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NHS Health Checks – a waste of money?

Many in the Department of Health, Public Health England and NHS England privately agree that the NHS Health Checks (NHSHC) programme is costly and ineffective, but are obliged in public to ‘toe the party line,’ according to a review published recently in the Journal of Public Health.1

The authors make the case that the NHSHC programme represents an ineffective strategy and is currently wasting scarce resources. The NHSHC programme invites everyone in England aged 40–74 without cardiovascular disease (CVD) for a check every five years. The NHSHC website advertises that health checks can:

  • prevent heart disease, diabetes, kidney disease stroke and dementia,
  • provide support and advice to help individuals manage and reduce their risk of future disease.

However, the authors say the programme fails to achieve both of these primary objectives, relying on weak concepts, denying strong scientific counter-evidence and ignoring persistent implementation issues. They assess the NHSHC against each of the 10 World Health Organization (WHO) Screening Criteria, to see whether the programme passes or fails.

Professor Simon Capewell (University of Liverpool)

Professor Simon Capewell (University of Liverpool)

The authors claims that adherence to the NHSHC represents a triumph of political obedience over scientific objectivity, presenting a hazard which is manifest in the continuing flawed NHSHC strategy for CVD prevention which, they argue, is resulting in many thousands of avoidable deaths every year.

They call for an independent Institute of Public Health, like those found in Finland and the Netherlands, to ensure ministers receive objective, scientific advice on public health.

Co-authors Professors Simon Capewell (University of Liverpool) and Walter Holland (London School of Economics) gave us the following commentary on their review:

Cardiovascular disease assessment

In view of the importance of CVD as a cause of both morbidity and mortality identifying individuals at risk is considered important. This is tempting since many of the factors involved in the development this disease, such as smoking, blood pressure, diabetes and high density cholesterol have been identified. With the development of computing a variety of risk scores have been developed, based on combining the values of these risk factors present in an individual to attempt to provide more accurate prediction of the risk of developing CVD, e.g. QRISK2 and the Framingham Risk Score.3

Professor Walter Holland (London School of Economics)

Professor Walter Holland (London School of Economics)

Frustratingly evaluation of these risk scores has shown4,5 that although populations with high risk scores have a greater propensity to develop cardiovascular disease their ability to predict the risk in an individual is not very good, e.g. QRISK only identifies about 30% of the subsequent cardiovascular events in men in the high risk group5 while “the Framingham algorithm would classify about twice as many of the men in the UK (one in five) as being at high risk, although this larger high risk group does not include twice as many of the men who had a cardiovascular event during follow-up (it included only 50%)”.5

The inability to develop a risk score that is both highly specific and highly sensitive in the prediction of the development of cardiovascular disease in an individual is frustrating, in view of our ability to identify high risk population groups and our knowledge of risk factors.

But we should not be too surprised – after all the development of risk scores from knowledge of some factors such as age, blood pressure, and cholesterol level is little different to the formulae developed by horse racing punters in betting.

To prevent the development of cardiovascular disease in both individuals as well as groups we can achieve success by tackling the factors that are involved in its development such as smoking, blood pressure and diet, improving education and child health rather than attempting to develop even more complex formulae than either QRISK or the Framingham equation.

References

1. Capewell S, McCartney M, Holland W. Invited debate: NHS Health Checks – a naked emperor? J Public Health 2015;37:187–92. http://dx.doi.org/10.1093/pubmed/fdv063

2. Hippisley-Cox J, Coupland C, Vinogradova Y, Robson J, May M, Brindle P. Derivation and validation of QRISK, a new cardiovascular disease risk score for the United Kingdom: prospective open cohort study. BMJ 2007;335:136. http://dx.doi.org/10.1136/bmj.39261.471806.55

3. D’Agostino RB , Vasan RS, Pencina M, Wolf PA, Cobain M, Massaro JM, Kannel WB. General cardiovascular risk profile for use in primary care: the Framingham Heart Study. Circulation 2008;117:743–53. http://dx.doi.org/10.1161/CIRCULATIONAHA.107.699579

4. Collins GS,  Altman DG.  Predicting the 10 year risk of cardiovascular disease in the United Kingdom: independent and external validation of an updated version of QRISK2. BMJ 2012;344:e4181. http://dx.doi.org/10.1136/bmj.e4181

5. Jackson R, Marshall R, Kerr,A, Riddell T, Wells S. QRISK or Framingham for predicting cardiovascular risk? BMJ 2009;339:b2673. http://dx.doi.org/10.1136/bmj.b2673

Published on: September 30, 2015

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