Community Pharmacy NHS Health Checks

Community Pharmacy NHS Health Checks

2010/11

2011/12

Service Specification

March 2010

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Community Pharmacy NHS Health Checks

Service Specification 2010/11

Contents

1.Purpose

2.Description of the Health Check service in community pharmacy

3.Scope

4.Patient pathways

5.Service Delivery

6.Referral, Access and Acceptance Criteria

7.Equipment

8.Patient and Carer Information

9.Quality Assurance

10.Marketing and Publicity

11.Activity

12.Payments to pharmacies

13.Information Governance

14.Monitoring, Evaluation and Service Improvement

15.Duration and Annual review

1.Purpose

1.1 Aims

The NHS Health Check programme is a national programme, launched in 2008, which aims to assess and manage individuals’ cardiovascular risk. In doing so, it intends to prevent the development of cardiovascular disease, including coronary heart disease, diabetes and chronic kidney disease, and reduce the incidence of heart attacks and stroke.

As part of its local delivery of the NHS Health Checks programme, NHS Islington will commission is commissioningNHS Health Checks in community pharmacies. These opportunistic community pharmacy Health Checks will support the early identification ofcardiovascular risk factors in 35 to 74 year olds across the most deprived wards in Islington. Up to ten community pharmacies will be commissioned to provide a cardiovascular risk assessment (Health Check) enhanced service. In addition to identifying and assessing cardiovascular risk factors, the programme seeks to support people to manage their risk through lifestyle advice, onward signposting and referral for additional support and pharmacological interventions where indicated.

1.2 Context and Evidence Base

Cardiovascular disease (CVD) is the biggest killer in London and the largest cause of health inequalities. Cardiovascular disease differentially affects black and minority ethnic groups and socially disadvantaged populations.

Islington is an area of multiple deprivation,ranked the eighth most deprived borough in England, and fourth in London. Deaths from CVD are the single largest contributor to the inequalities gap in life expectancy between Islington and England. The life expectancy for men and women in Islington (2005 - 2007) is 75.1 and 80.8 years respectively. This is significantly lower than that for men and women in England (77.7 and 81.8 years respectively).[1]

Rates of CVD mortality are higher in Islington than the average for England and Wales (E&W). Directly standardised mortality rates from all causes of cardiovascular disease in Islington are 240 per 100,000 compared with 193 per 100,000 population for England and Wales. Premature mortality rates for individuals below 75 years in Islington are also significantly higher than for England and Wales (120 per 100,000 compared to 79 per 100,000 population). (All data are for the 3 year period 2005-2007).[2]

Vascular disease also causes significant morbidity and poor quality of life for individuals who are affected by it.

The Department of Health has predicted that full implementation of the NHS Health Checkprogramme nationally will prevent at least 9,500 heart attacks and strokes a year (2,000 of which would be fatal), and prevent 4000 people from developing diabetes each year.[3]

1.3Overview of NHS Health Checks in Community Pharmacy

Ten community pharmacies that meet the eligibility criteria (refer tosection 3.1) will be commissioned to opportunistically identify patients aged 35 to 74 years, who are registered with an Islington GP (or who are resident in Islington and not registered with any GP) and are not currently being treated for CVD, diabetes, atrial fibrillation or peripheral artery disease. They willopportunistically assess individuals in order to establish their risk of developing cardiovascular disease over the next 10 years, through completion of a questionnaire, simple measurements and finger-prick blood testing. Following the cardiovascular risk assessment, pharmacists will offer individuals a tailored package of advice, support and signposting to enable them to manage and reduce their risk. Please note that the termNHS Health Check was previously known as the Vascular Risk Assessment or Vascular check, and these terms are often used interchangeably.

1.4Objectives

To conduct 2000 NHSHealth Checks per annum in a community pharmacy setting on eligible individuals aged 35 to 74 year olds across Islington.

Each commissioned community pharmacy will be expected to meet an indicative quarterly target of 50 Health Checks.

2.Description of the Health Check service in community pharmacy

Figures 1 and 2 (pages 14 and 15) provide a diagrammatic overview of the Health Check programme.

