Share, listen, act: Update on the NHS Health Checks in East London ~ Part 2

Part 2:

Following on from Part 1 of the 'Share, listen act' series where we had the initial reaction to last month's NHS Health Check conference, this post will focus on the achievements of the NHS Health Checks in ethnically-diverse East London.

Dr John Robson, a GP working in East London who co-authored the QRisk algorithm with Julia Hippisley-Cox, was responsible for delivering the latest findings in relation to coverage and uptake of NHS Health Checks in the area. 

For the purposes of the project, three Local Authorities comprised ‘East London'. These are listed below, as well as ranked out of the UK's 150 Local Authorities in terms of overall premature mortality:

- Newham (ranked #110)
- City & Hackney (ranked #132)
- Tower Hamlets (ranked #139)

Despite all featuring in the bottom third of UK LAs for premature deaths, the percentage uptake of the scheme in 2011/12 was 74%. This indicates that 21,194 people from those 3 areas had an NHS Health Check; a figure above the current national average of 50% and well above the upper target of 66% as set by Professor Kevin Fenton. Newham even managed 81% uptake.

In regards to the equity of the uptake of the health checks by age, ethnic group and deprivation, Dr Robson echoed much of what Health Diagnostics have seen in collating and analysing NHS Health Check data:

Main findings

1. Older people (>60 years) were more likely to attend a health check (perhaps because they are more likely to be high risk, are stratified as such and are therefore offered a health check).

2. There was no particular difference of uptake based upon quintile, although this is misleading in the three East London areas that the research covered, as the areas were almost exclusively in the 4th and 5th quintile. In 2011/12, 11% of health check attendees had a Townsend Quintile score of 4, whilst 88% had a Townsend Quintile score of 5.

3. There was a significant uptake of the health checks amongst South Asian and black African/Caribbean populations. In 2011/12, 41% of the Health Check attendees were from a South Asian or black African/Caribbean ethnicity band, compared to 28% of non-attendees. 

Overall 

Of those attending an NHS Health Check, 31% had a CVD risk score of at least 10%. In real terms this equated to 15,876 people identified as medium/high CVD risk. These figures would suggest a significant number of people could benefit enormously from identifying risk increasing behaviours earlier in life. For the Local Authorities concerned, responding with targeted educational and health awareness campaigns may prove crucial.

Following on from the risk identification of the health check, of those classified as at high CVD risk overall (200,000 people out of 2 million attendees), around a third (60,000) were prescribed a statin. This would result in an overall decline of instances of CVD by 25%, accounting for a reduction of CVD events by 1500 cases in 5 years. 

The findings from this study point to the significant, positive effect that the NHS Health Check programme can have in lowering CVD risk. In the face of such encouraging evidence, it is understandable that the debate on the utility of the health check programme has subsided in recent months.

Findings conveyed by Health Diagnostics’ Systems and Data Manager, Michael Storry.

Evidence and outcomes: research into pharmacy delivered NHS Health Checks

Questions over measurable outcomes have been a consistent feature of the NHS Health Check debate since the programme was rolled out in 2009. Given the scope and ambition of the service, as well the vocal opposition to it, articles calling for evidence have become a regular feature in public health journals. In this post, we’ll be drawing attention to some of the empirical studies that are currently informing the debate. Specifically, these studies focus on alternative delivery methods, particularly via pharmacy.

A crucial factor to bear in mind when considering the evidence is that despite the programme being nationally mandated, there is no single mandated way of delivering it. The systems in use across England vary widely in terms of the emphasis they place on design, user-friendliness, and encouraging lifestyle improvement. The studies cited here all use a patient-focussed solution developed by Health Diagnostics. A demo of the software component of the solution may be watched here).

Evaluating Leicester City’s Healthy LifeCheck programme

This evaluation focussed on a service that was delivered by community pharmacists in Leicester City.

