What happens after an NHS Health Check? A survey and realist review

Article history

The research reported in this issue of the journal was funded by the HSDR programme or one of its preceding programmes as project number NIHR129209. The contractual start date was in March 2020. The final report began editorial review in January 2022 and was accepted for publication in August 2022. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HSDR editors and production house have tried to ensure the accuracy of the authors’ report and would like to thank the reviewers for their constructive comments on the final report document. However, they do not accept liability for damages or losses arising from material published in this report.

Copyright statement

Copyright © 2023 Duddy et al. This work was produced by Duddy et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This is an Open Access publication distributed under the terms of the Creative Commons Attribution CC BY 4.0 licence, which permits unrestricted use, distribution, reproduction and adaption in any medium and for any purpose provided that it is properly attributed. See: https://creativecommons.org/licenses/by/4.0/. For attribution the title, original author(s), the publication source – NIHR Journals Library, and the DOI of the publication must be cited.

2023 Duddy et al.

The NHS Health Check programme

Cardiovascular disease (CVD) causes one-quarter of all deaths in the United Kingdom (UK) and is the largest cause of premature mortality in deprived areas. Early detection and prevention of CVD are a priority for the NHS and the NHS Long Term Plan (2019) makes a clear commitment to early detection of risk factors and rapid initiation of treatment, with the ambitious aim of preventing over 150,000 heart attacks, strokes and dementia cases over 10 years. 2

The NHSHC programme is one pillar of England’s CVD prevention effort. Launched in 2009, the NHSHC aims to offer a five-yearly assessment of CVD risk factors to all adults in England aged between 40 and 74 years. The check involves the measurement of key CVD risk factors and calculation of an overall 10-year CVD risk (using QRisk®3), followed by advice, discussion and agreement on lifestyle and pharmacological approaches to manage and reduce risk. The latter steps may include the delivery of advice and ‘brief’ or ‘very brief’ interventions, signposting or formal referral to ‘lifestyle support’ services, such as stop-smoking and weight-management services, and clinical risk management (including prescribing) per relevant National Institute for Health and Care Excellence (NICE) guidelines. 3

The total eligible population for the NHSHC programme has been estimated at 15.5 million. 4 The largest and most recently published analysis of national data relating to the programme found that 10 million eligible people were offered a check between 2012 and 2017. 5 Of these, 52.6% (just over 5 million) received an NHSHC. Although national uptake rates have generally increased over time, there is significant regional variation, with uptake rates calculated for upper-tier local authority (LA) areas ranging from 25.1% to 84.7%. 5 These findings are in line with previous analyses that have identified significant regional variation in the invitation and uptake rates for the programme,6 as well as variation in other aspects of delivery and follow-up, including variation in the delivery of advice and onward referrals to lifestyle services. 7,8

Covid-19 and the NHS Health Check

The Covid-19 pandemic had a major impact on delivery of the NHSHC. In April 2020, NHS England and Improvement (NHSE&I) issued guidance for the prioritisation of community health services as part of the pandemic response, which included guidance to stop delivery of NHSHCs altogether. 17 PHE’s April 2020 Health Check e-Bulletin confirmed this plan, and outlined a delayed schedule for routine data collection relating to the programme. 18 To support the resumption of programme delivery after this pause, PHE issued ‘restart preparation’ guidance for commissioners and providers in April 2021. This guidance made it clear that decisions to restart delivery of the programme should be taken by LAs, in light of local assessments of safety and capacity (especially taking into account the need for general practices to prioritise Covid-19 vaccination work). 19

In recognition of the potential ‘limiting factor’ of workforce capacity in general practice, this guidance explicitly recommends that LA commissioners consider ‘alternative’ delivery models for future provision. It is clear that the pause and restart of the programme provoked a range of responses at local levels, including the introduction of new delivery models in some areas. 20 In recognition of this fact, we designed the survey component of this project to gather information from LAs on the extent and nature of changes in programme delivery in response to Covid-19.

In addition to these operational changes, official communications from PHE have placed a new emphasis on the potential benefits of the NHSHC in relation to Covid-19 outcomes, recognising that many of the risk factors that the NHSHC is designed to assess are also associated with increased risk of severe illness and death from Covid-19. 21,22 The potential for the NHSHC programme to help address risk factors associated with severe Covid-19 is acknowledged in the UK government’s Covid-19 recovery plan. 23

The NHS Health Check Review (2021)

Plans for a major review of the NHSHC programme were announced by the DHSC in August 2019, with an emphasis on personalisation and consideration of potential digital delivery methods. 24 In August 2020, the NHSHC e-Bulletin confirmed that this review was being undertaken by PHE21 and formal terms of reference were published in November 2020. The scope of the review included an assessment of the existing programme’s effectiveness, cost-effectiveness and limitations, as well as consideration of evidence relating to potential changes that might be made to both the content and delivery methods for the check. 25

The review’s findings were published in December 2021 by the new OHID unit. 26 The report sets out a new ‘vision’ for the NHSHC and makes six recommendations to government to guide delivery of the programme over the next decade. We have taken these recommendations into account in developing our own set of recommendations based on the findings of this project, aiming to complement and add to the recommendations published by OHID (see Chapter 4, Discussion).

Overview of existing evidence

The NHSHC programme has been controversial since its inception, and the value of the evidence underpinning its design and demonstrating its effectiveness has been subject to dispute. 27 Opponents of the programme cite an absence of data from randomised controlled trials (RCTs) demonstrating the effectiveness of mass CVD screening and prevention programmes. 28,29 PHE have responded by commissioning and producing a range of evidence that aims to demonstrate the effectiveness of the programme, and by setting up the NHSHC Expert Scientific and Clinical Advisory Panel (ESCAP) to regularly review and support delivery of the programme. 30

Observational studies collated in two PHE-commissioned rapid reviews suggest that the NHSHC is associated with increased rates of the detection of CVD risk factors and disease, statin prescribing, and referrals to lifestyle support services (including smoking cessation, weight management, exercise and alcohol support services). However, regional studies demonstrate wide variation both in these outcomes and in service delivery across England. Evidence on behaviour change and improvements in CVD risk factors and outcomes post-HC is sparse. The rapid reviews identified only six primary studies examining behaviour change, assessing only smoking. A limited number of studies have assessed improvements in body mass index (BMI), diastolic blood pressure, total cholesterol and overall CVD risk, but results are inconsistent and some studies found no evidence of an effect. 7,8

A more detailed overview of the existing evidence underpinning the NHSHC is available in our published protocol paper. 1

Project focus: what happens after the risk assessment in an NHS Health Check?

Our scoping searches and review of the existing research evidence identified a clear focus in the existing literature on the reach of the NHSHC programme, including on how to improve invitation, uptake and coverage. Less attention has been paid to what happens after the measurements and risk assessment have been undertaken, especially in relation to the delivery of advice, onward signposting or referral and ongoing support for lifestyle and behaviour change. In consultation with our key stakeholder, PHE (now OHID), we confirmed the value of a focus on these steps in this review. Our wider public and professional stakeholder groups (see Chapter 2) were also consulted on this proposed focus and confirmed the need for research in this area, reflecting their interest in the NHSHC as a programme with the potential to prompt and support behaviour and lifestyle change in attendees. The ability of the NHSHC to promote such behaviour change is a crucial underpinning assumption for the programme in relation to its aim to help attendees reduce their risk of experiencing a heart attack or stroke or developing some forms of dementia. 3 The rationale for choosing this project focus is further elaborated in Chapter 2 below (see Step 1: Locate existing theories).

What should happen after the risk assessment is completed in a Health Check?

PHE’s Best Practice Guidance3 and programme standards31 for the NHSHC make a number of clear recommendations in relation to what should happen after the measurements and risk assessments have been completed during a check. The documents are aimed at both commissioners and providers, and describe a range of advice and referral options, as well as clinical interventions that can be offered to attendees, with two objectives:

1. To promote and improve the early identification and management of the individual behavioural and physiological risk factors for vascular disease and the other conditions associated with those risk factors.

2. To support individuals to effectively manage and reduce behavioural risks and associated conditions through information, behavioural and evidence-based clinical interventions. 3

For commissioners, the Best Practice Guidance document makes some limited recommendations in relation to providing and ensuring clear referral pathways to other services that may be commissioned to support lifestyle and behaviour change. For example, in relation to smoking cessation, it suggests that LAs ‘may wish to’ put in place pathways to refer smokers to local stop-smoking services. However, it is also made clear that clinical follow-up remains the responsibility of primary care, and there is an emphasis placed on LAs’ legal responsibilities in relation to NHSHC delivery and data reporting – both focused on invitation and uptake. There is no legal requirement to ensure that NHSHCs include the provision of advice or referrals beyond the requirement to ‘ensure the individual having their NHS Health Check is told their cardiovascular risk score, and other results are communicated to them’, and that relevant data are recorded and sent to general practices to ensure appropriate clinical follow-up as required. 13,14

Despite this, PHE’s guidance documents aim to provide a level of standardisation in setting out recommendations for the steps following the mandatory measurements and risk assessments. The recommendations are not new or specific to the NHSHC programme; instead, the guidance invokes relevant NICE guidelines and so reflects what should be ‘usual care’, at least for those providers based in general practice. Both the Best Practice Guidance and the programme standards explicitly echo the ‘Making Every Contact Count’ competencies, intended to promote the opportunistic delivery of ‘brief’ and ‘very brief’ lifestyle interventions during routine interactions with health and care staff. 32 The NHSHC encounter is positioned as a means of extending the opportunity to deliver these interventions to an otherwise healthy population who may not otherwise have contact with healthcare services. 3

A summary of the recommendations in relation to advice, brief interventions and referrals in relation to each risk factor assessed during an NHSHC is provided in Figure 1.

FIGURE 1.

Recommendations for advice, brief intervention and referral.

Data on these potential activity outcomes for attendees of the NHSHC are not routinely collected or reported to PHE. A recent cross-sectional observational study of the NHSHC extracted data from primary care records in 90% of English general practitioner (GP) practices for the 5-year period 2012–2017. 5 The findings included data on the percentage of NHSHC attendees recorded as receiving advice, information or a referral after a check, in relation to each risk factor assessed. Table 1 reproduces Table 3 from this study, showing the percentage of all NHSHC attendees who received advice, information or referrals, as well as the percentage of all NHSHC attendees meeting the threshold for these interventions who received them.

Although it is likely that data recording (coding into primary care records) for these activities is incomplete, the available data indicate that the rates at which they are delivered vary widely for different risk factors and appear to fall well below what the recommended thresholds for intervention suggest would be appropriate. These data also provide no detail on the nature of the advice, information and referrals offered, and the extent to which the specific recommendations made in the guidance are followed. These findings echo those from existing systematic reviews, which have also identified regional variation in ‘post-delivery management’ following an NHSHC. 7,8 In addition, this study and another recent observational study make it clear that most NHSHC attendees do not receive any treatment or referral after a check, and that statin prescribing in particular is much lower than guidelines recommend. 5,33 The rates recorded also fall short of those estimated in the initial economic modelling for the NHSHC programme. 34

Aims and objectives

Stakeholder groups

We recruited two stakeholder groups to provide us with content expertise and a range of perspectives throughout the project.

Throughout the project, our strategy for patient and public involvement (PPI) was informed by our PPI lead (VH). VH is an experienced PPI contributor (via the Public Involvement in Pharmacy Studies at Medway School of Pharmacy Group) and brought her valuable perspective as a member of the public and skills in group facilitation. In particular she supported us in developing lay summaries, advertising for further PPI contributors and supporting our PPI group throughout the project.

Our PPI group involved 10 members of the public from six different English regions, all of whom are eligible to receive the NHSHC. 37 This group was recruited by advertising via the Oxford Biomedical Research Centre website and the University of Kent’s Centre for Health Services Studies’ Opening Doors to Research group. We offered PPI contributors a shopping voucher as a token of our appreciation for their involvement, and covered any expenses they incurred in taking part. From those members of the public who came forward, we purposely selected a group who were as diverse as possible in relation to gender, age, ethnicity and geographical location, with the aim of capturing a range of different perspectives from individual members of the public.

Our ‘professional’ stakeholder group were recruited via our project team’s existing networks and snowballing from these, and included LA commissioners, NHSHC providers, an NHSHC trainer and representatives from relevant health charities. In addition, we maintained close contact with PHE’s (latterly OHID’s) CVD Prevention Programme lead throughout the project.

Both groups were consulted via regular online meetings throughout the project, using Microsoft Teams (Version 1.0, Microsoft Corporation) and Zoom (Version 5, Zoom Video Communications, Inc.) video conferencing software. Our approach to facilitating our meetings was driven by the need to work to ensure that these online discussions – necessary due to the Covid-19 pandemic – were as open and inclusive as possible. Based on the recommendation of our PPI lead (VH) we met with our PPI and professional stakeholder groups separately, to help ensure that members felt able to speak openly about their experience of receiving and/or commissioning/providing the NHSHC and to reduce the number of people in each meeting, giving individuals more opportunity to contribute. However, CD attended all meetings of both groups and, where relevant, reported discussions from the PPI group to the professional group and vice versa. Our PPI stakeholder group meetings were chaired by VH and our professional stakeholder group meetings by GW. To facilitate more in-depth discussion and give each participant more time to contribute, our PPI group was split into two smaller groups for the last two meetings.

