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Observational study of a locally enhanced service to increase uptake of primary care vascular checks ("NHS Health Checks")

Project title
 

Observational study of a locally enhanced service to increase uptake of primary care vascular checks (“NHS Health Checks”)

 
Project reference
 

98

 
Final report date
 

4th August 2016

 
Project start date
 

14 February 2011

 
Project end date
 

30th June 2015

 
Project duration
 

4 years

 
Project keywords
 

Cardiovascular, NHS Health Checks, population-based and preventative services, primary care, public heath

 
Lead investigator(s)
 
  • Dr Jeremy Horwood, Centre for Academic Primary Care, University of Bristol 
 
NIHR School Collaborators
 
  • Professor Gene Feder, Centre for Academic Primary Care, University of Bristol
  • Professor Alan Montgomery, University of Nottingham
 
Collaborators
 
  • Dr Ruth Riley (Senior Research Associate, Centre for Academic Primary care, University of Bristol)
  • Dr Nikki Coghill (Senor Research Associate, Centre fr Academc Primary Care, University of Bristol)
  • Vivienne Harrison (Consultant in Public Health, Bristol City Council)
  • Amanda Chappell (Commissioning Manager for NHS Health Checks, Bristol City Council)
 

Project objectives

The aim of this study is to investigate the effectiveness of a locally enhanced service (LES) for screening and treatment intervention for cardiovascular disease in primary care, and to understand patients’ and health care professionals’ views and experiences of NHS Health Checks. 

Specific research questions are:

  1. Does the LES result in increased and equitable (by socio-economic status and ethnicity) attendance for cardiovascular checks?
  2. Does the LES result in increased and equitable uptake of behavioural and drug treatments?
  3. Does the LES result in greater and equitable reductions in modifiable risk factors and estimated cardiovascular risk?
  4. What are the range of views and experiences of patients from varying socio-demographic backgrounds, regarding cardiovascular checks?
  5. What are the triggers and barriers to patients’ accepting/declining cardiovascular checks?
  6. What is the impact of receiving high or low risks result from cardiovascular checks and information needs?
  7. What is the acceptability and feasibility of cardiovascular checks for health care professionals?

This is a multimethod study, comprising of two components:

  1. An observational before-and-after study of the LES.
  2. A qualitative study using semi-structured interviews with patients and health care staff.

Changes to project objectives

Alan Montgomery was the original PI for the grant, but after moving to University of Nottingham was no longer able to lead the work and Jeremy Horwood took over as PI.

Due to extremely long delays in the Health Checks programme commencing in NHS Bristol PCT (as was), the start of the project was delayed. Further, the project duration was extended (at no cost) in order to allow the Health Checks programme to run for at least 12 months, so that sufficient data would be collected for analysis. 

Brief summary

Qualitative Methods

Semi-structured interviews were conducted with patients who had attended an NHS health check and healthcare staff, including GPs, and staff carrying out NHS health checks (practice nurses, healthcare assistants (HCAs) and  pharmacists).  Eight GP practices in Bristol were purposively selected to obtain practices with populations from a range of socio-economic situations (SES) using the practice level indices of multiple deprivation (IMD) scores. Practices in the most deprived quintile are designated as ‘1 SES’ and practices in the most affluent quintile are categorised as ‘5 SES’. Eligible patients for the interviews were identified through a search of patient records for a) patients who had undertaken a health check within the previous  6 months and b) patients with low (<10%), medium (>10% <20%), high (>20%)  Q risk 2 scores.  A total of 541 invitations were sent to patients who had attended a health check, 95 (14%) replied. For those who agreed to be contacted a purposive sample taking account of SES,  Q risk 2 scores, ethnicity, gender, and age.

A range of staff from participating practices were subsequently recruited via invitation letter. Interviews were conducted by one researcher (RR) and lasted between 20 and 60 minutes. This study was approved by the NHS Ethics Committee South West 4 (ref 10/H0102/39).

Data collection and analysis were conducted in parallel and interviews continued until data saturation was reached and no new themes were arising from the data. With written informed consent, interviews were audio-recorded and anonymised transcripts were imported into NVivo10 and were analysed using thematic analysis. Analysis was ongoing and iterative, informing further data collection.  RR initially coded the data and a subset of 6 transcripts were independently analysed by JH to contribute to the generation and refinement of codes and thematic categories to maximize rigor.

Analysis

Data collection and analysis were conducted in parallel and interviews continued until data saturation was reached and no new themes were arising from the data. With written informed consent, interviews were audio-recorded and anonymised transcripts were imported into NVivo10 and were analysed using thematic analysis. Analysis was ongoing and iterative, informing further data collection.  RR initially coded the data and a subset of 6 transcripts were independently analysed by JH to contribute to the generation and refinement of codes and thematic categories to maximize rigor.

