Screening

We divided the 148 screening papers into systematic screening and opportunistic screening, though the boundary was blurred because opportunistic screening may be used in general practice to increase screening uptake for systematic screening programmes (Health and Social Care Information Centre, 2012). We also categorised them by topic, 84 being evidence papers with the remainder being contextual or descriptive. Of the evidence papers, 16 examined sexual health screening, 13 diabetes screening, eight cervical cancer and six breast cancer with the rest predominantly CVD. NHS Health Checks combined accounted for nine papers. While many screening programmes are managed nationally there are several programmes in which general practice has a role; including cervical cancer screening, NHS Health Checks, child health surveillance, diabetes and CVD screening, and health checks for people aged over 75 years. Most studies focussed on screening coverage and women’s experiences, including such aspects as informed consent, reasons for non-attendance rather than aspects of how services were organised and delivered (Peckham et al., Reference Peckham and Wallace2015).

Screening programmes for CVD, diabetes and kidney disease have become an increasingly important part of UK screening programmes that involve general practice although there is inconsistency in the way screening activities were delivered despite attempts by programme designers to standardise it (Peckham et al., Reference Peckham and Wallace2015). The initial national health checks programme was for people with learning disabilities as distinct from the later NHS Health Checks Programme discussed below. There was a very wide variation in service delivery of the health checks programme for people with learning disabilities but it had been successful in detecting unmet health needs and provision of appropriate support. The checks were carried out in different locations (eg, GP surgeries and people’s homes), and were carried out by a diversity of practitioners including GPs, practice nurses and community nurses (Robertson et al., Reference Robertson, Roberts, Emerson, Turner and Greig2011). The ADDITION study examined screening and intensive management for people with diagnosed diabetes found only a small reduction in cardiovascular events and death, but this was not statistically significant and screening was not associated with a reduction in mortality over a 10-year period (Simmons et al., Reference Simmons, Echouffo-Tcheugui, Sharp, Sargeant, Williams, Prevost, Kinmonth, Wareham and Griffin2012).

In 2009 the national NHS Health Check programme was introduced in England to undertake screening of people aged between 40 and 74 for risk of heart disease, stroke, diabetes and kidney disease in primary care. There has, though, been substantial controversy over the effectiveness of NHS health checks (Capewell et al., Reference Capewell, McCartney and Holland2015; Waterall et al., 2015). Over time these screening activities have begun to be carried out in a wide variety of locations, including general practice, community pharmacy, workplaces and in one instance a mobile bus and by a variety of healthcare professionals and non-professionals (Peckham et al., Reference Peckham and Wallace2015). Where the screening took place in general practice, in the majority of cases, it was carried out by the practice nurse, although healthcare assistants and primary care staff were also mentioned. In community locations, there was a very wide range of personnel including practice nurses, health visitors, staff from an independent sector organisation and district nurses working with lay health workers but we did not identify any research that compared different delivery and organisational arrangements. Since completing the review the range of service providers has diversified following the transfer of commissioning NHS Health Checks to local authorities in 2013. This has led to less involvement by general practice (Price, Reference Price2016).

For people aged over 75 there has been a health check programme since its introduction as part of the 1990 GP contract. However, the ways in which practices implemented this has been variable. We found that some practices offered a health check to all patients on their practice list who were aged over 75. Others only identified older persons who might be ‘at risk’ using a postal questionnaire, only approached patients who had not responded to a call for a routine health check or who had not visited their GP in the last year. Where unmet needs were identified, patients were referred to a wide variety of services, but the highest percentage of referrals was to a GP.

In 2004 the introduction of the national QOF as part of the revised GP contract introduced performance payments for some screening activities – theoretically providing an incentive to screen patients. There have been a number of studies on the impact of QOF, but few have looked specifically at the identification of new cases of a disease. We identified two studies that suggested that the effect of QOF on uncovering previously undiagnosed conditions has been both modest and geographically variable. The analysis suggested that there remained a considerable amount of undiagnosed CHD and hypertension in 2007, three years after the introduction of QOF (McLean et al., Reference McLean, Guthrie and Sutton2007). However, Dixon et al. (Reference Dixon, Khachatryan, Wallace, Peckham, Boyce and Gillam2011) in their study of general practices in deprived areas, found that practices were screening opportunistically patients with family members with particular conditions, or patients who looked obese or overweight. The exact effect of QOF on this is difficult to pin down, as these practices stated that they were doing this before QOF was introduced.

