PUBLIC HEALTH LOCAL SERVICES AGREEMENTS 2016/17 SERVICE SPECIFICATION SIGN-UP. GP Practice NHS Health Check Service

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1 PUBLIC HEALTH LOCAL SERVICES AGREEMENTS 2016/17 SERVICE SPECIFICATION SIGN-UP GP Practice NHS Health Check Service Contract expiry date: 31 March 2017 Specific Training/Accreditation: Please refer to section 6 for full details of requirements. GP Practice: GP Practice Branch Code: GP Practice PPA Code: I declare that I am competent to provide this service. Name and designation: Signature: For and on behalf of EAST SUSSEX COUNTY COUNCIL County Hall, St Anne s Crescent, Lewes, East Sussex BN7 1UE To be signed only by the contractor or authorised person Signed.. Authorised Signatory 1

2 Payment NHS Health Check Invitation (patients first invitation for a Health Check*) 2.50 NHS Health Check using Pathology test NHS Health Check using Point of Care Testing (for practices using dual testing POCT equipment for both cholesterol & HbA1c) NHS Health Check using Point of Care Testing (for practices using cholesterol only POCT equipment) * Payment is made on the first patient invitation only. Subsequent patient reminders should not be reported for payment purposes. For practices using POCT, - there will be an additional payment for the liquid reagent used to run internal quality control checks. The cost of the liquid will be reimbursed each quarter in line with costs from the supplier. This is currently per quarter*. Any negotiated price reduction will be communicated to practices and the updated reimbursement payment will alter in the following quarter that new prices take effect. *The main supplier (ROCHE), charge 894 per year to provide 6 x 2 monthly packs for each lipid and HbA1c. POCT EQA there will be an additional payment to order and run the External Quality Assurance for using POCT for both lipids and HbA1c. Costs will be reimbursed in line with costs from the supplier (currently WEQAS). Payments for EQA are currently: Payment for EQA lipid service 9.32 per quarter Payment for EQA HbA1c service per quarter How to claim: Claims for this service will be requested by Public Health shortly before the end of each quarter and should be received by the following dates: Quarter 1 Friday 8 July 2016 Quarter 2 Friday 7 October 2016 Quarter 3 Friday 13 January 2017 Quarter 4 Friday 7 April 2017 Late submission of claims will result in delayed payments. 2

3 Public Health Local Service Agreement 2016/17 This service specification should be read in conjunction with the Public Health Local Service Agreement (PHLSA) contract document. In addition to the service specific elements set out in this specification all Terms and Conditions set out in the PHLSA must be adhered to by providers delivering this service GP Practice NHS Health Check Service Contract length: This service specification runs from 1 April 2016 up to 31 March 2017 Content Page Health Check Summary Sheet of key changes 4 1 Introduction 6 2 Background/Evidence Base 6 3 Aims/Outcomes 7 4 Service outline/standards 8 5 Equipment including POCT 14 6 Staffing & Training (workforce competences) 15 7 DBS Checks 16 8 Payment/Cost 16 9 Monitoring, Audit & Reporting Key Performance and Quality Indicators Contacts 22 Appendices Appendix A 23 Read codes for identifying the eligible population Appendix B New shortened patient invitation letter template 27 Appendix C 28 Read codes for NHS Health Check invitations and assessment Appendix D 30 East Sussex Health Checks Pathway incl. lifestyle advice/referrals Appendix E 31 Lifestyle service referral information For Quit 51 smoking cessation, Rebalance weight management, Health Trainers, STAR Alcohol services, Physical activity pathway Appendix F 40 Workforce competences and training 3

4 Health Checks Summary Sheet Please find below a summary of the key developments for the NHS Health Check programme described within this specification for both last year and this year. The service specification has been updated to ensure that we are compliant with the new national quality standards for NHS Health Checks produced by Public Health England. This summary sheet aims to assist practices in identifying the particular changes that have been introduced as a result of this guidance Identifying eligible patients - Current system public health produces an estimate of the number of eligible patients, practices run their own searches to identify eligible patients to call into a service. New system: Practices calculate their total number of patients eligible for a Health Check, either by using the free PRIMIS search tool or developing and running their own search using the read codes in Appendix A, and share the number of eligible patients with public health. The search should be run as near to 1 st April as possible and submitted to Public Health by 30 th April. Section 4, p9 2. Inviting eligible patients - Practices record all patient invitations in the patient record, including those that decline their Health Check, using the read codes provided in Appendix B. Section 4.3, p9. 3. Patient experience Practices encourage patients to feedback on their experience of their Health Check. Public Health will provide a paper and online survey for practices to use. Section 4.6.8, p POCT Practices using POCT identify a POCT Coordinator for their practice, to ensure the safe and effective use of POCT in line with changes to national guidance. The Coordinator should ensure: a. All staff are trained and competent to use the equipment. b. An appropriate internal quality assurance process is in place and adhered to. This should take the form of at least a daily "go/no go" control sample (use of a liquid sample) on days when the instrument is in use. The equipment may require other procedures e.g. optical check to be performed in addition to the use of a liquid control sample. c. Accurate records of registered users, training and the quality control tests are recorded. d. An accredited External Quality Assurance (EQA) scheme is in place*. Section 5, p14. Practices may organise delivery of NHS Health Checks according to practice preferences and to ensure convenience and accessibility for patients. Practices may wish to cluster health checks utilising point of care testing to support efficiency and ease of delivery. 5. Staffing & training Practices identify a Health Check lead who ensures all staff providing Health Checks meet the core and technical workforce competences. Section 6, p15 & Appendix E. 6. Recording the minimum dataset Practices ensure that the core minimum dataset is collected and accurately coded into the patient record using the read codes in Appendix B. 1 PHE (2014). NHS Health Check Programme Standards: A framework for quality improvement. Available at: 4

5 Public Health will seek to share templates or tools to help practices record the correct codes. Section 9, p Reporting Practices provide the full range of indicators requested in section 9. All reported data will be anonymous and not include any patient identifiable data. Public Health is investigating suitable data extraction systems that will support and enable practices to extract this data on a regular basis, and will be working with practices to agree approaches and systems with them. Section 10, p.18 Additional changes for Inviting the eligible population a. Additional information is provided on inviting your eligible populations. Section 4, p10. b. Additional information is provided on the effectiveness of using text prompts and reminders and shorter invitation letters to increase uptake of NHS Health Checks. Section 4, p.8. c. The new shortened letter template is available in Appendix B, p.25. d. Additional information clarifying that payment is made on the first invitation for an NHS Health Check and that only the first invitation should be reported on the quarterly claim form for reporting and payment purposes. Section 4.3.5, p Payments for NHS Health Checks a. New payments have been introduced for practices using POCT equipment that tests cholesterol only. This does not affect practices using the dual testing equipment for cholesterol and HbA1c such as the Roche Cobas b101. b. An additional quarterly payment has been introduced for practices using POCT to run the External Quality Assurance scheme for both lipids and HbA1c*. * Public Health supported the commencement of the EQA scheme for practices in East Sussex during by commissioning WEQAS to provide practices with lipid samples (3 x annually) and HbA1c samples (6x annually). From April 2016 practices are expected to order their own EQA samples from their preferred provider. Public Health will share details of the existing WEQAS scheme used. The cost for this will be reimbursed to practices quarterly, see payment section 7, p Recording data on gender for adults who are transgender there is additional information advising that patients who disclose gender reassignment, should have their gender recorded as the gender reported by the patient, but they should be provided with a CVD result for both genders and see their GP to discuss which results are most appropriate for them as an individual. Section 8, p16. 5

