The NHS Health Check programme: insights from a qualitative study of patients

Abstract

Objective

To provide an insight into the process of patients receiving Health Checks and to determine the extent to which patients were supported to reduce the risks of developing cardiovascular disease through behaviour change.

Methods

Semi‐structured qualitative interviews were undertaken with 45 patients about their initial experiences of undertaking a Health Check. They were followed up 1 year later to assess whether the behavioural changes reported after the Health Check had been maintained.

Results

Patients expressed a need for individualized support in order to stay motivated and to adopt long‐term diet and lifestyle changes.

Conclusions

Those involved in the delivery of the programme need to adopt a consistent approach in terms of explaining the purpose of the Health Check, communicating risk and consider the challenges and the barriers that influence behaviour change.

Introduction

Fifty‐five million deaths occurred globally in 2012. Two‐thirds of deaths were primarily due to four non‐communicable diseases: (i) cardiovascular diseases (CVDs), (ii) cancers, (iii) chronic lung diseases and (iv) diabetes.1 By far, the leading cause of death was CVD (mainly coronary heart disease, stroke, peripheral artery disease and aortic disease) which accounted for 17 million deaths worldwide.

In the UK, CVD is the leading cause of death affecting more than five million people,2 resulting in over 150 000 deaths each year. It is extremely resource intensive, accounting for around a fifth of all hospital admissions and incurring estimated health‐care costs of around £30 billion annually.3 Although mortality rates have decreased markedly in the last 40 years,4 the trend could be soon reversed. The main behavioural risk factors that are responsible for around 80% of coronary heart and cerebrovascular disease – such as alcohol use, physical inactivity and unhealthy diet – are all on the rise.5, 6 Moreover, the distribution of morbidity and mortality from CVD is skewed towards those from disadvantaged groups.7 In 2008, for example, mortality from CVD was 50% higher in the most deprived fifth of the population compared to the least deprived.8 Poverty is seen as one of the major determinants of CVD worldwide.9

In 2009, the NHS in England launched the vascular Health Check programme10 to prioritize and address the challenge of CVD. Known as the ‘Health Check’, it was one of the most ambitious and most expensive vascular risk reduction programmes ever undertaken with a projected cost of £4.5 billion in its first 20 years.11 The declared aims of the Health Check were as follows:

1. To identify and assess the risk of developing some form of CVD (mainly heart attack and angina), stroke, diabetes and kidney disease in individuals aged between 40 and 74;

2. To communicate the risk in a form that the patients clearly understood; and

3. To manage the risk through tailored advice, clinical management, signposting or referral to other lifestyle interventions and services.

The Health Check was designed to be implemented in general practices and other community settings, including pharmacies and work places, to make it accessible to a broader population.12 Patients considered to exhibit an elevated CVD risk greater than or equal to a 20% risk of developing CVD in the next 10 years were given advice and support about possible lifestyle changes that would help them to improve their health. Where necessary, treatments such as the prescribing of statins would be recommended or patients might be asked to return to have their diagnosed condition monitored, or referrals might be made to other services.

Economic modelling undertaken by the Department of Health11 concluded that, while the Health Check would cost around £332 million a year, it would lead to an annual benefit of over £3.7 billion (£64 billion over 20 years) and could potentially prevent 9500 myocardial infarctions and strokes per year.11 These costs are based on the assumption that 75% of patients offered a Health Check would take up the offer to participate. However, the Department of Health does not seem to have compared predicted with actual uptake. Data for 2011/2012 indicate that around 40% of those eligible did not attend,13 with variations of between 40 and 74% uptake between different health authorities. Furthermore, cost savings calculations assumed high levels of uptake and compliance from patients for both medication adherence and lifestyle intervention.11

Although a number of evaluative studies have been undertaken14, 15 looking at uptake, there is a dearth of research looking at the qualitative experiences of health checks. This study seeks to readdress the balance by exploring issues related to uptake, understanding of the programme and experiences of behavioural changes from the patients' perspective.

Methodology

Patients who had attended a Health Check were interviewed to explore the extent to which changes in behaviour had taken place post‐attendance. A follow‐up interview was conducted 1 year later to assess whether the changes in behaviour had been sustained.

