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
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It is profoundly disturbing as a member of the public to hear a GP undecided about what to do in the absence of evidence of benefit of an intervention she seems to think she has to go on offering.
The best evidence available is clear. Anticipatory health checks have not been shown to be useful. Therefore, don’t do them.
Are doctors having these checks themselves? Ask your conscience how to proceed. Listen to your conscience’s answer. Don’t listen to the devils on your shoulder, in the form of Public Health England, managers, whoever else.
It is wicked to call people to checks they haven’t asked for, for which there is no evidence of benefit and obvious harm, and to tell them, unwarrantedly and untruthfully, that by being checked they have a chance to avoid premature death, and also to fail to explain the chance of harm.
It would be incongruent, as I have said in connection with those prevaricating over breast screening, both to call people for a test and to tell them what is true, that they cannot be assured there is chance of benefit but they will certainly sustain harm ranging from slight to grave. As people try to resolve the contradiction between words and actions, trust in the health service will trump the words as they tell themselves, reasonably, “They wouldn’t do it if it wasn’t good so I’d better accept.” But the NHS does do what isn’t good.
It is cruel to treat people this way. The vast majority cannot be winners. They are sacrificed for the few if any who may get net benefit, and no-one knows who they are. The odds are poor and no-one who understood would accept them. People are hurt at the very least by inconvenience and the anxiety of wondering; at worst by the unspeakable violence of unnecessary treatment. They are also hurt by the betrayal. Safety in numbers doesn’t reduce individual doctors’ responsibility. Your patients are misled by you.
The only solution is not to offer the tests, and to resist pressure from above to do so because it is wrong for all the above reasons.
Dr Wookey seems clear that health checks are pointless. Why can’t doctors exercise their professional judgment and act accordingly? Her problem is not what to tell people. It is how to confront policymakers who need her to act unprofessionally and against her private conscience to fulfil their dubious agenda.
Why don’t doctors join together in their professional bodies and resist harmful and wasteful ideological meddling with their practice of their profession, to protect their patients and themselves? I want doctors to be on my side. I need them to fight for me and with me against futile, dangerous meddling, and for truth. My bitter experience is that they weren’t and they didn’t and they would rather kick the dog than stand up to the bully.
Incidentally, health checks don’t aim to reassure and cannot do so.
Competing interests: Diagnosed through breast cancer screening
The editorial by Goodyear-Smith on health checks nicely summarises the uncertainties about their effects [1]. She cites the recent report from Public Health England, "NHS Health Check: our approach to the evidence," for its criticism of our Cochrane review. This report refers to a commentary published on the website of the NHS Health Check. We respond here to the criticisms raised in both places and describe our unsuccessful attempt to have our response published.
Last autumn, we published a Cochrane review on general health checks in adults for reducing morbidity and mortality from disease [2,3]. Our review was large. It included 182,880 randomised participants and 11,940 deaths, and the median follow-up time in the meta-analyses was nine years. There was no reduction in morbidity or mortality whereas health checks may cause overdiagnosis and overtreatment. Subsequently, the NHS Diabetes and Kidney Care, in conjunction with the Department of Health, published an eBulletin, "Response to the Cochrane review," on the website of the NHS Health Check programme [4]. It is 800 words long and contains what looks like serious criticism of our work, but as we demonstrate below, it is misleading.
We were made aware of the eBulletin when a UK general practitioner copied us on a query she made to the NHS Diabetes and Kidney Care about whether she should continue doing NHS Health Checks in light of the results of our review, and what she should tell her patients about the benefits and harms. She was referred to the eBulletin.
We sent a detailed response to the criticism to the National Director of NHS Diabetes and Kidney Care on 7th January 2013 requesting that it be published on the website alongside the criticism. Two weeks later, we asked whether our email had been received, which was confirmed. On 18th February, we asked again for a reply to our request, and on 25th February we inquired where we could file a complaint about the lack of reply. The next day, we were informed that our response would not be published.
The letter stated that the decision had already been taken by Government that NHS Health Checks will be carried out as a national priority; that “the website is not a forum for debate or discussion on the merits of conducting NHS Health Checks;” and that “there are other more appropriate places to discuss Government policy.” If that was really the case, we wonder why the Programme chose to publish its criticism of our work on its website, and not in a scientific journal, and why it did exactly what it advised against: discussed the merits of health checks on its website [4]. As the Programme furthermore refers health professionals with questions about health checks to this information, it suggests to us that the NHS has sacrificed its own principles about evidence-based health care.
