Screening programmes and genetic testing
77 Although more effective treatments for cancer
continue to be developed, the need for early detection of the
disease remains vital. It is for this reason that the Government
remains committed to the development of screening programmes.
Currently, the Scottish Breast Screening Programme (SBSP)
invites women aged 50-64 to come for screening every 3 years,
and women aged over 64 can attend on request. The main aim of
the Programme, which costs £4.5m a year, is to reduce mortality
from breast cancer in the women screened by 25% by the year 2000.
In the period 1992-93 to 1994-95, 69% of women in Scotland accepted
their invitation to attend screening. Attendance for 1995-96
has risen to over 75%. Women attending screening who need further
assessment are offered an appointment within 8 weeks of the initial
screen, and 95% are seen within 5 weeks.
78 There has been considerable public pressure recently
to extend the age of invitation for screening to 69 years. UK
demonstration projects have now been set up to generate further
evidence on the benefits of doing so. In Scotland, the SBSP has
responded by undertaking a pilot study in Inverness involving
women aged 65-69.
79 The Scottish Cervical Screening Programme
of 3-yearly cervical screening (smear tests) of all women between
20 and 60 is now well-established, allowing the identification
of changes which may mean that a woman is at risk of developing
invasive cancer. Early treatment of these lesions results in
the permanent removal of the affected areas and prevents the development
of malignancy. Latest figures indicate that 83% of eligible women
in Scotland have been screened in the last 3½
years. The total number of smears examined runs at about 500,000
per year, 79% of them from women aged 20 - 49. During 1995, guidance
was issued to the Service on three aspects of cervical screening:
fail-safe procedures for dealing with abnormal smear results,
quality control in laboratories and management and purchasing
arrangements.
80 Scientific advance is bringing new possibilities
to the identification of people at risk of developing cancer.
The growing ability to map individualsí genetic makeup,
allowing predictions about susceptibility to disease to be made
at birth and even before, has resulted in a growing demand for
genetic screening. Advances in this field have far-reaching
consequences for health care provision and need careful consideration.
SCCAC set up a working group to assess the need for cancer genetic
services in Scotland, and further work is now being done on the
implications of the groupís recommendations. The emphasis
will be on carefully planned pilot studies rather than wholesale
population screening. This work and its implications will be
supervised by UK bodies such as the Screening Committee and the
Advisory Committee on Genetic Testing. Meantime, the Scottish
Health Service is in a very strong position to make a major contribution
to research in this area through the Governmentís support
of bodies such as the Scottish Molecular Genetic Consortium.
Development of Primary Care
81 Primary Care has always been the first and most
frequent point of contact patients have with the Health Service;
and it is in the GP surgery that the majority of patientsí
health needs are identified. In addition advances in medicine
and technology have significantly altered thinking about the boundaries
between secondary and Primary Care and offer real opportunities
to deliver a wider range of health services outwith hospitals.
It is therefore essential as the Scottish Health Service moves
forward, that we have a fully developed Primary Care system in
which:
ï services
are accessible and provided as close to patientsí homes
as possible; and
ï patient
care is properly planned and well co-ordinated between the Primary
and secondary Care sectors.
82 In this patient-focused Primary Care-centred service,
a broader range of services will be available locally with access
to a network of specialist support services on which they can
call.
83 Some significant developments have already taken
place to widen the range of services offered within Primary Care,
such as child health surveillance, chronic disease management
and minor surgery, and in the ways in which GPs have, through
their purchasing role, secured improvements in specialist services
(e.g. diagnostic services, more locally-delivered outpatient services,
shorter waiting times). There has also been a growing emphasis
on the promotion of good health and the prevention of disease,
including high levels of immunisation and screening for cervical
cancer.
84 Introduced in 1993/94, the Primary Care Development
Fund (currently £3.6m per annum) has supported some 600 local
initiatives and helped the expansion of Primary Care services
by enabling GPs and others to implement their own ideas. Increasingly,
practices are working together, not just to influence and purchase
specialist services for their patients, but also the delivery
of local services. The organisation of out-of-hours care is a
case in point. With the support of Government funding, practices
have established new services such as Primary Care centres where
patients can be given advice or treatment at night and at weekends.
The Government will maintain its support of these developments.
85 One practical step the Government has taken recently
to encourage more staff, including nurses, to choose a career
in Primary Care, is to enable practice staff to join the NHS pension
scheme. This change, which takes effect next September, removes
a long-standing anomaly affecting Scotlandís 1,500 practice
nurses and other staff employed in GP practices who, until now,
have had to make their own pension arrangements.
86 An important component of the Governmentís
plans for Primary Care is the continued development of GP fundholding,
which puts more decision-making about health care in the hands
of GPs. Between 1991 and 1996 the proportion of the population
covered by GP fundholding practices increased from 2% to 43%.
There are now 194 practices in the Primary Care Purchasing Initiative.
A further 23 practices are taking part in 7 Total Purchasing
Pilots, which allow practices, working with the local Health Board,
to purchase the full range of services for their patients. The
pilots are subject to national evaluation. Although the proportion
of Hospital and Community Health Services (HCHS) funding directly
spent by fundholders is still quite small (3.7% in 1995/96), their
influence has been significant in securing improvements for all
patients, and in giving GPs the flexibility to expand services
within their practice. In a number of areas, practices (fundholding
and non-fundholding) have been working together to plan what is
needed in a specific locality to inform and influence the local
Health Board and NHS Trusts. Increasingly, funds are being devolved
to local level to give these local groups more direct influence
over the services their patients need.
87 Consultation on the discussion paper Primary
Care - The Way Ahead (issued in August 1996) revealed widespread
agreement that the overall direction of these policies is correct,
but that there is a need to tackle a number of issues. A recurrent
and underlying message from the consultation is that local arrangements
have to be tailored to meet local needs. This means that more
local flexibility is needed than exists in some of the current
arrangements for Primary Care. The Government has responded by
setting out in the White Paper Choice and Opportunity proposals
for a new legislative framework which will enable the testing
of different approaches to the provision of general medical and
general dental services. Examples include practice- based contracts
instead of the national contract which has existed up until now;
a salaried option for GPs and dentists (either within partnerships
or with other bodies such as NHS Trusts); and a single budget
for general medical services, other hospital and community health
services and prescribing, with the practice responsible for providing
or purchasing services within that budget. It will also enable
additional services to be secured from community pharmacists and
optometrists.
88 Many of the other important issues identified
through the consultation are common to all parts of the UK, and
in relation to England have been discussed in the White Paper
Primary Care - Delivering the Future. Where appropriate,
these will be addressed on a UK basis, but a specific Agenda
for Action in Primary Care in Scotland will be published later
this month. It will set out in more detail a programme within
the broad themes identified in the consultation exercise, under
the general headings Quality of Service, Enhancing Organisational
Capacity, Strengthening Relationships, Involving Patients and
Carers and Resources and Infrastructure.
89 This is a substantial programme of action which
will be discussed with the professions involved. The specific
initiatives which follow, and those elsewhere in this Paper relevant
to Primary Care, are the first step in implementing parts of that
programme.
Initiatives
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