Foreword - Professor Kevin Fenton, director of Health and Wellbeing, PHE
I am pleased to use my first foreword of 2016 to report on the largest and most comprehensive national evaluation of the NHS Health Check programme to date. The study, published in the British Medical Journal Open this month, presents some very positive findings, while also recognising opportunities for improvement.
Researchers from three universities, led by Queen Mary University of London, conducted an observational study over four years (April 2009 to March 2013), analysing QResearch data from 655 general practices across England. The research team reviewed data relating to 214,295 people who attended an NHS Health Check and compared these findings against 1.4 million people who had not yet been offered or taken up their checks.
The study shows that coverage, while “lower than expected”, increased steadily as the programme progressed, from 5.8% of eligible adults in 2010 to 30.1% in 2012. We know that coverage has continued to improve since local authorities became responsible for commissioning, with 3.5 million people receiving checks since April 2013. Attendance by groups at greater CVD risk, such as the more socially disadvantaged, was higher than the more affluent (14.9% vs 12.3%), refuting criticism that the programme is skewed towards the worried well. The study also shows equitable provision in certain high-risk ethnic groups, which is most encouraging. However, people under 65 were less likely to attend a check than those over 65. This requires further investigation to establish whether it is the result of targeting those at high CVD risk or access difficulties for those of working age.
The findings provide evidence that NHS Health Check is fulfilling one of its key objectives, which is to promote and improve the early identification and management of behavioural and physiological risk factors for vascular disease and the other conditions associated with these risk factors. Comparisons between those receiving an NHS Health Check and those who have not yet received a check show improved risk factor recording, referral and diagnosis among the attendees. For example, those receiving an NHS Health Check were three times more likely to be diagnosed with hypertension than people who had not yet received checks. Alcohol identification and brief advice was significantly higher in the NHS Health Check group, with 33.9% vs 5.1% receiving a referral if found to need further support.
Another “important feature” of the findings was the detection of 7,844 new cases of hypertension (1 per 27 checks), 1,934 new cases of type 2 diabetes (1 per 110) and 807 new cases of chronic kidney disease (1 per 265). Identifying comorbidities earlier and referring people for evidence-based interventions are crucial preventative measures that will lessen future demands on the NHS.
The rate of statin prescribing leaves room for improvement, since only 1 in 5 of those found to have a ten-year risk score of greater than 20% received treatment. However, the authors believe that at national scale, treatment for 1 in 5 attendees at highest CVD risk was likely to have contributed to “important reductions in CVD events”. They estimate that, over five years, 2,529 people will have avoided a major CVD event as a result of treatments initiated by their NHS Health Checks.
The study has limitations. It is based entirely on data from GP practices (where more than 90% of NHS Health Checks are carried out) and may not include data from pharmacies or other community settings. Due to the nature of the study, it was not possible to make direct comparisons between attendees and non-attendees. The authors say referral rates were generally low and little is known about the attendance or the quality of behavioural programmes for those at higher CVD risk. The impact of NHS Health Checks on people at lower CVD risk also requires further research, as do patient behaviours after an NHS Health Check and the communication of results.
Evidence about the success of the programme comes at a difficult time for local authorities as a result of public health budgets being cut. However, this study should reassure them that investing in NHS Health Check will produce major benefits for their populations. Unless we get serious about prevention and early intervention, the increasing burden of avoidable illness will compromise the sustainability of the health and social care system in England. This research shows that NHS Health Check is helping to provide a more systematic approach to tackling many of the risk factors contributing to premature death and disability. Combined with wider population strategies, including effective health policy to tackle NCDs and their determinants, and targeted interventions to engage those at greatest risk, we have a genuine opportunity to protect and improve people’s health and wellbeing.
Link to article: http://bmjopen.bmj.com/content/6/1/e008840.full
Date of publication: 14/01/2016
Link to infographic:
Operational update - Jamie Waterall, National lead - NHS Health Check and blood pressure programmes
The start of a new year brings an opportunity to pause, reflect and consider what we could do differently in the year ahead. As we approach the end of the third year of local authority statutory responsibility for commissioning the NHS Health Check, I’m keen to understand the impact of our support and to consider priority areas of focus for the year ahead. This is why we have commissioned Research Works to conduct an online survey and interviews with local colleagues involved in the programme. These findings will then be used to update our NHS Health Check action plan . I want to relay my deepest thanks to those of you who have shared your views and experiences through this work. We will disseminate the initial findings at our conference on 1 March 2016.
It is important that we celebrate success and share important learning from the implementation of the programme. I would therefore like to thank HEART UK for hosting the second annual NHS Health Check awards, which took place at the Issues and Answers conference in November last year. Thank you to all those teams who submitted an entry, and congratulations to all of the winners. Further information about the awards and winners can be found here.
In November last year we published the latest data on offers and uptake of the programme. It is tremendous to see that most areas are on track for inviting 100% of their eligible population and I am aware that many local authorities continue to focus on ways to increase uptake, particularly those at greatest risk. Can I remind commissioning leads to submit your quarter three activity data by midday on 29 January 2016, which will then be published on 25 February 2016.
I would like to congratulate the primary care CVD leadership forum, which is chaired by Dr Matt Kearney, for their tremendous efforts in campaigning for primary care leadership to improve patient outcomes. The forum has been working closely with the national cardiovascular intelligence network and others to produce these helpful resources aimed at our primary care colleagues: Atrial Fibrillation Resource Hypertension Resource (available from 18 January 2016)
Over the past few months, Katherine Thompson (national programme manager) has been leading a refresh of the NHS Health Check dementia leaflet. I would like to thank Katherine and all those involved in producing this excellent resource. Copies of the leaflet will be available for ordering via the order line.
