Flattening the social gradient in cancer care

Disadvantaged groups generally experience worse health, for a complex variety of reasons. Furthermore, they are also less likely to take up services and, once they enter the health system, receive poorer levels of care. Professor Raine aims to document and understand these inequalities, and identify practical ways in which they can be overcome.

One recent major study examined the social gradient in screening for colorectal cancer. Established in 2006, the English national bowel cancer screening programme invites adults aged 60-74 to participate in screening every two years. Take up is lower than for other longer-established screening programmes, particularly among disadvantaged groups and certain ethnic minority populations [1].

Attempts to increase uptake of screening programmes often focus on specific populations. However, this can exclude other underserved groups, and may rely on intensive approaches that would be difficult to implement within a routine programme. Professor Raine therefore set out to develop an intervention that increased population-wide participation in the bowel cancer screening programme but also reduced the social gradient in uptake - and, importantly, would be readily implementable in the existing programme.

Her first task was to identify the reasons behind non-participation. Focus groups with target populations revealed several key factors influencing decision-making [2]. These included a sense of fatalism and a desire not to know until the last possible moment, attitudes that were more common among the economically disadvantaged. Discussions with those who had initially decided not to participate but then changed their mind were particularly fruitful, identifying approaches that were particularly effective at shifting people's intentions to participate. These included reminders stating that it was not too late to participate as well as information pointing out that early treatment was simple and much preferable to complex procedures at later stages of cancer [3].

Professor Raine's team also liaised closely with key stakeholder groups, particularly GPs and staff in the national screening programme. The idea was to develop interventions that took account of the qualitative findings and health psychology theory but worked within the constraints of the existing programme - even down to maintaining the size of information leaflets.

Four interventions were developed. Two focused on how information was presented - one telling stories about 'people like me' who benefited from screening and one focusing on presenting information as simply as possible. In the third intervention, GPs were brought on board nationally so that invites included a GP endorsement - addressing the issue that some recipients disregarded invites as 'junk mail'. The fourth intervention was based on an enhanced reminder letter.

After extensive piloting and refinement, the interventions were evaluated in a large randomised controlled trial integrated into the national screening programme. The two new leaflets had no significant impact on uptake (possibly because the research team was required to use them in conjunction with, rather than instead of, existing materials). GP endorsement increased uptake but had no impact on the social gradient, but the enhanced reminder achieved the holy grail - both increasing uptake and flattening the social gradient [4].

Modelling suggested that use of the enhanced reminder would increase the numbers screened by 59,000 a year and detect 340 additional suspect cancers, at no extra cost. It was rapidly implemented within the national screening programme and endorsed by the National Screening Committee within six months. GP endorsement has proven slightly harder to implement, but has been picked up by two out of five screening hubs and is likely to be adopted more widely.

Reasons for variation in care

Another important goal of Professor Raine's work in cancer is to understand reasons behind variations in care. In early work, her group used routinely collected health data to identify marked sociodemographic and age-related variations in care. Older people were less likely to be prescribed secondary stroke medication (even though they would be just as likely to benefit from it) [5]. In addition, socially disadvantaged groups were less likely to receive recommended treatments for cancer and were more likely to undergo emergency admission because of their cancer [6]. Further studies identified a lack of explicit clinical guidance as a key contributor to sociodemographic and age-related variations in care [7]. These findings were submitted in evidence to the deliberations that eventually led to the 2010 Equality Act.

Professor Raine has been keen to understand the part played by GP consultations in variation in care. Her group has developed short vignettes based on 10-minute consultations in which actors play the part of patients from different socioeconomic backgrounds. GPs can view these vignettes, accompanying notes and test results, pause films and ask questions, and then decide on a course of action.

Strikingly, this work revealed that clinicians' decision-making was influenced not just by objective clinical observations but by the nature of the individual they were dealing with. Apparently poorer patients were less likely to be offered recommended pathways of care.

Professor Raine's team has gone on to adapt these tools for use in medical education, to encourage trainee doctors to be more reflective about their clinical decision-making. Preliminary findings suggest that they are effective in encouraging medical students to consider the innate biases that might subconsciously influence their clinical decision-making.

1. von Wagner C et al. Inequalities in participation in an organized national colorectal cancer screening programme: results from the first 2.6 million invitations in England. Int J Epidemiol. 2011;40(3):712-8.
2. Palmer CK et al. Understanding low colorectal cancer screening uptake in South Asian faith communities in England--a qualitative study. BMC Public Health. 2015;15:998.
3. Palmer CK, Thomas MC, von Wagner C, Raine R. Reasons for non-uptake and subsequent participation in the NHS Bowel Cancer Screening Programme: a qualitative study. Br J Cancer. 2014;110(7):1705-11.
4. Wardle J et al. Effects of evidence-based strategies to reduce the socioeconomic gradient of uptake in the English NHS Bowel Cancer Screening Programme (ASCEND): four cluster-randomised controlled trials. Lancet. 2016;387(10020):751-9.
5. Raine R et al. Sociodemographic variations in the contribution of secondary drug prevention to stroke survival at middle and older ages: cohort study. BMJ. 2009;338:b1279.
6. Raine R et al. Social variations in access to hospital care for patients with colorectal, breast, and lung cancer between 1999 and 2006: retrospective analysis of hospital episode statistics. BMJ. 2010;340:b5479.
7. McBride D et al. Explaining variation in referral from primary to secondary care: cohort study. BMJ. 2010;341:c6267