Original ResearchAssessing potential local routine monitoring indicators of reach for the NHS health checks programme
Introduction
The number of companies offering health checks suggests that such checks are sufficiently popular to sustain a market for private provision. The commitment to give ‘everyone in England … the right preventive health check-up’1 appears at least in part a response to this assumed popularity. Official estimates of the potential impact2 of an NHS Health Checks (NHSHC) programme and the explicit intention to tackle cardiovascular mortality3 appear to justify substantial investment. But, to date general health checks have not demonstrated important health benefits in clinical trials.4 Alternative approaches to targeting health checks5,6 and better application of our understanding of behaviour change7,8 should both improve the chances of bigger impact. Trials of the NHSHC model are underway to establish efficacy of the prevailing approaches in England.9,10, 11 Trial based evidence is of course fundamental to determining the efficacy of any public health programme, which is in turn a key determinant of population impact.12
Efficacy is not the only aspect of programme design that can influence programme impact. Other features include: the size and characteristics of the target population and extent to which it is reached (denoted in the RE-AIM Framework as Reach), the adoption of the intervention among provider organisations, and the fidelity of implementation.12 Formal research studies already give insight into the potential reach of NHS Health Checks programme.13, 14 But as this nationally determined programme is locally commissioned, there will be inevitable variation in local delivery.15,16 This means that research findings must be complemented by local monitoring, which will have to compete with local service delivery resources for time, attention and funds. So, finding ways of exploiting existing data sources becomes crucial to the success of the NHSHC programme.
Programme reach of the NHSHC Programme is already monitored, in that numbers of Health Checks are collected and reported across England.17 But potential impact also depends on the characteristics of participants, particularly as those with the greatest risk profile are typically reluctant to participate in prevention programmes.18 This Prevention Paradox appears to hold true for general health checks, which are less appealing to men, those on low incomes, or with low socio-economic status, the unemployed and the less well educated19 and may limit potential impact.20 Despite this, some experiences of NHS programme suggests that these tendencies could be overcome.21, 22
Despite relatively recent publication of national standards for the NHSHC programme23 much of the service specification, operating procedures and contractual requirements are locally determined. So there will be variability in both the service model, and in the information about participants between local programmes. Even where common information is collected (perhaps about risk management planning), differences in data definition and quality assurance systems will make comparisons between programmes problematic using these data sets.
Some relevant standardised contextual information is however routinely available. The size of disease registers linked to cardiovascular disease is reported for GP practices covering the population of England.24 These registers include conditions whose relatively silent presentations (hypertension, diabetes and chronic renal failure) mean they are of particular significance when assessing the impact of health checks for asymptomatic individuals. If those at highest risk are indeed participating in the programme, then the size of these registered populations should initially grow, and the effect of improved disease management should have a predictable impact on premature mortality.
So there are several indicators that could be used to monitor reach of NHSHC locally. The purpose of this study is to evaluate each of these against explicit criteria for their suitability as indicators for local service monitoring.
Section snippets
Populations and programmes
This study included the GP practice populations of Gateshead (35 GP practices), South Tyneside (29 practices) and Sunderland (54 practices); together covering 650,000 people in the North East of England. These programmes were established and funded together by the NHS based public health teams in 2009. They had common support arrangements, operating procedures and administrative procedures. These arrangements diverged with the development of new arrangements for both commissioning of NHS GP
Results
Of the 118 GP practices in the three localities studied, complete data were available from 101 (86%) (Table 1), who together undertook 20,405 health checks in the first round of analysis (year to September 30th 2011) and 18,595 health checks in the later, but overlapping, validation period (year to March 30th 2012).
Much of the variance between practices in numbers of IHR (77–92%) was explained by the number of NHSHCs performed (Table 2, Fig. 1a). For every ten NHSHCs undertaken, GP practices
Main finding of this study
Practice diabetes registers grew during 2011/12, but there was no correlation at GP practice level between NHSHCs undertaken and change in either diabetes or hypertension register size. Growth in disease registers is therefore unsuitable for monitoring local programme reach.
An association at practice level was observed between NHSHCs undertaken by practices and both IHR (NHSHCs explaining up to 92% of the variance between practices) and ICHt (NHSHCs explaining up to 60% of the variance). For
Conclusions
Data routinely available to NHSHC commissioners can support programme monitoring. The numbers of new cases of hypertension identified by practices and by local programmes is the most promising indicator of reach.
Acknowledgements
With thanks to Andy Billett for his encouragement through this work, to Bob Gaffney, Kathryn Muckles and Julie Hansen for securing the data, and to Faye Taylor and Jake Abbas for their comments on an early version of this work. Thanks also to anonymous reviewers, whose comments were of great assistance in developing this paper.
Ethical approval
No data identifying individual patients or practitioners was used in the conduct of this study. No ethical approval was requested.
Funding
No specific funding was made available
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2018, Health PolicyCitation Excerpt :We reviewed the literature to identify factors predicting uptake of health check programmes in high income countries (details of the inclusion and exclusion criteria are available on request from the authors). We identified 31 relevant studies [3,4,12,16,19–45] and grouped factors using Andersen's Behavioral Model of Health Services Use [18]. Predisposing factors included age group, proportion of males, proportion of white ethnicity, and deprivation level (terciles).
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