Www.ncl.nhs.uk NHS Health Checks in the community pharmacy : a profile of the Islington experience Chrystal Greenwood Project Officer, NHS Health Checks.

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NHS Health Checks in the community pharmacy :

a profile of the Islington experience

Chrystal Greenwood

Project Officer,

NHS Health Checks and Long Term Conditions

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OVERVIEW OF NHS HEALTH CHECKS PROGRAMME IN ISLINGTON

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Phased implementation until 31st March 2012, across 3 delivery settings:

Implementation of the NHS Health Checks Programme in Islington: progress so far

General Practice

2009/10

Target risk group: QRisk2 > 20%

3,900 HCs delivered

2010/11

Target risk group:

QRisk2 > 15%

3,992 HCs delivered

2011/12 (plans)

Target risk group :

QRisk2 > 10%

7,000 HCs to be offered

4,900 HCs to be delivered

2012/13

Full roll out expected

Approximately 70,000 eligible pop14,000 checks to be offered every year10,500 checks to be delivered (70% uptake of offered)

Community

Pharmacies

2009/10

Pilot programme to test feasibility

2010/11

Target risk group:any

721 HCs delivered

2011/12

Target risk group: any

1,500 HCs to be delivered

Community Outreach

2009/10

n/a

2010/11Target risk group: any

1,742 HCs delivered

2011/12Target risk group: any

2,000 HCs to be delivered

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Who is our population?

12%10% 8% 6% 4% 2% 0% 2% 4% 6% 8% 10%12%

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

Percentage of eligible population

Ag

e < 10%

10% - 14%

15% - 19%

≥20%

Not calculated

Risk of heart attack or strokewithin the next 10 years (QRisk2)

Men Women

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Aim of Community Pharmacy programme

Deliver a minimum of 2,000 NHS Health Checks across 10 Community Pharmacies

200 per pharmacy per year = 50 per quarter (17 per week). Prioritise delivery to Islington residents who are not

registered with a GP, or who are registered and do not access primary health care on a regular basis

Expression of interest process open to all community pharmacies

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Referral or advice should be made on the basis of the risk factor with the greatest urgency according to the algorithm above

Random Finger-prick blood test

Blood Pressure

Height and weight, calculate BMI

Lifestyle

Diet

Physical activity

Alcohol

Family History

Patient details

Cholesterol <6.5mmol/l

Cholesterol ≥7.5mmol/l

≥180/110 ≥160/100 ≥140/90 <140/90

Calculate QRisk2 score

≥20% 10% to <20% <10%

Advise to see GP within 48 hrs

Advise to see GP / PN within 2 weeks

Advise to see GP / PN within 4 weeks

Advise to see GP / PN in 4 to 12 weeks

Lifestyle advice to maintain risk

BMI ≥30 or ≥27.5 if Asian origin

Fasting Finger-prick blood test

FBG ≤3.0mmol/l

FBG 3.0 to 5.6mmol/l

FBG 5.6 to <11.1mmol/l

FBG ≥11.1mmol/l

Repeat test immediately

Confirm eligibility and consent

Smoking

Appropriate advice and referral

Advise changes to lifestyle to reduce risk

Repeat BP after 48 hrs

Repeat Blood Pressure

Diabetes and hypertension filter. Complete initial NHS Health Check and recall patient after 48 hours

≥140/90 <140/90≥160/100≥180/110

Cholesterol 6.5-7.4mmol/l

Referral or advice should be made on the basis of the risk factor with the greatest urgency according to the algorithm above

Random Finger-prick blood test

Blood Pressure

Height and weight, calculate BMI

Lifestyle

Diet

Physical activity

Alcohol

Family History

Patient details

Cholesterol <6.5mmol/l

Cholesterol ≥7.5mmol/l

≥180/110 ≥160/100 ≥140/90 <140/90

Calculate QRisk2 score

≥20% 10% to <20% <10%

Advise to see GP within 48 hrs

Advise to see GP / PN within 2 weeks

Advise to see GP / PN within 4 weeks

Advise to see GP / PN in 4 to 12 weeks

Lifestyle advice to maintain risk

BMI ≥30 or ≥27.5 if Asian origin

Fasting Finger-prick blood test

FBG ≤3.0mmol/l

FBG 3.0 to 5.6mmol/l

FBG 5.6 to <11.1mmol/l

FBG ≥11.1mmol/l

Repeat test immediately

Confirm eligibility and consent

Smoking

Appropriate advice and referral

Advise changes to lifestyle to reduce risk

Repeat BP after 48 hrs

Repeat Blood Pressure

Diabetes and hypertension filter. Complete initial NHS Health Check and recall patient after 48 hours

≥140/90 <140/90≥160/100≥180/110

Cholesterol 6.5-7.4mmol/l

Aligned to national guidance

NHS Health Checks Steering Group includes clinical input

Patient pathway

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Software provider

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Training

1) Delivering the NHS Health Check

One day course delivered by CVD team at the Royal Free Hospital Designed to provide health professionals with an update on aspects of the NHS Health Check in line with the most recent evidence and current national guidelines.

