- Becky McCall — United Kingdom
Should health checks be mandated for all?
General health checks are often dismissed as a needless drain on time and money. Yet, their role in the early detection of risk factors and diseases grows in importance as lifespans increase. With technology aiding remote checks, the cost savings multiply, especially in low- and middle-income countries.
Only a small share of national healthcare budgets is dedicated to preventative healthcare and general health checks.
More people are living longer today than ever before, often with controlled chronic conditions such as diabetes, cardiovascular disease (CVD) and depression. Coupled with advances in the detection of risk factors and early signs of such disease, as well as robust evidence of the benefits of lifestyle changes or medication, it is an opportune time to highlight the importance of the oft-dismissed general health check.
At the very least, the checks would prove useful in the strata of population that is at higher risk for these diseases. Moreover, the pandemic-driven surge in remote care and wearable technology makes such routine health checks more viable in lower-income settings today than even three years ago.
Yet, despite the potential benefits associated with general health checks, only a small share of national healthcare budgets—just 3% across Europe—is dedicated to preventative healthcare.
In 2018, government or compulsory scheme spending on preventative care totalled 2.9% in the US, 5.9% in Canada, 2% in Japan and 1.8% in Australia. Lower-income countries spend nearly 10 times more than higher-income countries on preventative programmes; however, external aid plays a major role in funding primary healthcare.
Heart disease is a case in point. One-quarter of premature deaths is caused by CVD, yet nearly 80% is preventable if risk factors and early signs of disease are controlled. It is clear that routine general health checks can make a quantifiable difference to health outcomes.
Proactive checks to stay healthier for longer
Dr Rashida Ferrand, professor of international health at the London School of Hygiene and Tropical Medicine in the UK and The Health Research Unit Zimbabwe (THRU ZIM) Biomedical Research and Training Institute in Zimbabwe, advocates for general health checks. Her team is developing programmes for adolescents, healthcare workers and older people in Zimbabwe.
"Health needs to be tackled proactively and holistically, which is central to universal health coverage—a central goal of the World Health Organization [WHO]," she says.
The idea underlying routine health checks, she explains, “is to identify a potential condition, disease or disease risk factor at a point where you can intervene either as a preventative measure or, if you're identifying the condition early enough, as a treatment. Checks should be done at routine intervals, be cost-effective and cause no harm to the individual."
Preventative measures might include lifestyle changes such as giving up smoking or medication for blood pressure, for example; or cholesterol-lowering agents or anti-depressant drugs, or immunisations, among others.
"General health checks usually refer to multiple conditions of relevance to the chosen population and aim to help people stay healthy in the longer term."
Routine general health checks may seem similar to screening, but Ferrand explains how they differ. "General health checks usually refer to multiple conditions of relevance to the chosen population and aim to help people stay healthy in the longer term.” On the other hand, she adds, a screening programme, such as for colon or breast cancer, focuses on identifying a specific disease at an early stage.
Dr Robert H Shmerling is a corresponding member of the Faculty of Medicine at Harvard Medical School in the US and a semi-retired rheumatologist. He says a general health check aims to detect and intervene in a condition before downstream complications arise. "I think of it as pre-emptive care rather than reactive care,” he emphasises.
"Once a person has a symptom or a condition like diabetes or hypertension, the visit is not a routine health check—it's for a specific problem,” Shmerling says. “These are not mutually exclusive but, frequently, we will have some mix of the two during a single visit."
Routine health checks: Who, what and when
If the value of a routine general health check lies in the frequency of checks in order to spot a problem before it turns more serious, then the choice of the interval between visits is key. Which population subgroup—whether, say, adolescents, or people over 50 years, or healthcare workers—undergoes the checks also matters. The nature of checks varies according to the target sub-group, and may include cardiovascular risk factors, early signs of diabetes and mental health issues.
In the US, the most popular stratification is by sex and by age, Shmerling notes. "A common recommendation for routine checks in the US is every two to three years in those aged under 50, and every year in those over 50."
But, he adds, "there's nothing magical or physiological about 365 days. If the interval is too long, people forget about them; and if too soon, then you may be evaluating and medicalising whatever is going on in your life too often."
In the US, a preventative routine general health check might cover health history, medications, allergies, a physical examination and laboratory tests that look at cholesterol and triglyceride levels. There may also be discussions around lifestyle and opportunities for improvements.
One of the routine general health checks that Ferrand's research group is working on is called Y-CHECK, which is a WHO-coordinated initiative in Zimbabwe, Ghana and Tanzania. Involving adolescents, it goes some way in filling the huge gap between checks in early childhood and mid-life.
"Many risk factors for common diseases of adulthood like hypertension, diabetes and heart disease have their origins in adolescence, such as smoking, substance use, alcohol use and mental health morbidities, so it's really a chance to intervene."
The programme, currently in development, envisages providing a one-off check in early adolescence and another in older adolescence, each time looking for a discrete set of conditions that are age-appropriate. "There's this whole gap where the contact with health services is minimal right until the time people reach their 40s or 50s,” Ferrand says.
In the youngest adolescents, checks would cover vision, hearing and anaemia, as well as psychosocial problems like bullying or disturbance at home, she says. Older adolescents would be checked for sexual health, smoking, and some country-specific conditions including malaria in Ghana, or HIV in Zimbabwe.
