In the dying days of his Government, former Prime Minister Gordon Brown announced all adults over 40 would be entitled to a free health check every five years.
But if some GPs have their way, NHS Health Checks will suffer the same fate as the man from the Manse.
The scheme to assess cardiovascular risk has shown remarkable resilience, surviving two changes in government and criticism in several recent reviews.
Public Health England is committed to boosting access to the health checks to 15 million people by 2018 and is implementing NICE’s 10% 10-year risk threshold for intervention.
But the unprecedented financial squeeze facing the NHS over the coming Parliament prompts the question of whether a scheme with annual costs of around £200m a year is worth the money.
In its response to a public consultation on the scheme, the RCGP has called for a halt to health checks until ‘robust’ evidence for the scheme is available.
Pulse has also learned that an independent evaluation of the scheme, due out next month, will show poor uptake and limited benefits to those it identifies as high risk.
The review, led by Professor Azeem Majeed, head of primary care and public health at Imperial College London, looks set to question the project’s impact when it’s published this summer.
Professor Majeed, who is also a part-time GP in south London, says the findings will show that ‘essentially the uptake has been lower than predicted and take-up of statins is also relatively low in patients with high risk’.
He argues this is partly because the programme hasn’t been well publicised, ‘so lots of people weren’t really aware of it, including professionals as well as the public’.
A further publication from the review, due out later in the year, will evaluate whether the programme has changed the health status of patients identified as being high risk: for example, whether their risk factor profiles have changed since their health check.
Professor Majeed says the outcomes evaluation could mark a critical turning point for the programme, as a proper cost-effectiveness analysis will only be possible if the programme shows clear benefits in terms of clinical outcomes.
Lack of evidence
When it was first announced in 2008, Government advisors estimated full rollout of the scheme would cost between £180m and £243m a year. At the time they said the scheme was ‘highly cost effective’, with a cost per quality-adjusted life-year gained of around £3,000. This was well within the usual £20,000 threshold applied by NICE.
But its current cost is unclear, and Professor Majeed says: ‘I think that is the big question about the health checks: whether the programme needs to be funded in this way at all, or the money could be better spent elsewhere.’
Such questions over the validity of the scheme have been raised before, with the Cochrane Collaboration publicly berating the Government in 2013 for ignoring evidence against the programme.1
The Cochrane researchers said the Government’s persistence with the health checks threatened ‘the very idea of evidence-based public health care’. They said the funds used for the scheme could be ‘used for a better purpose, such as on interventions with documented benefits’.
More recently, a smaller independent evaluation commissioned by the Department of Health, based on data from three east London boroughs, found the scheme was having limited success in capturing and treating high-risk patients.2
The Government was heavily criticised by the GPC for initially rolling out the programme without consultation, and it failed to have it evaluated in advance by the UK National Screening Committee – which had already ruled out systematic vascular screening of adults in 2007.
Despite this, a recent consultation led by PHE’s chief knowledge officer, Professor John Newton, suggested it would continue with its ‘pragmatic’ approach of evaluating and optimising the scheme over time.
But this has elicited much criticism, with the RCGP taking its strongest stance yet on health checks, going as far as calling for the scheme to be stopped.
The college’s new working group on overdiagnosis and overtreatment, led by Glasgow GP Dr Margaret McCartney, told PHE it should suspend the programme altogether until it had properly assessed the intervention.
It stated: ‘Despite the evidence showing that this type of intervention… does not work, the programme of research does not acknowledge this. Public Health England is proposing further research that assumes the programme will work.
‘The programme should not be continued without robust evidence in support of it. PHE should seek governmental approval to search for high-quality evidence of mortality and morbidity benefit… and seek assurances that the programme can be disbanded on the basis of evidence.’
Such sentiments were echoed in a number of responses to the PHE consultation. Roughly half of the 53 respondents said they did not believe PHE had identified the most important research questions for evaluation, with some joining the RCGP in calling for the programme to be halted pending further evidence.
Dr Andrew Green, chair of the GPC’s clinical and prescribing subcommittee, says the argument that ‘as each part is based on NICE guidance then the exercise must be worthwhile as a whole’ is the ‘best that has been offered so far’.
