Health checks and screening: what works in general practice?

know that prevention is better than cure but it's still the bit of general practice I have always enjoyed least. It's hard to be motivated by something not happening. It's easier to be motivated by screening, where the aim is to detect early-stage disease and there is often compelling evidence for the effectiveness of treatment. But GP enthusiasm for prevention has been dampened by ill-conceived NHS policy initiatives since at least 1990. 1 Dalton et al 2 are not the first to ask whether NHS Health Checks are defensible when measured against World Health Organization screening criteria. 3 More evidence against health checks Enthusiasm for health checks will be further dampened by two other studies in the BJGP. Caley et al 4 reported that they have surprisingly little impact on the recognition of undiagnosed diabetes, hypertension, chronic heart disease, chronic kidney disease, or atrial fibrillation. Koekkoek et al 5 point out that the evidence favours targeted stepped interventions, which avoid investing scarce resources in the worried well. And the evidence from all three articles is consistent with the Cochrane meta-analysis which makes it quite clear that promoting health checks in unselected adult patients has limited impact on cardiovascular risk and no significant impact on cardiovascular mortality. 6 However, it is important not to throw out the baby with the bathwater. Many of the constituent elements of health checks (for example, smoking advice, blood pressure management, and statin prescribing) are trial-proven effective interventions. The studies by Korhonen et al 7 and Gil-Guillen et al, 8 as well as Caley et al, 4 confirm that population screening in primary care can detect undiagnosed cardiovascular risk. So what is going on here? Why is the evidence inconsistent? Why is the evidence inconsistent? The first half of the answer to this question is straightforward. We have known for more than 20 years that those at highest risk of cardiovascular disease are the least likely to attend for health check screening. 9 We have known for even longer that identifying risk does nothing but harm if you don't go on to manage it effectively. Effective management is less likely in programmes that try to deal with multiple rather than individual risks; for example, smoking cessation advice is less effective when given in the context of multifactorial health checks. 10 The second half of the answer is more nuanced: context is usually more important than content …