Objectives The NHS Health Check (NHSHC) programme in England, United Kingdom, aims to provide all adults (aged 40–74) with an assessment of their cardiovascular (CVD) risk factors and offer advice on pharmacological and non-pharmacological interventions to manage and reduce risk. The programme is commissioned at local levels and checks are delivered by a range of providers in different settings, although most are delivered in General Practice (Family Medicine Clinics). There is clear evidence of variation in commissioning, implementation, and delivery practice across England. Our review project focused on variation in the delivery of advice, brief interventions, referrals, and prescriptions at the end of, or following an NHSHC. We aimed to better understand how the programme works in different settings, for different groups - the drivers and consequences of the aforementioned variations - in order to make recommendations to improve delivery and maximise intended outcomes.

Method To better understand how the NHS Health Check programme works, we undertook a realist review and a survey of local government authorities responsible for commissioning Health Checks.

A realist review is a theory driven, interpretive approach to evidence synthesis that seeks to examine and interpret existing evidence to explain why, when and for whom particular outcomes occur. We gathered diverse evidence on the NHS Heath Check, including published research and grey literature such as local evaluation documents and conference materials. The data extracted from these documents was synthesised to develop our understanding of the important contexts that affect the delivery of NHS Health Checks and the underlying mechanisms that produce outcomes relating to the delivery of interventions following a check.

Our survey addressed an important gap in existing survey evidence, seeking responses from local commissioners about current delivery and monitoring of what follows each Health Check.

Results Our findings highlight a lack of clarity affecting how commissioners, providers and attendees understand the purpose of the NHSHC. Two ‘worldviews’ exist and may collide. When the programme is understood primarily as a CVD screening opportunity, responsibility rests with primary care providers and there is an emphasis on the volume of checks delivered, gathering essential data and communicating risk scores. When it is understood as an opportunity to prompt and support behaviour change, more emphasis is placed on the delivery of advice and referrals to ‘lifestyle services’. Practical constraints also affect what it is possible to deliver within the programme’s remit. Public health funding cuts limit delivery options and links to onward services, while providers may struggle when faced with competing priorities and limited time to devote to checks. Attendees’ responses to the check are affected by features of delivery models and constraints they face within their own lives.

Conclusions We have produced recommendations for policymakers, commissioners and providers to consider in shaping the future delivery of the NHSHC programme. There is a need to clarify the purpose and remit of the NHSHC, taking into account prevailing attitudes about its value, scepticism about its effectiveness (especially among providers) and what can be delivered well, within existing resources. Some variation in delivery models is likely to be appropriate to meet local population needs, but a lack of clarity for the programme overall may generate a ‘postcode lottery’ effect across England. Our findings also raise important questions about whether or not the NHSHC is adequately resourced to enable commissioners and providers to deliver a service that can have positive outcomes for attendees. The programme does not exist in isolation and questions about funding should also take into account other services that may need to exist to support attendees after a check.