Our final professional stakeholder group meeting was augmented with additional contributions from 36 individuals. They came from a range of professional backgrounds (LAs, Public Health, OHID and providers) and from geographically diverse parts of England. Individuals were recruited via OHID’s existing networks. These additional contributions were sought to ensure that we would get broader feedback and advice on our findings and recommendations.

We consulted the stakeholder groups in relation to the focus of the project and asked them to provide feedback on our emerging findings as they developed. To help facilitate discussion on our findings, we circulated summary material before each meeting and provided an overview slide presentation at the beginning of each meeting. We initiated discussions with sets of simple questions to help guide the participants; for example, we asked stakeholders how our findings related to their own knowledge and/or experience of commissioning, providing or attending the NHSHC, and we asked them about important influences on NHSHC delivery or the response to the NHSHC that seemed to be missing from our findings. Our aim was both to identify those findings with particular resonance for stakeholders, but also to highlight any important aspects of NHSHC delivery that are not well represented in the literature. We consulted the professional stakeholder group on the development of our survey questions, to ensure their relevance and importance, and on our survey design, with the aim of maximising clarity, validity and the likelihood of achieving a good response with full completion of questions.

The discussions held during these meetings helped to shape our analysis as the project progressed. Input from both the professional and PPI groups influenced the analysis of our survey responses and our interpretation of the data included in the review. For example, input from the professional stakeholder group informed the development of a typology of NHSHC delivery models and the identification of relevant factors to consider in our analyses. In discussions of the review’s emerging findings, our PPI group members emphasised the need for NHSHC attendees to have more control over what happens during and after a check, especially in relation to the discussion of ‘lifestyle’ advice and opportunities for referral to other services. As a result, we reconsidered our data on attendee responses to what providers offer or discuss at the end of an NHSHC encounter, to consider whether it could tell us more about potential mechanisms producing these important outcomes for attendees. (see e.g. CMOCs A16–A17, A30–32 in Chapter 3). Similarly, PPI members’ repeated observations on the ‘mismatch’ of the focus of the NHSHC with their own health needs and priorities helped us to shape our findings (see e.g. CMOCs A9–A11) and recommendations in this area. Overall, our PPI group felt strongly that they needed more clarity on the purpose of the NHSHC programme and the group’s in-depth discussions on this point are represented strongly throughout our findings and in our subsequent recommendations for policy and practice (see Chapter 3 and Chapter 4).

In the last meetings with each group, we asked the participants for their input to help us to develop and refine practical recommendations for NHSHC delivery based on our findings and to inform our dissemination strategies, to help us to develop tailored outputs and identify the key ‘players’ for dissemination amongst different audiences. We refined our recommendations and developed plans for dissemination activities and project outputs on the basis of feedback from both groups.

A summary of the stakeholder group meetings and important input from these groups is provided in Table 2.

Survey methods

Review methods

Step 1: Locate existing theories

The goal of this step was to identify existing theories that explain when, how and for whom the NHSHC programme is supposed to ‘work’, to achieve its desired outcome of reducing CVD risk and mortality. The rationale for this step is that interventions and programmes like the NHSHC are underpinned by implicit and explicit assumptions and theories about how they should work in practice. 43 To locate existing theories that might offer explanations for NHSHC processes and outcomes, we undertook two iterative processes:

1. We drew on the knowledge and experience of our own project team (including in general practice, pharmacy, public health and lived experience), and consulted with our stakeholders.

2. We informally searched the literature to identify:

   1. existing theories, consulting both grey literature in the form of NHSHC programme documentation, and published research studies that employed formal or substantive theories to understand the NHSHC

   2. existing reviews and evidence syntheses focused on the NHSHC programme to develop our understanding of the existing research landscape and identify gaps in knowledge.

For step (b), we identified NHSHC programme documentation via searching and browsing the NHSHC website (www.healthcheck.nhs.uk) and the UK DHSC website (http://dh.gov.uk), and archived versions of these websites (via the UK Government Web Archive (http://nationalarchives.gov.uk) and the Internet Archive WayBack Machine (http://archive.org/web/)). We identified existing theoretical literature by running searches in PubMed and Web of Science (Core Indexes – SCI-EXPANDED, SSCI, ESCI, AHCI), using a slightly modified version of Booth and Carroll’s BeHEMoTh approach for searching for theory. 44 We searched for the health context (the NHSHC) and terms relating to ‘theory’ and used citation tracking to identify additional studies. To identify published reviews, we consulted bibliographies produced by PHE, who have undertaken regular literature searches for evidence relevant to the NHSHC programme since 2015 (www.healthcheck.nhs.uk/commissioners-and-providers/evidence/literature-review/). The full details of the searches employed are available in Appendix 2.

Overall, we consulted 60 programme documents (policy papers and guidance) and identified 19 existing studies of the NHSHC that employed six formal theories or theoretical frameworks, and 10 existing reviews and evidence syntheses. Details of these documents are provided in Appendix 1.

In reviewing the existing research evidence relating to the NHSHC programme by consulting existing reviews and evidence syntheses, we identified an existing focus on the early steps of the initial programme theory (IPT) as outlined above, and especially on the processes involved in invitation and uptake of the NHSHC. Conversely, less research attention has been paid to later stages, and especially to what happens after measurements and risk assessment at the end of a check, in relation to advice, onward signposting and/or referral and ongoing support for lifestyle and behaviour change. As described above in Chapter 1 (see Project focus: what happens after the risk assessment in a Health Check?) we determined (in consultation with our stakeholder groups) to focus our own review on these later steps.

We combined our understanding of the programme from the literature reviewed with our own knowledge to develop and refine a coherent IPT for our realist review and to inform the subsequent stages of searching, data extraction and analysis. The IPT is presented in Figure 3; it maps out the steps involved in the delivery of an NHSHC and highlights our particular areas of focus and questions we considered in the course of the project.

FIGURE 3.

Initial programme theory for the realist review with project focus highlighted.

In recognition of the complex nature of the NHSHC programme, and the possibility (captured in our IPT) that important interactions and feedback loops may exist with earlier steps in the delivery of the check, we determined that we should not exclude evidence relating to other programme steps. Instead, we decided to focus initially on identifying those documents that could provide data relating to the later steps, and subsequently draw on data that may shed important light on relationships with other steps in the programme as necessary.

Survey findings

Services to support risk reduction/management

As shown in Table 11 below, the majority of responding authorities had at least one service to support smoking cessation, alcohol and drug misuse, weight management, diabetes prevention, psychological support and social prescribing. In many LAs, there were two or sometimes three service providers for some of these services. Five respondents indicated in the open comments that their LAs also commission physical activity/exercise on referral services; one mentioned a generic lifestyle service.

TABLE 11 - Number of LAs in which there are multiple service providers for support services

Service	Number of LAs in survey sample commissioning:
	Don’t know who commissions	No response / no service provider	1 service provider	2 service providers	3 service providers	4 service providers
Smoking cessation	1	2	45	18	8
Alcohol and drug misuse	3	0	52	15	3	1
Weight management	5	6	45	16	2
Diabetes prevention	7	2	60	4	1
Psychological support	20	6	39	7	1	1
Social prescribing	10	2	46	13	3
Other services			7

As shown in Table 12, the majority of lifestyle and other relevant support services were provided through public, private or third-sector commissioning, with fewer provided by GP or LA staff.

TABLE 12 - Survey Q10 – please indicate who provides each of these services to patients who have had an NHSHC in your area. If the services are not provided in your area, please leave blank

Service	Number of LAs responding that services are delivered in their area by:
	GP staff	LA staff	Public sector	Private sector	Third sector	Other	Total services
Smoking cessation	26	20	22	28	9	0	105
Alcohol	8	3	27	30	26	1	95
Weight management	10	10	16	38	9	0	83
Diabetes prevention programme	10	0	16	38	5	CCG: 2	71
Psychological support	5	0	33	6	13	CCG: 2 NHS Trust: 1	60
Social prescribing	30	12	11	3	23	CCG: 2	81
Other	0	0	4	2	1	0	7
Total services	89	45	129	145	86	8	502

Respondents were asked how confident they were that:

1. each set of services has sufficient capacity to meet the demand arising from NHSHCs. They were asked to think about, for example, waiting times, eligibility criteria, etc.

2. each set of services is accessible to NHSHC attendees requiring support. They were asked to think about, for example, days/times of services, location of services, cost to service users, etc.

Most of the 68 respondents gave their views on their level of confidence in the support services available in the LAs for which they were responding. Confidence in the capacity of these services was mostly positive (see Figure 4).

FIGURE 4.

Commissioners’ confidence in the capacity of services to support NHSHC attendees.

However, this level of confidence varied across the different services. Respondents told us:

We had increased our smoking cessation service just prior to Covid so they have the capacity, the rest have seen so many people coming through over the last year that there is a bit of a wait for some. (R66)

We have capacity within weight management, EoR and diabetes prevention. Concern is around IAPT [Improving Access to Psychological Therapies programme] capacity as there was a waiting list prior to COVID and I understand that there is now more pressure on this service. (R61)

Others expressed doubts about the capacity of services to meet potential demand:

If all who are eligible and ready to be referred were so, there would not be enough capacity in the system, specifically weight management and mental health alone. (R08)

[The LA] had capacity issues with its commissioned smoking cessation service following a huge increase in demand throughout COVID-19. There are known long waiting times for psychological support services and not all professionals are aware of social prescribing practices. (R28)

Three respondents cited financial difficulties in association with the availability of appropriate support services:

With austerity measures, the capacity in the system has become so limited that there is very little capacity available. (R13)

The local authority is unable to properly financially support referral services. (R34)

Both alcohol and psychological support services (mental health services) are far less well established and resourced. (R23)

One respondent suggested that ‘In general, capacity isn’t the issue. It’s the motivation and interest from the public that is the issue’, citing that group weight management sessions are offered, but not welcomed by the majority of the population (R18).

Responses to the question about confidence in capacity (shown in Figure 1) suggest that there are some LAs with significant gaps in commissioned support services. Indeed, one respondent commented:

There are no weight management and stop smoking services available locally. (R16)

However, several respondents felt unable to give a view about the capacity or accessibility of services, especially for services that were not commissioned by the LA. This is reflected in the variable amount of missing data and in several comments from respondents. This response highlights the difficulty of pulling together information across such a fragmented system:

NDPP [National Diabetes Prevention Programme] is funded by NHSE [NHS England] through CCG [Clinical Commissioning Group] who rarely provides information to LAs unless forced to do so; all others are LA funded except for tier 3 weight management – another CCG funded service which is non-existent in the last 4 years. (R54)

Confidence in the accessibility of the services (see Figure 5) was similar and directly correlated to confidence in the capacity (Spearman’s r = 0.752; p < 0.001). Respondents were least certain about whether psychological support services had sufficient capacity and accessibility, which may be because these services are generally commissioned by NHS organisations.

FIGURE 5.

Commissioners’ confidence in the accessibility of services to support NHSHC patients.

All respondents provided an opinion regarding the appropriate use made by NHSHC providers of the support services that are available. This was much lower, with over half of the respondents (n = 50; 68%) having relatively little confidence (Figure 6).

FIGURE 6.

Commissioners’ confidence in appropriate use made of support services by NHSHC providers.

Several respondents commented that the number of onward referrals from the NHSHCs remain low, for example:

There is a wealth of support available from [this council]. The issue is not all providers access the support available. (R18)

However, others mentioned that they ‘have no real data on referral to other services’ (R03), so they generally lack knowledge about uptake of referrals following NHSHCs:

I have been generous giving this a three [fairly confident]. We do highlight support services as part of our NHS Health check training but have no way of following patients through to know how many access support successfully. (R64)

The level of awareness of NHSHC providers was a major factor in low confidence in the use of these services:

A recent survey of our GP providers indicates lack of awareness and skills in initiating lifestyle conversations, communicating the NHS HC results or about the offer from the Lifestyle provider. Subsequently we suspect not all GP practices refer into the community offers that are available following a NHS HC. (R13)

However, where there was less fragmentation, this was seen to be improved:

Onward referrals from Health Checks into our own services are higher from our own team of Health Trainers, which suggests that we aren’t getting all the referrals we should be getting from other providers. (R23)

Several respondents noted that they are working (or were working, prior to Covid-19) on addressing low rates of referrals through training and through working closely with providers.

Forty respondents reported that there had been a change in either capacity or accessibility of support services since the Covid-19-related pause, 13 said there had been no change, and 15 said they didn’t know. In some cases, the move of some support services to online provision was perceived to affect both accessibility and capacity in both positive and negative ways.

Many of these services have had to move online for part of the time at least, possibly making them more accessible for some but less accessible for others. (R50)

Services moved onto telephone support where possible and this increased accessibility for people as in they did not have to travel to attend appointments. (R66)

For some services capacity has increased due to remote delivery. (R04)

F2F [face-to-face] services have moved online only which are more popular and more efficient, permitting advisers to see more clients. (R40)

In some cases, Covid-19 has prompted greater investment in support services:

Tier 2 weight management service has had increased funding and the service has expanded and lowered its referral threshold. There is more social prescribing as an increase in PCN [Primary Care Network] link workers funded by national scheme. More funding for substance misuse services as well. (R41)

Increase in funding for drug/alcohol services, plus increase in funding for weight management programmes have increased capacity and accessibility. (R10)

Monitoring and evaluation

Monitoring of the outcomes of NHSHC programmes by LAs was relatively poor, with only 22 (31%) respondents indicating they gathered data on referrals to the GP, and 30 (42%) on the outcomes from such referrals, for example, new diagnoses. A similar proportion indicated they gathered data on referrals to lifestyle support services (24; 34%) and the outcomes from these, such as weight loss (19; 26%). Very few indicated they had data on whether prescriptions were taken up (8; 11%) or whether prescribing had resulted in changes in biomarkers (4; 6%). Respondents representing 33 LAs (46%) stated that they had undertaken some evaluation of their local programme (see Figure 7).

