Picture of Health: Report 1 by Health Diagnostics

A Picture Of Health Making sense of the complexities: A guide to successful commissioning of health checks

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A Picture Of Health Report #1 of 3

Amid unprecedented changes being made to NHS service provision, this report – the first in a series of three - is intended as a guide for those interested in NHS health checks; how they will be commissioned from April 2013, their relevance and their value to current health needs. The ‘Picture Of Health’ reports have been written by Andy Cowper, editor of Health Policy Insight and Achieving Commissioning Excellence. This first report will include examples of best practice in health screening from Health Diagnostics, a well-established provider of health check services, which has commissioned the reports. The three reports together will present the case that successful commissioning of health screening relies on a truly integrated approach to gathering, analysing and sharing data. Also that successful screening requires a delivery model which has adequate flexibility to engage fully with the health workforce: A case of empowerment rather than mere ‘outsourcing’. The reports’ insights have been gathered from interviews with experts around England, including directors of public health, CCG clinical leads within clinical commissioning groups, and health economists. Report 1 is intended as an introduction to Reports 2 and 3 which can be downloaded below: - Report 2 Making Screening Work - Report 3 A New Future for Health Screening - NHS Health Checks in The North East - A Case Study

Towards 1st April 2013 - the new health structures The changes under way in the NHS aim to put clinical commissioners in charge of planning and provision of 1 April 2013, as part of the government’s plan to decentralise control over 60% of the NHS budget to 211 local clinical commissioning groups (CCGs). These CCGs are legally constituted public bodies, whose memberships are made up of the GP practices of each locality. CCGs are set to commission the providers of health services for ability to choose from ‘Any Qualified Provider’ (AQP).

Making sense of the complexities a guide to successful commissioning of health checks

“Screening is about finding the right balance between the cost in resources of screening across a whole population and targeting your programme so that your search focuses among populations where you’re most likely to find the condition in question prevalent. Screening only works if it works!” Nicola Close, chief executive of the Association of Directors of Public Health

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Public health back to local government At the same time, public health is being decentralised, and returns to be the responsibility of local government for the first time since 1974. The reasoning behind this is that many of the determinants of health for the poorest people - who tend to have the highest health needs - are already the responsibility of local authorities. (A series of thoughtful essays on this subject, written in response to the 2010 Marmot Review ‘Fair Society, Healthy Lives’ is available from the Local Government Association website1) Public health screening programmes will therefore become the responsibility of upper-tier and unitary local authorities, under their directors of public health. The Department of Health will give local authorities a ring-fenced public health budget, and has specified a short list of mandatory services, which include the NHS Health Check currently undertaken by primary care trusts (see Box 2 on page 4). Every local authority must appoint a director of public health, and must also form a Health and Wellbeing Board. Health and Wellbeing Boards will assume their legal responsibilities on 1 April 2013, at which point they will begin their scrutiny of all NHS-funded services and ensure that the CCGs are locally accountable for their aims and outcomes.

Box 1 The five ‘domain’ headings for the Health Secretary’s mandate to the NHS Commissioning Board 2

1. Preventing people from dying prematurely 2. Enhancing quality of life for people with long-term conditions 3. Helping people to recover from episodes of ill health or injury 4. Ensuring that people have a positive experience of care 5. Treating and caring for people in a safe environment and protecting them from avoidable harm

Making sense of the complexities a guide to successful commissioning of health checks

“My colleagues have worked very hard over the last five years to deliver and get traction on CVD screening, but were sometimes limited by the lack of flexibilities in a centralised approach. So public health going into local government will be good for this, as CCG localism will: local processes for local people!” Dr Amit Bhargava, chief clinical officer, Crawley Clinical Commissioning Group

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Box 2

The NHS Health Check – focus and funding Launched in 2009, NHS Health Checks are a mandatory activity in the NHS Operating Framework, provided to adults in England aged 40 - 74 who haven't already been diagnosed with any of these four common but often preventable diseases: heart disease, stroke, type 2 diabetes or kidney disease (http://www.healthcheck.nhs.uk/).

