Rounding-up 2013's public health debates and looking forward to the coming year

2013 has proved to be a significant year for English primary care. With the transition of public health from PCT to local authority, April saw the introduction of a whole new system of structures for healthcare commissioning and provision. Whilst it’s still too soon to say whether this move has delivered the desired effect of making local health services more relevant for the communities they’re provided for, the indications from the second half of the year suggest that there’s an increased sense of stability in the sector by comparison to this time last year. For many however, this will hardly come as a surprise given how many NHS departments, let alone individual positions, had uncertain futures twelve months ago.

Plain packaging

One of the biggest public health stories from 2013 was the debate around the plain packaging of tobacco products. The issue became increasingly mired in controversy after it emerged that Lynton Crosby – a campaign consultant at the heart of Downing Street – was also actively representing the interests of the tobacco industry. Although out of the limelight for the time being, this issue along with other public health measures such minimum unit pricing are unlikely to be out of focus for long. Their importance in combating what Dr Zafar Iqbal and others have described as the ‘social and market forces which help to perpetuate health inequalities’ will undoubtedly mean their re-emergence in 2014. Our coverage and perspective on the story can be revisited here.

CVD prevention

The summer also saw Public Health England placing an increased emphasis on promoting cardiovascular disease prevention. However as PHE and the Health Secretary served up the evidence on the predicted benefits of England’s flagship CVD prevention programme – the NHS Health Check – others were voicing their doubts as to the projected net gain. As it has emerged, many of the charges levelled against the programme by critics have been based on misrepresentations of the English model of CVD prevention. Again, our in-depth critique which draws out the specifics of the argument can be read here.

Going forward: the macro view

Fortunately, for those on the ground and working hard in communities to provide the health checks and increase awareness on the effects of poor lifestyle behaviours, the news looks positive. Recognising that ‘doing nothing’ in regard to national health inequalities ‘is not an option’, NHS England’s chief financial officer this week announced an increase in funding for NHS commissioners from £96bn to £100bn over the next two years. As well as the increased budget, a new funding formula for local health commissioners ‘that more accurately reflects population changes and includes a specific deprivation measure’ is said to be being introduced. With the NHS Health Check at the very centre of CVD prevention policy, these announcements should provide the means to continue increasing the efficiency and effectiveness of a programme that is already estimated to ‘prevent 1,600 heart attacks and strokes, at least 650 premature deaths, and over 4,000 new cases of diabetes each year’.

Developments at Health Diagnostics

With this comprising the macro-outlook, a big question going forward for us at Health Diagnostics is: how can we best support the drive to alleviate health inequalities and the growing social and economic burden of cardiovascular disease in our own capacity? We’ll certainly be working hard to continue providing a first-class service to all our NHS partners, however in addition a handful of the new developments will include:

• Working closely with reputable academic institutions to help establish empirical outcome data on the efficacy of the NHS Health Check. The potential benefit of using Health Options® software in delivering the health checks will be investigated in particular.

• A new software release is planned for January 2014. This latest version will include some exciting new developments including the integration of the Diabetes UK questionnaire.

• To coincide with this software release, Health Diagnostics are launching the new range of client report fact sheets. With a keen emphasis on design and clarity, the new reports are intended to facilitate the communication of essential health information. With tens of thousands set to be distributed, the team at Health Diagnostics have been working hard to make the reports as coherent, concise, and informative as possible.

• We’ll again be attending the Commissioning Show in June, with details set to be announced closer to the time. To view the findings of the events run in conjunction with the 2013 show, click here.

Until 2014 then, wishing you a happy and healthy Christmas and new year!

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 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.