Healthy Hearts

The NHS Health Check reaches more than a million patients each year. It involves cardiovascular risk assessments, which can be used to develop management strategies to help patients lower their risk of cardiovascular disease. But how often do these checks lead to sustained behaviour change? Here, Sophie Griffiths, Dr Brian McMillan, Dr Kiera Bartlett, and Professor David French discuss how new technologies and communication techniques can enhance the effectiveness of the Health Check in improving patients’ cardiovascular outcomes.

• To more effectively incentivise change in patients’ behaviour, the Health Check should focus on providing actionable, personalised advice.
• A digital component of the Health Check may have a role to play in this, allowing patients to access more bespoke information at their own pace.
• The Diabetes Prevention Programme also offers a strong model for how the Health Check can act as a cost-effective ‘front door’ to further support.

In the 2022-2023 period, 1.1 million Health Checks were delivered by the NHS and local authorities  to patients aged 40 – 74, who are eligible for a check every five years. These checks involve a cardiovascular risk assessment, alongside risk communication and management strategies for patients. However, these checks do not consistently lead to behaviour change, with patients expressing a need for more tailored, ongoing support to maintain their motivation and adopt long-term changes. Health Checks also often fail to reach the people who may benefit most, who are typically people from marginalised communities.

In the first instance, there is a challenge in determining how many patients act on the advice given during their Health Check. In one study, around 70% of attendees (45 out of 66) who responded to a survey after having received a Health Check reported that they made at least one lifestyle change. However, this figure is likely inflated, and qualitative evidence has found patients face numerous obstacles when attempting to change their behaviour.

One issue is that the funding and monitoring arrangements of the NHS Health Check programme currently focus on the number of checks conducted, resulting in an overemphasis on the volume of checks delivered – but potentially at the expense of the quality of the checks in supporting health behaviour change.  

Most health check attendees do not receive any treatment or referral after a check, and statin prescribing in particular is much lower than guidelines recommend. Evidence on behaviour change and improvements in CVD post-check is sparse – but the data that is available indicates the rate at which advice, information and referrals are given varies widely for different risk factors, and appears to fall well below the recommended thresholds for intervention.

Towards more effective risk communication

Research at The University of Manchester has shown that risk communication alone is often ineffective for behaviour change. The main barrier to change is frequently that people lack skills to  self-regulate their behaviour, i.e. put their good intentions into action, rather than low motivation. Therefore, a more effective approach to risk communication may be to use it to encourage individuals to join behaviour change programmes, where they can receive structured support to develop essential self-regulatory skills, such as goal setting and self-monitoring.

Changing self-efficacy (the belief in one’s ability to change or perform a behaviour) and helping people understand how behaviour changes will reduce disease risk will make risk communication more effective in driving behaviour change. This can be achieved by providing patients with explicit information on how altering their behaviour can reduce their risk, alongside specific strategies to build self-efficacy. Research at The University of Manchester is exploring how these approaches could be integrated into a digital NHS Health Check to support behaviour change.

It may also be helpful if they are accompanied by other behaviour change techniques, such as adjustments to the social or legislative environment, or those that target self-regulatory processes—like goal setting and planning.

Patients often leave Health Checks feeling reassured, even when risk levels require action. Effective communication should focus on modifiable risk factors rather than current risk scores, encouraging a proactive approach to health. Personalised advice and comparative risk measures, like "heart age," may motivate preventative actions better than general risk scores. Changes to NICE guidance now recommend lifetime risk assessments to engage those with lower short-term risk scores.

Moving beyond risk communication

Simply explaining cardiovascular risk may not be enough to prompt significant lifestyle changes. NHS Health Checks might benefit from integrating evidence-based psychological strategies, such as enhancing self-efficacy and self-regulation skills. Referrals to structured behaviour change programmes could complement Health Checks for better outcomes.

The NHS Diabetes Prevention Programme (DPP) offers insights into how a CVD prevention programme could operate, due to the similarities in risk factors and management. The NHS-DPP offers patients the option to participate either in group sessions or via digital platforms, helping them to understand the repercussions of type 2 diabetes and make changes to reduce their risk of developing the disease in the future. The programme includes behaviour change strategies that help individuals develop skills to support self-regulation of health behaviours. Research at The University of Manchester found that patients referred to the NHS-DPP had a lower incidence of type 2 diabetes compared to individuals at practices where the programme had not been deployed. It concluded that the introduction of the NHS-DPP reduced population incidence of type 2 diabetes in England for over 20,000 people in those practices that put the DPP in place, and is cost-effective, with a recent analysis showing projected savings close to £72 million over 35 years. Following this model, the NHS Health Check could be used as a referral into a similar prevention programme for CVD.

