Screening policy within the healthcare system

There should be a national and governmental context for planning of CRC screening. The programme needs political support with sustainable funding to succeed. If appropriate structures in the healthcare system are lacking, screening should not be implemented until they are developed, for example using the implementation phase to build up the needed structures.

 It is essential that the programme is integrated into the healthcare system and is accepted by both the population and health professionals involved in the diagnostic process for CRC. Organisation of the screening programme should integrate the structures of the entire health care system appropriately and it should comply with national guidelines and protocols. Within the organisational framework of the programme, the target population should be defined as well as the frequency of screening. Provisions should be made for the financing of the programme, including evaluation costs. 

The professional and organisational managers of a screening programme must have sufficient authority and autonomy, including an identified budget and sufficient control over the use of resources to effectively control the quality, effectiveness and cost-effectiveness of the programme and the screening service. The institutional structure must facilitate effective management of quality and performance. 

 Process and outcome indicators should be constantly evaluated to serve the needs of the individual and the health service. 

Adequate protection of all data should be ensured, following requirements set by European directives concerning data protection and national privacy legislation. 

Local conditions at the start of a programme 

Before implementation of a screening programme, an inventory of baseline conditions including information on opportunistic screening rates, background CRC incidence rates and availability of endoscopic resources should be made. 

In order to run a successful programme, adequate resources, in terms of both staff and facilities must be available, and an adequate infrastructure must be in place. 

Colonoscopy is the final common denominator of all the CRC screening strategies. Therefore, as the implementation of any form of population screening for CRC will place greater demands on colonoscopy resources, the feasibility of CRC screening also depends on the availability of colonoscopy services. There may also be limitations to access for subjects in rural or remote areas and in the public health sector. Clearly, CRC screening is only feasible if access can be guaranteed to individuals who participate in screening. 

In many European countries, CRC early detection activity exists in some form, e.g. testing personally initiated by patients, or as a component of private health care. According to the findings of a recent survey conducted in 10 European countries and in Canada, about 10% of colonoscopies are performed for screening (Burnand et al. 2006). However a wide variation was found in the occurrence and in the appropriateness of the exams. The inappropriateness rates ranged between 0% and 50%. Similarly the proportion of colonoscopies performed following clinical indications which were judged to be inappropriate was about 25%, suggesting overuse of the exam. Even if screening exams should be delivered within dedicated sessions (see also Chapter 5), promoting a more appropriate use of colonoscopy might therefore increase quality of care and favour an efficient use of available resources. As suggested by simulations conducted in the US (Seeff et al. 2004) a more efficient use of colonoscopy resources may result in an increase in the capacity to meet the demand of screening-induced colonoscopies. 

 It is unlikely, however, that simply providing funds to increase existing activity will enable the programme or screening policy to be successful. In parallel with introducing the general principles of organised screening, governments should consider the introduction of administrative measures (i.e. not paying for unnecessary exams) and implementing educational interventions aimed at enhancing appropriateness of colonoscopy referrals. In some countries, re-allocation of resources already used for opportunistic screening activities will be sufficient to cover the entire target population within a defined screening interval.