Picture of Health: Report 2

A Picture Of Health Making NHS Health Checks work for public health

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Introduction This is the second in a series of three independently written reports commissioned by Health Diagnostics, a leading provider of health check solutions. The first report entitled, Making sense of the complexities: A guide to successful commissioning of health screening provision, set out the forthcoming transfer of public health to top-tier local authorities. This will see clinicians and providers within primary care, plus public health colleagues, share responsibility for making health screening appropriate and effective with those based in local government.

It also discussed the most recent report from the Cochrane Collaborative which questioned the value of undifferentiated health screening across a whole population. This second report will provide evidence to support health screening, based on interviews with directors of public health and clinical leaders in the new clinical commissioning groups. It will conclude that whilst there are issues with population-wide screening programmes, health checks and screening as a whole, remain important tools in the preventative arsenal.

In the words of Dominic Harrison, director of public health for Blackburn with Darwen: “Cochrane researchers seem sceptical of the value of whole-population screening. Are directors of public health? We do need criteria for effective screening programmes, because of the enthusiasm of some clinical professions and researchers to identify need. With CVD screening, the evidence base is so strong that I think most DPHs would be supportive of the Health Checks programme.�

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Screening needs to be Targeted Those interviewed for this report widely agreed that screening must be targeted to the right people. Nicola Close, chief executive of the Association of Directors of Public Health, confirmed this is mainstream thinking in public health:

“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! So if you can get your targeting right, then screening in public health is a valuable tool. Of course, it can have the negative effect of false positives and there’s also a well-known negative psychological effect of too much testing over and above false positives”.

(False positives are explained effectively here www.screening.nhs.uk/screening) Professor Alan Maynard, a prominent health economist who is chair of York CCG, explained his position:

“Rightly or wrongly - and the Cochrane review suggests the latter - the Health Act has made NHS Health Checks a mandatory cost for the system to bear – so we must target its use in the most cost-effective way. This means practical steps: take your delivery of that screening down to pubs and betting shops, and don’t expect your target group to appear.

This is about the group - especially males who don’t present to their GP often for social and cultural reasons, and then turn up seriously ill with heart attacks and stroke, because they’ve not been screened and cost the system a lot - because it’s happened”.

Dr Niti Pal, chair of Sandwell and West Birmingham CCG concurs:

“CVD screening is not useful in the monolithic way. The government put it across as having to screen the whole population aged 40-74%, with 20% of registered patients screened each year over five years. But targeted CVD screening is very important to pick up patients at risk and who need intervention. What we need is to have targeted screening tools: not to screen the worried well. We need to get to the bloke in the pub who’s drinking 12 pints a day and doing no exercise.”

Health Diagnostics provide all the services and hardware required to perform health checks in a wide variety of settings, as its testing equipment is fully portable. Being able to carry everything required in a cabin-sized luggage bag enables those tasked with carrying out the checks to perform them in almost every setting, so targeting is made easier, and the leisure centres, shopping centres and so on, become screening locations.

When results from the tested individual’s pin prick blood test are combined with analysis of their blood pressure and personal data (smoking status, exercise habits etc) and are fed back within minutes, the benefits of screening as a motivator for positive behaviour change multiply. Sue Collins, health engagement lead for South Tyneside, explains the value of being able to offer instant feedback and advice:

“Point of care testing in general is beneficial because it can support somebody to change their behaviour. The further away a person is from their actual results, for instance if results are given over the phone or via letter, the less likely they are to take advice because it’s easier to ignore. Conversely, one-stop-shop testing enables support or advice to be provided instantly by a nurse or other healthcare provider.”

(Further insights from Sue Collins are included in A Case Study of the North East which accompanies these reports.)

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Going beyond the ‘Worried Well’ Certain criticisms of NHS health checks have focussed on the fact that it is the ‘worried well’ who tend to take the checks up, rather than those with unmet health needs. On this point, Nicola Close, chief executive of the Association of Directors of Public Health adds,

“For really valuable screening programmes, we need to really target it at those most likely to have unmet health needs, and not just on those tuning up in GP surgeries because they’re there anyway for another reason and probably don’t need it”.

As Professor Maynard adds,

“Take it out to building sites, or wherever this population are. Target the poorer, but go to where they go – Asda or Lidl, rather than Waitrose. The issue is that with a limited pot of money to spend, there’s a risk that with these annual NHS Health Checks, the low-risk patients are the ones who will turn up. We need to screen the poor males and disadvantaged ‘bad behaviour groups’, and also need to get to the DWP crowd – the elderly unemployed.”

