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NHS Health Checks

Introduction

 

Cardiovascular disease (CVD) is the collective term for a group of related conditions affecting the heart, arteries or blood vessels, including coronary heart disease (accounting for about 50%) and stroke (accounting for about 25%). It represents a huge burden to people, to health services and to the economy with the combined cost of CVD to the NHS and the UK economy at £30.6 billion. CVD is responsible for over a third of deaths and a fifth of hospital admissions in England each year (Public Health England, 2013).

 

The Care Quality Commission (2009) reported that up to 90% of the risk of a first heart attack is due to lifestyle factors that can be changed. Modifiable lifestyle factors such as smoking, poor diet, physical inactivity and excessive alcohol consumption play a major part in determining poor health with those with all four behaviours dying 14 years earlier than those with none.

 

The NHS Health Check programme is for adults aged 40-74 living without pre-existing CVD including: heart disease, high blood pressure and high cholesterol, diabetes, kidney disease, stroke or vascular dementia. The main components of the NHS Health Check include a cardiovascular risk assessment and individualised support and advice to help patients reduce or manage any potential risks identified.

 

In April 2013, the NHS Health Check became a mandated Public Health function and local authorities are responsible for making provision to offer an NHS Health Check to eligible individuals once every five years. The original Department of Health modelling showed the annual cost of the NHS Health Check programme to be £332m at full roll out and the benefit as £3.678bn with a cost per quality adjusted life year (QALY) of around £3,000. This modelling also suggests that it is cost-saving with estimated savings to the NHS of around £57m per year after four years, rising to £176m per year after 15 years, in addition to annually:

 

  • Preventing 1,600 heart attacks and strokes
  • Saving at least 650 lives
  • Preventing over 4,000 people from developing diabetes
  • Detecting at least 20,000 cases of diabetes or kidney disease earlier

 

The Public Health Outcomes Framework sets out the desired outcomes for public health and supporting indicators to measure progress. In Bedford Borough the following indicators are used to measure progress in relation to NHS Health Checks:

 

  • Cumulative percentage of people eligible for an NHS Health Check who were offered an NHS Health Check in the five year period 2013/14 - 2017/18
  • Cumulative percentage of eligible population offered an NHS Health Check who received an NHS Health Check in the five year period 2013/14 - 2017/18
  • Cumulative percentage of eligible population who received an NHS Health Check in the five year period 2013/14 - 2017/18

 

What do we know?

Facts, figures and trends:

Nationally NHS Check implementation has been highly variable and lower than expected. The average conversion rate achieved is low with less than half of all invited patients attending their NHS Health Check. To optimise the clinical and cost effectiveness of the programme the uptake needs to increase especially within populations with the greatest health needs to narrow health inequalities.

 

Feedback suggests that having to visit a GP Practice for a NHS Health Check is often inconvenient and prevents people from accepting their invitation. It is also evident that males are less likely to take up the offer of an NHS Health Check. In order to help overcome this, some localities commission outreach providers to deliver NHS Health Checks in the community, for example in workplace settings.

 

Current activity and services:

All GP practices in Bedford Borough [25] are currently contracted to deliver NHS Health Checks. Currently, GP practices are the sole provider of the programme. however performance varies for many reasons including:

  • competing priorities
  • capacity of clinical and clerical staff
  • lack of clinic space

 

Historically, Bedford Borough has not met targets associated with the NHS Health Check programme, and the same is expected for 2015/16. Figure 1 below shows annual NHS Health Check delivery from 2010/11 through to 2014/15 for one complete five year cycle. The rest of this chapter will refer to year to date data April-October 2015/16.

 

Health Check1

Figure 1- A complete 5 year cycle of the NHS Health Check delivery 2010-2015 in Bedford Borough

For each year of the five year cycle, a target to invite 20% of eligible population is set. Bedford Borough’s invitation target is 9,305 for 2015/16. So far this year (April-October 2015), among the 25 GP practices:

  • 13 (52%) are exceeding 90% of their year-to-date target for invitations
  • 4 (16%) are achieving less than 30% of their year-to-date target for invitations

 

Delivery targets are based on a 66% conversion rate so Bedford Borough is aiming to complete 6,214 NHS Health Checks for 2015/16. So far this year (April-October 2015), among the 25 GP practices:

  • 6 (24%) are exceeding 90% of their year-to-date target for delivery
  • 3 (12%) achieving less than 30% of their year-to-date target for

