The NHS Health Check programme: a survey of programme delivery in England before and after the Covid-19 pandemic response

Patient and Public Involvement

Prior to project funding, we involved members of the public and charities in the drafting of the protocol. We sought feedback on the importance of the proposed study and on what we should focus on from members of two established public engagement in research groups (Public Involvement in Pharmacy Studies at Medway School of Pharmacy and Opening Doors to Research at the Centre for Health Services Studies), and from representatives from several charities with an interest in NHS Health Checks. Feedback highlighted the importance of investigating variation in experience and quality of the NHS Health Check by region and by professional groups delivering them, and outcomes related to NHS Health Check attendance, including changes in lifestyle. This feedback informed our research questions and study design and highlighted the importance of a survey alongside our realist review of the literature.

Throughout the project, our strategy for patient and public involvement (PPI) was informed by our PPI lead and co-author (VH). VH is an experienced PPI contributor who brought her valuable perspective as a member of the public, and skills in group facilitation. Our PPI group involved ten members of the public from six different English regions, all of whom were eligible to receive the NHS Health Check. Members were purposively selected to be as diverse as possible in relation to gender, age, ethnicity and geographical location, with the aim of capturing a range of different perspectives from individual members of the public. The group was consulted via regular online meetings throughout the project, using Zoom (Version 5, Zoom Video Communications, Inc.). They provided feedback on our draft survey questions, discussed our emerging findings, helped to shape our analysis, helped to develop practical recommendations for NHS Health Check delivery, and informed our dissemination strategies.

A separate professional stakeholder group also provided us with content expertise and a range of perspectives throughout the project, via regular online meetings using Microsoft Teams (Version 1.0, Microsoft Corporation). For this group, we recruited (via our project team’s existing networks and snowballing from these) 14 people across the following categories: LA commissioners, NHS Health Check providers, NHS Health Check trainers, and representatives from relevant health charities. In addition, we maintained close contact with Public Health England’s (latterly the Office for Health Improvement and Disparities) CVD Prevention Programme Lead.

The online survey (see extended data: supplementary file¹⁸) was developed in collaboration with our professional stakeholder group, using Jisc Online Surveys, to complement data gathered in the previous national survey of 2020, and also to capture a) detail about the delivery of the programme following the risk assessment, and b) any changes in delivery because of the pandemic response. It asked how the programme outcomes were monitored and whether LAs had commissioned, conducted or been part of any assessments of the programme in the previous five years. It included a mix of closed- and open-ended questions (19 in total), the latter to enable respondents to explain their responses and add any further relevant information about commissioning and delivery (illustrative extracts of these are presented in the Results). Four-point rating scales were used to obtain level of confidence in capacity (considering e.g., eligibility criteria, waiting times), accessibility (considering e.g., opening times, location, cost to users), and usage of support services (range from 1 ‘not confident at all’ to 4 ‘very confident’). Designed to be completed by a lead person for CVD prevention or Health Check commissioning in each LA, the survey was piloted within seven LAs; three completed it fully and provided positive feedback, with one subsequent minor change made prior to launch.

Ethics approval was granted by the University of Kent SRC Ethical Review Panel (Division of Law, Society and Social Justice) (SRCEA id 0367).

The survey (with direct link and password) was disseminated to key individuals in all 151 LAs in England with responsibility for commissioning the NHS Health Check programme. Public Health England (PHE) (at the time responsible for overseeing the programme at national level) sent the survey on our behalf, using the same distribution methods as for their own previous surveys, via regional Health Check leads and the programme’s Local Implementor National Forum. It was also publicised via the established NHS Health Check webinar series. It opened 17^th May and closed 18^th July 2021, with two reminder emails sent by PHE, and a third targeted reminder sent to Health Check leads in regions where the response rate was below 35%. The questionnaire was preceded by an information page, a privacy notice and a consent form. Active consent was required to proceed with the form. Individuals completing the survey were invited to provide their name and email address if they wished, to allow us to send the findings of our research. Names and contact information were separated from the data file and stored separately from all other information.

Survey responses were downloaded into Microsoft Excel v2304 (RRID:SCR_016137) and IBM SPSS Statistics v27 (RRID:SCR_019096). Where individuals responded for more than one LA (where LA public health teams are merged), unique identifiers were given to both respondents and LAs. Single responses provided on behalf of multiple LAs were copied exactly. Open-ended question responses were used to clarify or amend responses where relevant.

Data analysis

Simple descriptive statistics were used to analyse quantitative responses, which were enhanced and illustrated by qualitative responses, where the open comments sometimes provided clarification or further detail. One response was amended, where the respondent had not ticked ‘pharmacist’ as a provider, but had told us in a free text comment that pharmacists were used to deliver the Checks. A typology of Health Check delivery was derived from the data, in consultation with our stakeholder group (see Results).