Digital health checks

The Department for Health and Social Care has announced a digital version of the Health Check. Three local authorities have been selected to pilot the new Health Check, with the aim of scaling it up to one million checks in the first 4 years. While the digital version is intended to complement, rather than replace, the face-to-face health check, policymakers must implement it carefully to avoid widening health inequalities, particularly among individuals with limited digital access or skills—the so-called 'digital divide'. Delivering Health Checks in community-based settings may be more effective at reaching underserved groups than those offered through GPs, highlighting the role of commissioning decisions in achieving equitable access.

As discussed previously, there is scope for a digital version of the Health Check in providing tailored support for patients. Research at Manchester has shown patients are keen on being signposted to services through a digital component of the face-to-face health check. This approach would allow patients more time to explore their risk information at their own pace and access tailored resources to support behaviour change, creating a more flexible and user-centred pathway to improve health outcomes. Patients have previously expressed dissatisfaction with the generic advice offered through Health Checks, so a more personalised approach delivered via digital platforms could be one way to improve this.

A Health Check for the 21^st Century

The majority of cardiovascular disease cases in the UK are preventable, but despite this, CVD costs the NHS £7.4 billion every year. The Health Check offers a reliable, recurring opportunity to identify CVD risks and engage individuals in making healthier changes, and policymakers should ensure every advantage is taken to reduce the danger to these individuals. This means changing how patients are engaged with during and after the check, including more personally-tailored individual support through digital channels, as well as using it as a stepping-stone to other services.

Nearly 10,000 cases of endometrial cancer are diagnosed in the UK each year. But for patients who survive their cancer, cardiovascular disease poses an additional and ongoing risk, accounting for a quarter of all deaths in endometrial cancer survivors. Here, Dr Heather Agnew, Dr Sarah Kitson, and Professor Emma Crosbie explain how a more targeted approach to tackling cardiovascular disease in cancer survivors could improve health outcomes, including for women from the most deprived socio-economic groups.

• Nearly 90% of endometrial cancer survivors have at least one undiagnosed or undertreated cardiovascular risk factor, with several factors common to both cancer and cardiovascular disease.
• A cancer diagnosis presents a ‘teachable moment’, where patients can be provided with personalised advice and support.
• To ensure support is maintained, a joined-up approach to CVD screening in endometrial cancer survivors is needed between primary and secondary care services.

Endometrial cancer is the fourth most common cancer in women in high income countries, with nearly 10,000 cases diagnosed every year in the UK alone. The incidence of the disease has doubled in the last 20 years, with this trajectory expected to continue. Despite relatively good survival outcomes compared to other cancers, individuals with a history of endometrial cancer have a higher risk of death than those without. Within this group, cardiovascular disease (CVD) is a significant risk.

Previous research from The University of Manchester found endometrial cancer survivors have a higher prevalence of undiagnosed and untreated cardiovascular risk factors than the general population, including high blood pressure and high cholesterol. This is perhaps to be expected, given that endometrial cancer and CVD share the common risk factors of obesity and diabetes. Indeed, women with diabetes have twice the risk of endometrial cancer compared to non-diabetic women, even after controlling for the effects of body weight, suggesting a close relationship between the two conditions.

However, despite the known association, screening and interventions for cardiovascular risk factors are not routinely undertaken in endometrial cancer survivors, meaning the true prevalence of CVD risk factors in this group is likely higher than previous estimates suggest. The findings of research led by the Manchester group support this, with screening of a cohort of endometrial cancer survivors finding 57% had previously undiagnosed diabetes or hyperglycaemia (high blood sugar), compared to just 11.5% of a control group. Within the same group, 89% of cancer survivors had undiagnosed or undertreated CVD risk factors, compared to 54% of controls. 22% of the survivors had three or more CVD risk factors.

Now, new findings show that 5+ years post-diagnosis, CVD is one of the leading causes of death for endometrial cancer survivors, accounting for 1 in 4 deaths.

Utilising the teachable moment of a cancer diagnosis, researchers at Manchester have conducted a study to assess cardiovascular risk in individuals with a history of endometrial cancer, and then provide these individuals with tailored advice on reducing their risk. 80 individuals with a history of endometrial cancer participated in the study, of whom 18% were of Asian or Black ethnicity, and 34% were from the most deprived socio-economic backgrounds.

All of the participants had at least one potentially modifiable CVD risk factor, with an average of four. After this risk assessment, each participant was then given tailored lifestyle advice and NICE recommended pharmacotherapy, alongside their routine cancer follow-up. At 12 months, 45% had successfully instigated some or all of the recommended changes, with 23% successfully implementing half or more of the changes recommended to them to target their cardiovascular health.

