HSYP806 Systems Science in Healthcare. Assessment 2022

HSYP806 Systems Science in Healthcare
Assessment 2
Case Study Report

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Introduction
The main purpose of the case study is to bring forth the breast cancer screening error in which
around 4, 50,000 older women were missed out from mammography invitations during the last 9
years simply due to IT systems failure.
Every year 3, 50,000 women should be invited for cancer screening but for the last 9 years, the
number was 50,000 less per year. It accounted for 4, 50,000 invitations missed by the Public
Health England (PHE). The overall problem that needs to be resolved is to contact and identify
those left over women who are alive and provide mammography to the interested ones. There is
a need to identify additional capacity to accommodate them so that routine screening should not
be affected.
Description
Initially the IT Systems failure was found to be responsible for the left over cases. However, later
on it was identified in the review that it was not the main cause and the mistake was due to
misunderstanding about the age at which the women should be stopped being invited for the
screenings. For example, age parameters set in the system considered a cut off 70 years of age,
which excluded the women who had not reached in 71st year. However, they should be included.
According to Hunt, this mistake caused shortening of lives in 135 to 270 women. According to
Paul Pharaoh, there are very less evidences of benefits of screening in older women. Moreover,
there are additional benefits of not being screened. The over diagnosis in mammograms often
identifies ductal carcinoma in situ, that may never grow and never cause problem if left
untreated. The over diagnosed symptoms may get over treated further increasing the burden of
screening. The false positive results, detection of clinically insignificant lesions and work up
refusals results into burden of screening in older women mainly associated to functional
impairment and severe comorbid conditions. Those with abnormal mammograms complain of

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anxiety, depressive symptoms and pain because of screening. Such cases may develop
psychological distress that may last for the next 3 years [1]. Therefore, the clinicians should
consider these things in consideration while making clinical decisions instead of focusing only
on chronological age.
The case study refers to IT systems failure as the main cause of breast cancer screening errors.
There was lack of clarity for the age at which the women should be invited for the mammogram
screening.
The IT systems used in the Programme were inefficient and outdated which made it difficult to
evaluate who should be invited for the screening.
Discussion
The screening program was based on the age of the participants and the IT systems were
woefully insufficient in carrying out the functions and they were mainly held responsible for the
missed appointments. After investigations of other 11 screening programmes in NHS England, it
was identified that none of them could meet the targets in 2017.
Failure to attend breast screening developed significant distress among hundreds and thousands
of women. The condition would be extremely distressing for the people who left their wife, sister
or mother due to breast cancer during the last 9 years. Mere the thought that their death could be
avoided would make the condition even worse for the sufferers and their families.
There was a lack of effective and clear ownership of the programme. The accountability of the
screening program was shared between the multiple bodies namely Public Health England, NHS
England, Department of Health and Social Care (DHSC), National Screening Committee and the
local providers. There was ambiguity in deciding the responsibility of any one Organisation over
smooth running of the screening Programme. There was lack of any shared understanding as
well. It shows there was structural confusion with consistent inability to monitor the screening
programme. We need to improve the attendance for such initiatives.

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The first priority of the NHS was to identify the women who are still alive and were left out in
the screening. The NHS would contact them by sending letters and would invite them for
appropriate mammogram. Potential benefits of getting the screening done should be discussed
with them.
The new service specifications in NHS England also did not align with the IT systems being used
at that time nor did it have any consistency in implementations at the screening units. None of
the stakeholders in different healthcare organisations identified this inconsistency with the past
policies and the change brought misalignment between the policy, IT systems, delivery, and the
algorithm of trial. The main cause of confusion persisted even during the investigations and
announcement of incident. The new changes in government policy were not informed to the
screening units or IT systems. The accuracy of It systems was not checked for their alignment
with the trial algorithm.
The information sent to the women through letters was also ambiguous and transmitted
misunderstood information. The three Organisations as of now responsible for the Programme
namely NHS England, Public Health England and Department of Health and Social Care need to
agree over a common age parameter ideal to invite the women for screening. The
implementation should reflect the national policy. Training and clear awareness should be there
to ensure clarity of information with everyone associated with the screening programme. There
should be quality as surance to ensure that right women are being invited at right time for the
programme.
Implications of the Issue for different Stakeholders
The stakeholders involved in the issue were the Policy makers (like Department of Health, NHS
England and Public Health England), the governance, IT Systems and Processes, Department of
Health and Social Care, Working Staff , AgeX Trial and the affected women. Effective
communication of the policy specifications was not timely and accurate. The issue brought
forward the necessary amendments in IT processes and systems in practice. The diagnostic
workforce at the screening centers was at crisis capacity, there was the requirement to recruit
more radiologists and mammographers to facilitate smooth functioning of the program. It was

