Delivering more with less? Making the NHS Health Check work in financially hard times: real time learning from Stoke-on-Trent.

BACKGROUND: The NHS Health Check Programme presents the opportunity to reduce death and ill health caused by cardiovascular diseases (CVDs). Owing to the current restructuring of health care in the UK, financial resources will in future be limited. It is important to develop cost-effective ways of delivering this programme. There are practical alternatives to strategies that advocate using existing data to pre-stratify patients and prioritise those aged between 50 and 74 years. METHOD: Data on patients eligible for a health check were retrospectively collected from two early implementer practice teams. The characteristics of attenders and non-attenders, such as demographic factors, consulting behaviour, clinical measures and lifestyle measures, were collected. Costs of two approaches to delivery (drop-in clinic with choice of booked appointment versus booked appointment alone) were compiled. RESULTS: Nearly half of all patients had accessed their GP or practice nurse with four or more appointments in the 12 months prior to their health check. There remained a margin of error between estimated CVD risk (calculated prior to the health check by the practice, using existing information) and actual CVD risk (calculated after a health check had been completed). Drop-in clinics with choice of booked appointment cost half the price of offering patients the option of booked appointments alone. DISCUSSION: The cost-effectiveness of drop-in clinics was achieved by a reduction in staffing costs through intensively offering health checks; this approach provides a practical solution to maintaining a population-wide approach. Using existing data to pre-stratify patients is dependent on the quality and completeness of data used to estimate CVD risk. Concentrating efforts on 50 to 74 year olds may improve sensitivity to detect CVD but would reduce the chance of engaging with patients about their health at an earlier stage. Offering health checks opportunistically and using existing data no older than 12 months to complete a health check provide the potential for further cost savings.

Randomised controlled trial of additional lifestyle support for the reduction of cardiovascular disease risk through primary care in Stoke-on-Trent, UK.

The purpose of this trial is to evaluate the effectiveness of providing additional support in modifying lifestyles and in reducing population cardiovascular disease risk compared with usual primary prevention care. A prospective, individually randomised controlled trial design is used, within which groups of patients are clustered by general practice. Multi-level modelling is proposed to account for clustering effects by practice and a two-stage least squares regression approach to account for expected contamination at the analysis stage. The research is set in Stoke-on-Trent, a mid-sized urban city in central England with a generally poor health profile. Patients included will be those aged between 35 and 74 years who have been identified as being at increased risk of developing cardiovascular disease. Approximately 920 patients will be recruited in each arm of the trial (20 control, 20 treatment in each of 46 practices). Usual primary prevention care (control) will be compared with usual primary prevention care plus bespoke lifestyle support (treatment). The primary outcome measure is the Framingham 10-year cardiovascular disease risk at one year. Intermediate outcomes: weight, physical activity and health-related quality of life, will be determined at six months to monitor progress with treatment. Change in individual risk factors: blood pressure, lipid profile, weight, body mass index, waist circumference, smoking, diabetes and cardiovascular disease status and medications will also be measured at one year to help understand the specific mechanisms by which the primary endpoint was achieved.