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The NHS Health Check Leadership Forum:

Summary and Findings

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This report represents the essential content presented and discussed at the first ever NHS Health Check Leadership Forum. The forum took place during the Commissioning Show where public health professionals came to learn and share expertise about best practice in delivery and management of NHS Health Checks. An expert panel presented latest findings and case studies from their regions. On the panel were:

Andy Cowper, Health Writer (Forum Chair)

Dr Michael Soljak, Clinical Research Fellow at Imperial College London’s Department of Primary Care & Public Health Jacqui Deakin, Quality and Health Improvement Lead for County Durham and Darlington NHS Foundation Trust Jayne Herring, Public Health Contracts Manager for Tees Valley Public Health Shared Service Julie Evason, Managing Director at Health Diagnostics Ltd (Forum host)

NHS Health Check Leadership Forum was organized and hosted by Health Diagnostics. Edited highlights of the meeting are available to view at www.healthdiagnostics.co.uk

5 Key considerations were identified as being key to the successful delivery of NHS Health Checks:

1. Flexibility to fit local needs

2. Complete quality assurance

3. Delivery of the check in a single session

4. A patient-focussed IT solution

5. Seamless data transfer to patient records

Introduction Andy Cowper

Dr Michael Soljak

Jacqui Deakin

Julie Evason

Jayne Herring

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approximately one tenth of the NHS budget is currently being spent on treating diabetes, translating to £1.5 million per hour, and this is predicted to rise sharply in coming years.) Dr Soljak’s team, which had developed a prevalence model based on the NHS Information Centre portal, is looking at adherence to recommended interventions (such as prescribing statins), and medium-term outcomes (BMI figures; risk factor levels and scores; changes in diet and exercise.) However, he admitted that their key challenge is to try to unscramble what NHS Health Checks are achieving from all that other noise.

Regardless of such challenges, Dr Soljak was keen to iterate that civil servants and the Health Secretary are very interested to hear about his team’s findings and are watching the Evaluation closely.

1. Flexibility to fit local needs:

Specific aims of the Imperial College evaluation are:

• To examine uptake of the programme and characteristics of persons at high risk of CVD, including by age, gender, ethnic and socioeconomic groups • To determine whether the programme has reduced the gap between recorded prevalence of CVD conditions and diabetes, and estimated prevalence derived from modelling • To examine adherence to interventions (attendance at smoking cessation clinics, statins) and changes in medium term outcomes (BMI, cholesterol, blood pressure) and global risk scores • To assess longer-term outcomes: development of CVD, acute CVD events such as myocardial infarction and stroke, mortality from CVD & diabetes. To measure key operational parameters for the health economic model and recalculate the model using ‘real’ data

Targeting health checks effectively to reduce health inequalities

The need to target NHS Health Checks at those in greatest need, thereby reducing health inequalities, is key. Individuals likely to be at highest risk from diabetes, kidney disease, stroke or cardiovascular disease need to be ‘found’, and this task has been discussed at length. It was therefore encouraging to hear about the positive preliminary findings from the National Evaluation of the NHS Health Check Programme. This study - which is being funded by the DoH and conducted by Dr Michael Soljak’s team of researchers at Imperial College London - aims to evaluate NHS Health Checks in the context of health inequalities, outcomes and disease prevelance.

Of particular interest was the fact that early findings from the study indicate that uptake of NHS Health Checks has been greater in more deprived areas. A paper detailing these early results is due for publication in the Journal of Public Health. This was a sign that PCTs had been targeting the checks effectively, which would be reassuring to public health professionals such as Jayne Herring, Public Health Contracts Manager for Tees Valley Public Health Shared Service, who pointed out that the life expectancy gap between the richest and poorest in her area is as high as twelve years.

Also encouraging was Dr Soljak’s suggestion that more cases of diabetes and coronary heart disease are being found now because of the checks, indicating that the investment was yielding returns in terms of preventing an extremely costly problems for the NHS. (According to Diabetes UK,

“We have seen lots of examples of people having to be signposted to their GP, who would never have dreamt of going because they thought they were fine.” - Service manager - in County Durham

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Targeting Well, Targeting Many

Jayne Herring pointed out the influence of lifestyle and health behaviours (particularly diet and alcohol) are of course major factors in inequalities persisting. In her region – Tees Valley - CVD is the most common cause of mortality and the biggest explanation of premature death and reduced life expectancy (followed closely by cancer).

