Authors' objectives: 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. (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. The National Health Service (NHS) Health Check (NHSHC) programme in England aims to provide adults aged 40 to 74 with a five-yearly assessment of their risk of developing cardiovascular disease (CVD) and offer advice on interventions to help manage and reduce this risk. The check involves the measurement of CVD risk factors and calculation of an estimate of overall CVD risk, followed by advice and discussion of the next steps attendees can take to help manage and reduce their risk levels. These may include the delivery of advice and brief interventions, signposting or formal referral to ‘lifestyle services’ and clinical risk management (including prescribing) per relevant National Institute for Health and Care Excellence guidelines. The programme is commissioned by local authorities (LAs) and delivered by a range of providers in different settings, although primarily in general practice. Until this year, it was overseen by Public Health England (PHE), who issued regularly updated recommendations and standards to guide commissioning and delivery of the programme. Responsibility for NHSHCs now lies with the new Office for Health Improvement and Disparities (OHID). The minimum standards for NHSHC delivery are a mandatory requirement, but LAs have flexibility in how and who is commissioned to provide checks, to meet local population needs. There is clear evidence of variation in commissioning and delivery of NHSHCs across England. This project focused on what happens after the measurements and risk assessments have been undertaken. We aimed to improve understanding of the variation in the advice, brief interventions, onward referrals and prescriptions offered to NHSHC attendees following a check. 1.To map how the programme is currently delivered across England, data collected via an online survey of LAs (with a specific focus on what happens after the measurements and risk assessment and on Covid-19-related changes to delivery models). 2.To conduct a realist review to enable understanding of how the NHSHC programme works in different settings, for different groups, to achieve its outcomes (with a specific focus on what happens after the measurements and risk assessment). 3.To provide recommendations on tailoring, implementation and design strategies to improve the current delivery and outcomes of the NHSHC programme in different settings, for different groups.

Authors' results and conclusions: 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. 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. Survey results We received 68 responses to our survey, representing 74 LAs (49%) across nine regions in England. Our survey results demonstrate the variation that characterises the delivery of the NHSHC programme across England. We developed a typology of three delivery models: general practice only, blended (involving community pharmacies) and blended with outreach (involving delivery in multiple venues including community settings). In response to questions about the impact and response to Covid-19, a small number of respondents reported the adoption of remote delivery methods for NHSHCs but there was a high degree of uncertainty about their effectiveness. The results also highlighted variation in the number of locally commissioned services to support CVD risk management, and confidence that NHSHC providers made appropriate use of these. We found a statistically significant association suggesting that LAs that commissioned NHSHCs with a ‘blended with outreach’ model also commissioned more support services. Only a small number of LAs routinely requested data on processes or outcomes relating to our project focus. The results of our survey and realist review have demonstrated and offered a series of explanations for the wide variation in delivery of the NHSHC, with a particular focus on what happens after the measurements and risk assessments have been completed. There is a mismatch between what the programme is intended to deliver and what is delivered and achievable ‘on the ground’. Variation is driven by differences in understanding and engagement with the programme, and is compounded by practical constraints on delivery, primarily constrained funding for the programme itself and the follow-up services that it depends upon. For attendees, variation in delivery inevitably affects understanding and engagement with the programme, but attendees’ responses to the check are also affected by their own prior knowledge, health priorities and the constraints they face in their own lives. Based on our findings, we developed a series of recommendations for policy-makers, commissioners and providers to consider, with the aim of potentially helping to reduce unwarranted variation and improve delivery of the programme. First and foremost, the evidence suggests the need to clarify the purpose and remit of the NHSHC, while also considering what can be delivered well, within funding constraints. While some variation in delivery of the check is likely to be appropriate to meet local population needs, a lack of clarity for the programme overall appears to increase variation and a ‘postcode lottery’ effect in delivery, especially in relation to what is available to support attendees after a check. With a clearer understanding of the purpose of the programme, policy-makers, commissioners and providers can better consider how to align local delivery, funding models, training provision and data collection and monitoring efforts. Our findings raise important questions about whether the programme itself and supporting services that it may feed into are adequately resourced to achieve positive outcomes for attendees, and whether current delivery models may produce inequitable outcomes.

Authors' methods: Survey of local authorities and realist review of the literature. 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. Survey response rate lower than anticipated; review findings limited by the availability and quality of the literature. We conducted a survey of LAs in England and a realist review of the literature. We followed the methods described in our published protocol and were guided throughout by input from two stakeholder groups, composed of members of the public eligible for NHSHCs, and professionals involved in commissioning and delivering checks. We conducted literature searches to assemble a set of documents likely to contain data that could be used to refine our IPT. We re-used existing resources to compile relevant material by screening the contents of PHE’s regularly updated bibliographies of evidence relating to the NHSHC and documents included in PHE-commissioned rapid reviews. We supplemented these with searches in MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Health Management Information Consortium, Web of Science (SCI-EXPANDED, SSCI) to identify material excluded from the existing bibliographies and reviews. In addition, we trawled the NHSHC website to identify local evaluation documents and conference materials, which we knew were an important source of data on learning from local NHSHC implementation and delivery.

Project Status: Completed

URL for project: https://www.journalslibrary.nihr.ac.uk/programmes/hsdr/NIHR129209

Year Published: 2023

URL for published report: https://www.journalslibrary.nihr.ac.uk/hsdr/RGTH4127

URL for additional information: English

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: England, United Kingdom

DOI: 10.3310/RGTH4127

Organisation Name: NIHR Health Services and Delivery Research programme

Contact Address: NIHR Journals Library, National Institute for Health and Care Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK

Contact Name: journals.library@nihr.ac.uk

Contact Email: journals.library@nihr.ac.uk