AGENDA ITEM: NHS HEALTH CHECKS (version 2)
REPORT TO:
ADULT HEALTH WELLBEING COMMISSIONING GROUP
DATE:
17 AUGUST 2015
REPORT OF:
STRATEGIC COMMISSIONER OF PUBLIC HEALTH
SUMMARY
The purpose of this report is to update the Adult Health and Wellbeing Commissioning Group on the progress of the review of NHS Health Check provision.
RECOMMENDATIONS
1. The Group are asked to note the contents of this paper and identify any queries.
BACKGROUND
2. The NHS Health Check programme aims to help prevent heart disease, stroke, diabetes, kidney disease and certain types of dementia. Everyone between the ages of 40 and 74, who has not already been diagnosed with one of these conditions or have certain risk factors, are to be invited (once every five years) to have a check to assess their risk of heart disease, stroke, kidney disease and diabetes and should be given support and advice to help them reduce or manage that risk.
3. The NHS Health Check programme is based on NICE guidance on using cost-effective pharmacologic agents and behavioural approaches. It is estimated that the programme has the potential to detect at least 20,000 cases, per year, of diabetes or kidney disease earlier, helping people to manage these conditions better and improve their quality of life, and to prevent:
· 650 premature deaths
· over 4,000 people a year from developing diabetes
· 1,600 heart attacks and strokes
4. The local Healthy Heart Check cardiovascular screening programme was established in 2008 ahead of the national programme which was introduced in April 2009. From April 2013, the provision of the NHS Health Check programme (the risk assessment component) became a mandated responsibility of Local Authorities. However LAs are required to work closely with NHS Commissioners to ensure that there is a joined up approach to clinical follow up and management (Appendix 1: Outline of Commissioners Responsibilities).
5. Prior to 1 April 2013 the NHS Health Check programme had been performance managed on an annual basis with a target for offers (20% of those eligible) and received (10% of those eligible). There is a new national aspiration to achieve 66% uptake by April 2015; and a longer-term aspiration for an uptake across the country of 75% (measured as percentage of those offered receiving a Check).
6. LAs are able to commission the risk assessment from any provider of their choice but need to ensure appropriate identification of individuals; that the delivery of NHS Health Checks meets national quality standards; robust data flows occurs between providers; and that there is a robust pathway to clinical follow-up and management. As LAs are also the Commissioners for services which support lifestyle modifications such as weight management, physical activity, smoking cessation, alcohol harm minimisation there are opportunities for LAs to influence pathway improvements in relation to the management of risk.
7. In Stockton (and the other Tees Authorities) the majority of NHS Health Checks are currently provided by General Practices with additional capacity to extend provision of Health Checks into workplace, community and other outreach settings via use of a Nurse Bank. In the first 5 years of the programme across Tees 149,054 were invited and 106,230 received a Check. To date there have been over 35,647 Health Checks provided in Stockton-on-Tees.
8. On behalf of the 5 Tees Valley Local Authorities, the Tees Valley Public Health Shared Service are currently managing a service review looking at the cost and quality of current delivery models, identifying opportunities for improvement; and making recommendations on future model(s) of delivery and scoping commissioning options.
SUMMARY OF REVIEW ACTIVITY TO DATE
REVIEW OF EVIDENCE BASE AND BEST PRACTICE
9. For the major non-communicable diseases, studies have shown that a small number of well-known risk factors contribute the bulk of the population health risk. These are poor diet, smoking, high blood pressure, obesity, physical inactivity, alcohol use and high cholesterol. Evidence suggests that in relation to cardiovascular disease individual and universal interventions have the potential to substantially reduce the impact of stroke and heart disease.
10. On 1 April 2008, the Department of Health published “Putting Prevention First” which set out plans for the NHS to introduce a systematic and integrated programme of vascular risk assessment and management for those aged between 40 and 74. The benefits of this approach were anticipated to be:
· To enable more people to be identified at an earlier stage of vascular change;
· To enable the prevention of diabetes in many of those at increased risk of this disease;
· To sustain the continuing increase in life expectancy and reduction in premature mortality that are under threat from the rise in obesity and sedentary living;
· And to offer a real opportunity to make significant inroads into health inequalities, including socio-economic, ethnic and gender inequalities.
