Summary

This case study describes Abbie, who was in relatively good health, with no clear CVD risk factors and who did not require any post-health check follow-up. CVD risk was communicated using heart age and risk manipulation prompted Abbie to make dietary changes to address her elevated cholesterol, which was identified in the health check.

Patient

Abbie is a 61-year-old white British female living in a relatively deprived area (IMD decile 2). She does not drink alcohol or smoke, walks at least 10,000 steps a day, and regularly undertakes gardening and housework. She has no family history of CVD and has lost 8 kg since her weight was last recorded (8 years previously). She feels that having this type of health check is important and expresses gratitude to the practitioner. Her total cholesterol is slightly elevated, but not enough to warrant follow-up.

Practitioner

This health check is delivered by a British Asian female HCA with 2 years’ experience of delivering health checks and who has received ‘on the job’ training (no formal training). The HCA is positive about NHSHCs in general and likes the JBS3 manipulation options. She feels confident in communicating the risk score as the ‘GP has explained it’ to her and thinks that, in general, patients understand the information presented to them.

The NHS Health Check

The health check is shorter than average (just over 17 minutes). However, the HCA talks for a smaller than average proportion of time (46.0%) and Abbie speaks a little more than average for the sample. Abbie’s QRISK2 score is calculated as 4.8% and her heart age is estimated as 61 (equal to her actual age).

What worked well

Abbie reacted positively to heart age:

I was pleased to hear that [heart age was 61] and encouraged really . . . I found the whole thing encouraging, it encourages me to make some changes and to look after myself, because I think that is my duty.

Abbie liked the visual element of heart age: ‘because it was on the screen, I think that is just such an aid to memory’ and ‘an understandable way of presenting it’. The HCA also recognised Abbie’s positive reactions. She felt that being able to show Abbie her heart age on screen had helped Abbie to understand the concept, and that it was helpful for the two of them to compare Abbie’s heart with her true age, to see whether it was ‘good or bad’.

During risk score manipulation, there was discussion around good and bad cholesterol, and how to reduce Abbie’s total cholesterol, which was elevated. Abbie and the HCA appeared to enter into a mutual discussion, which concluded with Abbie thanking the practitioner. Abbie later reflected:

I thought that was very well done actually, and because the nurse showed me . . . by changing some of the data . . . that was very clear and understandable to me, so I thought that was quite a good way of doing it.

This information was remembered by Abbie, who had implemented some changes: ‘[the practitioner] actually suggested cutting [cheese] down to a couple of times a week, which I have done already, so that definitely has had an impact’. Abbie said during her VSR interview that when ‘information was given to me in the recommendation . . . I have implemented that immediately’. The HCA also liked using the risk manipulation function within JBS3, describing it as an ‘eye opener’ for patients.

Areas to improve

Abbie highlighted the challenge for practitioners in reading patients’ reactions to CVD risk information, and the need to ask patients if they understand and tailor appropriately. Abbie could not remember her 10-year risk: ‘I am not sure I fully understood the importance of the cardiovascular part of it’. However, the HCA perception of Abbie’s response, when she watched the video clip of their consultation (‘they just nodded and quite calm’), and our ratings of engagement based on non-verbal cues identified Abbie as being generally positively engaged.

The HCA liked JBS3 and being able to ‘show [patients] on the screen, they can see what is going on’, but referred to event-free survival age risk as ‘a good way to show patients if you can control things, your life expectancy will increase’. This showed that the HCA misunderstood the score and, as a result, did not describe it clearly to Abbie during the health check: ‘So on average it’s [the system] picked inside 80–85 about a heart attack or stroke’.

In turn, Abbie did not understand or ask for clarification. Comparing it with heart age, she said she did not understand it ‘as clearly I don’t think . . . I don’t think I took it on board quite in the same way’. This lack of understanding was not obvious to the HCA, who attributed Abbie’s lack of reaction to the fact that she was reading the screen and taking in the information, rather than to a lack of understanding.

Risk score manipulation was performed using blood pressure, which was normal, rather than cholesterol, which was elevated. This highlighted the need for tailoring. Abbie left with unmet information needs. She was keen to learn more about how to implement a change, but did not follow-up:

Until you know what to do you can’t implement it and particularly over blood pressure. I would like to learn [more about] the blood pressure, but I don’t know how you go about doing that.

Had the HCA asked Abbie if she understood or required further clarification, this could easily have been addressed.

Summary

This case study describes Barry, a patient who presented with a number of CVD risk factors including increased alcohol consumption, poor diet and slightly elevated cholesterol. Barry was recommended to make a specific lifestyle change that he was already considering. Despite other elements of CVD risk communication being suboptimal, he made a positive change, demonstrating that the health check can serve as a prompt to initiate risk-reducing behaviour when patients are on the cusp of acting.

Patient

Barry is a 47-year-old white British male living in a deprived area (IMD decile 1) who drinks 40 units of alcohol per week, has never smoked and reports doing ‘a bit of running every now and again’. His diet is the main area of discussion, as he admits to eating ‘a whole pack of chocolate biscuits every single day’ and excessive consumption of dairy products. Barry has a family history of heart problems (maternal grandmother) and diabetes ‘runs in my family’.

