Evidence to Commons Science and Technology Select Committee Enquiry into National Screening Programmes
Author: Dr Rosemary Fox Director Screening Division Public Health Wales
Date: 08.04.14	Version:
Purpose and Summary of Document: This paper is to provide the Commons Science and Technology Select Committee with written evidence on national screening programmes, with particular emphasis on the Welsh experience.

1 Executive Summary

• This submission is prepared for the Committee by Public Health Wales.
• The process by which the UK National Screening Committee examines the evidence for non-cancer screening programmes is thorough, systematic and robust.
• Evaluation of evidence regarding cancer screening is less systematic, with the trigger being a decision taken on a case by case basis by the Director of the UK National Screening Committee.
• Evidence regarding risks of screening is less systematically collected than evidence of benefit
• The balance of benefit and harm is poorly understood by public and professionals alike
• Communication of benefits and harms is complex. Information developed to allow individuals to make an informed choice about participation may need further refinement to meet the needs of people with low levels of health literacy. 

2 Public Health Wales

Public Health Wales was established as an NHS Trust on 1 October 2009.

Public Health Wales has four statutory functions:

· To provide and manage a range of public health, health protection, healthcare improvement, health advisory, child protection and microbiological laboratory services and services relating to the surveillance, prevention and control of communicable diseases;

• To develop and maintain arrangements for making information about matters related to the protection and improvement of health in Wales available to the public; to undertake and commission research into such matters and to contribute to the provision and development of training in such matters;
• To undertake the systematic collection, analysis and dissemination of information about the health of the people of Wales in particular including cancer incidence, mortality and survival; and prevalence of congenital anomalies; and
• To provide, manage, monitor, evaluate and conduct research into screening of health conditions and screening of health related matters.

The Screening Division of Public Health Wales provides the following population screening programmes in Wales:

• Breast Test Wales, screening approximately 100,000 women aged 50-70 each year
• Cervical Screening Wales, screening approximately 220,000 women aged 25-64 each year
• Bowel Screening Wales, screening approximately 350,000 men and women aged 60-74 each year
• The Wales Abdominal Aortic Aneurysm Screening Programme, screening approximately 16,000 men aged 65 each year
• Newborn Hearing Screening Wales, screening approximately 35,000 babies each year.

Public Health Wales will shortly take responsibility for Newborn Bloodspot Screening Wales.

Public Health Wales also hosts the managed clinical network for Antenatal Screening in Wales, although the delivery of antenatal screening remains a Health Board responsibility. 

3 What evidence are the NHS Screening Programmes based on and how often is it reviewed?

Screening policy in Wales is set by Welsh Government, which has established the Wales Screening Committee to advise the Minister for Health & Social Services. The committee has members drawn from Government, Public Health Wales, Welsh Health Boards and Community Health Councils.

The Wales Screening Committee considers the recommendations of the UK National Screening Committee (UKNSC). The UKNSC advises Ministers and the NHS in the four UK countries about screening. It evaluates the evidence for proposed and existing screening programmes against a set of internationally recognised criteria covering the condition, the test, and the programme. Evidence is reviewed regularly, and the schedule for review is published on the UKNSC website:  http://www.screening.nhs.uk/about.

The evidence reviews carried out on behalf of the UKNSC are of a very high standard, and are made publically available as part of the public consultation involved in review process. Two UKNSC members are from Wales, including the Director of the Screening Division of Public Health Wales.

The UKNSC is responsible for making recommendations for screening across all clinical areas, and is the source of advice for Welsh Government, and therefore for screening in Wales.

However, in the case of cancer screening the Director of the UKNSC takes a view on a case by case basis on whether a proposal by the English cancer screening programmes constitutes a major change. When such a proposal is deemed to warrant a UKNSC policy, the arguments put to the English Advisory Structure are sought and presented to the UKNSC, in the form of a review against the UKNSC criteria. Thus the trigger for reviews of the evidence for cancer and non-cancer screening evidence differs, with non-cancer screening evidence being reviewed regularly according to a published timetable, and evidence relating to cancer screening being reviewed in a more ‘ad hoc’ basis.

As Welsh Government Policy is based on UKNSC advice, this can lead to uncertainty about the timescales for decisions about new evidence regarding cancer screening. For example the UKNSC did not examine the evidence for the age range and frequency of cervical screening until 2012, nine years after the English NHSCSP had changed its policy.

4 Could the evidence base and sources of scientific advice to government on health screening be improved?

The UKNSC is currently reviewing its role, terms of reference and membership. It is consulting on proposals to strengthen the lay membership and ethical representation on the Committee. In the opinion of Public Health Wales this would be a positive step.

A literature review undertaken as part of the review process suggests that the criteria used by the UKNSC in its appraisal of the evidence are robust. Public Health Wales agrees with this.

Public Health Wales would like to see a systematic approach to regular evidence review applied to cancer screening as it is to non-cancer screening.

5 How effectively are the potential risks and benefits of health screening communicated and understood by the public?

Public Health Wales believes that risks and benefits of screening are poorly understood by both professionals and the public, with benefits typically being over-estimated, and risks under-estimated. This is reinforced by a tendency to focus on levels of participation in screening as a measure of programme success.

The UKNSC explicitly considers harms of screening as well as benefits when considering evidence. However, much of the quantitative evidence considered by the committee relates to benefits- mortality reduction is a common end-point, for example. Risks are rarely as well quantified. Without robust estimates of the magnitudes of harms, it is difficult to give  a definitive estimate of the precise balance of good and harm resulting from screening. This is borne out by the recent review of the evidence for breast screening led by Prof Michael Marmot’s team.

The breast screening leaflet developed by the DH Advisory Committee on Informed Choice in Cancer Screening will be launched in bilingual format in Wales in the near future. Communication of benefit and risk is complex even when the estimates are robust. Focus Group work carried out by Public Health Wales’ Screening Engagement Team has found a resistance amongst volunteers to information regarding risks of screening, and provision of meaningful information balancing risks and benefits to groups with low levels of health literacy will remain very challenging.

6 How does health screening provided in the UK through the NHS compare with that offered by other countries?

Public Health Wales has little evidence on the organisation of, or effectiveness of screening programmes beyond the UK.