January was not the first time England’s NHS Health Check programme was dealt a blow by statistics – nor will it be the last.
Research by Queen Mary University published at the beginning of this year in the BMJ Open was, in NHS England’s words, “the first major evaluation” of the nationwide service that was introduced seven years ago, in 2009. It found “coverage lower than expected” and “limited evidence of effectiveness”.
And it prompted an NHS strategy director himself to admit, at a King’s Fund event the day after the research was published, that take-up of the service was weak.
Just four months later, in May, research by Imperial College London published in the Canadian Medical Association Journal concluded that the “overall programme performance was substantially below national and international targets”, and that clinical impact was “modest”. But this year is not the first time the effectiveness of the NHS Health Check service, which aims to reduce cardiovascular disease (CVD) risk and events, has been challenged. A cochrane review in 2012 led to several calls for the programme to be scrapped, as it concluded that “general health checks are unlikely to be beneficial”.
The high levels of interest in NHS Health Check are unsurprising. International protocols recommend CVD risk assessment and management programmes as a route to achieving the World Health Organization’s target of reducing premature deaths from CVD by 25% by 2025. But NHS Health Check was the first of its kind, and remains the largest CVD risk assessment and management programme in the world.
That in itself is something to be proud of, says Public Health England’s Jamie Waterall (pictured right), who leads NHS Health Check. “We are setting a precedent globally in trying to reduce the risk factors for premature death.”
But at an annual cost of £165 million to the NHS, it is expected there will be scrutiny of whether ‘trying’ is achieving.
Waterall – who is also Public Health England’s Deputy Chief Nurse and national lead for CVD prevention – points out that the Cochrane review analysed the effectiveness of health checks generally and not specifically the NHS Health Check programme. The Queen Mary researchers also point out that “12 out of 16 of the reported studies were conducted before statins or modern antihypertensive drugs were used”.
So perhaps criticism of the national programme based on this review is unfair. What, then, of the research published this year, focusing specifically on NHS Health Check? Waterall is firm that the results are, in fact, “promising”. Indeed, while the Queen Mary study found “limited” success, it also points out that this is “improving” and that it is still “early years”.
The researchers conclude: “This modest start to a major new programme at scale is likely to have made an important impact on CVD events in people who have been treated with statins and antihypertensives or who improved adverse risk factors.” Waterall says primary care nurses will no doubt be familiar with those risk factors, including blood pressure, cholesterol, smoking, alcohol and a sedentary lifestyle. And doing nothing about them is not an option, he says. “That combination of factors is what’s killing people in our country and we have clearly got to do something about it.”
He cites the statistic that there are 200,000 deaths from CVD each year in England, adding: “We know that a good number of those are preventable.”
The NHS Health Check offers a routine cardiovascular health assessment to those aged 40 to 74 years, without pre-existing CVD or diabetes, every five years. There are three elements: risk assessment, risk awareness and risk management. However, Waterall is clear that there is a fourth element that makes this particular programme so critical: scale. “This is about a systematic approach,” he says.
As the Imperial College researchers say, NHS Health Check is the “most ambitious risk assessment and management programme for CVD worldwide”.
The eligible population equates to around 15.5 million people; therefore just over three million people are invited to attend each year. Since responsibility for the programme was transferred from local primary care commissioners to local government in April 2013, and up until the end of the last financial year, 8.8 million people have been invited for an NHS Health Check. “That’s good,” concludes Waterall. “We’re only 3.4% off where we would want it to be at this time.”
However, there is a big difference between invitations and uptake. This is where the gap is: uptake nationally is shy of 50%. “That’s where we clearly need to do more,” admits Waterall, adding that it is “important” Public Health England looks at “how we can continue to work with local authorities to increase uptake”.
A starting point might be investigating why the uptake gap is so large. The answer, says Waterall, could be “a range of factors”. An obvious one is accessibility, he says: “That’s something we need to look at, and there are fantastic examples across the country.”
He cites the case of Cornwall, where the local council ran a scheme to encourage fishermen – who are at particularly high risk of poorer health outcomes when compared to the general population – to attend an NHS Health Check, by working with the industry to offer them in locations and at times that worked for the target audience. The campaign was such a success it was acknowledged in an event at the House of Lords, and run again in April this year.
The accessibility issue is one that overlaps with another uptake factor for investigation: which patients are attending, and which not. As Waterall puts it: “What we’re interested in is who’s taking it up.” This is more positive: the Queen Mary study indicated higher uptake among deprived communities.
“You often see a social gradient in terms of usage. That’s not happening with health checks,” Waterall says. “I think that’s because there has been very strong public health leadership with the programme and they are trying to target the people that need it most,” he adds.
Another factor in uptake is the messaging used to promote the NHS Health Check, something that Waterall and nurses agree is confusing for patients, particularly in the context of wider NHS messaging.
For example, says Waterall, NHS Health Check is asking patients to attend even though they feel well; this is at odds with other pleas for patients to use services only if they need them, to avoid strain on an already overburdened system.
