Primary Care Commissioning Committee Agenda

Transcription

1 Primary Care Commissioning Committee Agenda Date: 22 nd November 2016 Time: Location: Hove Town Hall, Council Chambers Members: Mike Holdgate (MH) Dr George Mack (GM) Peter Wilkinson (PW) John Child (JC) Pippa Ross-Smith (PRS) Soline Jerram (SJ) Lola Banjoko (LB) Ian Harper (IH) Bob Deschene (BDe) In attendance: Michelle Elston (ME) Katie Stead (KS) Rachael Hornigold (RH) Hannah Oliver (HO) Kristina Chapman (KC) Alex Holdcroft (AH) Apologies: Dr Jennifer Oates (JO) Dr Dinesh Sinha (DS) Brian Doughty (BD) Stephen Ingram (SI) Lay Member for Patient and Public Participation (Acting Chair) Lay Member for Governance Acting Director for Public Health Chief Operating Officer Chief Finance Officer Lead Nurse, Director of Patient Safety and Clinical Quality Director of Delivery and Performance Local Medical Council Representative Healthwatch Representative Head of Commissioning Primary Care and Community Services Clinical Lead, Primary Care (LCS & Quality) and Public Health Specialist Registrar in Public Health, BHCC Commissioning Manager Commissioning Support Manager Interim Governing Body Secretary Independent Clinical member, Registered Nurse (Co-Chair) Independent Clinical Member, Secondary Care Consultant (Co- Chair) Director, Adult Social Care, BHCC Head of Primary Care, NHS England 1

2 Conduct of meetings in relation to attendance by members of the public: Members of the public are asked to note that NHS Brighton and Hove Clinical Commissioning Group Primary Care Committee meetings are meetings held in public, they are not public meetings where members of the public can speak at any point. Agendas identify when the Chairman will receive questions and comments from the public. For all other agenda items speaking rights are reserved to Committee members and agreed representatives sitting at the table; members of the public should not speak or intervene in proceedings unless invited to do so. In all matters the Chairman s decision is final. The introduction by the public or press representatives of recording, transmitting, video or similar apparatus into meetings of Brighton and Hove Clinical Commissioning Group Primary Care Committee is not permitted. 2

3 Agenda Item no Item description Action Lead Paper Page no Time 49/16 Welcome and Apologies Mike Holdgate /16 Declaration of any conflicts of interests 51/16 (1) Minutes from the meeting held on 27 th September 16 Mike Holdgate Approval Mike Holdgate Pg /16 (2) Matters arising Discussion Mike Holdgate Pg Standing Agenda Items 53/16 Federations Update Information John Child /16 Update on Co- Commissioning Locally Commissioned Services (LCS) 55/16 (3) LCS Finance Paper Information Pippa Ross- Smith 56/16 (4) Innovation Proposal: NHS Health Checks from Cluster 4 Primary Care Transformation Board 57/16 (5) Approved Minutes from the Primary Care Transformation Board Any Other Business Information John Child Approval Katie Stead and Rachael Hornigold Pg Pg Information George Mack Pg /16 AOB Discussion Mike Holdgate Date of future meetings 24th January 17 28th March 17 3

4 4

5 Primary Care Commissioning Committee Draft Minutes Date: 27 September 2016 Time: Location: The Auditorium, Ground Floor, The Brighthelm Centre, North Road, The Brighton Centre Summary of resolutions taken at meeting taken on 27 th September 2016: Proposed Resolutions Item no Resolution Owner Review Date 044a/16 The committee approved the LCS Innovation Proposal- Opportunistic Case Finding for COPD. Michelle Elston N/A 044b/16 The committee approved the LCS Innovation Proposal- Young Persons Support Service on the condition that there is further development of performance and financial benefits. Michelle Elston November

6 Members: Dr Jennifer Oates (JO) Lola Banjoko (LB) John Child (JC) Soline Jerram (SJ) Dr George Mack (GM) Pippa Ross-Smith (PRS) Darren Tymens (DT) Peter Wilkinson (PW) Independent Clinical Member - Registered Nurse (Co-Chair) Director of Delivery and Performance Chief Operating Officer Lead Nurse, Director of Patient Safety and Clinical Quality Lay Member (Governance) Chief Finance Officer Local Medical Council Representative Acting Director of Public Health In Attendance: Michelle Elston (ME) Rachael Hornigold (RH) Jim Graham (JG) Murrey King (MK) Katie Stead (KS) Alexandra Holdcroft (AH) Head of Commissioning Primary Care and Community Services Clinical Lead Local Member Group GP Lead (Central) Interim APMS Procurement Lead NHS England SE Clinical Lead Temporary Governing Body Secretary (Minutes) Apologies: Bob Deschene (BDe) Brian Doughty (BD) Stephen Ingram (SI) Mike Holdgate (MH) Dr Dinesh Sinha (DS) Healthwatch Director Adult Social Care, Brighton and Hove City Council NHS England Lay member (Patient, Public Participation) Independent Clinical Member (Secondary Care Consultant) (Co-Chair) 6

7 Item No Item Action 038/16 Welcome and Apologies The chair welcomed everyone and noted the above apologies. It was also noted that Darren Tymens is attending in the place of Ian Harper. 039/16 Declarations of any Conflicts of Interest The GPs in attendance all declared their conflict of interest but noted that they were not attending in a voting capacity. 040/16 Minutes of the Last Meeting The minutes of the meeting held on 26 th July 2016 were agreed as accurate with the exception of a missing line on the 1 st page, which was corrected. 041/16 Matters Arising All matters arising were on the agenda. 042/16 Homeless Procurement MK, Interim APMS Procurement Lead NHS England SE, presented the item. MK highlighted the following as a summary: MK presented to the committee a number of months ago at the beginning of the procurement process. Since we are now in the middle, information must be a bit guarded The procurement process chosen is called the invitation to negotiate, which gives flexibility to the commissioner and provider to develop ideas as they go through the process. An expert panel has been arranged, who will receive presentation from bidders, formally score the responses and put questions to the bidders (part of the scoring). The contract is currently between the practice group and NHSE so the decision about the procurement methodology was formally taken through NSHSE and the steering group. Before the decision was made, SMT was made aware and there were no issues within the CCG. There are really high DNA rates from this practice into secondary care. This is specifically mentioned in the service specification and a question will be asked of the bidders as to how they will engage the homeless patients with the service. Baseline service is what you would expect from any GP, but the extended service allows for clinical outreach. This would be used, for example, if someone is discharged from the hospital onto the street. SCFT is happy to continue with the service on Morley Street, and it will remain there as long as we want it to be there. The location of this may change based on the estates strategy. The committee noted the update on the Homeless Service. MK left the meeting at this point. 7

