We hope our latest edition of Health Matters – on the subject of “Using NHS Health Checks to optimise CVD care” – will help you and other professionals by compiling key facts, figures and evidence of effective interventions.
The NHS Health Check programme provides a crucial means of delivering prevention-focused brief intervention to over 15 million people in England. Research shows that there is better access to lifestyle and clinical management among people that have a check.
There is also evidence that the NHS Health Check is being equitably accessed by certain high risk populations, such as those living in our most deprived communities.
Where we can, we’re also committed to answering your questions and taking on your feedback. In this blog we’ve published the answers to a number of Health Matters questions we received from professionals across the UK at the recent launch teleconference.
Our Q&A panel are Associate Professor Jamie Waterall, National Lead for CVD Prevention and Associate Deputy Chief Nurse at PHE and Dr Matt Kearney, National Clinical Director for CVD prevention at NHS England and PHE.
Question 1 (Involvement of community pharmacies in the NHS Health Check)
I’m calling from the National Pharmacy Association. We're doing some work nationally looking at how community pharmacy can provide expertise, scale, and contact in this space. We're doing some work around community pharmacy looking at the NHS Health Check pathway. We're looking at how we can provide an enhanced hypertension offer screening diagnosis, but also long-term management. Given that community pharmacy is the third biggest workforce in the NHS, what can we do to get the sector more involved in this and what's the appetite do you think at local public health level to commission and engaging community pharmacy directly?
(Jamie Waterall): I think it's a really good question and certainly, local authority commissioners out there definitely recognise the benefit of using pharmacy to reach certain high risk populations. We know across the country that there are many pharmacies already being commissioned to deliver NHS Health Checks. You also touched on the importance, beyond the NHS Health Checks, on how do we use pharmacy to identify things like high blood pressure? And if you haven't seen, I wrote a foreword for a publication that was led by Pharmacy Voice that made several recommendations of how we get pharmacy more involved in that end-to-end management of high blood pressure.
I was talking to a pharmacist only last week who was telling me that he was a practice-based pharmacist, who was now offering the service of both identifying people with high blood pressure, initiating investigations or ordering ambulatory blood pressure monitoring and then initiating treatment. I think that's the kind of model that we definitely want to see evolving out there - that pharmacy really can own some of this space and already is doing so. I think the challenge you said is how we scale this approach. PHE is already having conversations with NHS England, the Department of Health and Social Care and other colleagues about how we can achieve this ambition together.
(Matt Kearney): I agree. It’s a really important question because community pharmacy resource is enormous with a highly trained professional workforce that can help. Firstly, we're increasing the uptake, the access to initial NHS Health Checks for people in the community. But secondly it’s very important to consider the follow-up. The initial NHS Health Check is a pathway; it's not a one off event. It's a pathway that goes through primary care that requires proper assessment and management of conditions including high blood pressure and high blood sugar. And we know from the evidence that there's a lot of scope for improvement not just in follow-up from the NHS Health Check, but in the detection and management of these conditions. And frankly, I think that general practice needs help and new ways of working in order to deliver this. So I think absolutely, that community pharmacists and practice-based pharmacists are really well placed to bring that extra help to improve outcomes to patients.
Question 2 (Housing and the NHS Health Check)
My question is around the issue of housing and housing impacts on people's health. How can local authority private sector housing teams link with the NHS Health Checks that are currently being undertaken? We have funding through the better care funds, which we may be able to offer. I work in a local authority myself and we have things like local authority flexible eligibility schemes where if people have health conditions that are impacted by living in cold homes, we can actually help improve the energy efficiency of people's homes. I was just wondering if there's any way that we can all link together?
(Jamie Waterall): It's a great question and we actually know there's evidence around housing and the relationship with cardiovascular disease. I came across a case study a number of years ago where the local authority were working with the housing department to actually try and target NHS Health Checks, particularly people in social housing that arguably may be at greater risk of cardiovascular events. They were using that as a way of getting NHS Health Checks to individuals. So I strongly encourage you to look up your Director of Public Health within the local authority you're based in and maybe go and have a chat. See if there's something that potentially could work and certainly, it's given me some thoughts as to how we could perhaps bring out some of those case studies like you're describing.
Question 3 (Evaluating the NHS Health Check locally)
I'm a public health nurse on the Isle of Wight and I'm working on evaluating our local NHS Health Check programme. I'm specifically looking at process outcomes locally and I was wondering if you might be able to point me in the right direction to find data on the number of high risk individuals that we might find in our local service, perhaps as a percentage of the total number screened, and also nationally, how many people who are identified as having high CVD risks are actually prescribed statins.
(Matt Kearney): I don't know off the top of my head of the exact percentage that are identified through the NHS Health Check, but I think we do have an estimate and it was something like 25% or 30%; it was a significant number. So we can find that or point you to the John Robson data, which will give you an estimate of what you might expect to find locally. But what we also know very importantly is that in the NHS Health Check, we're identifying these risk factors. The pathway is crucial. What we are we doing about them and what we know from the early evaluation is that only about a fifth of people who are checked have even a 20% ten-year risk only about a fifth are getting put onto statins. If we don't provide the treatment, we're not going to influence the risk factor. And so I think as part of your local evaluation, it would be really worth looking into that as well. So it’s how we can support identification of these individuals, and how can we ensure they get appropriate follow-up.