While a positive step, it was important to understand why over three quarters of participants were unable to implement more than half of the recommended changes. Through interviews, they identified barriers and facilitators to implementing lifestyle changes. The challenges they faced included pre-existing health conditions, family, age, lack of knowledge, money, time, fixed mindset, and poor relationships with healthcare providers. The cost of healthy food and gym memberships were particular barriers for those from more deprived socio-economic groups.

Another common theme was the lack of individualised support, with generic information not appropriate for participants with underlying health problems, or non-Western dietary preferences.

Of the facilitating factors, perceived benefits to overall health and family were strong motivators for change, alongside a desire for independence in daily living and the impact of seeing results. Clear advice and information which promoted knowledge and awareness, alongside a good patient-healthcare provider relationship, were important facilitators of change.

Policy recommendations

Health policy must reflect that endometrial cancer survivors are at high risk of cardiovascular disease. There is a window of opportunity when these individuals are undergoing follow-up in which their cardiovascular risk factors can be targeted and treated, to potentially reduce preventable deaths. Barriers to making these changes reveal inequalities in survivorship care, and these changes must be addressed with consideration of diverse backgrounds, physical capabilities and socioeconomic context.

As such, routine screening for CVD in individuals with a history of endometrial cancer should be a shared responsibility of both primary and secondary care. Introduction of this screening, and subsequent interventions for cardiovascular risk factors in women following treatment for endometrial cancer, would be more effective than a similar programme aimed at the general population.

For those where risk factors are identified, individualised support to make lifestyle changes should be offered, including dietary and physiotherapy input, plus education on cardiovascular health in this context for both patients and healthcare providers. There is a role for social prescribing link workers in connecting at-risk patients to community-based support, as well as health and wellbeing coaches in setting and maintaining behaviour change goals.

Being diagnosed with cancer is a highly emotional experience, which inevitably leads to questions about risk and prevention. Treating this as a teachable moment presents an opportunity for discussions about cardiovascular risk; arguably, this is more important than the efforts made in routine follow-up to identify recurrent disease in women who have generally been cured of their endometrial cancer. Weight loss is an obvious intervention to reduce the risk of both CVD and cancer, but one that is difficult to sustain by dietary restriction and lifestyle change. Instead, health policymakers should adopt a strategy of identifying and improving undiagnosed or undertreated cardiovascular risk factors, with appropriate drug therapy one reasonable alternative.

The Health Mission adopted by the government includes goals to prioritise women’s health, as well as moving to a more preventative model of healthcare. A cardiovascular screening programme in endometrial cancer survivors captures both of these objectives. The evidence on the risk of cardiovascular disease to these patients is clear: now is the time to act on it.

There are strong links between renal and cardiovascular disease, with chronic kidney disease contributing to around 12,000 excess heart attacks each year in England alone. However, siloed models of care may fail to deliver adequate care due to potential complex interactions between multiple disease management and the lack of continuity of care. Here, Dr Saif Al-Chalabi, Professor Smeeta Sinha, and Professor Philip Kalra outline a new, patient-centred model of healthcare to improve outcomes across cardiorenal disease, adopted across the Northern Care Alliance NHS Foundation Trust.

• The speciality-specific model of care in the UK creates a fragmented approach to treatment for people with multimorbidity, leading to recurrent hospital visits and admissions.
• Optimising care for people with cardiorenal metabolic diseases requires a patient-centred care led by interdisciplinary healthcare teams and supported by shared care protocols, telemedicine, and new funding models.
• Establishing a holistic healthcare approach would build on previous shifts towards integrated care, as well as current health policy strategies to move to a more digital, community-focused care model.

Cardiorenal metabolic diseases—including heart failure, chronic kidney disease (CKD), diabetes, and obesity—share overlapping pathophysiological pathways and risk factors. These conditions impose significant burdens on healthcare systems, and negatively impact clinical outcomes. Worldwide, CKD alone is responsible for approximately 1.4 million annual cardiovascular deaths, and over 25 million disability-adjusted life years (DALYs, equivalent to the loss of one year of healthy life).

In England, CKD is estimated to affect more than 7 million patients, of whom nearly half are living with later stage CKD (stages 3 – 5, marked by progressive loss of kidney function). This costs the NHS around £6.4 billion pounds in direct costs, while CKD also contributes to poor cardiovascular outcomes. Between 2009 – 2010, CKD contributed to more than 7,000 excess strokes and 12,000 excess myocardial infarctions (heart attacks), and for every 100 patients with later stage CKD, 6 will experience cardiovascular health events.

As with many conditions, health inequalities play a role. Research led by The University of Manchester showed an association between CKD and deprivation, with unemployment, lower educational attainment, and lower household income all associated with poorer health outcomes.

