Abstract

Summary

Introduction:
This report is an update of a rapid review of evidence published on the NHS Health Checks
programme in 2017. This update includes evidence from the original review (studies published
between 2009 and 2016) alongside evidence indexed up until the end of December 2019. The update uses this enlarged body of evidence to re-address the following six research objectives:
1. Who is and who is not having an NHS Health Check?
2. What are the factors that increase take-up among the population at large and sub-groups?
3. Why do people not take-up an offer of an NHS Health Check?
4. How is primary care managing people identified as being at risk of cardiovascular disease
or with abnormal risk factor results?
5. What are patients’ experiences of having an NHS Health Check?
6. What is the effect of the NHS Health Check on disease detection, changing behaviours,
referrals to local risk management services, reductions in individual risk factor prevalence,
reducing cardiovascular disease risk and on statin and anti-hypertensive prescribing?
Methods
A rapid review of qualitative and quantitative data published between January 2016 and
December 2019 identified using a systematic search strategy within Medline, PubMed,
Embase, Health Management Information Consortium (HMIC), Cumulative Index of Nursing
and Allied Health Literature (CINAHL), Global Health, PsycInfo, Web of Science, Science
Citation Index, the Cochrane Library, NHS Evidence, Google Scholar, Google, OpenGrey,
Clinical Trials.gov, the ISRCTN registry, and through hand searching article reference lists.
Studies identified were initially screened by two researchers for relevance to the NHS Health
Checks and then against a set of pre-specified inclusion and exclusion criteria. Data were
extracted on to pre-specified, piloted data pro-forma by two researchers.
A 10% sample of the data reported in the original review were checked for consistency with
reporting in the primary studies from which data were extracted. As consistency was 100%
previously extracted and reported data were not re-extracted without indication.
The quality of the newly included studies were assessed by a single researcher using the
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relevant Critical Appraisal Skills Programme tools. Quality assessments were verified by a
second reviewer.
Synthesis of quantitative data was completed as an extension to the synthesis presented in the
original review. With a structured, narrative synthesis using, tables and data visualisation
undertaken as appropriate. Meta-analysis was not methodologically appropriate even where
feasible due to the high heterogeneity and low number of high quality studies reporting on each
domain in a consistent manner.
Synthesis of qualitative data was completed as an extension to that undertaken in the original
review. A three-stage thematic synthesis approach was completed with the newly identified
studies in order that we could add to and revise findings identified in the original review.
Completing a thematic synthesis incorporating just the new data alone to compare to the
original thematic synthesis, or re-completing the whole thematic synthesis were inappropriate
due to the lack of new qualitative studies identified.
GRADE, GRADE-CERQual and GRADE-Mixed methods were used to assess the certainty
and confidence in the research evidence contributing to each objective or sub-objective as
appropriate.
Findings
There were 97 studies (29 newly identified) addressing Objectives one to six. The 29 newly
identified studies contributed data to the synthesis addressing Objectives one (n=6/29), two
(n=9/31), four (n=3/21), five (n=2/22) and six (n=13/33). Of the 97 studies identified, 33
included data collected from 2014 onwards.
Who is and who is not having an NHS Health Check?
In total, 29 studies (six newly identified) contributed data to Objective one. Seven of the 29
studies reported on data from 2014 onwards.
The overall uptake of NHS Health Checks has increased by a small amount since the end of
2016, however, we are still a long way off having 75% of the eligible population attending.
Attendance patterns for 2017-2018 vary by region with uptake between 41.3 and 49.2%.
There is limited new data identified on coverage, most new evidence is on the unadjusted
characteristics of NHS Health Check attendees vs. non-attendees. This increasing body of
evidence shows that those most likely to attend an NHS Health Check are female, white British
and aged 60 or more. Further analyses are needed to understand why differences exist in the
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effects of ethnicity on attendance. New evidence indicates that smokers and those from high
levels of deprivation are less likely to attend. A single study using opportunistic invite within
a community setting observed an increased attendance from younger individuals.
There is low certainty in this body of evidence (29 studies) due to the study designs used, high
heterogeneity and inconsistency found.
What factors increase take-up among the population and sub-groups?
In total, 31 studies (nine newly identified) contributed data to Objective two. Twelve of these
31 studies reported on data from 2014 onwards.
These studies contribute evidence on the impact to uptake of the following:
Sociodemographic factors
Twelve quantitative studies (one newly identified) contained data on the demographics of those
attending vs. not attending an NHS Health Check after invitation.