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devastating to identify that the mistake sustained for 9 years. There was a need to investigate the
issue through independent enquiry about why this occurred and ensure that it should never be
repeated. The staff working in dedicated manner at the screening units had to work harder to
ensure that all the women who were estimated to have left from screening are contacted and
screened. The incident resulted into human consequences of administrative mistakes. The
governance did not take identify any clinical harm due to systems failure. The IT systems were
not reviewed timely to assess their functioning, policy adherence and delivery of policy.
The women who were left of the screening did not respond into reduced trust. However, those
diagnosed with the breast cancer were quite worried about if they would have been screened
earlier their health condition might be better [2]. Most of them were angry and anxious feeling
let down. Most of the women when told that they have missed the cancer screening felt worried
and severely tensed with the possibility of having cancer or with the fear that their illness could
have been diagnosed earlier. They were mostly angry with the system and said that they had
made a big mistake. The AgeX trial had no association with the randomization process and it
worked as specified.
Linking the Issue to the Academic Literature
There are multiple barriers to implementation of effective cancer screening programs. Many
women who are eligible for it do not find it easy to access the healthcare. Breast Screening
Mammography is the most effective method of identifying the breast cancer in women. The
countries having established mammography screening programmes find it hard to promote the
high attendance rate. UK Government ensures that 70% of the women should participate in the
screening programs regularly. However, the target always remains unachieved due to low
representation of black women and some other minority groups in the population.
According to theory of Complex Adaptive Systems of Healthcare, there is a distinction
between what was planned to be achieved through the screening programme and what was
actually achieved. It is due to involvement of multiples stakeholders, and a complex system of
healthcare in which it takes years to actually implement the policies and protocols passing

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through the regulators, executive management, department management, work management and
reaching the actual workplace [8].
The healthcare system involves complex structure with diverse populations, multiple interactions
between different parts, dynamic needs, bottom up governance mechanism and emergent rules
with different networks, patterns and non linearity. The social network of complex systems
integrating the researchers and clinicians in cancer care are getting more complex with time. The
outcomes are not predictable.
Systems Resilience
If –Then thinking improves the success rates of regular breast screening examination and helps
the women avoid prejudicial and stereotyping thoughts [9]. ‘If I go for monthly breast screening,
then I can protect myself from cancer.’ Such behaviors may improve their intention to go for
screening.
The potential reasons why the women do or do not participate in screening programs may be due
to factors like clinical factors, socio demographic factors, habits, norms, unawareness, age,
beliefs and external resources responsible to direct the behavior of women. The women would
undergo the screening if they think that the positive outcomes are more than the negative
outcomes. It implies the need of effective education and awareness in women.
The misunderstanding developed due to incorrect information transmitted to the women through
letters who were publicly sent. The wrong information was interpreted by the people. Moreover,
the women who were aware of the benefits of breast screening and who were sure of their age
factor for screening could have also availed it through other resources and should not depend on
the government screening programmes. This might be the case with few women but the majority
of them did not show intention to opt for a screening at personal level. This might be due to
social determinants of health like lack of access to healthcare services, lack of transport, lack of
awareness, financial constraints and cultural influence.

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Addressing the needs of Old age Women
The randomized number of screenings for old age women was very low in the study. This may
be attributed to the fact that care facilities for old age women mostly fail to address the
interdisciplinary and complex needs of old age populations. There are persistent disconnections
and gaps in the aged care service delivery [7]. For these people, the old age facilities and
Community care services should take initiative to assess the need of breast screening
interventions. Effective linking of correct aged care data sources should be done to facilitate
appropriate data transfer in different healthcare departments. It will give correct idea of the old
age patients and their health problems and need of mammography programme.
Suggested Solutions & Their Evaluation
Anxiety and Fear are the contributing factors which prevent the old age women from undergoing
breast screening. The incidents like this may encourage such feelings. Older women are mostly
unaware of the benefits of such screenings. They should be educated to make informed and
effective decisions to access the screening programmes. Expert guidance and support should be
available for them whenever they need. There should be clear guidelines about at which age the
women should be invited for breast screening, when they should be stopped and when they can
self refer themselves.
The developed countries should assist NHS England in detecting the cases of old women who
left or migrated England in their late 60s or 70s [3]. After identification they should be provided
catch up screenings at local screening centres. The additional screening sessions should be
carried out at the end of the day or in evenings to avoid influencing the regular screening
services.

