Local Enhanced Service for NHS Health Checks (Vascular)

Author(s): Rose Owens/Julia Booth

Issue Date: October 2010

Version no: 2

Status: FINAL

Review date: as required for service development

Agreed with LMC

Agreed with LPC

Specification: NHS Health Checks (Vascular)

INTRODUCTION

1.1.This specification sets out a joint Local Enhanced Service (LES) for GMS, PMS and Community Pharmacy contractors to provide NHS Health Checks(vascular risk assessment and management services).

1.2.All providers are expected to provide the full range of essential and those additional/advanced services as set out in their contracts. This enhanced service specification for the provision of a screening programme for NHS Health Checks (vascular) is designed to cover the enhanced aspects of the clinical care provided to the patient, all of which are beyond the scope of essential services. No part of the specification by commission, omission or implication defines or redefines essential or additional services.

1.3.With any provision of service, consideration must be given to addressing inequalities in health. This primary care service provides an opportunity to narrow the inequalities gap by providing services not only to the mainstream population but also to those in disadvantaged groups with poor health outcomes.As the service develops, ways of engaging people who do not normally access healthcare services will be explored.

1.4.The service will be introduced initially in early adopter sites which will be selected to ensure that the most disadvantaged groups in both a rural and urban setting can be targeted in the first instance. The service will be rolled out over a period of time across the remainder of the trust. The first phase of the programme will target those in the 40 to 74 age group who have an established or estimated CVD risk score of >20% over 10 years as identified by the Oberoi software, are recorded as current smokers (or who have no data regarding their smoking status) and are not already on any vascular disease register.

1.5.The LES will be comprised of two components –

Component A: The initial work required of GMS/PMS contractors to identify patients, set up call and recall systems, send invitations and record outcome data from all checks carried out in a timely and accurate way on the GP clinical system.

Component B: The process for GMS, PMS and community pharmacy contractors carrying out NHS Health Checks, as well as follow-up and referral pathways.

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 Dorset. 37.4% of deaths in 2005 (Office for National Statistics) were attributed to this, the highest cause of premature death. A structured approach to cardiovascular risk managementfor all people aged 40-74 years old, who are not already on any patient risk register, is expected to be established by 2012, with initial small scale early implementation in each PCT during 2009/10. The service is referred to as “NHS Health Checks”.

2.2.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. Based on 2008 figures, the total population in NHS Dorset eligible for a Health Check will be 139,684 once the service is fully established.

2.3.In order to reduce risk and prevent development of diseases such as diabetes,the emphasis will be placed on encouraging people into lifestyle interventions to address the modifiable risk factors. Only once these interventions and lifestyle changes have been tried will treatments such as medication be consideredunless there are clear overriding medical indications e.g. identification of diabetes, hypertension or familial hyperlipidaemia.

2.4.Patients must be offered a choice of venue (where available) at which the checks may be carried out.

SERVICE AIMS

3.1.To improve health outcomes and quality of life by enabling more people to be identified at an earlier stage of vascular change. This will give a better chance of putting in place positive ways to make substantial reductions in the risk of cardiovascular morbidity, premature death or disability.

3.2.To prevent the development of diabetes in many of those at increased risk of this disease.

3.3.To sustain the continuing increase in life expectancy and reduction in premature mortality that is under threat from the rise in obesity and sedentary living.

3.4.To make significant inroads into reducing health inequalities, including socio-economic, ethnic and gender inequalities.

3.5.To offer convenience and accessibility of testing facilities by providing a choice of location and extended hours of availability.

SERVICE OUTLINE

This Local Enhanced Service will fund the following:

COMPONENT A (GMS AND PMS CONTRACTORS ONLY):

PATIENT IDENTIFICATION, RECALL AND RECORDING

Identification of at risk patients

4.1.Practices will use the Oberoi software already installed on GP Clinical Systems to identify the patient cohort for the service. Eligible patients will be those who:

are aged between 40 and 74 years
are recorded as a current smoker or have no smoking status recorded
have an established or estimated CVD risk score of over 20%
and are NOT on one of the following disease registers:

Diabetes
CHD
Heart Failure
Atrial Fibrillation
Hypertension
Stroke/TIA
Renal disease / CKD

(All the above disease registers can be filtered using the Oberoi software and a spreadsheet.)

Palliative Care (practices will manually identify andexclude those patients that areon the palliative care register)

Establishment of call and recall process

4.2.Practices willset up a call and recall process for this group of patients. Using the template provided(Appendix A) written invitations,including a copy of the Department of Health information leaflet,will be sent to all patientseligible to attend a health check. The letter must be presented at the time of the Health Check as proof of invitation. Invitations must include details of available choice of provider and venue where applicable.

4.3.Practices are required to recordtwo attempts at contacting the patient. Where necessary, the second attemptmay be by telephone or text message. It is recommended that the time between contact attempts is approximately one month.