11. The DH announcement followed economic modelling that showed a policy of offering vascular checks was likely to be very cost effective and result in significant health improvements. The DH analysts modelled a population wide vascular risk assessment programme for the over 40s which included a range of interventions (brief exercise, weight loss, impaired glucose regulation, stop smoking, anti-hypertensives, and statins for primary prevention) and they also included the costs and benefits of earlier detection of diabetes. They concluded that a universal programme could be highly cost effective, with a conservative estimate of its cost per Quality Adjusted Life Year (QALY) of around £3,000 which compares favourably to other health interventions. [Department of Health. Economic Modelling for Vascular Checks: Department of Health, 2008]. An evaluation of the local Tees Health Check programme by the Centre for Health and Social Evaluation (CHASE) at Teesside University supported these findings.
12. In 2013, in preparation for commissioning responsibility transferring to LAs, Public Health England (PHE) who now provides strategic oversight and leadership for the NHS Health Check programme undertook a review of the evidence base for the programme. They set out the economic case for continued investment in NHS Health Check’s citing rising health and social care costs [NHS Health Check Implementation Review & Action Plan, PHE, 2013]. They believe that the most effective strategic approach to tackling cardiovascular disease is likely to be a combination of both individual and universal approaches citing evidence published by the World Health Organization, NICE and the National Screening Committee. They concluded that finding and managing those at high risk of vascular disease is likely to be both clinically effective and cost-effective; and that the NHS Health Check programme ‘adds value’ as a population approach, in conjunction with other population-wide strategies [NHS Health Check: Our Approach to the Evidence, PHE, July 2013]. In March 2013 DH also published ‘Living Well for Longer: A Call to Action on Avoiding Premature Mortality’ and the ‘Cardiovascular Disease (CVD) Outcomes Strategy both identified the NHS Health Check programme as a vehicle for delivering ambitions.
13. The investment in NHS Health Checks as a universal offer has not been without challenge and there is some criticism of the potential effectiveness of the programme within the media and health journals notably the Cochrane Systematic Review, ‘General Health Checks in Adults for Reducing Morbidity and Mortality from Disease’ (2012). However PHE argue that the Cochrane review looked at trials conducted many years ago and does not reflect provision of health checks through the current NHS Health Check programme as they bear ‘little relationship to the systematic risk evaluation and management recommended by the current NHS Health Check programme’. PHE believe that the combination of evidence for tackling CVD and its associated risk factors such as smoking, high blood pressure, physical inactivity, diabetes and obesity warrants continued action and investment in the provision of NHS Health Checks.
14. PHE aims to continuously review the programme against the emerging data and to add to best practice guidance to support Local Authorities to implement the programme at a local level. Members of the TVPHSS have attended conferences facilitated by PHE to gather intelligence on best practice and alternative commissioning models.
15. One of the original aims of national (and local) programme was to make significant inroads into health inequalities, including socio-economic, ethnic and gender inequalities. There has been some criticism that as the programme is based on a universal offer it may widen health inequalities. Ensuring that those offered a NHS Health Check actually receive a complete check is essential to optimise the clinical and cost effectiveness of the programme and a local areas ability to reach population groups with greatest health needs is key to addressing health inequalities. Every stage of the Health Check process can bring disadvantage to those with limited resources each being an opportunity for them to stumble known as the “staircase effect” [Tugwell et al. BMJ 2006, 332: 358–361].
REVIEW OF POPULATION NEED
16. Circulatory and heart disease, also known as cardiovascular disease (CVD), refers to a group of related conditions of the heart and blood vessels. These conditions include Coronary Heart Disease (CHD); Cerebrovascular Disease; Peripheral Vascular Disease (PVD): and Atrial Fibrillation (AF) & Arrhythmias. Many risk factors are associated with CVD. Some are non-modifiable risk factors that contribute to disease onset, including age, sex, family history and ethnicity. Other contributing factors are a consequence of lifestyle and can be modified or potentially reversed. These include smoking, elevated cholesterol levels, being overweight or obese, high blood pressure, sedentary lifestyle and poor diet. Cardiovascular (heart and circulatory) disease causes more than a quarter of all deaths in the UK, or around 160,000 deaths each year. There are an estimated 7 million people living with cardiovascular disease (CVD) in the UK.
