Vascular disease includes coronary heart disease, stroke, diabetes and kidney disease. It currently affects the lives of over 4 million people in England. It causes 36% of deaths (170,000 a year in England) and is responsible for a fifth of all hospital admissions. It is the largest single cause of long-term ill health and disability, impairing the quality of life for many people. The burden of these conditions falls disproportionately on people living in deprived circumstances and on particular ethnic groups, such as South Asians. Vascular disease accounts for the largest part of the health inequalities in our society (Department of Health, 2008).
One method of improving the detection of vascular disease may be through the initiation of the NHS Health Checks. Previous studies have shown that the NHS Health Checks programme will only be cost effective if it can achieve a 75% uptake. During the pilot phase within the NHS Bristol area there was a 48% uptake.
Uptake of NHS Health Checks may be lowest amongst lower socioeconomic groups (Cochrane et al, 2012, NHS Greenwich, Thorogood et al, 1993), men (Dalton et al, 2011, Thorogood et al, 1993) and black and other minority ethnic groups (Tower Hamlets, 2009). These groups are often categorised as ‘hard to reach groups’ and often include men.
In Bristol, percentage of the population of Bristol who fall into the categories of hard to reach groups, defined as those in lower socio economic groups, black and other ethnic minority populations and men, consist of: 22%% black and other ethnic minority groups (Bristol city council, 2012), 14% who live in the most deprived 10% of lower layer super output areas (LSOAs)(Bristol city council, 2011) and men who represent around 50% of the total population (NHS Bristol 2009). Reports from pilot studies that have evaluated the NHS Health checks have found that they are often inadequately marketed, resulting in low public awareness and low uptake.
Some evidence exists to support the role of outreach or community based facilities to increase the uptake of NHS Health Checks (Horgan et la, 2009, Greenwich NHS, 2011). The community outreach programme to encourage the uptake of NHS Health Checks in Greenwich reported a 44% uptake from their community clinics. High levels of satisfaction were reported from patients who attended community based NHS Health Checks, particularly amongst patients who attended clinics aimed at ethic minority groups, and where clinic locations were held in a temple or mosque. In conclusion, they found that in order to encourage the uptake of an NHS Health Checks, strategies needed to be clearly signposted and targeted at each discrete population.
NHS Bristol is proposing to establish several, specific outreach programmes to enhance the uptake of NHS Health Checks in the NHS Bristol area. These will include a range of targeted approaches for deprived populations and minority groups to include Somali, Asian, Afro Caribbean, Polish and Roma Gypsy populations. Additionally, NHS Bristol proposes to commission the two Walk-in Centres in Bristol to set up a number of ‘pop-up’ clinics in public places. The aim of these Pop-up clinics is to attract populations who may find it difficult to attend their GP practice. These may be set up in shopping Malls and in areas where there is a high density of workers. To support professionals in delivering NHS Health Checks, NHS Bristol is offering a range of different training programmes to include motivational interviewing. Running alongside the above initiatives will be a multi-media strategy to raise awareness of NHS Health Checks. These types of activity need to be evaluated for effectiveness and cost effectiveness.
Aims and reserach questions
The aim of this study is to evaluate the delivery, effectiveness, acceptability and outcomes of community outreach initiatives of the NHS Health Check in Bristol. The evaluation will focus on assessing the structure, process and outcomes of the community outreach initiatives and to evaluate the programme from the perspectives of service users as well as service providers.
The specific research questions are:
1. By how much do outreach sessions increase the number of patients attending for a health check?
2. What is the demographic profile of patients who complete a health check through a community outreach clinic compared to those who have an NHS Health check as a direct result of an invitation from the GP practice?
3. What is the incidence of vascular disease including coronary heart disease, stroke, diabetes and kidney disease, detected in patients who attend for an NHS Health check through a community outreach initiative compared to those who attend as a direct result of an invitation from their GP practice?
4. How cost effective is it to deliver NHS Health checks to patients using community outreach sessions?
5. What are the challenges in accessing / recruiting hard to reach groups for NHS Health Checks and how can these challenges be addressed?
6. What are the most effective methods for approaching hard to reach groups to participate in an NHS Health Check?
7. How do different models of community outreach initiatives compare and what are their relative advantages and disadvantages?
8. What is the impact of the setting in which the NHS Health check is delivered?
9. What is the impact of the process (e.g. how initiatives are conducted and delivered and patient engagement) on community outreach initiatives of the NHS Health Check?
10. What are the experiences and acceptability of patients from varying socio-demographic backgrounds, regarding community outreach initiatives of the NHS Health Check?
11. What proportion of primary care staff take up the opportunity of additional training to facilitate their deliver health checks?
12. What are the staff experiences of delivering community outreach initiatives to encourage uptake of an NHS Health Check?
Analysis revealed the value of community assets (community engagement workers, churches, and community centres) to publicise the event and engage community members. People were motivated to attend for preventative reasons, often prompted by familial experience of cardiovascular disease. Attendees valued outreach NHS Health Checks, reinforcing or prompting some to make healthy lifestyle changes. The NHS Health Check provided an opportunity for attendees to raise other health concerns with health staff and to discuss their test results with peers. For some participants, the communication of test results, risk and lifestyle information was confusing and unwelcome. The findings additionally highlight the need to ensure community venues are fit for purpose in terms of assuring confidentiality.
Conclusions: Outreach events provide evidence of how local health partnerships (family practice staff and health trainers) and community assets, including informal networks, can enhance the delivery of outreach NHS Health Checks and in promoting the health of targeted communities. To deliver NHS Health Checks effectively, the location and timing of events needs to be carefully considered and staff need to be provided with the appropriate training to ensure patients are supported and enabled to make lifestyle changes.