# Checking The Health Of The Nation: Implementing The Nhs Health Check Programme

Title │ Case studies Case studies

## Foreword

Across the country local authorities are using innovative ways to deliver the programme. Many local authorities are using the NHS Health Check to target individuals or communities at increased risk by focusing efforts among socio-economically disadvantaged communities and using proactive outreach programmes to get into those communities who are less likely to attend their general practice.  Areas across the country from Kent, to Manchester and Durham are using health buses and health trainers to target these communities.  
We know that local communities across England are facing an epidemic of largely preventable diseases, such as heart disease, cancer, Type 2 diabetes and liver disease. Whilst the good news is that premature deaths in the UK are falling, the bad news is that it's not falling as fast as other European countries. That's why the NHS Health Check is so important as it provides us with an opportunity to engage 15 million people to take stock of their own risk and take positive changes to reduce that risk. The programme offers eligible people between the ages of 40 and 74, advice to help delay or prevent conditions such as heart disease, stroke, diabetes, kidney disease and certain types of dementia.    
Since April 2013, local authorities have included dementia awareness and signposting for those aged 65-74 years of age. For example, Peterborough Council has integrated dementia services with the NHS Health Check, ensuring there is a strong link with their local memory services and wider dementia strategy. 

Since local authorities took over responsibility for NHS Health Checks in April 2013 the programme has made great strides with more than two million people having had their check.  Around 50 % of people invited for an NHS Health Check take up the offer. 

As the NHS Health Check provides us with a real opportunity to help people take control of their health its important we get as many people as possible taking up their offer.

Local authorities have also been expanding the range of providers beyond general practice by offering an NHS Health Check in pharmacies, major retailers and the voluntary sector. This helps provide a flexible programme that meets the needs of their local communities. Whilst we know there is a lot of hard work still to do to increase uptake, the NHS Health Check provides us with a real opportunity to help our local communities take control of their health and their future.

Many local authorities now consider NHS Health Check as a core programme within their adult health improvement programmes, since it provides a way of engaging people in early conversations about their health, risk and lifestyle changes.  The NHS Health Check also provides an opportunity to identify and refer at-risk people into locally commissioned health improvement and treatment programmes.

If you are interested in seeing how your local authority is doing compared to a similar authority, Public Health England has introduced a tool, which shows both offers and uptake of the NHS Health Check alongside a number of wider metrics. 

For further information about the NHS Health Check programme visit here.

## Contents

London Borough of Southwark: using volunteers to boost uptake	
06
Stoke-on-Trent City Council: using the power of research	
08
Leeds City Council: providing support to GPs	
10
Buckinghamshire County Council: going out to every corner of the community	
12
London Borough of Lewisham: using community pharmacies to deliver health checks	
14

## London Borough Of Southwark: Using Volunteers To Boost Uptake

- Southwark is using volunteers to help 
increase uptake of health checks.
- It forms part of an innovative approach, 
which also incorporates mobile and drop-in clinics, designed to engage hard-to-reach 
communities.
- Results show the numbers getting health 
checks are on the rise.
"Some of our volunteers speak four or five different languages. They help with translations, signpost people into other services and act as a way into different communities. For example, we have an increasing number of Latin American speaking people taking up health checks with the outreach team rather than from GPs or pharmacies." But the volunteers are just one element of the drive to improve uptake. The Council also runs an outreach programme of health checks. As well as offering them in traditional settings, such as pharmacies and GP surgeries, health check nurses also run drop-in clinics in libraries and at a local shopping centre. There is a mobile unit that tours the borough, offering people checks in town squares, markets and during local events such as festivals and in parks. The nurses have even been to pubs to encourage drinkers to take part.

The south London Borough of Southwark is home to a diverse population - a third of the population are non-white British and about 300 languages are spoken. So the Council has tapped into its local community to help encourage people to come forward for health checks by training two pools of volunteers under supervision. One comprises of lay health workers who offer their time as volunteers and are trained to deliver the health checks under supervision. They are nurses and doctors who have qualified overseas, but cannot currently practice in the UK until they have completed conversion training. 

Ms Edmans says: "We focus on the areas with high rates of deprivation where take up may be lowest and the work is most needed. That means going out to where they spend time rather than expecting them to come to us".

