Reviewing the evidence base for NHS Health Checks

The debate as to whether NHS Health Checks represent value for money was given renewed impetus towards the end of 2014 when two new studies into the programme were published in the Journal of Public Health and the British Journal of General Practice. 

The first of these—a cohort study by Forster et al published in October 2014 in the Journal of Public Health—used a significant sample of patient data (65,324 men and 75,032 women) ‘to estimate the yield of NHS Health Checks’ and assess the programme’s impact. The conclusions of this large-scale study were that the ‘universal prevention programme identifies substantial risk factor burden in a population without known cardiovascular disease’. In other words, NHS Health Checks are effectively revealing CVD risk factors in a large proportion of the 40-74 year old population that were previously presumed to be healthy.

Despite the weight of these findings, those calling for the programme to be abandoned appear to have paid little attention to them. The same however cannot be said for the amount of attention that critics gave to a recent study by Caley et al—published in August 2014 in the British Journal of General Practice—which claimed to assess ‘the impact of NHS Health Checks on the prevalence of disease in general practice’. The authors of this study assert that in 38 GP practices providing NHS Health Checks, the change in reported disease prevalence did not differ from 41 practices that did not provide the checks.

Whilst the programme’s detractors have cited this as evidence that the health checks should be scrapped, a number of researchers and clinicians have since pointed out that Caley et al’s study was, in fact, ‘not powered to support this conclusion’. In addition to there being concerns over the methodology and conclusions, further questions have been raised as to whether those calling for the national programme to be abandoned are basing their arguments on evidence that doesn’t accurately reflect the reality of what’s happening on the ground.

As Dr Matt Kearney—GP and National Clinical Advisor to Public Health England and NHS England—and others have identified, the study was ‘not randomised’, which may explain why it was underpowered to show an increase in disease prevalence. Perhaps more problematic however is that fact that researchers formed conclusions after having considered conditions that are not routinely included in the NHS Health Check.

Despite the authors examining the prevalence of 'hypertension, coronary heart disease (CHD), chronic kidney disease (CKD), atrial fibrillation (AF), and diabetes', as Dr Kearney and others note, CHD and AF are not assessed in the national programme. Although in the longer term you would expect CHD to fall if the health checks proved effective, this would take longer than the three year time frame that the study was confined to. 

This highlights a particular recurring issue in the debate; calls to abandon the health checks have often relied on research that doesn’t relate to the current model put forward by Public Health England (PHE). This was similarly found to be the case with the 2012 Cochrane Review, the conclusions of which the Department of Health say have 'little if any relevance to the NHS Health Checks'. There are a number of reasons for this, one of which was that most of the trials considered were out of date, some from as long ago as the 1960s.

Whilst a number in the health sector have identified Caley et al’s most recently published non-randomised study as lacking the evidence to justify its conclusions, rigorous randomised controlled trials into the NHS Health Check programme do exist. One such study monitored population changes in CVD risk factors over the first year of a new NHS Health Check service. This study – which is available in the Cochrane Library – concluded that the programme resulted in a 'significant reduction in estimated population CVD risk'.

The study also established that NHS Health Check programmes that incorporate Motivational Interviewing and ongoing tailored lifestyle support can 'significantly reduce the prevalence of central obesity'. Given that the UK was recently found to be among the worst in western Europe for the level of overweight and obese people, this insight into the value of high quality consultations is particularly timely. As the evidence suggests, the programme currently promoted by PHE – which is fundamentally conceived of as a supportive and motivational lifestyle intervention – will represent an important component in tackling the nation’s obesity problem, amongst other conditions.

For any public health agenda that takes seriously the notion of patient-centeredness, an essential consideration must clearly be the perspectives of patients themselves. As Janet Krska et al found from carrying out a study that investigated patients' views and experiences of the NHS Health Check, 'both attenders and non-attenders had positive views towards NHS Health Checks in general practice and resultant self-reported lifestyle change in attenders was high'. For this to be the case however, 'clear written information and explanation of personal CVD risk are required'. In other words, the quality of the consultation and support should be noted as repeatedly surfacing as the key to coordinating a successful programme. 

