Next Steps Guidance for Primary Care Trusts

Transcription

1 Putting prevention first Vascular Checks: risk assessment and management Next Steps Guidance for Primary Care Trusts

2 DH INFORMATION READER BOX Policy Estates HR/Workforce Commissioning Management IM & T Planning Finance Clinical Social Care/Partnership Working Document purpose Best Practice Guidance Gateway reference Title Vascular Checks: risk assessment and management: Next Steps Guidance for Primary Care Trusts Author Vascular Checks Programme Publication date 13 November 2008 Target audience PCT CEs Circulation list PCT CEs, SHA CEs, Care Trust CEs, Medical Directors, Directors of PH, Directors of Nursing, GPs, Communications Leads, voluntary organisations/ndpbs Description Putting prevention first, published in April 2008, outlined proposals for a system of vascular checks to be carried out in primary care. This document has been developed in consultation with PCT commissioners, those who will be carrying out the checks and the Learning Network, which has been set up to share learning across the NHS on vascular risk assessment and management. It draws on some real life case studies and examples of how PCTs have already implemented vascular checks in their areas. It provides practical tools to support commissioning and links to existing resources and guidance. Cross reference Putting prevention first (April 2008) Vascular checks: risk assessment and management: Impact Assessment Superseded documents N/A Action required N/A Timing N/A Contact details Vascular Checks Programme Department of Health 407 Wellington House Waterloo Road London SE1 8UG For recipient s use vascular.checks@dh.gsi.gov.uk

3 Putting prevention first Vascular Checks: risk assessment and management Next Steps Guidance for Primary Care Trusts

4 CONTENTS 1. Introduction Background National policy, local delivery the role of primary care trusts 4 2. Aim and coverage of vascular checks Aim of a vascular check Risk assessment Risk management Diagnosis of disease Strategic fit with other priorities and initiatives Public Service Agreements National Service Frameworks Vital signs Tackling health inequalities World Class Commissioning Possible models of delivery Settings Near patient testing Workforce Workforce and training Commissioning Timetable for implementation and phased roll-out Informatics Tools and guidance reference point 23 Annex: Vascular checks programme and World Class Commissioning 24 1

5 1. INTRODUCTION 1.1 Background From 2009/10, the NHS is being asked to implement a uniform and universal vascular risk assessment and management programme called vascular checks for people in England aged between 40 and 74, the proposals for which were set out in Putting Prevention First published on 1 April Vascular diseases, that is heart disease, stroke, diabetes and kidney disease, are the biggest cause of death in the UK, and the vascular checks programme could on average prevent 1,600 heart attacks and strokes and save at least 650 lives each year. The vascular checks programme could prevent over 4,000 people a year from developing diabetes and detect at least 20,000 cases of diabetes or kidney disease earlier, allowing individuals to be better managed and improve their quality of life. These figures have changed following the technical consultation on the economic model. 1 Vascular disease also makes up approximately a third of the difference in life expectancy between spearhead areas and the rest of England. This programme will help ensure greater focus on the prevention of coronary heart disease, stroke, diabetes and kidney disease, and will help people remain well for longer. Type II diabetes mellitus is a growing public health concern. Its prevalence is increasing and diabetes contributes significantly to overall health inequalities within England. This programme offers a real opportunity to make significant inroads in tackling health inequalities, including socio-economic, ethnic and gender inequalities, providing that primary care trusts (PCTs) ensure that their approach is appropriate for their own area and focused on reducing these inequalities. 1 As a result of the responses the Department received, changes have been made in some of the modelling assumptions. For example, the smoking cessation compliance ratio applied was made more conservative and so this has had an impact on the potential benefits of the programme. However, it continues to be both clinically effective and cost effective. Of course, one of the aims of the programme is to get more people to comply with the lifestyle interventions it will offer and so there is the potential to considerably increase this impact. 3

6 1.2 National policy, local delivery the role of primary care trusts Throughout England, many PCTs, particularly in spearhead areas, have already developed local versions of the vascular checks programme often formalised in Locally Enhanced Service (LES) agreements. The aim of the vascular checks initiative is to build on this valuable work so that the advantages of risk assessment and management are available to all who are able to benefit. There is a need therefore for a systematic approach to vascular risk assessment and management across England, and to base this approach on the best available evidence. In order to provide cost-effective care and make a real difference to the health of individuals, all PCTs are therefore being asked to ensure that they undertake the systematic and integrated approach set out in Chapter 2, and that this is introduced as a five-year rolling programme for everyone aged between 40 and 74 years old. This approach is based on economic modelling undertaken by the Department of Health to help ensure the most clinically effective and cost-effective format for the checks. Although the policy and the programme are national, delivery will be at a local level. The tests, measurements and risk management interventions that make up the checks can be delivered in different ways to suit the needs of local populations. There are many different ways to implement the programme and this guidance aims to inform and support PCTs in their implementation. Chapter 4 Possible models of delivery provides more information on how PCTs can approach their delivery. This guidance has been developed in consultation with PCT commissioners, those who will be carrying out the checks and the Learning Network, which has been set up to share learning across the NHS on vascular risk assessment and management. It draws on some real-life case studies and examples of how PCTs have already implemented vascular checks in their areas, some practical tools to support commissioning and links to existing resources and guidance. 4