Meanwhile, the second pool is made up of public volunteers who are taken on to encourage their local communities to come forward for the checks. The numbers on the books at any one time are small - about five or six in each - but they are helping to make a difference, says Southwark's Health Check Programme Manager Teresa Edmans. "It is a way of reaching out to communities," she says.

"We work closely with the voluntary sector and other services. We have been out on the housing benefit advice bus and traveller healthcare teams. That is one of the great things about local authorities having this responsibility - we can link in with these services." And it certainly seems to be working. There are over 60,000 people in the borough eligible for the five-year health checks programme, meaning Southwark aims to see about 13,000 a year. In 2012-13, before local authorities took on responsibility for health checks, 36 
per cent of the target population completed a health check.  Last year that rose to 55 per cent and the target this year is to see at least 60 per cent. If a health check does find someone is at risk - for example they have a body mass index of over 30 or identified as at risk of cardiovascular disease or diabetes - they can be referred to Southwark's Health Improvement Hub. The service offers people one-on-one motivational interviews and helps them structure a plan to improve their lifestyle through changes to their eating, physical activity, smoking and drinking habits. Southwark was also one of the first areas to include questions about dementia in the health check. Again, where concerns are raised, a referral is made to a GP for a full screening test. Councillor Barrie Hargrove, Cabinet Member for Public Health, Parks and Leisure, says the work of the health checks team is proving to be "essential". "The checks are crucial in both improving the health and wellbeing of the population of Southwark and reducing health inequalities."

Contact: teresa.edmans@southwark.gov
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## Stoke-On-Trent City Council: Using The Power Of Research

- Stoke-on-Trent has good uptake rates, but 
to decide whether they want to use this technique.

is now exploring new ways of engaging the hardest-to-reach groups.
- Extensive research has been carried out 
Stoke has also been doing some more focussed work on engaging these hard-toreach groups.

incorporating data mining, behavioural 
science and social marketing.
- A number of innovative approaches are 
now in the pipeline to boost the numbers coming forward.
One of the local GP federations has been "data mining" practice records to look for patterns, for example whether those not coming forward work in distinct professions.

Stoke-on-Trent City Council has always placed great faith in the power of research when it comes to health - and the Council's approach to NHS health checks is no different. Latest uptake rates show 52 per cent of people come forward for the checks - above the regional and national average. But an audit of those being tested by the local commissioning support unit for the Council found three distinct groups were underrepresented - people from south Asian communities, those who have not visited a GP 
in the last two years and men aged 40 to 49.

Meanwhile, the Council commissioned Gingernut Creative to carry out some research into barriers and attitudes to health checks. The work, which took place during November 2013 and February 2014 involved interviews with over 150 people. A number of issues were identified. These included a lack of awareness about the health checks generally to time constraints and a feeling, among some, that they were already healthy. The researchers then tested a variety of different concepts and designs on people. This included how to phrase the messaging on promotional material and where was best to display it and offer the health checks. 

Over the past year Stoke has been investigating how it can engage better with these groups. With the help of the Government's Behavioural Insights Team - the so-called nudge unit - a pilot was run in December 2013 and January 2014 at one GP surgery where patients were sent health check reminder letters with a pre-booked appointment - normally they are asked to make one.

Alistair Fisher, Stoke-on-Trent's Primary Prevention Strategic Manager, says: "We have largely been relying on them being delivered in GP practices - research shows that this is the most cost-effective way. We have run some evening and weekend events in some larger primary care practice, but this is the fifth year Stoke has been doing the health checks so we are now at the stage where we want to target those groups who do not traditionally come forward. It is important to find new ways of reaching out to them. That is what we have been trying to do.

The pilot found uptake rates increased "substantially", although one consequence was that did not attend rates also rose. It is now being left to individual practices 
"If the standard letters and calls from GPs are not working, you can't continue doing that and expect it to suddenly change." Following the research that has been done, 2015 will see the launch of a series of pilots in which the health checks will be delivered in a variety of new settings. The exact details have yet to be confirmed, but it is likely to involve working with the voluntary sector, places of worship and workplace settings. The Council is also looking into how you can reach out to people via other means. For example, the vehicle licensing services for taxis may be a good way of engaging those groups. Social media avenues such as Facebook and twitter are also being explored. Mr Fisher adds: "The research has given us a great insight into people's motivations. You need to be able to understand why they are not coming forward for things before you can do anything about it. We hope that the new ideas will help improve uptake." Contact: public.health@stoke.gov
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## Leeds City Council: Providing Support To Gps

- Leeds has focussed on providing good 
support to GPs to ensure they have good uptake rates.
A5 postcards to increase awareness of the health check to help improve levels of uptake. But extra support is given to those who are struggling to get patients to come forward too.

