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The NHS offers many health checks and screening programmes but does this approach work or merely cause concern among the worried well? We investigate

Health screening services are seen by the Government as a major area of development. In its annual Improving Outcomes cancer report, published in December 2013, the Department of Health (DH) said that “uptake of screening will be a priority for the coming year”¹. But is screening always a boon to societal health?

For every early diagnosis there are false positives that can cause unnecessary stress for those who are well and spark treatment that is not required. Such concerns are so widespread that they have prompted the Government to arrange for clear, independent guidance for patients on national testing².

There are also questions regarding cost-effectiveness. In 2010- 11, the UK spent £520m on screening, of which £128m went on raising patient awareness of the programmes³. Given the austere times we find ourselves in, is this really the best way to spend limited resources? Wouldn’t it be better to raise awareness of symptoms and encourage patients to make smarter health choices?

The national screening programmes

Twelve national screening programmes are available on the NHS. Most run in all home countries (see table opposite)⁴ with the vast majority for pregnant women and newborns. The checks cover everything from congenital conditions such as Down’s syndrome and sickle cell anaemia, to hearing tests and checks for infectious diseases such as HIV, hepatitis B, syphilis and rubella in pregnancy.

For adults, five tests are offered in all home countries:

• Bowel cancer for older patients
• Cervical cancer screening for adult women
• Breast cancer for all women aged 50-70 years
• Yearly retinopathy screening for all patients with diabetes aged 12 years and older
• Abdominal aortic aneurysm tests (this is currently being rolled out).

While these tests have been approved based on an analysis that includes the risk:benefit to patients and the cost-effectiveness of screening, there is a significant national variation when it comes to who is screened. For example, bowel cancer screening is for patients older than 60 years in all home countries; but tests for the over-50s are only available in Scotland. In England screening for breast cancer is being expanded to women aged 47-73 years on a trial basis.

How screening is performed also varies. In England, the NHS Bowel Cancer Screening Programme sends out home testing kits. As of November 2013, almost 21m kits had been sent out, with more than 12m returned. The kits have detected 17,500 cancers and more than 95,000 patients have had polyps managed¹. Other tests range from blood samples to urine tests, with some requiring attendance at a hospital clinic.

There is a final category of screening available in England comprising three allied programmes: chlamydia testing, prostate cancer testing and vascular risk assessments. These tests are not deemed to have met the set criteria for a national programme, but are still available. Indeed, many of the tests are already offered in pharmacies as part of a local enhanced service.

Did you know?

• Twelve national screening programmes are available on the NHS
• There is a significant national variation regarding who is screened
• Screening for breast cancer saves about one life for every 200 women screened

Screening risks

Given the wide variety of screening programmes available, it’s not surprising that there is patient confusion regarding whether they do more harm than good. And with medical misinformation far more prevalent via the internet, patients may read about ‘risks’ and be discouraged from being screened. “Offering tests is not a bad thing – late diagnosis is much more harmful ”

“There are always risks,” acknowledges Mahendra Patel, pharmacist and senior lecturer at the University of Huddersfield. “Generally, offering tests is not a bad thing. Late diagnosis can be much more harmful.”

Certainly it’s better to catch conditions early. This is the reason why screening was introduced, after all. And it’s particularly true of highly aggressive conditions, such as bowel cancer, where a delay in diagnosis often results in death.

But what about other screening programmes, such as those for breast cancer? In 2010/2011, 170,000 women – 75 per cent of those offered testing – were screened in Scotland and 1,700 cancers were detected³. This appears to be an excellent record but detection isn’t the most important figure.

According to the DH-commissioned King’s Health Partners, screening for breast cancer saves about one life for every 200 women screened. That’s around 1,300 lives a year in the UK². However, about three women in every 200 screened are diagnosed with a cancer that will never become life-threatening – so around 4,000 women a year are offered treatment they do not need.

In addition, only a quarter of women with abnormal results who require further tests will have a cancer², meaning a large number of women receive distressing news that later turns out to be wrong.

This level of over-diagnosis and potential over-treatment is considered acceptable by the programme: after all, it saves thousands of lives each year. And, remember, screening is not entirely effective either: it misses one in 2,500 cancers.

The latest addition to the national programmes is abdominal aortic aneurysm, which accounts for 2 per cent of deaths in men older than 65 years. However, treatment requires surgery, which causes death in around one in 2,000 patients. Despite this risk it is estimated that the programme saves around 52 lives for every 10,000 men screened⁵. The risks of treatment are outweighed by the benefits.

However screening is not always the best policy – a point perhaps best highlighted by prostate cancer. According to the Government, it would cost between £58m and £1 billion to introduce screening for men aged 50 years and older¹. However, although cancers are identified earlier, there is no increase in survival rates from screening, leading the DH to rule that the “risks of over-diagnosis far outweighed any potential reduction in mortality”.

It’s a move supported by Prostate Cancer UK policy and evidence manager Sarah Mee. “We don’t think there should be a national screening programme,” she explains. “Although it could prevent men dying, it could also lead to treatment for harmless forms of cancer. Instead, there should be an informed choice. It’s important that men have that conversation with a health professional.”

Pharmacy health checks

That conversation could begin in the pharmacy. Pharmacies already offer health checks, such as diabetes screening and vascular risk assessments, and the Royal Pharmaceutical Society in its November 2013 ‘Now or Never’ report cited health checks, including those for long-term conditions, as a key part of pharmacy’s future⁶.

“We know of pharmacies that are providing point-of-care testing as a local enhanced service, including health checks and INR testing, with a high level of success,” says Numark’s director of pharmacy services Mimi Lau. “The service offers convenience and choice for patients, as well as timely, accurate results, which are discussed with patients in a relaxed environment. At a time when there is intense pressure on other areas of the NHS, particularly on general practice and on hospital resources, the service through pharmacy helps manage that pressure.”

