New guidance on breast screening will stress the importance of individual choice in the context of access to (and understanding of) scientific information. It is now official NHS policy to draw attention to the fact that population-based breast cancer screening can lead to both over-diagnosis and over-treatment – both potential downsides from an individual point of view. From now on, women are to be encouraged to find out the facts, and then make a personal choice about whether or not to take part.
On the face of it, that seems like a pretty good place to be. But when you scratch the surface of this very reasonable sounding proposition, some serious issues about the background politics of Public Health are revealed. Although couched in the laudable language of freedom of choice, the new developments in breast screening represent the essentially illogical idea of Public Health à la carte. And if you travel too far up that route, your service actually ceases to qualify as Public Health.
A screening service relies on a multitude of individual actions occurring in the context of a “programme”. Successful screening needs millions of citizens to decide, individually, to attend an examination or test of some kind. Even though they, personally, will not have experienced symptoms, they understand that hidden cases of the illness are scattered throughout the population. Realising that finding these hidden cases needs everybody to attend, they behave en masse, creating the possibility that an entire population can be treated meaningfully as a unit of medical intervention. This is, in a nutshell, a fundamental principle of Public Health.
Until now the NHS breast screening programme has sent individual women over a certain age a personal invitation to take part. The invitation represents a framework of clear ‘official’ advice based on an expert analysis of scientific evidence. Women are essentially being asked – “please, take part”. The NHS backs this up by making access to screening easy – clinics and health centres being augmented with mobile caravans in public places.
What’s interesting about the recent breast screening developments is that they represent a shift in emphasis in some of these elements. In some respects, the new guidance makes population breast screening more like flu vaccination.
In the case of flu vaccination, a selective entitlement to the intervention is based on the risk profile of an individual patient. For those not falling within the officially delimited risk categories, the injection can be purchased from shops and private companies. In systems of this kind, GP’s are often paid a bonus to encourage them to actively “recruit” eligible patients to the programme by invitation or advertising.
For people in one of the recognised risk groups, the message being given is that there is clear “official” advice based on an expert analysis of scientific evidence. They are being told by the NHS – “we genuinely think it’s a good idea for you, personally, to have his injection”. The message to people outside the recognised risk groups is that they should examine the scientific evidence themselves, map the analysis onto their own lives and then make a personal judgement as to whether it is worth buying the injection on the open market.
Plainly breast cancer screening and flu vaccination are not the same thing. The former is about case finding and early treatment. The latter is about inoculation and prevention. However, as pieces of policy, they both share some very important attributes as far as the overarching philosophy of Public Health is concerned.
They are both based on the technological possibility of reducing the burden of illness in the community in general by dealing with the population as a unit. And in both cases the overall goal is not simply to reduce the overall amount of human suffering in the population. It is also to reduce the amount of public resources which need to be spent on dealing with illness in the medium and long term. By spending money on a campaign now we save money in the future because not as many people become seriously ill. It’s one of the reasons for having Public Health in the first place.
So what, concretely, are the real differences between the old approach to breast screening and the new advice? Crucially it is about the relocation and recasting of scientific evidence and what that evidence means in terms of real people’s decisions.
In the new guidance, individual women are being told to find out the scientific evidence, analyse it, and then exercise an individual choice. Statistical and epidemiological specialists in public institutions like NICE and academic networks such as the Cochrane Collaboration are either being sidelined by politicians or they are losing the will to give the populace a clear steer one way or the other. They will not from now on be providing policymakers and individuals with clear recommendations. Rather they will be saying “here is the data – make up your own mind”. As a taxpayer I’m tempted to ask – why have a dog and bark yourself?
Someone in British public life once famously said that there is no such thing as society, there are simply individuals and families. Whoever is re-making breast screening policy seems to be belatedly catching up with this idea. And in doing so they are losing touch with an important reality – that health is not just an individual experience. It’s a social and public good.