Health service or sickness service?

I don’t often manage to make the time to watch the daily Ted Talks, but I inevitably enjoy them when I do and they have always left me with something to think about.

In June, I watched a talk by Rebecca Onie, co-founder and CEO of an American organisation called Health Leads, which really got me thinking – so much so that I’ve been back and watched the video several times since.

Ms Onie talked about how and why Health Leads was established and the work that it does among disadvantaged citizens of the USA. This is inspiring stuff and I encourage you to watch her Ted Talk, but it was one line that really got to me. Rebecca described the frustration of physicians writing prescriptions for medications whose root cause was the conditions in which the patients were living: in essence doctors were dealing with their patients’ sickness without really focussing on their health – was this a health service or a sickness service, she wondered.

The UK Department of Health seems to have been asking itself similar questions. In 2009, it introduced the NHS Health Check – a voluntary screening programme for people aged ≥40 not being treated for cardiovascular disease, diabetes and kidney disease, which is just completing its roll-out phase. The health check uses simple screening tests (blood tests, blood pressure, BMI and patient histories) to identify extant disease or to assess risk factors for developing disease. Follow-up screening visits will occur at 5-yearly intervals.

In the fight against non-communicable diseases (NCDs) I think that this is a worthy programme – I’ve had a health check: it was over in ~15 minutes, the nurse who conducted the test was friendly and reassuring and offered me advice and encouragement when discussing the results of the tests.

It was rather a shame then, to see a review from the Nordic Cochrane Centre in Denmark published this week, which concluded that such programmes do not result in reductions in overall or disease-specific mortality and which recommended that ‘systematically offering general health checks should be resisted’. I was surprised at both the finding and the recommendation. When I had a look at the paper though, I noticed that many of the studies were initiated in the 1960s and 1970s and included subjects who had been born before 1940 – in fact in two studies the subjects had been born before 1920.

Although I’m no statistician and I’m conscious that this is a Cochrane Centre analysis, I’m not sure how helpful it is to make recommendations for today’s patients based on a population whose lifestyle will have been so very different to that of people born after 1960. And although the measurements taken at the screening visits are essentially the same, their accuracy and their meaning in the context of a much wider understanding of NCDs also must be very different. Moreover, the range and efficacy of available therapeutic interventions has changed beyond recognition, which will likely have a greater effect on morbidity and mortality rates in present-day subjects who undergo screening and are found to have disease.

One of the explanations that the Cochrane authors gave for their findings is that the people most likely to volunteer for screening are generally healthier than those who do not. They also voiced concerns that routine testing may lead to over-diagnosis and unnecessary treatment and they quote convincing (and more recent) examples of this.

If the DoH is to continue to offer health checks – and its response to a BBC article on the Cochrane findings implies that it has no plans to even consider stopping – these last two points deserve some attention. It is inconceivable that the NHS would mandate screening checks, so other ways to encourage people to attend need to be sought.

The NHS Future Forum has recommended that every healthcare professional (HCP) should: ‘… use every contact with an individual to maintain or improve their mental and physical health and wellbeing where possible, in particular targeting the four main lifestyle risk factors: diet, physical activity, alcohol and tobacco – whatever their specialty or the purpose of the contact [my emphasis].’ The Forum’s report, The NHS’s Role in the Public’s Health, gives as an example a dental surgery in Manchester which offers smoking cessation studies, BMI and blood pressure checks and even screening for STIs to its mainly young patients, who otherwise have little contact with the rest of the NHS. Also, GPs see women at regular intervals to prescribe contraception, and those consultations could, once every 5 years, be extended to include screening for NCDs.

And with regard to over-diagnosis and unnecessary treatment – well, to my mind, a disease prevention strategy should start with a presumption of no diagnosis and no necessary treatment. However, if you only start to screen at age 40, then this is perhaps a forlorn hope.

In order to prevent NCDs (ie to promote healthiness), I would suggest initiating screening in a much younger population, (perhaps even starting just as people leave school at 18) who can (probably rightly) assume that they are reasonably healthy and who should have fewer anxieties about volunteering to be tested. Over time, such a scheme would allow trends in indicators of healthiness to be monitored and changes addressed before disease sets in and the person has to begin a possibly life-long course of treatment, with all that means for his or her quality of life and for the NHS.

To find out more about me and my medical writing work, please visit my website at .

17 October 2012

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