Wednesday, 7 March 2007

Dr Ellis Friedman - editorial, Screening Matters, Issue 9

Dr Friedman is the Director of Public Health for East Lancashire and the North West Regional Director of Breast Screening Quality Assurance. His name may seem familiar – he was involved in the Shipman Inquiry, which resulted in Manchester GP Harold Shipman being convicted of the murder of 15 of his patients in 2000. At that time Dr Friedman was the Director of Public Health for the area where Shipman worked and it was his epidemiological study which first identified the large excess mortality amongst Dr Shipman’s practice population.

In the UK Dr Friedman is involved in breast, cervical, colorectal, hearing, newborn and Down syndrome screening programmes, at either regional or national levels. He takes a look at some of the similarities – and differences – to approaches to screening in the two countries.

“I believe there are four main similarities between approaches to screening in New Zealand and the UK, and quite a few differences. Firstly, both have an evidence based approach to screening and use very similar criteria to decide on the viability, effectiveness and appropriateness of a screening programme. Secondly, there are striking similarities in the screening pathways followed by both, with differences mainly due to variances in our health systems. It is of note that while New Zealand has a two-year screening interval for breast screening, the UK has a three-year interval. World literature supports the New Zealand approach.

Both New Zealand and the UK have a strong focus on the need for patients to be equal partners in healthcare, and there is a commitment to providing balanced information on the benefits and risks of screening. And finally, both are committed to reducing the health inequalities that are evident in screening coverage and survival rates.

However, there are also a number of differences in our approaches to screening programmes.

The existence of a population register in the UK allows personalised timetabled invitations for screening for all of our programmes. These registers are cost-effective, and promote higher coverage of the at-risk population. Most of Europe has had accurate registers and appropriate confidentiality safeguards for many years.

In the UK, we are very focused on continuous improvement, with challenging, realistic and dynamic standards. Typically, this is achieved by identifying the top quartile performance of providers and setting out the challenge ‘If a quarter of providers can achieve this desirable standard, why can’t you?’ Rewards and sanctions for providers are linked to their performance against key standards. In contrast, in New Zealand, although standards are revised, they are done in reference to international standards rather than programme performance.

The Breast Screening programme in the UK has developed the process of internal audit and data review, this process is then followed up by site visits, led by a Regional Director of Breast Screening Quality Assurance, assisted by a team of people who provide breast screening in other programmes – radiologist, radiographer, surgeon, pathologist, nurse, medical physicist, administration and clerical. Visits take place every screening round and lead to a publicly-available report with timetabled feasible recommendations which are monitored. The breast screening audit process in New Zealand is similar in some ways however, you might find it useful to adopt some of the other elements of the UK system.

The UK has clearer processes for identifying and managing screening incidents than New Zealand. Apparently New Zealand has fewer screening incidents than in the UK, but I wonder if this is accurate, or whether it is a case of fewer being detected? Mistakes will occur in systems –our focus is to try to avoid blaming people and to concentrate on how to improve the screening system. While in New Zealand I will be giving lectures on this topic, and hope to facilitate some changes in the system you have here. I recognise that New Zealand has a no fault compensation system –this is envied in the UK!

There is a much smaller private provider sector in the UK, compared to New Zealand, especially outside London. Thus the UK has more complete data than New Zealand –I believe you receive relatively little data from providers who are not nationally funded.

One striking similarity between New Zealand and the UK is the passion and commitment of the entire screening sector to deliver strong, consistent and effective screening programmes. I believe we are both on the right track.”