As a result, the NHS Health Check pilot carried out in Tees Valley had not just to be well targeted, but also rolled out “on an industrial scale.” Tees Valley health checks gained local momentum early on, and Jayne and colleagues received £3 million to roll out the programme in an enhanced form in 2008. Besides achieving 100% take up of their ‘Public Health Enhanced Service’ amongst local GP providers, the project has achieved year-on-year DH performance targets. Moreover, death rates from heart disease reduced at a faster rate in Teesside than in England overall. (Though this was probably, in part, due to secondary care improvements, and the introduction of the smoking ban).

However, Jayne stressed that continual review is essential to making improvements:“Five years in, we’re still learning constantly, and making daily changes to the rollout”. Jayne and colleagues hope soon to produce evidence demonstrating a strong ‘invest-to-save’ model, and they are awaiting publication of a paper on this subject from the University of Teeside in August 2013.

What proved so effective in Teeside?

Level of need: Strong business case secured £ investment

Delivery model: a GP enhanced service plus community/workplace provider

Targeted approach: Prioritisation list (70% conversion to high risk in the first two years of the programme)

Robust programme infrastructure: Investment in dedicated primary care informatics, nurse facilitation team, project management

Strong leadership: Directors of Public Health and Clinical Lead

Training & development: Investment in a rolling training programme

Target audience insight: Social marketing techniques informed the development of a communications and marketing strategy plus local identity ‘Healthy Heart Check’

Tees’ Pilot key learning: the challenges faced:

Data collation and analysis: There were coding issues and problems with incomplete data sets Competing provider priorities: QOF vs. Enhanced Service – significant practice variation in activity

Extension of programme to pharmacy settings: Proved not to be cost-effective for NHS Tees Valley

Being ahead of the curve: Local roll-out did not fit the DH national model, which led to significant challenges in performance reporting

Provider payment model: Shift from price per check to mixed payment model to incentivise coverage uptake and invite management

Maintaining provider momentum: Negative media coverage of benefits of the programme can impact on local buy in IT infrastructure for community-based health checks: Shift from in house solution to Health Options* improved delivery and data capture Transition: Managing contract transfer, maintaining momentum and impact on programme infrastructure

*Health Options is the software designed by Health Diagnostics for use by NHS

Health Check providers.

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The need to target the NHS Health Checks using innovative methods and ‘smart’ thinking was something Jacqui Deakin, Quality and Health Improvement Lead for County Durham and Darlington NHS Foundation Trust, also described. However, quality was also found to be paramount.

Jacqui explained that provision of the checks by GP practices varied widely in County Durham, so her team took up the baton to complement (rather than compete with) GP practices. This was greatly needed for Durham’s worse than average health within the north of England, where the health gap is widening rather than narrowing.

Quality must apply to both delivery and performance of the Checks. Jacqui’s approach on both fronts was to ‘brand up’ the NHS Health Checks by creating a hybrid using the nationwide ‘Change4Life’ campaign, to create a new, ‘Check4Life’ logo and branding, perceived locally as highly credible. Check4Life was used as follows:

An member of the audience raised the issue of quality as judged by Health & Wellbeing Boards: “A big push from our health and wellbeing board (HWB) is to execute on quality, not process. We have done well on process, but quality’s been very variable. CCG leads have been looking at, and asking, ’How can we make this work?’ Data is on EMIS and other systems that are more or less capturable at GP level. [But] Transmitting that data to make sense to our HWB seems practically impossible: What do you have for a body with no time and no interest, which just wants figures?”

Julie Evason replied,”We provide monthly and quarterly analysis,” and pointing out the practicality, “If you put the questions in at the start, we can get you the answers out at the other end.’ We have to make our software compliant to clients’ requirements.”

Julie also explained Health Diagnostics offers analysis breakdown for BMI, alcohol consumption, CVD risk, and do project performance targets so that commissioners can have a league table of health check sites and how many consumables they’re using. “This means that as providers, they can ask, ‘If you’re getting more consumables than you are delivering health checks, why?’ This adds a quality assurance element to the GP programme”.

2. Complete Quality Assurance

• In community settings, using community-based staff • By targeting specific areas and groups • To support individuals to help them manage their risk of developing CVD – greater emphasis on lifestyle change • As a complement to the GP practice-based Health Check screening programme

A few example pages selected from

an analysis report. Health Diagnostics

complete and submit this information to

commissioners.

• Since October 2008, Jacqui’s teams have carried out 78,826 health checks in the population aged 40 to 74 of 240,000. • Their target population is 120,000. • A five-year programme means a 20% target each year: 24,000 health checks a year.

