Views and experiences of the NHS Health Check provided by general medical practices: cross-sectional survey in high-risk patients

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1 Journal of Public Health Vol. 37, No. 2, pp doi: /pubmed/fdu054 Advance Access Publication August 11, 2014 Views and experiences of the NHS Health Check provided by general medical practices: cross-sectional survey in high-risk patients Janet Krska 1, Ruth du Plessis 2, Hannah Chellaswamy 3 1 Universities of Greenwich and Kent, Chatham Maritime, ME4 4TB Kent UK 2 Cheshire and Merseyside Public Health Collaborative Service, Southwood Road, Bromborough, CH62 3QX Wirral, UK 3 Sefton Council Public Health Department, Deputy Director of Public Health, Stanley Road, L20 3DL Bootle, UK Address correspondence to Janet Krska, j.krska@kent.ac.uk ABSTRACT Background Since the NHS Health Check programme was initiated in 2009, no survey has sought patients views of Checks provided by GP practices and few studies have reported views of the wider public. This study sought the views and experiences of patients with potentially high-cardiovascular disease (CVD) risk. Methods Cross-sectional postal survey of all the patients with an actual or estimated CVD risk score of at least 20% over 10 years, registered with 16 general practices in Sefton, North West England, with no follow-up. Results The response rate was 23.4% (644/2958), 67.4% had attended and 73.8% of those not yet invited indicated willingness to attend. Both groups had positive views towards Health Checks, but more non-attenders agreed these should only be performed by doctors. Attenders had better self-reported health and healthy lifestyle than non-attenders. Overall 86.6% of attenders recalled receiving one or more pieces of lifestyle advice and 71.0% claimed to have made at least one lifestyle change; however, perception and understanding of CVD risk appeared limited. Conclusion Both attenders and non-attenders had positive views towards NHS Health Checks in general practice and resultant self-reported lifestyle change in attenders was high. Clearer written information and explanation of personal CVD risk are required. Keywords Primary care, Public health, Screening Introduction Recent research shows that the UK has significantly greater rates of age-standardized years of life lost due to ischaemic heart disease, other cardiovascular and circulatory disorders than in 18 comparable countries. 1 Estimates suggest that a significant proportion of disability-adjusted life years can be attributed to tobacco (11.8%) increased blood pressure (9.0%) and high-body mass index (8.6%), with diet and physical inactivity accounting for 14.3%. 1 The strategy recently published by Department of Health in England for improving outcomes for people with cardiovascular disease (CVD) 2 endorses the NHS Health Check programme. This programme was launched in April 2009 and aims to ensure that all people aged between 40 and 74 have a regular (5-yearly) free assessment of their individual risk of developing coronary heart disease, stroke, diabetes and chronic renal disease. 3 The Check can be delivered through general medical practices, community pharmacies or other community-based providers. Patients found to be at CVD high risk (risk score 20% or.10 years) are placed on a general practice CVD high-risk register and offered an annual review. 3 Several studies have been published evaluating NHS Health Checks provided in general medical practices, which have focused on a delivery mode, uptake rates among those eligible and immediate outcomes, such as statin prescribing Janet Krska, Professor of Clinical and Professional Pharmacy School of Pharmacy Ruth du Plessis, Public Health Healthcare Lead Hannah Chellaswamy, Deputy Director of Public Health 210 # The Author Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please journals.permissions@oup.com.

