The cost of saving a life through cervical cytology screening: implications for health policy.

Through a review of the published literature on routine cervical cytology screening, this paper seeks to establish a likely range for the cost of saving a life through this screening programme as presently organised in England and Wales. The current performance of the programme may be expressed in several ways: a cost of 270,000 pounds to 285,000 pounds per life saved, 40,000 smears and 200 excision biopsies per death averted, or 1000 to 1500 avoidable deaths annually in England and Wales alone. The policy problems are thus of two kinds. First, there is a substantial misallocation of the limited resources available to an insurance based system of health care. Further, the money which is spent on this service does not avoid the mortality and morbidity which could reasonably be expected if the system were performing adequately. It is suggested that substantial improvements in the performance of the programme may well be possible if managers are appointed. Nevertheless a deeper policy issue is raised: to be delivered efficiently, any service based on population rather than individual considerations will require some acceptance by the medical profession of a limit to their traditional view of clinical freedom. The unresolved clash between population and individual considerations which poses such a fundamental challenge for policy making in insurance based health services is particularly well illustrated by the dilemma of publicly funded cervical cytology screening.