Practitioner

This health check is delivered by a white British female PN who has 8 years’ experience of delivering health checks and had previously attended two NHSHC training courses with the last being ‘at least 2 years ago’. The PN felt that she did not ‘have any problems’ with communicating CVD risk to patients and preferred JBS3 over QRISK2 because ‘you can actually communicate far better, and it’s got visual . . . everything about it, the patient can actually understand it better than just me talking’.

The NHS Health Check

This health check lasts just over 22 minutes, approximately average for the JBS3 sample, but is relatively dominated by the practitioner, who speaks for 56% of consultation time, and Barry speaks for 18.4% of the time. Barry’s 10-year risk is 3.1%. Only total cholesterol was considered ‘a little bit high’, at 5.3 mmol/l (ideally < 5 mmol/l). Barry’s heart age was estimated at 54, which was 7 years older than his actual age, which the PN attributes to his family history and elevated cholesterol. Based on a discussion of lifestyle, the main recommendations are to reduce consumption of chocolate biscuits and increase fruit and vegetable intake.

What worked well

About 3 weeks post health check, Barry had implemented dietary changes and felt that this was sustainable. Although he had ‘wanted to reduce my biscuit intake anyway’, the health check ‘prompted’ this change, and he had not ‘eaten chocolate biscuits now for over a fortnight’. The discussion around alcohol had also moved Barry to consider moderating his alcohol, but he saw this as a next step. A blood test 3 weeks post health check showed that cholesterol had fallen to within the normal range and, after an appointment with Barry’s GP, no further action was taken.

Areas to improve

Barry said that he was ‘expecting more’ from the health check, ‘something more in depth’, with more tests.

Although the PN was confident in delivering 10-year CVD risk and believed that ‘the majority of them [patients]’ understand, when watching the video clips of her interview she ‘did wonder sometimes whether they [patients] actually fully understood’. Barry could not remember his 10-year risk when asked by the researcher, even when prompted with a video clip. Although he interpreted the score as ‘quite low’, he said that he ‘didn’t remember it no, I don’t understand it’.

In line with current findings from the VSR patient interviews (see Chapter 5), the PN felt that being told heart age would be shocking, but Barry did not react in this way. His interview demonstrated that he had not fully understood how this information had been derived. The consultation would have been improved by the PN picking up on the trigger of this apparently contradictory result (of old heart age, but low 10-year risk).

There was misinterpretation of the discussion of event-free survival age, from which Barry took away that he had survival age of 73 (rather than event-free survival). Barry’s response was to ‘live my life to the full’, but such misunderstandings could have significant negative consequences including a sense of futility in relation to lifestyle that negatively affects health behaviour. The practitioner’s VSR interview revealed that the PN had similarly misinterpreted this risk score.

Finally, the PN altered the blood pressure as an example of how making small changes can be effective, but this point was missed by Barry, who was confused by the different numbers being entered: ‘I thought my blood pressure was low?’.

Summary

This case study illustrates a patient, Carl, who presented with a number of CVD risk factors, and in whom presentation of heart age had a significant impact. This resulted in Carl making a number of small lifestyle changes following his health check.

Patient

Carl is a 59-year-old white British male who lives in a relatively affluent area (IMD decile 9). He reports rarely drinking and that he stopped cigarette smoking in 2015, after ‘40 odd years’. He does little exercise because of ‘spinal problems’ and had a paternal grandfather who ‘had a stroke . . . he was late 60s, 70s’. Carl reveals that his friends and family ‘think I’ve got type 2 diabetes’, which was one of the reasons for attending the health check.

Practitioner

This health check is delivered by a white British female HCA with 5 years’ experience of delivering health checks. She received training in health checks prior to delivering them, but this primarily focused on PoC testing, and she cannot otherwise recall the training content. The HCA is ‘quite happy communicating’ CVD risk to patients’ and ‘primarily do[es] it in the same way’ for all patients she sees. She prefers ‘JBS3 because it has got the heart age on it’.

The NHS Health Check

This health check lasts longer than average (> 27 minutes) and involves more patient speaking than most (32.9% of total time), and CVD risk is discussed for > 2 minutes. Carl’s QRISK2 is 11% (medium risk), described as ‘a little bit higher than we’d like it to be’, and his total cholesterol has ‘gone up a little bit’, to 4.9 mmol/l from 4.5 mmol/l (in 2016). It is suggested that Carl considers improving his good cholesterol. His blood pressure is ‘just sort of on the higher end of where we’d want it to be’ and his body mass index (BMI) is 28.4 kg/m².

What worked well

Carl said the health check was ‘what I expected and I’m very happy, yeah’ and was ‘now more mindful of, of what I am or I’m not doing’.

The visual presentation of heart age had the most impact on Carl. He reported that it ‘shocked me, no it concerned me’, and made him think ‘yeah, I ought to do something about that’. He remembered ‘the picture on that screen, the 65 . . . being in the middle’ and ‘thinking bloody hell I ain’t 65’.