6 1 National NHS Health Check Programme 1.1 The NHS Health Check programme is a mandated public health service for all local authorities. The NHS Health Check is a systematic vascular risk assessment and management programme to help prevent cardiovascular diseases (CVD) including heart disease, stroke, diabetes, dementia and kidney disease. The eligible cohort is people between 40 and 74 years of age who 1) have no previous diagnosis of CVD and 2) are not currently taking statins. 1.2 The NHS Health Check is a 5 year rolling programme, such that 20% of the eligible population are invited for a check each year, ensuring the full eligible population are invited once every 5 years. The national aspiration is that 75% of people who are eligible for a NHS Health Check take up their offer. 1.3 The aim of the NHS Health Check programme is to enable the population to stay healthier for longer by identifying their risk of developing these conditions, and offering information and support to reduce or manage this risk. 2 Evidence Base 2.1 The Department of Health proposed the NHS Health Check programme, based on the evidence and cost benefit presented in the Impact Assessment 2 document. Modelling work 3 undertaken by the Department of Health (DH) found that offering an NHS Health Check to people between the ages of 40 and 74, and recalling them every five years was both clinically and cost effective. 2.2 Cardiovascular Disease, which includes heart disease, stroke, diabetes and kidney disease are the biggest causes of death in the UK. The national Health Checks programme could on average: Prevent 1,600 heart attacks and strokes Prevent at least 650 premature deaths Identify over 4,000 new cases of diabetes each year. Detect at least 20,000 cases of diabetes or kidney disease earlier, allowing individuals to be better managed to improve their quality of life. 2.3 NICE guidance is available for some of the components of the health check and on interventions in associated referral pathways following the health check e.g. physical activity and smoking cessation. Public Health England has produced a briefing outlining the evidence base supporting the mandated NHS Health Check programme 4. 2 Department of Health, Putting Prevention First Vascular Checks: Risk Assessment and Management. Available at URL: 3 Department of Health, Economic Modelling for NHS Health Checks. Available at URL: 4 PHE, NHS Health Check: Our approach to the evidence. Available at URL: 6

7 East Sussex Programme Benefits 2.4 Public Health England estimate that full roll out of an effective NHS Health Check programme in East Sussex will have the following benefits at the current uptake rate of 55%. Improving uptake over the course of the programme towards the national aspiration will increase these benefits will complete a weight loss programme 290 will increase physical activity 21 will quit smoking 289 will complete a diabetes prevention lifestyle programme 670 will take statins 506 will take anti-hypertensive drugs 156 will be diagnosed with diabetes 428 will be diagnosed with chronic kidney disease 3. Aims 3.1 This East Sussex NHS Health Check service aims to improve health outcomes and quality of life amongst East Sussex residents by identifying individuals at an earlier stage of vascular change, and provide opportunities to make lifestyle changes to substantially reduce their risk of cardiovascular morbidity or mortality. In turn this will lead to a reduction in the incidence of acute cardiovascular events in the East Sussex population. 3.2 Service Objectives To identify individuals eligible for the NHS Health Check service (and exclude those who are not eligible) To systematically offer an NHS Health Check to 20% of the eligible population every year as part of a 5 year rolling programme, through a pro-active call and recall system To assess cardiovascular risk in line with the NHS Health Check Best Practice Guidance To encourage uptake of the Health Check, with uptake levels of at least 50% expected, working towards an uptake level of 50-75% to reduce health inequalities To offer a convenient, flexible and accessible service to improve access and address health inequalities To provide an NHS Health Check service by trained and competent staff To communicate to individuals their cardiovascular risk in a way that the individual understands To enable the early detection of hypertension and chronic kidney disease To enable the prevention and early detection of diabetes To identify individuals with a high risk of future cardiovascular disease To initiate the appropriate medical management of newly diagnosed chronic diseases, in line with local clinical best practice pathways To increase awareness of dementia specifically among 65 to 74 year olds To work collaboratively with individuals who require lifestyle modification and provide advice and information to enable individuals to make lifestyle changes Where appropriate to offer on-going support for lifestyle change through referral to one or more of the following local lifestyle intervention services : Quit 51 smoking cessation service Rebalance weight management service Health Trainer service STAR (alcohol service) Physical activity interventions such as Health Walks To collect and record data in the clinical system, in line with the national health check minimum dataset for every patient that attends the service and produce anonymised reports for the Public Health commissioner 7

8 4. Service Outline 4.1 Overview of the service The NHS Health Check Programme pathway model is illustrated in figure 1.The service is made up of several key elements, including: Identify and invite eligible patients for a Health Check Risk assessment Risk communication Risk management Figure 1: Diagrammatic overview of national NHS Health Check programme In delivering this service practices are required to comply NHS Health Check programme standards: a framework for quality improvement. Practices may undertake the NHS Health Check utilising Point of Care Testing or local laboratory services. Where Point of Care Testing is utilised practices must ensure that they comply with the specific guidance on POCT set out in the NHS Health Check Programme Standards (2014). Practices may organise delivery of NHS Health Checks according to practice preferences and to ensure convenience and accessibility for patients. Practices may wish to cluster health checks utilising point of care testing to support efficiency and ease of delivery. 8

9 4.2 Identify eligible patients The Health Check requires each practice to pro-actively identify and invite eligible patients to receive the Check. Practices may also offer checks opportunistically, to encourage uptake, however should not rely on opportunistic contact alone. This is because the target cohort includes those with minimal contact with GP practices Practices will run a search to identify all individuals who are eligible for an NHS Health Check at the beginning of each financial year. This eligible cohort will include: All patients who are aged between 40 and 74 years with no pre-existing diagnosis of: Coronary heart disease Stroke Diabetes Chronic kidney disease (stages 3 to 5) Hypertension Atrial Fibrillation Transient Ischaemic Attack (TIA) Familial Hypercholesterolaemia Heart failure Peripheral Arterial Disease (PAD) Treatment with a statin and also exclude: Those who previously had a NHS Health Check in the preceding 5 years Those who previously had a health check or any other check and found to have 20% risk of developing cardiovascular disease over the next 10 years, and placed on a high risk register The practice will submit the actual number of eligible patients in the practice to East Sussex County Council each year by 30 th April. This number will be used as the baseline denominator for performance monitoring Practices can identify their eligible population by either of the 2 following options: Develop and run their own search using the read code list provided in Appendix A to ensure selection of the correct eligible population. Use the free NHS Health Check recall tool available from PRIMIS, which will identify the eligible population. The tool also has a built in mail merge facility Invite the eligible population Each practice will select 20% of their eligible population to be invited and offered a Health Check each year, so that all eligible patients will be offered a Health Check over the 5 year rolling programme. Practices can choose how they prefer to select the 20% each year, for example in age bands, or patient birthdays that fall in selected months etc. Practices may choose to prioritise invitations to those considered to be at greater risk of CVD for example those in the older age groups, men, adults living in deprived areas or those with known risk factors for CVD e.g. high BMI or a smoker Eligible people identified from the GP list should be invited verbally, by telephone, or by letter. Literature in a range of languages and formats is available via Health Promotion Resources at: 9

