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A service pledge for breast cancer

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A Breakthrough Breast Cancer initiative is empowering patients to improve services

In this article…

  • The development of Breakthrough Breast Cancer’s service pledge for breast cancer
  • An evaluation of the service pledge
  • How the service pledge was used to improve services at Frenchay Hospital in Bristol



Shauna Freeman is a senior health improvement officer and service pledge lead at Breakthrough Breast Cancer.


Freeman S (2011) A service pledge for breast cancer. Nursing Times; 107: 25, early online publication.

The service pledge for breast cancer is an improvement initiative from the charity Breakthrough Breast Cancer. This article describes the development of the service pledge and how it can be used in practice. It also provides an evaluation of the initiative, and discusses how it was used at a breast unit in Bristol to improve services.

Keywords: Breast cancer/Breast cancer/Breakthrough Breast Cancer/ Service pledge

  • This article has been double-blind peer reviewed

Breakthrough Breast Cancer is a charity dedicated to the prevention, treatment and eradication of breast cancer. It works on three fronts: research; campaigning; and education.

Its aim is to bring together experts and rally the support of all those whose lives have been affected by breast cancer, or may be affected by the disease in the future.

The service pledge

In 2003, Breakthrough Breast Cancer launched its service pledge for breast cancer, an initiative designed to empower patients to work in partnership with health professionals to improve services.

The pledge was launched following a public consultation in October 2002. More than 700 service users, health professionals, and key stakeholders received
consultation packs on the draft pledge, along with information on the rights of breast cancer patients. Twenty-two women treated for breast cancer also took part in a one-day discussion forum. The charity used feedback from the consultation and forum to establish the needs and preferences of patients and health professionals.

The service pledge for breast cancer is based on the standards of care and treatment Breakthrough Breast Cancer believes all breast units should offer. Some example standards include:

  • You will have all your consultations in a comfortable setting where your privacy will be respected;
  • You will be diagnosed using a triple assessment of tests – clinical examination, imaging (mammogram and/or ultrasound) and biopsy, as appropriate;
  • You will be allocated a named breast care nurse who you can contact for information and support;
  • Before any treatment, you will receive information about anticipated benefits, potential risks and side-effects;
  • You will be given written information on wound care, advice on exercise, and information on dealing with the after-effects of surgery, including guidance on when to seek help.

More than 19,000 patients in 26 breast units have benefited from the service pledge, and more than 58,000 will benefit over the next three years when it is rolled out to more than 90 breast units. Each site appoints a service pledge lead, usually a breast care nurse, who acts as the main point of contact between Breakthrough Breast Cancer and the breast unit team. Every pledge lead attends a training day run by the charity to ensure they have the skills to manage the project successfully.

Project development

Breakthrough Breast Cancer sends a questionnaire to every breast unit involved in the service pledge to gain information about local issues. Patients are encouraged to suggest improvements, take part in interviews, or become patient representatives.

To help understand the patient experience, patients treated at pledge sites are interviewed by members of our Cancer Advocacy Network (CAN), many of whom have experienced breast cancer themselves.

Once the interviews and surveys are complete, the service pledge team at Breakthrough Breast Cancer works with a patient representative to review the responses. Each site is presented with the findings of the consultation and a report.

The pledge lead, patient representatives, breast unit staff and CAN interviewers then meet to discuss and agree improvement goals. These goals form the final service pledge booklet. Breakthrough  Breast Cancer covers the cost of producing the booklet, and funds survey materials, postage, and any travel and accommodation costs.

