Revised for: 1 April 2014 APPENDIX 2.4 SERVICE SPECIFICATION FOR THE PROVISION OF NHS HEALTH CHECKS IN BOURNEMOUTH, DORSET AND POOLE
DORSET COUNTY COUNCIL Page 2 of 12 1. INTRODUCTION 1.1. This Specification sets the requirements for the provision of a service for provision NHS Health Checks (vascular risk assessment and management services).by Community Pharmacies. The focus of the Service is to provide NHS Health Checks within the Pharmacy setting. 1.2. Participation by Community Pharmacies in this Service is currently voluntary and guided by localised need. 2. BACKGROUND 2.1. Cardiovascular disease is a major cause of morbidity and mortality and is a significant contributory factor towards the current level of health inequalities in Bournemouth, Dorset and Poole. Approximately 21% of deaths under 75 years of age (2010 2012) were attributed to circulatory disease, the highest cause of premature death in the local population. The NHS Health Check programme provides a structured approach to cardiovascular risk management for all people aged 40-74 years old, who are not already on any patient risk register. 2.2. Everyone is at some risk of developing heart disease, stroke, diabetes, kidney disease and some forms of dementia. The NHS Health Check aims to help individuals to reduce their risk of developing these common but often preventable diseases. Those eligible are invited for a NHS Health Check once every five years. Through the check, their risk of heart disease, stroke, kidney disease and diabetes is assessed through some straightforward tests and standard questions about your lifestyle and family medical history. Personalised advice and support is then offered to help lower the risk of developing cardiovascular disease. Those with low or moderate risk are likely to receive advice about changes to lifestyle, whilst individuals with a higher risk may also be offered medical support through primary care and onward referral to other specialist support services e.g. smoking cessation and/or weight management. 2.3. It is calculated that NHS Health Checks and appropriate management of risk could prevent 1,600 heart attacks and strokes a year nationally, and provide a real opportunity to tackle the gap in life expectancy between deprived and less deprived populations. The total population in Bournemouth, Dorset and Poole eligible for a Health Check is 258,000. 3. AIMS AND OBJECTIVES OF THE SERVICE / SERVICE OUTCOMES 3.1. The Service aims to: 3.1.1. Improve population health outcomes and quality of life by reducing the risk of vascular disease in adults attending for a risk assessment and lifestyle advice (NHS Health Check). 3.1.2. Identify at an earlier stage, adults with previously undetected vascular conditions who are not currently being managed in primary care specifically type 2 diabetes, coronary heart disease, stroke and TIA, chronic kidney disease and vascular dementia and to signpost/refer to appropriate primary care and lifestyle services.
DORSET COUNTY COUNCIL Page 3 of 12 3.2. The Service objectives are to: 3.2.1. Work together with GP practices to provide Health Check assessments for the 20 per cent of all eligible adults offered a Health Check within Bournemouth, Dorset and Poole aged 40-74 years each year. Pharmacies will operate the Service in accordance with national Best Practice Guidance; 3.2.2. Offer Health Check assessments on an opportunistic basis for eligible adults accessing the pharmacy. 3.2.3. Offer convenience and accessibility of one-stop testing facilities by providing a choice of location and extended hours of availability; 3.2.4. Offer support and signposting to people identified at increased risk of cardiovascular disease to enable them to make changes to lifestyles to reduce their overall risk. 4. DESCRIPTION OF SERVICE 4.1. The Provider shall provide NHS Health Checks in accordance with the process outlined below: 4.1.1. Service Users that have received an invitation to attend a Health Check from their GP Practice can choose to have their assessment in a pharmacy setting. The Provider shall offer a Health Check assessment to all eligible Service Users that present in the pharmacy with an invitation letter from their GP practice, where they are resident in Bournemouth, Dorset or Poole. 