8 043/16 Update on New LCS Indicative Budget PRS, Chief Finance Officer, presented the item for the committee to note. PRS highlighted the following as a summary: This item is based on an action from a previous meeting. For the next update on quarter 2 performance, there will be a forecast column. Most of the schemes are underspending right now, but we are not sure whether these are slippage or timing, so the forecast column will help us understand this. Committee Questions/Comments: There are significant under-spends in COPD and ambulatory services. The COPD specification has changed, and is presented today, since the previous one was difficult to deliver. For the ambulatory service, new NICE guidelines have been in place and the under-spend may be due to not everyone taking them up yet. The committee noted the new LCS indicative budget. 044a/16 LCS Innovation Proposal- Opportunistic Case Finding for COPD RH and KS, Clinical Leads, presented the item for the committee s approval. RH and KS highlighted the following as a summary: This addresses a local and national issue. COPD is underdiagnosed, where 17% of people who died with it were not on the register. There are new policies and guidance around this, but there are different approaches to implementing them. The new LCS for COPD which will start in October 2016 uses targeted case finding, going straight to patients to get diagnosed. This paper presents an alternative method that would be used in Clusters 1 and 3 as a pilot of the opportunistic case-finding. Cluster 3 has highest prevalence gap and Cluster 1 has the most diagnoses. This would allow us to determine which method would be best for Brighton and Hove going forward. The cost is 6.90 per test and the diagnostic procedure is easier and more comforting for patients. Committee Questions/Comments: This business case has been approved by CSG, SMT, and the Primary Care Transformation Board. There will be a criteria questionnaire pre-screen first, before performing the test on patients. The test has a positive impact on those who test negative as well because they will be given a lung score, encouraging them to quit smoking. The committee approved the business case. 8

9 044b/16 LCS Innovation Proposal- Young Persons Support Service RH and KS, Clinical Leads, presented the item for the committee s approval. RH and KS highlighted the following as a summary: Cluster 5 and University Practice, would like to try a new way of dealing with mental health concerns in their population. This is supported by the Children and Young People Mental Health Team and deals with recommendations that came out last week reporting the mental health distress in students. This will be a preventative and proactive way of dealing with issues as they arise and will reduce distress in waiting for support and prevent A&E admission. The three parts of the proposal include: o A full time nurse across the cluster with support from a GP, signposting and trying to reduce DNAs. o On-site counselling services where students would come in on Monday and be seen by Friday. This will be subcontracted to SPFT. o Bringing the service into the community, due to the high rate of DNAs. Experts will come into clinics and run sessions with GPs and see patients. The practice will nominate subject areas and learning. It is proposed that the service run for 2 years, but the commissioning team would like to eventually absorb this into their services in the long term. The psychiatry registrar will work on evaluation method to find a method that works. Committee Questions/Comments: There was some discussion on the definition of young people, and whether the children and young people budget can pay for those over 18. Also, when subcontracting out to SPFT it is important to ensure we are not paying for a service twice. It was clarified that this is the adult psychiatry team who the Registrar has spoken to. Both adult and children psychiatrists are interested in being part of the service. The university practice already has innovative counselling sessions, however they currently have a 6 week wait and this is not appropriate for urgent student circumstances. This wouldn t be instead of the current service because this would just be 2 sessions. If patients need more long term support, they would go to the university service. The committee recognised that the service doesn t change for young people at 18, we shouldn t be bound by our structure but should meet the needs of the age group and it is clear that the low 20s are important to meet in this service. The committee would like to see baseline data at the beginning of the service so the impact can be appropriately judged. The data should be base-lined now and the data currency defined. The committee approved the paper on the condition that there is further development of performance and financial benefits. 9

10 045/16 Federations Update JC, Chief Operating Officer, gave a verbal update for the committee to note. JC summarised the update as follows: There was a recent vote by the membership around federating and various options were presented. 20 practices have voted in favour of federating. The next step is to reinvigorate the federation working group to become an implementation group to start the work and discussion around how to make it happen. There is no set timescale as of yet. Committee Questions/Comments: It is important to remember those practices that don t choose to federate, as we need to commission for the whole population. Clusters might have to reconfigure to best implement this as well. The role of the CCG needs to be clarified as we are helping to set up the federation, but once it is established we need to view it as a provider. The LMG chair noted that they suspect that one solution will naturally develop for the whole city once people see the value of the federation and it starts to work. It was agreed that an update on the federation would be a standing agenda item moving forward. Action: The Governing Body Secretary is to ensure there is an update on Federations at future committee meetings. The LMC remains agnostic about federations as they represent all providers whether or not they choose to be part of the federation. The GPC have promoted federations for the last 2 years and have noted that having everyone on board is critical. It is also important to have a clear vision as a CCG as to how you see the provider landscape. It might be better for the landscape if there were alternatives to providing things in hospitals, which a federation will help with. The LMC has in-house experience of setting up a federation, and have offered to attend the implementation group to discuss how federations have worked elsewhere in the patch. It was useful that the vote did eliminate one of the possible options of a second type of federation. GB Sec The committee noted the update on the GP federation. 046/16 Update on Co-Commissioning JC, Chief Operating Officer, gave a verbal update for the committee to note. JC summarised the update as follows: 27 practices voted in favour of co commissioning, which is a majority. The CCG will be making an application to NHSE for delegated commissioning by the beginning of December and has drawn up a proposal around the governance for that. Recruitment is imminent for additional resources to help with 10

