Why January is a testing time for GPs

Life would be so much easier if I believed that well people should frequently have lots of unvalidated tests. At this time of year, when newspapers devote column inches to health checks that people should have, what an attractive business private healthcare screening appears: self selected, upwardly mobile, possible guilty patients, accompanied by luxury appointment times, and possibly even the fragrance of freshly cut flowers wafting somewhere overhead.

Of course, I'm not bitter. Not even with the prospect of dealing with surgeries full of patients who have read this stuff. I was pleased to see Scotland's Sunday Herald in a piece called “Checks and balances” (2 January 2005) starting off with stop smoking, drink moderately, do some exercise, and even mentioning sexual health as something to think about getting screened for. But then it got interesting. Self examine your breasts or testicles monthly, the paper said, and although “many basic checks” can be carried out by the NHS, “more invasive checks can't be done unless there is definite reason for doing so. However, many checks can be carried out privately and while this may be expensive you could consider it a sound investment for your future health.”

The NHS should not be handed the mop to sort out borderline results

I hate disappointing people. But it is impossible to lie when patients come in with a bundle of nebulous results from private healthcare screens. My patients expect me to look pleased, since they have spent time, effort, and money for “the good of their health.” It's no fun being a spoilsport. Pro-activity—any activity—is always easier to sell than the dull old business of grey areas and uncertainties that surround much of private health company screening, or even the decidedly lacklustre advice that sometimes not having a test might even be better for your health than having it done.

The NHS gets far less credit than it deserves for providing evidence based screening tests. The Daily Telegraph ran a piece in late November that outlined the ability of the NHS to provide screening. Christine Doyle wrote that there was no need to spend £350 for private screening: “Anyone can undergo a checkup with their GP, where appropriate.” Absolutely, and the NHS offerings of child development, breast and cervical screening, as well as the plans for bowel screening were given due regard. She also wrote that “All adults are entitled to a general health check-up with their GP if they have not seen their GP for three years...” However, quite apart from routine and sensible things like blood pressure recordings and personal and family history being taken, she also suggested prostate and testicular examination, as well as chest x rays for smokers.

It is one thing to use an opportunity for appropriate health education, or build a rapport with an infrequently attending or anxious person. It is quite another to start performing tests of no proven benefit and possible harm. I am rather glad that doctors are no longer deities, but we seem to have been replaced with the fervent belief that all tests are good, and more tests are even better.

And so to the Times. On 3 January the paper published a long piece by Dr Thomas Stuttaford about the “full MOT that could help save your life.” He said, “Unfortunately the criteria for assessing the usefulness of a screening test often have to be judged subjectively rather than objectively. A prime argument against screening for hidden disease is that it may cause anxiety to sensitive people while they await their results.” I find this alarming, and the list of tests he recommends, more so. Annual haematology, biochemistry, blood pressure “every time a patient visits a doctor, even when you're in for flu,” annual resting and exercise electrocardiograms, electron beam cardiac scanning, annual mammography, prostate specific antigen (PSA) testing, computerised body mole mapping, and ophthalmoscopy—all are on his long list.

So much for evidence based medicine. The NHS should fund screening tests that give good returns on morbidity and mortality, and if people want to pay for any other “screening tests,” fine. But a real, informed choice is needed about all screening—not simply for the amount of evidence or value for time and money, but also about the real risk of false positives and false negatives in unvalidated and unproven tests. To minimise the dangers of this, in an argument that anxiety is the only drawback, is to avoid the fact that patients deserve to have accurate, disinterested information about what exactly they are getting involved with.

The advantage of patients asking their NHS doctors what screening tests they need is that there should be no pecuniary interest—allowing for the GP contract—in what doctors recommend. Yet dozens of private healthcare clinics offer standard, premium, deluxe, or ultimate screening packages with little or no information about how accurate, useful, or proven they are. The NHS should not be handed the mop to sort out borderline results, or explain normal variations that are given back with the mantra to “see your GP.”