The NHS Health Check will take place in a private consultation room and will be conducted as a face-to-face check between the pharmacist and the individual. Delivery of an NHS Health Check in a community pharmacy setting comprises the following three main components:-

• The initial assessment process
• Recall and Referral
• Life style advice, support and signposting

Each of these components is described in more detail below.

2.1Phase I: The initial screening process

All individuals participating in the NHS Health Check will be required to sign a consent form. Pharmacists will print out this consent form using the dedicated software package in order for this to be signed and a copy retained by the pharmacist. Individuals will not receive an assessment without signing the consent form.

The initial screening session and NHS Health Check will be facilitated by a dedicated software package (Cardiopod) and will include an assessment of lifestyle habits and a range of health measurements and tests. These standard questions and assessments are described below.

Standard questions:

• Age (calculated from date of birth and recorded in years)

• Gender (recorded as male or female)

• Ethnicity(self assigned from a pre-defined list)

• Patient’s address and postcode
• Registered GP (state postcode/location/name of GP practice- selected from a drop down list)

• Smoking status (recorded as smoker or non-smoker)
• Alcohol consumption based on the AUDIT-C Screening Tool

• Physical activity based on GPPAQ
• Consumption of fruit and vegetables

• Family history (any history of coronary heart disease, in a first degree relative under the age of 60 years. First degree relative means biological mother, father, brother or sister)

• Known pre-existing cardiovascular disease, diabetes, atrial fibrillation or peripheral artery disease

• Current prescriptions specifically for the treatment of cardiovascular disease (includes aspirin, beta blockers, calcium channel blockers, ACE inhibitors, A2 receptor blockers, alpha blockers, diuretics, and other medications used to treat CVD).

Measurements:

• Height (recorded in cm)and Weight (recorded in kg) for calculating Body Mass Index (BMI)

• Blood pressuremeasurements (recorded in mmHg)

Simple blood test: (Finger-prick test):

• Total cholesterol (TC) and HDL cholesterol(non-fasting) (for all individuals receiving an NHSHealth Check).

• Fasting blood glucose(for selected patients who meet the specified criteria - refer to section 2.2.3)

2.1.1CVD risk score and risk communication

Using the standard information obtained from the patient, the dedicated Health Check software package will then generate a CVD risk score for the individual. The risk score uses the QRISK2risk engine. The QRISK2 engine, validated for use in the UK, gives a risk score which takes into account factors such as ethnicity, family history, and deprivation status. For these reasons, QRISK2 is the preferred risk engine for use in Islington.[4]

All individuals accessing the service should receive a full explanation of their results and be provided with a printed copy of them, along with relevant information on health lifestyles and provided documentation by the accredited pharmacist.

Depending upon the results of their Health Check, individuals will be offered a range of appropriate advice and support (see sections 2.2 and 2.3 below). This will include:

• Lifestyle advice:
• Smoking cessation advice for smokers, and referral to in-pharmacy or other local smoking cessation services for ongoing support and encouragement to quit
• Dietary advice, healthy eating and ways to increase fruit and vegetable consumption
• Advice on sensible alcohol consumption
• Advice on keeping active and getting involved in regular exercise. Individuals will be referred to the Exercise on Referral (EoR) scheme, where they meet the criteria for inclusion (see section2.3.5for EoR criteria)
• Referral to a health trainer, where the individual meets the eligibility criteria for the health trainer programme.

• Recall back to the community pharmacy for a fasting blood glucose and repeat BP measurement for eligible patients (see paragraphs 2.2.2 to 2.2.4).

• Referral to their GP for further assessment. In this service level agreement “GP” means “General Practitioner” or “Practice Nurse”, depending on their individual circumstances and their registered practice’s policies.

2.2Phase II: Recall and Referral

2.2.1Individuals requiring direct referral to their GP (HIGH RISK)

The high risk group includesall individuals with a 10-year CVD risk score ≥20%. In addition, individuals with a 10-year CVD risk score <20%but who are found to have any one of the additional risk factorsdescribed below will also be included in the ‘high risk’ group. These individuals will require direct referral to their GP for further assessment, review of their risk factors and pharmacological interventionswhere indicated. The pharmacist conducting the assessment should offer a full explanation of the individual’s CVD risk and the reason for referral,and provide lifestyle advice on managing CVD risk.

