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Editorials

Government’s plans for universal health checks for people aged 40-75

BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f4788 (Published 30 July 2013) Cite this as: BMJ 2013;347:f4788
  1. Felicity Goodyear-Smith, academic head
  1. 1Department of General Practice and Primary Health Care, University of Auckland, PB 92 019 Auckland 1142, New Zealand
  1. f.goodyear-smith{at}auckland.ac.nz

No certainty that they’ll do more good than harm

The UK government recently prioritised plans for all adults aged 40-75 (about 15 million people) to receive regular, free health checks. Originally introduced in 2009, primary care trusts were required to screen for “diabetes, chronic kidney disease, cardiovascular disease, and stroke risk,” regardless of patients’ risk profiles.1 Since April 2013, local authorities have overall responsibility for provision of these checks, which have been extended to include assessment of alcohol consumption and dementia and are specifically for people at low risk. People with existing disease, already taking statins, or with at least a 20% risk of cardiovascular disease are excluded.2 However, implementation (measured by the proportion of eligible patients invited to participate) has been patchy, and about half of people accept the invitation, hence the current push to scale up the programme and increase its coverage.3

Increased life expectancy has come with a global rise in the number of years people now live with illness, accompanied by personal, social, and health costs.4 The health check programme aims to reduce morbidity and preventable deaths by targeting hypertension, smoking, hypercholesterolaemia, obesity, poor diet, physical inactivity, and alcohol consumption.5 Evidence suggests that risk can be reduced through improvements in healthy behaviours (reduction in smoking and alcohol consumption, increased exercise, and healthier eating) and the use of drugs such as statins6—hence the drive to implement this screening programme.

However, a 2012 Cochrane review concluded that such health checks reduce neither morbidity nor mortality.7 The review was criticised for its inclusion of old studies and its poor definition of what constituted a health check.8 Public Health England says that the country’s pressing health challenges require urgent action, with no time to wait for long term trials to provide definitive supportive evidence. National health checks can prevent people developing disease, enable earlier detection, and save lives, the agency maintains.5

Nevertheless, the question remains: do health checks meet the criteria for screening?9 In particular, do benefits outweigh harms, do false negatives lead to inappropriate reassurance, or do false positives lead to over-investigation and over-intervention? Screening always comes with social and financial costs. Does the health check programme’s estimated cost of £332m (€385m; $511m) per year1 represent value for money?

Health checks offer a bundle of tests to people at the lower end of the risk spectrum. This means that the pre-test probability is low, with a high chance of false positives. By combining several screening tests, any benefits could be offset by harms produced through wrong diagnoses and unneeded treatments. Another confounder may be that people who present for health checks are likely to be of higher socioeconomic status, with fewer health risks, less morbidity, and higher life expectancy. Health checks could increase health inequalities through self-selection by the “worried well.”

Screening is justified only if effective early interventions are available, offered, and accepted. Findings from health checks will be complex and variable. When the thrust is to conduct as many checks as possible to reach the target (and tick the box), follow-up with appropriate action—such as scheduling another appointment—might not always occur. When general practitioners do decide to act, evidence may be lacking in relation to best practice for people at low risk. For example, salt restricted diets now seem to have little health gain,10 and the benefits of drug treatment for mild hypertension might not exceed the harms.11 The potential positive and negative consequences of intervening or not intervening is complicated, and could be difficult for doctors to explain and for patients to understand.12 Patients justifiably might choose not to make lifestyle changes when their demonstrated risk reduction is negligible. Conversely, patients typically overestimate the benefit from preventive drug treatment, which could lead to increased pharmacological use without improved health outcomes. Even where reasonable health gains are clear, the information provided from an invited health check might not be enough to encourage behaviour change, such as smoking cessation.

Health checks require general practitioners to select eligible patients, invite them to attend, screen the respondents, follow them up to explain risk, and offer suitable risk management options. Patients then need to decide whether to take particular courses of action and to comply with these interventions. Although the goal is improved health outcomes, the pathway is long and tenuous, with attrition at each point along the way.

Healthcare, including available time for general practice consultation, is a finite resource. Time and money spent on health checks are not available for other primary care provision. Although there may be good evidence for targeted screening of people at high risk, the generic approach of composite screens for the entire population could produce many false positives and false negatives, might not be value for money, and has the potential for harm. Further research needs to determine whether the UK health check experiment delivers its promise of “saving lives and preventing ill health.”5

Notes

Cite this as: BMJ 2013;347:f4788

Footnotes

  • Competing interests: I have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: I am lead investigator in research pertaining to patient-entered identification of mental health and lifestyle issues pre-consultation in general practice, assessing patients’ help seeking behaviour, and providing stepped care decision support; we are seeking to establish whether this approach is effective in improving health outcomes. I declare no other relevant interests.

  • Peer review and provenance: Commissioned; not externally peer reviewed.

References

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