NHS over-40s health check: how nurses can make it bigger and better

It was never just for the worried well, but now a major revamp will extend its reach

• The NHS Health Check programme is here to stay, but uptake is patchy and a review will look at how to improve it
• Some say the cardiovascular focus of the checks should be widened to encompass other non-communicable disease risk, as well as mental health
• Nurses will deliver more personalised interventions, with the option of online health checks

When he worked in front-line practice, Jamie Waterall confesses, he would not have had a clue about just how potent prevention actually is.

Now as deputy chief nurse for Public Health England, he knows only too well – which is one of the reasons he is such a big fan of the NHS Health Check programme, which is currently being reviewed.

Preventable myocardial infarction levels are high

‘I’m a cardiology nurse by background and worked in acute care and cardiology, and if you’d asked me at that time what percentage of patients coming in with myocardial infarction under the age of 75 that we could prevent I don’t think I’d have been able to tell you,’ he says.

‘But now, working in public health, I do know, and it’s 90%. So if 90% of those things can be avoided, why do we continue, as a system, to invest most of our resource and efforts in just treating people when they finally get these diseases?

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‘The idea of the health check is bringing the evidence-based risk-reduction interventions for those big risk factors – smoking, obesity, physical inactivity, blood pressure, cholesterol, and so on – and trying to scale up the interventions we know work.

‘That’s still at the centre of what we do, but now’s the time to think about how we make that bigger and better.’

A whole-population approach to health screening

The NHS Health Check, in which everyone in England aged between 40 and 74 is invited every five years for a kind of MOT, mainly focusing on cardiovascular risk and tailored health and lifestyle advice, has not been without controversy.

Critics have pointed to patchy uptake and argue that resources would be better spent on targeting those most at risk, rather than taking a whole-population approach. And it is likely to change. In summer 2019, the Department of Health and Social Care (DH) in England published a green paper on prevention, with a review of the current NHS Health Check programme as a central plank.

‘There’s been strong local public health leadership in driving this programme… and going out and trying to get to those high-risk vulnerable communities’

Jamie Waterall, deputy chief nurse for NHS England

‘We’ve learned a huge amount from NHS Health Check – it’s been around for ten years – but now’s the time to think about how we can build on the existing programme and make it bigger and better’, says Professor Waterall, who was until recently national lead for the NHS Health Check programme.

‘Unfortunately, some read into a recent announcement about the review and said that the programme was being stopped, and that absolutely is not the case.’

NHS Health Check uptake in deprived communities

So why is England persisting with a policy that has attracted some controversy? According to Professor Waterall, successive evaluations of the scheme have refuted many of the claims made by critics and have shown that it is worthwhile.

The evidence shows it is reaching high-risk, vulnerable communities and that there is no social gradient in uptake – in other words, it’s not just the middle-class, worried-well who respond to the invitation to attend. ‘The largest national evaluation showed there were actually slightly higher numbers of the most deprived population getting the check, compared to the most affluent,’ he says.

‘It’s definitely time to revisit why we aren’t engaging larger numbers of people’

Professor Waterall

‘There’s been strong local public health leadership in driving this programme forward over the past ten years, and one where local areas are going out and trying to get to those high-risk vulnerable communities.’

The evaluations have been ‘hugely helpful’, Professor Waterall adds. ‘We know that around 50% of people offered the check aren’t taking it up. So it’s definitely time for us to be revisiting why we aren’t engaging larger numbers of people.’

Reducing health inequalities and addressing mental health

The RCN has expressed some scepticism about the programme’s impact and says it hopes the review will consider how the programme can act to reduce health inequalities and better meet the needs of deprived and excluded groups. It also calls for mental health to be addressed more effectively.

‘We don’t see the health check as a single isolated practice – we see it as the start of health improvement for people’

Lesley Hardman, head of primary care development, Bolton Clinical Commissioning Group

The college adds: ‘Nurses can help to design creative and unique approaches that target hard-to-reach groups for health checks, such as through collaborative working with local health improvement teams.’

Across the country, clinical commissioning groups and local authorities are taking imaginative approaches to health checks, and the review will look at ways of harnessing new technology to reach more people.

The town where the health check is just the start of ill-health prevention

With uptake levels of more than 80%, Bolton in Greater Manchester has every right to be proud of its health checks.

The programme is jointly commissioned by the local authority and clinical commissioning group (CCG), and is at the heart of the Bolton Quality Contract, which all 49 local GP practices sign up to every year.

Nurses are key to the programme’s success, says CCG head of primary care development Lesley Hardman – as is seeing it as part of a systemic approach to illness prevention and population health.

‘The start of health improvement’

‘We don’t see the health check as a single isolated practice – we see it as the start of health improvement for people. If you just do a health check and find that people are at high risk of developing cardiovascular disease in the next ten years, say, it would be really naïve just to say to them they need to make some changes to their lifestyle.

‘These people don’t feel ill – they go away and don’t do anything about it. So for us, getting them into the health check is the start of the journey. If we identify people who are at high risk, we bring them back every year and do an annual review.’

A flexible approach that involves the whole general practice team

Health checks are seen as everyone’s business, and are performed by practice nurses, GPs, healthcare assistants and health improvement practitioners. The idea is that every contact counts – and people can request a health check when they want one, not just when offered it.

