Margaret McCartney: Cancer screening review diminishes informed choice
We should resist the push for financial incentives, increased screening uptake, reorganisation, and restructuring, says Margaret McCartney
Mike Richards' independent review of adult screening programmes in England is out and can be summarised as: "nothing is too much." [1] Calling for financial incentives, increased uptake, reorganisation, and restructuring, Richards writes: "Every day of delay is a missed opportunity to catch a person's cancer or disease at an earlier point, and potentially save their life."
Healthcare in the UK is a shifting entanglement of policies and politics, frequently at odds with each other. Initiatives launched with aplomb are reversed later in quiet. We get soundbites, not substance, and crucially, little chance to permanently embed learning and improve the way evidence and policy meet. The last decade saw acknowledgement of overdiagnosis and the ethical need for choice in screening. This report waves that off. It misunderstands what screening is, and what it can and cannot do.
First: there's the idea that a days' delay can kill someone in the screening process. Let's recap: screening is designed to find disease at an early stage (or as Wilson and Jungner put it, at "latent" stage). Taken to its logical conclusion, people would need to be screened daily to prevent "delay"—an absurd proposition that would do untold harm.
We should, however, be concerned about delays—but which one? What about the 62-day wait for first treatment for cancer following an urgent GP referral—below target, worse than last year, and falling. Or the incompetence of Capita, who didn't invite many thousands of women to cervical screening, or inform several thousand of their results. That's where to sling your arrows.
As for "Lung Health Checks"—CT scans for heavy smokers in some areas—which the report describes as being "piloted" and "rolled out nationally" if they succeed. This despite the fact that lung cancer screening has not been approved by the UK National Screening Committee— a cause for concern—and where are the pre-specified standards, planned to be independently assessed, that would tell us whether or not this "pilot" has succeeded? The standards of screening to be adopted should be those of Wilson and Jungner. It is because it is rare for screening programmes to offer more good than harm that we need specialist consideration that understands the science which underpins it—and this includes rigorous cost effectiveness analysis. Resources spent on screening healthy people cannot be given to people who are dealing with the reality of deprivation, early multimorbidity, and under resourced mental health services.
We must, I am afraid, go on—to the bald statement that "a decreasing proportion of women are being screened. This is a major concern and must be reversed." Now, this might be of note if, for example, some women want screening, but can't access it, or find the means unacceptable—for example, a self taken HPV test may be more acceptable to some. But if a woman has made an informed choice that she does not want to have screening, it is bewildering, and unethical, that the system seeks to reverse her choice. Rather than the recommendation seeking "implementation of evidence-based initiatives to increase uptake," we should want to improve the quality of the informed decisions people make—no matter what they are. Have we forgotten autonomy? It seems so, for the recommendation is to offer financial incentives to GPs to increase uptake, rather than improve the quality of decision making. This is a return to the worst of the Quality and Outcomes Framework, and creates an inherent conflict of interest. We should reject this absolutely.
The UK National Screening Committee is one of the few bits of the NHS which works very well. It stands for evidence, for cool assessment of cost effectiveness and potential harms, and calm consideration. As I have written before, it is deeply boring, and we should be grateful for that. It is light not heat, and science before soundbites. Anything that threatens, rather than strengthens that function is to be resisted. Richards wants a reorganisation, placing this function in NHS England. Not only does this threaten the independence of the UK National Screening Committee, it drives wedges between the four nations. For despite the cover claims that this report is "independent," secretariat was provided by NHS England. A repeated problem for the NHS is not realising what is good until it is gone.
Margaret McCartney is a GP partner, Glasgow.
Competing interests: MMC is a senior fellow for evidence and values at the RCGP, and a freelance writer and broadcaster who also receives royalties for three books. She has written frequently about screening and complained to regulators about advertising for non evidence based screening and around informed choice. She gives a small amount regularly to Keep our NHS public and is honorary fellow at the CEBM Oxford.
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