4.1.2. The Provider shall also offer Health Check assessments on an opportunistic basis for eligible adults accessing the Pharmacy. 4.2. Eligible Service Users: 4.2.1. are aged between 40 and 74 years and have not previously received an NHS Health Check; and 4.2.2. are NOT on one of the following disease registers: Diabetes; CHD; Heart Failure; Atrial Fibrillation; Hypertension; Stroke/TIA; Renal disease (stages 3 to 5) / CKD; Familial Hypercholesterolaemia; Peripheral Arterial Disease (PAD); Palliative Care (practices will manually identify and exclude those Service Users that are on the palliative care register); Those taking statins; Those taking blood pressure medication. 4.3. The Service shall be provided in accordance with NHS Health Check Best Practice Guidance (Oct 2013) at all times. This together with other key documents can be found at the NHS Health Checks website 1. 1 www.healthcheck.nhs.uk/commissioners_and_healthcare_professionals/national_guidance
DORSET COUNTY COUNCIL Page 4 of 12 4.4. The National Screening Committee has published updated information/guidance on the key components of the Health Check assessment (including an explanation of the QRISK II risk equation used locally) and this can be found at the NHS Health Checks website 2. 4.5. Providers across Bournemouth, Dorset and Poole shall undertake the alcohol risk assessment (using the AUDIT-C questionnaire) and raise awareness of Dementia as part of the full NHS Health Check assessment in line with this guidance, regardless of any local agreements that may have been agreed with commissioners previously. 4.6. Staff conducting Health Checks will have attended the introductory training course organised by Dorset. Details of forthcoming dates for training will be on the Dorset website 3. 4.7. The Provider shall ensure that an appropriate record of activity is developed and maintained for audit and payment purposes, and which meets the requirements of this Service Specification. Summary data shall be provided to Dorset (via PharmOutcomes), thereby enabling the Purchaser to fulfil its legal duty to upload summary data as required by the Department of Communities and Local Government Single Data List 4. 4.8. Every Health Check assessment shall be recorded in the lifelong patient record, including the full data set (measurements, values, follow-up, referral and outcome) collected as a result of Health Checks carried out at any venue by any approved provider. This requires the Provider to establish an effective and secure mechanism for sending the required Service User information collated as part of the Health Check assessment to the Service User s GP practice. 5. QUALITY STANDARDS 5.1. The Provider shall have adequate mechanisms and facilities, including premises and equipment, as are necessary to enable the proper provision of the Service. 5.2. The following equipment is required to be provided by the Pharmacy to deliver the Service: 5.2.1. scales; 5.2.2. height measurers; 5.2.3. electronic blood pressure monitoring machine or sphygmomanometer; 5.2.4. point of care testing devices for measuring cholesterol 5.3. The Provider shall be required to sign up and pay for the Internal Quality Control (IQC) scheme for their point of care testing equipment (LDX machine or equivalent). All equipment used as part of the Service must be cleaned, calibrated and serviced as advised by the manufacturer with appropriate protocols in place. The results of internal quality assurance tests for point of care testing equipment should fall within the acceptable range. The Provider is required to supply and fund appropriate equipment, supplies and training of their use as needed to deliver the NHS Health Checks programme. 2 www.healthcheck.nhs.uk/document.php?o=310 3 www.publichealthdorset.org.uk 4 www.healthcheck.nhs.uk/commissioners_and_healthcare_professionals/national_guidance