Qualitative Findings

In total 28 patients (11 men and 17 women, aged 40-74 years) and 16 HCPs (4 health care assistants, 5 GPs, 5 practice nurses, 1 pharmacist, 1 administrator; 5 men and 11 women, aged 25-62 years) were interviewed.  Main findings:

The findings suggest that the motivations for attending NHS health checks for many patients were underpinned by health beliefs associated with the value of preventative health care.  Patients wanted to prevent heart attacks or stroke, particularly when there was a family history of CVD. Highlighting the value of early detection and the prevention of CVD could be used to inform future promotional strategies in the hope of increasing patient uptake of the service.  Other accounts reported in this study such as not wishing to be a burden on family or society may reflect the adoption or influence of prevailing discourses relating to the “burden” of an ageing population 1. However, as reported previously 2 3,  a few patients viewed the NHS Health Check as a general screening programme to identify non-CVD related diseases.  This highlights the importance of ensuring the purpose of the NHS Health Check is communicated clearly by practices and in NHS publicity.

HCPs highlighted their concerns about inequity in uptake and evidence of the inverse care law, in terms of low attendance from those who are most likely to benefit.  As a result, practices and commissioners may need to consider the expansion of NHS Health Checks into community settings (workplace, community pharmacies) to ensure equitable uptake.

These findings from both professional and patient accounts are a reminder of the need to ensure HCPs are suitably equipped to interpret and communicate information accurately, sensitively and informatively to patients. Suitable guidance and training needs to be provided to HCPs to ensure that high risk results are followed up swiftly and managed sensitively to avoid patients experiencing anxiety.  In circumstances where patients are invited for follow up tests in response to high, medium or borderline risk results, HCPs need to provide reassurance and clear information about options, to avoid or alleviate anxiety amongst patients. Some patients in this study had not understood the significance of CVD risk factors such high blood pressure or high QRisk2 scores which may limit the value of attending. Consequently, HCPs need to ensure that risk information is communicated both verbally and in written formats, adopting a patient centred approach which takes account of the individuals’ circumstances and preferences.

The findings from this study suggest that HCPs may be failing to provide personalised lifestyle advice tailored to the individual in order to meaningfully inform, motivate and support patients to make lifestyle changes, as suggested in NHS Health Checks guidance4.  HCPs need to consider and acknowledge the psychosocial constraints which may influence a person’s ability or preparedness to make changes. Adopting such approaches has also been highlighted in a recent draft competency framework for HCPs delivering NHS Health Checks which has emphasised the need to ensure HCPs employ behaviour change techniques ‘to deliver patient appropriate lifestyle advice and how it can reduce their risk’ 5 pp20.  Public Health England 6 require NHS Health Check commissioners to provide high quality training to HCPs carrying out NHS Health Checks and will therefore need to consider ways of meeting the above training needs to ensure HCPs are competent to carry out health checks and support patients to make lifestyle changes.

Accounts from patients and HCPs have highlighted the implications of attending a health check with mixed reactions from patients. This relates to benefits from attendance, including relief and reinforcement of healthy lifestyles and lifestyle change for some. However, for some, anxiety may be experienced in relation to unexpected results and whilst awaiting re-tests.  The emotional impact associated with NHS Health Checks in terms of their potential to raise anxiety is highlighted as a potential drawback in the general screening literature yet has not been widely reported in relation to NHS Health Checks. 

Qualitiative Conclusion

This study has identified the varied motivations for attending an NHS Health Check and the potential benefits and challenges associated with doing so. The findings suggest the potential benefit of highlighting the prevention and early detection of cardiovascular disease to increase attendance. To improve patient satisfaction and improve facilitation of lifestyle change, it is vital that HCPs conducting the NHS Health Checks receive the appropriate training to equip them with the necessary skills and knowledge to deliver the service using a patient-centred approach.

Quantitative Methods

A cross-sectional, observational study of patients registered at primary care practices in Bristol, and who met the eligibility criteria for an NHS Health Check from 18th February 2010 to 23rd October 2014 (56 months).

All participating practices were encouraged to sign up and provide permission for their practice electronic patient records to be interrogated remotely by the commissioning support unit in Bristol (CSU); the CSU are an independent organisation, commissioned by Public Health Bristol to provide selected data to local health care commissioners.

The CSU wrote electronic searches to extract anonymised, individual, patient-level data from these practices using the electronic medical record systems’, (EMIS) Search and Report facility (ESR).