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It was also agreed amongst the panel that delivery and completion of health checks should be done via a single session. Julie Evason, Managing Director at Health Diagnostics Ltd, stated that research shows half of attendees don’t show for the second session if it’s delivered in two parts, so miss out on the important ‘risk communications’ session. Added to this, there’s the potential for GP providers to miss out financially as they are often paid based on the second session being attended.

In addition, delivery of health checks can be significantly cheaper in a single session. In 2009, research done by Dr Shane Gordon showed that using Point of Care analysers for cholesterol testing can be up to 35% cheaper.

Indeed, as the checks are now not delivered in the main by GPs (as was the case back in 2009), the cost-effectiveness of single-session delivery should now be even greater. Most importantly though, single session delivery maximizes the chance to influence behavior change because an individual gets to hear their results, and immediately gets an opportunity to discuss their own lifestyle, including factors such as smoking, drinking and exercise habits. Jacqui Deakin and her team in County Durham originally had concerns that GP-delivered health checks focused more on ‘the health risk assessment’ than ‘interventions and signposting to behaviour change services’. As a result, Jacqui ensured that her health trainers take the time to explain the results of the health check, and local feedback has confirmed the population appreciates this.

3. Delivery of the check in a single session

County Durham Patient Satisfaction Levels

NHS Health Checks

• 483 patient experience questionnaires completed • 82.2% were very satisfied with the NHS Health Check • 99.6% would recommend a NHS Health Check to other people

Client Comments

“Very pleased I attended as the check revealed I have AF. Subsequent to the check an ECG confirmed this. Medication has been prescribed and an appointment for an echocardiogram is in the pipeline to be arranged. Many thanks”

“I think these are a great opportunity to get checked out. The length of time taken to see a doctor is far too long and puts people off from going so this is a great way to get to know if you’re in good health or not”

“Coming here and speaking to the staff has motivated myself in changing my lifestyle”

An example of the CVD risk page from a personal report

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Taking the time to explain the results of a NHS Health Check is important, and this needs to be done intelligently and sensitively. Such an undertaking requires well-trained staff who are able to spot cues from the patient. The approach that underpins Motivational Interviewing (MI) accepts that individuals are far easier convinced by their own arguments than they are those imposed by others. MI therefore looks to elicit an individual’s inner motivation to change. Julie Evason referenced the new DH Behaviour Insight Unit, and underscored the need for a non-judgmental attitude in order to facilitate conversation that is relevant to the concerns of the person having the health check.

The Health Options® software that Health Diagnostics provides includes prompts for the provider to help guide the conversation appropriately. Combining the conversation with compelling, high quality images gives an extra opportunity for patients to take on-board information and remember it. The use of images can be extremely useful, and culturally-appropriate diagrams or pictures can reinforce the messages about risk, which some people find difficult to understand.

A question from the floor asked about the quality of motivational interview techniques given by providers, assuming this is a skill that perhaps not everybody can deliver. Jacqui Deakin explained,“In Durham, this was part of our workforce competency framework and learning needs assessment framework: we asked, ‘What did teams believe their workforce skill needs were?’

Training in motivational interview techniques is something they need. This is about ‘making every contact count’. It’s relating better health and quality of life to physical activity, stopping smoking, eating more healthily. And it’s about being able to offer access to lifestyle intervention services’.

Durham offers checks known as ‘Mini MOTs’ to individuals aged 16+ to complement the work taking place in GP practices. Jacqui continued, “Staff need to understand the role of lifestyle change, and how to signpost to local services. If people are at high risk, staff will recommend they visit their GP. So, successful delivery needs more skilled advisers to support individuals to make different and easier choices.

4. Patient-focused IT solution

The Motivational Interviewing resource and guidance pack

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The new DH Behavioral Insight Unit, headed by Daniel Berry and Dan Metcalfe, aims to help boost the delivery of Health Checks through:

Use of simple messages • Delivery of health checks at convenient times and locations • Going out to find the individuals • Appointment reminders • Positively-framed messages, not ‘Are you a heart attack waiting to happen?’

Effective ‘nudge’ tools include:- • Social norms: ‘Recommended by a friend’ who might say, ‘Look at my nice report…. and it didn’t hurt’ • Being invited by a trusted person could be effective • ‘Lucky cogs’ scratch cards to identify eligibility

Julie Evason added, “In motivational interviews, using the right IT can provide advisers carrying out health checks with tools within the software. Advice and intervention needn’t completely rely in the individual’s memory and skills. For instance, our software includes consumer magazine-style ‘hints and tips’. People are all different, and each health check operator needs to be able to pick up on this. Not all can do this really well, but the better people are trained and the more practice they have, the better they’ll get”.

