Southwark NHS Health Check evaluation v1
Research type
Research Study
Full title
Evaluation of the Southwark NHS Health Check service
IRAS ID
322199
Contact name
Russell Jago
Contact email
Sponsor organisation
University of Bristol
Duration of Study in the UK
1 years, 4 months, 31 days
Research summary
The NHS Health Check programme aims to detect early signs of long-term conditions among 40-74 year olds in England. If a person is found to be at high risk of developing a condition, they may be offered support to change their behaviour (e.g., help to quit smoking) or medications to lower their risk. Roughly 25% of adults who are eligible for a Health Check actually attend. Unfortunately, people who do not have a Health Check tend to be those more at risk of developing long-term conditions.
To encourage more people to have a Health Check, Southwark Council have made a digital version that people can complete online using a smartphone, tablet or computer. The digital Health Check is going to be trialled in central Southwark in January-March 2023. Approximately 6000 people in this area will be sent invitations to complete the digital Health Check - they will be able to choose to complete it at their GP practice (i.e., a standard Health Check) if they prefer.
In this project, we will investigate who uses the standard and digital Health Check services, what people think of them and whether they help people take action to improve their health. We will also evaluate the costs associated with digital and standard Health Checks, and explore whether we can estimate the long-term cost-effectiveness of the digital Health Check intervention. We will look at health record and survey data from January – March 2023. We will compare data for those sent invitations to standard Health Checks (N=3000) with those sent invitations to the digital Health Check (N=6000). We will also conduct interviews with Southwark residents (N=30), practice nurses, healthcare assistants and GP practice managers (N=10). The findings from this project will help Southwark and other councils throughout the UK to improve the Health Check service.
Summary of results
Adults aged 40-74 years in England are invited to attend an NHS Face-to-face Health Check service at GP surgeries every five years. The London Borough of Southwark recently launched a Digital Health Check to increase Health Check uptake, especially among those who need it most. This briefing summarises findings from a mixed methods evaluation study of both digital and Face-to-face Health Check services.Key points
The Digital Health Check was launched in the London borough of Southwark as an additional option to face-to-face delivery with the potential to reach a broader audience and offer additional capacity to the NHS Health Check programme as a service that could be easily scaled.
There was greater uptake of Health Checks among those invited to the Digital Health Check compared to the Face-to-face Health Check, especially among younger, white and more affluent individuals.
Most people who completed the Digital Health Check received advice based on a population-level risk rating. This pathway was associated with an estimated lower cost per service user. However, these people did not receive advice based on their specific physical measures, therefore the intervention is not comparable to the Face-to-face Health Check.
Methods for collecting and updating the physical measures (BMI, blood pressure, cholesterol and HbA1c) to identify users at high risk of cardiovascular disease or type 2 diabetes in the Digital Health Check were tested as part of this study and require further development. This limited the identification of high-risk users in the Digital Health Check and were associated with comparatively high costs compared to the Face-to-face Health Check.
Interviews with service users and Healthcare Professionals identified several benefits and barriers for both services.
Background: Eligible adults aged 40-74 years in England are invited to attend a NHS Face-to-face Health Check service at GP surgeries every five years. This aims to detect early signs of cardiovascular disease, type 2 diabetes, kidney disease, stroke and dementia. Behavioural support or further tests and clinical intervention to reduce the risk of disease are offered following the service. Between 2014 and 2019, 51% and between 2022 and 2023, 58% of the eligible people invited for an NHS Health Check in Southwark attended their Health Check. In January 2019, a pilot of the Digital Health Check was launched by the London Borough of Southwark to explore a digital solution to increasing health check uptake especially among those who need it most. This study covered the rollout phase of Digital Health Checks between January and April 2023.
STUDY AIMS
To firstly compare the uptake of both Health Check pathways and secondly to assess whether the Digital Health Check (DHC) was effective at engaging groups that the Face-to-face (F2F) service was not.
To estimate the costs associated with both service pathways.
To understand service users' and Healthcare Professionals' (HCPs) perceptions of both Health Check services.
Study methods: Between January and April 2023, 9000 eligible service users in North Southwark were invited at random to either attend either a F2F Health Check (n=3000) or a DHC (n=6000). Those invited to the DHC had the option to choose a F2F Health Check if they preferred. Those who attended the DHC had the option to do their Health Check based on their recent physical measures (BMI, blood pressure, cholesterol and HbA1c), if available, or going to get their measures taken elsewhere and updating the DHC afterwards. If they did not input any values for the physical measures then their results were calculated based on population-level risk ratings. Uptake rates and Health Check data were collected from Health Checks and used to calculate cardiovascular disease and type 2 diabetes risk.
Demographics and data on GP practice appointments, medications and referrals within the study period were extracted from patient records.
Cost estimates were based on resource data supplied by the London Borough of Southwark and national published data for the F2F pathway.
Semi-structured interviews took place with 30 service users and 8 HCPs. Questions were included on understanding why service users chose a type of Health Check, their experiences of the service, and suggestions for improvement.
FINDINGS
Uptake and Effectiveness of the Health Check Service
Uptake of Health Check Service
Health Check uptake among those allocated to DHC was higher than for those allocated to F2F. The completion rate was 11% for those allocated to F2F, whereas for those allocated to DHC, 21% completed the DHC health assessment section, with a further 3% choosing to take up a F2F appointment instead. While uptake of any type of health check was consistently higher for those allocated to DHC among all subgroups, there was no evidence that DHC uptake was disproportionately higher among groups less likely to engage in NHS Health Checks. There were differences in DHC-allocated uptake between ethnic groups which were not present for F2F, with DHC uptake of 29% for white and 14% for Black ethnicity, compared to F2F uptake of 12% and 12% respectively.