2 VIEWS AND EXPERIENCES OF THE NHS HEALTH CHECK 211 and support with lifestyle changes. Considerable variation has been found in all these measures. 2,4 7 Few studies to date have sought the views of those receiving the Health Check in general practices. One study reported experiences derived from eight interviews with patients, 8 which concluded that there was low awareness of the purpose of Health Checks. They were seen mostly as a form of reassurance, not for detection of problems and greater clarity was needed to address this misconception. Only two brief user surveys have been reported addressing satisfaction with the Health Check process in this setting. One was in an area targeting only men for the Check and was conducted outside clinics immediately after the Check. This survey showed that 99% were satisfied about the way in which they were contacted, how the tests were conducted, how the results were explained and with the clinic overall. 9 The other consisted of two questions asked immediately following the Health Check, finding that 98% considered the appointment very useful and 96% the venue suitable. 10 The objectives of this study were to obtain the views of those eligible for the Health Check provided by their general practice, regardless of whether they had attended, together with the experiences of those who had received the Check. Methods Setting The study was conducted in Sefton, an area of North West England, where practices sent invitations to individuals who were estimated to be at high-risk based on actual or estimated values in medical records, as part of a wider evaluation of the programme. The early mortality rate from CVD is similar to the England average, 11 but the area is diverse in terms of deprivation, with 23.8% of the population residing in the most deprived national quintile and 13.9% in the least deprived quintile. 12 Both the CVD mortality rate and the prevalence of lifestyle factors contributing to CVD differ between areas of high and low deprivation. At the time of the study, there were residents of Sefton eligible for an NHS Health Check, of whom were estimated to have a risk of at least 20% over 10 years and all general practices in the former Primary Care Trust (PCT) area were providing the Check. The protocol for this evaluation was approved by Liverpool John Moores University Research Ethics Committee and Sefton PCT. Practice selection The number of patients on the registers of all 55 practices in the area estimated to have a high CVD risk had previously been determined, with support from the PCT, based on existing data in clinical records, substituting proxy data for missing values to generate an estimated CVD risk score. All practices provided data to the PCT on the number of patients identified as high risk and number seen for a Health Check. A sample of 25 practices was initially selected to ensure divergence in the following characteristics: proportion of patients on practice register identified as being at high risk, proportion of these seen for a Health Check, geographic location/deprivation, overall list size/number of GPs and practice nurses and clinical computer system/software used to identify high-risk patients. All 25 practices were invited by letter to participate in the patient survey, of which 22 agreed. A purposive selection of 16 practices was then made from these 22 practices. Questionnaire development and distribution The questionnaire was developed from a previous study of pharmacy Health Check provision in the same area 13 and sought information from all recipients about their views on Health Checks in general and reasons for attending or not attending for a Health Check. In those who had attended, additional questions covered: recollection of lifestyle advice received and self-reported lifestyle changes, medication prescribed, satisfaction with the Health Check processes and perceived CVD risk before and after the Health Check. Mostly closed questions were used, but several open questions were included to elicit free-text responses in relation to reasons for attending or not, perceived CVD risk and experiences of the Health Check. Demographic details were also requested, together with questions derived from locally used lifestyle survey instruments to elicit smoking, drinking, exercise and dietary behaviours and a measure of self-reported health status. Questionnaires were distributed to all patients identified as being potentially at high risk from CVD in all 16 practices during October and November 2011, together with a freepost envelope for return direct to research staff. The questionnaires were addressed and posted from each practice to avoid the need for patient-identifiable information leaving the practice. No reminders were sent. Data handling and analysis Responses were entered into SPSS version 19 for analysis. Frequency analysis was performed for closed questions, excluding missing data. Correlations between perceived CVD risk and health were performed using Spearman s coefficient and differences between attenders and non-attenders assessed using Chi-squared tests. Responses to free-text questions were categorized and examples selected from each category to illustrate views.