Ferrand says routine general health checks for adolescents help in identifying and managing risk factors for diseases of adulthood. "Many risk factors for common diseases of adulthood like hypertension, diabetes and heart disease have their origins in adolescence, such as smoking, substance use, alcohol use and mental health morbidities, so it's really a chance to intervene."
Exploring population benefits beyond health
Good health and socioeconomic wellbeing are closely connected, and there is potential for routine health checks to transform a broad range of outcomes in low- and middle-income countries (LMICs). "Checking for and intervening in vision, hearing, and anaemia can have an immediate and significant impact on wellbeing and morbidity, but also on the socioeconomic potential of the young people as individuals and as members of society, especially given the very big youth bulge in Africa [around 50% of the population is under 18 years],” Ferrand says.
Likewise, prioritising the physical and mental wellbeing of the healthcare workforce is fundamental to overall general population health and socioeconomic wellbeing, as became evident across the globe when covid-19 incapacitated many clinicians during the peaks of the pandemic.
While running the covid-19 clinical service in the biggest public sector hospital in Zimbabwe, Ferrand's group offered a check-up visit for HIV, diabetes, tuberculosis, vision and hearing, as well as covid-19 test for healthcare workers, she explains. "The health service depends on the health of its workers. There was really low morale, high attrition rates, overworked people. It was really important to support them, so we developed check-up visits for health workers."
Ferrand hopes the results of this work will inform innovative WHO guidelines related to routine general health check-ups for healthcare workers.
General health checks are associated with increased detection of chronic diseases like cardiovascular disease.
Personalised healthcare for early detection
It is often more cost-effective to identify chronic conditions and their risk factors earlier, Ferrand says, because treatment is far costlier than prevention and outcomes are more successful, especially in countries where healthcare systems are underfunded and overburdened.
She also highlights that many of the conditions that can be flagged by a routine health check-up are often otherwise invisible until they manifest as “a big event”. A typical example is hypertension. "You're symptomatic for a long time, and unless you have a check-up you're not going to identify it. Untreated hypertension can then lead to a massive stroke,” Ferrand says.
Since 2008, the UK’s National Health Service (NHS) has invited people aged 40 to 74 for routine general health checks every five years; these are designed to spot early signs of stroke, kidney disease, type 2 diabetes, CVD and dementia.
"Attending an NHS health check means that there is greater chance of disease detection because the individual is exposed to diagnostic tools," says Vincent Grigori Nguyen, a research fellow at University College London who studies this issue in relation to type 2 diabetes outcomes.
"As such, it may seem that those who attend the health check are more likely to get a disease, but it's just that they are more likely to get diagnosed, including for pre-existing but undiscovered conditions."
Nguyen says preliminary, unpublished work has shown that the NHS health check at the individual level might be useful for specific diseases. "We may find that the NHS health check can show a benefit when we hone into certain populations, such as those who are high-risk but don't quite [yet] satisfy the diagnostic guideline—for example, people with high blood sugar who are just short of a type 2 diabetes diagnosis.
"We know that those who are at high risk of type 2 diabetes and are detected through the NHS health check are often referred to the NHS Diabetes Programme, which we know is effective," he adds, referring to his own research.
"If detecting chronic disease matters, which is a premise of modern medicine, then detection itself is a good thing."
A 2021 JAMA review of general health checks found that they were associated with increased detection of chronic disease like CVD and depression, and improved recognition and control of risk factors such as blood pressure and cholesterol levels. However, routine general health checks were not associated with reduced mortality and cardiovascular events.
"If detecting chronic disease matters, which is a premise of modern medicine, then detection itself is a good thing," says Shmerling, referring to the review's findings. "Even if you can't measure it in terms of mortality outcomes, there are moderate improvements in controlling risk factors; for example, high cholesterol, which is a big risk factor for cardiovascular problems."
The uptick in cancer screening associated with regular health checks, as well as other recommended routine care, including immunisations and lifestyle improvements like physical activity and a healthy diet, "all show it matters if the healthcare providers make suggestions around lifestyle factors," Shmerling says.
Support for routine general health checks is also visible in the rise of video consultations and wearable and home medical monitoring technology. "Blood pressure, weight, heart rate and breathing rate can all be monitored on devices, and replicates much of what we do in a routine, in-person visit,” Shmerling says.
Not to mention the potential to combine in-person and video consultations. “You could have a video call from home to receive counselling or discuss results," Shmerling says. "Other things such as diet, exercise and sleep can also be addressed on video call."
Technology aside, there is growing recognition for the more human side of routine health checks, namely the relationship that develops between primary care provider and patient in LMICs and high-income countries alike. Routine general health checks speak to multiple agendas, including the WHO goal to achieve universal health coverage and reorient health systems towards primary healthcare. Perhaps, most significantly, they epitomise some of the fundamental principles underpinning personalised healthcare.
"If routine health checks mean everyone has a primary healthcare provider who knows them, then that is a good way to build trust between healthcare provider and patient," Shmerling says. "The patient has someone they can call, and someone they already know, when there's a problem. That has to be a good thing."