KATHIE APPLEBEE
BA(Hons) MSc DMS
Psychologist and Management Consultant
Strategic Management Partner (part-time)
Tamar Valley Health, Cornwall
Kathie juggles her own primary care consultancy with a part-time partnership in a large, rural practice. After nearly 30 years spent working nationwide with practices and PCTs, she can testify to the fact that each year in general practice is busier than the last. When not working, Kathie rides her horse on Bodmin Moor and tries to forget about work
Vascular disease includes coronary heart disease (heart attacks and angina), strokes, diabetes and kidney disease. It is the single largest cause of chronic ill health and disability, affecting more than 4 million people in England alone and causing 36% of deaths and one fifth of all hospital admissions.(1) Its prevalence is greatest amongst deprived communities and certain ethnic groups, such as South Asians.(1)
The Department of Health is planning a primary care screening programme, to be known as the NHS Health Check, targeting those aged 40–74 who have not been diagnosed with vascular disease. The information published to date includes Vascular Checks: risk assessment and management (including an associated annex, Options Stage Impact Assessment for Vascular Risk Assessments) and NHS Health Check: Vascular Risk Assessment and Management Best Practice Guidance, which contains a wealth of technical information about the requirements and is essential reading.(1,2)
There is also a resource website called NHS Health Check (see Resources), where you can sign up for an email newsletter, access documentation as it is published and download resource materials, including leaflets and an invitation letter template.
The risk factors that this programme is seeking to target are:
- High blood pressure.
- Raised cholesterol levels.
- Smoking.
- Physical inactivity/a sedentary lifestyle.
- Obesity.
Impact on GP surgeries
The Options Stage Impact Assessment annex considers the value of the programme and the impact it would have on general practice. Using a practice of 5,600 as an average size, the authors modelled the impact of offering such checks to patients aged 40–74 every five years as being approximately 330 additional checks per annum (based on a 75% uptake of invitations and excluding patients already being managed).(1)
Of these, an estimated 65% (215) would require lifestyle advice and/or interventions (see below) and about 20% (66) would need to be prescribed statins and/or antihypertensives.(1)
The frequently asked questions published on the NHS Health Check website suggest an additional 3–5 appointments per week – a slightly lower figure but one which may be taking missed appointments into account.
Because these figures are based on averaged statistics and estimates, the exact amount will vary between practices. Those with proactive screening programmes should find that they have already dealt with some of the target group members.
Box 1 shows the formula for calculating the number of appointments for individual practices.
[[KA_Box1]]
While the final details are being clarified, practices should begin planning the practicalities. They will need to arrange for:
- Search and recall systems for identifying and recalling eligible patients, and systems for following up non-attenders.
- Training for record keeping (for example, the use of tailored data-entry screens).
- Systems for notifying patients of test results and follow-up appointments.
- Audit systems to ensure that all patients are recalled and any required claims are made.
- Additional healthcare assistant (HCA) and nursing time.
- Some additional GP time.
- Systems for internal referrals between the HCAs, nurses and GPs.
- Administrative resources for additional recalls, booking of appointments, test-result handling and referrals.
Patient assessment
The checks currently proposed include:
- A standard assessment using “straightforward” questions and measurements, recording:
• Age and current medication (which should already be part of the patient’s computer record).
• Height and weight.
• Ethnicity and family history of heart disease (see pages 3-4 and 14 of the Best Practice Guidance regarding use of risk factor predictive software(2)).
• Smoking status and blood pressure.
• A simple blood test for cholesterol (random, not fasting).
• Where indicated, glucose levels (see page 21 of the Best Practice Guidance for the indicators for this test, which include a high BMI(2)). - Further blood and urine tests for those with risk factors for kidney disease.
Each patient would then be given an “individually tailored assessment”, which would inform them of their level of vascular risk and what they could do to reduce this, where necessary.
- Low-risk patients would usually need general advice on staying healthy (for example, sensible eating, weight management, exercise, stopping smoking, reducing alcohol consumption and trying to minimise stress).
- Moderate-risk patients might be recommended to a weight management programme, a smoking cessation service, or a brief intervention programme to increase exercise.
- High-risk patients might need to be prescribed statins (for high cholesterol) or blood pressure treatment, and/or be referred to an intensive lifestyle management programme if impaired glucose regulation had been diagnosed.
- Highest-risk patients might need to be referred to secondary care.
The length of the initial appointment will depend on several factors, including the expertise of your HCAs; whether the phlebotomy for the blood tests is included; and whether you plan to include the health education/feedback sessions in the initial appointments (where appropriate).
- Patients with low-risk factors (satisfactory lifestyle, blood pressure and BMI, and a benign family history) could be given their assessment and any required health education advice, and arrangements made regarding notification of the outcome of the blood tests by phone. If these tests subsequently indicated moderate or high risk factors, they would then be treated as belonging to one of these other categories.
- Moderate-risk patients could be treated in the same way, or brought back for a follow-up appointment and/or referred to a nurse if the practice protocol requires.
- High-risk patients should be referred to a practice nurse with expertise in the relevant areas of chronic disease management, or possibly referred to a GP if indicated by the protocol.
Implementation
The NHS Health Check is already behind schedule, and we should expect the pace of implementation to increase by next April, with primary care trusts outside pilot areas being expected to offer local enhanced service (LES) funding to cover increased costs. It should be noted that any new diagnoses would increase Quality and Outcomes Framework (QOF) prevalence in the relevant disease areas and thus increase the value of the QOF points for these areas.
The changes planned will enable your practice to build up the numbers of patients screened until the full programme can be implemented over a five-year cycle. This programme should be viewed as an adjustment to existing services rather than a major overhaul: chronic disease management is an essential part of general practice and screening is an essential element of this, which is now being given greater prominence.
Because of the overall value of this programme, suppliers outside of general practice will be interested in trying to offer it – so make sure you get in first with your patients.
References
1. Department of Health. Putting prevention first. Vascular Checks: risk assessment and management. London: DH; 2008. Available from:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati…
2. Department of Health. NHS Health Check: Vascular Risk Assessment and Management Best Practice Guidance. London: DH; 2009. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati…
Resources
NHS Health Check
CVD screening in Scotland: Heart Health: prevention, evidence and policy
Information about plans for Wales
Service Framework for Cardiovascular Health and Wellbeing for Northern Ireland
