Provider focus: Delivering NHS Health Checks via GP practice

Having recently revamped their health check service, Bewick Crescent Surgery in County Durham conducted almost six times as many health checks as they had done prior to implementing their new approach; they’re now amongst the top performing practices in the local authority for the delivery of NHS Health Checks. We caught up with Tracy Fleming – the surgery’s NHS Health Check Lead – to find out what the team had done to turn their service around…

Q: What was it about Bewick Crescent’s previous approach to delivering NHS Health Checks that wasn’t working well? 

A: Our doctors were telling people that they needed an NHS Health Check, but we found that people often weren’t turning up to their appointments despite having been booked in. This meant that we were often allotting time that ended up being wasted when patients didn’t attend. We also found however that when patients were in a less formal situation – with the healthcare assistants for example – they would often have the confidence to say ‘well actually I don’t want one’. We saw that taking advantage of this would allow us to be far more efficient with our time and resources.

Q: How did you take advantage of this and alter the service?

A: I’ve taken it upon myself to start asking people as they come in. For example, a patient might feel unwell and come into the surgery for a blood test; if they’re eligible I’ll ask them if they’re interested in having a health check and, if so, book them in there and then. I’ve found you tend to get a much better response when the person is in front of you. For us, it works better than sending out letters that you might not get a reply to

Q: So does Bewick Crescent Surgery not send out invite letters? 

A: We do send invite letters, yes. With those people that we can’t get on the telephone to make an appointment, we send a letter informing them of the service and asking them to ring us if they’d like to book in for a health check. Instead of saying ‘come in at this time on this day’ – which we’ve found doesn’t really work – those that are interested get in touch and those that aren’t don’t ring back. This just allows us to be more efficient and not waste our time with unattended appointments. 

Q: It sounds like efficiencies are at the heart of a lot of the changes? 

A: Yes, that’s true; the fact that I’ve taken a leadership role in delivering the service has made that easier. Patient-centeredness is also really important. We’ve made sure that patients come first and any changes work for them. For example we’ve introduced a Tuesday evening clinic that runs between 5pm and 7.30pm. 

Q: What was the rationale for putting on this out-of-hours service? 

A: We put on the evening clinic to accommodate for those people that wanted to have a health check but who weren’t able to get the time off work during the day. It means that we’re engaging a large number of people that we wouldn’t otherwise get to see. It’s been really well received by patients, as has the quality of the health checks that we’re delivering.

Q: What is it about your health checks that patients appreciate? 

A: Health Options software is a lot nicer and more patient-friendly than the software we used before. I tilt the screen so that I’m not talking at the patients, but instead we go through the process together. They can see what I’m doing – I don’t hide anything – and I use the on-screen info to help explain things to them. In that sense, the computer becomes more of a shared focal point; patients therefore don’t feel as though they’re being spoken at, they’re actively involved in their health check. 

Q: And what do people leave with after their health check? 

A: Everyone gets a colourful personal report in a folder; this is another thing that’s really well received. The reports are full of good information on blood pressure, cholesterol, weight management etc, as well as containing the patient’s results. Often people don’t grasp everything that’s said to them when they come into a doctor’s surgery but with this, they’re able to go home and digest the information at their leisure. The report also contains a graphic that clearly explains the individual’s heart age, cardiovascular risk and the potential effects of lifestyle change. This tends to have a much more powerful impact that just saying ‘stop smoking’ or ‘eat healthily’.

Q: Do you see the health checks having an impact then? 

A: Yes, we’ve had a number of patients take up our smoking cessation service after having had their health check. People are also very interested to learn about the different types of cholesterol – HDL (good) and LDL (bad) – and what they can do about their levels. I’ve found people leaving saying ‘I didn’t realise eating more fruit and veg and stopping smoking could make the difference’. There have also been individuals like a man we had in recently who was quite fit – on his bike all the time – but the health check revealed he had dangerously high cholesterol levels. When he looked into his family history, he saw that high cholesterol was a hereditary trait that he hadn’t known about. This was something he was then able to address.

Q: What sorts of things are you doing to promote the service? 

