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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
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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.