Service Specification Cardiovascular Risk Assessment Health Check Programme Release: Draft Date: 19/01/11 Author: Lynne Shaw CVD Primary Prevention Programme Manager Owner: Tony Morkane Director of Public Health Erewash Document Reference: Health Check Service Specification (v2.4) 1 of 18
Document Information Document location : This document is only valid on the day it was printed. Document source: Primary Care Commissioning \Fairer Funding Implementation \ Specifications Authorship: This document has been prepared by: Name Designation Organisation Lynne Shaw CVD Primary Prevention Programme Manager NHS Derbyshire County Revision history: The current version of this document supersedes all previous versions. Revision date Summary of changes Dec 2010 Document updated for fairer funding and clinical quality elements 2.2 updated. 15 Dec 2010 Amendment following final Clinical Reference Group review 2.3 19/01/11 Amendment following further scrutiny by CRG members 2.4 Version Approvals: This document requires the following approvals: Name Jackie Pendleton Tony Morkane Designation Assistant Director of Commissioning : Primary Care Director of Public Health Distribution: This document has been distributed to: Recipient Date of Issue Version 2 of 18
Date for Service Specification to be reviewed: Date of review Name Designation and Organisation November 2010 Karen Martin Clinical Quality review and input January 2011 Include DH Health Check minimum data set Update if finance situation is clear Update blood sample method if required March 2011 Update from guidance issued by DH 3 of 18
Contents: Section Page Document information 2 1 Introduction 5 2 Definition of service 5 3 Overall aims 6 4 Key objectives 7 5 Key outcomes 7 6 National context 8 7 Local context, demographics, needs 8 8 Service outline 8 9 Model for the service pathways / interfaces 11 10 Client group served / eligibility / access criteria 12 11 Exclusions 13 12 Quality targets 13 13 Output and outcome measure requirements 14 14 Service monitoring, evaluation and review 14 process / timescales 15 Workforce / staffing 19 16 Clinical and corporate governance 20 17 Policies / protocols / legal requirements 20 18 Appendices 20 19 References 21 4 of 18
1 Introduction: Cardiovascular disease (CVD) includes coronary heart disease (myocardial infarction, angina, revascularisation), stroke and TIA, diabetes, chronic kidney disease (CKD) and peripheral vascular disease (PVD). All are a significant cause of premature morbidity and mortality, contributing to inequalities in health. Vascular disease makes up about a third of the difference in life expectancy between spearhead areas and the rest of England. The cardiovascular diseases may present in different ways but all have very similar risk factors. The risk factors interrelate with each other and people with more than one risk factor have a greater probability of disease. In addition to individual characteristics such as increasing age and male sex, modifiable risk factors include poor diet, obesity, high blood pressure, lack of exercise, excessive alcohol consumption and smoking. Smoking is the most significant risk factor. In recent years more information has been obtained on risk factors for CVD and software developments have meant that a person s absolute risk can be calculated accurately using the different risk variables during a consultation. Risk is defined in terms of absolute risk, which is the probability of an individual having a cardiovascular event such as a stroke, heart attack or sudden death over a 10 year period. A high risk is considered to be a 20% chance i.e. a 1:5 chance of this occurring within 10 years. NHS Derbyshire County wishes to commission a primary care programme of CVD risk assessment or Health Checks (not to be confused with the Learning Disability Health Check) across the county. The Health Check Programme will operate as a practice based systematic programme (like a screening programme). Practices delivering the programme should be working towards being registered with the CQC and be compliant with the essential standards for quality and safety. The Derbyshire County Health Check programme fulfils the essential requirements of, and the timelines are consistent with the Department of Health (DH) NHS Health Check programme 1. It also includes an assessment of alcohol tolerance, motivation to change, and also atrial fibrillation in those over 65 years. It will increase the proportion of the practice population aged 40-74 years, for whom the CVD risk is known, enable practices to develop a CVD high risk register, provide opportunities to communicate healthy lifestyle messages to all those who engage with the programme and facilitate referral of patients requiring lifestyle interventions and/or medical intervention. 2.Definition of service: The DH expects all processes to be in place to ensure that people aged 40-74 years without existing CVD are being offered a Health Check every 5 years 5 of 18
