UK Health Check contradicts best evidence

The United Kingdom’s National Health Service (NHS) Health Check program was created to help prevent heart disease and other ailments, but critics say it is unproven, expensive and will lead to problems.

“There are bound to be incidental findings in asymptomatic individuals that [general practitioners] pick up during these health checks which will have to be followed up with further investigations and unnecessary tests,” said Dr. Clare Gerada, council chair for the Royal College of General Practitioners in the UK.

According to its website, the Health Check program recommends that all adults aged 40–74 be assessed once every five years for risk of heart disease, stroke, kidney disease and diabetes. Piloted in 2009 in select areas, the program is to be rolled out nationally this year. The annual costs for the estimated 2 million checks per year could be up to £300 million. Data on the efficacy of the pilot program are currently unpublished and unavailable to the public.

The program has been widely criticized and deemed by some health experts to be a waste of money and resources. Critics claim that general practitioners already routinely practise “opportunistic screening” for lifestyle diseases, asking patients about exercise, diet, smoking and other behaviours and choices during visits. Furthermore, they note, the best available evidence suggests that general health checks are ineffective.

According to a 2012 Cochrane systematic review and meta-analysis, periodic general health checks do not reduce morbidity or mortality (BMJ 2012;345:e7191). “Since health checks probably increase the number of diagnoses, the absence of benefits suggests overdiagnosis and overtreatment,” states the paper. “Current use of general health checks is not supported by the best available evidence.”

General health checks fell out of favour in Canada and United States decades ago in favour of a more focused and risk-based approach based on patient-specific risks.

Image courtesy of © 2013 Thinkstock

Upon reviewing the evidence, however, Public Health England, the government body responsible for the program, still decided to proceed with implementation. In a press release, though, the organization did acknowledge that the program is “not supported by direct randomized controlled trial evidence,” while stressing there is “nonetheless an urgent need to tackle the growing burden of disease which is associated with lifestyle behaviours and choices.”

“This isn’t best practice,” said Gerada. “The program should have been based on trials that took place before implementation. We shouldn’t be assessing the benefit as the program goes on.”

In Canada and the United States, general health checks fell out of favour decades ago. The Canadian Task Force on the Periodic Health Examination (now known as the Canadian Task Force on Preventive Health Care) recommended against annual general health checks in 1979, as did the US Preventive Services Task Force 10 years later, noted Stephanie Thompson, a clinical lecturer of general internal medicine at the University of Alberta in Edmonton.

“Instead, both groups recommend a more focused and risk-based approach based on patient-specific risks at variable intervals,” Thompson in an email. “That said, the routine general health check is one of the two most common reasons patients visit their doctor in Canada and the US.”

In an editorial published last year, Thompson and a colleague noted that the 2012 Cochrane systematic review of research on general health checks (cited above) found that they do not reduce overall or disease-specific mortality and had no effect on several other outcomes, including hospital admissions, unscheduled doctor visits and work absences (Cochrane Database Syst Rev 2012; 10:ED000047).

Current evidence supports a case-based approach according to a patient’s age and sex, with specific recommendations for further testing to be offered only for high-risk individuals, explained Thompson. “The NHS initiative in the UK is based on the premise that everyone is at some risk and therefore should be evaluated,” she added. “This approach is in conflict with the best available evidence and ignores different degrees of risk.”