Intended for healthcare professionals


Maximising benefit and minimising harm of screening

BMJ 2008; 336 doi: (Published 28 February 2008) Cite this as: BMJ 2008;336:480
  1. J A M Gray, director1,
  2. J Patnick, director 2,
  3. R G Blanks, epidemiologist 3
  1. 1National Knowledge Service, Oxford OX3 7LG
  2. 2NHS Cancer Screening Programmes, Sheffield
  3. 3Institute of Cancer Research, Sutton, Surrey
  1. Correspondence to: J A M Gray muir.gray{at}
  • Accepted 13 September 2007

Gordon Brown has pledged to increase screening services in the NHS. Muir Gray, Julietta Patnick, and Roger Blanks show how experience with the UK breast screening programme can help ensure that they are effective

All screening programmes do harm; some do good as well, and, of these, some do more good than harm at reasonable cost. The first task of any public health service is to identify beneficial programmes by appraising the evidence. However, evidence of a favourable balance of benefit to harm in a research setting does not guarantee that a similar balance will be reproduced in practice, so screening programmes need to be introduced in a way that allows their quality to be measured and continuously improved.

The policy decision

The decision to implement a breast cancer screening programme in the United Kingdom in 1987 was based on evidence of efficacy from other countries, especially Sweden. The Department of Health set up a committee to review the evidence, chaired by Pat Forrest, a leading researcher in treating and screening for breast cancer. His committee’s analysis of evidence and recommendations1 has been criticised,2 but the government accepted the review’s conclusions and decided not only to introduce screening for breast cancer for women aged 50-64 but also to fund a project to ensure that screening was introduced in a way most likely to ensure that the benefits found in the Swedish trial3 would be reproduced throughout the UK. Four crucial decisions were taken:

  • To introduce a standardised screening system across the whole country

  • To recommend a minimum size of screening unit to optimise quality and enable evaluation

  • To fund quality assurance and training centrally and develop continuous quality improvement

  • To fund an implementation project.


A small implementation team was set up, with its director held accountable both to the Department …

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