Health Needs Assessment- NHS Health Checks

Health Needs Assessment- NHS Health Checks Document Purpose: NHS Health Checks Re-Procurement Author: Amanda Chappell Publication Date May 2017 ( final ) Topic Owner Bristol Behaviour Change Integrated Healthy Lifestyle Programme Steering Group Contact Details: Amanda.Chappell@bristol.gov.uk Chapter information Chapter title Chapter reference group Chapter author(s) Quality reviewed by who/date Chapter endorsed by Chapter approved by Linked JSNA chapters NHS Health Checks Bristol Behaviour Change Integrated Healthy lifestyle Programme Steering Group Amanda Chappell Public Health Principal Bristol Behaviour Change Integrated Healthy lifestyle Programme Steering Group (1 st March 2017) Bristol Behaviour Change Integrated Healthy lifestyle Programme Steering Group date tbc Bristol Behaviour Change Integrated Healthy lifestyle Programme Steering Group (tbc) Cancer, Cardiovascular Disease, Respiratory disease, Adult Mental health, Tobacco Control and Smoking, Adult Weight Management, Substance Misuse (including Alcohol). Mental Health and Inclusion Executive Summary Introduction This needs assessment was completed in May 2017 by the Public Health Principal for NHS Health Checks (with support from Magda Szapiel and Jackie Beavington), within the Adults and Older People s Strategic Public Health Team in Bristol City Council (BCC). Identifying the gaps between what is needed and what is available, and planning how these gaps will be addressed within available resources is at the heart of this document, as the key driver in developing this document is to inform the re-procurement of NHS Health Checks. NHS Health Checks are part of a wider programme of Local Authority commissioned services. Going forward, NHS Health Checks will be included within the proposed behaviour change procurement programme, due to be completed by April 2018. This assessment should be seen as part of a wider commissioning programme of Behaviour Change emphasising early 1

intervention and prevention work across the life course and reducing future preventable cardiovascular mortality, health inequalities and health and social care needs within the adult population. This document examines NHS Health Checks in the context of national and local policy and identifies populations groups who have high premature mortality prevalence rates across the city. The needs assessment found evidence of gaps in current service provision, poor local intelligence and poor uptake of commissioned services for specific population groups who are nationally known to have high premature CVD mortality and prevalence. Our current commissioned services are not always delivered in a way in which risk identification and reduction is central. The re-procurement opens up the opportunity to review the current service model and to target population groups with high health need and inequalities. A radical cultural shift is required to reduce the increasing prevalence trend for CVD premature mortality across the city. A shift that requires an alternative way of thinking to ensure that behaviour change is central to the NHS Health Checks Programme. Currently the program is set up to find and treat disease. A predict and prevent approach for commissioning preventative programmes is both timely and of urgency in Bristol. Key issues and gaps (summary of section 8) Invites In most deprived areas of the city, invite rates did not meet the national expectation. In 9 areas (many of which are deprived and have high premature CVD mortality rates) there is no provision. s who do not offer Health Checks, often refuse to share their eligible patients lists. Some practices have high invite rates and the conversion to uptake is poor., Some practices have high uptake rates against low invite rates. Current arrangements include an incentive payment for invite, often this does not result in an actual check. Cardiovascular rates across the city are increasing, especially in area of high deprivation. There is limited knowledge about the high risk population groups locally, in relation to modifiable lifestyle behaviours and mortality rates. This is due to poor equality monitoring in primary, secondary and death registry data. Actual NHS Health Check Patients and Health Care Professionals reported that the skill sets required to deliver health checks in primary care (mainly delivered by health care assistants) was questionable. staff reported that they do not have time to focus on the behaviour change aspect of the health check, more focus was towards the clinical aspect of the check and not in reducing the risk. 2

Some patients expressed that they did not understand their risks following a health check. Uptake rates across the city are variable. In some practices with high deprivation or premature CVD the uptake rate is unacceptable. The NHS Health Checks Programme is interpreted as a disease finding process within primary care with a minimal focus on modifiable risks and behaviour change. Follow Up The Local Authority does not have access to Emis, resulting in a lack of understanding of who has been clinically followed up in primary care. The number of referrals to a Nurse or GP for clinical follow up post health check is of great concern. The low number of referrals to lifestyle services following a health check in practices where CVD prevalence and deprivation is high is unacceptable. It is not possible to identify if patients are clinically followed up by General after having a health check delivered by an alternative provider in the community, or how this data is uploaded on to the system once it has been received from the outreach provider. Recommendations Invites Use best practice guidance for invite method, this includes telephone outreach. Explore opportunities to use Acorn, council tenant, council tax and Open Exeter data to target populations. Ensure invites are targeted at Bristol residents and not those registered with a Bristol GP. Include access to eligible lists (Local Authority provided) as part of the reprocurement to attract high quality and diverse bidders. Use Acorn data and other insight sources to understand why specific populations do not engage with services. Develop local behavioural insight plans to change this. Target deprived areas and population groups who have the highest prevalence of premature CVD by using a risk stratification approach. Identify the return on investment for specific population groups to help to identify who to prioritise. Improve local intelligence on the prevalence of premature CVD amongst population groups who are nationally known to have high CVD rates. As recommended in the local authority corporate strategy, ensure that Health Checks are place based and delivered where local communities are at. Work alongside local communities to engage with targeted population groups. Provide outreach provision to target those who will benefit most. Actual NHS Health Check Invest in more training around behaviour change and risk reduction amongst providers. 3

Shift the focus of health checks from a find and treat to a prevent and predict model. Ensure that qualitative evaluation is included within the program moving forward to understand if the risks were understood and if changes have been made to lifestyle behaviours. Explore alternative models for delivery to increase the uptake amongst targeted population groups. Follow Up Work alongside NHS England, CCG and The Health and Wellbeing Board to develop ways to identify if clinical follow up is taking place and how, where possible link this to existing incentives within primary care such as QoF Ensure that as part of the above, data flows are in place to ensure information from the check is sent back to the practice (if delivered by an alternative provider) and that there are processes in place to ensure this is uploaded and read coded by each practice. Ensure future specifications include governance and quality standards around following patients up post check to identify if they have been followed up in primary care. Weight future payment tariffs around behaviour change and lifestyle modification made to reduce risks. Ensure NHS Health Checks are directly linked to behaviour change for healthy lifestyle programmes where possible. Set up processes to identify those who are now being invited for their second health check (five years later) to understand if and how risks (clinical and behavioural) have been modified. JSNA Chapter Report 1. What do we know? Introduction NHS Health Checks is a national programme that aims to help prevent heart disease, stroke, diabetes, kidney disease and certain types of dementia. Everyone between the ages of 40 and 74, who have not already been diagnosed with one of the conditions or have certain risk factors, must be invited, once every five years to have a check. The NHS Health Check provides an individual review of the modifiable behaviour factors including smoking, inactivity, harmful drinking and obesity that increases the risk of developing a heart attack or stroke within the next ten years, and offers professional advice and referral to lifestyle services to support behaviour change. Although the disease prevalence projections are expected to be a small percentage of the total Health Checks completed, it also helps to detect undiagnosed serious conditions such as hypertension, diabetes and chronic kidney disease as early as possible. 4

NHS Health Checks is a Public Health mandated service and Local Authorities are required to plan for a programme that will enable all of their eligible mean resident population to be invited over a five-year rolling cycle. This means that 20% of a Local Authorities eligible population need to have had an offer of a NHS Health Check each year. National targets include a 66% uptake conversion for those who are invited for a Health Check. In its first five years, the NHS Health Check is estimated to have prevented 2,500 heart attacks or strokes nationally. This is the result of people receiving either lifestyle advice or treatment after their Health Check (Robson et al., 2015). To be most effective the checks have to reach those who are most likely to have a premature death, and to identify risks early on, to reduce the risk of cardiovascular disease within the next ten years. National and Local Policy Drivers National Policy Drivers National reports and policies, including the NHS Five Year Forward Plan (NHS England, 2015), recognise the importance of good health and wellbeing in reducing levels of chronic disease and premature death and placing a priority in investing in prevention. Since April 2013 Local Authorities have a legal duty to seek continuous improvement in the percentage of eligible individuals taking up their offer of a NHS Health Check as part of their statutory duties. The higher the take-up rates for the programme, the greater the reach and impact of the programme and the more likely the programme is to tackle health inequalities. Although Local Authorities are required through the regulations to make an offer to all eligible persons, Public Health England supports a proportionate universalism approach. Local Authorities are free to target a greater extent of their resource towards higher risk and vulnerable communities, whilst keeping a universal offer to all eligible persons. Commissioning and monitoring the risk assessment element of the NHS Health Check is a mandatory public health function cited in the Health and Social Care Act 2012.Requirements upon councils are set out in The Local Authorities Public Health Functions and Entry to Premises to Local Health Watch Representatives Regulations 2013. The risk reduction elements of the NHS Health Check are the shared responsibility of both Local Authorities (lifestyle interventions) and Clinical Commissioning Groups (clinical interventions). In order to operate effectively, the NHS Health Check programme requires systematic and integrated activity across the Council, Providers, Partner Organisations and Clinical Commissioning Groups. Health and Wellbeing Boards (HWBs) ensure that NHS Health Checks are reflected in the commissioning plans stemming from locally agreed joint Health and Wellbeing Strategies and that it is resourced to operate effectively. 5