The following individuals requiredirectreferral to their GP or practice nurse, based on the results of the initial screen(Phase I of the NHS Health Check):

• Individuals with a 10-year CVD risk score (QRisk2) ≥ 20 %shouldbe asked to see their GP within 4 weeks

• Individuals with a Blood Pressure≥ 160/100mmHg, or with an isolated systolic or diastolic BP reading ≥ 160 or ≥ 100mmHg respectively, irrespective of their 10-yearCVD risk score.[5]

• Individuals with arandom cholesterol reading ≥ 7.5 mmol/L, irrespective of their 10-year CVD risk score. (Where the initial cholesterol reading is ≥7.5 mmol/L, the test should be repeated by the accredited pharmacist to ensure that the elevated level is not a false reading. Referral is indicated if the repeat cholesterol value is ≥7.5mmol/L).[6]

2.2.2Individuals requiring recall to the community pharmacy

Individuals who have a calculated 10-year CVD risk score less than 20% may or may not require recall to the community pharmacy for further tests. The presence or absence of risk factors, as described below, will govern whether an individual requires further assessment. In order to identify whether recall to the pharmacy is required, the diabetes and hypertension filters should be applied. These are described in detail in 2.2.3 and 2.2.4 but are summarised briefly below. Where recall is indicated, individuals should be asked to return to the community pharmacy after 48 hours. This allows patients to prepare for a fasting blood test, which requires that the patient does not eat or drink anything other than plain water for at least 8 hours before the test.

The following individuals should be recalled to the community pharmacy for further assessment, based on the results of their initial screen(Phase I of the Health Check):

• Individuals with a 10-year CVD risk score (QRisk2) less than 20% AND a blood pressure reading

≥140/90mmHgbut <160/100 mmHg,OR with an isolated systolic BP reading ≥ 140 but < 160 mmHg oran isolated diastolic BP reading ≥ 90mmHg but < 100mmHg.

AND / OR

• Individuals with a 10-year CVD risk score (QRisk2) less than 20% AND a BMI ≥ 30, or ≥ 27.5 if Indian, Pakistani, Bangladeshi, South Asian, other Asian or Chinese ethnic origin.

Individuals who are recalled to the community pharmacy after 48 hours will be offered a repeat blood pressure measurement anda fasting blood glucose (FBG) using finger-prick testing.This is discussed further in the subsections below headed Diabetes filter (2.2.3) and Hypertension and Chronic Kidney Disease filter (2.2.4).

2.2.3Diabetes Filter (please also refer to the patient pathway for diabetes and hypertension, Figure 2, grey shaded area, page 13)

The purpose of the diabetes filter is to identify those individuals who are deemed to be at high risk of developing diabetes, based on the presence of risk factors;and to facilitate GP referrals for further assessment where indicated. Risk factors associated with an increased risk of developing diabetes include:

• High blood pressure (BP)
• High body mass index (BMI)

Individuals, who have a BP reading of  140/90mmHg but <160/100mmHg, OR an isolated systolic BP reading of 140mmHgbut <160mmHgor an isolated diastolic BP reading  90mmHgbut <100mmHgrespectively, will be invited back to the pharmacy for a fasting blood glucose using finger-prick testing, plus a repeat BP measurement (see hypertension filter, section 2.2.4 below). They will be asked to return to the pharmacy after 48 hours for these tests.

Individuals with a BMI  30 (or  27.5 if Indian, Pakistani, Bangladeshi, south Asian, other Asian or Chinese ethnic origin) will also be invited back to the pharmacy for a fasting blood glucose test, using finger-prick testing and a repeat BP measurement. They will be asked to return to the pharmacy after 48 hours for these tests.

Individuals will need to return for the second assessment 48 hours after the initial assessment, in view of the fact that they are required to have a fasting blood test on the recall visit.