Sampling

The evaluation took place in one of the largest cities in England ranked 44th of 354 local authorities in terms of deprivation and with a minority ethnic population of 16%.16 We wrote to all seven General Practitioner (GP) surgeries that were chosen by the local Primary Care Trust (PCT) to pilot the Health Checks and five (see Table 1) agreed to participate. From the two that declined, one was yet to start delivery due to staff shortages and the other was still negotiating with the PCT about which patient populations to target first. Ethical approval was granted for the entire study in August 2011 (10/H1304/22) by East Yorkshire & North Lincolnshire ethics committee.

Table 1.

GP practice profile

GP practice	No GPs	List size	Deprivation (percentile)	Experience of the health check	1st interviews	Follow‐up interviews
A	8	13 903	4th	12 months 9 months	15	14
B	2	2819	1st	10 months 24 months	8	6
C	7	11 687	1st	15 months 16 months	10	8
D	4	7104	5th	9 months 11 months	4	3
E	7	13 550	2nd	22 months 16 months 20 months 19 months 24 months	8	4
Total	Average GP practice size 7041			45		35

Three of the selected practices were in the most deprived quintile; the remaining two were in more mixed areas economically. In the three deprived practices, 50–90% of patients were categorized as ‘non‐white British’. Practice managers and staff involved in the delivery of the Health Check were briefed about the evaluation and informed about the recruitment procedure. All patients were provided with details about the study in the form of an information sheet and consent form after they had completed their Health Check. Patient interviews lasted approximately 30–45 min and were carried out in their homes or on NHS premises.

Topic guides were developed based upon the aims of the study and review of the relevant literature, these were tested and further adjustments were made after a piloting phase. The topic guides began with questions around patient demographics, reasons for attendance and general advice received. More specific questions followed exploring challenges and barriers encountered in terms of behaviour change linked with smoking, health eating and alcohol consumption. After the piloting phase adjustments were made, the order of questions was changed to provide more coherence and further questions were added to elicit more detail around intentions to change.

In total, 45 baseline patient interviews were conducted with patients who attended a Health Check (24 men and 21 women) with an average age of 58 (see Table 2). Thirty‐seven described themselves as ‘White’, 5 ‘South Asian’ and 3 as ‘African Caribbean’. Thirty‐eight follow‐up interviews were carried out with patients 1 year later. From the seven patients not followed up, we could not receive in contact with four despite repeated attempts, one interviewee had died and two refused to participate on the basis of ill health. Despite the patients lost to follow‐up, a particular strength of the study was that we managed to collect data from 83 interviews.

Table 2.

Patient interview sample

Patient no	Gender	Age	Ethnicity	Occupation	Comorbidities
1	M	53	White	Cleaner	Back pain
2	F	64	White	Retired (cleaner)	Back pain (work injury)
3	M	67	A/C	Retired (bricklayer)	High BP
4	M	72	White	Retired (catering manager)	COPD
5	M	58	S/A	Store manager	Asthma
6	F	65	White	Retired (office clerk)	Arthritis (knee)
7	F	48	White	P/T shop assistant	Thyroid
8	M	54	White	Credit manager	Back pain (car accident)
9	F	58	White	Payroll clerk	Sciatica
10	M	71	White	Retired (pharmacy assistant)	Arthritis (knee)
11	M	49	White	Incapacity benefit	COPD (awaiting transplant)
12	F	70	White	Retired (nurse)	None
13	F	52	White	Customer services assistant	Back pain (recovering from surgery)
14	F	63	White	P/T shop assistant	Asthma/thyroid
15	F	57	White	Incapacity benefit	Thyroid/ME
16	M	43	A/C	Unemployed (bricklayer)	Depression
17	M	48	White	Health & safety manager	High Blood pressure
18	F	46	A/C	Administrator	High Blood pressure
19	M	49	White	Transport consultant	Back pain
20	M	65	White	S/E computer consultant	Eczema
21	F	68	White	Retired social worker	Chronic headache
22	M	61	White	S/E housing exec	None
23	F	49	White	Support manager	None
24	M	59	White	Technical sales	Heart disease (SVT)
25	M	66	White	P/T Lecturer	Acid reflux/Prostatitis
26	F	60	White	Call centre operative	Asthma
27	F	50	White	Project manager	None
28	F	54	S/A	Unemployed (PPI co‐ordinator)	Lichen sclerosis
29	M	48	White	Engine fitter	None
30	M	56	White	SE electrical contractor	None
31	M	72	White	Retired business exec	Mental breakdown
32	F	74	S/A	Retired nurse	Asthma
33	M	50	White	Plasterer	Paranoid schizophrenia
34	F	54	White	Accountant	None
35	F	42	White	Lecturer	None
36	M	55	White	S/E handyman/property developer	High Blood pressure
37	F	47	White	Unemployed (cook)	None
38	M	61	White	Contractor	Previous MI
39	F	68	White	Retired Teacher	Eczema
40	F	49	White	Homeopath	None
41	F	52	White	Social Worker	None
42	M	64	White	Head teacher	None
43	M	58	S/A	Cleaner	Osteoarthritis
44	M	54	White	Handyman	Spondylitis
45	M	71	S/A	Retired (postman)	COPD/diabetes

