Cost-Effectiveness, Workforce Impact, and Diagnostic Performance of Radiographer-Led Double Reading in NHS Breast Screening

Theme 4: Applied Economic Evaluation   

Rationale:

Beast screening in England is a high-volume early-diagnosis route. In 2023–24, 2.5 million women aged 50 to <71 were invited and uptake returned to 70.0%, meeting the programme’s acceptable standard for the first time since before the pandemic (NHS Digital, 2025; NHS England, 2025). However, the proportion of eligible women who are up to date with screening remains below pre-pandemic levels (NHS England, 2025).

Screening mammography relies on independent double reading with arbitration for discordant cases, making it labour-intensive (NHS England, 2024). At the same time, the NHS faces sustained imaging workforce pressures. The RCR’s 2024 clinical radiology workforce census reports a 9% shortfall in UK consultant radiologists (470 WTE) and extensive reliance on paid workarounds: in 2024, 97% of departments used insourcing and 95% used outsourcing, with total spending of £325 million (Royal College of Radiologists, 2025). Workforce constraints are also evident in breast services: substantial mammographer vacancy rates have been reported, with risks for timely diagnosis (Society of Radiographers, 2024; Breast Cancer Now, 2024).

Radiographer image readers are already part of the NHSBSP skill mix in most services. Recent evidence shows no statistically significant differences in first-reader cancer detection, recall, or positive predictive value between radiologists and trained radiographer readers in England’s double-reading programme (Chen et al., 2023). Earlier UK evidence suggests comparable cancer detection with radiographer-only double reading, but potentially higher recall (Bennett et al., 2012). However, studies have not translated these findings into system-level implications for costs, workforce capacity, or downstream impacts under current NHS governance. This motivates a synthesis of comparative performance evidence alongside an explicit opportunity-cost assessment: if some screening reads can shift from radiologists to radiographers without compromising outcomes, radiologist time could be redeployed to other high-value activities (e.g., symptomatic imaging, MDT meetings, assessment work, or addressing diagnostic backlogs). This study aims to provide that link by combining comparative performance evidence with economic and workforce modelling to inform service decisions. This is increasingly salient as the NHS tests workforce-saving approaches in breast screening, including large-scale evaluation of AI-supported reading in the EDITH trial (Department of Health and Social Care, 2025; NIHR, 2025).

Aims:

The project will generate policy-relevant evidence on whether, and under what conditions, radiographer-led double reading in the NHS Breast Screening Programme could be cost-effective and ease workforce pressures. Specifically, we will:

(i) assess the workforce and labour implications of changing the screening skill mix, including implementation requirements (training, supervision, and governance), the opportunity cost of substituting staff groups, and knock-on effects on assessment capacity, clinic workflow, and downstream diagnostic services;

(ii) critically appraise the comparative evidence on radiographer and radiologist performance in mammography image reading, including impacts on cancer detection, recall, and subsequent assessment;

(iii) build a transparent economic and workforce model to compare the impact of feasible service configurations (including reduced radiologist involvement in routine reads).

Methodology (including limitations):

Work package 1: Using published evidence alongside programme data, we will examine staffing requirements and skill mix across screening units, reflecting plausible variation in service configuration and local workforce context. This will include numbers of radiographers and radiologists required; training pipelines; recruitment and retention constraints; and the opportunity cost of radiologist time, including potential redeployment to symptomatic imaging, MDT participation, assessment clinics, and backlog reduction. We will also consider projected workforce trends (capacity pressures, retirement profiles, and reliance on insourcing/outsourcing) and how these interact with alternative approaches to screening delivery. Comparative evidence on radiographer versus radiologist mammography reading will be appraised to inform modelling assumptions on diagnostic performance, recall, and downstream impacts (Chen et al., 2023; Bennett et al., 2012).

Work package 2: Modelling. We will update an advanced decision-analytic model developed at the University of Sheffield to represent the screening pathway and cost-effectiveness of alternative reading configurations. Outcomes will include detected cancers, QALYs, recalls, assessment episodes, downstream assessment activity, and NHS costs. The base case will be parameterised primarily from NHS programme data where available (e.g., Chen et al., 2023), supplemented by evidence on recall/workflow implications and reading time where applicable (e.g., Bennett et al., 2012; Partridge et al., 2024). We will run deterministic and probabilistic sensitivity analyses and scenario analyses exploring changes to current practice (e.g., reduced or no radiologist involvement in routine reads) with different yet feasible configurations within quality assurance frameworks (Perry et al., 2013). Scenario analysis will also consider plausible future pathways, such as AI-assisted reading.

References

Breast Cancer Now (2024) ‘Breast Cancer Now responds to latest vacancy rates among screening mammographers’ (statement, 15 August 2024).

Bennett, R.L., Sellars, S.J., Blanks, R.G. and Moss, S.M. (2012) ‘An observational study to evaluate the performance of a unit of two radiographers to read screening mammograms’, Clinical Radiology, 67(2), pp. 114–121. doi:10.1016/j.crad.2011.06.015.

Chen, Y., James, J.J., Michalopoulou, E., Darker, I.T. and Jenkins, J. (2023) ‘Performance of Radiologists and Radiographers in Double Reading Mammograms: The UK National Health Service Breast Screening Program’, Radiology, 306(1), pp. 102–109. doi:10.1148/radiol.212951.

Department of Health and Social Care (2025) ‘World-leading AI trial to tackle breast cancer launched’ (press release, 4 February 2025).

NHS Digital (2025) Breast Screening Programme, England, 2023–24 (publication date 18 February 2025).

NHS England (2024) ‘Breast screening: guidance for image reading’ (GOV.UK guidance, updated 27 September 2024).

NHS England (2025) ‘Record breast screening level as NHS campaign urges women to take up invitations’ (news release, 18 February 2025).

NIHR (2025) ‘World-leading AI trial to tackle breast cancer launched’ (news, 4 February 2025).

Royal College of Radiologists (2025) Clinical Radiology UK Workforce Census 2024 (report published 5 June 2025).

Society of Radiographers (2024) Evidence to the NHS Pay Review Body – February 2024 (submission).

Contact

Harry Hill harry.hill@sheffield.ac.uk