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GPs go forth

Review the evidence for health checks? Why bother

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The NHS Health Check is under review and proposals are being sought for the inevitable public consultation process that seems de rigueur for all consultations these days.

To me, the key question is why they have to get any consultation on the Health Check, since they should already know what needs to be fixed.

And they should know, because we have a publicly-funded body whose entire remit is to look at these questions, the UK National Screening Committee (NSC): a body that has already looked in detail at each and every aspect of the Health Check.

For instance, take the assessment of vascular risk in adults over 40, which is backbone of the Health Check. The UKNSC recommends that we don’t do it. There isn’t a good enough balance between its benefits, and harm to patients, and the benefits of an active screening programme (over opportunistic assessment, as per now) has not been shown to be cost-effective.

What about assessment of the risk of diabetes? The NSC is clear: don’t do it.

Obesity? Not recommended.

Kidney disease? You guessed it, the NSC says not to screen for that either.

The committee has systematically looked at the evidence and found not a lot of benefit for patients on all fronts.

This is all a bit awkward for Public Health England (PHE). Health Check supporters are so convinced that they can save lives by encouraging people to get a health MOT that they don’t want listen to the NSC. They are singing a loud metaphorical, ‘La-la-la, I’m not listening!’ while stomping angrily around their bedroom. And like any child knows: when you don’t like what one parent tells you, the best tactic is to ask the other parent and hope for a better answer.

A new 28-strong group – the Expert Scientific and Clinical Advisory Panel (ESCAP) - now meets every three months to provide ‘strong scientific and clinical grounding and steer’ the Health Checks programme.

ESCAP exists as a sort of NSC for the Health Check topped up with single-disease enthusiasts. Minutes of its meetings read like the collective views of a group of opinion leaders rather than a rigorous assessment of the evidence. And it is incapable of removing any of the key components, which would be too much of a U-turn to be politically acceptable. Calling into question the need for a Health Check would destroy its very raison d’etre.

And while this consultation has been going on, with the great and the good in public health being called to expensive quarterly meetings in order to determine how best to entice the well to attend for Health Checks they don’t want or need, there was a GP practice in Devon that was so overstretched in its attempts to treat the genuinely ill that it felt the need to remind its patients that there might be other services they could use.

Might they not have had a slightly greater capacity if they weren’t so busy dealing with Health Checks?

Dr Martin Brunet is a GP in Guildford and programme director of the Guildford GPVTS. You can tweet him @DocMartin68. 

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Readers' comments (8)

  • but its the core of academic GP's and Public health dr's who are pushing this.

    recognising work to be done should be accepted once evidence is established not using primary care to run the experiment!

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  • Public consultation has to take place before any change of commissioning arrangement.

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  • I do wonder why so many policy developments, that are based on screening seem to have absolutely no "consultation" with the UK National Screening Committee?

    In Scotland, one example is screening all those 65 and over for "cognitive impairment" and delirium. This has been mandated by Healthcare Improvement Scotland with full support of the Scottish Government.

    My concern with this approach that is based on "brief" "screening tools" and it is effectively mandatory. Thus there is NO consent, informed or otherwise.

    Why does this worry me, given that I share the concerns about failing to "detect" delirium or dementia?

    Well, I will list possible outcomes of using brief "screening tools" without consent:

    (1) false-negative diagnosis of delirium/dementia

    (2) false-positive diagnosis of delirium/dementia

    (3) over-simplification of complex and serious conditions

    (4) heightening of fear in our elders

    (5) increased reliance on pathways started with said "screening tool"

    (6) medical confusion: the ‘parabolic distribution of cognition with age’ risks being turned completely into disease

    (7) risk of even greater prescribing of antipsychotics (by following said pathways)

    (8) loss of autonomy: the "screening tool" indicates you may not have "capacity"

    Thank you Dr Brunet for writing this post. I hope it stimulates healthy discussion

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  • Martin, an excellent and thought provoking analysis (as ever)!
    And not a headline grabbing moment in sight!!

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  • Dr Brunet, you are I expect aware of the old politicians credo of if you don't like the answer to the question you ask, either a) ask another question or b) ask someone else. Primary care was politicised a long long time ago, there's no room for independent thinkers or evidence based practitioners here, thank you. Oh, and while we are at it, how often do you have more than three alcoholic drinks at one sitting? And yes, chocolate liqueurs do probably count. Please collect a PHQ9 and a smoking cessation leaflet from reception, there's a good chap. NEXT!

