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Screening chief cautious over GPs' future role

CVD assessment and gene tests next for GPs, but private tests face clampdown

'We're not talking about a screening programme,' says the director of the National Screening Committee.

Professor Sir Muir Gray is very keen to get this point across. He is very sure what is, and what isn't, screening. In April, guidance will reach PCTs on how they should be assessing cardiovascular risk across the UK population.

If, as everyone expects, the 2008 edition of the quality and outcomes framework pays GPs for assessments, every man and woman in the UK will have their risk calculated at key points in their lives.

But Sir Muir insists: 'We didn't feel the word screening was appropriate. It's not like breast cancer screening where you find some people have breast cancer and others don't. Everyone's at risk – so we call it a cardiovascular risk assessment programme.'

Whether it is screening or just mass risk assessment, the planned programme is one of Sir Muir's key achievements in 20 years of work, which has also focused on screening for cancer and in pregnancy.

But given that he is the country's leading expert on the subject, Sir Muir is surprisingly cautious about screening's value. 'When you think of screening programmes, the first thing to remember is they all do harm,' he insists. 'Some screening programmes do good as well. And some do more good than harm at a reasonable cost.'

He has major concerns about private screening, which again it seems, is not really screening at all. 'We define screening as a set of activities that lead to a diagnosis. The people who advertise what they call screening are just offering the initial test and the health service then has to pick up the consequence.

'Lots of GPs I know are very concerned about people who go to a private clinic for a blood test and then the people who run it say: "Oh your kidney results look a bit funny – just go and see your GP."'

Tougher regulation

Tougher regulation is going to be a key future focus of the committee.

But Sir Muir feels other forms of testing will be much more valuable. He predicts a big increase in use of genetics in general practice, describing it as the 'dominant theme' for the next few years.

Vascular assessment will also have clear benefits, he believes.Details of the forthcoming programme are currently being settled by the UK's four different departments of health, but it is clear assessing cardiovascular risk will become a key part of general practice.

'If you look, they're doing it at the moment,' he says. 'There's terrific activity because of the QOF, but almost everyone is doing something different from the person next door.'

He neatly sidesteps the issue of how GPs will be paid, saying: 'One of my principles in 35 years is never to understand how GPs are paid.'

This isn't so much a wilful blindness to doctors' concerns – more a refreshing disdain for target-driven, incentive-based medicine.

'I never understood the Red Book,' he adds. 'When I used to go into the LMC they always said: "Oh the Red Book says we can't do this." And I used to say I've never opened the Red Book – let's discuss what is the right thing to do and the payment system has to adapt to that.'

In comparison with some in the current health service, Sir Muir is – almost shockingly – unconcerned about money.'The one thing people are short of in the health service is time, not money. Money may be short but you can find more – you can't find more time. From our point of view the number one thing we think of is time.'

This is not to say that pragmatism has not played a part in his strategies – witness the committee's stance on PSA testing, where it said men could have a test for which there is no real evidence, provided they understand there is no real evidence.

'This has been one of our very difficult areas,' he admits. 'Simply saying to GPs to tell men to go away is not possible with the pace of a morning clinic. Some men become anxious about prostate cancer.'

In summing up the core of a GP's role, Sir Muir comes to a simple conclusion: 'The best role for GPs is dealing with these very complex health problems with remarkable speed and skill. You wouldn't want to see GPs spending a lot of their time measuring the blood pressure of healthy people.' Presumably that really would be screening.


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