An economic view of high compliance as a screening objective

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Abstract
Accepted wisdom holds that high compliance is essential for a screening programme to be successful. Indeed, a reason that the national breast screening programme is not routinely offered to women aged 65 or more is on the grounds of predicted poor compliance by older women. Increasing compliance is often associated with increased costs. These costs represent a lost opportunity for screening alternative target populations. We question the need for screening programmes to achieve high compliance, and we argue that a screening programme can be efficient with very low levels of compliance. Adopting compliance as a screening objective and as a measure of the success of screening may be detrimental to the efficiency of a screening programme. The level of compliance in a screening programme is often seen as one measure of its success.1 Compliance can be defined as the proportion of a target population that actually has the screening test, and compliance rates feature strongly in policy recommendations regarding screening. The new general practitioner contract has targets of 50% and 80% compliance for cervical screening, and, for people aged over 75, 100% compliance for annual health checks is expected.2 Forrest recommended that routine breast screening should not be extended to women aged over 65 because of expected poor compliance in this age group.3 This emphasis on the importance of compliance as a measure of success in breast screening was repeated in a recent report on the NHS breast screening programme.4 The aim of this paper is to assess whether compliance is a good measure of success in screening. This is important because compliance in itself is not, of course, the real objective of screening. Compliance is merely a proxy objective that may be more easily measurable than the real screening objective. In order to assess whether …