Findings of a newly included study, a high quality RCT, almost mirror those from studies of
unadjusted characteristics of NHS Health Check attendees vs. non-attendees. The RCT showed
females, those >60 years old and those with lower levels of deprivation were more likely to
attend. Converse to the findings of unadjusted studies on characteristics of NHS Health Check
attendees vs. non-attendees, it showed that white British were less likely to attend than those
from an African/Caribbean, Asian or mixed background. Across the whole body of evidence
there is a lack of consistency in findings on the impact of ethnic background on uptake. Further
analysis are needed to understand these effects.
The certainty in the body of evidence informing these findings was rated as low as only one of
the included studies was an RCT. However, no other criteria affected the quality of this
evidence.
Invitation method
Thirteen quantitative studies (six newly identified) investigated the effects of variations in
invitation method on take up of an NHS Health Check.
Evidence shows that opportunistic invites in a general practice or community setting increase
uptake in particular amongst those at high risk of CVD and from ethnic minority groups.
Personalised invitational letters, an SMS pre- and post-invitational letter and invite via
telephone have also been shown to increase uptake. The strength of effect being greatest for
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telephone invite.
The certainty in the body of evidence informing these findings was rated as ‘very low’ as most
contributing evidence was observational and studies were identified as being at a high risk of
bias.
Six qualitative studies (one newly identified) contained data on the effect of invitation method
on take up of an NHS Health Check.
In the original review, telephone invitations were identified as preferred by patients due to their
informative immediacy and the perceived value of this. The single newly identified study
yielded no first or second order constructs leading to further analytical themes. However, its
findings added richness and depth to the following themes ‘Benefit of community ambassadors
for ethnic minority groups’ and ‘Differing opinions on opportunistic invitation dependent on
setting’.
Review findings for invitation method are supported with moderate to high confidence.
However, data from the primary publications that informed these findings lacks adequacy. In
particular, the whole body of evidence has limited richness and sufficiency to allow themes
and findings to emerge or to allow for dimensional comparisons.
Setting
Two newly identified quantitative studies assessed whether the setting of the NHS Health
Checks (community or pharmacy or general practice) influenced uptake.
Uptake did not differ dependent on whether invite was to a general practice or community
pharmacy, however, when NHS Health Checks were completed opportunistically there was
higher uptake at community outreach services. A greater number of those at high risk of CVD
and from hard-to-reach groups were more likely to take-up an NHS Health Check if it was
opportunistic, in both community and general practice settings. However, opportunistic
methods can only target people attending the settings within which they are conducted.
Qualitative data shows the need to allow those taking up an opportunistic invite time to digest
the invite information and to allow for informed decision making on their attendance.
The certainty in this evidence was rated as very low as both contributing studies are
observational, and showed imbalances in baseline characteristics between groups as well as
being deemed at risk of bias due to plausible confounding.
Why do people not take up an offer of an NHS Health Check?
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There were no new studies informing why people do not take up an offer of an NHS Health
Check. Ten studies in the original review found reasons for non-attendance were as follows: a
lack of knowledge on the purpose of the NHS Health Check, time constraints and an aversion
to preventative medicine. These analytical themes have been identified within the qualitative
data on individual’s experiences of NHS Health Checks, indicating their applicability and
transferability.
How is primary care managing those at Risk of CVD?
No further studies were identified reporting on delivery, recall systems, lifestyle advice
provided or service availability. It is likely the large regional variation in NHS Health Check
delivery and post-delivery management (lifestyle advice, referral to services or interventions
and follow up) identified in the original review remain.
Long-term impact of NHS Health Checks
One (newly identified) large, high quality quantitative study found NHS Health Checks were
associated with a decrease in CVD risk, BMI, smoking prevalence, blood pressure and total
cholesterol. Reductions could be due to improved patient management as lifestyle advice,
smoking cessation, prescriptions for statins and for anti-hypertensives all increased amongst
those who had an NHS Health Check. However, onward referral to lifestyle services varied
geographically. There was also an increase in the detection of new morbidities, however, the
effect varied by gender and deprivation level. Although this data is from a single study, the
study recruited nationally across England and could therefore be representative of the wider
population.
Healthcare professionals views towards NHS Health Checks and Delivery
Eighteen (three newly identified) studies provided qualitative data on how NHS Health Checks
affect risk management and health-care workers views of this. These data contribute to the
synthesis of healthcare workers views on the implementation and delivery of the NHS Health
Checks programme. No new first or second order constructs leading to further analytical
themes were identified. Extracted findings aligned with the analytical theme of ‘Doubts about
long term cost-effectiveness’ and ‘Inadequate training’. Studies identified add adequacy,
richness and thickness to the body of evidence included within the previously conducted
thematic synthesis.
Confidence in the evidence supporting concepts and outcomes on how CVD risk is managed
in primary care were judged as being moderate mainly due to a sparsity of quantitative
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evidence, plausibility of responder bias and potential lack of objectivity in studies identified.
What are patients’ experiences of having an NHS Health Check?