11 delegated commissioning, and the Executive Team has approved this. The team met with NHSE last week for touch base on where at and past April there may be a shadow period for 3 months while we take on this role. Committee Questions/Comments: The LMG Chair noted that many members agreed with what their CCG leaders thought and the vote was really about when, not if, to take on co-commissioning. The LMC has moved from being slightly hostile to ambivalent around the idea. Co-commissioning has potential to do good, but also some potential to cause trouble, especially when there is a CCG that hasn t been clear on their plans for general practice. If there is good practice for co-commissioning, we will support it as long as the members agree with it. The update on co-commissioning will also be a standing item going forward. It will be important to see how quality and performance is monitored and how the information might be used when performance managing primary care. Action: The Governing Body Secretary is to ensure there is an update on co-commissioning at future committee meetings. The CCG is heading into another cultural change towards openness and it is important to do this this in a sensible way. We have been challenged on how we could foresee quality issues in practice. We can only foresee issues by being provided with information from GPs and having transparency and collaborative working so we can target, support, and help. There will be some cultural challenges to resolve. There will be a quality primary care dashboard. This will allow us to see what information we already hold rather than reinventing the wheel. It will be more systematic. The CCG will be relying on the LMG chairs to engage with their peers to support co-commissioning and help with the cultural challenges. The committee noted the update on the Co-Commissioning. GB Sec 047/16 Approved Minutes from the Primary Care Transformation Board The committee noted the minutes from the Primary Care Transformation Board. 048/16 Any Other Business Mike Holdgate, Lay Member for Patient and Public Participation will chair the next meeting due to the absence of JO and DS. It was agreed that a GP would be present at all future meetings of the committee. Action: The Governing Body Secretary is to ensure there is a GP rep at all future committee meetings GB Sec 049/16 Dates and Venues of Future Meetings 22nd November 16 24th January 17 28th March 17 11

12 12

13 Matters Arising/Action Matrix Template Agenda Date Item Item Title Action Required Member to Action 24th Nov MS to include wording which describes the co chair role and action Complete Status 26th July 16 34/16 LCS innovations proposal The Locally Commissioned Outcomes Framework to come back to the next meeting ME September meeting Comments On November Agenda 26th July 16 35/16 27th September 16 44b/16 LCS innovations proposal - diabetes prevention programme LCS Innovations Proposal- Young Person' Support Service 27th September 16 45/16 Federations Update 27th September Update on cocommissioning 16 46/16 27th September 16 AOB Further detail to be provided on costs, how the impact is going to be measured over the next year against the years project. Plus what the supervision management arrangements will be. ME Monday 1st August KS and RH to work with Director of Delivery and Performance and CFO on further development of performance and financial benefits. ME Not Started The Governing Body Secretary is to ensure there is an update on Federations at future committee meetings. GB Sec On-going The Governing Body Secretary is to ensure there is an update on co-commissioning at future committee meetings GB Sec On-going The Governing Body Secretary is to ensure there is a GP rep at all future committee meetings GB Sec On-going Completed Meeting administrators are to keep one "master" copy of the Action Log- adding new lines onto the bottom of the table as each meeting is held, and continuing to update actions as they are completed. A reduced version of the master spreadsheet, showing only those actions still outstanding/ongoing/for inclusion on that meeting's agenda, should be included within each set of meeting papers. The Chair should go through the Action Log and ask for a verbal update against each outstanding item at the start of each meeting, once the minutes have been agreed. 13

14 14

15 Name of Meeting: Primary Care Commissioning Committee Date of meeting: 22/11/16 Item Number: 55/16 Title of report: Locally Commissioned Services (LCS) Performance against Budgets at Q2 Recommendation: The Primary Care Commissioning Committee is recommended to note the current reported position for the Locally Commissioned Services (LCSs) at Q2 of 2016/17. Summary: Actual spend at Q2 is reported against current indicative budgets. The overall position for proactive care is also presented for information. Work continues to reflect planned changes to LCS budgets. Four LCS have been targeted to be delivered at a cluster level to ensure city-wide coverage. Estimated activity reflecting this change is shown in table 2 as costs still need to be finalised. Budgets will be updated to reflect appropriate costs once prices are agreed. 15

16 Sponsor: Pippa Ross-Smith Chief Finance Officer Author: Cherry Cozens Date of report: 11/11/16 Review by other committees: n/a Health impact: n/a Financial implications: As noted in this report Legal or compliance implications: In compliance with SFI/SOs Link to key objective and/or assurance framework risk: n/a Patient and public engagement: n/a Equality impact assessment completed: Underpins the Operating Plan 16

17 LCS Update: Table 1 The first section of Table 1 shows the budget and expenditure by LCS for 2016/17. The actual amounts claimed for April to September are compared to the budget for the first six months of the year and an estimated year end forecast position based on arrangements as set out in the current contract is shown. For a number of LCSs we do not yet have sufficient information to inform a year to date position, the forecast year end expenditure assumes that activity levels will remain in line with those provided in 2015/16. In total the LCS budget remains underspent, but in the context of the 2017/18 and 2018/19 planning round, all the LCSs are being reviewed to ensure that they are delivering, that their KPIs remain relevant and that their budgets are appropriate. Spend on diabetes and drug monitoring continue to grow in line with national data. COPD, SMI, Palliative have which have all historically had a relatively low take up are being targeted as part of the new LCS contract. The specification for COPD is changing and the forecast assumes this will increase take-up to around 80% of budget. The Children s LCS payment is based on a fixed sum per practice and will therefore be less than expected due to practice closures. This same data is presented below by cluster, for information only. As Proactive Care makes up a large part of the budget, a breakdown of the costs against budget is also presented. Table 2 The plan for the LCS contracts is to encourage delivery by Clusters to improve the citywide coverage for patients, thereby improving their health outcomes. The contracts are being restructured and four LCSs, where the treatment involves more than just a simple test which is counted for payment, have been targeted. The aim eventually is to match or exceed the national prevalence of treatment for each of these LCSs. However we recognize that this will take time, and are therefore aiming in the first year to reach a position where each cluster overall, performs at the level of the best practice within that cluster. We are still in the process of agreeing the costing for the new contract and have therefore focused on activity for this report. Once prices are finalised planned and estimated costs will be included in future reports. The table shows the projected activity with 2015/16 activity numbers being the actual as claimed by the practices, while the 2016/17 columns show the estimates if a) performance remains at normal practice level and b) with the adoption of cluster-working all perform as well as the best within their cluster. 17

