The adage Prevention is Better than Cure should be a guiding star for doctors but is not always practiced due to resource constraints and customary routines in both public and private healthcare.
The genesis of Echelon Health lay in Chairman and Medical Director Dr Paul Jenkins’ frustration at seeing relatively young patients with serious disease that could have been prevented, in his role as an endocrinology hospital consultant and medical researcher who has published extensively, including 80 peer-reviewed scientific papers.
“Dozens of lives have been saved by our screening. One corporate client went from one-two heart attacks per year to zero for the next five years,” says Jenkins. The Echelon website includes case studies of insidious diseases identified: nascent brain fistulas, lung cancer, coronary heart disease and kidney tumours were spotted and treated at a very early stage – in cases where there had been no symptoms. Notwithstanding the great strides made in treating some types of cancer, lung cancer has a 10-year survival rate of just 5%. Taken together with heart and colon cancer, it accounts for most premature deaths in the UK.
My father helped develop the CT technology 50 years ago at Atkinson Morley hospital in South London. It then took two days to get the image. It now takes a few minutes.
Dr Paul Jenkins, Chairman and Medical Director, Echelon Health
“Many patients may have an annual medical, but it is often based on superficial and probabilistic tests, which assign probabilities to conditions such as heart attacks in a very crude and non-specific way. This leads to false positives and false negatives. Half of people with heart disease demonstrate no risk factors for it. Lung cancer is obviously associated with smoking, but is increasingly prevalent in non-smokers, and especially women,” says Jenkins. Meanwhile in the NHS, patients may have long waits for scans due to shortages of both machines and the technical experts needed to operate them.
Consequently, millions are missing out on advances in imaging and screening technology, which allow for more precise optimized analysis tailored to the individual, rather than based on statistics. Tests are getting better all the time in terms of quantum resolution of scans. For instance, the most advanced scanners can now see inside the arteries at a resolution of a fraction of a millimetre, and the process has become expedited: “My father helped develop the CT technology 50 years ago at Atkinson Morley hospital in South London. It then took two days to get the image. It now takes a few minutes,” points out Jenkins.
“No single scanning machine will work for all screens, so we use the appropriate scanner for the question,” explains Jenkins.
“A computerized tomography (CT) scanner with X-ray tubes rotating around the body is good for the heart, and the only option for lungs and virtual colonoscopy. Its resolution is now down to 0.3 millimetres of tissue for arteries, and 1-2 millimetres for lung cancer. Visually, 640 slices of 0.5 millimetres gives a full view,” says Jenkins. “It can also cover pelvis, abdomen, kidneys, liver, spleen and adrenals,” he adds. Just as the latest mobile phones have cameras with more pixels of definition, this scanner has sharper eyes than a traditional X-ray, which might only find 1-centimetre-long tumours. CT scans can pick up soft plaques in the arteries, which are often observed in individuals with no other risk factors, and they can spot minute polyps in the colon.
“An MRI (magnetic resonance imaging) scanner uses magnetic waves to generate radio frequencies, and works well for brain and prostate, as well as spinal cord, neck arteries, bones and joints. Specifically, a 3 Tesla MRI scanner is more powerful than other models. A 3T MRI scan together with a prostate-specific antigen tumour marker blood test is the gold standard for prostate cancer in males,” says Jenkins.
“Back problems can be identified using a unique Upright Skeleton scanner, which was developed to image children’s spine curvature with ultra-low doses, using Nobel Prize winning technology from the CERN laboratory. Lower back pain is a risk for anyone in sedentary jobs and is influenced above and below by the whole skeleton, including hips and spine curves,” he points out.
“Ultrasound jelly probes are mainly suited for thyroid, testes, and ovaries,” says Jenkins. Meanwhile, digital mammograms are appropriate for breasts. Bone problems such as osteoporosis are more common in women and can be identified through bone density CT scans.
The latest scanning machines have reduced the radiation dose by as much as 90%, thanks to more sensitive detectors, better electrical signals, and more powerful X-rays.
A comprehensive blood test is also part of the package. “Blood scans that are often done in isolation will not reveal any early warning signals of heart, lung or colon problems. Half of all people with heart disease have no risk factors and have normal cholesterol. Blood tests need to be done in conjunction with other screens to provide a more informative picture,” says Jenkins.
