Mid-life health checks go digital - 5 things we have to get right for patients and practitioners

The recent  announcement on the cover of The Times was a pretty enormous milestone in the world of preventative health. Mid-life health checks are going digital. A new regional pilot in Cornwall has been kickstarted to assess whether moving away from face-to-face checks and replacing them with a ‘digital-first’ approach of an online questionnaire plus an at-home test-kit could boost uptake levels and reduce pressure on GPs. 

What is the NHS Health Check? Why go digital?

Currently, everyone between the ages of 40 and 74 living in England is eligible for an NHS health check, once every five years. These checks have been shown to improve quality of life and clinical outcomes and provide huge cost savings to the NHS. Health economic evaluation has demonstrated that for every 1% increase in uptake for health checks, the NHS saves £3.4 million on downstream treatment costs.

However, only 44% of people who are offered a check attend it; this is especially true for men in their 40s and 50s and for ethnic minorities. The reasons for the observed low attendance are multiple, but the limited flexibility and capacity of traditional Primary Care organisations and the hectic nature of life play a huge role. 

Most of what the health check is designed to catch are the behaviours that will put patients at great risk of developing costly, debilitating and burdensome diseases such as heart disease, stroke, diabetes, kidney disease and some forms of dementia: these include being overweight, being physically inactive, not eating healthily, smoking, drinking too much alcohol, high blood pressure, high cholesterol…

A shift to a patient-centric, digital approach naturally lends itself to offering greater convenience and flexibility for many time-poor, digital-savvy patients. And just as importantly, we hope this will mean fewer appointments are needed with GPs, giving them more time to focus on other patients.

The mid-life MOT can be a real ‘teachable moment’ in a person’s life, and leave patients better prepared for the future and able to take steps to maintain or improve their health.

“But, that’ll never work…”

Many aspects of Primary Care are being digitised and much of the media response surrounding this focuses on the ability to access an appointment or a referral - virtual appointments, practices moving to total triage, the vastly increased use of messaging are some examples. The digitisation of the health check is a natural next step.

Cynics may say that’ll never work:

1. The case FOR face-to-face consultation: The health check isn't just about running a few tests and filling in some digital forms - it's a rich, quality conversation between doctor and patient that is inspiring and galvanising. 
2. Complexity: How will people be expected to test themselves at home with the required precision and care? If this is about convenience, making people take their own samples and fill in lengthy forms is just shifting the burden.
3. Digital exclusion: What about those traditionally excluded from this sort of digital access to care? Are we not just making inequalities worse?

The curious case of PILOTITIS

The objective of any pilot like this is to a) learn a lot, on the way to b) safe, effective and speedy scale up. The public sector has a habit of running pilots that never scale and this condition has developed an affectionate nickname: ‘pilotitis’.

Like all ‘test and learn initiatives’, we should expect this pilot to generate a set of mixed results - some positive aspects, some negative. Neither a slam-dunk success nor a total meritless failure.

But there are steps that will seriously increase the chances of things going right. 

5 THINGS A DIGITAL HEALTH CHECK MUST GET RIGHT

• Allow this to be the option and not the default 

What may make this tricky is the relatively small but critically important number of people for whom the digital check is not the preferred choice. Forcing someone to take part against their will when they would rather have a traditional face-to-face appointment is unwise.

The enormous benefit of the health check is the renewed motivation and the behavioural change, sparked by the conversation and the internal health insights made comprehensible. This will be a non-starter if the very medium of the check is a source of frustration and tension on the part of the patient.

How can we strike the correct balance between encouraging the digital check, while recognising that for many individuals, this might lead to more complexity along the way? For example, we can predict patients whose samples are highly likely to clot in the post. What good is it to send this patient an at-home kit?

Screening criteria that prevents this poor experience should be factored into the design well, and other creative options for where the sample can be taken if not the GP should be included e.g. pharmacies.

• Ruthlessly focus on a seamless patient-experience

The fragmented bits of technology underpinning a digital check won’t be a problem: most practices have one-way messaging functionality now as standard, people are well used to completing digital forms, remote NHS lab-grade blood testing for markers such as cholesterol have existed for years, virtual consults have become routine…

What will harm uptake levels and exacerbate churn during a check is if the experience feels clunky and disjointed.

Taking the learnings from the Covid vaccine programme, from the sign-up process to the questionnaires being completed, through to the kit delivery, to the sample collection, and on to the way the results are shared…patients will want to feel that this check is being treated with the professionalism, ruthless efficiency and precision that it warrants. After all, this might be our one opportunity to interact with a patient for 5-years and deliver some health promotion home truths.