18 Table 1 LCS Spend - 16/17 at Quarter 2 Budget Budget Year to date Q1& Q2 Spend Variance Year to date Forecast 16/17 Forecast Variance Phlebotomy 290, , ,320 (14,173) 288,903 (2,082) Diabetes Care Plans 234, , ,060 5, ,425 24,230 Ambulatory BP 60,286 30,143 25,610 (4,533) 51,220 (9,066) Drug Monitoring 58,856 29,428 41,466 12,038 82,932 24,076 Rabies Domestic Phlebotomy 12,899 6,450 2,606 (3,844) 5,212 (7,687) Wound Care 434, , ,496 3, ,993 6,028 Intermediate Care (53) 72 (178) COPD 52,700 26,350 5,540 (20,810) 42,160 (10,540) Serious Mental Illness 92,000 year end payment 73,600 (18,400) Young People 135,000 year end payment 119,659 (15,341) Palliative Care 76,000 year end payment 70,069 (5,931) reserve 42,828 will be used to top-up as required 0 (42,828) sub-total 1,491, , ,590 (22,230) 1,434,085 (57,379) Proactive Care 2,489,491 1,244,748 1,119,742 (125,006) 2,233,892 (255,599) Total 3,980,955 1,817,568 1,670,332 (147,236) 3,667,977 (312,978) LCS Spend by Cluster - 16/17 at Quarter 2 Please note - this EXCLUDES Proactive Care as there is currently a high volume of accruals representing estimated values for missing invoices. If this was reported at cluster level it would be difficult to ensure that the figures accurately reflected individual cluster costs. Budget Budget Year to date Q1& Q2 Spend Variance Year to date Forecast 16/17 Forecast Variance Cl us ter 1 217, , ,626 3, ,018 4,763 Cl us ter 2 178,958 89,479 89,094 (385) 182,882 3,924 Cl us ter 3 182,910 91,455 87,563 (3,892) 186,921 4,011 Cl us ter 4 165,605 82,803 89,108 6, ,236 3,631 Cl us ter 5 181,931 90,966 47,148 (43,818) 185,920 3,989 Cl us ter 6 218, , ,051 15, ,779 4,801 TBC 303,000 year end payments 263,328 (39,672) Reserve 42,828 will be used to top-up as required 0 (42,828) Total 1,491, , ,590 (22,230) 1,434,084 (57,381) Proactive Care Spend - 16/17 at Quarter Budget Budget Year to date Q1& Q2 Spend Variance Year to date Forecast 16/17 Forecast Variance Collaborative working 286, , ,233 (1,242) 243,213 (43,736) GP cos ts 1,083, , ,540 (130,349) 803,754 (280,024) Care Coachs 407, , ,842 6, ,163 43,806 Project Mgmt & Leadership 455, , ,647 (0) 455,293 (0) Care Planning software etc 48,907 24,454 24, ,907 0 Risk Stratification (Sollis) 60,000 30,000 30, , set up costs/integration/training 43,757 21,879 21, , MDTs - BSUH 37,343 18,672 18,626 (46) 37,252 (91) MDTs - volutary sector 10,800 5,400 5, ,000 13,200 Vol Sector Engagement 55,308 27,654 27,554 (100) 66,000 10,692 Primary Care Total 2,489,491 1,244,748 1,119,742 (125,006) 2,233,892 (255,599) Clusters 1 & 4 currently have no GP 18

19 Table 2 SUMMARY OF ESTIMATED LCS TARGET ACTIVITY This tabel illustrates activity levels for the four LCS to be delivered at cluster level a Activity 15/16 Activity Apr- Sep 2016 Business As Usual Estimated Total Activity 16/17 Clusterworking Estimated Additional over final 4months of 16/17 b Clusterworking Estimated Total Activity 16/17 Diabetes - care plans cluster cluster cluster cluster cluster cluster Total Diabetes - care plans COPD -additional tests cluster cluster cluster cluster cluster cluster Total COPD -additional tests SMI - patients treated cluster cluster cluster cluster cluster cluster Total SMI - patients treated Palliative - patients on recluster cluster cluster cluster cluster cluster Total Palliative - patients on register

20 20

21 Name of Meeting: Primary Care Commissioning Committee Date of meeting: 22 nd November 2016 Item Number: 58/16 Title of report: LCS Innovations proposal maximising the impact of NHS Health Checks Recommendation: The Primary Care Committee is asked to approve the business case for the proposed project. Summary: The NHS Health Check programme is a mandated public health service. It consists of a systematic vascular risk assessment and management programme to help prevent cardiovascular diseases (CVD) including heart disease and stroke, as well as diabetes, dementia and kidney disease. Its aim 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. Evidence shows that offering an NHS Health Check to people between the ages of 40 and 74, and recalling them every five years is both clinically and cost effective. Each year in England NHS Health checks are thought to prevent 1,600 heart attacks and save at least 650 lives; prevent over 4,000 people from developing diabetes and detect at least 20,000 cases of diabetes or kidney disease allowing people to manage their condition and prevent complications. 1 The estimated cost per quality adjusted life year (QALY) is approximately 3,000 2, well below the 20,000 cut-off often used to guide cost-effectiveness by the National Institute for Health and Care Excellence (NICE). 2 The NHS Health Check can be divided into three parts: cardiovascular risk assessment; communication of that risk; management of that risk through referral to health improvement and lifestyle services and medication. We know that individuals who reside within the areas of highest deprivation have the highest risk of morbidity and premature mortality from cardiovascular disease. 3 Within cluster 4, 17.8% of the population live within the most deprived 20% of areas of England. 7 This innovations proposal will address all three of the areas of the health check mentioned above in the most deprived quintile. This will optimise the value of the NHS Health Check and work towards reducing health inequalities and ultimately aim to reduce premature mortality in the cluster. This case proposes the funding of a full-time band 4 coordinator who will work across Cluster 4. They will work primarily with the most deprived quintile of patients, maximising the impact of the NHS Health Check at all stages using innovative methods based on best evidence. If successful, this pilot has the potential to be extended across the City, with the aim that the role eventually is adopted as standard practice by clusters. The cost of this proposal is 30, 314 for a one-year pilot, and based on the NHS Health Checks Ready Reckoner 8 should prove cost-neutral at 5 years, with additional savings due to health promotion services (such as stop smoking and weight management services) not included in this calculation. The ultimate aim is to reduce the gap between the burden of cardiovascular morbidity and mortality in the most and least deprived residents in the cluster. 21

