Medical Matters: Unnecessary checks sap resources better spent on poor people
They might seem sensible, but there is little evidence that having a periodic health check does any good
Among the many ill-thought-out elements in the recent GMS draft contract to provide free GP care to all children under the age of six was the provision of regular health checks on otherwise well children.
Thankfully now discredited and deemed unworkable because of the extent of indemnity requested of family doctors and their insurers by the Department of Health, the contract contained many clauses indicating a Walter Mitty-type disconnect with reality.
One of the bedrocks of medicine and healthcare must be to follow evidence-based practice. And there is precious little evidence to support the validity of regular health checks by GPs. However, this hasn’t stopped governments from latching on to them. In England, the NHS has recently introduced health checks for all 40-74 year olds at five-year intervals.
The health checks consist of an appointment with a healthcare professional at which people are asked about their family history and lifestyle, and have their body mass index, blood pressure and cholesterol concentration measured.
Dr Margaret McCartney, a columnist with the British Medical Journal (BMJ) and an advocate of evidence-based medicine, is not impressed. Calling the policy a “high-stakes gamble”, she says many public-health physicians are concerned about the direction the politicians have set for public health.
She quotes Gabriel Scally, a senior public-health doctor: “The science of screening is not well understood by politicians and this was exploited by the medical interventionalists.
“What civil servants have been doing is playing with the language – calling the programme health checks rather than screening – to bypass the system we have in the UK to protect people from mass unscientific interventions.”
No trial plans Amazingly, for such a sweeping health intervention, there are no plans to carry out a randomised trial to see whether it works.
Other research is hardly reassuring: a 2012 randomised trial of screening for diabetes in the UK found no evidence of improvements in all-cause mortality over 10 years; a Cochrane systematic review found no evidence that general health checks could reduce morbidity or mortality, although they did increase the number of diagnoses; and last year a study in BMJ Open found that one-third of people at high risk of having or developing type 2 diabetes were not identified through the health check.
A recent graduate of the Sligo specialist training scheme in general practice, Dr Mark Murphy, and some of his colleagues, have just had a paper published in the European Journal of General Practice.
The study of “the asymptomatic general check-up (AGCU) looked at GPs’ experiences and attitudes to such requests from patients”.
Some six out of 10 respondents felt the AGCU had some clinical merit, with the assessment of cardiovascular risk, taking a family history of illness, evaluating a patient’s hidden concerns and an analysis of a urine sample the most commonly performed tasks. However, many GPs expressed frustration with a request for a check-up. Here are some of their comments: n“A major concern that it could increase workload, which would diminish time for treating ill patients
n“Creating a worried well by the need for a check-up. Where do you stop?”
n“Very frustrating concept: no evidence showing any benefit for most of what we do in this”
n“When one is requested, my heart sinks; I do not know what the term means, what the patient’s expectations are
n“Check-ups are largely patient-driven secondary to media/ public-health-generated anxiety
n“Patient can have too much faith in the value of the check-up. Private companies abuse the public by ordering these . . .”
For me, the biggest concern, in the absence of an evidence base for AGCUs, is the risk of medicalising social inequalities. Why not put scarce resources into healthcare for disadvantaged communities rather than creating a growing population of the “worried well”?