3 212 JOURNAL OF PUBLIC HEALTH Results Response rate A total of 2958 questionnaires were distributed and 644 valid responses were received, giving an overall response rate of 23.4%; response rates differed between the 16 practices, from 12 to 43%. Respondent characteristics and attendance at NHS Health Checks The majority of respondents were male, white and aged 65 or over (Table 1). These characteristics, as well as deprivation levels, are in line with the population identified as having high CVD risk in these practices. The large majority of respondents considered their health to be very good (97; 15.2%), good (354; 55.5%) or fair (154; 24.1%) and only 33 (5.2%) considered their health to be poor or very poor. A high proportion self-reported taking 30 min of exercise at least three times per week and having a good or very good diet. The Table 1 Demographic and self-reported lifestyle characteristics between Health Check attenders and non-attenders Characteristic Attended for health check (n ¼ 434) (%) Have not had health check (n ¼ 210) (%) Total responders (n ¼ 644) (%) Sex (male) 350 (81.0) 164 (79.6) 514 (80.6) Age over (68.2) 141 (67.5) 435 (68.0) Ethnicity (white) 426 (99.5) 202 (99.5) 628 (99.5) Disabled 51 (12.3) 30 (15.2) 81 (13.2) Current smoker 49 (11.3) 28 (13.5) 77 (12.1) Drink alcohol 341 (78.9) 166 (80.2) 507 (79.3) Drink at least maximum recommended intake 27 (6.7) 20 (10.2) 47 (7.8) Exercise 3 times/ week* Health good/very good* Diet good/very good* 274 (64.0) 110 (53.1) 384 (60.5) 318 (73.8) 133 (64.2) 451 (70.7) 342 (79.0) 132 (63.8) 474 (74.1) Deprivation level Highest 1 31 (7.7) 27 (14.6) 58 (9.9) 2 55 (13.7) 25 (13.5) 80 (13.7) (36.7) 63 (34.1) 210 (35.8) (28.2) 53 (28.6) 166 (28.3) Lowest 5 55 (13.7) 17 (9.2) 72 (12.3) *P, 0.05; difference between attenders and non-attenders; Chi-squared test. proportion of smokers was relatively low at 12.1%, which is in contrast to the 35% identified from practice high-risk register data. While 79.3% drank alcohol, only 7.8% reported an alcohol intake at or above recommended limits. Of the 644 respondents, 450 (69.9%) had been invited for an NHS Health Check, 171 (26.6%) had not been invited, 16 (2.9%) did not recall and 7 did not respond. Most of the 450 invited (422; 93.7%) had attended for the NHS Health Check and 12 additional respondents completed the remaining questions, indicating attendance. Thus, just over two-thirds of the total questionnaire respondents (434; 67.4%) had received a Health Check. Data from the practices showed that invitations had been issued to 67.9% of patients with estimated high CVD risk and that 51.5% of these had attended, thus these 434 questionnaire respondents represented 38% of attenders. Among respondents who had not received an invitation, 155 (73.8%) indicated willingness to attend. Many positive reasons were volunteered for having the Check (Table 2). In contrast, only 15 respondents gave reasons for not attending or expressed negative views about NHS Health Checks. Personal circumstances prevented nine people from attending, two were unconvinced about preventive medicine and two had concerns about a lack of follow-up. (Table 2) The demographic characteristics of respondents were similar between attenders and non-attenders, but there were some differences in responses to lifestyle questions between these two groups (Table 1), suggesting a trend towards attenders having fewer lifestyle risk factors than non-attenders. Perceptions of CVD risk A perception of personal CVD risk prior to the NHS Health Check was provided by 425 attenders, 233 (54.8%) of whom considered their risk as average, with most of the remainder believing it to be lower than average (106; 24.9%) or very low (46; 10.8%) and only 40 (9.4%) considering themselves to be at higher than average risk. (Table 3) There was a weak negative correlation between the perception of risk and perception of health (r ¼ ; P, 0.01). Only a minority of respondents (90; 21.6%) were in fact worried about their risk before attending, with a further 96 (23.0%) being unsure. There was an association between perceived CVD risk and worry (P, 0.001). There were 378 respondents who provided information on how their perceptions of their personal risk changes after the Health Check (Table 3). The majority found their risk was as expected (202; 53.4%), with only 110 (29.1%) having a risk higher than expected and 66 (17.5%) lower than expected. However, responses to an open question inviting an explanation of their CVD risk suggested that most patients

