Mobile breast screening round: reduced capacity, a symptomatic woman and a consent question
A breast screening mobile unit is due to begin a four-week round in a rural town in three weeks. Two of the four mammographers have gone on extended sick leave, leaving capacity for around 380 of the 620 women already invited. The programme screens women aged 50 to 69. During the first week's calls, a 47-year-old woman rings to say she found a lump and asks to be given her mother's cancelled appointment; a 62-year-old woman with a mild intellectual disability attends with her sister, who answers most of the questions and asks that her sister 'not be told if anything is wrong'; and a local GP asks whether the unit can 'squeeze in' six patients who are anxious. The regional manager wants a decision by Friday on which appointments to keep and which to defer.
1. How would you allocate the reduced capacity, and what would you do about each of the three requests?
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Triage on risk, not on who asks loudest. With 380 slots for 620 women, roughly 240 must be deferred, and the decision needs a written rationale.
Who keeps an appointment: anyone with a previous abnormal result or recall; women with a documented higher risk; first-round invitees and women approaching the upper age limit, because deferral may push them out of the programme entirely; and anyone whose deferral would breach the programme's screening interval.
The three requests:
- The 47-year-old with a lump: do not give her the cancelled appointment. She is outside the eligible age range and, more importantly, is symptomatic - screening mammography in a woman with a lump is the wrong test and can falsely reassure. Telephone her the same day, explain that she needs triple assessment through the symptomatic breast clinic, and help her get there via urgent GP referral. Offer to ring the GP practice so it is not left to her to relay.
- The GP's six anxious patients: anxiety alone is not a clinical prioritisation criterion. If they are eligible and due, they are already in call-recall and will be invited; explain the capacity position and give a date. Ask the GP to flag any who has symptoms or a strong family history, and handle those on clinical grounds.
- The 62-year-old: she is eligible and should be screened; the question is consent and confidentiality, not capacity to attend.
Also check whether additional sessions, overtime or support from a neighbouring unit can close part of the gap before deferring 240 women.
2. How would you approach consent and confidentiality for the 62-year-old woman whose sister asks that she not be told about any problem?
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Start from the presumption of capacity, decision-specific. Mild intellectual disability does not itself remove the ability to consent to a mammogram. Ask whether she can understand, retain, weigh and communicate a choice about this particular decision, with supports.
- Support the decision: easy-read information in advance, extra time, plain language, checking understanding by asking her to explain back, and allowing her sister to help her understand - but speaking to the woman directly, not only to her sister.
- The sister's role: a supportive companion is not automatically a substitute decision-maker. Under Ireland's Assisted Decision-Making (Capacity) Act 2015, a person may have a support person or a legally appointed decision supporter; the sister should not be treated as one unless she holds that role. Establish what, if any, arrangement exists.
- The request not to be told: this cannot simply be agreed. The woman is the patient and is entitled to her own results. A decision to withhold information would need to be made with her, with support, and documented; if she wants her sister present for results, that is her choice and should be recorded.
- If she lacks capacity for the decision, follow the Act's processes, identify the relevant decision supporter, and record the assessment.
- Practical: give the sister information about how to support attendance, but keep the clinical conversation with the patient.
This is a short conversation done properly, not a reason to skip the appointment.
3. What governance and communication would you put around deferring roughly 240 women?
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A deferral is a clinical decision with an audit trail, not an administrative by-product of sickness absence.
- Tell people before the round starts, individually. A letter with a new date, plus a phone call where possible. 'We will be in touch' generates complaints, non-attendance and lost trust. Give a reason in plain language and an apology.
- Keep the deferral inside a defined window that does not breach the screening interval, and check that nobody is pushed past the upper age limit by the delay.
- Record the reason on the register against each deferred woman so the decision is auditable and reversible, and so that no one is quietly lost.
- Equity check: this is a rural round; deferral means more travel later. Consider clustering appointments, offering the nearest alternative unit, or transport support where the programme provides it.
- Escalate staffing as a governance issue: occupational health, bank and agency mammographers, mutual aid from a neighbouring unit, overtime. If the gap cannot be closed, the decision to defer is made with the programme director and documented - including the clinical risk accepted.
- Report to the regional and programme board with the numbers deferred, the mitigation and a recovery plan, plus a complaint and incident log so the pattern is visible if it recurs next round.
- Brief the local GPs so they know the round is reduced and can direct symptomatic women to the correct pathway rather than to the unit.