FIGURE 7.

Monitoring data routinely requested by commissioners.

Associations between delivery category and other survey data

The number of commissioned services reported by each respondent to support smoking cessation, weight management, alcohol use, the diabetes prevention programme, psychological support, social prescribing and any other relevant services was totalled. Overall, there were 502 services reported for the 74 LAs (mean 6.78; median 6.0). The LAs were grouped into three categories, dependent on the number of services reported (see Table 16). Just over a third of the LAs (25; 34%) reported having a higher than average number of providers, over half of which (n = 14) were in the blended with outreach category of delivery.

TABLE 16 - Number of commissioned support services (categorised)

Number of commissioned support services	Number of LAs (n = 74)
Below average (5 or fewer)	20 (27%)
Average (6/7)	29 (39%)
Above average (more than 7)	25 (34%)

The mean number of commissioned services was significantly higher in the LAs which fell into the blended with outreach category (7.6) compared to the general practice (6.6) or blended categories (5.9) (F = 3.85; p = 0.026) (see Figure 8).

FIGURE 8.

Association between commissioned support services and NHSHC delivery category.

The total number of different referral processes into all support services reported by each respondent was 560. As three LAs reported no information about referral processes for any service, the overall mean number was 7.57, median 8.0, range 1 to 16. A third of the remaining 71 LAs (24; 34%) reported a below average number of referral processes, equivalent to one or fewer referral processes per major service (see Table 17).

TABLE 17 - Number of referral methods for support services (categorised)

Number of referral methods for support services	Number of LAs (n = 71)
Below average (6 or fewer)	24 (34%)
Average (7/8)	16 (23%)
Above average (more than 8)	31 (44%)

The LAs which were categorised as offering blended with outreach delivery had the highest mean number of referral processes (8.0), compared to those categorised as general practice (7.5) and blended delivery (7.0), although the difference was not statistically significant (F = 0.311, p = 0.764) (see Figure 9).

FIGURE 9.

Association between referral processes and NHSHC delivery category.

The respondents’ average rating of confidence in both capacity and accessibility for each of the six main services was calculated, excluding missing responses. Their confidence in usage was rated as a single score for all support services. Confidence in the capacity, accessibility and usage of the support services varied little across the categories of delivery, although trends were visible in the confidence in accessibility and usage with the increasing use of non-general-practice-based NHSHC delivery (Table 18).

TABLE 18 - Confidence in support services by NHSHC delivery category

Delivery category	Overall confidence ratings for all services
	Capacity average (n = 72)	Accessibility average (n = 73)	Usage (single rating) (n = 74)
General practice	2.80	2.69	2.00
Blended	2.63	2.73	2.14
Blended with outreach	2.68	2.82	2.41

The total number of methods used to prioritise invitations was calculated for each LA both pre- and post-Covid-19. The number of methods was not related to the category of delivery, either pre- or post-Covid-19. In general, the number of prioritisation factors increased in all categories post-Covid-19. However, the increase in the mean number of prioritisation factors used was higher in the blended and blended with outreach categories, compared to the general-practice category (see Table 19 and Figure 10).

TABLE 19 - Prioritisation of invitations by NHSHC delivery category

Delivery category	Mean number of factors used to prioritise invitations
	Pre-Covid-19	Post-Covid-19
General practice	1.08	1.37
Blended	1.10	2.10
Blended with outreach	1.10	1.59

FIGURE 10.

Change in prioritisation pre- and post-Covid-19 by category of delivery.

The degree of monitoring and evaluation reported as being undertaken was generally low: mean number of aspects reported = 1.92; median 1.5. There were 19 LAs reporting doing none, 30 reporting monitoring/evaluating one or two aspects (minimal), and the remaining 25 reporting monitoring/evaluating more than two aspects (above average). The degree of monitoring and evaluation was not related to the category of delivery (see Figure 11).

FIGURE 11.

Monitoring and evaluation of NHSHCs by delivery category.

Associations between delivery category and data at local authority level

With regard to geographic region, there were notable differences in the proportions of LAs in the three NHSHC delivery categories in each PHE centre. Whilst five out of the seven responding LAs in Yorkshire and Humber fell in the ‘blended with outreach’ category, seven out of the nine responding LAs in the North West fell in the ‘general-practice delivery’ category (see Figure 12).

FIGURE 12.

Proportion of LAs in NHSHC delivery categories by geographic region.

With regard to LA size, there were no significant differences in the relative size of the LAs falling in each NHSHC delivery category, although there does appear to be a trend that those LAs delivering via community outreach tend to be larger (see Figure 13).

FIGURE 13.

Size of LAs in each NHSHC delivery category.

With regard to budget, there were no significant differences in the relative size of the public health budgets of LAs falling in each NHSHC delivery category (see Figure 14).

FIGURE 14.

Public health budgets of LAs in each NHSHC delivery category.

With regard to deprivation, there were no significant differences in the relative deprivation of LAs falling in each NHSHC delivery category. Below (see Figure 15) we have reported on the indicator ‘Rank of proportion of LSOAs in most deprived 10% nationally’, but other indicators (e.g. rank of local concentration) paint a similar picture.

FIGURE 15.

Deprivation within LAs in each NHSHC delivery category. LSOA, lower-layer super output area.

Finally, with regard to NHSHC programme delivery performance, according to the measures captured by PHE and published in Appendix 1 of their programme review41 (proportion of eligible people receiving an NHSHC between 2015/16 and 2019/20) LAs delivering NHSHCs using a ‘blended with outreach’ model achieved, on average, a lower coverage (37.8%) than those delivering using a general practice (46.7%) or blended (45.4%) delivery model (F = 3.217; p = 0.046) (see Figure 16).

FIGURE 16.

NHSHC performance measures (2015/16 to 2019/20) for LAs in each NHSHC delivery category.

Summary of survey findings

Our survey, covering 74 LAs across England, clearly demonstrates the variation in delivery of the NHSHC in terms of where and how it is provided and by whom. Whilst HCAs and/or nurses deliver the NHSHC in most (85%) responding LAs, GPs deliver at least some of the checks in two-thirds of the LAs. There is a wide range of other professionals responsible for delivering the checks, to a greater or lesser extent in different LAs. Some commissioners do not specify and are not aware of the type/grade of professional that delivers the check.

Our information on the delivery of the NHSHC before and after the Covid-19 pause has enabled us to create a typology of NHSHC delivery for the first time. We identify three main models in use prior to the Covid-19 pause: delivery in general practice only (used by 32% of responding LAs), delivery in general practice but also offering remote delivery (such as by phone or video consultation) and/or delivery in pharmacy (28%), and delivery in a range of settings that include community venues, with or without remote delivery (39%).

Our survey also provides new insight into what happens to attendees after their risk assessment. Whilst our survey found that most LAs commission at least one service to support key aspects of behavioural change (in relation to smoking, alcohol consumption and weight management), there are some LAs in which significant service gaps exist. Our survey shows that even though commissioners overall might feel reasonably confident about the capacity and accessibility of support services, they are much less confident that appropriate use is being made of the support services by NHSHC providers.

Our analyses show that LAs using a blended with outreach model tend to have a higher number of support services to support behaviour change following the check. The blended with outreach model is also associated with more post-Covid-19 prioritisation of NHSHC candidates, and greater confidence in the accessibility and usage of follow-on support services. There does appear to be a pattern with regard to LAs in the different regions commissioning different delivery models. For example, seven out of nine LAs in the North West employ a general-practice delivery model, whilst only one out of 13 LAs in the South East, one out of seven in Yorkshire and Humber and one out of six in the South West do so. Whilst there is no significant association, there appears to be a trend that those LAs delivering via community outreach tend to be larger in population size. However, our data show no apparent association between delivery model and the size of the public health per head, or level of deprivation. Finally, when looking at the programme performance indicators captured by PHE, programme coverage might be slightly less overall for LAs delivering via a blended with outreach model.

Review findings

Documents included in the review

The identification, screening and inclusion of documents in the review are summarised in Figure 17 (an adapted version of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram). 53 A total of 124 included documents contributed data to the review.

FIGURE 17.

Summary of searching and screening.

Of the 124 documents included, 59 were published research papers or reports, 20 were documents reporting local evaluations of services, 34 were conference materials (including presentations, abstracts and posters) and 11 were other types of documents, including policy reports, guidance, news articles and theses. Seventeen per cent (n = 21) of included documents contributed data describing the NHSHCs programme in relation to all of England; the rest focused on a single local area or small group of areas. The geographical distribution of included documents that represent individual local areas in England is illustrated in Figure 18. Details of the full set of included documents are provided in Table 20.

FIGURE 18.

Map of England showing geographical focus of included documents.

TABLE 20 - Characteristics of included documents

nd, no date

Commissioning period here refers to whether the data included in the document relate to the period when NHSHCs were commissioned by PCTs or LAs. Documents contributing data that spans the ‘transition’ period (from mid-2012 to 2013) are also noted.

Identifying details of LAs have been removed where unpublished material was shared by survey respondents.

