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NIHR Signal Postal invitations, even with added incentives, don’t improve NHS health check attendance

Published on 21 February 2017

doi: 10.3310/signal-000386

Being sent an invitation which included questions about their intention and readiness to attend did not encourage people to have an NHS health check. This was true even when people were offered a £5 voucher to complete the questionnaire.

More people had an opportunistic health check when offered one while they were attending their surgery for another reason, than people who received an invitation letter. People who had health checks after the written invitations had a lower risk of cardiovascular disease than those who had opportunistic checks.

Fewer than half of people invited for NHS health checks actually have them. The target is for 75% of those eligible to have checks. This study suggests that postal invitations, even with added incentives, don’t work well.

Though it is unclear how many people who were sent the invitation might already have been pursuing healthy lifestyles, the postal invitation might not be the best way to get people at high risk of heart disease to have a health check.

  •   Health management, Screening, Primary care
Postal invitations, even with added incentives, don’t improve NHS health check attendance

Why was this study needed?

Heart disease and stroke cause more than a quarter of UK deaths and costs the NHS nearly £11 billion a year. Premature deaths and disability caused by this vascular disease costs the economy even more.

NHS health checks identify people at risk of vascular disease. People are asked about factors that affect their risk, like smoking. They are also tested for weight, high blood pressure and diabetes. People at high risk are offered advice, referrals or medicines to help them improve their health.

However, less than half of the people who are invited to have a health check attend. This study looked to see if different invitation methods could encourage better uptake of tests. It also compared people who had a health check after receiving an invitation to people who had a health check when they were offered one while at their surgery, to see which method best targeted those at higher risk.

What did this study do?

This was a three-armed randomised control and linked cohort study based in 18 general practices in London.

Researchers included 12,459 people in the randomised part of the study. Researchers tested three different ways to invite people to attend a health check.

  • Sending a standard GP letter.
  • Sending a specially-designed questionnaire before the standard letter.
  • Sending a specially-designed questionnaire before the standard letter with the offer of a £5 voucher for filling in the questionnaire.

They then looked at results for everyone who had a health check during the study period, whether they had been invited by the researchers or had a health check without receiving a written invitation.

They also analysed attitudes to health checks expressed in the questionnaires that had been returned.

What did it find?

  • Only 14.4% of people sent an invitation then attended for a health check within six months. Adding a Question Behaviour Effect questionnaire made no significant difference. The absolute increase was 1.43%, (95% confidence interval [CI] –0.12% to 2.97%).
  • Only 15.85% of people offered a £5 shopping voucher then had a health check - a non-significant difference of 1.52%, (95% CI –0.03% to 3.07%)
  • Most people who had a health check during this study had not responded to an invitation letter and were offered one while attending their surgery for another reason. In fact only 37% of people who had health checks during this study had responded to an invitation letter.
  • People responding to a letter were healthier than those checked opportunistically. More of those who had opportunistically checks had a high cardiovascular disease risk (more than 10% over the next 10 years) compared to people who attended after an invitation (adjusted odds ratio 1.70, 95% CI 1.45 to 1.99). They were also more likely to come from poorer backgrounds and be obese.

What does current guidance say on this issue?

Public Health England has provided guidance on NHS Health Checks (2016).

All people eligible for a NHS health check should receive an invitation. However, to reduce health inequalities Public Health England supports prioritising invitations to people at highest risk.

There are no prescribed methods of inviting people to health checks. Patient leaflets and template letters are available from the NHS Health Check website.

The website includes detailed advice about behavior changes that can reduce cardiovascular risk. Results of local and national programme evaluations are also shared on the website.

What are the implications?

This study suggests that spending money on financial incentives to fill in questionnaires may be ineffective, and resources could be better targeted at increasing uptake of health checks among those at highest risk of cardiovascular disease.

More use of targeted opportunistic health checks might do more to reduce health inequalities.

In questionnaire answers, people were skeptical of the checks value and said finding time for a health check and making appointments with their GP was difficult. Making it easier to attend health checks may be more effective at increasing uptake than changing the invitation system.

Citation and Funding

McDermott L, Wright AJ, Cornelius V, et al. Enhanced invitation methods and uptake of health checks in primary care: randomised controlled trial and cohort study using electronic health records. Health Technol Assess. 2016;20(84).

This project was funded by the NIHR Health Technology Assessment Programme (11/129/61).


Bhatnagar P, Wickramasinghe K, Williams J, et al. The epidemiology of cardiovascular disease in the UK 2014. Heart. 2015;101(15):1182-9.

British Heart Foundation. CVD statistics – BHF factsheet. Birmingham: British Heart Foundation; 2016.

Capewell S, McCartney M, Holland W. Invited debate: NHS Health Checks—a naked emperor? J Public Health. 2015;37(2):187-92.

NHS Choices. NHS Health Check website. London: Department of Health; 2016.

NICE. Cardiovascular disease: risk assessment and reduction, including lipid modification. London: National Institute for Health and Care Excellence; 2014.       

Public Health England. NHS health check: Best practice guidance. London: Public Health England; 2016.

Robson J, Dostal I, Sheikh A, et al. The NHS Health Check in England: an evaluation of the first 4 years. BMJ Open. 2016;6:e008840.

Expert commentary

Uptake of the NHS health checks programme following invitation is generally low. This study found that a questionnaire intended to prompt behaviour change made little difference either with or without a financial incentive. Persuading an extra 1.5% of patients to attend is probably clinically unimportant. Uptake of the health check after invitation is generally low and those that attend are disproportionately at lower risk. These patients benefit least from health checks. They may not benefit at all. The research cannot recommend questionnaires or incentives but does raise a question. Could invitations be better targeted at high risk patients?

Tom Marshall, Professor of Public Health and Primary Care, Institute of Applied Health Research, University of Birmingham


People aged 40-74 without a pre-existing medical condition should be invited to have an NHS health check every five years. Doctors or nurses carry out health checks. They are designed to reduce the impact of cardiovascular disease. People are checked for risk factors like obesity and diabetes. People at risk are helped to improve their health.

The questionnaire in this study was designed using Question Behaviour Effect (QBE) techniques. QBE is meant to affect a person’s future behaviour by asking them questions about that behaviour. In this study, people were asked about their intention, readiness and motivation for attending a health check to try to increase their future chances of attending one.