NHS Health Check programme wastes £450m a year, report saysBMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h5039 (Published 22 September 2015) Cite this as: BMJ 2015;351:h5039
All rapid responses
We thank Duncan Selbie, chief executive at PHE, for his BMJ Rapid Response posted on September 25. He queries our recent critique of NHS Health Checks (1), notably the science, the cost and the strategy of prevention.
In terms of the science, our review cites extensive evidence which questions the effectiveness of the NHS Health Checks Programme (1). It is therefore slightly frustrating that PHE is apparently not prepared to consider the publications by WHO, several randomised controlled trials summarised in a Cochrane report (4), a more recent RCT (5) and many other peer-reviewed publications. This risks sending unfortunate signals about the selective application of evidence to support current and future public health decisions.
In terms of costs, our paper suggested that the fully developed NHS health check programme could cost approximately £450million per annum (1). Firstly, this figure was extracted from the official Department of Health and PHE reports (2a and 2b). Secondly, the PHE Knowledge Officer informally confirmed this same figure to WH two years ago (on 25/ 9/2013), and to SC (on 16/6/2015). Thirdly, the figure was not queried by Selbie’s PHE colleagues in the recent debate in the Journal of Public Health (3a and 3b). Fourthly, no individual from PHE has queried the figures since the original publication in June 2015.
The figure of £59million per annum now quoted by Selbie is novel and dramatically different. It might therefore be advantageous for PHE to publish the real cost figures to permit independent scrutiny. The total sum might usefully be split into the costs of the initial NHS Health Checks, the consequent expenditure on confirmatory tests of those individuals considered to have positive findings, and the costs of all interventions resulting from the Health Check.
Furthermore, even if the fully developed scheme does really only cost around £60m per annum, that still appears rather expensive given the very low returns calculated by DH and PHE modelling. It also contrasts dramatically with the cost-saving approaches detailed below.
In terms of prevention strategies, we strongly agree that around two-thirds of deaths among people under the age of 75 are avoidable. We would therefore hope that PHE might prioritise and energetically champion the most effective preventive policies. These include regulations to reduce salt and eliminate industrial transfats in processed foods, a duty on sugary drinks, and an additional levy on tobacco. These population-wide, upstream measures are very likely to be effective in substantially reducing preventable diseases such as stroke, heart disease, chronic obstructive pulmonary disease, diabetes and many common cancers.
Furthermore, compared to NHS Health Checks, these policy measures would be more powerful, rapid, equitable and cost saving (6). Indeed, it has been repeatedly shown over many years that upstream population-wide policy interventions are far more effective in reducing the burden of preventable diseases than attempting to influence individual behaviour. Such an upstream approach has long been recommended by Derek Wanless, by NICE (6) and now by Simon Stevens, CEO at NHS England (7)
Duncan Selbie and PHE colleagues have the power to prioritise and implement this powerfully effective, population-wide approach. But do they have the political independence?
1. Capewell S, McCartney M, Holland W. NHS Health Checks – a naked emperor?
J. Public health, 2015, 37, 187 – 192.
2(a). Department of Health. Putting Prevention First. Vascular checks risk assessment and management. Impact assessment. London:DH, 2008
2(b). Public Health England. Annual report and accounts 2013/2014
3(a). Waterall J, Greaves F, Kearney M, Fenton KA. Invited debate- NHS Health Check: an innovative component of local adult health improvement and well-being programmes in England. J.Public Health 2015, 37, 177 – 184
3(b). Waterall J, Greaves F, Kearney M, Fenton KA. Response to Capewell et al
J.Public Health, 2015, 37, 193 – 194
4. Krogsboll LT, Jorgensen KJ, Gronhoj Larsen C et al. General health checks in adults for reducing morbidity and mortality from disease. Cochrane database Syst.Rev., 2012, 10:CD009009
5. Jorgenson T, Jacobsen RK, Toft U et al. Effect of screening and lifestyle counselling on incidence of ischaemic heart disease in general population: Inter 99 a randomised trial. BMJ, 2014, 348: g 3617
6. NICE Public Health guidance; Prevention of cardiovascular disease at population level. 2010:http://guidance. Nice.org.uk/PH25
7. Five Year Forward View. https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf
Competing interests: No competing interests
Public Health England (PHE) disagrees with the claims in a report on NHS Health Check, cited in the BMJ.
The BMJ quotes academics’ estimates that the programme costs £450m a year.  We would point out that local authorities actually spent around £59m in 2013/14 on the risk assessment part of NHS Health Check.  This figure does not include interventions such as drug treatment or referral to smoking cessation services, which are supported by guidelines from the National Institute for Health and Care Excellence (NICE) and which may follow an NHS Health Check.
The article also suggests that instead of delivering NHS Health Check – a statutory duty of local government – we would be better off investing in other interventions, such as promoting healthy food. This is a false dichotomy. An NHS Health Check is a way of raising awareness about risks to health and managing these for individuals. But we also support effective and popular campaigns and programmes that promote health and wellbeing across the population, from smoking cessation to healthy weight in children, as well as work that focuses on the wider determinants of health. Both individual-based and population-wide interventions are necessary.
The BMJ repeats a claim that NHS Health Check “relies on weak concepts, denies strong scientific counter-evidence and ignores persistent implementation issues”. We strongly disagree with this.
The NHS Health Check programme focuses on the leading and modifiable risk factors that we know drive preventable mortality and morbidity.  The NHS Health Check assesses these risks and manages them through lifestyle and medical interventions, which are based on NICE guidance.
PHE keeps under review data relating to NHS Health Check. If the data suggested the programme was harmful, or demonstrably cost-ineffective, we would advise the Department of Health accordingly.
Furthermore, we have set out specific measures to improve the scientific governance of NHS Health Check as well as its implementation.  We, together with colleagues in local authorities, are focused on the quality and consistency of delivery and of NHS follow-up. We are committed to rigorous monitoring and evaluation. Local research and evaluations are already adding to the evidence base on the programme’s acceptability, outcomes and impact. These data can, in turn, help to improve programme management and identify opportunities for enhancement.
NHS Health Check is a once-in-a generation opportunity to create a universal programme for adult health. We should seize it because the status quo is unacceptable. Millions of people are living with undiagnosed and untreated hypertension, diabetes and kidney disease. It’s estimated that around two-thirds of deaths among people under the age of 75 are avoidable. We can and must do better for the whole population.
 Capewell S, McCartney M, Holland W. Invited debate. NHS health checks – a naked emperor? J Public Health (Oxf)2015;37:187-92
 Local authority revenue expenditure and financing England: 2013 to 2014 individual local authority data – outturn. Department for Communities and Local Government. 28 August 2014. https://www.gov.uk/government/statistics/local-authority-revenue-expendi... (25 September 2015, date last accessed).
 Newton JN et al. Changes in health in England, with analysis by English regions and areas of deprivation, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015 Sep 14. pii: S0140-6736(15)00195-6. doi: 10.1016/S0140-6736(15)00195-6
 Waterall J, Greaves F, Kearney M, Fenton KA. Invited debate. NHS Health Check: an innovative component of local adult health improvement and well-being programmes in England. J Public Health (Oxf)2015;37:177-184
Competing interests: Public Health England provides national leadership for NHS Health Check and supports local authorities, which are responsible for commissioning the programme in their areas