COVID-19 and the National Breast Imaging Academy

For many years breast centres across the UK have been struggling to provide diagnostic imaging services. This has arisen because in the last 10 years the number of women referred by their GPs to breast units has doubled, the breast screening service has increased by 24 per cent and the incidence of breast cancer has continued to rise. It has been further exacerbated by an increase in the complexity of diagnostic investigations, with a huge rise in the number of biopsies undertaken, the introduction of tomosynthesis and an increasing demand for MRI. However, the imaging workforce of specialist breast radiologists, radiographers and breast clinicians has not increased in line with this demand and this has resulted in the closure of several breast centres, delays in breast screening and reduced space and training time available for trainees.

In 2018 Health Education England provided funding to establish the National Breast Imaging Academy (NBIA). Its aim was to help develop new training courses for breast imaging professionals across the country, together with a large online resource of training packages to support these programmes. In the last two years NBIA, in collaboration with hundreds of healthcare professionals across the UK, has helped establish a level 4 apprenticeship training programme for associate mammographers, a national fellowship training programme for breast radiologists, a pilot credential in breast disease management for breast clinicians and new online training courses.

Since the start of the pandemic, breast services, like so much of the NHS, have been severely disrupted and this in turn has had an impact on the trainees – much training has been paused or moved online. NBIA has been working to maximise training opportunities at this time and support all trainees through this process.

Apprentices
The new level 4 mammography associate apprenticeship training programme was established in 2019 as a collaborative project involving all breast training centres across the country. It has provided improved access to careers within the NHS, and a training course funded through the apprenticeship levy. The national group is also considering the feasibility of setting up apprenticeship programmes for trained radiographers seeking further development in advanced clinical practice roles.

Currently there are 62 apprentices enrolled across the country. More than 40 of them are due to finish their training within the next few months. One of the challenges posed by the pandemic is that we have had to rethink how to undertake their final endpoint assessment, and are now developing a pathway to enable this to be carried out online, thus ensuring their qualification is not significantly delayed.

Another effect of the pandemic is that trainees can feel isolated and unsupported, especially if their work has been reduced or temporarily ceased. To help address this we are providing Zoom tutorials for our trainees, together with individual support should they request it.

With the reduction in the number of mammograms performed it has been very difficult for apprentices to continue training in their respective centres. However, many units have tried wherever possible to prioritise this and continue their hands-on training on symptomatic referrals.

Despite the pandemic, demand for the apprenticeship programme remains high, so NBIA is currently exploring the feasibility of revising the current format of the apprenticeship programme to offer content that is delivered predominantly online.

Radiologists
NBIA has established a national fellowship training programme for radiologists and the first cohort of trainees are now in post. However, the training for many has been disrupted during the pandemic as they have been redeployed or seen their training opportunities greatly reduced. We are now seeking ways to support them to extend their training in order to acquire the skills they will need for the future.

Online resources
One very large part of NBIA has been the development of an extensive online breast training programme for all breast imaging professionals. This has involved writing around 160 e-learning modules to be made available on the e-Learning for Healthcare website. To support this project we have recruited more than 120 authors from across the country. Our aim was to have these ready for release in the autumn. However, in response to the pandemic, we are now releasing these modules as they become available and a number of these can now be accessed online. We have developed Zoom tutorials for radiologists undertaking their 2B examination, and these will also be uploaded as a teaching resource. We are also looking at ways to deliver more of the apprenticeship training using online tutorials and seminars.

Next steps
The pandemic has affected all aspects of life in the UK, and is going to pose a significant challenge to training and service delivery for a long time. It will have a disproportionate effect on patients who develop cancer over the coming months. Recent articles suggest that the excess mortality from cancer may be more than 20 per cent.

Because of the reduction in GP breast clinic referrals there are many hundreds, if not thousands, of women across the country now needing to be seen and within this group will be many patients whose diagnosis will have been delayed.

To further exacerbate this, the breast screening programme, which diagnoses more than 18,000 cancers each year, faces many challenges in how to deliver screening in a safe and appropriate manner. The SCoR and the RCR have just released new guidance for safe service provision during the pandemic and post- pandemic phase but, given the challenges of social distancing, it is inevitable that providing mammography training will be extremely difficult. There is a working group within PHE currently considering these issues.

With the longer appointment times that will be needed for breast screening and the backlog in the demand for symptomatic services that will become apparent over the coming weeks, the demands on an already depleted mammographic workforce will further increase. While many may feel that undertaking training at such a time will prove challenging, it is more pressing than ever that we seize every opportunity over the coming months to maximise all training opportunities to provide the highly skilled and sustainable diagnostic breast imaging workforce needed for the future.

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