Haringey NHS Health Checks

Care PathwayNovember 2014

Review date November 2015

Haringey NHS Health Checks

Care PathwayNovember 2014

Review date November 2015

Programme Overview

The NHS Health Check programme is a public health programme in England for people aged 40-74 which aims to keep people well for longer. It is a risk assessment and management programme to prevent or delay the onset of diabetes, heart and kidney disease and stroke.

Pathway Overview

1a. Identification and Invitation

•NHS Health checks are available for all individuals aged 40-74 years inclusive who have no pre-existing diagnosis/history of diabetes, heart disease, hypertension, atrial fibrillation, heart failure, familial hypercholesterolemia, chronic kidney disease, stroke, peripheral arterial disease or Transient Ischaemic Attack (TIA).

•There is a systematic call/recall system for health checks: low- risk individuals (10 year CVD risk <20%) are recalled every 5 years, high risk individuals (10 year CVD risk ≥20%) every year.

•General practices will be responsible for sending out invitation letters and make appointments for the health checks.

•DH guidance is that individuals should be invited for the check and invitation is the preferred method, however patients can be checked opportunistically.

•Please record invitations.

•Sample invitation letter templates are in the standard operating procedure.

1b. Invitation Process• It is possible to extract a list of patients who qualify for a NHS health Check on all

Primary care clinical systems (Vision and EMIS web) .

• Practices who are participating in the NHS Health Checks need to run an IT search extracting 40 to 74 year olds, excluding those on the relevant disease registers (CHD, Hypertension, Stroke/TIA, Diabetes, CKD and Familial Hypercholesterolemia etc.) and other diagnoses of any cardiovascular diseases and excluding patients who had a health check in the past (READ codes 38B1 or 8BAg)

• Practices should systematically record which individuals have been invited (READ codes 9mC0, 9mC1, 9mC2, 9mC3, 9mC4, 9m25)

• Practices are able to individually decide on the best method of invitation (e.g. phone, verbal, letter, SMS, combination of methods) as well as the order in which patients are invited (by age, alphabetically, by postcode or risk factors e.g. smokers)

• Practices should check their list on a regular basis to identify newly registered patients eligible for the NHS Health checks as well as patients entering the eligible age group

2. Risk Assessment- Minimum DatasetItem Required data Comment

Consent Informed consent

Name and address Include the postcode Postcode used by QRisk to adjust the risk score for deprivation

Age Years Should be between 40 and 74 inclusive

Gender M/F Self reported

Risk Score A figure between 1-100% Using Qrisk2 Framingham

Family History Any history of coronary heart disease or stroke in a first degree relative under 60 years oldAny history of Diabetes Mellitus in a first degree relativeAny family history of hypertensionAny family History of Chronic Kidney disease

First degree relative means father, mother, brother or sister

Ethnicity using ONS categories

Smoking status Current smoker, has quit within one year or non-smoker Framingham risk calculation defines smoking as•Cigarette smoking or quit within the past year•Otherwise (non smoker or quit over a year ago)QRISK defines smoking as:•Smoker•Non-smoker (incl ex-smoker)

Diet Intake of fruit and vegetablesDietOily fish intakeDietary sodium

Intake of fruit and vegetables: ≥ or < 5x/wkDiet: low in fat, average high saturated fatsOily fish intake: ≥ or < 2x/weekDietary sodium: low/average/high

Alcohol Alcohol consumption Based on Audit C screening tool

Physical activity Classification according to GPPAQ http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_063812

Body mass Index BMI= weight(kg)/ height (m)2

Cholesterol measured in mmol/L Random plasma cholesterol. If choelsterol has been checked within the past 6 months, this value can be used

Blood pressure Measured in mmHg Using a validated, calibrated and well maintained blood pressure device. BP can be measured several times initially for an appropriate reading if deemed necessary

Individuals with an initial BP measurement of 140/90 or more will also require further blood pressure investigations, as described in NICE clinical guidance 127 . Creatinine and blood sugar measurements should not be delayed while blood pressure investigations are being undertaken

Individuals with an initial BP measurement of 140/90 or more will also require further blood pressure investigations, as described in NICE clinical guidance 127 . Creatinine and blood sugar measurements should not be delayed while blood pressure investigations are being undertaken

2a and 2b. Applying Diabetes & Hypertension Filters

Is BMI >30 (>27.5 for South Asian or Chinese descent)

Yes No

Is the systolic BP ≥ 140 mmHg

OR

The diastolic BP ≥ 90mmHg

Yes Test blood glucose and serum creatinine (to calculate eGFR)

Test blood glucose and serum creatinine (to calculate eGFR)

NoTest blood glucose

No further investigation for diabetes or hypertension

2a Diabetes Screen• All individuals with a BMI>30 (27.5 for individuals of South Asian or Chinese descent) or a BP ≥ 140/90 mmHg will need a fasting plasma blood glucose

or an HbA1c/IFCC measurement.