22 Sponsor: Katie Stead, Clinical Lead, Primary Care (LCS and Quality) and Public Health John Child, Chief Operating Officer Author: Rachael Hornigold, SpR Public Health Date of report: 31 st October 2016 Financial implications: 30,314 salary costs for one year pilot (based on 1 full-time band 4 agenda for change coordinator + 20% management costs). Note - Cluster 4 LCS innovations indicative budget is 126,714 per annum. Legal or compliance implications: Not applicable Link to key objective and/or assurance framework risk: NHS 5 year forward view: Facing particular challenges in areas such as mental health Radical upgrade in prevention and public health Hard-hitting national action on obesity, smoking, alcohol and other major health risks Brighton and Hove CCG 5 Year Strategic Commissioning Plan: Align our commissioning to the health needs of our population and ensure we are addressing health inequalities across the city Promote health and wellbeing, pro-actively identify and manage long term conditions and other illnesses NHS Outcomes Framework: Preventing people from dying prematurely Maximising the contribution that the NHS can make to preventing disease Finding the missing millions and diagnosing earlier and more accurately Treating people in an appropriate and timely way Addressing unwarranted variation in mortality and survival rates Ensuring people have a positive experience of care Sustainability and Transformation Plan (2016) Local focus on early diagnosis and prevention of cardiovascular disease and improving public awareness of NHS Health Checks. 22

23 LCS Innovations proposal improving access to NHS Health Checks 1. Background information The NHS Health Check programme is a mandated public health service. It consists of a systematic vascular risk assessment and management programme to help prevent cardiovascular diseases (CVD) including heart disease and stroke as well as diabetes, dementia and kidney disease. Its aim 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. The eligible cohort is people between 40 and 74 years of age who have no previous diagnosis of CVD and are not currently taking statins. The NHS Health Check is a 5 year rolling programme, with the aim 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. The NHS Health Check can be divided into three parts: 1. Cardiovascular risk assessment; 2. Communication of that risk; 3. Management of that risk through referral to health improvement and lifestyle services and consideration of statin and anti-hypertensive medication (see figure 1). Figure 1. The NHS Health Check. From NHS Health Check implementation review and action plan July

24 Evidence shows that offering an NHS Health Check to people between the ages of 40 and 74, and recalling them every five years is both clinically and cost effective. Each year NHS Health checks are thought to prevent 1,600 heart attacks and save at least 650 lives; prevent over 4,000 people from developing diabetes and detect at least 20,000 cases of diabetes or kidney disease allowing people to manage their condition and prevent complications. 1 The estimated cost per quality adjusted life year (QALY) is approximately 3,000 4, well below the 20,000 cut-off often used to guide cost-effectiveness by the National Institute for Health and Care Excellence (NICE). Cardiovascular disease is one of the conditions most strongly associated with health inequalities the burden of morbidity and mortality is disproportionately shouldered by the groups with the lowest socio-economic status. 3 Therefore steps have been taken both nationally and locally to target NHS Health Checks to those living in the areas of highest deprivation. Brighton and Hove background Brighton & Hove has significantly higher mortality rates from preventable causes than England as a whole and also than the South East region as a whole. 5 Around one third of all deaths in the city are in those aged years. For many people under 75 years, deaths related to three key diseases (cardio-vascular disease (CVD), chronic obstructive pulmonary disease (COPD) or diabetes) can be prevented or averted. It is estimated that there are up to 20,000 people aged 40 to 74 in Brighton and Hove at high risk of developing CVD in the next ten years. 5 The Preventing Premature Mortality Audit (PPMA) was undertaken in an attempt to understand the high mortality rates in Brighton and Hove. It was found that there was a large variation in premature mortality rates within areas of the City, with a link to levels of deprivation. 6 Additionally, premature mortality was also linked to lifestyle; with rates of smoking, alcohol use and obesity significantly higher in those who had died prematurely. 6 Contact with secondary care services was high in individuals who had died prematurely, with 60% having a hospital inpatient admission in the two years prior to their death. Around one in three people dying from CVD were not on a disease register, which implies that they may have been missing out on preventative care. 6 The NHS Health Check offers an opportunity to identify individuals who are at a higher risk of premature mortality and to offer clinical and lifestyle interventions to try and mitigate this risk. However, in order to succeed in this respect, those most at risk need to: 1. Be invited to and attend the check to have a risk assessment 2. Have that risk communicated to them appropriately 3. Be offered risk management (medication where appropriate, referral for health improvement services). Health Checks in Brighton and Hove From April 2015, the NHS Health Checks programme in Brighton and Hove has been predominantly based within primary care. Practices offer checks via a systematic invitation system to all eligible adults registered with a GP. In addition to the standard fee, an additional payment is also made for referrals to health improvement services. A number of additional measures are already in place to attempt to address health inequalities in Brighton and Hove, by targeting those in the most deprived quintile (based on 24

25 postcode). An increased payment is made in addition to the standard payment for a health check delivered to those living in the most deprived part of the city. A community outreach service is currently run by the Trust for Developing Communities to support practices to deliver NHS Health Checks and follow up target populations, targeting the most deprived areas, this is currently a part-time role covering the whole city. A community nursing service is also commissioned by Brighton & Hove City Council, to offer the NHS Health Check in locations outside of primary care. In 2015/16 there were 72,981 individuals eligible for an NHS Health Check in Brighton and Hove. A total of 8287 (11.4%) were invited, below the 20% target, and 4859 (6.7%) received a Health Check. This compares to 17.4% invited and 8.5% received in the South East in the same time period, and 18.8% invited and 9% in England as a whole. 7 There is a wide variety in practice delivery of Health Checks throughout the City, as can be seen in the anonymised chart below: Figure 2. Number of Health Checks delivered per GP practice in Brighton and Hove, 2015/16. Cluster 4 practices indicated with black dot (From Public Health Intelligence, Brighton and Hove City Council, August 2016) In 2015/16 in Cluster 4, 13,463 individuals were identified as being eligible to receive an NHS Health Check. The target was therefore for 2693 individuals to be invited (20%) and 1346 health checks to be carried out (10 %). A total of 187 individuals were invited (1.4% of eligible) and 142 attended. 6 Within the same time period, the cluster delivered the majority of their health checks to the least deprived quintile, with only 15% (9) delivered to the most deprived quintile. 7 For those checks that were delivered, there have been minimal recorded referrals to health improvement services, none in quarter 2 of It is clear that there is an issue with the number of invitations being sent for an NHS Health Check, both across the City, and particularly in Cluster 4. However, steps have been taken to address this. As part of the new Locally Commissioned Services contract, all clusters have signed up to performing NHS Health Checks as per their Cluster Action Plans, due to 25