Beyond these national programmes and initiatives, there is a wide range of screening activity within general practice. Most of the screening activity for Chlamydia occurs in contraception/sexual health services and general practice where both practice nurses and GPs offer the chlamydia test. We also found papers describing how practices involved receptionists in giving out leaflets or discussing screening with patients (McNulty et al., Reference McNulty, Freeman, Oliver, Ford-Young and Randall2008; Freeman et al., Reference Gavagan2009). Screening for alcohol misuse has also become increasingly important with GPs reporting asking about alcohol consumption ‘all of the time’ or ‘most of the time’ – but not routinely – in situations where patients do not ask them first. However, some screening and brief interventions for alcohol misuse are also undertaken by a wide range of practitioners including pharmacists – but again not routinely. GPs have described feeling awkward about enquiring about alcohol consumption GPs may be unaware of potentially problematic drinking behaviour in patients whose alcohol consumption is only slightly above recommended levels (Rapley et al., Reference Rapley, May and Kaner2006). As a result, some GPs embed the question in a list of questions about lifestyle, which they say they ‘ask everyone’.

Other screening activities identified in the review included antenatal screening for haemoglobin disorders, screening for dementia, falls, osteoporosis, atrial fibrillation, domestic violence, depression, adult hearing, hepatitis C, human immunodeficiency virus, oral cancer, syphilis and tuberculosis. These activities have been driven by personal interest, organisational contexts, perceived needs, QOF and other local public health initiatives. General practice also has a supportive role with respect to screening programmes that are carried out outside the practice, such as the breast screening and bowel cancer programmes which GPs support by verbally recommending screening, or sending out letters of invitation or information leaflets to increase participation. We found that QOF and NHS Health Checks were clearly associated with an increase in systematic approaches to, and organisation of, primary and secondary prevention advice and activity – especially related to smoking, diet and lifestyle with an increasing use of nurses and healthcare assistants being employed in practices.

Primary prevention

The King’s Fund identified primary prevention as a key element in transforming healthcare systems (Naylor et al., Reference Naylor, Imison and Addicott2015). Primary care is seen as an ideal location for primary prevention given that most patient contacts occur in this setting. We identified 326 papers that were classified as primary prevention. Of these, 50 related to child health, 49 to smoking, 22 to vaccination, and 40 to exercise and weight. In addition to these there were a small number of papers relating to falls, diabetes and mental health. Some of these categories overlapped, providing higher numbers of papers for some topics. There were also a substantial number of papers focussing on child health (just under 205 of the total primary prevention papers). This specifically reflects the way child health services are organised in the United Kingdom where GPs, practice nurses, health visitors and school nurses provide a wide range of child health services in conjunction with community health services.

Studies on child health spanned a wide range of topics including accident prevention, breastfeeding, weight management and exercise. Many of the papers examined changes in patient behaviour as a result of an intervention. Studies fell into three broad categories:

1. 1. Interventions either within practices or by the primary healthcare team that were aimed at identifying children who might be at risk of health problems, and these activities often targeted particular groups of children.

2. 2. Interventions that were aimed at intermediary organisations such as training for teachers.

3. 3. Interventions or activities in schools or the community.

Again few studies explicitly discussed the delivery and organisation of public health services. Primary care practitioners support national programmes such as the childhood vaccination programme (often delivered through schools) as this tends to support increased uptake. Conversely, GPs were less likely to engage in lifestyle advice for children.

One of the few papers that addressed the context of a public health intervention policy discussed the variance in outcomes of a RCT of a community based breastfeeding support group (Hoddinott et al., Reference Hoddinott, Britten and Pill2010). Through ethnographic enquiry of the complex intervention, they found there was variation in the way that services were organised, which could be explained through a Hierarchy of Service Attributes Model. In the study sites where breastfeeding rates increased, the model was underpinned by good personnel resources and organisational stability, and demonstrated reflective action cycles at its apex. In localities where breastfeeding declined, the authors found that managers focussed on solving the problems within the model, such as staff shortages, rather than ways to deliver the policy. The model provides a useful approach to understanding and explaining delivery of public health interventions in primary care and could be usefully applied to other scenarios.

There were 49 papers on smoking cessation covering a wide range of interventions, and it was not always possible to distinguish between those interventions which targeted all smokers (primary prevention) and those that focussed on smokers who already had an existing health problem (secondary prevention). There is good evidence to suggest that services for helping people to quit smoking are clinically and cost effective. Almost all GPs (98%) say that they follow NICE guidelines to ask patients about their smoking status and record this in patient records – although a number of studies highlighted poor recording of smoking status. Compliance with NICE guidelines was driven by the inclusion of payment criteria in QOF but despite this, fewer than half of GPs consistently advise patients to give up smoking. Although complex, the main reason seems to be concerned with damaging the relationship with the patient by raising the issue of smoking cessation, especially if the GP believes that the patient is not motivated enough to quit (Pilnick and Coleman, Reference Pilnick and Coleman2010). Overall, few papers examined the organisation and delivery of smoking cessation services, and only two compared different service approaches. Although there were many smoking cessation activities taking place in general practice, there was little evidence on how best to organise services.

