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NHS Health Checks

Introduction

The NHS Health Check programme aims to prevent heart disease, stroke, type 2 diabetes and kidney disease, and raise awareness of dementia both across the population and within high risk and vulnerable groups. Local authorities are responsible for making provision to offer an NHS Health Check to eligible individuals aged 40-74 years once every five years (Public Health England, 2016) .  A recent review by Queen Mary University of London found that up to 8,400 heart attacks and strokes have been avoided as a result of people taking up the offer to have a health check. The review also revealed an increase in diagnosis of 30 per cent in new cases of diabetes, 50 per cent in new cases of hypertension and 80 per cent in new cases of chronic kidney disease in people who had an NHS Health Check compared to those who had not’. (Robson, R et al. 2016)

 

The NHS Health Check is made up of three key components: risk assessment, risk awareness and risk management. During the risk assessment standardised tests are used to measure key risk factors and establish the individual’s risk of developing cardiovascular disease. The outcome of the assessment is then used to raise awareness of cardiovascular risk factors, as well as inform a discussion on, and agreement of, the lifestyle and medical approaches best suited to managing the individual’s health risk.

 

Population-level interventions are the most effective in tackling the structural causes of ill health (Public Health England, 2016). The NHS Health Check programme offers an opportunity to help people to live longer, healthier lives by promoting earlier awareness, assessment, and management of the major risk factors and conditions driving premature death, disability and health inequalities in England.

 

In April 2013, the NHS Health Check became a mandatory Public Health function for local authorities. The original Department of Health (DH) 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 (defined as 75% of the total five year eligible population receiving an NHS Health Check once every five years).   

 

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

 

To optimise the clinical and cost effectiveness of the programme the uptake needs to increase especially within populations with the greatest health needs, in order to narrow health inequalities.

 

What do we know?

Facts, figures and trends:

The Public Health Outcomes Framework sets out the desired outcomes for public health and supporting indicators to measure progress. These are:

  • 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

 

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.

 

The first major evaluation of the NHS Health Check in England was published in January 2016 and provides encouraging evidence about the reach and the impact of the programme. At the same time, the study shows that there is still room for improvement. The programme so far has been most effective at targeting the older end of the eligible population – those aged over 60 – and more work is needed to encourage uptake among the younger age group of 40 to 60 (Robson, Dostal, 2016).

 

A revised payment structure for the delivery of health checks was implemented from the 1st October 2016 to encourage a more targeted approach. Focusing on those at highest cardiovascular risk and positively encouraging good quality and onward referral to relevant lifestyle services.

 

Point of Care Testing (POCT) equipment has been purchased and offered to all Bedford Borough GP practices on a leased basis. POCT enables the patient to complete the required blood test at the time of the NHS Health Check via a finger-prick sample, rather than having to attend an additional appointment. Many GP practices have reported an increase in uptake as a result of introducing POCT.

 

An invitation to tender for the provision of a NHS Health Checks community outreach service to help maximise uptake from the most vulnerable community members, was released in September 2016. Unfortunately the contract was not awarded on this occasion. Discussions are in place regarding the plans for future outreach provision.

 

As patients are entitled to one Health Check every five years, Practices only invite 20% of their eligible population each year.

 

Bedford Borough GPs invited 9,131 patients for their Health Check in 2015/16 and delivered 4,140. Delivery targets for 2015/16 were based on a 66% conversion rate; Bedford Borough achieved a conversion rate of 45% in 2015/16.

 

 

Figure 1 shows the number of patients invited to attend an NHS Health Check and the number delivered. This chart reflects three years (2013-2016) of the current five year cycle in individual years and as a whole.

Health Checks

 

Figure 1 – 2013-2015, 3 years of current 5 year cycle

 

Figure 2 compares activity in Bedford Borough with England during the first three years of the current five year cycle (2013-2016). Bedford Borough both invited and delivered a higher percentage of individuals than England.

Health Checks

Figure 2 - 3 Years of 5 Year cycle Bedford Borough and England

 

All GP practices in Bedford Borough [25] were contracted to deliver NHS Health Checks for 2015/16 however due to recent closures of GP practices the overall number will be reduced for 2016/17.

 

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

 

Figure 3 below shows the performance of Bedford Borough GP Practices for 2015/16

 

Health Checks

Figure 3 - NHS Health Check activity by GP practice (2015/16)

Local views

 

Alcohol screening and dementia awareness were added to the NHS Health Check programme in 2013.