4 VIEWS AND EXPERIENCES OF THE NHS HEALTH CHECK 213 Table 2 Quotations from patients showing varying degrees of satisfaction with the Health Check processes and outcomes Aspect of Health Check Comment Source Purpose positive As with an old vehicle, a regular MOT is a good idea to prevent unexpected failures Male age I think it is good to have annual health check to possibly highlight any potential health issues, especially Male age for men who do not see their GP all that often Outcome positive The check picked up my higher cholesterol level so I would definitely go again Female age After check-up I changed my diet and exercised more and felt a lot better Male age Process positive The nurse was who carried out the health check was extremely easy to talk to... The only things that Female age I might have wanted to discuss did not come up because I did not think about them until afterwards! I have heart trouble, so was able to ask lots and lots of questions during the heart check. It was very helpful to me Female age Lack of understanding or purpose Process negative Risk scores As a general health check it was not a series of tests as I expected. Only centred around the result of a Male age blood test. Not comprehensive as I would have expected There were plenty questions to ask. But they did not seem to have the time. There was a new Male age phlebotomist at the surgery who seemed very flustered and inexperienced! She had problems taking blood! and my wife was very upset. More time for each patient there was standing room only in the surgery and everything seemed rushed! More time possibly. Written/printed information given at the end of health check session. Difficult to Male age retain verbal information Did not feel confident that the Healthcare Assistant was qualified to discuss my concerns þ felt that it Male age was most inappropriate to be speaking to her at all. I was under the impression that the interview would be with a qualified practice nurse She could have asked me what I wanted out of it she might have shared the video screen with me she Male age might have asked me if I had any questions to ask Do not remember being given NHS risk score. Risk of having a heart attack is low as can be expected Male age given my lifestyle, i.e. exercise, diet, non-smoker and check-ups I have at surgery I was unaware of how high the risk was of me having a stroke/heart attack aware of the risk now and Male age have responded I have no idea, because I have always eat healthy food all my life been a sporty person constant exercise, Female age swim 1/2 mile 5 days a week and walk as well as being active daily. My mother died at 94 years my father 69 with thrombosis so a 50/50 chance for me? Table 3 Perceived risk before and after Health Checks (n ¼ 425) Perceived risk prior to Health Check Low/very low Average High/very high Total 152 (35.8%) 233 (58.4%) 40 (9.4%) 425 Perceived risk after Health Check As expected Higher than expected Lower than expected Missing response had received limited information about their actual risk, as they provided estimates based on their lifestyle and other factors. Furthermore, it appeared that few had been given any explanation of cardiovascular risk levels. Only 12 provided a clear indication of having received a risk score, while nine specifically stated they had not received one (Table 2). There were 150 respondents who provided an estimate of their personal risk, of whom 84 (56%) considered it to be low or very low, 34 (23%) average and 33 (22%) above average.