The HCA manipulated Carl’s information within JBS3 to illustrate that reducing his total cholesterol and increasing HDL cholesterol through simple changes to his diet and physical activity levels would reduce his CVD risk to 9.3% and lower his heart age to 62. The HCA thought ‘it’s really good having that option’ because ‘they can actually visually see the changes’. Carl did ‘remember that’, but had ‘already got the message’ by that point.

Carl found a diet sheet provided by the HCA ‘helpful’. He reported several positive behaviour- and health-related outcomes:

• ‘ordered a small blood pressure monitor’, which he admitted he had ‘never done anything like that before’
• felt ‘more mindful’, and was trying to ‘do a bit more exercise’ and ‘now looking at certain foods’
• had ‘been researching because of my concerns about diabetes’
• diabetes was later diagnosed following a full blood check at 6 weeks post health check and Carl was prescribed metformin.

Areas to improve

Ten-year risk was not explained by the HCA and, subsequently, was not recalled or understood by Carl. On watching the corresponding video clip, he said that it ‘didn’t make a significant impact on me’. In the absence of an explanation from the HCA, Carl questioned ‘exactly how she arrived at that percentage’, only remembering that ‘they’d like me to be 10% or less and I’m only 11’.

The HCA did not understand and, therefore, miscommunicated event-free survival age: ‘currently you can sort of expect to survive the age of 79 based on your lifestyle factors’. The HCA found it ‘the hardest one to try and communicate’. In this health check, it did not create a serious issue as Carl reported that seemed ‘a long way off, you’re looking like 20 years in the future’ and recalled thinking ‘well that’s better than what my dad or what my grandparents had’.

Summary

This case study presents Deborah, a patient in good health, for whom the health check provided reassurance. In this example, Deborah attended with a positive attitude to her health. She tried to lead a healthy lifestyle and was grateful of the health check as an opportunity for reassurance.

Patient

Deborah is a 63-year-old white British female living in a relatively affluent area (IMD decile 10) who has never smoked, reports modest alcohol consumption (‘7–10 units per week’), ‘excellent . . . varied diet, nice portion sizes’ and is a ‘Pilates teacher’ who teaches aerobics, and practises yoga for 2 hours each day. She has no known family history of CVD, but is aware of high cholesterol in the family (including herself).

Practitioner

The health check is delivered by a white British, female, newly qualified PN. She has 9 months’ experience of conducting health checks and has ‘had a lot of shadowing’, but no formal health check training. She felt confident ‘explaining what the QRISK is . . . yeah I’m fine with that’.

The NHS Health Check

This health check is relatively short (17 minutes), but includes > 3 minutes of CVD risk discussion, and Deborah speaks for > 28% of the health check (above average). Deborah’s 10-year risk is 4.7% and her heart age is 58 years. Total cholesterol is slightly elevated (5.8 mmol/l) but, in the context of LDL and HDL figures, her cholesterol level is described as ‘within normal range’.

What worked well

Overall, Deborah reported that the health check ‘was as I expected’ and that it was ‘good to actually have some reassurance that everything is OK’. She said, ‘I have always been interested in my health, so, erm, for me it’s a positive thing’ and was ‘grateful that [they] had the opportunity’ to have the health check.

Heart age was the CVD risk information that affected Deborah most positively: ‘when she told me that my heart age was 5 years less than my actual chronological age’ it served as ‘a positive reinforcement both for me and within my job’. The PN reported that heart age came ‘more naturally the more I used it’ and felt that patients ‘generally responded really well’.

The PN correctly described event-free survival age and, in turn, Deborah later interpreted it to mean that ‘I should be alright until I am in my 80s, yeah, before anything might start to develop . . .’. This emphasises the importance of practitioners having accurate knowledge of CVD risk scores in order to convey this to patients and mitigate against misinterpretation.

Using JBS3 had led to a change in practice. The PN suggested that they ‘much prefer using [JBS3]’ as they ‘think it gives the patients a better understanding’ and ‘still use it now’ following the conclusion of the study.

Areas to improve

First, information presented without a visual aid was forgotten. Deborah was unable to recall her 10-year risk and, when watching the corresponding video clip, reflected that she ‘understood’ it and ‘wasn’t confused at all’. The PN also thought that ‘they [patients] all understood fully the 10-year risk’, but that QRISK2 is ‘lacking . . . the visual aids’.

Second, event-free survival age was communicated accurately by the PN in the health check, perhaps as they read the information from the screen, during the VSR interview, their discussion of this risk score indicated some misunderstanding: ‘really good you know . . . [patients can think that] “I am going to survive to 82” ’.

Third, risk manipulation could have been better tailored to Deborah by showing potential CVD risk reductions through lowering cholesterol (which was raised), rather than how risk would increase should they start smoking. Deborah had never smoked and confirmed the irrelevance of this scenario: ‘would never happen’. In contrast, the PN thought that manipulating patients’ risk scores ‘had a positive effect’ and that patients ‘really responded to that’. This highlights a mismatch between practitioner perceptions of how patients received CVD risk information and the reality.