It is interesting to contrast the reactions to our review in the UK with the reactions in Denmark. In the UK, an anonymous Department of Health representative told BBC News that “The NHS Health Check programme is based on expert guidance”[5] and the eBulletin cites a simulation study [4]. These are hardly sources of evidence that can compete with a comprehensive systematic review of the randomised trials, which showed a clear negative result. In Denmark, systematic health checks had not yet been implemented, but they were high on the then new government's agenda. Even so, the Danish Minister of Health stated: “The analysis from the Nordic Cochrane Centre does not come as a surprise... I have put our old suggestion of systematic health checks on ice because they will not have the desired effect” [6].
THE MISLEADING CRITICISM
The eBulletin states that our review does not specify what constitutes a general health check, its content, or its objectives [4]. This is not correct. It is a requirement that Cochrane reviews clearly define the interventions they examine, and we detailed this both in the peer-reviewed protocol, in our Cochrane review, and in its BMJ version [2,3].
Other comments are similarly misleading, e.g. “some interventions included relevant measures such as blood pressure and cholesterol, but not all” [4] gives the impression that these measures were not general features of the included studies. In actual fact, blood pressure was measured in 13 of the 14 trials (the last trial was unclear about this), and cholesterol was measured in 11 trials (unclear in one trial, and in the remaining two trials it was very likely measured).
It is also stated that there was no specification of the follow-up actions to identified abnormalities [4]. However, we mentioned in both of our papers that some trials used follow-up by specialists or by using treatment algorithms, which likely bias results towards greater effect [2,3]. In most trials, follow-up of identified abnormalities was done by the participant's regular physician, which gives a more realistic and generalisable picture of the effect.
Our inclusion of unpublished mortality data from the OXCHECK trial is described as an “unusual approach,” which is “unlikely to be considered appropriate in other circumstances” [4]. This reflects a disturbingly poor understanding of the fundamental principles for systematic reviews. Searching for and including unpublished outcome data is very important since negative results are less often published than positive ones and our approach is standard Cochrane methodology.
Another argument is that none of the included trials precisely match the NHS Health Check. This argument can be used to denigrate any systematic review results that are unwelcome. The overlap between the tests used in the trials in our review and those used in the NHS Health Check is large and include cornerstones of the intervention (e.g. blood pressure, cholesterol and weight). Screening for diabetes was done in seven of our trials, and these trials did not show positive effects either. A recent trial of screening people at high risk for diabetes also failed to find beneficial effects [7].
The eBulletin states that trials with long follow-up are necessarily older than those with short follow-up, and that this reduces the relevance of trials with long follow-up [4]. This is essentially a peculiar argument against using trials with meaningful outcomes and long follow-up in general. Surely, old trials with clinically relevant outcomes are more important than recent trials with surrogate markers such as blood pressure and cholesterol. Furthermore, there was less opportunistic screening when the old trials were performed, and it would therefore have been easier to find an effect of health checks if there was one.
Several other points raised were largely identical to those raised in rapid responses to the BMJ version of our review. We therefore refer readers to our reply [8].
IMPORTANT LESSONS
The NHS Health Check programme operates in clear conflict with the best available evidence and in violation of the criteria of the UK National Screening Committee: “There should be evidence from high quality randomised controlled trials that the screening programme is effective in reducing mortality or morbidity“ [9].
An administration's automatic defence of an existing screening programme can be viewed as a defence of its own interests and of the public funds and personal prestige that have been invested, but it threatens the very idea of evidence-based public health care, particularly when it involves censorship of an open scientific debate.
We urge the NHS Health Check Programme to start a discussion with the Government about closing the programme. The programme consumes vast resources, £332m per year [1], that could be used for a better purpose, e.g. on interventions with documented benefits.
Lasse T. Krogsbøll
Karsten Juhl Jørgensen
Peter C Gøtzsche
REFERENCES
1 Goodyear-Smith F. Government's plans for universal health checks for people aged 40-75. BMJ 2013;347:f4788.
2 Krogsbøll LT, Jørgensen KJ, Grønhøj Larsen C, Gøtzsche PC. General health checks in adults for reducing morbidity and mortality from disease. Cochrane database of systematic reviews 2012;10:CD009009.
3 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. BMJ 2012;345:e7191.
