Public health screening puts a heavy responsibilty on the State. It must be certain that the screening programme is justified by bringing about demonstrable improvements in survival and quality of life.
It must be explicit in explaining the possible harm that can be caused by the investigation and that the test may, in some cases, fail to reveal the condition it is designed to detect.
The dialogue between State and citizen should be one of partnership, not patronage. An essential element is truthful transfer of information in a way that is candid and compassionate, and in a setting that is appropriate and unrushed. A habit of truth must be ingrained in a health screening process.
Before introducing a screening programme, the State must be sure the programme is affordable and the highest available standards can be achieved and maintained
In societies in which good medical care is delivered, abundant evidence is available throughout the world that screening programmes prevent disease, render potentially fatal illness curable, improve the quality of life among those affected, and confer social and economic benefits to society.
Screening programmes can improve a nation’s health and the health of a nation.
However, in order to succeed, the highest attainable standards must be in place. They must be validated regularly by internal and external reviews. They should also be adaptable in the light of fresh evidence.
Population-based screening is expensive; additional resources are always needed. Before introducing a screening programme, the State must be sure the programme is affordable and the highest available standards can be achieved and maintained by reference to current international best practice.
It must ensure that effective high-quality care is available and accessible when the disease is confirmed. To introduce a screening programme while expecting existing stretched health services to cope with the consequences of screen-detected disease would be to put its success at risk.
In many programmes, screening stops when the condition is diagnosed and the individual is referred to the treating services. But in order to ensure the best outcomes, the best available treatment should also be in place. It was for this reason that the BreastCheck programme includes the primary treatment of the screen-detected breast cancer in a specialised breast cancer centre.
For each programme the screening test should be co-ordinated with the complete treatment process. Relationships between those providing the test and subsequent treating services should be close so that a collaborative team becomes established.
A secretariat is being put together to assemble and analyse information related to current practice, evolving trends and validated evidence around screening programmes
Elements of the screening process should always include participation of the public. They should be drawn together in a system of care that goes far beyond a legal contractual arrangement.
The establishment of a National Screening Committee (NSC) was one of the recommendations of the Scally Report into the CervicalCheck Screening Programme (September 2018).
The Minister for Health has now initiated this process. The function of the NSC is to advise the Department and the Minister on all new proposals for population-based screening and revisions to current programmes.
Drawing on expertise from programmes in the UK and across Europe, the National Screening Committee – Ireland will develop criteria to be applied to new applications and to evaluate them against internationally recognised standards.
Importantly, it will be independent and members will be chosen on the basis of their specific expertise and skills and not on the basis of institutional representation. It will include two members of the public and those with specialised expertise in public health medicine, genetics, ethics, metabolic medicine, cancer, general practice, immunology, pathology, obstetrics and gynaecology, law as applied to medicine, paediatrics and child health, nursing, laboratory services, social science, psychology and journalism. Committee members will not be remunerated for their work.
It is expected that appointments will be made in October and the first meeting will take place in November. Expressions of interest for committee membership are now being sought.
The structure of the committee will ensure its independence; its obligation will be to provide disinterested recommendations based on the current evidence. Implicit in this function is the intention to re-assess programmes in the light of new information. A dedicated budget has been allocated for the work of the committee.
A secretariat is being put together to assemble and analyse information related to current practice, evolving trends and validated evidence around screening programmes. The secretariat is impartial and respects the committee’s independent role.
At present, population-based screening programmes are in place for cancer of the breast, bowel and uterine cervix and retinal screening for patients with diabetes. Neonatal screening has been in place for many years and the bloodspot (heelprick) test currently involves checking for eight conditions which are detectable in the newborn.
The committee will send its recommendations to the Department of Health and communicate with stakeholders and to the public. It is hoped that combining the work of the committee with a vigorous information campaign by the Department of Health, the HSE, the professional training organisations and the medical profession as a whole will do much to restore public confidence on the proven advantages of screening to the health of the nation.
Prof Niall O’Higgins is chairman of the National Screening Committee and Professor Emeritus of Surgery at University College Dublin.