NHS Health Checks: The Successes and Failures of this Public Health Campaign
Health priorities are driven by the recognition of a particular problem, available solutions, groups who shape action, national governments who participate in health issues, and how and why decisions are made. ‘Cardiovascular disease refers to conditions affecting the heart or blood vessels’ (National Health Service, 2018) and includes health conditions such as heart disease, heart attacks, hypertension and stroke but is not limited to these specific diseases alone. ‘CVD remains a significant cause of death and disability’ (PHE 2018) in England and internationally. Approximately £15.8b is spent on CVD in England and ‘around seven million people’ are affected by CVD in the United Kingdom (NHS England, 2018).
The Department of Health, Public Health England and NHS England sought to address this health concern through policy measures. The NHS Health Checks was launched in England as a CVD prevention programme and though there are many features to this programme this paper will strictly focus on the free national health screening, implementation and delivery of the national programme, the Local Authorities duty to invite 100% of the eligible population and the age requirements of the eligible population as these are most urgent in their consequences. I will outline the NHS Health Check Programme, explore the features which have contributed to its success and failure, the impact of Covid-19 and how this changed the policy image and policy venue and what lessons can be learnt for general health campaigns.
Whilst the success of the NHS Health Checks is primarily driven by early detection of non-communicable diseases and modifiable risks, evidence shows that groups that are most likely to benefit most from these checks are not accessing them. The broad and undifferentiated approach of this national programme alongside regional variations has resulted in striking differences across the nation.
The NHS Health Check
Prioritisation of diseases emerge ‘when its burden becomes high relative to others and when researchers develop cost-effective means of interrupting transmission’(Shiffman et al, 2002). In 2008, the Department of Health developed the NHS Health Checks based on an economic model which claimed to be ‘cost-effective…and generate significant health benefits’ (NHS England, 2014). One may argue that based on the initial development of this policy the rational model which is the ‘logical selection based on global burden and the availability of cost-effective interventions’ (Shiffman et al, 2002) would best describe the decision-making process for the NHS Health Checks. Moral concerns surrounding the health of the nation from outcomes such as obesity and deaths caused by CVD may have also led to prioritisation of this health issue.
The NHS Health Check was launched in England for adults aged 40–74 in 2009. The free health screening ‘is designed to spot the early signs of stroke, kidney disease, heart disease, type 2 diabetes and dementia’ (NHS England, 2019). A healthcare professional will explain the individual’s risk of CVD over the next 10 years and give personalised lifestyle advice. The programme was relaunched in April 2013 and LAs were made responsible for implementation and delivery of the programme. LAs also had a statutory duty to invite 100% of the eligible population.
Key features of the NHS Health Check
- Free health screening for early detection of CVD risk
- LAs are responsible for implementation and delivery of the programme
- LAs have a duty to invite 100% of the eligible population every 5 years
- Age requirement of the eligible population is between 40–74 and they must not have a pre-existing condition
Successful features of the NHS Health Checks
Free national health screenings
Free health screenings and the emergence of new technologies that detect non-communicable diseases have undoubtedly driven the success of this national campaign. The National Clinical Director for CVD prevention for NHS England, Dr Matt Kearney highlights that ‘around 1.5m people take up this offer every year’(NHS, 2017). Between 2013–2018, 4.9m people attended their NHS Health Check. NHS England estimates that ‘250–500 heart attacks have been prevented each year’(ESCAP, 2017) and ‘650 premature deaths a year’(Carter et al, 2015).
Uptake of this free national risk assessment allows for earlier identification of modifiable risk factors that interact and affect CVD and here healthcare professionals can introduce lifestyle conversations using behavioural change techniques. A study assessed the NHS Health Checks in ethnically diverse populations and found that the national CVD prevention programme was ‘the first step to introducing behavioural change dialogue in the community’ (Pearce, 2016). Overall, this key feature supports individuals in leading healthier lives and ‘increase their chances of living longer’ (NHS, 2019) which is a successful feature of the programme.