Whilst a number of the aforementioned studies firmly support the value of conducting NHS Health Checks, a nation-wide evaluation is yet to be completed. A forthcoming study by Imperial College London however will address specifically that issue by evaluating whether the national programme 'reduces the burden of heart disease and stroke and other vascular diseases while reducing inequalities in them'. In addition, researchers are investigating the effect of providers delivering patient-focussed health checks that 'extend beyond ticking the contractual boxes'. As has been emphasised in this article, (and as many in the sector would affirm), assessing the quality of health checks must be a fundamental consideration for any meaningful evaluation. 

The politics of wellbeing: how health checks can help us to know ourselves

Much of the debate surrounding the NHS Health Checks has focussed, quite rightly, on how the programme is most effectively delivered and the ways in which communities are best engaged. At times, opponents of the scheme have even raised questions as to whether the national programme should feature as part of public health policy. Whilst these issues are amongst the main topics to have been featured on this blog, this post looks more generally at the politics of wellbeing and how individuals are being empowered to take the reigns when it comes to their heart health. 

As Jules Evans – the author of Philosophy for Life – explores, as far back as the Ancient Greeks the promotion of physical and mental health has been an important concern of many governments. Indeed, Aristotle and Plato’s idea that the state should encourage the flourishing of its citizens has become the overwhelming consensus today. For Evans, the fact that the UK government recently agreed to spend half a billion pounds training 6,000 new CBT therapists shows the extent to which the nation’s wellbeing has become a prominent concern of policy makers.

As the ancient philosophers would be the first to acknowledge however, taking steps to improve mental wellbeing represents only part of the whole picture. Working to improve the nation’s physical health and lifestyle are equally fundamental to a progressive wellbeing agenda, particularly at a time when waistlines are steadily expanding and populations are ageing.

In the UK today, the NHS Health Check programme represents perhaps the most comprehensive and wide-ranging attempt to improve peoples’ general awareness of their health and cardiovascular risk. Indeed, the Socratic assertion that one should ‘know thyself’ is arguably, in the physical sense at least, exactly what an NHS Health Check aims to promote.

During a health check, individuals are presented with an opportunity to find out about how factors such as their cholesterol and blood pressure may be affecting their health. With this knowledge in hand, these individuals are then able to discuss with a trained health professional the ways in which they might go about making any lifestyle changes they regard as important. Information about local support services is also on offer, with providers able to make any appropriate referrals.

As Rashmi, a 55 year-old service user reports in this interview, ‘if it wasn’t for the health check', he would not have known that he had diabetes. After gaining the insights into his personal health, Rashmi decided it was time ‘to take control’ of the situation and began looking closely at his lifestyle in order to make the changes that would bring his diet and weight under control. In essence, that short appointment with his GP allowed Rashmi to address some fundamental questions about how he felt he should have been living. Rashmi has since been able to come off using insulin and tablets altogether and now manages his diabetes with a controlled diet.

Whilst a number in the medical profession continue to cite a lack of evidence for the national programme, feedback from service users repeatedly points in a different direction. For many like Rashmi, the NHS Health Checks bring the notion of making lifestyle changes to the very top of their personal agendas. It's case studies such as this that show how these brief consultations are helping many individuals take personal responsibility for their cardiovascular wellbeing.

Why however should 'knowing our numbers' be so important and conducive to improving our lifestyles? One suggestion may be that becoming aware of one's health status and prospects makes a crucial difference to the way in which health messages are received. Though it seems common that people choose to turn a blind eye to the well-known virtues of eating healthily for example, clearly and tangibly seeing how diet may be influencing the personal likelihood of developing heart disease gives these messages a potency and an immediacy that's difficult to ignore.

As the British Heart Foundation reaffirmed by including it as one of their 'top 10 tips to lead a heart healthier lifestyle', taking up an NHS Health Check can be the gateway to making the changes that make the difference. What's more, in terms of England's NHS Health Check model, harnessing peoples' ability to reconfigure their own lives is seen as essential to any profound and long-lasting improvement in our collective cardiovascular health. At a time when GPs are increasingly under pressure and with that trend looking to continue, promoting this preventative and patient-focussed agenda is as important as ever.

