Screening position statement
Screening is the process of testing people who are well, or believe themselves to be well, or have no symptoms relating to the testing being done. It identifies people in an at-risk group who can potentially benefit from earlier treatment of the identified condition.
The UK National Screening Committee has been in operation in the UK since 1996. It has served the function of overseeing the evidence for screening programmes and recommending for or against their implementation. Although now hosted by Public Health England, the UK NSC is an independent body who commission and research policy in relation to screening, independent of government. NICE makes occasional recommendations about screening. Health improvement and public health bodies of Scotland, Wales and Northern Ireland tend to follow the UK NSC guidance.
The UK NSC has rigorous processes to approve screening programmes. For many years the Wilson and Jungner criteria1 have been used internationally to assess the likely benefits and harms of proposed screening tests. The evidence for screening requires to be interrogated and understood along with continuous quality assurance and audit together with regular updates of the best available evidence.
However, numerous private companies and other organisations are currently offering screening (without high quality clinical trials). This screening is not recommended by the UK NSC or NICE in settings such as hotels, private clinics, online, and supermarkets.
There is a lack of academic research on how many private screening results are presented to NHS services and the level of burden this presents. However, a poll of 500 doctors conducted in 2018 via social media (and therefore subject to sampling biases) revealed that 91% of doctors have encountered meeting a patient at an NHS appointment to discuss the results of a private health screening. Only 13% of the time professionals thought this was a reasonable use of NHS resources. 75% of the time, further resources within the NHS were allocated, like follow-up appointments, blood tests, or imaging.2
This is of serious concern, given that this type of screening may lack evidence of benefit, and may cause more harm than good. For example, such screening may lead to the identification and/or treatment of conditions which would not otherwise have caused mortality or morbidity. They may introduce lead time bias (where earlier diagnosis has no positive impact on outcomes, and may only have negative effects). Plus, they may cause the patient to experience stress or experience side effects from the tests themselves. It may also be performed without independent scrutiny and cost effectiveness evaluation. Such screening has the potential to mislead patients and citizens, and exacerbate health inequalities. It runs counter to initiatives in all four countries to promote evidence-based care (such as: Choosing Wisely, Realistic Medicine, Prudent Healthcare, and Rethinking Medicine). The opportunity costs for health services are potentially significant.
Furthermore, many of the private clinics pass back results to the NHS, often via general practice, to be assessed and followed up. Some private companies even advise clients to routinely speak with their NHS GP about their results. This can be an inappropriate use of NHS resources and can have a potentially significant negative impact on primary care.
The RCGP does not support non-evidence-based screening which has not approved by the UK National Screening Committee (NSC) or NICE, or Health Improvement Scotland (HIS), Public Health Wales (PHW), or the Department of Health Northern Ireland (DHNI).
The RCGP believes that if presented with results of screening which has not been approved by the UK NSC, NICE, HIS, PHW or DHNI, the organisation initiating the screening should not assume that general practitioners will deal with the results. Organisations offering these interventions must organise and fund follow-up so that patients are adequately supported and so that the interventions do not impact negatively on the use of NHS resources.
Currently, private companies are offering screening that is not approved by the UK NSC or NICE. People seeking private screening are not routinely told that the screening they are offered is either:
- available within the NHS, if evidence-based,
- or not available within the NHS on the grounds of evidence.
There are no regulations on private companies to prevent them from undertaking screening that is not evidence-based. In England the Care Quality Commission do not regulate the information provided by private companies in advertising or information leaflets or validate the evidence for the services they provide; and nor does HIS in Scotland, the Regulation and Quality Improvement Authority in Northern Ireland, or the Healthcare Inspectorate in Wales.
Guidance from the Department of Health and Social Care (DHSC) in England and the BMA states that the NHS should not be used to support private healthcare services.
For example, the BMA say:
"Patients who have had a private consultation for investigations and diagnosis may transfer to the NHS for any subsequent treatment. They should be placed directly onto the NHS waiting list at the same position as if their original consultation had been within the NHS. The patient should bear the full cost of any private services and NHS resources should never be used to subsidise the use of private care. You cannot choose to mix different parts of the same treatment between NHS and private care. For example, you cannot have a cataract operation on the NHS and pay privately for special lens implants that are normally only available as part of private care.
Your private healthcare provider will normally treat any non-emergency complications that result from the private part of your care – for example, you might have side effects that need extra treatment."3
“in order to ensure that there is no risk of the NHS subsidising private care: It should always be clear whether an individual procedure or treatment is privately funded or NHS funded;
Private and NHS care should be kept as clearly separate as possible
Private care should be carried out at a different time to the NHS care that a patient is receiving;
Private care should be carried out in a different place to NHS care, as separate from other NHS patients as possible. A different place would include the facilities of a private healthcare provider, or part of an NHS organisation which has been permanently or temporarily designated for private care;.
The patient should bear the full costs of any private services. NHS resources should never be used to subsidise the use of private care;
The patient should meet any additional costs associated with the private element of care, such as additional treatment needed for the management of side effects."4
The latest advice in Scotland (not updated since 2009) from the then CMO states:
Any arrangements which they may wish to facilitate for patients to receive elements of NHS and private healthcare in combination are lawful, maintain the integrity of the founding principles of the NHS, can be fully separated for delivery purposes and do not compromise patient safety, clinical accountability, governance and probity.
These guidelines do not specifically mention screening and were written in advance of the burgeoning private screening market. There is a gap in current guidance and this position statement is intended to fill the gap.5
- When presented with results of screening that is not UK NSC approved, GPs should use their clinical judgment and interpret results as per usual NHS care. It may be appropriate to advise patients of the reasons why the NHS does not offer such interventions.
- GPs could consider notifying the service who requested the test, or the relevant regulator, reminding them of their responsibility to adhere to the guidance/ ensure that providers adhere to the guidance produced by government that the NHS should not subsidise private care.
Departments of Health and the NHS:
- Ensure that their policy and procedures do not put NHS providers under any obligation to follow up the results of non UK NSC approved private screening which would not otherwise have been performed in the NHS.
Private screening providers:
- Should only offer screening that is recommended by the UK NSC or NICE.
- If screening is performed despite this, providers should ensure that patients are aware of what is, and is not, approved of by the UK NSC at the point of sale, and give fully informed consent.
- Should ensure that they offer follow-up and provide appropriate care to manage the results of the tests.
Health service regulators and commissioners:
- Should remind private providers that it is their responsibility not to put the NHS at risk of subsidising private care.
- Should ensure information provided through advertising and consent is fair, accurate, acknowledge what is available on the NHS and why other screening is not recommended, ensure that standards of consent are in keeping with GMC guidance.6
- Should ensure private clinics routinely arrange follow up at their cost.
- Should encourage reporting of unjustified use of NHS services to them for their action.
- Wilson JMG, Jungner G. Principles and practices of screening for disease. Geneva, Switzerland: World Health Organization; 1968. Report No.: Public Health Papers No. 34.
- Survey Monkey survey 3/5/19 (available from Margaret McCartney on request)
- Guidance on NHS patients who wish to pay for additional private care. Department of Health, 2009
- CMO Scotland letter, 5 March 2009, SGHD/CMO(2009)3
- GMC Good Medical Practice. Consent: doctors and patients making decisions together
Dr Margaret McCartney