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Preventing and detecting disease before it harms people’s health

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It’s always encouraging to hear how an NHS Health Check has changed someone’s life. Take Rajiv, who discovered he had type 2 diabetes after taking up the offer of an NHS Health Check. On the doctor’s advice, he reduced sugar in his diet and started to walk more every day. Within time, he was able to come off insulin and control his blood sugar levels just by diet and being more active, which of course was also beneficial for his wider health and wellbeing

That’s just one man. Imagine that story multiplied thousands of times. According to the first major evaluation of NHS Health Check, published in the British Medical Journal Open last month, the programme is helping to identify an estimated 10,000 new cases of diabetes, 4,500 new cases of kidney disease and 44,000 new cases of hypertension every year.

The research also suggests that, over the first five years of the programme, at least 2,500 people would have avoided a heart attack or stroke as a result of medication recommended and started after their Check.

In other words, we’re finding potential or early stage diseases before they become a danger to people’s health. By identifying these conditions earlier and referring people for evidence-based interventions, the NHS Health Check is providing a valuable prevention programme that will help people live longer, healthier lives and reduce future demands, and importantly costs, on the NHS.

NHS Health Check is the first programme of its kind in the world. It seeks to reduce the burden of largely preventable disease by encouraging people to take an active part in improving their health. Adults aged 40 to 74, who have not previously been diagnosed with a vascular disease, are offered a free Check every five years to assess risk factors such as high blood pressure, smoking, cholesterol, inactivity, harmful drinking and obesity and, if necessary, provide medical treatment or referral to a range of lifestyle interventions.

During the latest evaluation of the programme, a study team, led by Queen Mary University of London, analysed data from 655 general practices in England in the four years from April 2009 to March 2013. Data relating to 214,295 people who attended an NHS Health Check was reviewed and compared against 1.4 million people who had not yet been offered or taken up a Check.

The researchers found that the NHS Health Check has made a ‘modest, but successful start’ in identifying people at risk of cardiovascular disease (CVD) and other chronic conditions. On a positive note, the study found that the programme is helping to tackle health inequalities. It is reaching black and minority ethnic groups and people from deprived areas, who are most at risk of their condition being missed or diagnosed too late. For example, attendance by the most socially disadvantaged people was higher than the most affluent (14.9% vs 12.3%), refuting criticism that the Checks are skewed towards the ‘worried well’.

Overall, one new case of hypertension was identified for every 27 Checks carried out. For diabetes, one new case was found every 110 Checks and for kidney disease the detection rate was one case per 265 Checks. One in eight attendees were found to have a high risk of CVD.

The evaluation - the largest and most comprehensive to date - also usefully highlight a number of areas where there is room for improvement. For example, people under 65 were less likely to attend a Check than those over 65. We need to investigate whether this is the result of targeting those at high CVD risk (those aged over 65) or whether people of working age have difficulty accessing the Checks.

While attendance has increased progressively since 2009, the programme’s coverage across the target population needs to further expand. We are making good progress. During 2014/15, an additional 100,000 people received a Check compared to the year before, and latest figures show that 48% of all eligible people attend when invited. Ideally, however, we want uptake rates of 75% and beyond. PHE is working with local authorities, who commission NHS Health Checks in their areas, to increase uptake so that the programme reaches its full potential.

There is also scope to increase treatment with statins. The study found that only 20% of those at highest CVD risk were prescribed medication. While the researchers say this could be higher, they believe that at a national scale, treatment for 1 in 5 attendees at highest CVD risk was likely to have contributed to “important reductions in CVD events.”

In England, two-thirds of deaths among people under the age of 75 are thought to be avoidable. In addition, there are many, many cases of undiagnosed disease, including largely preventable illnesses such as type 2 diabetes, stroke, cancer and heart disease. That’s why the NHS Health Check programme is so important. Through early identification, people have a chance to address lifestyle or clinical risk factors before it is too late.

We should be encouraged, and influenced, by the results of this important research. For members of the public, it provides a persuasive argument to attend their Checks when invited. The results should also galvanize health professionals and commissioners into improving rates of uptake, referral and follow-up of the interventions that are included in the NHS Health Check.