Joint Local Government Association (LGA) and Public Health England (PHE) guidance suggests that it is important to ensure that the risk management and reduction elements of the NHS Health Check (lifestyle interventions such as stop smoking services, weight management courses, and drug and alcohol advice) are sufficiently linked to other council commissioned services that include education, housing, debt management and family support. Co-ordinating the programme with wider strategic decision-making by the whole council will avoid duplication, and can help maximise the programme s impact and value for money (Local Government Association & Public Health England, 2013) In the past, Primary Care Trust s largely commissioned NHS Health Checks through Local Enhanced Services (LES) agreements with General providers. However, Local Authorities (LA s) do not have access to LES agreements therefore must commission the NHS Health Check Programme in the same way as any other LA commissioned service. This provides Commissioners and the Health and Wellbeing Boards with an opportunity to assess the potential to commission other providers of the NHS Health Check, such as Pharmacies, Community and Voluntary Sector, and wider commercial, third sector providers. The NHS Health Check is one of the three mandatory public health functions included in the 2012 Health and Social Care Act and has ministerial commitment to the programme. The Programme is also a key action in the Cardiovascular Outcomes Strategy Department of Health (2013). Local Policy Drivers The responsibility for the NHS Health Check programme moved to councils in April 2013 and this presents a major opportunity for councils to tackle public health issues by helping individuals to take responsibility for their own health, and by reducing health inequalities arising from the conditions and lifestyle risks covered by the programme. Councils are responsible for the following aspects of the NHS Health Check programme: Commissioning the risk assessment element of the programme (mandatory). Monitoring of offers made (mandatory). Monitoring and seeking continuous improvement in take-up (mandatory). Promotion / branding of the programme. Monitoring NHS Health Check provision in their area to ensure that individuals who receive information on their identified risks are signposted and or referred to and receive either Local Authority Commissioned Lifestyle Services that are appropriate or NHS England Commissioned Clinical Follow Up. Risk management and reduction (lifestyle interventions). The Corporate Strategy (Bristol City Council, 2017-2022) sets out a direction of travel, with a vison for the city in which all services and opportunities are accessible and where life chances are not determined by wealth and background. To achieve this the strategy outlines the way it will conduct its business in the future, including: The council reshaping services looking at ways of delivering services more efficiently. 6

Working closely and collaboratively with partners and communities, joining up services where it is possible. Seeing people living and working in Bristol as part of the solution. This will involve communities taking control of their own change, by reducing demand on services where they can, and by taking control of their own issues or changing behaviour. Bristol Health and Wellbeing Board was set up in 2013 bringing together a range of partners with an interest in, or responsibility for improving health in Bristol. The Board has a duty to encourage integrated working and is responsible for producing the Joint Strategic Needs Assessment and the Joint Health and Wellbeing Strategy. It is jointly chaired by the Mayor of Bristol and the chair of the Clinical Commissioning Group (CCG). Bristol Health and Wellbeing Board have recently refreshed their Joint Health and Wellbeing Strategy and have committed to focus on three areas that have potential to reduce both health inequalities and improve the long term health of Bristol residents. Two of the focus areas, alcohol and healthy weight are covered in the NHS Health Check programme. The third area is Mental Health. People who experience serious mental illness are twice as likely to die from coronary heart disease. Rates of hypertension are also high amongst this population group. The recent adoption of European Legislation for Procurement and The Social Value Act gives Bristol City Council the opportunity to test the market and its suppliers. It is hoped that the procurement of The Bristol Behaviour Change for Healthy Lifestyle Programme will enable more creative and innovative models for commissioning lifestyle services. Who is at risk and why? The Director of Public Health Annual Report for 2016(Bristol City Council, 2016) shows that on average 1,111 people die prematurely in Bristol before the age of 75 years (early death). 815 (73%) of these deaths are due to just four main diseases: Cancer (434 deaths) Cardiovascular disease, for example heart failure (230 deaths) Respiratory disease, for example COPD (106 deaths) Liver disease (45 deaths) Around 60% of cancer and cardiovascular disease deaths, half of respiratory disease deaths and over 90% of liver disease deaths could be prevented by taking public health action. Poor diet, smoking, high alcohol use and physical inactivity are the four main lifestyle behaviours that are linked to the four main diseases that cause 73% of all the early deaths in Bristol. All four lifestyle factors are associated with cancers and cardiovascular disease. Smoking is the key risk factor for respiratory disease and alcohol the key risk factor for liver disease. Demographics and Demand The Office for National Statistics (ONS) published the first results of the 2011 census in July 2012. Bristol s population was then 428,000 and is currently growing faster than the national average. In 2015 the total population of Bristol was 449,328. It is the 10th largest Local Authority in England and Wales. The total number of eligible 7

residents in Bristol is 105,297 (Bristol population of 40-74 year olds in 2015, minus the estimated ineligible population, which is assumed to be 30% of the total population of 40-74; ONS mid-year estimate for 2015). The Office for National Statistics estimates that the population in Bristol will continue to grow with an average rate of 1% per year for the next 10 years. The estimated number of residents eligible for an NHS Health Check will increase to 108,290 in 2019 and 112,070 in 2024 (ONS 2014-based Subnational Population Projections for Local Authorities and Higher Administrative Areas in England). In Bristol it is estimated that there were 105,297 eligible residents entitled to a NHS Health Check in 2016/17. Previously eligible populations had been based on those who were registered with a Bristol GP. As part of the re-procurement of NHS Health Checks we are keen to ensure that the mean resident, i.e. the number of people actually resident in Bristol are included within the eligible population and that this takes into consideration all Bristol residents, even those who are not registered with a Bristol General. Each Local Authority is expected to ensure that 66% of those residents invited for a NHS Health Check attend as a result of the invite. This has been unofficially set locally at 55% in Bristol for all eligible populations as a more achievable target. The take-up, i.e. the number of health checks received, must also be monitored by Local Authorities as an indicator for Health Improvement, as stated within The Public Health Outcomes Framework for England 2013-2016. As noted above, to be most effective, health checks must reach those people who are most at risk of early death. The Department of Health published Living well for longer: a call to action on avoiding premature mortality and the Cardiovascular disease (CVD) outcomes strategy on 5 March 2013. Both identify the NHS Health Check programme as a vehicle for delivering its strategy on reducing premature mortality and disability. Cardiovascular Disease and Socio- Economic Status People in lower socioeconomic groups are five times more likely than higher socioeconomic groups to have a combination of three or four lifestyles behaviours that can damage health. Lower socioeconomic groups would include people in unskilled work (or no work), with little educational achievements, a low income, little in the way of savings, and living in an area of inequalities. This clustering of potentially harmful behaviours increases the risk of a person developing poor health. The strong and persistent link between deprivation and ill health underlines the importance of targeting health checks at the most at risk populations. Cardiovascular Disease and Health Inequalities Public Health Outcomes Framework (Public Health England, 2017) protected characteristic data identifies population groups that experience higher rates of premature CVD as listed below: Cardiovascular Disease-Under 75 mortality rate - considered preventable. Closely linked with deprivation. Men are three times more likely to have heart disease. Some BAME Groups have higher rates of CHD (South Asian) and Hypertension (Stroke) African Caribbean. 8

People with a diagnosis of Serious Mental Illness (SMI) are twice as likely to die from coronary heart disease. Rates of hypertension are also high amongst those with SMI. People with learning disabilities have a higher risk of ischemic heart disease than the general population and this is the second most common cause of death in people with learning disabilities. People with learning disabilities are 58 times more likely to die before the age of 50 than the general population. Ex-offenders are more likely to have high rates of CVD. NHS Health Checks is an important health improvement programme to identify and help people change their lifestyle behaviours and contributes to an improvement in healthy life expectancy and reducing the vast health inequalities in Bristol. Future efforts to identify CVD risks amongst the population groups listed above should be a key priority and allocation of resources should be weighted towards this greater need. Many of the population groups identified above live within deprived areas, each intersection of inequality increases the risk of health inequalities Targeting populations will be paramount if the Bristol NHS Health Check programme is to deliver on the outcomes of reducing premature morality and disability (Living Well for Longer: A Call to Action on Avoiding Premature Mortality, Department of Health, 2013) (Cardiovascular Disease (CVD) Outcomes Strategy, Department of Health, 2013) and (The Corporate Strategy 2017-2022, Bristol City Council, 2017). 2. What is the size of the issue in Bristol? Premature Mortality Rates Cardiovascular Disease Cardiovascular disease (CVD) covers a range of conditions including coronary heart disease, stroke and peripheral vascular disease. These are diseases which occur when the arteries or vessels supplying the heart or brain become blocked or rupture preventing the normal flow of blood and oxygen (World Heart Federation,2016). CVD is the second leading cause of premature deaths in Bristol. The premature mortality rate (age standardised, 2013-15) as a result of CVD for Bristol is 82.3 deaths per 100,000 population, which is significantly worse than the England average of 74.6 (PHOF, indicator 4.04i - Under 75 mortality rate from all cardiovascular diseases (Persons)). However, this is the lowest value for core cities. Trends in early deaths from heart disease and stroke There is a general downward trend within Bristol, as in England, in early deaths from heart disease and stroke. Between 2006-08 and 2013-15, there has been a 30% reduction in the premature mortality rate in Bristol due to CVD; the England average reduced by 25% in the same period. Differences between the Clinical Commissioning Group (CCG) localities have also reduced over time, as it did by deprivation quintile. Figure 1: Premature (under 75) mortality rate from CVD by Bristol CCG Locality 9

Age-standardised rate per 100,000 population 140 Under 75 mortality rate from CVD; age standardised rates per 100,000 population, Bristol by locality, 2006-2008 to 2013-2015 120 100 80 60 40 North & West Inner City & East South Source: Primary Care Mortality Database, ONS population estimates, England figures Public Health Outcomes Framework CVD and Inequalities CVD mortality for people aged less than 75 years by deprivation: the chart below highlights that most deprived areas consistently experience higher rates of premature mortality due to cardiovascular disease. The gap has narrowed, but a persistent inequalities gap remains. In the last 3 years this gap seems to have increased. Figure 2: CVD Mortality rates for Bristol residents Pooled 3-year premature (<75yrs) CVD mortality rates (DSR) per 100,000 for Bristol residents 2006-2008 to 2013-2015 250 200 most deprived least deprived Bristol 150 100 50 0 2006-08 2007-09 2008-10 2009-11 2010-12 2011-13 2012-14 2013-15 10

In 2009-11 the absolute gap in CVD mortality rates for all ages between the most and least deprived areas in Bristol was 50.6 deaths per 100,000 populations. However, in the 3 year period of 2013-15 this gap has increased in Bristol to 84 deaths per 100,000 populations. The following maps below (figures 3-6) show the distinct differences in premature morbidity rates (for CHD, stroke and cancer, under 75 years, CVD under 75 yeas old, stroke under 75 years old, coronary hear disease under 75 years old, ) across the City of Bristol. 11

Figure 3: Premature (under 75 years old) 2011-15 Cancer, CHD and Stroke Mortality 2011-2015 12

