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CMOs’ recommendations for the expanded remit of the UK NSC

Updated 22 June 2022

The 4 UK chief medical officers (CMOs) made the following recommendations for the expanded remit of the UK National Screening Committee (UK NSC).

Recommendation 1

The new screening committee with its expanded remit should retain its current branding of ‘UK National Screening Committee’.

Recommendation 2

The UK NSC should adopt the following definitions:

Risk assessment as part of routine clinical care:

The person (patient) seeks healthcare, usually because of symptoms of active disease and/or concerns about their health. The clinician assesses the person’s risk of disease and may use their judgement to offer test(s) for associated conditions. Invitations for such testing and subsequent management are not centralised or nationally organised and therefore are not considered as screening programmes.

Population screening:

A nationally delivered^{[footnote 1]}, proactive^{[footnote 2]} screening programme which aims to improve health outcomes in people with the condition being screened for and/or offer information to enable informed choices. It is offered to a group of people identified from the whole population and defined demographically such as by age or sex as appropriate.

Targeted screening:

A nationally delivered proactive screening programme which aims to improve health outcomes in people with the condition being screened for, among groups of people identified as being at elevated/above average risk of a specific condition. Compared to the general population, the people targeted may have higher risk because of lifestyle factors, genetic variants or having another health condition.

Targeted screening differs from population screening as it aims to identify groups of people with a higher risk of a specific condition beyond demographics such as age or sex. For example, individuals who smoke are at a higher risk of developing lung cancer regardless of their age or sex.

Stratified screening:

A nationally delivered, proactive approach to screening, offering testing which varies in frequency and modality (type of test offered), according to the level of individual risk. This is designed to achieve a more favourable balance of benefits and harms at individual as well as population level. Stratified screening can be used to complement both targeted and population screening programmes. For example, people with a family history of breast cancer can be referred to a high risk clinic and are screened more often depending on their level of risk.

Recommendation 3a

It is recommended that the UK NSC will:

• continue to use the current population criteria to assess proposals for population screening programme; and,
• separately, assess proposals for targeted screening programmes

Recommendation 3b

The UK NSC should adopt the following targeted screening criteria as part of its evidence review process:

i. The health impact of the condition and its course should be understood, with evidence that serious disease can be identified or predicted by an agreed level of identifiable risk or marker.

ii. There should be evidence from appropriately designed studies and models on cost effectiveness for the:

• screening test – this should be a simple test that has evidence of suitable accuracy and technical performance derived from studies in the population in which the test is being used
• intervention – there should be better outcomes from early intervention/ those at a pre-symptomatic stage, for the screened individual, compared with usual care

iii. There should be a diagnostic investigation available for individuals with a positive test screening result, with evidence that subsequent tests can distinguish between those who would benefit from interventions, from those who would not.

iv. The overall benefits from the screening programme should outweigh the harms; for example, from overdiagnosis, overtreatment, false positives, false reassurance and uncertain findings.

v. There should be a robust and inclusive evidence-based selection criteria for identifying those eligible for targeted screening.

vi. There should be evidence that the screening programme is acceptable to the public and health professionals, with appropriately balanced information available to those invited to attend screening.

vii. The UK NSC carries out a feasibility assessment (informed by NHS practice) that indicates the screening programme would be achievable; with evidence for monitoring and quality assuring the programme, adequate staffing and facilities being available to meet the requirements of programme delivery.

Recommendation 3c:

The targeted screening criteria should be regularly reviewed by the UK NSC to ensure they remain relevant and that any potential disparities in recommendations for population and targeted screening programmes can be monitored and addressed.

Recommendation 4a:

The UK NSC secretariat should establish a closer working relationship with NICE and SIGN by appointing expertise in clinical care guidelines to the committee.

Recommendation 4b:

It is suggested that the secretariat for the new UK NSC expands the evidence review process to include potential targeted screening programmes and should consider as a minimum:

• any additional steps that need to be factored in for proposals for targeted screening programmes
• the process for working with NICE and SIGN on clinical care guidelines
• any additional steps for evaluating a stratified screening approach for either population or targeted screening programmes

Recommendation 5:

Following a positive recommendation from the UK NSC, the minister asks the committee to convene a feasibility assessment sub-group to assess how a new screening programme or modification to an existing programme might feasibly be introduced. The assessment would indicate what resources and changes would be required to ensure a screening programme would be delivered and to an agreed timescale, with evidence to show what monitoring and quality assuring the programme, adequate staffing and facilities would be required to meet the requirements and timescales of programme delivery.

Recommendation 6a:

The secretariat for the UK NSC should continue with its efforts to improve stakeholder engagement and considered whether additional/different engagement will be needed for decisions made around targeted and stratified screening.

Recommendation 6b:

Once the expanded remit of the UK NSC is established, the secretariat should consider how to reduce the burden on PPV representatives in attending 3 UK NSC main meetings per year, sub-group meetings and the associated reading.

Recommendation 7:

In order to foster greater horizon scanning and research links the UK NSC should:

• hold an annual horizon scanning forum to identify potential developments related to screening; and

• establish a research sub-group to keep abreast of ongoing research related to screening, identify research requirements, and advise on mechanisms to address them

Recommendation 8:

The UK NSC secretariat adopts the following revised terms of reference for the new UK NSC and that these are reviewed on a regular basis.

The new UK NSC is an independent scientific committee that:

• is accountable to the 4 CMOs, who agree work plans for the UK NSC on an annual basis

• advises ministers and the NHS in the 4 UK countries about all aspects of screening including the case for introducing new population and targeted screening programmes and for continuing, modifying or withdrawing existing population programmes against a set of internationally recognised criteria

• supports implementation of screening programmes in the 4 countries including the development of high-level standards and maintains oversight of the evidence relating to the balance of good and harm as well as the overall cost effectiveness of existing programmes

• works with partners to ensure it keeps abreast of scientific developments in screening, including screening research, screening policy in other countries and emerging technologies with a particular focus on stratified screening

• works with partners to facilitate research that is required to provide evidence for new programmes or modifications to existing programmes

• ensures that screening recommendations are embedded in a robust ethical framework and that they reduce inequalities

• works with partners to optimise communication with the public, government and health professionals on all screening matters

• engages with the National Institute for Health and Care Excellence (NICE) and the Scottish Intercollegiate Guidelines Network (SIGN) at the interface between screening programmes and clinical guidance

Recommendation 9:

The new screening committee should expand its membership in line with the expanded remit, including but not limited to:

• clinical care guidelines
• disease and cost effectiveness modelling including stratification expertise
• genomics in the NHS
• research in screening – expertise for the research sub-group
• implementation science
• use of big and linked data sets
• reducing inequalities

1. Nationally delivered in England, Scotland, Wales and Northern Ireland ↩

2. Individuals are actively invited for screening ↩