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Implementing the NHS Health Check in general practice

Jagdish Kumar
BA(Hons)
NHS Health Check - Project Manager

Yvonne Mawby
RGN Dip Nursing
Clinical Nurse Strategic Lead

Ruth Chambers
BM BS B Med Sci DM FRCGP
GP and clinical champion for the Lifestyle Support Programme

Christopher Leese
BA(Hons)
Principal Health Improvement Specialist

Zafar Iqbal
MBBS DCH MRCGP MFPHM Part I & 11
Acting Director of Public Health
NHS Stoke on Trent

NHS Health Check was launched by the Department of Health in England in 2009 to drive down four preventable diseases. This article describes three broad approaches to delivering the programme by NHS Stoke on Trent

NHS Health Check is a programme of five-yearly invitations for 40-74 year olds with no known diabetes, coronary heart disease, chronic kidney disease or stroke to complete a health check. The programme was launched by the Department of Health in England in 2009 to drive down incidence of all four of these preventable diseases, and full implementation is expected across all primary care trusts (PCTs) by 2013.

This article describes three broad approaches to delivering the NHS Health Check that have worked well in general practice as alternative methods of inviting patients to make booked appointments. They have been developed through ongoing experience and real-time learning in Stoke-on-Trent since the scheme was set up in 2008. Each practice will have its own way of working, but there will be elements of these approaches that can be applied in most practice settings.

Drop-in clinics
In our experience, around 30% of patients invited for a health check will attend; however, drop-in clinics give them the chance to attend without needing to book an appointment.1 Figure 1 charts the process involved in delivering a clinic of this kind. Having identified eligible patients through suitable computer searches, invitation letters can be prepared. Get them signed by the practice nurse and doctor, keep the content brief and language informal, and make the text patient friendly. We included a coloured flyer with each letter using a Department of Health design to catch the patient's eye and encourage them to make the link with local social marketing material.

[[Fig 1 health check]]

An important part of completing a health check is how and when blood tests are undertaken. The "how" relates to the use of point of care testing (POCT) vs venepuncture, and the "when" relates to whether the blood test is completed before, or during, the health check. POCT is convenient but can be costly both in terms of money and time. At our drop-in clinic a mixture of POCT and venepuncture was used to collect
blood samples.    

Venepuncture can be offered before the health check either at a blood clinic in the practice or using community phlebotomy services. However, this means patients need to make two visits (for venepuncture and the health check) rather than one. Venepuncture offered during the health check means that, without the results, a cardiovascular risk score cannot
be calculated.

A GP needs to review the blood test results when they are returned from the pathology lab. If uptake is good it might be worth sharing out the task of checking blood tests between GPs; at one of our drop-in clinics a GP had to check over 50 blood test results from a single clinic.

Once the results are available the cardiovascular risk score needs to be calculated there and then along with the communication of risk to the patient. An individualised, branded letter should then be sent to the patient describing the outcome of the health check.

For patients who require further clinical management as a result of their raised cardiovascular disease (CVD) risk score (eg ≥20%) or where a long-term condition has been identified, a repeat visit to the practice nurse or GP must be encouraged.
Our first drop-in clinic for the NHS Health Check took place in a practice with a list size in excess of 10,000 patients. The event was scheduled to take place from 1-7 pm on a Thursday, when the practice was usually closed so that room availability was not a problem.

Two practice nurses, two PCT-employed project support workers, a PCT strategic clinical nurse, lifestyle GP champion, two receptionists and a project manager were all available to staff the clinic. We did not know what the uptake would be from the 300 or so letters that were sent out to patients. By 12.30 pm around 10 patients were already queuing for the check. From then on we had a steady influx of patients, and a ticket system was used to make sure that patients were seen in order.

As more patients attended than we had anticipated, the strategic clinical nurse managed the patient flow to match the skills and capacity of the team so that patients moved between staff to complete different parts of the health check. This wasn't ideal, but being flexible was vital to cope with the workload. By 9 pm staff had seen approximately 80 patients. This was a big learning curve and future drop-in clinics/events ran more smoothly as we addressed a number of factors, including:

  • Advertising a closing time for the drop-in clinic one hour earlier than we intended to finish to allow for late arrivals.
  • Incorporating lifestyle coaches/health trainers to provide general information and local services and opportunities to address lifestyle issues, helping to reduce consultation times with nursing staff.
  • Estimating future numbers of attendees based on this take up rate of 30%, to judge staffing and resource requirements.
  • Allocating subsequent practice capacity for patients who had venepuncture, to ensure their CVD risks were calculated and communication of risks done.