Individuals will be given clear verbal and written instructions by the pharmacist, NOT to eat anything, and not to drink anything (except plain water) for 8 to 14 hours (usually overnight) prior to the blood test.[7] Individuals need to have a clear understanding about what a fasting blood test entails, and must be advised that failure to comply with the instructions given will distort the results of the blood test, and may lead to unnecessary GP referrals and subsequent investigations.

Individuals who are found to have a FBG level > 3.0 mmol/L but 5.6 mmol/L do not need a referral to their GP and should be given appropriate lifestyle advice. (See section 2.2.7)

Individuals who are found to have a FBG level ≥ 5.6 mmol/L but ≤11.0 mmol/L will be referred to their GP for further assessment and diagnostic tests to exclude or confirm the presence of Impaired Fasting Glucose (IFG), Impaired Glucose Tolerance (IGT) or Diabetes Mellitus (DM).[8] Patients should be advised to see their GP within 2 weeks. Pharmacists should be aware that failure to adequately cleanse the finger from which blood is drawn may lead to an artificially high glucose reading.

Where individuals are found to have a FBG level ≥ 11.1 mmol/L, the pharmacist should repeat the blood test ensuring that the patient’s and pharmacist’s hands are clean and dry, as failure to adequately cleanse the finger from which blood is drawn may lead to an artificially high glucose reading. Where a reading of ≥11.1 mmol/l is confirmed by a second blood test, the patient should be advised to see their GP within 48 hours. Where the patient complains of feeling unwell,the pharmacist should contact the patient’s GP for further advice. Where the patient is not registered the pharmacist should contact the nearest GP for advice.8

Where the FBG level is ≤3.0mmol/L,[9] the pharmacist should carry out the internal quality control procedure (IQC) on the point of care analyser,as a low glucose reading in an otherwise apparently well individual would be unusual. If the results of IQC are normal, re-test the patient’s blood ensuring that the correct quantity of blood is drawn and correctly inserted into the analyser. If on the second test the FBG level remains ≤3.0mmol/l, the pharmacist should contact the patient’s GP for further advice. Where the patient is not registered with a GP, the pharmacists should call the nearest GP for advice. The patient may be given a sugary drink or biscuit if (s)he is feeling unwell.

Pharmacists should be aware that there will be a cohort of individuals who do not meet the criteria for the diabetes filter, but who will still be at significant risk of developing diabetes mellitus. These individuals include:

• Individuals with a first degree relative with diabetes.
• Individuals with end-organ damage known to be associated with diabetes, for example retinopathy, kidney disease, neuropathy.
• Women who have had previous gestational diabetes.
• Individuals with existing medical conditions known to be associated with diabetes, for example, polycystic ovarian syndrome, severe mental health disorders.
• Individuals currently taking medications known to increase the risk of developing diabetes, for example, oral corticosteroids.

Pharmacists should consider the situation of each individual, and offer fasting blood glucose testing where they regard this as being appropriate.

2.2.4Hypertension and Chronic Kidney Disease Filter (CKD) Filter (please also refer to the patient pathway for hypertension and CKD, Figure 4, p17)

High blood pressure is a known risk factor for developing CVD. The purpose of the hypertension and CKD filter is to identify those individuals who may already have established hypertension, and refer them to their GP for further assessment. This further assessment in general practice may include a venous blood test to detect the presence of early CKD changes (serum creatinine and eGFR).

Individuals, who have an initial BP reading of  180/110mmHg, OR anisolated systolic or diastolic readings of  180mmHg and 110mmHg respectively, should be referred directly to their GPfor a hypertension assessment. Patients should be advised to request to see the GP within 48 hours. Such individuals will need GP-led assessments and are more likely to require pharmacological interventions to manage their blood pressure.

Individuals, who have an initial BP reading of  160/100mmHg, OR an isolated systolic or diastolic readings of  160mmHg and 100mmHg respectively, should be referred directly to their GP or Practice Nurse for a hypertension assessment. Patients should be advised to see their GP/Practice Nurse within two weeks.

Individuals, who have a BP reading of  140/90mmHg but <160/100mmHg, OR an isolated systolic BP reading of  140mmHg but <160mmHg or an isolated diastolic BP reading  90mmHg but <100mmHg respectively, will be invited back to the community pharmacy for further assessment after 48 hours.