The battle for people's attention and health in a commercial market is a threat to sustainability.
Photo: Sturlason
Google searches for health check and medical check-up result in numerous hits from commercial suppliers of health services. Many have campaigns offering lower prices before the summer; it's a case of shopping your way to one less worry before the holidays. But it will not make you any healthier (1) .
In a commercial health market, there are many actors who wish to accommodate people's concerns about their health by offering services that include thorough examinations of presumptively healthy individuals. Unfortunately, such health checks run counter to wise choices and clinical advice; healthy people with no symptoms or known risk generally have no need for regular health checks (2) . In a Cochrane analysis with more than 230 000 study participants, health checks were associated neither with a reduction in morbidity, nor with deaths from cancer or cardiovascular disease (1) .
What do the health checks consist of, and when are they unwarranted? Health checks are unwarranted when healthy individuals with no clinical problem, symptoms or known risk are nevertheless examined and tested. The extent and content (and price) of the checks varies. Most often the focus is on clinical examinations and blood tests, while some also offer extensive ultrasound examinations.
Of course, there are exceptions. National screening programmes, the public health centre programme and pregnancy checks are examples of well-founded health checks for healthy individuals. These are a publicly funded services with documented health benefits supported by health economic assessments, where the cost-benefit ratio can be assessed against other services and provide a basis for prioritisation.
Widespread use of unwarranted health checks, blood tests and other diagnostic investigations are a threat to sustainable health services, whether privately or publicly financed
Health services generally, and healthcare personnel especially, are scarce resources. Widespread use of unwarranted health checks, blood tests and other diagnostic investigations are a threat to sustainable health services, whether privately or publicly financed (3) . In the UK health service, unwarranted health checks and blood tests have led to such pressure from patients needing follow-up that the Royal College of General Practitioners has issued a warning that these will not necessarily be followed up by a GP, and that such activity can result in more drawbacks than benefits (4) . Likewise, the Norwegian Association of General Practitioners recommends that GPs avoid referring patients for examinations and treatment covered by private health insurance, without a good clinical indication (2) .
For the OECD countries it is estimated that one-fifth of health budgets are spent on services that do not result in health gains (5) . Commercial providers are thus far from alone in generating unnecessary examinations. In a Canadian registry study, 30 % of the participants in the over-74 age group were given one or more tests with a low expected clinical utility in the course of a three-year period (6) . PSA testing was a particular offender, with unnecessary screening of upwards of half of older men where there was no suspicion of prostate cancer.
Here in Norway, the authorities have ordered the regional health trusts to work together to reduce hospital examinations and treatment with low gains (7) . To date, shoulder surgery, gastroscopy in those under the age of 45 years, and coronary angiography are selected as clinical areas for the managed reduction in activity. Relevant private providers can also contribute to this collaboration. The impetus for the Choosing Wisely Norway campaign having come primarily from the medical community, it was high time that the authorities also came up with a pervasive, long-term initiative.
The health services themselves must continue the work to secure sustainable services, and in 2024 the majority of healthcare providers have their own sustainability profile, frequently based on the UN Sustainable Development Goals. Here, we as the medical community and as individuals can apply pressure to make sustainable health services an explicit part of the business strategy of many of the private providers. It is also conceivable that sustainability offers a potential for marketing and competitive advantage in the commercial health market (8) . An example to emulate and inspire is the collaboration between the Norwegian University of Science and Technology, the Choosing Wisely Norway campaign and two of the large private providers of radiological services (9) .
Just as striking as the search hits on health check and medical check-up, with well-designed websites offering 'a total health check' and 'a spectrum of blood tests', is the absence of documentation on the benefits (and drawbacks) of the services offered. This is in contrast to the marketing of prescription medicines aimed at doctors, where the companies must document every statement and piece of information. Given our knowledge of predictive value, overdiagnosis and uncertain test results, a requirement for such information would not be unreasonable in the marketing of health services aimed at the population.
Commercial providers who choose to support the Choosing Wisely Norway recommendations and document the professional standard of the services they offer, contribute to sustainability, spare the public health service and appeal to resource-conscious customers. They will also be able to contribute to healthier self-regulation in a market for health checks that plays on people's concerns about their health – at a time when sustainability concerns are greater and better documented.