A: We have a big Check4Life banner and notice board in the waiting room with leaflets that patients can take away. These tend to catch peoples’ eye. The notice board clearly says who’s eligible so people can make appointments while they’re waiting if they’re interested. We also include stuff for kids – things like the Change4Life activity wheel – as we’ve found that if the kids start getting into it, it can help mum and dad to keep moving. Word of mouth within families is also a really powerful way to promote the service. We have a lot of people saying ‘‘This is brilliant, I need to my husband to have one’. A lot of wives actually book their husbands in whilst they’re here and make them come down! 

Top tips from Bewick Crescent 

1. Have a member of staff take the lead on the service 

2. If people in the surgery are interested and eligible in having a check, book them in there and then 

3. Use patient-friendly software and share the screen with the patient 

4. Adapt to patients’ needs and put on evening clinics if necessary

5. Advertise the service and look to involve kids in any lifestyle change programmes 

Thanks Tracy. Wishing you all a happy and healthy Christmas and New Year!

Motivational Interviewing and the NHS Health Check

The big picture

When it comes to the UK’s heart disease problem, the social and economic costs are dizzyingly high. Every year the condition is responsible for around 74,000 deaths; the cost to the economy comes in at £29 billion. At the current rate, Britain is spending more of its health budget on heart disease than any other EU country. 

Whilst the figures are bleak, many of the risk factors associated with the condition – including high cholesterol, high blood pressure, smoking, inactivity and diabetes – are largely, if not entirely, preventable. This being the case, the simple answer to reversing the trends lies with the not-so-simple process of changing collective lifestyle behaviours. It’s with precisely this preventative agenda that the NHS Health Check programme is concerned.

Despite representing the most comprehensive effort to proactively bring down the national burden of ill health, the success of the programme lies, according to Public Health England (PHE), ‘in part with the ability of the chosen provider to inspire behaviour change in those attending’. To this end, the practice of Motivational Interviewing (MI) has become a central feature of the programme delivery framework.

The inclusion of MI is not without justification. According to the research, MI is ‘effective when delivered in brief consultations’ and has the potential to have ‘robust effects across outcomes’ when used in medical care settings. This consensus is perhaps unsurprising however if we accept that health and care are improved when patients are at the forefront of any decision-making. Such patient-centeredness is exactly what effective MI is able to support and enhance.

Integrating MI into the NHS Health Check framework

As was emphasised in the previous blog post on Reviewing the evidence base for NHS Health Checks, quality is key to the success of the programme. Whilst a number of factors go in to making a quality consultation – from the professionalism of the provider to the functionality of the systems – on a personal level, they’re fundamentally characterised by engagement, empowerment and respect. As was highlighted during a recent MI workshop for the Health Diagnostics team, these are precisely the principles fostered by a truly motivational session.

The coordinator of that two-day workshop was Brett Nicholls (pictured right), Chief Executive of Get Berkshire Active and MI trainer. With nearly two decades of experience using MI in his role as an RAF officer, Nicholls brought to the table both a high-level overview of MI philosophy and a host of nuanced insights on how the techniques can be used in different settings. Focusing in on the NHS Health Check, the core objective in this instance was to further develop the ways in which Health Diagnostics support the process of making every contact count.

Working on the principle that ‘people learn best that which they discover themselves’, Nicholls and the Health Diagnostics team explored how the behaviour change techniques originally developed by Drs Rollnick and Miller can be adapted and applied to the context of a 20-30 minute cardiovascular health check. Despite only offering a brief window of opportunity, the reach and availability of the checks mean that people often use them as a gateway to lifestyle change. Whether this change is catalysed by an individual realising what the future may hold for their health, or simply gaining a knowledge of the local support services on offer, many who’ve had a check confirm that the personal discoveries they make cause them to stop, think and very often take action.