With yesterday having been World Heart Day, it's as good a time as any to acknowledge that ultimate responsibility lies with individuals themselves; whilst many of the most common lifestyle related diseases are preventable, taking steps to avoid them may mean making decisions to change. That said, the tools with which we can generate insight and implement this change have been put in place. For anyone between the ages of 40 and 74 who's not been previously diagnosed with a chronic condition and hasn't had a health check in the past 5 years, they're here to be taken advantage of.

Operational Update from PHE: NHS Health Checks in the North East

This month’s NHS Health Check e-Bulletin focuses in on the North East of England: a region that’s becoming widely known for its pioneering approaches to delivering public health programmes.

In the Operational update, Jamie Waterall – National NHS Health Check Lead – gives a snapshot of the innovative work that’s going on in places like Newcastle, Tees and County Durham. With these areas ranking in the lowest third of local authorities in terms of premature mortality, reaching deprived and high-risk communities has been a crucial priority for those involved in the NHS Health Checks. 

As the update outlines, the region is particularly effective at using targeted methods to access hard-to-reach groups. From Gateshead’s ‘community incentive scheme’ to County Durham’s unmistakable Check4Life bus (pictured right), Waterall’s overview paints a picture of innovation and enthusiasm for a programme that’s accessing those most at risk of CVD. What's more, with these local authorities now being cited by Public Health England as examples of what can be achieved when stakeholders are fully engaged, the North East’s model is set to be widely replicated. 

For those on the front line, an extensive support network has been essential to delivering health checks that empower people to take control of their health and lifestyle. As is recognised by the region’s public health directorate, this represents an important factor in coordinating projects that spearhead the evolution of best practice.

A key component in the North East's support network has been the IT and data management infrastructure supplied by Health Diagnostics. As Waterall notes in his update, he was ‘particularly impressed with the IT system’ used by County Durham’s community outreach programme ‘which is able to systemically collect and transfer data from the NHS Health Check back to general practice’. To view a video of a Check4Life provider delivering a consultation using the system, click here.

County Durham have recently put the same system into a number of general practices within the local authority in order to ensure consistency across all providers. This means that regardless of whether health checks are carried out in community venues or by GPs, the service is delivered to the same high standard. Those that have had a health check in the area will recognise the front cover of the personal report (pictured left) which is issued by all providers following a health check.

You can read Jamie Waterall’s Operational Update in full by following this link. These e-Bulletins offer regular insight into the national programme and are well worth signing up to, particularly for those involved with the organisation and delivery of health checks. More detailed information on the approach of the local authorities featured in this post can be found in the published findings from last year's NHS Health Check Leadership Forum.

Health+Care show, 2014: Showcasing the latest tools for NHS Health Check delivery at London's ExCeL centre

With the 2014 Health+Care show getting under way in London today, the country’s public health authorities are gathering to discuss the state of the nation’s health and the innovative ways in which the NHS is evolving to manage the £2 billion funding gap it’s faced with.

Health Diagnostics are present and amongst the show’s official top 20 ‘must see’ exhibitors. In addition to showcasing Health Options® – one of the leading risk assessment software programmes for NHS Health Checks – we’ll be taking delegates through some of the latest tools for delivering and managing the national programme.

Amongst the tools displayed on stand M40 will be the new 'call and recall' system that’s allowing public health leads to find, invite and deliver health checks to their target cohorts. Our secure data transfer module for returning patient data to any GP system will also be on show alongside a series of new health check training videos that we've produced with the help of our NHS and Local Authority partners.

With all the elements in place, Health Diagnostics’ system represents the complete solution for delivering health checks:

Identify and invite with 'call and recall'

As the first link in the chain of delivery, the call and recall module allows for targeted NHS Health Check invites to be sent to individuals. By sampling the population, the software can determine precisely those that are eligible and at risk, as well as generate tailored invites for the identified cohort.

