The potential burden of overinvestigation

Why is the NHS currently involved in a £150m trial of the Galleri blood test? The test can detect more than 50 types of cancer, says Grail—the US based biotechnology company that makes it—and could help diagnose cancers at an earlier stage. But an investigation by The BMJ raises concerns that evidence is insufficient to justify its use as a screening tool (doi:10.1136/bmj.q1706).1

The NHS trial of the blood test, with more than 100 000 participants, is taking place despite previous research finding that the test sensitivity for stage I cancers was only 16.8%. Another study in asymptomatic patients found that 1.4% had a positive test, but 62% of these results were false positives. These findings indicate a risk of patient harm from overdiagnosis and highlight the impact that a wider rollout of the test could have on resources—potentially increasing the demand for imaging and further testing and increasing waiting lists. So, the benefits of the Galleri test are not clear. The “success criteria” for the trial include that the test detects 75% more cancers with the Galleri test than in the control group—but increased detection rates don’t necessarily translate into improved survival for patients, says Clare Turnbull, professor of cancer genetics at the Institute of Cancer Research in London.

Meanwhile, costs to the NHS are high. If the £150m trial is successful NHS England has committed to piloting a further million tests, with a possibility of five million more rolled out by 2030. This could be a lucrative deal for the manufacturer, Grail—brokered after involvement from UK government ministers, without the contract being put out to tender. There are concerns about industry influence and whether the test will live up to its promises.

One organisation currently under scrutiny for failing to deliver on expectations is the Care Quality Commission (CQC), as an interim report found “significant failings” (doi:10.1136/bmj.q1686).2 David Oliver argues that this extends to other health regulators and calls for an overhaul of the system (doi:10.1136/bmj.q1721).3 Helen Salisbury, a GP, describes the impact of CQC inspections on staff (doi:10.1136/bmj.q1713)4: “For most GPs, the overwhelming feelings when they hear that an inspection is imminent are of weariness and dread.” Perhaps it’s no surprise that GPs have voted overwhelmingly in favour of collective action for the first time in 60 years—a verdict that, says Katie Bramall-Stainer, chair of the BMA’s General Practitioners Committee for England, reflects the fact that GPs are “at the end of their tether” (doi:10.1136/bmj.q1717).5

The UK’s maternity care workforce has also come under intense pressure recently, with several reports highlighting serious failings and “issues around leadership, staffing, and communication.” Ranee Thakar, president of the Royal College of Obstetricians and Gynaecologists, echoes the argument that constant inspection harms staff morale (doi:10.1136/bmj.q1708).6 Medical teams are overburdened by investigations, she says, when they want to focus on improving patient care. What’s needed is clarity on how to effect longlasting change, particularly around reducing persistent health inequalities in maternity care.

Two policy areas that we know can help drive change are restricting junk food advertising aimed at children, along with the sale of high caffeine energy drinks. Adam Briggs and Grace Everest welcome recent plans by the UK government to tackle children’s ill health and obesity (doi:10.1136/bmj.q1707),7 but they warn that more needs to be done, as “the burden of preventable ill health is rising, and inequalities are widening.” This isn’t just a UK problem: new research finds that consumption of sugar sweetened beverages increased by 23% in 3-19 year olds in 185 countries from 1990 to 2018, which parallels rising rates of obesity in this population worldwide (doi:10.1136/bmj-2024-079234).8 Government action needs to tackle the wider commercial and environmental factors behind these trends.