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  • Dr Brunet asks why we should bother with the NHS Health Check. He is right that there is no clear evidence to prove whether a national programme of this nature will be effective at reducing mortality and morbidity from CVD. Evidence published to date, including the Cochrane review, has been of limited value either because the studies were underpowered or the interventions or populations served were significantly different from those in the NHS Health Check.
    So why is the NHS Health Check being implemented despite this lack of evidence. Firstly we don’t have the luxury of waiting for perfect evidence. We have an ever growing burden of non-communicable disease that risks overwhelming our health and social care systems, with two-thirds of deaths under 75 being avoidable through prevention or better treatment. Secondly the NHS Health Check is no more than a delivery mechanism for interventions that are all based on robust evidence of effectiveness and cost effectiveness.
    So the NHS Health Check is a reasonable national response in the absence of clear evidence. At the same time Public Health England has challenged itself to make the NHS Health Check as effective as it can be while evidence of impact is generated. Commissioners are being supported to maximise uptake and reduce health inequalities. Providers are being supported with new standards and competency guidance. ESCAP (a group of clinicians, academics and public health experts – not politicians) is monitoring emerging evidence, developing research priorities and taking a systematic approach to reviewing content of the health check.
    And we would argue that as GPs and nurses we should be equally challenging in relation to our own impact. Despite almost universal registration with a GP, 5 million people in England with hypertension remain undiagnosed and 40% of those diagnosed are inadequately treated, increasing their risk of cardiovascular events. Large numbers of people with diabetes, atrial fibrillation and CKD are unaware of their conditions and untreated. Only one out of five people whose 10 year risk of a heart attack or stroke exceeds 20% is being treated with statins: of course some people may choose not to take tablets, but one out of five suggests we could be doing a lot better for our patients.
    We agree that we are experiencing intense workload pressures in primary care at the moment and we need help to relieve those pressures. We don't have to provide the NHS Health Check but if we choose to we are paid for it. But Dr Brunet's suggestion that we should stick to curing the sick and abandon prevention ignores the threat we are facing and is certainly not an evidence based option.

    Dr Matt Kearney
    Dr Chris Arden
    Dr George Kassianos
    Professor Mike Kirby
    Ms Jan Proctor-King
    Dr Clare Hawley
    Dr Ivan Bennett
    Dr Matt Fay
    Professor Ahmet Fuat

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  • I thank Kearney et al for their comment, which certainly justifies a response.

    Firstly, it is disappointing that they have failed to mention the UKNSC, which confirms my assertion that the proper body for the assessment of screening programmes has simply been sidelined in this debate.

    Kearney states that:

    'We don’t have the luxury of waiting for perfect evidence. We have an ever growing burden of non-communicable disease that risks overwhelming our health and social care systems'

    Is this true? The incidence of cardiovascular disease has been falling steadily since the 1950's and life expectancy has never been better - why is there an urgent crisis that cannot wait for robust evidence? When people are sick and suffering (as in West Africa with Ebola) there can be an urgency which justifies intervention without robust evidence, but this programme involves taking perfectly well people, telling them that they have risk factors for disease and asking them to take treatments that can be immediately harmful on the basis that they might stop something happening in the future. Such an intervention might be able to be justified, but we surely need robust evidence before we inflict this on the nation.

    The health check is not, as Kearney claims, simply 'a delivery mechanism for interventions that are all based on robust evidence of effectiveness and cost effectiveness,' since population screening is not recommended by the UKNSC for any of the individual interventions - on the grounds of insufficient evidence of benefit or analysis of harms. Evidence for opportunistic identification hypertension or diabetes, is very different to that required to justify population based screening.

    Apart from vaccination, the big winners in public health have always been to change the health environment of the nation rather than to encourage health interventions in the individual - factors like better hygiene, the smoking ban, minimum alcohol pricing and legislation on sugar in foods are where the nation's health is really affected.

    If there is any actual benefit at all in the health check it is likely to be small, and unjustified by the huge cost, not of the test itself, but of the years of medicalisation that follow it.

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  • I though the reason for doing them was £28 a time and nothing more?

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