• A fasting plasma glucose <6 mmol/L or a Hba1c < 6% (IFCC<42/mmol/mol) excludes diabetes and healthy lifestyle advice should be provided

• A plasma fasting glucose ≥ 7 mmol/L or a Hba1c ≥ 6.5% (IFCC ≥48 mmol/mol) in asymptomatic patients will require a second Hba1c test. A second Hba1c ≥ 6.5% (IFCC ≥48 mmol/mol) is diagnostic of diabetes. A second Hba1c ≥ 6% (IFCC ≥42 mmol/mol) and <6.5% (IFCC <48 mmol/mol) will require an OGTT.

• A plasma fasting glucose between 6-6.9 mmol/L or a Hba1c ≥ 6% (IFCC ≥42 mmol/mol) and <6.5% (IFCC <48 mmol/mol) will require dietary advice and a second HbA1c/IFCC after 3 months. If the Hba1c ≥ 6% (IFCC ≥42 mmol/mol) but <6.5%, then an OGGTT is required. Patients with a second Hba1c ≥ 6.5% (IFCC ≥48 mmol/mol) or FPG ≥7 mmol/L should be added to the diabetes register and managed accordingly.

• The OGTT will determine if the individual has diabetes or impaired glucose tolerance, and appropriate management should follow according to diabetes guidelines

• Patients with a fasting plasma glucose ≥ 7mmol/L or a HbA1c ≥6.5% (IFCC ≥48 mmol/mol) and symptoms of diabetes should be treated as newly diagnosed diabetics without the need for an OGTT

• If point of care testing is being used, a value of less than 5.5mmol/L is considered normal and healthy lifestyle advice should be dispensed. A value above 5.5mmol/L would require venous blood sample for laboratory testing.

Checking for Diabetes Risk

An eGFR calculator can be found at http://www.renal.org/eGFRcalc/

NICE guidelines on chronic kidney disease can be found at http://www.nice.org.uk/CG73

Individual with no prior history of hypertension or chronic kidney disease

has blood pressure ≥ 140/90 mmHg

Check patient’s creatinine

Calculate estimated glomerular filtration rate (eGFR)

from creatinine result

If eGFR ≥ 60ml/min/1.73m2

No further renal assessment is required

If eGFR < 60ml/min/1.73m2Management and assessment for chronic

Kidney disease required inline with NICE clinical guideline 73

2b. Hypertension/Serum Creatinine Screen

3. Risk Assessment and Communication

• QRISK2 risk calculator is the preferred risk calculator in Haringey.

• This should be available in GP IT systems e.g. EMIS web, Vision and ISoft Torex.

• Levels of risk, and what it means for individual should be clearly explained.

• Patients should be provided with a written copy of their results and their calculated CVD risk.

• Nice clinical guidelines 181 “Lipid modification: cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease” provide some pointers on communicating the risk of cardiovascular disease.

• The use of a risk engine to calculate the individuals’ risk of developing cardiovascular disease in the next ten years is required, and everyone who undergoes a NHS Health Check must have their cardiovascular risk score communicated to them.

4. Risk Management-Lifestyle• Every person receiving an NHS health check should receive individually tailored lifestyle

advice, regardless of their risk of vascular disease. This should be delivered using a patient-centred approach such as motivational interviewing.

• A number of risk management and lifestyle interventions can support individuals to help manage their risk of developing vascular disease:

• 4a Smoking• 4b Physical activity• 4c Weight management• 4d Alcohol• 4e NHS Mid-life LifeCheck• 4f Health trainers

• More information can be found in the healthy lifestyles information pack found on the CCG intranet.

4a. Smoking

• All smoking cessation interventions should be delivered in accordance with NICE public health guidance on Brief interventions and referral for smoking cessation in primary care

• Information on local smoking cessation services can be found on the Smokefreelife Haringey website: http://www.smokefreelifeharingey.co.uk

4b. Physical Activity– The physical activity status of all patients should be assessed using the General Practice Physical Activity

Questionnaire (GPPAQ), a validated screening tool. GPPAQ can be found at: https://www.gov.uk/government/publications/general-practice-physical-activity-questionnaire-gppaq

– The GPPAQ provides a simple, 4-level Physical Activity Index (PAI) categorizing patients as Active, Moderately Active, Moderately Inactive, and Inactive that is correlated to CVD risk.

– It is used to help inform a practitioner of when a brief intervention to increase physical activity is appropriate. All patients who receive a score less than ‘Active’ should be offered a brief intervention supporting behavior change to increase physical activity.