4 NHS Health Check eBulletin. Response to the Cochrane Review. www.nhshealthcheck.nhs.uk/?iid=11 (accessed 9 April 2013).
5 www.bbc.co.uk/news/health-19964600 (Accessed 9 April 2013)
6 Minister: Vi har lagt helbredstjek på is. Ugeskr Læger 24 October 2012. www.ugeskriftet.dk/portal/page/portal/LAEGERDK/UGESKRIFT_FOR_LAEGER?publ... (Accessed 9 April 2013)
7 Simmons RK, Echouffo-Tcheugui JB, Sharp SJ et al. Screening for type 2 diabetes and population mortality over 10 years (ADDITION-Cambridge): a cluster-randomised controlled trial. Lancet 2012;380:1741–8.
8 Krogsbøll L, Jørgensen K, Gøtzsche P. Re: General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis. BMJ 2013;14 March. www.bmj.com/content/345/bmj.e7191/rr/636040 (accessed 9 April 2013).
9 UK national screening committee. Programme appraisal criteria. www.screening.nhs.uk/criteria (accessed 9 April 2013).
Competing interests: No competing interests
Felicity Goodyear-Smith makes many valid points in her editorial, but, possibly, draws the wrong conclusions
Cardiovascular Disease (CVD) is largely preventable.
The aim of Cardiovascular risk assessment is:
1. To reduce incidence of CVD in the community
2. To identify those individuals who are at risk by considering fixed and modifiable risk factors
3. To improve the quality of life
4. To improve life expectancy
These are all key elements of primary healthcare
In 2011 the American Heart Association issued a policy statement " Value of Primordial and Primary Prevention for Cardiovascular Disease" 1 which presented the evidence that policy, community and pharmacological interventions are likely to be cost-effective and cost-saving. They proposed future preventive research should include clarifying the independent and additive benefits of lifestyle modification and clarifying potential benefits, harms & costs of early interventions such as prophylactic statin usage 2
In the US costs related to CVD in 2010 were $ 450 billion pa. It has been estimated that by 2030 the costs could rise to $ 1 trillion pa
The long time frames involved in evaluating preventive interventions make cost-effectiveness analysis difficult and necessarily flawed. High direct medical care and indirect cost of CVD make this a critical medical & societal issue
The willingness for individuals to change their lifestyle behaviours is affected by a number of factors such as different stages of readiness, perceived threat or susceptibility of developing a health condition, perceived benefits of changing behaviour
NHS health checks present a golden opportunity to assess the benefits of lifestyle modification
Dr Harald M Lipman
Executive Director International Cardiac Healthcare & RiskFactor Modification
Competing interests: No competing interests
The plan for health checks for people aged 40 to 75 makes sense, especially in a country like the UK that has achieved an impressive reduction in cardiovascular mortality in the last decades.
To be cost effective, it must prioritize the patient that have a high probability of cardiovascular risk in the first place, then the other patients (low risk), who can be motivated.
The simplest way to prioritize is to make an assessment of the Body Mass Index (BMI), the Resting Heart Rate (RHR) and the Blood Pressure (BP), focusing on those with a BMI of 30 or more, a RHR of 85 or more, or a BP of 140/90 or more.
It is also very simple and practical to combine these data and obtain a Pulse Mass Index or PMI (BMI x RHR). If the product is over 2100, those are to be prioritized.
In a similar way it is possible to obtain the Pulse Mass Pressure Product or PMPP (BMI x RHR x SBP), a more sensitive assessment. Those with a PMPP of 260000 or more should be prioritized.
These assessments can be done by the Nurse and the Physician can concentrate on those with a high PMI or high PMPP.
We should also keep in mind that the cardiovascular prevention can be also significant to prevent Diabetes, Cerebrovascular diseases, Dementia and last but not least, Cancer.
Prof. Enrique Sanchez Delgado
Hospital Metropolitano Vivian Pellas
Managua, Nicaragua
esanchez@metropolitano.com.ni
Competing interests: No competing interests
Congratulations to Dr Goodyear-Smith on her excellent article. I was particularly concerned by Public Health England’s claim that the need was so pressing that there is no need to wait for long-term trials to confirm efficacy. This most unscientific approach is particularly inappropriate when the present evidence does not support and the group involved includes a disproportionate number who do not present ‘pressing health challenges’. Much of the support for the proposal comes from disease specific studies where the primary outcome measure is related to the disease itself and not as it should be in public health studies, healthy overall survival. Furthermore any study involving screening must assume a non-specific adverse effect because the status quo (presumed good health) is broken by an out-side agency. This is likely to be greater if there is any element of compulsion or coercion to participate. As this is in the opposite direction to the desired effect comparative benefit in a controlled trial of an intervention cannot be assumed to indicate net absolute benefit. This makes assessment of outcome in trials involving low risk subjects difficult to interpret unless a naïve un-screened population is included.