7 2. AIM AND COVERAGE OF VASCULAR CHECKS 2.1 Aim of a vascular check The purpose of a vascular check is to identify an individual s risk of coronary heart disease, stroke, diabetes and kidney disease, for this risk to be communicated in a way that the individual understands, and for that risk to be managed by appropriate follow-up, including being recalled every five years for reassessment. It is essential that the appropriate risk management advice and interventions are offered as part of the vascular check to accrue the benefits of this programme. It is therefore vital that PCTs have the necessary services in place to support individuals in the management of their risk at the time they roll out their programme. A diagrammatic representation of the vascular risk assessment and management programme is provided in Figure 1. The different aspects of the checks are covered in more detail below. 5

8 Figure 1: A diagrammatic representation of the vascular risk assessment and management programme Key: DM: Diabetes Mellitus egfr: estimated Glomerular Filtration Rate IFG: Impaired Fasting Glucose IGT: Impaired Glucose Tolerance RECALL EXIT Diabetes register EXIT High Risk annual reviews EXIT Hypertension register EXIT CKD register Vascular Checks Programme Risk assessment Communication of risk Risk Management Age Gender Smoking status Physical activity Family history Ethnicity Body Mass Index Cholesterol test BP Measure Diabetes filter Raised blood pressure Risk Assessment Sign post or refer to life style interventions IFG/IGT Behaviour change tool e.g. Mid Life LifeCheck NHS stop smoking services referral Exercise on prescription or other physical activity intervention Weight management on referral IFG/IGT lifestyle management advice Initially, PCTs decide which people to call first and where the checks can be accessed (e.g. General Practice, pharmacy etc) bearing in mind the need to tackle health inequalities If at risk If blood sugar high Oral Glucose Tolerance test^ DM Statins prescription offered* Assessment for hypertension^ High Anti-hypertensives prescription * ^People recalled to separate appointments for diagnosis Serum Creatinine^ egfr Low All to be undertaken by GP Practice Team Blood sugar test If CVD risk assessed as >20% *or professionals with suitable patient information and prescribing rights CKD assessment 6

9 2.2 Risk assessment PCTs need to ensure that their vascular checks include and record the following for everyone eligible: l Age Gender Smoking status Physical activity Family history l l l l l Ethnicity Body Mass Index (BMI) Cholesterol Blood Pressure (BP) Diabetes risk Everyone undergoing the checks will have a cholesterol test which is a random, nonfasting cholesterol test. The science on how best to test for diabetes and impaired glucose tolerance is complex and developing. To test everyone is not clinically effective or cost effective. Best practice is to use a filter to determine those at risk and who should be tested. The UK National Screening Committee s Handbook for vascular risk assessment, risk reduction and risk management provides a discussion of suitable filters to identify those at risk who should be tested, and further guidance from the Department will follow on this topic. Only people who are at high risk of having or developing diabetes need a blood sugar test under the vascular checks programme. An individual in whom a measurement of blood sugar is high will need to be called back for an Oral Glucose Tolerance Test (OGTT) to assess for diabetes or impaired fasting glucose (IFG)/ impaired glucose tolerance (IGT). Again, it is not clinically effective or cost effective for everyone to have a serum creatinine test. Only those whose initial blood pressure is high need a serum creatinine test under the programme. Where this is required, and appropriately trained staff are available, blood should be collected at the first face-to-face appointment where possible and sent for analysis. This can be requested on the same sample taken for cholesterol. Wherever possible, it is important to avoid sending individuals away for their blood to be taken elsewhere to help ensure maximum take-up of the checks. 7

10 Additional guidance is in development by the Department, and will follow early in 2009, detailing thresholds for the above tests and further advice on testing for diabetes and impaired glucose tolerance. The vascular checks programme sets out the tests that must be included for all those between the ages of 40 and 74. The Department s economic modelling has only covered the tests and measurements that are set out above, using the available evidence on clinically effective and cost-effective interventions. This is the service that PCTs will have additional funding to implement from April However, some PCTs may wish to extend the range and scope of the programme where they have particularly high-risk groups within their populations. For example, some PCTs may decide to widen the age range for risk assessing IFG/IGT or kidney disease where they have large populations of South Asians or Afro-Caribbeans. Other elements that PCTs may wish to add to the core test could include: l taking the pulse in older groups to identify atrial fibrillation, the most common arrhythmia; identifying and managing this effectively reduces the incidence of stroke; and taking a blood pressure measurement in the arm and the leg to diagnose peripheral arterial disease (PAD). In deciding whether to add additional tests, PCTs need to consider the costs that will be incurred by them and balance these against the potential benefits. It will also be important to consider how much information can usefully be obtained and discussed with an individual at any one time. If too many procedures are added to the vascular check, there is a risk that it will lose some of its focus and effectiveness. 2.3 Risk management Once the person s level of vascular risk has been assessed, it is essential that the necessary lifestyle advice and interventions are available for the programme to be effective and to support people to maintain or reduce their risk. Everyone, including those at low risk, should receive general advice on how to stay healthy. Others at moderate risk may be advised to start a weight management programme, increase their physical activity or access a stop smoking service. Those at highest risk may, in addition, require medication with statins (which help control cholesterol levels) or blood pressure treatment, or, for those identified with impaired sugar tolerance, an intensive lifestyle management programme may be appropriate. 8

11 The table below shows possible relevant interventions and corresponding National Institute for Health and Clinical Excellence (NICE) guidance. All these interventions are recommended by NICE and are cost effective. Links to the relevant guidance documents are available on the NHS Improvement vascular checks website at Table 1: Interventions offered and their respective NICE guidance 2 Intervention offered Brief exercise intervention Multi-component weight loss programmes Impaired glucose regulation (IGR) intensive lifestyle management Stop smoking services Antihypertensives for those with hypertension Statins for primary prevention Renin angiotensin system blockers for those with proteinuria Existing guidance NICE guidance PHI002 Four commonly used methods to increase physical activity, March 2006 NICE clinical guideline CG43 Obesity, December 2006 NICE clinical guideline CG43 Obesity, December 2006 NICE guidance PHI001 Brief interventions and referral for smoking cessation in primary care and other settings, March 2006 NICE clinical guideline 34 Management of hypertension in adults in primary care: partial update, June 2006 NICE technology appraisal 94 Statins for the prevention of cardiovascular events, January 2006 NICE guidance on chronic kidney disease 2 PCTs are strongly advised to work through the service provision, workforce and prescribing implications of introducing vascular checks in their population before taking decisions about the rate at which they plan to roll out the programme locally. The appropriate services should be costed and in place in order to meet the demand generated by numbers of people being risk assessed. Failure to do this will seriously impair the clinical effectiveness of the programme and also risk damaging its credibility with the target audience. 2 The NICE guidance on chronic kidney disease was published on 24 September 2008 and the interventions within it have not been included in the Department s economic modelling. 9

12 2.4 Diagnosis of disease The vascular checks programme is a programme for preventing disease and managing an individual s risk of developing it. The programme does not cover the management of those who have been previously diagnosed with coronary heart disease, kidney disease or diabetes, or who have had a stroke. Patients who have been diagnosed previously with these conditions should be managed using the existing care pathways and should not be called for a vascular check. PCTs may, however, wish to take the opportunity to ensure that GPs are reviewing and treating these patients as they should. Although the aim of the vascular checks programme is not to find existing disease, we do expect that the checks will identify some people who have undiagnosed vascular disease, particularly diabetes and chronic kidney disease. In such cases, individuals should be started on the appropriate disease management programmes that already exist to manage their condition and prevent adverse complications. The care of these individuals should be reviewed annually as part of their care pathway, and they should not be recalled for a further check as part of the vascular checks programme. 10

13 3. STRATEGIC FIT WITH OTHER PRIORITIES AND INITIATIVES The vascular checks programme has been designed to fit within the Department s wider policy framework, in particular the increasing emphasis on prevention and to further progress work on tackling health inequalities. 3.1 Public Service Agreements (PSAs) Vascular checks are featured in the Next Stage Review, High Quality Care for All, Our Vision for Primary and Community Care and the Pharmacy White Paper. The vascular checks programme, where delivered sensitively, has the potential to substantially contribute to key delivery targets for PCTs. It provides an opportunity to strengthen and improve performance in the following areas: l reducing health inequalities (PSA 18.2); improving life expectancy (PSA 18.1); and reducing mortality from circulatory diseases (SR 2004 PSA 1.1 and 6.1). Not only are these departmental priorities for action, they are also key Local Area Agreement indicators that many Local Strategic Partnerships have agreed to focus on, particularly in areas of deprivation, to improve the health of their population. 3.2 National Service Frameworks The vascular checks programme is underpinned by three National Service Frameworks (NSFs) Coronary Heart Disease, Diabetes and Renal Disease and the National Stroke Strategy, which was launched in December It offers a tool to provide shared primary prevention elements from the NSFs and the Stroke Strategy. The programme will strengthen the work across all four disease areas by drawing together common elements and existing activity, specifically on risk assessment and management. 11

14 3.3 Vital signs Vascular risk score (VSC23) is a Tier 3 indicator in the NHS Operating Framework Vital Signs 2008/09. The vascular checks programme will also contribute to a number of improving health and reducing health inequality vital signs, such as: l l the all-age all-cause mortality rate per 100,000 population; the cardiovascular disease (CVD) mortality rate among people under 75 years of age; l l implementation of the Stroke Strategy; smoking prevalence among people aged 16 or over in routine and manual groups; l healthy life expectancy at age 65; and the proportion of people where health affects the amount/type of work they do. 3.4 Tackling health inequalities PCTs will want to balance a strategic and localised approach to the delivery of the vascular checks programme to ensure that it maximises the use of available resources. On a strategic level, they will wish to engage third sector organisations, the private sector and the local authority, and consider consulting their Overview and Scrutiny Committee, on how best to provide, for example, some of the lifestyle activities supporting the programme. It will be particularly important to consider health inequalities across the patch and ensure that there is a strategy to reach those with a high level of need or who are not in touch with services. At a local level, PCTs will wish to consult different communities to ensure that their particular needs are reflected in the delivery of the programme and to ensure that the programme is accessible to all those eligible to use it. For disabled and ethnic minority groups, this is a requirement of the race and disability legislation. Local Strategic Partnerships usually provide the framework for accessing and bringing together these different groups, especially where they can coalesce around a particular task. 12

15 Health inequalities intervention tools (available at provide local information on the impact of CVD on health inequalities in life expectancy and all-age all-cause mortality, and a ready reckoner showing the impact of key interventions (smoking cessation, antihypertensives and statins). 3.5 World Class Commissioning The World Class Commissioning (WCC) assurance system, launched in June 2008, is a national system to hold commissioners to account, reward performance, and ensure that health outcomes are improving. The vascular checks programme has the potential to substantially contribute to PCT performance under the WCC assurance system as PCTs move towards world class. The assurance system includes an assessment of outcomes against a PCT s chosen strategic priorities, and will also review a PCT s potential for improvement. PCTs will align strategic priorities with the key health outcomes that they will deliver for their population. They will choose a small number of priority outcomes that will be assessed as part of their strategic plan priorities and that have been agreed with partners, including the public, patients, community partners and clinicians. CVD mortality is one of the priorities that could be chosen under the assurance system, and the vascular checks programme will directly contribute to the improvement of health outcomes against this priority. A tool showing how PCTs could use their vascular checks programme to demonstrate how they meet WCC competencies is included as the Annex of this guide. 13

16 4. POSSIBLE MODELS OF DELIVERY Primary prevention is not new to the NHS and there are many models of vascular risk assessment and management being used by PCTs. PCTs up and down the country have shared their learning with us, to help develop this guide through the Learning Network, established by NHS Improvement on behalf of the Department. A number of real-life case studies demonstrating different models and approaches to delivery can be viewed on the NHS Improvement vascular checks webpages ( It is important that PCTs devise and use a model that is best suited to their population and that when doing so they consider tackling the health inequalities that exist within their area. Evidence from work in this area already being done by PCTs is that a thorough understanding of the characteristics and needs of the local population is the key to a successful programme. All PCTs will already be working with their local authorities to develop and undertake a Joint Strategic Needs Assessment (JSNA) of the health needs of their local population. This will help to identify populations at a higher risk of vascular disease and where more effort may need to be focused to ensure that they access the programme. Consideration will need to be given to different approaches required to reach different groups, for example different black and minority ethnic groups, men and women, people with disabilities (physical and mental) and people of different ages. A discussion across a range of partners, possibly facilitated through the Local Strategic Partnership for the area, may help to foster a better understanding of where and how to successfully access high-risk groups to ensure that the programme narrows rather than widens health inequalities. PCTs will wish to take a consultative approach with different groups (for example people with disabilities and ethnic minority communities) in order to develop co-produced models of delivery to ensure that access and uptake are maximised. There are a number of approaches that PCTs can use to drill down to a local level to ensure that potential health inequalities are reduced, including the use of cardiovascular health equality audits, patient and public involvement work, work with community development workers and clinical involvement. PCT-level social marketing, including ward-level work and work with specific high-risk communities, will also help to design more effective local delivery programmes. 14

17 4.1 Settings Vascular checks are suitable for delivery in a number of settings, as demonstrated by the case studies on the NHS Improvement website. Initial modelling costs were based on a general practitioner practice-based system. The use of pharmacies and other settings are, however, equally suitable to help improve access to the checks by those who are less likely to see their GP. The second phase of the modelling has used a pharmacy setting; more information can be found in the Impact Assessment on the Department s website ( PCTs will want to consider the implications of all settings in terms of safety, cleanliness and privacy, and the issue of quality assurance is discussed below in section 4.2. The discussion in Chapter 8 Informatics is also relevant here, as PCTs will need to consider the issue of data transfer when commissioning the checks in various settings. Chapter 8 provides some examples of how this is currently being done, as do the case studies available on the NHS Improvement website. 4.2 Near patient testing Some PCTs are using, or planning to use, near patient testing (NPT) to support their vascular checks. NPT (other terms include point-of-care testing or extra-laboratory testing) is an analytical test performed for an individual outside the laboratory setting. NPT analytical systems range from reagent strips (dip sticks) to small analysers (glucose meters) and benchtop analysers. All devices used for NPT should be CE-marked, denoting compliance with the relevant essential requirements of the Medical Devices Directives covering aspects of safety and performance. The use of NPT, of course, has distinct advantages. Results and lifestyle advice can be provided for a person in one appointment. This may increase uptake and motivation to adjust lifestyle. There are, however, important safety, quality assurance and training issues that need careful consideration and monitoring. While NPT technologies for cholesterol and blood sugar are generally reliable and give similar results to laboratory methods if used appropriately by competent operators, there can be differences. It is important that any NPT technology is properly evaluated before being put into routine use. Operators should be aware that results may not be interchangeable with those from tests carried out in a laboratory because of differences in methodology. This can affect reference ranges and whether a decision is made to offer treatment and/or other interventions. The local pathology department can offer advice on reference ranges and the interpretation of results. 15

18 NPT should only be used by healthcare professionals and staff who have been trained (by a competent trainer) to use the equipment. They should have an understanding of analytical principles, interpretation of test results, limitations of use, and quality assurance. Clear lines of responsibility should be agreed and documented for clinical governance, health and safety, infection control, maintenance of equipment, quality records and audit. This should be evident in documented standard operating procedures, which provide detailed information on how to operate a device to give accurate results. A high-quality assurance system is required which ensures: l that users are trained and competent; that there are internal quality assurance procedures; and participation in a relevant external quality assurance scheme. The Department is currently developing an accreditation scheme for pathology NPT, in conjunction with the United Kingdom Accreditation Service (UKAS), e-learning for Healthcare, and Skills for Health. This will include e-learning systems to deliver training in the competencies developed by Skills for Health. The scheme will be able to support NPT for the vascular checks programme in the future but will not be ready for its initial roll-out. The scheme will require a quality management and clinical governance system which is based on national and international best practice guidelines issued by professional bodies (for example the Royal College of Pathologists and the Association for Clinical Biochemistry), the Medicines and Healthcare products Regulatory Agency and the International Organization for Standardization (ISO 22870). In the meantime, pathology NPT providers should have regard to these standards. 4.3 Workforce The workforce needed to deliver the checks has been addressed in a variety of ways by different PCTs. The use of health trainers, healthcare assistants and pharmacy assistants in both primary care and pharmacy has been crucial to many approaches. In some instances, new teams of primary care nurses and healthcare assistants have been mobilised for the sole reason of implementing vascular risk assessment and management. 16

19 5. WORKFORCE AND TRAINING Depending on the model of delivery PCTs choose, consideration may need to be given to workforce capacity and recruitment. In partnership with Skills for Health, the Department is compiling a Skills Competency Framework for Vascular Checks to support PCTs in the training of their staff. It will contain relevant competencies for all staff who may be involved in vascular checks, including health trainers, pharmacists, pharmacy staff, healthcare assistants, nurses and GPs. Competencies covered will include, among others: l phlebotomy; infection control; communication of risk; and lifestyle advice. The competencies and their underpinning criteria can be used to support the commissioning of training for those who will be involved in the vascular checks service and will be available on the Skills for Health website at 17

20 6. COMMISSIONING PCTs will be responsible for commissioning the necessary services to deliver both the risk assessment element of the programme and adequate provision to deliver the risk management element of the programme. PCTs using multiple providers will need to be very clear in their Service Level Agreements (SLAs) about who is responsible for what and to what standard activities need to be carried out. All providers will need to demonstrate that they have met the necessary standards. Commissioners will want to consider the full range of providers that can help deliver the vascular checks programme, ensuring that the programme is accessible to all the different sections of the community and providing support to help people make the lifestyle changes they need to keep them healthy. In doing this, PCTs need to give consideration to different levels of need among the local population and people s preferences, cultures and beliefs, and assess how they can reasonably provide for those with disabilities and those in prison and inpatient mental health care as well as gypsies, travellers, migrant and refugee populations. In the negotiation of contracts, PCTs will need to ensure that the promotion of equality and prevention of discrimination are transferred to the provider for the duration of the contract. The risk assessment element of the programme is suitable for almost any setting and no specific equipment is needed to adapt the checks for those with a disability. PCTs will be responsible for ensuring that those with disabilities can access their vascular checks when invited to attend and are already responsible for making conscious reasonable adaptations in accordance with disability legislation. In relation to those with physical disabilities, this may involve making changes to premises providing healthcare to help disabled access, and for those with learning disabilities an example may be the provision of appropriate signage. PCTs can refer to the Equality and Human Rights Commission website for further information ( Some PCTs are currently using community pharmacies, many of which are open outside normal working hours, to ensure that their programme is more widely accessible when other services may not be available. Many PCTs are also providing the necessary lifestyle interventions and are commissioning weight management services for adults to support overweight or obese individuals in moving towards and maintaining a healthier weight. These have involved providers such as weight management organisations in the independent sector or teams of dietitians and 18

21 other staff. Case studies of how PCTs have approached this will be made available on the NHS Improvement website ( Commissioners will need to consider all providers that can deliver weight management services for adults and be innovative if they are to cater for different preferences and circumstances. It might seem obvious but not everyone will want to go to the gym and many will not be able to get there easily. Similarly, traditional weight management services may be of less interest to men. In terms of primary care, a Primary Care Service Framework has been produced for the management of obesity in primary care ( This enhanced service framework, developed by NHS Primary Care Contracting, can be adapted and used as a basis for an enhanced service via a primary care contract or SLA. Links to other existing tools and guidance on adult weight management services are available on the NHS Improvement website. In addition, NHS Primary Care Contracting has developed a Primary Care Service Framework for Vascular Checks on behalf of the Department to support high-quality commissioning of the necessary services needed to implement the checks. This will be made available on the Primary Care Contracting website ( 19

22 7. TIMETABLE FOR IMPLEMENTATION AND PHASED ROLL-OUT All PCTs will be expected to begin implementing and delivering the vascular checks in 2009/10. The economic modelling underpinning the vascular checks programme is based on the assumption that PCTs will complete roll-out by 2012/13. However, the actual pace of implementation is for PCTs to decide, and some PCTs will be able to do this faster than others. The pace of roll-out is also subject to the overall funding made available to the NHS in the next Spending Review period, the outcome of which is unknown. It is important that all services are in place to support delivery of the programme. PCTs should commission the risk assessment service in proportion to the availability of the risk management services they have commissioned to ensure that there is sufficient capacity to manage all those who have been assessed as needing them. It is better to start small, with an overall programme of risk assessment and management in place, than to initiate a large number of checks only to find that the risk management infrastructure cannot cope with demand or is underdeveloped. PCTs may decide to target certain groups to begin with, initiate a whole population approach (where risk management services are in place to support this) or use a combination of the two. The Department does, however, expect all PCTs to consider how to tackle health inequalities in their area and to work to ensure that these are narrowed. Many PCTs already undertaking some form of vascular risk assessment and management have begun their programmes by targeting certain groups in order to ensure that health inequalities are narrowed. Again, case studies of approaches taken by PCTs will be provided on the NHS Improvement website ( The economic modelling undertaken by the Department assumes that 3 million people across England will be invited for a vascular check each year at full roll-out, as part of a five-year rolling programme. This is based on an assumed take-up rate of 75 per cent, the take-up rate achieved by the breast cancer screening programme. Were all the checks to take place in general practice, this would work out, on average, as an extra five appointments per week for each practice. 20

23 The Department is working with stakeholders to develop an identity for the programme working under the NHS brand and an information leaflet for people who are invited for a check. These will be made available for PCTs to use from early spring The Department s Impact Assessment can be used by PCTs to help anticipate workloads and estimate costs at full roll-out. Funding will be provided in PCT allocations from April 2009 to support the roll-out of the programme. 21

24 8. INFORMATICS Ultimately, the aim is for a national call and recall system, linking locally, to help ensure that a systematic and universal programme of vascular checks is offered to everyone eligible. This will be developed by the Department but will not be ready in the first years of the programme. PCTs will therefore need to devise their own datarecording and transfer solutions for use in the interim to ensure that the individual s GP receives their results of their checks. Where people are not registered with a GP, they should be encouraged to do so. PCTs will also need to devise their own system to collect and collate core data to ensure that all sections of the community are participating in the programme and that additional effort is made to ensure that health inequalities are being narrowed. This data will be collected later at a national level in order to gain a national picture of activity over the first few years. Many PCTs already have measures in place. Some are simple and effective carbon-copy paper-based approaches, while others have opted for IT-based solutions. Some case studies on their approaches will be made available on the NHS Improvement website ( to help support others considering which approach to take. 22

25 9. TOOLS AND GUIDANCE REFERENCE POINT NHS Improvement has set up a Learning Network to ensure that we capture what works in the delivery of vascular checks-type programmes. The Learning Network is supported by an e-bulletin and the vascular checks section of the NHS Improvement website ( These communication vehicles will be used to update those involved in the implementation of the programme and will provide links to other relevant and supporting material. Further details about how to join the Network and on related events can also be found on the NHS Improvement website. The Department of Health s website ( will contain all policy updates relating to vascular checks. 23

26 Annex: Vascular checks programme and World Class Commissioning This annex outlines how the vascular checks programme can be used by PCTs to demonstrate how they meet World Class Commissioning competencies. World Class Commissioning competencies 1. Locally lead the NHS PCTs should lead and steer the local health agenda in their community Vascular risk assessment PCTs can demonstrate community leadership by example through: 1. Working with local people to ensure that the vascular checks programme is accessible to all those eligible Using local leaders (professionals as well as local people) to gain buy-in to the programme Dedicated personnel to lead and implement Reliable/accurate audit to interpret the effectiveness of the strategy s implementation and the development of a way forward Using quantitative as well as qualitative data to measure outcomes and monitor performance 24

27 World Class Commissioning competencies 2. Work with community partners Vascular risk assessment Work collaboratively with local partners to ensure that vascular health is high on the agenda of all services by: Work collaboratively with community partners to commission services that optimise health gains and reductions in health inequalities Assuming joint responsibility for the Joint Strategic Needs Assessment with local authorities and directors of public health. Partners will include local government, other PCTs, healthcare providers, third sector organisations and clinical partners (for example practice-based commissioners and specialist consortia) Developing partnership agreements for public campaigns, for example on lifestyle interventions Developing partnership agreements for service development implementation, for example for exercise regimes with local authority swimming pools Collaborating with existing services for smoking cessation, obesity, etc, including those provided by the independent sector (Weight Watchers, gyms) Using the vascular checks programme to develop and enhance existing partnership relationships, for example with the Local Strategic Partnership and its delivery/ themed partnerships Sharing across the local community the ambitions for health improvement, innovation and preventative measures to improve well-being and tackle inequalities, for example via library and leisure services Database management establishing IT infrastructure to join up all the different agencies 25

28 World Class Commissioning competencies 3. Engage with the public and patients Proactively seek and build continuous and meaningful engagement with the public and patients, to shape services and improve health Vascular risk assessment PCTs can build meaningful pathways into communities to ensure that information is available and that the importance of undergoing regular vascular checks is understood. PCTs can use the vascular checks programme to fulfil process and knowledge requirements by: 1. Engaging with local people or particular groups within it to help design a service that will help tackle health inequalities Utilising existing patient/public forums (for example, patient forum for cardiac networks, cardiac, diabetes or renal patients) and support groups and charities (for example, British Heart Foundation, Stroke Association, Diabetes UK or National Kidney Federation) to underpin the development of the programme Accessing relevant hospital and existing PCT groups Including vascular checks in public information strategies Utilising checks as a working opportunity for staff to engage with the public and patients Developing health and well-being educational material which is focused on specific local communities 26

29 World Class Commissioning competencies 4. Collaborate with clinicians Lead continuous and meaningful engagement with clinicians to inform strategy, and drive quality, service design and resource utilisation Vascular risk assessment Clinicians need to understand the importance of vascular health and ensure that they communicate this to a range of patients. Specific activities that PCTs can undertake to achieve this are: Identifying and using clinical leaders to drive the implementation and delivery of the programme across the PCT Ensuring that all those involved in delivering the programme understand its aims and impact so they can communicate to patients and other individuals in its delivery Utilising the skills and knowledge of clinicians to inform commissioning, for example through conferences or workshops Supporting clinical networks across provider boundaries Supporting clinical engagement (primary and secondary care) in strategic decision making 27