Based on anonymised, linked, patient level data from participating practices, quantitative data was collected at an individual level and further anonymised prior to receipt for analysis. Identifiable data such as date of birth was converted to age, deprivation status was derived by converting postcode, to Lower Super Output Area (LSOA), a small geographical area with a mean population of 1,500 people, which was further converted to an index of multiple deprivation (IMD), (Lad 2010) at source. We intended to ascribe ethnicity based on the 2001 census definitions (ref), from data recorded in EMIS, the electronic, primary care medical records system. ESR identified data on any cardiovascular medication prescribed up to three months after the date of the check and referrals onto lifestyle services up to eight weeks after the completed check.

To compare our data against the total eligible population we used a snapshot of data taken on 1st February 2010, from eligible patients prior to our data collection period.

Stata V13.1 was used to clean and analyse all data. Descriptive statistics were employed to describe the populations. Binary logistical regression equations were constructed to explore associations between invitation or attendance for an NHS Health Check and potential demographic determinants of health and the management of cardiovascular risk factors; these included, the number and types of medication prescriptions and referrals or signposting to behavioural lifestyle services such as smoking cessation, weight management and alcohol support services. Results are reported using 95% confidence intervals (CI).

Primary analysis: to investigate the associations between deprivation status and ethnicity in those who attended for a cardiovascular check.

Secondary analysis: to examine associations between deprivation status and management of cardiovascular risk factors.

Quantitative Findings

Eligible patients who received an invitation for an NHS health check, and who were between the ages of 39-75 were included in the analysis.

On 1st February 2010, out of the 53 GP practices in Bristol, 110,288 patients were eligible for an NHS Health Check. 38 practices agreed to provide data and 14 declined. IMD scores were normally distributed across participating practices and non-participating practices.

Invitations

During the data collection period, June 2010 – October 2014, 31,881 patients were invited for an NHS Health Check. Over twice as many patients were invited from the three most deprived quintiles compared with those in the first two least deprived quintiles.

Attendance

NHS Health Checks were completed on 13,733 patients Over the four-year data collection period (2010-2014) the number of NHS Health Checks completed across the 38 practices increased from 68.4 to 459.8 checks per month.

In summary, men were less likely to attend compared to women (P<0.01, OR 0.7, CI: 0.67-0.80), older rather than younger patients were more likely to attend (P<0.01, OR 2.5 CI: 1.89-3.39 for > 70 years compared to aged 45-49 years).

Due to the poor recording of ethnicity particularly in those who did not attend for their NHS Health Check following an invitation, it was not possible to examine ethnicity as a predictor of attendance

Cardiovascular medication prescription: Within three months following completion of an NHS Health check, 1161 new prescriptions for cardiovascular medications were issued to patients. Age and gender were significant predictors for the prescription of CVD’s.

After controlling for age, gender, national IMD quintile, ethnicity and QRisk score, compared to men, older women, <70 years (P<0.01,OR 1.64, CI: 1.14-2.35), who were classified as being at high risk of CVD (P<0.01, OR 6.16, CI: 4.51- 8.40), were most likely to be prescribed cardiovascular medication.

Referral to lifestyle services: Within eight weeks following the completion of an NHS Health Check there were 695 recorded referrals onto lifestyle services: weight management n=414, smoking cessation service n=250, physical activity service n=37, dietician n=26, health trainer n=13, alcohol service n=1. Additionally, a further 10,381 patients were either signposted or given lifestyle advice within eight weeks of their NHS Health Check. However, several practices felt this was an underestimation of the number of referrals to lifestyle services.

The following groups were most likely to be referred to lifestyle services: younger women (p<0.01, OR, 2.22, CI: 1.69-2.94), those in the most deprived national IMD quintile (P<0.01, OR 3.22, CI: 1.63-6.36) and those who were at highest risk of CVD (P<0.01, OR, 2.77, CI: 1.91-4.02). There was no trend for GP practices either the most or the least deprived areas to refer patients to a lifestyle service.

Quantitative Conclusions

There was no evidence of inequity of attendance for an NHS Health Check. Controlling for age, gender or socio-economic status, women and those with a high Q-risk score, were most likely to be prescribed a cardiovascular drug or referred to lifestyle services. Additionally, those in the most deprived nation quintile for IMD were most likely to be referred to a lifestyle service. 

References

  1. Mort M RC, Callén B. Ageing with telecare: care or coercion in austerity? Sociol Health Illn 2013;35(6):799-812.
  2. Chipchase L, Waterall, J., & Hill, P. Understanding how the NHS Health Check works in practice Practice nursing 2012;24(1):24-29.
  3. Burgess C, Wright, A. J., Forster, A. S., Dodhia, H., Miller, J., Fuller, F., Cajeat, E. and Gulliford, M. C. . Influences on individuals’ decisions to take up the offer of a health check: a qualitative study. . Health Expectations 2014.
  4. Department of Health. NHS Health Check Programme Best Practice Guidance. In: England PH, ed., 2013.
  5. NHS. NHS Health Check competence framework: Draft for consultation April/May 2014, 2014.
  6. England PH. The NHS Health Check implementation review and action plan. In: England PH, ed., 2013.

