Screening in general practice and primary care.

General practice and its associated primary care services are the final common pathway for the delivery of most screening programmes. The absence of nationally agreed priorities, guidelines and identifiable resources has meant that screening in primary care remains somewhat arbitrary, practice varies widely and programmes remain largely unevaluated. Discussion of screening has focused largely on test characteristics and performance with less attention being given to issues of policy formation, priority setting, implementation and quality assurance. Without these elements, quality and test performance deteriorate, recruitment and follow-up are incomplete and a poorly discriminating test of doubtful utility is applied inequitably and inefficiently. For general practice there are two major concerns. The first is to improve delivery of programmes of proven efficacy, such as breast or cervical screening, that already have a national framework. The second is to develop and provide a national structure for preventive programmes for cardiovascular and smoking-related disease. For cardiovascular disease, the issue is no longer whether to screen and advise whole populations for multiple risk factors, but how best to implement this programme. In this chapter, the case for screening for cardiovascular disease is reviewed and potential strategies for improving delivery of screening in general practice and primary care discussed.