Successful medical intervention must always be regarded as at best cost neutral in the long run, because the survivors live to have medical needs they otherwise would not have had. The narrowly defined cost of the proposal may be low, but the impact on resources available for the doctor’s primary duty of treating might prove unacceptable.
For all these reasons the arrogant approach of Public Health England in assuming it knows best is unjustified. The programme’s introduction should have been restricted to some regions of the country with controlled studies of interventions within those regions and comparison of healthy survival between those where screening was and was not undertaken. Whilst this could never be perfect because the population un-screened areas would never be truly naïve, it would at least be an attempt at a scientific approach rather than dictat from above.
Competing interests: No competing interests
In the next 20 years, more than 40% of the US population is expected to have some form of cardiovascular disease, and this will triple the total direct medical costs of caring for hypertension, coronary heart disease, heart failure, stroke, and other forms of cardiovascular disease from the current $273 billion to more than $800 billion, according to a new policy statement from the American Heart Association (AHA) [1].
In addition, the AHA estimates that the prevalence of cardiovascular disease will increase by approximately 10% over the next 20 years given no changes to prevention and treatment trends.
At present, cardiovascular disease is the leading cause of death in the US and accounts for 17% of overall healthcare expenditures. In the past, the medical costs of cardiovascular disease increased at an average annual rate of 6%, and this growth in costs has been associated with an increase in life expectancy. That said, there are "many opportunities to further improve cardiovascular health while controlling costs," according to the AHA.
By 2030, the prevalence of cardiovascular disease is expected to increase 9.9%, with the prevalence of heart failure and stroke increasing approximately 25%. Total direct costs will increase to $818 billion by 2030, according to the AHA estimates, and the total indirect cost to the US in terms of lost productivity is close to $275 billion [1,2].
Hypertension has the greatest projected medical cost, in part because of the aging population, although the increase in prevalence and cost is not explained fully by age. Rising obesity rates are also contributing to the increasing rates of hypertension. The AHA notes that the downstream medical costs of high blood pressure--including its impact on cardiovascular disease and stroke--approximately double the cost of hypertension, making it a "particularly valuable target to modify the future total costs of cardiovascular disease."'
Data from the Coronary Artery Risk Development in Young Adults (CARDIA) study [3] suggest that cardiovascular disease prevention should begin earlier in life. In CARDIA, risk-factor levels in individuals younger than 30 years old were predictive of subclinical atherosclerosis 15 years later. The data, they write, also show that modest improvements in risk factors earlier in life have a larger impact than more substantial reductions later in life.
Of 58 million deaths globally, 60% were attributed to chronic diseases in 2004 (4). Deaths from chronic diseases are projected to increase dramatically between now and 2030 (5).
Considering all risk factors trends together, the forecast for cardiovascular disease burden in low-income and middle income countries over the next few decades comprises a population emergency that will cost tens of millions of preventable deaths, unless rapid actions are taken by governments and health care systems worldwide. In the long term, the most effective strategic approach is through a population level risk factors control (6).
However, a recent analysis of 23 low income and middle income countries indicated that the capacity of these countries to effectively deal with existing and projected burden of non communicable disease is limited (7). The decision by the United General Assembly to convene a “high level meeting on the prevention and control of non-communicable disease worldwide” in September 2011 provides a unique opportunity to elevate chronic diseases to the global political agenda.
More evidence-based effective policy should be applied in the prevention, early detection, and management of cardiovascular disease risk factors. Through a combination of improved prevention of risk factors and treatment of established risk factors, the dire projection of the health and economic impact of cardiovascular disease can be diminished. [1-3].
On the basis of the available data the American College of Cardiology Foundation and American Heart Association have stated in their guidelines that screening is of limited value in individuals at low risk (10 year Framingham risk scoring <10%). However, in individuals at intermediate risk (10 year Framingham risk scoring 10-20%) the finding of coronary calcium scoring of 400 or higher would increase the risk to that noted with diabetes or peripheral disease, altering clinical-decision making. Individuals with a high 10 year Framingham risk score (> 20%) should be treated aggressively according to the current National Cholesterol Education Program (NCEP) III guidelines and do not require additional testing (8,9).