Figure 4: Premature (under 75 years old) for CVD 2011-2015 Under 75 mortality rate from cardiovascular diseases (age standardised rate per 100,000 population), Bristol wards 2011-2015 Source: Primary Care Mortality Database, ONS population estimates Avonmouth & Lawrence Weston Henbury & Brentry Southmead Stoke Bishop Westbury on Trym & Henleaze Redland Horfield Bishopston & Ashley Down Lockleaze Eastville Frome Vale Hillfields From To 28.2 47.2 60.5 71.8 78.2 92.1 94.5 116.3 116.5 153.8 Bristol: 82.8 Clifton Clifton Cotham Down Hotwells & Harbourside Bedminster Southville Central Ashley Windmill Hill Lawrence Hill Knowle Easton St George West Brislington West St George Troopers Hill Brislington East St George Central Filwood Bishopsworth Stockwood Hartcliffe & Withywood Hengrove & Whitchurch Park Map-a-Tuesday 13

Figure 5: Premature (under 75 years old) for stroke 2011-2015 Under 75 mortality rate from stroke (age standardised rate per 100,000 population), Bristol wards 2011-2015 Source: Primary Care Mortality Database, ONS population estimates Avonmouth & Lawrence Weston Henbury & Brentry Southmead Stoke Bishop Westbury on Trym & Henleaze Redland Horfield Bishopston & Ashley Down Lockleaze Eastville Frome Vale Hillfields From To 1.4 7.3 8.4 12.7 14.0 17.8 18.1 24.1 24.5 32.8 Bristol: 15.1 Clifton Clifton Cotham Down Hotwells & Harbourside Bedminster Southville Central Ashley Windmill Hill Lawrence Hill Knowle Easton St George West Brislington West St George Troopers Hill Brislington East St George Central Filwood Bishopsworth Stockwood Hartcliffe & Withywood Hengrove & Whitchurch Park Map-a-Tuesday 14

Figure 6: Premature (under 75 years old) for CHD 2011-2015 Under 75 mortality rate from coronary heart disease (age standardised rate per 100,000 population), Bristol wards 2011-2015 Source: Primary Care Mortality Database, ONS population estimates Avonmouth & Lawrence Weston Henbury & Brentry Southmead Stoke Bishop Westbury on Trym & Henleaze Redland Horfield Bishopston & Ashley Down Lockleaze Eastville Frome Vale Hillfields From To 13.0 21.1 22.2 38.7 39.6 46.7 47.2 63.2 66.0 82.4 Bristol: 41.7 Clifton Clifton Cotham Down Hotwells & Harbourside Bedminster Southville Central Ashley Windmill Hill Lawrence Hill Knowle Easton St George West Brislington West St George Troopers Hill Brislington East St George Central Filwood Bishopsworth Stockwood Hartcliffe & Withywood Hengrove & Whitchurch Park Map-a-Tuesday 15

3. Targets and Performance Local Services: The NHS Health Check Programme Budget The Public Health annual budget for NHS Health Check programme in 2016/17 is 350,000. Performance in Bristol From April 2013 to December 2016 68,837 residents have been invited to attend NHS Health Checks appointments. This figure represents 65.4% of the total eligible population. Of these, 31,688 (46%) attended resulting in 30.1% of the total eligible population receiving an NHS Health Check. The percentage of invited patients who attended an NHS Health Checks is referred to as a percentage of uptake. In line with national trend, there has been an increase year on year in uptake over this period. In 2013/14, there was a 34.3% invitation uptake rate. This rose to 41% in 2014/15 and in 2015/16 the uptake increased to over 56% - above the England and AGW average. It has continued to rise with the uptake increasing to over 59% in the first three quarters of 2016/17. Figure 7: Number of patients invited to and patients attending an NHS Health Check in Bristol. Source: EMIS Search & Report extract for Bristol CCG and self-reported figures from GP practices Year Annual eligible population Number of invited patients % of eligible population invited Number of patients receiving NHS Health Check % of invited patients receiving an NHS Health Check (uptake) % of total annual eligible patients receiving NHS Health Check 2013/14 24,352 19,464 79.9% 6,668 34.3% 27.4% 2014/15 20,768 20,317 97.8% 8,329 41.0% 40.1% 2015/16 20,909 17,860 85.4% 10,074 56.4% 48.2% 2016/17 Q1-Q3 21,060 11,196 53.2% 6,617 59.1% 31.4% 16

Figure 8: % Uptake of NHS Health Check Invitations: 2015/16. Comparison of rates: England, AGW, Core Cities and Bristol 70% 60% 50% 40% 30% 63.3% % Uptake of NHS Health Check Invitations: 2015/16 Comparison of rates: England, AGW, Core Cities and Bristol 56.4% 52.1% 51.2% 48.9% 47.9% 46.8% 40.3% 40.0% 20% 14.3% 10% 0% Source: NHS Health Check website http://www.healthcheck.nhs.uk/ and EMIS Search & Report extract for Bristol CCG Service Providers The main provider for NHS Health Checks in Bristol is General and the total Public Health primary care allocated budget is 350,000 (per year). Providers are paid by results, each has an expected activity level, and an incentive is in place to encourage providers to achieve more. Under the current commissioning arrangements NHS Health Checks are mainly offered to General providers, who previously held Locally Enhanced Level agreements. There is no guarantee that any particular provider will be asked or willing to sign up to the programme each year. For those that do sign up, we cannot guarantee expected performance levels. 40 out of the 49 practices are signed up to, and are actively delivering, health checks. This leaves a gap in service provision for eligible populations. Some of the General s who have declined have refused access to their eligible list registers. For those who engage in the programme, many struggle to reach their expected targets each year of 20% of their eligible population invited and 55% of those invited actually receiving a health check (the local uptake rate has been set unofficially and is lower than the expected national uptake rate of 66%). In 2014/15 Bristol uptake rates for Primary Care providers was 41%, but this increased to 56% in 2015/16. As previously stated, invite rates are expected to be 100% over a five year period and at the end 2015/16 almost 73% of the eligible population has been invited (see table below). 17

Locality Annual eligible population Invited 1st time Health Checks % population invited % uptake Annual eligible population Invited 1st time Health Checks % population invited % uptake Figure 9: Number of patients invited to and patients attending an NHS Health Check in 2014/15 and 2015/16 in Bristol, by locality. Source: EMIS Search & Report extract for Bristol CCG and self-reported figures from GP practices 2014/15 2015/16 Inner City & East North & West 6,871 5,392 2,394 78.5% 44.4% 6,871 7,429 3,580 108.1% 48.2% 9,100 5,030 2,370 55.3% 47.1% 9,100 5,746 3,143 63.1% 54.7% South 8,518 9,895 3,565 116.2% 36.0% 8,518 4,685 3,347 55.0% 71.4% Bristol 24,489 20,317 8,329 83.0% 41.0% 24,519 17,860 10,070 72.8% 56.4% total* * Please note: the annual eligible population for GP practices has been determined using practice registered populations which is higher than the eligible population among Bristol residents. That is because some of the practices register patients from the neighbouring local authorities Service Provision, Coverage and Equitable Access There is a wide variation of Bristol City Council commissioned NHS Health Checks across the city, and a marked disparity in the number of NHS Health Checks provided across the Localities/Neighbourhood Partnerships. The uptake rates amongst GP s in Bristol ranged from 10.4% to 100% in the first two quarters of 2015/16. During 2015-16 out of 49 practices, 9 do not offer Health Checks to their local populations. A high proportion of the practice populations registered with the 9 GP s within these wards have high deprivation and rates of premature CVD mortality. It is the duty of the Local Authority to ensure that all eligible populations are offered a NHS Health Check and inequity across the city is unacceptable. This undermines the Local Authorities approach to reducing health inequalities and promoting good health and wellbeing for Bristol citizens. Public Services need to be driven by population need rather than the provider market. In the practices of highest deprivation and premature CVD mortality (excluding those who do not offer any Health Checks at all) 8 failed to invite 50% (the target is 100%) of their annual eligible population during 2015-16. Limited access to a NHS Health Check equates to a limited access to Local Authority commissioned lifestyle services. A referral to these services is predominately picked up following an NHS Health Check and most of these services are delivered from General or require a referral via this route. The charts below (figures 10-14) shows the percentage of the NHS Health Checks annual target (66% of eligible practice population receiving the health check) achieved by practices in Bristol within three Localities. Caution should be added as the uptake rate is calculated against the actual (not expected) invite rate and not by the eligible practice population. 18

Avonmouth Medical Bishopston Medical Bradgate Fallodon Way Gloucester Road Greenway Helios Medical Centre Horfield Health Centre Monks Park Pembroke Road Ridingleaze Medical Sea Mills Shirehampton Health Southmead And The Family Westbury-On-Trym Whiteladies Medical Air Balloon Beechwood Medical Broadmead Medical Centre Charlotte Keel Medical Eastville Medical Fishponds Family Lawrence Hill Health Centre Lodgeside Montpelier Health Centre St George Health Centre The Maytrees The Old School The Wellspring Figure 10: Inner City & East Locality, Health checks by GP 2015/16 140% 120% 100% 80% 60% 40% 20% 0% Inner City & East Locality: Health Checks in 2015/16 by GP practice - percentage of annual targets achieved % annual target achieved Figure 11: North and West Locality, Health checks by GP 2015/16 180% 160% 140% 120% 100% 80% 60% 40% 20% 0% North & West Locality: Health Checks in 2015/16 by GP practice - percentage of annual targets achieved % annual target achieved Figure 12: South Locality, Healthchecks by GP 2015/16 19

Bedminster Family Birchwood Medical Gaywood House Grange Road Hartwood Healthcare Hillview Family Nightingale Valley Priory St Martins Stockwood Medical The Armada Family The Crest Family The Lennard The Malago The Merrywood The Southville The Wedmore Wells Road Whitchurch Health South Locality: Health Checks in 2015/16 by GP practice - percentage of annual targets achieved 140% 120% 100% 80% 60% 40% 20% 0% % annual target achieved 66% annual target Source: EMIS Search & Report extract for Bristol CCG and self-reported figures from GP practices Figure 13: NHS Health Check uptake rates in Bristol by locality Locality 2014/15 2015/16 Inner City & East 44.4% 48.2% North & West 47.1% 54.7% South 36.0% 71.4% Bristol total 41.0% 56.4% Figure 14: NHS Health checks uptake rates in Bristol 2014/15 against 2015/16 80% 70% 60% 50% 40% 30% 20% 10% 0% NHS Health Check uptake rates in Bristol, 2014/15 vs 2015/16, by locality 44.4% 48.2% Inner City & East 47.1% 54.7% 36.0% 71.4% 41.0% 56.4% North & West South Bristol total 2014/15 2015/16 Source: EMIS Search & Report extract for Bristol CCG and self-reported figures from GP practices NHS Health Checks and CVD Premature Mortality 20