from April 2012, unless they are already on a CVD secondary prevention register, or a related register. In Derbyshire County we are aiming to get the processes in place to meet this target during 2011/12. However, depending on the outcome of the National Spending Review and any future new guidance issued from the DH the programme may have to be modified in terms of the pace of the complete rollout across the County, and the priority given to the different risk groups The programme will initially focus on individuals who are at high CVD risk, using the QRisk2 10 year CVD risk score. Using an electronic QRisk2 CVD risk tool from The Computer Room (TCR) to identify eligible patients, general practices will initially invite all patients at or estimated to be at high CVD risk either by high risk order or using the following order: Male smokers aged 55-74 Male smokers aged 40-54 Male non-smokers aged 55 74 Male non-smokers aged 40-54 Female smokers aged 55-74 Female smokers aged 40-54 Female non-smokers aged 55 74 Female non-smokers aged 40 54 When all the high risk patients have been invited for a Health Check practices will invite the rest of the eligible population aged 40-74 years over the following four years. Individuals who following a Health Check, are found to be at high risk of CVD will be put onto a practice CVD high risk register and their risk factors will be managed appropriately. NHS Derbyshire County has developed a CVD High Risk Register Policy that is included in the Programme Handbook. 3 Overall aims: The aim of the programme is to reduce the morbidity and mortality from CVD and reduce health inequalities from these diseases. The programme is based on DH guidance (www.dh.gov.uk/publications) that is directed towards risk assessing the population aged 40-74 years and is in line with the 2008 NICE guidance on vascular risk assessment. The adoption of a healthy lifestyle and early detection of risk factors will not only directly impact on CVD premature morbidity and mortality over time but also will have a positive effect in mental health, overweight and obesity, reduction in prevalence of diabetes, reduced incidence of some cancers, and improved musculoskeletal function in older age. 6 of 18
The programme will ensure that Health Checks are performed in a consistent manner that meets the requirements of the DH NHS Health Check national programme. From 2012 onwards all people aged 40-74 years will be offered a Health Check every 5 years unless they are already on a CVD secondary prevention or related register, or following the Health Check Assessment have been found to be at high CVD risk. Patients found to be at high risk following the Health Check assessment will be put onto a practice CVD high risk register and will be provided with appropriate management of their risk factors through lifestyle improvement advice and support and/or pharmaceutical intervention. These individuals will exit the programme and not be recalled again for a Health Check. 4 Key objectives: Programme objectives:- 1. Every practice in Derbyshire County will provide Health Checks by trained members of staff (usually Health Care Assistants (HCAs)) by 2011/2012. 2. A Health Check will have been offered to 100% all high risk people aged between 40-74 years by April 2013. 3. An overall uptake of 75% of those people invited to attend for a Health Check. 4. All Health Checks are performed in a consistent manner and meet the NHS Health Check: Vascular Risk Assessment and Management Best Practice Guidance. 5. The provision of lifestyle support and clinical management as appropriate. 6. Collection and capture of Read Coded data to ensure an accurate evaluation of the programme. 7. Identification of hard to reach groups and development of initiatives to engage these groups. 8. Provision of a Health Check training programme. 9. Establishment of communication links and provision of update sessions for all staff managing the programme in primary care or performing Health Checks. 5 Key outcomes: Short/Intermediate Term 2013 1. All practices ensure that all eligible high risk patients are offered Health Checks. 2. Percentage uptake of those patients invited into the programme with a target of 75%. 3. Increased physical activity from referrals made as a result of the Health Check programme. 7 of 18