10 4.3.3 Practices should consider the communication requirements of their patients when choosing an invitation method/literature e.g. easy read, braille, language etc. Pilots led by Public Health England have found that sending text prompts and reminders in addition to a shortened letter increased NHS Health Check uptake by approx. 12% compared with sending the longer standard letter alone. Sending the shortened letter alone increased uptake by approx. 5% compared with sending the longer older letter format. Practices are encouraged to use the new shortened letter for inviting their patients by letter, the template is available in Appendix B. Texting prompts and reminders - for practices with texting facilities who would like to encourage more of their patients to access their Health Check we recommend using the prompt and reminder texts in addition to the letter. Suggested text could include: Prompt (1 week prior to letter invite) - <Practicename>: Dear <firstname2>, your NHS Health Check is due at your GP practice. We will post you a letter soon with info about how to book your apt Reminder (1 week after letter) <Practicename>: Dear <firstname2>, Your GP recently sent you a letter inviting you to attend your NHS Health Check. Call xxxxxxxxx to book an appt Eligible patients should be invited as above and those who do not respond should be sent at least one reminder, this can be verbally, by telephone, text or letter. Frequent reminders may prompt patients to access their Health Check For reporting and payment purposes, practices should only report the first invitation on the quarterly claim form, as payment is made on the first invitation for all invites and reminders. Therefore all eligible patients should be reported as invited for a Health Check once in a five year period, though you will have invited those who do not respond to their first invite at least twice, When a person has been invited (verbally, by letter or telephone) or declines a health check, practices should update patient notes using the appropriate Read code, shown in appendix B. This will enable monitoring and evaluation of the effectiveness of different methods of invitation In addition to the systematic invitation of 20% of eligible patients each year, practices are encouraged to increase uptake of their Health Checks through opportunistic contact at the practice, for example through promotions in the practice or, using clinical system alerts to identify patients eligible for a Health Check when they are attending the practice. 4.4 Risk Assessment The practice should offer all patients sufficient time to conduct the full risk assessment, communicate the results in a way the patient understands and offer ongoing referral to relevant lifestyle support services. National guidance indicates that the full NHS Health Check takes around minutes to complete. Practices may choose to utilise Point of Care Testing Equipment (POCT) to undertake the full health check in one appointment, or may utilise laboratory testing and offer patients a follow up appointment to discuss results and provide lifestyle advice The Risk assessment should be performed in line with the recommendations set out in NHS Health Check Best Practice Guidance. This includes the following elements: The Risk assessment will consist of the following elements: History: Age Gender Family history of coronary heart disease in 1 st degree relative under 60 years Ethnicity 10

11 Measurements: Body Mass Index (requiring weight and height measurement) Blood Pressure (for hypertension, diabetes, CKD assessment) Random total cholesterol and HDL - (either point of care sample or a venous sample) Diabetes risk assessment including blood glucose/hba1c if required (see below) Lifestyle: Physical Activity level (using GPPAQ questionnaire) Smoking Status (current, non-smoker, ex-smoker for at least the last four weeks). Alcohol status (using AUDIT C assessment tool) Dementia awareness (for people aged 65-74) Practices must record the outcome of all the elements on the patient s notes, in the clinical system, using the specified Read codes provided in Appendix B (also see section 8 for further detail) The use of Point of Care Testing machines (POCT) or laboratory tests are acceptable for the cholesterol and HbA1c tests as part of the East Sussex NHS Health Checks Programme and should be used with appropriate quality assurance mechanisms, (see section 5. for further information) The practice will carry out further relevant assessments for diabetes, hypertension, chronic kidney disease, full alcohol risk assessment and familial hypercholesterolemia on patients with abnormal parameters after the initial standard risk assessment. The practice should have in place protocols for additional testing and clinical follow up identifying review timeframes for further investigations, these should be updated annually Diabetes Risk Assessment The practice will perform a diabetes risk assessment to detect impaired glucose tolerance (IGT) and Diabetes Mellitus for any patient who meets any of the following criteria. A blood glucose or HbA1c test should be offered to all adults with either one or both of: BMI 30 (or 27.5 if Indian, Pakistani, Bangladeshi, other Asian or Chinese). Blood pressure 140/90mmHg, or where the SBP or DBP 140mmHG or 90mmHg. Gestational diabetes or other known risk factor such as polycystic ovarian syndrome, severe mental health disorders, first-degree relatives with type 2 diabetes or heart disease It is estimated that 44% of adults in East Sussex will exceed the diabetes filter, requiring a blood test for diabetes Hypertension Assessment and pulse check Patients with a blood pressure 140/90mmHg or where the SBP or DBP exceeds 140mmHg or 90mmHg respectively will require a further assessment for hypertension by the GP practice team. Practices are recommended to assess and manage patients with Hypertension in line with NICE guidance 5. This guidance advises that practitioners should perform a pulse rhythm check prior to taking blood pressure to detect any pulse irregularities that could affect the reading from an automated device. Individuals who are found to have an irregular pulse rhythm should be referred to the GP for further investigation. 5 Hypertension: clinical management of primary hypertension in adults. NICE clinical guideline 127. August

12 Patients diagnosed with hypertension should be added to the hypertension register and treated through existing disease management care pathways. They should be reviewed in line with NICE guidance, including provision of lifestyle advice CKD assessment Patients with a blood pressure 140/90mmHg, or where the SBP or DBP exceeds 140mmHg or 90mmHg respectively, will require an assessment for chronic kidney disease by a GP. All patients who meet these criteria should receive a serum creatinine test to estimate glomerular filtration rate (egfr). Practices are advised to assess patients in line with NICE guidance Familial hypercholesterolemia assessment Patients with a Total cholesterol >7.5 mmol/l should have further assessment for familial hypercholesterolemia by the GP practice team Full alcohol AUDIT assessment A full AUDIT assessment is required for patients who exceed an AUDIT C score >5 in the initial alcohol screening questions. Results of full AUDIT: If the individual meets or exceeds the AUDIT threshold of: 8 (increasing risk drinker) - brief advice should be given, and a referral offered to STAR or the Health Trainer Service for those who would like support to reduce harm for drinking. 20 (possible dependent drinker) a referral to local STAR alcohol treatment services should be offered in line with NICE guidance Risk Communication The practice will clearly explain the results of the NHS Health Check to the patient, and ensure the patient captures their written results in the East Sussex Health Check Patient Results leaflet. The patient results leaflets will be sent to practices. If you require further booklets then please contact the Public Health commissioner at Hayley.martin@eastsussex.gov.uk Calculating CVD Risk - The practice will calculate the individual s risk of developing vascular disease using the QRISK2 risk assessment tool. QRISK2 is recommended by NICE 8 as the most appropriate risk engine for use with a UK population. QRISK2 is available in most clinical systems, and is also available to use free at 6 Chronic kidney disease: National clinical guideline for early identification and management in adults in primary and secondary care. NICE clinical guideline 73. September Alcohol-use disorders: preventing harmful drinking. NICE public health guideline 24. June NICE clinical guideline 181. July Lipid modification: cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease 12

13 4.5.3 When communicating individual risk, staff should be trained to: communicate risk in everyday, jargon-free language so that individuals understand their level of risk and what changes they can make to reduce their risk use behaviour change techniques (such as motivational interviewing) to deliver appropriate lifestyle advice and how it can reduce their risk Create a two-way dialogue to explore individual values and beliefs to facilitate a client-centred risk-reduction plan. 4.6 Risk Management The practice will provide lifestyle advice to ALL patients having a Health Check, regardless of their risk score on how to maintain/improve their vascular health, unless deemed clinically inappropriate The practice will provide relevant brief advice and onward referral for patients with identified risk factors including: CVD risk score 10% Physical inactivity Smoker BMI >25 Alcohol Audit score > 8 High risk diabetes / IGR - HbA1c: > mmol/mol (6%-6.4%) or FPG: > mmol/l CVD Risk Score - Individuals identified with a cardiovascular risk score 10% must be managed according to current NICE guidelines 7 (Lipid modification: cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease). For patients low risk < 10% - Practices should explain the risk to the patient and discuss the impact of increasing risk with age, this can be demonstrated on the Qrisk2 tool at and reinforce lifestyle advice for risk maintenance. For patients at risk 10% but < 20%: Practices should explain how risk can be reduced through changing behaviours. This can be demonstrated visually using the QRISK2 tool NICE 7 recommend statins for primary prevention in individuals with 10 year risk 10%, and this would require referral to the GP practice team for consideration of the most appropriate intervention for the patient. Practices should ensure that lifestyle advice & support is offered to reduce risk. For patients high risk 20%: Practices should explain how risk can be reduced through changing behaviours. This can be demonstrated visually using the QRISK2 tool Ensure lifestyle advice & support is offered to reduce risk. NICE 7 recommend statins for primary prevention in high risk individuals with 10 year risk 20%. Patients identified with a high-risk score for CVD must be entered onto a practice high-risk register and subsequently be offered annual review as per the NICE guidelines. Once entered on to a high-risk register these individuals will leave the NHS Health Check programme and will not be eligible for recall in 5 years. The practice must record the offer of statin and whether this was accepted or declined For the other risk factors, the practice will provide brief advice and where appropriate offer referral to local lifestyle interventions including: Quit 51 smoking cessation service Rebalance weight management service Health Trainer service 13