Nine quantitative studies and 17 (two newly identified) qualitative studies provided data on
patients experiences of NHS Health Checks.
There were no newly identified quantitative studies reporting patients’ experiences. Previously
high levels of satisfaction with the programme were reported. However, satisfaction is likely
linked with temporal factors and new patient survey findings could plausibly differ.
Two newly identified qualitative studies report patients’ experiences of having an NHS Health
Check. No new first or second order constructs that lead to new analytical themes were
identified within these studies. Extracted findings aligned with the analytical themes on
‘Understanding of the risk score’, ‘Quality of information (format detail and personalisation)’
and being ‘A potential trigger for behaviour change’. The following barriers to change were
identified: ‘Pressure to change rather than facilitation from practitioners’, ‘Perceived genetic
determinism (including of longevity)’, ‘Practical issues in joining change interventions’,
‘Environmental factors’, ‘Resources such as access to services’, ‘Cost and time to the
individual’ which are not always controllable.
Evidence contributing quantitative or qualitative data to the concept of patients’ experiences of
the NHS Health Checks were rated as low to moderate, with inferences made reflected across
both data types.
What is the effect of the NHS Health Check on:
Disease detection
There were 17 studies (five newly identified) reporting data on disease detection.
NHS Health Checks led to an overall increase in the detection of raised risk factors and
morbidities (raised hyperglycemia, pre-diabetes, diabetes mellitus, cholesterol, hypertension,
chronic kidney disease), however, the effect varied between diagnoses and in relation to gender
and deprivation level.
The certainty in the body of evidence on disease detection was judged to be very low due to
large variations in effect (likely due to ecological effects) and indirectness.
Changing behaviours
There were six studies (one newly identified) which assessed the impact of attendance at an
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NHS Health Check on health behaviour change.
The only intended behaviour change assessed is smoking. Findings from the newly identified
study indicate net reductions in smoking prevalence for NHS Health Check and control
participants over a six-year period following the intervention. However, comparative reduction
in smoking was greater for participants in the control group. Three studies in the earlier review
reported NHS Health Check participants were more likely to stop smoking compared to
baseline and, or, non-attendees. However another study reported no significant change over
time in smoking prevalence amongst NHS Health Check attendees following the intervention.
The certainty in the evidence is very low due to the observational study types identified,
opportunistically collated self-report outcome data with high risk of bias, inconsistency and
imprecision.
Referrals to local risk management services
Ten studies (four newly identified) report the effect of NHS Health Checks on referrals to local
risk management.
There was consistent evidence across the studies that amongst those attendees of an NHS
Health Check compared to non-attendees stop smoking advice and weight management advice
were more commonly given. As well as evidence of increases in referrals to smoking cessation,
dietician support, a physical activity service or an alcohol service.
The certainty in the evidence was rated as very low due to the observational nature of the
studies included, confounding, risk of bias, inconsistency in outcome measurement, poor
internal validity and large heterogeneity of effects.
Reductions in risk at the individual level
Five studies (one newly identified) included data on the effect of the NHS Health Check on
risk factor prevalence and cardiovascular disease risk.
Across the studies, after an NHS Health Check the following risk factors decreased: BMI,
diastolic blood pressure, total cholesterol and cardiovascular risk. Results for other risk factors
were inconsistent across studies although none saw an increase.
The certainty in the body of evidence was rated as ‘very low’ as study designs were mainly
observational and the largest study had high risk of bias related to the outcome which could
lead to poor internal validity.
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Reducing prescribing of statins/anti-hypertensive medication
Sixteen studies (four newly identified) report prescribing after an NHS Health Check. All
report an increase in statin prescribing amongst those who attend an NHS Health Check. Four
of five studies report an increase in anti-hypertensive prescribing; a single cohort study reports
a decrease in anti-hypertensive prescribing. The certainty in the evidence on prescribing was
rated as low because the majority of data came from observational studies and heterogeneity
of effects was present.
Modelling
In the earlier review, three microsimulation studies were identified which assessed the costeffectiveness of the NHS Health Checks programme based on different implementation
approaches. A further three economic modelling studies were identified. Two of these studies
were allied with one another assessing implementation and re-design scenarios using
demographic data from Liverpool’s population, risk factor exposures and CVD epidemiology
to assess health benefits, equity and cost effectiveness. The third assessed whether the impact
of the NHS Health Checks on BMI were sufficient to justify its costs. The findings from the
newly-identified studies indicated that equitability and cost-effectiveness of the NHS Health
Check Programme would be increased through the addition of policies targeting dietary
consumption; through combining current provision, with targeting of the intervention towards
deprived areas; and that modest changes in BMI from the NHS Health Check programme are
associated with significant cost-saving benefits making the programme cost-effective.