate breast surgery or radiology TFC. c) Specialty associations, coding bodies and others to work together to identify a solution that enables trusts to capture at least 95% of outpatient attendances for (oncoplastic) breast surgery using TFC103. d) NHS Digital to develop means of accurately recording and coding cross-disciplinary/multi-disciplinary surgery, for example by allowing the use of multiple appropriate TFCs for a single procedure. e) GIRFT to work with specialty associations and NHS Digital to develop guidance on standardising the use of OPCS and ICD codes with particular regard to oncoplastic reconstructive surgery, where necessary.

Ensure that HES and NCRAS patient level data is linked to support outcome monitoring. a) GIRFT and NHS England to work together to continue to link NCRAS and HES data, to enable better case mix adjusted comparison of breast conservation, repeat surgery rates and the impact on local recurrence rates.

Improve the consistency and accuracy of data capture in the BCIR and UKNFR with the aim of 95% completeness within three months of surgery. a) BCIR and UKNFR data submission to become mandatory for all providers who use breast devices/flaps, including data about surgical meshes used in breast surgery. b) GIRFT to work with NHS Digital and others to consider options to improve data capture processes. c) Specialty associations to work with trusts and commissioners to develop a framework to allow the safe introduction of new devices and techniques – 'No innovation without evaluation'. d) GIRFT to explore how BCIR and UKNFR data can be linked to HES and Spend Comparison Service, to avoid duplication and enrich data collection on outcomes. e) CQC to support GIRFT in ensuring that providers capture and enter at least 95% of data into the breast implant and flap registries.

Enable improved procurement of devices and consumables through cost and pricing transparency, aggregation and consolidation, and by sharing best practice. a) Use sources of procurement data, such as Spend Comparison Service and relevant clinical data, to identify optimum value for money procurement choices, considering both outcomes and cost/price. b) Identify opportunities for improved value for money, including the development of benchmarks and specifications. Locate sources of best practice and procurement excellence, identifying factors that lead to the most favourable procurement outcomes. c) Use Category Towers to benchmark and evaluate products and seek to rationalise and aggregate demand with other trusts to secure lower prices and supply chain costs. At least 80% of NHS spend in breast surgery to be channelled through NHS Supply Chain, and market dominance issues addressed.

Reduce litigation costs by application of the GIRFT programme's five-point plan. a) Clinicians and trust management to assess their benchmarked position compared to the national average when reviewing the estimated litigation cost per breast surgery admission. (Trusts will receive this information in the GIRFT 'Litigation data pack'.) b) Clinicians and trust management to discuss with the legal department or claims handler the claims submitted to NHS Resolution included in the data set to confirm correct coding to that department. Inform NHS Resolution of any claims which are not coded correctly to the appropriate specialty via CNST.Helpline@resolution.nhs.uk. c) Once claims have been verified clinicians and trust management to further review claims in detail including expert witness statements, panel firm reports and counsel advice as well as medical records to determine where patient care or documentation could be improved. If the legal department or claims handler needs additional assistance with this, each trusts panel firm should be able to provide support. d) Claims should be triangulated with learning themes from complaints, inquests, and serious untoward incidents (SUI)/serious incidents (SI) / patient safety incidents (PSI) and where a claim has not already been reviewed as SUI/SI/PSI we would recommend that this is carried out to ensure no opportunity for learning is missed. The findings from this learning should be shared with all front-line clinical staff in a structured format at departmental/directorate meetings (including Multidisciplinary Team meetings, Morbidity and Mortality meetings where appropriate). e) Where trusts are outside the top quartile of trusts for litigation costs per activity, GIRFT will be asking national clinical leads and regional hubs to follow up and support trusts in the steps taken to learn from claims. They will also be able to share with trusts examples of good practice where it would be of benefit.

Identify breast surgery clinical negligence claims at a national level to allow early detection of variation in breast surgery. a) NHS Resolution, supported by GIRFT, to categorise clinical negligence claims related to the specialty of breast surgery to enable these claims to be differentiated from general surgery and improve taxonomy of claims so that surgery of the breast can be easily identified when carried out by other specialties outside of breast surgery.

Align breast surgery workforce recommendations to the NHS People Plan. a) Oncoplastic breast and plastic surgeons to practice at the top of their licence which includes: all WTE oncoplastic breast surgeons to be allocated at least two, and ideally three operating sessions a week; trusts to address over-reliance/utilisation of oncoplastic breast surgeons to support non-surgical activities. b) Ensure training for breast and plastic surgery trainees is fit for purpose. c) Address the shortage of trained microvascular plastic surgeons, so that free flap reconstructions are available more widely and equitably. d) Specialty associations to work with the GMC to develop a road map for the further development of training in oncoplastic breast surgery.