The economic burden of CVD healthcare on the NHS has been long documented. In 2004, the UK spent £29.1b on CVD and 60% of this was spent on healthcare (Fernandez et al, 2006). The British Heart Foundation estimate that in 2020 £19b was spent on CVD in the UK. Although there has been a reduction of £10m in the last 16years, there is no direct evidence to suggest that this is a direct result of the NHS Health Checks. However, the Centre for Health Economics found that NHS Health Checks ‘are likely to be a cost-effective use of limited NHS resources’ (CHE, 2017).
Although critics argue that the programme is ineffective and not cost-effective, PHE estimates that the NHS Health Checks will ‘save the NHS of around £57m per year after four years, rising to £176m per year after 15 years’ (PHE, 2015) which are calculations based on the original economic modelling. PHE’s Chief Executive Officer Duncan Selbie also highlights that follow-up interventions are also ‘both clinically and cost-effective’ (NHS, 2015). These findings suggest that despite financial austerity as a result of public spending cuts and limited NHS funding, early detection measures from this programme have the potential to reduce the economic burden of CVD.
Unsuccessful features of the NHS Health Check
Implementation and delivery of the national programme
Proportionate universalism refers to the improvement of ‘the health of the population, across the social gradient, while rapidly improving the health of those most disadvantaged’ (PHE, 2018). This concept is said to underpin the aims of the NHS Health Check. However, one key failure of this national campaign is that it is too broad and undifferentiated. As a national programme it has failed to recognise that we are not all the same. The current programme does not target specific vulnerable groups who will benefit the most from these health checks.
Findings from an updated rapid review show that the national campaign ‘still had a long way to go’ (Tanner et al, 2020) in achieving the desired 75% national attendance rate. The White British Female aged 60 and above were more likely to attend an NHS Health Check than any other group. NHS Digital 2020 data and Chang et al’s study in 2016 echo these findings at a national level. The Expert Scientific and Clinical Advisory Panel argue that the national programme reaches deprived communities as well as Black Caribbean’s, Bangladeshi’s and Indians. Yet, a study which assessed the differences in attendance between ethnic groups over a 4year period using 665 GP surgeries across England found that Pakistani, Indian and Bangladeshi groups had the highest attendance rates during this period at 19.2%.
Black Africans had the lowest attendance rates at 15.7%, and overall, White people had the highest attendance rates at 17.4% and BAME groups at 16.9%. There was no data to illustrate what effect gender had. However, what was clear was that ethnic minority groups were not attending NHS Health Checks at the same rate as White people which reinforced the need for differentiated campaigns that target specific high-risk population groups.
Another reason why NHS Health Checks are not reaching those who need them the most is due to regional variations in implementation and delivery of this national programme. A study conducted in Northwest London found that LA budgets ranged from £69,000-£1.4m ‘per 100,000 eligible population’ (Graley et al, 2011). The postcode lottery effect has resulted in differences in implementation of the NHS Health Checks between LAs and variations in the programmes impact in the community. Thrive Tribe provides integrated healthy lifestyle services and has been commissioned by Somerset County Council to provide NHS Health Checks in accessible community settings which has been a success in the area as access barriers have been reduced for local residents. The same service provider is also commissioned by The Royal Borough of Kensington and Chelsea Council to increase the uptake of the programme among high-risk BAME groups. However, the same flexibility has not been awarded in the borough despite the high-levels deprivations in particular wards and requests from community groups to have community-based health checks.
In communities like the Black community, where there is a long history of institutionalised racism it is important that health campaigns engage effectively with these marginalised communities to rebuild trust and address the barriers that prevent them from accessing health care services. ‘64% of Black People do not believe their health is protected by the NHS like White peoples’ (Guardian, 2020) and ‘47% of Black men believe the NHS does less to help them than White peers’ (Guardian, 2020). In Bristol, a community centred approach was adopted with the Afro-Caribbean community, and the use social settings to engage with the community assisted with reducing access barriers to the programme. Targeted approaches for specific groups and greater regulation of regional implementation and delivery is required to prevent the ‘undesirable effects of the postcode lottery’ (Graley et al, 2011).