In the introduction to the research that was published in the Journal of Public Health in March 2013, the rationale for evaluating the pharmacy-led programme is explained:

‘‘In the past, risk screening programmes have been exclusively undertaken within primary care sites. It has been suggested that such an approach may widen health inequalities by excluding those who do not routinely access organized health care… Subsequently, emphasis has been placed on the importance of incorporating second sector organizations in delivering a vascular risk assessment service’

This work thus assess precisely how important it is to have a ‘many-pronged’ approach when tackling local health inequalities. The study involved a sample of 2,521 individuals, which were recruited from 39 pharmacies. The method and results may be read in full here.

In short, the conclusions to the study spoke resoundingly in favour of pharmacy’s ability to identify and engage with people that may otherwise slip under the radar:

‘‘Cardiovascular risk assessment led by community pharmacists can successfully assess people from large, multi-ethnic UK populations and identify those at high cardiovascular risk or with undiagnosed cardiovascular disease. The service may improve rates of assessments undertaken by individuals who do not access health care through traditional routes.’’

By way of a comment on the particular advantages offered by pharmacy, the study’s authors noted:

‘‘The current study demonstrates the suitability of a pharmacy-led system in including those from a minority ethnic background; perhaps due to the extent to which pharmacies are integrated within local communities and their ability to provide information in a number of languages and formats.’’

Evaluating Sefton PCT’s Cardiovascular screening programme

This second study was carried out in the School of Pharmacy and Biomolecular Sciences at Liverpool John Moores University. It engaged 10 pharmacies delivering the NHS Health Check programme and was published in June 2010.

The report makes the following comment in regard to the collated views on the pharmacy CVD screening service:

‘‘Almost all of the participants had a positive experience of the screening process, with 96 (99.7%) agreeing that they were given enough time for the screening and that pharmacists made them feel at ease. Similar high numbers felt comfortable discussing their lifestyle with the pharmacist. Indeed for many, their expectations of what the screening would cover were exceeded. A further 91 (93.8%) participants agreed that the screening had been done in a suitable place. However, nine (10.8%) had questions that were not discussed during their consultation.’’

Seeing empirical research confirm that NHS Health Checks are being well-delivered by providers outside of GP practices is dispelling the myth that targeted lifestyle interventions can only be carried out by doctors. Given the strain that GP’s are under, as well as the pressing need to raise widespread awareness about the importance and practicalities of leading a healthy lifestyle, looking to the secondary sector should really be something for local authorities across England to consider.

For further information or a localised appraisal of the potential impact of extending the provider network, contact Health Diagnostics at info@healthdiagnostics.co.uk or on 01244 311811. All reports are produced using evidence-based economic modelling.

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.

The NHS Health Check Leadership Forum

On Wednesday 12^th June 2013, London’s Excel centre will be playing host to this year’s Commissioning Show. With keynote speakers that include the Minister for Care and Support, the Chair of NHS England, and the Shadow Health Secretary, the event is set to attract an audience keen to stay abreast of current developments in health.

In conjunction with the Commissioning Show, the NHS Health Check Leadership Forum will be staged for those individuals specifically involved in the commissioning and coordination of the NHS Health Checks.

The Leadership Forum – made up of a panel and a select audience – will provide the only event specific to the NHS Health Checks at this year’s show. As such, the platform it offers will be catering for all and any discussion associated with the challenges and benefits currently facing those deploying population-based cardiovascular screening programmes.

Panel members involved in innovative service delivery will talking about their experiences at the sharp end. Others concerned with researching the evidence base and developing systems to get data into GP practices will be sharing their findings.

The panel will be made up of the following individuals:

Andy Cowper: Comment Editor at Health Service Journal, Editor of Health Policy Insight and Event Chair and programmer for Wellards. Andy will chair the session

Dr. Michael Soljak: As a Clinical Research Fellow at Imperial College London, Dr. Soljak is part of the research team evaluating the NHS Health Check programme. With work published in both the British Medical Journal and the Journal of Public Health, Dr. Soljak is in an ideal position to respond to questions concerning the emerging NHS Health Check evidence base.

