Re: The value of conducting periodic health checks
Response to Krogsboll et al.(1) (Cochrane Review) and MacAuley(2) (BMJ Editorial)
The recent Cochrane Review(1) and associated Editorial(2) highlight a number of interesting issues relating to health checks, most notably the potential dis-benefits for patients and possible conflict between preventive action (in the form of health checks) versus diagnosis/treatment. In the context of NHS Health Checks, we should be cautious in what conclusions can be drawn on the basis of this review. The Department of Health response (http://www.nhshealthcheck.nhs.uk/?iid=11) identified some key points in this regard, including: the lack of consistent definition of what constitutes a 'general health check'; lack of detail on subsequent lifestyle support; and the substantial contribution of data from old studies.
Arguably, the NHS Health Check programme is another example where large scale programme implementation has preceded a supporting evidence base, as we have seen with other national initiatives.(3,4) The result is a need to develop evidence specific to this model and use this to inform practice.
We have recently published data from a randomised controlled trial comparing CVD risk changes in individuals with elevated baseline risk scores (≥20% 10-yr Framingham Risk Score) who received NHS Health Check (plus usual general practice care), versus those also receiving additional lifestyle support.(5) Our trial data revealed a significant 12-month reduction in estimated population CVD risk in all NHS Health Check participants, without evidence of further benefit of the additional lifestyle support services. Although a ‘no health check’ group was not included (given the original aim to explore the additional benefit of subsequent lifestyle support), our finding is consistent with the notion that targeted health checks could offer some health benefit.(2) Given the advanced stage of programme implementation, this also supports the case for further controlled research to determine population health benefits,(6) whilst acknowledging the role and value of other forms of evidence.
Our experience of delivering and evaluating the NHS Health Check programme in Stoke-on-Trent has highlighted a number of likely influences on participant benefit, such as: inequitable access; uptake of medical treatment and/or lifestyle support; the capacity of primary care to deliver such a programme and effective communication of risk. Some of these issues have also been discussed in other studies.(7,8) Emerging evidence and pilot work is already providing potential solutions to overcome such barriers. For example, issues relating to access have already been discussed(9,10) and warrant further study, as have the means of cost-effective programme roll out.(10) The potential dis-benefit of patients having ‘inappropriate reassurance’ from heath checks(2) could be overcome by communicating what the NHS Health Check can and cannot do, with clear guidance to seek advice as appropriate; however this needs to evaluated.
In conclusion, we believe it would be rash to rule out the potentially beneficial role of the NHS Health Check programme on the basis of the recent Cochrane review of general health checks. We agree entirely with the assertion that ‘policy should be based on evidence of wellbeing, rather than on well meant good intentions’,(2) but think it prudent that such decisions about NHS Health Checks be underpinned by robust evidence specific to this national initiative.
Dr Christopher Gidlow
Senior Research Fellow
Centre for Sport, Health and Exercise Research
Health Improvement Specialist – Long Term Conditions
NHS Stoke on Trent
Dr Zafar Iqbal
Acting Director of Public Health
NHS Stoke on Trent
Dr Ruth Chambers
Clinical Director of Practice Development and Performance
Stoke-on-Trent Clinical Commissioning Group
Health Improvement Manager - Long Term Condition
NHS Stoke on Trent
1. Krogsbøll LT, Jørgensen KJ, Larsen CG, Gøtzsche PC. General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis. BMJ 2012;345.
2. MacAuley D. The value of conducting periodic health checks. BMJ 2012;345.
3. Attree P, Clayton S, Karunanithi S, Nayak S, Popay J, Read D. NHS health trainers: a review of emerging evaluation evidence. Critical Public Health 2011:1-14.
4. National Institute for Health and Clinical Excellence. Four commonly used methods to increase physical activity: brief interventions in primary care, exercise referral schemes, pedometers and community-based exercise programmes for walking and cycling: NICE, 2006.
5. Cochrane T, Davey R, Iqbal Z, Gidlow C, Kumar J, Chambers R, et al. NHS health checks through general practice: randomised trial of population cardiovascular risk reduction. BMC Public Health 2012;12(1):944.
6. Petticrew M, Chalabi Z, Jones DR. To RCT or not to RCT: deciding when ‘more evidence is needed’ for public health policy and practice. Journal of Epidemiology and Community Health 2011;66(5):391-96.
7. Dalton ARH, Bottle A, Okoro C, Majeed A, Millett C. Uptake of the NHS Health Checks programme in a deprived, culturally diverse setting: cross-sectional study. Journal of Public Health 2011;33(3):422-29.
8. Lambert AM, Burden AC, Chambers J, Marshall T. Cardiovascular screening for men at high risk in Heart of Birmingham Teaching Primary Care Trust: the ‘Deadly Trio’ programme. Journal of Public Health 2011.
9. Cochrane T, Gidlow CJ, Kumar J, Mawby Y, Iqbal Z, Chambers RM. Cross-sectional review of the response and treatment uptake from the NHS Health Checks programme in Stoke on Trent. Journal of Public Health 2012;in press.
10. Kumar J, Chambers R, Mawby Y, Leese C, Iqbal Z, Picariello L, et al. Delivering more with less? Making the NHS Health Check work in financially hard times: real time learning from Stoke-on-Trent. Quality in Primary Care 2011;19(3):193-99.