Fourth, there was some inaccuracy in how the PN relayed patient HbA_1c information in relation to a result in the normal range, which ‘put a big red flag up in my head when I heard that’. Despite describing it as ‘up at the top end’, the PN did not engage in a discussion around this, but rather spoke about what would happen if it was in the pre-diabetes range. This resulted in Deborah deciding to ‘work on that although my solution to that is not to buy [sugar] and not have it in the house’. This could be an unnecessary burden resulting from inaccurate information.

Finally, Deborah was positive about the overall experience. However, her body language during CVD risk discussion was rated as either passive or slightly positively engaged. If picked up by the practitioner, this could have triggered a discussion to address some of the above issues with how CVD risk information was provided and received.

Summary

This case study presents, Eid, a patient with a generally healthy lifestyle in whom the health check identified mild hypertension. Although this prompted lifestyle changes, follow-up tests and an appointment, heart age was the only CVD risk information that he could recall and no lifestyle advice was offered.

Patient

Eid is a 58-year-old Asian British male who lives in a relatively deprived area (IMD decile 2). He has never smoked, does not drink alcohol and ‘play[s] a bit of sport’ including football and table tennis. Eid reports ‘eat[ing] a lot of fruit’ and has no known family history of CVD. He felt having a health check ‘would[n’t] do any harm’ as there is ‘nothing wrong with making sure everything is OK’.

Practitioner

The health check is conducted by an Asian British female HCA who has been delivering health checks ‘ever since the NHS programme started’ and received training ‘when it started’ and ‘. . . last year as well, and then it’s online as well’. The HCA feels ‘OK’ about communicating risk to patients and as ‘I know what I am saying, I am more confident and happy to speak to the patient’. She thought JBS3 was ‘really good, because it tells you the heart age, erm, it tells you the lifespan’ (reflecting a misunderstanding of event-free survival age observed among other practitioners). The HCA ‘enjoyed using it [JBS3]’, preferring it to QRISK2 ‘because it’s visualised, the patients you know they are seeing what their results are. It is not just more score’.

The NHS Health Check

The health check lasts just over 15 minutes. The HCA speaks for only 36% of the time, but Eid’s contribution is low (20%) and a relatively high proportion of the health check passes without either participant speaking. Eid’s 10-year risk of 15% is described as ‘medium’ and his heart age is estimated at 59, approximately 6 months older than his actual age. As Eid’s blood pressure is ‘high’, the HCA tells him that she will speak with the GP, who will ‘get back to you [Eid]’, and advises Eid that he is likely be called ‘in for a 24-hour blood pressure’ check.

What worked well

Overall, Eid felt that the health check was ‘helpful for me because, obviously, it gives me an idea of how things are’, as he rarely attended the surgery. Ultimately, the success of this health check was in identifying and following up the identified hypertension. Eid remembered that his blood pressure ‘was a bit on the high side’ and was ‘surprised’ as he had not ‘had any issues with it before’.

The most impactful element of CVD risk communication was heart age, with which Eid was ‘quite happy’ and found it ‘very useful to know’. The result ‘reassured what I already knew, that I was quite healthy’. The HCA suggested that patients ‘understood [heart age] a lot more . . . because obviously . . . they know how old they are’ and believed that the visual presentation was helpful (‘them seeing it, I think it’s a big difference’) compared with relaying the percentage risk score, as is usual practice.

Areas to improve

Eid did not recall the HCA telling him ‘what I needed to do’. Indeed, the HCA did not offer advice aside from clinical follow-up (re-test/GP appointment). Consequently, Eid had received ‘a few tips on what to do’ to reduce his blood pressure from his sister. Eid assumed that this was because the HCA ‘wouldn’t know until’ she had completed further blood pressure monitoring.

There were several issues with CVD risk communication. First, Eid had a medium–high 10-year risk, yet could not recall it, nor did he ‘put any importance on it’ (when reminded in his VSR interview) because he was ‘well within the percentage of being healthy’ and ‘thought the risk out of 100 was minimal’. The HCA reported using only the risk categories (‘high/medium and low’) because patients ‘don’t really understand the percentage of the number’. This seemed to be an assumption and was not checked by enquiring about Eid’s understanding or feelings.

Second, in the health check, the HCA communicated event-free survival age by saying ‘on average expect to survive is 80 for yourself without a heart attack or a stroke’. The HCA later discussed how this was a challenging screen and her communication suffered as a result: ‘telling them that your life expectation, it could be . . . I think I find it a bit hard’. This highlights a mismatch between what the HCA read from the screen in the consultations (which was correct) and her apparent understanding of this score as expected survival age. Moreover, the HCA thought that Eid ‘knew exactly what I was saying’ on watching the video clips. In contrast, Eid could not ‘recall it, I think she said . . . something about 80 something’, again misinterpreting event-free survival age as expected age of mortality: ‘I’ve got a few more years to live’.

