The NHS Health Check programme is ineffective and currently wasting £450 million a year in scarce resources, according to a new report from LSE and University of Liverpool.
The programme invites everyone in England aged 40–74 without cardiovascular disease (CVD) for a check every 5 years. Its website advertises that health checks, branded as “mid-life MOTs”, can prevent heart disease, diabetes, kidney disease stroke and dementia, as well as provide support and advice to help individuals manage and reduce their risk of future disease.
However, according to the report, Invited Debate. NHS Health Checks—a naked emperor?, published in the Journal of Public Health, the NHSHC programme fails to achieve both of these primary objectives. Furthermore, it “relies on weak concepts, denies strong scientific counter-evidence and ignores persistent implementation issues.”
NICE (The National Institute for Health and Care Excellence) also comes in for strong criticism for doubling the number of people eligible for treatment following the health checks. It argues that the money could be better spent on more effective interventions, such as those targeted at child and maternal health, or effective strategies promoting healthy food which have the potential to halve the burden of premature CVD.
The programme is assessed against each of ten World Health Organization (WHO) Screening Criteria which have been evaluated and refined over four decades. The report explains that this is crucial, because all screening has the potential for harm, and screening science can be counterintuitive.
The programme passes the following three criteria:
- The condition should be an important health problem.
- There should be a recognisable latent or early symptomatic stage.
- The natural history of the condition including development from latent to declared disease should be adequately understood.
CVD, diabetes, dementias and other non-communicable diseases together account for some 80% of deaths and of disability in the UK. Furthermore, these diseases all share the same four major risk factors: poor diet, tobacco, alcohol and physical inactivity.
However, the NHSHC programme fails all but one of the remaining WHO screening criteria:
- Test suitability - An individual patient’s likelihood of future cardiovascular and related disease is usually assessed by a GP or practice nurse using a global risk score. These scores have frustratingly low sensitivity and specificity for the individual patient. Most current risk calculators miss over one-third of people who subsequently have a heart attack or stroke. That mismatch between predicted and actual events might approach 50%, says the report.
- Test acceptability - Low acceptability of NHS Health Checks is suggested by the persistently low attendance rates. Uptake averages 50% of a target population. This is often even lower in young men, smokers and some ethnic minority groups, and routinely much lower in deprived areas. These factors may potentially widen inequalities.
- Finding cases should be a continuing process, not a ‘once and for all’ - Much risk management is already being done opportunistically for many patients by GPs in the course of normal consultations. Resourcing a separate NHSHC programme might therefore have unintended consequences in terms of changing the content of consultations in primary care. Additionally resources will inevitably be sometimes spent on replicating tests already done in general practice.
- Facilities for diagnosis and treatment are available - This is technically correct for CVD though less so for dementia. However this criterion is rapidly superseded by subsequent criteria.
- Treatment effectiveness –over three decades of field research with actual measured outcomes has shown that screening has failed to substantially reduce death rates –at best modelling suggests that perhaps 1000 deaths may be prevented.
- Eligibility – It is debatable as to whether the programme passes or fails this.
- Cost-effectiveness - The annual cost of the fully operational scheme was originally estimated at £350 million in 2008. The report estimates that this is now around £450 million per year.
The report comments: “Thus, preventing 1000 deaths annually could cost up to £450,000 per death avoided. And costs will obviously spiral substantially now that NICE have roughly doubled the number of potentially eligible people for treatment. These high costs are rarely acknowledged and often dismissed. They also make the much quoted NICE estimate of ‘around £3000 per QALY (quality-adjusted life-year)’ look rather fanciful.”
It adds: “Health care professionals, services and local authorities are all mandated to implement NHSHCs. In spite of austerity policies, they are required to commit time and scarce resources to activities of debatable effectiveness and cost-effectiveness…This saps morale, particularly considering the substantial opportunity costs of failing to invest those scarce resources in alternative, more effective interventions. For instance, many child and maternal health interventions are proven to be cost-saving.”
The report concludes by calling for public health decisions in the NHS to become independent of government:
“We believe that many of our colleagues in the Department of Health, Public Health England and NHS England privately agree that NHSHC are costly and ineffective. However, as civil servants they are obliged in public to ‘toe the party line’. Lacking an independent voice, they must be seen to support ministers even when the scientific evidence points in the opposite direction – they are obliged to see the Emperor’s clothes where none exist.
“This dominance of political obedience over scientific objectivity is hazardous, and that hazard is manifest in the continuing flawed NHSHC strategy for CVD prevention which, we argue, is resulting in many thousands of avoidable deaths every year. This is but one example of why Britain urgently needs an independent Institute of Public Health, as enjoyed, for instance, in Finland and the Netherlands. Only then will ministers receive objective, scientific advice on public health. The British people deserve no less.”
The report's authors are:
Walter Holland, Emeritus Professor of Public Health Medicine and Visiting Professor, LSE. W.W.Holland@lse.ac.uk Tel: 020 7955 6277
Simon Capewell, Department of Public Health and Policy, Institute of Psychology, Health and Society, University of Liverpool. firstname.lastname@example.org Tel: 0151 794 5576
Margaret McCartney, GP, Glasgow. Margaret@margaretmccartney.com
For a copy of the reportor any queries, please contact Joanna Bale, LSE Press Office, email@example.com or 07831 609679.
21 September 2015