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The value of conducting periodic health checks

BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e7775 (Published 20 November 2012) Cite this as: BMJ 2012;345:e7775

Rapid Response:

Re: The value of conducting periodic health checks

England’s NHS Health Checks

Domhnall MacAuley argues in his editorial(1) that, based on the meta-analysis of Krogsbøll et al.(2), regular health checks are ineffective and the available evidence robustly shows they have little benefit.

England has its very own “health check” scheme. It is known as NHS Health Checks and is a national primary prevention programme targeting all individuals aged 40-74 without previously diagnosed cardiovascular disease or diabetes.(3) It was launched in 2009 and is the first programme of its kind in the world. The NHS Health Checks programme arose from improvements in secondary care via the National Service Framework (a 50% decrease in mortality from coronary heart disease).(4) Despite this success, secondary care costs are high, the personal and economic burden of vascular disease remains significant(5) and coupled with decreasing costs of cardiovascular medications, particularly statins(6), focus has moved upstream to primary prevention of vascular conditions.

While it is too early to comment on the long-term effect that the NHS Health Checks scheme will have, from time spent on the frontline of the programme, it does appear that it is facing deployment problems. It raises the question of not whether population-wide health prevention in general is an ineffective approach, but rather will the NHS Health Checks programme be looked at unfavourably due to failures in its execution.


Choice of risk factors in the NHS Health Checks algorithm

Determination of diabetes risk using blood glucose testing is a key component NHS Health Checks. However, only those deemed to be at highest risk receive testing; selected using body mass index (BMI) (≥30kg/m2) and first blood pressure measurement (≥140/90mmHg) in a risk factor-driven protocol. BMI and blood pressure are the only two parameters used as onward determinants of diabetic risk. However, Waugh and colleagues in their literature review(7) on diabetes screening for the National Screening Committee deemed the five most important factors in heightened diabetes risk were increasing age, obesity, family history of diabetes, ethnicity and cardiovascular co-morbidities. All bar the last of these could be incorporated into the Health Check and indeed, the data is already collected as per protocol.

 

Poor penetration

Another important determinant in the success of health checks is the degree to which those responsible (currently primary care trusts) take up the challenge and implement the programme. In 2011-12, seven PCTs offered an NHS Health Check to <1% of their eligible population and three PCTs did not offer a single person an NHS Health Check. Nationally, <40% of those who were eligible received one in 2011/12, comparing poorly to uptake rates of cervical (78%) and breast (77%) cancer screening.(8) This is despite delivery of NHS Health Checks being deemed a mandatory service by the Department of Health.

  

Health Check provision is in the hands of local government

The reasons for the lack of uptake are unclear; perhaps a general lack of marketing and awareness (have readers of this journal ever seen any NHS Health Checks advertising?) as well as the transition of control for NHS Health Checks delivery from PCTs/CCGs to local authorities (local government). From April 2013, local authorities will be directly responsible for public health improvement and the compulsory provision of certain services(9) including sexual healthcare (a well-publicised issue in mainstream media)(10), the National Child Measurement Programme and the NHS Health Checks. What are the implications of lay politicians taking over control of healthcare budgets and services? Is cardiovascular and diabetic disease prevention a vote winner? Will local authorities attain the minimum targets set by DH and no more? With local government budgets being cut each year until 2015 will health checks be prioritised or marginalised? With the NHS Health Checks facing these challenges, it is not difficult to understand why delivery of this programme may be sub-optimal in the coming years.

 

An ever-expanding remit

From 2013, the programme will also include an element concerned with the prevalence of liver disease and reducing alcohol consumption as well as raising awareness of memory assessment clinics for those attending health checks who are ≥65 years old.(11) Despite being a bold programme, winning praise for being the first of its kind and attempting to tackle cardiovascular disease from a primary prevention standpoint, one fear is that the NHS Health Checks programme has become a public health catch-all: tricky public health issues have latched on to the programme, diluting what was initially an ambitious, yet relatively tight remit, into something now rather unwieldy. With so much data being collected across so many parameters, it makes it even more necessary to ensure that feedback loops are robust so that onward management is effective and successes can be captured.

 

Conclusions

The review by Krogsbøll et al. analyses old data and health check programmes which did not have in place the therapy options, lifestyle advice or onward care pathways which the NHS Health Checks utilise. However, the obstacles that have been put in place of the NHS Health Checks programme both in terms of design and current execution means that significant challenges lie ahead of it. Is it the case that this population-based prevention strategy, with £600 million of spending already behind it and considered to be cost effective(12), is not being given the chance to succeed?

 

References

1.      MacAuley D. The value of conducting periodic health checks. BMJ 2012;345:e777

2.     Krogsbøll LT, Jørgensen KJ, Grønhøj Larsen C, Gøtzsche PC. General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis. BMJ2012;345:e7191

3.     Department of Health. Putting Prevention First, Vascular Checks: Risk Assessment and Management. London: Department of Health 2009.

4.     Department of Health. National Service Framework for Coronary Heart Disease. London: Department of Health; 2000.

5.     Department of Health. Putting Prevention First: ‘Next Steps’ Guidance for Primary Care Trusts. London: Department of Health; 2008.

6.     National Institute for Health and Clinical Excellence. Statins for the prevention of cardiovascular events. London: NICE; 2008.

7.     Waugh N, Scotland G, McNamee P, Gillett M, Brennan A, Goyder E, Williams R, John A. Screening for type 2 diabetes: literature review and economic modelling. Health Technol Assess 2007; May;11(17):iii,iv, ix-xi, 1-125

8.     The NHS Health Check Programme: Let's Get It Right. Available at: http://www.diabetes.org.uk/Documents/Reports/nhs-health-check-lets-get-it-right-0912.pdf. Accessed Nov/25, 2012.

9.     Department of Health. Healthy Lives Healthy People. London: Department of Health; 2010.

10.   Sexual healthcare 'at risk from NHS changes'. Available at: http://www.bbc.co.uk/news/health-19991579. Accessed Nov/25, 2012.

11.   NHS Health Check - Changes to content 2013-14. Available at: http://www.nhshealthcheck.nhs.uk/default.aspx?aID=31. Accessed Nov/25, 2012.

12.   Department of Health. Economic Modelling for Vascular Checks: Department of Health; 2008.

Competing interests: No competing interests

26 November 2012
Mihir M Sanghvi
Medical Student
Barts and The London School of Medicine and Dentistry
29a Saffron Hill, London