“The number of NHS Health Checks offered during April – September was 1,185,090 with NHS Health Checks being received by 566,193 people .” 3

From 1 April 2013, ring-fenced DH funding will be available to directors of public health in local authorities to fund the offer of the NHS Health Check for 20% of their eligible population each year. The health check aims to help the public lower their risk of these ‘big four’. Eligible adults are invited for a health check once every five years, which assesses the individual’s risk of these four diseases, and offers personalised advice and support to help lower that risk. The NHS Health Check programme has been included as an indicator in the new Public Health Outcomes Framework for England 2013 – 2016.4 Local authorities will be required through section 6 C of the NHS Act 2006 to offer the NHS Health Check to everyone eligible every five years, and to ensure that the tests and measures contained in the risk assessment comply with those specified by the Department of Health.5

Future changes The NHS Health Check content will change from 1 April 2013.

Making sense of the complexities a guide to successful commissioning of health checks

The government’s alcohol strategy6 refers to the NHS Health Check programme, and ministers have decided to include an element on reducing alcohol consumption into the NHS Health Check. This will mean those diagnosed with hypertension as a result of the NHS Health Check, and found to be drinking above the lower-risk guidelines, are to be offered brief advice or referred to a specialist alcohol service if appropriate. Another change follows from the government’s dementia strategy, which makes reference to regular checks for over-65s. The intention is only to raise awareness of memory assessment clinics for those over 65 attending an NHS Health Check - should the need arise. Under the Prime Minister’s Challenge on Dementia, from April 2013, as part of the NHS Health Check programme, people aged 65 to 74 will be given information at the time of the risk assessment to raise their awareness of dementia and the availability of memory services. Around 60% of people with dementia have Alzheimer's disease, around 20% have vascular dementia, and some have a mixture of the two. There are other less common forms of dementia. Risk factors that increase the chance of developing cardiovascular disease, also increase the chance of developing dementia. These risk factors include being physically inactive, poor diet, obesity, high blood pressure, smoking, high cholesterol and type 2 diabetes. Evidence shows that taking action to adopt a healthier lifestyle can help to reduce the risk of developing dementia, as well as other conditions such as cardiovascular disease and cancer.

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A common cause for clinical commissioners and directors of public health Clinical commissioning groups and local authorities have a common interest in identifying those in their population at the highest risk of developing a range of costly long-term ill-health conditions such as diabetes, asthma, coronary heart disease, chronic obstructive pulmonary disease, hypertension and other forms of cardiovascular disease. The changes in motion therefore offer an opportunity for health stakeholders in the new system – primarily the clinical commissioning groups and the local authority directors of

public health – to work collaboratively to use screening to deliver more upstream and preventative approaches. There is a much-used line in healthcare debate and discussion about creating ‘a health service, rather than a healthcare service’. In reality, both are important, but it is often suggested that public health and preventative measures have had less attention and resources: The availability of ring-fenced funding for NHS Health Checks offers an opportunity to address this.

The relevance and value of screening There are sceptics of the effectiveness of general population health screening. A recent Cochrane systematic review7 concluded that “general health checks did not reduce morbidity or mortality, neither overall nor for cardiovascular or cancer causes, although the number of new diagnoses was increased … with the large number of participants and deaths included, the long follow-up periods used, and considering that cardiovascular and cancer mortality were not reduced, general health checks are unlikely to be beneficial”. The lead researcher, Lasse Krogsboll, told BBC News8 that "a likely explanation is that physicians are doing a good job of preventing illness anyway. From the evidence we've seen, inviting patients to general health checks is unlikely to be beneficial”. However, this position is not without its share of opposition. Reaction has come from charities such as Diabetes UK, the chief executive of which has publically argued that ‘The NHS Health Check programme, launched four years ago by the Department of Health in England, has huge potential to detect people with Type 2 diabetes and to identify those at high risk.’

