involve shifting funds from other services. In addition, the ‘inverse care law’ (Hart 1971),
which suggests that those who seek out tests most frequently are often those who
need them the least, when applied to screening, highlights a shifting of finances to the
most healthy individuals in society.Is screening cost-effective?
The second problem with screening concerns its cost-effectiveness. A cost-effectiveness
analysis involves assessing either how to achieve a set objective at minimum cost or how
to use a fixed resource to produce the best output. In terms of screening, this raises issues
about the objectives of screening (to detect asymptomatic illness, which can be treated)
and the degree of resources required to achieve these objectives (minimum interventions
such as opportunistic weighing versus expensive interventions such as breast screening
clinics). The economic considerations of screening have been analysed for different pol-
icies for cervical screening (Smith and Chamberlain 1987). The different policies include:
(1) opportunistic screening (offer a smear test when an individual presents at the sur-
gery); (2) offer a smear test every five years; (3) offer a smear test every three years; and
(4) offer a smear test annually. The results from this analysis are shown in Figure 9.1.
These different policies have been offered as possible solutions to the problem of screening
for cervical cancer. The results suggest that annual screening in England and Wales
would cost £165 million and would potentially prevent 4300 cancers, whereas smears
every five years would cost £34 million and would potentially prevent 3900 cancers.
The problem of cost-effectiveness is also highlighted by a discussion of the OXCHECK
and Family Heart Study results (Muir et al. 1994; Wood et al. 1994). Both studies
indicated that intensive screening, counselling and health checks have only a moderate
effect on risk factors and the authors discuss these results in terms of the implications for
government policies for health promotion through doctor-based interventions.Fig. 9-1 Costs per potential cancer prevented for different screening policies (after Smith
and Chamberlain 1987)224 HEALTH PSYCHOLOGY