NHS Health Check special e-bulletin by Duncan Selbie, CEO of Public Health England
I am sure you have been following the public arguments surrounding the NHS Health Check programme. Whilst we are firm in our view about the evidence, we only benefit from constructive argument as this almost always improves the thinking and particularly about how they land in the real world. We have replied to concerns published by the Journal of Public Health and repeated by the Guardian and the BMJ and I thought you may want to see this. As you know the NHS Health Check programme aims to support frontline staff with a systematic approach to assessing and managing those risks that increase the toll of disease and disability. Given that two-thirds of deaths among people under 75 are thought to be preventable, this is a sensible investment.
As our frontline champions for this programme I know that you are often engaged in conversations about the value of the programme. Your leadership is vital in supporting the implementation of the NHS Health Check programme. So I thought it would also be helpful to not only share some of the criticisms that have been levelled at the programme, which we don’t agree with, but why.
1. NHS Health Check wastes £450m a year because the checks don’t spot people who are at risk of stroke/heart attack
On both prevention of disease and early diagnosis, we can do a lot better. Millions of people are living with undiagnosed and untreated hypertension, diabetes, kidney disease and high cardiovascular risk. Missing these diagnoses has terrible human consequences and cost implications. Meanwhile, around two thirds of deaths among people under the age of 75 are thought to be avoidable.
The system we have for assessing and managing risk of preventable disease is not perfect and can be improved.
2. The checks are not based on sound evidence
The interventions in NHS Health Check (behavioural and pharmacological) are consistent with NICE guidelines: the gold standard.
NHS Health Check is not there to treat people who don’t need it but to ensure that people who would benefit from an intervention are not missed and that everyone receives the information and support that’s relevant to them.
Given levels of overweight and obesity in the population (67% of men and 57% of women), and low levels of physical activity, most people could do with some level of advice.
3. Money would be better spent on encouraging people to eat more healthily
This is a false dichotomy. Both individual-based and population-wide interventions are necessary and Public Health England (PHE) leads the way in promoting, implementing and evaluating population-wide measures as well as supporting NHS Health Check.
4. Cost of NHS Health Check is not good value for money: costs NHS £450,000 per death avoided compared with £3,000 per QALY that NICE claims
Early modelling has suggested that a prevention programme such as NHS Health Check could, in fact, be cost-effective compared with other NHS activities. An impact assessment done by Department of Health (DH) in 2008 estimated that vascular checks could produce an annual average benefit of £3.6bn.
In comparing a ‘cost per death avoided’ to a QALY, the authors are comparing apples with oranges. NHS Health Check is projected to save lives but also to reduce ill-health and improve quality of life. These have to be factored into the calculation of cost-effectiveness.
We’ve said that there’s a need for further research on cost-effectiveness to demonstrate the economic value of the programme.
Economic modelling estimated the annual average cost of the programme at £332m and a total cost, which is the cost of the check and net lifetime costs of interventions given to people checked in the first 20 years of £450 million. The follow-up interventions included are all recommended by NICE and shown to be both clinically and cost effective.
Local authority expenditure was around £59m for 2013/14: that’s the cost of delivering the NHS Health Check and does not include the cost of lifestyle and clinical follow-up (the interventions that a GP or health professional may prescribe based on the results of the check-up).
5. NHS Health Check only complies with one of WHO screening principles
NHS Health Check is a public health programme. It provides risk awareness, risk assessment and risk management. In this sense, it’s a novel approach to today’s health challenge of multi-morbidity. Because it is a new approach does not mean it’s not scientifically and clinically rigorous. It is.
6. Barely half of those invited for a NHS Health Check turn up – with younger men, poorer people and some ethnic groups reluctant to attend
Cumulative uptake of NHS Health Check for the last nine quarters (April 2013 to June 2015) is 48.4%. This means that 3.2 million people received a NHS Health Check over this period.
PHE is working with local authorities who now have responsibility to commission the programme to improve uptake.