Dr Amit Bhargava, chief clinical officer of Crawley Clinical Commissioning Group agrees with the pressing requirement for a targeted approach:

“We need to focus and prioritise screening on the areas of greatest needs or people at highest risk. These, for example, may be overweight men who are drinking too much, smoking and not doing enough exercise: not usually the ones who easily come to a GP surgery.

Jill Thornton, lead nurse in the Community Delivery Team at NHS South of Tyne and Wear, told of the efforts she and her team have made to access this demographic:

''Once we targeted a working men's club, and had a lot of resistance to start with, so we sought to earn the trust of one of the men on the committee. So he had a NHS Health Check and was then able to go back to the others and say, 'It only lasts 20 minutes, and there's only a pin prick blood test, not a full venous sample!'

This approach really helped.''

Now is the time to act Dominic Harrison, director of public health for Blackburn with Darwen points out,

“Another issue often ignored in screening debates is the temporal aspect. In a borough like ours, if I want to prevent heart disease deaths in the next two years, I have no doubt that screening in primary care is my best bet, as there are people out there undiagnosed with diseases from which they will die early in the next 2-5 years. But if I don’t address determinants of that ill-health - the causes of causes - then in 100 years our grandkids will spend the same on screening, rather than putting things in place to avoid the need.”

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

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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 heads of public health found that uptake varied markedly in terms of patients’ age, gender and socio-economic profile. The response came in 2011 with a community programme piloted to target younger populations by offering a ‘Mini Health MOT’ to those aged 16 to 40. Dr Mike Lavender, a Consultant in public health medicine at NHS County Durham, 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.”

There is a widespread concern amongst public health practitioners that with the exponential rise in type 2 diabetes diagnoses, and childhood obesity now seen, there is no time to lose. Targeting individuals at the ‘teachable age’ is key to reversing this trend.

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Using Local Knowledge from Local Authorities Local knowledge within local authorities will be key to helping reduce health inequalities; however certain areas of England have particularly acute needs, as Dominic Harrison, director of public health for Blackburn with Darwen, points out:

“If you look at our joint strategic needs assessment in Blackburn with Darwen, we have a focus on cardiovascular disease (CVD), and on those people who will die within the next 2 years if they remain unscreened and untreated. This group are walking around with undiagnosed disease, but may not have been called in for health checks by their GP. Quality and outcomes framework (QOF) analysis shows that our uptake of screening and health measures is significantly below what we model it should be, based on our demographics. The QOF section in our joint strategic needs assessment (JSNA) found high levels of CVD, indeed on the edge of the English population’s worst quintile. This shows that health checks continue to be important as public health moves into local government.”

Health Diagnostics is working with all except one PCT in the North East of England – an area of particularly acute needs, compared to the rest of the country. (The life expectancy of a man in County Durham is 8 years shorter than his counterpart in Kensington and Chelsea.) The successes in getting a high level of testing within County Durham has relied to a large extent on using local knowledge, including practical considerations. Durham’s top 30 per cent deprivation percentile is targeted via Check4Life road shows and community events which are held in areas of high footfall, such as town centres and supermarkets. Practicalities follow direction from local ambassadors and volunteers to establish the busy areas which are also those most in need of help. Jacqui Deakin, health improvement lead explains:

“We’ve learnt a huge amount in terms of what a potential setting needs to have for a successful Check4Life Road show venue - for example, adequate car parking.”

Harrison suggests that local authorities may be better able to deliver screening services, given the detailed local knowledge of their staff:

“The poorest 20% of the population is at most risk of ill-health, for reasons we all know. A local

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authority has a lot of contact with that vulnerable group, due to its work in management and delivery of social housing, revenues, benefits allowances, neighbourhood development services. Local government has huge investment in infrastructure and contacts where the most vulnerable people live and have leisure time.

Here's a real opportunity for public health to get to the non-working population. This group is in touch already with the council for benefits and other forms of advice. The NHS traditionally thinks they are ‘hard to reach’ and this group sometimes won’t go to a GP but do end up in A&E.” Dr Amit Bhagarva is also optimistic about the potential for localised control of health screening:

“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!”

