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The NHS breast screening programme (pathology) EQA: experience in recent years relating to issues involved in individual performance appraisal
  1. D M Parham1,
  2. D Coleman2,
  3. S Kodikara2,
  4. S Moss2,
  5. I O Ellis3,
  6. S Al-sam4,
  7. N Anderson5,
  8. L Bobrow6,
  9. I Buley7,
  10. C E Connolly8,
  11. N S Dallimore9,
  12. S Hales10,
  13. A Hanby11,
  14. S Humphreys12,
  15. F Knox13,
  16. J Lowe14,
  17. J Macartney15,
  18. R Nash16,
  19. J Patnick17,
  20. S E Pinder6,
  21. C M Quinn18,
  22. A J Robertson19,
  23. J Shrimankar14,
  24. R A Walker20,
  25. C Wells21,
  26. R Winder22,
  27. N Patel23
  1. 1Department of Pathology, Royal Bournemouth Hospital, Bournemouth, Dorset BH7 7DW, UK
  2. 2Institute of Cancer Research, Cancer Screening Evaluation Unit, Sutton, Surrey SM2 5NG, UK
  3. 3Department of Histopathology, Nottingham City Hospital, Nottingham NG5 1PB, UK
  4. 4Department Histopathology, Broomfield Hospital, Chelmsford, Essex CM1 7ET, UK
  5. 5Department of Pathology, Royal Group of Hospitals Trust, Belfast BT12 6BA, Northern Ireland, UK
  6. 6Department of Histopathology, Addenbrooke’s Hospital, Cambridge CB2 2QQ, UK
  7. 7Department of Histopathology, The John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK
  8. 8Pathology Department, University College Hospital, Galway, Ireland
  9. 9Department of Histopathology, Llandough Hospital, Penarth, S Glamorgan CF64 2XX, Wales, UK
  10. 10Department of Pathology, Countess of Chester Hospital, Chester, Cheshire CH2 1UL, UK
  11. 11Department of Histopathology, St James’ University Hospital, Leeds LS9 7TF, UK
  12. 12Medical Solutions, Harley Street, London W1G 9QP, UK
  13. 13Department of Histopathology, Wythenshaw Hospital, Wythenshaw, Manchester M23 9LT, UK
  14. 14Department of Histopathology, University Hospital of North Tees, Hardwick, Stockton on Tees TS19 8PE, UK
  15. 15Department of Histopathology, University Hospitals Coventry and Warwickshire, Coventry, West Midlands CV1 4FH, UK
  16. 16Department of Cellular Pathology, St Georges Hospital, Tooting, London SW17 0QT, UK
  17. 17NHS Cancer Screening Programmes, Sheffield ST10 3TH, UK
  18. 18Department of Histopathology, St Vincent’s University Hospital, Dublin 4, Ireland
  19. 19Department of Pathology, University of Dundee, Dundee, Tayside DD1 9SY, UK
  20. 20Department of Cancer Studies and Molecular Medicine, University of Leicester, Leicester Royal Infirmary, Leicester LE1 5WW, UK
  21. 21Department of Histopathology, St Bartholomew’s Medical School, London EC1A 9DS, UK
  22. 22NHS Breast and Cervical Screening Programmes, Sheffield ST10 3TH, UK
  23. 23Department of Histopathology, Royal Sussex County Hospital, Brighton, East Sussex BN2 5BE, UK
  1. Correspondence to:
 Dr D M Parham
 Department of Pathology, Royal Bournemouth Hospital, Castle Lane East, Bournemouth, Dorset BH7 7DW, UK; consultant.histopathologist{at}


Background: The original role of the National Health Service breast screening programme (pathology) external quality assessment (EQA) scheme was educational; it aimed to raise standards, reinforce use of common terminology, and assess the consistency of pathology reporting of breast disease in the UK.

Aims/Methods: To examine the performance (scores) of pathologists participating in the scheme in recent years. The scheme has evolved to help identify poor performers, reliant upon setting an acceptable cutpoint. Therefore, the effects of different cutpoint strategies were evaluated and implications discussed.

Results/Conclusions: Pathologists who joined the scheme improved over time, particularly those who did less well initially. There was no obvious association between performance and the number of breast cancer cases reported each year. This is not unexpected because the EQA does not measure expertise, but was established to demonstrate a common level of performance (conformity to consensus) for routine cases, rather than the ability to diagnose unusual/difficult cases. A new method of establishing cutpoints using interquartile ranges is proposed. The findings also suggest that EQA can alter a pathologist’s practice: those who leave the scheme (for whatever reason) have, on average, marginally lower scores. Consequently, with the cutpoint methodology currently used (which is common to several EQA schemes) there is the potential for the cutpoint to drift upwards. In future, individuals previously deemed competent could subsequently be erroneously labelled as poor performers. Due consideration should be given to this issue with future development of schemes.

  • EQA, external quality assessment
  • NHSBSP, National Health Service breast screening programme
  • RCPath, Royal College of Pathologists
  • breast
  • cancer
  • pathology
  • screening
  • external quality assessment

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  • The authors of this paper are members of the external quality assessment (EQA) scheme management group of the UK national coordinating committee for breast pathology, which is responsible for pathology quality assurance in the UK National Health Service breast screening programme and preparation of minimum dataset standards in breast cancer pathology for the Royal College of Pathologists. The committee acts as the steering committee for the UK national breast screening histopathology EQA scheme.

    Membership of the UK national coordinating committee for breast pathology: Dr Al-Sam, Dr N Anderson, Dr L Bobrow, Dr I Buley, Mr D Coleman, Professor C E Connolly, Dr N S Dallimore, Professor I O Ellis, Dr S Hales, Professor A Hanby, Dr S Humphreys, Dr F Knox, Mrs S Kodikara, Professor S Lakhani, Dr J Lowe Dr J Macartney, Dr S Moss, Dr R Nash, Dr D Parham, Mrs J Patnick, Dr S E Pinder, Dr C M Quinn, Dr A J Robertson, Dr J Shrimankar, Professor R A Walker, Dr C A Wells, and Mr R Winder.