Deliver a health check with Health Options® software

We’ll be taking delegates through the CVD risk assessment software that’s used by Local Authorities up and down the country. Having been designed with ease-of-use in mind, the software structures and supports the delivery of motivational consultations. With a range of additional functions for data management, the IT solution is both at the core of the data transfer process and the front-line of health check delivery.

Receive detailed public health analysis

We’ll be showing examples of our reports that provide commissioners with detailed analysis on local health trends and provider performance. Generated by analysing data that’s been securely sent to us over an encrypted network, these reports are there to help those in charge make fully informed decisions when shaping local public health policy.

Transfer data to any GP system

Returning data to any GP clinical system securely via the N3 network has, for a long time, been the holy grail of a complete ‘end-to-end’ delivery model. Health Diagnostics have responded to this need and will be taking delegates through the tool we’ve developed for transferring data back from service providers, to individual patient records.

Use the latest training resources

We've worked closely with our Local Authority and NHS partners to produce training videos demonstrating full consultations that adhere to best practice. In addition, a promotional video that can be used by providers in venues and online has been made freely available. These can be viewed here.

So if you're at the show today or tomorrow and are interested in how NHS Health Checks are being managed centrally and delivered locally, we'd love to have a chat. You'll find us at stand M40!

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.

Share, listen, act: Reaction to Public Health England’s NHS Health Check conference, 2014 ~ Part 1

Part 1:

This year’s NHS Health Check conference was the largest to date, with hundreds of delegates from across England and Wales coming together to share best practice. 

Taking place at London’s Kennington Oval cricket ground (right), the invited audience was comprised of individuals currently designing the future of this country’s preventive health and lifestyle services.

Amongst the range of speakers asked to present their expertise was Health Diagnostics’ MD, Julie Evason, who after 30 years in the health check business, was ‘‘very pleased to be able share the accumulated learning!’’

Commercial providers role in the NHS Health Check programme: featuring Julie Evason as a panel member

Julie took to the panel after lunch alongside Public Health England’s (PHE) Director of Health and Wellbeing, Professor Kevin Fenton, and a number of other commercial providers from the likes of Boots and Asda. 

Taking the opportunity to discuss some of the pressing issues facing those coordinating health check programmes, Julie outlined Health Diagnostics’ approach to developing answers to the most commonly-voiced problems. Emphasising a particular interest in IT, she stated that Health Diagnostics ‘‘strive to create simple solutions to what can often appear to be overly complex scenarios.’’

The importance of partnering with organisations in order to be able to generate swift resolutions to local authority (LA) issues was a key feature of the speech. As Julie stressed, ‘‘Health Checks are here now. The solutions are required now.’’ Giving an example of precisely what's required, Julie informed the audience:

‘‘Health Diagnostics partner with a number of like-minded specialist companies who can see the strength in working together and they have helped fast track the development of our range of IT solutions which now include modules for cohort identification (that all elusive call and recall) and the ability to return data to any GP clinical systems well within the expected 48 hours.’’ 

Moving from topics such as the available range of delivery mechanisms, to the financial advantages to using point of care equipment, this address covered significant ground in speaking directly to the concerns of the commissioners and programme leads present.

Reflecting on the discussion, Julie remarked that it ‘‘really feels like momentum is building for the NHS Health Checks and I’m very pleased that Health Diagnostics’ offer fits the bill so well. It was a pleasure to be invited onto the panel. It’s really refreshing to see that PHE recognise us as a quality provider in this arena.’’

Conference feedback from Health Diagnostics' delegates

Jen Sutherland, Systems Support and Account Manager

‘‘There was a real buzz about the place - a very pro-active and can-do feel. LAs that are currently using a spreadsheet to record the health check results were very impressed with Health Options® software for recording the information, receiving reports and also how patient focused it is. It really feels like we have an answer to a lot of the problems they’ve experienced.

A number of people commented on their existing software companies taking a long time to implement new changes, (e.g. dementia awareness and pulse palpation requirements). They were pleasantly surprised to learn that we listen carefully to customer feedback and respond quickly to new changes.’’