14 STAR (East Sussex Alcohol Advice and Treatment Service) Physical activity opportunities e.g. Health Walks The thresholds for relevant brief advice and onward referral are illustrated in the East Sussex Health Check pathway in Appendix D. Referral information for all lifestyle services are provided in Appendix E and available on the local primary care based DXS system Goal setting will be used by the practice to allow the patient to determine for themselves what steps they feel able to take to improve their health and CVD risk. The patient results leaflet can be used as an aid to record this Dementia Awareness The practice will provide information for all patients aged 65 74, to raise their awareness of dementia and the availability of memory services. The PHE Dementia Awareness leaflet should be used. These are available free, information on how to order from DH can be found at: Practices will encourage patients to feedback their experience and understanding of their Health Check, by supporting completion of the Health Check patient experience survey (see section 9) Newly diagnosed conditions - The practice will manage newly diagnosed diabetes, hypertension or chronic kidney disease according to existing local clinical pathways and relevant NICE guidance, under the terms and conditions of the General Medical Contract with NHS England. Newly diagnosed patients with diabetes, hypertension, chronic kidney disease or patients at high-risk of a CVD event will be placed on the respective register. These patients will exit the NHS Health Check programme, will not be eligible for recall in 5 years, and should be managed in accordance with local clinical guidance, disease management pathways and NICE guidance.. 5 Equipment including POCT 5.1 The practice will be responsible for the procurement of all equipment and consumables required to provide the NHS Health Check service described in this specification. 5.2 The practice will ensure all equipment used for the NHS Health Check is: fully functional, used regularly, CE marked, validated, maintained and recalibrated according to the manufacturer s instructions. This includes height and weight measuring devices, blood pressure monitors and point of care testing equipment. 5.3 The practice will report any adverse incidents involving medical equipment to the relevant manufacturer as well as the Medicines and Healthcare products Regulatory Agency (MHRA), follow the ESCC Incident Reporting Policy and process, and manage in accordance with providers governance arrangements and council requirements. An adverse incident is an event that causes, or has the potential to cause, unexpected or unwanted effects involving the accuracy and/or safety of device users (including patients) or other persons. For practices using Point of Care Testing (POCT): 5.4 The practice is required to adhere to POCT guidance set out NHS Health Check programme standards: a framework for quality improvement 9, and the Medicines and Healthcare Regulatory 9 NHS Health Check Programme Standards: A framework for quality improvement: February

15 Agency (MHRA) 2013 guidelines on POCT, and any relevant guidelines issued by equipment manufacturers 10. This includes advice on training in its use and ongoing management, troubleshooting, and quality assurance processes that ensure the accuracy and ability to reproduce results Practices will ensure that an appropriate internal quality control (IQC) process is in place. Practices should note that NHS Programme Standards 9 indicate that an appropriate internal quality control (IQC) process for POCT should be delivered in accordance with the MHRA guidelines 10 on POCT, Management and use of IVD point of care test (POCT) devices. This should take the form of at least a daily "go/no go" control sample (use of a liquid sample) on days when the instrument is in use. This may require other procedures e.g. optical check to be performed in addition to the use of a liquid control sample. A record of this should be maintained and all record keeping on this process should be accurate & contemporaneous. 5.6 ESCC will circulate any updated Programme Standards and national guidance including on use of POCT as/when any guidance is updated, amended and published. 5.7 Practices using POCT will ensure healthcare professionals and staff are trained and competent in using the POCT equipment safely and keep an up to date register of trained/competent operators 5.8 The practice will identify and provide ESCC details of a named POCT Coordinator to ensure the implementation of the safe use of the POCT, that all staff are adequately trained, relevant quality control processes are implemented and adhered to in line with NHS Health Check Programme Standards: A framework for quality improvement 9 and MHRA guidance. 5.9 The practice must have evidence of registration in an accredited external quality assurance scheme (EQA) reporting to the National Quality Assessment Advisory Panel through an accredited (CPA or ISO 17043) provider that reports poor performance to the National Quality Assessment Advisory Panel (NQAAP) for Chemical Pathology. This can be checked on UKAS or CPA websites: / The practice must provide evidence of this registration upon request by the Commissioner. 6 Staffing and Training (workforce requirements) 6.1 Practices will ensure that all staff providing NHS Health Checks are competent, demonstrating competence against the core and technical competences specified in the NHS Health Check Competence Framework Further detail about the competences and training available are provided in Appendix E. 6.2 Practices will identify a named Health Check lead that is responsible for ensuring all staff providing NHS Health Checks meet the competences for the role. 6.3 The practice is required to: Support, train, supervise and appraise all staff who are employed to ensure they remain competent and engage. 10 MHRA device bulletin. Management and use of IVD point of care test devices 2013 December NHS Health Check Competence Framework. Public Health England. July

16 Ensure that all staff are trained to use any equipment according to the manufacturer s instructions. Ensure staff members are trained to collect and submit accurate and timely monitoring and performance data. Ensure staff members engage with continued professional development, including appropriate training provided by key partners. 6.4 The ESCC commissioner will ensure that training is provided to support practitioners to develop key technical competences for delivering the Health Check risk assessment and provide brief advice to encourage risk reduction and management. Further details of the training are available in Appendix F. 6.5 Practices will keep records of staff training to evidence that the staff delivering health checks meet the core and technical competences, including completion of the online Dementia Awareness module (see appendix F). 7 DBS Checks A DBS check must be in place for all staff delivering this service. Providers should assure themselves that the appropriate DBS check, for the type of service being undertaken is in place for each member of staff providing the service. Please see guidance The County Council policy is that DBS checks are refreshed every three years. 8 Payment Cost For payment purposes, practices must submit quarterly summary figures along with the core data set that outlines activity undertaken. The price to be paid for the service is as follows: NHS Health Check Invitation (patient first invitation only*) 2.50 NHS Health Check using Pathology test NHS Health Check using Point of Care Testing (for practices using dual testing POCT equipment for both cholesterol & HbA1c) NHS Health Check using Point of Care Testing (for practices using cholesterol only POCT equipment) * Payment is made on the first patient invitation only. Subsequent patient reminders should not be reported for payment purposes. For practices using POCT, - there will be an additional payment for the liquid reagent used to run internal quality control checks. The cost of the liquid will be reimbursed each quarter in line with costs from the supplier. This is currently per quarter*. Any negotiated price reduction will be communicated to practices and the updated reimbursement payment will alter in the following quarter that new prices take effect. *The main supplier (ROCHE), charge 894 per year to provide 6 x 2 monthly packs for each lipid and HbA1c. 16