DORSET COUNTY COUNCIL Page 5 of 12 5.4. The Provider can contact Alere, who have supplied all LDX machines and co-ordinate the existing IQC scheme, through their customer care team on 0161 483 5884. Where the Provider choose s to acquire their equipment and supplies from an alternative supplier, the quality and functionality of any equipment must be of an equivalent standard and certified by the Cholesterol Reference Method Laboratory Network. The two certified point of care testing devices available in the UK are the Cholestech LDX (Alere) and the Cardiochek PA (Polymer Technology Systems/BHR Pharmaceuticals). 5.5. The health care professional carrying out the procedures listed in Appendix A must demonstrate the relevant competencies to do so and have completed the training and accreditation programme as specified by Dorset. This includes: 5.5.1. Specific training as required for Point of Care testing equipment; 5.5.2. Staff involved in the provision of the service undertaking CPD relevant to this service on at least an annual basis. 5.5.3. The Provider shall be required to work with Dorset to review progress and identify any further training needs. The Provider shall: 5.6 Ensure that there is a suitable amount of trained Employees with the relevant knowledge to adequately meet the potential levels of demand. 5.7 Ensure that this Service is available during the normal opening hours of the Pharmacy for 52 weeks of the year 5.8 Ensure that there are suitable contingency plans in place to cover leave (both anticipated and unanticipated) or any staff leaving the Provider. 5.9 Notify the Team immediately if the Service is not available due to workforce issues. 5.10 Have internet access in place at all times and shall use PharmOutcomes to fully record all consultations and activity and make claims for payment for provision of this service. 5.11 Ensure that thorough recruitment and selection processes are in place for Employees which includes full tracking of previous employment history, checking of qualifications and two written references. 6. CONTRACT MONITORING Community Pharmacy Contractual Framework 6.1. The Provider must remain compliant with all the essential services under the Community Pharmacy Contractual Framework as part of this Agreement. 6.2. No part of this Specification by commission, omission or implication defines or redefines essential or advanced services.
DORSET COUNTY COUNCIL Page 6 of 12 Monitoring and Review 6.3. The Provider shall ensure that the necessary documentation, as detailed in this Service Specification, is maintained and made available to the Purchaser to enable the service to be monitored and for the purpose of post payment verification. 6.4. The Purchaser may undertake a visit to the Pharmacy to inspect the provision of the Service and to ensure that the Provider is meeting the service specification. Use of PharmOutcomes 6.5. The Provider shall ensure that all consultations are logged on PharmOutcomes to enable the Purchaser to monitor activity and verify payments for Services provided. 7. SERVICE SPECIFICATION REVIEW 7.1. It is recognised within this Specification that the Service may be subject to change due to a range of national and local policy initiatives. For example, government guidance and legislation, industry professional standards, NICE Guidance or Dorset County Council Policy. 7.2. The Service Specification shall be reviewed annually and updated to reflect the changes in legislation. Adequate notice will be given to the Provider of any significant changes which may impact on the service provided and will ensure sufficient transition arrangements are secured to ensure service continuity. 8. FINANCIAL INFORMATION Payment Structure 8.1. A fee of 28.00 will be paid to the Provider for each completed Health Check. 8.2. This price is fully inclusive of all equipment, consumables, attendance at training, administration costs and a professional fee relating to the carrying out of the health check. 8.3. Payments will be made on a monthly basis. Claims for Payment 8.4. Details of every NHS Health Check must be accurately entered on to PharmOutcomes in a timely manner to meet claims deadlines. 8.5. Where requested by Purchaser, the Provider shall supply the Dorset Team with any additional information/evidence required, to establish whether the Provider has fulfilled its obligation under the Service arrangements. 8.6. Only under exceptional circumstances will paper claims be accepted, this will require prior authorisation from Dorset,. 8.7. No claim should be submitted more than one month after the end of this agreement. 8.8. Claims for activity more than 3 months old will not be paid.
