Unanswered questions over NHS health checksBMJ 2011; 342 doi: https://doi.org/10.1136/bmj.c6312 (Published 26 January 2011) Cite this as: BMJ 2011;342:c6312
All rapid responses
Professor Khunti and colleagues clearly document many of the
potential risks to the NHS Health Check programme, with the need for
effective information technology and the large workload created to name
but two. They state that the National Institute for Health and Clinical
Excellence (NICE) "recommend targeted case finding rather than a
population approach." I believe this statement touches on, not a threat to
the NHS health Checks but a threat of the programme.
The bipartite nature of prevention has been apparent for many
years.(1) Many authors have noted that "high-risk and population
strategies are complementary(2)" however the situation in the UK does not
seem to correspond to this. We see a focus on secondary prevention in the
Quality and Outcomes Framework, and the high risk approach of NHS Health
Checks and the national guidance on lipid modification.(3) The success of
high risk strategies for prevention is heavily at the whim of the uptake
achieved in a programme.(2) The authors point to the very real threat of a
high uptake not being achieved; this threat to success cannot be
overstated enough. There are however alternatives; focusing on prevention
rather than cure is as the authors say crucial, but there is a danger the
programme will draw attention away from the population approach.
Internationally there has been success in population level prevention,(4)
with for example smoking legislation, salt reductions and interventions on
trans fats. A more equitable share of our attention and resources between
high risk strategies and population prevention is the only way to
successfully lower risk, and moreover to do this equitably.
The quote stated above points to another risk which echoes a concern
I noted when speaking to NHS and Department of Health colleagues at
national learning network events; with the NHS Health Checks open to all
patients in the specified age group with no co-morbid conditions, a
universal programme, many think they are a population strategy for
prevention. The risk ensues that people believe that the programme will
have the equitable nature of a population approach. In short a clear
distinction between universal high risk and population prevention is
vital, nor should the NHS Health checks disrtact us from the population
level prevention of cardiovascular disease.
(1) Rose G. Strategy of prevention: lessons from cardiovascular
disease. BMJ 1981;282:1847
(2) Cooney MT, Dudina A, Whincup P, Capewell S, Menotti A, Jousilahti
P et al. Re-evaluating the Rose approach: comparative benefits of the
population and high-risk preventive strategies. European Journal of
Cardiovascular Prevention & Rehabilitation 2009;16:541.
(3) National Institute for Health and Clinical Excellence. Lipid
modification: Cardiovascular risk assessment and the modification of blood
lipids for the primary and secondary prevention of cardiovascular disease.
London: NICE, 2008. www.nice.org.uk/CG67.
(4) National Institute for Health and Clinical Excellence. Guidance
on the prevention of cardiovascular disease at a population level. London:
NICE, 2010 www.nice.org.uk/PH25.
Competing interests: No competing interests
We have been advocating respiratory health checks locally for the
last few years. These focus primarily on ever smokers over 40 years. The
key items obtained include occupations, smoking status, smoking pack years
and Forced expiratory lung volume checked against predicted value. The
smoking pack year calculator freely available on the web
www.smokingpackyears.com (11,000 web visits and calculations January 2011)
makes pack years recording easy to do in primary care sessions. The new
copd screeners (pulmolife and vitalograph) make obtaining predicted FEV1
Although the respiratory health check was designed to find
potential Chronic Obstructive Pulmonary Disease patients for further
spirometry checks it also helps to target the patients most at risk of
smoking induced disease. Smoking is a known preventable cause of
numerous diseases from cancers, cardiovascular disease to some
inflammatory disorders eg thyrotoxicosis so I predict that recording a
pack year number on ever smokers will be as routine as blood pressure or
cholesterol recording in determining future disease risk!
Competing interests: Dr Nigel Masters with Catherine Tutt developed the smoking pack year calculator .