Skip to main content

Health policies should incorporate public health priorities

In a letter published in the British Medical Journal (BMJ), Michale Soljak, Chris Millett and I discuss the call by Krogsbøll to abandon the NHS Health Check Programme.As members of one of the research teams evaluating the national programme, we challenge their view that a randomised controlled trial (RCT) of the current programme should be the sole arbiter on which to base national health policy decisions. As noted in comments on the Cochrane review, the dearth of RCTs of screening for cardiovascular (CVD) risk since 1999 is unfortunate, but there were many RCTs of individual screening components over this period that have been used in subsequent NICE guidance.

There are other reasons why Krogsbøll et al’s views should be challenged. Firstly, RCTs are expensive and time-consuming, and as a result, a lack of evidence from RCTs may deprive millions of people of potential benefits from interventions.  RCTs should therefore be complemented where possible by well-validated modelling studies. Screening for CVD risk in six European countries has been evaluated using the Archimedes simulation model, which has been extensively validated against many RCTs. The cost per quality adjusted life year of a universal check was €11,595 in Denmark and €2,426 in the United Kingdom (UK), and if targeted on the top quartile of risk costs would be €1,800 and cost-saving respectively. This is much better societal value than many healthcare interventions, and is very similar to the UK Department of Health’s original health economic impact assessment of the programme.

Secondly, Krogsbøll et al’s conclusion takes no account of the societal costs of waiting for RCT results. A UK analysis of current patterns of statin treatment showed substantial waste and inequity, with overuse in low CVD risk and underuse in high risk (600,000 and 850,000 patients respectively since 2007). There was wide variation between practices in statin prescribing to patients at high CVD risk. Perhaps this is not the case in Denmark, but the UK should not wait for the inverse care law to grind to its eventual outcome. Universal screening programmes  can increase health inequalities if uptake varies, but the Scottish Health Check Programme targets deprived populations as a policy, and in England coverage is significantly higher in PCTs in the most deprived areas. RCTs and Cochrane reviews have little to tell us about health inequalities or the foregone costs and benefits.

Our local early evaluations of the English programme show large increases in appropriate statin prescribing after a Health Check, and significant reductions in mean CVD risk score, diastolic blood pressure, total cholesterol levels and lipid ratios. Uptake is lower than planned, but the equivalent New Zealand programme shows that 75% coverage can be achieved with effective implementation.


Popular posts from this blog

Improving discharge planning in NHS hospitals

Factors that need to be considered in discharge planning that have been identified in previous projects include:

Ensuring that discharge arrangements are discussed with patients, family members and carers; and that they are given a copy of the discharge summary.Adequate coordination between the hospital, community health services, general practices, and the providers of social care services.There is a follow-up after discharge of patients at high risk of complications or readmission - either in person or by telephone - to ensure that the discharge arrangements are working well. Medicines reconciliation is carried out. This is the process of verifying patient medication lists at a point-of-care transition, such as hospital discharge, to identify which medications have been added, discontinued, or changed from pre-admission medication lists.Ensuring that any outstanding test results at discharge are obtained and passed on to primary care teams; and ensuring there are clear arrangements …

Can GPs issue private prescriptions to NHS patients?

The NHS prescription charge in England is currently £8.60 per item. At this level, many commonly prescribed drugs will cost less than the prescription charge and so some NHS patients may occasionally ask if they can have a private prescription rather than an NHS prescription.

In the past, some GPs have been advised that they could issue both an NHS FP10 and a private prescription, and let the patient decide which to use. But the British Medical Association's General Practice Committee has obtained legal advice that said under the current primary care contract, GPs in England may not issue a private prescription alongside or as an alternative to an NHS FP10 prescription. In any consultation where a GP needs to issue an FP10, the concurrent issue of a private prescription would be a breach of NHS regulations.

The issuing of a private prescription in such circumstances could also be seen as an attempt to deprive the NHS of the funds it would receive from the prescription charge. Fur…

What will Brexit mean for the NHS?

On the 29 March 2017, the Prime Minister of the UK Theresa May, formally notified the European Union (EU) Council President, Donald Tusk, of the UK’s intention to leave the EU. Theresa May’s letter to Donald Tusk triggers a two-year process during which the UK will have to negotiate both the terms of its exit from EU and the arrangements that will replace those we have had for over 40 years with the other member states of the EU. The consequences of the United Kingdom’s departure from the EU (commonly referred to as ‘Brexit’) will be wide-ranging and will affect all areas of UK’s society, including the National Health Service (NHS).

For the NHS, Brexit comes at a time when it faces many other major challenges. These include severe financial pressures, rising workload, increased waiting times for both primary care and specialist services, and shortages of health professionals in many key areas (such as in general practice and in emergency departments). The NHS also faces challenges fr…