17 POCT EQA there will be an additional payment to order and run the External Quality Assurance for using POCT for both lipids and HbA1c. Costs will be reimbursed in line with costs from the supplier (currently WEQAS). Payments for EQA are currently: Payment for EQA lipid service Payment for EQA HbA1c service 9.32 per quarter per quarter Where practices are seeking to enter into an agreement with another practice to provide health checks on their behalf, for the patients of another practice, a request to undertake this should be put in writing and agreed in advance with the commissioner. Any such agreements will be subject to the practice provider demonstrating that there are robust data protection and information governance arrangements in place. 9 Data reporting and monitoring 9.1 Practices will be required to collect and share anonymised aggregated patient outcome data, to monitor the impact of the NHS Health Check programme on meeting it objectives in reducing CVD risk, improving health and reducing health inequalities. 9.2 All practices must record the number of eligible people they invite; reminders sent, nonresponders and those who decline, using the read codes outlined in the read code template in appendix B. 9.3 All practices must record the core minimum data set (outlined below) for all Health Checks undertaken. Demographic: a. Age b. Gender * c. Ethnicity d. Carer, disability, race, pregnancy/ maternity, religion or belief and sexual orientation Assessment: e. Smoking status f. Family history of coronary heart disease in first degree relative g. Blood pressure, systolic (SBP) and diastolic (DBP) h. Body mass index (height and weight) i. General practice physical activity questionnaire (GPPAQ) j. Alcohol use score (AUDIT-C can be used as the initial screen, and AUDIT for those who exceed the threshold) k. Cholesterol level: total cholesterol and HDL cholesterol (either point of care or venous sample) l. Cardiovascular risk score (QRISK) m. Dementia awareness (for those aged 65 to 74) n. Diabetes filter (BMI and BP) o. HbA1c or blood glucose for those who exceed diabetes filter (see 4.4.6) Information, Brief advice and Interventions: p. Information and brief advice provided (E.G. Stop Smoking, Physical Activity, Weight Management, Alcohol, Dementia) q. Signposted to the Healthy Lifestyle services (E.G. Health Trainers, Quit 51 Stop Smoking, Rebalance weight management, STAR Alcohol, Health Walks etc) r. Referrals offered to lifestyle interventions s. Referrals accepted to lifestyle interventions t. Referrals declined to lifestyle interventions 17

18 Data required: the gender should be recorded as reported by the individual. If the individual discloses gender reassignment, they should be provided with CVD risk calculations based on both genders and advised to discuss with their GP which calculation is most appropriate for them as an individual. 9.4 Practices will record the NHS Health Check minimum dataset onto the clinical system, using the specified Read Codes in Appendix B. Many clinical systems have a national template for recording the patients Health Check results, with the relevant read codes. An EMIS WEB local template has been designed and shared along with other CCG Locally Commissioned Service templates. The Health Check template can be found at Practices will provide reports quarterly to the Commissioner summarising the minimum dataset outcomes, as specified in the Key Performance Indicators (KPIs) in section 9. Practices will be required to use a data extraction and reporting system as recommended by East Sussex County Council, subject to robust and appropriate data sharing agreements and information governance policies being in place. 9.6 Practices will provide an annual audit of NHS Health Check outcomes as specified in the KPIs in section For payment purposes, practices must submit quarterly summary figures along with the minimum core data set that outlines activity undertaken. 10 Performance and Quality indicators 10.1 Practices must provide an NHS Health Check service in line with best practice. The service specification has been developed in line with the NHS Health Check Best Practice Guidance, NHS Health Check programme standards: a framework for quality improvement 2014, and relevant NICE guidance cited throughout the specification, including: NHS Health Check Programme Standards: A framework for quality improvement: 2014 NHS Health Check Competence Framework, PHE, NHS Health Check Best Practice Guidance, DH & PHE, September 2013 All documents are available at: 18

19 10.2 Practices will ensure the quality and outcomes of the NHS Health Checks service they provide for their patients through the following performance and quality indicators. Performance Quality Indicator Proportion of the eligible practice population to be invited annually for an NHS Health Check. Annual uptake of NHS Health Checks The service is safe, appropriate and complies with requirements Number of patients who are satisfied with the service and understand their CVD risk results and how to reduce their risk. Threshold 20% of the eligible population to be invited for a health check each year. Practices must not to exceed 25% of the eligible population each year. Work towards a minimum uptake of 50% of those offered a Health Check. The service has the following in place: Named Health Check lead List of staff meeting competences. Named POCT lead (for practice using POCT) POCT IQC processes Work towards at least 20% of all patients who have a Health Check completing a Health Check experience questionnaire. Aim for at least 80% of patients rating the following positively : Service Quality Service Accessibility Staff knowledge & skills Understanding of their CVD risk Knowledge of how to reduce their risk Method of Measureme nt Public Health quarterly claim form Public Health quarterly claim form Application form Health Check survey captured by Public Health. Numbers received will be fed back to practices quarterly, and a summary of the feedback annually. Frequency of Monitoring Quarterly Quarterly At commencem ent of contract. Quarterly 19

20 Performance Quality Indicator Monitoring and reporting of invitations and uptake of eligible patient s for a Health Check Threshold Full aggregation of anonymised Health Check activity outcomes for the following: Invitation and uptake of Health Checks Invites (last quarter and year-to-date) total number five year age bands breakdown (e.g , etc.) gender breakdown ethnicity breakdown (census 2011) Carer, disability, race, pregnancy/ maternity, religion or belief and sexual orientation breakdowns deprivation score average score of invited (or postcodes) Attendees (last quarter and year-to-date) total number five year age bands breakdown (e.g , etc.) gender breakdown ethnicity breakdown (census 2011) Carer, disability, race, pregnancy/ maternity, religion or belief and sexual orientation breakdowns deprivation score average score of invited (or postcodes) Method of Measureme nt Number of invites and Health Checks completed reported quarterly for payment. All other data reported once a suitable data extraction system has been agreed and is in place. Frequency of Monitoring Quarterly Quarterly Non-attendees - those invited for a Health Check with no completed Health Check/risk score (Q, Y2D) total number five year age bands breakdown (e.g , etc.) gender breakdown ethnicity breakdown Carer, disability, race, pregnancy/ maternity, religion or belief and sexual orientation deprivation score average score of invited (or post codes) 20

21 Performance Quality Indicator Collection and reporting of patient Health Check outcomes Threshold Full aggregation of anonymised Health Check activity outcomes for the following: BP: number and percentage of attendees with BP 140/90 BMI: number and percentage of attendees with BMI grouped as underweight, normal weight, overweight, obese and morbidly obese Cholesterol: number and percentage of attendees with raised cholesterol number & % of service users with a total cholesterol level above 7.5 mmol/l Physical Activity: number and percentage of attendees with a GPPAQ status of active, moderately active, moderately inactive and inactive. Smoking: number and percentage of attendees with a smoking status of either current (heavy, moderate, low), non-smoker or ex-smoker (quit more than 4 weeks). Alcohol: number and percentage of attendees with AUDIT C alcohol scores for the categories: 0-7 lower risk, 8-15 Increasing risk, 20+ possible dependence CVD Risk: number and percentage of patients with a low risk score (<10%), at risk score (10-19%) and high risk score ( 20%) for CVD (QRISK2). Diabetes Filter: number and percentage of patients exceeding the diabetes filter and requiring a blood test (FPG or HbA1c) Diabetes: number and percentage of attendees with raised sugar: moderate risk HbA1c - 42mmol/ mol (6%) or FPG - < 5.5 mmol/l; high risk HbA1c: > mmol/mol (6%- 6.4%) of FPG: diabetes > mmol/l; HbA1c: > 48mmol/mol (6.5%) or FPG: > 7 mmol/l Method of Measureme nt Data reported once a suitable data extraction system has been agreed and is in place Frequency of Monitoring Quarterly 21