1.2 Engagement with the Digital Health Check Service
55% of those invited to DHC clicked on the link in the text message, and around half of those started the Health Check.
21% of those invited completed the DHC health assessment section, and 60% of those went on to complete the support & advice section.
Effectiveness of the service at identifying risk and increasing healthy actions
The DHC resulted in low levels of physical measurements. Only 23% of those completing DHC knew their blood pressure with a further 3% measuring and updating values, 7% knew cholesterol (3% updated) and 4% knew HbA1c (2% updated). Most users therefore received an estimated risk of cardiovascular disease and type 2 diabetes based on population-level risk ratings.
A higher percentage of those completing F2F were identified as at high risk of diabetes.
56% of those completing DHC were recommended to make a non-urgent appointment with their GP, and 1% were recommended to make an urgent appointment. Half (53% non-urgent; 50% urgent) did so within the time frame of the study. GP appointments, medications and referrals were higher for those completing F2F Health Checks than for DHC; these may be for any purpose, and not necessarily as a result of a health check.
Estimated Costs of the Health Check Services
The pre-study development costs were estimated at £261,000. The study management costs totalled £80,720 across both pathways. The operational costs of the DHC pathway were estimated to be £70,424 across the three phases of the pathway, relating to completion of the digital assessment - DHC completed - (42%), digital support (18%) and physical measures (40%). The operational costs of the F2F pathway were estimated to total £20,309, relating to uptake and identification (43%) and Health Check (57%). The estimated management and operation costs for completing the DHC health assessment section were £68.48 per user, compared to £154.80 per user for completed F2F appointments. The estimated management costs were allocated pro-rata between DHC and F2F users. These costs were specific to this study setting. Management costs have been omitted from other health check studies and would be comparatively low in standard F2F services. The estimated total cost per user at each stage of the pathways reflects the level of engagement with users. Note that these costs are for the completion of the health check only, and do not include downstream impacts such as preventing unplanned hospital admissions.
Understanding service users’ and Healthcare Professionals’ perceptions of both Health Check services
Face-to-face Health Checks
Benefits: Having health related discussions with healthcare staff. Adding context/individual factors to lifestyle questions. Immediate feedback. Ability to schedule follow-up appointments immediately. Barriers: Lack of available appointments and GP clinics and time constraints with running the service.
Quote: What bothered me is going to the GP physically, queuing there for I don’t know how long. Then, even if you have a slot where you should be, they always overflow time wise. And my issue is I don’t have time.
Digital Health Checks (Healthcare Professional perspective)
Benefits: Increases awareness of Health Check services.
Barriers: Lack of in-person contact. Accuracy of submitted answers and physical measures can’t be guaranteed. Unclear how F2F and DHC systems integrate patient information which may lead to confusion. Multiple steps involved for users. If service users come in to get physical measures taken and ask questions, HCPs were unsure if that saves time compared to a F2F appointment. Concerns about whether service users understand results.
* For clarity, half of HCPs interviewed were not aware of the DHC and half had only recently heard of the DHC. One HCP had experience of a service user who had used the DHC then returned to the clinic for follow ups.
Quote: I feel like people would then just be put off from doing it but if they just know that they can have it all done in the one go, it’s just going to take 25 minutes of your time, rather than completing this survey, sending it off… It then takes a couple of weeks, you know
Digital Health Checks (service user perspective)
Benefits: Straightforward and easy to use. Convenient. Allowed service users to take ownership of their health. Potentially alleviates NHS pressures. Personal preferences. No perceived judgement. Barriers: Lack of immediate in-person discussions. Forced response answers for survey. Physical measures led to mixed reactions; some did not want to do physical measures themselves/ would prefer a HCP to do them. Some found the advice too general, the results alarming and did not understand them.
Quote: Personally, yes, I think I prefer online. It’s maybe because I’m mostly introverted. Just going and meeting someone I think would be extra hard. Also, it’s in my own time. I think I’ve done that sometime late after work, so convenience is important.
BELOW ARE KEY FEATURES OF THE DHC DELIVERY THAT CANNOT BE CHANGED BUT SHOULD BE CONSIDERED FOR FUTURE ROLLOUT:
Lack of immediate discussion between service users and HCPs during the health assessment section.
Lack of ability for service users to clarify/add context to responses during the health assessment section.
The DHC may be more appealing to some population groups compared to others.
CONCLUSIONS AND RECOMMENDATIONS
While offering the DHC may make people more likely to take up a Health Check initially, this is seemingly at the detriment of doing a more thorough F2F Health Check, and so the DHC should be considered a complementary programme to face-to-face delivery rather than an alternative. While there is a clear desire for interaction during health assessments, some people prefer online services. However, strategies to extend Health Checks to reach under-served groups are still needed. Cholesterol and HbA1c were not generally known and the current options to obtain these measures require further development. In the meantime, Southwark’s DHC does not offer a viable alternative to the F2F service for estimating CVD and diabetes risk. Currently there is confusion with how the two systems integrate, particularly from the HCP perspective around patient information integrating into primary care records. Although the advice section in the DHC was engaged with, interview findings suggest some service users had a desire for more tailored advice.
RECOMMENDATIONS FOR FUTURE DIGITAL HEALTH CHECK ROLLOUT DESIGN:
Healthcare Professionals' awareness of the DHC needs to increase and improve.
The DHC needs to be better integrated with the existing F2F Health Check in terms of patient record systems and HCPs need to be made aware of this.
The methods for collecting, updating, and responding to physical measure data needs further development and piloting before potential rollout.
REC name
East Midlands - Nottingham 1 Research Ethics Committee
REC reference
22/EM/0280
Date of REC Opinion
21 Dec 2022
REC opinion
Further Information Favourable Opinion