5 214 JOURNAL OF PUBLIC HEALTH Table 4 Respondent-provided outcomes of the NHS health check (n ¼ 434) Advice/action at health check n Proportion of total receiving health check (%) Action taken after health check n Proportion of total (%) Receiving health check Receiving advice About smoking Stopped/cut down About drinking Cut down About diet Improved diet About exercise Increased exercise Prescribed statin Taken statin Outcomes of NHS Health Checks In total, 376 (86.6%) of those attending claimed to have received at least one piece of lifestyle advice during their Health Check (Table 4). Thirty-two respondents described other advice, mostly about weight, reducing fatty foods or blood pressure control. Ninety-four (21.6%) recalled being started on a statin and 31 claimed to have been prescribed other new medicines as a result of their Health Check, mostly for hypertension. A high proportion of attendees 308 (71.0%) indicated that they had attempted to make at least one lifestyle change since the Health Check, particularly diet and exercise (Table 4). Views on the NHS Health Check processes In general, the majority of respondents were satisfied with the Health Check, felt comfortable discussing lifestyle, were able to ask all the questions they wanted to, understood everything discussed and felt they had benefited (Table 5). However, there were 55 (13.5%) who would have liked more help with lifestyle changes, 31 (7.4%) whose concerns had not been dealt with and 61 (14.7%) who still had unanswered questions about their risk of heart disease. Many respondents added comments indicating that they felt there was potential for improvement in the process, relating to the multiple appointments required for measurements to be taken, the time available for the Check and lack of follow-up and information provision. Several respondents voiced concerns that the Check was done by someone unknown to them who failed to take account of their personal history. Some comments indicated a lack of understanding of how the measures included in the Health Check relate to cardiovascular health, while some patients appeared to expect a broader health check, rather than one focused on cardiovascular risk (Table 2). Views on the NHS Health Check in general General views on the NHS Health Check programme are shown in Table 5. While there was overwhelming support for the Health Check, with almost all respondents agreeing that your surgery should invite you for a Health Check, a substantial proportion of respondents were also of the view that Health Checks could be done outside a doctor s surgery, by health professionals other than doctors and that they should be available in lots of places. Significantly more attenders than non-attenders agreed that Checks are valuable, whereas more non-attenders agreed that everyone over 40 should have one, they should be available in many places and more widely promoted, but also that the Check should be done by a doctor. Discussion Main findings This survey of a population of patients identified by their general practice as potentially at high CVD risk found that almost all viewed the Health Check programme positively and of those attending, the majority reported making at least one lifestyle change as a result. However, although the majority of attenders indicated that the Health Check helped them to understand what their risk of a heart attack was, relatively few perceived their risk as high, even after attending for the Check. This contrasts with data from practice records, which indicates that 79.4% of all attenders had a risk level of 20% or over, which could be due to the high proportion aged over 65 years. Many respondents considered that any health professional could provide a Health Check, however, some comments indicated that in their opinion not all staff delivering the check were suitably qualified or trained. Similarly, while most expressed satisfaction with the time given and opportunity to ask questions, some comments were critical of the processes they experienced. What is already known on this subject Previous work has sought the views of Health Check attenders using mainly qualitative methods 8,14 and only two studies have explored wider views. 13,15 The awareness of Health Checks

