Half a Century of Wilson & Jungner: Reflections on the Governance of Population Screening.

Background: In their landmark report on the "Principles and Practice of Screening for Disease" (1968), Wilson and Jungner noted that the practice of screening is just as important for securing beneficial outcomes and avoiding harms as the formulation of principles. Many jurisdictions have since established various kinds of "screening governance organizations" to provide oversight of screening practice. Yet to date there has been relatively little reflection on the nature and organization of screening governance itself, or on how different governance arrangements affect the way screening is implemented and perceived and the balance of benefits and harms it delivers. Methods: An international expert policy workshop convened by Sturdy, Miller and Hogarth. Results: While effective governance is essential to promote beneficial screening practices and avoid attendant harms, screening governance organizations face enduring challenges. These challenges are social and ethical as much as technical. Evidence-based adjudication of the benefits and harms of population screening must take account of factors that inform the production and interpretation of evidence, including the divergent professional, financial and personal commitments of stakeholders. Similarly, when planning and overseeing organized screening programs, screening governance organizations must persuade or compel multiple stakeholders to work together to a common end. Screening governance organizations in different jurisdictions vary widely in how they are constituted, how they relate to other interested organizations and actors, and what powers and authority they wield. Yet we know little about how these differences affect the way screening is implemented, and with what consequences. Conclusions: Systematic research into how screening governance is organized in different jurisdictions would facilitate policy learning to address enduring challenges. Even without such research, informal exchange and sharing of experiences between screening governance organizations can deliver invaluable insights into the social as well as the technical aspects of governance

General practitioners are key to increasing Australia’s low rate of breast reconstruction

In Australia, the rate of breast reconstruction after mastectomy for breast cancer has unacceptable variation between socioeconomically and geographically similar areas. While some centres offer a full range of options and contemporary best practice, others do not give women information about options that should be available for all. General practitioners (GPs) have a key role to play by ensuring their patients have the opportunity for an informed discussion with multidisciplinary teams (MDTs) that offer choice

Fifteen years of bowel cancer screening policy in Australia: putting evidence into practice?

Bowel cancer kills over 4000 Australians each year. From the late 1980s to October 2005, research evidence guided the development of bowel cancer screening policy proposals, but political, financial and institutional constraints restricted implementation options. Since 2006, the Australian Government has provided a limited bowel cancer screening program, based on what the government deems it can afford, rather than on evidence of what is required to implement a successful population-based screening program. Even a partial program can be implemented in an evidence-based way, and failure to do so threatens to undermine the potential public health gains of a national bowel cancer screening program. To realise the expected public health gains from a national bowel cancer screening program, bowel cancer screening policy should return to its evidence-based beginnings, starting with an analysis of Australian age-specific cost-effectiveness data

A comparative case study of bowel cancer screening in the UK and Australia: Evidence lost in translation?

Objectives (i) To document the current state of the English, Scottish, Welsh, Northern Irish and Australian bowel cancer screening programmes, according to seven key characteristics, and (ii) to explore the policy trade-offs resulting from inadequate funding. Setting United Kingdom and Australia. Methods A comparative case study design using document and key informant interview analysis. Data were collated for each national jurisdiction on seven key programme characteristics: screening frequency, population coverage, quality of test, programme model, quality of follow-up, quality of colonoscopy and quality of data collection. A list of optimal features for each of the seven characteristics was compiled, based on the FOBT screening literature and our detailed examination of each programme. Results Each country made different implementation choices or trade-offs intended to conserve costs and/or manage limited and expensive resources. The overall outcome of these trade-offs was probable lower programme effectiveness as a result of compromises such as reduced screening frequency, restricted target age range, the use of less accurate tests, the deliberate setting of low programme positivity rates or increased inconvenience to participants from re-testing. Conclusions Insufficient funding has forced programme administrators to make trade-offs that may undermine the potential net population benefits achieved in randomized controlled trials. Such policy compromise contravenes the principle of evidence-based practice which is dependent on adequate funding being made available

Getting evidence into policy: The need for deliberative strategies?

Getting evidence into policy is notoriously difficult. In this empirical case study we used document analysis and key informant interviews to explore the Australian federal government's policy to implement a national bowel cancer screening programme, and the role of evidence in this policy. Our analysis revealed a range of institutional limitations at three levels of national government: within the health department, between government departments, and across the whole of government. These limitations were amplified by the pressures of the 2004 Australian federal election campaign. Traditional knowledge utilisation approaches, which rely principally on voluntarist strategies and focus on the individual, rather than the institutional level, are often insufficient to ensure evidence-based implementation. We propose three alternative models, based on deliberative strategies which have been shown to work in other settings: review of the evidence by a select group of experts whose independence is enshrined in legislation and whose imprimatur is required before policy can proceed; use of an advisory group of experts who consult widely with stakeholders and publish their review findings; or public discussion of the evidence by the media and community groups who act as more direct conduits to the decision-makers than researchers. Such deliberative models could help overcome the limitations on the use of evidence by embedding public review of evidence as the first step in the institutional decision-making processes.Australia Health policy Decision-making Evidence Knowledge utilisation Bowel cancer Screening Deliberative