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Squaring the circle for NHS Health Checks

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How will NHS Health Checks help us in our priority of reducing health inequalities? It's a question I get asked a lot because of the nature of the programme. It's intended as a population-based prevention programme, which will raise awareness and assess individuals’ risk factors for the leading causes of death and disability.

But many people worry that prevention programmes can get taken up by the "worried well" and divert resources from the very people who are most at risk – for instance, people who are living in very deprived areas or members of vulnerable communities. How can we square the circle of a programme that is universal but also manages to ensure, in a systematic way, that its impact is felt where it’s most needed? The challenge is to put into practice Professor Sir Michael Marmot's call for "proportionate universalism": a universal approach that is applied 'with a scale and intensity that is proportionate to the level of disadvantage.' The stakes are high because if we get this wrong, there is a risk that we end up with worse, not better health equity and more unequal access to services.

The first step is to be aware of this risk as we set about supporting local authorities in developing, implementing and monitoring the NHS Health Check. The second step is to stress the flexibility that local authorities have to focus their efforts where they think they are most needed. The basic elements of the NHS Health Check will be the same for all adults between the ages of 40 and 74, and we are working with partners to agree NHS Health Check quality standards, which will soon give local teams the support they need. But the programme will work to maximum effect when it is responsive to local input and where it has systematically assessed the distinctive needs of local populations. This requires a strategic approach to innovation. We want to promote new ideas for improving the take-up of NHS Health Check in groups that are most at risk of not receiving them. But the ideas have to be rooted in evidence – evidence of who is at risk and how they would prefer to receive the service.

The third, and perhaps most important step, is ensuring that we monitor and evaluate our implementation efforts to determine the acceptability, effectiveness and cost-effectiveness of these approaches.

As I travel the country, visiting PHE Centres and engaging with local authorities, I'm struck by the innovation I'm seeing as local authorities assess the health priorities of their communities and set about meeting them. In addition to ensuring that those who need to be offered the programme receive it, local partners are using the opportunity to intensify their efforts among individuals and communities in greatest need, either because of high disease burden or because they traditionally have poor access to, or uptake of, preventive services.

So for instance, in Plymouth and Somerset there is work underway to understand how the NHS Health Check can reach people who may have relatively little contact with primary care, such as fishermen, dockyard workers and farmers, as well as members of vulnerable communities such as Travellers, refugees and people living with mental difficulties.

Some great ideas are also emerging about where to site services so they are closer to where people need them. In Cornwall, for instance, they’re experimenting with campervans on the quayside. In Somerset, they’re locating them in special dedicated “health rooms” in a farmer’s market. In Manchester they're taking NHS Health Checks into local communities in Harpurhey and Rusholme in a double-decker bus. This initiative is the result of extensive work with local GPs and councillors to establish which people are least likely to access NHS Health Check in primary care, how best to invite them and how to raise awareness of the programme. It is also guided by the preferences of residents on the timing of the appointments: earlier in the day for Harpurhey compared with Rusholme, making it easier to pre-book appointments that are most convenient for users.

There will be many more examples of such creative thinking and we will capture this in a rigorous way as implementers review their programme data to examine coverage, uptake and outcomes results. Using these data to evaluate and refocus the NHS Health Check is an essential component of good programme management and one to which we are committed. In the PHE Implementation Plan for the NHS Health Check programme, PHE has committed to supporting improved clinical and scientific governance of the programme combined with a commitment to support implementation research. We must “learn as we do” so that the evidence from local delivery and innovation is used to inform future directions for the programme.

We don’t believe that NHS Health Check is the silver bullet that can, at a stroke, reduce all of the most challenging health inequalities that persist across the country. But we do think that NHS Health Check offers an opportunity to engage earlier with individuals about their health, assess their risks and start a new and different conversation around raising awareness and risk management.

The ability to combine the universal offer with intensified targeting will help ensure that those who could most benefit are not left behind. We are committed to a strategic approach to research and evidence. We are committed to evaluating and promoting implementation science. This will help ensure we take full advantage of this opportunity to get at the root causes for preventable death and disability in England – a burden that we know tends to fall hardest on those who are most disadvantaged.

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  1. Comment by Azeem Majeed posted on

    At Imperial College London, we have been carrying out local and national evaluations of the NHS Health Checks Programme. I have appended a list of our current publications. Additional papers are in preparation.

    Prof. Azeem Majeed, Twitter@Azeem_Majeed

    1. Artac M, Dalton AR, Majeed A, Huckvale K, Car J, Graley C, et al. Assessment of cardiovascular risk factors prior to NHS Health Checks in an urban setting: cross-sectional study. JRSM short reports 2012;3(3):17.
    2. Artac M, Dalton ARH, Babu H, Bates S, Millett C, Majeed A. Primary care and population factors associated with NHS Health Check coverage: a national cross-sectional study. J Public Health (Oxf) 2013;35(3):431-39.
    3. Artac M, Dalton ARH, Majeed A, Car J, Huckvale K, Millett C. Uptake of the NHS Health Check programme in an urban setting. Family Practice 2013;30(4):426-35.
    4. Artac M, Dalton ARH, Majeed A, Car J, Millett C. Effectiveness of a national cardiovascular disease risk assessment program (NHS Health Check): Results after one year. Preventive Medicine 2013(0).
    5. Dalton AR, Soljak M, Samarasundera E, Millett C, Majeed A. Prevalence of cardiovascular disease risk amongst the population eligible for the NHS Health Check Programme. European Journal of Cardiovascular Prevention & Rehabilitation 2011.
    6. Dalton ARH. Evaluation of the NHS Health Check Programme; Local and National Findings from the Early Stages of the Programme. Imperial College London, 2011.
    7. Dalton ARH, Bottle A, Okoro C, Majeed A, Millett C. Uptake of the NHS Health Checks programme in a deprived, culturally diverse setting: cross-sectional study. J Public Health (Oxf) 2011;33(3):422-29.
    8. Dalton ARH, Bottle A, Okoro C, Majeed A, Millett C. Implementation of the NHS Health Checks programme: baseline assessment of risk factor recording in an urban culturally diverse setting. Family practice 2011;28(1):34-40.
    9. Dalton ARH, Soljak M. The Nationwide Systematic Prevention of Cardiovascular Disease: The UK's Health Check Programme. The Journal of Ambulatory Care Management 2012;35(3):206-15 10.1097/JAC.0b013e318240be9d.
    10. Majeed A, Banarsee R. General health checks may not reduce morbidity or mortality but do increase the number of new diagnoses. Evidence Based Nursing 2013.
    11. Soljak M, Majeed A, Millett C. Response to Krogsbøll and colleagues: NHS health checks or government by randomised controlled trial? BMJ 2013;347.