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QIPP: Checks and measures

QIPP: Checks and measures

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If the potential savings of the NHS health check programme are to be actualised, commissioners need to consider the role of community pharmacies

Uncharacteristically, this is a medicines management article which does not focus on drugs. While prescribed medicines have their rightful place in the prevention and management of chronic disease, behavioural change tools and services have an increasingly important role to play in managing future prevalence and the associated costs of chronic diseases. The NHS health check has faced a lot of criticism since its launch in 2009. This article explores how our current purveyors of prescribed drugs in the community – pharmacists – can play an integral role in delivering on the NHS health check agenda.

The case for the health check 

A Public Health England (PHE) review has shown that checking 40-74 year-olds’ blood pressure (BP), cholesterol, weight and lifestyle could identify problems earlier and prevent 650 deaths, 1,600 heart attacks and 4,000 cases of diabetes per year, and detect at least 20,000 cases of diabetes or kidney disease earlier.1 This was also highlighted in The Commissioning Review online article published on the 22nd July 2013.2

The plans unveiled by PHE in July 20131 set out how it will run the flagship screening programme with local authorities, which took control of organising checks in April 2013. GP practices will now be benchmarked on how many checks for blood pressure, cholesterol, weight and lifestyle they provide, with data on local areas’ performance published on a new website to boost transparency. The new drive aims to improve the coverage of the NHS health check scheme in order to reach its goal of providing them to 15 million patients by 2018/2019.3

The review estimates savings to the NHS are around £57 million over four years, rising to £176 million over a fifteen-year period. It is estimated that the programme will pay for itself after 20 years as well as having delivered substantial health benefits. 

The NHS health check programme is both clinically and economically effective. Economic modelling has shown that the programme would cost around £3,500 per quality-adjusted life year (QALY) gained. QALYs are a measure of how many extra years of life of a reasonable quality a person might gain as a result of treatment. This is considerably below the £20,000-30,000 per QALY threshold that the National Institute for Health and Care Excellence (NICE) uses to assess cost effectiveness and according to this test, therefore, the programme is highly cost-effective.4

The critics

Critics of the initiative argue that the £300 million-a-year screening programme, which has led to 1.3 million receiving a health ‘MOT’ over the last year, is a waste of money, causing needless worry and diverting resources from sick patients.5

It has been mentioned that in April 2013, responsibility for commissioning and providing health checks transferred from the NHS to local authorities. Historically, since the launch in 2009, there has been huge inequality in the provision of health checks within and between primary care trusts (PCTs).  As a general rule, people with poor health behaviours who live in areas of relative deprivation are often those who don’t show up for a health check. This is why health economists such as Professor Alan Maynard urge: “Target the poorer, but go to where they go – Asda or Lidl rather than Waitrose.”6

Barbara Young, chief executive of Diabetes UK, supports routine checks, believing they could uncover an estimated 850,000 people with undiagnosed Type 2 diabetes.1,4

The hefty outlay of £300 million to run the programme needs to be balanced against the costs associated with managing the major chronic diseases, which we know cost the UK economy £21.6 billion in lost productivity and account for 70% of the NHS budget. 

Cardiovascular disease 

Almost 180,000 people died in 2010 from cardiovascular disease (CVD); around 80,000 of these deaths being from coronary heart disease (CHD) and around 49,000 from strokes. In 2011, around 292 million prescriptions were issued for CVD in England. 

In 2009, CVD cost the UK healthcare system £8.7 billion and the UK economy £19 billion in total.7 More than 150,000 people have a stroke every year in the UK but, according to The Stroke Association, up to 10,000 of these could be prevented if more people were aware of the symptoms and sought emergency treatment.

Hypertension

More than 9 million people died as a consequence of high blood pressure in 2010.8 The clinical management of hypertension accounted for approximately £1 billion in drug costs alone in 2006,9 through the prescription of anti-hypertensive medication. 

Chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is the fifth biggest killer in the UK and the second most common reason for admission to hospital. It costs the NHS almost £1 billion a year.10

Diabetes 

The current UK prevalence of known, diagnosed diabetes is estimated at 2.9 million11 of the adult population, 85% of which is attributed to England. In terms of the UK economy, it is currently estimated that 10% of the NHS budget is spent on diabetes care,12 which if we use the NHS budget for 2011/12 of approximately £106 billion,13 equates to £10.6 billion per year. For the UK as a whole, total diabetes drug spend reached an estimated £3.1 billion in 2010.14

Other chronic diseases of concern include cancer and liver disease.15

Barriers to benefits realisation

The economic argument does stack up, so why are we not seeing better outcomes? The reasons boil down to:

 - Participation levels - less than half of those invited for a health check (49%) attend the appointment. The aim is 70% to 75%.