Making sense of the complexities a guide to successful commissioning of health checks

Cathy Moulton, a clinical adviser for Diabetes UK explains,

“Far better to raise somebody’s awareness of what could lead to type 2 diabetes than just let them go on in blissful ignorance until they present in a coronary care unit with a heart attack. That’s a tragedy, and that’s why we’re really backing the NHS health checks.” “Overall, the [Cochrane] review conclusions can have little, if any, relevance to NHS Health Checks. What the review does, however, is underline very clearly the need to evaluate the effectiveness of the programme at a national level, including outcomes” NHS Diabetes & Kidney Care – and – DH for NHS Health Check Learning Network 8a

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Targeting Health Checks It is therefore crucial that NHS Health Checks do not simply involve gathering measurements without education and motivation. They must be targeted at high risk groups and provide clear health information and support in order to halt the increase of risk. Diabetes is preventable, but it’s not curable. Clearly then, patients need to be given the facts to allow them to make informed lifestyle choices. The NHS Health Check is ideally placed to offer a relaxed opportunity to talk about health, particularly when conducted through community locations and pharmacy. It is also worth noting that the research which underpins the Cochrane review is based on trials which took place a decade ago. Since then we have seen obesity and diabetes grow at an alarming rate, all of which is having a massive effect on the NHS budget. The debate about screening is not new. A 2008 article published in the Bulletin of the World Health Organisation9 reviewed the classic 10 principles of Wilson and Jungner on health screening from 1968: The WHO Bulletin authors proposed the following guidelines which represent a synthesis of the research that has emerged over the past 40 years, as well as those founding principles of the Wilson and Junger approach:

• The screening programme should respond to a recognised need • The objectives of screening should be defined at the outset • There should be a defined target population • There should be scientific evidence of screening programme effectiveness • The programme should integrate education, testing, clinical services and programme management • There should be quality assurance, with mechanisms to minimise potential risks of screening • The programme should ensure informed choice, confidentiality and respect for autonomy • The programme should promote equity and access to screening for the entire target population • Programme evaluation should be planned from the outset • The overall benefits of screening should outweigh the harm.

One conclusion that directors of public health, local authorities and clinical commissioners might draw from the Cochrane research might be that they should use market research, demographic and social marketing techniques to

Making sense of the complexities a guide to successful commissioning of health checks

focus their efforts with health checks on those at the highest risk of ill-health.

“Cochrane researchers seem sceptical of the value of whole-population screening. Are directors of public health? With CVD screening, the evidence base is so strong that I think most DPHs would be supportive of the Health Checks programme...” Dominic Harrison, director of public health for Blackburn with Darwen

Managing the transition At present, the NHS Health Checks are a mandatory activity in the NHS Operating Framework. The checks are commissioned by directors of public health in PCTs, and provided by GPs, pharmacists and other private providers in a range of settings. To date, about 50% of health checks have been delivered by GPs and around 20% by pharmacy.

“Whenever we do accuracy checks on our prescriptions, at the same time we look to see if the patient is eligible for a health check. If they’re within the age bracket and not taking any medicines which would make them ineligible, we’ll include a health check leaflet with their prescription.” Dawn Cruickshank, Chief Superintendent Pharmacist, Jon Low pharmacy chain The change ahead among commissioners of screening checks is no small upheaval. Clinical commissioners will be establishing themselves in new organisations, at the same time that local authority directors of public health will be establishing themselves in a system that is new to them, having previously been employed by PCTs. At such times of change, working with the right partners is important. As the transition to the new system takes place, it will remain vitally important to ensure that the data which forms the basis of any meaningful screening is accurate, high-quality, timely and secure – and will reliably get to the right part of the health system at the right time. As well as this, effective screening should provide patients with appropriate, comprehensible and helpful resources that not only explain the results of their test but allow the individual to understand how sustained changes to their lifestyle can offer them health benefits.