Jayne Herring: As a member of the Directorate of Public Health in the North East, Jayne oversees the management of public health contracts in North Tees. Having been commissioning population based CVD screening since before the NHS Health Check programme came into being, Jayne has had to recognise and overcome many challenges. She’ll be sharing this experience in innovative public health provision.

Jacqui Deakin: As Durham’s Quality and Health Improvement Lead, Jacqui’s knowledge covers the spectrum of roles and responsibilities associated with the NHS Health Checks. From getting different providers to ensure a consistent delivery, to engaging with communities and motivating providers to perform, Jacqui will be talking about the practical considerations of the programme.

Julie Evason: Managing Director at Health Diagnostics. For 30 years Julie has been developing health screening solutions and has supported the rollout of NHS Health Checks projects across 25 PCTs. Latest developments include coordinating the return of granular data to any clinical system.

Due to the specialist topics under discussion, attendance at the event is via invite only. If you’re you’d like to attend, please send your declaration of interest to info@healthdiagnostics.co.uk. Include your name, organisation and job role.

The NHS Health Check Leadership Forum will take place at a venue on the doorstep of London’s Excel on the 12^th June @ 12.30.

FREE delegate passes to the Health+Care show (which includes the Commissioning Show) are available for healthcare and public sector professionals. To book a complimentary pass to the show, click here

The public’s health: pitfalls and possibilities

And so it begins...

Welcome to Health Diagnostics’ new blog. Having developed a cutting edge cardiovascular health screening solution, it seemed time to take to the online message boards to tell people about it!

That’s precisely what we’ll be doing here. Expect to read about the latest developments within population health screening, with particular attention being paid to England’s NHS Health Check programme.

The challenges currently facing primary care will prove demanding, whilst the changes afoot are equally as diverse. With the UK economy set to have to accommodate for an extra 11 million obese adults by 2030, a central question public health is asking itself is, ‘how can we meaningfully intervene now and prevent this predicted burden from overwhelming the NHS?’

The diabetes epidemic associated with this dangerous hike in obesity levels has been well documented, with charities such as Diabetes UK doing valuable research on the likely economic and social impacts. The simple fact has been stated – we’re ‘sleeping walking into a crisis’. The question now arising is ‘are we’re really doing enough to shake ourselves into action?’

The anticipated response needs to be as profound as the potential problem. For the UK to avoid a situation whereby the average person leads an inactive and inhibited life due to largely preventable ill-health, the measures that Public Health England take now will have a drastic effect on the shape of the coming years.

Fortunately PHE appear to be rising to the challenge. The recently published Our Priorities 2013/14 document explicitly states the organisation's intent towards:

'Helping people to live longer and more healthy lives by reducing preventable deaths and the burden of ill health associated with smoking, high blood pressure, obesity, poor diet, poor mental health, insufficient exercise, and alcohol'

And a primary way in which they’re going to support people to live healthier lives is: 

'By implementing NHS Health Checks to 15 million eligible people. We will support the roll-out of the Health Check programme by local authorities, assuring full implementation across the country'

The proof will lie in the pudding – and specifically whether more people pick the healthy option more of the time – however the intent from the newly endowed health authorities is loud and clear.

There will be trying tests associated with carrying out these aims well and ensuring the programme is both targeted with measured outcomes. However with experience in health screening that long pre-dates the inception of the NHS Health Check programme in 2009, Health Diagnostics are well placed to analyse and coordinate the solutions.

As such, some of the topics you’ll see appearing on this blog over the coming weeks will involve:

-         Plans for the NHS Health Check Leadership Forum

-         Developments in behavioural science and how they’re being integrated into provider training

-         Details on getting patient data back into all GP clinical systems electronically

Comment is encouraged on this blog, and please do also share your views with us on Twitter.

Details on the panel and programme for the NHS Health Check Leadership Forum, which is taking place at this year’s Commissioning Show, will follow next week.

Thanks for reading.