First author	Year	Document type	Aim or purpose of document	Study design (if applicable)	Perspective(s)	Local area(s)	Commissioning perioda	Contributed data to CMOCs			Total contributions to CMOCs	Source
								C-CMOCs	P-CMOCs	A-CMOCs
Alageel54	2018 (1)	Conference presentation	Summary of results of qualitative interview study (Alageel 2018)	Qualitative interview study	Providers	Lambeth and Lewisham	LA		P7		1	NHSHC website
Alageel55	2018 (2)	Journal article	To identify barriers and facilitators to implementing multiple health behaviour change interventions for CVD risk reduction in primary care	Qualitative interview study	Providers	Lambeth and Lewisham	LA	C14	P1, P2, P6, P7, P8, P10, P11, P13, P15, P20, P22, P24, P27	A1, A2, A27, A30, A32, A35, A38, A39	22	Existing review
Alageel56	2020	Journal article	To examine factors that might influence engagement and adherence to lifestyle change interventions and medication amongst people recently assessed at medium or high risk of CVD	Qualitative interview study	Attendees	Lambeth and Lewisham	LA	C14	P23	A2, A6, A10, A12, A15, A25, A28, A30, A31, A32, A35, A36, A38, A43, A44	17	Existing review
Alford57	2010	Evaluation report	To explore behaviour changes made following community-based NHSHC and experience of NHSHCs	Qualitative interview study	Attendees	Knowsley	PCT			A40, A44	2	Existing review
Al-Osaimi58	2020	Conference abstract	To describe the implementation of software to manage the NHSHC	n/a	Commissioners	Sandwell	LA	C2, C7			2	NHSHC website
Artac59	2013	Journal article	To assess whether the NHSHC was associated with a reduction in CVD risk after one year	Pre/post	Attendees	Hammersmith and Fulham	PCT		P12		1	Existing review
Atkins60	2020	Journal article	To identify behaviours and actors relevant to uptake, delivery and follow-up of NHSHCs and influences on those behaviours	Systematic review	n/a	n/a	n/a	C14		A35	2	Searches – MEDLINE
Baker61	2014 (1)	Evaluation report	To assess the impact of the NHSHC programme and inform future commissioning (summary)	Cross-sectional	Attendees	Gloucestershire	PCT	C9	P12, P17		3	NHSHC website
Baker62	2014 (2)	Journal article	To investigate the perceptions and opinions of patients who attended an NHSHC	Survey	Attendees	Gloucestershire	PCT	C14	P1, P8, P20, P25	A1, A15, A18, A22, A23, A26, A34	12	Existing review
Baker63	2015 (1)	Journal article	To investigate health professionals’ experiences and perspectives of implementation of the NHSHC	Survey including qualitative analysis of free-text responses	Providers	Gloucestershire	PCT	C2	P10, P11, P18		4	Existing review
Baker64	2015 (2)	Journal article	To investigate how the local NHSHC pathway was followed and interpreted	Cross-sectional	n/a	Gloucestershire	PCT		P2, P12		2	Existing review
Bell65	2019	Conference abstract	To describe the outcomes of NHSHCs delivered in an integrated model with lifestyle services	Cross-sectional	Commissioners	Medway	LA	C3	P19		2	NHSHC website
Boase66	2012	Journal article	To explore the perspectives of PNs in their role of communicating CVD risk to patients	Qualitative interview study	Providers	Cambridge	PCT		P4, P22, P27	A8, A19	5	Searches – MEDLINE
Boseley67	2020	Conference presentation	To describe a local model of NHSHC delivery with integrated lifestyle services	Mixed methods	Commissioners	East Sussex	LA	C3, C6, C7	P14, P15, P19	A4	7	NHSHC website
Brutus48	2013	Evaluation report	To review the design of the local NHSHC programme and analyse delivery options available	Cross-sectional	Various	Croydon	PCT	C1, C2, C7	P1, P13, P15, P19	A6, A40	9	NHSHC website
Burgess68	2016	Conference presentation	Summary results of a qualitative interview study (Alageel 2020)	Qualitative interview study	Attendees	Lambeth and Lewisham	LA		P1, P23	A2, A5, A10, A20, A23, A28, A33, A42	10	NHSHC website
Burke69	2015	Conference presentation	To describe local delivery of NHSHCs with a focus on vulnerable groups	n/a	Commissioners	Leeds	LA			A5, A38	2	NHSHC website
Carter49	2016	Journal article	To evaluate local outcomes of NHSHCs with a focus on diagnosis and management after checks	Retrospective cohort	Attendees	Leicester	PCT, Transition	C1			1	Existing review
Centre for Public Scrutiny70	2014	Other report	A report on the role of Council Scrutiny in local reviews of NHSHC programmes	n/a	n/a	Various	LA	C1, C11	P1		3	Searches – HMIC
Chatterjee71	2017	Journal article	To assess the knowledge, use, and confidence in national physical activity and Chief Medical Officer guidelines and tools among GPs in England	Survey	Providers	England	LA		P21		1	Searches – MEDLINE
Chipchase72	2011	Evaluation report	To explore people’s views and experiences of the NHSHC	Qualitative interview study	Various	Birmingham	PCT		P1, P14	A1, A2, A11, A12, A19, A20, A40	9	Existing review
Clarke73	2020	Conference presentation	To describe the of data to inform local CVD prevention work	n/a	Commissioners	Barnsley	LA	C8		A33	2	NHSHC website
Cochrane74	2012 (1)	Journal article	To compare changes in population CVD risk factors between those who receive an NHSHC and those who receive an NHSHC with additional lifestyle support	RCT	n/a	Stoke on Trent	PCT		P26	A9	2	Existing review
Cochrane75	2013	Journal article	To review response, attendance and treatment uptake following NHSHCs	Cross-sectional	n/a	Stoke on Trent	PCT			A9	1	Existing review
Coffey76	2014	Evaluation report	To assess the level of uptake of NHSHCs	Cross-sectional	n/a	Salford	PCT		P12, P20		2	Existing review
Coghill77	2018	Journal article	To assess uptake and outcomes of NHSHCs in general practice	Cross-sectional	n/a	Bristol	PCT, Transition, LA		P12, P16		2	Existing review
Collins78	2011	Evaluation report	To evaluate the effectiveness of an ‘outreach’ delivery model for NHSHCs	Mixed methods	n/a	Medway	PCT		P17	A4	2	NHSHC website
Corlett79	2016	Journal article	To assess the findings of NHSHCs delivered in pharmacy settings, referrals to GPs and client views	Mixed methods	n/a	Lewisham	Transition, LA			A2, A13, A15, A25, A35, A38	6	Existing review
Coward80	2020	Conference presentation	To describe processes linking NHSHCs with local services that aim to promote physical activity	n/a	n/a	Dorset	LA	C2, C7, C8	P17, P19, P26, P27, P28		8	NHSHC website
Cupit81	2018	PhD thesis	To explore how patients’ and healthcare professionals’ knowledge and practices about CVD prevention are socially organised	Ethnography	n/a	Unknown	LA	C8, C13, C14	P2, P4, P9, P10, P20, P24	A11, A23, A25, A27, A31, A35, A38, A44	17	NHSHC website
Dalton82	2011	Journal article	To examine the uptake of NHSHCs and statin prescribing	Cross-sectional	n/a	Ealing	PCT		P2, P3		2	Existing review
Derbyshire County Council83	2015	Evaluation report (Health Equity Audit)	To identify health inequalities in relation to the NHSHC programme	Cross-sectional	Commissioner	Derbyshire	LA	C9, C10	P2, P12, P15, P16, P17, P20, P22, P25	A35	11	NHSHC website
Edmans84	2013	Other report	To describe local training provision in relation to the dementia component of NHSHCs	n/a	Providers	Southwark	LA		P20		1	NHSHC website
Fenton85	2018	Conference presentation	To describe local CVD prevention work and NHSHCs	Cross-sectional	n/a	Southwark	LA		P1, P3		2	NHSHC website
Forster86	2015	Journal article	To evaluate the ‘yield’ of NHSHCs (in relation to identification of risk factors, diagnoses and prescribing)	Retrospective cohort	n/a	England	PCT, Transition, LA		P2, P6, P12, P16		4	Existing review
Forsyth87	2012	Conference abstract	To test a delivery model using pharmacists to deliver health checks to the South Asian community (NB describes checks delivered in Scotland)	Mixed methods	n/a	Glasgow	PCT			A17	1	Searches – Embase
Frazer88	2020	Conference presentation	To describe the delivery of NHSHCs with integrated lifestyle services	n/a	Commissioners	West Sussex	LA	C3			1	NHSHC website
Gidlow89	2020	Journal article	To examine the content of NHSHC, patient-practitioner communication balance and differences when using QRISK2 versus JBS3 CVD risk calculators	Observation (video recorded NHSHCs)	n/a	West Midlands	LA		P10, P20	A6, A13, A39	5	Searches – MEDLINE
Gidlow90	2021 (1)	Research report	To explore the extent of physical activity and alcohol measurement in the NHSHC	Observation (video recorded NHSHCs)	n/a	West Midlands	LA		P20		1	NHSHC website
Gidlow91	2021 (2)	Research report	To explore practitioner and patient understanding of CVD risk, associated advice or treatment and the response of patients to the NHSHC supported by the QRISK2 or JBS3 risk calculators	Mixed methods	n/a	West Midlands	LA		P10	A9, A10, A13, A29	4	Search alerts
Graley92	2011	Journal article	To describe a ‘postcode lottery’ effect in relation to NHSHCs	Cross-sectional	Commissioner	North-west London	PCT	C9, C10, C13, C14	P12, P13		6	Existing review
Greaves93	2015	Journal article	To assess the feasibility of delivering an intervention to promote healthy eating and physical activity and of conducting a full-scale RCT	Pilot RCT	n/a	Bath	PCT		P28	A30, A37, A40	4	Searches – MEDLINE
Green94	2018	Evaluation report	To understand the NHSHC patient journey from invitation through to behaviour change or clinical intervention	Mixed methods	Attendees	East Sussex	LA	C7	P10, P24	A1, A8, A12, A24, A29, A35	9	Stakeholder group
Gregory95	2018	Conference presentation	To describe the role of healthcare professionals in treatment of tobacco dependency	n/a	n/a	England	LA		P25		1	NHSHC website
Gulliford96	2018	Journal article	To compare CVD risk scores for ‘invited’ and ‘opportunistic’ NHSHCs	Retrospective cohort	n/a	Lambeth and Lewisham	Transition, LA		P11		1	Existing review
Hardman97	2014	Evaluation report	To describe local delivery of an NHSHC programme with Health Trainers	n/a	Various	Bolton	PCT	C3	P7, P14, P19	A13, A30	6	NHSHC website
Haringay Council98	2012	Evaluation report	Scrutiny review focused on men’s health needs and life expectancy gap	Mixed methods	n/a	Haringay	PCT	C7		A10, A13, A14, A16, A30, A37	7	NHSHC website
Hawking99	2018	Conference poster	To describe a visual risk communication tool designed for use in NHSHCs	n/a	Providers, attendees	Newham	LA			A44	1	NHSHC website
Hawking100	2019	Journal article	To explore patient perspectives and experiences of a personalised risk report during an NHSHC	Qualitative interview study	Attendees	Newham	LA		P28	A1, A9, A10, A18, A19, A20, A40, A44	9	Existing review
Hinde101	2017	Journal article	To assess the cost-effectiveness of NHSHCs	Economic evaluation	n/a	England	LA	C12, C13			2	Existing review
Homer102	2015	Journal article	To determine the characteristics of patients prescribed statins for primary prevention according to their CVD risk	Cross-sectional	n/a	Newham, City & Hackney, Tower Hamlets (London)	LA		P3		1	Serendipity
Honey103	2013	Journal article	To identify the attitudes of primary healthcare professionals towards the delivery of lifestyle advice in NHSHCs	Q methodology	Providers	Leeds	PCT		P2, P6, P7, P18, P22, P24, P27		7	Searches – MEDLINE
Honey104	2015	Journal article	To examine the perspectives of patients identified as being at ‘high risk’ of CVD events	Qualitative interview study	Attendees	Leeds	PCT		P27	A2, A3, A4, A5, A7, A9, A10, A13, A19, A20, A22, A27, A29	14	Searches – MEDLINE
Hooper105	2014	Journal article	To estimate the case detection of five health conditions by NHSHCs	Cross-sectional	Attendees	Warwickshire	PCT	C10			1	Existing review
Hyseni106	2020	Journal article	To report the results of a workshop that aimed to facilitate engagement with stakeholders who will be involved in co-production of an NHSHC modelling tool for commissioners	Qualitative interview study	Commissioners, providers, policy-makers	Various	LA	C5, C7, C11, C12, C13, C14	P12		7	Searches – MEDLINE
Ismail50	2015	Journal article	To explore the challenges and barriers faced by staff involved in the delivery of the NHSHC	Qualitative interview study	Providers	Leeds	LA	C1, C7, C9, C14	P6, P10, P12	A35, A36, A44	10	Existing review
Ismail107	2016	Journal article	To provide an insight into the process of patients receiving NHSHCs and determine the extent to which they were supported to reduce CVD risk through behaviour change	Qualitative interview study	Attendees	Leeds	PCT		P2, P27	A2, A6, A8, A11, A12, A30, A31, A38	10	Existing review
Ismail108	2019	Research report (NIHR)	To test the clinical and cost effectiveness of an ‘enhanced lifestyle motivational interviewing’ intervention for patients at high risk of CVD in group and individual settings, compared with usual care	RCT	n/a	South London	LA		P6, P7	A6, A16, A17, A26, A27, A30, A31, A32, A34, A40, A44	13	Searches – WoS
Jones52	2020	Conference poster	To describe local CVD prevention work and NHSHCs	n/a	n/a	Telford	LA/CCG	C1	P6, P17	A14	4	NHSHC website
Kearney109	2015	Conference presentation	To describe factors that influence GP engagement with NHSHCs and potential solutions	n/a	n/a	n/a	LA	C4	P1		2	NHSHC website
Kennedy110	2019	Journal article	To evaluate uptake, risk factor detection and management from the NHSHC	Quasi-RCT	n/a	Hampshire	PCT, Transition, LA		P13		1	Existing review
Kirkpatrick111	2016	Conference presentation	To describe staff development and training for NHSHC providers	n/a	Providers	Salford	LA		P8		1	NHSHC website
Krska112	2010	Evaluation report	To evaluate a CVD screening service offered in pharmacy settings and obtain views of prospective users about the acceptability of the service	Mixed methods	n/a	Sefton	PCT		P25	A2	2	NHSHC website
Krska113	2013	Conference abstract	To compare the views of the general public, pharmacists and patients invited to the NHSHC and to compare experiences of NHSHCs delivered by pharmacies and general practices	Survey and qualitative interviews	Providers, attendees	Sefton	PCT			A14	1	Searches – Embase
Krska114	2014	Journal article	To explore the views and experiences of patients with potentially high CVD risk	Survey	Attendees	Sefton	PCT		P7, P10	A15	3	Existing review
Krska115	2016 (1)	Journal article	To seek the views of GPs and practice managers on NHSHC implementation	Survey	Providers	Sefton	PCT	C9	P10, P13		3	Existing review
Krska116	2016 (2)	Journal article	To evaluate NHSHC implementation in relation to data recording, advice provided, referrals, prescribing and new diagnoses	Cross-sectional	Providers	Sefton	PCT	C10			1	Existing review
Kumar117	2015	Conference presentation	To describe work to improve GP engagement with NHSHCs	n/a	n/a	Stoke on Trent, Havering (London)	LA	C1			1	NHSHC website
Lake118	2010	Conference presentation	To describe a community-based NHSHC service	n/a	n/a	Camden	PCT	C11	P19, P28	A5, A14	4	NHSHC website
Lambert119	2016	Journal article	To assess indicators of programme reach available to local service commissioners	Assessment of indicators	n/a	NE England	PCT, Transition		P12		1	Existing review
Lennon120	2020	Conference presentation	To describe local responses to Covid-19 in relation to NHSHCs and social prescribing	n/a	n/a	Redbridge	LA	C6			1	Stakeholder group
Liverpool City Council121	2020	Conference poster	To describe the local Health Trainer service available to NHSHC attendees	n/a	n/a	Liverpool	LA		P6, P8, P19, P26, P27, P28	A6, A14, A16, A30, A36, A40	12	NHSHC website
Local Government Association122	2015	Other report	Report on the transfer of public health responsibilities to LAs	n/a	Commissioners	Various	LA	C1, C5, C8, C11, C12, C13			6	Existing review
LA A123, b	2019	Evaluation report	Evaluation of local NHSHC programme	Mixed methods	Commissioners	[Redacted]	LA	C1, C2, C11	P16, P17	A15	6	Survey respondent
LA B124, b	2019	Evaluation report	Evaluation of local NHSHC programme	Mixed methods	Commissioners	[Redacted]	LA	C7, C11, C12			3	Survey respondent
LA C125, b	nd	Working document	Report describing quality assurance considerations in relation to NHSHCs	n/a	Commissioners	[Redacted]	LA	C1, C2, C4, C7	P9		5	Survey respondent
LA C126, b	2019	Evaluation report	To measure, monitor and report on performance and quality of NHSHCs against a quality framework	Mixed methods	Commissioners	[Redacted]	LA	C2, C7, C10, C12			4	Survey respondent
London Borough of Bromley127	2018	Conference presentation	To assess the prevention of diabetes through NHSHCs	Cross-sectional	n/a	Bromley	LA	C14	P8, P25		3	NHSHC website
Loo128	2011	Conference abstract	To derive information on community pharmacists’ activities and attitudes in relation to NHSHCs	Survey	Providers	Various	PCT		P13		1	Existing review
Lumley129	2015	Conference presentation	To describe the role of the NHSHC in addressing high blood pressure	n/a	Commissioners, providers	Blackpool	LA	C1, C7			2	NHSHC website
Maddern130	2020	Conference abstract	To describe the role of local political scrutiny in developing and improving NHSHCs	n/a	Commissioners	Wiltshire	LA	C11			1	NHSHC website
Martin131	2011	Practitioner article	To describe challenges in delivery of NHSHCs	n/a	Provider	East Sussex	PCT	C13	P14		2	Searches – CINAHL
McDermott132	2015	Conference presentation	Summary of research exploring the implementation of NHSHCs in primary care settings	Qualitative interview study	Providers	Lambeth and Lewisham	PCT, Transition	C9	P1, P10, P13		4	NHSHC website
McMillan133	2018	Journal article	Report on a workshop with members of the public to inform design of a ‘digital adjunct’ intervention for the NHSHC	Co-production	Attendees	Manchester	LA			A6, A44	2	Searches – MEDLINE
McNaughton134	2011	Journal article	To evaluate delivery of the NHSHC in community pharmacies	Qualitative interview study	Providers	Tees Valley	PCT	C13	P20, P27	A14, A15	5	Existing review
McNaughton135	2014	Journal article	To understand factors that influenced adherence to medication and advice in ‘high risk’ patients identified by the NHSHC	Qualitative interview study	Attendees	North East England	PCT			A3, A9, A10, A25, A27, A28, A35, A38, A40, A42	10	Existing review
Mills136	2017	Journal article	To synthesise data concerning the views of commissioners, managers and healthcare professionals towards the NHSHC	Systematic review	Commissioners, providers	n/a	n/a		P10, P13		2	Searches – MEDLINE
Nahar137	2020	Journal article	Protocol for a mixed-methods implementation study of a community-based CVD risk assessment and coaching intervention	Mixed methods (protocol)	n/a	Sussex, Nottingham	LA			A14	1	Searches – MEDLINE
Nasir138	2018	Conference abstract	To describe a local project that aimed to increase NHSHC uptake and referrals to local lifestyle services	Cross-sectional	n/a	Kingston (London)	LA			A35, A37	2	NHSHC website
Newman139	2018	Conference presentation	To describe Health Coaching techniques	n/a	n/a	n/a	LA		P27		1	NHSHC website
NHS Greenwich140	2011	Evaluation report	To assess the outcomes of a community-based NHSHC delivery model	Mixed methods	n/a	Greenwich	PCT		P14	A4, A13, A17	4	Existing review
NHS Midlands and East141	2011	Evaluation report	To evaluate a pilot programme aiming to deliver lifestyle interventions through the NHSHC	Mixed methods	n/a	Bedfordshire; Great Yarmouth and Waveney	PCT	C2, C7	P1, P7, P10, P17, P19	A40	8	NHSHC website
NICE142	2014	Guidance	Guidance for LAs on commissioning and delivery of the NHSHC	n/a	Commissioners	England	LA	C11			1	Searches – HMIC
Nicholas143	2012	Journal article	To evaluate the organisation of the NHSHC in general practices	Survey	Providers	Lambeth and Lewisham	PCT		P2		1	Existing review
O’Flaherty144	2021	Research report	To develop a model for commissioners to quantify cost-effectiveness and potential for equitable population health gain of the NHSHC	Mixed methods	Commissioners	Various	LA	C7			1	Search alerts
Onyia145	2016	Conference presentation	To describe the impact of Health Trainers on uptake of lifestyle services after NHSHCs	Cross-sectional	n/a	Halton	LA		P6, P8, P25, P26		4	NHSHC website
Oswald146	2010	Evaluation report	To evaluate the implementation and outcomes of the ‘Tees Vascular Assessment Programme’ (precursor to NHSHC)	Mixed methods	n/a	Tees Valley	PCT	C8, C9, C13, C14	P1, P2, P7, P11, P14, P28	A1, A2, A4, A9, A13, A10, A18, A28, A29, A31, A32, A33, A40, A41, A42, A43	26	Existing review
Palladino147	2020	Journal article	To assess associations between coverage of the NHSHC and detection and management of incident cases of non-diabetic hyperglycaemia and type 2 diabetes	Retrospective cohort	n/a	England	PCT		P5		1	Searches – MEDLINE
Patel5	2020	Journal article	To describe the uptake and outputs of the NHSHC programme	Cross-sectional	n/a	England	Transition, LA		P3, P12		2	Searches – MEDLINE
Paxton148	2020	Journal article	To assess the fidelity of delivery of NHSHCs in general practice	Fidelity assessment	n/a	East of England	PCT		P20, P21		2	Searches – MEDLINE
Perkins149	2020	Conference presentation	Presentation describing CVD prevention initiatives	n/a	n/a	England	LA			A2, A38	2	NHSHC website
Perry150	2014	Journal article	To explore experiences of engaging with a community-based NHSHC	Qualitative interview study	Attendees	Knowsley	PCT		P14, P28	A2, A4, A7, A13, A18, A25, A35, A38, A40, A44	12	Existing review
PHE3	2020	Guidance	Best Practice Guidance for commissioners and providers	n/a	n/a	England	LA		P12	A12	2	NHSHC website
Rawlinson151	2019	Journal article	To evaluate an ‘enhanced health promotion service’ in a physiotherapy-led musculoskeletal service providing NHSHCs and diabetes checks	Mixed methods	n/a	Salford	LA	C6	P6, P7, P8, P14, P17, P19, P26		8	Searches – CINAHL
Research Works51	2013	Evaluation report	To assess commissioners’ and providers’ experiences of the NHSHC and gain an understanding of the engagement of public health professionals with NHSHCs	Qualitative interview study	Commissioners, providers	Various	PCT, Transition	C1, C4, C7, C11, C13	P7, P9, P10, P13, P14, P19	A13	12	Existing review
Richardson152	2016	News article	Article responding to research demonstrating lower coverage of NHSHCs and limited evidence of effectiveness of NHSHCs	n/a	n/a	n/a	LA		P18	A16	2	Searches – CINAHL
Riley153	2015	Journal article	To examine the feasibility and acceptability of community outreach NHSHCs targeted at the Afro-Caribbean community	Ethnography	Providers, attendees	Bristol	LA		P10	A2, A3, A13, A14, A16, A17, A21, A23, A25, A26, A40, A44	13	Existing review
Riley154	2016	Journal article	To examine the experiences of patients attending and healthcare professionals conducting NHSHCs	Qualitative interview study	Providers, attendees	Bristol	LA		P4, P8, P10, P27	A1, A3, A11, A19, A20, A21, A22, A25, A33, A35, A38, A44	16	Existing review
Robson155	2015	Journal article	To describe implementation and results of the NHSHCs	Cross-sectional	n/a	City & Hackney, Newham, Tower Hamlets	PCT		P9		1	Existing review
Robson156	2017	Journal article	To describe the coverage and impact of NHSHCs on cardiovascular risk management and identification of new comorbidities	Retrospective cohort	n/a	City & Hackney, Newham, Tower Hamlets	PCT, Transition, LA		P9		1	Existing review
Saramunee157	2015	Journal article	To explore the experience of and willingness to use seven pharmacy public health services related to cardiovascular risk among the general public in England (including the NHSHC)	Mixed methods	Attendees	Sefton				A15, A29	2	Searches – MEDLINE
Shaw158	2015	Journal article	To explore healthcare professionals’ and patients’ experiences of delivering and receiving the NHSHC	Qualitative interview study	Providers, attendees	Birmingham	PCT	C14	P8, P12, P23, P24, P27	A2, A3, A4, A6, A9, A24, A26, A32, A35, A36, A38, A40	18	Existing review
Shaw159	2016	Journal article	To evaluate the implementation of the NHSHC from the perspective of GPs	Qualitative interview study	Providers	Birmingham	PCT		P1, P5, P6, P9, P10, P11, P13, P17, P20, P21, P26, P27	A1, A6, A10, A12, A20, A30, A39	19	Existing review
Simon160	2020	Conference presentation	Presentation describing physical activity interventions for prevention and management of health conditions	n/a	n/a	England	LA		P26		1	NHSHC website
Solutions Strategy161	2017	Evaluation report	To evaluate the pilot and assess the feasibility of extending the NHSHC to include a dementia risk reduction component	Mixed methods	n/a	Birmingham, Bury, Manchester, Southampton			P26	A13, A15, A26	4	Searches – HMIC
Strutt162	2011	PhD thesis	To investigate patients’ experiences of and responses to NHSHCs	Qualitative interview study / ethnography	Attendees	n/a	PCT		P1, P16	A2, A5, A6, A7, A11, A13, A15, A20, A21, A22, A25, A26, A29, A30, A34, A35, A44	19	Existing review
Tanner8	2020	Research report	To update PHE-commissioned rapid evidence synthesis and summarise evidence to address several research questions relating to the implementation of NHSHCs	Systematic review	Various	n/a	n/a		P2		1	NHSHC website
Thompson163	2016	Conference presentation	Presentation describing PHE’s ‘StARS’ framework for assessment of NHSHCs	n/a	Commissioners	England	LA	C11			1	NHSHC website
Thompson164	2019	Conference abstract	Summary of implementation and outcomes of an integrated cardiovascular service	Cross-sectional	Commissioner	Slough	LA	C3	P19		2	NHSHC website
Trueland165	2013	News article	Article based around an interview with NHSHC supporter Professor Michael Kirby	n/a	Commissioners	n/a	LA	C8			1	Searches – HMIC
Turner166	2013	Journal article	To evaluate variation in statin take-up following risk assessment in the NHSHC	Qualitative interview study	Attendees	Nottingham	PCT			A15, A28, A41, A42, A43	5	Searches – HMIC
Usher-Smith7	2017	Research report	To provide a rapid synthesis of published research evidence on NHSHCs	Systematic review	n/a	n/a	n/a		P8		1	NHSHC website
Visram167	2012	Evaluation report	To investigate the implementation and accessibility of the ‘health trainer community check’ service	Mixed methods	Various	Durham	PCT, Transition	C1, C5, C9	P6, P12, P19, P27	A2, A3, A4, A5, A31, A32, A33	14	NHSHC website
Williams168	2018	Conference presentation	Presentation describing physical activity training and use of the GPPAQ tool to assess physical activity levels	n/a	n/a	England	LA		P21, P26		2	NHSHC website