Finally, Eid had never smoked and presented with mild hypertension. Yet, for risk manipulation in JBS3, the HCA showed how Eid’s risk would increase if he were a smoker. He appreciated being ‘reassured . . . that what I’m doing with my health is good and I’ve got to keep it going’, but a more relevant and tailored manipulation of risk would have been preferable.

Summary

This case study describes Freddie, a male patient with a range of CVD risk factors, and a medium–high 10-year CVD risk. Freddie was aware of the need to change his lifestyle. He attended with an ‘open mind’, and received quick and multiple follow-ups after the health check. In this way, the health check served as a catalyst for change and Freddie subsequently made multiple positive lifestyle changes. Quickly, his efforts were rewarded with weight loss and a reduction in blood pressure.

Patient

Freddie is a 64-year-old white British male who lives in an area of approximately average affluence (IMD decile 6) and has not visited his GP for 13 years. He has no family history of CVD, but presents with a range of risk factors: BMI of 45 kg/m² (morbidly obese category), moderate hypertension (167/90 mmHg) and very high alcohol consumption. His main reason for attending is to achieve weight loss, but he also has concerns about the physical effects of his alcohol intake. Freddie is positive about the health check, which he recognises as being about ‘prevention rather than cure’.

Practitioner

The health check is delivered by a female white British HCA with 2.5 years’ experience of delivering health checks and who has attended generic NHSHC training and shadowed a colleague. Despite positive perceptions of the programme, she feels that it ‘needs tweaking’, and thinks that the primary purpose of QRISK2 is to identify patients to refer to the GP, rather than to facilitate discussion around CVD risk.

The NHS Health Check

This general practice has access to Informatica, which offers some of the JBS3 functionalities, including heart age and risk score manipulation, which were used in this health check. At 27 minutes, this health check is considerably longer than most, and Freddie speaks more than the sample average (31% of total time). Freddie’s 10-year risk is 17% (approaching high risk, 20%), which he interprets as being ‘. . . lucky that’s quite low really – I was expecting it to be higher’. The HCA is disappointed with her delivery of 10-year risk information when watching the corresponding video clip (‘like a parrot’; ‘maybe I don’t do enough on that’).

What worked well

Freddie appeared engaged throughout the health check and spoke more than many other patients in the sample. He was ready to make changes, and the suggestions made by the HCA resonated with the issues of which he was already aware. This meant that Freddie was later able to recall parts of the health check conversation with the HCA (e.g. ‘wine has got sugars in them – sugars go to the wrong places’). This appeared to make Freddie receptive to suggestions and meant that the HCA did not need to convince him of the importance of CVD risk or lifestyle.

Freddie received a telephone consultation with a specialist nurse practitioner within ‘a couple of hours’ of his health check to reinforce the messages given (telephone reinforcement). This appeared to facilitate understanding and retention of 10-year risk, as he was able to recall ‘an analogy of you know like 100 people in a room – 17 can be expected . . .’ (words not used in his health check). A barrier to exercising was identified (could not afford gym membership), and the health check and subsequent telephone consultation led to a series of outcomes:

• discussion of statins
• exercise referral for 12 weeks of subsidised gym sessions at a local authority leisure centre
• Freddie changed his diet and alcohol intake ‘. . . I have dropped all the things that I know I should not be eating and it seems to be having an effect . . . I seem to have dropped a few pounds . . . I have dropped the booze a lot – well totally for the minute, erm, which has helped me sleep a lot better’
• reduction in blood pressure to the normal range.

Areas to improve

Freddie’s 10-year risk put him close to the high risk category, yet he did not recognise the risk severity.

Freddie could not recall being provided with heart age or the HCA manipulating risk scores, which contrasted with the HCA’s perceptions that ‘heart age is most effective’. Heart age is likely to have been forgotten because the follow-up telephone consultation focused on 10-year risk. There was scope to better tailor CVD risk discussion; for risk manipulation, the HCA showed how heart age would increase if Freddie were a smoker, yet he had never smoked and subsequently forgot his heart age. It would have been more appropriate to show changes in a risk factor more relevant to Freddie, such as reducing blood pressure through modifying alcohol and diet: ‘Well that just reaffirms my thinking about smoking and I did think, erm, the alcohol side might come into it’.

Summary

This case study of Grace illustrates that, even when relatively short with minimal discussion of CVD risk, a health check can be valuable in identifying areas for change, if the patient is already actively trying to improve their health.

Patient

Grace is a 56-year-old white British female who lives in a relatively deprived area (IMD decile 2). Her parents died suddenly of heart failure in their 70s. She stopped smoking 14 months earlier, attends Slimming World^® (Alfreton, UK), has not gained weight since her last visit to the GP, and reports moderate alcohol intake. Grace is engaged with, and has a positive view of, preventative health care (‘usually have the well-woman check’) and describes the health check as a way ‘to find out if there’s any underlying problems which you may have and it’s just really good to keep on top, because you feel fine but you don’t know what is going on inside’.

