TITLE:Islington Pharmacy Based Cardiovascular Risk Assessment Pilot

TITLE:Islington Pharmacy Based Cardiovascular Risk Assessment Pilot

AUTHOR:Pharmacy Pilot Steering Group

MEETING:Briefing Paper for the Pharmacy Contract Meeting June 10th

CONTENTS:

1. Background / rationale

2. Pilot overview

3. Patient pathway

4. Recruitmentof pilot sites

5. Pilot Training

6. Re-imbursements

7. Evaluation & monitoring

8. Steering Group

9. Pilot roll out timetable

This paper will provide a complete overview of the proposed 6-month Pharmacy Based Cardiovascular Risk Assessment Pilot, including patient pathway, service structure, reimbursement plan, evaluation methodology and timetable.

The paper will also outline the justification for the pilot and how it has evolved to date.

CVD remains a major killer in the UK, despite a dramatic fall in death rates over the last two decades. In Islington, more than a quarter of all premature deaths are due to CVD. CVD deaths are also a major driver of the gap in life expectancy between Islington and England.

Applying national estimates of the societal costs of CVD (which overlap with costs associated with smoking and obesity) to Islington, adjusted for the social, economic and demographic characteristics of the borough, suggest that CVD costs Islington about £254 million a year (£73 million in direct economic costs and £180 million in other societal costs), second only to mental health.

Programme budgeting data showed that spend on CVD per needs-weighted head of population in Islington in 2005/6 stood at a reported £94-95 in 2005/6, slightly above the London spearhead cluster average (£90-89) but below the London centre and national averages (£117-29 and £123-58 respectively). Islington’s 2007 Annual Public Health Report showed that comparisons of programme budget spend between areas showed that there is a correlation at the level of overall resource allocation between higher levels of spend on CVD and better outcomes.

Further analysis showed that the majority of health improvement for CHD could be best achieved through investment in lifestyle factor improvements in the community preventing or reducing the risk of CHD, particularly smoking cessation, diet modification and blood pressure reduction, and prevention through primary care (principally lifestyle advice and adjustment and medical treatment). Additional surgical interventions would account for relatively little (about 4%) additional reduction in CHD mortality.

There is evidence to support the following as cost-effective interventions to improve outcomes, and reduce events and mortality from CVD.

-Risk registers

-Case finding

-Control of blood pressure

-Use of drugs – aspirin, anti-hypertensives, statins – and lifestyle advice

-Cardiac rehabilitation in community or hospital settings

These strategies and interventions will support the identification and treatment of those at greatest risk, and deliver gains in the short term, as well as in the medium and longer term. Local baseline indicators and audit show that there is significant scope to develop the use and coverage of these interventions. The levels of activity identified, together with smoking and obesity activity, are designed to achieve sufficient reduction in <75 mortality to close the health inequalities CVD trajectory between Islington and the national average.

In December 2007, the PCT’s Public Health team developed a “Business Case for Prevention”, which made an evidence-based case for significant new investment in key prevention activities and programmes. In January 2008, IPCT’s senior management team approved the majority of the investment set out in the Business Case (totalling approx £1.4 million in 2008/09). This new investment will be focused in the following key priority areas:-

• Cardiovascular disease – case finding and risk registers
• Obesity
• Alcohol
• Mental health
• Cancer screening
• Tobacco control

Of the total moneys identified for the CVD and obesity work-streams (£220,000 and £180,000 respectively), £60,000 has been earmarked for the development, implementation and evaluation of pharmacy-based pilot to case find people at increased risk of vascular disease. The purpose of this pilot is to assess whether pharmacies have a role in offering vascular risk assessments to attract new groups of patients that do not routinely approach GMS services, and whether such a pharmacy service could be cost effective and deliver a service to agreed quality standards and protocols. The evidence base for case finding in pharmacy is limited (and what evidence is available is largely focused on case finding diabetes), therefore evaluation of the scheme will be particularly important in determining its impact and whether there is a case for wider roll out.

Pilot Duration:6 months

Participating Pharmacies:11

Target Population:Men & Women over 40, registered in Islington

Participating pharmacists would be reimbursed for undertaking structured lifestyle and risk factor assessments with patients/customers, including age, sex, ethnicity, family history (CVD and diabetes), fruit and vegetable consumption, physical activity, BMI and/or waist circumference, smoking and BP.

Using a validated tool/scoring algorithm, patients would then be assigned a score and offered appropriate lifestyle advice and signposting, or offered blood glucose and cholesterol testing if they fell into the high risk group.

Depending on the results of these subsequent tests, patients would then be given advice or onward referral to their GP for a full clinical CVD risk assessment and risk factor management as appropriate.

This approach to assessing vascular risk could not only provide opportunities to case find patients at high risk of CVD, but also identify patients at high risk of diabetes and patients with single modifiable risk factors who can be offered advice and signposting into available services e.g. smoking cessation, weight management/obesity.

All pharmacies will be offered the opportunity to partake in the 6-month pilot.

An offer letter will be sent to all 46 Pharmacies asking them to apply, but only those able to meet ALL criteria (below)will be able to apply. The Steering Group will be responsible for reviewing all applications and making the final decision.

► Pharmacy to have a consultation room with alcohol gel wipes

► Pharmacists must work on site for minimum of 16 hours per week

► Have access to the internet

► Pharmacy to offer extended hours (Mon-Fri 9am-7pm and Sat opening)

► Pharmacists must attend full day training, only trained pharmacist will be able to deliver service

Each pharmacy will be offered £225 full day locum cover to attend the training. We are requesting a maximum of3 pharmacists attend from each pharmacy. Only trained pharmacists will be able to partake in the pilot and deliver the service, this is required for quality assurance purposes.

10am – 4pm training day will be provided including

► Health of Islington (public health overview)

► Pilot overview

► Vascular disease and risk

► Healthy eating

► Physical activity

► Stop smoking service

► Health promotion

► BHR CardioChek PA equipment training

All Pharmacies will require 1 lead Pharmacist for the pilot. The lead Pharmacist will be responsible for signing off the Service Level Agreement and will be the main point of contact for the PCT.

Payment will be monitored via submission of CVD1 and CVD2 forms. In addition a monthly monitoring report will be issued from the PCT to the Pharmacy Lead for audit purposes.

Payment to pharmacies will be made at the 3 and 6 month mark.

Total Budget Breakdown:

A robust evaluation framework will also be built into the pilot in order to assess the effectiveness of this approach to case finding. It will be the responsibility of the Islington Pharmacy Based Cardiovascular Risk Assessment Pilot Steering Group to monitor pilot progress.

Pharmacies will be asked to submit CVD1 and CVD2 forms to the PCT, information will be derived from the forms.

Key process and outcome measures will be:-

• Uptake of the service and socio-demographic profile of service users to determine its “reach”
• Prevalence of vascular risk factors in service users and overall risk profile/scores (low/medium/high)
• Numbers ‘recalled’ for blood glucose and cholesterol testing, test outcomes and DNA rates
• Interventions offered by patient risk category – e.g. lifestyle advice and brief interventions within pharmacy, referral to general practice, referral to other services e.g. smoking cessation, weight management
• Uptake of above advice/interventions including impact on general practice.
• Cost of the scheme and measure of cost effectiveness e.g. cost per patient with CVD risk >20%

1

Pharmacy Contract Steering Group Meeting 10.06.08.

Helen O’Keefe, Public Health Prevention Manager.

1

Pharmacy Contract Steering Group Meeting 10.06.08.

Helen O’Keefe, Public Health Prevention Manager.