Create commissioner design history (#429)

design history page about commissioners for forecasting and planning
discovery

---------

Co-authored-by: Veronika Jermolina <47607210+veroje@users.noreply.github.com>
Co-authored-by: Frankie Roberto <frankie.roberto1@nhs.net>

Author: 3 people

app/breast-screening-pathway/2026/03/commissioners-in-breast-screening/commissioning-actors-in-the-system.png

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+---
+title: What we learned about commissioners in breast screening
+description: Findings from interviews with screening and immunisation commissioners in England
+date: 2026-03-27
+author: Marianne Brierley
+opengraphImage:
+  src: /breast-screening-pathway/2026/03/commissioners-in-breast-screening/commissioning-actors-in-the-system.png
+  alt: Image showing how commissioners, programme team and quality assurance work together to support BSOs, Trusts and other neighbourhood health partners with achieving intended health outcomes. 
+tags:
+  - commissioning
+  - forecasting
+  - reporting
+---
+
+The discovery into [forecasting and planning within breast screening](../what-bsos-told-us-about-forecasting-and-planning/) included understanding the needs and working practices of commissioners. This helped the team understand more about the role of commissioners, the interactions they have with BSOs and the data they require from services. 
+
+**This design history will share insights on:**
+
+- the definition and variable nature of the commissioner role 
+- their experience and understanding of breast screening planning 
+- things that would help support more strategic commissioning 
+
+
+## The role of commissioners  
+
+‘Commissioner’ encompasses any role involved in commissioning services, resulting in a wide range of job titles (e.g. Screening and Immunisation Managers/ Coordinators/ Leads, Programme Managers, Heads of Public Health). There are roles that operate at a national level, and regional level. There is also a difference in the range of services they oversee, with some focused solely on breast screening, to others being across several screening and/or immunisation services within [Section 7A](https://www.gov.uk/government/publications/public-health-commissioning-in-the-nhs-2023-to-2024/nhs-public-health-functions-agreement-2023-to-2024#:~:text=The%20provision%20of%20section%207A%20services%20are%20steps%20that%20the,2A%20of%20the%202006%20Act). 
+
+### Commissioners have 3 core responsibilities: 
+
+#### 1. Escalation and unblocking
+Serving as an escalation point to help services unblock issues so they can meet outcomes.
+
+>Part of the job is helping things happen when they wouldn’t otherwise. 
+
+Commissioners may support when: 
+
+- Trusts are blocking them from performing at the expected level  
+- BSOs are struggling to find new mobile unit locations, and need buy in from landowners  
+- BSOs need support with negotiations with local authorities on screening sites 
+- BSOs feel understaffed and underfunded 
+- operational issues impact performance 
+
+#### 2. Monitoring and accountability
+Monitoring outcomes and holding services accountable to delivery standards laid out in the [service specification (NHS Futures)](https://future.nhs.uk/vaccsandscreening/view?objectId=71116816). This includes monitoring problems, vacancies, staffing, and demand to determine if additional funding is needed. 
+
+#### 3. Funding and strategic oversight
+
+Directing funding and activities with a strategic view on overall health goals, for example, initiating a review of screening sites for accessibility or advising cancer charities where best to focus effort for an area. 
+
+ 
+
+## Working in partnership with SQAS 
+
+There is some overlap in the data needs between commissioners and Screening Quality Assurance Service (SQAS), but their responsibilities differ. Commissioners rely on expert clinical advice from SQAS for service evaluation and to directly manage incidents. However, both roles require similar data on service performance and outcomes through KPI reports. 
+
+<table>
+  <caption>Roles and responsibilities of Commissioners and SQAS</caption>
+  <thead>
+    <tr>
+      <th scope="col">Task</th>
+      <th scope="col">Commissioners</th>
+      <th scope="col">SQAS</th>
+    </tr>
+  </thead>
+  <tbody>
+    <tr><th scope="row">Monitor performance (round length, uptake etc)</th><td>Yes</td><td>Yes</td></tr>
+    <tr><th scope="row">Conduct site visits</th><td>Yes</td><td>Yes</td></tr>
+    <tr><th scope="row">Manage incidents</th><td>No</td><td>Yes</td></tr>
+    <tr><th scope="row">Operational support</th><td>Yes</td><td>Yes</td></tr>
+    <tr><th scope="row">Clinical oversight and advice</th><td>No</td><td>Yes</td></tr>
+    <tr><th scope="row">Provide additional funding/manage contracts</th><td>Yes</td><td>No</td></tr>
+    <tr><th scope="row">Sign off on exceptions reports</th><td>Yes</td><td>Yes</td></tr>
+  </tbody>
+</table>
+
+![](commissioning-actors-in-the-system.png 'Image shows how commissioners, programme team and quality assurance work together to support BSOs, Trusts and other neighbourhood health partners with achieving intended health outcomes.')
+
+
+## How commissioners interact with breast screening services 
+
+Commissioners use a mix of regular weekly checks (e.g. checking Futures data or dashboards), monthly ‘Provider returns’ for KPIs, and more in-depth quarterly sessions with programmes to discuss ‘Position statements’ and ‘Exceptions reports’ (via the Assurance Dashboard). Position statements are drafted by the BSOs to give commissioners a narrative and context behind how their programme is performing, or not.  
+
+There is some variety in how commissioners get KPI and performance data more regularly:  