(Jamie Waterall): If you look at the full content of this edition of Health Matters, you'll see that the reference to an ESCAP report, that's our expert scientific and clinical advisory panel report, that concludes a really important piece of work that Cambridge University undertook, looking at all the published studies. In fact, it gives you the data that Matt is referring to. It gives you national level data for the number of people that are identified with diabetes, with high blood pressure, with high cardiovascular risk. So that should be a good starting point. And then the other thing I'd advise you go and have a look at is PHE's National Cardiovascular Intelligence Network, which has really good tools and reports that enables you to look at specific Isle of Wight data. So do go and use some of those materials.
Question 4 (Evaluating the NHS Health Check locally)
I’m a consultant in public health in the northeast. I suppose it's more of an observation around increasing the breadth of NHS Health Checks and where they take place. At present there's a real lack of a systematic way to record those that take place particularly in the volunteering community sector and then being able to share that information back into the primary care pathway. As the commissioner of our local NHS Health Checks, getting that data back from providers can be difficult. But also secondly, if you widen it out there isn't really a mechanism other than commercial packages, which are very expensive for the volunteering community sector, in particular, to actually undertake those NHS Health Checks and have the mechanisms for recording them.
(Jamie Waterall): What you raise is obviously hugely important and without the recording of that information, then you're right, we won't know the impact and the quality and the effectiveness of what people receive diminishes. So I share that anxiety with you. Clearly, the regulations do say that if NHS Health Checks are being delivered then there has to be the endpoint of the information being recorded on the clinical system. Certainly from a policy point of view, we absolutely emphasise that that has to happen – it is really important.
Now, from a practical point of view, as you describe, it clearly is a challenge. You’ve referred to there being solutions out there. I'm not going to name some of them, but there are providers out there that you can purchase services from and they will push data back directly into GP clinical systems. At PHE we're just embarking on a really exciting project around digital and the NHS Health Check and we're about to undertake some work looking at what solutions are available that enhance the NHS Health Check, whether it be encouraging people to take it up, through to delivering it, through to what happens after the NHS Health Check. This is one of the areas we definitely want to look more into. And when we start to see evolving work around people being able to access their own clinical records, I totally see that that is where the NHS Health Check needs to align. So we'll continue to look at this as opportunities develop in this space.
(Matt Kearney): Speaking as a practising GP, as I mentioned before, the pathway is crucial here and the NHS Health Check on its own will have limited benefit if we don't get the follow-up support of people to change their behaviours or to have their clinical conditions managed. And that relies very much on an integrated pathway through primary care. I know that across the country, there's variation in the degrees to which GPs and practitioners signed up for this and I know in some areas there are going to be more challenges around sharing of data and recording of data. I think that is shifting; I think the public discourse in the NHS is shifting on the value of the NHS Health Check. But also the Care Quality Commission (CQC) is very interested in this and Jamie and I have had conversations with them over the last few months and I'm doing a webinar with their inspectors in a week or so. Because in their key lines of inquiry when they visit practices, they have a section on CVD prevention and the key lines of inquiry for their inspectors include questions like do you share information required by commissioners of the NHS Health Check? When you receive information about your patients who've had an NHS Health Check, do you record that information? And when you have the information do you then act on it? So I think that's going to be very helpful that the CQC will be engaging in mature discussions about our responsibility within general practice to ensure the integrity of the pathway through the NHS Health Check.
Question 5 (Evaluating the NHS Health Check locally)
I am from a clinical network. Do you have any examples nationally where there is a strong interface between the NHS Diabetes Prevention Programme and other clinical conditions - such as dementia, that the rest of us can learn from?
(Jamie Waterall): I think the point that you're making around the relationship with other programmes is really critical here. In fact yesterday we published a new stock take and action plan on the NHS Health Check and I encourage you and colleagues listening in to this to go and have a look at that plan. What that publication is doing is firstly celebrating where we've come from over the last few years and what are we going to focus on in the coming five years. The point you're making is how we can get better at connecting to other programmes. Through the NHS Health Check we can identify people with non-diabetic hyperglycaemia and they then need to be referred through. Due to the shortness of time on this call, I would recommend you look at one of the case studies that we've produced for this edition of Health Matters, which looks at that relationship between the diabetes prevention program and the NHS Health Check and how colleague in Bromley try to bring those together and improve referrals.
Question 6 (How can local authorities find the names of their at-risk population)
I'm really pleased to hear that PHE wants to take the approach of broadening out the NHS Health Check to other agencies and that's certainly the model that we have in my area, where the Council provides NHS Health Checks to our population. It comes down to the sharing of information from GP practices. How do we get that eligible population from the GP records in the first place? I'd be really interested to hear what PHE's plan is to support that sharing, because in the way that the data is collected, it feels that we're at a bit of a disadvantage where we can't even identify who our eligible population is.