26 commence in November 2016, with the aspiration to reach the national target for invitations and attendances. Cluster 4 have prioritised NHS Health Checks, and are working to increase their capacity to deliver health checks across the cluster. However, in order to fully maximise the benefits of the NHS Health Check, it is essential that not only is the check undertaken and risk assessed; this risk needs to be communicated appropriately and risk management offered following the check. Current targets, both nationally and locally, predominantly involve inviting people for and delivering health checks, however many local stakeholders are concerned with what happens next. Is the check effective in not only identifying risk but also communicating it appropriately and providing help for people to make lifestyle changes to reduce their risk of cardiovascular disease? There are a number of preventative services and lifestyle interventions that are already commissioned by the CCG and County Council, including: stop smoking services; weight management; exercise referrals; health trainers; alcohol services and the NHS diabetes prevention programme. It is through ensuring that these services are made accessible following a health check, particularly in the higher deprivation groups, that we can really optimise the impact of the NHS Health Check. Although a financial incentive is made to refer to health improvement services following the health check ( 2 additional payment per check if a referral/s made following a health check), we know that referral rates across the City remain low. In quarter 2 of 2016, 828 health checks were delivered and only 14 health improvements referrals were claimed for, none in Cluster 4. The management of risk by prescribing antihypertensive medication and statins also appears to be under-utilised. We have no accurate measure of this in Brighton and Hove; however national figures indicate that only one in five people who would benefit from these medications are actually prescribed them following an NHS Health Check Current position and case for change Cluster 4 have now expressed that a key cluster priority is to increase the number of NHS Health Checks delivered. They have signed up to the specification for the Public Health Commissioned LCS for NHS Health Checks, which specifies the national targets above and this commences in November However they wish to go further in tackling cardiovascular health inequalities in the cluster. There is concern within the cluster that simply inviting individuals for their NHS Health Check in the standard way will not be sufficient to make a significant impact on patient outcomes. In order to fully maximise the health benefits of the NHS Health Check for patients in the most deprived areas of Cluster 4, all three areas of the health check need to be addressed. This innovations proposal will tackle all three parts of the health check (risk assessment; communication of risk; risk management) in the most deprived quintile to optimise the value of the NHS Health Check and ultimately work towards reducing premature mortality in the cluster, and in Brighton and Hove. 3. Proposed change This aim of this business case is to optimise the NHS Health Check as a vehicle to reduce health inequalities in Cluster 4, in response to the Preventing Premature Mortality Audit. If successful the model could be rolled out in other clusters across the City. This case is for an initial one year pilot, and lessons learnt during this time should allow education and training of 26

27 staff delivering the health checks in practices, to eventually help this model become part of normal practice in the long-term, promoting sustainability within general practice. The case proposes the funding of a full-time band 4 co-ordinator who will be employed by a practice within Cluster 4, working across all practices in the cluster. They will be IT literate and prepared to work with Cluster 4 on new innovative IT solutions that may be trialled during the pilot. They will be offered training on motivational interviewing to support their practice. Their role will be to optimise all three parts of the NHS Health Check for those within the most deprived quintile in Cluster 4: 1. Be invited to and attend the check to have a risk assessment Eligible individuals in Cluster 4 will be invited for a health check as per standard practice, however this will be augmented for those in the most deprived groups by the co-ordinator with primers (a phone call, text message or other contact before invitation is sent) and follow-up to those who have not booked an appointment (a phone call, text message or other contact after invitation is sent.) These techniques have been investigated by the Behavioural Insights Team at Public Health England and been shown to be effective in increasing attendance at the NHS Health Check by up to 21%. 8 The post-holder will maintain a register of those in the most deprived quintile who have been offered a health check and the outcomes. The coordinator will also be able to deliver the first part of the check over the phone, for example for those in the most deprived quintile who have not attended following their first invitation. This again has been piloted in the UK and has been shown to increase the attendance rate and also make the health check appointment shorter/allow more time for communication of results. The coordinator will also liaise with local community resources, such as Food Banks, Sure Start Centres and voluntary services to increase the awareness of NHS Health Checks in the local population. They will attend community events to promote the service and increase awareness, using their local knowledge. They will work closely with other commissioned services, such as the National Diabetes Prevention Programme Co-ordinators (LCS innovations funded), community navigators, the Homeless team and drugs and alcohol team to ensure those most vulnerable have access to a health check. For those unable to access health checks at their GP practice, the coordinator will liaise with the Community Outreach nursing team to arrange a health check in an appropriate place outside of general practice. They will follow up on invitations with personalised messages and calls and work with individuals to reduce any barriers to attending the health check. They will use the qualitative research commissioned by Brighton and Hove County Council (see appendix) to identify an remove barriers that we know may prevent the most vulnerable groups from attending a health check. They will also ensure that actions and recommendations following the health check are taken, such as liaising with smoking cessation, Brighton and Hove food partnership, Pavilions etc. They will interlink the patient and the surgery with community navigators, care coaches and health trainers and organise regular, timely communications from the surgeries to the patient so that the NHS Health Check is seen as a part of a continuum of ongoing health care. The post-holder will also be required to undertake regular audit to evaluate the impact of the service. This case is initially for a one year pilot to assess the impact across the cluster on invitations and checks delivered and patient experience and outcomes following the NHS Health Check. 27

28 2. Have the risk communicated to them The coordinator will have a role to ensure that any risk identified in the health check is appropriately communicated to the individual. This will involve close working with those delivering the checks to ensure that all efforts are taken to communicate the risk, particularly with those who have additional communication needs. They will work with local commissioned services, such as Advocacy services, translators and peer support to ensure that additional needs are anticipated and organised. They will also work to evaluate how the risk is communicated during the health check appointment, for example by surveying those who have had a health check to identify any areas of risk communication that need further work. 3. Be offered risk management (medication where appropriate, referral for health improvement services) The coordinator will work with the health check provider and patient to ensure that medication and referrals are made where appropriate, ensuring that all professionals delivering the service in the cluster have a good knowledge of the local services they can refer to. They will collect details of quintile 5 patients who have undergone a health check and the outcome. Where medication is advised, they will check that a GP appointment has been made, and if the medication has not been started they can work with the individual to ensure that they have enough information to inform this decision. Where a health improvement service is recommended, they can work with the person delivering the check, the individual and the health improvement service to remove barriers to attendance, such as the use of a heath trainer for someone who is house-bound. They will use their motivational interviewing techniques to encourage attendance and also keep track of outcomes to help evaluate the service, such as changes in cardiovascular risk due to reduced BMI, blood pressure or stopping smoking. 4. Performance and activity Key performance indicators will be: Number of primer and follow-up calls to those invited from most deprived quintiles Attendance of those contacted above to the NHS Health Check Number of partial health checks delivered by co-ordinator (prior to NHS Health Check appointment) Number of individuals commenced on medication and/or referred to and attending health improvement services as a result of the NHS Health Check The following will also be measured: Number of NHS Health checks delivered in Cluster 4, and proportion in most deprived quintile Education and training sessions attended and delivered. Patient reported outcome measures following contact with the co-ordinator and after the health check process 28