Crawley CCG is working practically with local government for a smooth handover. When asked how, Dr Bhargava explained,

“We have a public health consultant and manager in our CCG office for 2-3 days a week. Public health is very integrated and central to what we do in population health and wellbeing improvements. We are all involved in the joint strategic needs assessment (JSNA) and the preventative agenda, dementia care pathways, smoking cessation and other public health priorities.

We also have a GP with a special interest (GPwSI) in cardiology, with a particular interest in Health Checks and prevention”.

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Changing brings the opportunity for new thinking Harrison thinks that a lot of DPHs will be at an early stage of this thought process and highlights a key question to be,

“How can delivery of any service be supported by existing local government delivery infrastructure? "These are opportunities to discuss whether that LA infrastructure can deliver well-targeted added health contact of a non-traditional kind. Thinking about raising awareness of health risks and wider social determinants, there's also an issue of what political leaders locally could do to mobilise and lead their communities."

Dr Brambleby, formerly director of public health across Croydon Council and Croydon PCT, is now an independent public health consultant. When asked about integrating local services for the purposes of the third report in this series, he pointed out,

"Local authorities control things like swimming pools, gyms and basketball courts. So commissioners in health and local government have to think imaginatively: they might find a local employer sponsor for a football or basketball mini-league. The health aim would be to get more people more active more often, and to make healthier choice easier."

This call for new and enterprising delivery structures is echoed by those on the ground currently providing checks in the community. Jill Thornton explains:

''A lot of people we come across say they'd never dream of taking up their GP's time by asking for a health check'' (Jill's team uses Health Diagnostics' services to provide NHS Health Checks.)

Integration of services and putting patient wellbeing at the centre The move of public health responsibility to local authorities presents new opportunities, putting the individual at the centre of services, and in effect, tailoring services to their needs in an integrated fashion. Dominic Harrison explores this concept:

“A lot of local authorities, ours included, are having a discussion about integrated neighbourhood services rather than a big central office: a 'one-stop shop' for what councils offer: neighbourhood working and investment.

"We are discussing (at an early stage) how to connect primary care infrastructure to local government service one-stop. You may go to a GP with the problem of asthma: the GP then

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finds your home below the statutory 'decent home' standards, which probably led you to be admitted twice over the past year to acute care for severe asthma attacks. Instead, in future, a GP could refer you to housing service for the ‘Warm Homes’ service (insulation etc) as a priority, connecting up clinical treatment with prioritised social determinants intervention . Locally, many directors of public health are looking at taking that approach into local government to develop some version of an ‘integrated wellbeing service’."

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Predicting and analysing efficacy through data management Dominic Harrison went on to mention the need for prediction within public health:

“We’ll see a lot of development linked to risk profiling in general practice. There are a number of commercial packages now in primary care to help GPs look at how to risk-profile their practice population, so from records of disease register and diagnostic records, GPs can see who of their registered list is most likely to go into acute care over the next 12 months, and what interventions could be most effective to prevent that."

It is increasingly important to manage public health data ‘holistically’ – data which is meaningful, and which can identify whether resources are being used efficiently.

Behaviour modification programmes can be lengthy –

often lasting 12 weeks or up to a year - and are therefore costly. With this in mind, the health improvement team at NHS County Durham asked Health Diagnostics if the health check software could also be used to capture outcomes from additional services as a way of tracking the outcomes of its weight loss, exercise, smoking cessation programmes, and so on. Health Diagnostics was able to develop its Health Options software to incorporate the trackers used by Durham’s team. This provided the health improvement team with a near-live indication of the patient’s progress, as well as their return on investment.

This feature is now available to all PCTs and providers, allowing those running programmes to determine, for example, whether or not someone identified as ‘obese’ during a health check went on to attend and complete the recommended weight-loss programme they were signposted to.

Informed choice and the challenges of change Clearly, patients being screened should also be given appropriate information that can help them make informed choices. The provision of an immediate printed report at the point of screening, which offers them examples of benefits they could get from improving aspects of their health through diet, exercise or other changes, offers an opportunity for local health economies to move their populations closer to the ‘fully engaged’ scenario set out in Derek Wanless’ influential 2004 report for HM Treasury1 It is important for commissioners and directors of public health to be realistic that helping the poorest and most disadvantaged in their communities to adopt healthier lifestyles is not easy to do.

Community nurses such as Jill are able to provide a wide variety of engaging tools to demonstrate the benefits of positive behaviour change. Diabetes UK's waste tape measures, for example or the 'Smoke Free' wheel which

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calculates how much money a smoker of 20 cigarettes a day would save if they quit: £50 per week, £213 per month, up to £51,500 over 20 years. When health messages don't succeed, financial ones can.