Finally, if you have not yet registered for the annual NHS Health Check conference, I would urge you to book your place soon, as we have almost reached our maximum delegate registration numbers. Further information can be found on the conference website.
NHS Health Check StARS framework
PHE has worked with key partners to develop a systems approach to raising standards in the delivery of the NHS Health Check programme (StARS).
The StARS framework draws on advice and standards from existing national guidance. It brings together criteria into ten themes from leadership and planning to commissioning and the delivery of the risk assessment and management. It also adopts a systems approach, with the involvement of key internal and external partners at the heart of the process. This means that using the framework provides:
- an opportunity to review and reflect on the local delivery of the NHS Health Check programme, to identify gaps and recognise achievement
- a baseline against which you can compare future activity and demonstrate progress
- an opportunity to raise awareness of the programme with internal and external stakeholders
- a legitimate reason to begin a conversation about the NHS Health Check and establish new relationships
- elected members with assurance that legal obligations have been met
Some other benefits identified by local authorities that have used the StARS framework include a:
- checklist for developing a new service specification
- reason for engaging GPs in a constructive and meaningful discussion
- lever for raising the profile of the NHS Health Check among local authority executives and elected members
- legitimate reason for undertaking a service audit
To learn more about the StARS framework and to book on to the required one day training, contact your PHE centre lead or Katherine.email@example.com
Promoting NHS Health Checks in Kent
Kent Community Health NHS Foundation Trust is the commissioned provider for NHS Health Checks in Kent. GP practice staff carry out most NHS Health Checks and outreach clinics are delivered in the community to people who may not want to visit a GP.
In 2015, the trust decided to undertake some active promotion of the programme because just half of all people invited for a check have had one. This involved delivering a summer-long roadshow called ‘Live Well, Live Longer’ at 25 different local festivals and events to promote the checks and provide them opportunistically. Nearly 500 on-the-spot checks were completed; importantly, HALF of the people having a check needed an onward referral to a GP. Many said that they had the check because it was convenient and they didn’t need to make an appointment.
In November 2015 delivery of the checks was concentrated on reaching people in Thanet – the area of highest prevalence of CVD and CHD in the county and the lowest for take-up of NHS Health Checks – with the Big Thanet Health Check. A mobile clinic was provided at the local ASDA and meant that more than 160 checks were carried out in a week. To promote the Big Thanet Health Check the trust issued a press release focussed on the prevalence of disease. This, in conjunction with the week-long presence at ASDA, provided an excellent ‘hook’ to hang news stories on. This led to a series of stories in the run up to and during the event in the Isle of Thanet Gazette as well as substantial feature stories on ITV Meridian News (local TV news) and KMFM (local radio station), and shorter features on KMFM and the local BBC website.
A short film to promote the programme can be viewed here.
Jo Treharne -social marketing manager (Health and Wellbeing), Kent Community Health NHS Foundation Trust
Data update: Building a better understanding of the impact of NHS Health Check
PHE is committed to reviewing data that will enhance our understanding of the impact of the NHS Health Check (NHS HC) programme and its individual components. The NHS HC team has been working with the Health and Social Care Information Centre (HSCIC) to explore using the HSCIC’s general practice extraction service (GPES) to review progress of the implementation of NHS HC. The process to commence an extraction is complex, since it covers multiple data indicators, different IT suppliers and information governance issues.
Final approval for the data extract is yet to be confirmed, but its purpose would be to monitor comparable data from different localities. Data would aim to cover people who have been invited to attend an NHS HC, their assessment, any interventions following the NHS HC, and records of outcomes following the NHSHC. In addition to the GPES work, PHE will continue to pursue other strategies to review the programme.
As part of the revisions to its data guidance, the NHS HC team is also creating an appendix to the guidance that will show the relevant clinical codes for the requirements of the NHS HC. The codes will be shown for Read Version 2, CTV 3 and SNOMED CT. The codes will include essential risk assessments that are prescribed as part of the NHS HC; diagnosis and risk codes; and codes for risk management and interventions recommended to providers. Universal use of the codes will help ensure greater consistency of data input and recording of the NHS HC programme.
Quality assurance of data
Every quarter PHE publishes data returned by all local authorities on the number of NHS Health Checks offered and the number of checks received. This data is an official statistic and is used in the calculation of the NHS Health Check indicators on the Public Health Outcomes Framework and in the NHS Health Check profile.
As the data returned by local authorities is an official statistic PHE have a duty of care to follow a code of conduct regarding the production, management and publication of the data. In fulfilling part of that duty analysts quality assure the data by applying statistical rules, agreed by the NHS Health Check data intelligence and information governance group. This ensures that errors and inaccuracies are detected and followed up with the nominated person in a local authority.
Through this quality assurance process we have identified a particular challenge with the way invitations are reported in some areas. In addition to counting the first invitation, some areas are also counting reminder letters or prompts to individuals. Reminders, prompts and follow-up invites to people that have already been invited for a check should not be included in the quarterly data returns. An invitation is ‘per individual every five years,’ so second and third invitations to the same person within that time should not be included in quarterly returns.
This means that the rate of invitations seems extremely high. This is not only misleading, but also dilutes local authorities’ take up rate, since take up is calculated as ‘number of people having a check divided by the number of people offered a check’.
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