Author: Christine Heron, LGiU Associate
Date: 11 September 2013
Local authorities took over responsibility for the NHS Health Check programme in April 2013 as part of their new public health responsibilities. This September the first set of local authority performance data was published by Public Health England (PHE). This Policy in Practice briefing:
- describes the NHS Health Check and the role of councils and clinical commissioning groups (CCGs)
- identifies some examples of good practice
- suggests questions for councils and health and wellbeing boards to consider.
NHS Health Check overview
NHS Health Check is a national programme which identifies people at risk of developing preventable illness including heart disease, stroke, diabetes and kidney disease so they can take action to avoid or delay ill-health. The programme targets the seven top causes of preventable mortality – high blood pressure, smoking, cholesterol, obesity, poor diet, physical inactivity and alcohol.
Everyone in England between the ages of 40 and 74 who is not already diagnosed with a relevant condition or being treated for certain risk factors should be invited for an NHS Health Check once every five years. NHS Health Check involves two components which can take place separately or together:
- risk assessment – a face-to-face meeting with a trained professional who asks set questions about an individual’s health and carries out simple tests such as blood pressure
- risk management and reduction – feedback on results, personalised advice about healthy lifestyles and, where necessary, referral to health improvement services such as stop-smoking or to the individual’s GP for clinical follow-up.
Although the programme has shifted to councils it is important that it retains the national ‘NHS’ brand to increase public recognition and to distinguish it from other health checks that people may have to pay for and which may not have an extensive evidence base.
- Following a period of research and modelling, the Government developed a risk assessment programme for vascular disease – NHS Health Check.
- PCTs were given responsibility for ensuring local delivery, phased-in over three years.
- The Government included NHS Health Check in NHS reforms; the programme became a mandatory public health function in the Health and Social Care Act 2012.
- The first full year of operation.
- The Government expressed its commitment to preventing premature deaths, and NHS Health Check was identified as a key measure in documents such as the Mandate to NHS England and Living well for longer: a call to action on avoiding premature mortality.
- Councils took over responsibility for the programme as part of their new public health role. NHS Health Check was extended to cover alcohol screening and dementia awareness and signposting for people aged 65-74. PHE took over national oversight and support.
The NHS Health Check programme published first quarter 2013-14 data for local authority performance. See interactive map.
Impact on health
Over four million people in England are estimated to have vascular disease which is recognised as the largest single cause of long term ill health, disability and death – responsible for a third of deaths in England each year. However, much of vascular disease is preventable. For example, research has shown that in more than 90 percent of cases the first risk of a heart attack is related to modifiable factors such as high blood pressure.
3.7 million people in the UK have diabetes and the number is expected to rise to around 5 million people by 2025. Unmanaged diabetes is associated with complications including blindness and amputation which can lead to the need for intensive health and social care support. Estimates by Diabetes UK suggest that around 850,000 people are unaware that they have the condition.
The Department of Health indicates that each year the NHS Health Check can:
- prevent up to 1,600 heart attacks and save at least 650 lives
- prevent over 4,000 people from developing type 2 diabetes
- detect 20,000 cases of diabetes or kidney disease earlier allowing people to manage their condition and prevent complications.
DH conducted economic modelling using the NICE quality adjusted life year (QALY) approach and was assessed as very cost effective. The DH estimates that the programme will pay for itself after 20 years based on savings to the NHS alone. It is likely that the financial benefits for social care and the wider economy are also considerable and PHE intends to undertake cost-modelling to estimate these benefits.
Variation in performance
There has been a large variation in performance, with some PCTs performing very well and others giving less priority to the programme. For instance, offers in 2011-12 ranged from one percent to 25 percent of the local population against a target of 20 percent.
A shared local programme
An effective NHS Health Check programme requires close joint working between councils and CCGs, and will be of key interest to health and wellbeing boards (HWBs).
NHS Health Check has an important role in local plans to reduce premature mortality and health inequalities; there is considerable information pointing to the link between preventable disease and its risk factors, and deprivation, ethnicity and gender. NICE guidance advises local areas to target support at people at highest risk of developing vascular disease.
