Primary care as a commercial enterprise

Since the Quality Outcomes Framework (QOF) was introduced in primary care, GP practices have worked within a financial model which provides remuneration for the provision of good quality care and for entering patients onto the diabetes register, for example. Similarly, GPs were financially incentivised to recruit patients to the NHS Health Check programme through the locally enhanced services. This meant that for some, financial issues featured strongly in their decision to offer the NHS Health Check.‘In order to get good payments we had to reach 50% target within three months otherwise, if you delayed it, remuneration wasn't that good…it was important for us to get the targets very very quickly.’ (GP8)‘Some doctors won't do it because they think it's a lot of work to be done for the amount of finance that they will be reimbursed and they are just financially driven whereas other doctors, and I hope I'm one of them, are actually bothered about their patients and actually care.’ (GP1)

Most of the GPs interviewed discussed the financial context of delivering the Health Check programme because it was fundamental to their practice as a whole. GP practices function as a commercial enterprise and thus take seriously the financial elements of any service they deliver. However, the second extract from GP1 conveys frustration at needing to prioritise financial reward in a practice that should be focused on caring for patients. This frustration is confounded when GPs perceive that government departments that set targets are not apprised sufficiently in how things work on the ground and what other issues need to be addressed.‘I mean the biggest problem with the screening programme has been I think because it's target driven…and the people who set these targets don't understand how the practice works.’ (GP2)

Surgeries had to develop methods to maximise recruitment and reach targets for remuneration through the locally enhanced service agreements to make running the NHS Health Check financially viable. This was more or less challenging for different practices depending on their size and staffing levels. In some cases, this meant blocking out appointment times, employing new staff and actively seeking out eligible patients by carrying out reviews of notes. This was time intensive and put surgeries under additional pressure.‘What we have had to do is um block some appointments off for healthcare assistants so when people are in the surgery they could be fitted in’. (GP3)

In order to meet targets, some GPs said they screened patients opportunistically when they came to surgery for other reasons and conducted the Health Check there and then. Most GPs we spoke to took up a coordinating role and it was healthcare assistants and practice nurses who carried out the checks, but not exclusively. This was a more efficient use of time and financial resource, although some expressed concern about not being fully aware of how their patients were managed.

‘Buy in’ to concordance in preventive healthcare

Concordance is the process by which GPs work with patients to reach agreement about treatment; it involves GPs understanding patients' views and patients making sense of the importance of treatment and consequences of (not) taking it.14 Challenges to concordance are arguably multiplied when working in preventive healthcare. Nevertheless, among GPs interviewed, there was support for the NHS Health Check based on strong feelings about preventive healthcare. This evaluation took place in an area with a high proportion of South Asian patients, and so issues relating to diabetes were particularly persuasive in terms of supporting the need for the check.‘I think it's a very good idea. We have a very high proportion of our patients who suffer with diabetes, almost 10% of our patients are diabetic so I thought this was an excellent opportunity to screen those earlier and pick them up and then you know be able to do something about it, you know, lifestyle management…The money was also very useful. I'm not going to lie. That was an added bonus.’ (GP5)

The GP above was persuaded because of the potential to help patients prevent conditions like diabetes by buying into preventive health rhetoric. There was also an underlying motivation in the financial reward the practice would receive for participating in this programme. Another GP stressed how important it was for Health Checks to be available through the NHS rather than losing patients to the private sector.‘I think there should be an emphasis on preventing the ‘deadly trio’, diabetes, kidney disease and cardiovascular disease for middle aged patients. And I think a lot of patients expect this. A lot of them to go to the private sector for them and I think it's good that the NHS should be doing it.’ (GP9)

A key aspect of the NHS Health Check, as designed by the Department of Health following the National Institute for Health and Care Excellence (NICE) guidelines, is the focus on lifestyle. This meant that when risks were identified in the biomedical tests, attempts were made to address lifestyle factors. In the area evaluated here, this was to be done using a goal-setting sheet to be worked through with patients to develop a set of lifestyle change goals that is unique to them. The idea here was that this was a collaborative exercise which mirrored a concordant approach to healthcare, that is, an approach where patient and healthcare professional negotiate issues, discussions are equitable and patients are able to make active informed choices. In some cases, this approach was not always taken, as we have reported elsewhere,4 and instead the focus was on giving advice. Language like that in the extract below, betrays such a paternalistic approach.‘Personally, I don't give them goals. The practice nurse will follow them up. Whether she sets a target I'm not sure about that.’ (GP9)

This is almost the opposite of what was intended; instead of working together with patients to set goals which suit them, their family, their situation, this suggests a traditional approach where healthcare consultations are purely didactic. Some GPs were aware of this issue and knew the onus was on the patient to make their own lifestyle changes; however, there was some doubt about whether patients would be capable or willing to make such changes.‘Young Asian men…they've got a 60% high risk, they walk in and I say, ‘look you're a man, you're Asian, and you've got family history, you can't change your sex right, you can't change your race, you can't change your family, you've already got three risk factors already without you doing anything which is why you need to be aggressive in your lifestyle change…you're doomed’…that may work quite well, but it may not work quite well…they may say ‘oh yeah I need to do something because I'm already kind of in the negative’ but then you get some people who say ‘you know what's the point because I'm already at risk anyway’.’ (GP1)

While this GP admits this approach works for some, it does not for others. Clearly, there is a need to establish what else would work. Conducting a consultation in a concordant manner (ie, collaboratively involving the negotiation of treatment and active decision-making on the patient's behalf) requires rapport and a focus on the patient's unique situation. That does not mean the healthcare professional conducting the check needs to know all the patients; it means healthcare professionals need the skills to elicit information from patients which will help them identify which approach will work best with them. Focusing on setting goals that are tailored to each individual is one way of working out what is important to them and what will therefore motivate change.