Conversion rate is hindered by over-inviting and this is apparent at this stage of the year in Bedford Borough as shown in Figure 2. GP practices may invite their eligible population at different stages throughout the year and therefore conversion rates vary across the locality. Current year to date activity (April-October 2015) shows:

  • 9 (36%) of GP practices are achieving a conversion rate of <33%
  • 11 (44%) of GP practices are achieving a conversion rate of ≥33-65.9%
  • 5 (20%) of GP practices are achieving a conversion rate of ≥66%

 

HC2

GP practices are encouraged to prioritise patients at highest risk and have functionality to order their eligible patient list by estimated cardiovascular risk score. This method aims to target those with the greatest health needs to narrow health inequalities.

 

Point of Care Testing (POCT) equipment has been purchased and offered to all GP practices on a leased basis. 17/25 (68%) of GP practices now use POCT to collect required blood samples. Practices were issued with a starter pack of consumables with the expectation that they will fund the ongoing cost of consumables, an estimated £3.44 per NHS Health Check. The costs of internal and external quality control processes to maintain the accuracy of the equipment are met by the commissioner.

 

POCT enables the patient to complete the required blood tests at the time of the NHS Health Check via a finger-prick sample, rather than at an additional appointment for a venous blood sample. Many GP practices have reported an increase in uptake as a result of introducing POCT; one GP practice’s delivery is now three times higher than at the same point in 2014/15.

 

Between April and October 2015 the following health outcomes were recorded as a result of an NHS Health Check:

  • 1 in 3 were identified as physically inactive
  • 1 in 5 patients were identified as obese
  • 1 in 20 patients have been moved onto a high risk register for cardiovascular disease
  • 71 patients (3%) were prescribed statins for high cholesterol
  • 46 patients (2%) were diagnosed with high blood pressure
  • 8 patients (<1%) were diagnosed with diabetes

 

Local views

 

The NHS Health Check has evolved over time. Alcohol screening and dementia awareness were added to the programme in 2013 and both the patient and practitioner experience has changed over the past six years.

 

Anecdotal feedback from NHS Health Check delivery staff tends to be in favour of the programme, in particular for identifying high blood pressure and/or high cholesterol that the patient was not aware of prior to attending.

 

The Portfolio Holder for Public Health, Cllr Louise Jackson, recently received her NHS Health Check at the De Parys Medical Centre in Bedford and feedback from her experience will be incorporated into future campaigns.

 

“The appointment was genuinely more helpful than I thought it would be. Before I came in, I knew I would be asked some lifestyle questions, and I thought I would be totally honest otherwise what is the point of making the appointment? I got some excellent healthy lifestyle tips, which were delivered in a personable and friendly manner.” Cllr Louise Jackson, Portfolio Holder for Public Health.

 

National and Local Strategies

 

 

The Department of Health published ‘Living Well for Longer’ (2013) which is about reducing avoidable, premature mortality caused by the big killer diseases, among which is cardiovascular disease. 

 

Reducing premature mortality and helping people to live longer and healthier lives is a priority within Bedford Borough’s Health and Wellbeing Strategy where increasing uptake of NHS Health Checks is an objective.

 

All providers of the NHS Health Check are expected to follow Public Health England’s NHS Health Check Best Practice Guidance and NHS Health Check Competency Framework.

 

There are no national campaigns that support the NHS Health Check programme. Local authorities are encouraged to market the programme locally and Public Health England has created national branding guidelines to follow and shared some template resources. Bedford Borough Council is leading on the development of communications action plan on behalf of Central Bedfordshire Council and Bedfordshire Clinical Commissioning Group. Achievements to date include:

  • Promotional resources to be used in future local communication campaigns
  • Local campaign to include digital marketing and external advertising to enhance the promotional materials on display in GP practices

 

There is no national standardised data collection method; however in 2014 Bedford Borough introduced a local solution. Prior to this Public Health was unable to validate invoices submitted by GP practices. Progress to date includes:

  • A local NHS Health Check template for the GP practices’ computer system (SystmOne) and supporting resources were developed and implemented in 2014
  • Use of SystmOne template and resources made mandatory within the service level agreement - contains all required components and national read codes for the NHS Health Check so local quality can be assured
  • Implementation of data extraction tool is complete and all GP practices are actively using the tool
  • NHS Health Check quality is closely monitored by the commissioner
  • Payments now are based on the number of eligible NHS Health Checks completed

 

What is this telling us?