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Lessons should be learned from this incident and there should be initiatives to increase the
screening uptakes and integrate the artificial intelligence and other technologies in benefiting
these services [5].
The government will make sure that such incidents never happen again. For this an independent
review will be commissioned to investigate the IT systems, screening processes, improvements
and changes that can be made in the existing system to mitigate the repetition.
Feedback from the existing IT systems should be used as an opportunity to develop AI and more
advanced technologies for screening process [6].
Conclusion/ Recommendations
An independent review was commissioned by the government to assess the case and suggested
recommendations to prevent similar mistakes in future. The key recommendations of review for
the case were:
1. NHSC England and DHSC need to frame clear guidelines regarding the age at which a
woman should be sent final invitation for breast screening. The government should have
identified the mistake at an early stage.
2. The public information should be regularly updated to enable the women understand
when they have to get invitation for final screening. The new specification for the breast
screening should be informed to all the stakeholders and should be taken as core
document for implementation of the program.
3. The current IT systems should be checked for their efficiency and validity.
4. The accountability for smooth functioning of IT systems should be clearly given to
respective organisation. The IT systems are overseen and owned by multiple
organisations like NBSS, BS-Select and NHAIS. There was no information about their
interaction and working as a system.
5. The reviews of all such programmes should ensure that they are governed in a best way.
6. Guidance should be provided to the women about the age related factors. They should be
aware of the routine screening and similar programmes and their benefits. It will
maximize their participation.

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7. All the women should be provided catch up screening for the left over cases.
8. Investments in new technology, recruitment and training of new experts and IT
infrastructure should be done [4].
Thousands of women experienced unnecessary distress simply due to lack of clear ownership
and effective leadership. There was structural confusion and consistent inability to monitor what
was happening under the screening programme.
The trial of AgeX should go until the planned year (2026) extending the screening process for
both the older and younger age group women. This trial has been very helpful in inviting greater
number of women for breast screening.
The mismatch between the execution of the screening protocols and the specifications was main
reason for the errors in breast screening. According to the results of Independent Review, 85% of
the women agreed that the most appropriate age to be called for breast screening invitations
should be 50 to 70 years. Every 7 in 10 women (69%) knew that they should be invited for
screening every third year. Half of the women (aged 78 years and more) came to know about the
errors when they received letters. Nearly all the left over women attended the catch up screening.
The letters sent to the affected women should be sensitive and personal with acknowledgements
about their diagnosis with cancer. There should be more details about what steps can be taken to
make sure the error would not be repeated. New investments in technology and IT systems
should be done, new recruitments and trainings should be done for the experts to address
increasing demand of breast cancer prevention and early detection.

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Reference List
[1] Bond,M., Pavey,T.,Welch, K., Cooper,C., & Garside,R.(2013). Systematic review of the
psychological consequences of false-positive screening mammograms. Health Technol
Assess. 2013 Mar;17(13):1-170, v-vi. doi: 10.3310/hta17130.
[2] House of Commons (2018). The Independent Breast Screening Review. UK: APS Group.
[3] Whitford,P.,(2018). In the NHS breast-screening scandal, the first priority must be the
women. Retrieved from https://www.theguardian.com/commentisfree/2018/may/03/nhs-breast-
screening-it-error-women-affected
[4] Breast Cancer Now (2019). Breast screening invitation error caused by ambiguity in the
screening programme. Retrieved from https://breastcancernow.org/news-and-blogs/blogs/breast-
screening-invitation-error-caused-by-ambiguity-in-the-screening-programme
[5] Matthews,A.(2018). Cancer screening overhaul announced by NHS in wake of Capita
cervical smear blunder. Retrieved from https://www.independent.co.uk/news/health/cancer-
screening-cervical-breast-nhs-england-outsourcing-privatised-capita-a8634976.html
[6] Downey,A.(2019). Outdated NHS cancer screening IT systems ‘woefully inadequate’.
Retrieved from https://www.digitalhealth.net/2019/05/nhs-screening-it-systems-woefully-
inadequate/
[7] Georgiou,A.(2018). Assessing the effectiveness of community aged care services to improve
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Research. Macquarie University. Pp.1-41.

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[8] Lawal,O., Murphy,F., Hogg,P., & Nightingale,J.(2017). Health Behavioural Theories and
Their Application to Women’s Participation in Mammography Screening. Journal of Medical
Imaging and Radiation Sciences. 48 (2017) 122-127
[9] Braithewaite,J.(2019). Introduction: Welcome to systems Thinking. Australian Institute of
Health and Innovation. Macquaire University.