4. Reduce the prevalence of smoking for patients registered with GP practices by increased quit rate for people referred to smoking cessation programmes. 5. All high risk patients are placed on a CVD high risk register and managed appropriately. 6. Complete Read coded data capture of all clinical and lifestyle activity following a Health Check. Long Term 2013 2030 1. The CVD risk score will be known for 75% of the eligible population aged 40-74 years. 2. Reduction in emergency admissions for CVD. 3. Contribute towards reducing the County smoking prevalence to 10% by 2020. 4. Reduction in inequalities as determined by the CVD contribution to the Derbyshire Slope Index. 5. Reduction in mortality from CVD particularly the younger age group specific rates. 6 National context: The programme fulfils the essential requirements of, and the timelines are consistent with the DH NHS Health Check programme. The programme conforms to the Vital Sign Target of reducing mortality from CVD and reducing inequalities. 7 Local context, demographics, needs: The Joint Strategic Needs Assessment (JNSA) outlined the need for this programme and it is a commissioning priority for NHS Derbyshire County with an emphasis on reducing inequalities. CVD contributes to 34% of all deaths in Derbyshire. If the other smoking related diseases are included this increases to 50% of all deaths. The Health Check programme links well with other secondary prevention programmes eg cardiac and stroke rehabilitation programmes which are being commissioned in the County. 8 Service outline: NHS Derbyshire County will fund the computerised QRisk2 CVD risk tool download from TCR. The TCR tool will use clinical variables currently stored on the practice IT system to identify eligible patients with a calculated or estimated CVD risk score. Where the required clinical variables are not recorded, or where they were recorded more than 5 years ago, age and gender specific estimated data will have been inserted to calculate a CVD risk score. This is to ensure that people who may be at high risk of CVD are prioritised and invited for a Health Check first. 8 of 18
The TCR tool automatically excludes anyone who has already had an myocardial infarct (MI), angina, stroke or diabetes. These people will be being managed under secondary prevention protocols in the practice and should be on the relevant practice register. The practice will have the opportunity, and will be expected, to check that this is the case if these individuals are identified through the TCR tool. In addition in order to meet Vital Signs reporting requirements and in line with DH Best Practice Guidelines the TCR tool will exclude patients with hypertension, atrial fibrillation, a family history of hypercholesterolaemia and those prescribed statins from the lists of patients identified as being eligible for a Health Check. The responsibility for performing CVD risk assessments as part of the management of these patients lies with Primary Care. The practice will generate a list of eligible individuals without existing CVD with a calculated or estimated Qrisk2 CVD risk score. Uploading of the data will provide the PCT with the number of patients aged 40-74 years who require a Health Check. Practices will be expected to invite 100% of the eligible patients for a Health Check over 5 years ie 20% each year. Patients with a calculated or estimated high CVD risk score of 20% will be prioritised and invited for a Health Check first. Estimated activity, based on current national uptake would mean 37 Health Checks per 1000 weighted population per year. The Health Check assessment involves: Identifying lifestyle (eg smoking) and clinical risk factors (eg raised blood pressure and/or cholesterol). Giving information and advice, and signposting to lifestyle services. Referring high risk people whose blood pressure and/or cholesterol may require further investigation and management into the general practice. The clinical measurements taken are: Blood pressure BMI Waist circumference TC:HDL ratio Pulse rate and rhythm in patients aged 65 years and over In addition a BMI and blood pressure filter will be used to determine those people who are at high risk of diabetes: Fasting blood glucose on patients with a BMI of 30 (or 27.5 in individuals from the Indian, Pakistani, Bangladeshi, Other Asian and Chinese ethnic categories) or a blood pressure of 140/90 mm/hg (or where the systolic exceeds 140mm/Hg, or the diastolic exceeds 90mm/Hg) 9 of 18
