Response to NHS Health Check criticism

The following post was submitted as a letter to the editor of the Times newspaper last week in response to their leading article on the benefits of NHS Health Checks:

Given the recent conflicting headlines in regard to NHS Health Checks, providers of the programme are understandably confused and frustrated by the inconsistency of the messages being reported in the press.

On 21^st July 2013, Public Health England (PHE) announced a drive to extend the national health check programme and widely praised its potential to ‘save up to 650 lives a year’.

Less than a month later on 20^th August, the Times ran with the front page headline ‘NHS checks on over-40s condemned as ‘useless’’, with an accompanying article that focussed on a study from the Nordic Cochrane Centre that was originally published and reported on last October. The study alleges that health checks don’t have an impact on morbidity.

Both of these mutually exclusive claims cannot be true at the same time. The pressing question is therefore ‘which is accurate and relevant to the English NHS Health Check programme?’

It should be noted that one of the major criticisms of the Cochrane Review is that it doesn’t actually apply to the current model put forward by PHE. According to the Department of Health’s (DH) response to the Cochrane Review:

‘Most of the trials considered are old, dating from as long ago as the 1960s when understanding of health risks and particularly how they may be modified was at an early stage of development.  Most of the risk reduction measures now used post-date these trials.’

As a result:

‘The review conclusions can have little if any relevance to NHS Health Checks.’

Given how separate the research conditions are from what’s actually happening in this country, it can hardly come as a surprise that the DH rebuffed the Cochrane Centre’s request for the research to be posted on the NHS Health Check website. It was this declined request that the Danish researchers took issue with and condemned in their letter to the Times that acted as the original catalyst for the story.

However, far from being an attempt by the NHS ‘to stifle debate’, it is difficult to see how there could be any assumed requirement for the DH to publish findings which bear no relevance to the English model.

The current approach championed by PHE is – first and foremost – a targeted lifestyle intervention which should encourage positive behaviour change if an individual has poor lifestyle habits. Individuals are made aware of their risk of cardiovascular disease, offered advice and signposted for further support if necessary.

The point is that through the effective communication of risk and appropriate service referral, individuals can fully grasp their likelihood of having a heart attack or stroke and, if needed, be offered support to do something about it.

Moreover, the NHS Health Check is unique in the fact that it combines a number of elements and tests – all of which are ‘based on evidence of clinical and cost-effectiveness from trials’ – and brings them into a single risk assessment programme. As Dr Bill Kirkup, retired Chief Medical Officer at the Department of Health, noted, ‘none of the trials assessed by Lasse Krogsbøll and colleagues tested this’.

I must stress that we fully encourage lively and healthy debate on this blog and recognise that such dialogue is essential to ensure that public health programmes such as the NHS Health Checks are worth the money that’s spent on them.

The issue in this instance is that recent criticism has rested on research that does not accurately reflect or relate to what’s happening on the ground. From an academic perspective, it’s essential that the studies being used in evidence are not disconnected from the reality of the situation.

The discussion as to the merits of the NHS Health Checks is not new. As mentioned, the Cochrane Centre’s findings were first published and in the news last October. This time however the chair of the Royal College of GPs also came out in staunch opposition to the programme.

One of Dr. Clare Gerada’s main claims was that the programme constitutes ‘a waste of money for asymptomatic people’; a statement which translates as ‘if you’ve not already developed complications, you shouldn’t be receiving a health check’.

In response, public health experts appropriately drew attention to the burden of ill health that threatens to overwhelm the NHS during the coming decades. PHE’s official statement written by the organisation's Medical Director - Dr. Paul Cosford - can be viewed here.

It is for precisely these reasons that the programme targets lifestyle factors associated with preventable diseases before they become unsustainably costly for the NHS.

One needs only to look at the facts staring us in the face. It has been estimated that by 2050, ‘90 per cent of today’s children will be overweight or obese.’

Even by 2030, ‘Three in four adults are likely to suffer illnesses such as heart disease or diabetes’ according to the Daily Telegraph’s article from the 21st August; ironically, a publication that only the day before ran with the story about health checks being ‘useless’.

Specifically in terms of diabetes, treating the condition currently costs the NHS £1million an hour. Given the other estimates, the direction in which this financial burden is likely to move looks bleakly clear.

The net financial benefit of acting whilst there’s an opportunity to do so has hard evidence associated with it. As Barbara Young, Chief Executive of Diabetes UK stated to the BBC:

‘Once you factor in the savings in healthcare costs, the NHS Health Check is actually expected to save the NHS about £132 million per year.’

The DH assures that the above figures are based on expert guidance, all of which can be viewed here. 

Furthermore, research published in the BMJ on the 13th May 2011, found conclusively that:

'A programme across the entire population of England and Wales... that reduced cardiovascular events by just 1% would result in savings to the health service worth at least £30m a year compared with no additional intervention.' 