An evidence-based preventative programme based on scientific international guidelines is essential to identify asymptomatic individuals at the highest risk requiring preventive lipid lowering medication or blood pressure treatment. Treating people at high risk of cardiovascular disease with aspirin, a statin, and two blood pressure lowering drugs is highly cost effective and would save about as many premature deaths as the population strategies (11).
Cardiovascular disease is largely preventable through training an adequate workforce, using clinical practice guidelines to improve care, improving management of population risk factors.
1. Heidenreich PA, Trogdon JG, Khavjou MA et al on behalf of the American Heart Association. Forecasting the future of cardiovascular disease in the United States- A policy statement from the American Heart Association. Circulation 2011; 123:
2. Michael O'Riordan. Cost of Cardiovascular Disease to Triple by 2030. Heartwire © 2011 Medscape, LLC
3. Ogunyankin KO, Liu K, Lloyd-Jones DM, Colangelo LA, Gardin JM. Reference values of right ventricular end-diastolic area defined by ethnicity and gender in a young adult population: the CARDIA study. Echocardiography. 2011 Feb;28(2):142-9. Epub 2011 Jan 7.
4. WHO. Global infobase. https://apps.who.it/infobase/mortality aspx
5. Mothers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. Plo S Med 2006; 3: e442
6. Anand SS, Yusuf S. Stemming the global tsunami of CVD. The Lancet 2011; 337: 529-532
7. Alwan A, Maclean DR, Riley LM et al. Monitoring and surveillance of chronic non-communicable disease: progress and capacity in high burden countries. The Lancet 2010; 376: 1861-1868
8. Greenland P, Bonow RO, Brundage BH et al. ACCF/AHA expert consensus document on coronary artery calcium scoring. Circulation 2007; 115: 402-426
9. Third report on the NCEP Expert Panel on detection, evaluation and treatment of high blood cholesterol in adults (Adult Treatment Panel III) final report. Circulation 2002; 106: 3143-421
10. Writing Committee Members: ACCF/AHA Task Force Members. 2010 ACCF/AHA Guideline for assessment of cardiovascular risk in asymptomatic adults: Executive summary: A report of the American college of cardiology foundation/American heart association task force on practice guidelines. J Am Coll Cardiol 2010; 56 (25): 2182-2199
11. Shiffman J, Smith S. Generation of political priority for global health initiatives: a framework and case study of maternal mortality. The Lancet 2007; 370: 1370-79
Competing interests: No competing interests
Should it not be required that before any health policy can be started, as well as having good evidence of possible benefit, the harms should have been investigated? Neither applies in this case. No-one demands perfection: Kevin Fenton addressed a straw man.
He concedes there is inadequate evidence of benefit. We already know the conditions to be checked for are overdiagnosed – pure harm. Screening for risk of disease is even more dubious than screening to detect disease early. It shouldn’t be done without prior counselling because some people on realising the implications will prefer not to know. Informed consent is a sine qua non yet in practice inadequately carried out, and should not be conducted by those with an interest in take-up of an intervention. Lifestyle advice can be given without screening and already is.
Health checks will do great harm. Healthy people called in by trusted doctors will be told untruthfully the checks provide a chance to avoid premature death, raising false expectations and subtly engendering fear and dependency. There will be futile angst-inducing follow-ups for inconsequential signs. Well people taking doctors’ time will be presented with ifs, buts, and maybes that cannot be resolved as tests yield possibilities and unknown probabilities, cascading them further into the system as they acquiesce from fear to treatments that will definitely harm when the chance of benefitting is minute to non-existent. The cost in avoidable physical and mental damage will be high, generating complaints. The genuinely ill will be forced to wait for staff overwhelmed and undermined by the multifarious repercussions of a misguided health ideology. People encouraged to believe they can keep death and decrepitude at bay by pre-emptive checking will become neglected patients as they develop genuine illnesses not detected by health checks, and become disillusioned and distrustful of professionals who make big promises and meddle in their lives to no avail causing personal havoc but who aren’t there when they need them.
These checks cannot reassure. Negative results can at best mean that the tests didn’t detect anything. You’re only as good as your last test. People testing negative on Monday will realise by Friday that they might have missed something, or have something they aren’t tested for, and that anything can happen between checks.
