Association of the NHS Health Check with all-cause mortality: a longitudinal cohort study in primary care

Jasjot Saund; Hiten Dodhia; Jacopo Vanoli; Pierre Masselot; Stephen O’Neill

doi:10.3399/BJGP.2025.0451

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Association of the NHS Health Check with all-cause mortality: a longitudinal cohort study in primary care
Christopher E. Clark

Published on: 07 September 2026

Published on: (7 September 2026)
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Association of the NHS Health Check with all-cause mortality: a longitudinal cohort study in primary care
Christopher E. Clark, Clinical Associate Professor of Primary Care Cardiovascular Medicine, University of Exeter Medical School
Saund et al report an impressive overall hazard ratio of 0.68 (0.63 to 0.74) for all-cause mortality in association with attendance at a NHS Health Check.¹Their study benefits from a long length of follow-up, examining hard rather than surrogate outcomes, and focuses on communities often excluded from healthcare research. These are strengths, although the selected population also makes it hard to generalise the findings to the general English population.

The authors acknowledge the risks of residual confounding. Certainly, inspection of Table 2 demonstrates the significant differences in almost all lifestyle and demographic factors between the exposed and unexposed groups, so residual confounding must indeed be a risk, and these data seem to support a Healthy Attendee bias in the populations studied. Unfortunately, absolute blood pressure seems to have been totally disregarded. No adjustment for baseline blood pressure is mentioned during the study. Our experience has shown that eligible NHS Health Check non-attenders have significantly higher baseline blood pressures than attenders, differing by 5/3 mmHg; differences persist after adjustment for age, gender, BMI, smoking and total cholesterol levels.^2,3

Whilst one third of the adult population has hypertension, so would be excluded from NHS Health Checks, most of the remaining two thirds will be eligible. Absolute blood pressure over a lifetime presents a continuum of mortal...
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Saund et al report an impressive overall hazard ratio of 0.68 (0.63 to 0.74) for all-cause mortality in association with attendance at a NHS Health Check.¹Their study benefits from a long length of follow-up, examining hard rather than surrogate outcomes, and focuses on communities often excluded from healthcare research. These are strengths, although the selected population also makes it hard to generalise the findings to the general English population.

The authors acknowledge the risks of residual confounding. Certainly, inspection of Table 2 demonstrates the significant differences in almost all lifestyle and demographic factors between the exposed and unexposed groups, so residual confounding must indeed be a risk, and these data seem to support a Healthy Attendee bias in the populations studied. Unfortunately, absolute blood pressure seems to have been totally disregarded. No adjustment for baseline blood pressure is mentioned during the study. Our experience has shown that eligible NHS Health Check non-attenders have significantly higher baseline blood pressures than attenders, differing by 5/3 mmHg; differences persist after adjustment for age, gender, BMI, smoking and total cholesterol levels.^2,3

Whilst one third of the adult population has hypertension, so would be excluded from NHS Health Checks, most of the remaining two thirds will be eligible. Absolute blood pressure over a lifetime presents a continuum of mortality risk which starts to rise from "normal" levels.⁴ Hypertension is the single most prevalent modifiable cardiovascular risk factor and is the leading cause of morbidity and mortality worldwide.⁵ Therefore, any residual blood pressure difference between attenders and non-attenders in Saund's cohort should investigated, acknowledged and adjusted for, before the results presented can be fully attributed to the NHS Health Check process.

References

1. Saund J, Dodhia H, Vanoli J, et al. Association of the NHS Health Check with all-cause mortality: a longitudinal cohort study in primary care. Br J Gen Pract 2026;76(770):e724-e33. doi: 10.3399/bjgp.2025.0451.
2. McDonagh STJ, Norris B, Fordham AJ, et al. Inter-arm blood pressure difference and cardiovascular risk estimation in primary care: a pilot study. BJGP Open 2022;6(3):BJGPO.2021.0242. doi: 10.3399/bjgpo.2021.0242.
3. Clark CE, Norris B, Fordham AJ, et al. Costs of hypertension detection within the NHS Health Check programme compared with an opportunistic approach. 2017 01/02/2017. DOI: 10.13140/RG.2.2.36259.48162.
4. Rapsomaniki E, Timmis A, George J, et al. Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1.25 million people. Lancet 2014;383(9932):1899-911.
5. Murray CJL, Aravkin AY, Zheng P, et al. Global burden of 87 risk factors in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet 2020;396(10258):1223–1249.
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Competing Interests: CEC Chairs the British & Irish Hypertension Society (BIHS) Blood Pressure Technology Committee, and was a guideline committee member for the most recent NICE hypertension, cardiovascular risk and lipid modification guidelines. Views expressed are the author's own, and not necessarily those of the BIHS, NICE, NIHR or the University of Exeter.

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