GPs are under pressure, but the answer is not to scrap health checks
Letter from cardiology GPs
Pulse has reported that the RCGP urges halt to NHS Health Checks until robust evidence exists, citing ‘leading GPs’ warning that it leads to overtreatment and diversion of resources to the worried well. Many GPs disagree with this analysis.
There is a lack of evidence to prove or disprove that the NHS Health Check is an effective and cost effective method for risk assessment and management.
However, there is wide consensus about the interventions that the NHS Health Check delivers and there is robust evidence for their effectiveness. Behaviour change support for overweight, physical inactivity, smoking and excess alcohol, and the investigation and management of high blood pressure, diabetes, high diabetic risk and chronic kidney disease (CKD) all have a good evidence base that is reflected in NICE guidance.
For people identified at high CVD risk, NICE is clear in recommending informed discussion with the individual about the potential benefits and harms of behaviour change and blood pressure and statin treatment. The collective prevalence of risk factors for vascular disease in this population is high, with little overlap between the risk factors.
Emerging information on the first five years of the programme indicates that uptake is growing with high levels of coverage in some CCGs, and that around 20-30% of people at high CVD risk are treated with important overall benefit.
We agree that over-diagnosis and over-treatment, particularly among the very old and people with multiple conditions, are important concerns. But so too is the co-existing and widespread problem of under-diagnosis and under-treatment.
Despite having one of the best primary care systems in the world and almost universal registration, we still have five million people with undiagnosed hypertension and substantial numbers with undiagnosed diabetes, CKD and atrial fibrillation. There is no evidence to suggest that identifying these conditions is associated with overall harm to individuals. It is estimated that around 40% of the threefold reduction in heart attacks and strokes since 1970 has been due to medical treatments for which there is good evidence up to the age of 85.
Yes, there is room for debate about appropriate management and avoidance of harm in such individuals, but it is clear that many are at a high risk of catastrophic cardiovascular events because routine care is not detecting their underlying and treatable risks and offering them the choice of treatment. Addressing the harms of over-diagnosis should not blind us to the need to address the harms of under-diagnosis.
We have a growing public health crisis. CVD deaths have fallen dramatically but are being offset by the rise in obesity and type 2 diabetes. Preventable heart attacks and strokes will continue to be a major issue for the next generation. This needs both a public health, population-level response and a front line NHS response. The population-level response to reduce lifestyle risk factors requires concerted action by national and local government. The NHS Health Check offers a tool to help the NHS support behaviour change and risk reduction in our patients.
We are under a lot of pressure in general practice with a massively burgeoning workload and this needs to be addressed urgently. But the solution cannot be to withdraw from our role in prevention if the NHS is to be sustainable. It is worth noting that practices are not contractually obliged to provide the NHS Health Check, and where they do they receive an additional payment.
In conclusion, there are indeed gaps in the evidence. We need a comprehensive research programme to address these gaps and we must ensure that the NHS Health Check is modified and continuously improved in response to emerging research findings.
But faced with the growing public health threat to our patients, taking no action while we await the perfect evidence is not an evidence-based option.
The interventions in the NHS Health Check have a sound and improving evidence base. Together with population-level interventions they provide us with a systematic, rational and pragmatic response to the growing burden of preventable disease.
From Dr Matt Kearney, Dr David Fitzmaurice, Dr Helen Williams, Dr Sarit Ghosh, Dr Mike Kirby, Dr John Robson, Dr Bruce Taylor, Dr Chris Arden, Dr Ruth Chambers, Dr Alison Morgan, Dr Stephen Kirk, Dr Jan Procter-King, Dr Ivan Benett, Dr Kamlesh Khunti, Dr Clare Hawley, Dr Kathryn Griffith, Dr Matt Fay, Dr Chris Harris, Dr Yassir Javaid, Dr George Kassianos, Dr Joanne Whitmore, Dr Ahmet Fuat, Dr Quincy Chuka on behalf of The Primary Care CVD Leadership Forum.