Objectives: the knowledge to carry out the NHS Health Check knowledge on quality assurance in near patient testing. knowledge on interpretation of the biochemical measurements in the

NHS Health Check

2) Supporting Behaviour Change training

One day course delivered by Whittington Health

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WEQAS

External quality assurance scheme. Pharmacy sent samples on a bi-monthly basis to test within the specified

timeframe. Commissioner uploads the results to determine any tests which fall

outside of the acceptable range Second sample is sent to pharmacies with an unacceptable result to

identify any ongoing issue with equipment Results are analysed and sent to Consultant Biochemist to review

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WHO DID WE REACH IN THE PHARMACY?

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HCs in community pharmacy by sex and age

0

5

10

15

20

25

30

35

40

45

50

35-44 45-54 55-64 65-74

Perc

enta

ge

Age group

Age group in men, women and persons who had Health Checks in Islington pharmacies, Jul 2010 - Mar 2011

Men Women Persons•The majority of pharmacy HCs were in persons aged under 55 (78%), with a similar proportion aged 35 to 44 as 45 to 54.

• This pattern was similar for men and women and is similar to the age distribution of health checks in community settings.

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HCs in community pharmacy by registration status

0

100

200

300

400

500

Male Female

Num

ber o

f Hea

lth C

heck

s

Number of Health Checks in pharmacies by sex and registration status, persons aged 35-74, Islington, Jul 2010 - Mar 2011

Can't remember Unregistered

Registered

• There were 721 HCs carried out in pharmacies, against an original target of 1,500.

• Six percent of persons who had Health Checks in pharmacies were unsure of whether they were registered with a GP practice (n=40).

• There were more pharmacy Health Checks in women than in men (64%, n=465 versus 36%, n=256), mirroring the gender profile of health checks in community outreach settings.

• Seven percent of men (n=19) said they were unsure of whether they were registered with a GP practice whereas the equivalent percentage was 5% for women (n=21). Overall 6% of health checks in pharmacies were in unregistered patients or patients who were unsure if they were registered.

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Ethnicity

Ethnicity of people having a NHS Health Check in the community pharmacy setting (1 July 2010 - 31 March 2011)

0

50

100

150

200

250

300

350

Ethnic group

Nu

mb

er

Persons

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Clinical results

Number of high clinical results requiring referral to GP within 4 weeks(Community Pharmacy setting, 1 July 2010 - 31 March 2011)

0

10

20

30

40

50

60

70

80

Blood pressure(diastolic) >90

Blood Pressure(systolic) >140

Total cholesterol> 6.5

QRisk2 score>20%

Fasting bloodglucose > 5.6

Clinical result

Nu

mb

er

Persons

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HCs in community pharmacy by QRisk2 score

0

10

20

30

40

50

60

70

80

90

100

Less than 10% 10-14% 15-19% 20% or more

Perc

enta

ge

QRisk2 category

QRisk2 category in men, women and persons who had Health Checks in Islington pharmacies, Jul 2010 - Mar 2011

Men Women Persons

• Four-fifths of persons (n=581) having HCs in pharmacies were found to have a low QRisk2 score (QRisk2 <10%).

• Six percent (n=41) of persons had a QRisk2 score of >20%.

•This distribution of CVD risk identified via HCs in pharmacies is very similar to the distribution in HCs carried out in the community outreach programme.

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Lifestyle information

Lifestyle information collected as part of the NHS Health Check(Community Pharmacy setting, 1 July 10 - 31 March 11)

0

100

200

300

400

500

600

< 5 fruit & veg per day BMI >27.5/30 < 3 hours physical activity perweek

Current smoker

Lifestyle category

Nu

mb

er

Persons

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PROGRESS TOWARDS TARGETS

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Performance by month

Number of NHS Health Checks in Community Pharmacy setting 1 July 2010 - 31 October 2011

0

20

40

60

80

100

120

140

160

180

200

Jul-10

Aug-10

Sep-10

Oct-10

Nov-10

Dec-10

Jan-11

Feb-11

Mar-11

Apr-11

May-11

Jun-11

Jul-11

Aug-11

Sep-11

Oct-11

Month

Nu

mb

er

Month Target

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Support

NHS Health Check branded posters for display in pharmacy Incentive scheme for pharmacy assistants – ‘whole-

pharmacy’ approach Branded NHS Health Check Prescription bags sent out to

pharmacies to use when dispending medication (not always easy when people have pre-existing diagnosis)

Monthly feedback

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Pharmacist perspective

“The NHS Health Check has worked really well, as both myself and team members believe that we can contribute to a reduction in the number of medicines given out for blood pressure and cholesterol by actually detecting it [disease] early and instructing the individual to improve their lifestyle….in addition it actually boosts the reputation of the pharmacy and portrays an image of a "caring and friendly team taking steps to help the community".

