Jennifer Trueland on efforts to drive up the low uptake of NHS health checks − as councils take a pivotal role
The figures are seductive: simple NHS health checks could save more than 650 lives and could prevent 1,600 heart attacks and 4,000 cases of diabetes every year. Yet uptake has been patchy since the programme was introduced in 2009, with fewer than half the target group coming forward to be tested.
According to the latest figures, published last month, 598,876 NHS health checks were offered in the first quarter of this year, and a total of 286,717 people received one.
‘NHS health checks could save more than 650 lives and prevent 1,600 heart attacks and 4,000 cases of diabetes cases early year but uptake has been patchy’
Across England, average uptake among the target group was 47.9 per cent, up slightly on the same quarter last year but still way short of target. Little wonder then that, in July, Public Health England published a “call to action” in an attempt to push the initiative up a gear.
According to Professor Kevin Fenton, director of health improvement and population healthcare for Public Health England, it’s time for a big push - and good information, as well as close working between local authorities and primary care teams, will play an important part.
“The latest statistics show local programmes have held steady over the transition from primary care trusts to local government, which means they have a secure platform for the important work ahead in accelerating the coverage, uptake and impact of NHS Health Check,” he says.
“Part of the success of that will come through strengthening programme governance and ensuring that robust information systems are in place to target, shape and evaluate local programmes.
“Reliable, transparent and accessible information is critical for programme involvement and is a key issue from our implementation review; it is also an area where local authority public health and primary care teams can support each other.”
Originally the responsibility of PCTs, NHS Health Check is aimed at the approximately 15 million people in England aged 40 to 74, and is focused on preventing key conditions such as heart disease, stroke, diabetes and kidney disease.
Since April 2013, responsibility for implementing the programme has passed to local authorities and to Public Health England, with the commissioning and monitoring of the risk assessment element of the check being a mandatory public health function for local authorities.
With so many other competing demands and priorities on their resources and budgets, however, will local authorities see health checks as a positive way to improve the wellbeing of their populations? Will the new health and wellbeing boards have the will - and the influence - to ensure the necessary boost to uptake and effectiveness?
According to Katie Hall, chair of the Local Government Association’s Community Wellbeing Board, the move to local authorities is good news for the success of the health checks policy, and for local communities.
“Even before the formal transfer of public health responsibilities, many local authorities worked with their health partners to improve the effectiveness and reach of NHS Health Check,” she says.
“One of the long-standing concerns of councils is that people who are most at risk of developing heart disease, stroke, diabetes and dementia are often least likely to take up the offer. In areas such as Bolton, partnership working between the council and the PCT has led to a marked increase in take up of Health Check, especially among socioeconomically deprived communities, by organising Health Check opportunities in supermarkets, neighbourhood events and away from traditional health settings.”
NHS Health Check is not just one of the mandatory public health functions specified in the Health and Social Care Act 2012, she says; it also aligns with the priorities of health and wellbeing boards.
“Health Check provides individuals with a systematic risk assessment of the top seven causes of preventable mortality and, as such, addresses many of the issues that health and wellbeing boards have prioritised in their joint health and wellbeing strategies: health inequalities, physical activity, obesity, smoking, alcohol consumption.
“The key issue for local authorities will be making sure that, as well as improving the uptake of NHS Health Check for those who would most benefit, individuals have access to information and services that can support them to reduce their risks - for example, better information on where, and how, to get support for healthy diet and weight management, smoking cessation programmes and access to leisure services and green spaces.”
One of the biggest challenges, Ms Hall says, is ensuring that the health checks work to reduce health inequalities by reaching deprived communities.
“Historically, take-up has been fairly patchy with the ‘worried well’ far more likely to go for a health check,” she says. “It is crucial to make sure that everyone has this opportunity, and one of the most effective ways is by providing NHS Health Check in community settings.
