Delivery and impact of the NHS Health Check in the first 8 years: a systematic review

Adam Martin; Catherine L Saunders; Emma Harte; Simon J Griffin; Calum MacLure; Jonathan Mant; Catherine Meads; Fiona M Walter; Juliet A Usher-Smith

doi:10.3399/bjgp18X697649

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Delivery and impact of the NHS Health Check in the first 8 years: a systematic review
Christopher E. Clark, Ben Norris, A Jayne Fordham, Maria R. Greenwood, Suzanne H. Richards and John L. Campbell

Published on: 24 July 2018
Delivery and impact of the NHS Health Check
Nicholas Summerton

Published on: 05 July 2018

Published on: (24 July 2018)

Delivery and impact of the NHS Health Check in the first 8 years: a systematic review
Christopher E. Clark, Senior Clinical Lecturer in Primary Care, University of Exeter Medical School
Other Contributors:
Ben Norris, Foundation Doctor, Royal Devon and Exeter NHS Foundation Trust

A Jayne Fordham, Practice nurse, Mid Devon Medical Practice

Maria R. Greenwood, Practice nurse, Mid Devon Medical Practice

Suzanne H. Richards, Professor of Primary Care Research, Leeds Institute of Health Research

John L. Campbell, Professor of General Practice and Primary Care, University of Exeter Medical School
With reference to the systematic review by Martin et al,¹ we report our own experience over two years of NHS Health Checks in one practice. We invited 636 patients (35% of eligible list) and 340 attended (53% uptake (95% CI 50 to 57)).² We too found attenders to be older (mean 3 years) than non-attenders, more likely to be female, and have higher HDL cholesterol levels and lower total cholesterol: HDL ratios. Non-attenders had twice the smoking rate of attenders (18% vs. 9%).

We followed up 94/340 (28%) of attendees for findings outside of target, most commonly blood pressure (BP) >140/90 (79; 23%). Ultimately, new diagnoses of hypertension were made for 14 (4%) attenders, diabetes mellitus for 7 (2%) and chronic kidney disease (CKD) stage 3 for 5 (1%). This low yield has previously been reported,³ and questions the cost effectiveness of this intervention.⁴

Regarding the 79 people followed-up for a BP >140/90, 76 (96%) already had a BP entry in their records (pre-dating the Health Check) above 140/90 but without a diagnosis of hypertension. We estimated costs per Health Check using published data,⁵ and derived costs per new diagnosis of hypertension. Within the Health Check Programme these were £1083.73 (95% CI £686.57 to £2132.63). An alternative targeted approach to BP checks, inviting attendance based on existing records of eleva...
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With reference to the systematic review by Martin et al,¹ we report our own experience over two years of NHS Health Checks in one practice. We invited 636 patients (35% of eligible list) and 340 attended (53% uptake (95% CI 50 to 57)).² We too found attenders to be older (mean 3 years) than non-attenders, more likely to be female, and have higher HDL cholesterol levels and lower total cholesterol: HDL ratios. Non-attenders had twice the smoking rate of attenders (18% vs. 9%).

We followed up 94/340 (28%) of attendees for findings outside of target, most commonly blood pressure (BP) >140/90 (79; 23%). Ultimately, new diagnoses of hypertension were made for 14 (4%) attenders, diabetes mellitus for 7 (2%) and chronic kidney disease (CKD) stage 3 for 5 (1%). This low yield has previously been reported,³ and questions the cost effectiveness of this intervention.⁴

Regarding the 79 people followed-up for a BP >140/90, 76 (96%) already had a BP entry in their records (pre-dating the Health Check) above 140/90 but without a diagnosis of hypertension. We estimated costs per Health Check using published data,⁵ and derived costs per new diagnosis of hypertension. Within the Health Check Programme these were £1083.73 (95% CI £686.57 to £2132.63). An alternative targeted approach to BP checks, inviting attendance based on existing records of elevated blood pressure, would have invited 113 (33%) of those attending for Health Checks and still identified 12/14 (86%) of the new cases of hypertension at a cost of between £188.70 and £274.51. This approach would also have detected 4/5 (80%) of our new CKD cases

Given the limited evidence for impact, and substantial costs of the NHS Health Checks we propose that an alternative approach targeting those with pre-exiting risk markers, and therefore the most to gain from assessment and intervention, should be evaluated against the current universal model for effectiveness and cost effectiveness.

References

1. Martin A, Saunders CL, Harte E, et al. Delivery and impact of the NHS Health Check in the first 8 years: a systematic review. Br J Gen Pract 2018;68(672):e449-e459.
2. Clark CE, Fordham J, Greenwood M, Richards S, Campbell JL. Costs of hypertension detection within the NHS health check programme compared to opportunistic detection. J Hypertens 2014;32(e-Supplement-1):e44.
3. Robson J, Dostal I, Sheikh A, et al. The NHS Health Check in England: an evaluation of the first 4 years. BMJ Open 2016;6(1).
4. MacAuley D. The value of conducting periodic health checks. BMJ 2012;345.
5. Curtis L. Unit costs of health and social care. Canterbury: PSSRU; 2013.
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Competing Interests: None declared.
Published on: (5 July 2018)

Delivery and impact of the NHS Health Check
Nicholas Summerton, GP, East Yorkshire, Unaffiliated - locum
Martin and colleagues must be congratulated for their hard work in seeking to assess the delivery and impact of the NHS Health Check programme.¹ However, although they have identified some positive outcomes from the programme these are, at best, marginal.

But I would not to wish to see the initiative dropped as, unlike the various national NHS Screening Programmes, it promotes a much more patient-centred and risk-oriented approach. Coverage is also higher among older people and those living in the most deprived areas. What is needed now is a careful re-assessment of the programme in order to seek to deliver better value.

Based on my own review² I would argue that the current exclusions are too broad and the scope is too narrow. For example, individuals on treatments for high blood pressure or elevated cholesterol should also be checked. Moreover, bowel cancer screening (using FIT) or diabetes risk assessment (using HbA1c) are additional areas to consider alongside the current cardiovascular focus.

References

1. Martin A, Saunders CL, Harte E, et al. Delivery and impact of the NHS Health Check in the first 8 years: a systematic review. Br J Gen Pract 2018; DOI: https://doi.org/10.3399/bjgp18X697649.

2. Summerton N. Better value health checks: a practical guide. London: CRC Press, 2018.

Competing Interests: None declared.