29 Outcomes following attendance at health improvement services, such as stopping smoking, reduction in BMI etc. Proposed activity targets (monthly) priming and following up invitations for most deprived quintile (based on 50% of Cluster 4 target of 1800 health checks in 12 months, targeting most deprived quintile) Month Number of managed invitations to quintile 5 Cumulative invites Feb Mar Apr May Jun Jul Aug Sep Oct Noc Dec Jan Referrals will be monitored, initially monthly, and measured against the above targets. The number of completed NHS Health Checks will also be monitored monthly. The post-holder will also maintain a register of those in quintile 5 invited for an NHS Health Check and ensure they follow-up if they do not attend, ensure risk is communicated effectively where appropriate, and that they are offered appropriate risk reduction measures. 5. Expected costs, savings and benefits Spend - Band 4 Agenda for Change coordinator = 30,314 per annum (Base salary is mid-point band 4: 21,052 [from Health Careers NHS UK], plus 20% for NI, pensions contributions, plus 20% management costs to include clinical supervision etc, line management etc.) Training time is included within normal working hours; training courses such as motivational interviewing are provided free by local providers (e.g. Pavilions). 29

30 Investment (+) Brief Description Band 4 coordinator plus 20% managemen t costs) Provider Practice in cluster 4 Planned Start Date* 16/17 17/18 18/19 20/21 21/22 22/23 Feb ,261 Costs (+) (cumulative) ,314 30,314 30,314 30,314 30,314 Potential savings (-) ,465 (cumulative) Net savings (-) (cumulative) Potential savings (Using NHS health checks ready reckoner for Brighton and Hove) 8 It is difficult to fully evaluate the potential savings of this proposal to the CCG in a concrete way as its main function is reduce health inequalities and prevent premature deaths from cardiovascular disease these are hard to measure as short-term savings. However the NHS Health Checks ready reckoner is a location specific tool that does attempt to demonstrate some relatively short-term benefits. 8 The assumption is that this model leads to an additional 675 health checks being delivered in a year in the cluster (75% of those pro-actively engaged by the coordinator). In the first year following an NHS Health Check, estimated savings for 675 checks delivered in Brighton and Hove is In the fifth year following the check, this rises to a total of 33,465 (cumulative) when this proposal should prove cost-neutral. The savings are based on the estimated strokes, heart attacks, amputations due to diabetes, blindness due to diabetes and renal replacement therapy due to diabetes and the early diagnosis of chronic kidney disease that will be prevented as a result of the interventions put in place following the NHS Health Check. No estimate of the savings due to weight loss programmes and increase exercise are included in the estimates due to insufficient robust evidence on the financial impact of these interventions. This is likely to mean that the estimated savings are conservative. All prices are also for 2010/11, therefore 2022/23 are likely to be higher due to inflation. Other benefits Additional benefits of this service are potentially large, and particularly aim to reduce health inequalities within the cluster. It is hard to fully predict the short-term financial savings of this proposal (see above) but long-term the NHS Health Check is predicted to provide significant benefits to the nation s health and subsequently to the NHS and other services, hence its position as a mandated service nationally. The targeted approach to the most deprived population should help to address issues raised in the Preventing Premature Mortality Audit. 30

31 This project will allow for the development of knowledge of NHS Health Checks and motivational interviewing within the Cluster. It will pilot innovative methods of managing health checks to ensure the greatest value for money such as having the administrator partially delivering the check. 6. Patient and public engagement The proposal has been discussed with the Community Outreach Worker who works alongside vulnerable groups. He is fully supportive of the proposal as their advocate. In 2015 Brighton and Hove CCG and Brighton and Hove City Council asked excluded groups to gather intelligence around the Health checks programme within the city, looking specifically at the reasons why people are perhaps not accessing this preventative service and how it can be improved this feedback has been utilised in the development of this business case. (see full report in appendix of full business case). 7. Stakeholder engagement Meetings have been held with the following stakeholders, all of whom are supportive of the proposal: Victoria Lawrence Commissioner for NHS Health Checks, Brighton and Hove CC; Peter Sutcliffe Community Outreach Worker for Health Checks; Rick Jones Practice Manager lead for Cluster 4. The proposal has been discussed at the Health Checks Steering Group, and also with the Public Health England Health Checks lead (South East). 8. Delivery plan Proposed timings: LCS business case approval: CSG, PCC November 2016 Recruitment and Governance Develop JD and person Specification, agree management and governance with cluster, recruitment December 2016/Jan 2017 Band 4 coordinator in post, training and induction Feb 2017 Managed invitations, database, follow up and evaluation of role and service start Feb 17. Evaluation will be built into this project from the start. The post-holder will be responsible for keeping up-to-date records of numbers of individuals invited, followed up and attended. This data is also available to the CCG via the CSU and claim forms, and will be monitored quarterly by the Commissioner for NHS Health Checks (currently Victoria Lawrence) comparing target data with actual outcomes. Patient reported outcome measures will also be reported to the Commissioner on a quarterly basis. Sponsor: Katie Stead, John Child 31

