NHS Health Checks: Equity and outcomes 2009-17: An observational study

Background: The NHS Health Check cardiovascular prevention programme is now 10 years old. Aim: We describe NHS Heath Check attendance, new diagnoses and treatment in relation to equity indicators. Design and Setting: Using a national general practice database 2009-17, we compared NHS Health Check attendance and new diagnoses and treatments, by age, gender, ethnic group and deprivation. Results: In 2013-17, 590,218 eligible people age 40-74 years attended an NHS Health Check (16.9%) and 2,902,598 (83.1%) did not attend. South Asian ethnic groups were most likely to attend and women more than men. New diagnoses were more likely in attendees than non-attendees; hypertension 25/1000 attendees vs 9/1000 in non-attendees; type 2 diabetes 8/1000 vs 3/1000; chronic kidney disease 7/1000 vs 4/1000. In people aged 65 or older, new atrial fibrillation was diagnosed in 5/1000 attendees and 3/1000 non-attendees and for dementia 2/1000 versus 1/1000 respectively. Type 2 diabetes, hypertension and CKD were more likely in more deprived groups, South Asian and black African/Caribbean ethnic groups. Attendees were more likely to be prescribed statins, 26/1000, than non-attendees 8/1000; and anti-hypertensive medicines, 25/1000 vs 13/1000 non-attendees. However, of the 117,963 people with 10% or greater CVD risk eligible for statins only 9,785 (8.3%) were prescribed them. Conclusions: NHS Health Checks uptake remains low. Attendees were more likely than non-attendees to be diagnosed with type 2 diabetes, hypertension and CKD and receive treatment with statins and antihypertensives. Most attendees received neither treatment nor referral. Of those eligible for statins, fewer than 10% were treated.

Incorporating a brief intervention for personalised cancer risk assessment to promote behaviour change into primary care: a multi-methods pilot study

Background Approximately 40% of cancers could be prevented if people lived healthier lifestyles. We have developed a theory-based brief intervention to share personalised cancer risk information and promote behaviour change within primary care. This study aimed to assess the feasibility and acceptability of incorporating this intervention into primary care consultations. Method Patients eligible for an NHS Health Check or annual chronic disease review at five general practices were invited to participate in a non-randomised pilot study. In addition to the NHS Health Check or chronic disease review, those receiving the intervention were provided with their estimated risk of developing the most common preventable cancers alongside tailored behaviour change advice. Patients completed online questionnaires at baseline, immediately post-consultation and at 3-month follow-up. Consultations were audio/video recorded. Patients (n = 12) and healthcare professionals (HCPs) (n = 7) participated in post-intervention qualitative interviews that were analysed using thematic analysis. Results 62 patients took part. Thirty-four attended for an NHS Health Check plus the intervention; 7 for a standard NHS Health Check; 16 for a chronic disease review plus the intervention; and 5 for a standard chronic disease review. The mean time for delivery of the intervention was 9.6 min (SD 3) within NHS Health Checks and 9 min (SD 4) within chronic disease reviews. Fidelity of delivery of the intervention was high. Data from the questionnaires demonstrates potential improvements in health-related behaviours following the intervention. Patients receiving the intervention found the cancer risk information and lifestyle advice understandable, useful and motivating. HCPs felt that the intervention fitted well within NHS Health Checks and facilitated conversations around behaviour change. Integrating the intervention within chronic disease reviews was more challenging. Conclusions Incorporating a risk-based intervention to promote behaviour change for cancer prevention into primary care consultations is feasible and acceptable to both patients and HCPs. A randomised trial is now needed to assess the effect on health behaviours. When designing that trial, and other prevention activities within primary care, it is necessary to consider challenges around patient recruitment, the HCP contact time needed for delivery of interventions, and how best to integrate discussions about disease risk within routine care.