LAs duty to invite 100% of the eligible population
Since 2013, LAs have been under a legal duty to invite 100% of the population. Invitation via letter is typically the main method of systematic invitation. Research has identified that the simplified commitment letter increased uptake by 13–27% (PHE, 2016). However, this form of invitation can form barriers to attendance for particular groups. A study in Luton assessed ethnicity and uptake of the NHS Health Checks via invitation method. It was found that different ethnic groups required different invitation methods.
Black Africans had the lowest uptake from the invitation letter at 0.36% (Cook, 2016), whilst Black Caribbean men and Indian women had the highest uptake at 0.69% and 0.76% (Cook, 2016). Luton City Council used tele-campaigns the least yet Bangladeshi and Pakistani men and Black Caribbean and Pakistani women had highest uptakes. Data suggests that optimising various methods may reduce some barriers to attendance than reliance on letters as the main method of invitation which a large number of LAs rely on.
Lower attendance among younger patients within the eligible population
Professor Kamlesh Kunti argues that NHS Health Checks for BAME groups should start at 25. However, multiple studies have shown that older patients are more likely to uptake the NHS Health Check than younger patients. A study in England showed that the attendance of adults aged 60–74 was 19.6%, whilst those aged 40–59 was lower at 9.0% (Robson et al, 2015). This pattern was also confirmed in a regional study (Atwood et al, 2015). Experts argue that young patients who are ‘non-attenders may not believe in the effectiveness of the screening’ (Dalton et al, 2011). It can also be said that they may not see the importance of these checks as the symptoms of these non-communicable disease have not hindered the day-to-day activities of these individuals. Whilst PHE acknowledges this disparity, it appears that not much has been done nationally to appeal to the younger patients despite the primary aims of the programme being early detection and prevention.
The impact of Covid-19 on the NHS Health Checks
The Coronavirus undoubtedly disrupted the policy image and policy venue of the NHS Health Checks (Shiffman et al, 2000). Black and Asian Londoners were 1.5, 1.7 times more likely to die from Covid-19 (PHE, 2021). For LAs like Westminster City Council and The Royal Borough of Kensington & Chelsea, CVD prevention and its interaction with Covid-19 became central to in addressing at risk groups which moved the NHS Health Checks to the top of local agenda. The NHS Health Checks was transformed from a rational model into the punctuated equilibrium model (Cohen et al, 1972) as senior public health strategists sought to transform the programme delivery and address the existing health inequalities that the pandemic amplified. A targeted tele-campaign was adopted to invite eligible high-risk ethnic minority patients for their NHS Health Check. Although the programme was halted during lockdown, the NHS Health Checks was still used as a means of engaging with high-risk groups to find out barriers to the programme and re-introduce health conversations into the community.
Lessons that can be learnt for general health campaigns
General health campaigns will benefit from not applying broad undifferentiated programmes to all population groups. Strategists must acknowledge that some groups are harder to engage with and adopt tailored programmes to effectively reduce barriers that prevent engagement within these groups.
Whilst different actors may work in partnership to roll out national or global health campaigns greater collaborative efforts, shared intelligence, and transparency is required between the various stakeholders to ensure that regional variations are minimised. Whilst some actors may have greater financial power and freedoms to decide how health campaigns are implemented and delivered, some regulation by the relevant regulatory bodies, should be adopted to avoid unfair and undesirable disparities among marginalised groups.
Conclusion
The success of this national campaign in England has been driven by the early detection of non-communicable diseases through free health screenings. Despite not achieving the national attendance rate of 75%, annually 1.5m people up this offer nationwide which shows that this key feature has produced overall benefits for wider society. Nonetheless this national campaign still has a long way to go in reaching the most vulnerable groups, particularly ethnic minority groups. Despite the programmes aims of achieving proportionate universalism, regional variations in the implementation and delivery of this broad national campaign have limited the success of the programme. Multiple studies across the nation have shown that the most vulnerable groups do not benefit from the current CVD prevention programme. Greater emphasis is required in targeting specific population groups through community focused tailored initiatives to effectively reduce attendance barriers for these groups.