“It’s not just about delivering a health check and saying ‘Here are your results, that’s it.’ People have to understand what those results mean so they can take responsibility for their own health.” Julie Evason, CEO, Health Diagnostics

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How Health Diagnostics can help The sponsors of this report, Health Diagnostics, supply clients with an ‘end to end’ solution to deliver all aspects of screening that commissioners and providers of health checks require. This ranges from the equipment used at the point of care, including all consumables and patient information material, to the ‘Health Options’ software that allows fast, secure transmission of the data to general practice. (Health Diagnostics’ software is compatible with all the GP software systems.) It is essential that patients’ GPs are kept informed when a test result may mean a patient requires further care. However, Health Diagnostics do not deliver the service directly to patients. Instead, they champion an approach that maximises the existing network of providers. The company also provides accredited training to front-line staff on how to use the testing system, and works with partners to ensure the cardiovascular screening equipment is correctly calibrated and maintained. Courses include advice on setting up the service, including: Behaviour change counselling, safe disposal of clinical waste, and internal and external quality assurance.

52% of Chemist & Druggist readers feel health checks are good for pharmacy and patient health.

Reporting back to Commissioners

efficient, allowing providers of screening to offer the tests in non-healthcare settings. This is important when seeking to target populations who may not traditionally engage with conventional health services (such as men, those in lower socio-economic groups, immigrant communities, those not registered with a GP and the homeless).

“Target the poorer, but go to where they go – Asda or Lidl rather than Waitrose... We need to screen the poor males and disadvantaged ‘bad behaviour’ groups, and also need to get to the DWP crowd – the elderly unemployed.” Professor Alan Maynard, health economist Health Diagnostics’ CVD risk assessment software is designed so that health professionals can conduct an approved health check whilst guiding the patient through a comprehensive consultation. The screening equipment and software can also be used to record data for conditions other than cardiovascular disease such as alcohol awareness and weight management.

“Health Diagnostics’ software, Health Options, is commented upon by all parties, including patients, nurses, and so on, because it is very user-friendly. It leads the user naturally through the process, and is very visual - which helps in explaining things.” Sue Collins, South Tyneside’s Health Engagement Lead.

Health Diagnostics’ software can also be adjusted to meet individual clients’ particular requirements. It also has a useful reporting function for commissioners, allowing them to analyse the uptake of tests by providers as well as progress and results of the screening among a population. Health Diagnostics has a long record of successfully working in partnership with the NHS to deliver professional, accurate and motivational health checks. This will be further detailed in the following two reports, The Health Diagnostics cardiovascular screening solution is designed to be portable as well as functional and

Health Diagnostics Ltd Chatham House Dee Hills Park Chester CH3 5AR T: 01244 311811 F: 01244 311814 E: info@healthdiagnostics.co.uk www.healthdiagnostics.co.uk

Making sense of the complexities a guide to successful commissioning of health checks

A Picture Of Health Making sense of the complexities: A guide to successful commissioning of health checks

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List of Acronyms AQP CCG COF CVD DPH DH DWP JSNA LA NHSCB NICE PHOF

Any Qualified Provider Clinical Commissioning Group Commissioning Outcomes Framework Cardiovascular Disease Director of Public Health Department of Health Department of Work and Pensions Joint Strategic Needs Assessment Local Authority NHS Commissioning Board National Institute for Health and Clinical Excellence Public Health Outcomes Framework

References 1. (http://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmotreview is available from the Local Government Association website (http://www.local.gov.uk/ web/guest/health/-/journal_content/56/10171/3510830/ARTICLE-TEMPLATE 2. http://www.dh.gov.uk/health/files/2012/07/A-draft-mandate-to-the-NHS-Commissioning -Board-Annexes.pdf 3. http://mediacentre.dh.gov.uk/2012/11/15/statistical-press-notice-integratedperformance-measures-return-quarterly-update-2/ 15 Nov, 2012. 4. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAnd Guidance/DH_132358 5. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/ dh_131901.pdf 6. http://www.homeoffice.gov.uk/publications/alcohol-drugs/alcohol/alcohol-strategy 7. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009009.pub2/abstract 8. http://www.bbc.co.uk/news/health-19964600 8a. NHS Health Check - Response to the Cochrane Review http://www.nhshealthcheck.nhs.uk/ - November 2012 9. http://www.who.int/bulletin/volumes/86/4/07-050112/en/index.html