The research team and stakeholder groups were interested in whether delivery method was associated with support service availability, accessibility and use, and whether commissioners with more complex delivery methods also used additional factors to prioritise Health Check invitations and/or engaged in more monitoring of their providers. Therefore, we assessed associations between category of delivery and: total number of commissioned support services reported, total number of referral processes reported, average reported confidence in capacity, accessibility and usage of support services, total number of methods used to prioritise invitations pre- and post-Covid-19 pause, and total monitoring and evaluation reported.

Our emerging review findings and discussions with our professional stakeholder group pointed to additional key variables understood to be of significance to Health Check programme delivery. For each of these variables, statistics were obtained from publicly available data, and associations assessed between these and delivery category. The variables used were: geographic region; estimated population for 2019; Public Health budget per head, 2019/20; Indices of Multiple Deprivation (IMD), 2019; and proportion of eligible people receiving a Check between 2015/16 and 2019/20 https://www.healthcheck.nhs.uk/. Rurality was an additional factor perceived likely to influence Health Check delivery but was not possible to include given the way it is classified at district, rather than county council level.

One-way analysis of variance was used to assess associations. Relationships between variables were assessed using Spearman’s correlation coefficient.

Typology of NHS Health Check delivery

A typology of delivery was developed through an iterative process, looking across the data to compare and contrast delivery locations, modes and staff involved (these aspects are presented in more detail in the sub-sections below). The professional stakeholder group were consulted regarding various iterations of the typology. The 74 LAs represented in our sample were categorised as:

This typology is depicted diagrammatically in Figure 1.

Figure 1. Typology of NHS Health Check delivery.

Location and mode of Health Check delivery

In 64/74 LAs, delivery of Checks had resumed since the Covid-19 pause. General practice was the most common setting for face-to-face delivery both pre- (73/74) and post-Covid pause (64/64). Other commonly used venues pre-Covid were community settings such as workplaces, community centres and places of worship (n = 30; 41%) and pharmacies (n = 16; 22%); however, these had reduced after the pause in delivery to 15 and 9 respectively. The use of alternative (remote) methods of delivery increased, mostly via the telephone (two pre- and 26 post-Covid pause) and video (one pre- and 11 post-Covid) and the range of venues expanded to include a Covid vaccination centre. Several LAs used multiple remote methods, including on-line self-completion of the Health Check assessment. Two had used a remote digital check pre-Covid; one discontinued this post-Covid pause, while the other increased its availability.

To provide partially remote Health Checks, 11 LAs required the patient to attend the practice for blood tests; six others used data on file, providing they were sufficiently recent. In two LAs, a drive-through blood testing service was used. The future potential use of remote methods combined with face-to-face testing was regarded positively by most respondents (n = 54; 75%). Several described how they were operationalising these, for example:

Online completion of a lifestyle questionnaire prior to a face-to-face appointment was variously seen as a way of reducing the time taken for the Check, but also offering the potential for prioritising those most able to benefit and to enable the face-to-face appointment to focus on risk communication, personal support and advice. Conversely, others (e.g., LA04, LA07, LA20) were gathering the physical measurements in a face-to-face appointment followed by a telephone consultation to discuss the results and offer interventions. Many were uncertain about what would work best in the future. Some were trialling these new methods; others were waiting for guidance on how to proceed.

Health professionals involved in Health Check delivery

Several respondents indicated within the open comments some uncertainty about which health professionals were currently employed (in 2021/2022) to deliver the programme, due to the commissioning process. For example:

Overall, respondents indicated that the professionals most frequently involved in delivering Checks were health care assistants and/or nurses, followed by GPs, both face-to-face and remotely (Table 2). Other providers included wellbeing advisers, health improvement practitioners, lifestyle coaches and paramedics. Seven respondents reported that the category of professional delivering the Checks had changed following the Covid pause. Delivery by leisure centre and primary care staff was reported to be more problematic. As staff were mobilised for the vaccination campaigns, more healthcare assistants were involved in Health Check delivery and fewer nurses or GPs. Some areas reported making less use of health trainers, and in some areas LA staff and paramedics were taking over delivery.

Prioritisation of eligible candidates

Data in Table 3 shows that many LAs did not consistently use factors such as ethnicity, deprivation or other risk factors to prioritise invitations to the Health Check. The most frequently used factor for prioritisation pre-Covid was deprivation (Table 3). After the Covid-19 pause, more LAs used a range of factors to target individuals, including Covid risk, with some areas starting to prioritise where they hadn’t previously done so.

Examples cited in the ‘other’ factors category included: diagnosed mental illness, homeless, from a traveller community, inactivity, routine and manual workers, and gender/age (e.g., men over 65).

Some respondents recognised that targeting by risk was desirable but not always feasible, as illustrated by the following comment:

Services to support risk reduction/management

The majority of responding authorities reported at least one service being available to support smoking cessation, alcohol and drug misuse, weight management, diabetes prevention, psychological support and social prescribing; some indicated no service, or that they didn’t know who provided the service (Table 4). Many reported having more than one provider for some services. Five respondents reported also commissioning physical activity/exercise on referral services. Most of these services were provided through public, private or third sector commissioning; some were provided by GP or LA staff.