COPD, Chronic Obstructive Pulmonary Disorder.

Data analysis

Interviews with patients were recorded and transcribed verbatim. The process of interpreting the transcripts took place as interviews were still being conducted as this gave the researcher the opportunity to explore emerging themes in greater detail in subsequent interviews. The interviews were analysed using the framework approach,17 which involved detailed familiarization with the data, identifying key themes, interpreting the findings within the context of similar research studies, and considering policy and practice. The emerging analysis was thematic and iterative and was discussed with the steering group and analysed independently by colleagues.

The outcome of analysis led to the identification of four main inter‐related themes: understanding of the programme, advice from health professionals, barriers encountered in changing behaviour and responsibility for behaviour change.

Findings

Understanding

In any health screening programme, clear information needs to be provided about what the screening entails with possible benefits and potential harm identified so that patients can make an informed choice about whether or not to attend.18, 19 A choice to attend screening based on relevant knowledge leads to a positive attitude and can result in implementing changes in behaviour. Furthermore, evidence suggests that better knowledge of screening reduces anxiety in those recalled for further testing.20

Patients were invited to attend by letter, a telephone call or while they were in the GP practice for a unrelated appointment (opportunistically). While 28 patients were recruited opportunistically around a third (9) disliked this method and felt that they did not have enough time or information to make an ‘informed’ decision:

Didn't really explain what it was about, didn't really know what it was about, thought it was to do with the kidney and that – the nurse didn't explain nothing, she just said go over there and get checked. If a nurse says that to you, you don't argue (43‐year‐old African Caribbean male).

No not really. Not straight away. Do they know something I don't? Sort of got a bit frightened at first cause no one explained anything about it! a bit out of the blue to tell you the truth (58‐year‐old white female).

There was confusion about the Health Checks from some patients who associated it with a visit to the surgery for a variety of reasons (e.g. cholesterol or blood pressure check or weight measurement) and not specifically CVD. In part, the confusion arose from some health professionals referring to the programme as a ‘Health MOT’ and not specifically mentioning CVD.

Ten (22%) patients did not understand the purpose of the Health Check at all. They acknowledged that this was in part due to their paying insufficient attention to the information sent to them. For example, one patient wanted to have her blood pressure monitored as well as attending a weight reduction programme like Weight Watchers and felt that the NHS should provide this:

I don't see why I should be paying…if it wasn't for my blood pressure I probably would go to Weight Watchers, but because of the state my blood pressure was in and it was always, seemed to be climbing up, I have to keep pushing to have it checked the proper way (46‐year‐old African Carribean female).

Other unmet expectations included other types of screening; for example, one person who had previously experienced a health check provided by her employer, thought the check should include breast/testicular cancer screening and an assessment of mental well‐being. Another patient wanted an ECG while another would have liked a test for anaemia. Although these suggestions did not fit within the stated aims of the Health Check, the unmet expectations left patients feeling that their appointment could have given them more information. However, this did not mean that they felt dissatisfied with the Health Check – only one patient indicated that they were not satisfied.

