Community Pharmacy Vascular Check Service

Transcription

1 Hampshire & Isle of Wight LPC Community Pharmacy Vascular Check Service Overview Building on strengths, delivering the future H&IOW LPC

2 Document History Preliminary Draft January 08 Approval Draft February 08 Hampshire Draft October 08 Hampshire draft 2 December 08 Hampshire draft 3 January 09 Final Draft February 09 First Published First Revision Second Revision Third Revision Hampshire & Isle of Wight LPC Old Bank House 59 High Street, Odiham Hampshire RG29 1LF Tel Fax office@hampshirelpc.org.uk Web: H&IOW LPC

3 Background Hampshire PCT Healthy Horizons Strategy This strategy document highlights the challenges facing the NHS in Hampshire, makes the case for change to address them, provides a basis for prioritising action and defines a broad direction of travel. Whilst Hampshire has generally good health indicators overall, there are significant health inequalities including lifestyle related conditions such as coronary heart disease. This has a higher prevalence in the areas of Gosport and Havant with a life expectancy gap of up to 3.5 years compared to the highest area in Hampshire. Hampshire PCT has chosen to utilise the accessibility and skills of community pharmacy in those areas of health inequalities by commissioning a vascular check pilot from five pharmacies to run in 2009 as part of the Vascular Inequalities project. This is in line with recent documents from the National Screening Committee, Department of Health (Putting Prevention First, Vascular Checks: risk assessment and management 1 and Next Steps guidance for PCTs 2 ) and the Pharmacy White Paper. 3 Hampshire PCT Joint Strategic Needs Assessment (JSNA) The JSNA highlights the significant contribution that cardiovascular disease makes to the causes of death in Hampshire (28% in total for stroke and CHD). The document also reports that the main areas of health inequalities are Gosport and Havant where smoking prevalence is above the Hampshire average of 20.3% (Gosport 27.4%, Havant 21.8%) yet successful quit rates are below the county average; obesity levels are equal to or above average with consumption of five or more portions of fruit and vegetables are also below average and activity levels are below the county average. Coronary Heart Disease Coronary Heart Disease (CHD) affects 3.5% of the UK adult population 4. CHD accounts for 128,500 deaths annually, representing 21% of deaths in England/Wales in Although deaths from CHD have reduced by 4% annually over the past 20 years in the UK, the UK has one of the worst CHD death rates for all of the populations monitored by the World Health Organisation 1.The National Service Framework (NSF) for CHD aims to reduce death rates from heart disease and related illnesses by two-fifths by The NSF for CHD recommends that the NHS should put in place models of care in order to ensure that they: use a systematic approach for identifying people at high risk of CHD; identify and record modifiable CHD risk factors of people at CHD risk; provide and document the provision of advice and treatment, and offer regular review to people at high risk. 6 Implementing a systematic approach to CHD risk assessment will take a substantial amount of effort in primary care. 7,8 Obesity It is well recognised that excess weight and obesity increases the risk of the biggest killer diseases: coronary heart disease and cancer as well as diabetes, hypertension and osteoarthritis. Worldwide, around 58% of type-2 diabetes, 21% of CHD and between 8% and H&IOW LPC

4 42% of certain cancers are attributable to excess body fat 10. In England alone, obesity is responsible for more than 9000 premature deaths each year, reducing life expectancy on average by nine years. The cost to the economy is estimated at 2.5 billion per annum, which is forecast to rise to 3.6 billion by Almost 24 million adults are either overweight or obese and levels are increasing with 21% of men, 24% of women and 15% of fifteen year olds now clinically obese 8 and a further 47% of men and 33% of women overweight. Children are now presenting with type-2 diabetes, normally exhibited in middle and older age groups. There are also health inequalities issues with large socio-economic and ethnic group differences 11. Summary In March 2008 the Government announced the development of a vascular risk assessment programme for people aged between 40 and 74 years to be implemented from April 2009 over three years. Healthcare professionals will need to work together more closely to deliver this. There is a need to provide seamless patient care through the development and implementation of enhanced services at a local level. In November 2008 the Government released a Next Steps 2 guidance document for PCTs which reinforces the key role of community pharmacy in this initiative. The document confirms that vascular diseases (heart disease, stroke, diabetes and kidney disease) are the biggest cause of death in the UK. This Community Pharmacy Vascular Prevention service supports the utilisation of the skills and accessibility of community pharmacists in line with the Pharmacy in the Future 12 and Vision for Pharmacy in the New NHS 13 documents, the Community Pharmacy Contractual Framework, the General Medical Services Contract (GMS), Your health, your care, your say a new direction in community services and, most recently, the White Paper Pharmacy in England - Building on strengths delivering the future. 3 H&IOW LPC

5 Aim To provide a community pharmacy based Cardio-Vascular Risk Assessment Service to identify people with CVD risk of 20% or more who are unaware of risk and refer /recommend client to visit GP for further assessment and intervention. Objectives The objectives of the programme are to: 1. provide, particularly for hard to reach/easily overlooked people, an accessible Cardio-Vascular advisory and assessment service within their community; 2. evaluate the number of people assessed for risk; 3. quantify the number and type of pharmacists interventions; and 4. quantify and evaluate the number of people referred to a GP. Outcome Measures Quantitative Number of people approached and those assessed at each pharmacy Age and gender Number and nature of pharmacists interventions Number and nature of referrals made to GPs. Qualitative Peoples, pharmacists and other HCPs views on the programme Perceived changes to lifestyle following intervention Target Group Entry criteria (all must apply) Of residents in Gosport and Havant, men aged years and women aged years with the following exclusions: Diagnosed CVD, hypertension, diabetes On GP CVD risk register e.g. been invited or attended for CVD risk assessment in past 3 months Principles Avoid duplication of payment with the GP CVD service Targeted to those at risk, not population wide approach Identify as many CVD cases as possible This is a limited pilot to test pharmacies ability to utilise their accessibility to these hard to reach groups and deliver the service H&IOW LPC

6 Standards The agreed criteria will be identified, assessed and used to address an individual s concerns in order to meet both their information needs and reduce their risk factors. 1. Risk Assessment: Consenting people should: Have measured (where appropriate) and recorded their: o Sex o Smoking status o Height o Weight o Body Mass Index o Blood Pressure (average of two readings) o History of Heart Disease in immediate family be assessed for cardiovascular risk using Q-Risk2 ( (see appendix 1) be supported and followed up by the pharmacist within agreed criteria and protocols be referred for additional support from a smoking cessation service provider if this is indicated and client consent given be referred to a GP where appropriate. 2. Self-care All should: o o o be given suitable health promotion advice (e.g. not smoking, healthy diet, sensible alcohol consumption and regular physical activity) supplemented by approved printed support materials be given a copy of and have explained to them their ten year cardiovascular risk assessment have the opportunity to discuss healthy lifestyle factors that can minimise the risk of diabetes, CHD, hypertension and related complications. Pharmacy Selection Criteria The service will be offered openly to all community pharmacy practices within the defined localities but only five will be selected based upon the following criteria: Located in the areas of health inequalities of Gosport or Havant Has a suitable private consultation area with sufficient space and facilities to support the provision of the service History of consistent quality service delivery Has a consistent pharmacist and appropriate skill-mix within the pharmacy team to deliver the service Commitment to deliver this service over the period of the pilot IT system in the consultation room with access to the internet, potentially able to run additional software and capable of using NHSmail. H&IOW LPC

7 Service outline Supplementary Training Participating pharmacies will be given additional training in: Effective behavioural change techniques (Motivational Interviewing) to be used when giving lifestyle advice and support Training in the use of all equipment The required record keeping process will be explained The claims process will be explained. Recruitment Members of the public will be encouraged to participate in the service by the use of posters and leaflets within the pharmacy and also within local surgeries, libraries, other public areas and the use of local publicity. In addition, patients may be identified by: Pharmacist intervention Other Healthcare or Social Services professionals Carers Family members and friends of family. Selection Members of the public will be asked to complete a simple questionnaire (age, sex and smoking status) which, if they meet the inclusion criteria, will be invited to undergo the vascular check. Assessment Measure and record: o Height o Weight o Waist measurement o Body Mass Index o Blood Pressure o Family history of heart disease Assess cardiovascular risk using Q-Risk2 (see Appendix 1) Advice & Information All will be given targeted and individualised advice about what they can do to reduce their own individual risk. The terminology needs to be clear. Rather than screening one should use the terms risk assessment and risk reduction. Advice will be supported by the use of approved printed materials to supplement the advice they have been given and perhaps to share with other members of the family. Treatment Those assessed as being in need of further support to stop smoking will be sign-posted to a local NHS commissioned service. If this is provided by the pharmacy the individual will be offered the choice of using the in-house facility. Referral - where appropriate based on agreed criteria. Feedback can be obtained from patients, pharmacists and GPs on the programme. Monitoring Equipment Appropriate, validated monitoring equipment for blood pressure, clinical scales and height measures to be sourced together with appropriate training. Data Collection & Input All interventions will be documented, captured and evaluated anonymously. Community pharmacists are bound by the Data Protection Act 1988 and the RPSGB Code of Ethics. H&IOW LPC

8 Support and Referral Criteria The following are the agreed criteria to be considered for assessment and referral: Entry: Opportunistic self selection from poster or identified by pharmacist, technician or healthcare assistant when purchasing smoking cessation related products for self or by referral/recommendation. Self completion of eligibility questionnaire YES Meets criteria of age and gender? NO Assess according to following categories Offer healthy lifestyle advice under Pharmacy Contract Essential Services and signpost to smoking cessation service if appropriate Male smoker years Male smoker years Male non-smoker years Female smoker years Male non-smoker years or Female nonsmoker Assess vascular risk Refer to GP YES Vascular risk 20%? NO 4-week follow up Monthly data submission and payment claim to PCT Prompt payment through PPSA H&IOW LPC

9 Costs The following table contains estimates based on five participating pharmacies in two localities and 100 clients per pharmacy: Fees per client (capped at 500 clients): Initial assessment week follow up TOTAL H&IOW LPC

10 References 1. Putting Prevention First. Vascular Checks: risk assessment and management. DH April Putting Prevention First. Vascular Checks: risk assessment and management. Next Steps guidance for Primary Care Trusts. DH Nov Pharmacy in England, Building on Strengths Delivering the Future. DH April McGlynn S, Reid F, McAnaw J, Chinwong S, Hudson S. Coronary Heart Disease. Pharm J 2000; 265: Death registrations 1999: cause England and Wales. Health Statistics Quarterly, summer London: the Stationary Office, National Service Framework for coronary heart disease. Modern standard and service models. Department of Health: London. March National Prescribing Centre. Assessing cardiovascular risk (part 1). MeReC Bulletin 2000; 11: National Prescribing Centre. Assessing cardiovascular risk (part 2). MeReC Bulletin 2000; 11: WHO. Obesity: preventing and managing the global epidemic. Geneva NAO. Tacking Obesity in England. 11. Health Survey for England DH. 12. Pharmacy in the future implementing the NHS plan. A programme for pharmacy in the National Health Service. Department of Health: London Department of Health. A Vision for Pharmacy in the New NHS. DH 2003, London. Appendices 1. QRisk2 CVD Calculator 2. Cardiovascular Risk Assessment Inputs 3. Cardiovascular Risk Assessment Outputs 4. Vascular Checks Audit Document 5. Vascular Checks Service Summary Document 6. Behavioural Change H&IOW LPC

11 Appendix 1 QRisk2 CVD Calculator H&IOW LPC

12 Appendix 2 Vascular Check Inputs BMI & waist measurement Height & weight Ä Vascular check Age & sex Smoking status BP Family history Data fed into risk calculator H&IOW LPC

13 Appendix 3 Vascular Check Outputs Diagnose & treat LTC support Diagnose & treat Hypertension risk GP referral Ä Vascular check GP referral Vascular Risk >20% Smoking cessation Activity advice Weight management H&IOW LPC

14 Appendix 4 H&IOW LPC

15 Appendix 5 H&IOW LPC

16 Appendix 6 Supporting Behavioural Change in Patients Background Within your practice you will be faced with patients unsure about changing their behaviour. They may be facing choices such as whether or not to stop smoking and if so, how; whether or not to take their medicines; and whether or not and how to best make lifestyle changes such as losing weight, taking more exercise or improving their diet. Motivational Interviewing is an evidence-based and proven approach to behaviour change counselling which is being increasingly applied within healthcare settings to help patients make important changes in aspects of their lifestyle. Motivational Interviewing is a key skill for practitioners engaged in delivery of patient services where behavioural change is required: Medicine Use Review, Smoking Cessation, Sexual Health, Weight Management, etc. And with patient services increasingly measured on outcomes achieved such as smoking quit rates, we believe now is the time to invest in developing key competence in this growing healthcare area. Motivational Interviewing is a client centred directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. The aim is for the client (patient) to express concern about their current behaviour and express arguments in favour of change so that they might lead a healthier lifestyle. The approach involves: Listening to the patient Understanding the patient s motivations, empowering the patient to change and resisting jumping in with imposed solutions Asking open questions and allowing the patient to elaborate Affirming positive aims, thoughts, actions already made Recognising and be aware of clues to intrinsic motivation revealed through change talk o o o o Desire I want to do this Ability I can do this Reason I am doing this Need I have to do this Agreeing and summarising a plan The Training Two days, normally one week apart, in an interactive workshop environment, followed by blended learning and/or distance coaching where appropriate. An alternative is a one-day course followed by additional blended learning an/or coaching. Outcomes Understand the principles and underpinning concepts of Motivational Interviewing Develop skills and confidence in using several simple tools and strategies decisional balance, assessing and improving readiness and confidence, noticing change talk, building commitment, negotiating and agreeing behaviour change plans, rolling with resistance, developing empathy and rapport, and preventing relapse. Learn how and when to use the approach in your daily settings H&IOW LPC

17 Learn how to fuse or blend motivational interviewing with other styles and approaches Content The workshops will include: Origins of and evidence for Motivational Interviewing Core Concepts: Readiness, Resistance, Ambivalence, Discrepancy and Confidence Using your OARS: Open Questions, Affirmations, Reflective Listening and Summaries Tools and Strategies: Setting the Scene, Agreeing the Agenda, Typical Day, Good Things / Less Good Things, Importance and Confidence Rulers, Two Possible Futures, Exploring Option and Agreeing a Plan Rolling with Resistance and Recognising and Eliciting Change Talk Applying the approach for everyone s benefit in your daily work settings NICE summary on behavioural change Plan carefully interventions and programmes aimed at changing behaviour, taking into account the local and national context and working in partnership with recipients 2. Interventions and programmes should be based on a sound knowledge of community needs and should build upon the existing skills and resources within a community 3. Equip practitioners with the necessary competencies and skills to support behaviour change, using evidence-based tools based on theoretically informed, evidence-based best practice 4. Evaluate all behaviour change interventions and programmes, either locally or as part of a larger project. Wherever possible, evaluation should include an economic component. H&IOW LPC