22 Performance Quality Indicator Threshold Advice, signposting and referral Weight Management: Number & % of patients with a BMI given brief advice for weight management Number & % of patients with a BMI 30 given advice, signposted, referred, declined weight management Smoking Cessation: Number & % of smokers given advice, signposted, referred, declined smoking cessation Physical Activity: Number & % of individuals less than active given advice, signposted, referred to a Health Trainer, Health Walks or Physical activity Opportunity Alcohol: Number & % of patients with an audit score of 20+ referred, declined Alcohol services Number & % of patients with an audit score of 8 19 offered brief advice on alcohol high sugar (FPG: 5.5 to <7mmol/l, HBA1c: 6% to 6.4% or mmol/mol) referred, declined IFG/IGT (pre-diabetes) service (weight management or Health trainer) Method of Measureme nt Frequency of Monitoring Annual Diagnosis Number & % of patients who have had a Health Check in the last year and subsequently been diagnosed with: Hypertension Diabetes High Risk Diabetes (Impaired Glucose Regulation) Familial Hypercholesterolemia Chronic Kidney Disease Atrial Fibrillation 22

23 Performance Quality Indicator Additional Testing and follow-up: - Hypertension - CKD - CVD high risk Where thresholds met: - Proportion of individuals with investigation s undertaken - Proportion of individuals with outcome recorded Threshold For all patients who have had a Health Check in the previous 12 months: Number and percentage of those with BP 140/90 offered a serum creatinine test for CKD Number and percentage of those with BP 140/90 further assessed for hypertension Number and percentage of CVD highrisk ( 20%) patients prescribed statins or declined statins within 6 months of a Health Check Number and percentage of CVD at risk ( 10% - <20%) patients prescribed statins or declined statins within 6 months of a Health Check For all those patients who had a Health Check since the start of the scheme: Number & percentage of CVD high risk ( 20%) patients reviewed within 18 months of the Health Check Method of Measureme nt Annual reporting once a data extraction system has been agreed and is in place. Frequency of Monitoring Annual 11 Contacts Should you have any further queries about the NHS Health Check Service then please contact either: Hayley Martin, Health Improvement Specialist NHS Health Checks. hayley.martin@eastsussex.gov.uk Tel Peter Aston, Health Improvement Principal peter.aston@eastsussex.gov.uk Tel Tracey Houston, Business Manager tracey.houston@eastsussex.gov.uk Tel

24 Appendix A Read codes for identifying the eligible population The query must identify all adults aged and exclude patients: Who have been prescribed statins Who have had an NHS Health Check (including from 3 rd party provider) in the last 5 years: o NHS Health Check Completed by 3 rd party 8BAg0 (v2) or XaZPq (CTv3) o NHS Health Check completed 8BAg (v2) or XaRBQ (CTv3) Who have had an NHS Health Check or CVD risk assessment that resulted in a high CVD risk ( 20%) And who have an existing CVD condition (Read codes below) Read codes for CVD Conditions to exclude READ Versi CODE Description (Original Spec) on V 2 G573.% Atrial fibrillation and flutter V 2 G5731 Atrial flutter V 2 G3 % Ischaemic heart disease V 2 Gyu3.% [X]Ischaemic heart diseases V 2 G30A. Mural thrombosis V 2 G331. Prinzmetal's angina V 2 G332. Coronary artery spasm V 2 G341.% Aneurysm of heart V 2 G37.. Cardiac syndrome X V 2 1Z12. Chronic kidney disease stage 3 V 2 1Z13. Chronic kidney disease stage 4 V 2 1Z14. Chronic kidney disease stage 5 V 2 1Z15. Chronic kidney disease stage 3A V 2 1Z16. Chronic kidney disease stage 3B V 2 1Z1B. Chronic kidney disease stage 3 with proteinuria V 2 1Z1C. Chronic kidney disease stage 3 without proteinuria V 2 1Z1D. Chronic kidney disease stage 3A with proteinuria V 2 1Z1E. Chronic kidney disease stage 3A without proteinuria V 2 1Z1F. Chronic kidney disease stage 3B with proteinuria V 2 1Z1G. Chronic kidney disease stage 3B without proteinuria V 2 1Z1H. Chronic kidney disease stage 4 with proteinuria V 2 1Z1J. Chronic kidney disease stage 4 without proteinuria V 2 1Z1K. Chronic kidney disease stage 5 with proteinuria V 2 1Z1L. Chronic kidney disease stage 5 without proteinuria V 2 G63y0 Cerebral infarct due to thrombosis of precerebral arteries V 2 G63y1 Cerebral infarction due to embolism of precerebral arteries V 2 G64..% Cerebral arterial occlusion V 2 G66..% Stroke and cerebrovascular accident unspecified V 2 G6W.. Cerebral infarction due to unspecified occlusion or stenosis of precerebral arteries V 2 G6X.. Cerebral infarction due to unspecified occlusion or stenosis of cerebral arteries V 2 Gyu62 [X]Other intracerebral haemorrhage V 2 Gyu63 [X]Cerebral infarction due to unspecified occlusion or stenosis of cerebral arteries V 2 Gyu64 [X]Other cerebral infarction V 2 Gyu65 [X]Occlusion and stenosis of other precerebral arteries V 2 Gyu66 [X]Occlusion and stenosis of other cerebral arteries V 2 Gyu6F [X]Intracerebral haemorrhage in hemisphere, unspecified V 2 Gyu6G [X]Cerebral infarction due to unspecified occlusion or stenosis of precerebral arteries 24

25 Read codes for CVD Conditions to exclude READ Versi CODE Description (Original Spec) on V 2 G617. Intracerebral haemorrhage, intraventricular V 2 G669. Cerebral palsy, not congenital or infantile, acute V 2 66AJ1 Brittle diabetes V 2 C10% Diabetes mellitus V 2 Cyu2% [X]Diabetes mellitus V 2 C1098 Reaven's syndrome V 2 C10F8 Reaven's syndrome V 2 C10J. Insulin autoimmune syndrome V 2 C10J0 Insulin autoimmune syndrome without complication V 2 C10K. Type A insulin resistance V 2 C10K0 Type A insulin resistance without complication V 2 C10L. Fibrocalculous pancreatopathy V 2 C10L0 Fibrocalculous pancreatopathy without complication V 2 C3200 Familial hypercholesterolaemia V 2 C3205 Familial defective apolipoprotein B-100 V 2 G58..% Heart failure V 2 662f. New York Heart Association classification - class I V 2 662g. New York Heart Association classification - class II V 2 662h. New York Heart Association classification - class III V 2 662i. New York Heart Association classification - class IV V 2 G20..% Essential hypertension V 2 G24..% Secondary hypertension V 2 G2y.. Other specified hypertensive disease V 2 G2z.. Hypertensive disease NOS V 2 G24z1 Hypertension secondary to drug V 2 be1..% DIAZOXIDE [CARDIOVASCULAR USE] V 2 be4..% SODIUM NITROPRUSSIDE V 2 bkg..% AMBRISENTAN V 2 G73.. Other peripheral vascular disease V 2 G733. Ischaemic foot V 2 G73y. Other specified peripheral vascular disease V 2 G73y1 Peripheral angiopathic disease EC NOS V 2 G73yz Other specified peripheral vascular disease NOS V 2 G73z. Peripheral vascular disease NOS V 2 G73z0 Intermittent claudication V 2 G73zz Peripheral vascular disease NOS V 2 Gyu74 [X]Other specified peripheral vascular diseases V 2 Gyu7A [X]Peripheral angiopathy in diseases classified elsewhere V 2 bxd% SIMVASTATIN V 2 bxe% PRAVASTATIN SODIUM V 2 bxg% FLUVASTATIN SODIUM V 2 bxi.. ATORVASTATIN V 2 bxj.. CERIVASTATIN V 2 bxk.. ROSUVASTATIN V 2 F4236 Amaurosis fugax V 2 G65..% Transient cerebral ischaemia V 2 ZV12D [V]Personal history of transient ischaemic attack V 2 G655. Transient global amnesia 25