Whilst the Bristol and CCG locality activity data comparisons are helpful, a broader and more in depth analysis is required to help us understand, as Public Health Commissioners, how are we addressing health inequalities in the City and to identify where we may need to target more resources in the near future to reduce the prevalence of CVD premature mortally over the next ten years. CVD Premature mortality for Bristol (aged less than 75 years) by deprivation: The table below (figure 15) highlights the most deprived to least deprived practices in Bristol and the prevalence and premature mortality of CVD rates compared against the invite and uptake rates against each individual practice. Although the national invite rates are expected at 100% of the annual eligible population (20% of the total population each year, over a five year period), a low, medium and high invite and uptake rate formulary was applied to accommodate such large variances in invite rates (ranging from 0%-346.1%) and conversion uptake rates (ranging from 0%- 1500%) across the city. Such differences in uptake and conversion rates can result in inaccurate average uptake rates at a locality and Bristol level. In figure 15, practices that invited 75% and over of their annual eligible population were coded as green, practices who had invited 50-74% of their annual eligible population were coded as amber and practices that had invited 0-49% of their annual eligible population were coded as red. In most cases although practices were coded as green only 14 (out of 46) achieved the expected annual invite rate of 100%. As previously mentioned, the expected national uptake conversion rate is 66%, as mentioned this should be approached with caution, as it does not equate to a 66% uptake rate amongst annual eligible populations but a 66% uptake rate based on actual invites sent. Therefore, if only 100 invites of a total eligible annual population of 1000 were sent out over a period of a year, and 50 people attended for an actual check, the conversion rate would be calculated at 50% even though only 10% of the eligible population had been invited. practices were colour coded on their uptake conversion rates as follows: practices that converted actual invites (not expected at 100%) to actual health checks at 55% and over were coded as green, practices that converted invites to actual health checks at 25-54% were colour coded as amber and practices that converted invites to actual health checks at 25% or below were colour coded as red. 21

Figure 15: Deprivation: invite and uptake rates 2015-16 Green 75% and over 55% and over Amber 50-74% 25-54% Red under 50% under 25% Code name Ward 2016 Health Checks Invited 1st time Annual eligible population % of annual eligible population invited % uptake Ward deprivation IMD 2015 CVD prevalence (CVD-PP Primary Prevention (30-74)) Ward CVD mortality under 75 (DSR pper 100,000) L81041 L81054 L81083 L81015 L81061 L81089 L81094 L81095 Hillview Family Grange Road Hartwood Healthcare Charlotte Keel Medical The Wellspring Lawrence Hill Health Centre The Merrywood The Crest Family Hartcliffe & Withywood Hartcliffe & Withywood Hartcliffe & Withywood 212 72 302 23.90% 294.40% 58.8 0.64 116.4 286 164 534 30.70% 174.40% 58.8 0.95 116.4 21 0 371 0.00% 0.00% 58.8 0.96 116.4 Lawrence Hill 680 1189 860 138.30% 57.20% 57.7 1.12 153.7 Lawrence Hill 35 100 376 26.60% 35.00% 57.7 0.49 153.7 Lawrence Hill 239 1524 440 346.10% 15.70% 57.7 0.63 153.7 Filwood 126 232 322 72.10% 54.30% 50 0.93 117.6 Filwood 207 137 290 47.30% 151.10% 50 0.93 117.6 22

L81067 L81098 L81022 L81012 L81008 L81023 L81648 TOTAL most deprived Southmead And Henbury Family Greenway Community Horfield Health Centre Montpelier Health Centre Shirehampton Health Centre Eastville Medical The Maytrees Southmead 312 249 577 43.10% 125.30% 39.7 1.06 124.5 Southmead 167 185 376 49.20% 90.30% 39.7 1.21 124.5 Lockleaze 212 334 687 48.60% 63.50% 34.3 1.23 115.4 Ashley 338 603 819 73.70% 56.10% 33.2 0.8 103.5 Avonmouth & Lawrence Weston 233 448 633 70.80% 52.00% 32.9 1.12 86.8 Easton 209 495 406 122.00% 42.20% 32 1.28 116 Easton 106 264 190 139.30% 40.20% 32 1 116 3383 5996 7182 83.50% 56.40% 46.2 1 122.1 23

L81088 L81037 Lodgeside The Pioneer Medical Group Hillfields 332 621 557 111.50% 53.50% 31.3 1.06 82.3 Henbury & Brentry 102 95 1024.52 9.30% 107.40% 30.9 0.72 89.5 L81084 Priory Knowle 260 522 529 98.80% 49.80% 30.9 0.98 65.5 L81093 St Martins Knowle 15 1 316 0.30% 1500.00% 30.9 1.21 65.5 L81125 Wells Road Knowle 84 155 372 41.70% 54.20% 30.9 1.31 65.5 L81038 Air Balloon St George Central 485 983 750 131.10% 49.30% 29.9 0.85 84.5 L81062 St George St George Health Centre Central 369 950 573 165.70% 38.80% 29.9 1.23 84.5 Broadmead Y02578 Medical Central 92 285 132 216.10% 32.30% 28.9 0.78 147.6 Centre L81013 Fishponds Family Frome Vale 348 195 740 26.40% 178.50% 28.5 1.29 61.3 L81075 The Old School Frome Vale 14 1 426 0.20% 1400.00% 28.5 0.9 61.3 L81087 Beechwood Medical Frome Vale 333 219 603 36.30% 152.10% 28.5 1.37 61.3 L81009 Stockwood Medical Stockwood 184 233 542 43.00% 79.00% 23.6 0.82 68.6 Centre L81031 The Armada Family Hengrove & Whitchurch 353 367 1041.6 35.20% 96.20% 23.6 0.3 66.6 Park L81007 The Southville Southville 202 220 386 57.00% 91.80% 23 0.81 149.3 24

L81035 L81082 TOTAL average deprivation The Malago Bedminster Family Southville 193 239 494 48.40% 80.80% 23 0.88 149.3 Southville 288 690 569 121.20% 41.70% 23 1 149.3 3654 5776 9055 63.80% 63.30% 27.8 1 90.8 L81669 L81053 L81032 L81057 L81033 L81120 L81077 L81622 L81081 L81078 Monks Park The Lennard The Wedmore Gaywood House Nightingale Valley Birchwood Medical Sea Mills Helios Medical Centre Pembroke Road Gloucester Road Medical Horfield 263 646 244 264.70% 40.70% 22.2 0.97 94.3 Bishopsworth 131 135 459 29.40% 97.00% 21.6 1.62 35.3 Windmill Hill 287 455 367 124.00% 63.10% 21.5 0.98 101.4 Bedminster 45 77 415 18.60% 58.40% 19.8 0.81 108.6 Brislington West 287 602 860 70.00% 47.70% 19.6 0.92 71.6 Brislington West 166 384 351 109.50% 43.20% 19.6 0.89 71.6 Stoke Bishop 36 103 384 26.80% 35.00% 13.7 1.06 45.3 Stoke Bishop 85 254 246 103.10% 33.50% 13.7 1.33 45.3 Clifton 273 1143 632 180.70% 23.90% 12.4 1.05 44.1 Bishopston & Ashley Down 320 450 664 67.80% 71.10% 11 1.1 77 25

Centre L81090 L81091 L81112 L81017 L81131 TOTAL least deprived The Family Whiteladies Medical Group Bishopston Medical Westbury-On- Trym Fallodon Way Medical Centre Clifton Down 40 49 684 7.20% 81.60% 11 0.55 28.3 Clifton Down 124 428 929 46.10% 29.00% 11 0.94 28.3 Redland 256 500 626 79.90% 51.20% 8.5 1.21 42.8 Westbury-on- Trym & Henleaze Westbury-on- Trym & Henleaze 293 345 555 62.20% 84.90% 5.7 0.85 47.2 427 517 526 98.30% 82.60% 5.7 1.99 47.2 3033 6088 7941 76.70% 49.80% 14.5 1.1 59.2 26

Further analysis of the data shown in figure 15 suggests the following: amongst the most deprived practices in Bristol (15 in total) 4 scored a green for invites, but out of those four only one achieved converted invites to actual checks at 55% or above. CVD premature mortality rates amongst the deprived practices directly age standardised rates (DSR) per 100,000 range from 86.8 to 153.7 (average rate of 122.1) in the most deprived practices down to 28.3 to 108.6 (average rate of 59.2) in the least deprived practices. Standardised invite and uptake rates should reflect the level of need and where the greatest reduction in health inequalities can be achieved. More practices (in terms of actual numbers) were able to achieve a higher invite rate on average and least deprived practices and practices in the average deprivation quintile were able to convert more invites in to actual checks. Future opportunities to re-commission services should include incentives and alternative delivery models to target those population groups with the highest CVD mortality rates and to demonstrate creative ways of engaging those population groups who are less likely to respond to a GP invite. It is not possible to explain how some practices have significantly higher actual uptake than invite rates. A small percentage may be due to invites that were made at the beginning of the year (and before the beginning of quarter 1) and for the checks carried out opportunistically within the practice. Further analysis is required to understand more about the demographical picture of those who received a check without an invite and the quality of the NHS Health Check. Contrary to this, some practices demonstrate high levels of invites sent with minimum return against uptake rates. Currently providers are paid for invites, even if this does not equate to an actual heath check. 27

Figure 16: Premature CVD Mortality (under the age of 75 years old) Invite and uptake rates 2015-16 Green 75% and over 55% and over Amber 50-74% 25-54% Red under 50% under 25% Code name Ward 2016 Health Checks Invited 1st time Annual eligible population % of annual eligible population invited % uptake Ward deprivation IMD 2015 CVD prevalence (CVD-PP Primary Prevention (30-74)) Ward CVD mortality under 75 (DSR pper 100,000) Estimated smoking prevalence (QOF 2015/16) L81015 L81061 L81089 L81007 L81035 L81082 Charlotte Keel Medical The Wellspring Lawrence Hill Health Centre The Southville The Malago Bedminster Family Lawrence Hill 680 1189 860 138.30% 57.20% 57.7 1.12 153.7 27 Lawrence Hill 35 100 376 26.60% 35.00% 57.7 0.49 153.7 29.5 Lawrence Hill 239 1524 440 346.10% 15.70% 57.7 0.63 153.7 27 Southville 202 220 386 57.00% 91.80% 23 0.81 149.3 18.3 Southville 193 239 494 48.40% 80.80% 23 0.88 149.3 23.6 Southville 288 690 569 121.20% 41.70% 23 1 149.3 22.3 28