Part of that experience we must take seriously is sharing the test results in a way that is both comprehensible and actionable. This isn’t about pages of medical jargon and Red-Amber-Green reports that make you catastrophise unnecessarily. And there is a danger that concepts such as HDL and LDL cholesterol can become lengthy ideological discussions. In reality, we need a patient to be empowered to make changes in their own life that are often remarkably simple to know and hard to act upon.

And if we want to be smart about this and play the long-game, the NHS App could effectively become the home for this sort of health information and enable longitudinal tracking over time, linking in with all sorts of fantastic tech (e.g wearables, digital therapeutics, self-management). 

• Start with the end in mind - health economic evaluation 

A nightmare scenario for any health economist is to run a pilot like this with little or no thought given at the outset to how data will be collected throughout, such that it can be useful in indicating whether it has been effective or not - clinically and economically.

Let’s do that hard work now and consider practically how insight will be fed back and analysed:

• Does uptake improve generally?
• Are the questionnaires and kits effective? What's the feedback? Failure rates? Non-returns?
• Does the check triage in the correct way? Do we see the right pathways being followed post-result?
• Does the check strike the balance between preserving HCP capacity today, and screening for tomorrow?
• How much does it cost per patient vs. traditional methods? What's the downstream cost-saving when extrapolated?
• In harder to reach groups, what's the impact?
• Does it remain easy for people to have their health check F2F if they don't want it digitally? What happens when samples fail? Or when people can't extract enough blood?
  
  
• Incentivise doctors and patients appropriately 

To date, practices have been forced to make the choice between pushing hard on health checks to deliver QOF (Quality and Outcomes Framework) targets and gain much needed income (albeit a capped source of income per practice), and focusing their administrative and clinical time on other things such as disease registers, which squeezes the focus on health check uptake.

If the digital check makes the delivery of the testing and the consultation (where required) more straightforward, what is it we really want to measure and incentivise? Uptake? Uptake in harder to reach groups? Follow-on care? Health improvement from check-to-check?

Unless the activity is adequately counted,  reimbursed and incentivised, initiatives like this may sit on the ‘too difficult’ pile for many councils and practices where resources are stretched and the ‘to do’ list is already long.

Similarly, from the perspective of an eligible patient who is busy and on the fence about whether or not to sign-up and complete their check, are there things we can do to nudge patients, either by impressing upon them the importance or by making it worth their while?

Simple incentive schemes may work, emulating some of the things we saw during the vaccine programme, such as discounting on selected restaurants if you can prove you’ve had your check. Or perhaps being really transparent about how much the health check costs the taxpayer will incentivise individuals to do their civic duty.

For many, potentially finding out you are at risk of a disease is motivation enough. We know however that many others need more of an incentive to step forward - and it’s often these people we need to reach most urgently. 

• Start now on the things that will take the digital health check to the next level

As we know, the health Check is potentially the most comprehensive and scalable public health instrument available to us - triggered at a critical point in a person’s life.

If we’re going to do this, let’s do it properly and put innovative tools and technology to work: 

• The personal dashboard/report needs to be compelling - consider sophisticated visualisation techniques, predictive results, contextual information etc.
• ‘Talk to a health professional today’ - spin up a virtual consult easily with different professionals e.g. with a GP, nutritionist, physio etc.
• ‘Next steps’ functionality - broker safe, effective, digital tools that have the NHS’s stamp of approval to support with diet and regimens, or for specific goals and conditions/health areas - and make it ORCHA (Organisation for the Review of Care and Health Apps) approved.
• ‘Make the change stick’ - allow patients to forge health plans and commitments following their check. And enable ongoing monitoring - allow patients to opt in to more regular screening/tests to see change over time.
• ‘Top up tests’ - the basic tests are free, but patients may wish to test for other specific things on top e.g. hormone tests, polygenic risk.
• Opt-in to have checks more regularly than every five years
• Auto-enrol onto other preventative or treatment pathways based on results such as ‘You & Type 2 Diabetes’ and the ‘Low Calorie Diet Programme’.
• Replace Q-Risk with a more personalised Polygenic Risk calculation.
• At PCN, ICS/regional and national level, offer the ability to produce national and regional dashboards of aggregated insights across operational, demographic and health measures..

Conclusion

The digital health check should be viewed as a big step along the way to ushering in a new way of doing preventative, lifestyle-focused healthcare at enormous scale. But this is only the first step.

Carving out whole chunks of Primary Care activity and suggesting it can all be done digitally in one swoop is understating the complexity of what these checks catch, and just as importantly what they rule out.

At Thriva, that’s precisely why we’re continuing to build sophisticated software and flexible diagnostics infrastructure that can make this work convenient and flexible for the health service and for patients.