I once owned a Soviet Lada Riva—it seemed like a good deal. The mats didn’t fit, it skidded at 10 mph going round corners, and, for a car built for the Siberian wastes, it never started in the cold. But it was a good way to meet my neighbours, who helped to push it every morning. One day an engine fire blazed my Lada to Valhalla, despite regular servicing check ups and an MOT test. I was glad.
Gordon Brown, our new politburo boss, has promised a revolution of American-style screening “check ups” (BMJ 2008;336:62-3; doi: 10.1136/bmj.39454.738912.4E). Should we recalcitrant general practitioners resist this centralised diktat, then private sector workers are on standby to be bused across our picket lines. For screening is a simply a good idea, isn’t it? Detect a life threatening disease early, treat it early, and save lives. The popular media have long bemoaned the lack of screening in the United Kingdom, compared with more “advanced” countries. So, seduced by the temptation of this populist health initiative, Mr Brown has seized the headlines.
Unfortunately, people aren’t cars. Screening is based on a number of established criteria: specificity, sensitivity, acceptability, reliability, and, above all, that early diagnosis makes some difference to outcome. The screening announced by Gordon Brown for diabetes, aneurysms, kidney disease, and the rest simply does not meet these criteria. Even for established screening programmes, the benefits over risks are contested. Consider cervical cancer as an example: It is necessary to screen 1000 women for 35 years to prevent one death—which means, therefore, that 999 women will receive no benefit from screening. Worse, some 40% may have a positive smear and 5% may have needless invasive treatment (BMJ 2003;326:901; doi: 10.1136/bmj.326.7395.901). Screening is not the simple, one way street of benefit that the media suggested, but an anarchic highway full of dangerous machinery and meandering livestock. The only certainties of screening are uncertainty and anxiety.
The inverse care effect will, as ever, see the predictable, miserable lines of low risk, worried well clogging up NHS services. The high risk, unworried sick will continue happily to ignore our screening initiatives.
MOT “check-ups” are stupid and nothing but a medical charade. The check-up culture was spawned in private practice, where it was driven by greed, not need. If Mr Brown is serious about improving health, might I respectfully suggest some deeply unpalatable public health medicine: limit personal car use, build cycle paths, tax processed food, subside fresh foods, and re-establish a food culture. The mats don’t fit on these plans, which will spin off at the first corner, burst into flames (I hope), and go to hell.