Incidentally, more advanced blood tests can detect cancer, but not the earliest signs. A single blood test for cancer may sound like a silver bullet but is not. “The problem is that the cancer would need to be advanced to be leeching bad DNA into the blood, by which stage palliation rather than cure would be the outcome. By that time, 5-year survival rates could be as low as 20%. In contrast a CT scan picking up a 2-millimetre tumour can alert patients to the need for another scan some months later,” points out Jenkins.
“We review all machines to keep abreast of the latest models. Though much scanning technology was discovered in the UK, it no longer has manufacturers,” says Jenkins. Echelon uses a CT scanner made by Canon Medical Systems of Japan; an open MRI scanner made by Paramed Medical Systems of Italy; a specialist upright CT scanner made by EOS Imaging of France, and a 3T MRI scanner made by Siemens of Germany. Taken together, these can scan for over 90% of diseases. Each machine costs a seven-figure sum and maintenance, servicing and staff all add up to the same again on an annual basis.
The technology alone is not sufficient. “It is not only the hardware. People think that scanners are just about plug and play, but they are like Formula One cars. It takes time to operate them. We need technicians and radiographers to tweak and optimize performance and get the right images, and we need the right specialists to report the data. We use the best radiologists in the country. I have hand-picked them all, including top cardiac radiologists, a lung specialist, and the head of gastro imaging at Hammersmith. Each assessment gets reviewed by seven or eight top consultants,” says Jenkins.
Medical knowledge helps to distinguish what is important from what is not. “There can be false positives or false negatives. Realistically we aim for accuracy in the high 90s, based on image or pattern recognition rather than a statistical or probabilistic approach,” points out Jenkins.
To what degree can artificial intelligence (AI) assist with interpreting the data? “AI is getting better all the time, but every time a new feature is introduced, it needs to be re-validated and re-evaluated. It may be good for initial screens of large populations, but for individual assessments, there is no substitute for a top consultant,” asserts Jenkins.
Genetics and family history can reveal some patterns, but it does not deliver on its promises, according to Jenkins. “If you trawl through hundreds of thousands of patients you can find associations of genes with disease, but it is not useful at the individual level, where it could give either false comfort or false alarms. You need to identify a problem in multiple genes, not only one. Certain ethnic groups may also have a higher incidence of conditions including prostate cancer and coronary heart disease, but ultimately individual analysis is needed,” he explains.
Some of the scans involve a degree of exposure to radiation. Naturally this is in accordance with IRMA guidelines. “A recent audit of CT radiation dose at Echelon Health shows excellent performance with radiation exposure substantially below national reference levels,” said Dr David Wilson, consultant at St Luke’s Oxford and past President of the British Institute of Radiology.
Radiation from the most modern scanners is much lower than on older models of machines. “The latest machines have reduced the radiation dose by as much as 90%, thanks to more sensitive detectors, better electrical signals, and more powerful X-rays,” says Jenkins.
To put things into perspective, a CT heart scan is equivalent to spending three weeks on holiday in Cornwall, which has relatively high natural radiation from its granite geology. Argentina also has high radiation rates. Neither has higher cancer rates. Long haul flights also entail some exposure to radiation.
The actual science on radiation impacts is based on limited datasets. “All of the data is extrapolated from Hiroshima and suggests a linear level of danger. Alternative theories include that a certain amount of radiation can even weed out weak cells,” says Jenkins.
That said, individuals with cancer can have a different screening program, with more CT scans.
And higher radiation risks for younger people are one reason why the service is generally recommended for men aged at least 35 and women over 40. Additionally, “We need to strike a balance between causing unnecessary concern when there is a very low chance of significant disease,” says Jenkins.
We believe that the offering is superior to more expensive services from some US health groups.
Dr Paul Jenkins, Chairman and Medical Director, Echelon Health
“We understand individual client profiles. We are not a processing plant, but we take time and effort to work with every client, to get a deep understanding of their health status and what is medically and clinically appropriate,” says Ahmed El Barkouki, CEO of Echelon Health.