6 VIEWS AND EXPERIENCES OF THE NHS HEALTH CHECK 215 Table 5 Respondent views on the Health Check experience and general perceptions of Health Checks Statement Strongly agree/agree Not sure Strongly disagree/ disagree A. Health Check experiences (n ¼ 434) I felt that I was given enough time for the Health Check 504 (89.6) 20 (4.7) 28 (6.7) I was able to ask all the questions I wanted to 379 (90.2) 20 (4.8) 21 (5.0) The Health Check helped me to understand what my risk of heart disease is 345 (83.0) 32 (7.7) 39 (9.4) I felt comfortable discussing my lifestyle 395 (93.6) 12 (2.8) 15 (3.5) I understood everything discussed at the Health Check 387 (91.9) 21 (5.0) 13 (3.1) I feel I benefited from having the Health Check 362 (85.6) 41 (9.7) 20 (4.7) I would have liked more support with changing my lifestyle than I was offered 55 (13.5) 77 (18.8) 278 (67.8) All my concerns about my risk of heart disease have been dealt with 302 (72.2) 85 (20.3) 31 (7.4) I still have questions about my risk of heart disease 61 (14.7) 87 (20.9) 268 (64.4) Statement Attended Strongly agree/agree Not sure Strongly disagree/disagree B. General perceptions of Health Checks (n ¼ 644) NHS Health Checks are valuable* Y 425 (98.6) 5 (1.2) 1 (0.2) N 191 (92.7) 16 (5.3) 4 (2.0) Everyone over 40 should be invited for a Health Check* Y 371 (84.5) 40 (9.3) 18 (4.2) N 184 (88.5) 17 (8.2) 7 (3.4) NHS Health Checks should only be done by doctors* Y 152 (35.6) 112 (26.2) 163 (38.2) N 124 (59.6) 47 (22.6) 37 (17.8) NHS Health Checks should be promoted more widely* Y 388 (90.5) 35 (8.2) 6 (1.4) N 191 (91.8) 9 (4.3) 8 (3.8) NHS Health Checks should be available in lots of places* Y 309 (72.7) 72 (16.9) 44 (10.3) N 168 (82.0) 27 (13.1) 10 (4.9) Any health professional can provide NHS Health Checks Y 184 (43.0) 156 (36.4) 88 (20.6) N 83 (40.3) 82 (39.8) 41 (19.9) NHS Health Checks should only be done in a doctor s surgery Y 188 (43.8) 116 (27.0) 126 (29.3) N 90 (43.4) 65 (31.4) 52 (25.1) Your surgery should invite you for an NHS Health Check Y 408 (95.8) 8 (1.9) 10 (2.3) N 200 (96.2) 2 (1.0) 6 (2.8) *P, 0.05; difference between attenders and non-attenders; Chi-squared test. among the public is relatively low, but many are supportive in principle. However, some attenders had little understanding of the focus of the Check and some were unwilling to engage with the programme or prevention in general. 13 Previous studies using medical records found provision of or referral for lifestyle support following Health Checks in general practice was low, ranging from 6.4 to 9.7% of attenders. 6,7 Health Checks in community settings, however, appear to provide lifestyle advice fairly frequently; for example, one study estimated over 40% received some lifestyle advice, 15 while in another, 76% of smokers received advice on stopping and 16, 80 and 85% of all attenders were given advice about alcohol, physical activity and diet, respectively. 16 What this study adds Both attenders of Health Checks in general practice and patients with potentially high CVD risk who have not yet attended had positive attitudes towards the NHS Health Checks programme. Satisfaction with the processes was slightly lower than that found among those receiving Health Checks from community pharmacies in the same region. 13,17 Such positive views of the programme among attenders are essential in encouraging attendance in others. Recommendation by others (health professionals, friends or family) is the method most likely to encourage people to utilize public health services in pharmacies and could be important for those invited by their medical practice. 18 Implementing this in the form of pass

7 216 JOURNAL OF PUBLIC HEALTH it on cards given to Health Check attenders has proved successful elsewhere. (L Hardman, personal communication) The results suggest a trend towards patients with fewer modifiable lifestyle risk factors attending for an NHS Health Check. Strategies which encourage patients with known risk factors who are most likely to benefit from the NHS Health Check may therefore be valuable, for example, those known to be overweight/obese. Such a strategy could potentially improve the programme s cost-effectiveness. 19 There is also a need for greater clarity in what the Check covers, increased provision of written information and a much clearer explanation of personal CVD risk. The latter is an essential aspect of the Health Check and research into optimal methods of risk communication within the programme is needed. The introduction of the Joint British Societies JBS3 Risk Calculator may help to improve understanding of personal risk. 20 The extent to which attenders at practice-based Health Checks recall receiving advice and self-report lifestyle changes has not been reported previously. Our study suggests that this aspect of the Health Check is being delivered routinely by practice staff, hence has potential to result in beneficial lifestyle changes; however, the quality of the advice given is also important. Longer-term follow-up studies involving attenders are required to determine the extent to which such advice translates into long-term changes to lifestyle and health benefits or whether additional support, as requested by some respondents, is required to effect such changes. Limitations As with many