Plain English summary

Background:  The NHS Health Checks programme is a mandatory public health service to help prevent vascular conditions. Patients aged between 40 and 74 are invited every five years for a Health Check, to assess their risk of developing vascular conditions. We examined the experiences of patients attending and health care professionals (HCP) conducting NHS Health Checks, as well as examining the equity of uptake of an NHS Health Checks and the management of any identified risk factors for cardiovascular disease (CVD).

Findings: Interviews were conducted with a purposive sample of 28 patients and 16 HCP recruited from eight general practices across a range of socio-economic localities.  Patients were motivated to attend a NHS Health Check because of health beliefs, the perceived value of the programme, a family history of cardiovascular and other diseases and expectations of receiving a general health assessment.  Some patients reported benefits including reassurance and reinforcement of healthy lifestyles.  Others experienced confusion and frustration about how results and advice were communicated, some having a poor understanding of the implications of their results. HCP raised concerns about the skill set of some staff to competently communicate risk and lifestyle information.

There was no evidence in inequity of uptake for an NHS Health Check. Patients at greatest risk of CVD were most likely to be prescribed medication for this or be referred to an appropriate lifestyle service. Additionally, those living in the most deprived areas were most likely to be referred to a lifestyle service. 

Conclusions: Publicising the value of early detection of cardiovascular risk may increase attendance. To improve the satisfaction of patients attending and improve facilitation of lifestyle change, HCP conducting the NHS Health Checks require sufficient training to equip them with appropriate skills and knowledge to deliver the service effectively.

There was no evidence of inequity in attendance for an NHS Health Check. In Bristol, the NHS Health Checks programme was successful in treating those patients at greatest risk of CVD compared to those with a lower risk of CVD, and referring those in the most deprived areas of Bristol to lifestyle services.

Dissemination

Published articles

  1. Riley, R., Coghill, N., Montgomery, A., Feder, G., & Horwood, J. (2015) Experiences of Patients and Health Care Professionals of NHS Cardiovascular Health Checks: a Qualitative Study. Journal of Public Health. September, 1-9. Available at: http://jpubhealth.oxfordjournals.org/content/early/2015/09/24/pubmed.fdv121.short?rss=1

  2. Riley, R., Coghill, N., Montgomery, A., Feder, G., & Horwood, J. (2015) The Provision of NHS Health Checks in a Community Setting: an Ethnographic. BMC Health Services Research, 15:546. Available at: http://www.biomedcentral.com/1472-6963/15/546

  3. Coghill, N., Montgomery, A., Horwood, J, & Feder, G. NHS Health Checks: A cross- sectional, observational, quantitative study on equitability of uptake and selected outcomes. Journal of Public Health. https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-018-3027-8

Presentations

Horwood, J. Riley, R. Coghill, N. Montgomery, A. Feder, G. (2014) An Ethnographic Account of the Benefits and Challenges of Providing NHS Health Checks at Community Outreach Events. Society for Academic Primary Care Annual Research Meeting, 9-11th July, University of Edinburgh.

Horwood, J. (2014) Benefits and Challenges of Providing NHS Health Checks at Community Outreach Events. Public Health England Avon, Gloucestershire and Wiltshire NHS Healthchecks Learning Network. Public Health England, Bristol. 6th April.

Riley,R. Coghill, N. Feder, G. Montgomery, A. Horwood, J. (2014). An Ethnographic Account of the Benefits and Challenges of Providing NHS Health Checks at Community Outreach Events. South West Society for Academic Primary Care Annual Research Meeting, University of Bristol, 6-7th March.

Public involvement

This was an observational study so no PPI was involved in designing the study

Impact

The work has heightened the need for staff delivering NHS Health Checks to be adequately trained to deliver results and provide lifestyle advice. These recommendations have been taken up by Bristol City Council who have included them in their quality assurance guidelines and have prompted them to deliver motivational interviewing training to staff delivering NHS Health Checks.

Additionally, as men were less likely than women to complete an NHS Health Check, recommendations relating to targeted promotion for men have been made to Bristol City Council. These recommendations are now being implemented through the targeting of male drivers at taxi ranks and men in betting shops.

This project was funded by the National Institute for Health Research School for Primary Care Research (project number 98)

Department of Health Disclaimer

The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR School for Primary Care Research, NIHR, NHS or the Department of Health.