The findings from our realist review describe what our included data tell us about what happens after the measurements and risk assessment are completed in an NHSHC. Our explanations of what happens (and what does not happen) in practice during and after a check centre on the reasoning and responses of three groups of actors:

• Commissioners, who make decisions about who will provide the NHSHC in local areas, how the programme should be delivered, how providers will be remunerated and how delivery will be monitored, and may also be responsible for commissioning other local lifestyle services that may be available to NHSHC attendees.

• Providers, who make decisions about the advice, brief interventions, referrals and clinical interventions that it is appropriate to offer to each attendee, and who deliver and record the delivery of these activities during the NHSHC.

• Attendees, who respond to the NHSHC and the offer or provision of advice, brief interventions, referral or prescriptions, and may ultimately choose to make lifestyle changes or take medicine to lower their CVD risk, or not.

Final programme theory

Our final programme theory is presented in Figure 19, which summarises our findings and the CMOCs on which they are based. This figure is intended to illustrate the important contexts that affect the delivery of the NHSHC after the measurements and risk assessments are completed. In particular, it aims to highlight that both variation in understanding and engagement with the programme can affect the way in which it is commissioned and delivered. The figure also includes the important practical constraints that limit what can be delivered within the programme’s remit and affect the delivery of advice and referrals after a check. Finally, the diagram identifies connections between delivery models and processes and the experiences of NHSHC attendees; these experiences are equally various, and may or may not meet their expectations and needs.

FIGURE 19.

Final programme theory.

Variation in NHSHC delivery: street-level bureaucracy

Our findings draw attention to wide variation in delivery of what happens after the measurements and risk assessment are completed during an NHSHC. Large-scale observational studies indicate that the Best Practice Guidance relating to the delivery of advice, ‘brief interventions’, referral and prescriptions is not always followed, with rates of delivery falling well below guideline thresholds. 5,33 Regional and local studies indicate wide variation in the delivery and uptake of these activities. 7,8 Inconsistencies in the recording and collation of data relating to the delivery and uptake of advice, referrals and prescribing post-check mean that it is not currently possible to produce a comprehensive picture of this variation across England. 5,119 However, the data that we gathered in our survey and synthesised in our review provide a starting point to understand delivery in this area and highlight the roles that LA commissioners and providers play.

Our survey identified variation between LAs in commissioned NHSHC providers and both variation and gaps in the commissioning and use of services to support risk management and reduction for attendees post-check. Our review underlines these findings and identifies other factors at work, centred on commissioners’ and providers’ understanding of the purpose of the NHSHC, local levels of engagement with the programme and a range of practical constraints that limit what can be achieved within the programme’s remit.