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Conclusion Just as vital as targeting screening at the most at-risk population, interventions to support change, which are based on screening data, need to be focused and targeted at the aspirations and culture of the at-risk group.

Health screening offers a potentially important opportunity as a starting point for changing health behaviours in at-risk groups, but the leaders of health economies on CCGs and local government need to think about how to support their populations in making the changes. Despite budget cuts, and amid serious life-style related issues, this support is needed now, and time is of the essence. In the words of Dominic Harrison, director of public health, Blackburn with Darwen:

"Using the NHS Health Checks programme to increase uptake of population screening for CVD in primary care is probably one of the most important tasks to reduce preventable deaths in the short term. In some cases, it can find those who have existing, advanced and undiagnosed disease from which they will probably die in the next three years, for which effective treatments and interventions are available. In terms of improving adult life expectancy and reducing preventable mortality, CVD checks are probably the most effective thing we can do in the short term."

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However ensuring the effectiveness of any NHS Health Check programme requires a delivery network that invariably puts the patient at the centre. Jill Thornton explains:

“It’s about not being judgemental or ‘telling’ people to do something. It's offering advice.

Most people soften at that. It’s also about letting people have 20 minutes dedicated just to their health and their future health, which they don’t normally get.”

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Data security and quality assurance Screening programmes clearly require timely and robust data, which can be transmitted back securely and swiftly to a patient’s GP. They also require support from analytical packages to demonstrate health need and uptake across a population.

To avoid the risks of false positives in screening, the equipment also needs to be reliably accurate, and the staff delivering the testing need to be well-trained (see Box 1)

Background: Health Diagnostics

Box 1 Screening programme characteristics • Accurate, portable and reliable testing equipment • Well-trained staff • Patient-friendly report of the test results, signposting to resources that can facilitate healthy lifestyle changes and showing potential health and wellbeing gains from change • Bespoke and secure software that links back into GP data systems

The sponsors of this report, Health Diagnostics, provide products and services that can meet the needs set out in Box 1 above. Health Diagnostics provides CE-marked analysers and software; ISO 27001 certification for information governance; and an accredited training programme. The equipment HD sell is recommended by the DH buyer’s guide, and HD work with leading NHS partners such as Royal Bolton Hospital who run the scheme for the quality control checks on the HD cholesterol analysers.

Health Diagnostics Ltd are an Information Governance SoC level 2 company and operate an Information Security Management System [ISMS] certified to ISO 27001:2005. A copy of the ISMS is available on request.

Health Diagnostics Ltd is also registered with the Information Commissioners Office.

Health Diagnostics never have any direct contact with patients. The software package, Health Options®, gathers patient data relative to the NHS Health Check criteria and the data gets collated to enable it to be processed and analysed for the client. Health Diagnostics hold anonymised results on behalf of the client from screening or NHS Health Check providers,which are used for data analysis purposes. Health Diagnostics do not contact patients, nor pass the data to any third party.

HD’s method and policy is that screening and NHS Health Check data from several computers is synchronised to a central database in an encrypted format, where a copy is held in accordance with the ISMS. Express patient consent is provided before screening data is recorded. The collated data is used for analysis purposes only.

Another vital area for commissioners and DPHs to consider is data security and IT governance issues. In the NHS, this has traditionally been the responsibility of ‘Caldicott Guardians.2’ Finally, public confidence in the security and confidentiality of their data and how it is handled will help provide reassurance to patients about screening programmes.

Health Diagnostics Ltd Chatham House Dee Hills Park Chester CH3 5AR T: 01244 311811 F: 01244 311814

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E: info@healthdiagnostics.co.uk www.healthdiagnostics.co.uk Making NHS health checks work for public health

A Picture Of Health Making NHS Health Checks work for public health

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List of Acronyms CCG CVD GPwSI ISMS JSNA LA LTC PCT QOF

Clinical commissioning group Cardiovascular disease GP with a special interest Information Security Management System Joint strategic needs assessment Local authority Long-term conditions (chronic disease) Primary care trust Quality and outcomes framework

References 1. http://webarchive.nationalarchives.gov.uk/+/http://www.hm-treasury.gov.uk/ consult_wanless04_final.htm 2. http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/ Managingyourorganisation/Informationpolicy/Patientconfidentialityandcaldicottguardians/ DH_4100563

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