There were 40 papers on exercise, weight reduction and diet which were mainly aimed at a general adult population, although one referred specifically to people with mental health issues and was therefore excluded, and there were three papers that focussed on older people. The majority of papers on weight loss were related to secondary prevention or identifying risk factors for a health issue – usually CVD. Interventions ranged from advice about lifestyle to specific recommendations concerning exercise or weight loss classes. However, there were very few good quality studies. In particular, those studies examining weight loss and obesity were generally of low methodological quality. Although the GP is a trusted source of advice regarding diet, they are rarely the first port of call for overweight and obese people. The evidence suggested that GPs regarded adult obesity as being the responsibility of the patient, and felt they had very limited ability to effect changes in their patients’ diet or behaviour (Ogden and Flanagan, Reference Ogden and Flanagan2008). In addition, many GPs were hesitant to raise the issue of weight loss with overweight and obese patients if they feel it will negatively impact on their relationship with the patient (Hankey et al., 2003), and many believe that it does not belong within the medical domain. On the whole interventions and referrals tended to be undertaken haphazardly (by both GPs and practice nurses). Recent research on changes in the public health system in England identified a number of problems related to the organisation and commissioning of services for helping obese and overweight people – particularly since the reorganisation of public health services in 2013 (Peckham et al., Reference Peckham and Wallace2015).

Secondary prevention

It was not always easy to separate primary from secondary prevention as there was often insufficient information in the papers reviewed about whether patient groups were symptomatic or asymptomatic. Thus many aspects of secondary prevention were also covered in papers on primary prevention. Of those papers specifically classified by the research team as secondary prevention, most (43) addressed CVD (including health checks), and there were 25 papers addressing weight and exercise for people with symptomatic disease.

Studies that examined services for cardiovascular prevention mainly focussed on attempts to modify lifestyle risk factors in both symptomatic and asymptomatic patients but doctors did not always follow guidelines and procedures. Risk factors included obesity, poor diet, lack of exercise alcohol use and smoking. Other areas included monitoring of blood pressure in symptomatic patients – especially those with peripheral arterial disease, and patient compliance with medications, especially statins. Ten papers specifically addressed lifestyle risk factors in asymptomatic patients, of which five also looked at trying to change people’s behaviour, such as encouraging exercise, or changing to a healthier diet or smoking cessation. They covered a range of interventions – including Tai Chi, exercise classes, guided walks, counselling sessions, and in one case, a home exercise kit. Few papers were more than descriptive with no assessment of the best delivery or organisational methods for delivery or how services were selected. Few papers specifically looked at gender and CVD. These studies showed that women tended to receive suboptimal care with regard to prescribing and diagnostic tests, risk factor assessment, secondary prevention therapy, cardiac investigation and coronary revascularisation.

Two papers examined ethnicity and CVD. Murray et al. (Reference Murray, Saxena, Millett, Curcin, de Lusignan and Majeed2010) examined a 10 year strategy to reduce health inequalities in Wandsworth, London. However, there was insufficient data in the paper to assess whether this had actually made any impact on health inequalities. The second study examined the feasibility of using screening to reach hard to reach groups in Sandwell. Although the screening seemed popular, it was unclear if this had actually resulted in any lifestyle risk factor change (Patel et al., Reference Patel, Gunarathne, Lane, Lim, Tracey, Panja, Lip and Hughes2007). However, these papers like many of those reviewed did not provide sufficient detail, about how the intervention was provided (by who, where, when, etc.).

As stated earlier, most papers on preventive interventions did not provided sufficient details about the organisation and delivery of those interventions to assess their effectiveness. One exception was in relation to welfare advice given in general practice by trained staff from organisations such as the Citizens Advice Bureaux or by specialist welfare advisors. These papers concluded that it was an effective intervention and a way to address the social, economic and environmental influences on the health of their practice population. Such services tended to be highly valued by both patients and the practice staff and lead to positive outcomes for patients (Abbott et al., Reference Abbott, Hobby and Cotter2006; Burrows et al., Reference Burrows, Baxter, Baird, Hirst and Goyder2011).