Our review goes a step further and considers how these differences in commissioned and actual delivery models for the NHSHC influence how individual NHSHC encounters are experienced by attendees, as well as the additional, external influences that affect their response to what they are offered by NHSHC providers. Data from research focused on attendee experience of the NHSHC suggest that responses to the programme are as varied as its delivery but that understanding and engagement and practical constraints also play a major role in how much attendees are willing and able to do to address any risks identified during their check.

Our understanding of the processes at work in driving this variation draws on Lipsky’s concept of ‘street-level bureaucracy’, borrowed from the international relations literature. 47,181 We are not the first to make use of this concept to aid understanding of how the NHSHC programme182 and wider health policies in the UK setting have been implemented in practice. 183,184 Lipksy’s framework emphasises the discretion of those charged with implementing policies and the resulting significant influence of their decisions on outcomes, as well as street-level bureaucrats’ responses to limited resources.

Within the broad constraints of the legal framework13,14 and Best Practice Guidance3 underpinning the NHSHC programme, our analysis clearly demonstrates that the ways in which NHSHC providers actually deliver checks in everyday practice affect how attendees’ experience the programme, and effectively determine the actual remit and purpose of the programme on the ground. As Lipsky describes it

the decisions of street-level bureaucrats, the routines they establish, and the devices they invent to cope with uncertainties and work pressures, effectively become the public policies they carry out. 181

For NHSHCs, the extent to which discretion can be exercised may be greater towards the end of the programme pathway. Processes relating to the identification of eligible attendees, invitation and the measurements and risk assessment that should be administered during each check are restricted by the legal framework underpinning the programme13,14 and supported by clearer guidance offering less room for local adaptation. 3 The subsequent steps are less prescribed, more dependent on local delivery models (and the availability of other local services) and activity is less well recorded and monitored, leaving commissioners and providers with more discretion to determine what local delivery will look like.

Although much of the existing work that uses this framework to understand how health policies have been enacted on the ground focuses on those engaged in delivery of policies, and on those who interact directly with the recipients of those policies – in our case, NHSHC providers – our analysis is novel in that it also highlights the discretion exercised by LA commissioners in decision-making about local programme specifications and support. Although not directly public-facing, LA commissioners interpret the requirements of the NHSHC programme, exercising discretion of their own to adapt the programme to meet local needs and fit within local constraints. Their decisions and overall approach directly influence NHSHC providers, forming important local contexts in which local versions of the programme are delivered.

Our analysis points to commissioners’ and providers’ understanding and engagement with the NHSHC programme, as well as a range of practical constraints in driving decision-making about programme delivery. These two aspects mirror Lipsky’s focus on street-level bureaucrats’ discretion in the enactment of public policies, and their response to and attempts to implement policies within the confines of limited resources. Finally, our analysis also draws out outcomes relating to attendees’ experience of the NHSHCs programme that are related to the contexts created by commissioners’ and providers’ decision-making. Commissioner and provider decisions and resulting delivery models and practice inform attendees’ own understanding and engagement with NHSHCs, but their experience and response to what the programme offers are also affected by other external factors relating to their individual attitudes and circumstances.

Understanding and engagement with the NHSHC

Our review findings identify variation in how the primary purpose of the NHSHC programme is understood as a crucial factor driving variation in commissioning and delivery. The NHSHC programme was designed to fulfil two purposes, seeking both to identify cases of diagnosable illness or individuals at ‘high risk’ and to support individuals to manage and reduce CVD risk, via prescribing or by prompting behaviour change in relation to ‘lifestyle factors’ associated with CVD. Both purposes focus on the individual attendee, but while the former reflects a purely biomedical approach, the latter requires an extension to consider wider psychosocial factors that influence CVD risk, albeit with a focus on ‘lifestyle’ and individual behaviour.

Our data suggest that both commissioners and providers may tend to prioritise one purpose over the other, and that this prioritisation is then reflected in commissioning decisions and delivery models. In particular, differences in understanding or prioritisation of one aim of the programme at the expense of the other can affect delivery of what happens after the measurements and risk assessments have been completed during a check (see Figure 19). For example, favouring a particular purpose can drive variation in who delivers the check and the training they have received, where checks are delivered, the time allocated to each check, the availability, accessibility and referral pathways to local lifestyle services and important differences in data collection and monitoring, as well as funding models. As commissioners and providers set about implementing the programme at ‘street-level’, their values and intentions for the programme can be understood as informing their exercise of discretion in commissioning and delivery of these aspects. However, it is important to be aware that the NHSHC has been in existence for 13 years and that commissioning and delivery in individual local areas are not static, but rather may have undergone multiple changes over this period – a fact that was emphasised by our professional stakeholder group.

The double layer of discretion (at commissioner and provider levels) in how the NHSHC programme is enacted in each locality in England means that the relationship between LA commissioners and providers is crucial. Commissioners determine service specifications and funding models and engage in monitoring of NHSHC delivery. But, unless they are also acting as providers themselves (as is the case for some provision in some local areas), there is a limit to the extent that they can influence the day-to-day practice of all providers. Shared understanding and levels of engagement with programme delivery have the potential to underpin a coherent local delivery model and work at both levels to achieve the programme’s aims. However, there is also a potential here for commissioners or providers to undermine and contradict each other. In particular, the data included in our review point to problems where LA commissioners or public health teams may struggle to engage local general practices. Different levels of engagement with the programme may reflect differences in understanding of its purpose, scepticism about its ability to deliver positive outcomes for attendees, but also more practical concerns, especially around competing priorities, workload and delivering NHSHCs within limited resources – these constraints can create tension between potentially competing models in commissioning and delivery (see below, Practical constraints).

The delivery models commissioned and implemented locally send important signals to NHSHC attendees that inform their understanding and engagement with the programme in turn. Delivery of checks in general-practice settings and a focus on completing measurements and risk assessment may suggest to attendees that the check should be understood as a screening tool or clinical intervention. Delivery elsewhere, in community settings, or with a greater focus on the delivery of advice, space for discussion and offers of referral to lifestyle support services, sends a very different message. In some local areas, NHSHCs are delivered alongside integrated lifestyle services, and the programme facilitates links to link workers or social prescribing functions, enabling providers to offer more holistic support to attendees that may better reflect individual needs. As our data suggest that attendees’ engagement with offers of advice and referral may depend on what they expect to receive during a check, it is important to ensure that local advertising and communication about the programme accurately depict its purpose. Providers themselves can also (un)intentionally transmit ‘softer’ signals to attendees. In particular, the extent of provider engagement with the programme is often apparent during a check, and providers have the potential to convey urgency, but also the potential to imply that the check is not much more than a ‘box-ticking’ exercise. This finding underlines the importance of work to engage providers and generate a shared understanding and ‘buy in’ for its intended aims.

Overall, just as providers can exercise discretion in how they deliver advice, offer referrals or recommend prescriptions, attendees themselves can exercise discretion in their response. The focus of the check on individuals and their behaviour also carries the important implication of the ‘responsibilisation’ of attendees – there is an expectation that attendees will engage in individual work to address identified ‘lifestyle risk factors’. 185 However, just as commissioners and providers face practical constraints that affect what they are able to deliver within the programme’s remit, attendees must also contend with constraints in their own lives – individual limited resources that affect the extent to which they are able to consider taking on board advice, taking up referrals, and, ultimately, making changes to their behaviour to help manage or reduce their CVD risk. Others have drawn attention to the risks inherent in this strategy, including the potential for any positive health impacts to be unfairly distributed amongst attendees. 186

Practical influences on the NHSHC

Commissioners’ and providers’ approach to organising and delivering NHSHCs is influenced by much more than their understanding and engagement with the programme. Practical factors influence decision-making about the programme and limit what it is realistic to deliver locally, within each NHSHC encounter. LA commissioners have the discretion to set important boundaries for providers in setting service specifications and determining funding models for the programme. The extent to which commissioners’ focus on ensuring delivery of the mandatory measurements and risk assessment during checks versus the delivery of aspects of the check that might prompt and support behaviour change affects what providers are able to offer. This includes, for example, how local funding models incentivise different delivery methods, the relationship between funding and the time allocated for each check, the availability of local lifestyle services and the ease with which referrals can be made to these services.

Providers contracted to deliver the NHSHC are also influenced by the need to ensure that staff involved in delivering checks have confidence in every aspect of delivery. Our data suggest that not all providers feel they have the knowledge and skills required to deliver those elements of the check that are more focused on prompting behaviour change, including delivering advice or offering referrals. These findings raise questions about when and how providers receive training to deliver the check, and whether this training focuses on the completion of measurements and risk assessment, or whether it includes training focused on the delivery of advice and supporting discussions about lifestyle with attendees. In addition, when checks are delivered in settings where providers may face competing demands on their time (in general-practice or pharmacy settings, for example) these workload and time pressures may translate into ‘leaner’ delivery of checks, with a focus on the essential mandatory parts of the NHSHC that are more closely monitored. There is a risk that personalised advice, discussion and offers of referral become secondary concerns and may not be delivered consistently in these settings.

Delivery is affected by the availability of resources across primary and community healthcare and public health, and in particular for disease prevention and health improvement activities. These resources include funding envelopes for public health programmes, workforce capacity and structural, cultural and status differentials that present challenges to collaborative working across the many different organisations involved in these activities. Community health services are diverse, with complex patterns of commissioning and provision; the dynamic relationship between these services and the other parts of the system is often overlooked. The identification of practical constraints that influence NHSHC commissioners and providers has implications for national and local policy. In particular, it is clear that the delivery of personalised, individual advice and discussion at the end of a check is a more intensive and costly proposition than the delivery of a simpler programme focused on case-finding. In addition, increasing referrals from the NHSHC to local and national lifestyle support services requires an assessment of their capacity.

Our data suggest that there is a relationship between the practical influences facing commissioners and providers and their understanding and engagement with NHSHCs. Both groups of actors may to some extent exercise discretion and adapt their understanding of the purpose of the programme based on their knowledge and experience of the potentially limited resources available to deliver it. Despite the common mantra of ‘doing more with less’, the realities of the funding envelopes available send clear signals to commissioners and providers to prioritise efficient and lean delivery models, and, as our data make clear, these models tend to favour the ‘case-finding’ function of the NHSHC programme. Local scepticism about the likely impact of the programme on the part of providers is likely to be compounded by the perception that both the NHSHC programme itself and the lifestyle support services on which it depends are difficult to access.

We have shown that these influences also affect attendees’ experience of the programme and place significant limitations on what they can be offered post-check. The extent to which attendees can be offered meaningful, personalised advice and support for behaviour or lifestyle change within the current programme is open for debate. Attendees’ own lives and needs are more complicated and are unlikely to be improved using generic advice about ‘healthy lifestyles’. Ethnographic work that has explored NHSHC delivery has identified the ways in which the highly structured nature of the measurements and risk assessment are conducted within checks and limited time available to providers to complete these can ultimately impede meaningful discussion and exploration of attendees’ priorities and personal circumstances. 81,162 Similarly, limited availability of lifestyle services in some localities and difficulties in accessing services that will fit into individual attendees’ lives mean that these options are unrealistic or very limited for many. There is an ethical component to the effects of these limitations – attendees faced with results that indicate that their risk of CVD is elevated may be left without support to help them to attempt or sustain lifestyle changes, leaving them with limited options (e.g. inaction, medication and/or attempting to make changes alone). This ethical dilemma and the potential harms for attendees are absent from the literature that we have reviewed and are an area that would benefit from future exploration and research (see Chapter 5). If local implementation of the NHSHC cannot accommodate and respond to the constraints and priorities of individual attendees, its potential role in prompting and supporting behaviour change is weakened.

Covid-19 and the NHSHC

Our survey gathered data from 74 LAs on their local responses to the Covid-19 pandemic in relation to NHSHC programme delivery. Findings suggest that the pandemic has prompted further changes in programme delivery, perhaps leading to even greater variation across the country. Our results suggest that commissioners may be placing a greater emphasis on prioritising candidates amongst those eligible, following the pandemic (i.e. targeting potentially higher-risk groups and individuals). Many commissioners have commissioned or are considering different delivery models, particularly to shift the focus from currently overburdened general-practice settings. These changes could result in wider uptake of community-based or outreach delivery models, using a range of settings and a range of provider organisations and staff. Within this there is some novelty, for instance, in using paramedics to deliver the NHSHC, or in delivering the NHSHC within a flu or Covid-19 vaccination clinic. The changes might also see increased use of remote methods of delivery, with some LAs already using or actively considering a digital self-directed completion, or the use of phone or video consultations for a part of the check. This is one area of innovation where several survey respondents told us they were waiting for evidence-based guidance and direction.

In addition to prompting some innovation in NHSHCs delivery, the effects of the Covid-19 pandemic and the associated pause in delivery of checks have the potential to exacerbate existing contexts, and to create new contexts that put pressure on the delivery of checks. In particular, calls for a ‘catch up’ following the pause and concerns about delayed or missed diagnoses may result in a shift in emphasis towards the programme’s case-finding function. 187 In addition, the spiralling workload crisis in primary care and significant competing priorities for general practice (not least in relation to the continuing Covid-19 vaccination programme) may increase disengagement amongst general-practice-based providers of the check. At the time of writing this report, NHSE&I had issued new guidance to divert resources to ‘increase capacity’ to deliver Covid-19 vaccinations and boosters,188 which is likely to result in reduced or paused delivery of NHSHCs in settings involved in delivering the vaccination programme.