 - Large resource requirements (time, space, logistics, man power) to conduct the health checks, and support behavioural change and follow-up.

This makes it difficult and at times prohibitive for GP practices to deliver.

Official Department of Health (DH) figures show that almost a million patients ignored a GP’s letter inviting them for an NHS health check between April and December 2012. Uptake fell below a 50% minimum target for the NHS. By January this year, two-thirds (64%) of primary care trusts (PCTs) were set to miss a key target to offer screening to 20% of eligible patients in 2012/13. More than 250,000 eligible patients missed out on an invitation, as problems with the scheme’s roll-out continued, and were not offered health checks at all. Almost 950,000 eligible patients ignored invitations, and 52% of patients turned down a vascular check.16

Aside from the perceived lack of evidence of their benefits, it is no wonder that health checks are met with lukewarm reception by the GP community. There is some truth in the views of the GP community; however the potential of the health check cannot be disputed. In their current form, the PHE review estimated savings which could be viewed as modest. If the health check offering was amended however, perhaps a greater financial impact may be achieved.

A perspective from a pharmacist and wellbeing architect

Health checks do not address true prevention [of illness], disease management and behavioural change adequately.

The existing system is set up predominantly to support the healthcare professionals get through the process of conducting a health check and sharing that data with the GP so that targets can be met. It doesn’t focus enough on outcomes and misses a key participant - the patient. Even the ‘health options’ add-on feature provided by Health Diagnostics, a software and medtech company, only provides a questionnaire for the carer to tick off that their patients have attended certain milestone meetings, with self-reported updates on their physical activity achievements. Anything that relies on self-reporting is subject to inaccuracies.

There is insufficient budget to make them available to all eligible people within the population. There is only sufficient funding to support 20% of the eligible population. How can we expect to achieve significant improvements in health outcomes and reduction in disease prevalence when the service delivery is so restricted?

Follow up between health checks is far too long. A lot can happen to an individual in five years.

There is a lack of a robust wellness support system and infrastructure for the patients that can be offered at scale. Supporting them through behavioural change is where we can hope to make a dent in the downstream healthcare costs, morbidity and mortality.

There is inadequate engagement of the patient. The patient needs to be a more ‘active’ participant in the process rather than a currently ‘passive’ player in the process.

As a consumer of the NHS health check, if I complete a health check, and a risk has been flagged against my blood sugar levels and BP with a referral back to my GP and a few leaflets (which inevitably get thrown away), I want to:

 - Be given access to that data that has been collected about me, so that I am more self-aware and have a baseline upon which to grow.

 - Be given access to an engaging service or tool which is going to enable me to take some positive steps around changing my lifestyle habits.

 - Give my carers (with my consent) the ability to get an accurate view of how well I’m doing in terms of health outcomes. How much weight did I lose? By how many units have I reduced my alcohol intake by, exactly how active have I been?

In other words, it needs to be a much more proactive end-to-end process.

Pockets of success

Some regions of the country have approached the health check in creative and effective ways. The North East has reached out to their community, targeting the right locations where they stand a higher chance of accessing hard-to-reach groups. The North East is well known for being an area of relative poor health compared to much of the rest of England, with the average life expectancy of a man in County Durham being eight years lower than that of his counterpart in the UK’s most affluent borough, Kensington and Chelsea in London.17 The reasons are complex, but many are rooted in differences in lifestyle and behaviour.

The following two case studies are referenced from a series of reports authored by Health Diagnostics.5

Case study 1

In the spring of 2011, the first six months of a pilot GP-based NHS health check ‘Point of Care Testing (POCT)’ was held across South of Tyne and Wear (SOTW), led by Sue Collins, South Tyneside’s health engagement lead. The pilot proved highly successful with GPs, and since then the number of GP practices offering the checks has risen exponentially. In 2011, 34% of practices in Gateshead were delivering checks and 30% in Sunderland, whereas in 2012, 67% of practises in Gateshead offered checks, and 54% in Sunderland.The annual report for SOTW published the following results about individuals who were checked:

 - 3,617 health checks completed in total.

 - 27% (n=976) of individuals were classed as ‘high risk’.

 - 34% (n=1,234) of individuals were classed as ‘moderate risk’.

 - 39% (n=1,403) of individuals were classed as ‘low risk’.

 - 70% (n=2,526) of patients experienced the check as a ‘one-stop shop’.

 - 1,820 questionnaires were received; a 50% response rate.