Most respondents provided ratings for their level of confidence in the capacity and accessibility of the support services available in their LAs. However, several felt unable to do so, especially for services that were not commissioned by the LA. This is reflected in the variable amount of missing data and in several comments from respondents, which highlighted the difficulty of pulling together information across a very fragmented system.

Confidence in the capacity to support Health Check referred patients was mostly positive, but this varied across the different services (see Figure 2).

Figure 2. Commissioners’ confidence in the capacity of services to support Health Check patients.

Several comments explained the variation in level of confidence around capacity, including reasons for poor provision, with one reporting no local services at all for weight management and stop smoking services:

Confidence in the accessibility of the services (Figure 3) was similar and directly correlated to confidence in the capacity (Spearman’s r = 0.752; p <0.001). Respondents were least certain about whether psychological support services had sufficient capacity and accessibility.

Figure 3. Commissioners’ confidence in the accessibility of services to support Health Check patients.

All respondents provided an overall confidence rating for the extent to which appropriate use was made by Health Check providers of the available support services. This was generally low, with over half of the respondents (n = 50; 68%) having relatively little/no confidence. Reasons for the lack of confidence varied, including lack of awareness among providers and lack of data on use of these services:

Changes in either capacity or accessibility of support services since the Covid-19 pause were reported by 40 respondents while 13 reported no change, and 15 didn’t know. Several described the impact of moving support services to online provision as affecting both accessibility and capacity both positively and negatively.

In some areas, Covid-19 has prompted greater investment in support services, e.g., increased funding for and an expansion of tier-two weight management service, more social prescribing due to an increase in Primary Care Network link workers, and more funding for substance misuse services.

Referral processes

Multiple processes were reported for enabling Health Check attendees to access follow-on services in many LAs, although some respondents did not know the referral processes in place in their area (Table 5). As with the services themselves, awareness of the referral processes was least well known for psychological support services. Smoking cessation services had the greatest range of referral options. The number of referral processes reported was strongly related to the number of services commissioned across the LAs (Spearman’s r = 0.423; p <0.001).

In 12 LAs, respondents reported that referral processes had changed following the Covid-19 pause. Changes were mainly positive, with increased accessibility to self-referrals and clearer gateways to a range of services.

Monitoring and evaluation

The number of LAs that monitored the outcomes of Health Check programmes was relatively low. Twenty-two (31%) respondents gathered data on GP referrals, and 30 (42%) on the outcomes from such referrals, e.g., new diagnoses; 24 (34%) gathered data on referrals to lifestyle support services, and 19 (26%) on the outcomes from these, e.g., weight loss. Information gathered on the uptake of prescriptions (8; 11%), and on the outcomes of prescribing, e.g., lowered cholesterol (4; 6%) was even lower. Fewer than half the LAs (33; 46%) reported any evaluation or assessment of their local programme in the last five years.

Associations between delivery category and other variables

An association was found between the delivery category and the total number of commissioned follow-on services reported. The mean number of commissioned services was significantly higher in the LAs categorised ‘blended with outreach’ (7.6) compared to ‘general practice’ (6.6) or ‘blended’ (5.9) (F = 3.85; p = 0.026). The LAs falling in the blended with outreach delivery category also had the highest mean number of referral processes (8.0), compared to those categorised as general practice (7.5) and blended delivery (7.0), although the difference was not statistically significant (F = 0.311, p = 0.764).

Respondents’ confidence in the capacity, accessibility and usage of the support services varied little across the categories of delivery, although trends were visible in the confidence in accessibility and usage with the increasing use of non-general practice-based delivery (Table 6).

The number of methods used to prioritise invitations was not related to the category of delivery, but LAs in the blended and blended with outreach categories reported a greater increase in the number of factors used post-Covid pause compared to LAs in the general practice delivery category. The degree of monitoring and evaluation reported as being undertaken was also unrelated to the category of delivery.

There were notable differences in the proportions of LAs in the three delivery categories in each geographical region. Whilst five out of the seven responding LAs in Yorkshire and Humber fell in the blended with outreach category, seven out of the nine responding LAs in the North West fell in the general practice delivery category (Figure 4).

Figure 4. Proportion of LAs in the Health Check delivery categories by geographic region.

There were no significant differences in the relative size of the LAs falling into each delivery category, although the LAs delivering via community outreach tended to be larger than those in other categories.

There were also no significant differences in the relative size of the public health budgets of LAs, or in the relative deprivation of LAs falling in each delivery category. With regards to Health Check programme delivery performance, LAs delivering Checks using a blended with outreach model achieved, on average, a lower coverage (37.8%) than those delivering using a general practice (46.7%) or blended (45.4%) delivery model (F = 3.217; p = 0.046). However, as the boxplots show, the medians (the lines within the boxes), interquartile ranges (the box lengths) and the overall spread (whiskers) were overlapping, indicating that the categories were not significantly different in respect to programme delivery performance (Figure 5).

Figure 5. Health Check delivery performance by category of delivery.