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Health check programme boost

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Over the next five years, 15 million middle-aged people in England are due to have an NHS health check - a sort of 'human MOT' - that can provide early warning signs of chronic disease.

The health check is not new - it dates back to the previous Labour administration in 2009, and has a precursor in the 1990s' Well Person checkup. But take-up remains modest. Last year 2.7 million people were offered NHS health checks and 1.28 million accepted.

However, last month the coalition government gave the programme a boost and set ambitious new targets, spurred by a report that compared the health of Britons unfavourably with that of their continental peers.

According to the report Living Well for Longer1, 'rates of premature mortality have not improved as quickly as other European countries, worsening our relative position by 2010. This relative decline is strongest for men and women aged 20 to 54.'

Public Health England (PHE) estimates that checking 40-to-74-year-olds' blood pressure, cholesterol, BMI and lifestyle factors every five years could prevent 650 deaths, 1,600 heart attacks and 4,000 cases of diabetes a year. It could also identify 20,000 cases of diabetes or chronic kidney disease at an earlier stage.

The aim is now to give health checks to 20 per cent of the eligible population each year for the next five years until 15 million people have received them. The same population is then checked five years later (those with existing chronic conditions are excluded).

The revamp this year has seen local authorities take over responsibility for commissioning health checks from the NHS. Added to the check is a section to raise awareness about signs and symptoms of dementia.

'We haven't made the same inroads in reducing premature morbidity and mortality compared with other high income countries - we need to improve our position on this,' said Jamie Waterall, interim director of the NHS Health Checks Programme and a consultant nurse in public health.

'We know as nurses that the major causes of death and disability such as cardiovascular disease, cancer, diabetes and respiratory disease share certain common risk factors - smoking, hypertension, physical inactivity, high cholesterol, alcohol use, obesity and diet.

'This is our opportunity to engage with the population in understanding their risk and help them with the lifestyle factors and the clinical elements of that, such as diabetes and blood pressure.

'The aim is to shift the focus on long term conditions from the NHS being a reactive service to a focus on prevention.

He added: 'Nurses absolutely get this. Practice nurses are finding more people with diabetes - they are seeing significant changes in people coming into surgeries. They know that people in their communities are dying prematurely of cardiovascular and respiratory diseases.'

Local government has been given £5.3 billion for its public health responsibilities over two years, including commissioning NHS Health Checks and the National Child Measurement programme and funding sexual health clinics. The initial check-up costs around £23.80. Follow-up checks, for those identified as having an undiagnosed condition such as hypertension, should be funded through the general practice Quality and Outcomes Framework.

Under NHS control, the bulk of checks were being done in traditional settings such as GP surgeries and pharmacies, although a number of roadshows and temporary clinics aimed to reach wider.

Last year only eight per cent of the eligible target group was screened - at that rate only 40 per cent of the population would have the check within five years. 'We are aspiring to an uptake of 75 per cent, a similar uptake to some of the national screening programmes,' said Mr Waterall. This suggests that the proportion screened each year needs to double. One way this could be done is if more people who are offered the check accept it (only half do at present).

Helen Donovan, the RCN's adviser on public health, said: 'We know that access has been quite patchy across the country. Some areas have been doing some really innovative things like opening temporary shops or initiatives with specific known risk groups, such as the Sheffield project with Asian taxi drivers. In other areas it's been seen as something of a tickbox exercise.'

'Local authorities may decide to opt for more roadshow events, where en-masse checks can offer economies of scale. One advantage is that this may catch more at risk groups - some ethnic minorities (who are more at risk from cardiovascular disease and diabetes), or people with chaotic lifestyles, mental health problems or learning disabilities.

'I dislike the term 'hard to reach' - people will happily take up health checks if they are put in accessible areas,' said Mr Waterall. 'We have evidence of high uptake in vulnerable communities and not just the worried well.'

But larger-scale ventures also tend to rely more on healthcare assistants, health trainers and even trained volunteers to perform initial checks.

'We have got some very skilled healthcare assistants and health trainers, who do things very competently for the initial stages of the health check,' said Mr Waterall.

'But we have to recognise their limitations too. Nurses should be providing supervision and oversight, and in terms of communicating the results back and managing the outcomes, they are crucial.

