Table 2

Practice conditions reported by GPs that might explain differences in practice

Situation in the UKSituation in AustraliaDifferential effect on PSA testing
Prostate screening cultureDoctors screening healthy people, or healthy people demanding this, considered strange; ‘it doesn't happen. People don't come in and say “they feel fine, they just want all their blood checks”…I don't think the NHS could really do that’ (GP21).GPs report routinely offering (and encouraging) patients to have multiple tests, perhaps including PSA; healthy patients request health checks regularly. Some considered this ‘normal’ and/or ‘responsible’.‘Screening culture’ likely influences default screening practices; in Australia PSA has “become a fairly entrenched part of the male [annual] health check up” (AGP17).
GP trainingUK GPs felt trained to avoid PSA testing, a ‘really big topic’ and ‘classic case’ in medical exams and training. “The training that we received is … how you would have a discussion … when we're asked for [the test], and you almost felt like they were sort of trying to dissuade asymptomatic men from having it…that was definitely the sort of slant” (GP16).GPs in Australia did not comment much about their medical training and PSA testing; one GP who did said “it's one of the areas where it's pretty much self-taught and you develop your own opinion” (AGP4).GPs in the UK are specifically trained how to advise asymptomatic men against screening, so seem likely to have more skills to do so, and to default to this practice.
Funding modelsUK GPs spaced appointments to allow for appropriate care, because “the expectation from the UK government as purchasers of the care would be that [men] be counselled around the limitations” (GP15). They were acutely aware of “a responsibility [for] spending the finite [NHS] resources” (GP23). UK GPs and practices did not gain financially from test-ordering. Conversely: PSA testing “just creates more work” (GP6).Some Australian GPs had systems to shorten consultations about PSA testing, for example, including PSA in routine bloodwork/‘bucket testing’, automatic recall so patients could be tested without seeing the GP. Some GPs blamed Australia's fee-for-service health system, which encouraged seeing (and testing) more patients:“it feeds itself to making more diagnoses” (AGP23).The Australian fee-for-service funding model incentivises [over]servicing; the UK's NHS scarce resources model incentivises caution in creating burden on a limited system.
GuidelinesUK GPs saw NICE guideline (a clear policy directive) as authoritative, trustworthy, impartial advice against testing; the national guideline influenced practice. “I think people are wary of practicing not in line with that and then they have potential then for criticism” (GP3). The established norm is structured communication with men who ask about testing, using a written information resource.GPs found Australia's competitive information environment about PSA testing hard to navigate: “there's plenty of guidelines, but they're all different and there's nothing official…there's no hard and fast rule” (AGP9). “It's a very tricky area because…opinion is divided depending on who you talk to” (AGP20). Many GPs did not use a guideline, citing patient demand, lack of time, unfamiliarity or a preference for their own judgement; some said RACGP guidance was an unclear ‘cop-out’.Having one authoritative guideline seems to encourage consistent practice. At the time of this study, such guidance did not exist in Australia, probably contributing to variation in PSA testing practice.17
Mass media and public profileUK GPs reported that prostate cancer is sometimes in the news media but is “certainly not something which is on the front page of newspapers everyday” (GP8) and “doesn't translate into a lot of men coming and asking for PSA tests” (GP1). Many said patients would only hear about PSA testing from their doctor.Australian GPs said “there has been a lot of media attention to PSA testing over the years” (AGP15), a “part of the big problem with the prostate cancer stuff” (AGP23). Requests increased after media coverage; ‘media-influenced’ patients had preconceived ideas, assuming screening was widely endorsed if sanctioned on TV, “so they see it as their right to have it” (AGP15). “Men know that it's available…so it's hard not to bring it up” (AGP2).Conflicting messages and promotion of PSA testing in Australia drives demand from patients; this is absent in the UK.
Practice protocolsAll GPs within a single practice in the UK tended to test in a similar way: they “practice as a group and with group support” (GP20). This occurred via ‘verbal agreement’ rather than formal written protocols. Internal practice protocols sometimes permitted practice nurses to PSA-test asymptomatic men without GP involvement.In the absence of Australian consensus guidelines, GPs developed their own testing protocol over years, “I have built up my own idea of practice” (AGP36). Practices need not have formal protocols as “it is a judgement call at the moment” (AGP39).Presence or absence of protocols at practice level does not seem to explain differences between the two countries: both lacked protocols.
Method of screeningWhen UK GPs screened (rarely) they often did DRE before or instead of PSA. They thought DRE good or standard practice, and valued the information it provided: “the two tests go together” (GP14), “it's a two-part process” (GP23), “doing a PSA alone is worse than doing nothing at all” (GP7). UK urologists reportedly expect GPs to do DRE (although urologists will repeat it).Australian GPs reported rarely doing DRE in asymptomatic men. Australian GPs were unsure they could detect abnormality via DRE.In the UK, DRE was used prior to or instead of PSA, but was not recommended; conversely, until recently Australian guidelines recommended DRE with PSA but it was rarely done.
Referral systems for men with abnormal resultsIn the UK, referral pathways following particular test results are well defined: if PSA was abnormal, GPs would always refer to NHS urology to see the next available (possibly unnamed) consultant, entirely publicly funded. GPs’ cancer referrals were audited and GPs made accountable for referrals.After abnormal PSA test results, Australian GPs varied greatly in when, how and to whom they referred. In urban Australia, where there were more urologists, immediate referral after abnormal PSA was common; in rural Australia (fewer urologists) GPs managed abnormal PSA tests for months or years before referral. Australian urologists may be seen publicly or privately; private urology is a competitive marketplace.Australia lacked a clear referral pathway for PSA testing, so decisions were made by individual GPs and patients, influenced by a business model of healthcare and a private health sector. In the UK, referral was streamlined and publicly funded.
Position taken by urology as a professionUK GPs said urologists “certainly do not push us to screen men who are otherwise well—if you asked any of them they'll probably say it's actively discouraged” (GP1). (While not reported by these GPs, we know anecdotally and from the literature that some UK urologists have advocated PSA screening.) GPs described close communication and ‘strong links’ with urology colleagues and “total confidence in their department” (GP14)Australian GPs said urologists “encouraged PSAs to be done a lot more urgently” (AGP37). Some GPs accepted this advice; others “politely ignore[d] the advice from urologists in that respect. And from their organizations” (AGP19), as “they have made life very difficult because they're being very unfair on the evidence that's out there” (AGP18). In rural areas, fly-in urologists ran monthly clinics, and influential seminars encouraging testing. Some GPs thought these urologists had conflicted interests: “they want a lot of work for themselves… unfortunately it has become an industry and they earn a living out of people's fear” (AGP37).There was strong variation in GP perceptions and collaborations with urologists, within and between countries. Some Australian GPs were strongly sceptical of some urologists’ position; UK GPs were less sceptical.
Perceived threat of not testingUK GPs said medicolegal risk (which was not a common concern) hinged on quality of communication about PSA testing. They thought it highly unlikely a patient would complain about consent processes.Many Australian GPs were concerned about medicolegal risk and felt obliged to at least discuss PSA testing with men. Active PSA testing could also maintain status and reputation as a ‘good’, thorough GP; “I guess I do it because I want to practice good medicine…I want my patients to perceive that I practice good medicine…you do have to be seen to be proactive and do a quality job and quality job is screening” (AGP1).Australian GPs were much more concerned than UK GPs that PSA test-ordering had medicolegal implications, likely contributing to testing patterns.
  • DRE, digital rectal examination; AGP, Australian general practitioner; GP, general practitioner; NHS, National Health Service; PSA, prostate-specific antigen (test); RACGP, Royal Australian College of General Practitioners.