DORSET COUNTY COUNCIL Page 7 of 12 Reason for Rejected Claims 8.9. No payments will be made for: 8.9.1. Checks carried out on Service Users who do not fall into any of the groups specified in the Service User Eligibility section of this document 8.9.2. Service Users who do not attend (DNAs) 8.9.3. Those who have already had a NHS Health Check in the past five years (unless this is not disclosed by the Service User and no record can be found by the Provider and the Health Check is therefore undertaken in good faith by the Provider) 8.9.4. Services that are outside this Specification and for which prior approval has not been sought and granted
DORSET COUNTY COUNCIL Page 8 of 12 Appendix A THE NHS HEALTH CHECK 1. PROCESS 1.1 The Provider shall ensure that Service Users offered an NHS Health Check are informed about the process and are given the opportunity to ask questions. 1.2 The following information and measurements shall be collected in order to establish the CVD risk over 10 years as well as the appropriate referrals or interventions required: Age Gender Ethnicity Smoking status Physical activity Alcohol consumption level Family history of vascular disease Body Mass Index Random Cholesterol measurement (TC:HDL ratio) Blood pressure measurement 1.3 The Provider shall calculate the estimated individual 10 year CVD risk using the Q- Risk2 score tools (as per best practice guidance page 14). Providers can access the Q-risk2 calculator at http://www.qrisk.org 1.4 The risk assessment pathway is presented in detail in NHS Health Check Best Practice Guidance (October 2013). 1.5 All data collected from NHS Health Checks carried out shall be recorded in a robust, accurate and timely manner using PharmOutcomes. 1.6 All Service Users undergoing a Health Check shall be given a copy of their results. 1.7 The Provider shall communicate the level of risk (high, moderate, low) to the Service User, and an individually tailored management programme, with appropriate advice, support and interventions depending on the level of risk identified will be agreed as follows: Brief healthy lifestyle advice and support will be given to all Service Users receiving the Service to assist them with managing and / or reducing their risk. Service Users who are found to be at moderate risk will be offered, where appropriate, interventions such as stop smoking or weight management. Where these services are not available in house, appropriate referrals should be made. In addition to the above, Service Users who are found to be at high risk or where a pre-existing disease is suspected or identified (e.g. Diabetes), will be further investigated and managed. (see Appendix B to the Service Specification) 1.8 The Service User will be actively involved in agreeing what advice and/or interventions they will follow. Any decisions must be made in partnership with the Service User and with their informed consent. 1.9 The Provider shall to demonstrate a clear understanding of the services available locally to Service Users to support healthier lifestyles and communicate this information to the appropriate individuals. 1.10 The Provider shall supply the Service User with information appropriate to their needs, as identified by the Health Check. Links to appropriate information is available in Appendix C to the Service Specification.
DORSET COUNTY COUNCIL Page 9 of 12 Appendix B REFERRAL AND FOLLOW UP Factor Threshold Action Referral or GP follow up Cardiovascular risk assessment CV risk is assessed as >20% over 10 years Offer intensive lifestyle advice and refer to GP for follow up after 3 months Management of risk and consideration of statin prescribing (if lifestyle advice has been attempted for 3 months) Inclusion on annual high risk register Total Cholesterol TC is 7.5 Refer to GP To assess for possibility of familial hypercholesterolaemia Hypertension risk assessment BP is 140/90 BP is 180/110 Refer to GP for assessment Refer to GP the same day Management for hypertension, (NICE Clinical Guidelines CG127 August 2011) Diabetes risk assessment BMI is 27.5 in individuals from Indian, Pakistani, Bangladeshi, Other Asian and Chinese ethnicity categories BMI is 30 in other ethnicity categories Refer to GP for Fasting Plasma Glucose Test or HbA1C Service users with symptoms of diabetes must be referred immediately Follow up at GP practice with oral glucose tolerance test or repeat HbA1c as per diabetes filter to establish possible diagnosis of diabetes Chronic kidney disease risk assessment (as for hypertension risk above) BP is 140/90 (either measurement) BP is 140/90 BP is 180/110 Refer to GP for assessment Refer to GP the same day Service user requires assessment for CKD by GP