Given the links between renal and cardiovascular disease, it is clear that a holistic, patient-centred approach is needed to care. However, traditional, siloed specialty-specific models of care often fail to address the complexities of these interrelated conditions. This fragmented approach leads to inconvenience for patients, who face a greater number of healthcare appointments and interactions, and limits continuity of care. The result is complicated management, variable and inconsistent treatment, and diminished patient engagement.

The need for a patient-centred approach

Optimising health for individuals with cardiorenal metabolic diseases requires a patient-centred approach led by an interdisciplinary care team with appropriate competencies. This approach should leverage shared care protocols, integrated care across primary and secondary care as well as harnessing innovation. This may include utilising technology to support remote monitoring and delivery of care closer to home. To support these efforts, stakeholders and policymakers must adopt innovative policy models by allocating targeted funding and implementing frameworks that promote investment in prevention of long-term conditions, integrated and comprehensive care as well as  ensuring healthcare providers are well-equipped to deliver care for people living with multiple long-term conditions.

Moving away from traditional frameworks to adopt a strategic organisational approach that focuses on patients rather than a single disease or organ is essential. This shift allows funding to flow from individual services towards services with shared goals. Funding can be used to develop interdisciplinary teams, digitally enabled healthcare services, and patient self-management programmes. One way to divert more funding to these care models is to fundamentally change the predetermined set of outcomes, from disease-specific to patient-centred outcomes. This can be achieved by creating incentive structures for healthcare providers that reward the delivery of high-quality, coordinated care, including performance-based reimbursements that consider patient outcomes, satisfaction, and improvement in healthcare utilisation such as reductions in hospital readmissions. Reform of funding mechanisms to enable multi-year spending offer prevention focused offer may also enable systems to invest in prevention endeavours.

Reforms are needed to equip healthcare professionals with the necessary skills to care for patients with this cluster of interrelated conditions. General medical training includes cardiology, nephrology and endocrinology; however, services are largely confined to single specialties. The re-design of service models will enable medical teams to review patients across cardiovascular, renal, and metabolic conditions, rather than within the confines of an individual specialty.

This redesign applies to other healthcare professionals, who may benefit from the development of cardiorenal metabolic (CKM) competencies through modular training pathways. For instance, heart failure nurses may be able to develop competencies in CKD and diabetes recognition and optimisation.  

Digital and physical infrastructure needs

Enhancing clinical services for cardiorenal metabolic diseases requires significant improvements in digital and physical infrastructure. Examples include systems that link electronic patient records between primary and secondary care, electronic alert systems to identify early changes in important cardiovascular parameters, and wearable technology for remote monitoring of cardiovascular parameters such as blood pressure. The main barrier to developing these services is cost, which can be addressed by evaluating the value of these services in preventing cardiovascular and renal events, thereby reducing medical care costs and sickness-related work absences.

Benefits of comprehensive services

Establishing comprehensive services for cardiorenal metabolic diseases can improve the uptake of cardio-renal protective therapies, optimise metabolic management, enhance clinical outcomes and quality of life, and allow rapid translation of advances in cardiorenal metabolic diseases into clinical practice. A cardiorenal metabolic service localises care through primary-secondary care coordination, enabling personalised and less fragmented treatment. It empowers patients with digital tools to manage their health and prevents prolonged illness by addressing cardiorenal metabolic risks early, reducing complications like cardiovascular events.

Aligning with government health strategies

This approach aligns with current health policy’s three strategic shifts in care delivery: hospital to the community, analogue to digital, and sickness to prevention.

The priority of moving from analogue to digital includes elements such as shared electronic patient health records, digital infrastructure, and data safeguarding. The University of Manchester is already leading work in this area, and an integrated cardiorenal care service would build on this learning. In particular, a shift to telehealth has the potential to address the disparity in health outcomes identified in more deprived areas, by improving access to healthcare service via remote technologies.

Community care, including the expansion of Community Diagnostic Centres and the shift to a ‘Neighbourhood Health Service’ approach for the NHS, play crucial roles in moving cardiorenal care to a more community-based, preventative focus. Identifying high-risk individuals in the community allows for early intervention to correct their disease trajectory, reducing morbidity and disability. For example, early identification of identification of increased levels of albuminuria (an early sign of kidney disease) in a patient with diabetes and starting appropriate medications can significantly halt CKD progression and reduce cardiovascular events.

Conclusion

Transforming care for cardiorenal metabolic diseases from siloed to comprehensive, patient-centred approaches is essential for improving clinical outcomes and reducing healthcare burdens. By adopting strategic funding, educational reforms, and enhancing digital and physical infrastructure, we can create a more integrated and effective healthcare system that benefits patients, healthcare providers, and the NHS as a whole.