NHS Health Checks

Cardiovascular disease is the leading cause of death in the UK and accounts for one third of all deaths in this country. It is estimated that 2.6 million people in the UK are living with cardiovascular disease.1 Smoking, obesity, poor diet and lack of physical exercise are major causes of cardiovascular disease.

Experts estimate that between 80% and 90% of deaths from cardiovascular disease in people under the age of 75 could be prevented by making lifestyle changes such as stopping smoking.2

NHS Health Checks is a risk assessment programme in England for people between the ages of 40 and 74 that aims to identify people at risk of cardiovascular disease, and take steps to prevent them suffering a heart attack, stroke or other vascular disease. NHS bodies were instructed to begin offering Health Checks in 2009.3

NHS Health Checks use assessment tools to estimate a person’s risk of disease in the next 10 years and help the individual to identify the steps that can be taken to reduce that risk. These may include taking medication such as statins, stopping smoking, losing weight and increasing exercise. A number of different assessment tools are available, and currently there is no clear guidance in respect of which tool should be used.4

Evidence of the possible benefits

There is clear evidence that taking statins can help prevent cardiovascular disease, and NICE has produced guidelines on their use.5 It is also well known that making lifestyle changes, such as stopping smoking, can reduce the risk of cardiovascular disease and NICE has also produced guidelines on a range of lifestyle issues including smoking and obesity.67

What is less well understood is whether having a Health Check and knowing your risk of cardiovascular disease actually leads to lifestyle changes. To date, there has been no published evaluation of the NHS Health Checks programme.

A similar programme of nurse run health checks was introduced in five GP practices across Bedfordshire in the early 1990s. Patients that had a health check were followed up after three years and were found to have reduced their intake of saturated fat resulting in lower cholesterol levels, compared to patients who had not had a health check. However, the health check had no impact on smoking behaviour or alcohol intake.8 It is not possible to determine whether the effect on cholesterol resulting from the dietary changes would lead to reductions in rates of cardiovascular disease.

Evidence of the possible risks

As with any screening service there are risks with the NHS Health Checks programme. Research has found that one of the commonly used risk assessment tools overestimates the risk of disease in low risk groups and underestimates the risk in high risk groups.910 This can lead to people being prescribed medication that is unnecessary or being falsely reassured about their risk and not taking appropriate action.

In addition, understanding one’s personal risk of disease may not necessarily motivate people to change behaviour. Evidence is scarce to support the assumption that telling someone they are at high risk of disease will lead to them making significant behaviour changes. An evaluation of a health check programme in Australia found that less than half of those who took part made any changes.11

Studies have also found that understanding the personal health risks of smoking, for instance, is associated with intentions to quit, but the effect is short lived and does not lead to successful quit attempts.12

Implications for health and well-being

Many premature deaths from cardiovascular disease could be avoided by identifying individuals at high risk of disease and intervening early.

However, it should be recognised that there are risks of inaccurately calculating risk of disease, and understanding risk of disease does not necessarily result in lifestyle changes.

There is currently little published evidence to support the assertion that the NHS Health Checks programme will lead to a reduction in the incidence of cardiovascular disease. A full evaluation of the programme is needed.

Author: Sarah Theaker, Specialty Registrar in Public Health, NHS Nottinghamshire County

References

1. British Heart Foundation (2010). UK Coronary Heart Disease Statistics 2009/10. London: British Heart Foundation.

2. Capewell S, Allender S, Critchley J, Lloyd-Williams F, O’Flaherty M, Rayner M, Scarborough P (2008). Modelling the UK Burden of Cardiovascular Disease to 2020. London: British Heart Foundation.

3. Department of Health. Vascular checks: risk assessment and management.
‘Next Steps’ guidance for Primary Care Trusts. London: The Stationary Office 2008

4. National Institute for Health and Clinical Excellence (2008). Lipid modification: cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease (CG67). London: NICE.

5. National Institute for Health and Clinical Excellence (2006). Statins for the prevention of cardiovascular events in patients at increased risk of developing cardiovascular disease and those with established cardiovascular disease (TA094). London: NICE.

6. National Institute for Health and Clincial Excellence (2008). Smoking cessation services in primary care, pharmacies, local authorities and workplaces, particularly for manual working groups, pregnant women and hard to reach communities. London: NICE.

7. National Institute for Health and Clinical Excellence (2006). Obesity – the prevention, identification, assessment and management of overweight and obesity in adults and treatment (CG43). London: NICE.

8. Muir, J, Lancaster T, Jones L, Yudkin P. 1995. Effectiveness of health checks conducted by nurses in primary care: final results of the OXCHECK study. BMJ 310: 1099-1104.

9. Brindle P, Beswick A, Fahey T, Ebrahim S. Accuracy and impact of risk assessment in the primary prevention of cardiovascular disease: a sytematic review. Heart 2006 92:1752-1759.

10. Tunstall-Pedoe H, Woodward M. By neglecting deprivation, cardiovascular risk scoring will exacerbate social gradients in disease. Heart 2006 92:307-310.

11. Amaroso C, Harris MF, Ampt A, Laws RA, McKenzie S, Williams AM. The 45 Year Old Health Check. Australian Family Physician 2009, 38(5):358-362

12. Bize R, Burnand B, Mueller Y, Cornuz J. Biomedical risk assessment as an aid for smoking cessation. Cochrane Database Syst Rev 2005;(4):CD004705