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GPs go forth

We've lost momentum in our fight against cervical cancer

Dr Ellie Cannon

I feel like I document this very often after a brief conversation with the female patient in front of me. But the truth is, after that QOF tick, I don’t often think about what happens next.

The worrying reality is that it’s probably not what we would all like to think.

This year marks the 10th anniversary of Jade Goody’s death, and screening rates for cervical cancer are at their lowest since records began in 1995. Just 71.4% of those eligible are being screened, with an estimated 1.28 million women not taking up their screening opportunities.

It is time for GPs to ask ourselves why and what we can do as individuals, practices and CCGs to improve rates. There are big conversations to be had. I took the sobering step of looking up cervical screening rates in my CCG and I recommend you do the same: I discovered my CCG to be in the bottom five for the lowest rates of screening across all age groups. Something has gone pretty wrong.

There are many barriers to screening for all eligible women, and as primary care has evolved since 1995, it would appear just getting through the door for many women has just become a pain. It’s not easy any more for a woman to pop into her local sexual health clinic and get a smear while she gets her Pill – many sexual health clinics have closed and even in those remaining, changes in commissioning means that smear access has declined. So the onus is very much on the GP surgery, more than it ever was.

But women find accessing GP or practice nurse appointments difficult, as we all know only too well, but more so for a smear test. The test isn’t deemed important enough to take an hour off work - and the lack of evening and weekend appointments puts off these women with far greater priorities in the daytime.

Practice nurses are hard to recruit in some areas and not all GP practices are lucky enough to have one full time. Combine that with many GPs not being registered smear takers, and the chances of a suitable appointment just go down and down. And then the male GPs need a chaperone. It is easy to see how the barriers are so high.

GP endorsement has a positive effect on attendance rates - let's invite and welcome, not summon

And these are merely the barriers for the average enabled female patient. Once we look at the more vulnerable groups, there are even more problems.

Although annual NHS figures do not reveal ethnic groupings, figures from Jo’s Trust reveal a disparate and prejudicial state of affairs when it comes to smears, that I expect many GPs do not realise.

While 8% of white women have never attended a screening, the figure rises to 12% for BAME women. A staggering 30% of Asian women do not know what cervical screening is; for this community, language and cultural barriers often empower an erroneous view of the screening process and a low perceived risk of cancer associated with no sex before marriage. And whereas 45% of white women would talk to a male GP about cervical screening, only 28% of BAME women would. Leaving the other women talking to whom about screening? Possibly no-one.

And other groups may be similarly at risk. Figures from the LGBT Foundation show 17.8% of lesbian, gay and bisexual women of screening age have never attended their smear, with a staggering 40.5% of LGB women being incorrectly told at some point that because of their sexual orientation, they do not need one. Along with added embarrassment from having to disclose sexuality, this adds to declining rates within this community. HPV is not a virus exclusive to women who sleep with men, but there are still pervasive myths that it is.

Likewise, we are missing those who have suffered sexual assault and trauma, women with FGM and those with physical or learning disabilities who can find access and support much harder than most, yet they are still being burdened with the same risk. Even with everything else on our shoulders in primary care, we can surely do better.

After a hugely engaging campaign in January from Jo’s Trust, Public Health England will be launching a national screening campaign this March, to encourage all eligible women to accept their invitation of cervical screening.

As well as reaching out to the public with this message and changing behaviours, there is at least something healthcare professionals and especially we GPs can do to increase uptake of screening amongst women.

Have a look at your invitation letter. Evidence demonstrates that GP endorsement does have a positive effect on women attending – each standard letter can include welcoming data for your practice: the opening hours, the gender of the smear takers and an offer of a conversation prior to a smear to allay fears. Let’s invite and welcome, not summon.

Can your disabled patients access smears? Should your team be considering home visits for a smear or arrangements for them to access in the hospital?

Embarrassment is still a big deal for many and that can be hard for healthcare professionals to empathise with. A third of women said embarrassment stops them attending: it’s well within our remit to acknowledge this and discuss it, not dismiss it. The simple matter of how a consulting room looks and feels to a patient can help.

3,000 women are diagnosed with cervical cancer each year in the UK and it is the most common cancer in women under 35. It is one of the few cancers for which we have a screening programme, and it’s simply our duty to enable our female patients to access it.

Dr Ellie Cannon is a portfolio NHS GP in London and broadcast media doctor

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Readers' comments (8)

  • It's not really clear whether non-attendence for smear is a significant problem, given that I understand that cervical screening has not been shown to improve all cause mortality.

    (see, for instance,

    Perhaps the women who do not attend are making a reasonable choice?

    If anyone has found data showing reduced all-cause mortality, please do post below!

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  • Cobblers

    Not sure that screening of any kind should be part of a GPs remit. We have done it in the past, sure, but now with the pressure of work?

    Happy to be shot down on that but don't use the argument that there's no-one else to do it!

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  • And yet death rates for cervical cancer continue to plummet-as they have done since the early 1970s!!

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  • Cobblers

    Food for thought.

    Cervical cancer mortality rates have decreased overall in some broad age groups in females in the UK since the early 1970s, but have remained stable in others. Rates in 20-24s have remained stable, in 25-34s have remained stable, in 35-49s have decreased by 67%, in 50-64s have decreased by 83%, in 65-79s have decreased by 75% and in 80+s have decreased by 65%.

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  • Another Dr trying to volunteer everyone else for more unpaid work. With friends like this....

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  • Ah yes,"after that QOF tick...I don't often THINK what happens next.".

    Add it to the list of things which are also done badly (apart from the keyboard flourish which applies the tick in way that Picasso would applaud) but are less emotive than "Cancer".

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  • National Hopeless Service

    Access in my practice hasnt changed. Its a societal issue. Free healthcare has downsides. In insurance/co-payments systems you pay higher rates/dont get cover if you dont participate in screening schemes.

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  • As always causes are multifactorial and depend on the definition of 'success'.

    First, the continuous erosion of patients being required to take responsibility for their own welfare.
    Second, The loss of the 'Jade Goody effect'.
    Third, the overwhelming workload in GP which has to lead to prioritising what we do - and national screening programmes do not feature highly.
    Fourth, and as indicated by other commentators above, professional realism about the success of the programme. Yes, if you measure success in terms of percentage of women screened, then the programme is failing. But, if you measure it in terms of mortality, then there is little to indicated that the scheme does any good at all. And then there are the downsides (unnecessary interventions, cervical incompetence etc) which are always played down in all screening programmes.

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