26 Read codes for CVD Conditions to exclude READ Versi CODE Description (Original Spec) on CTv3 G573.% Atrial fibrillation and flutter CTv3 G5730% Atrial fibrillation CTv3 G310. Post-myocardial infarction syndrome CTv3 G342. Atherosclerosis CTv3 G343. Generalised ischaemic myocardial dysfunction CTv3 G36..% Certain current complications following acute myocardial infarction CTv3 G364. Rupture of chordae tendinae as current complication following acute myocardial infarction CTv3 G365. Rupture of papillary muscle as current complication following acute myocardial CTv3 G366. infarction Thrombosis of atrium, auricular appendage, and ventricle as current complications following acute myocardial infarction CTv3 X202r. Post-infarction mural thrombus CTv3 XE2uV% Ischaemic heart disease CTv3 G341.% Aneurysm of heart CTv3 X200B% Coronary spasm CTv3 X200c Cardiac syndrome X CTv3 Xa07j% Myocardial ischaemia of newborn CTv3 XE0df% Chronic renal failure CTv3 XaLHI% Chronic kidney disease stage 3 CTv3 XaLHJ% Chronic kidney disease stage 4 CTv3 XaLHK% Chronic kidney disease stage 5 CTv3 X00D1% Cerebrovascular accident CTv3 XE1Xs% Vascular dementia CTv3 C10..% Diabetes mellitus CTv3 L180. Diabetes mellitus during pregnancy, childbirth and the puerperium CTv3 L1800 Diabetes mellitus - unspecified whether during pregnancy or the puerperium CTv3 L1801 Diabetes mellitus during pregnancy - baby delivered CTv3 L1802 Diabetes mellitus in the puerperium - baby delivered during current episode of care CTv3 L1803 Diabetes mellitus during pregnancy - baby not yet delivered CTv3 L1804 Diabetes mellitus in the pueperium - baby delivered during previous episode of care CTv3 L180z Diabetes mellitus during pregnancy, childbirth or the puerperium NOS CTv3 L1805 Pre-existing diabetes mellitus, insulin-dependent CTv3 L1806 Pre-existing diabetes mellitus, non-insulin-dependent CTv3 L1807 Pre-existing malnutrition-related diabetes mellitus CTv3 L1808 Gestational diabetes mellitus CTv3 Q441. Neonatal diabetes mellitus CTv3 X40JF Transitory neonatal diabetes mellitus CTv3 Xa08a Small for gestation neonatal diabetes mellitus CTv3 X40JE Metabolic syndrome X CTv3 X40JS Hyperproinsulinemia CTv3 XaJlP Fibrocalculous pancreatopathy without complication CTv3 C3200% Familial hyperbetalipoproteinaemia CTv3 X40X5 Familial defective apolipoprotein B-100 CTv3 CTv3 XaR4h XaR4i Familial hypercholesterolaemia due to heterozygous low density lipoprotein receptor mutation Familial hypercholesterolaemia due to homozygous low density lipoprotein receptor mutation CTv3 XaR4k Familial defective apolipoprotein B

27 Read codes for CVD Conditions to exclude READ Versi CODE Description (Original Spec) on CTv3 G58.. Heart failure CTv3 G5y4.% Post cardiac operation functional disturbance CTv3 XE0Ub Hypertension CTv3 G2 % Hypertensive disease CTv3 G202. Systolic hypertension CTv3 G24..% Secondary hypertension CTv3 XE0Uc% Essential hypertension CTv3 XSDSb Diastolic hypertension CTv3 Xa0Cs Labile hypertension CTv3 Xa3fQ Malignant hypertension CTv Hypertension induced by oral contraceptive pill CTv3 G24z1 Hypertension secondary to drug CTv3 X203Q% Peripheral ischaemia CTv3 X203R% Upper limb ischaemia CTv3 G65z0 Impending cerebral ischaemia CTv3 G65z1 Intermittent cerebral ischaemia CTv3 XE0VK% Transient ischaemic attack CTv3 XaX16 [V]Personal history of transient ischaemic attack 27

28 Appendix B: Updated shortened invitation letter Date: Dear Xxxx Your NHS Health Check is due next month. Please call us on XXXXXX as soon as possible to make sure you get your appointment at your GP surgery and record on the tear off slip below. Take a look at the enclosed NHS Health Check leaflet to see how it can benefit you. Yours sincerely, Dr XXXXXXXXXXX Please record the date and time of your appointment and stick it on your fridge. I am going to my Health Check at on at location date time For info & videos on the Health Check 28

29 Appendix C Read codes for Health Check invitations and assessment Invites Health Check completed (DNA) Gender Ethnicity Medical/ Family History Clinical Values BP Cholesterol Read code description Version 2 CTv3 Letter first letter invitation 9mC1 XaRBT Letter 2 nd letter invitation 9mC2 XaRBU Letter 3 rd letter invitation 9mC3 XaRBV Verbal invitation 9mC4 XaR9z Telephone invitation 9mC0 XaRBS NHS Health Check declined 8lAx XaX8h Failed to respond to NHS Health Check invitation 9Nj5 XaRAF Did not attend NHS Health Check 9NiS XaRAA NHS Health Check completed by GP practice 8BAg. XaRBQ NHS Health Check completed by third party (for use recording Health Check results completed 8BAg0 XaZPq by another provider) Male 1K0.. X768D Female 1K1.. X768C White British 9i0.. XaJQv White Irish 9i1.. XaJQw Other White background 9i2.. XaJQx Traveller 9i2D. XaJSC White and Black Caribbean 9i3.. XaJQy White and Black African 9i4.. XaJQz White and Asian 9i5.. XaJR0 Other Mixed background 9i6.. XaJR1 Indian or British Indian 9i7.. XaJR2 Pakistani or British Pakistani 9i8.. XaJR3 Bangladeshi or British Bangladeshi 9i9.. XaJR4 Other Asian background 9iA.. XaJR5 Black Caribbean 9iB.. XaJR6 African 9iC.. XaJR7 Other Black background 9iD.. XaJR8 Chinese 9iE.. XaJR9 Other Ethnic Category 9iF.. XaJRA Ethnic Category not stated 91G.. XaJRB F/H premature coronary Heart disease F/H cardiovascular disease 1deg male relative<55yrs 12CV XaP9K F/H cardiovascular disease 1deg female relative<65yrs 12CW XaP9M F/H diabetes mellitus in 1 deg relative 1253 XaKYz F/H hypercholesterolemia 1 deg relative 126B XaKZ0 F/H Kidney Disease 14D.. XM1RS Sitting Systolic BP reading 246Q. XaJ2E Sitting Diastolic BP reading 246R. XaJ2F Serum cholesterol (Total) 44PJ. XaJe9 Serum cholesterol (HDL) 44P5. 44P5. Serum cholesterol normal 44P1 44P1 Serum cholesterol borderline 44P2 44P2 Serum cholesterol raised 44P3 44P3 29