Following protocol

To run the NHS Health Check according to protocol required equipment and training in the approach to be taken with patients. The focus was on collaborative healthcare and setting lifestyle goals tailored to individual patients if they were found to have elevated risk in the biomedical tests. There were problems when the programme first started with equipment.‘When it first started…the training wasn't officially organised until a bit later…the support materials didn't arrive at the start, they arrived later on, we got a big box delivered.’ (GP3)

Practices participating in the programme were required to meet a particular technology specification to enable them to manage patient recruitment and results data to ensure the checks conducted were recorded. Some GPs used this software to opportunistically screen patients.‘When a patient comes in an alert will come up saying this person needs cardiovascular screening and there's a template so while the patient's there I'll say, ‘look you know what, you're over the age of 40′ I'll say, ‘you're at risk of having a heart attack in the next 10 years and hence I'm going to do some blood tests, ask you a few questions to alleviate that risk.’ (GP1)

There are a number of issues here. Opportunistic screening may not always elicit informed consent; a patient may feel unable to decline their GP even if they are not clear what the tests are for or understand what the results will mean. This description is likely to be a shorthand for a longer explanation; however, it suggests a focus on the biomedical tests with no mention that risk may be reduced by changes in lifestyle. Relatedly, asking questions will not alleviate risk. This would be confusing for a patient making informed consent unlikely.

Developing lifestyle goals was encouraged in the area evaluated by using goal-setting sheets. We asked GPs whether they carried out this aspect of the check alongside the biomedical tests.‘Some people use it more than others but I personally did use some but it depended on which person they ended up seeing because we did have training, myself our practice nurse and the healthcare assistant had the training for that, but not everyone had training for that aspect of things. But then we talked about it in our practice meetings and we conveyed the message to others, not everyone did it as formally as that.’ (GP3)

In one practice, there was variation in how the check was delivered. The way this GP described the use and non-use of the goal-setting chart intimates a lack of understanding in the rationale for doing this part of the check. There was some inconsistency in training received and clearly a lack of investment in the activity.

Support provision

In order to run the NHS Health Check effectively, it must be followed up by lifestyle support in the shape of services that can help patients maintain the changes they proposed and reach their goals. In some cases, practices employed their own healthcare assistants to deliver these support services, for example, in smoking cessation counselling, weight loss and activity programmes.‘The bulk of it is done by the healthcare assistant. Mainly it's weight loss and exercise and diet advice. They may be filtered through to the practice nurse, she does most of that sort of thing.’ (GP9)

The tone in this extract implies a lack of significance on this element of the Health Check. The issue is not who delivers this support, but whether it is prioritised as a key part of the process; it is not simply about identifying risk but also reducing it through lifestyle change. This is not simply an issue at the level of the practice though. There is a lack of well-funded support services in the wider community as well as a lack of knowledge about what is available.‘We have regular contact with the ‘Be Active’ person. He comes and sees us and says ‘I'm not getting enough across’…I would say we've seen him probably a minimum of three months…I know we used to have sessions fairly regularly.’ (GP7)

It is not only inconsistency of services which prevents GPs from maintaining established links with lifestyle support services, but also lack of financial resource. Previously in the area evaluated GPs were able to prescribe to the free gym at off-peak times, which meant accessing it was challenging for people in this area who often worked long hours. Coupled with cuts in local authority leisure services, this means there is a large proportion of patients who cannot access gyms or cannot afford gym membership.‘What the government needs to do is to supplement some money…and say to the gyms we'll give you this much money but what we want as part of that is we want you to accept patients from inn city practices like this.’ (GP1)

This also raises the issue of what constitutes physical activity. Despite government recommendations that walking is a good form of physical activity available to the majority of the population, there was little mention of this as a possible way of making a lifestyle change. Perhaps there is some work to be done with GPs as well as patients regarding the benefits of walking and stair climbing, for example.

Managing high-risk levels of alcohol consumption was challenging for some GPs and staff delivering the Health Check. One GP was concerned that patients would not be honest about alcohol consumption to GPs because often they came from the same religious background and there was a stigma to be managed.‘It's mainly an Islam religion practised in this area and the main population are Muslims. I think they'd probably be a bit more open to my nurses about drinking because they are not necessarily Muslims so they're a bit more open to them.’ (GP5)

Contrary to prior assumptions about the benefits of healthcare professionals being from the same communities as their patients, this GP raises the possibility that difference may be beneficial in this context. Linked to that, one GP described an anonymous counselling service for patients concerned about their alcohol consumption.‘It's a service we run here that is anonymous. They come in and see one particular counsellor. It's all alcohol based but the onus is on the patient, we do it upstairs. We are lucky in that we have a room the counsellor can use, in other practices they may not have it. So, we actually get patients from other practices coming to see the counsellor here.’ (GP4)

As the extract suggests, this was an unusual case. On top of the availability of drug and alcohol services though is the potential stigma associated with them especially in communities like this one. These data suggest that for the NHS Health Check to fulfil its remit of offering lifestyle support to reduce risk, some investment is required now to ensure associated savings are made in terms of healthcare costs for people diagnosed with diabetes, cardiovascular disease, stroke and dementia.