- Electronic patient searches and templates 
for recording information have been 
provided.
- A pilot is now being run with Asda in-store 
pharmacies to widen access to health checks.
The Council uses quarterly reporting to extract performance information to monitor uptake of practices against their given target. Ms Burke says: "We meet quarterly with the clinical commissioning groups to review quality and performance so that the CCGs can work with the practices to support them to improve uptake where required. Sometimes there could be a staffing issue, but equally sometimes it's just a coding issue."
In the drive to increase uptake rates for health checks via outreach work, it can be overlooked that GPs still need support. However in Leeds, the Council has taken a number of steps to ensure practices are able to reach as many people as possible. From the start of the process, Leeds recognised that providing help to GPs would ensure good engagement with the process. Practices were provided with a number of robust search programmes, which allowed them to explore their databases for their eligible patients to call and re-call them.

Leeds has also enjoyed good success in engaging people from more deprived communities, which tend to be the more hardto-reach groups. It has done this by taking the unusual step of targeting areas of inequalities first. This contrasts with many places that ended up getting good uptake in more affluent areas and then seeing performance drop as they have been left with the more hard-to-reach groups later on in the five-year cycle.

A suite of pre-formatted clinical templates was also developed so they could record all aspects of the health check and patient information. Diane Burke, the Council's Health Improvement Principal, Public Health, says: 
The health checks were rolled out to the 42 practices in the most deprived areas at the start, before they were extended to all 109 in the city. That meant in the areas with the people least likely to come forward there has been the longest and most sustained exposure to the health check programme.

"We wanted to make it as easy as possible for GP practices as they are busy so the electronic searches mean they can quickly identify who they need to target. It can narrow down patients to the correct age range and then exclude those who already have existing conditions and don't need a health check." Like many areas, Leeds has also provided GP practices with promotional literature, such as posters, leaflets, refer-a-friend cards and A combination of this and the support given to GPs has meant Leeds has been able to consistently achieve high levels of uptake - hovering just below the 60 per cent mark - over the past few years. It has also resulted in uptake rates in the most deprived areas almost mirroring that in other areas. Leeds is now looking to build on what it has achieved so far. This year Public Health England has set the 'Route 66' challenge encouraging areas to reach 66 per cent uptake as a stepping to the ultimate target of 75 per cent. To help it work towards this, Leeds has just started a pilot with the supermarket chain Asda. Health checks are now being offered at the store's pharmacies at four sites across the city.

Ms Burke says: "The great thing about this is that it provides flexible access to health checks. Some of the pharmacies are open until 10pm and at weekends. We hope as people do their shopping they will take halfan-hour to have one - and it will help improve our uptake rates even further." Contact: diane.burke@leeds.gov
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## Buckinghamshire County Council: Going Out To Every Corner Of The Community

- Tackling hard-to-reach groups has become 
a key part of Buckinghamshire's health checks work.
- Outreach clinics have been run at over 40 
checks, yet they are the ones most likely to have a stroke or develop cardiovascular disease. We wanted to do something that would reach out to them - and that meant exploring new ways of engaging them."

different locations, including everything 
from a local football club to libraries.
- It has enabled the Council to identify which 
settings work best for which groups. 
An external organisation was commissioned to road-test different settings and during the pilot period went to 46 different locations. This included holding clinics at a local football club, DIY store, libraries, shopping centres, supermarkets, at high street shops, mosques, housing estates, workplaces and at community events.

Buckinghamshire County Council has sought to increase uptake rates for health checks by exploring a wide variety of community settings. Health checks have been offered in everything from libraries and mosques to football clubs and shopping centres during a pilot programme lasting from November 2013 to September 2014. The outreach work was launched after the number of people coming forward for health checks started declining. Like many areas, Buckinghamshire aims to target a fifth of the eligible population each year.

In total, more than 3,800 people were given health checks by the outreach workers - with successes seen among all three groups. Overall, 3 per cent of health checks carried out by GPs are among south Asian communities, 12 per cent among the most deprived groups (defined as the least affluent quintile) and 50 per cent on men (considered low as more invites are sent out to men).