Service pledge evaluation

The service pledge initiative was evaluated in 2006 by an independent consultant. Working closely with Breakthrough Breast Cancer and the nurses involved in the project, the evaluation engaged patients, staff and managers at the participating hospitals. The evaluation found the following:

  • The service pledge booklet provides clear information, sets out clear expectations and helps provide reassurance to patients;
  • Improvement goals reflect the views of patients, either in identifying new issues or providing evidence to address issues staff are aware of;
  • Staff recognise the appropriateness of the goals set and see the project as a positive and effective way of involving patients in service improvement;
  • Breakthrough Breast Cancer adds value by giving credibility to the findings of the patient involvement, and provides well organised and well targeted support;
  • The service pledge improves the patient experience. This is mainly through the implementation of goals to improve patient information, significant changes to the care environment, and expanding access to and availability of treatment and support.


Breakthrough Breast Cancer continues to develop the service pledge model, based on our ongoing monitoring and evaluation. This is to ensure the project remains relevant, effective and a current model of best practice in patient involvement in service improvement.

To find out more about the work of Breakthrough Breast Cancer, including the service pledge, visit The service pledge team can be contacted at or on 020 7025 2400.

Case study: Service pledge in practice

At Frenchay Hospital we believe our services should be shaped by patients, and the only way of ensuring this is by asking them what they think.

We are often told that one of the worst aspects of being diagnosed with breast cancer is the feeling of helplessness. We found that asking patients about their experiences, and how these could be improved, empowered them and gave them a purpose during treatment.

The service pledge

We began working with Breakthrough Breast Cancer in November 2008 to develop and implement a service pledge.

Patients who had received treatment at our unit in the previous 6-12 months were sent a questionnaire and information on becoming a patient representative, and invited to take part in interviews. They were given a number to call if they had any questions or concerns to ensure they felt supported and informed at every stage.

Patient interviews

Packs with information about the project, a survey and forms for patients to take part in interviews or become patient representatives were sent to 120 patients.

Seventy-six patients returned the surveys and 12 took part in interviews, which were carried out by members of Breakthrough Breast Cancer’s Campaign and Advocacy Network. The 30-minute interviews took place at the hospital. Each patient was asked 11 questions about their experience. Questions included:

  • How would you describe the feel of this breast unit?
  • What are your thoughts on the level of information provided at each stage of your diagnosis and treatment?
  • Is there any information you would have found helpful that you didn’t receive?
  • What one change in the service do you think would make the most difference to you as a patient?

The interviews were transcribed and returned to Breakthrough Breast Cancer. The service pledge team collated the results and identified key themes.

Interview findings

As a team, we pride ourselves on the care we offer our patients, and the overall results of the surveys and interviews reflected our hard work. Patients praised staff and were extremely positive about the way staff communicated with them. Patients also said the amount, complexity, and format of the information they were given was appropriate.

Issues identified

Unsurprisingly for a busy breast unit, there were some issues raised in the surveys and interviews that needed addressing.

Although patients praised the effectiveness of the appointment system, almost all were negative about their experiences in the waiting room. Many felt it was crowded and cramped, and some said having an alternative exit for newly diagnosed patients would be helpful.

Post-treatment information was also insufficient, and some patients did not always have positive experiences on wards.

While most interviewees were happy with their experiences, there was room for improvement. This encouraged the team to look at the unit and its patients through fresh eyes.

Changes to practice

Key findings were fed into our final service pledge plan, broken down into positive and negative groups. A number of changes were made. These included:

  • Redecorating the waiting room and using the maximum space for seating;
  • Offering patients the chance to leave the unit without walking through the waiting room after diagnosis;
  • Formalising social care needs following discharge from hospital;
  • Including parking instructions and breast care centre locations in all new patient appointment letters, and providing a map showing the radiology department.

When a patient is undergoing treatment, it is the small things that help make their experience less stressful and overwhelming. The service pledge has enabled us to listen to our patients; we now send out annual questionnaires and conduct small focus groups so we do not lose sight of the patient experience.

We also found that working on the service pledge helped us to unite as a team. Hearing what patients had to say, discussing it together and agreeing on common improvement goals helped create a strong sense of shared purpose.

Jane Barker is breast care clinical nurse specialist and service improvement lead, Frenchay Hospital, Bristol

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