Y02578 L81067 L81098 L81094 L81095 L81041 L81054 L81083 L81023 L81648 TOTAL highest CVD mortality Broadmead Medical Centre Southmead And Henbury Family Greenway Community The Merrywood The Crest Family Hillview Family Grange Road Hartwood Healthcare Eastville Medical The Maytrees Central 92 285 132 216.10% 32.30% 28.9 0.78 147.6 31.5 Southmead 312 249 577 43.10% 125.30% 39.7 1.06 124.5 26.4 Southmead 167 185 376 49.20% 90.30% 39.7 1.21 124.5 23.6 Filwood 126 232 322 72.10% 54.30% 50 0.93 117.6 33 Filwood 207 137 290 47.30% 151.10% 50 0.93 117.6 31.4 Hartcliffe & Withywood Hartcliffe & Withywood Hartcliffe & Withywood 212 72 302 23.90% 294.40% 58.8 0.64 116.4 35.4 286 164 534 30.70% 174.40% 58.8 0.95 116.4 28.9 21 0 371 0.00% 0.00% 58.8 0.96 116.4 36 Easton 209 495 406 122.00% 42.20% 32 1.28 116 25.2 Easton 106 264 190 139.30% 40.20% 32 1 116 24.8 3375 6045 6624 91.30% 55.80% 43.2 0.9 132.6 27.7 L81022 Horfield Lockleaze 212 334 687 48.60% 63.50% 34.3 1.23 115.4 22.8 29

Health Centre L81057 Gaywood House Bedminster 45 77 415 18.60% 58.40% 19.8 0.81 108.6 21 L81012 Montpelier Health Centre Ashley 338 603 819 73.70% 56.10% 33.2 0.8 103.5 31.5 L81032 The Wedmore Windmill Hill 287 455 367 124.00% 63.10% 21.5 0.98 101.4 25.6 L81669 Monks Park Horfield 263 646 244 264.70% 40.70% 22.2 0.97 94.3 20 L81037 The Pioneer Henbury & Medical Group Brentry 102 95 1025 9.30% 107.40% 30.9 0.72 89.5 23.1 L81008 Avonmouth & Shirehampton Lawrence Health Centre Weston 233 448 633 70.80% 52.00% 32.9 1.12 86.8 24.8 L81038 Air Balloon St George Central 485 983 750 131.10% 49.30% 29.9 0.85 84.5 21.3 L81062 St George St George Health Centre Central 369 950 573 165.70% 38.80% 29.9 1.23 84.5 24.4 L81088 Lodgeside Hillfields 332 621 557 111.50% 53.50% 31.3 1.06 82.3 20.4 L81078 Gloucester Bishopston & Road Medical Ashley Down Centre 320 450 664 67.80% 71.10% 11 1.1 77 16.4 L81033 Nightingale Valley Brislington West 287 602 860 70.00% 47.70% 19.6 0.92 71.6 19.9 L81120 Birchwood Medical Brislington West 166 384 351 109.50% 43.20% 19.6 0.89 71.6 21.1 L81009 Stockwood Medical Stockwood 184 233 542 43.00% 79.00% 23.6 0.82 68.6 22.2 Centre L81031 The Armada Hengrove & 353 367 1042 35.20% 96.20% 23.6 0.3 66.6 16.4 30

TOTAL average CVD mortality Family Whitchurch Park 3976 7248 9527 76.10% 54.90% 25.5 0.9 87.1 22.1 L81084 Priory Knowle 260 522 529 98.80% 49.80% 30.9 0.98 65.5 18.4 L81093 St Martins Knowle 15 1 316 0.30% 1500.00% 30.9 1.21 65.5 19.4 L81125 Wells Road Knowle 84 155 372 41.70% 54.20% 30.9 1.31 65.5 19.7 L81013 Fishponds Family Frome Vale 348 195 740 26.40% 178.50% 28.5 1.29 61.3 18.6 L81075 The Old School Frome Vale 14 1 426 0.20% 1400.00% 28.5 0.9 61.3 16.3 L81087 Beechwood Medical Frome Vale 333 219 603 36.30% 152.10% 28.5 1.37 61.3 22.9 L81017 Westbury-on- Westbury-On- Trym & Trym Henleaze 293 345 555 62.20% 84.90% 5.7 0.85 47.2 8.1 L81131 L81077 L81622 L81081 Fallodon Way Medical Centre Sea Mills Helios Medical Centre Pembroke Road Westbury-on- Trym & Henleaze 427 517 526 98.30% 82.60% 5.7 1.99 47.2 7.6 Stoke Bishop 36 103 384 26.80% 35.00% 13.7 1.06 45.3 19 Stoke Bishop 85 254 246 103.10% 33.50% 13.7 1.33 45.3 10 Clifton 273 1143 632 180.70% 23.90% 12.4 1.05 44.1 11.5 L81112 Bishopston Redland 256 500 626 79.90% 51.20% 8.5 1.21 42.8 17.2 31

L81053 L81090 L81091 TOTAL lowest CVD mortality Medical The Lennard The Family Whiteladies Medical Group Bishopsworth 131 135 459 29.40% 97.00% 21.6 1.62 35.3 19.6 Clifton Down 40 49 684 7.20% 81.60% 11 0.55 28.3 12.8 Clifton Down 124 428 929 46.10% 29.00% 11 0.94 28.3 16.4 2719 4567 8026 56.90% 59.50% 18.8 1.2 49.6 15.8 32

Figure 16 correlates the prevalence of premature CVD to individual practices across Bristol and ranks the practices as follows; highest, average and low premature CVD mortality. Although the majority of practices within the highest deprivation quintiles can be associated with high premature CVD prevalence, some practices that are less deprived have high rates of CVD prevalence. Explanations could include the differences in population groups within each practice at a granular level and their increased lifestyle risks and genetic disposition to CVD and where practices have mixed practice population groups with both high and low deprivation scores. Individual practices with average CVD mortality rates sent out less invites than practices with high CVD mortality rates. Individual practices with low CVD prevalence rates have slightly better conversion rates than individual practices with average CVD mortality rates. Invitations and Targeting Current service specifications encourage practices to invite all of their annual eligible patients over a five year period. Recent changes to specifications include risk stratification guidance to prioritisepopulation groups who are known to have higher rates of premature CVD. The delay in introducing this approach has been largely due the limited local intelligence related to which population groups experience high CVD premature mortality. Much of the Bristol Public Health focus is towards deprivation. There less understanding of the intersections of inequality for those population groups who experience inequalities in a broader sense, due to their environment and protected characteristics, many of whom live in the most deprived areas in the city. Such population groups are more likely to experience higher rates of inequalities and health inequalities as a result. Poor equality monitoring in primary, secondary and death registry data, limits Local Authorities ability to fully understand which lifestyle risks are associated with specific population groups and how these lifestyle risks are linked to preventable deaths amongst specific population groups. More work is required at a local level to understand how the national CVD premature prevalence rates reflect our local populations. Where providers do record and report on equality data it is of poor quality and not specific enough to draw conclusions. For example Black, Minority and Ethnic Groups are often clustered in to one population groups with little acknowledgment of the differences between such groups and the associated health inequalities experienced. Often equality monitoring is present in provider contracts and specifications, but this is not enforced or performance managed by commissioners. The amendments to the specifications include the following population groups and risk indicators: Priority Population Groups Living in the deprived area (1st and 2nd most deprived quintile) Mental health Those with a history of Substance Misuse BAME ( South Asian, Chinese, Black British ( Caribbean) or Black African Origin -risk factors occur earlier and individuals in this category are eligible between ages 30-39 with a BMI of >23 BMI 30+ (or 23+ if South Asian) 33

Include other excluded groups such as homeless/ex-offenders Those with a family history of CHD under 60years old Those who have not attended the GP in the past 12 months Priority Risk Indicators Current smoker GPPAQ physical activity index: inactive AUDITC score 8+ QRisk2 score 10+ EMIS software searches or queries will need to be developed and coded at a practice or consortium level. Many of the indicators listed above can be extracted from the quarterly reports submitted by the Clinical Support Unit to the Local Authority., Commissioners are able use this data to verify that we are targeting those who will benefit most. Minimal capacity is currently available with the Bristol Public Health Knowledge Service to estimate expected activity levels by practice or to analyse and report on the quarterly reports to ensure we are meeting the needs of those who will benefit most. Competing priorities within Public Health undermine the Public Health and corporate commitment and responsibility to identifying and addressing health inequalities within the city. NHS Health Checks and Lifestyle Referrals As highlighted earlier in this document, those receiving a NHS Health Check risk assessment need to be supported to manage their risk through appropriate followup. The Government mandates local authorities to offer everyone eligible between the ages of 40-74 a Health Check assessment every five years. While the provision of lifestyle advice and interventions is not mandated, there is an expectation that local authorities will commission appropriate behaviour change and lifestyle services and ensure that the NHS Health Check assessments are adequately followed up. Future models for delivery of NHS Health Checks will need to be closely aligned to lifestyle and behaviour change to address the unacceptable referral and signposting rates to Local Authority commissioned behaviour change programmes following a NHS Health Check. 34

Figure 17: Premature CVD Mortality and Referral Lifestyle Services 2015-16 Identified from health checks data Code name Ward 2016 Smokers Number of patients with BMI 30 (or 27.5 if South Asian) Number of patients with AUDIT C score 20 L81015 L81061 L81089 L81007 L81035 L81082 Y02578 L81067 L81098 L81094 L81095 L81041 Charlotte Keel Medical The Wellspring Lawrence Hill Health Centre The Southville The Malago Bedminster Family Broadmead Medical Centre Southmead And Henbury Family Greenway Community The Merrywood The Crest Family Hillview Family No. Referrals No. Referrals No. Referrals Lawrence Hill 181 2 219 14 7 1 Lawrence Hill 3 0 12 1 0 0 Lawrence Hill 52 3 70 9 3 1 Southville 33 0 26 6 1 0 Southville 4 0 46 1 3 0 Southville Not available Central 25 0 15 5 0 Southmead 74 15 88 6 0 0 Southmead 27 0 50 4 0 0 Filwood 34 2 52 5 3 0 Filwood 52 2 55 12 4 0 Hartcliffe & Withywood 79 71 92 25 0 0 35