The risk score is determined by putting the following clinical, physical and lifestyle measurements into an electronic QRisk2 risk calculator: Age (years) Sex Systolic blood pressure (mmhg) Total serum cholesterol HDL cholesterol Smoking within past year Social deprivation (Townsend Score) for the area of the practice BMI Family history of CVD in a first degree relative. Rheumatoid arthritis (based on GP diagnosis rather than any treatment) Chronic renal disease (based on GP diagnosis of CRD rather than any biochemical measurement) Type 2 diabetes Atrial fibrillation (based on existing GP diagnosis) The absolute risk score is calculated. An individual is considered to be at high risk when their absolute risk is 20% or greater. This means that they have a 1:5 chance of having a cardiovascular event over the next 10 years. Individuals found to be at high CVD risk following the Health Check assessment will be referred to a GP and/or provided with appropriate lifestyle advice. These patients will be entered as appropriate to the practice registers for hypertension, statins, and/or diabetes or added to the practice CVD high risk register for ongoing management their risk factors. Following the Health Check, some patients may not be at high risk and will be given healthy lifestyle advice and recalled for a Health Check in 5 years. NHS Derbyshire County has developed an electronic CVD template for practice IT systems that will take the risk assessor through the complete Health Check process. Information recorded using the CVD template will be Read Coded. Health Checks will be offered during the core hours of 0800-1830, however appointments should be offered at a variety of times including some outside of 0900-1700 so that people who work have a choice of clinics. Following implementation in each practice alternative strategies, including community based settings may need to be considered to assess hard to reach people. 9 Model for the service pathways / interfaces: This service will be delivered within a general practice setting. The Primary 10 of 18
Prevention CVD Care Pathway is attached to this document. (Appendix 1) NHS Derbyshire County will: 1. Provide an overview of the service and operation to the Practice Manager (or nominated representative) prior to commencement of the service. 2. Provide a set of bariatric scales and an electronic Omron sphygmomanometer. The practice will be expected to ensure that this equipment is maintained and calibrated, and to keep records of this. 3. Provide a POCT device and an initial supply of consumables. 4. Fund an Internal Quality Control and External Quality Assurance Scheme that will be facilitated by Derby Hospital Foundation Trust POCT Dept. 5. Provide one printed copy of the Programme Handbook. This contains all the information needed by the practice to undertake the CVD Programme. The practice will be notified by email when amendments have been made to the Handbook so that the updated sections can be downloaded from the CVD Sharepoint intranet site (http://share.derbyshirecounty.nhs.uk/sites/cvd/pages/default.aspx). 6. Organise and fund a Health Check training programme for practice staff (usually HCAs) who will be undertaking the Health Checks. There is a total of 7 days training. The first 4 days are basic CVD training and measurements. This is mandatory before any Health Checks are undertaken. There follows 2 days of Motivational Interviewing and 1 day of Equality and Inclusion training. These 3 days should be undertaken within 6 months of the 4 days of basic training and are independently certificated. 7. Fund an induction session in the practice following the CVD training in order for new practice staff to familiarise themselves with the practice procedures, IT system and Health Check template. 8. Provide an electronic CVD template (all data from the Health Check should be recorded using this template). The practice will: 1. Provide the necessary facilities to undertake a Health Check. This will include a room with a desk, chairs, wash hand basin and hand washing facilities, waste paper bin, clinical waste bin, sharps bin, gloves, height measure and tape measure, swabs and finger plasters. 2. On a monthly basis run the TCR CVD tool and upload the data to NHS Derbyshire County. 3. Follow the guidance for inviting people in for a Health Check and for following up non responders, as detailed in the programme Handbook. The practice will be expected to keep the Handbook updated. 4. Invite eligible patients into the programme by sending out 2 letters of invitation, followed by 2 telephone calls (at different times of the day). 11 of 18
5. Ensure that trained members of staff (usually HCAs) undertake the Health Checks. 6. Ensure that the staff undertaking Health Checks are aware of when it is appropriate and the procedures for referring people into the practice to see a GP or Practice nurse for clinical management of their risk factors. (The programme Handbook provides guidance regarding referring people into the practice but it is acknowledged that individual practice protocols may vary.) 7. Follow up people who do not attend their appointment. 