Practitioner

The health check is delivered by a white British female HCA with 2.5 years’ experience of delivering health checks. After participating in the recorded health checks, the HCA completed training in NHSHC, after which she concluded ‘I don’t think you should give these health checks unless you have had the training’.

The NHS Health Check

The Health Check lasts just 16 minutes and Grace speaks for only 10% of the total time. CVD risk is discussed for just over 40 seconds. During the health check, Grace’s 10-year risk is calculated at 6.9% (low). Slightly raised total cholesterol (6.1 mmol/l) and blood pressure are flagged as initial concerns.

What worked well

This health check identified a rise in Grace’s cholesterol, which she attributed to less healthy dietary habits ‘creeping in’. Risk management discussion focused on this also; the interview data demonstrated that Grace was clear about her related goals:

I really am going to like get the cholesterol down that’s my main thing . . . So I am really, really saying right ‘no, we are not even having that in the house, we are not eating this, we are not having that any more,’ and we are definitely eating better . . .

Two in-clinic blood pressure measurements showed Grace’s blood pressure to be raised, but, at home readings were found to be normal, no further action was deemed to be necessary.

Areas to improve

The HCA spent very little time discussing 10-year risk:

HP:

I’m going to access your QRISK2 score, erm which is, which tells us your likelihood of contracting cardiovascular disease within the next 10 years . . . So it’s 6.85, which is still OK, it’s below 10.

P:

Hmm.

HP:

So, erm so it’s not something that we really need to worry about, but getting your cholesterol down.

Grace could not recall her 10-year risk, only that it was ‘low’, and said she ‘just didn’t really absorb it . . . afterwards I thought “well she said it was under 10”, but what it was, I couldn’t quite put my finger on it’. Despite that, Grace was motivated to reduce her cholesterol. Encouraging Grace to maintain her good lifestyle while making small changes, particularly given her positive engagement with the health check, could prevent further decline.

Summary

Harry presented with multiple CVD risk factors and the PN spent > 3 minutes explaining his CVD risk. This seemed to convince him of the need to go back on to a low-dose statin, despite initial reluctance. However, following the apparent success of his health check, Harry could not recall his 10-year CVD risk, remained reluctant to take statins and had no intention of changing his lifestyle.

Patient

Harry is a 61-year-old white British male, who lives in an area of approximately average affluence (IMD decile 5). He has a family history of heart attack (father) and has previously taken statins, but managed to come off them with the support of his GP. His blood sugars have been in the pre-diabetic range for 3 years, which is Harry’s motivation for attending the health check: ‘for the last couple of years the doctors been saying I am on the edge of becoming diabetic . . . that was the thing that was pushing me just to make sure I got the health check’. However, when asked if he had heard of the NHSHC he commented ‘Yes, but I wasn’t particularly bothered’.

Practitioner

The health check is delivered by a female white British, PN. She has 2 years’ experience of delivering health checks, but has not received formal training: ‘when I first started, I perhaps would have shadowed somebody doing them’. Despite feeling ‘fairly confident’ in communicating 10-year risk, she conceded that ‘all I have ever been told is anything over 10% needs to be started on a statin. Anything below 10% are fairly low risk, you know, and obviously yeah I discuss that with the patients, but other than that I don’t know a huge amount about that with the QRISK score at all’.

The NHS Health Check

The health check is one of the longest (> 37 minutes). Harry speaks for 29% of the total time, and CVD risk is discussed for > 3 minutes. During the health check, Harry’s 10-year risk is calculated as 14.2%, and blood results showed slightly elevated total cholesterol (5.4 mmol/l) and blood sugars in the pre-diabetes range. Blood pressure was normal. Both the PN’s assessment and our analysis of patient engagement from non-verbal cues of the video-recorded consultation suggested that Harry was positively engaged throughout the CVD risk discussion.

What worked well

The PN explained some factors from which Harry’s 10-year risk was calculated to highlight the need for him to consider going back on to a low dose statin as a means of lowering risk:

So this is your risk of getting heart disease in the next 10 years . . . that puts it to a calculation of your weight, your smoking, or lack of smoking . . . and your cholesterol, that sort of thing . . . it’s come out with a risk score of 14.2%. So ordinarily anything over 10% we would offer a cholesterol-lowering tablet . . . we would recommend that you start back on your statin.

The PN then went on to explain that Harry’s risk was above average for a man of his age:

. . . let me just go back on to that and I explain in a bit more detail. So like I say, erm ,this is coming out that your risk score is 14.2% the average 61-year-old male is 10.1%. So you’re slightly above the average . . .

After additional information was given, Harry appeared to recognise the severity of his CVD risk (‘I don’t like the fact . . . about the risk score’) and moved towards action:

HP:

So how do you feel about starting back on it?

P:

I didn’t want to.

HP:

OK.

P:

I will if that what it takes.

Harry showed confidence and positive engagement in requesting a discussion of his pre-diabetic status, which was his primary concern, and sought specific details: ‘What does that mean? Does it mean tablets, does it mean injections?’. This allowed the PN to explain and again highlight the importance of lifestyle (as well as medication) to prevent progression to diabetes.