L81054 L81083 L81023 L81648 TOTAL highest CVD mortality Grange Road Hartwood Healthcare Eastville Medical The Maytrees Hartcliffe & Withywood Hartcliffe & Withywood 66 3 80 8 0 0 Not available Easton 37 0 44 7 2 0 Easton 20 0 35 1 2 1 687 98 884 99 30 3 L81022 L81057 L81012 L81032 L81669 L81037 L81008 L81038 L81062 L81088 L81078 L81033 Horfield Health Centre Gaywood House Montpelier Health Centre The Wedmore Monks Park The Pioneer Medical Group Shirehampto n Health Centre Air Balloon St George Health Centre Lodgeside Gloucester Road Medical Centre Nightingale Valley Lockleaze 23 0 58 20 2 0 Bedminster 5 0 10 2 1 0 Ashley 67 0 73 4 8 0 Windmill Hill 75 9 87 16 1 0 Horfield 34 0 76 1 0 Henbury & Brentry Avonmouth & Lawrence Weston St George Central St George Central 18 0 28 2 4 0 39 0 63 21 0 0 75 5 106 25 1 0 67 7 92 15 2 1 Hillfields 54 2 92 32 3 0 Bishopston & Ashley Down Brislington West 26 1 41 8 0 0 Not available 36

L81120 L81009 L81031 TOTAL average CVD mortality L81084 L81093 L81125 L81013 L81075 L81087 L81017 L81131 L81077 L81622 L81081 L81112 L81053 L81090 Birchwood Medical Stockwood Medical Centre The Armada Family Priory St Martins Wells Road Fishponds Family The Old School Beechwood Medical Westbury- On-Trym Fallodon Way Medical Centre Sea Mills Helios Medical Centre Pembroke Road Bishopston Medical The Lennard The Family Brislington West Not available Stockwood 29 0 57 3 4 0 Hengrove & Whitchurch Park 35 0 104 15 0 0 547 24 887 163 27 1 Knowle 34 0 47 1 1 0 Knowle Knowle Not available Not available Frome Vale 46 0 84 6 1 0 Frome Vale 3 0 5 0 0 0 Frome Vale 60 2 108 13 2 1 Westbury-on- Trym & Henleaze Westbury-on- Trym & Henleaze 17 4 46 7 1 1 28 0 49 9 0 0 Stoke Bishop 4 0 7 2 0 0 Stoke Bishop 11 70 14 5 0 0 Clifton 24 1 27 9 1 0 Redland 22 1 29 3 2 0 Bishopsworth 23 0 37 9 3 0 Clifton Down 2 1 4 1 1 0 37

L81091 TOTAL lowest CVD mortality Whiteladies Medical Group Clifton Down 7 1 14 2 1 0 281 10 471 67 13 2 Figure 17 shows the prevalence rates for premature CVD by each General provider, with high premature mortality rates listed at the top of the table through to low CVD mortality rates by practice at the bottom. Each of the practices listed, has associated data relating to how many referrals they have made to Local Authority Commissioned Lifestyle Services. Tobacco and Smoking Smoking is the biggest single cause of inequalities in death rates between rich and poor in the UK (Department of Health, 2011). Local smoking cessation services offer the best chance of success, yet fewer people are now using such services. They are up to four times more effective than no help or over the counter nicotine replacement therapy (NRT) (Director of Public Health Annual Report, Bristol City Council, 2016) Although the Quality Outcomes Framework (QOF) tool embedded within figure 17 gives the reader an indication of the expected smoking prevalence in each practice, disappointingly, unacceptably low numbers of people are being referred on to support to stop smoking services as a result of an NHS Health Check. Often this lifestyle service is provided within the GP practice. Weight Management and Obesity This lifestyle issue is affecting the population of Bristol and impacting on the local rates of cardiovascular disease, diabetes and some cancers. The rates of obesity in Bristol are currently lower than the national average; however, there is an increasing trend in prevalence. Referral rates to locally commissioned Weight Management Services are significantly low despite the financial incentive offered as part of QoF. Some of this can be explained by the indicator related to the Obesity QoF, where incentive by payment is offered to record BMI, but not to signpost or refer on to support services or offer healthy lifestyle advice. Brief Alcohol Intervention The majority of people who misuse alcohol do not seek treatment. The national commissioning guidance 39 recommends that 10-15% should access treatment each year (Department of Health, 2009) It is not understood why the referrals or signposting rates to our local substance (including alcohol) misuse service is low, or how high audit C (an alcohol assessment tool used in primary care) scores are being managed within the practice or how people are supported to reduce this risk. Physical Activity It is estimated that the NHS in Bristol spends 3.2 million each year treating people for ill health caused by physical inactivity (Public Health England, 2016). It is expected that each person receiving an NHS Health Check is offered advice on how to be active (if they are inactive) and signposted to local community assets. Current 38

practice providers are encouraged to use online directories such as Well Aware to identify local activities within their practice population wards. Articulating the Results and Joint Goal Setting As each lifestyle risk associated with premature CVD mortality is identified (see listed above) each individual is informed of their risks (included within a your result leaflet. They are given advice to reduce these risks, encouraged to set their own goals for reducing the risk(s) and signposted or offered a lifestyle or behaviour change service if available and appropriate. Smoking cessation, weight management and alcohol services are currently commissioned by the Local Authority. Leisure Services are commissioned by the Local Authority, which also has a responsibility for Public Transport, Green Spaces and Parks. To what extent risk articulation and joint goal setting happens within each practice is uncertain. Health check advisors often feedback on the limited time available to offer the check and as a result focus on the clinical aspects of the check (which would be similar to their key roles within the practice as health care assistants) and less on behaviour change and onward referring (which may be a new skill set for many health care assistants and often registered nurses within the practice who oversee health care assistants). Future models need to shift the focus away from a detect and treat model (NHS Health Checks is a health improvement, behaviour change programme and not a screening programme) to a predict and prevent model, where behaviour change, risk awareness and reduction is at the heart of the NHS Health Check. If we do not make this radical shift now we are unlikely to reduce the prevalence of premature CVD over the next ten years. Such efforts would also be belter aligned to the Local Authority s strategic direction for reducing the demand on social care. Future developments will include a better joining up of health checks with lifestyle changes made later on, e.g. number of those referred on to support to stop smoking and the percentange of those that have successfully achieved a quit etc. Motivational Interviewing (MI) for Behaviour Change and Lifestyle Intervention The Local Authority has invested in various workshops and group sessions facilitated by external motivational interviewing experts in the field (in year one the founder of MI held a workshop in Bristol) to support health care assistants and registered nurses based in each practice (A few GPs have attended also) to have conversations about behaviour change as an integral part of the NHS Health Check. Attendees were given the opportunity to work through each element of the lifestyle risk factors ( including Qrisk, an online tool that is used as part of the health check to articulate the risk of a heart attack or stroke over the next 10 years) and to integrate the principles of motivational interviewing as part of this. Future models for delivery would need to include a review of how people understood and reduced their own risks following a NHS Health Check. Previous evaluations (local) have included the lack of knowledge around the risks by the health check provider and a result, motivational interviewing and a local pathway (with workshops arranged as part of the launch) were set up to address this gap. Since this quality assurance arrangements and an online competency tool kit has been developed locally to address this. All eligible residents are invited back for a NHS health Check every five years. In 2018 we would expect that those who received a check in 2013 are invited back (unless they were removed from the eligible list as they are no longer suitable for a 39

check e.g. diagnosed with high blood pressure or diabetes etc, since the last check). Future commissioning arrangements will need to include comparator indicators for those who have previously received a check and qualitative evaluations to understand how the previous health check had (or not) supported the awareness and reduction of risk for each individual. An understanding of this is paramount to future service improvement purposes. NHS Health Checks and Clinical Follow Up National guidance recommends that Local Authorities will need to work closely with Clinical Commissioning colleagues to ensure that people identified as high risk through their assessment, or requiring additional testing or medical interventions are provided with the services they need. Figure 18 (below) shows the following: Out of the total NHS Health Checks carried out in 2015-16 (10,110) either carried out within the GP (95%) or as part of the Outreach (5.3%) 9.4% of people were followed up. 40

Figure 18: Qrisk Scores and Clinical Follow Up 2015/2016 QRISK QRISK QRISK ICE Total % % % GP's Outreach GP rate PN rate Combined >10<20 >20 >10 No. rate rate rate Qtr 1 755 714 41 25 3.3% 50 6.6% 9.9% 180 23.8% 53 7.0% 233 30.9% Qtr 2 808 752 56 30 3.7% 43 5.3% 9.0% 147 18.2% 34 4.2% 181 22.4% Qtr 3 986 894 92 39 4.0% 77 7.8% 11.8% 137 13.9% 40 4.1% 177 18.0% Qtr 4 970 935 35 41 4.2% 44 4.5% 8.8% 171 17.6% 64 6.6% 235 24.2% N&W Qtr 1 715 703 12 32 4.5% 23 3.2% 7.7% 108 15.1% 26 3.6% 134 18.7% Qtr 2 642 634 8 46 7.2% 28 4.4% 11.5% 120 18.7% 35 5.5% 155 24.1% Qtr 3 970 949 21 56 5.8% 48 4.9% 10.7% 185 19.1% 43 4.4% 228 23.5% Qtr 4 986 918 68 44 4.5% 55 5.6% 10.0% 176 17.8% 52 5.3% 228 23.1% South Qtr 1 836 831 5 31 3.7% 14 1.7% 5.4% 158 18.9% 53 6.3% 211 25.2% Qtr 2 820 799 21 57 7.0% 44 5.4% 12.3% 125 15.2% 65 7.9% 190 23.2% Qtr 3 811 745 66 33 4.1% 31 3.8% 7.9% 122 15.0% 41 5.1% 163 20.1% Qtr 4 811 726 85 37 4.6% 25 3.1% 7.6% 150 18.5% 43 5.3% 193 23.8% Totals 10110 9600 510 471 4.7% 482 4.8% 9.4% 1779 17.6% 549 5.4% 2328 23.0% 95.0% 5.3% 41