When probed on the reasons for attending the Health Check, patients' primary objectives were to ensure they were in good health, that nothing serious was wrong with them and to identify whether they were suffering from a condition such as diabetes, high blood pressure or high cholesterol. Other motivating factors for attending for around half of the interviewees were a family history of heart disease or knowing someone who had been diagnosed with a heart condition or other life changing illness:

I think me history in't looking too good, family history in't looking over‐brilliant. My father died quite a few years ago. He died from a massive heart attack, From what I can remember, he got double pneumonia and jaundice, which left him with leaking heart valve (53‐year‐old white male).

I thought it was a good idea because in, in my family we've got the curse of cancer, right through my, my relatives, mum and dad's side, everything, my mother's side mostly. She's lost all her brothers and sisters, lost her mother through cancer (71‐year‐old White female).

The majority (82%) of participants had other health conditions, ranging from relatively minor/well‐controlled conditions like asthma/eczema to more serious conditions like Chronic Obstructive Pulmonary Disorder (COPD). Participants with more serious conditions either now or in the past were especially keen to check whether they were also at risk of developing a heart condition:

I have COPD and am waiting for a lung transplant so I think my heart could be weak anyway but its good to make sure (49‐year‐old White male).

As a child I had a heart condition and took medication for years – it eventually cleared up but you never know if something is lurking (59‐year‐old White male).

Advice from health professionals

A primary objective of the Health Checks was to generate a risk score to estimate the likelihood of a patient developing CVD in the next 10 years. However, only around a quarter of people interviewed could recall their score, with most describing it as either good or bad showing only a partial understanding of the outcome. A few interviewees did not understand what their score meant and this caused them to be anxious.

There was also some confusion over the results of cholesterol scores. Only 6 interviewees could recall their score although most patients had a sense of whether their score was good or bad. However, around a third of interviewees said that they were confused even after they had seen the GP as they had not understood what they were told in the appointment. They were unable to absorb the information during the follow‐up appointment and thought of questions that they might have asked only after they had left.

Some patients suggested that, in addition to an appointment with a doctor, a written confirmation of the test score would have been helpful:

Well I suppose it's good to have a question and answer thing cos you can have somebody explain it to you. But I suppose you could, something written'd be quite useful, they could actually also give you like a printout of it…to say your weight's this, your BMI's this, your cholesterol's whatever, and this is what it means, this is the risk factor, this is what you can do, and if you've got any questions contact this number, or something like that (54‐year‐old White female).

She [nurse] give me the results over the phone for me and wife, she said, I'm nought point something, you've got to score over twenty to be worried. I'm nought point, no, me wife's nought point summat percent didn't get a word of it? Why didn't she write it down and send it in the post (67‐year‐old African Caribbean male).

While the majority of participants (35) were on the whole satisfied with the interpersonal skills of the person delivering the Health Check, problems were identified in terms of how risk was communicated to them, as they reported either receiving mixed messages regarding their health status or being given incomplete advice.

Health checks were mainly conducted by health‐care assistants (HCAs) or practice nurses, and this was appreciated by patients as it gave them more time than if they were with a doctor. Nevertheless, a third of participants reported that they would have liked more time at the Health Check to have issues explained to them more clearly.

The way the results of the Health Check were delivered varied significantly. Some patients were told that if they did not hear from the practice everything was fine, while others were recalled several weeks or, in one case, months later. Most participants said they would have liked a follow‐up letter clearly outlining the outcomes of the check. Over two‐thirds said they were not informed of their CVD risk score. According to some patients, the risk score was described in terms of ‘low, medium, high’, while others were told they were ‘normal’ or in the ‘red zone’.

Some GP practices interpreted the Department of Health guidelines10 above and insisted on a follow‐up appointment with the doctor, regardless of their risk score. This was appreciated by patients as an opportunity to discuss health matters in depth:

I think I have a very good relationship with my doctor and my, you know, I think she takes the time to listen and I think she's excellent. So yes, we talked, she explained the difference between good and bad cholesterol (49‐year‐old White female).