'Nurses are well positioned in terms of giving motivational interviews around behaviour change - in helping people to change their behaviours that are contributing to those risks.'

Ms Donovon agreed and added. 'You need to know how to talk to people. If you discover that someone is overweight, do you have those skills to have the difficult conversation about behaviour change? It requires a lot of skill and careful handling.

'The dementia screen that's been added is quite difficult. People are very worried: Do I want to know if I'm in the early stages of dementia?'

In March this year, PHE's director of nursing Viv Bennett, highlighted the public health role as a priority for nurses, including having 'difficult conversations' about behavioural change, being equipped with up-to-date knowledge and coordinating national campaigns.

Despite widespread backing for the health checks campaign, there are some dissenting voices. Among them some GPs who suggested that using existing GP patient records to identify patients at high risk of developing diabetes may be more efficient than rolling out a universal service.

Mr Waterall disagrees: 'Using existing GP data to target those at greatest risk is a valid approach to targeting health checks. That's happening in some areas.

'But take the homeless community, who are at a phenomenally increased risk of dying prematurely. They have multiple risk factors. To assume that a GP record has all the information on those individuals is not right.

'There has to be a balance between using existing intelligence and data to target the checks and not closing the door to any new intelligence.'

Ms Donovan agreed: 'We know that not all GP records are as accurate as we would like, unfortunately.'

Research evidence for the effectiveness of health checks is mixed. A study which looked at changes in cardiovascular disease risk for 4,748 patients who had been given a complete or partial NHS health check found a 'significant but modest' reduction of 28.2 per cent in their 10-year risk of developing disease.2 Some local data suggests that high-risk individuals are being identified. Of the 2,300 people checked in North Somerset GP surgeries, 12 per cent were found to have a high risk of developing a cardiovascular disease. Of the 105,482 given the check in Birmingham over three years, 7.1 per cent were found to have chronic health conditions.

However, a Cochrane Review of 16 randomised controlled trials of general health check programmes found that they produced no significant reduction in morbidity and mortality.3

Commenting on this study, PHE pointed out that the trials were old and the content of the 'health checks' they studied varied considerably. 'However the fact remains that the [NHS] programme is being implemented in the absence of direct randomised controlled trial evidence to guide it,' PHE conceded.

A more specific study found that the health check's diabetes filter failed to identify one third of patients at high risk of having or developing diabetes.4

This problem has still not been fixed. PHE intends to establish an expert scientific advisory panel to keep the content of the health check in line with the latest knowledge.

Data from the programme for individual local authorities will also be published on the NHS Health Checks website.

However, hitting these ambitious new targets for the programme will involve effective partnership between local authorities - who are new to public health - and an NHS in a state of transition to CCGs.

'It's vital that health and social care work together on this, and the local authority Health and Wellbeing Boards will be critical,' said Mr Waterall. 'I see nurses playing a vital role in the commissioning element - in designing and developing the system - right through to provision, to delivering the risk assessments.'

Ms Donovan said GP practice-level knowledge of local populations should be used to ensure that the most at-risk patients were given health checks and identified. 'The success of the programme will come down to who is doing it, how its managed, the skills of the staff involved and whether people have taken into consideration their local population,' she said.

For more information on some of the innovative health check schemes in your area please see the link below:

https://www.internurse.com/public/IN_Graphic_Map[1].pdf

Resources

1. Department of Health. Living Well for Longer: A call to action to reduce avoidablepremature mortality. March 2013

2. Artac M, Dalton ARH, Majeeda A, Cara J,Millet C. Effectiveness of a national cardiovascular disease risk assessment program (NHS Health Check): Results after one year. Preventive Medicine 2013; 57: 129-134.

3. Krogsbøll LT, Jørgensen KJ, Larsen CG, Gøtzsche PC. General health checks in adults for reducing morbidity and mortality from disease. Cochrane Library,October 2012

4. SmithS, Waterall J, Burden FAC. An evaluation of the performance of the NHS Health Check programme in identifying people at high risk of developing type 2 diabetes. BMJ Open 2013; 3:e002219

5. www.qresearch.org/SitePages/qriskInformationforPatients.aspx (accessed 13 August 2013)

6. www.framinghamheartstudy.org/risk/gencardio.html (accessed 13 August 2013)

NHS health checks - best practice

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