Areas to improve

Harry could not recall his 10-year risk and reported that being shown the video clip ‘brought the disappointment back to me because I was expecting to be better than that’. However, ‘it didn’t make me feel any different . . . it hasn’t made me change my lifestyle at all’. He revealed that he had not yet picked up his statins, but ‘I still got my old ones which I had stopped taking. So I have been taking half of one of them every day’.

Harry’s description of the health check highlighted two issues that prevented more engagement with the PN’s recommendations. First, the PN’s explanation of his above average 10-year risk did not empower him:

Mainly to do with the fact that you got family history of cardiovascular disease . . . So although everything else is pretty good . . . we can’t help what you’re already predisposed to unfortunately, which is your dad.

This left Harry feeling like ‘there was nothing in there that I am not already doing. There was nothing to do’.

Second, a more tailored approach was needed. Harry expressed a desire for specific lifestyle guidance, as he left feeling that ‘without any clear direction, I haven’t got anything to change . . . the nurse said “keep walking the dogs, keep doing the exercise . . . just try and do healthy things, eat your greens and you know have your five a day”. . . do those things which I am doing anyway’. The lack of specific advice was acknowledged by the PN on watching the corresponding video clip of this health check:

I did notice when the diet one came up, I did just put a piece of paper in front of them, and I didn’t read it. So actually in hindsight, perhaps I should have said, ‘you shouldn’t eat this, you shouldn’t eat this, you shouldn’t eat this’ . . . in hindsight, I could have explained a little bit better. Like the statins, he wasn’t overly keen on taking the statins was he?

Finally, Harry thought that it would have been useful to have the opportunity to reflect and then ask further questions ‘In some kind of follow-up, even if it’s a week later on or whatever’. This confirms the potential role of telephone reinforcement.

Summary

This case study describes Ian, a male who was very positive about the overall health check experience, the practitioner and the advice given, and had implemented some lifestyle changes. Ian had excessive alcohol intake and had made beneficial changes. The CVD risk discussion was brief and, ultimately, forgotten; however, in this case it did not matter.

Patient

Ian is a 48-year-old white British male who lives in a relatively affluent area (IMD decile 10) and is active through his job as a postman. He is an ex-smoker (of 4 years) and has been trying to improve his diet to manage his cholesterol, but reports excessive alcohol consumption (> 30 units per week). He has not heard of NHSHC.

Practitioner

This health check is delivered by a female white British HCA who has 6 years’ experience of delivering health checks and attended generic training several years earlier, but cannot remember the details. Although reporting confidence in communicating a 10-year risk, when asked about her understanding of the score, the HCA focuses only on the thresholds:

. . . anything over 10% is a higher risk, erm . . . so then other risk factors need to be taken in consideration like family history and things, erm . . . to see, like I say, if it’s worth going on a statin . . . those people are then would forward onto the doctor for further review or we’ve got a pharmacist.

The NHS Health Check

The health check lasts just under 19 minutes and Ian speaks for just 18% of the consultation. CVD risk is discussed for just over 1 minute. The HCA collects information on Ian’s lifestyle and offers advice before his 10-year risk is discussed. Ian’s 10-year risk is 4.5% (low risk), but he is noted to have a slightly elevated total–HDL cholesterol ratio and excessive alcohol intake. Discussions around dietary changes to manage cholesterol and reducing alcohol intake account for the majority of the health check.

What worked well

Ian thought it would be longer (‘I’d thought I’d been in there half an hour, at the most I were in there 10 minutes’), yet felt that the HCA ‘was excellent . . . she gave me some great advice’. The way in which the HCA communicated was clearly appropriate for him:

It weren’t sterile . . . we had a chat . . . it was like visiting a friend.

Ian’s alcohol consumption identified a risk of alcohol-related harm. The impact of the corresponding discussion was clear during Ian’s VSR interview: ‘I didn’t think it was a problem . . . and maybe it did become a problem’. Ian made immediate changes, ‘as soon as I talked to her I’d stopped drinking for a fortnight’. Although he had since had a drink, he had also made dietary changes to address the elevated cholesterol ratio through eating more fish (albeit tinned tuna, rather than the recommended oily fish) and vegetables: ‘I actually feel healthier’.

The health check ended with the HCA saying that ‘we are going to set some goals for you’, and Ian had responded. This was something the HCA specifically mentioned in her VSR: that she tends to set goals with the patient’s agreement:

I sometimes find if I ask the patient to set a goal they sort of sit there . . . they don’t really know what goals to set, so I do find that I do, sort of instigate . . . but they agree . . . It’s rare that I’ll instigate a goal and patients don’t agree with it.

In the light of the low 10-year risk, the HCA tried to emphasise the importance of prevention in general:

As we get older our percentage naturally goes up because we are older, so when we are a young age because that is a young age, that’s my age, so when we are of that age we have to look after yourselves and prevent, it’s all about preventative measures OK.

