Due to a high prevalence of cardiovascular disease morbidity and mortality, both NHS Stoke on Trent and NHS Birmingham East & North have implemented their NHS Health Check programmes since 2008 by piloting various delivery strategies to ensure population-wide coverage.

NICE has recently emphasised the importance of tackling cardiovascular risk both at the individual level and by population level changes with legislative, regulatory and voluntary involvement.

In Stoke on Trent, high risk patients with CVD risk scores ≥ 20% were identified using the Oberoi screening tool. Of those invited 40% (4000 of a possible 16,000 patients) with CVD risk ≥ 20% have been screened to date in general practice settings with 1500 of these attending a lifestyle coach; (around 1000 too had a partial check in community settings) – see Table 1.

LES options allowed practices to provide the service in-house or via the PCT’s project support workers. Practice teams were incentivised to refer patients with a proven CVD risk ≥ 20% to bespoke lifestyle support via a six month programme with a lifestyle coach and access to physical activity, weight management, healthy cookery and mental/emotional wellbeing programmes. Practises took on usual medical management for identified health problems and utilised existing smoking cessation and alcohol misuse services – combining medical and social models.

Table 1: Key learning from models piloted by NHS Stoke on Trent

Delivery Strategy

 

Key Learning
Primary prevention (general practice settings) and Lifestyle Programme
  • Patients trust their GP teams
  • Patient information easily entered into practice records
  • Continuity with medical management for identified problems
Voluntary group providing community check
  • Commissioning third sector provider is not cost effective; no blood tests so CVD risk score not calculated
  • Difficulty targeting eligible patients (40-74, no pre existing conditions) at open events.
  • Relaying patient sensitive information to GP practices is bureaucratic, costly and may be incomplete
  • Accessing marginalised communities can be time consuming with poor uptake if suspicion about who you are and what happens to information   
Pharmacy pilot
  • Additional costs of health checks in pharmacy (compared to GP settings) include transmission patient data to GPs, near patient testing, software, licence, training
  • Culture change - some GPs anxious about ability of pharmacies to deliver service
  • Patients like having health checks in evening /weekend
Saving costs
  • Drop in clinics achieved 30% uptake at half cost of booked appointments
  • Opportunistic checks – build on existing clinical information e.g. lipids, to calculate CVD risk score
  • Around two-thirds of patients had consulted at GP surgery in previous 6 months; can fix health check then and address barriers to engagement

Birmingham East & North has focused more on community events. Table 2 summarises their learning. Around 9000 people have so far received an NHS Health Check.

Table 2: Key delivery models and learning - NHS BEN

Delivery StrategyKey Learning
Male targeted community screening events delivered by third sector provider

-          Screening venues such as football grounds can increase uptake in targeted groups

-          Frequent data extraction required to ensure appropriate invitation

-          Transfer screening outcome data to primary care records in timely and systematic way to ensure continuity of care 

NHS Health Check by general practice teams

-          Effective delivery is highly dependent on workforce capacity

-          Robust Key Performance Indicators (KPI) monitor outcomes (eg initiate statins) in patients with high risk CVD scores

-          Easily accessible referral to lifestyle services ensures uptake

-          Investment in programme informatics such as cohort identification and evaluation is crucial

Locality HCA workforce delivered programme

-          Additional workforce capacity increases number of people invited and screened

-          Sound informatics structure is required to ensure effective delivery

-          Dedicated workforce results in systematic approach to screening and referral to lifestyle services/follow-up 

Workplace screening programme

-          Offering screening during work time results in high uptake of service

-          Effective communication of screening outcomes to patient’s general practice is necessary for follow-up and management

Both PCTs have developed effective delivery strategies to ensure that the 116,000 (Stoke on Trent) and 124,000 (BEN) eligible population are offered an NHS Health Check if they do not already have diabetes, CVD, hypertension or chronic kidney disease in required time frame.

Workforce capacity and training is fundamental to effective programme delivery to regularly screen and manage huge numbers across the population; NHS Stroke on Trent has a LES of £20 per health check for general practices in support. Programme informatics systems to identify /invite the eligible population, transfer data from community based clinics to individual patient records and lifestyle services, and a robust audit mechanism are essential to ensure effective and high quality delivery on a large scale