Evidence
Alert

NHS health check attendance improves with changes to the invitation letter

Invitation letters improve uptake when they address common concerns and reasons for not attending the free NHS Health Checks. People are invited to attend a check every five years between 40 and 74 years, but uptake has been low.

This trial of 6,313 patients from six general practices in Northampton found that presenting reasons for non-attendance countered by a GP response increased uptake of NHS Health Checks by 5.5%.

The ‘counterarguments’ included the reduced longer-term cost to the NHS if risk factors including high blood pressure are identified and managed earlier, lowering the likelihood of more severe and costly conditions such as a stroke. A second version of the letter included ‘sunk-cost’. It explained that the money has already been allocated for the Health Checks, therefore not attending would be a waste of NHS resources. This, on its own, improved uptake by 4.3%.

The results are encouraging but uptake was still less than half of those invited. This highlights the challenge in engaging people in preventative healthcare that helps them make behavioural changes to their lifestyle.

 

Why was this study needed?

Prevention and early intervention are cost-effective ways of improving public health outcomes, as well as reducing the demand and cost of future health care interventions.

In 2009, free NHS Health Checks were introduced in England to identify and treat modifiable risk factors or early signs of cardiovascular disease. By 2050, it is projected that 1 in 4 people in the UK will be aged 65 years and over.

Approximately a fifth of the population is invited for a check each year. In 2018/19, 1.3 million invited adults attended an NHS Health Check; a 45.9% response rate. This was lower than the 48% response in the 2014/15 period when this study was conducted. Public Health England aspires to an uptake rate of 75% and is interested in testing ways to improve uptake.

 

What did this study do?

This randomised controlled trial compared uptake of an NHS Health Check according to the type of invitation letter. The usual national template letter was sent to 2,123 adults, the 'counterargument’ letter to 2,085 people, and the ‘sunk-cost’ letter to 2,105 people.

The two new letters were shorter and simpler:

The ‘counterargument’ letter contained three boxed sections at the end of the letter. The first emphasised that the check could prevent serious illness down the line and that this was not a ‘waste of time’ - a common concern of patients. The second addressed misconceptions that family history of cardiovascular disease was more important than lifestyle factors and looking after your body. The third explained that some conditions can have hidden symptoms, so may only be picked up by a health check.

The ‘sunk-cost’ letter explained that the appointment had already been paid for, therefore it would waste resources if people did not attend.

All letters included the same NHS Health Check leaflet and were sent between February 2014 and January 2015.

Patients and health professionals did not know which letter had been sent which increases the reliability of the result.

 

What did it find?

  • Uptake of NHS Health Checks increased by 5.5% in patients receiving the counterargument invitation letter, to 39.7% (827/2,085) compared with 34.2% (726/2,123) for the template letter (adjusted odds ratio [aOR] 1.32, 95% confidence interval [CI] 1.16 to 1.51).
  • Uptake of NHS Health Checks increased by 4.3% in patients receiving the sunk-costs invitation letter, to 38.5% (811/2,105) compared with 34.2% (762/2,123) for the template letter (aOR 1.25, 95% CI 1.10 to 1.42).
  • Women were more likely to attend NHS Health Checks than men, at 44.6% compared with 33.1% (aOR 1.21, 95% CI 1.08 to 1.36).
  • Increasing age made uptake more likely (aOR 1.05, 95% CI 1.04 to 1.06).

 

What does current guidance say on this issue?

Public Health England (2016) recommends the use of behaviourally informed messaging to increase uptake of NHS Health Checks. The inclusion of a tear-off slip to prompt a patient into planning their NHS Health Check is beneficial and has been incorporated into the national template letter.

In the uptake of health interventions more generally, NICE (2018) recommends that invitations should come from a healthcare practitioner known to the patient, and be tailored to a patient’s situation.

A related study found that sending text message reminders following an invitation letter further increases attendance.

 

What are the implications?

Invitation letters which present counterarguments to common concerns or indicate that resources have already been allocated for a patient’s care encourage patients to attend population-level screening such as NHS Health Checks.

The level of attendance was below the national average and less than half the 75% coverage that Public Health England is aiming at. Reasons for ignoring the invitation are likely to be complex. Other factors could be tested in the same way in an attempt to improve uptake further.

 

Citation and Funding

Sallis A, Gold N, Agbebiyi A et al. Increasing uptake of National Health Service Health Checks in primary care: a pragmatic randomized controlled trial of enhanced invitation letters in Northamptonshire, England. J Public Health. 2019:1-8.

This project was funded by Public Health England.

 

Bibliography

BMA. Exploring the cost effectiveness of early intervention and prevention. London: British Medical Association; 2017.

Martin A, Saunders CL, Harte E et al. Delivery and impact of the NHS Health Check in the first 8 years: a systematic review. Brit J Gen Pract. 2018;68(672): e449–59.

NHS England. Report of the independent review of adult screening programmes in England. London: NHS England; 2019.

NHS website. NHS Health Checks. London: Department of Health and Social Care; reviewed 2019.

NHS website. NHS screening. London: Department of Health and Social Care; reviewed 2018.

PHE. Health Profile for England 2017. Chapter 1: life expectancy and healthy life expectancy. London: Public Health England; 2017.

PHE. Inviting debate around the NHS Health Check Programme. London: Public Health England; 2015.

PHE. Top tips for increasing the uptake of NHS Health Checks. London: Public Health England; 2016.

PHE. NHS Health Check - data. London: Public Health England; 2019.

Sallis A, Sherlock J, Bonus A et al. Pre-notification and reminder SMS text messages with behaviourally informed invitation letters to improve uptake of NHS Health Checks: a factorial. BMC Public Health. 2019;19(1):1162.

Produced by the University of Southampton and Bazian on behalf of NIHR through the NIHR Dissemination Centre

 

Definitions

Template content only

Commentaries

Author commentary

This paper presents two modifications to the invitation letter for the NHS Health Check, which were both effective at increasing uptake. The interventions did not add any extra costs to the process, since they were modifications of a letter that was being sent anyway.

It may be possible to generalise them to other situations where patients are sent an invitation and we would like to improve uptake, for instance screening, vaccinations, or attendance at the National Diabetes Prevention Programme.

Dr Natalie Gold, Principal Behavioural Insights Advisor, Public Health England Behavioural Insights