LA commissioners may need to respond to these ongoing problems by considering whether alternative delivery models based elsewhere could help to ensure continued delivery of NHSHCs, and potentially free general practices from one burden too many.

Comparison with existing literature

Most previous research on the NHSHC undertaken using survey methods has focused on providers, especially general-practice staff and managers,63,115,128,143,189,190 or on actual or potential NHSHC attendees. 79,113,114,191,192 One previous study included a survey of eight LAs. 92 A systematic review (based on a PHE-commissioned rapid review project) collating studies on the views of commissioners, managers and healthcare professionals identified only two existing studies including the perspectives of commissioners: one qualitative interview study, and one including commissioner interviews as part of a wider mixed methods evaluation. 136 More recently, an NIHR-funded study to develop a cost-effectiveness modelling tool for local commissioners involved a survey of the 16 ‘best-performing’ LAs, that is, those that achieved the highest rates of uptake in the 2013–2017 delivery cycle. 144 Our survey therefore extends the current survey literature, capturing detailed delivery information and the views of LA commissioners in relation to the programme.

Our survey of LAs complements and extends previous survey work undertaken by PHE. 15,16 Collectively, these surveys have all highlighted the considerable variation in delivery practice across England. With regard to whom the NHSHC is delivered by, the PHE surveys have asked which provider organisations deliver the NHSHC. However, they have never asked which health professionals are commissioned to conduct the check. Our review highlights the importance of the discretion and capacity of the delivering professional, and their relationship with the attendee, for influencing the attendee’s experience and subsequent action following a check. However, there is limited knowledge, even amongst some commissioners, about who, exactly, is delivering the checks.

Our survey is the first to create a typology of delivery models. The previous PHE surveys found that the majority of LAs commission general practice to deliver the NHSHC. Our survey also found that general practice remains by far the most typical setting of the NHSHC, both before and after the Covid-19 pause, with almost a third of responding LAs providing NHSHCs only in this setting. Looking across the PHE surveys and our data, the use of community outreach in NHSHC delivery reduced from 2014 to 2020, but may be seeing a subsequent increase again following the Covid-19 pause. Unfortunately, there are currently no data that would enable a comparison of different delivery models and programme outcomes, such as reach (particularly in relation to potentially higher-risk groups), referrals to support or subsequent changes in behaviours and/or risk scores.

Whilst PHE’s 2014 survey found that ‘lifestyle interventions’ were provided in (and usually commissioned by) most LAs, these data were not collected in their 2020 survey. Our survey therefore was an important first attempt to systematically collect data focused on services and referrals for attendees post-assessment, and to find out whether data related to this part of the programme are routinely collected by commissioners. It revealed the complexity and fragmented nature of this follow-on support, with multiple services being provided by different providers in different areas. Whilst this might help to ensure a range of different services to suit a range of different people, it is also likely to be difficult for the providers of the NHSHC programme to navigate. Unfortunately, commissioners are not generally in a position to assess the use being made of support services, since only a minority of respondents told us they routinely requested data on whether referrals were taken up, or indeed what the outcomes are of any subsequent support offered.

Our review is the first realist review to focus on the NHSHC programme, but the programme has been the subject of several previous evidence syntheses (see Appendix 1 for details of review projects that we identified at the outset of this project). Previous reviews have focused on a wide range of areas and steps in the NHSHC programme pathway and have identified significant variation in delivery models. 8,193 Our review is the first to focus solely on what happens after the measurements and risk assessments are complete, although four existing reviews have synthesised evidence that relates to this step and the findings correspond well with those of our review. The evidence included in two PHE-commissioned rapid reviews is discussed in more detail in Chapter 1. Briefly, these reviews include evidence of geographical variation in referral to ‘lifestyle services’ and capture some data relating to healthcare professionals’ doubts about the NHSHC’s long-term effectiveness and training needs. These reviews also identified broad themes describing NHSHC attendee experience, including attendees’ perspectives on the quality of the information provided during checks, perceptions of ‘genetic determinism’ (fatalism) and the important ‘environmental’, ‘resource’ and ‘cost and time’ factors that constrain individual attendees’ ability to respond to advice and offers of referral.

In addition to these, Shaw et al.’s 2016 international review of qualitative evidence focused on patient experience of CVD and diabetes prevention programmes and mapped this evidence using the Theoretical Domains Framework (TDF). 194 As in our project, the authors found evidence relating to attendees’ perception of the purpose of such programmes, their attitudes and understanding of their own ability to make lifestyle changes, the resources and infrastructure that existed to support programmes. Atkins et al.’s 2020 review coded evidence relating to the behaviours of commissioners, providers and attendees using the capability-opportunity-motivation-behaviour and TDF models. 60 Reflecting our own review, most included studies related to the behaviour of NHSHC attendees (called patients in this review). This review identified evidence relating to several behaviours that are relevant to our project’s focus. In particular, their findings relating to providers’ knowledge, skills and attitudes towards the delivery of advice or behavioural interventions, providers’ belief in those interventions, the resources available to deliver checks, the need to take account of attendees’ wider ‘social context’ in the delivery of advice and the availability of funded services that can accept referrals from the programme all echo aspects of our findings. Our review complements and extends the work undertaken in these reviews, by developing causal explanations for the variation in how NHSHCs are delivered, and how attendees experience the programme. The broad inclusion criteria in our review have allowed us to include much more data related to commissioners and providers, and to relate this directly to data focused on attendees. This has helped us to demonstrate how commissioner and provider discretion can affect attendees’ experience of the NHSHC, as well as how variation in delivery can influence how attendees respond to what they are offered during their check.

During this project, PHE were commissioned by the DHSC to undertake their own review of the NHSHC programme. This review was published by OHID in December 2021,26 accompanied by a summary of the evidence and analyses that were used to inform the recommendations made in the report. 41 Several aspects of the evidence gathered here echo our own findings, including the evidence presented on follow-up (section 2.7 of the main report) which highlights the crucial influence that providers have over attendees in relation to supporting behaviour change, the ‘structural factors’ that can impede the delivery of advice and onward referrals, and the potential need for ongoing follow-up. The evidence annex also includes the observation that data recording and collection during checks may be incomplete and presents new data in relation to what NHSHC attendees are offered during their check (termed ‘Outputs’ in the review report annex). These data indicate that the type of intervention offered to attendees (which could be advice, referral, prescriptions or further tests) varies according to age, ethnicity and deprivation. Although this is presented positively in the report, as evidence that providers are tailoring offers to meet differing needs, there is no evidence that this apparent tailoring is appropriate or beneficial for attendees. Our own findings demonstrate clearly that what providers offer attendees during checks is subject to a wide range of influences and it is unclear from the data if these patterns reflect the needs of attendees’, or even represent the outcomes of rational decision-making processes for providers. More research is needed to build on our review findings and develop a better understanding of how providers’ make decisions in relation to what to offer NHSHC attendees (see Chapter 5).

The OHID review presents three goals for a ‘transformed’ NHSHC programme, as follows:26

• engage people in maintaining good health and preventing non-communicable disease by empowering and supporting them to understand their risks and to take early, sustained action to reduce those risks

• reduce the health inequality that results largely from different levels of major non-communicable diseases and their underlying risk factors

• act as a gateway to the wider wellness ecosystem by integrating the service with other non-communicable disease prevention programmes and by promoting joint-working and cost-sharing.

These goals appear to put the programme’s focus on supporting behaviour change and the development and maintenance of ‘healthy lifestyles’ front and centre, and we have reflected this emphasis in how we have framed our own recommendations below. We also note that the third goal for the NHSHC to become a ‘gateway’ programme through which attendees could access other services is echoed in our own recommendations and was well-supported by our professional and PPI stakeholder groups. However, we note that the findings of both our survey and our review raise a note of caution for the second goal, to reduce health inequalities. Our project has demonstrated the extent of local variation in commissioning and delivery of the NHSHC, especially in those aspects of the check that might most directly support the reduction of CVD risks. Our review shows that the causes of this variation are multifaceted, and achieving this aim will require solutions that address the complexity that affects delivery at this step of the NHSHC pathway.

The OHID review was also accompanied by an annex describing the governance arrangements for their project, including the role of its steering group and expert panel. 195 A letter from the panel chair raises important questions about the programme’s effectiveness and implementation, and notes the limitations of what can be achieved by the NHSHC alone. The panel have made a strong recommendation for a ‘thorough evaluation’ of the programme, ‘to assess the effectiveness of the end to end pathway (from identification through to outcomes (or good proxies thereof))’. Our own findings have provided a starting point and highlighted the need for more thorough examination of what happens at one particular step of the pathway – what happens after the measurements and risk assessments are complete – and would support the case for such an evaluation, to include a focus on this under-researched step (see Chapter 5 for more detail).

Recommendations for policy and practice

Based on our survey and review findings, we have drawn out the implications for the NHSHC programme, with the overall aim of increasing the focus on, and improving delivery of, what happens after the measurements and risk assessments are completed. Our recommendations below sought to respond to a series of questions that were raised by our survey and review findings:

• What is the NHSHC for?

• Do people think the NHSHC ‘works’?

• Is there a mismatch between NHSHC priorities and those of attendees?

• Is the NHSHC adequately resourced?

• What other services does the NHSHC depend on?

• Can the NHSHC take attendees’ real lives into account?

Our recommendations suggest potential changes in programme design, guidance, and commissioning and delivery on the ground, hence are differentially aimed at NHSHC policy-makers (in OHID), LA commissioners and NHSHC providers. These were developed in consultation with our stakeholder groups, composed of members of the public eligible to receive NHSHCs and a range of professionals involved in NHSHC policy, commissioning and delivery (see Chapter 2, Stakeholder groups). The recommendations are derived from four important implications that arise from our findings. These are the need for: clarifying the purpose of the NHSHC, working to create ‘buy in’ and engagement with the programme, focusing NHSHCs on attendee needs, and improving the links between the NHSHC and other parts of the system.

OHID have also made recommendations for the programme: (1) build sustained engagement; (2) launch a digital service; (3) start younger; (4) improve participation; (5) address more conditions; and (6) create a learning system. Within these headline recommendations, there are many specific recommendations that echo our own; wherever this is the case, we have highlighted this.

Our nine recommendations for policy and practice, the major implications from our findings and the evidence on which they were based are set out in Table 24.

We note that while some recommendations in the OHID review fall outside the scope of our own work, our findings raise concerns about the implementation of others. In particular, two of the recommendations – to ‘start younger’ and ‘address more conditions’ – propose to significantly expand the scope and coverage of the NHSHC. Our review findings relating to the experience of attendees suggest that the latter recommendation to make the NHSHC more ‘holistic’ by including other health concerns may be welcomed by some, but overall, our findings suggest that policy-makers should be cautious about any expansion of the programme. Assessment of the feasibility of these recommendations must take into account current conditions in the wider health system, including the limited capacity of primary care and community and public health services. Without appropriate follow-up services, these extensions of the programme risk leaving attendees with few or no options for ongoing support to help them to manage any risks or conditions identified. In the absence of additional investment, the availability of accessible follow-on services and of convincing evidence of clinical and cost-effectiveness, expansion could risk increasing provider scepticism and disengagement from the programme. There is also a risk that expanding the programme’s scope and coverage could increase confusion about its purpose, and so drive increasing variation in commissioning and delivery.

The OHID review’s second recommendation to launch a digital offer for the NHSHC should take into account the findings of our review. In particular, any digital offer should not neglect the final steps in the NHSHC pathway and the need to ensure that attendees are offered personalised advice and referral as appropriate. There are risks inherent in any digital offer that some attendee groups could be excluded, but also a need to evaluate the effectiveness of digital versus face-to-face delivery of checks, to identify what works and for whom.

OHID’s fourth recommendation to ‘improve participation’ continues the existing emphasis on invitation and uptake, although we note that there is also a focus here on targeting those groups at highest risk of CVD. Nonetheless, policy-makers should be cognisant that measures that encourage high-volume delivery may inadvertently detract attention and focus away from more intensive delivery of personalised advice and support for behaviour change.

Summary of key findings

This project set out to understand how the NHSHC programme works in different settings for different groups, in order to recommend improvements to maximise intended outcomes. Within this broad remit, we focused on the end of the NHSHC pathway: what happens after the measurements and risk assessment have been undertaken, especially in relation to the delivery of advice, onward signposting or referral and ongoing support for lifestyle and behaviour change?

Our survey of LAs has collected novel data describing local delivery models of both the NHSHC itself and the support services essential for enabling behaviour change. It has revealed significant variation areas across the country in how NHSHCs are provided and the extent to which relevant support services are available. In particular, it is clear that some areas offer greater accessibility of both the NHSHC and support services than others, regardless of public health budget, although this is not matched by greater uptake. Our survey has also gathered novel data detailing local responses to the Covid-19 pandemic, including innovations in NHSHC delivery that deserve further consideration, development and evaluation in their own right.