 

The programme has been running nationally since 2013 and is currently in the third year of the five year cycle. Bedford Borough has been delivering the programme as part of a pilot scheme since 2010. Consequently, Bedford Borough is in its sixth year of delivery, or year one of its second five year cycle, meaning that many patients are now being recalled to attend their second NHS Health Check. This makes it difficult to compare Bedford Borough performance to other local authorities.

 

Whilst the data collected using the data extraction tool is most accurate and reliable, outcome data needs to be treated with caution. Direct referrals from NHS Health Check to lifestyle services are low as the data does not capture referrals made via the local Lifestyle Hub. Many GP practices also have Stop Smoking Advisers within their practice and therefore do not refer to the specialist team. Some health outcomes will also be identified by GP practices that complete venous blood tests for the NHS Health Check prior to the appointment and consequently are coded on the patient record as being diagnosed with diabetes. This coding will exclude the patient from an NHS Health Check and so the outcomes do not reflect all newly diagnosed cases that have been identified as a result of being invited for an NHS Health Check. These identified blood results also negatively impact upon conversion rate.

 

What are the key inequalities?

 

Conversion rate is better in females than males, with 51.7% of females attending their NHS Health Check after being invited in comparison to only 32.4% of males as shown in Figure 3, despite more males being invited. GP practices are encouraged to prioritise invitations to patients at higher cardiovascular risk; men are typically at higher risk than women and this may explain the larger number of men invited.

 

HC3

Figure 3 - Gender difference in uptake of the NHS Health Check (April-October 2015/16)

The breakdown by age group can be seen in Figure 4. Conversion rate improves with age with 52.2% of those aged 70-74 attending in comparison to only 28.2% of those aged 40-44. This may be accountable to those of a working age finding it more difficult to make time to attend their GP practice.

HC4

Figure 4 - NHS Health Check uptake by age group (April-October 2015/16)

 

When comparing uptake amongst BME groups, as shown in Figure 5, caution must be taken with the data as 36% of all patients invited for an NHS Health Check in Bedford Borough did not have an ethnicity recorded on their patient record.

 

Out of those with an ethnicity recorded, uptake of the NHS Health Check amongst White patients is good at 65.4% conversion, just short of the national 66% target. Uptake is lower amongst BME groups, though it is positive to note that some figures are not too dissimilar to national average, with 47% of invited Asian patients and 46.5% of invited Black patients attending their NHS Health Check.

 HC5   

Figure 5 - Uptake of the NHS Health Check amongst BME groups (April-October 2015/16)

What are the unmet needs/service gaps?

 

The programme is only available in GP Practices which somewhat limits the accessibility of the NHS Health Check. Nationally, a range of locations including pharmacies, community venues and workplaces have been trialled with limited success.

 

Theoretically, targeting populations with the highest cardiovascular risk could improve the cost effectiveness of the programme and deliver better health outcomes.

GP practices are currently able to target invitations to those predicted to be at highest risk first, and while this is encouraged, it is not a requirement of the current contract.

 

Public Health is in discussion with existing commissioned services, including mental health and substance misuse providers, to consider upskilling staff to enhance their offer to include the NHS Health Check

Recommendations

  • Encourage uptake of the NHS Health Check to all service users, with a greater emphasis on males and BME groups
  • To strongly encourage the remaining 8 GP practices to implement POCT as a strategy to increase uptake of the NHS Health Check and to improve patient experience
  • Continue to deliver high quality and consistent NHS Health Checks to Bedford Borough residents
  • Promote the NHS Health Check

 

Local promotional resources are available upon request. National resources are available on NHS Choices website www.nhs.uk/nhshealthcheck. Other resources for healthcare professionals are available at http://www.healthcheck.nhs.uk/

This chapter links to the following JSNA chapters:

 

 

References

 

Care Quality Commission (2009) Closing the gap. Tackling cardiovascular disease and health inequalities by prescribing statins and stop smoking services. (Accessed Dec 2015)

 

Department of Health (2013) Living Well for Longer: A call to action to reduce avoidable premature mortality.(Accessed Dec 2015)

 

Public Health England (2013) NHS Health Check implementation review and action plan. (Accessed Dec 2015)

 

Public Health England (2015) NHS Health Check Best Practice Guidance.(Accessed Dec 2015)

 

Public Health England (2015) NHS Health Check competence framework.(Accessed Dec 2015)

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