32 Date: 31/10/2016 References 1. Public Health England, NHS Health Check implementation review and action plan. NHS_Health_Check_implementation_review_and_action_plan.pdf [accessed 31/10/16] 2. Department of Health, 2008.Economic Modelling for NHS Health Checks. +for&x=0&y=0 [accessed 9/8/16] 3. Heart UK. Bridging the Gaps: Tackling inequalities in cardiovascular disease _cardiovascular_disease.pdf [accessed 31/10/16] 4. Department of Health, 2008.Putting Prevention First Vascular Checks: Risk Assessment and Management. [accessed 9/8/16] 5. [accessed 9/8/16] 6. Preventing Premature Morbidity Audit. J Simpkin et al. _Tackling_premature_mortality_in_Brighton_and_Hove.pdf [accessed 9/8/16] 7. Data Intelligence, Public Health Department, Brighton and Hove City Council se/ [Accessed 9/8/16] 9. John Robson, Isabel Dostal, Aziz Sheikh, Sandra Eldridge, Vichithranie Madurasinghe, Chris Griffiths, Carol Coupland, Julia Hippisley-Cox. The NHS Health Check in England: an evaluation of the first 4 years. BMJ Open 2016;6:1 e doi: /bmjopen

33 LCS Innovations proposal maximising the impact of NHS Health Checks Business Case Purpose: This is a living document to be used during the planning and delivery of all programmes/ projects. See the 7 Steps for Planning Success for more information on development and sign-off. Owners Author / Commissioner: Clinical Lead: Executive Sponsor: Rachael Hornigold Katie Stead John Child Amendment History Version Date Author Details of Amendments 1.0 9/8/16 RH 2 31/10/16 RH Following CSG Last Updated: April

34 Business Case & Options Appraisal Table of Contents SECTION ONE: PLANNING Executive Summary Introduction Current Position & Case for Change Proposed Change Strategic Context Performance, Activity & Finance Performance & Activity Finance Expected Benefits High-level Benefits Detailed Benefits Quality Impact Assessment Enablers for Design, Development & Delivery Clinical Informatics Requirements Patient & Public Engagement Medicines Management Procurement Options Contract Options Stakeholder and Public Communications Options & Investment Appraisal Risk CCG Resource Requirements Delivery Plan Evaluation Plan Conclusion & Recommendations SECTION TWO: POST-DELIVERY END PROJECT REPORT Summary of Performance Lessons Learned Risk Summary of Recommendations

35 SECTION ONE: PLANNING Initiation Checklist Business Case & Options Appraisal This checklist has been designed to enable you to access support in initiating a project. Using information on this form, the Programme Management Office (PMO) will convene a matrix project team that will support the development of the Business Case. As a guide, this checklist should take no longer than two days to complete. All sections of this table must be completed before sign off, as evidence of the involvement of key teams in the production of this Business Case. Function / Area Lead Name Details of Input Required& Date Business Intelligence Vincent Hau Public Health Rachael Hornigold Finance Cherry Cozens Clinical Informatics DRG Quality Katie Stead Communications Engagement Jane Lodge Procurement Contracting Planning, Delivery and Evaluation Carl Burns Supporting Documents Document Title Required For File Location Date & Details Equalities Impact Assessment (EIA) 2 nd Level Quality Impact Assessment (QIA) 2 nd Level Privacy Impact Assessment (PIA) 2 nd Level Sign Off Log All Business Cases must be signed off by the relevant committee to approve the clinical model and associated finances respectively. The PMO Support Group should be convened at the start of developing the Business Case to help with its completion and coordinate input from specialist areas. No Business Case will be authorised for approval by P&G without a preceding PMO Support Group. Level Version 1 Approval Group Date Details of Approval 1 st Level Sign-off (Outline) CSG SMT 2 nd Level Sign-off (Full) PCC 1 Refer to Amendment History on cover sheet 2 35

36 Business Case & Options Appraisal 1. Executive Summary Summary: The NHS Health Check programme is a mandated public health service. It consists of a systematic vascular risk assessment and management programme to help prevent cardiovascular diseases (CVD) including heart disease and stroke, as well as diabetes, dementia and kidney disease. Its aim 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. Evidence shows that offering an NHS Health Check to people between the ages of 40 and 74, and recalling them every five years is both clinically and cost effective. Each year in England NHS Health checks are thought to prevent 1,600 heart attacks and save at least 650 lives; prevent over 4,000 people from developing diabetes and detect at least 20,000 cases of diabetes or kidney disease allowing people to manage their condition and prevent complications. 1 The estimated cost per quality adjusted life year (QALY) is approximately 3,000 2, well below the 20,000 cut-off often used to guide cost-effectiveness by the National Institute for Health and Care Excellence (NICE). 2 The NHS Health Check can be divided into three parts: cardiovascular risk assessment; communication of that risk; management of that risk through referral to health improvement and lifestyle services and medication. We know that individuals who reside within the areas of highest deprivation have the highest risk of morbidity and premature mortality from cardiovascular disease. 3 Within cluster 4, 17.8% of the population live within the most deprived 20% of areas of England. 7 This innovations proposal will address all three of the areas of the health check mentioned above in the most deprived quintile. This will optimise the value of the NHS Health Check and work towards reducing health inequalities and ultimately aim to reduce premature mortality in the cluster. This case proposes the funding of a full-time band 4 coordinator who will work across Cluster 4. They will work primarily with the most deprived quintile of patients, maximising the impact of the NHS Health Check at all stages using innovative methods based on best evidence. If successful, this pilot has the potential to be extended across the City, with the aim that the role eventually is adopted as standard practice by clusters. The cost of this proposal is 30, 314 for a one-year pilot, and based on the NHS Health Checks Ready Reckoner 8 should prove cost-neutral at 5 years, with additional savings due to health promotion services (such as stop smoking and weight management services) not included in this calculation. The ultimate aim is to reduce the gap between the burden of cardiovascular morbidity and mortality in the most and least deprived residents in the cluster. 3 36

37 Business Case & Options Appraisal 2. Introduction Background information The NHS Health Check programme is a mandated public health service. It consists of a systematic vascular risk assessment and management programme to help prevent cardiovascular diseases (CVD) including heart disease and stroke as well as diabetes, dementia and kidney disease. Its aim 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. The eligible cohort is people between 40 and 74 years of age who have no previous diagnosis of CVD and are not currently taking statins. The NHS Health Check is a 5 year rolling programme, with the aim 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. The NHS Health Check can be divided into three parts: 1. Cardiovascular risk assessment; 2. Communication of that risk; 3. Management of that risk through referral to health improvement and lifestyle services and consideration of statin and anti-hypertensive medication (see figure 1). Figure 1. The NHS Health Check. From NHS Health Check implementation review and action plan July