Creating a viable alternative to the practice-centric model of prevention

What's in this Article:

• How can local systems alleviate pressure on primary care and enhance prevention in the community
• Understanding the current model of detecting CVD risk 
• Introducing the NHS Health Check 
• The changing world since 2020 and the growing challenge of primary care access
• So, what does the future hold for the NHS Health Check?

How can local systems alleviate pressure on primary care and enhance prevention in the community

This article is part 3 of a series looking at how local systems and their providers can improve CVD prevention within their local populations, and ultimately lead to better CVD outcomes. In the first article we introduced five inherent challenges that local systems face, offering some strategic aims that could help underpin real improvements.

In this post we delve into the second of these challenges: that we’re reliant on a practice driven model of patient finding, testing and activation to drive behaviour change, and pose that local systems need to alleviate pressure on primary care sites, and to make better use of the community, especially in population health management and prevention.

Understanding the current model of detecting CVD risk

As we explored in the previous article, there is a strong and growing focus on building more sophisticated and versatile local services that meet the needs of those hardest to reach, those who statistically have the greatest risk of developing CVD, and who are likely to be most impacted by having this condition.

Prevention is not one activity, intervention or moment but a chain of events. Good prevention needs to segment target groups based on need and then engage and intervene in different ways as part of this chain.

Yet when we consider those needs, and the national ambition to build proactive, personalised, and preventative care models, the simple fact is that the existing way that we drive prevention is pretty uniform.

To better understand the current model, the future model and what local systems will need to think about in the coming years we need to delve into the NHS Health Check.

Since the NHS Health Check focuses on a wider range of clinical risk areas, many of which are lifestyle driven diseases closely related and often combined with CVD, I’m going to talk more broadly about these conditions, with CVD being one of them.

Introducing the NHS Health Check

The NHS Health Check is a nationally driven free health check-up for adults in England aged 40 to 74 that is designed to spot early signs of stroke, kidney disease, heart disease (CVD), type 2 diabetes or dementia. It was launched in 2009 as a CVD intervention but has evolved to check for a wider range of clinical risk areas.

For the last 12 years local authorities have been responsible for paying local healthcare providers in their area to deliver this, as part of a legal responsibility to offer an NHS Health Check to 100% of their eligible population once every 5 years.

Based on the findings of the most recent review by Public Health England in 2020, the vast majority of these checks have been delivered by General Practice (93% of LAs), however, community outreach providers (27% of LAs) and Pharmacies (19% of LAs) are also commissioned to a lesser extent. Exact numbers in each area are not published.

In 2020 a major review of NHS Health Checks was conducted by the government , offering really interesting insights into the effectiveness, uptake and whether it was deemed to be effective and successful, offering better outcomes, and health economic benefits.

In short, the review found the NHS Health Check to be a successful programme, with around 40% of eligible adults taking part (albeit with huge variation from area to area), achieving £2.93 return for every £1 spent, and suggesting an opportunity “to reduce absolute health inequality by 2040”.

There were also a number of recommendations, based on the view that “multiple opportunities exist to improve the NHS Health Check across the entire pathway”. They were:

• Build sustained engagement - shifting from an isolated check to a relationship of ongoing engagement and support.

• Launch a (national) digital service, and more widely to take advantage of technology to improve provision, increase access and reduce the cost to serve

• Start ten years younger

• Improve participation - by all eligible people, but especially the people likely to benefit most – those who live in more deprived areas, those from black and minority ethnic groups who are more susceptible to CVD, and men.

• Address more conditions, such as mental and musculoskeletal ill-health.

• Create a learning system to drive more evidence and better evaluation.

Considering the powerful opportunity to reduce absolute health inequality by 2040, these ambitions feel sensible, practical and something we can, and should, grab with both hands.

However, they are also ambitious, and require those delivering, organising and funding these activities to do more and in different ways, with greater sophistication.

A lot has also changed in the NHS, including within General Practice, since the report was published in 2020.

The changing world since 2020 and the growing challenge of primary care access.

There are very few people in the UK unaware of the major challenges the NHS is facing right now, that have been taking place since the COVID pandemic, and arguably bubbling well before its emergence, due to workforce pressures, an ageing population, and of course, increasing lifestyle disease prevalence.

As I illustrated above, the heavy reliance of delivering the NHS Health Check through General Practice, means operationally we have our eggs in one basket, and high susceptibility when General Practice is under pressure, which is now the case.

One of the top ticket items within the NHS over the last few years has been access to primary care, especially general practice, with many local systems and their practices struggling to deal with demand for appointments. This is very much illustrated in how much emphasis has been placed on access within the last two GP contracts, and less emphasis on national quality measures. I’d be curious to see how this has impacted prevention activities, such as uptake and delivery of the NHS Health Check.

On the other side, this perhaps presents a circumstantial opportunity to provoke differently designed approaches for this initiative. At a policy level, and due to ongoing challenges elsewhere, there is greater emphasis on the clinical role that community pharmacies and other healthcare providers within the community (including care at home) can play in supporting challenges in both primary and acute care. After all, a key ambition of the NHS Long Term Plan is to “dissolve the historic divide between primary and community health services”. In the likely event that Labour will become the next government, the trend of redesigning care within the community, further utilising pharmacy, and using these channels to target prevention adds to this direction of travel.

So, what does the future hold for the NHS Health Check?

Whilst the prospect of prevention-oriented services reaching into the community are enticing and could do much to engage with priority segments of our local communities, the family doctor and local practice need to remain at the centre of how we then respond, intervene and support those who are at high risk of developing CVD.

Additionally, as the recommendations within government review of the NHS Health Check suggest, “technologies and digital innovations provide the means for improvements”, not just within the anticipated national service, which I’ll consider more in my next article, but also in well considered local initiatives that focus on joining up local multidisciplinary services closely embedded within different parts of the community.

This hugely resonates with our experiences when using our own digital solutions to enable a number of different CVD screening models within the community, which I’ll expand upon in the next article.

In the different models that we have tested, and evaluated, within two local ICBs, and working with different providers from pharmacies to practices and community outreach groups I wanted to share my observations on what I believe is needed to respond positively to both the challenges and opportunities of further modernising the NHS Health Check.

1. Community pharmacy is a fantastic resource that could hugely improve the uptake of the NHS Health Check, with the right infrastructure. I’m always surprised how underutilised they are, and how impressive their approach to the checks when enabled.

2. The target ‘community’ segment (as per population health management) is hugely addressable, and our partner services have found many willing candidates for CVD testing, IF we’re willing to go to them, rather than call them to us.

3. Splitting activities away from general practice can risk fragmented working, but well considered digital can play a significant role in bridging this.

4. We could deliver and evidence much more within these community segments. The government recommendations on addressing more conditions and flagging more risks in different ways could again be captured and used as part of population health management activities, if we have the tools to collect and use this data.

These pilots, observations and lessons have helped to guide what we’re building at PocDoc and will continue to do so in the future.

What's Next?

In the next article I will be looking at building on the topics within the article and consider how local systems can create accessibility in the places where testing and detection would be most effective, connected to but not solely within practice settings.