Objectives-To examine the eVectiveness and cost-eVectiveness of two interventions based in primary care aimed at increasing uptake of breast screening. Setting-24 General practices with low uptake in the second round of screening (below 60%) in north west London and the West Midlands, UK. Participants were all women registered with these practices and eligible for screening in the third round. Methods-Pragmatic factorial cluster randomised controlled trial, with practices randomised to a systematic intervention (general practitioner letter), an opportunistic intervention (flag in women's notes prompting discussion by health professionals), neither intervention, or both. Outcome measures were attendance for screening 6 months after the practices had been screened and cost-eVectiveness of the interventions. Results-6133 Women were included: 1721 control; 1818 letter; 1232 flag; 1362 both interventions. Attendance data were obtained for 5732 (93%) women. The two interventions independently increased breast screening uptake in a logistic regression model adjusted for clustering, with the flag (odds ratio (OR) 1.43, 95% confidence interval (95% CI) 1.14 to 1.79; p=0.0019) marginally more eVective than the letter (OR 1.31, 95% CI 1.05 to 1.64; p=0.015). Health service costs per additional attendance were £26 (letter) and £41 (flag). Conclusions-Although both interventions increased attendance for breast screening, the letter was the more costeVective. Any decision to implement both interventions rather than just the letter will depend on whether the additional (£41) costs are judged worthwhile in terms of the gains in breast screening uptake. (J Med Screen 2001;8:91-98) Keywords: cluster randomised controlled trial; breast screening; uptake; primary careBreast cancer is the most common female cancer in the United Kingdom, with an estimated 33 000 newly diagnosed cases and 15 000 deaths occurring each year.1 In 1986, the Forrest Report 2 recommended the provision of a national breast screening programme in the United Kingdom for women aged 50-64 years.The National Health Service breast screening programme (NHSBSP) provides mammographic screening in specialised breast screening units which call women for screening every 3 years through their general practice using "prior notification lists" generated by health authorities. Forrest estimated that if 70% of eligible women attended for screening, a 25% reduction in mortality from breast cancer could be achieved in the United Kingdom. 2The programme as a whole is reaching current targets: in England, 75% of invited women attended for screening in 1996-7.3 However, these national figures hide considerable geographical diversity-at the time of the study, 18 out of 100 health authorities had an uptake rate less than 60%. Health promotion interventions aiming to improve uptake of breast screening often involve the primary healthcare team.4 Such interventions can be systematic, for example, a letter encouraging attendance sent from the general practitioner to all elig...

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Objectives-To examine the eVectiveness and cost-eVectiveness of two primary care based interventions aimed at increasing breast screening uptake for women who had recently failed to attend. Setting-13 General practices with low uptake in the second round of breast screening (below 60%) in north west London and the West Midlands, United Kingdom. Participants were women in these practices who were recent non-attenders for breast screening in the third round. Methods-Pragmaticfactorial randomised controlled trial, with people randomised to a systematic intervention (general practitioner letter), an opportunistic intervention (flag in women's notes prompting discussion by health professionals), neither intervention, or both. Outcome measures were attendance for screening 6 months after randomisation and cost-eVectiveness of the interventions. Results-1158 Women were individually randomised as follows: 289 control; 291 letter; 290 flag; 288 both interventions. Attendance was ascertained for 1148 (99%) of the 1158 women. Logistic regression adjusting for the other intervention and practice produced an odds ratio (OR) for attendance of 1.51 (95% confidence interval (95% CI 1.02 to 2.26; p=0.04) for the letter, and 1.39 (95% CI 0.93 to 2.07; p=0.10) for the flag. Health service costs/ additional attendance were £35 (letter) and £65 (flag). Conclusions-Among recent nonattenders, the letter was eVective in increasing breast screening attendance. The flag was of equivocal eVectiveness and was considerably less cost-eVective than the letter. (J Med Screen 2001;8:99-105) Keywords: randomised controlled trial; breast screening; uptake; recent non-attenders; primary careFollowing the recommendations of the Forrest Report in 1986, the United Kingdom National Health Service breast screening programme oVers 3 yearly mammography to all women aged 50-64 years. 1 The results from recent meta-analyses of the eVectiveness of mammography in reducing mortality from breast cancer in women are contradictory.2 3 The current view in the United Kingdom is that mammography is likely to oVer some reduction of risk but that it is important that women make an informed choice as to whether or not they wish to attend. 4 The success of a screening programme is dependent on achieving high uptake among the eligible population.5 Although the programme overall continues to reach the 70% uptake target, there is considerable variation across the United Kingdom. At the time of the study 18% of health authorities had an uptake rate of less than 60%, 6 most of which included inner city areas.Several observational studies have reported that a primary care physician's recommendation can be the most influential determinant of uptake of mammography, 7-9 and hence it is plausible that interventions involving the primary care team could improve rates of uptake. Indeed, a letter from the general practitioner to recent non-attenders has been shown to be eVective in one small trial in the United Kingdom. 10 Manual prompts in medical records to remind heal...

one. The fact that doctors perceived that they listened, explained things and gave advice less, and gave other help and examined patients more when the patients were from social classes IV and V may reflect the doctors' tendency with patients from these social classes to undertake physical activity more and educate patients less. This trend, and the fact that the doctors gave explanations more to men than to women, may reflect difficulties for the four male doctors from social class I in relating to patients of a different sex and different social classes.The fact that the proportion of patients who were aware of the nature of their problem rose from 28% before the consultation to only 32% after the consultation suggests that the consultation had little educative value. When we look at the causes patients perceived for their problems, however, the most frequently mentioned causes were infection, trauma, stress and social problems, physical and environmental factors, and pregnancy. These relate to a belief that health is governed largely by external factors not under the control of the individual.'0 With regard to lifestyle factors that affect health, such as obesity, alcohol, and smoking, these were perceived by doctors -but not by patients-to cause problems. Only in the case of smoking was this view adopted by patients after the consultation.The wide divergence between doctors and patients about how ill the patient is, the cause and nature of the problem, and the content of the consultation emphasises the gap between doctors' and patients' perceptions. The BMJ 1991;303:292-4 AbstractObjective-To ascertain general practitioners' views about which quality specifications should be included in contracts for hospital care.Design-In depth interview study and postal survey.Setting-General practitioners in City and Hackney Health District.Subjects-Fourteen doctors were interviewed in depth; 77 of 131 doctors (59%) returned postal questionnaires.Main outcome measure-Rating of listed quality specifications.Results-The most popular items which doctors thought should be included in contracts by April 1991 related to the availability of patients' notes in outpatient clinics, respect shown to general practitioners in telephone communications with hospital doctors, supply ofmedicines after discharge, patient management plans for general practitioners, the earlier arrival of discharge slips, the type of hospital doctor to see new outpatients, and the unnecessary duplication of investigations.Conclusions-A high premium was attached by general practitioners to effective organisation, effective communication between primary and secondary sources of care, and effective communication with patients.