– When providing physical activity advice, primary care practitioners should take into account the individual’s needs, preferences and circumstances.

– They should also provide written information about the benefits of activity and the local opportunities to be active.

– Where appropriate, offer a referral into the ‘Active for Life’ physical activity on referral programme.

– For those with a CVD risk of greater than 30% over ten years, GPPAQ should be completed annually.

– Details on local physical activity programmes are detailed in the Healthy Lifestyle Information Resource Pack.

4c. Weight Management

Classification BMI Suggested Action

Healthy weight 18.5-24.9 Healthy eating and physical activity advice

Overweight 25.0-29.9 General advice on losing weight, healthy eating and physical activity (DH - Why Weight Matters card); Offer follow-up appointment

Obesity I 30.0-34.9 Diet and physical activity

Obesity II 35.0-39.9 Diet and physical activity; consider drug treatment

Obesity III >40.0 Diet and physical activity; consider drug treatment; consider surgery if BMI>50 or >45 with co-morbidities and all alternatives have been considered

There are a number of opportunities for HARINGEY residents to participate in community based weight management programmes. These are detailed in the Healthy Lifestyle Information Resource Pack

There are a number of opportunities for Haringey residents to participate in physical activity. These are detailed in the Healthy Lifestyle Information Resource Pack on the CCG intranet .

The North Central London Adult obesity care pathway and resource pack advises on diet and physical activity interventions and referral to specialist services.

Further details on weight management can be found in the NICE clinical guideline 43: Obesity: http://www.nice.org.uk/CG43

4d. Alcohol

This pathway is based on AUDIT-C, a shortened alcohol screening questionnaire.

Information on brief intervention for alcohol is available at:www.alcohollearningcentre.org.uk

The full version of the alcohol screening tool can be found on the HAGA website:

http://www.haga.co.uk/Tools.htm

Ask 3 AUDIT-C questionsusing 2-sided Haringey Screening Tool.

AUDIT Score 8 -15

AUDIT Score 16-19

AUDIT Score 20+

Congratulate and reinforce benefits of lower risk drinking.

Deliver 5 mins Brief Advice

using 2-sided Haringey Brief

Advice Tool&/or book for

20-30 min follow-up session of Extended

Brief Advice using 2-sided

Extended Brief Advice

Tool.

Deliver 5 mins Brief Advice using 2-sided Haringey Brief Advice Tool.

With patient consent, refer to Haringey

Advisory Group on Alcohol

for specialist assessment and a

range of treatment options offered through

HAGA, including community/residential

detoxification, counselling, one-to-one

support, family work and access to

structured aftercare.Refer via FAX with the

completed AUDIT, individual’s contact details and proof of

consent for referral to 0208 802 0081.

Phone: 020 8800 6999590 Seven Sisters Road,

Tottenham, N15 6HR

AUDIT Score 0-7

Where individual scores 5+, ask further 7 AUDIT screening questions using 2-sided Haringey Screening Tool.

Where individual scores below 5, no further action required.

Where individual requires further Brief Advice or Extended Brief Advice sessions (i.e. does not reduce their drinking), arrange up to 5 further sessions. Please note: most people require 1-3 sessions.

Where 6 sessions do not result in reduced drinking, consider referral to HAGA or other options. Call HAGA for advice 020 8800 6999.

4e. Health Trainers

• The NHS health trainers initiative is a local programme. Health trainers are drawn from the communities within which they work or are knowledgeable about the community.

• They support local people at a greater risk of poor health and are trained to use evidence based techniques to help people change behaviours known to cause ill health. (Smoking, alcohol, physical activity and weight management).

• Local health trainers can be contacted on 0208 3795269. More information can be found on the Haringey council website: http://www.haringey.gov.uk/healthtrainerservice and the Healthy Lifestyle Information Resource Pack

5. Risk Management- Medical

• When diabetes, hypercholesterolemia, chronic kidney disease or hypertension are newly diagnosed as a result of the NHS health check, relevant care pathways should be followed.

• The management of these conditions is outlined in individual care pathways and summarised in the following pages of this document.

• All care pathways are consistent with NHS Haringey approved care pathways and North Central London Cardiac and Stroke Network guidelines.

5a. Lipid Modification•A cholesterol test is compulsory for the NHS Health Check.

•Statins should be considered for primary prevention in people with a calculated CVD risk of ≥20%, using clinical judgment and alongside lifestyle changes, regardless of plasma cholesterol

•Initial therapy should be simvastatin 40mg daily. See Nice clinical guidance 181 for details

•There is no target total cholesterol or LDL for primary prevention

•All persons with a total cholesterol >7.5mmol/L and/or LDL > 4.9mmol/L should be assessed for familial hypercholesterolaemia (FH) and statin therapy

5b. Hypertension Management• An initial BP≥ 140/90 should trigger a further BP measurement using ambulatory

blood pressure monitoring or home blood pressure monitoring.

