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‘Doctor, I’ve just had my health check done through work, and been told to come and see you to discuss the results’. A large wedge of paper gets deposited on your desk with lots of bar charts and colour coding. I’m sure this is a scenario that most of us are seeing increasingly, and if you’re like me it tends to lead to a twitchy eye and images of the boiling head emoji 🤯.
So it was with a little internal cheer that I read the Screening Position Statement from the RCGP and BMA in October relating to screening that has not been approved by the UK National Screening Committee. There is a burgeoning private screening market offering everything from simple blood tests to full body scans, ultrasounds and questionable bone density tests, so this paper sets out to fill the huge gap in guidance regarding use of these tests, and where responsibility lies for reviewing the results. All too often the results are simply pushed back to us in General Practice to review, which as the paper states is ‘an inappropriate use of NHS resources and can have a potentially significant negative impact on primary care’. The paper states that the RCGP does not support non-evidence-based screening and that ‘the organisation initiating the screening should not assume that general practitioners will deal with the results. Organisations offering these interventions must organise and fund follow-up so that patients are adequately supported and so that the interventions do not impact negatively on the use of NHS resources.’ As discussed in the BMJ after its publication (BMJ 2019;366:l5707), the lead author Margaret McCartney is realistic that this won’t solve all the problems of non-evidence based screening, but it hopefully ‘will lead to positive change’.
In a time when NHS budgets are as tight as they have been for many years, we simply cannot waste precious resources on interventions that have no proven benefit, and screening in general is an area that I think we need to be looking at much more critically. We are incredibly luck in this country to have the National Screening Committee (NSC), which gives objective recommendations on the benefits and harms of population screening, yet as is happening in the private sector, screening ‘pilots’ and ‘programmes’ are getting introduced into the NHS without good evidence to support them. The NHS Health Check is one such anomaly, and is conspicuous by its absence in the list of NSC recommendations. The latest review of the literature on the NHS Health Check programme (British Journal of General Practice 2018; 68 (672)) suggests that overall uptake is <50% and that current modelling estimates the programme prevents one CVD event for every ~5000 people screened, and there is a lack of evidence as to whether the programme has had any impact on health-related behaviours. The initial modelling suggesting that health checks would be a cost effective initiative was based on the improbably optimistic premise that >75% of people would attend screening and that >85% of those picked up with high cholesterol or high CVD risk scores would be prescribed statins. The fact that the Health Check seems to be making minimal impact should come as little surprise. The latest Cochrane review on general health checks published earlier this year concluded they have little or no effect on total mortality, cancer mortality, fatal and non-fatal IHD and probably have little or no effect on fatal and non-fatal stroke and cardiovascular mortality (all moderate to high certainty evidence). Unusually they go as far as to suggest that further research is not indicated on general health checks as ‘it seems futile based on the large amount of available data’.
Applying the mantra that ‘all screening causes harm; some does good, and some more good than harm at a reasonable cost’ is something we collectively need to mindful of when considering both individual and population screening. And as for direct to consumer genetic testing…well that is another whole can of worms that we will be discussing in our Spring 2020 reviews!
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