I wasn't really expecting to be called back in for a chat as before when I have been for blood test results no one has called me back to say if it was ok or not…it made a nice difference… like someone really cares (58‐year‐old South Asian male).

Barriers encountered in changing behaviour

Evidence suggests that health professional's attitudes towards patients, including their beliefs and prejudices, can have a profound impact on the clinical encounter.21, 22 A number of participants felt that the nurses/HCAs had adopted a patronizing attitude and had already assumed that they did not care about their health. They recognized that being told by nurses/HCAs that they were overweight, that they needed to take more exercise and/or quit smoking and being given a leaflet was not adequate.

Participants reported that they would have liked further engagement on an individual basis and needed support to stay motivated and to adopt long‐term diet and lifestyle changes that would make a difference to their lives. In terms of changing behaviour, the four main areas of lifestyle identified were as follows: (i) smoking cessation, (ii) physical activity, (iii) healthy eating and (iv) alcohol consumption. Weight management advice was linked to either physical activity or healthy eating or both, depending on patients' responses. Although some patients expressed their intention to change their behaviours, most had been offered a behaviour intervention strategy by their GP practice prior to attending a Health Check appointment. Figure 1 compares patients' intentions to change their behaviour prior to and after the Health Check with the extent of the change 1 year later.

Figure 1.

Intentions to change.

Smoking

Smoking was a significant recurring theme, as over half the participants were previous smokers and around one‐third identified themselves as current smokers.

Nine of the smokers said that they wanted to give up and intended to try to quit smoking, comparison of baseline data with 1‐year follow‐up showed that only one person was persuaded to do so as a result of the Health Check. While smokers highlighted receiving verbal advice about their smoking behaviour, the majority were not offered any assistance in how to give up.

Physical activity

Almost all participants were asked about the levels of exercise they undertook. Over half were physically active, undertaking activities such as gardening, walking, playing sports but did not necessarily meet recommended levels of activity. Worryingly, the remainder were not undertaking any exercise. The majority of participants (37) were advised to increase their exercise levels and were given practical tips such as getting off the bus one stop early, or taking part in sports.23 Ten felt that the nurse/HCA failed to provide tailored advice that took into account their individual capabilities such as injuries and other health problems or their particular circumstances such as availability of recreational spaces and childcare issues.

Healthy eating

While around two‐thirds of the sample said that they wanted to improve their diet (see Fig. 1), 17 said that they wanted to do so as a direct result of the Health Check after being given advice and leaflets on how to make small changes to their diet. However, a number of patients, especially from lower socio‐economic groups, encountered barriers in adopting healthy eating, citing the cost of eating fresh fruit and vegetables.

Alcohol consumption

The overwhelming majority (40 of 45) interviewees drank alcohol.

Only eight participants intended to reduce their alcohol consumption and only four of the eight as a result of the Health Check. Medical staff discussed alcohol in terms of units without further elaboration/explanation:

Well she (nurse) were talking about units but I don't do units cos I don't know what they are, I don't understand what a unit, what a unit is. Well she just said “You need, you need to cut it down to” I think she said about three, I might be wrong, three units or three drinks? (50‐year‐old White female).

When I smoked I was quite a heavy drinker. I was sort of eight pints a day man. I have cut down now to about 3‐4 pints a day. The nurse asked me and I told her…she looked shocked and started going on about recommended daily allowance… what does that even mean? (72‐year‐old White male).

Changes to lifestyles

Patients were interviewed 1 year later to see whether they had implemented the changes to their lifestyle discussed in the first interviews (see Fig. 1). While a number of changes had been sustained – most notably an increase in physical activity and health eating – smaller gains were achieved in smoking cessation and alcohol reduction. The attribution of these changes to the Health Check is uncertain, as people had attended other NHS appointments as well as the Health Check in the meantime.

A recurring theme present throughout analysis was that of ‘responsibility’. Participants from across all socio‐economic groups felt that responsibility for changing behaviours and adopting healthier lifestyle choices was down to them and not the responsibility of the NHS:

I think, I, I personally don't think it's up to NHS to help me lose weight, I think I should be, I should be doing that myself. I think the NHS have got enough to do, you know, with people that are ill, I think the responsibility's down to the person, yeah all you can get from the NHS really is advice (53‐year‐old White male).