To warrant these checks there would have to be good evidence of benefit in length and quality of life to very many at a cost in risk of harm the informed public is willing to pay. No such evidence will be forthcoming because that cannot be achieved. Mr Fenton wants to go ahead anyway not to benefit people but to use them to gather evidence. He ought to be transparent and not use an unconsented public in an experiment with no control group rather than underhand in promising unrealisable benefits without disclosing harms. That lesson should be learned from the breast screening debacle.
Doctors should refuse to do the checks as they are incompatible with professional standards and a clear conscience.
Competing interests: Diagnosed through breast cancer screening
I refused my GP surgery's offer of a free health check. I resent the current trend for more and more health checks and screenings - which extol the benefits, yet fall far short when it comes to information on risks and harms. And I resent doctors being paid when people attend, and even being paid to encourage people to attend (eg breast cancer screening - as confirmed with the Department of Health by telephone - although signposted as a source of (unbiased?) information and support for invited women's decision-making).
But then, having read Dr Margaret McCartney's splendid book, 'The Patient Paradox - why sexed up medicine is bad for your health', I am a little more clued up than Jo and Josephine Bloggs.
A new patient at my surgery was being told the process for registration which included, 'and then we'd want you to see the nurse for a health check' -which came across as part of the deal for being accepted - a demand to be met, which the newbie could hardly refuse. So if they can't make the numbers up one way, they haul them in by other means.
I'd like the money spent on such 'intrusive' practice (well, I am labelled if I do not comply!) to be spent instead on treating patients with symptoms. I'd also like those living with side effects of treatments to be able to access adequate care, support and treatment. For example, I have mid-line lymphoedema as a side effect of cancer treatments but, though I once received a successful 'one-off' treatment locally, further treatment was denied and I have had to travel a 90 mile round trip for appropriate treatment. Now financial constraints mean even that treatment is to be denied me: the distant clinic can only afford to treat new patients and I'm to be discharged. Yet again it's a case of NHS DIY - and 'pay for it or you don't get it': back-door privatisation.
Competing interests: No competing interests
Re: Government’s plans for universal health checks for people aged 40-75
Like many GP practices we have implemented health checks for 45-70 year olds. We benefit financially from offering the service. The checks are popular and appreciated.
If the conclusions from the Cochrane review (1) are correct these checks confer no benefits on our patients.
I am not sure what I should do next.
I can think of 3 possible options
1) carry on as before
2) carry on as before but report myself to the GMC on the grounds of professional misconduct for promoting an intervention from which I profit financially and which I believe to be ineffective
2) halt the service
3) continue to offer the service but enclose with the invitation an information leaflet which tries to explain the lack of benefit, such as:
"Important Information about your NHS Health Check
General health checks involve multiple tests in a person who does not feel ill in order to find disease early, prevent disease from developing, or provide reassurance. Health checks are routinely provided in many countries.
To many people it seems common sense that health checks lead to better outcomes for those who have them, but experience from screening programmes for individual diseases have shown that the benefits may be smaller than expected and the harms greater.
In fact, this type of health check has been closely studied, and has not been shown to reduce illness or early death. (Cochrane Systematic Review 2012)
Harm can be caused by health checks as some conditions which would not have progressed to cause illness or death are picked up and treated. The problem is that it is impossible to determine which condition is an over diagnosed one which would never have progressed further, and which is one, which left untreated, would progress to cause harm. Once there is a suspicion of a condition it is very difficult not to go ahead and investigate further, and treat any disease found. The treatment may end up causing the patient more harm than if nothing had been done in the first place.
People who respond to invitations to have health checks are often already interested in looking after their health and are not given any new information as a result of a health check. Those who are less able to take the same interest and who may have greater health needs are less likely to respond an invitation to a health check.
There is a possibility that some people might feel relieved by being given some reassuring information, such as a low cholesterol and feel that they can safely continue with high risk activities, like smoking, as a result.
The department of health has decided to recommend health checks, so we are inviting you to come for one. We feel it is important that you are aware of the uncertainty over whether you will be more likely to be alive and healthy in the future as a result of having had the check, before you decide whether or not to go ahead with it.
If you would like further information or would like to talk to your doctor then please get in touch with us."
I would welcome any other suggestions
1) 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.
Competing interests: No competing interests