Areas to improve

When 10-year risk was conveyed, it was quickly given as a relative and then absolute percentage risk score, without much explanation or checking of Ian’s understanding:

OK, so, for your age group, the risk of developing heart disease in the next 10 years is 3.5%. Your risk is 4.5%, so it’s slightly up. Erm, is still a low risk percentage when no major concerns of that but we do need to say to you is that obviously you just need to make sure you keep active, which you are . . .

Communication of the risk score was brief, and Ian did not retain anything from the information given. During the interview he indicated that this information was not important to him and he had made changes without understanding this: ‘it don’t really bother me to be honest . . . don’t really register with me’.

The lifestyle goals could have been more tailored. They combined specific behavioural goals and general outcome goals, covering three lifestyle behaviours, and included an inappropriate exercise-related goal, which has not been implemented:

‘cos I’m a postman you see, so I was shocked when she says err, cos I walked 10–15 miles a day . . . with a big bag on me back and everything, and I was surprised when she said . . . ‘do you go home and do any gardening?’ . . . I just wanna go home and sit and chill.

Finally, Ian thought that it would have ‘helped turning the computer round and showing me the information . . . ’cos visual has always been better than audio for me for everything’.

Summary

This case study describes the health check for a patient, Jessica, who had already made lifestyle changes following an ‘episode . . . they thought might have been a mini stroke’ 12 months prior (this was not confirmed as this would preclude her from NHSHC). Jessica’s engagement with, and positive experience of, the health check appeared to result from the reassurance that it provided around the success of steps she had already implemented.

Patient

Jessica is a 64-year-old white British female who lives in an area of approximately average affluence (IMD decile 5). She experienced an episode the previous year, which was initially suspected to be a ‘mini stroke’ (but was not confirmed). She was prescribed statins at that time, but ‘thought, “I don’t want to do this” ’ and consequently made dietary changes, reducing her cholesterol and successfully losing weight. She had not heard of NHSHC before and assumed it was a general health check, and wondered why it was focused on CVD: ‘why can’t you go into everything at the same time?’.

Practitioner

The health check is delivered by a white British, female HCA, who has 4 years’ experience of delivering health checks and received some training when she started, which she describes as: ‘slides and screen presentations . . . talked through it erm and then it was moving on to how to use the [point-of-care] machine . . . it was pretty straightforward really’.

The NHS Health Check

This health check lasts < 18 minutes, during which the HCA speaks for over 70% of the time. PoC testing confirms that Jessica has reduced her total cholesterol (from 6.7 mmol/l to 6.1 mmol/l) and total–HDL cholesterol ratio (from 3 to 2.8). CVD risk is discussed for about 1 minute, which shows a reduction from a measurement (recorded several years earlier): ‘you were at 10% just before, it is now 5%, so you have halved the risk in that time’. The HCA congratulates and encourages Jessica to keep going with changes she has made to lower her cholesterol and recommends that she increase her activity levels (as she is classified moderately inactive):

The one thing that will help you with that, is being a bit more physical, get doing something that is a little bit more cardiovascular, even if it’s upping your walking and doing it as a power walk, or doing hills, on an incline, it gets you out of breath.

What worked well

Overall, Jessica thought that the HCA was ‘very good’. At the start of the health check, the HCA made clear to the patient that it was ‘all to do with cardiovascular disease, so what we are looking for is how at risk you are of developing cardiovascular disease within the next 5 to 10 years’. This provided useful context for the subsequent discussion of risk factors and management.

Jessica appreciated feedback and reassurance regarding changes already made, and was pleased to see that ‘the work had been paying off’. She remembered clearly the main point to address and had made further small changes to her commute to work to incorporate moderate-intensity activity into their day: ‘I go to [work] on the school bus . . . it picks me up from outside the house, but I’ve started to go out a few minutes earlier and walking up the hill [laughs] . . . and meeting it up the hill [laughs] . . . it’s just a few minutes a day . . . might make a difference’.

She also appreciated the written report, as ‘you can’t take everything in straight away, so it’s nice to have that printout’ to ‘go back and have a look’.

Areas to improve

The 10-year risk score was mentioned briefly, but not explained. Jessica could partially recall the information as ‘. . . 5% over the next 5 years’. She had retained the correct percentage, but the timescale was incorrect (reflecting the HCA’s incorrect description, above) and she could not demonstrate a clear understanding of what it meant for her.

Patients attending already motivated to make changes

Health checks with patients who were already motivated to make lifestyle changes or, as in some cases, had started to implement changes had positive outcomes regardless of how CVD risk was communicated. These patients attended with a specific focus (e.g. behaviour change in mind), which provided the practitioner with an obvious focus to tailor risk management.

Cardiovascular disease risk communication

Risk management

Post-health check telephone reinforcement

Telephoning patients soon after their health check seemed to have a range of benefits: allowing patients time to reflect on the health check discussion and identify questions or areas of uncertainty; further explaining CVD risk, answering questions and confirming patient understanding; confirming recommendations for risk management; and making specific plans where appropriate (e.g. referrals, follow-up appointments, further measurement).