8. Ensure that people found to be at high risk are put onto a CVD high risk register and their risk factors managed appropriately. The programme will involve blood tests done by near patient or point of care testing (POCT). POCT devices are to be compliant with internal and external quality assurance systems. NHS Derbyshire County will provide the POCT device and an initial supply of consumables. Information on how to order further supplies is provided in the Programme Handbook. The POCT Department Derby Hospitals Foundation Trust will provide ongoing training and facilitate internal and external quality assurance procedures for the near patient testing. This service will be funded by NHS Derbyshire County. 10 Client group served / eligibility / access criteria: The programme will be available to all people aged 40-74 years unless they are already on a CVD secondary prevention or a related register, have not had a Health Check in the past 5 years and who have not previously been found to be at high CVD risk as a result of a Health Check. People with established CVD ie those who have already had an MI, angina, stroke or have heart failure, diabetes or CKD stages 3-5 will not be included in the programme. These people will be being managed under secondary prevention protocols in practice and should be on the relevant practice register. In addition patients with hypertension, atrial fibrillation, a family history of hypercholesterolaemia and those prescribed statins will be excluded from the lists of patients identified as being eligible for a Health Check. The responsibility for performing CVD risk assessments as part of the management of these patients lies with Primary Care. Eligible people will be able to request a Health Check if they have not been called for an assessment, although the number of these requests is likely to be small. 11 Exclusions: Inclusion of people on the palliative care register will be at the discretion of the practice. (NHS Derbyshire County is waiting for further guidance from the DH.) 12 of 18
12 Quality targets: People will be sent 2 letters on invitation for a Health Check 4 weeks apart. If there is no reply to the second invite letter after 2 weeks 2 telephone calls will be made. These should be made at different times of the day, when the individual is most likely to be at home which may be early morning or early evening in the case of someone working. This will be monitored by undertaking an audit. Appointments will be offered at a variety of times including some outside of 9am-5pm. Maintenance of equipment Practices will undertake POCT internal quality assurance and external quality assurance procedures as instructed by The POCT Department Derby Hospitals Foundation Trust. The device will not be used if it does not meet the quality assurance (QA) standards. Instances of failure of the device to meet the QA standards are to be reported to the POCT Department Derby Hospitals Foundation Trust and no further blood test performed until the device meets QA standards or a replacement device is supplied. POCT consumables must be used within the expiry date and stored according to the manufacturer s instructions. Infection control procedures must be adhered to. The practice will be expected to ensure that any equipment used to undertake the Health Check is maintained and calibrated and records are kept to support this. This includes the bariatric scales, sphygmomanometers and POCT devices provided by NHS Derbyshire County. Training and staff development The practice will ensure that staff who undertake the Health Checks are trained appropriately. The practice will be expected to ensure that they have attended the 4 day basic CVD course prior to undertaking any Health Checks and have also attended the 2 day Motivational Interviewing training and 1 day Equality and Inclusion training course within 6 months. Clinical supervision It is expected that the practice will provide the necessary supervision and support, particularly during the first 6 months following completion of the Health Check training programme and will identify and provide any reasonable ongoing training and development as defined through the Practice Performance Development and Review process. Record keeping For individuals attending for a Health Check appointment, the practice will ensure appropriate and accurate recording of their details, POCT blood results, risk assessment score, onward referral and management are kept. 13 of 18