surveys, the findings are limited by the use of closed questions with pre-determined options and the low response rate, which could have been in part due to the lack of follow-up reminders. Return to an independent research team was designed to encourage truthful responses, which was perhaps evidenced by the many critical comments received. However, the interval between the Health Check and questionnaire distribution was not controlled and responses are subject to both recall and social desirability bias. Changes to lifestyle were inevitably self-reported and no comparison to any medical records was undertaken. The respondents were representative of those identified by these practices as potentially high risk in terms of age, sex, ethnicity and deprivation level, although the proportion of smokers responding was much lower than among the highrisk population. At the time of the survey, 37% of all the patients identified as being potentially high risk had attended in these practices, hence our response rate was biased towards attenders and those with better health. The programmes used to estimate risk included age as an important predictor, with the result that almost 70% of high-risk patients were over 65 years of age. Acknowledgements The authors would like to acknowledge the help of Julia Taylor with questionnaire design, Nicholas Hatton with questionnaire distribution and data entry, Mark O 0 Keefe with data analysis, Dr Julian Childs and Diane Bolton-Maggs with literature searching. The work of other staff in Sefton PCT and practices in questionnaire distribution is also gratefully acknowledged. Funding This study was funded by Sefton PCT. References 1 Murray CJL, Richards MA, Newton JN et al. UK health performance: findings of the Global Burden of Disease Study Lancet 2013;381: Department of Health. Cardiovascular Disease Outcomes Strategy: Improving outcomes for people with or at risk of cardiovascular disease. DH March Available at: government/uploads/system/uploads/attachment_data/file/217118/ CVD-Outcomes_web1.pdf (30 July 2014, date last accessed). 3 Department of Health/Public Health England. National Health Service. NHS Health Check Programme Best practice guidance Available at: healthcare_professionals/national_guidance/ (30 July 2014, date last accessed). 4 Nicholas JM, Burgess C, Dodhia H et al. Variations in the organization and delivery of the NHS health check programme in primary care. J Pub Health 2013;35: Dalton ARH, Bottle A, Okoro C et al. Uptake of the NHS Health Check programme in a culturally diverse setting: cross-sectional study. J Pub Health 2011;33: Artac M, Dalton A, Majeed A et al. Uptake of the NHS Health Check programme in an urban setting. Fam Pract 2013;30: Cochrane T, Gidlow CJ, Kumar J et al. Cross-sectional review of the response and treatment uptake from the NHS Health Checks programme in Stoke on Trent. J Pub Health 2012;35: Chipchase L, Hill P. An insight into the NHS Health Check Programme in Birmingham; Summary Report Grayland J, Wilson R. Improving male life expectancy in Birmingham. Pub Health 2009;123:e Richardson G, van Woerden HC, Morgan L et al. Healthy Hearts A community-based primary prevention programme to reduce coronary heart disease. BMC Cardiovasc Dis 2008;8:18.

8 VIEWS AND EXPERIENCES OF THE NHS HEALTH CHECK South East Public Health Observatory Cardiovascular disease local authority health profile: Sefton. Available at: org.uk/nationalcvd/docs/00ca_cvd%20profile.pdf (30 July 2014, date last accessed). 12 Public Health England. Health Profile Sefton Available at: (30 July 2014, date last accessed). 13 Taylor JC, Krska J, Mackridge AJ. A community pharmacy-based cardiovascular screening service: views of service users and the public. Int J Pharm Pract 2012;20: Visram S, Geddes L, Carr SM. Formative evaluation of the health trainer community health check service in County Durham Oswald N, McNaughton R, Watson P et al. Evaluation of the Tees Vascular Assessment Programme: Main Project Report. Centre for Health and Social Evaluation, Teesside University Ramsay S, Davidson J, Taylor S et al. Evaluation of NHS Health Check PLUS Community Outreach Programme in Greenwich Krska J, Taylor J, du Plessis R. Views and experiences of the NHS health check in pharmacies and general practices. Int J Pharm Pract 2013;21(Suppl. 1): Dewsbury C, Saramunee K, Mackridge AJ et al. Promotion of pharmacy public health services: Which method is best? Int J Pharm Pract 2014;22(Suppl. 1): Schuetz CA, Alperin P, Guda S et al. (2013) A standardized vascular disease health check in Europe: a cost-effectiveness analysis. PLoS ONE 8(7): e doi: /journal.pone JBS3 Board. Joint British Societies consensus recommendations for the prevention of cardiovascular disease (JBS3). Heart 2014;100:ii1 ii67.