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Once Is Not Enough

Sydney Local Health District
Project Added:
14 April 2015
Last updated:
1 September 2015

Once Is Not Enough


The project aims to address barriers that impact the attendance of women aged 50 to 69 years in the BreastScreen program, including health literacy, access for Culturally and Linguistically Diverse (CALD) women and awareness of the program among General Practitioners (GPs) in Sydney Local Health District (SLHD).

Poster Poster from the Centre for Healthcare Redesign Graduation, April 2015. 


To increase breast screening participation rates of women aged 50 to 69 years in SLHD, so cancer is detected at an earlier stage.


  • Increase the number of target age women in SLHD returning for their subsequent mammogram, from 46.2% in 2013 to more than 60% by the end of 2016.
  • Increase the number of GP or nurse referrals to the BreastScreen program from 24% as of April/May 2014 to more than 30% by June 2015.


  • Improves the health of women in SLHD by detecting breast cancers earlier and therefore providing better treatment options for women.
  • Improves client satisfaction with the BreastScreen program.
  • Increases service capacity.
  • Reduces the cost to the health service, as early detection allows for less invasive and more affordable interventions.
  • Builds a strong partnership between BreastScreen SLHD and Inner West Sydney Medicare Local (IWSML), which enables more effective outcomes and better engagement with general practice.
  • Improves the health literacy of women aged 50 to 69 years, so they can make informed choices in relation to breast screening.

Project Status

Project status: Sustained - the project has been implemented, is sustained in standard business.

Project started:  23 July 2014.


According to the Cancer Institute NSW, BreastScreen SLHD had a participation rate of 45.9% as of February 2014, which was the third-lowest participation rate in NSW.

One of the major issues for BreastScreen SLHD is the service’s rescreen response rate, which describes the percentage of women returning for subsequent mammograms. In 2013, the rescreen response rate for BreastScreen SLHD was 46.2%, which is extremely low in comparison with other state services.

The number of GP referrals to the program is also an area of concern. As of May 2014, the number of GP and nurse referrals only accounted for 24% of all referrals to the program.
If these statistics don’t begin to improve, SLHD may see an increase in the number of women presenting with advanced stages of breast cancer, with increased fatalities from the disease.


The below solutions were developed from a range of methods including brainstorming sessions with BreastScreen staff, a focus group on financial incentives for GPs, several executive meetings with project sponsors and site visits to other BreastScreen NSW Services.

Improving access to BreastScreen

Royal Prince Alfred Hospital (RPAH) has improved access to BreastScreen by introducing new signage, a new map, new access point, a main entrance door at RPAH and enhanced communication with the manager of the information service desk. New signage at Croydon, including a sign facing Liverpool Road and a new sandwich board, will also be implemented once BreastScreen NSW has completed its brand refresh.

Increasing health literacy

Two campaigns titled ‘Once is Not Enough’ and ‘Two Reasons’ have been undertaken to improve the health literacy of women aged 50 to 69 living in SLHD. The campaigns involved educational DL flyers sent with rescreen invitation and electoral roll letters, as well as promotional postcards distributed to cafes, libraries and gyms in the local area. Campaign messages were also displayed on the SLHD intranet and Facebook page and the BreastScreen NSW Facebook page.

Increasing access for CALD women

Interpreter sessions will be made available in different languages on a regular basis at Croydon Health Centre. A promotional flyer will be developed and translated into the appropriate languages.

The BreastScreen Information System was used to collect rescreen response data and determine common characteristics of overdue women, such as language spoken at home and interpreter requirements.

Increasing GP awareness

A resource was developed to illustrate the pathway from the point of referral, to when the client is due for her subsequent mammogram. It clearly outlines the role of the GP or nurse in this referral pathway and highlights key messages such as the current target age range. The GP result letter was amended across all state services in NSW, to remind GPs that a recall needs to be added for their patient’s next due date.

Implementations sites

  • BreastScreen fixed sites at Croydon Health Centre and RPAH.
  • BreastScreen mobile units.
  • General Practitioners in the Sydney Local Health District. 


  • Inner West Sydney Medicare Local
  • Cancer Institute NSW


The project has been successful in identifying the major issues affecting the low participation rate of the BreastScreen program in SLHD. Significant improvements have been made, to the rescreen response rate and GP referrals to the service. Both objectives are on track to reach the project’s target by June 2015 and the end of 2016. 

Further evaluations will continue in 2015 and 2016 to gain an indication of the projects success, particularly in relation to GP referral and rescreen response rates.

Before project After project Evaluation method
Overall participation rate 45.9% (Feb 2014) 47.6% (Dec 2014) NSW Cancer Institute participation data
Rescreen response rate 46.2% (Jan-Dec 2013) 56.9% (Jan-Dec 2014) BreastScreen Information System data
GP referral rate

All sites 24% (May 2014)

RPAH 22% (May 2014)

All sites N/A

RPAH 27% (March 2015)

Patient experience trackers, source of referral was included in the survey
Client access at RPAH 72.1% (April/May 2014) 78.3% (February 2015) Patient experience trackers
Screening numbers (50 to 69 year) during Two Reasons campaign 875 women (October, 2012) 1293 women (October, 2014) BreastScreen Information System data

Lessons Learnt

  • This project was successful because both parties were committed to the strategies that were proposed and implemented.
  • In order to maintain enthusiasm and commitment to the project, it remained on the agenda within both organisations. Regular meetings were established and maintained throughout each stage of the project.
  • It was extremely difficult to engage GPs in the diagnostic and solution phase. However, providing a financial incentive to this stakeholder group was crucial in understanding the issues affecting BreastScreen’s participation rate.
  • It was also crucial that the strategies implemented were closely linked to the strategic plans of both organisations.



Cancer Institute NSW. 2014. Participation Report, February 2014.
Cancer Institute NSW. 2014. Participation Report, December 2014. 


Melanie Ireland
Marketing and Recruitment Officer
Sydney Local Health District
Phone: 02 9515 8749

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