Guidance

Top tips for increasing the uptake of NHS Health Checks

Published 4 August 2016

This guidance is being reviewed and will be updated in due course.

Use the national template invitation letter

Increase uptake using this behaviourally informed, evidence based letter. Medway and Southwark council used this simplified letter with deadline commitment, with a tear off slip (commitment contract), and increased uptake by a relative 13 to 27%.

Text message primers and reminders

Use primers and reminder text messages (prompts) to remind patients to book an appointment for their NHS Health Check. In Southwark, Low cost ways to increase NHS Health Check attendance increased uptake by 12 percentage points, and cost £3.70 per additional completed NHS Health Check and at no extra cost for providers already using a text messaging system.

Computer prompts to clinical staff

Prompts on GP IT systems increased uptake by a relative 65% in Southwark. Prompts remind clinical staff to invite eligible patients to complete their NHS Health Check in a timely manner. Since many clinical systems have the facility to add prompts, no/minimal additional costs are required.

Behaviourally informed messaging

Behaviourally informed messaging increased the uptake of NHS Health Checks in Northamptonshire by a relative 12 to 15% compared to the previous national template letter (simplification). These messages can be implemented for no extra costs; however, if used in conjunction with the new template letter, or within leaflets or inserts alongside the invitation letter, they should be evaluated for effectiveness.

Myth busting

Letters which address excuses such as ‘I don’t want to bother the NHS’ and offer counter arguments ‘Your GP says: I want you to attend the NHS Health Check, as it can help prevent you developing more serious conditions which will take up more NHS resources’ increased uptake by 5%.

Targeted telephone outreach

Telephone outreach is both labour and cost intensive. However, if calls are targeted at groups at high risk of cardiovascular disease and part of the check is completed over the phone, the patient is more likely to go on and complete their check in a GP surgery (commitment). In Bristol, 78% of eligible patients who completed part of their check over the phone went on to complete their check in person.

Costs

Letters like ‘Your GP has already set aside funding to pay for your appointment’ that highlighted the cost of the NHS Health Check increased uptake by 4%.

Using GP TV

While using promotional videos can be fun and creative (salience), there is an absence of evidence on their impact on take up of an NHS Health Check. In Salford, a promotional video, which contained messages to increase awareness of the NHS Health Check and its benefit but no call to action, played in GP surgery waiting rooms did not change the number of checks completed.

Evaluate and adapt

Make the most of your resources by using evidence based interventions, testing new ideas, and evaluating programmes and campaigns. It’s worth the investment to find out what works and most importantly, what doesn’t.

Network

Join PHEs webinars to share and learn from research and best practice. Connecting with local academics will help with developing robust evaluations.

Evidence roundup: applying behavioural insights to increase NHS Health Check take up

This document suggests innovative approaches to increasing NHS Health Check take up. Some of these techniques have been previously trialled and tested, and others are suggestions for innovative ways to improve programming, noting that evaluation is always important to identify best practices.

Prompts

Prompt people when they are likely to be most receptive, such as when interacting with clinical staff at a GP surgery. Behavioural literature demonstrates that people are often influenced by the context they are in, so they may be more receptive to book an appointment when they already have their physical well-being on their mind.^{[footnote 1]}

Additionally, text messages notifying individuals of the arrival of a letter can help people to plan their response to future events, such as an invitation to an NHS Health Check. Since there is often a gap between intentions and behaviour, a solution is to help people make concrete specific plans.

Salience

Salient, attractive, and novel placement of the desired behaviour can improve uptake of these behaviours. We unconsciously filter out much information and focus only on what draws our attention.^{[footnote 2]} These are likely to be stimuli that are novel, accessible and simple. It is recommended that these signs are placed in decision locations (eg in reception), opposed to reactively. However, a lesson learned from our trial using promotional videos in Salford is that even if it is salient, it may not be effective. Like all interventions, it is important to evaluate.

Default

Research has shown that we have a strong tendency to go with default or pre-set options.^{[footnote 3]} For example, most mobile phone users will never change any settings that are provided by default, and newsletter subscriptions increase if a box is ticked automatically. An increasing body of literature demonstrates the use of defaults for intervention purposes. For example, when default enrollment in retirement savings is used more people save more money for retirement.^{[footnote 4]},^{[footnote 5]} Defaults could be applied by automatically assigning appointment times for NHS Health Checks.