• If the average recorded blood pressure remains over 135/85 mmHg, it should be treated pharmacologically if the 10 year CVD risk is ≥20%, otherwise the relevant lifestyle advice should be given.

• If blood pressure is ≥ 160/100 mmHg, it should be treated pharmacologically regardless of the 10 year CVD risk

• An initial blood pressure ≥ 180/110 should be treated immediately

Further details on the management of hypertension in primary care can be found in the NICE clinical guidance 127: http://guidance.nice.org.uk/CG127

5c. Chronic Kidney DiseasePatients without diabetes and an eGFR <60ml/min/1.73 m2 should have the result confirmed by a

repeat test within 14 days and their albumin:creatinine ratio (ACR) or protein:creatinine ratio (PCR)

tested

Blood results (ml/min/1.73 m2)

eGFR 30-59 eGFR<30

Confirmed by a repeat test within 14 days

Urine results (mg/mmol)

ACR<30 or PCR<50 See NICE clinical guideline 182 for more details

Consider referral for specialist opinion; See NICE clinical guideline 182 for more details

ACR 30–69 or PCR 50–99 confirmed on early morning sample

No haematuria

Haematuria

ACR ≥ 70 or PCR ≥ 100 Consider referral for specialist opinion. See NICE clinical guideline 182 for more details

The management for patients with diabetes differs.

Details can be found in the NICE clinical guidance 73

NICE clinical guidance 73: Early identification and management of chronic kidney disease in adults in

primary and secondary care can be found at http://www.nice.org.uk/guidance/cg182

6. Data Collection, Management and Sharing

• The Health Checks template should be used for data entry if Emis web template is not available. (this can be sent out on request).

• Interventions given and outcomes should be recorded. Appropriate clinical coding should be used.

• A register of people found to be at high risk of vascular disease should be kept (i.e. ≥20% risk over 10 years).

• The health check data must be returned to Haringey public health team on a monthly basis.

• Practices should record and report back on how many individuals have been invited.

• Data should be shared with Haringey Public Health for monitoring purposes as required (See the Standard Operating Procedure for more details).

7. Recall• Patients with a risk score ≥ 20% should be recalled annually.

• Patients with a risk score <20% should be recalled every 5 years.

• To recall patients, a search will need to be run to extract the recall dates attached to the read codes (38B1 or 8BAg) which were entered at the health checks consultation, then the patients can be invited on the relevant recall dates throughout the year.

• Practices should record when patients have been recalled.

• Practices are expected to individually decide on the best method of recall(e.g. phone, verbal, letter, combination of methods)

• Patients diagnosed with vascular disease (Diabetes mellitus, Chronic Kidney Disease, Cardiovascular disease or hypertension) following further investigations should be placed on the appropriate disease register and will not be eligible for further NHS Health Checks

5 yearly invitation

Risk assessment10 CVD risk based on age, gender, smoking status, physical activity, alcohol family history, ethnicity, BMI, Blood pressure

Individual Lifestyle Advice

Tailored to risk*

Further BP assessment

Blood Sugar

DIABETES REGISTER

HYPERTENSION REGISTER

CKD REGISTER

HIGH RISKANNUAL REVIEW

BP ≥ 140/90

Fasting plasma glucose ≥ 7 or HbA1c ≥ 6.5% (IFCC ≥48)

OGTT

BP ≥ 160/100

BP ≥ 135/85

BMI >30 (or 27.5 in Asians) or BP ≥ 140/90

Regardless of risk

Serum creatinine

2 hr glucose between 7.8 and 11: IGT

BP ≥ 180/110

10y CVD risk ≥ 20%

10y CVD risk < 20%

eGFR>60 10y CVD risk ≥ 20% : consider lipid modification therapy

10y CVD risk < 20%

*Includes behaviour change tool, smoking cessation, weight management, alcohol, physical activity, IFG/IGT advice†diabetes pathway may be further changed

2hr glucose

≥ 11.1

eGFR<60

Haringey NHS Health checks: summary†

Fasting plasma glucose < 6 or HbA1c < 6 % (IFCC<42)

6 ≤Fasting Plasma Glucose<7 or 6% ≤ HbA1c< 6.5%(42 ≤ IFCC<48)

Further HbA1c(IFCC)

sym

ptom

atic

asymptomatic

≥6.5

% (

IFC

C ≥

48) 6≤HbA1c<6.5%

(IFCC <48)

HbA1c < 6 % (IFCC<42)

Repeat Serum creatinine

eGFR<60

eGFR>60