“The reason for our success is the continued and active training of staff members to always be on the lookout for anyone who is eligible to undertake a health check. We will continue to carry out this additional service, as the positive impact that it has on the community is something which we witness every day."

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Outcomes from NHS Health Checks

(All HCs in Islington, 1st April 2010 – 30th March 2011, all settings)

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• This analysis is based on all HCs conducted in Islington in 2010/11, irrespective of setting. However, for a proportion of health checks undertaken in community settings, where these have not been entered in GP systems, it is not possible to follow up the outcomes of these HCs ie identify new diagnoses made as a result of the HC.

•A total of 250 new diagnoses for hypertension, PVD, heart disease, stroke/TIA, atrial fibrillation, diabetes, chronic kidney disease, and hypercholesterolaemia following Health Checks in Islington were made.

• Hypertension accounted for the largest number of new diagnoses (n=133), followed by diabetes and hypercholesterolaemia (n=46 and n=45 respectively).

•New diagnoses are defined as those following the HC, but no time limit is specified between the HC and the new diagnosis. Source: EMIS (June 2011), NHS Health Checks in persons aged 35-74, Islington

registered population.

0

20

40

60

80

100

120

140

Hype

rten

sion

Diab

etes

Hype

rcol

este

rola

emia

Hear

t dise

ase

Stro

ke/T

IA

CKD

-Sta

ge 3

Atria

l fibr

illatio

n

PVD

Num

ber o

f new

dia

gnos

es

Number of new diagnoses following HCs in Islington by sex, persons aged 35-74, Apr 2010 - Mar 2011

Men Women

New diagnoses following HCs

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• 64% of new diagnoses were in men (n=161) and 36% in women (n=89)

•Slightly more than 30% of new diagnoses were in persons in each of the age groups 55 to 64 (32%) and 65 to 74 (30%).

• The largest number of new diagnoses in men was in the age group 55 to 64 (35%). In contrast, for women the largest numbers were in the age groups 45 to 54 and 65 to 74 (both 32%).

Source: EMIS (June 2011), NHS Health Checks in persons aged 35-74, Islington registered population.

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0

5

10

15

20

25

30

35

40

35-44 45-54 55-64 65-74

Perc

enta

ge

Age group

New diagnoses in men, women and persons aged 35-74 by age group, Health Checks in Islington, Apr 2010 - Mar 2011

Men Women Persons

New diagnoses by sex and age

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•Forty-four percent of persons given one or more new diagnoses following Health Checks had a QRisk2 score of 20% or more (n=105).

•However, it is worth noting that more than a fifth had a low QRisk2 score (<10%) (22%, n=53).

• This pattern differed for men and women. More than half of men given a new diagnosis had a QRisk2 score of 20% or more (51%, n=76). For women the equivalent figure was 33% (n=29).

•In contrast, 36% of women given a new diagnosis had a low QRisk2 score (<10%) (n=31), whereas it was only 15% for men (n=22).

Source: EMIS (June 2011), NHS Health Checks in persons aged 35-74, Islington registered population.

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0

10

20

30

40

50

60

Less than 10% 10-14% 15-19% 20% or more Missing

Perc

enta

ge

QRisk2 category

New diagnoses in men, women and persons aged 35-74 by QRisk2 category, Health Checks in Islington, Apr 2010 - Mar

2011

Men Women Persons

New diagnoses by QRisk2 category

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Where to from here?

Targeted small-scale campaign planned for January 2011

Pharmacy visits during Q3, 2011/12 Further evaluation to compare NHS Health Checks in

community pharmacy to other settings.

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Thank you.

Contact details:

Chrystal Greenwood

Project Officer, Long Term Conditions

[email protected]

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Number of Health Checks by setting, sex and QRisk2 score

0

500

1000

1500

2000

2500

Men Women Men Women Men Women

General Practice Community Pharmacy

Nu

mb

er o

f pat

ien

ts

Risk score missing

≥20%

15-19%

10-14%

<10%

Risk of heart attack or stroke in the next 10 years

• In GP practices, 58% of checks were in men and 42% on women.

•However, in community and pharmacy settings, around 60% of checks were in women and 40% in men.

•41% of checks in GP practices were in persons with a low QRisk score, compared to 80% in community and pharmacy settings.

•20% of checks in GP practices were in persons with QRisk2 of 20%, compared to 6% in pharmacy and community settings.