Simplification

Clear, simple messages often result in increases to response rates to communication. It’s very useful to identify how complex goals can be broken down into simpler, easier actions.^{[footnote 6]} A trial in Northamptonshire demonstrated that messages that dispelled myths about the NHS Health Check, such as NHS Health Checks are a burden on the NHS or there’s nothing one can do about their family history of illness, increased uptake of the check by a relative 15%.

Commitment

We have a powerful desire to maintain a positive self-image^{[footnote 7]} which fuels individuals to remain consistent with their public promises and commitments. One RCT found that asking participants to publically sign commitment contracts increased adherence from 31% in the control group to 81% in the intervention group.^{[footnote 8]:} A form of commitment contract is the tear off slip on the bottom of the NHS HC national template invitation letter, as this allows patients to write down the date and time of their appointment. The foot in the door technique is also another form of commitment, as when someone has already completed part of their check on the phone, they are more likely to remain consistent with their past behaviour by continuing the check at the GP surgery.

Social norms

Using feedback messages about peer behaviours has been highly effective in a variety of areas.^{[footnote 9]} Using an RCT, PHE’s Behavioural Insight Team significantly reduced prescriptions of antibiotics by providing feedback to the highest prescribing practices:

The great majority (80%) of practices in [NHS Area] prescribe fewer antibiotics per head than yours.^{[footnote 10]}

Feedback messaging about social norms could be used to engage GP surgeries to increase the number of invitations they make to the NHS Health Check, or to encourage eligible patients that ‘people like you’ are attending their check.

Ease access

Most individuals want to adhere to a desired behaviour (eg attending an NHS Health Check) but don’t want to put effort into achieve it.^{[footnote 11]} Making it simple for people to comply can help to increase action. For example, Pharmacies, which have more flexible opening times and more convenient locations, could reduce obstacles to attending appointments during standard work hours.

References

1. The Behavioural Insights Team (2014). EAST: Four Simple Ways to Apply Behavioural Insights. London: Behavioural Insights. ↩

2. Kahneman and Thaler (2006) Anomalies: Utility Maximisation and Experienced Utility. Journal of Economic Perspectives 20(1):221-234. ↩

3. The Behavioural Insights Team (2014). EAST: Four Simple Ways to Apply Behavioural Insights. London: Behavioural Insights. ↩

4. Choi JJ, D Laibson, B Madrian, A Metrick (2004), “For better or for worse: default effects and 401(k) savings behaviour”, in Perspectives in the Economics of Aging (ed. David Wise), University of Chicago Press. ↩

5. Benartzi S, RH Thaler (2004), “Save more tomorrow: using behavioural economics to increase employee saving”, Journal of Political Economy. 112(1):S164-S187. ↩

6. The Behavioural Insights Team (2014). EAST: Four Simple Ways to Apply Behavioural Insights. London: Behavioural Insights. ↩

7. The Behavioural Insights Team (2014). EAST: Four Simple Ways to Apply Behavioural Insights. London: Behavioural Insights ↩

8. Williams, B.R., Bezner, J., Chesbro, S.B. and Leavitt, R., 2005. The effect of a behavioral contract on adherence to a walking program in postmenopausal African American women. Topics in Geriatric Rehabilitation, 21(4), pp.332-342. ↩

9. The Behavioural Insights Team (2014). EAST: Four Simple Ways to Apply Behavioural Insights. London: Behavioural Insights ↩

10. Hallsworth, M., Chadborn, T., Sallis, A., Sanders, M., Berry, D., Greaves, F., Clements, L. and Davies, S.C., 2016. Provision of social norm feedback to high prescribers of antibiotics in general practice: a pragmatic national randomised controlled trial. The Lancet. ↩

11. Gilson, N., Straker, L., & Parry, S. (2012). Occupational sitting: practitioner perceptions of health risks, intervention strategies and influences. Health Promotion Journal of Australia, 23(3), 208-212. ↩