But Dr Green says this is ‘no justification for the spending of vast amounts of public money at a time of austerity when the existing evidence is that health outcomes are not improved’.
However, PHE seems set to press ahead with its ongoing evaluation of the health checks.
In its own response to the consultation, PHE suggested it would carry on evaluating and amending the programme, rather than overhaul it, stating it would ‘continue to encourage the development of new research that will help to establish the evidence we need to ensure an effective programme’.
Pragmatic approach
Dr Matt Kearney, national clinical advisor on cardiovascular prevention at both NHS England and PHE, and a GP in Cheshire, says he and others on the recently formed Primary Care CVD Leadership Forum support this approach.
Dr Kearney says: ‘There are challenges to the evidence base for this, but the debate within primary care is: do we wait 10 years for perfect evidence?
‘Or do we do something now and generate evidence as we go – and I think that’s just a more pragmatic approach that many of us support.’
And backing for this stance goes all the way to the top of the organisation.
Professor Kevin Fenton, executive director of health and wellbeing at PHE, said: ‘PHE is committed to bringing greater scientific oversight to the NHS Health Check programme, to review emerging evidence and to inform future policy and programme developments.’
But it looks unlikely that such an approach will silence the scheme’s increasingly vociferous GP critics.
Unanswered questions on NHS Health Checks
Does the scheme actually reduce cardiovascular risk?
This is being looked at by Imperial College London in an independent evaluation commissioned by the Department of Health (DH), due later this year. The signs so far are not good.
Earlier studies of the scheme found poor uptake, with only around 40% of those invited attending for their check-up, while those it identified as high-risk had only ‘modest’ improvements in their cardiovascular risk.(3)
Another study revealed the programme was likely to miss a third of people with diabetes among those who did attend.4 Another DH-commissioned evaluation, published earlier this year, said the scheme had had ‘limited success’ and was failing to reach high-risk patients, with only one in 10 people identified as high risk and only a third of these getting a statin.(2)
Is it cost effective?
The Imperial College team plans to assess the scheme’s ‘value for money to the NHS’. The Government initially estimated it would cost between £180m and £243 a year – but was likely to be cost effective, at £3,000 per Quality Adjusted Life Year gained.(5)
However, it is unclear if the programme has been implemented in full in all areas, with the most recent estimate of expenditure showing local authorities spent £85m last year on the programme.(6)
Why is it based on age?
The DH set out to do population-wide screening defined by age, selecting the range 40-75 years on the basis of available CV risk tools and economic modelling.(5)
However, a leading PHE advisor recently admitted targeting people at highest risk would be preferable(7), a call backed by a leading GP academic.(8)
‘Health checks should be abandoned’
Public Health England’s latest consultation on its health checks scheme highlights a need to demonstrate effectiveness – that it leads to a reduction in CV and non-CV mortality and morbidity, and that it saves money – as its ‘greatest priority’ for research.
But it is astonishing that a programme that uses such significant resources – in terms of finance and of diversion of healthcare staff from other, higher-value activity – was ever started and continues to run with a total absence of evidence around these critical questions.
Indeed, a huge amount of research over decades has shown that health checks make no difference to the outcomes that really matter.
Given the current strains on primary care, which are unlikely to change for the foreseeable future, surely the NHS Health Checks programme should be abandoned outside the context of a randomised controlled trial and the resources liberated to go elsewhere.
Dr Julian Treadwell is a GP in Bath and vice-chair of the RCGP standing group on overdiagnosis and overtreatment
References
1 BMJ 2013;347:f4788. tinyurl.com/qdsmk6b
2 BMJ Open 2015;5:e007578.
tinyurl.com/qb5ju2y
3 Preventive Medicine 2013;57:129–134.
tinyurl.com/nweptro
4 BMJ Open 2013;3:e002219
tinyurl.com/q4gldr3
5 DH: Economic Modelling for Vascular Checks.
tinyurl.com/otsdcd7
6 Department of Communities and Local Government.
tinyurl.com/n9ljtur
7 Pulse.
tinyurl.com/nj5zfjb
8 Br J Gen Pr 2014; 64: 627:493-494.
tinyurl.com/p76c6t9
9 Pulse.
tinyurl.com/nlajg9s