Last year 45 per cent of those targeted came forward - down from 53 per cent the year before.

As would be expected, mosques were good for reaching people of south Asian origin. Out of the 155 health checks carried out, 95 per cent were of south Asian origin. However, they also provided a good source of male participants with 72 per cent of those taking part men.

Public Health Consultant Veena de Souza says: "The problem is that many of those that are most likely to engage with health checks have been reached so we are now left with the more difficult-to-reach groups."
Costcutter stores were also good venues for engaging both groups. Of the 20 carried out there, half were men and a quarter people of south Asian origin. 

The data showed that three distinct groups were under represented by the GP-run health checks - men, people from deprived communities and those from ethnic minority groups, particularly people of south Asian origin.

Meanwhile, the local adult learning centre proved particularly effective at reaching deprived communities. Over 20 checks were carried out and half were from less affluent groups and 22 per cent were of south Asian Dr de Souza says: "These three groups are the ones least likely to come forward for health origin.

Bus stations were effective at reach men and deprived communities with 75 per cent and 57 per cent respectively of the 55 health checks carried out among those groups. Meanwhile, a visit to Instron, a local manufacturing firm, saw 45 checks carried out, 69 per cent of which were men, while a clinic at Wycombe Football Club saw 71 per cent of checks given to men. Dr de Souza says: "The results were really positive. By looking at so many different settings we were able to work out what was best at reaching the different groups. We are now looking to commission more outreach work and will be focussing at the settings that worked best. It will really help us tailor our approach at engaging these hard to reach groups. "We also want to look at how we can increase uptake among other hard-to-reach groups, such as those with mental health problems or learning difficulties. Experience shows that with the right approach low uptake really can be addressed." Contact: vdesouza@buckscc.gov
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## London Borough Of  Lewisham: Using Community Pharmacies To Deliver Health Checks

- The London borough of Lewisham started 
using pharmacies early on to deliver health checks.
- A quarter of all of the checks now carried 
out are done via the 17 pharmacies signed 
up to deliver them.
- Research shows they are effective at 
Ms Fuller says: "One of the things we have learnt is that it is important to support all the pharmacy staff to do this. We have trained the whole team to assist in the health check service and become healthy living champions. They help the pharmacists in providing part of the assessment such as the weight and height measurements."
engaging hard-to-reach groups.  
Lewisham recognised from the start of the roll out of the health check programme that there was merit in broadening access beyond GP practices. 

To ensure the system works smoothly, staff have been given direct access to a secure web-based recording system, which allows them to check eligibility and transfer the results securely to the patient's GP practice.

From the onset in 2011 patients were offered the option of going to either their GP
, a local pharmacy or via community outreach clinics in libraries, shopping centres and at community events.

Pharmacies can also make direct referrals to the Lewisham Lifestyle Hub, which offers access to local programmes such as physical activity taster classes, healthy walks and weight management programmes. And, where appropriate, patients have been offered smoking cessation services at the community pharmacy.

Health checks are now offered in 17 pharmacies across the south London borough with more expected to sign up in the coming year.

Those who have used the pharmacy service have provided extremely positive feedback, praising the patience, availability and thoroughness of the checks.

Frances Fuller, Lewisham's Cardiovascular Prevention Programme Manager, says: "One of the great benefits of the pharmacy is that the opening hours are more flexible. People can have the health checks done in the evenings and at weekends. When we send out the invitation letters we give people the choice. It is about giving people greater access."
One said: "I think the service is a brilliant idea and we're lucky to have it"; while another added: "It was the closest place and very convenient as the cholesterol test could be done on site with results available straight away."
And, according to latest figures, it is one they are only too happy to take up. About a quarter of all health checks in Lewisham are carried out in participating community pharmacies. 

A recent evaluation of the community pharmacy service has also shown that it is a better setting for engaging to hard-toreach groups. Pharmacies see a higher proportion of black African and black Caribbean residents and people from deprived communities - and because of this it identifies a greater proportion of people at risk of diabetes and cardiovascular disease. Indeed, 40 per cent of referrals to the Lewisham Lifestyle Hub come from pharmacy-based health checks. Ms Fuller says: "I think because the pharmacies are so convenient they have been able to reach out to people who may not routinely access their GP surgery. It has been really successful and we will be looking to build on it in the future." Contact: media.relations@lewisham.gov
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