Julie Evason, Managing Director

‘‘The quality of the delegates was excellent. We had more focused discussions in that one event than at any other show going over two or three days. The fact that this year's event involved as many people as it did really stimulated discussion across all areas with lots of practical advice and tips being shared.

I was surprised by the misconception that much of the IT capability isn’t available when it is, however it’s great to know that we’re fulfilling the evolving requirements of the programme.

What seemed slightly strange was that so many LAs are spending months researching the requirements to put a tender in place. It would make a lot of sense if PHE could provide a template that could be tweaked locally.’’

Selina Donnelly, Training and Account Manager

''It was refreshing that everyone I spoke to was looking for a way to really drive the quality of the health check service.

Hearing that PHE are in favour of looking to alternative providers to GPs was very exciting. It’s great to have been closely involved in the research that’s helping to inform the debate.''

Keep an eye out for parts 2 and 3 of the Share, listen, act blog series, which will feature:

• Part 2: A report on the National evaluation update by Health Diagnostics’ Systems and Data Manager, Michael Storry.
• Part 3: A report on the The new guidelines for NHS Health Check information governance and data flows by Pete Roberts, Senior Solution Developer & Information Security Manager
 at Health Diagnostics.

New NHS Health Check training videos: service users share their experiences

March 2014 is set to be a significant month for the NHS Health Check campaign, with the release of the JBS 3 cardiovascular prevention guidelines and a series of comprehensive new training videos for providers and service users.

Featuring full-length consultations, the training videos will offer providers an invaluable insight into what best practice looks like in action. The individuals carrying out the checks are all experienced Check4Life providers who’ve been responsible for delivering a consistently high volume of checks for a number of years.

In addition, the materials – which will be freely available on YouTube – will serve as an information source for any member of the general public interested in finding out what having a check is all about.

With the health checks being real as opposed to staged, the videos really capture the impact that effective, non-judgemental consultations can have. Keith and Bruce, two men that received consultations as a part of the project had only positive things to say about their experiences:

Bruce, 40 years old, from Durham, was given a health check by Dawn from John Low’s Medical Centre in Consett, County Durham

Bruce before his first health check five years ago

‘‘It was really interesting. I actually came for a health check five years ago when the scheme was first being introduced and functioned as a bit of a guinea pig for the pharmacists to train on!

The results I got today are phenomenal in comparison to last time. When I came first time around, I was leading a completely different lifestyle to what I am now and it was a real eye-opener when I saw my results. I was drinking a huge amount more than I am now and I was a heavy smoker as well. As a result of the health check, I put a stop to both these habits and began eating a lot healthier.

In short, the health check had an extremely positive impact, so much so that I’ve since been able to complete a number of Ironman challenges and am planning to race seven marathons in seven days across the Sahara this year! I couldn’t even run to the pub five years ago!

Even last time, I remember Dawn being really professional and very non-judgemental in her style. Today was no different, I felt very relaxed and comfortable.

I’d recommend it 100% to others. Five years ago, I thought that I was pretty healthy because my job’s always been fairly active. It turned out that I really wasn’t doing enough though. In fact, because of my lifestyle I was building up real problems for myself. My results today have confirmed that I’ve been able to turn all this around.’’

Bruce in August, 2013

Keith, 55 years old, from Durham, was given a health check by Nicola of County Durham’s Check4Life team:

‘‘From the greeting onwards, I thought the whole thing was really professional. Nicola explained everything really well for me and I understood precisely what was going to happen.

What was quite surprising was how I wasn’t being judged in any way, shape or form. I wasn’t told I was fat, drinking too much or not exercising enough, Nicola just gave me the information and let me make my own judgement about it.

The health check has certainly given me the evidence and incentive to make more changes to my lifestyle.

I’d definitely recommend it to anybody; there’s nothing to be frightened of. Even the finger-stick sample is nothing really. The thing is, it lets us find out how we are because we don’t know what we’re like inside until somebody helps you to see what you are.’’

The training videos will be officially released in March. Keep an eye on this blog for details.