17. The health of people in Stockton-on-Tees is generally worse than the England average. Deprivation is higher than the England average and life expectancy for both men and women is lower than the England average. Mortality rates from CVD are significantly higher than the national rate but rates have decreased by 54.8% since 1995-97. Stockton-on-Tees is also significantly worse than the England average on a number of other key issues including acute myocardial infarction (AMI) mortality (18 per 100,000 as compared to England at 16.3), and stroke mortality (18 per 100,000 compared to England at 12.8). Stockton-on-Tees is significantly worse for a range of other measures including smoking prevalence, estimated obesity, and emergency admissions for CHD and stroke.
18. In 2008 Tees DsPH were committed to tackling health inequalities and narrowing the gap in life expectancy. The leading underlying cause for both males and females in Stockon-on-Tees was CVD. Although there has been some significant improvement in mortality rates from CVD since 2008 (attributable to the smoking ban and improvements in primary and secondary interventions); rates of cardiovascular disease and the prevalence of its associated risk factors within the local population remain notably high and tackling CVD and its associated causes remains a priority.
19. As of April 2015, in Stockton-on-Tees there are estimated to be 53,195 residents eligible for a NHS Health Check (based on GP practice systems).
20. Dr Tanja Braun, TVPHSS Consultant in Public Health, presented a summary of the evidence base and population need to the Tees Valley Directors of Public Health in February 2015. She is currently in the process of a refresh of the CVD JSNA.
REVIEW OF NATIONAL PROGRAMME OBJECTIVES & QUALITY REQUIREMENTS
21.1 The provision of NHS Health Checks is now a Local Authority mandated responsibility and forms part of the NHS Constitution. It is recognised that there is a continuous need to monitor the overall success, uptake, benefit and value for money of the programme. Public Health England has published best practice guidance and quality standards. The information and measurements that are required for the NHS Health Check risk assessment are clearly defined [Appendix 2] and the programme quality standards are intended to support local commissioners in assuring themselves of the quality of the service they commission. These standards are not mandatory but provide a benchmark for quality improvement where reducing variation and assessing quality is particularly important. To support local implementation there is an abundance of best practice guidance including but not limited to data management, workforce competences, point of care testing, marketing and branding.
21.2 Summary of Quality Requirements
There are 10 standards which define quality across the whole pathway from the identification of an individual as eligible and through their subsequent care to safe exit from the programme:
1. Identifying the eligible population and offering an NHS Health Check2. Consistent approach to non-responders and those who do not attend their risk assessment appointment
3. Ensuring a complete health check for those who accept the offer is undertaken and recorded
4. Equipment use
5. Quality control for point of care testing
6. Ensuring results are communicated effectively and recorded
7. High quality and timely lifestyle advice given to all
8. Additional testing and clinical follow up
9. Appropriate follow up for all if CVD risk assessed as 20% and greater
10. Confidential and timely transfer of patient identifiable data
21.3 Summary of Performance Requirements
There is a statutory duty for councils to commission the risk assessment element of the NHS Health Check programme as part of a 5 year rolling programme and the impact of the programme will be monitored by the Public Health Outcomes Framework (PHOF). The PHOF focuses on two high-level outcomes that is (i) increased life expectancy and (ii) reduced differences in life expectancy and healthy life expectancy between communities. There are 3 indicators within the PHOF that relate to Health Checks:
(i) Cumulative % of the eligible population aged 40-74 offered an NHS Health Check 2013/14
(ii) Cumulative % of the eligible population aged 40-74 offered an NHS Health Check who received an NHS Health Check 2013/14
(iii) Cumulative % of the eligible population aged 40-74 who received an NHS Health check 2013/14
There are no nationally prescribed targets in relation to NHS Health Checks. However, PHE suggest that Local Authorities should aim to offer checks to 20% of their eligible population every year and achieve an uptake of 66% rising to 75% (in line with national screening programmes). NHS Health Checks is a rolling five-year programme meaning that 100% of the eligible population should have been offered a check at the end of the period. Within a 5 year period only the first invite is counted towards the performance measurement for offers. Uptake has been measured nationally as a percentage of eligible people offered that received a NHS Health Check (locally this has been measured as the percentage of eligible people that received a NHS Health Check). High performing areas are perceived as those that offer to a high proportion of the eligible population cohort and then achieve a high transfer rate (i.e. conversion of Health Check offered into Health Checks received).