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5. Seamless data transfer to patient recordsIt goes without saying that the investment and effort required to obtain NHS Health Check data should never be wasted. However, there is much evidence to point to the fact that too often, data is failing to reach GPs. This can be for various reasons, including the simple fact that data gets lost in the post.

As a result, it is highly likely that poor data management protocols have resulted in completed checks not making their way onto the clinical systems which, in turn, means that they’re excluded from the published figures for local authorities. Robust control of data flow is therefore crucial: Facts about an individual must get back into the relevant patient record cost-effectively and without error. The Leadership Forum cited this as a key challenge that all local authorities will need to engage with going forward.

Much data is still being collected manually in the community, rather than digitally, and this presents an additional cost, requiring manual inputting of the data by staff in the GP surgery. Julie Evason acknowledged the burden placed on providers to achieve,“Miraculous data entry… Data collection, entry and sharing are usually found to be a lot of hard work.” However she made the point that there is much innovation in this area now. For instance, Health Diagnostics can return data to any of the major GP patient records software systems, as illustrated in the diagram below: Paperless from Provider to Practice.

Julie explained that, ‘’The Health Diagnostics data module uses DTS Messaging to transfer health check information direct to GP practices. DTS is used by pathology departments within secondary care already; what we’ve done is to appropriate that methodology primary care. All data is sent over a secure N3 connection.’’

In reference to the data management side of Durham’s NHS Health Checks programme, Jacqui Deakin praised Health Diagnostics’ support, adding, “We couldn’t do what we do without Health Diagnostics. They’re a very ‘can do’ team.”

A member of the audience asked about whether there is a duty of care as a community provider to ensure data goes directly into the patient’s medical record at the GP surgery, and asked whether, if a very high risk is found, an alert is issued to the GP: “Does the health check provider become responsible for acting if they didn’t screen and warn?” Julie confirmed that in Health Diagnostics’ system, there is a flag for high risk patients who are given a high-risk referral letter to take to their GP. She added, “Lots of providers make a follow-up phone call to ask, ‘Did you go to your GP, and what was the outcome?’ For very high risk people who are screened, there is a clear duty of care”.

“I can’t underestimate the importance of investing in good primary care informatics and also in IT solutions to support the delivery of the programme.” - Jayne Herring

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Conclusion

About Health DiagnosticsSo far, over 25 local authority areas have used Health Diagnostics software in the management of NHS Health Checks. The company provides all consumables, equipment, software, and IT required for the checks, although it does not carry out the checks.

A film of the Leadership Forum is available at www.healthdiagnostics.co.uk

Feedback from delegates was overwhelmingly positive. Julie Evason, Managing Director at Health Diagnostics, summarised, ‘‘We feel the audience got a lot out of the event. The importance of support networks has rightly been recognised by Public Health England, so it’s great to see ambassadors for successful programmes taking up the baton and sharing their learning on which strategies have worked effectively. Health Diagnostics offers its sincere thanks to all of this year’s speakers for their participation, and for their highly engaging and compelling presentations.”

‘‘I learnt about a lot of interesting things that are going on around the country, and was able to have some questions answered about how I can improve the Health Checks that we’re doing locally. One thing that will stick in my mind is that we need quality data that we can use to prove the effectiveness of the health checks.’’ - Dr Peter Newman – NHS Health Check Lead for Buckinghamshire and Locality lead for Chiltern CCG:

‘‘The event was very good. I looked for the opportunity to discuss issues that are of concern to me about the programme locally and nationally; I had that opportunity and I think people shared those concerns... I raised the issue about it being a screening programme that should be kite-marked by the National Screening Committee, and I think steps are taking place to try and ensure that happens... I’m perhaps more optimistic than I was when I came into the room!’’ - Dr Anthony Morkane – Associate Director of Public Health at Derbyshire County Council

‘‘This event has a lot of synergies with the sort of research that I’m doing so I found it very interesting... The fact that we’re now able to collect and aggregate data is crucial because there’s no point in running these sorts of programmes unless we can show that we’re actually making a difference, and are getting better health outcomes in a cost-effective way.’’ - Professor Felicity Goodyear-Smith, Academic Head of Department, General Practice and Primary Care, University of Auckland and Editor-in-Chief of the Journal of Primary Care

‘‘I thought the event was really well put together. I like the fact that it was succinct, the speakers were excellent, there was a good range of presentations, and I got quite a lot out of it... As a commissioner, we have very big key decisions to make around investing in the IT infrastructure; that’s my overriding impression of today, and I’m going to be going away and talking to colleagues and stakeholders about how I can make that happen in my local area.’’ - Claire Harris – Public Health Department, East Sussex County Council: