30 October 2019
The final report of a review of adult screening programs in England led by Prof Sir Mike Richards, has been published.
Screening looks for early signs of disease in apparently healthy people to aid earlier detection and treatment for improved health outcomes. All screening programmes also pose a risk for potential harms, such as overdiagnosis. The Richards review was originally commissioned to look at cancer screening, but subsequently expanded to consider all adult screening programmes in England. The final report is mostly concerned with ensuring that future screening makes the most of opportunities to save lives and prevent illness.
The interim findings, released earlier this year were focused on halting the decline in the number of women attending breast and cervical screening, and ensuring that the IT systems supporting screening programmes are fit for purpose. The final report revisits these same themes while building on additional findings.
Alhough publicity around the review has centred on proposals to increase flexibility in the availability of screening appointments, it is the recommendations around accountability and governance of screening programmes that could potentially have the greatest impact.
One of the reviews key recommendations is to establish a single advisory body that combines the functions of the two that make screening recommendations currently. The UK National Screening Committee makes recommendations on national population screening programmes – these include the programmes for breast, cervical and bowel cancer – while the National Institute of Health and Care Excellence (NICE) makes recommendations on screening for people at elevated risk of serious conditions, for instance, women at increased risk of breast cancer due to inherited mutations in BRCA1 or BRCA2.
Combining these two bodies into one – intended to advise Ministers across all four UK nations – not only levels the playing field in terms of investment in different types of screening programmes, but also allows consideration of how they can best help the government and wider health system meet its goals in terms of disease prevention.
The review also recommends that delivery of screening programmes in England should fall solely under NHS England, in contrast to the current model where oversight is shared between NHS England and Public Health England. Which means that commissioning of different aspects of screening services and expertise is divided between the two. There are also issues due to data being held in different systems, making data exchange difficult and prone to error. This mixed model creates challenges around decision-making and digital infrastructure, with a plethora of committees in both organisations providing advice and oversight. The review concludes that placing responsibility for screening with one organisation will streamline processes and decision-making. Including targeted screening in NHS England's responsibilities for commissioning and delivery arrangements should also improve uptake.
The review acknowledges that weaknesses in digital infrastructure and systems are an ongoing issue, with IT failures having contributed to two publicly reported incidents prior to the review. These were the failure to invite an estimated 450,000 women between the ages of 68 and 71 to their final screening appointment of the breast screening programme, and failing to provide up to 48,500 women with required information about the cervical screening programme.
The review welcomes the fact that NHSX is taking overall responsibility for updating and replacing IT systems that support screening – a development wholly in line with PHG Foundation's calls for better information systems and infrastructure. Having a centralised and coordinated approach to digital provision can only support services and users, as well as underpinning more effective evaluation and research – both important elements in the review.
Recommendations for new and improved quality assurance processes will be a critical factor in success for any population screening programme, and will require robust implementation, whilst proposals to streamline approvals and facilitate data sharing for research purposes will underpin ongoing improvement.
Looking to the future, what might be in store for screening programmes? Though the review focuses on the governance of screening programmes with a view to increasing uptake in the short-term, it does so with an eye firmly to the future, noting that technological developments and scientific evidence (such as in genomics and artificial intelligence) will provide new opportunities to refine and improve screening – for instance in better targeting and stratification, an element of personalised prevention. Prof Richards notes that: “Urgent change is needed if NHS screening programmes are to have any chance of realising this potential”.
The review is more concerned with making changes to current screening programmes and systems to improve performance and creating scope for future innovations than it is with the impact that specific new technologies may have. This will become an increasingly important issue to address, however.
The review highlights the SUMMIT study, a clinical trial partnership between University College London, UCL Hospitals and GRAIL. Inc. to develop a circulating tumour DNA (ctDNA) test for early cancer detection. This is an area of ongoing interest at the PHG Foundation; many of the challenges with GRAIL that we have previously outlined remain, and considerable evidence will be required before the viability of such an approach to screening can be determined. Care will also be needed to ensure that new technologies are implemented in a way that minimises potential harms (for example from overdiagnosis or increasing health inequalities) – as outlined in our recent report, Our healthy future and associated publications.
There is also a question around the impact of proposed changes to the NHS Health Checks programme – offering personalised health checks that take into account patients’ specific risk factors – and the impact of the Accelerating Detection of Disease (ADD) Challenge, which plans to gather health information from a 5-million strong volunteer cohort and use AI approaches to explore this data and support new approaches to early disease detection. Health Checks is not a formal screening programme, so its role in the new frameworks proposed in the Richards review needs to be considered, as well as how data from the ADD challenge and other research should be considered when developing screening programmes in the future.
Overall, the new review proposes significant system changes. For these transformational proposals to succeed, robust planning and sufficient resources are essential to putting in place the new screening commissioning arrangements, delivery and quality assurance systems, and to address any risks to ongoing screening programmes during this process.