Case study 2

NHS County Durham has taken a long-term, pragmatic view in terms of health prevention, and started delivering health checks in 2009 via general practice to help reach its targets of closing the ‘gap in health inequalities by 0.4 years’ and adding ‘1.5 years to life expectancy by 2013.’ However, not long afterwards, the county’s heads of public health found that uptake varied markedly in terms of patients’ age, gender and socioeconomic profile. Dr Mike Lavender, a consultant in public health medicine at NHS County Durham, explained: ‘‘There was a huge variation in terms of health checks being delivered by GP practices, so we knew we had to do something in the communities which the practices weren’t reaching. That was the first step. We also saw that men and women in the younger age-groups (40s to mid 50s) really weren’t going in for the health check. This isn’t particularly surprising for that age group, as they may not see heart disease as particularly being a problem. They may be working, they can’t get time off etcetera, so the community programme was aimed at that younger adult population.’’

The response came in 2011 when a community programme was piloted which targeted the younger populations by offering a ‘mini health MOT’ to those aged 16 to 40. Dr Lavender explains that by broadening the age bracket, “you’re accessing people at the teachable moment, as well as maximising all the effort and investment that has gone into training the staff who deliver the service”. 

The pilot used Health Diagnostics’ services and support, and the pilot’s success meant it moved into its second year in 2012, having secured the following outcomes between April 2011 and March 2012:

 - 3,378 people accessed a mini health MOT.

 - 483 clients were eligible for an NHS health check.

 - 418 clients in total were signposted to lifestyle intervention services, including 113 to physical activity, 64 to local stop smoking services, 183 to the health trainer team and 58 to healthy cooking courses.

The decision to offer mini health MOTs happened to tie in well with freshly-voiced concerns from Diabetes UK about the need to screen between the ages of 25 and 40 for diabetes among people of Asian, African and Caribbean descent, due to their higher risk compared to Europeans.

The role of community pharmacy

The local community pharmacy presents a credible and obvious environment for the provision of NHS health checks for the following reasons:18

 - There are over 11,000 community pharmacies in England.

 - 99% of the population can get to a pharmacy within 20 minutes by car; 96% by walking or using public transport.

 - Estimated 1.8 million visits a day in the UK.

 - 84% of adults visit a pharmacy at least once a year, 78% for health-related reasons.

 - Most frequent users are females; 89% visit at least once a year.

 - Those with long-term conditions or disabilities or living in rural areas are more likely to visit the same pharmacy.

 - The majority of people (>75%) use same pharmacy all the time.

 - They offer convenience, anonymity, privacy and easy access without appointment. Developing this argument further, the ‘healthy living pharmacy’ (HLP) is ideally designed to deliver health checks on a consistent basis. HLP is a concept developed in Hampshire, supported by the Department of Health (DH) and pharmacy organisations to increase use of community pharmacies.

As of March 2013, there were 478 HLPs across 28 areas, and the number of areas taking forward the concept continues to increase.19

The programme to develop HLPs has found that nearly two-thirds of the patients that visited them for advice would have gone to GP practices instead.20

An evaluation published by the Pharmaceutical Services Negotiating Committee in April 2013, found that of the 1,034 people surveyed about their experiences in one of the pharmacies in the ‘pathfinder’ pilot, 21% said if they hadn’t accessed the support they would not have done anything, while 61% said they would have gone to their GP instead.17

The pharmacies in the trial offered NHS services such as weight management, stop smoking programmes, emergency contraception and NHS health checks and had trained ‘health champions’ available to give brief advice on health issues including smoking, activity, sexual health, healthy eating and alcohol.

The evaluation report revealed that teams within healthy living pharmacies engaged with people who would otherwise have done nothing and would not have sought out healthy lifestyle support or advice. Furthermore, 60% of individuals participating would have otherwise gone to their GPs, showing that there may be opportunities for community pharmacy to support GP practices in delivering health and wellbeing support, including health checks, which could reduce the workload burden within GP practices.18

The definition of a healthy living pharmacy is a pharmacy that:

 - Consistently delivers a range of health and wellbeing services to a high quality.

 - Has achieved defined quality criteria requirements and met productivity targets linked to  -  - Local health needs, eg. a number of stop smoking quits at four weeks.

 - Has a team that proactively promotes health and wellbeing and proactively offers brief advice on a range of health issues such as smoking, physical activity, sexual health, healthy eating and alcohol.

 - Has a trained health champion (also known as a ‘healthy living champion’ and ‘health trainer champion’) who is proactive in promoting health and wellbeing messages, signposts the public to appropriate services and enables and supports the team in demonstrating the ‘ethos’ of an HLP.

 - Has premises that are fit for purpose for promoting health and wellbeing messages as well as delivering commissioned services.