+
+- ‘monthly returns’ from BSOs via email through commissioner-owned templates to report on KPIs 
+
+- using data provided to Futures as part of QA processes (additional data processing required to be suitable for commissioning purposes) 
+
+- BSO owned performance dashboards (in excel) using RAG status to help commissioners know where to focus attention 
+
+
+## Biggest blockers to achieving round length (from a commissioner's perspective) 
+
+BSOs must ensure they screen their entire eligible population [every 3 years](https://www.gov.uk/government/publications/breast-screening-set-and-maintain-round-length/achieving-and-maintaining-the-36-month-round-length-aug19). This is known as “round length”. You can read more about it in an [earlier design history](/breast-screening-pathway/2026/03/what-bsos-told-us-about-forecasting-and-planning/). 
+
+Breast screening was noted as being more complex than other services due to: 
+
+- the service delivering the whole pathway; invitation, screening, assessment and outcome 
+
+- staffing issues such as unfilled posts, long term sick leave and retirement, sharing staff with symptomatic services and the impact this has on screening capacity 
+
+- delivery challenges such as finding mobile unit locations 
+
+### Staff capacity 
+
+Staff capacity is directly linked to service capacity. A service is limited by the number of staff they have available, and how many appointments they can provide. There is additional complexity for breast screening, as it provides the whole pathway (selection, invitations, screen and assessment), meaning more screening = more assessments.  
+
+Common issues with staff capacity were: 
+
+- not being able to recruit  
+
+- losing staff to sick leave  
+
+- losing staff to other units  
+
+- staff reaching retirement age  
+
+- trusts prioritising symptomatic screening (the [Faster Diagnosis Standard](https://www.england.nhs.uk/clinically-led-review-nhs-access-standards/cancer/) could be a driver for this behaviour) 
+
+**58% of BSOs reported staffing as a blocker to maintaining round length in a recent survey** (Feb 2026) 
+
+### Mobile van locations 
+
+Commissioners were aware of the effort required by providers to find and keep mobile sites. In some areas, this has become so difficult that providers have opted to turn mobile units into static sites instead.  
+
+They noted a shift in attitudes towards mobile units, where landowners (such as supermarkets) had started using their car parks for other services such as ‘click and collect’. 
+
+**78% of BSOs reported experiencing issues with site locations in a recent survey** (Feb 2026) 
+
+### Inconsistent approaches 
+
+Whilst they understood the need for some local variation, they also queried if there could be one consistent approach used by all BSOs e.g. some visit sites annually, some every 3 years. 
+
+This inconsistency made it harder for commissioners to advocate for operational changes if there were performance issues and provide temporary support from other units. Commissioners wanted services to be more resilient, and less reliant on individual staff (who know how things work). 
+
+
+## What commissioners would like to see in breast screening services 
+
+### More accessible data 
+
+Commissioners know how overstretched BSOs are. Some have already taken steps to reduce the admin burden required to provide monthly KPI reports. However, Commissioners would like to have more instant access to data, so they might be more proactive in preventing performance issues, or directing supportive activities. This includes: 
+
+- peaks in demand  
+
+- performance and population trends (supported by AI analysis) 
+
+- combined data (across years, not in quarters) 
+
+- status reports for KPIs 
+
+### Clearer guidance on the ‘right’ approach  
+
+Alongside planning methods, commissioners were interested in recommendations for minimum staffing levels for a good service. Breast screening is ['block funded’](https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/funding/models-for-paying-providers-of-nhs-services#:~:text=become%20more%20dominant.-,Block%20contracts,-A%20block%20contract), which means funding isn’t linked to performance or activity, but based on historical data linked to the population the service provides for. This can mean over time, as populations in an area change, that BSOs become underfunded. One benchmarking exercise in a region highlighted this disparity between services, resulting in a 40% increase in funding for one provider.  
+
+Commissioners were keen to have staffing level recommendations, similar to other services such as [AAA](https://shorturl.at/2euTs). 
+
+### Easier sharing of resources between trusts 
+
+Currently it is difficult to share staff between BSOs due to differences in standards between trusts such as mandatory training, which means staff who may be qualified to the same level and in the same role cannot operate equipment at another trust. 
+
+>Could we do this on a wider basis, agreeing on an SLA between trusts? Having this ready to go if that capacity is needed? We are keen to do this but nationally we might have spare capacity, we just can't get it into the right place at the right time.  
+
+
+## How we’ll use this insight in digital screening 
+
+1. Improve awareness and opportunities to make service reporting easier and more efficient  
+
+2. Increase communication and collaboration with commissioners as part of any policy changes with the national programme team 
+
+ 
+
+### How we got this info: 
+
+The research involved 13 people across 7 interviews, representing 5 out of 7 regions in England. Participants held a mix of roles, ranging from Heads of Public Health to Screening and Immunisation Assistants. 
+
+
+