Re: Where’s the evidence for NHS health checks?
The current debate around the NHS Health Check (NHS HC) raises some important issues about the worth of conducting a population based cardiovascular disease risk assessment programme. Our view in Stoke-on-Trent is that the NHS HC programme is an opportunity to address the health inequalities facing our local population. Evidence from evaluations; the detection of new cardiovascular diseases in our population and our ongoing learning through delivery show that this programme has potential to improve quality of life of patients as well as life expectancy.
Arguably, the NHS HC programme is another example where large scale programme implementation has preceded a supporting evidence base, as we have seen with other national initiatives (1,2). The result is a need to develop evidence specific to this model and to use this to inform practice. While we acknowledge the evidence from Krogsbøll et al (3), we do not agree that this on its own should be used to abandon this programme. Nonetheless, this evidence and the ensuing debate, highlights important issues which the current programme should seek to address and future research should endeavour to resolve.
The central aim of the NHS HC programme is early detection of CVD risk or new CVD condition/s; followed by effective management of that risk/condition to avert further complications such as strokes, heart disease or other circulatory diseases. However, gathering such evidence is not easy and it takes a considerable amount of time to see if benefits are realised. There is evidence that identifying CVD risk earlier, addressing lifestyle risk factors through medical and social interventions can have a positive effect on patient outcomes (4). Preliminary data from a local audit estimate that, from a sample of 39 general practice teams, our NHS HC programme has supported the diagnosis of 437 diabetics, 57 chronic kidney disease, and 57 atrial fibrillation patients. This does not take into account the number of hypertensive, impaired glucose tolerance and patients identified to be at high risk of CVD. Without the NHS HC as a vehicle to engage with these patients it remains unclear if they would have been diagnosed in a timely manner, especially when risk factors such as raised BP and cholesterol can often be asymptomatic.
In addition, evidence gathered from a randomised trial to assess the benefits of intensive lifestyle support versus usual GP care; revealed a significant 12-month reduction in estimated population CVD risk in all NHS HC participants, without evidence of further benefit of the additional lifestyle support services (5,6,7). Although a 'no health check' group was not included (given the original aim to explore the additional benefit of subsequent lifestyle support). This also supports the case for further controlled research to determine population health benefits (8), whilst acknowledging the role and value of other forms of evidence to challenge the current programme to deliver more.
Therefore, we firmly disagree with the proposition to abandon the NHS HC programme. What would be the alternative if we were to do so? Dr Gerada suggests focusing on 'hard to reach' groups and policies like plain packaging (9). Targeting the most at risk patients could be another option, but what would be the challenges in doing this? Our experience is the ability to target such patients effectively is dependent ultimately on the quality, completeness and timeliness of the data held on patient's records. Our local evaluation highlighted that 16% of patients who we estimated had a CVD risk of < 20% actually had a CVD risk > 20% (10). This for us highlights the importance of taking a population wide approach.
Another criticism of the current programme is that it targets the 'worried well' whilst not engaging with the very people who could benefit from the health check the most. If a targeted approach was taken this problem would still be present. If this issue isn’t tackled there is potential to replicate a situation in smoking cessation, where the most affluent groups have disproportionately benefited from smoking cessation, thus widening health inequalities (11). In Stoke-on-Trent we are conscious of this and we are piloting ways of effectively targeting non responders by working with our local GP practices.
A further criticism of the programme is that in other trials there has been no improvement in CVD reduction. However, our view is that the NHS HC is about early identification of those at risk or with new conditions. Ongoing effective management falls within the wider medical and social management of CVD risk. The greater numbers of patients requiring effective management of their CVD risk has led us to explore new methods of engagement, for example tele-health, or engaging the voluntary sector in supporting lifestyle change. Keeping GPs involved in this agenda is important because they are regarded as the main point of care for most patients. Clearly, there is potential to complement the targeted nature of the NHS HC programmes with other initiatives working at a community and population level in order to influence and sustain positive changes in lifestyle. However, this will continue to take place against a backdrop of negative economic circumstances and social and market forces which help to perpetuate health inequalities. The NHS HC programme could be an important asset in working at multiple levels to contribute to addressing lifestyle risk factors.
Overall, the current debate around the NHS HC programme is healthy in directing the future developments of what this programme could achieve. That said, identifying patients at high risk of CVD or with new CVD conditions and then providing effective medical and social interventions to reduce CVD risk over a sustained period of time is a significant societal challenge. The NHS HC programme provides us with a mechanism to take up this challenge and to monitor our progress into the future. Our view is simple, give it more time and conduct more robust evaluation and research.
Dr Zafar Iqbal, Jagdish Kumar, Dr Ruth Chambers, Prof Tom Cochrane, Dr Christopher Gidlow, Alistair Fisher
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2. National Institute for Health and Clinical Excellence (NICE). Four commonly used methods to increase physical activity: brief interventions in primary care, exercise referral schemes, pedometers and community-based exercise programmes for walking and cycling. London: NICE; 2006.
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4. National Institute for Health and Clinical Excellence (NICE). Prevention of cardiovascular disease at a population level. London: NICE; 2010.
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7. Gidlow C, Cochrane T, Davey R, Beloe M, Chambers R, Kumar J, Mawby Y, Iqbal Z. One-year cardiovascular risk and quality of life changes in participants of a health trainer service. Perspectives in Public Health 2013; < http://rsh.sagepub.com/content/early/2013/05/07/1757913913484419>
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9. Roberts M. Doubtrs over 40-plus health checks. BBC News Health. August 28 2013. < http://www.bbc.co.uk/news/health-23765083>
10. Kumar, J., Chambers, R., Leese, C., and Mawby, Y. (2011) Healthy Communities Collaborative for CVD Prevention in Stoke-on-Trent: Promoting the early identification, assessment and management of people at increased risk of cardiovascular disease. Stoke-on-Trent: NHS Stoke on Trent. (unpublished).
11. Jarvis, J,W. & Wardel, J. Social patterning of individual health behaviours: the case of cigarette smoking. In: Marmot, M. & Wilkinson, G,R. (eds) Social Determinants of Health, 2nd Edition, Oxford, Oxford University Press, 2006, p.224-237
Competing interests: No competing interests