Wednesday, 28 August 2013

Response to NHS Health Check criticism

The following post was submitted as a letter to the editor of the Times newspaper last week in response to their leading article on the benefits of NHS Health Checks:

Given the recent conflicting headlines in regard to NHS Health Checks, providers of the programme are understandably confused and frustrated by the inconsistency of the messages being reported in the press.

On 21st July 2013, Public Health England (PHE) announced a drive to extend the national health check programme and widely praised its potential to ‘save up to 650 lives a year’.

Less than a month later on 20th August, the Times ran with the front page headline ‘NHS checks on over-40s condemned as ‘useless’’, with an accompanying article that focussed on a study from the Nordic Cochrane Centre that was originally published and reported on last October. The study alleges that health checks don’t have an impact on morbidity.

Both of these mutually exclusive claims cannot be true at the same time. The pressing question is therefore ‘which is accurate and relevant to the English NHS Health Check programme?’

It should be noted that one of the major criticisms of the Cochrane Review is that it doesn’t actually apply to the current model put forward by PHE. According to the Department of Health’s (DH) response to the Cochrane Review:

‘Most of the trials considered are old, dating from as long ago as the 1960s when understanding of health risks and particularly how they may be modified was at an early stage of development.  Most of the risk reduction measures now used post-date these trials.’

As a result:

‘The review conclusions can have little if any relevance to NHS Health Checks.’

Given how separate the research conditions are from what’s actually happening in this country, it can hardly come as a surprise that the DH rebuffed the Cochrane Centre’s request for the research to be posted on the NHS Health Check website. It was this declined request that the Danish researchers took issue with and condemned in their letter to the Times that acted as the original catalyst for the story.

However, far from being an attempt by the NHS to stifle debate’, it is difficult to see how there could be any assumed requirement for the DH to publish findings which bear no relevance to the English model.

The current approach championed by PHE is – first and foremost – a targeted lifestyle intervention which should encourage positive behaviour change if an individual has poor lifestyle habits. Individuals are made aware of their risk of cardiovascular disease, offered advice and signposted for further support if necessary.

The point is that through the effective communication of risk and appropriate service referral, individuals can fully grasp their likelihood of having a heart attack or stroke and, if needed, be offered support to do something about it.

Moreover, the NHS Health Check is unique in the fact that it combines a number of elements and tests – all of which are ‘based on evidence of clinical and cost-effectiveness from trials’ – and brings them into a single risk assessment programme. As Dr Bill Kirkup, retired Chief Medical Officer at the Department of Health, noted, ‘none of the trials assessed by Lasse Krogsbøll and colleagues tested this’.

I must stress that we fully encourage lively and healthy debate on this blog and recognise that such dialogue is essential to ensure that public health programmes such as the NHS Health Checks are worth the money that’s spent on them.

The issue in this instance is that recent criticism has rested on research that does not accurately reflect or relate to what’s happening on the ground. From an academic perspective, it’s essential that the studies being used in evidence are not disconnected from the reality of the situation.

The discussion as to the merits of the NHS Health Checks is not new. As mentioned, the Cochrane Centre’s findings were first published and in the news last October. This time however the chair of the Royal College of GPs also came out in staunch opposition to the programme.

One of Dr. Clare Gerada’s main claims was that the programme constitutes ‘a waste of money for asymptomatic people’; a statement which translates as ‘if you’ve not already developed complications, you shouldn’t be receiving a health check’.

In response, public health experts appropriately drew attention to the burden of ill health that threatens to overwhelm the NHS during the coming decades. PHE’s official statement written by the organisation's Medical Director - Dr. Paul Cosford - can be viewed here.

It is for precisely these reasons that the programme targets lifestyle factors associated with preventable diseases before they become unsustainably costly for the NHS.

One needs only to look at the facts staring us in the face. It has been estimated that by 2050, ‘90 per cent of today’s children will be overweight or obese.’

Even by 2030, ‘Three in four adults are likely to suffer illnesses such as heart disease or diabetes’ according to the Daily Telegraph’s article from the 21st August; ironically, a publication that only the day before ran with the story about health checks being ‘useless’.

Specifically in terms of diabetes, treating the condition currently costs the NHS £1million an hour. Given the other estimates, the direction in which this financial burden is likely to move looks bleakly clear.

The net financial benefit of acting whilst there’s an opportunity to do so has hard evidence associated with it. As Barbara Young, Chief Executive of Diabetes UK stated to the BBC:

‘Once you factor in the savings in healthcare costs, the NHS Health Check is actually expected to save the NHS about £132 million per year.’

The DH assures that the above figures are based on expert guidance, all of which can be viewed here

Furthermore, research published in the BMJ on the 13th May 2011, found conclusively that:

'A programme across the entire population of England and Wales... that reduced cardiovascular events by just 1% would result in savings to the health service worth at least £30m a year compared with no additional intervention.' 

As a result, once the evidence is examined and objectively considered, the claim coming from the programme’s critics that the Cochrane Centre’s findings constitute the ‘best available evidence’ seems to look less and less empirically accurate.

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