If it can reach its full potential, the programme will not only save thousands of more lives, but help large numbers of people live healthier and have a better quality of life for longer – as well as hugely contributing to reducing the burden on the NHS.

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  1. Comment by Peter Baker posted on

    At last - some very welcome positive news about the Health Checks programme. As a men's health advocate, I firmly believe that Health Checks have huge potential as a way not only of preventing health problems in men and diagnosing them early but also of improving men's sub-optimal engagement with primary care services. But currently just 12% of eligible men are receiving a Health Check. If the programme takes better account of men's health attitudes and behaviours, and targets them much more sensitively, this proportion can be greatly increased.

    • Replies to Peter Baker>

      Comment by Susan Bewley posted on

      Dear Peter. I agree with your concern about lack of engagement when men do actually feel unwell. However, all screening can cause harm as well as good. Men may well be protected from harm by avoiding the unnecessary screening of health checks that have not been shown to save lives (despite the false health claim in the press release and this blog). Please read the original paper on which this blog is based and the criticisms. The numbers don't add up. The paper was not an evaluation of the benefit.

  2. Comment by Tom Frost posted on

    As recognised in the BMJ by the study's authors, there's was NOT the first evaluation. This was Chang KC-M, Soljak M, Lee JT, Woringer M, Johnston D, Khunti K, Majeed A, Millett C. Coverage of a national cardiovascular risk assessment and management programme (NHS Health Check): Retrospective database study. Preventive Medicine, 2015;78:1-8. It's conclusion was "These findings raise a question about whether recommendations by WHO to develop CVD risk assessment programmes internationally will deliver anticipated health benefits."
    Robson's paper is more description than evaluation, does not mention possible harms and does not use intention to treat as the basis for analysis. All factors that could improve the study, the paper and understanding of the merits of the Health Check programme.
    It is also worth reading the comments from various academics in the replies section of the BMJ which provide some balance to the commentary from Kevin above.

  3. Comment by Susan Bewley posted on

    It is wrong for Dr Fenton to make a claim of a 'made up' number of heart attacks and strokes prevented in a press release and a blog - especially when they were not made in the research paper. There was no evidence of effectiveness reported. Indeed there was no evidence that Health checks work before they were implemented. A lot of money is being wasted by PHE.
    Health checks are a form of screening (which inevitably has harms as well as purported benefits) and should be formally passed through the National Screening Committee.

    • Replies to Susan Bewley>

      Comment by Kevin Fenton posted on

      The estimated number of heart attacks and strokes avoided is included by the authors in the implications for practice section of the research paper. We have established the NHS Health Check Expert Scientific and Clinical Advisory panel which welcomes the findings from all research on the programme and will use this information to keep the programme under review.

  4. Comment by Walter W Holland posted on

    It is surprising that Kevin Fenton in his blog,makes unjustified and unverifiable statements on the effects of the Health Check programme. He neglects referring to any of the critical comments which have already been published on the description of the process by Robson et al. May I recommend that he reads the WHO Public Health Paper,no 34, published in 1968 by Wilson and Jungner, which deals in detail with the subject and methods of evaluation as well as practice ,and is still in date ! It is sad that a Public Health agency is unwilling to accept evidence but relies on estimates,projections,expectations and anecdotes.

  5. Comment by Lee Dawson posted on

    The Health Check is, in most places, much more than a screening programme, when delivered properly it will establish 2 fundamental aims, to find existing disease and to support people to make changes in their life to be healthier, in all senses of the word. I suspect that emphasis on disease prevention and therefore the perception that it is mainly a screening programme is to satisfy and justify the programme to the politicians who think health = Ill health. Health behaviour change programmes have notoriously poor outcomes as there are many factors at play. Does that mean we should scrap them and let people get on with it. I applaud efforts so far by PHE, I certainly would like more emphasis and time in supporting patients to make changes, rather than referring on to specific 'courses' over 7, 12 weeks etc. Health Trainers were doing this well, shame those programmes have diminished too!