 - Engages with the local community and other health and social care professionals.

 - Is recognisable by the public through the display of the HLP logo.

Pharmacy-delivered health checks, however are not restricted to the healthy living pharmacy and can be provided by any local pharmacy which meets the service and capability requirements set by the commissioning organisation.

Developing the health check service

Health checks should not stop at simply performing an assessment and presenting the ‘patient’ with advice. There are three groups in particular which can benefit from accessing health checks via the local pharmacy (see Figure 1):

 1. Newly diagnosed: eg. type-2 diabetics who have been told to change their dietary and exercise lifestyle habits.

 2. Well-intentioned: they know they have risk factors, and should make some changes to their lifestyle habits. Often quickly revert back to bad habits.

 3. Hard-to-reach groups: eg. those who very rarely see their GP’s and/or densely ethnic communities where cultural habits and attitudes may present challenges.

Community pharmacies are best placed to develop an encyclopaedic knowledge of the local services available to signpost ‘patients’ to, for support around weight management, smoking cessation, counselling, cooking skills, etc. They are also much better placed than the GP practice to access and recommend digitally-based health and wellness tools, and to support the patients’ initial use of these tools, while encouraging their role in follow-up sessions. Introducing patients to such tools can start to make the process of behaviour change more guided, supported, and enjoyable. NHS England unveiled on 12 March 2013 a library of NHS-reviewed health apps that will help people manage their health, as well as ten brand new apps for people to use.21

HLP and non-HLP Pharmacies may wish to provide their own lifestyle management services. For example, Central Lancashire local pharmaceutical committee (LPC), which comprises 10 pharmacies, offered a weight management service – a structured behavioural change 12-month programme. The target group were people over 18 years old with BMI >25 and <40, with 85,000 people with a BMI > or equal to 30. The service was based on setting achievable interim goals, supported by holistic lifestyle advice including diet and exercise.  

The outcomes:

 - Average loss of 2.9kg or a reduction in BMI of 2.4.

 - Cost = £160 per patient per year.

Conclusion

The health check in its current form – being delivered primarily by the GP, in practice, with a focus on the assessment process rather than the outcome and post-assessment process - will deliver respectable, but modest financial and health outcome benefits. However, to capitalise on its full potential, more creative approaches for reaching out to eligible populations and an increased focus on ‘follow-up’ and the behavioural change process need to be implemented. To access the enhanced resource pool and support infrastructure required to be able to achieve this, the local community pharmacy needs to be acknowledged and engaged as the ideal partner to deliver on this agenda and to relieve GP’s from some of this workload.

 

References

1. Public Health England. NHS Health Check Implementation Review & Action Plan. July 2013.

2. The Commissioning Review. Public Health England drive to increase Health Checks. 11 July 2013. 

 3. Pulse. Public Health England launches drive to widen NHS Health Checks. 22 July 2013. 

 4. PCC. Briefing on NHS health checks for local authorities. 25 April 2013. 

 5. Daily Mail. Are NHS over-40s health checks a waste of time? 20 August 2013. 

 6. Cowper A. A Picture of Health; NHS Health Checks Case Study: The North East of England. Health Diagnostics; 2012.

 7. Coronary Disease Statistics: A Compendium of health statistics. British Heart Foundation; 2012.

 8. A systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380: 2095-128

 9. NICE CG127.

 10. An Outcome Strategy for COPD and Asthma: NHS Companion Document. May 2012.

 11. Diabetes UK. Diabetes prevalence 2011. October 2011. 

 12. Diabetes UK. Diabetes in the UK 2010: Key statistics on diabetes, March 2010

 13. Department of Health Spending Review 2010. 

 14. Kanavos P, et al. Diabates expenditure, burden of disease and management in 5EU countries. LSE Health, London School of Economics, January 2012. Available at: 

 15. BBC News. Unhealthy Britain: nation’s five big killers. 25 March 2013. 

 16. GP Online. Exclusive: Future of health checks in doubt. 12 April 2013. 

 17. Department of Health Putting prevention first – vascular checks: risk assessment and management. 2008.

 18. HLP presentation for LPCs. May 2013. Available at: http://psnc.org.uk/wp-content/uploads/2013/08/HLP-presentation-fo-LPCs-May-2013.ppt

 19. Evaluation of the Healthy Living Pharmacy Pathfinder Work Programme 2011-2012. April 2013.

 20. Pulse. Pharmacy scheme ‘may reduce GP workload’. 24 April 2013. 

 21. NHS England. 12 March 2013. NHS Commissioning Board launches library of NHS-reviewed phone apps to help keep people healthy.

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