4.4.All practices must order and maintain supplies of the DoH leaflets to send out with the letters of invitation. Orders are made directly from the DoH by following the link:

4.5.By 2012/13, the PCT will be required to ensure that 20% of the population isoffered screening annually, with a 5 year call and recall system in place. The call and recall system will ultimately be a national arrangement, but until that is in place, local arrangements will need to be made.

Recording

4.6.GP practices will record in the patient’s clinical record 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.

4.7.A clinical system template will be provided by the PCT to assist data entry(Appendix D). An electronic copy of this will be supplied to all pharmacy contractors to complete with a responsibility to ensure safe and timely transfer to the patient’s registered GP for entry into the patient record.

COMPONENT B

(GMS, PMS AND COMMUNITY PHARMACY CONTRACTORS):

“THE HEALTH CHECK”

5.1.The service to be provided will be underpinned by the values and principles detailed in the following documents:

Putting Prevention First (DOH, March 2008)
The Handbook for Vascular Risk Assessment, Risk Reduction and Risk Management (UK National Screening Committee, March 2008)
Putting Prevention First – Best Practice Guidance (April 2009)(
Be Active Be Healthy: (DOH, February 2009)

It is a requirement that best practice guidance is followed at all times.

Process

5.2.The service provider will ensure that people presenting for an NHS Health Check are informed about the process of the service and are given the opportunity to ask questions. The provider will seek consentfor the assessment and the communication of results to their GP. Invitation letters will contain a clause stating that consent to share information with their GP is a requirement for having a Health Check. Persons who decline this consent should be refused a Health Check. Pharmacy contractors are required to record this on the monthly data submission form (Appendix F)

5.3.The following information and measurements will 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

5.4.The service providerwill calculate the estimated individual 10 year CVD riskusing the Framingham or Q-Risk2 score tools (as per best practice guidance page 14). GP practices will have access to one or both of these tools. Pharmacies can access Framingham at
The Q-risk calculator can be found at

5.5.The risk assessment pathway is presented in detail in the DoH publication Putting Prevention First – Best Practice Guidance (April 2009). The diagrams in appendix B are taken from the guidance and describe the risk assessment pathway and diabetes filter. Some patients may need to return for a subsequent fasting blood glucose measurement or additional blood pressure measurements.

5.6.The service provider will document the measurements and assessed level of CVD risk using the data template provided (appendix D). In GP practices this will be entered directly on to the clinical system. In community pharmacies the template must be completed electronically and sent via secure NHS e-mailto the agreed e-mail address at the at the patient’s registered GPpractice for entry by the practice on to the clinical system.

5.7.All data collected from NHS Health Checks carried out either in the GP practice or by a community pharmacy contractor will be recorded in a robust, accurate and timely way to enable effective monitoring.

5.8.The records in pharmacies must be kept securely for two years to enable audit and post payment verification. The records may be kept electronically or in paper form.

5.9.All persons undergoing a Health Check will be given a copy of their results.

5.10.The service provider will communicate the level of risk (high, moderate, low) to the person, and an individually tailored management programme, with appropriate advice, support and interventions depending on the level of risk identified, will be agreed as follows:

5.11.Brief healthy lifestyle advice and support will be given to all people receiving the service to assist them with managing and / or reducing their risk.

5.12.People who are found to be at moderate risk will be offered, where appropriate, interventions such as stop smoking or weight management. Where theseservices are not available in house, appropriate referrals should be made.

5.13.In addition to the above, people who are found to be at high risk or where apre-existing disease is suspected or identified(eg Diabetes), will be referred to their GP for further investigation and management. This includes instances where blood pressure measurement is ≥ 200/100 or total cholesterol is ≥ 7.5

5.14.The person will be actively involved in agreeing what advice and/or interventions they will follow. Any decisions must be made in partnership with the person and with their informed consent.

5.15.The service provider will be expected to demonstrate a clear understanding of the services available locally to individuals to support healthier lifestyles and communicate this information to the appropriate individuals.

5.16.The service provider will supply the individual with a pack of information, appropriate to their needs, as identified by the Health Check. PCT recommended resources are listed in appendix E. Providers will order these resources directly and maintain adequate supplies.

5.17.The service will be expected to be available at suitable times which maximise uptake in populations at highest risk. Providers will not be expected to offer the service outside their normal opening hours.

5.18.All service providers will attend clinical meetings to share best practice and discuss service development and improvements. Ideally these meetings will be organised on a locality or sub locality basis, but where this is not possible, a practice meeting will be held. The meetings will be multidisciplinary and include representation from both GP practices and community pharmacies.

Equipment

5.19.NHS Dorset will provide all equipment and consumables required if the service provider does not already have such equipment. Any equipment supplied by the PCT will remain the property of the PCT. All instructions for the equipmentmust be followed each time it is used. The following equipment will be required:

Scales
Height measurers
Electronic blood pressure monitoring machine or sphygmomanometer
Point of care testing devices for measuring cholesterol and blood glucose

5.20.The service provider will undertake external quality assurance testsfor point of care testing equipment. All equipment used as part of the service must be cleaned, calibrated and serviced as advised by the manufacturer with appropriate protocols in place. Any problems or faults with NHS equipment must be reported to the PCT immediately.