The inclusion of alcohol and dementia means that the programme will have even greater potential to improve health. Over ten million people in England are drinking at levels which increase their risk of ill-health while problem drinking in older people, and associated problems such as falls, is increasingly recognised. In relation to dementia there is some evidence that rates are lower in people who are mentally and physically active.
Councils are responsible for commissioning the risk assessment element and for monitoring the number of invitations and take-up. These are mandatory responsibilities and indicators within the Public Health Outcomes Framework 2013-16. Councils are also required to make continuous improvement in the percentage of people taking-up the offer; the LGA and PHE recommend that 20 percent of the eligible population is invited every year, and that councils should aim for a 75 percent take-up rate – comparable to NHS screening programmes.
Councils will also need to promote their local programme to encourage take-up and ensure that people identified as at risk have access to lifestyle interventions commissioned as part of their wider public health responsibilities. These are not mandatory elements and councils are free to make arrangements on a local basis.
CCGs are responsible for ensuring that there is appropriate clinical follow-up such as additional testing, diagnosis, referral to secondary care and ongoing treatment. It is essential that primary care risk-reduction is joined-up with the NHS Health Check programme.
PCTs mainly commissioned NHS Health Check from GP practices under Local Enhanced Service (LES) agreements; some also commissioned local pharmacies and a few commissioned services in the voluntary and community sector. Councils do not have access to LES agreements and will need to work within their HWB to determine the most effective way of commissioning the programme to meet local needs. This could be through primary care, pharmacies, community trusts, the private sector, the voluntary and community sector or a combination of providers.
It is likely to be too early for major changes to local NHS Health Check following the transfer to councils, but many areas are already delivering effective programmes.
Web-based reporting and quality assurance in Buckinghamshire
Buckinghamshire County Council is keen to make sure that NHS Health Checks are delivered in the most effective and cost-effective way. To do this, a web-based reporting system was commissioned to collect data from GP practices to see if the programme is meeting the stated aims of reducing heart disease, stroke, diabetes and kidney disease. Early findings show risk factors such as smoking, physical inactivity and excess weight are being addressed to reduce the risk of developing these conditions, and one NHS Health Check attendee lost four stone after being referred to Weight Watchers. In addition, a comprehensive quality assurance (QA) framework, based on national standards, was developed as one of three national pilot sites, and a programme of GP practice QA visits commenced to ensure a safe, consistent, effective, and cost-effective service. Since the move of Public Health into the County Council in April, the team has been able to utilise community networks to promote and deliver the NHS Health Check to ensure those population groups most at risk receive this check and appropriate advice about healthy lifestyles.
Contact: Graham Skeggs, Media Team, E: c-Gskeggs@buckscc.gov.uk
Community access in Southwark
Southwark Council’s NHS Health Check webpage includes monthly dates and venues for NHS Health Checks in pharmacies, community settings such as shopping centres and libraries, and the mobile unit. The programme is advertised to vulnerable groups through the local press and community groups such as Community Action Southwark. People assessed as at risk following the Health Check have free access to healthy lifestyle support through the Health Improvement Hub. Online booking for lifestyle support is available through the council website, outreach team and participating pharmacies and via a free phone number.
Contact: Teresa Edmans, E: email@example.com
Research in Stoke on Trent
Stoke-on-Trent Public Health Department implemented a local approach to health checks in advance of the national programme and set up academic research to investigate delivery methods and cost effectiveness. Initially the local programme considered three types of delivery: GP, pharmacy and community outreach via a voluntary organisation. GPs were found to be the most cost effective delivery mechanism, while community outreach was best for awareness raising.
Further research investigated the impact of lifestyle support for people identified at high risk; results suggested that the main area of benefit was in reducing obesity, and the lifestyle programme was valued by those who participated. In addition, evidence gathered from a randomised control trial to assess the benefits of intensive lifestyle support versus usual GP care revealed a significant 12-month reduction in estimated population cardiovascular disease risk in all NHS Health Check participants, with limited evidence for additional lifestyle support.