14 Details of service monitoring, evaluation and review process / timescales: Performance monitoring data will be provided by the practice, facilitated by the Read Coded information collected using the CVD electronic template, which will be provided by NHS Derbyshire County. Monthly MiQUEST reporting from practices will be required to enable evaluation and monitoring of the uptake and outcome from the programme. Appropriate action will be taken with individual practices that fail to meet the requirements of the programme. Practices will be expected to use the CVD electronic template to record Health Check information. This will ensure the data is collected using appropriate Read Codes. The practice will update their patient records with any information received from the Health Promotion services to support the monitoring process. From these outcomes the success of the programme in identifying and managing people who require medical intervention to reduce their CVD risk will be measured in addition to its impact on affecting healthy lifestyle changes in the population. 15 Workforce / staffing: A sample job description/person specification is provided in the programme Handbook. The practice will be expected to ensure that staff undertaking Health Checks have the required skills and experience. Staff should have the following competencies and be able to carry out an assessment with individuals at risk of developing CVD. This will include obtaining physiological measurements of: Weight Height BMI Waist measurement Blood pressure Pulse Blood cholesterol level by near patient finger prick testing. In addition staff undertaking Health Checks must be aware of, and understand, the importance of lifestyle factors that may affect the level of risk of CVD. These include: Smoking Physical activity 14 of 18
Diet Alcohol consumption Psychosocial factors They must also be able to: Convey an individual s risk score in a clear and understandable manner Provide information and advice about how to reduce the risk of CVD in appropriate ways to suit individuals Obtain and test capillary blood samples safely and accurately Assess an individual s motivation to change in order to know when it is appropriate to refer on to the lifestyle services All staff undertaking Health Checks will be trained. The training is organised by NHS Derbyshire County. Funding for backfill, up to mid-point Band 3 (Afc) will be paid for one member of staff to attend from each practice, although two members of staff from each practice can attend the free training programme. Attendance of the 4 day CVD basic training programme is mandatory before staff commence Health Checks. This will include POCT training. The Motivational Interviewing training days (2) and Diversity and Inclusion day must be completed within 6 months of the 4 day training course. In addition the practice will be expected to identify and provide any reasonable training and development as defined through the Practice Performance Development and Review process. Additional training events may be required to meet the needs of the programme. Staff undertaking Health Checks must know when it is appropriate to make a referral into the practice using practice protocols. Reference: DH Vascular Risk Assessment: Workforce Competencies CVD EF3 April 2009 16 Clinical and corporate governance: Any GP practice delivering this service will be expected to be working towards the Care Quality Commission (CQC) registration and be compliant with the essential standards for quality and safety. 17 Policies / protocols / legal requirements: The programme Handbook provides clinical policies and guidelines for: CKD Management of Hypertension Statins Type 2 Diabetes 15 of 18
Infection Control - Personal Protective Equipment and Hand washing Guidance for Referring Individuals to GP or Practice Nurse 18 Appendices: Appendix A: Glossary Term CVD CKD PVD Health Check TCR tool POCT Definition Cardiovascular Disease (includes coronary heart disease, cerebrovascular disease, peripheral vascular disease, abdominal aortic aneurysm) Chronic Kidney Disease Peripheral Vascular Disease Vascular Risk Assessment Computerised CVD risk tool download from The Computer Room Point of Care Testing Appendix B: Primary Prevention CVD Care Pathway References: 1. Derbyshire County PCT CVD Risk Assessment Handbook for General Practice Oct 09 Version 4 2. Putting Prevention First NHS Health Check: Vascular Risk Assessment and Management Best Practice Guidance 16 of 18
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Appendix B Derbyshire County PCT Primary Prevention CVD (Health Check) Programme Practice Download CVD Tool Practice runs CVD Risk Assessment Tool Practice has patient identifiable information Box 1 Male 55 74 smoker 40 54 smoker 55 74 non-smoker 40 54 non-smoker Female 55 74 smoker 40 54 smoker 55 74 non-smoker 40 54 non-smoker Refer to Alcohol Advisory Service Follow up by HCA Follow up by practice Practices invite high risk patients into practice by order of highest risk first or according to Box 1 Self-Care Patients seen by HCA for risk assessment Referred to Weight Management Programme Referred to Exercise Referral Scheme 18 of 18 Lifestyle Advice Once ALL high risk patients seen, remaining people aged 40-74 will be seen Refer to Stop Smoking Session Refer to Health Trainer