NHS Health Check Programme: a qualitative study of prison experience

Background NHS Health Checks began in England in 2009 and were subsequently introduced into English prisons. Uptake has been patchy and there is limited understanding about factors that may limit or enhance uptake in prison settings. Uptake of this programme is a key policy in reducing the risk of cardiovascular disease and death in these settings. Method Semi-structured focus groups were conducted with groups of prisoners (attendees and non-attendees to the health check), prison healthcare staff, custodial staff and ex-prisoners (n = 50). Participants were asked about their awareness and experiences of the NHS Health Check Programme in prison. Results All groups highlighted barriers for not attending a health check appointment, such as poor accessibility to the healthcare department, stigma and fear. The majority of participants expressed a lack of awareness and discussed common misconceptions regarding the health check programme. Methods of increasing the uptake of health checks through group-based approaches and accessibility to healthcare were suggested. Conclusions This study reports on prisoner, staff and ex-prisoner perspectives on the implementation of NHS Health Checks within a restrictive prison environment. These findings have potentially substantial implications for successful delivery of care within offender healthcare services.

Fidelity of the delivery of NHS Health Checks in general practice: an observational study

BackgroundThe NHS Health Check programme aims to reduce the risk of common preventable diseases by providing risk information and behaviour change advice. Failure to deliver the consultation appropriately could undermine its efficacy. To date, to the authors’ knowledge, there are no published data on the fidelity of delivery of NHS Health Checks.AimTo assess the fidelity of delivery of NHS Health Checks in general practice.Design & settingFidelity assessment of video and audio recordings of NHS Health Check consultations conducted in four GP practices across the East of England.MethodA secondary analysis of 38 NHS Health Check consultations, which were video or audio recorded as part of a pilot study of introducing discussions of cancer risk into NHS Health Checks. Using a checklist based on the NHS Health Check Best Practice Guidance, fidelity of delivery was assessed as the proportion of key elements completed during the consultations.ResultsThe mean number of elements of the NHS Health Check completed across all consultations was 14.5/18 (80.6%), with a range of 10 to 17 (55.6% to 94.4%). The mean fidelity for risk assessment, risk communication, and risk management sections was 8.7/10 (87.0%), 4.1/5 (82.0%), and 1.7/3 (56.7%), respectively. Clinically appropriate lifestyle advice was given in 34/38 consultations. Elements with the lowest fidelity were ethnicity assessment (n = 12/38; 31.6%), family history of cardiovascular disease (CVD) assessment (n = 25/38; 65.8%), AUDIT-C communication (n = 13/38; 34.2%), and dementia risk management (n = 6/38; 15.8%).ConclusionAlthough fidelity of delivery was high overall, important elements of the NHS Health Check were being regularly omitted. Opportunities for behaviour change, particularly relating to alcohol consumption and dementia risk management, may be being missed.

Influences on NHS Health Check behaviours: a systematic review

Background National Health Service Health Checks were introduced in 2009 to reduce cardiovascular disease (CVD) risks and events. Since then, national evaluations have highlighted the need to maximise the programme’s impact by improving coverage and outputs. To address these challenges it is important to understand the extent to which positive behaviours are influenced across the NHS Health Check pathway and encourage the promotion or minimisation of behavioural facilitators and barriers respectively. This study applied behavioural science frameworks to: i) identify behaviours and actors relevant to uptake, delivery and follow up of NHS Health Checks and influences on these behaviours and; ii) signpost to example intervention content. Methods A systematic review of studies reporting behaviours related to NHS Health Check-related behaviours of patients, health care professionals (HCPs) and commissioners. Influences on behaviours were coded using theory-based models: COM-B and Theoretical Domains Framework (TDF). Potential intervention types and behaviour change techniques (BCTs) were suggested to target key influences. Results We identified 37 studies reporting nine behaviours and influences for eight of these. The most frequently identified influences were physical opportunity including HCPs having space and time to deliver NHS Health Checks and patients having money to adhere to recommendations to change diet and physical activity. Other key influences were motivational, such as beliefs about consequences about the value of NHS Health Checks and behaviour change, and social, such as influences of others on behaviour change. The following techniques are suggested for websites or smartphone apps: Adding objects to the environment, e.g. provide HCPs with electronic schedules to guide timely delivery of Health Checks to target physical opportunity, Social support (unspecified), e.g. include text suggesting patients to ask a colleague to agree in advance to join them in taking the ‘healthy option’ lunch at work; Information about health consequences, e.g. quotes and/or videos from patients talking about the health benefits of changes they have made. Conclusions Through the application of behavioural science we identified key behaviours and their influences which informed recommendations for intervention content. To ascertain the extent to which this reflects existing interventions we recommend a review of relevant evidence.