Each client deals with their own client liaison manager from start to finish on the phone for bookings, and accompanying them on the journey from one scan to the next. It is a stressful, heavy and intrusive health assessment and some patients will be nervous, anxious or hesitant. They may feel out of their comfort zone.
CT scans are less claustrophobic but about 5% of patients find an MRI is too claustrophobic. “Some clients are sensitive to the banging noise of an MRI scan, and they can prepare for it with audio file breathing exercises from a local hypnotherapist,” says Barkouki.
A car service can be provided, and hotel rooms can be booked at the Mandarin Oriental for out-of-town clients. Clinically trained interpreters could be provided for non-English speakers.
Echelon has an extensive knowledge of mainly London-based doctors, who contribute to the process in three ways.
First, for the platinum service, each screening report is scrutinized by 8 or 9 expert specialists, who help to appraise imaging reports and results.
Second, if scans do identify any signs requiring further diagnosis, investigation or treatment, Echelon can refer patients to a little black book of consultants and other medical experts. Jenkins and his colleagues are confident about recommending eminent practitioners. “No remuneration is received for such referrals, and the objective is only to provide the best treatment. Patients can of course use their existing medical professionals,” he says. Next steps could involve stents, keyhole surgery or tumour removal.
Third, a medical advisory committee of distinguished experts, in cardiology, neurology and radiography, help them to keep abreast of new technological screening techniques, and the latest advances in thinking in areas including heart and brain disease, and cancer. This complements the team’s ongoing continuing professional development and attendance at conferences.
Packages include Healthy Heart, Gold and Platinum. Echelon’s Platinum service, combining multiple scanning machines and blood tests, can pick up 92% of preventative conditions (based on ONS data) in men and 95% in women versus just 55% for an MRI alone or even less for an ultrasound by itself.
“We are constantly benchmarking our offering against alternatives, not only in the UK but also globally. We believe that the offering is superior to more expensive services from some US health groups,” says Jenkins. Dr David Wilson, has also endorsed the quality of the service, concluding that “The service they are providing at present is, in my opinion, the best that can be achieved in current practice with existing knowledge”.
There are however some omissions, in hard-to-reach areas of the body. “The esophagus or food pipe, and stomach, cannot be imaged with machines,” says Jenkins.
Mental health is not formally tested through screening, but patients complete detailed questionnaires as part of their initial assessment to make sure they are not overly stressed. “Critics of health screening may argue that it encourages hypochondria, but ultimately people need to be worried about their health to require the reassurance of a screen,” says Jenkins. “Clients should not do an Echelon assessment on a whim. They need to be emotionally ready for a detailed review. The administrative preparation and paperwork also takes some time,” says Jenkins.
Some individuals opt for an Echelon medical, with or without health insurance and companies are increasingly aware of the benefits. If a key person is unwell, that can have a tremendous impact on a family or business. Other doctors, including Jenkins himself, get the Platinum service every 4 years.
The client base includes some hedge fund managers who have decided to provide the service to all staff. For UK companies, employees can receive one medical checkup per year, arranged by the employer, without it being deemed a taxable benefit in kind, and the cost is also an allowable expense for employers. Hedge fund manager Martin Hughes of Tosca, whose entire firm receive Echelon medicals, provides a testimonial on the website. Other testimonials come from athletes, sports managers, and captains of industry. Law firms are also a typical client group.
Employers can also obtain bulk discounts and may wish to customize the offering for specific tests if they do not want the full service.
In theory health insurers should derive long term benefits from effective screening and early warnings. In practice the devil is in the detail of individual policies, which may allow for medicals up to certain spending thresholds.
The Platinum service takes about six hours. The Platinum service and costs can be staggered over monthly payments, as can the Evergreen Service.
The service is constantly being honed and refined to keep abreast of best practices as medical technology continues to advance.
Extra options can be added to the package and are available on a standalone basis.
They include scanning for pre-malignant moles, such as basal cell carcinoma, which can show up on blood tests and scans.
Diagnosing Long Covid, and distinguishing it from any pre-existing conditions, is increasingly in demand. Jenkins has great experience of assessing chronic fatigue from his role as a leading endocrinologist, investigating whether thyroid or adrenal issues could be a cause. “The body’s extreme immune response to Covid can be what blows a fuse and causes collateral damage,” he observes.