 

Local 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. However feedback from GP practice staff is that year-on-year, it has been increasingly challenging to engage patients to attend their NHS Health Check

 

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 the Bedford Borough Health and Wellbeing Strategy increasing uptake of NHS Health Checks is an objective.

 

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

 

Public Health England has developed national branding guidelines and templates. Bedford Borough Council is leading on the development of a communications action plan in collaboration with Central Bedfordshire Council and Bedfordshire Clinical Commissioning Group. Activity to date includes:

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

 

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/

 

In 2014, Bedford Borough introduced local solutions to data collection:

  • A SystmOne template for NHS Health Check and supporting resources were developed and implemented
  • Implementation of data extraction tool i.e. TCR is complete and all GP practices are actively using it
  • NHS Health Check activity and quality  monitored through TCR

 

What is this telling us?

Although the programme has been running nationally since 2013, Bedford Borough GPs have been delivering Health Checks as part of a pilot since 2010. Consequently, Bedford Borough is in its seventh year of delivery, 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 via TCR is accurate and reliable, outcome data should be treated with some caution. For example, referrals to the local Lifestyle Hub cannot currently be captured; the majority of GP practices have their own Stop Smoking Advisers and therefore do not refer to the specialist team; and some staff continue to request a full blood test prior to the patient’s appointment and any diagnosis as a result will not be recorded as part of the health check pathway.

 

What are the key inequalities?

The most recent annual data from PHE shows that about 48% of all eligible people now attend when invited (conversion rate). 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 (Robinson, Dostal, 2016).

 

Conversion rate is better in females than males, with 54.7% of females attending their NHS Health Check after being invited in comparison to only 37.8% of males as shown in Figure 4, 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.

Health Checks

Figure 4 - Gender difference in uptake of the NHS Health Check ( 2015/16)

 

The breakdown by age group can be seen in Figure 5. 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.

Health Checks

Figure 5 - NHS Health Check uptake by age group (2015/16)

 

When comparing uptake amongst BME groups, as shown in Figure 6, caution must be taken with the data as 32% of all patients invited for an NHS Health Check in Bedford Borough did not have ethnicity recorded on their patient record.

 

Out of those with ethnicity recorded, uptake of the NHS Health Check amongst white patients is good with a 68% conversion rate, just above the 66% national target. Uptake is lower amongst BME groups, with 53.1% of invited Asian patients and 56.9% of invited Black patients attending their NHS Health Check

Health Checks

Figure 6- Uptake of the NHS Health Check amongst BME groups (April-October 2015/16)

 

What are the unmet needs/service gaps?

NHS Health Checks are not currently available in all GP Practices which limits accessibility. Nationally, a range of locations including pharmacies, community venues and workplaces have been trialled with varying success and this continues to be explored locally.

 

More work needs to be done to ensure those individuals who meet the threshold for referral are directed through the appropriate pathways in accordance with the NHS Health Check Best Practice Guidance (Public Health England, 2016), such as those individuals that meet the threshold for diabetes screening.

 

Three-quarters of premature deaths from heart disease and two-thirds of premature deaths from diabetes occur among men. Men make up the majority of those who could benefit from NHS Health Checks, but are less likely to attend ( Todd, 2016)

Recommendations

  • Continue to monitor performance and support those poorer performing practices.
  • Continue to explore other opportunities for NHS Health Check outreach provision
  • Identiy opportunities to link with other programmes such as the National Diabetes Prevention Programme.
  • Increase referrals to lifestyle programmes.
  • Encourage practices to deliver a full health check to those patients receiving a diagnosis following a venous blood test.

 

This chapter links to the following JSNA chapters:

 

 

References

Robson, R et al. 2016. NHS Health Check comorbidity and management: an observational matched study in primary care, British Journal of General Practice, 67 (655): e86-e93. DOI: https://doi.org/10.3399/bjgp16X688837

 

Public Health England, 2016, NHS Health Checks Best Practice Guidance. London, PHE

 

Public Health England, 2016,Action on Cardiovascular Disease: Getting Serious about Prevention. London, PHE

 

Robson J, Dostal I, Sheikh A, et al, 2016. The NHS Health Check in England: an evaluation of the first 4 years, BMJ Open, 6 (1)

 

Tod, M,  NHS health Check E-Bulletin, [online] Available at:

http://www.nhshealthcheck.nhs.uk/nhs-health-check-e-bulletin-november-2016/front-page/foreword-by-martin-tod-chief-executive-mens-health-forum [Accessed 12th December 2016]

 

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