Intended for healthcare professionals

Editorials

Screening for cardiovascular risk in general practice

BMJ 1994; 308 doi: https://doi.org/10.1136/bmj.308.6924.285 (Published 29 January 1994) Cite this as: BMJ 1994;308:285
  1. N Stott

    One of the most controversial components of the new contract imposed on British general practitioners in 1990 was the requirement to offer regular health checks to the public. This requirement came even though multiphasic health checks had been shown to be ineffective in terms of their impact on morbidity and mortality.1,2

    During the 1970s case finding and health promotion had become to be regarded as options available to general practitioners during consultations,3 but during the 1980s the value of blanket (population) screening of all adults was disputed.4,5 The professional and scientific concerns were, nevertheless, ignored when the government required general practitioners (or their staff) to perform health checks of the population and also to identify cardiovascular risk factors for all adults and intervene appropriately.6

    This week's BMJ publishes the early results of two large scale evaluations of health checks and interventions for cardiovascular risk factors from general practice (p 308, p 313).7,8 In both studies general practitioners were supported by nurses trained to screen and intervene. The Oxford and Collaboration health check (OXCHECK) study was mounted two years before the government's new policy was imposed and entailed a four year block randomised evaluation of the introduction of health checks by practice nurses.7 The British family heart study is a randomised controlled trial in general practices in 13 towns in Britain to measure the impact of a programme of cardiovascular screening and lifestyle intervention led by nurses.8

    Both studies cover large numbers of patients. The OXCHECK study is being conducted in five urban practices in Bedfordshire and the family heart study in a nationally scattered sample of 26 small town practices. The intervention of the OXCHECK study is health checks and counselling by nurses of patients about risk factors, with an emphasis on ascertaining patients' views on change and targets. In the family heart study the intervention is cardiovascular screening of men and their partners, with lifestyle interventions based on a client centred family approach. The measures in both studies include the change in the main risk factors for cardiovascular disease, but the family heart study also used the Dundee risk score for coronary heart disease and blood glucose assay.

    Both studies found very modest changes in the intervention groups despite intensive intervention. In the family heart study a 12% lower risk of coronary heart disease (on the Dundee risk score) occurred in the group subjected to intensive lifestyle intervention, and this was more apparent in those at highest risk. The authors of the OXCHECK study found that the prevalence of smoking, the rate of stopping smoking, and body mass index were not significantly different between the two groups studied; there was a significant difference between the groups in cholesterol concentration, but the difference was small, particularly in men. Both sets of authors point to the need for longer term follow up, but neither is optimistic about the likelihood of further improvement in its results. So the impact on public health is likely to be marginal.

    This style of approach to the population through primary care alone is not going to produce large reductions in the risk of cardiovascular disease. Instead, the government will need to put more effective legislation in place to control use of tobacco and promote the consumption of healthy food. It will also need to reconsider the controversial new arrangements for paying general practitioners for health promotion activity, with their emphasis on data collection.6 In the meantime, these studies should not be interpreted as casting doubt on general practitioners' opportunistic use of routine consultations for health promotion.

    General practice teams have good evidence for the effectiveness of clinical efforts in secondary prevention of vascular disease9 and growing evidence that a little professional support for people who are ready to change their lifestyles will improve outcomes.10 These are large tasks in themselves, and there seems to be no justification for the ritualistic collection of risk factors when the public health benefits are marginal, less motivated patients are upset by the process,5,11 and the primary care professionals are demoralised by bureaucratic payments linked to targets and population coverage. The ethics of screening are clearly being ignored in the new contract imposed on general practitioners,12 and the scientific evidence that existed before 1990 has been strengthened by the two papers in today's journal.

    References