Ms Hardman, a public health specialist by background, has four specialist nurses in her team whose role it is to support GP practices in health improvement. ‘We also have a nurse responsible for education and training of practice nurses, so every year we do health check updates with all the nurses in Bolton. We also have specific education for new practice nurses,’ she says.

The specialist nurses work one-to-one with practices that are performing less well, she adds. This includes finding the right patients, persuading them to come in for health checks, then using motivational interviewing skills to persuade them to make lifestyle changes. ‘It’s supporting nurses to improve their practice, which obviously has a big impact on the patient.’

She believes the current review should recognise health checks as the start of prevention and cautions against trying to add too much ‘extra’ into them. ‘If you try to cram in any more, it loses its value,’ she warns. 

How digital technology can enhance the health check offering

‘We’ve tested and looked at ideas on digital, and its role, particularly as future generations are so engaged in this,’ says Professor Waterall.

‘How do we use digital to enhance a programme like this, to support people taking up the check, but then to support the subsequent risk-reduction interventions? And how can we be using digital to support and signpost people with, say, weight management, or stopping smoking, or even some of the clinical elements of this around blood pressure or high cardiovascular risk?’

Health checks via mobile phone can reach people who will not engage in the traditional way

Some services have already adopted digital methods of getting to people who have not traditionally taken up their health check invitations. Southwark Council in London offers a digital version of the NHS Health Check. The idea, says cabinet member for public health councillor Evelyn Akoto, was not to replace face-to-face appointments, rather to reach more people.

‘Some people think health checks will be a waste of time – they don’t really think about the deeper implications of finding out what’s really going on with their body’

Evelyn Akoto, cabinet member for public health, London Borough of Southwark

Only around half of eligible residents in her borough responded to the standard health check invitation, she adds. So now, those who do not take up the offer are invited to do a digital health check instead.

This involves answering a series of questions about health and lifestyle to calculate the individual's cardiac risk, and each person is then given advice about maintaining a healthy lifestyle. Anyone assessed digitally as having a high risk of cardiovascular disease is encouraged to make a face-to-face appointment.

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‘Everyone is busy and some people think health checks will be a waste of their time – people don’t really think about the deeper implications of finding out what’s really going on with their body,’ says Ms Akoto. ‘So this is about making it an easier process for everyone, and to get them to start thinking about reviewing and checking their health.

‘Everyone – more or less – has got a phone now, so this is a very accessible way of supporting people, because they can do it at any time.’

Uptake so far has been encouraging – in the first eight months, 300 people who had previously not responded to the face-to-face invitation had completed the digital version, and 10% of those had been advised to contact their GP because of their cardiovascular risk.

Promoting uptake by going out into the community 

That does not mean the smartphone will be the way forward for all, says Professor Waterall.

‘I worked in Birmingham as a nurse consultant for a number of years and we were doing health checks even before the national programme came out, but we were going to places like the dog track and the football club. And actually, if you offer something like that in those settings, people take them up.’

NHS Health Check: now and in the future

• The service should be offered to everyone in England aged 40 to 74, every five years
• Different areas have developed their own ways of offering the checks, some through GP practices, others through community pharmacies, for example
• The health check aims to spot early signs of major conditions that cause early death, including stroke, heart disease, kidney disease and type 2 diabetes
• The review is exploring how to personalise the health check and offer interventions based on individual factors including age, where in the country the individual lives, and even their DNA. In practice, this could mean drinking advice might be aimed at people aged 40-49 because it is known that alcohol use is common in this age group, while people aged 70-74 could receive targeted advice on reducing blood pressure
• The review is also considering: a special check-up for those nearing retirement age to help prevent or delay future care needs; increasing the range of advice the checks offer to include, for example, musculoskeletal issues
• The review is exploring the digitisation of health checks where appropriate – for example, those at low risk of cardiovascular disease might benefit from online check-ups at less frequent intervals than those now offered
• The government will consider responses to the prevention green paper before setting a timetable for any changes

The role of nurses in steering the programme’s development

The DH will consider the responses to the green paper consultation before any decisions are made. Professor Waterall adds: ‘I certainly hope we’ve had nurses responding, but we’ll obviously continue to engage with multiprofessional colleagues.

‘I’ve advocated for a long time that this programme is underpinned by nurse leadership. Obviously until recently we had me as a nurse leading the programme nationally, but the delivery of the checks is being managed and delivered by our nursing community.

‘It’s vital we consult our nursing colleagues closely to make sure the future design of what is proposed works’

Mr Waterall

‘In the bulk, it’s practice staff that are managing the checks with healthcare assistants, so it’s vital we consult our nursing colleagues closely to make sure the future design of what is proposed works. It clearly also needs to be very practical and we need to test the ideas out and work with colleagues before scaling anything up.’

In the future, he hopes the programme will shift its focus from something that is primarily looking at cardiovascular risk. ‘Really it’s a non-communicable disease (NCD) prevention programme,’ he says.

‘It’s looking at the top behavioural and physiological risk factors that we see in the Global Burden of Disease study, contributing to the huge tide of NCDs, including cardiovascular disease, cancer, respiratory disease and dementia that’s driving the big burden of either premature death or health inequalities in our country.

‘And that is very important for all of us.’

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Jennifer Trueland is a health journalist