(Matt Kearney): I'm certainly aware that in some places, that is difficult, and some GPs are not freely providing that information. We're taking a number of approaches. One approach is to build the conversation and the professional relationship with my college, the Royal College of GPs, and to have discussions around this. We need national professional leadership - not just around the NHS Health Check but around the gaps and opportunities in cardiovascular disease prevention through the things we do in primary care. The NHS Health Check is part of that conversation. Clearly one wants to get this right by building good relationships locally. Sometimes that's difficult and sometimes it doesn't feel possible. I would just re-emphasise the interest of the Care Quality Commission (CQC) in this. So, when the CQC are making local visits and talking to practices - this will be in their key lines of inquiry. Now, which key lines of inquiry they use and the questions they raise depends on the intelligence they have. If they have intelligence that there is a problem for the local authority and the NHS around access to this information, you should raise that with the CQC. They need that intelligence, without it, they won't know there's a problem. If they do know there's a problem, it's for them to manage sensitively but assertively in their conversations with local practices. And, it's in their remit to do that.
(Jamie Waterall): And, just briefly to add, we have produced some information governance guidance on how to access this data and actually sometimes there's a myth in itself that people don't think that we can share this information and it is absolutely possible to share that information. If you haven't already seen it, do look at the Information Governance on Data Sharing guidance we produced. I think it was updated last year.
Question 7 (Targeting eligible populations and potential digital approaches to the NHS Health Check)
I'm currently working on re-designing the NHS Health Check programme in Greater Manchester on behalf of the Health and the Social Care Partnership here. I note in the guidance now that you are recommending that local teams target resources towards those at highest risk.
What we're particularly interested in doing in Greater Manchester is segmenting the population to some extent and developing a digital offer for those who don't appear at high risk. We really like the Heart Age tool. In fact, I think it's probably the most user-friendly version of anything like that I've used. We were looking at, maybe, developing something like that to encompass the whole NHS Health Check. Clearly, people need to know their actual blood pressure and ideally, people would have that extracted directly from their GP records. But, I think in this modern digital age, there is an opportunity to have the conversation and the behaviour change nudge within that digital platform for certain people. I am aware of most of my colleagues who either decide it's not relevant or don't wish to take up the offer or don't have time who, if they had opportunities to have a digital Health Check, I am certain it would impact on the way they live their lives in the future. So, I would urge us to think collectively about how we can, perhaps, try and test this, perhaps, in Greater Manchester. We've started discussions with Health Innovation Manchester, but I'm thinking it would be useful to do that together with PHE, if you’re also looking in that area. In terms of identifying those at highest risk - presumably if we develop something that we feel comfortable is going to make the biggest impact, that's in line with your guidance?
(Jamie Waterall): I've heard of the great work that is going on across in Manchester and would be delighted to have a follow up discussion with you beyond today's call. The point around how we target our resources, PHE’s position on the NHS Health Check programme is that we have definitely supported the proportionate universalism approach for some time. Although the regulations require that everybody is invited for an NHS Health Check, we totally would expect to try and target that resource or the large proportion of that resource to those people that are going to benefit most from an NHS Health Check.
The point around a digital offer, again, is something we're very interested in and will, no doubt, want to link up some of the work we want to do on looking at the future role of digital. The Heart Age tool that we've been developing with various colleagues is certainly an interesting approach. As for an NHS Health Check offer though, the regulations require that to be a face to face consultation. However, should emerging evidence demonstrate that a digital offer is equally as good, then that's something we'd put to our expert clinical and scientific advisory panel and then make recommendations to ministers in government whether we feel the programme should be changed.
Question 8 (Reaching potential people at high-risk of CVD at the places they visit)
I'm a GP in Kent, with an interest in public health. I've really enjoyed the discussion, and this has been really useful to us. We do NHS Health Checks here in my practice. In terms of targeting the people who would most benefit, and I'm aware that there's an issue with who would do this, but I think we should use places like job centres, food banks and the housing team to publicise this - because, that is where a lot of the people who would benefit most might be found. Many overstretched GPS may be thinking well, someone else is dealing with it now. I think we really need to engage other GPs, like me, who are interested in helping to fill in the gaps. I think there is a real opportunity to do that because all policies seem to have, apart from this NHS Health Check, a very short-term view - chronic disease, the ageing population and so on and, if we have this long-term view, then we're going to really make an impact. I agree about information sharing and that's as much about sharing information about services that are available through local public health teams so that the population and clinicians also know about them, as much as sharing records.
(Matt Kearney): Thank you and really great to hear from you as a fellow GP really bringing these insights. It does remind me that although a lot of the talk is about how can we extend the NHS Health Check beyond general practice, actually what we bring in general practice is a real insight into our populations that is often not captured well elsewhere. Capturing that information to inform programme development is really key and the creative ideas you've come up with to target people in job centres and elsewhere is really helpful.
And, I would just underline that we have this emerging CVD prevention program across PHE and NHS England which is all about building on what is done in general practice but putting other things in to support it, to as you say, join things up. Use other settings, go to where people are and provide services in the way that suits them. Because, that's the only way, frankly, we're going to detect more of these high-risk conditions and manage them in the way that people need them to be managed.
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