NHS Health Checks: London Borough of Hounslow

Hounslow uses a population health management framework to target public health services at people who would most benefit from them. A health outreach team travels around the borough engaging with residents about their health and delivering NHS Health Checks in the heart of local communities.

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The challenge and response 

Hounslow’s public health team introduced a population health management framework (PHMF) three years ago. The framework is used to review, prioritise and develop the programme of public health activity – particularly to tackle difference in health risk and need.  

The PHMF has enabled a more systematic approach to tackling health inequalities. It helps the team to: 

  • use data and engagement to understand the needs of residents  
  • identify and target those with the greatest health risk and who would benefit most from interventions 
  • develop evidence-based interventions that are produced with the target community 
  • embed evaluation to understand impact, which builds evidence of ‘what works for whom’.  

Kelly O’Neill, Hounslow’s Director of Public Health, said: “It enables us to ask questions about health need and healthcare services within our population and then think about data, intelligence and insight, and how we triangulate all of that information to really target the population most at risk.” 

This approach has helped the team to re-design service models to benefit particular population groups. New interventions can be trialled, evidence gathered and evaluated, and decisions made on whether that approach is effective. If something doesn’t work, the team can move quickly to a different way of working. 

“The framework helps us to be more systematic, more robust, and to develop a really good evidence base. It gives us an opportunity to think about different ways of delivering services that may increase access, lead to a better experience and improve outcomes for people.” 

Two years ago, the team used the PHMF to review the delivery of NHS Health Checks. The Health Check is an important tool in prevention and early intervention to reduce the health risk of long-term conditions. However, it was not reaching some community groups that had been identified as vulnerable to future ill health. 

Using the PHMF led to some changes to NHS Health Check delivery, including a stronger focus on key population groups. At first, this was based on Hounslow’s more deprived areas. Working with the Hounslow Borough Based Partnership (a partnership of health, social care and council services), each primary care network (PCN) was contracted to an extra 25% above the NHS Health Checks cap to target those on the GP’s 20% most deprived list. PCNs were incentivised with an additional payment for each of the extra 25% Health Checks completed. Since then, the priority group has changed to people in any part of Hounslow who have never had an NHS Health Check, or not in the last 10 years.

Outreach services   

This focus on population health led Hounslow to review its health and wellbeing service. ‘Healthy Hounslow’ was launched in April 2023, replacing the previous healthy lifestyle service. Investing in prevention and early intervention was a priority, Kelly O’Neill said. “An important part of this was to build on our in-reach/outreach offer. We looked at how we could move services into our communities, particularly those that are vulnerable to that high level of risk.” 

Feltham & Bedfont (FaB) PCN was commissioned to provide the new Healthy Hounslow Outreach Team – a mobile service staffed by NHS professionals. They use a converted ambulance to visit community settings across Hounslow. This walk-in service provides blood pressure checks, advice and guidance. Where someone is eligible and aged between 25-74, they can receive a full NHS Health Check (Hounslow’s GP practice Health Checks are available to people aged 40-74). 

This represents a new approach to outreach work in the borough. “Rather than commissioning with a focus on ‘inputs achieving outputs’, we have tried to reach those people who would not usually engage with services. Commissioning that additional FaB resource on top of the GP resource means that we’ve got a very visible and accessible service that goes exactly where it needs to go, based on what our data is telling us.” 

Looking ahead 

The outreach service will be developed over time to go further towards tackling health inequalities. In terms of digital NHS Health Checks, Hounslow’s public health team think that a hybrid digital/in-person approach may work well, with the digital offer supporting the administrative side of the process. They are also looking at how the NHS Health Check could include screening for dementia and mental health issues. 

Kelly O’Neill said: “Using the [PHM] framework, we have tried to think in a logical way about how we can get the best outcomes for people. There is some trial and error but it is helping us to be more creative and innovative.”  


For further information contact Kelly O’Neill, Director of Public Health: [email protected]