“It is contradictory to some of the messages we have had in the past,” says Waterall.
Kathryn Yates, the Royal College of Nursing’s lead on primary, community and integrated care, agrees: “The information to engage people with the process lacks a bit of lustre.”
One issue, Yates says, is the range of settings and practitioners that can offer the health check – from doctors, nurses and healthcare assistants in general practices, to pharmacists, other allied healthcare professionals and other community settings.
“There’s a range of practitioners doing this, and a range of settings, and I think for choice that’s brilliant,” Yates explains, “but I also think about consistency.”
Louise Brady, clinical and strategic development lead in practice nursing for Manchester clinical commissiong groups (CCGs) and a practice nurse in Manchester, agrees. “The proliferation of roles has become more confusing for patients.”
Brady also notes that patients are confused about why the service is necessary. “I don’t think the public are absolutely clear when they get a letter inviting them to an NHS Health Check… as to the full reason why. I don’t think we’re communicating risk very well.”
One sticking point here is individual versus population health, and the wider implications of ill-health risk for NHS capacity and finance. Waterall suggests there could be more information about why identifying early risk factors will avoid future cost to the NHS. “But that’s quite a complex message to get across to the public,” he says.
Overall, though, Brady says, patients should be given more, and clearer, information. “From a nurse’s point of view there needs to be more PR and information about the NHS Health Check from Public Health England specifically targeted at patients.”
Yates agrees: “It’s a brilliant concept and it’s got opportunity but how it’s being marketed and delivered could do with further explanation incorporating user feedback.”
And what about the effectiveness of the health checks themselves?
Another element of the NHS Health Check (after at-scale risk assessment, awareness and management) is intervention where necessary, points out Waterall. Sometimes this will be clinical, for example antihypertensive medicines, but more often it will be signposting to support for behavioural change.
The Queen Mary researchers point out, as a limitation of their study, that there is a lack of information about uptake after referral for behavioural change support. And Brady says that nurses lack feedback on the effectiveness of these interventions.
“We’re all doing different things with regard to behavioural interventions – for example, structured education or coaching,” she says. “We don’t have any information on the quality of those behavioural interventions. For us as nurses it’s particularly important that we know we’re signposting correctly and that we know the NHS Health Check is effective both for individuals and populations.
“I think that’s where it falls down: how do we measure the quality of those interventions? If we’re going to make any kind of impact on population health – and that’s the whole idea of the NHS Health Check – we need to know what’s effective with those defined populations and how we build on that as a nursing team.”
One way, says Waterall, that nurses can improve their own NHS Health Check interventions is through what is known as health coaching, sometimes also recognised as motivational interviewing. Waterall is “convinced” it is the future of NHS Health Check.
The idea is to help patients gain the knowledge, confidence and motivation to identify and reach their own health goals. Waterall says: “It’s about having conversations with people in a way they want to. Often they hold the best solutions.
“This is where there’s a real opportunity for nurses to embrace this coaching approach, letting the patient take control of the conversation – and then our skills as nurses will guide them through. I’m convinced it’s what’s been missing in our consultations to date.”
If so, says Brady, “Nurses need more support in health coaching so we change the focus from a disease model to a wellness model.”
Another way nurses can improve their use of NHS Health Check is by engaging with what she refers to as patient educators – former or current patients who have become very engaged and knowledgeable about their conditions and are able to provide “the power of peer support”.
“We don’t tap into those assets at all,” Brady says. “There’s
a role for those educators and for nurses in primary care to link with them.”
Meanwhile Public Health England has further plans for NHS Health Check.
The NHS Diabetes Prevention Programme (DPP), launched last year and rolling out throughout 2016, “stands hand in hand” with NHS Health Check and the link between the two will enable development of both, says Waterall. “These two things are complementing one another and need each other.”
Public Health England is also working on the link between CVD risk factors and vascular dementia. “There’s a clear acknowledgement that the factors that contribute to CVD risk are also contributing to the risk of vascular dementia,” Waterall says. Further details are yet to be announced but “two or three” pilot sites will this year explore how NHS Health Check can use that link to support patients better.
“They will look at how we can enhance the risk reduction message,” explains Waterall. “A good number of people fear dementia so trying to have that conversation is, I think, important.”
More generally, says Waterall, the programme is trying to increase the use of digital tools to engage patients with their CVD risk and NHS Health Check. An example is last year’s launch of an online tool to assess heart age (nhs.uk/Tools/Pages/heartage.aspx), which over a million people have used to date. And, says Waterall: “We’re looking to relaunch that tool later this year with new developments and enhancements.”
So, despite the rather lukewarm results of recent research, NHS Health Checks are alive and kicking as far as policy makers are concerned.
Waterall concludes: “There’s still huge commitment to this programme from Public Health England and NHS England and the Government… This is very much live, it’s an important area.
“For me the overarching check as to where we’re up to is that the statistics show promising findings but also highlight areas to do better.”