Our realist review of the literature has generated evidence-based theoretical causal explanations for this variation, building an understanding of when (in which contexts) and how (by which mechanisms) a range of outcomes occur. The outcomes of interest in this review are those that relate to the commissioning, delivery and response to NHSHCs, with a focus on what happens after the measurements and risk assessments have been completed. Our analysis suggests that the variation reported in the literature and by our survey respondents is the result of the exercise of discretion by commissioners and providers in the delivery of checks. Commissioners’ decisions in relation to local programme implementation, funding and monitoring, and providers’ decisions about how checks are delivered on the ground and their behaviour during those checks are influenced by multiple factors. These factors include their understanding of the purpose of the NHSHC and their engagement with the programme and its aims – but this understanding, and their actual behaviour in relation to delivery, is constrained by important practical factors.

Prevailing conditions, including existing funding envelopes, current funding and monitoring arrangements and workforce pressures for providers, tend to push commissioners and providers towards a delivery model that focuses on the ‘case-finding’ purpose of the NHSHC, to the detriment of work that could prompt or support behaviour change. However, in some local areas, commissioners and providers have been able to work against this tide and attempt to deliver NHSHCs that focus on its purpose as a means of supporting attendees to make changes to help reduce their CVD risk. Whether or not these efforts can be sustained in the aftermath of Covid-19 is uncertain at present, especially given ongoing and increasing workload pressures in primary care.

Recommendations for future research

In addition to the recommendations for policy and practice set out above (in Chapter 4) we make several specific recommendations for future research in relation to the NHSHC programme. We first make a general recommendation that more research efforts should be directed to consider the final steps in the NHSHC pathway (i.e. on what is delivered after the measurements and risk assessments are complete) and on the role and place of the NHSHC programme within the wider prevention and inequalities agenda. In addition, we support the call from the NHSHC Expert Panel for a thorough ‘end to end’ evaluation of the programme and would urge those undertaking such an evaluation to ensure detailed consideration of what is delivered and offered to attendees, and the links between the NHSHC, primary care/general practice and national and local ‘lifestyle services’.

Other more specific recommendations for future research that have arisen from this project are as follows:

• Our survey findings could be complemented and extended by:

  • Survey and qualitative research with NHSHC providers and attendees about the delivery and experience of the NHSHC, with a focus on the final steps in the pathway and delivery of advice and offers of referral and/or prescriptions, including work to explore the routes between the NHSHC and support services;

  • Work to build on the typology of NHSHC delivery models that we have developed in this review, for example, to consider whether this typology could be refined with additional data, to map all English LAs against these categories and to compare outcomes across these different delivery models;

  • Additional research (via survey, freedom of information request or document analysis using information from LA and provider websites) to address the gaps in our survey response and build a more complete picture of delivery across all areas in England;

  • Follow-up surveys to assess delivery, timed to capture the results of commissioning decisions made post-Covid, which may reflect the outcomes of innovations employed during the pandemic, pressures affecting general-practice providers and/or commissioners’ actions in relation to the recommendations made in the OHID review;

  • Additional research into innovations including digital delivery methods and new methods for prioritising NHSHC invitations (to assess their feasibility and acceptability to different groups, potential equality impacts and impact on NHSHC uptake and outcomes).

• Our review findings raise a number of areas for further development and exploration:

  • Future research with a focus on the final steps in the NHSHC pathway should include a range of perspectives and use a variety of methods to help to improve our understanding of the delivery of offers of advice and referrals.

    • Qualitative research with providers could provide further insight into their decisions about which interventions are offered to which NHSHC attendees.

    • Qualitative research with providers and attendees should use an ethical framework to consider problems posed where NHSHCs are delivered but options for attendees post-check are limited (e.g. because access to local lifestyle services is limited).

    • Quantitative and qualitative research is needed to address the relative scarcity of data that could be used to assess equality and diversity in relation to what is offered to attendees during and after their check. OHID have published evidence indicating that offers of prescription and referral vary by age and ethnicity. Additional work to collect and analyse data on these activities and variables is needed to assess potential disparities in delivery; new qualitative work could compare the experience of different groups of attendees, or provider attitudes and approach to different groups.

    • Anecdotal data suggest that some NHSHC attendees make and maintain significant lifestyle changes. In-depth qualitative work with NHSHC attendees could help to identify important contexts that may help to explain why a small number of people are motivated to do this and the role of the NHSHC itself.

  • Survey and/or qualitative research to address the relative scarcity of literature focused on LA commissioners and public health teams in relation to the NHSHC. Such research should focus on answering questions related to the important contexts identified in our review: what informs commissioner understanding and engagement with the NHSHC programme? How do they respond to the local practical constraints they face and make decisions about local delivery models? How do LA-provider relationships vary across England, and what informs these? Our professional stakeholder group informed us that LA ‘ethos’ and political stances may play an important role and could be explored.

  • Survey and observational research to assess and model local capacity for NHSHC delivery, to help inform local decisions about delivery models and workforce planning (e.g. which and how many providers can be commissioned).

Strengths and limitations

Our project has a number of key strengths. The two components (survey and realist review) complement each other, providing both new primary data and new interpretations of existing secondary data relating to what happens at the end of the NHSHC pathway. Our project focus on what happens in NHSHCs after the measurements and risk assessments have been completed helps to address the relative lack of research on this particular aspect of NHSHC delivery.

The project as a whole was strengthened by close working with our PPI lead, Vivienne Hibberd, and our committed PPI and professional stakeholder groups. Both groups were diverse: our PPI contributors represented a range of ages, gender, ethnicities and local areas in England; our professional stakeholders comprised members from a variety of professional roles and representing different localities. Our stakeholders helped us to focus the project, provided detailed feedback on our emerging findings and helped to shape our interpretations of our data and the recommendations that we developed as a result. We are continuing to involve these groups in the development of additional outputs from this project, which we plan to produce to communicate our findings and recommendations to non-academic audiences, including policy-makers (OHID), LA commissioners and providers of NHSHCs. At the time of writing, our plans for these additional outputs centre on providing brief and accessible information about our main findings, and are likely to include briefing documents for these audiences, and a short video.

Our survey of LAs complements previous surveys undertaken by PHE, gathering new data relating to our project’s focus on what happens after the measurements and risk assessments are completed in an NHSHC. To our knowledge, it is the first survey of LAs to gather data on local availability of lifestyle support services, referral processes and routine monitoring of the programme, and it has allowed us to develop a novel typology of NHSHC delivery models. Our typology of LAs clearly demonstrates wide variation in delivery. In addition, our survey is the first attempt to systematically gather data in relation to LAs’ responses to Covid-19 in relation to the NHSHC programme. However, it was limited by the low response rate, covering just under half of all LAs in England. This is lower than previous surveys undertaken by PHE, but was anticipated in view of extensive work being undertaken by LAs during the ongoing pandemic. Given the large proportion of non-responding LAs, we considered it was not feasible to search their websites for additional data. Unfortunately therefore, our findings, the typology we have developed and the analysis of external factors associated with different delivery models inevitably fail to take account of any delivery models or approaches being used by non-responding LAs. We were unable to access data from the most recent PHE survey as planned, but the relevant findings were available for comparison, hence this did not detract from our analysis.

As noted above, the qualitative survey data and discussions with our stakeholders have made it clear that the picture of delivery generated by our survey data is a snapshot in time, and that delivery models are likely to undergo significant change.

Our realist review followed the RAMESES quality standards for realist synthesis. By adopting a realist approach to our analysis, we have been able to develop explanations for the causes of variation in commissioning, delivery and response to the NHSHC programme, and to draw on substantive theory (street-level bureaucracy) to help further elucidate our findings.

Our review drew on a diverse range of material and in particular on data extracted from a wide range of grey literature. Our approach allowed us to synthesise data from conference materials and local documentation and evaluation work (including some unpublished internal documents) with data extracted from published research studies and helped to enrich our findings with local contextual detail. We had hoped that more of the material shared by our survey respondents could have been included for this reason, but (as with the literature more widely) most of the material shared with us focused on the common issues of invitation, uptake and coverage of NHSHCs.

As with any review project, our findings were limited by the availability and quality of the available literature. We must acknowledge that the material identified for the review covers a wide date range and some older material describes NHSHCs delivery when the programme was commissioned by PCTs. This may limit its applicability to the present day, although we considered each piece of data on its own merits before inclusion in our analysis and aimed to select data that it was reasonable to consider still relevant in terms of identifying contexts that still apply, or mechanisms likely still to be in operation. Our stakeholder groups also helped us to ensure that our findings resonated with contemporary experience of commissioning, delivering or attending NHSHCs.

Our chosen project focus did limit the availability of material that could be included in the review and we note that some of our findings touch on areas that are well-researched in their own right, including shared decision-making about medication, risk communication and behaviour and lifestyle change. Deeper consideration of these aspects of the NHSHC was beyond the scope of this project, but we acknowledge that links to these wider literatures are important and could help to deepen understanding of some aspects of programme delivery and responses to it. The documents included in this review were diverse in type but also in rigour. The CMOCs developed in the course of the project vary in terms of the volume, type and robustness of the data that underpin them. We have provided a full transparent account of those data, so that the strength of each CMOC is made apparent to those reading this report, including those CMOCs that are underdeveloped and could benefit from additional data. Where relevant, we have identified particular areas where new research would be welcome and help to develop the evidence base further.

Contributions of authors

Ms Claire Duddy (https://orcid.org/0000-0002-7083-6589) (Realist Reviewer) developed the research project and led the review work, devised, piloted and carried out the scoping and main literature searches for the review, screened the resulting references, carried out data coding, applied a realist logic of analysis to the data, developed and refined the CMOCs and final programme theory, presented emerging findings to the PPI and professional stakeholder groups, and drafted and revised the final report.

Dr Erica Gadsby (https://orcid.org/0000-0002-4151-5911) (Senior Research Fellow, Public Health) developed the research project and led the survey work, devised, piloted and administered the survey, analysed the survey data, carried out consistency checks on data coding for the review, contributed to the development and refinement of the CMOCs and final programme theory, and contributed to the final report.

Ms Vivienne Hibberd (https://orcid.org/0000-0001-6863-9562) (PPI lead) developed the research project, provided PPI input, facilitated PPI group meetings, contributed to the development and refinement of the CMOCs and final programme theory and contributed to our final report.

Professor Janet Krska (https://orcid.org/0000-0002-4148-5652) (Professor of Clinical and Professional Pharmacy) conceived and developed the research project, analysed the survey data, provided relevant methodological and content support and input, contributed to the development and refinement of the CMOCs and final programme theory, and contributed to the final report.

Associate Professor Geoff Wong (https://orcid.org/0000-0002-5384-4157) (Associate Professor of Primary Care) conceived and developed the research project, led and facilitated the professional stakeholder group meetings, carried out consistency checks on the screening and data coding for the review, provided relevant methodological and content support and input, contributed to the development and refinement of the CMOCs and final programme theory, and contributed to the final report.

Publications

Duddy C, Wong G, Gadsby EW, et al. NHS Health Check programme: a protocol for a realist review. BMJ Open 2021;11:e048937. doi: 10.1136/bmjopen-2021-048937

Gadsby EW, Krska J, Duddy C et al. The NHS Health Check programme: a survey of programme delivery in England before and after the Covid-19 pandemic response [version 1; peer review: awaiting peer review]. NIHR Open Res 2023;3:32. https://doi.org/10.3310/nihropenres.13436.1

Data-sharing statement

All data requests should be submitted to the corresponding author for consideration. Access to anonymised survey data may be granted following review. The full set of extracted data used to inform our realist review is available on request.

Ethics statement

Ethics approval was granted by the University of Kent SRC Ethical Review Panel (for the Division of Law, Society and Social Justice) in February 2021 (SRCEA id 0367). NHS Research Ethics Committee approval was not required for this study. Individual participants were able to respond to the survey anonymously, only choosing to enter their name and email address if they wished to receive further information on the outputs of the research. Informed consent was given by participants based on the information we provided about the purpose of the survey, how the data were to be handled, our plans for analysing the data, and how their confidentiality would be ensured in the reporting of any data.

Disclaimers

This report presents independent research funded by the National Institute for Health and Care Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, the HSDR programme or the Department of Health and Social Care. If there are verbatim quotations included in this publication the views and opinions expressed by the interviewees are those of the interviewees and do not necessarily reflect those of the authors, those of the NHS, the NIHR, the HSDR programme or the Department of Health and Social Care.

Existing studies using substantive theories to understand the NHSHC

NHSHC programme documentation

Major National Health Service Health Check (NHSHC) programme documents were identified via browsing and searching current and archived versions of United Kingdom (UK) government and NHS websites. Major programme milestones and publications are outlined on the timeline below.

Existing reviews focused on the NHSHC

We identified existing reviews and evidence syntheses relating to the NHSHC by consulting PHE’s regularly updated bibliographies, available on the NHSHC website (https://www.healthcheck.nhs.uk/commissioners-and-providers/evidence/literature-review/). We identified 10 published reviews; 4 of these present findings from the PHE-commissioned rapid review by Usher-Smith et al. (2017).

Searches to locate existing theories (Step 1)

We searched PubMed and Web of Science (Core Collection) using a combination of terms relating to HCs, and terms relating to theory, adopting a slightly modified version of Booth and Carroll’s (2015) ‘BeHEMoTh’ approach. As the HC programme is a specific health context (H) and we were interested in theorisation of all steps in the programme, no individual behaviours (Be) were specified.

Searches for evidence on NHSHC (Step 2)

Additional searches for theory

A short series of highly focused searches for documents describing street-level bureaucrats or street-level bureaucracy were run in Google Scholar in October and November 2021. The details of these searches and results screened (on screen) are provided below.