Background: The National Health Service Health Check in England aims to provide adults aged 40 to 74 with an assessment of their risk of developing cardiovascular disease and to offer advice to help manage and reduce this risk. The programme is commissioned by local authorities and delivered by a range of providers in different settings, although primarily in general practices. This project focused on variation in the advice, onward referrals and prescriptions offered to attendees following their health check.
Objectives: (1) Map recent programme delivery across England via a survey of local authorities; (2) conduct a realist review to enable understanding of how the National Health Service Health Check programme works in different settings, for different groups; (3) provide recommendations to improve delivery.
Design: Survey of local authorities and realist review of the literature.
Review methods: Realist review is a theory-driven, interpretive approach to evidence synthesis that seeks to explain why, when and for whom outcomes occur. We gathered published research and grey literature (including local evaluation documents and conference materials) via searching and supplementary methods. Extracted data were synthesised using a realist logic of analysis to develop an understanding of important contexts that affect the delivery of National Health Service Health Checks, and underlying mechanisms that produce outcomes related to our project focus.
Results: Our findings highlight the variation in National Health Service Health Check delivery models across England. Commissioners, providers and attendees understand the programme's purpose in different ways. When understood primarily as an opportunity to screen for disease, responsibility for delivery and outcomes rests with primary care, and there is an emphasis on volume of checks delivered, gathering essential data and communicating risk. When understood as an opportunity to prompt and support behaviour change, more emphasis is placed on delivery of advice and referrals to 'lifestyle services'. Practical constraints limit what can be delivered within the programme's remit. Public health funding restricts delivery options and links with onward services, while providers may struggle to deliver effective checks when faced with competing priorities. Attendees' responses to the programme are affected by features of delivery models and the constraints they face within their own lives.
Limitations: Survey response rate lower than anticipated; review findings limited by the availability and quality of the literature.
Conclusions and implications: The purpose and remit of the National Health Service Health Check programme should be clarified, considering prevailing attitudes about its value (especially among providers) and what can be delivered within existing resources. Some variation in delivery is likely to be appropriate to meet local population needs, but lack of clarity for the programme contributes to a 'postcode lottery' effect in the support offered to attendees after a check. Our findings raise important questions about whether the programme itself and services that it may feed into are adequately resourced to achieve positive outcomes for attendees, and whether current delivery models may produce inequitable outcomes.
Future work: Policy-makers and commissioners should consider the implications of the findings of this project; future research should address the relative scarcity of studies focused on the end of the National Health Service Health Check pathway.
Study registration: PROSPERO registration CRD42020163822.
Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health Services and Delivery Research programme (NIHR129209).
Keywords: CARDIOVASCULAR DISEASES; HEALTH PROMOTION; LIFESTYLE; PREVENTION; PUBLIC HEALTH; REALIST REVIEW; SCREENING; SURVEY.
The National Health Service Health Check aims to help people understand their risk of developing some health conditions, including heart disease, stroke, diabetes, kidney disease and dementia. During a check, providers take measurements and ask questions about lifestyle. They calculate a ‘risk score’ to predict how likely someone is to have a heart attack or stroke in the future. An important next step is for providers to offer advice and support to help people to reduce their risk. This might include referring them to their general practitioner to discuss prescribing medicines, for advice and to offer referrals to other services, such as stop-smoking or weight-management services. We know this activity varies across England. Our project focused on understanding this step: what affects what people are offered after they are told their risk score? We undertook a survey of local authorities, who are responsible for organising and funding the health check. We reviewed the literature on the health check using an approach called ‘realist review’, to see what it could tell us about how checks are delivered. We found wide variation in what people are offered after being given their risk score. This variation depends on what local authorities and providers think the programme is for, and especially if they think it should be used to find people who have certain health conditions, or if they think it is an opportunity to encourage people to change their lifestyle. Funding and workforce pressures have affected how much time is available during checks for personalised discussion and advice, and limited the services available to help people make lifestyle changes. Based on our findings, our recommendations for policy-makers, local authorities and providers are to make the purpose of the health check clearer and improve links with services that could support people with lifestyle changes.