So absolutely it's completely and utterly my responsibility, and I tried to make it my responsibility about three or 4 years ago, cos my dad had a stroke and my kids were younger and I thought well I need to sort of be a bit more serious about myself for them (58‐year‐old White female).

Discussion

The findings suggest that there was a feeling amongst patients that the Health Check programme had failed to communicate adequately the importance of risk, for example how having a 2% risk differed from having an 18% risk. Patients believed that the programme preferred to recommend statins rather than to encourage behavioural changes and that it focused too much on physical health to the detriment of mental health. Work‐related stress, which can have a negative impact on smoking, drinking, eating and sleeping patterns, was mentioned by a number of patients. Although the educational and advisory element of the Health Check was valued by some patients, they reported that merely knowing what an individual should do did not automatically lead to a change in behaviour. This echoes findings that most people do not think that they can reduce their personal risk of developing heart disease by following a particular lifestyle.24 Patients wanted health professionals to be more proactive in advocating health‐related messages and outlining the lifestyle services available.

In this study, we found insufficient evidence to suggest that behaviour change was an outcome of attending the Health Check. While on the whole it was seen as a potentially worthwhile exercise for those that stood to benefit the most, the experience left most patients with unfulfilled expectations. It is widely recognized25, 26 that motivating diet and lifestyle changes is much more than a matter of increasing awareness of the availability and benefits of the service. The particular challenge is that of changing behaviour when a person feels well and has no physical symptoms of ill health and therefore no compelling reason to take action. That said, some patients were able to point to success stories, particularly in relation to weight loss or smoking cessation where this was linked to particular interventions and in‐practice services.

In terms of study limitations, although this was a modest qualitative study carried out in one city, we believe that we interviewed a sufficient number of patients and that our sample was representative of Health Checks attendees. We also acknowledge that face to face interviews as a data collection tool for assessing behaviour change can be problematic in terms of social desirability bias.27 This occurs when the interviewees do not answer questions honestly because they perceive the truth to be socially unacceptable or undesirable or may feel judged by the interviewer.28 We did, however, aim to minimize this type of bias29 by ensuring privacy at the outset and making it clear that we were in no way connected to the NHS. Additionally, taking into consideration that the list of patients from which we purposively sampled was chosen by health‐care staff, could have potentially excluded those that may have been critical of the service or biased towards those who were likely to give a more positive account. The very limited involvement of non‐English speaking patients in particular black and other minority ethnic groups and other hard‐to‐reach groups (homeless, drug users) highlights, the need to explore further the specific needs of these groups.

Even though the UK Government has an agenda of self‐management30, 31, 32 for patients at risk of chronic conditions, and this is incorporated into the Health Check programme, terms such as ‘self‐care’ and ‘self‐management’ were not mentioned by participants; instead, the term ‘responsibility’ was widely used. A number of participants felt that responsibility for changing behaviours and adopting healthier lifestyle choices was theirs and not that of the NHS. However, the idea of self‐management is itself problematic, as it assumes that positive behaviour change will automatically follow after patients are provided with information that increases their knowledge of risk. Even though patients are empowered when they receive information, their ability to change is highly dependent on other factors such as family support, peer group influence and socio‐economic circumstances.

Conclusions

Participants were generally very supportive of the Health Check programme, and examples of behavioural change and earlier detection of risks were recorded. This study has highlighted several areas where improvements could be made in future. More detailed recording of the uptake of the Health Check and the changes indicated by the risk score needs to be carried out, and a greater consistency of approach is required, particularly in relation to the follow‐up to the Health Check. This should take into account both individual health factors and their overall risk score.

Recent changes in the delivery of primary care services have seen responsibility for Health Checks devolved to local authorities from Primary Care Trusts, and it remains to be seen whether they will critically evaluate delivery with a focus on longer‐term outcomes and introduce the necessary changes to increase uptake.

Declaration of conflicting interests

The Authors declare that there is no conflict of interest.