Out of the total number of health checks carried out the following Qrisk scores were identified: Qrisk 0-10% = 23%, Qrisk 10%-20% = 17.6% and Qrisk 20% = 5.4%.It is difficult to correlate the Qrisk scores to the GP or Nurse follow up, as people could have been followed up for a number of reasons or risks, such as high blood pressure or diabetes risk. The rate of referrals for clinical follow raise concerns for the Local Authority and this should instigate further investigation and discussions with both NHS England and the Health and Well Being Board. It is not known how many of those referred to the GP or Nurse had a NHS Health Check delivered as part of the outreach NHS Health Checks. The local Authority is unable to access Emis Search and Report data, so it is impossible to understand who has ( and has not) been clinically followed up. Last year, commissioners added two fields to the report to identify who had be referred to the GP or Nurse. Although clinical follow up responsibilities vary amongst practices, this does give the local authority the opportunity to better understand who is more likely to be clinically followed up as a result of being referred to the GP or Nurse. As part of the NHS England global contract GP practices have a duty of care to follow up on results received from external agencies. To reassure local authority commissioners and mitigate risk, commissioners in some parts of the country have included clinical follow up and information governance process pathways in to their specifications. This includes guidance around following up moderate to high risk patients to ensure they have been seen by their GP (and the outcomes are reported as part of this) and as a risk reinforcement to those who have had a health check. Data flow two: transfer of data from alternative providers back to the GP practice When residents have an NHS Health Check carried out by a provider other than their GP there are two data flows back to the GP: 1. The GP must be notified who has had a NHS Health Check. This should be read coded in the GP clinical system to enable later reporting about the uptake of NHS Health Checks and to manage call-recall. 2. Clinical information about the NHS Health Check should be returned to the GP as required by the Local Authorities (Public Health Functions and Entry to Premises by Local Health watch Representatives) Regulations 2013.12 Patient consent is not required for this data flow as it is a legal requirement, but the patient should be informed that such data will be returned to the GP. This information must be transferred securely in order to comply with the requirements of the Information Governance Toolkit which states that all transfers of personal and sensitive information are conducted in a secure and confidential manner. A number of commercial providers offer electronic solutions to transferring data to GP practices as part of their NHS Health Check service (Public Health England, 2013). 42

Community Outreach Programme In an attempt to offer NHS Health Checks to population groups with higher prevalence rates of premature CVD mortally, two outreach models have previously been developed in areas of high deprivation across the city. Allocated funds ringfenced within the primary care budget were/are used to fund this. Outreach Model 1 In acknowledging very early on (2013) in the programme, the need to outreach to population groups who are both less likely to respond to a letter invite by their GP and who have higher premature Mortality rates, an inner city outreach was set up, whereby pop up health checks were offered at various community based venues. As part of this, practices were given the opportunity to outreach to various local communities and be supported by NHS Health Check Champions who were employed through local Voluntary and Community based organisations. The health check champion s role was to recruit eligible people from their own communities to enable attendance for a health check at place based community settings e.g. Sikh temples, Black churches, faith based events, Somali Resource Centre, Roma Gypsy and Polish popular locations etc. Although some of the inner city practices agreed to outreach, many were unable to offer out of hours or weekends and the events became increasingly difficult to resource and coordinate as a commissioner within the Local Authority. Following several calls out to Bristol based practices, two (out of 49) agreed to loan their staff out for outreach and arrangements were made to pay the outreaching practice at the set tariff for each check. The outreach proved to be very successful in reaching priority populations, and in supporting the social value principles of working alongside communities to develop positive health and wellbeing. It also provided job opportunities (our current uptake for Black and Minority Ethnic Population Groups is above the local average as a result of this initiative). However,the model was not sustainable and required a lot of coordination by the commissioner between the champions, the community based venues and the practice based staff. As a result, it was agreed that this model would cease and be replaced by a voluntary and community sector based model whose organisations could both identify targeted populations within their community and deliver the health check. The evaluation of this initiative concluded that outreach events provide evidence of how local health partnerships (family practice staff and health trainers) and community assets, including informal networks, can enhance the delivery of outreach NHS Health Checks and promote the health of targeted communities. To deliver NHS Health Checks effectively, the location and timing of events needs to be carefully considered and staff need to be provided with the appropriate training to ensure patients are supported and enabled to make lifestyle changes. Outreach Model 2 The Healthy Living Centre consortium delivers an assertive outreach programme for those who are unlikely to have completed a health check at their GP practice. They will deliver NHS Health Checks to their current service users, at various workplace and community bases (e.g. Mental Health Services, Job Centre Plus) and in areas where GP provision is either not available or scarce. Initially the uptake target was 43

set at 2,500 health checks over the course of a year. However the target was over ambitious. Further mobilisation time was required to ensure that local people, who were recruited, were trained to deliver the checks and were competent in doing so. The learning to date has given commissioners the opportunity to focus on performance management measures that are linked to targeting high risk groups as opposed to a focus on quantity. The model allows commissioners to assess the potential added value of health checks being offered where people live and work, and the opportunities to develop pathways within each local community to address the wider determinates that have an impact of individual and community health and wellbeing e.g. debt management, social prescribing etc. In 2016 the pilot was extended for a further year, and the Healthy Living Centres are on track to meet their reduced expected targets, which include referral on to lifestyle services. Figure 19 (below) gives an over view of: the number of check delivered, the risks identified and the onward referrals made to lifestyle services and to GP practices for clinical follow up, during the first year of the pilot. 44

Figure 19: NHS Health Checks outreach performance data collection spreadsheet, July 2015 to March 2016 Total Number of patients invited to Health Checks [9mC] 576 Number of patients invited to Health Checks for the first time in the quarter [9mC] 366 Number of Health Checks [8BAg] 477 Number of Health Checks performed by Outreach clinics [9NI] 477 Number of patients with QRisk2 score [38DP/38DF]: <5% 189 5-9% 83 10-14% 29 15-19% 16 20% and over 7 Number of patients Referred to: NHS Stop Smoking Service [8HkQ] 50 Weight Management on Referral Services [8HHH] 64 Dietician [8H76] 0 Physical activity programme [8H7s] 0 Alcohol treatment service [8HkG] 6 Health Trainers [8HIF] 0 GP/ for further intervention 250 Community activity 99 Number of patients: Received Lifestyle advice and information 57 Received diet advice / leaflet 70 Received Audit C [9k17] 86 Put on a disease register as a result of Health Checks 0 Figure 19 shows us that 10.9% of the check carried out included a Qrisk score of 10% or above. 52.4% had risk factors that required a clinical follow up. 10.48% of those completing a NHS Health Check were referred on to smoking cessation Services. 13.42% were referred to weight management and 1.26% referred on to alcohol services. 45

Figure 20: Demographics of those receiving a health check during outreach 2015-16 White British 223 Bangladeshi / British Bangladeshi 35 Pakistani / British Pakistani 13 African 115 White / Black African 1 Caribbean 1 White / Black Caribbean 4 Indian / British Indian 17 Other White 7 Other 4 Although the outreach demonstrated the ability to target some high risk groups in terms of ethnicity, better equality data will be required in future to understand how we are meeting the needs of other priority population groups, including those who have protected characteristics. Whilst the cost for outreach can be higher, the return on investment could be far greater. Further work will need to be carried out to understand the return on investment for targeted populations and if, and how, this impacts on the way in which people own and manage their risks. The added value of inviting local people to be part of the solution within their communities, by recruiting and offering health check jobs to their communities, demonstrates additional social value. s who do not offer health checks to their local populations have refused to share their data with the Healthy Living Centres (or others GP s). This has resulted in commissioners accessing local authority owned council tenant data as a way of targeting social gradients in areas where there is currently no provision. (Public Health England, 2014). NHS Health Checks and information governance and data flows guidance highlights the following; If GP practices are not able to provide an eligible population list, local authorities can ask their NHS England local area teams for a list of 40-74 year olds from NHAIS and a data processor can be commissioned to send invitations. NHS England is the data controller for NHAIS and a data processing contract needs to be in place between the area team and the commissioned data processor. The NHAIS list can be converted to an accurate eligible population list if GP practices can work with the area team to remove exclusions. If this is not possible, then the list of complete 40-74 year olds can be used. Pp 16 New models will need to explore alternative ways of accessing eligible invite registers. Some local authorities have purchased (at a small cost) Open Exeter data from NHS England, so that individual invites can be sent out by alternative providers. In some parts of the country, commissioners have used market segmentation tools to identify priority populations and used this to send blanket invites out through community settings. Whilst alternative options may seem a challenge for the future, the national guidance around shifting invites to mean resident populations and not those who are registered with GPs gives the local authority the mandate to explore creative ways to invite local populations. Some private organisations use mosaic 46

data to target invites, and screen for eligibility as part of this process. They report low numbers of people who are ineligible and view residents as sensible and responsible citizens who are able to articulate their eligibility. Future commissioning specifications will need to state how commissioners will support potential providers to access invite lists to attract a high quality and diverse market. Previously qualitative outreach evaluations were carried out and can be viewed in the local views section of this document. Telephone outreach A telephone outreach model was first piloted in a deprived area of South of Bristol. A local member of the community was employed by a GP practice, via a local voluntary sector organisation, to telephone patients who were eligible for an NHS Health check. Her role was to introduce the concept of the heath check and with the patient s permission, ask them some questions that are included as part of the health check. Once these questions were completed, she invited them to the GP practice to complete the remaining aspects of the health check. Uptake of an NHS health check at this practice using the traditional form of a letter invite was 36%. Using a telephone outreach model it increased to 86%. Of these, 100% who accepted the invite for a health check over the phone, attended for their complete health check. This approach has since been rolled out across Bristol practices (10 out of 14) with high deprivation. Invite and conversion rates for primary care providers (2015-16) can be seen below. 47

Figure 21: Telephone Outreach Activity 2015-16 code name Locality Number of phone calls Average cost per call ( ) % phone calls resulting in an invite % phone calls resulting in an appointment % phone calls resulting in a health check Number of telephone invites Number of appointme nts made Number of health checks as a result of TO invites L81015 Charlotte Keel Medical ICE 1140 2.8 51.60% 34.60% 27.90% 588 394 318 L81013 Fishponds Family ICE 514 6.2 37.00% 25.70% 21.60% 190 132 111 L81089 Lawrence Hill Health Centre ICE 324 9.9 32.70% 19.40% 16.40% 106 63 53 L81648 Maytrees ICE L81012 Montpelier Health Centre ICE 332 9.6 35.80% 26.20% 20.80% 119 87 69 Total ICE 2310 5.5 43.40% 29.30% 23.90% 1003 676 551 L81098 Greenway Community N&W 319 10 47.00% 43.60% 28.80% 150 139 92 L81022 Horfield Health Centre N&W 280 11.4 30.00% 17.90% 12.90% 84 50 36 L81067 Southmead & Henbury Family N&W 777 4.1 39.90% 35.50% 26.80% 310 276 208 Total N&W 1376 7 39.50% 33.80% 24.40% 544 465 336 L81095 Crest Family South 355 9 47.60% 37.20% 29.90% 169 132 106 L81094 Merrywood South 379 8.4 44.60% 35.40% 29.80% 169 134 113 Total South 734 8.7 46.00% 36.20% 29.80% 338 266 219 48