How then do we maximise the opportunities offered by the health check? In short, by an approach that draws out and bolsters commitment to lifestyle change when it emerges in the session. In this regard, a chief finding from the workshop was that ‘the spirit’ of MI should be present right from the point at which the client walks through the door (rather than the provider only thinking within an MI framework when results are being discussed). In other words, the entire consultation should be defined by the understanding that:

• A non-judgemental style that favours collaboration, evocation and autonomy will offer the best chance of success.
• Motivation to change is elicited from the client, and not imposed from the outside.
• It’s the client’s task to resolve their mixed feelings towards their lifestyle behaviours, not the provider’s.
• The provider is there to encourage this reflection and offer the tools with which the client can generate insights and pursue their own goals.
• Expressing empathy, affirming self-competence and helping to strategise clients’ next steps are key provider qualities.

       (Insights drawn from Brett Nicholls' MI course manual and training days)

Whilst these elements form the backdrop of a motivational approach, a number of specific strategies and skills are on hand to facilitate a discussion about the client’s personal concerns and potential changes. Ranging from asking open and evocative questions that establish the priorities of the person having the health check, to showing attentive engagement by reframing and reflecting client statements, these and other techniques give MI its signature quality. Despite requiring training and practice, when used well, the basic skills can often have the powerful effect of helping individuals connect with the things that are important to them. Health Diagnostics have produced a digital workbook for any providers seeking more in-depth guidance.

As the name Motivational Interviewing would also suggest, the techniques are particularly well suited to reinforcing a client’s ability to take control of their lifestyle. Whilst the principle of a ‘non-judgemental style’ is regarded as key to exploring and imparting this confidence, it remains the case that making certain judgements may in fact have the effect of encouraging behaviour change. Although resisting negative judgements is essential to the practice of MI, it should be noted that making the assumption that clients have the capacity to achieve their goals can, in itself, influence behavioural outcomes.

Dubbed the ‘Pygmalion effect’, research has found that people may be positively and negatively influenced by the expectations of others. In other words, holding high expectations can positively affect real performance. For the NHS Health Check provider then, preconceived ideas of a certain type may in fact be beneficial. In addition to helping avoid unnecessary resistance and bringing about a constructive conversation, a positive approach that assumes clients have the capacity to change their lifestyles may itself be a factor in bringing about behaviour change.

Whilst maintaining faith in the possibility and benefits of change, the latest research on Evidence-based risk communication also underlines the importance that providers are able to ‘effectively communicate evidence’ on the harms of certain lifestyle behaviours. Working on the principle of patient-centeredness, Health Diagnostics has developed interactive tools with which providers can demonstrate to clients their current cardiovascular risk and the effects that any lifestyle change could have. 

Intuitive icon arrays, ‘heart age’ calculations and simple-to-understand betting probabilities are used to express both ‘current’ and ‘what if you change’ risk scores to the client. What’s more, thanks to these uniquely personal risk calculations, clients are free to draw their own conclusions without providers needing to extol the virtues of a healthy lifestyle. Providers are therefore able to fill the role of supporting and reflecting any concerns, as well as helping to strategise the next steps that clients may be motivated to take.

Whilst this blog offers only a snapshot of how MI is being integrated into Health Diagnostics' systems and training, the principles of behaviour change are at the core of a number of exciting software and service developments. If you'd like to find out more about how Health Diagnostics are advancing and enhancing the NHS Health Check delivery model for local authorities, please contact info@healthdiagnostics.co.uk. To find out more details about MI training opportunities contact brett.nicholls@getberkshireactive.org.

Health+Care show, 2014: Showcasing the latest tools for NHS Health Check delivery at London's ExCeL centre

With the 2014 Health+Care show getting under way in London today, the country’s public health authorities are gathering to discuss the state of the nation’s health and the innovative ways in which the NHS is evolving to manage the £2 billion funding gap it’s faced with.

Health Diagnostics are present and amongst the show’s official top 20 ‘must see’ exhibitors. In addition to showcasing Health Options® – one of the leading risk assessment software programmes for NHS Health Checks – we’ll be taking delegates through some of the latest tools for delivering and managing the national programme.

Amongst the tools displayed on stand M40 will be the new 'call and recall' system that’s allowing public health leads to find, invite and deliver health checks to their target cohorts. Our secure data transfer module for returning patient data to any GP system will also be on show alongside a series of new health check training videos that we've produced with the help of our NHS and Local Authority partners.

With all the elements in place, Health Diagnostics’ system represents the complete solution for delivering health checks:

Identify and invite with 'call and recall'

As the first link in the chain of delivery, the call and recall module allows for targeted NHS Health Check invites to be sent to individuals. By sampling the population, the software can determine precisely those that are eligible and at risk, as well as generate tailored invites for the identified cohort.

Deliver a health check with Health Options® software

We’ll be taking delegates through the CVD risk assessment software that’s used by Local Authorities up and down the country. Having been designed with ease-of-use in mind, the software structures and supports the delivery of motivational consultations. With a range of additional functions for data management, the IT solution is both at the core of the data transfer process and the front-line of health check delivery.

Receive detailed public health analysis

We’ll be showing examples of our reports that provide commissioners with detailed analysis on local health trends and provider performance. Generated by analysing data that’s been securely sent to us over an encrypted network, these reports are there to help those in charge make fully informed decisions when shaping local public health policy.

Transfer data to any GP system

Returning data to any GP clinical system securely via the N3 network has, for a long time, been the holy grail of a complete ‘end-to-end’ delivery model. Health Diagnostics have responded to this need and will be taking delegates through the tool we’ve developed for transferring data back from service providers, to individual patient records.

Use the latest training resources

We've worked closely with our Local Authority and NHS partners to produce training videos demonstrating full consultations that adhere to best practice. In addition, a promotional video that can be used by providers in venues and online has been made freely available. These can be viewed here.

So if you're at the show today or tomorrow and are interested in how NHS Health Checks are being managed centrally and delivered locally, we'd love to have a chat. You'll find us at stand M40!

Share, listen, act: Update on the NHS Health Checks in East London ~ Part 2

Part 2:

Following on from Part 1 of the 'Share, listen act' series where we had the initial reaction to last month's NHS Health Check conference, this post will focus on the achievements of the NHS Health Checks in ethnically-diverse East London.

Dr John Robson, a GP working in East London who co-authored the QRisk algorithm with Julia Hippisley-Cox, was responsible for delivering the latest findings in relation to coverage and uptake of NHS Health Checks in the area. 

For the purposes of the project, three Local Authorities comprised ‘East London'. These are listed below, as well as ranked out of the UK's 150 Local Authorities in terms of overall premature mortality:

- Newham (ranked #110)
- City & Hackney (ranked #132)
- Tower Hamlets (ranked #139)

Despite all featuring in the bottom third of UK LAs for premature deaths, the percentage uptake of the scheme in 2011/12 was 74%. This indicates that 21,194 people from those 3 areas had an NHS Health Check; a figure above the current national average of 50% and well above the upper target of 66% as set by Professor Kevin Fenton. Newham even managed 81% uptake.

In regards to the equity of the uptake of the health checks by age, ethnic group and deprivation, Dr Robson echoed much of what Health Diagnostics have seen in collating and analysing NHS Health Check data:

Main findings

1. Older people (>60 years) were more likely to attend a health check (perhaps because they are more likely to be high risk, are stratified as such and are therefore offered a health check).

2. There was no particular difference of uptake based upon quintile, although this is misleading in the three East London areas that the research covered, as the areas were almost exclusively in the 4th and 5th quintile. In 2011/12, 11% of health check attendees had a Townsend Quintile score of 4, whilst 88% had a Townsend Quintile score of 5.

3. There was a significant uptake of the health checks amongst South Asian and black African/Caribbean populations. In 2011/12, 41% of the Health Check attendees were from a South Asian or black African/Caribbean ethnicity band, compared to 28% of non-attendees. 

Overall 

Of those attending an NHS Health Check, 31% had a CVD risk score of at least 10%. In real terms this equated to 15,876 people identified as medium/high CVD risk. These figures would suggest a significant number of people could benefit enormously from identifying risk increasing behaviours earlier in life. For the Local Authorities concerned, responding with targeted educational and health awareness campaigns may prove crucial.

Following on from the risk identification of the health check, of those classified as at high CVD risk overall (200,000 people out of 2 million attendees), around a third (60,000) were prescribed a statin. This would result in an overall decline of instances of CVD by 25%, accounting for a reduction of CVD events by 1500 cases in 5 years. 

The findings from this study point to the significant, positive effect that the NHS Health Check programme can have in lowering CVD risk. In the face of such encouraging evidence, it is understandable that the debate on the utility of the health check programme has subsided in recent months.

Findings conveyed by Health Diagnostics’ Systems and Data Manager, Michael Storry.

Share, listen, act: Reaction to Public Health England’s NHS Health Check conference, 2014 ~ Part 1

Part 1:

This year’s NHS Health Check conference was the largest to date, with hundreds of delegates from across England and Wales coming together to share best practice. 

Taking place at London’s Kennington Oval cricket ground (right), the invited audience was comprised of individuals currently designing the future of this country’s preventive health and lifestyle services.

Amongst the range of speakers asked to present their expertise was Health Diagnostics’ MD, Julie Evason, who after 30 years in the health check business, was ‘‘very pleased to be able share the accumulated learning!’’

Commercial providers role in the NHS Health Check programme: featuring Julie Evason as a panel member

Julie took to the panel after lunch alongside Public Health England’s (PHE) Director of Health and Wellbeing, Professor Kevin Fenton, and a number of other commercial providers from the likes of Boots and Asda. 

Taking the opportunity to discuss some of the pressing issues facing those coordinating health check programmes, Julie outlined Health Diagnostics’ approach to developing answers to the most commonly-voiced problems. Emphasising a particular interest in IT, she stated that Health Diagnostics ‘‘strive to create simple solutions to what can often appear to be overly complex scenarios.’’

The importance of partnering with organisations in order to be able to generate swift resolutions to local authority (LA) issues was a key feature of the speech. As Julie stressed, ‘‘Health Checks are here now. The solutions are required now.’’ Giving an example of precisely what's required, Julie informed the audience:

‘‘Health Diagnostics partner with a number of like-minded specialist companies who can see the strength in working together and they have helped fast track the development of our range of IT solutions which now include modules for cohort identification (that all elusive call and recall) and the ability to return data to any GP clinical systems well within the expected 48 hours.’’ 

Moving from topics such as the available range of delivery mechanisms, to the financial advantages to using point of care equipment, this address covered significant ground in speaking directly to the concerns of the commissioners and programme leads present.

Reflecting on the discussion, Julie remarked that it ‘‘really feels like momentum is building for the NHS Health Checks and I’m very pleased that Health Diagnostics’ offer fits the bill so well. It was a pleasure to be invited onto the panel. It’s really refreshing to see that PHE recognise us as a quality provider in this arena.’’

Conference feedback from Health Diagnostics' delegates

Jen Sutherland, Systems Support and Account Manager

‘‘There was a real buzz about the place - a very pro-active and can-do feel. LAs that are currently using a spreadsheet to record the health check results were very impressed with Health Options® software for recording the information, receiving reports and also how patient focused it is. It really feels like we have an answer to a lot of the problems they’ve experienced.

A number of people commented on their existing software companies taking a long time to implement new changes, (e.g. dementia awareness and pulse palpation requirements). They were pleasantly surprised to learn that we listen carefully to customer feedback and respond quickly to new changes.’’

Julie Evason, Managing Director

‘‘The quality of the delegates was excellent. We had more focused discussions in that one event than at any other show going over two or three days. The fact that this year's event involved as many people as it did really stimulated discussion across all areas with lots of practical advice and tips being shared.

I was surprised by the misconception that much of the IT capability isn’t available when it is, however it’s great to know that we’re fulfilling the evolving requirements of the programme.

What seemed slightly strange was that so many LAs are spending months researching the requirements to put a tender in place. It would make a lot of sense if PHE could provide a template that could be tweaked locally.’’

Selina Donnelly, Training and Account Manager

''It was refreshing that everyone I spoke to was looking for a way to really drive the quality of the health check service.

Hearing that PHE are in favour of looking to alternative providers to GPs was very exciting. It’s great to have been closely involved in the research that’s helping to inform the debate.''

Keep an eye out for parts 2 and 3 of the Share, listen, act blog series, which will feature:

• Part 2: A report on the National evaluation update by Health Diagnostics’ Systems and Data Manager, Michael Storry.
• Part 3: A report on the The new guidelines for NHS Health Check information governance and data flows by Pete Roberts, Senior Solution Developer & Information Security Manager
 at Health Diagnostics.

Rounding-up 2013's public health debates and looking forward to the coming year

2013 has proved to be a significant year for English primary care. With the transition of public health from PCT to local authority, April saw the introduction of a whole new system of structures for healthcare commissioning and provision. Whilst it’s still too soon to say whether this move has delivered the desired effect of making local health services more relevant for the communities they’re provided for, the indications from the second half of the year suggest that there’s an increased sense of stability in the sector by comparison to this time last year. For many however, this will hardly come as a surprise given how many NHS departments, let alone individual positions, had uncertain futures twelve months ago.

Plain packaging

One of the biggest public health stories from 2013 was the debate around the plain packaging of tobacco products. The issue became increasingly mired in controversy after it emerged that Lynton Crosby – a campaign consultant at the heart of Downing Street – was also actively representing the interests of the tobacco industry. Although out of the limelight for the time being, this issue along with other public health measures such minimum unit pricing are unlikely to be out of focus for long. Their importance in combating what Dr Zafar Iqbal and others have described as the ‘social and market forces which help to perpetuate health inequalities’ will undoubtedly mean their re-emergence in 2014. Our coverage and perspective on the story can be revisited here.

CVD prevention

The summer also saw Public Health England placing an increased emphasis on promoting cardiovascular disease prevention. However as PHE and the Health Secretary served up the evidence on the predicted benefits of England’s flagship CVD prevention programme – the NHS Health Check – others were voicing their doubts as to the projected net gain. As it has emerged, many of the charges levelled against the programme by critics have been based on misrepresentations of the English model of CVD prevention. Again, our in-depth critique which draws out the specifics of the argument can be read here.

Going forward: the macro view

Fortunately, for those on the ground and working hard in communities to provide the health checks and increase awareness on the effects of poor lifestyle behaviours, the news looks positive. Recognising that ‘doing nothing’ in regard to national health inequalities ‘is not an option’, NHS England’s chief financial officer this week announced an increase in funding for NHS commissioners from £96bn to £100bn over the next two years. As well as the increased budget, a new funding formula for local health commissioners ‘that more accurately reflects population changes and includes a specific deprivation measure’ is said to be being introduced. With the NHS Health Check at the very centre of CVD prevention policy, these announcements should provide the means to continue increasing the efficiency and effectiveness of a programme that is already estimated to ‘prevent 1,600 heart attacks and strokes, at least 650 premature deaths, and over 4,000 new cases of diabetes each year’.

Developments at Health Diagnostics

With this comprising the macro-outlook, a big question going forward for us at Health Diagnostics is: how can we best support the drive to alleviate health inequalities and the growing social and economic burden of cardiovascular disease in our own capacity? We’ll certainly be working hard to continue providing a first-class service to all our NHS partners, however in addition a handful of the new developments will include:

• Working closely with reputable academic institutions to help establish empirical outcome data on the efficacy of the NHS Health Check. The potential benefit of using Health Options® software in delivering the health checks will be investigated in particular.

• A new software release is planned for January 2014. This latest version will include some exciting new developments including the integration of the Diabetes UK questionnaire.

• To coincide with this software release, Health Diagnostics are launching the new range of client report fact sheets. With a keen emphasis on design and clarity, the new reports are intended to facilitate the communication of essential health information. With tens of thousands set to be distributed, the team at Health Diagnostics have been working hard to make the reports as coherent, concise, and informative as possible.

• We’ll again be attending the Commissioning Show in June, with details set to be announced closer to the time. To view the findings of the events run in conjunction with the 2013 show, click here.

Until 2014 then, wishing you a happy and healthy Christmas and new year!