The National Institute for Health and Care Excellence (NICE) and Health Improvement Scotland (HIS) issue evidence‑based recommendations to guide the clinical management of many health conditions. They label recommendations ‘strong’ if evidence suggests most practitioners, commissioners and service users would choose the recommended intervention. This is typically if the benefits of the recommendation clearly outweigh the harms and it is likely to be cost effective.
However, in some cases, strong NICE and HIS recommendations may not be applied consistently. If this happens, the UK National Screening Committee (UK NSC) sometimes receives proposals to introduce a screening programme in order to improve adherence to the guidance. Yet a screening programme is not designed – or intended – to fix problems arising from inconsistent implementation of clinical guidance.
UK NSC‑recommended screening programmes are built around structured systems: defined pathways, IT systems, call/recall mechanisms, quality assurance, and national oversight. These features help make sure asymptomatic people who did not ask for the test receive safe, effective, and evidence‑based care minimising harm. Clinical guidance, by contrast, rarely comes with this infrastructure. But the solution to that gap is to strengthen clinical systems – not to introduce screening where it is inappropriate.
Important differences between screening and clinical management
Screening is specifically for people without symptoms or a diagnosis of the condition they are being offered screening for. The process must therefore minimise harms, such as unnecessary treatment or anxiety resulting from false positive test results. This level of caution is less relevant for people who have a diagnosed condition or are in clinical care. They have already sought clinical care or advice for a problem. They are in direct contact with a clinician so they can discuss the merits or otherwise of tests and treatments, rather than simply being provided with generic information to read. They have symptoms or a reason to worry. This means their test is much more likely to represent a true positive result, unlike in screening when people have a greater chance of receiving a false positive result.
People in clinical care expect follow-up and face a smaller risk of harm from predictive tests. The ethical position, the ability of an individual to discuss issues with a clinician, and the likelihood of having a condition, all therefore differ significantly between clinical management and screening.
Care for long-term conditions accounts for the majority of NHS activity. Creating screening programmes for each of these long-term conditions would not be a feasible or sensible use of limited public resources. Screening requires substantial infrastructure and workforce capacity. Expanding it beyond suitable conditions would overburden services. Efforts should instead focus on improving adherence to clinical guidance so resources can be directed where they will have the greatest impact.
Principles that can be applied to both
Certain principles from screening can be applied within clinical services to support better implementation of clinical guidance without turning that guidance into a screening programme.
For example, the screening pathway section of the UK NSC's Screening in Healthcare: Principles of screening manual explains what needs to be in place to support safety and effectiveness. Transferable strategies include:
- creating a database of people who should be getting the recommended care
- setting up a call/recall system to ensure people are invited for appointments at the right time
- getting the IT right – keeping patient lists accurate, and tracking who has been invited, who has attended, and what their outcomes were (the UK NSC has detailed guidance on screening IT systems which contains applicable information)
These strategies allow clinical management to gain some of the organisational benefits of screening, while reflecting the evidence base, staying appropriate to patients’ needs and staying aligned with clinical pathways.
See Cross-partner working on targeted screening: UK NSC, NICE and HIS for more information on how the work of the UK NSC interacts with the bodies responsible for clinical guidance.
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