Nationwide health check program by patients with severe mental illness or long-term antidepressants

Background The English NHS Health Check is a unique national risk assessment, awareness and management programme for preventing cardiovascular disease (CVD), diabetes and chronic kidney disease (CKD). We aimed to assess their uptake and association with new diagnoses (CVD, hypertension, type-2 diabetes and CKD) in patients with severe mental illness (SMI) compared to patients without this condition and for patients on long-term antidepressant treatment (LTAD) (≥6 prescriptions vs < 6). Methods Cohort study (2013-2017) using the QResearch database. 1,319 general practices across England contributed of over nine million patients aged 40-74 years. 3,492,186 patients were eligible for NHS Health Checks of which 590,218 attended. Outcomes: hazard ratios (HR) with 95% confidence intervals (CI) for uptake of NHS Health Checks and for new diagnoses within 1 year in attendees. Models were adjusted for sex, age, ethnicity, deprivation and region. Results 65,490 people with SMI and 46,437 people on LTAD (20% of the total eligible with SMI/LTAD, respectively) attended an NHS Health Check. People with SMI or on LTAD were more likely to attend compared to people without those conditions, adjusted HRs 1.05 (95% CI 1.02-1.08) and 1.10 (95% CI 1.08-1.13), respectively. Among attendees, people with SMI and on LTAD were 23% and 55% more likely to be diagnosed with CKD (95% CI 1.12-1.34 and 1.42-1.70, respectively) than people without these conditions. Attendees on LTAD were 66% more likely to have a major CVD event within 1 year than those without LTAD (95% CI 1.41-1.94) or a new diagnosis of hypertension and type 2 diabetes, HRs 1.12 (95% CI 1.05-1.20) and 1.45 (95% CI 1.31-1.60), respectively. Conclusions People with SMI or on LTAD were more likely to attend NHS Health Checks than people without these conditions. Higher rates of CKD in patients with SMI/LTAD and CVD, hypertension and type 2 diabetes in the latter might indicate increased risks and unmet need in these patient groups Key messages People with SMI/LTAD were more likely to attend NHS Health Checks. People on LTAD were more likely to be diagnosed with CVD, CKD, hypertension and type-2 diabetes than people without these conditions. SMI attendees were more likely to be diagnosed with CKD.

Influences on NHS Health Check behaviours: a systematic review

Background National Health Service Health Checks were introduced in 2009 to reduce cardiovascular disease (CVD) risks and events. Since then, national evaluations have highlighted the need to maximise the programme’s impact by improving coverage and outputs. To address these challenges it is important to understand the extent to which positive behaviours are influenced across the NHS Health Check pathway and encourage the promotion or minimisation of behavioural facilitators and barriers respectively. This study applied behavioural science frameworks to: i) identify behaviours and actors relevant to uptake, delivery and follow up of NHS Health Checks and influences on these behaviours and; ii) signpost to example intervention content. Methods A systematic review of studies reporting behaviours related to NHS Health Check-related behaviours of patients, health care professionals (HCPs) and commissioners. Influences on behaviours were coded using theory-based models: COM-B and Theoretical Domains Framework (TDF). Potential intervention types and behaviour change techniques (BCTs) were suggested to target key influences. Results We identified 37 studies reporting nine behaviours and influences for eight of these. The most frequently identified influences were physical opportunity including HCPs having space and time to deliver NHS Health Checks and patients having money to adhere to recommendations to change diet and physical activity. Other key influences were motivational, such as beliefs about consequences about the value of NHS Health Checks and behaviour change, and social, such as influences of others on behaviour change. The following techniques are suggested for websites or smartphone apps: Adding objects to the environment, e.g. provide HCPs with electronic schedules to guide timely delivery of Health Checks to target physical opportunity, Social support (unspecified), e.g. include text suggesting patients to ask a colleague to agree in advance to join them in taking the ‘healthy option’ lunch at work; Information about health consequences, e.g. quotes and/or videos from patients talking about the health benefits of changes they have made.Conclusions Through the application of behavioural science we identified key behaviours and their influences which informed recommendations for intervention content. To ascertain the extent to which this reflects existing interventions we recommend a review of relevant evidence.