All local general practice teams are signed up to deliver NHS Health Checks. The next phase of development in the programme is focusing on NHS Health Check non responders and developing an assertive outreach programme to support an increase of uptake from 50% towards Public Health England’s aspirational target of 75%. The project is in its initial stages of planning; building on previous learning it is envisaged the outreach will take place from general practice teams to ensure non responders are targeted effectively and follow on care is initiated when required.
Overall, in Stoke-on-Trent NHS Health Check Programme is viewed as an opportunity to systemically and at scale address health inequalities the city is facing. The programme is evolving and improving through constant evaluation and learning through practice.
Contact: Jagdish Kumar, E: firstname.lastname@example.org
NHS Health Check – debate about evidence
There has been some debate about whether NHS Health Check is the most effective way of tackling preventable deaths, and this could have resulted in inconsistent support for the programme in some areas.
A review of several health check programmes by the Cochrane Centre not including NHS Health Check concluded that health checks were unlikely to have health benefits. In response, the national NHS Health Check support team produced an analysis of the Cochrane review indicating that its conclusions ‘have little if any relevance to NHS Health Checks’ because the programmes studied were not directly comparable. Public Health England points to the strong evidence base for the programme and indicates that it is ‘fully supportive of its roll-out’. Local evaluations are now starting to demonstrate the positive impact of NHS Health Check.
Councils wishing to understand more about this issue can discuss this with their Director of Public Health who will have access to advice and information from their local NHS Health Check team and from the PHE Health Check team.
Development and support
NHS Health Check is an ambitious and complex programme and PHE and its national partners LGA, NHS England, DH and others have published an action plan based on a review of implementation so far, which identifies a number of areas to tackle when commissioning the programme. National and local priorities are as follows.
- Leadership – developing a collaborative governance structure including stakeholder and expert/scientific advisory panels.
- Improving uptake – working with local Health Check teams to test recruitment and marketing interventions.
- Providing the Health Check – a thorough review of previous approaches to commissioning and delivery to learn from good practice; collaboration with the Centre for Public Scrutiny on several test-bed sites.
- Information governance – exploring long term solutions to enable flow of data, including to and from GP practices.
- Supporting delivery – continued support to established national, regional and local implementation support networks; advancing NHS Health Checks through the sector-led improvement agenda.
- Programme governance-establishing clear governance arrangements including advisory panels (above).
- Provider competency– working with Health Education England to build on existing competency frameworks for training options and working with local areas to develop a professional development programme.
- Consistency – providing regular best practice guidance including on quality standards; exploring opportunities for quality assurance programmes.
- Proving the case – future research and evaluation of the programme at national and local level e.g. further economic modelling to take into account the new components of alcohol and dementia awareness, and identifying potential savings to social care and the wider economy.
- Expected roll-out – supporting councils to achieve 100 percent offers to the eligible population over five years.
PHE will continue to support local teams. The dedicated NHS Health Check website includes extensive information and advice about running a programme including:
- an interactive ready reckoner to identify potential health benefits at council level
- a map showing offers-made and take-up, now at local authority level
- regular e-Bulletins with up-to-date-information about the programme.
Questions for councils and HWBs to consider
- Is NHS Health Check included in Joint Health and Wellbeing Strategies (JHWSs) in relation to prevention, early intervention, health improvement and reducing health inequalities?
- Has the HWB considered an integrated approach to healthy lifestyle interventions, including NHS Health Check?
- How has the NHS Health Check been integrated with strategies for dementia and alcohol?
- Does the council have plans in place to ensure that offer and take-up will meet recommendations from the LGA and PHE?
- How has the HWB ensured that the programme is operating seamlessly across the council and primary care?
- If in an area of previously low levels of offers/take-up, have the reasons for this been analysed and addressed?
- Does the council have plans in place to ensure that NHS Health Check addresses health inequalities such as NHS Health Checks targeted at groups or communities at risk of poor health?
- Will the scrutiny committee consider NHS Health Check as part of any review of premature mortality or health inequalities?
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