The NHS Health Check drop-in clinic was hard work but worth the effort. This intensive working meant that health checks could be delivered in block sessions and extra resources allocated to ensure there was enough capacity, rather than trying to fit the additional work into the everyday workloads of practice nurses and healthcare workers. A costing evaluation in two local practices highlighted that drop in-clinics/events provided considerable cost savings in comparison to giving patients the choice to book an appointment.

Our evaluation estimated that the clinics offered a cost saving of 37% when compared with offering the choice of booked appointments alone.1 The bulk of the saving was achieved through a reduction in staffing costs generated through intensive clinics rather than booked appointments frequently not attended by patients. 

Opportunistic health checks
Comparison between the characteristics of those who attended for a health check and those who did not was based on the 1,606 patients aged 40-74 years, in two neighbouring practices with a combined patient population of 14,000. We found that many were already accessing their practice team regularly before their invitation to an NHS Health Check. A total of 272 (55%) attendees for a health check and 756 (68%) non-attendees had previously accessed their practice team between 1/9/09-31/7/10 (please see Table 1).

[[Tab 1 health check]]

In the previous 12 months of the health check 172 (35%) attendees and 386 (35%) non-attendees had up to three consultations with a GP or nurse. Furthermore, 271 (55%) attendees and 485 (44%) non-attendees had had four or more consultations in the previous 12 months. The constant and regular access of GP services by patients who fit the criteria for an NHS Health Check led us to consider ways in which we could offer the health check opportunistically. An outline of the process is given in Figure 2.

[[Fig 2 health check]]

Placing electronic flags on patients' notes is not a new concept and is often used to gather information for the Quality and Outcomes Framework (QOF). When suitable patients have been flagged they can be tackled by the next clinician from the practice team whom they consult - practice nurses, healthcare workers or doctors - or invited by the receptionists when they book in, who can help to sell the benefits of the health check.
Adopting motivational interviewing techniques is key. One practice nurse involved in piloting this method said: "Offering health checks during a consultation has helped to improve the number of people having [them] … when the excuses [are] 'I'm OK', or 'That's not for me duck' … [I] can easily explain to them the importance of why they should attend."

Partial health checks
The final approach involves using existing information to partially complete a health check. Considering that so many eligible patients are already accessing primary care, it is likely that some of the information and measures required for an NHS Health Check have already been recorded.

We were able to negotiate with West Midlands Strategic Health Authority the use of existing information to complete the health check. Figure 3 outlines the process of delivering a partial health check. Gathering data on which information is
available and what is required may take some time. Try to limit this to a few measures, such as height, and questions on physical activity and alcohol consumption, and during the consultation some of these measures can be checked quickly with the patient, saving time.

[[Fig 3 health check]]

The real strength of this approach is the ability to use existing blood test results; in doing so a health check could be completed in one consultation. This reduces duplication, costs and patient inconvenience. Using existing information may not be acceptable to all, but we would take a more pragmatic view especially in relation to existing blood test results.

It is widely acknowledged that POCT testing has a level of imprecision when compared with venous samples tested in laboratories.2 We would argue that using the results of a slightly dated but higher-quality blood test would be acceptable in most instances. Using clinical common sense and other information from the health check such as family history of CVD, BP and pulse should allow you to use these results without compromising quality of care, while reducing time, effort and costs.

Initial feedback about this approach by staff and patients has been good. Variations are already being developed with one practice running a search for patients who meet the criteria for an NHS Health Check, filtering patients who have had a cholesterol test in the last 12 months and focusing on inviting those patients for a check.   
 
Conclusions
Offering NHS Health Checks to patients, either at the drop-in clinic or opportunistically, provides an alternative to the routine approach of asking patients to book an appointment by letter. Drop-in clinics do have the potential to save staff time and resources, and boost uptake. Partial checks minimise the waste of unnecessary duplication of blood test results, which also reduces patient inconvenience.

As each practice is different, some of the ideas and techniques discussed in this article could easily be adapted to suit varying needs and preferences. Some of the approaches outlined here will ease the delivery of this important programme with the competing pressures in general practice.

References

  1. Kumar J, Chambers R. Evaluating the NHS Health Check for people with a CVD risk
  2. Whitehead SJ, Ford C. A comparative evaluation of the Cholestech LDX and CardioChek PA point-of-care testing lipid and glucose analysers for the Wolverhampton PCT. Wolverhampton: Royal Wolverhampton Hospitals NHS Trust, 2010.

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