Analysis of the data Although the data shows the number of calls made, it does not compare uptake rates to previous uptake rates, prior to this intervention, in some practices, no health checks were being delivered at all. Out of the total number of calls that resulted in an invite (1892), 1411 appointments (74.58%) were secured. Out of the total appointments secured, 1111 resulted in an actual health check. This demonstrates an uptake conversion rate of 79%. The telephone outreach was evaluated using both quantitative and qualitative methods and the key findings can be seen below. Although the data shows the invite and uptake rates, it does not capture the value of this approach in relation to the higher numbers of BME groups who attended for a health check and their identified risks, or how this demonstrates a return on investment for each pound spent. Since the evaluation and as the telephone outreach has developed, telephone outreach callers now capture lifestyle risks and directly refer people on to either smoking cessation services or community based services, many of which are linked to social prescribing. Quantitative Results Intervention practices were more successful at attracting ethnic minority patients to complete their check (25.6%), compared to control practices (7.2%). However, intervention practices showed a 24% rate of uptake compared to 36% in control practices. Intervention patients were more likely to attend their GP practice to complete their check, following their phone call if: female, aged over 70 or less deprived. (Coghill, Nikki, 2016, University of Bath (unpublished)) Conclusions Only the first nine months of the initiative were evaluated. Previous initiatives to encourage uptake of health checks in Bristol, have shown a lag in adoption. Feedback on improvements, from this evaluation, may result in enhanced uptake as the intervention embeds within practices. Qualitative Results Results Twenty four patients (15 female, 9 male, 40-66 years of age) were interviewed. Seven different ethnicities were self-reported, although a clear majority categorised themselves as White British. Five participants did not have English as their first language. Participants were pleased to be proactively contacted by telephone and offered a health check. Half the participants stated that they did not believe that they would have signed up for a health check if only invited via letter. In some cases this was because they would not get around to making an appointment, but others stated that they would not even read the letter. The ease and immediacy of being able to book an appointment on the telephone was a key factor in accepting the health check invitation for most participants. A smaller number of participants had found it useful to speak to someone rather than receiving a letter, mentioning the ability to ask questions. Participants generally had 49

a positive view of the person who had called them, but rarely felt that they had needed to be persuaded to accept the health check. In two cases the language skills, and cultural identity, of the caller was particularly important in facilitating the interaction. Patients assumed that the outreach caller was a member of staff from their primary care practice (although this was rarely the case), and beyond this, and being identified as pleasant or friendly, caller identity was not presented as an important factor in patient interviews. Ten participants reported actual (7) or potential future (3) lifestyle changes relating to physical activity or diet in response to either the outreach call (4) or the health check itself (6). Conclusion Shared cultural background, and first language, between outreach callers and the patients they contacted were considered key factors in designing this service. However these factors were much less to the fore in the majority of patient interviews. This may be partly due to limitations of the data recruitment of patients, whose first language was not English, and who had been called by an outreach worker who shared their first language, was challenging and this group were underrepresented. However the patients interviewed valued the telephone outreach intervention, and reported that it prompted them to attend an NHS health check.(horwood et al. (2016, Unpublished. Collaboration for Leadership in Applied Health Research & Care in the West (NIHR CLAHRC West)) 4. What is the evidence of what works (including cost effectiveness)? The University of Cambridge (Public Health England, 2017) used a model to help estimate the benefits of the NHS Health Check. The model shows that the impact of the programme can be maximised as follows: Actual Health Checks 1. Increase Statin and anti-hypertensive prescribing 2. Increase referrals to Smoking Cessation Services 3. Increase referrals to effective Weight Management Services 4. Prioritise Invitations 50

5. What is on the horizon? Figure 22: CVD Mortality Rates ( see figure 2) Pooled 3-year premature (<75yrs) CVD mortality rates (DSR) per 100,000 for Bristol residents 2006-2008 to 2013-2015 250 200 most deprived least deprived Bristol 150 100 50 0 2006-08 2007-09 2008-10 2009-11 2010-12 2011-13 2012-14 2013-15 Increasing CVD prevalence rates In 2009-11 the absolute gap in CVD mortality rates for all ages between the most and least deprived areas in Bristol was 50.6 deaths per 100,000 populations. However, in the 3 year period of 2013-15 this gap has increased in Bristol to 84 deaths per 100,000 populations. Predictive modelling linked to alternative models of delivery and the return on investment will help us to understand how this trend can be reversed. Increased demand The Office for National Statistics estimates that the population in Bristol will continue to grow with an average rate of 1% per year for the next 10 years. The estimated number of residents eligible for an NHS Health Check will increase to 108,290 in 2019 and 112,070 in 2024 (ONS 2014-based Subnational Population Projections for Local Authorities and Higher Administrative Areas in England). Targeting At a local level, more resources will be allocated to target population groups who experience the highest prevalence of premature CVD and health inequalities. Alternative models of delivery As part of the re-procurement process (to be completed by April 2018), potential providers will be invited to bid demonstrating alternative and innovative models to address the increasing prevalence of CVD mortality in Bristol. 51

A Shift from treating illness to promoting wellness A radical cultural shift is required amongst commissioners and providers to place behaviour change at the centre of NHS Health Checks as opposed to disease finding. Future developments will better align themselves with an ambition to reduce demand on Social Care and to focus on a place based approach that is driven by self-responsibility and wellness. Improved processes in place for clinical and lifestyle follow up Work within the local authority to heavily weight lifestyle assessment and behaviour support in to future specifications. Work in partnership with NHS England, the CCG and the Health and Wellbeing Board to ensure that there are effective pathways in place to follow people up following a health check and that the offer of antihypertensives and statins are prescribed for those who will benefit most. Qualitative research and ongoing service improvement Future provision will need to include evaluations that assist the local authority to understand how people have acknowledged their risks and if and how they have modified their behaviours as a result of a NHS Health Check. 6. Local views The provision of NHS Health Checks in a community setting: An ethnographic account. (Riley et al, 2015) Outreach 1 Analysis revealed the value of community assets (community engagement workers, churches and community centres) to publicise the event and to engage community members. People were motivated to attend for preventative reasons often prompted by familial experience of cardiovascular disease. Attendees valued outreach NHS Health Checks, reinforcing and prompting some to make healthy lifestyle changes. The NHS Health Check provided the opportunity for attendees to raise other health concerns with health staff (GP practice staff) and to discuss their test results with peers. For some participants, the communication of test results, risk and lifestyle information was confusing and unwelcome. The findings additionally highlight the need to ensure community venues are fit for purpose in terms of assuring confidentiality. Experiences of patients and health care professionals in Bristol - Main findings. (Riley et al, 2015) Patients were motivated to attend an NHS Health Check due to their health beliefs, the perceived value of the programme, family history of cardiovascular and other diseases and expectations of receiving a general health assessment. Health Care Professionals (HCPs) raised concerns about the potential for inequity in uptake and the effectiveness of the programme. Patients indicated that they do not always feel well informed about the implications of their results and did not always receive detailed and personalized lifestyle information or advice to accompany these results. This was supported by HCPs who had concerns about the skill set of some HCPs to communicate risk and lifestyle information effectively. They reported experiences of some patients who were given a high QRisk2 score had not fully understood its significance. Perceived benefits of the check included reassurance, relief and 52

reinforcement of healthy lifestyles with some patients making positive lifestyle changes. Some patients identified psychosocial barriers to lifestyle change or experienced anxiety from unexpected results or whilst waiting follow-up tests. Telephone outreach to enhance uptake of NHS Health Checks in more deprived communities: Patient experiences and perspectives (Horwood et al., 2016) Twenty four patients (15 female, 9 male, 40-66 years of age) were interviewed. Seven different ethnicities were self-reported, although a clear majority categorised themselves as White British. Five participants did not have English as their first language. Participants were pleased to be proactively contacted by telephone and offered a health check. Half the participants stated that they did not believe that they would have signed up for a health check if only invited via letter. In some cases this was because they would not get around to making an appointment, but others stated that they would not even read the letter. The ease and immediacy of being able to book an appointment on the telephone was a key factor in accepting the health check invitation for most participants. A smaller number of participants had found it useful to speak to someone rather than receiving a letter, mentioning the ability to ask questions. Participants generally had a positive view of the person who had called them, but rarely felt that they had needed to be persuaded to accept the health check. In two cases the language skills, and cultural identity, of the caller was particularly important in facilitating the interaction. Patients assumed that the outreach caller was a member of staff from their primary care practice (although this was rarely the case), and beyond this, and being identified as pleasant or friendly, caller identity was not presented as an important factor in patient interviews. Ten participants reported actual (7) or potential future (3) lifestyle changes relating to physical activity or diet in response to either the outreach call (4) or the health check itself (6). Commissioning Stakeholder Event Key themes emerging: Organisational Culture Culture of provider organisation and customer centred service Culture of commissioner and top down approach Diversity of workforce that reflects the local communities (negative imagery- non representative) Ambassadors branding good reputation on behalf of the organisation (supporting local employment, learning and development) Service users used as expert users to inform the service developments, Client led services Providers feeding back to service users on performance of services Partnership working identifying strengths/experiences of other organisations Better use of technology build with service users and not for them More evidence of equality and harassment policies in place 53

Better customer service for service users (confidentiality, friendly, nonjudgemental, diverse & welcoming and respectful front line staff, longer hours not just peak, less jargon, less complicated application forms, has too many appointments by post and too many options voiced recognition phone lines. Less assumption that service users know everything about their service) Better training for workforce Assumptions that people are heterosexual (include transgender) Better child care facilitates Recruit locally, create hubs and link in with local hub Find every way possible to engage with everyone in community i.e. restaurant advertising, word of mouth through community peers Opportunities for peers to review the service e.g. Trip Advisor, airbnb be, Uber Over researched or no researched at all, especially where innovation is community based Front line staff medicalising the social model Lots of KPI s with minimal benefits for service users Focus Groups 54

Local Authority Online Consultation Survey 55