These are strong arguments and play to pharmacy’s strengths of patient access. But point-of-care testing services offered through primary care still attract criticism. “With vascular health checks, there’s no real evidence that they reduce mortality,” says pharmacist Joseph Bush, senior lecturer at Aston University. “So there are resource implications. It’s not just that you’re only seeing the worried well, but you are wasting resources. You could spend the money on promoting healthy lifestyles.”

Smoke screen – does health screening sometimes do more harm than good?

This potentially wasted resource doesn’t stop at the check itself. Ultimately, a health check for cardiovascular disease could result in a patient taking antihypertensives or statins. And while statins have proven a cost-effective method of primary prevention⁷, therapy has the same drawback as screening – it only saves the life of a minority of patients. Yet simvastatin is still the most prescribed drug in the UK, and the class cost the NHS £383.4m last year⁸.

A case could be made for the money to be spent on preventing patients developing cardiovascular risk problems at all, with the pot used to advertise healthy living and encourage exercise. RPS English Pharmacy Board vice-chair Ash Soni disagrees. His pharmacy provides vascular risk assessments and he views them as a useful service.

“We provide health checks and get a very wide mix of people, not just the worried well. There is a curiosity and it’s really useful to have a discussion. You can have conversations about weight, cholesterol, and chat about lifestyle to reduce a person’s risk.”

This argument rebuts the idea of spending the money on promotion. With checks you still get that added benefit of having conversations around health. And such checks are an area where the increasing skills of the pharmacy team can come to the fore.

“The health check [in my pharmacy] is done by a healthy living champion,” says Ash. “It is a real opportunity to ask about smoking, alcohol, food – it’s all part of the conversation without telling the patient what to do.”

Mahendra Patel agrees. “Healthy living champions as part of the pharmacy team could do more with, say, hypertension,” he says. “It could be a way in to hard-to-reach people. We could educate them – healthy living champions could bridge that gap.”

There is an additional argument against spending money solely on patient education. The unfortunate reality is that screening programmes exist because symptoms are difficult to identify. There are usually no visible signs of aneurysm or prostate cancer, so patient education will make little difference.

And even where there are symptoms, these are often very general and do not reveal the full picture. Currently the NHS campaign to raise awareness of bowel cancer focuses on blood in the stool or a change in bowel habits for three weeks. Neither is definitive of bowel cancer and both would require further investigation. Mahendra Patel also has wider reservations about the testing available through pharmacies – specifically in ensuring there is a uniform level of quality available.

“One of the key things in healthcare is consistency,” he argues. “Blood pressure monitoring doesn’t do anything of itself. Do the people come back? It’s true you could identify a problem on a ‘one off’ but we need greater scrutiny and robustness. You don’t want to drive people away from using their pharmacy because there is no end point. You could do all the screening in the world, but who follows it up?”

Follow-up is indeed crucial. NICE recommends ambulatory monitoring for hypertension, meaning that any one-off test for blood pressure is only going to provide a snapshot, which cannot be used for diagnosis.

And the issue isn’t just about the public perception of pharmacy, Mahendra suggests, but a matter that reflects on the whole pharmacy profession. “We want our colleagues to respect us. We have to have carried out an intervention. But it’s got to be robust – it’s patchy at the moment.”

Home tests

This concern over patchy health provision expands to the new frontier of diagnostics: home testing. Already pharmacies across the UK are selling home screening kits, offering to test everything from prostate cancer to biomarkers suggestive of Alzheimer’s disease. And as we have already seen, home testing is even incorporated as part of England’s bowel cancer screening programme.

Obviously the evidence for a kit’s effectiveness depends on what it claims to test but, generally speaking, do home testing kits have a place in screening and potential therapy?

Mimi Lau urges caution. “Where pharmacies are engaging in the retail sale of self-testing kits, it is essential that they research the efficacy of the products they are selling. Are they of a suitable standard, and have their claims regarding levels of accuracy been validated?

“What must be avoided is a panicked patient who uses the test and misinterprets the results. While self-testing kits have a place, they should be sold with caution.”

Ultimately any form of screening is only as good as the interpretation

Ash Soni agrees. “Home testing kits are a reasonable option,” he says, “but the problem is the patient’s independence. It’s understanding what to do with the results and going back to talk to someone.” The issue with home testing is access to counselling, says Sarah Mee of Prostate Cancer UK. “With home testing this wouldn’t happen.”

Any form of screening is only as good as the interpretation. Ultimately, a kit simply produces a number, with rough guidelines. It’s important that a health professional is available to give that number context and meaning for the patient.

The worried well

Even with context, there is still one major argument against screening – the worried well for whom health checks, rather than providing a valued source of patient information, merely serve to increase anxiety. But is engaging with the worried well really an issue?

“We shouldn’t rule out the worried well,” maintains Mahendra Patel. “If they know tests are available and they can access them, it increases awareness. The only way we are going to achieve change is through education.”

Health education is a persuasive argument and increased awareness means that a domino effect can occur. One of the most notable examples of this is the ‘Jade Goody effect’, which saw more than 400,000 women have cervical smears between mid-2008 and mid-2009⁹.

Far from being ‘worried well’ patients returning for an early screen, a significant portion of these women were those who had missed a scheduled test as part of the national programme.

Perhaps this effect demonstrates that a happy medium is the answer. The national programmes provide a valuable service and are used in specific patient groups where it is clear the potential benefits outweigh the risks. Increasingly, health education and awareness are essential but these, too, have limits. Only when used together can they produce the best outcomes.