It’s not the case that NHS Health Check will inevitably be skewed towards the ‘worried well’ or be taken up by the more affluent. The data are not that clear cut. A national evaluation[1] of NHS Health Check coverage found that coverage was similar in patients living in deprived and affluent areas. It did also find, though, that coverage was lower in some ethnic minority groups, so it’s a complex picture. (Coverage is: proportion of eligible population who attend health check in first four years)
Local authorities have a lot of freedom in how they implement NHS Health Check and can tailor it to the needs of local communities (by targeting socioeconomically disadvantaged groups, for example)
7. Risk scores (QRISK in England) fail to detect risk of heart attack/stroke in 1/3 to ½ of all patients
QRISK is the tool referenced in NICE’s CVD risk assessment and management. Furthermore, NHS Health Check is more than just a number or a risk score: it’s an opportunity to discuss prevention and lifestyle with millions of people, which is clearly needed given the burden of preventable disease in England.
8. The £450m should be spent on tackling poor diet, smoking, drinking and physical inactivity that causes 80% of strokes and heart attacks
This is a false dichotomy. Both individual-based and population-wide interventions are necessary and PHE leads the way in promoting, implementing and evaluating population-wide measures as well.
9. DH, PHE and NHS England privately agree that NHS Health Check is costly and ineffective but they’re obliged to ‘toe the party line’
PHE is proud of this valuable opportunity to tackle the burden of chronic diseases through a universal programme for adult health and wellbeing.
We’ve been honest about the challenges of implementing a large-scale prevention programme – in some areas we know uptake needs to improve, as does referral into effective interventions such as weight management. We’ve shown how we can do this. It won’t happen overnight but the building blocks are there in our focus on scientific governance, support to implementers, evaluation and capacity building.
10. NHS Health Check should be a targeted scheme based on good evidence, directed at certain groups of people who stand to gain most from regular check ups
Local authorities have the flexibility to target individuals or communities at increased risk. They can focus their efforts among socio-economically disadvantaged communities and are using proactive efforts to reach certain groups (health buses and health trainers).
For local authorities, NHS Health Check can be a valuable opportunity to meet specific health needs of local communities, for example by promoting services/interventions (such as HIV testing, stop smoking services, screening) alongside NHS Health Check.
11. Question whether large-scale health checks are the best use of GPs’ time that could be used more effectively elsewhere
NHS Health Check is not duplicative: it’s not there to replace the case-finding that GPs do anyway or to replicate the tests they order. It’s there to support GPs with a systematic approach to deliver interventions that are based on evidence.
12. Health checks have repeatedly been shown to be ineffective
There have been reviews of health checks, which have found they don’t reduce overall morbidity or mortality or produce positive outcomes at a population level.
We’ve argued that these reviews don’t replicate the NHS Health Check in England.
We don’t think the right response is to abandon the programme on the basis of these reviews, but to consider the risks that matter and optimise the programme so that we minimise the risks and evaluate its potential to prevent disease.
13. Health workers, services and local authorities are all forced to promote the health checks
Local authorities have a statutory duty to commission the NHS Health Check programme, and there are a number of providers who do so.
GPs can choose to be among them, and are paid extra to do so.
14. This ‘saps morale considering the substantial opportunity costs of failing to invest in those scarce resources in alternative, more effective interventions’
The programme is there to support GPs and the wider primary care workforce, as a systematic approach to case-finding and delivery of evidence based interventions recognised by NICE
15. UK needs an independent Institute of Public Health
PHE is a scientific organisation, and we base our advice on the highest standards of evidence and research. We speak to where the evidence lies.
[1] Chang et al. Coverage of national cardiovascular risk assessment and management programme: retrospective database study. Preventive Medicine 78 (2015) 1-8. http://www.ncbi.nlm.nih.gov/pubmed/?term=Coverage+of+a+national+cardiovascular+risk+assessment+and+management+programme+(NHS+Health+Check)%3A+Retrospective+database+study