As a result, once the evidence is examined and objectively considered, the claim coming from the programme’s critics that the Cochrane Centre’s findings constitute the ‘best available evidence’ seems to look less and less empirically accurate.

NHS Health Checks in pharmacy: Hillingdon’s high performer

(Rishi Verma from Ruislip Manor pharmacy takes a patient through an NHS Health Check)

The context

In recent weeks, Public Health England (PHE) declared that 15 million NHS Health Checks will be delivered between now and 2018/19. In an article with Pulse, Prof Kevin Fenton, Director of Health and Wellbeing at PHE, stated the opportunity this represents for pharmacy:

‘‘What we’re also seeing as local authorities take up leadership of the programme is that they’re beginning to identify other key partners in the primary care family who can also be a part of health checks. This may involve community pharmacies, particular voluntary or community sector providers who can also be involved in the risk assessment and management activities associated with the community.’’

However, in order for pharmacy to make a meaningful contribution to the programme, a proactive and engaged mind set is key. A common discussion topic amongst those who commission and manage the delivery of the NHS Health Checks has been ‘what level of value can pharmacy bring to a health check delivery network?’

The answer is that it depends entirely on how committed and enthusiastic the pharmacies are. The variation in performance can be wide, however when done well pharmacy carries the potential to be an incredibly valuable weapon in the public health arsenal.

Making it happen in Hillingdon

Of the 20 pharmacies delivering the health checks across the London borough of Hillingdon last financial year, a standout performer was Ruislip Manor pharmacy. The person responsible for driving the CVD assessments is Rishi Verma, the pre registration student at the pharmacy.

Of all the health checks conducted in the pharmacy last year – of which there were well over a hundred – the overwhelming majority were done when Rishi began working in the pharmacy and took it upon himself to champion the health checks.

‘Every interaction is an opportunity’ Rishi explained; ‘delivering the health checks can be really rewarding and they’re great for building patient rapport... Crucially, if you offer someone good care, they’ll keep coming back to you.’

The impact of Rishi taking responsibility for the checks underlines how important strong leadership is at every stage of health check delivery. Regardless of if you're commissioning the service or delivering the checks, the success of the programme depends hugely on energised individuals taking the reins.

‘It’s about creating an atmosphere of positivity and opportunism’ said Rishi. ‘The pharmacy team all got on board and found potential patients in the client group. This gave us a good cohort to target. Additionally however, if anyone comes into the pharmacy and they’re over the age of 40, I let them know that there’s a brilliant scheme to help them find out their risk of developing cardiovascular disease. What surprises a lot of people is if I tell them that the same test done privately could cost the upwards of £80.’

Rishi openly admits that he’s obsessively driven to do the best he can possibly achieve; so much so that he’s taken it upon himself to go round local businesses handing out leaflets during his lunch hour. One particularly motivating factor was identified as a training day that was run by Health Diagnostics last year. ‘We were really enthused by the PCT meeting where the agenda was set and the staff trained’ explained Rishi.

Going forward, Rishi has big ideas for hosting community events in his locality: ‘I’ve even engaged a local library where I’ve been delivering health checks. The libraries have community targets to meet so I said to them that I’d come in and deliver the assessments for a day; all they’ve needed to do is promote the event.’

Having championed the checks at Ruislip Manor and completed a university project on public health which fit closely with the NHS agenda, Rishi has accumulated some valuable learning. For those providers who’d are looking for advice on how to boost your numbers, Rishi has a series of recommendations:

-  Mention it to anyone and everyone that looks eligible

-  Have yourself a ‘pitch’ at the ready

-  Stick your individual pharmacy stamps on the leaflets so that people register your venue as the place to get checked

-  Word of mouth can work wonders. Tell people to inform their loved ones who may be eligible

-  Pharmacies can use MURs to determine eligible clients

-  Maximise any community events that go on in the area. Ruislip pharmacy, for example, do well off the back of the local fun day that runs twice a year where local businesses open up a stall on the main street

If pharmacy is to ‘stand up and be counted’ in the reformed NHS – as Chemist and Druggist put it in an article published in April – this kind of innovative and ambitious approach will need to be exploited by pharmacists everywhere. And with PHE aiming to do 15 million NHS Health Checks, the opportunity is certainly there for those that want to make a name for themselves and their business.

Sanjay Doegar, the pre registration tutor at Ruislip Manor had this to say: 'Rishi's performance in health checks is outstanding and his drive to bring on new services has been exemplary. Through his actions we have successfully taken on the free condom service a key performance target for both prevention of STI and teenage pregnancy. We are also a high performer in the Chlamydia screening service.'

(Rishi Verma and Sanjay Doegar at Ruislip Manor)