The GPs in this study were generally positive towards the introduction of the BCSP, regardless of their involvement in the pilot phase of screening. However, GPs held a number of reservations with regard to the programme. Prominent amongst these were concerns for the welfare of potential screening participants, relating to the impact of an increasing culture of screening on people's lives, the potential anxiety caused by the screening process, and issues with the reliability of the FOB test which may impact on patients. The need for good information materials to support the whole primary care team was emphasized, as was the importance of quality patient information. GPs also expressed concerns relating to levels of patient participation in the programme, and the additional workload which the new programme may generate for primary care. Both pilot and non-pilot GPs held similar concerns with regard to the introduction of the BCSP. However, these concerns were rarely confirmed through the experience of the pilot GPs.
The study provides a unique qualitative examination of the attitudes of GPs towards the first new cancer screening programme to be introduced in England for several years. The sample included both GPs who have been involved in the bowel cancer screening pilot and those who have not. GPs practiced in a range of locations, and with diverse patient populations. A possible limitation of the study is the small number of GPs involved, although the vast majority of GPs came from different practices. Whilst data saturation was reached, a convenience sample was used to recruit non-pilot GPs which may have been biased towards individuals holding positive attitudes regarding screening for bowel cancer. Furthermore, only a small number of GPs in the sample reported practising in areas with large numbers of ethnic minority patients. Ethnic minority groups were associated with lower levels of participation in the pilot [10
], and those GPs in the current sample who did practice in areas with large numbers of these participants reported increases in patient appointments. Therefore, further work with GPs such as these, who may have different experiences with the programme, is required.
The concerns raised by GPs relating to the welfare of screening participants are not unique to bowel cancer screening. UK GPs are generally positive about breast screening, for example, although hold concerns relating to pain and discomfort caused by testing, false reassurance derived from results, and problems caused by false positive results [11
]. Evidence from outside the UK healthcare system has also highlighted GPs' concerns with screening for Bowel Cancer (although primary care involvement in screening differs in countries outside the UK). Family Doctors in one Canadian study reported rarely using FOB testing for screening due to a number of serious limitations, including low yield, high rates of false positives and false negatives, and a number of technical problems [12
]. Similarly, only 38% of GPs in an Australian survey study indicated the belief that FOB testing was an effective means of reducing premature death from bowel cancer [13
The GPs in this study highlighted the importance of the provision of high quality information to all parties involved in the National Health Service Bowel Cancer Screening Programme – both health professionals and patients. The significance of providing evidence based information to support GPs and promote shared decision making in bowel cancer screening has been highlighted elsewhere [12
], and in the UK, primary care teams are provided with detailed information to assist in providing information to patients on the risks and benefits of the PSA test as part of the Prostate Cancer Risk Management Programme [14
]. The provision of high quality information to patients is similarly important in decision making regarding screening, and decision aids can increase knowledge and reduce decisional conflict in individuals deciding whether or not to participate in screening [15
]. Informed choice is a central theme of the new screening programme [8
], and whilst GPs in the current study indicated that they would be willing to promote informed choice amongst potential screening participants, they stressed that their own information needs must first be addressed. It is important that information materials for primary care are matched to GPs information preferences. The most important factor for many GPs related to ease of use on a day to day basis. Concise information that can be quickly digested by GPs, understood by patients, and used by all members of the primary care team would maximise the efficiency of information provision to potential screening participants. Similarly, whilst GPs accepted that managing patient anxiety is an acceptable use of their time, a number felt that the risks of screening ought to be made more apparent to potential participants at the outset. GPs felt that the provision of high quality information to patients would promote understanding of the risks and benefits of screening, and may therefore help to alleviate some of the potential problems experienced by patients. This in turn could alleviate some of the additional workload impact on the GPs themselves.
GPs and other members of the primary care team will not be directly involved in organisational aspects of the BCSP, although they are a potentially important point of contact for patients with queries relating to any stage of the screening process. Pilot GPs in this study did not report large numbers of additional appointments, reflecting the "modest but discernable" increase reported in a previous survey and audit of practices participating in the pilot [4
]. However, survey data from the first round of the screening pilot indicated that a significant proportion of individuals with positive test results and screen-detected cancers consulted their GPs [10
], and it is inevitable that there will be some increase in patient queries during the roll out of the programme. Therefore, the support of primary care will be important for the new programme. It is interesting to note that whilst pilot GPs reported rarely meeting worried patients and surprise at the apparent high level of participation, data from the first round of the screening pilot indicates that overall uptake was 59% in England, with uptake lowest in areas with the highest proportion of residents from the Indian-subcontinent [10
]. Indeed, the GPs in the current sample with significant numbers of ethnic minority patients proved to be an exception in that they did experience significant increases in patient consultations, reporting that they were happy to be in a position to assist these individuals. When the national programme commences, primary care may be well placed to assist in providing information and support to hard to reach groups with special needs, such as those with poor English language skills, complications caused by pre existing medical conditions, or unusually high levels of anxiety.
It is also important to note that pilot enjoyed particularly high standards of efficiency, which compelled a number of GPs to comment unprompted on how well it had been run. The pilot GPs in our study rarely reported using the educational materials provided to them. The main reason cited for this was the exceptional quality of briefing sessions, and the high level of support provided both to primary care and to patients by the screening team. If this quality is not maintained, therefore, then the provision of high quality information will be of greater significance both to primary care and to patients during the programme itself than during the pilot.