30 World Class Commissioning competencies 5. Manage knowledge and assess needs Vascular risk assessment Specific activities that PCTs can undertake to achieve these include: Manage knowledge and undertake robust and regular needs assessments that establish a full understanding of current and future local health needs and requirements Encouraging the acquisition of knowledge and intelligence relating to the whole community through well-defined and rigorous methodologies, including data collection with local partners, service providers and other agencies The meaningful exchange of key data and analysis within the PCT and with partners, including local people and potential providers Understanding the current and future local population s health and well-being needs, especially relating to inequalities in health outcomes and experience Mapping and identifying areas of greatest need and relatively poorest health and well-being access and outcomes Developing an implementation and delivery strategy that enhances and builds on the needs assessment data sets and analysis Demonstrating that the PCT has sought and used all relevant data and local intelligence to work with communities and clinicians, prioritising strategic commissioning decisions and longer-term workforce planning Providing a comprehensive map of local service provision, including lifestyle interventions provided by the public, private and third sectors Providing information through a variety of outlets to inform the public about vascular health Using and drawing attention to relevant research as necessary and as it becomes available 28

31 World Class Commissioning competencies 6. Prioritise investment Prioritise investment according to local needs, service requirements and the values of the NHS Vascular risk assessment Cardiovascular disease is the biggest killer in the UK and a major cause of health inequalities. The economic modelling provides evidence that the vascular checks programme is cost effective. A locally focused health needs assessment or health equity audit could help to determine whether priorities need to be set within the programme itself, for example if specific populations need to be targeted. Specific activities that PCTs can undertake include: Supporting programme budgeting and marginal analysis capability linked to transparent investment decision-making processes Identifying and commissioning against key priority outcomes (that is, risk assessment and interventions to support risk management) Supporting requirements that the selected clinical, health and well-being outcomes are desirable, achievable and measurable and align with partners commissioning strategies Facilitating the development of short-, medium- and long-term commissioning strategies to ensure that local service design continues to be innovative and flexible to meet the needs of those using those services Identifying and tackling inequalities of health status, access and resource allocation Completing comprehensive risk assessments to feed into the wider decision-making process and all investment plans Seeking and making available valid benchmarking data to develop service standards and monitor performance Sharing data with partner organisations, including practice-based commissioners and current and potential providers Using agreed procurement processes to achieve the best possible health outcomes and the best healthcare possible within available resources 29

32 World Class Commissioning competencies 7. Stimulate the market Effectively stimulate the market to meet demand and secure required clinical and health and well-being outcomes Vascular risk assessment The vascular checks programme offers the opportunity for PCTs to stimulate the delivery capacity of local partners, markets and service providers to meet the requirements for the checks themselves. Lifestyle interventions are an essential component of the programme and therefore an increase in demand for these services following the implementation of the programme should be seen. Specific activities that PCTs can undertake include: Establishing and developing formal and informal relationships with existing and potential providers of vascular checks, educational materials and lifestyle interventions Enhancing patient, public and staff engagement skills Enhancing signalling to current and potential providers of future priorities, needs and aspirations Providing analysis and monitoring skills (including gap analysis), risk assessment and management Supporting the skills needed to work effectively in this area, for example presentations, negotiation and influencing skills Mapping and understanding the strengths and weaknesses of current service configuration and provision Translating strategy into short-, medium- and longterm investment requirements, allowing providers to align their own investment and planning processes with specified requirements Developing relationships with potential future providers whose services may be of interest and may be relevant to meeting need and demand Developing benchmarking approaches so that providers can compare service outcome measures with each other to drive up performance 10. Encouraging business to see the benefits of partaking in promotional and actual health check programmes for their staff 30

33 World Class Commissioning competencies 8. Promote improvement and innovation Promote and specify continuous improvements in quality and outcomes through clinical and provider innovation and configuration Vascular risk assessment The vascular checks programme offers the opportunity to promote and specify continuous improvements in achieving positive outcomes and service quality through new service design and provider innovation. The vascular checks programme can: 1. Encourage and improve relationship management skills: seek and maintain networks and relationships that identify best clinical and service innovation, research and knowledge Enhance information management skills: seek and share knowledge and intelligence with local clinical and service providers, including current and potential providers Facilitate communication with clinicians and providers to challenge established practice and drive services that are both convenient and effective 9. Secure procurement skills Secure procurement skills that ensure robust and viable contracts 4. Improve the understanding of the role of local community and third sector providers to deliver innovative services and increase local social capital PCTs will have the opportunity to enable a range of delivery options to improve outcomes, ensure value for money and stimulate innovation. The vascular checks programme can support the PCT s processes and knowledge requirements in order to: Procure and contract in proportion to risk and in line with the clinical priorities and wider health and well-being outcomes described in the commissioning strategy Work with commissioning partners to ensure that its procurement plans are consistent with wider local commissioning priorities Reflect NHS values through clear and accurate service specifications Design and negotiate open and fair contracts that provide value for money and are enforceable, with agreed performance measures and intervention protocols Clear contract specifications linked to expected outcomes 31