Cardiovascular screening is a no-brainer, so why are we failing to provide it?
Dr Mohamed Roshan says the NHS Health Check programme needs to be at the forefront of patient care – not an afterthought
The NHS Health Check programme was launched in 2008 to provide a cardiovascular screening programme to the majority of the population aged 40-75 years. The programme was to be rolled out fully in 2012, with a national target to offer a health check to 20% of eligible patients annually. The new Health Check had special significance for health researchers at the University of Leicester, where I work, since the UK National Screening Committee had been advised by a report authored by our own Professor Melanie Davies and Professor Kamlesh Khunti.
Back in 2006 I had set up a local scheme to provide health screening in a deprived area of Leicester. We couldn’t keep the doors open long enough, such was the demand, despite the fact local charities also provide screening programmes from mobile units and community centres in that area already. The long queues of people suggested that the public appetite for health screening is high.
Yet the recent publication ‘Let’s Get it Right’ by Diabetes UK finds that the Health Check screening programme is far from effective. The majority of PCTs set lower targets than required for offering the NHS Health Check. A minority of PCTs offered checks to less than 1% of the eligible population, and three PCTs failed to offer anyone a check in 2011/12.
Cardiovascular disease affects 4 million people in England every year, causes 36% of all deaths and is the single most common cause of death and disability. If the uptake for the screening programme was universal, it is estimated that we could prevent 9,500 myocardial infarctions and strokes every year.
For diabetes the figures are equally staggering. There are an estimated 850,000 people with undiagnosed type 2 diabetes; the numbers of people with the condition has more than doubled in the past six years alone. The prevalence of diabetes is reported to be nearly four times higher than all the cancers combined. The case for early detection has never been stronger.
So why does it seem to have gone so drastically wrong? The problems were evident as early as 2010. Reports suggested that PCTs were underperforming to a large extent. GP leaders were quick to point out that the programme had been implemented without adequate consultation. There were accusations and admissions by senior DH officials that the flagship screening programme had been rushed forward for political reasons. Average-sized practices were being asked to carry out 350 vascular checks per year with most of them failing to provide half of this number.
In general practice, the implementation plan for the programme felt flawed from the outset. PCT strategies were unclear and there were ad-hoc implementation plans across the country. The funding arrangements varied every year and details were relayed to primary care late in the year, compromising the programme. The recommended risk assessment tools also changed over time, which led to wide confusion.
The bureaucracy in deciding who would be invited, and the fragmented roll-out of the programme, meant that primary care was on the back foot from the start. Information technology was incapable of capturing data from the different organisations that provide screening services, such as research centres and pharmacies. Plans for the prevention programme for patients at high risk of diabetes were also unclear. In general practice, where the workload is being stretched to unmanageable levels by recent QIPP programmes, CCG work and changes to QOF indicators, the NHS Health Check programme was just another challenge in a long list of NHS priorities.
The human cost of cardiovascular disease, and of type 2 diabetes in particular, is high, so we owe it to our patients to provide an effective screening programme. The NHS Commissioning Board and CCGs owe it to their population to remove barriers and make such screening possible. For type 2 diabetes there is compelling evidence that screening is cost effective – even cost beneficial for people from black and ethnic minority groups.
CCGs around the country need to be more innovative in increasing attendance to screening programmes. Measures could include removing upper limit allocations and accelerating the screening programme but practices need the freedom to achieve a more rapid pace of screening, if this can be provided. Pragmatic solutions are needed for issues such as providing blood collections for tests carried out in the afternoon or out of hours, and publicity campaigns in the media and community centres will be essential.
Where practices face insurmountable challenges in achieving these targets, local systems need to be set up so patients can access screening at nearby practices under shared funding arrangements. Personal correspondence with local CCGs suggests that some of these changes are being made for 2012-2013, but it is imperative that all CCGs around the country deliver on this initiative. Let’s be smarter about screening.
Dr Mohamed Roshan is a GP in Leicester, diabetes lead for LLR County CCG and a senior diabetes research fellow at the University of Leicester