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Making screening fairer: progress with our inequalities strategy

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The concept of population screening is inherently equitable. We offer screening to everyone in the target group (such as pregnant women) regardless of disability, ethnicity, socio-economic status or other characteristics.

But that doesn’t mean we don’t need to worry about potential inequalities. These can be defined as avoidable differences in health between different groups of people. For instance, although the offer of screening should be universal (that is, to everyone in the target group), this doesn’t always happen. We know that some population groups are not able to access screening as readily as others and this can result in those with the greatest need being the least likely to participate in screening.

Specifically we know some population groups need more support to reach an informed choice about screening. We also know other groups may need more practical support (as described in the accessible information standard) and sometimes our screening pathways and processes simply don’t enable everyone to access services readily.

For example, in the case of diabetic eye screening, perhaps not everyone with diabetes is known to their GP. And even if someone is offered screening, they might not understand the offer, perhaps if they don’t read English or have a learning disability. Or their culture or background might mean they don’t see screening as being something important to consider.

Developing our inequalities strategy

Public Health England (PHE) recognises the importance of reducing health inequalities. Such an approach is intrinsic to all the work we do. We feel that the time is right to work with our partners to develop our own screening inequalities strategy. This builds on the priorities identified by the screening inequalities workshop in September 2015.

It is important to clarify that reducing inequalities in screening is not necessarily, or predominantly, about increasing uptake. Screening in England is based on the concept of informed choice, so people can always choose not to be screened if that’s the right choice for them. But we do need to ensure that everyone has the ability to make that choice fairly, for instance that they are offered screening in a way that works for them and supports their decision.

Image of mind the gap on a tube platform.
The PHE inequalities strategy will aim to close the screening inequalities gap and ensure equitable access to screening to all eligible populations.

Progress so far

We’ve set up an inequalities strategy oversight group to steer this project. I chair the group, which is a real honour. I used to work in screening policy at the Department of Health, so it’s a subject that’s close to my heart. It’s also good to be working with Linda Syson-Nibbs, head of screening QA in the Midlands and East, who’s helping to lead this project.

The oversight group consists of members of the PHE screening division, experts on inequalities from other parts of PHE, screening and immunisation leads,  NHS colleagues and voluntary sector representatives. It’s a strong group and everyone is extremely engaged with the work.

The purpose of the group is to oversee the development of a national screening inequalities strategy that will include a 3 year programme of action. The strategy will ensure that:

  • PHE works in partnership with screening stakeholders to proactively address screening inequalities
  • stakeholders are able to meet their legal duties in relation to health inequalities

We are developing a set of principles to guide the development of the strategy. These will include, for instance, the need for the strategy to be:

  • respectful of someone’s right not to be screened
  • systematic
  • sustainable in terms of long-term and consistent impact
  • evidence-informed
  • solution-focused, taking a ‘do things once and sharing’ approach for local and national action
  • innovative
  • impactful in ending up with more accessible screening services
  • outward-facing
  • focused on where actions can achieve the greatest impact
  • co-productive in terms of working across organisations

It will be important to measure the impact of the strategy. One output could be carrying out some evaluation of screening services with members of the public.

Next steps

We’ll be putting the draft strategy out for comments later in the year. The strategy will contain an action plan, which we will work with stakeholders to produce. This will contain actions for specific screening programmes as well as cross-cutting themes relevant to all types of screening.

We hope to have an early version of the strategy ready to consult on later in the autumn. The final version will then be ready early in 2018.

The ultimate aim is for this work to make a practical difference in reducing screening inequalities and we hope to work with as many of you as possible to achieve this.

We’ll be blogging regularly about the development of the strategy, so please do let me know if you have any contributions to make to the work or suggestions for future blog articles. You can add your comments below or contact the helpdesk in the usual way.

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  1. Comment by Julie Stein Hodgins posted on

    I too work in Breast Screening. I agree with Jim's comments, I am looking forward to more sharing. We are looking to cervical and bowel screening as our cohorts overlap. A group that is poor at attending are the first time women. They are working, they think they are ok....a lot of misinformation around. This is an area worth a targeted approach.

    Also required is bring the service to the local units fulfil this requirement however it is becoming increasingly difficult to find sites to use that are in that area.

  2. Comment by Jim Steel posted on

    In breast screening for years we have known that some areas, particularly inner city areas, have low uptake yet also have the highest mortality for breast screening. In the past we have been good at starting, but not completing initiatives, and haven't shared with other centres as well as we might have. There has been an emphasis on disability, ethnic minorities and LGBGT groups. These all matter, and progress has been made, but what became clear was that LGBGT didn't feel disadvantaged in screening - the approach was orientation-neutral. Learning disabled needed more investment in targeted assistance that worked in some units (and still does) but wasn't funded in others, and those with physical disability didn't need what we thought they did. The huge ignored group for me were the socio-economically deprived group who culturally were not that engaged, and need better access with other routes to understand and make a choice than a letter that to some felt threatening and to others pointless. I'm really glad to see a well-configured group is going to change things. Great. Thank you.

  3. Comment by Phil Bullock posted on

    Its good to see this getting some thought. In cervical one key issue has been the decommissioning of screening in CASH and GUM clinics in some programmes on the back of commissioning and funding uncertainty. The client group accessing these services is one which often does not present to primary care where the main delivery of cervical screening takes place and in which the disease rate is up to 2.5 times higher than in other groups so clients accessing these services are high risk.