30 Diabetes assessment BMI Lifestyle Smoking Status Alcohol (AUDIT) GPPAQ Physical Activity Read code description Version 2 CTv3 Serum cholesterol very high 44P4 44P4 Total cholesterol:hdl ratio 44PF. 44PF. Diabetes mellitus screen (those exceeding diabetes filter requiring blood test) HbA1c (IFCC standardised) 42W5. XaPbt Fasting Blood Glucose 44g1 44g1 O/E - height O/E - weight 22A.. 22A.. Body Mass Index 22K.. 22K.. Current smoker 137R. 137R. Ex smoker 137S. Ub1na Non-smoker (& [never smoked tobacco]) XE0oh Ex Smoker 137E check Alcohol screen-audit C questions completed 9k17 XaMwb AUDIT C Score (must add score separately) 38D4. XaORP Full AUDIT Score (must add score separately) 38D3. XM0aD Alcohol Units per week 136V. Ub173 GPPAQ index: inactive 138X. XaPP8 GPPAQ index: moderately inactive 138Y. XaPPB GPPAQ index: moderately active 138a. XaPPD GPPAQ index: active 138b. XaPPE CVD RISK QRISK2 CVD 10 year risk score 38DP. XaQVY Advice Given Smoking Cessation advice given 8CAL. Ua1Nz Brief intervention for Physical Activity given 9Oq3 XaPjx Advice given weight management 8Cd7 XaX5f Advice given about Alcohol 8CAM XaJIr Dementia Awareness 67DF. XaaD1 Opportunity Signposted Stop smoking service signposted 8CdB. XaXnG Weight management service signposted 8CdC. XaXnI Physical activity opportunity signposted 8Cd4. XaREx Referrals and declined referrals Smoking Alcohol Physical Activity Weight Management Health Trainer IGR/High risk diabetes Referral to smoking cessation advisor 8H7i. XaItC Declined referral to smoking cessation advisor 137d XalkY Referral to specialist alcohol service 8HkG XaORR Declined referral to specialist alcohol service 8IEA. XaXkb Referral to Physical Activity service 8H7s. XaIQY Declined referral to Physical Activity service 138S. XaL1X Referral to Weight Management 8HHH. XaJSu Declined referral to Weight Management 8IAM. XaQUp Referral to Health trainer 8HlF. XaQAA Declined referral to Health trainer 8IAL. XaQAN Referral for impaired glucose management 8HIS XaXR7 30

31 Appendix D East Sussex Health Check Pathway (with lifestyle advice and referral 31

32 Appendix E Lifestyle Services Information & Referrals There are a number of Public Health commissioned lifestyle services that will provide the ongoing support for individuals wishing to address risk factors identified in their Health Check. The key lifestyle services available include: Quit 51 smoking cessation service Rebalance weight management service Health Trainer service STAR (alcohol service) Information on each service, including contacts and referral information are below. Health Trainer Service Health Trainers can provide one-to-one tailored support to individuals wanting to make successful changes across a range of health behaviours. They are based within local communities across East Sussex and work with individuals within the capacity of the client and in the context of the everyday pressures and circumstances experienced by the client. Health Trainers offer support and encouragement to enable clients to meet their behaviour change goals such as: Eating a Healthy Diet Getting more active. Losing weight Sensible drinking Health Trainers can also triage for lifestyle services, signposting patients/clients to a broad range of services, projects and programmes within the proximity of the client s community. Referral: Tel: The referral form is below and is also available in the DXS primary care system. STAR Alcohol Service East Sussex County Council commission the STAR service to provide the community alcohol service. STAR East Sussex Drug and Alcohol Recovery Service works with adults who want help to deal with a drug or alcohol problem and who want to build a healthier happier life for themselves. They also support, friends, families and carers. Referral information Practices can refer patients on the referral form below (also in DXS system) or patients can self-refer by calling free on: Telephone: Further information and flyer (below) on alcohol services can be found at: 32

33 QUIT 51 Smoking Cessation Service Smokers are 4 times more likely to successfully quit using NHS Stop Smoking Services. Patients can be offered one of two options for smoking cessation support. Option 1: GP Practice Smoking Cessation Service Option 2: Quit 51 East Sussex Stop Smoking Service ESCC has commissioned Quit 51 to provide the Smoking Cessation Specialist service for East Sussex. They are one of only 4 services in the whole country to be awarded Approved Provider status, providing confidence that the service is effective and evidence based. Referral information practices can refer a patient using the referral form below (also in the DXS system) or the patient can self-refer by contacting Quit 51 by telephone, text or . Tel: contact.quit51@nhs.net Text: Text the word smokefree to Web: Re-balance Weight Management Service ESCC has commissioned the Re-balance weight management service to provide weight management groups for adults in East Sussex. re:balance is 12 week group weight loss programme, provided at a range of local leisure or community centres. It is a scientifically developed programme to help individuals lose weight and keep it off. It is not a diet. re:balance East Sussex is a free 12 week weight loss course for adults who are: Aged 16 years + and have a BMI (Body Mass Index) of 30 and above Live in the county of East Sussex (excluding Brighton and Hove) Have not suffered a stroke or heart attack within the last 3 months Referral information patients can sign up by telephone or online via their website to the programme. Tel: enquiries@rebalanceeastsussex.co.uk Website: 33

34 East Sussex Health Trainer Referral Form Name Date of Birth. Address. Post Code. Contact number . Making healthy lifestyle changes can improve your health and wellbeing Please tick as many as apply: Healthy eating and weight watching Becoming more physically active Sensible drinking Stopping smoking Any additional information that may be relevant: Signed (client) Date:... Name and address of referrer (if self referring please leave blank) Name/Role Organisation Address Phone Signed (referrer). Date:... Please return this form to the Health Trainer Service in your area Eastbourne, Hailsham and Seaford, and High Weald, Lewes and Havens areas 32 Hyde Gardens, Eastbourne. East Sussex BN21 4PX Hastings & Rother area Innovation Centre Unit 22 Highfield Drive, St Leonards East Sussex TN38 9UH

35 Referral details Name of client: Date of birth: Stop Smoking Service Referral form NHS number (if known): Address: GP and/or practice (if known): Telephone number: (Landline) Consent to text: Y/N Postcode: Mobile: Consent to leave voic Y/N Consent to send letter: Y/N Pregnant? Y/N Breastfeeding: Y/N Any special instructions or needs e.g. language, mobility? Best times/days to contact by phone? Client signature consenting to referral: Referrer details Name of referrer: Organisation: Contact number: Please complete and send by Fax to (safe haven fax): (scanned) to: Mail to: Freepost Lifestyle Services Phone these details through to

36 Referral Form Telephone: Fax: Forename: Surname: Date of Birth: Gender: Marital Status: Address: Telephone: GP details: Post Code: Mole: Telephone: Ethnicity: White British White Irish Other White White & Black Caribbean White & Black African Nationality: White & Asian Other Mixed Indian Pakistani Bangladeshi Other Asian Caribbean African Other Black Chinese Other Not Stated First Language (if not English) Parental status: (Do you have any children under 18) Reason for Referral: Number of children living with client: Referral Date: Self GP Drug service statutory Arrest Referral DIP Criminal Justice Other Drug service non statutory Other Probation DRR Nature of substance misuse? CARAT/Prison Psychiatry services Social Services Education Service Community care assessment A&E Employment Service Needle Exchange Connexions Hospital Psychological Services Relative Concerned other Community Alcohol Team Outreach Job Centre Plus Employer ATR Sex Worker Project Peer How substance is administered: Typical number of days nicotine smoked in the last 28days: 36

37 Physical Health Issues: Mental Health Issues: Past Present Does the client have a Dual Diagnosis? (Is the client currently receiving care from mental health services for reasons other than substance misuse?) Yes No Armed Forces: Has the client or any member of their immediate family ever served in the UK armed forces? Yes No If yes, please completed the Armed Forces Questionnaire Known risk to self or others: Personal circumstances (i.e. domestic/housing etc) Other agencies worked with: Past Present Additional information: Action to be taken: Brief non structured treatment intervention has been provided (i.e. advice and information, harm minimisation etc) Structured treatment required, referral to LASAR LASAR assessment appointment made Appointment date: Referral taken by: Date: 37

38 38

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