COMMENTARY

Is It Time to Improve the NHS Health Check Programme?

Prof Kamlesh Khunti 

Disclosures

June 18, 2021

This transcript has been edited for clarity.

Hello, my name is Kamlesh Khunti. I'm professor of primary care diabetes and vascular medicine at the University of Leicester. Thank you for joining me, and I'd like to discuss the NHS Health Check programme with you today.

As you all know, cardiovascular disease remains the largest cause of premature mortality. But there have been significant improvements with cardiovascular disease reduction in all Western countries, but still widening in socio-economic gradients still remain in the UK, and in many developed countries.

In 2009, the NHS Health Check 5 yearly programme started in England, with the aim of reducing heart attacks and strokes and identifying people with dementia – who were aged 40 to 74 years - by assessing their major risk factors. The programme measures a number of markers, such as body mass index, blood pressure, cholesterol levels, and includes lifestyle questions regarding alcohol intake and physical activity.

Interventions

Following testing, patients receive lifestyle advice or subsequent interventions to reduce the risk of developing cardiovascular disease in the future. When risk factors are found, people can get behavioural support, and treatments with medications.

In 2020, the programme completed its first decade, with coverage averaging around one million people annually.

A recent paper has just been published in the British Journal of General Practice, which is describing the NHS Health Check Programme, including the attendance, new diagnoses, and treatment in relation to a number of equity indicators.

In terms of the study, they used a nationally representative database. The QResearch database is derived from 1500 general practices, capturing data from 2009 to 2017, covering around 35 million people.

Attendance Data

The authors compared the NHS Health Check attendance, new diagnoses and treatments by age, sex, ethnic group, and deprivation.

The key results were that between 2013 and 2017 around 17% of eligible people aged 40 to 74 years attended an NHS Health Check, with 83% not attending, and attendance was variable.

South Asian ethnic groups are most likely to attend and Black and Chinese ethnic groups less likely to attend compared to the White ethnic groups. Females were also more likely to attend than males.

In terms of new diagnoses, they were more likely in attendees than non-attendees, as one would expect.

For example:

  • Hypertension was diagnosed in 25 per 1000 attendees compared to 9 per 1000 non-attendees

  • Type 2 diabetes in 8 per 1000 versus 3 per 1000 non-attendees

  • Chronic kidney disease in 7 per 1000 attendees versus 4 per 1000 non-attendees

  • In people aged 65 years and over, atrial fibrillation was newly diagnosed in 5 per 1000 attendees compared to 3 per 1000 non-attendees

  • And finally, dementia was diagnosed in 2 per 1000 attendees versus 1 per 1000 non-attendees

Type 2 diabetes, hypertension, and CKD were more likely to be diagnosed in deprived communities, and in certain ethnic minority groups, such as South Asians, Black African and Black Caribbean ethnic groups.

Statins

Attendees were also more likely to be prescribed statins than non-attendees, as well as antihypertensive medications.

In terms of statin prescribing in those who had a 10-year cardiovascular risk greater than 10%, of those who were eligible, only 8.3% were prescribed them.

In terms of attendees with a 10-year risk of between 10% to 19%, only 6% were treated with a statin.

In those who had a 10-year risk greater than 20%, about 18% were treated with a statin.

South Asians were more likely than Black African, Black Caribbean and Chinese ethnic groups to be prescribed statins compared to the White ethnic groups.

In terms of top line results of those who attended health checks:

  • One new case was diagnosed for hypertension for every 40 people attending

  • One new case of type 2 diabetes for 130 attendees

  • One new case of CKD for every 138 attendees

  • One new familial hypercholesterolemia case for every 1118 attendees

  • And in attendees aged 65 to 74 years of age, 1 new case of atrial fibrillation was detected for every 209 people who attended

Type 2 diabetes diagnosis was between three to six times more likely in South Asian ethnic groups compared to the White ethnic groups, and CKD and hypertension were more likely in Black Caribbean, and Black African groups.

Further Evaluations 

So, in summary, NHS Health Checks has contributed to finding a number of people with diseases, such as hypertension, diabetes, those at high risk of cardiovascular disease, CKD, and dementia.

However, the study conclusions were that policy review should consider a targeted approach prioritising those at the highest cardiovascular risk for face-to-face contacts, and they should consider other options for those at low risk.

The results showed that increasing attendance rates is key.  The COVID-19 pandemic has disrupted the NHS Health Check programme, and maybe it's now time to reflect and review and improve attendance rates in those who are at the highest risk.

We need further evaluations in terms of what the attendance has resulted in, in terms of risk factor control. We need to look at follow up of prescription for appropriate therapies for those who are at the highest risk, including CKD, hypertension, those at high CVD risk, and glucose lowering therapies.

We also need to start evaluating the longer-term benefits of such an ambitious programme in terms of mortality benefits, and we need to ensure that the wide socio-economic and ethnic disparities that were present before the pandemic, and highlighted by the pandemic, are reduced in the near future.

Thank you very much for joining me.

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