“Another challenge is to ensure that we commission the most effective model - both in terms of reach and cost effectiveness. There’s no national tariff for NHS Health Check so costs vary considerably. Local authorities will want to consider a range of providers - from GPs and community pharmacies to community trusts, voluntary and community organisations - to ensure they get the model that is best for their communities and provides best value.”
But does the policy actually work? This summer, Dr Clare Gerada, chair of the Royal College of GPs, said the government was promoting NHS Health Checks against good evidence, and that the money would be better spent on targeted intervention for hard to reach groups.
She was speaking after a review by Danish researchers questioned the value of health check initiatives more generally, saying they did not help patients and could cause them unnecessary worry and treatment.
Supporters of the NHS Health Check programme pointed out that this research did not include the English Health Check programme post-2009. Dr Paul Cosford, medical director at Public Health England, cited evidence on the benefits of NHS Health Check, adding: “Our statement outlined that, although we recognise that the programme is not supported by direct randomised controlled trial evidence, there is nonetheless an urgent need to tackle the growing burden of disease which is associated with lifestyle behaviours and choices.
“All elements of the health checks follow well recognised and evidenced clinical pathways approved by the National Institute of Health and Care Excellence and the existing relevant evidence, together with operational experience accruing on the ground, is compelling support for the programme.”
Hard to reach groups
Councillor Hall believes the transfer to local authorities will help health checks get to the hard to reach groups mentioned by Dr Gerada. “Councils and health and wellbeing boards will be developing NHS Health Check to ensure it reaches communities that could most benefit,” she says.
Professor Fenton echoes this, saying local authorities and health bodies have complementary strengths that can make the programme a success. “Council teams have real expertise around population-level data analysis. That can be used by clinical commissioning groups and practices to see how the NHS Health Check can support them in addressing inequalities, contributing to joint strategic needs assessment and the work of the local health and wellbeing board,” he says.
“We also know from our research that the direct and robust link between the risk assessment, prevention advice and referral to appropriate risk management services are at the core of effective NHS Health Check programmes.
“Ensuring these activities are integrated and recorded within the individual patient record, held by their GP, is important for people as it provides a joined up pathway to clinical care, should they need it.”
The value of health checks
The NHS Health Check programme is a national initiative targeted at people aged between 40 and 74 who do not have an existing diagnosis of a major disease. It aims to detect major risk factors for individuals and allow early lifestyle interventions to be made before disease develops. In the two years 2011-13, NHS Health Checks were given to approximately 2.4 million people, potentially averting 3,200 heart attacks, 1,300 deaths and 8,000 cases of diabetes.
For individuals, the benefit of the programme is clear: early warning of raised blood pressure, cholesterol or blood sugar levels can be the wake-up call required to avoid or delay the onset of disease. A personal risk score is calculated, assessing a person’s likelihood of developing disease over the next decade and how far above or below the average this is.
Lifestyle interventions to help people make the required changes need to follow the initial health check, and are a core part of the benefits gained from health checks.
Benefits also arise for commissioners of NHS Health Check. As a mandated service for local authorities to commission, it is vital they extract the maximum value from the Health Check programme. This might be in the form of the near-contemporaneous data on local population health the health checks can deliver.
Such data can be generated no matter how or where the check is provided, and be a powerful tool in future service planning. Furthermore, it will include information from health checks given to unregistered populations - those not registered with a GP - that are usually outside the scope of routine health data collection.
This also highlights another direct benefit of the programme: community outreach health checks can play an important role in reducing health inequalities by detecting risk of disease in people who would otherwise remain out of contact with local health services.
Having delivered over 50,000 health checks, many in community outreach settings, ToHealth has developed first hand experience of these benefits. Our software platform provides commissioners with detailed data analysis on their local population and bespoke patient information, with a view to facilitating efficient and effective resource allocation.
Rosie Cunningham Thomas is chief executive of ToHealth
Critical point for checks − an HSJ/LGC supplement
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Critical point for checks − an HSJ/LGC supplement