5.21.All providers must ensure that there are processes in place to ensure robust compliance with current infection control guidelines.

5.22.Each participating contractor will need to have access to a clinical waste disposal service. The contractor will allocate a safe place to store equipment required for the provision of the service and the resultant clinical waste. Contractors should ensure that all sharps and waste are disposed of appropriately, following their own Standard Operating Procedure (SOP).

5.23.The contractor must ensure that all staff are made aware of the risks associated with the handling of clinical waste and the correct procedures to be used to minimise those risks. SOPs for needle stick injury and the handling of clinical waste (including dealing with spillages) must be in place.

Accreditation and Eligibility to Provide the Service

Workforce requirements

5.24.The contractor will:

ensure that all staff involved meet the training, registration and competence requirements
be able to guarantee an adequate and stable workforce at all times to meet the potential demand
notify the PCT immediately if the service is not available due to workforce issues
demonstrate that the NHS Health Checks are performed by a suitably trained and competent healthcare professional who has completed the PCT training and accreditation programme
be expected to work in collaboration with NHS Dorset to ensure that this occurs in a timely manner and in accordance with guidelines
ensure that the Hepatitis B status of all staff involved in blood collection is recorded and uptake of immunisation isrecommended if required in accordance with national guidance.

Training

5.25.All staff who are involved in the delivery of the screening programme will be expected to attend training provided by NHS Dorset.

5.26.The training requirements for GP practice and pharmacy staff are variable and the following options will be available:

5.27.Pharmacy staff:

Completion of CPPE Vascular Risk Focal Point Learning Programme(only available to pharmacists and registered technicians)

Attendance at one of the PCT organised “Putting Prevention First” training days covering the background to the programme, risk assessment and management

PLUS

Attendance at a separate training evening to cover practical use of equipment and the details of the NHS Dorset Health Checks programme.

Each participating pharmacy must have pharmacist/s who have attended both elements of the training to take the clinical lead for the service and who must be present in the pharmacy when the service is being provided.All other members of staff involved in the delivery of the service must also complete both elements of the training.

5.28.GP practice staff

Clinical lead for the service within the practice and clinical staff involved in delivery of the service:

Attendance at one of the PCT organised “Putting Prevention First” training days covering the background to the programme, risk assessment and management
Specific training as required for Point of Care testing equipment

Practice manager and / or designated administrator for the service:

Attendance at a PCT organised meeting to cover the details of the NHS Dorset Health Checks programme.

Service providers will be required to work with NHS Dorset to review progress and identify any further training needs.

Consultation Area in Community Pharmacies

5.29.A consultation area, at least at the level required for the provision of the Medicines Use Review service, which provides sufficient privacy (including visual privacy) and safety, must be used for provision of the service. Hand washing facilities will be required within the consultation area or nearby. The service provider must ensure that NHS infection control standards are complied with.

Duration of Service

5.30.This service is offered initially for the period from January 2010 to January 2011, to be extended with agreement between the PCT and the contractor thereafter. This early implementation phase of the programme will inform future developments and the detail of the service is likely to change over time.

Termination

5.31.It is not envisaged that either party would give notice to terminate the Local Enhanced Agreement during this one year period. However, should this issue arise, NHS Dorset and the provider must jointly agree an appropriate strategy to manage existing services.

5.32.The contractor must advise NHS Dorset of its wish to opt out of the LES. NHS Dorset will seek to secure an alternative provider within a three month notification period.

5.33.This Local Enhanced Service may be suspended or terminated:

Immediately if the provider becomes bankrupt or insolvent;

If either party commits a fundamental breach of the terms of the agreement at any point during the period of agreement.

Pricing and Payment Mechanisms

5.34.Each practice or pharmacy contracted to provide this service will receive fees attached to the service components that they are contracted to provide.

Component A

5.35.For confirmation of participation in the scheme and agreement to deliver Component A,including provision of audit data as requested by the PCT: -

A one-off paymentbased on the practice list size will be paid. This payment to be made upon receipt of approved sign-up form. (see back of this document)

The payment will be £250 for the average list size of 6,666. The minimum payment will be £125 for a list sized of 3,333 or less and the payment will be capped at £500 for practices with list sizes of 13,332 or above.

5.36.A payment of £1.00 will be made for each patient invited to attend for a Health Check in accordance with Oberoi data, when all the following criteria have been met –

Invitation sent and recorded
Follow up invitation sent if required
Data template completed for any Health Checks carried out by GP Practice
Data template completed for any Health Checks carried out by any other provider
Patients failing to attend after 3 month period to be exception reported as non-responders.

5.37.Claims to be made on the quarterly enhanced services claim form.