DORSET COUNTY COUNCIL Page 10 of 12 Factor Threshold Action Referral or GP follow up Smoking status Smoker Ask and record smoking status. Advise Service User of health benefits. Act on Service User s response Offer 1:1 SmokeStop support in pharmacy if available or referral to local SmokeStop service (see Appendix C to Service Specification) Weight management BMI is 30 Consider: Overall readiness to commit to making changes Barriers to change Self-esteem Life stage Cultural preferences Offer 1:1 weight / lifestyle management service in pharmacy if available or referral to appropriate commercial weight loss provider (see Appendix C to Service Specification) Physical activity Activity levels are below the recommended levels of 150 minutes weekly or 30 minutes at least 5 times per week/less than active on GPPAQ** Brief intervention in physical activity Goal setting Information Exercise referral may be appropriate if service user is at highest CVD risk (>20 per cent in 10 years) Alcohol Service user scores 5 or more on AUDIT-C** measure Ask Service User to complete remaining AUDIT questions Refer to alcohol brief interventions service for assessment and support ** GP Physical activity questionnaire can be accessed at http://www.nice.org.uk/nicemedia/live/11927/40195/40195.pdf AUDIT-C** is the short form of the full AUDIT questionnaire and can be accessed at http://www.alcohollearningcentre.org.uk/_library/audit-c.doc
DORSET COUNTY COUNCIL Page 11 of 12 Appendix C RISK MANAGEMENT LIFESTYLE INTERVENTIONS SMOKESTOP SERVICES REFERRAL: Offer one to one smokestop support within the pharmacy or make a referral to the local Smokestop team on: 0300 30 38 038 (Bournemouth and Poole), 0800 00 76653 (Dorset). There are a number of free resources to support people interested in quitting available from http://smokefree.nhs.uk/resources/. As a general leaflet we recommend It`s so much easier since I quit. Order No. 9000a Smokefree Guide. January 2011. DoH 302496. Produced by the Department of Health. Information is also available at http://www.dorsetsmokestop.co.uk/ PHYSICAL ACTIVITY: Active Choices is a twelve week physical activity programme which may be appropriate for those people identified as inactive and at higher risk (>20 per cent in 10 years) of CVD. The programme is ran through Healthy Living Wessex tel: 01305 765200 Alternatively, there are a number of local exercise referral schemes run by leisure services in Bournemouth, Dorset and Poole. Consider referral of people identified at high of CVD risk. DoH s validated tool GPPAQ identifies individuals less than active: http://www.nice.org.uk/nicemedia/live/11927/40195/40195.pdf Get Active, Stay Active Booklet: http://www.bhf.org.uk/publications/view_publication.aspx?ps=1001248 Alternatives for over 50 s: Be Active, Stay Active: http://www.bhf.org.uk/publications/view-publication.aspx?ps=1001242 Let s get moving is a set of resources to support getting people more physically active see http://www.bhfactive.org.uk/sites/exercise-referral-toolkit/downloads/resources/lets-getmoving-guide.pdf for a pack and activity diary Walking For Health link to local health walks: http://www.walkingforhealth.org.uk ALCOHOL Please ensure that the Service User fills out the short AUDIT-C form provided from: http://www.alcohollearningcentre.org.uk/_library/audit-c.doc. Anyone scoring over 5 should complete the full AUDIT on the reverse of the form. If the Service User s AUDIT score is 20 or more, this may indicate alcohol dependence and consideration can be given to referring the person to more structured alcohol treatment services for a full assessment and any needed treatment. Those wanting to stop drinking who are experiencing difficulty should be considered for referral to specialist services using locally agreed referral methods. This referral can be made from the person s GP. General advice on safer drinking and a range of resources including drinks diaries can be accessed from: http://www.nhs.uk/livewell/alcohol/pages/alcohol-units.aspx
DORSET COUNTY COUNCIL Page 12 of 12 WEIGHT MANAGEMENT: Referral to the Healthy Choices (weight management) Programme is ran through Healthy Living Wessex tel: 01305 765200 http://www.healthylivingwessex.co.uk/healthy_choices.html Raising the issue of weight with adults information leaflet order from: http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidan ce/dh_4134408 The NHS Change4Life website also provides useful resources to support making changes to support a healthy weight. See http://www.nhs.uk/change4life/pages/change-for-life-adults.aspx RAISED CHOLESTEROL Moderately raised cholesterol in the absence of a high CVD risk score does not require referral to primary care. In the first instance people should try making simple dietary changes. A general leaflet to support this can be down loaded from http://www.bhf.org.uk/publications/view-publication.aspx?ps=1000139