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LPC Support Seminars

Vascular Risk Assessment

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Introductions…

Alastair BuxtonHead of NHS Services

Mike Dent Head of Finance

Mike King Head of LPC and Contractor Support

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Today's objectives• A background briefing on vascular disease

and clinical risk factors

• A description of the policy, the government programme and the service details

• Learning from examples of current pharmacy vascular risk services

• How to prepare and cost a compelling bid

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Today's objectives

• Why community pharmacy should be commissioned

• How to sell into PCTs

• Securing contractor motivation and engagement

• Pricing the service looking at costs, market potential and service value

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VRA overview

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VRA – where did it all start?

• Diabetes, Heart Disease and Stroke (DHDS) Pilot Prevention Project - screening for type 2 diabetes

• ‘Vascular syndrome’ tackle risk factors

• National Screening Committee decision 2005

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Gordon Brown announcement

...there will soon be check-ups on offer to monitor for heart disease, strokes, diabetes and kidney disease - conditions which affect the lives of 6.2 million people, cause 200,000 deaths each year and account for a fifth of all hospital admissions.

Jan 2008

• Putting prevention first March 2008 Vascular checks

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VRA features in:

• Next Stage Review

• High Quality Care for All

• Our Vision for Primary and Community Care

• Pharmacy White Paper

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Underpinned by:

• Coronary Heart Disease NSF

• Diabetes NSF

• Renal Disease NSF

• National Stroke Strategy

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It can help with...

• reducing health inequalities (Public Service Agreement 18.2)

• improving life expectancy (Public Service Agreement 18.1)

• reducing mortality from circulatory diseases (SR 2004 Public Service Agreement 1.1 and 6.1)

• All DH and Local Area Agreement priority areas

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Vital signs• Vascular risk score (VSC23) is a Tier 3 indicator in the

NHS Operating Framework Vital Signs 2008/09• The VRA programme will also contribute to a number of

improving health and reducing health inequality vital signs, such as:– the all-age all-cause mortality rate per 100,000 population;– the cardiovascular disease (CVD) mortality rate among

people under 75 years of age;– implementation of the Stroke Strategy;– smoking prevalence among people aged 16 or over in

routine and manual groups;– healthy life expectancy at age 65; and– the proportion of people where health affects the

amount/type of work they do.

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The aim of the VRA programme

• To offer a straightforward risk assessment for diseases affecting the vascular system, including diabetes and chronic kidney disease, to everyone over 40 years (up to 74 years)

• Prevent 1,600 heart attacks and strokes a year• Save at least 650 lives a year• To reduce premature death from vascular

conditions including CHD, CKD, DM, stroke, TIA and PAD

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The vascular checks programme

• Starts April 2009

• PCTs must ’show some evidence of participation’ with the programme during 2009

• Gradual increase in activity (Spearheads likely to lead)

• £250m cost phased in over 5 years

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The VRA service

• Determine a person’s ’risk’ of developing a number of chronic conditions which affect the vascular system

– Coronary heart disease (heart attacks and angina);– Stroke;– Diabetes; and– Kidney Disease

• All linked by a common set of risk factors:– obesity, physical inactivity, smoking– high blood pressure, disordered blood lipid levels

(dyslipidaemia)– impaired glucose regulation (higher than normal blood

glucose levels, but not as high as in diabetes)

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The overall approach

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The VRA process

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Stage 1 - Identification

• National Call and recall system• Local call and recall• Opportunistic approach

• Likely initial PCT approach?

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Risk assessment Risk Management

RECALL

Cholesterol test

Smoking status

Physical activity

Body Mass Index

Age

Gender

Ethnicity

Diabetes filter

BP Measure

Statins prescription offered*

Exercise on prescription or other physical activity intervention

NHS stop smoking services referral

Weight management on referral

Vascular Checks Programme

Family history

EX

ITH

igh Risk

annual

reviews

RiskAssessment

EX

IT

Hypertension register

EX

IT

Diabete

s register

EX

IT

CK

D

register

^People recalled to separate appointments for diagnosis

Anti-hypertensives prescription *

Serum Creatinine^

Assessment for hypertension^

IFG/IGT lifestyle management advice

Oral Glucose Tolerance test^

DM

High

Blood sugar test

Raised blood pressure

IFG/IGT

If at risk

eGFR Low

Communication of risk

Sign post or refer to lifestyleinterventions

All to be undertaken by GP Practice Team

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Key:

DM: Diabetes Mellitus

eGFR: estimated Glomerular Filtration Rate

IFG: Impaired Fasting Glucose

IGT: Impaired Glucose Tolerance

Behaviour change tool e.g. Mid Life LifeCheck

If CVD risk assessed as >20%

If blood sugar high

*or professionals with suitable patient information and prescribing rights

CKD assessment

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Stage 2 – risk assessment

• Primary Care Framework

• PSNC service specification

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Stage 3 - Intervention

• Basic advice to all• Impaired Glucose Tolerance (IGT) lifestyle

intervention• Pharmacological interventions• Exercise chat• Stop Smoking services• Diabetes management• Weight loss programmes

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VRA – issues for providers

• Consultation facilities– Hand washing– Visual privacy– IT– Storage space

• POCT equipment– Effective procurement– Quality Assurance– Operator training– DH accreditation system

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VRA – issues for providers

• SOPs (DH)• Clinical waste disposal• Infection control – processes and premises• Protective equipment• Needle stick protocol• Hepatitis B vaccination• Skill mix and competencies• Training – CPPE etc.

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VRA – issues for providers

• IT and data transfer• Risk engines• Service outcomes (PROMs)• Audit and review• Patient satisfaction assessment• Marketing

– Social marketing– Link to Essential services– Reduce your risk campaign / brand image

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Key reading

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Still to come from DH

• SOPs and guidance on thresholds• Read/SNOMED CT codes for Minimum data set • Diabetes element of VRA• Call and recall system • Guidance on risk engine• Marketing programme / Branding • PCT performance management• Guidance on monitoring of providers

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Pharmacy examples of VRA

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Islington PCT

• 11 pharmacies in deprived areas

• Launched August 2008

• Assessed 1000 patients within 6 weeks

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Birmingham PCTs – Heart MOT

• Opportunistic approach:– Nearly 900 patients screened– 49% referred to GP– 27% referred due to high CVD risk 82% male 18%

female– High level of uptake in deprived areas with low male

life expectancy

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Birmingham PCTs – Heart MOT• Mass screening events using GP records based call

system:– On average 70 to 80% attendance rate if appointment

confirmed by phone– Over 9,500 males over the age of 40 have been screened– 65% of patients were referred

• 30% identified with elevated BP• 35% identified with elevated cholesterol• 18% identified with elevated blood glucose• 36% identified as having a high CVD risk

– 99% satisfied with appointments, with the tests and the explanations given

– 98% would recommend the service to a friend– 75% had a wait of less than 30 minutes– 76% ‘plan to make changes’ as a result of the clinic

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Table discussion

a)Who are the competitors and what strengths and weaknesses do they have?

b) Why use community pharmacy? What are our strengths and weaknesses?

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Preparing the bidStep 1 - LPC decision to investigate the provision of a VRA service

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General guidance

• LPC Briefing – How to develop a successful service proposal

• Less need to sell the requirement for VRA as it is a national priority

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Step 1 - LPC decision to investigate the provision of a VRA service • General assessment:

– The ability of pharmacy contractors to effectively deliver the service

– The willingness of contractors to provide the service (template survey)

– The risk of non-participation in the VRA service– Potential or pre-existing competitors

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Step 2 - Identify and approach local stakeholders• Gathering information and garnering support

– LMC / GPs– Other healthcare professionals– Local patient groups– PCT staff:

• Director of Commissioning;• Director of Public Health;• Director of Primary Care;• Medical Director;• Pharmacy commissioning manager; and• Head of Pharmacy/Medicines Management

– Identify a PCT champion and the lead commissioner

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Step 2 - Identify and approach local stakeholders• Use an informal chat with the PCT to obtain

background information:– How much of a priority is VRA for the PCT? – Does VRA feature in the Pharmaceutical Needs

Assessment or the Joint Strategic Needs Assessment?– What are the locally agreed vital signs for your PCT – is

VRA or a linked vital sign mentioned?– How will the service be commissioned? Will it be an ‘any

willing provider’ approach?– Is there an agreed service specification available?– What are the main targets set for the service?– How will outcomes be measured?– What role do they see for pharmacy in the delivery of the

service?– What is the timetable for commissioning and roll out?

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Step 3 – Competitor assessment• Likely competitors:

– GP practices– Nurse led screening service providers, e.g. Innovex– NHS health trainers– Third sector (charitable) organisations, e.g. British

Heart Foundation– Mobile units run by occupational healthcare

providers– Health club/Gyms, e.g. Nuffield Health and Wellbeing

Centres (formerly Cannons Health Clubs)

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Step 4 – Meet the PCT

• Requires good preparation and presentation

• Agree your objectives before the meeting

• Opportunity to clarify issues

• Sell the benefits of pharmacy! (Access, choice, reducing health inequalities)

• Template PowerPoint presentation includes key points

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Step 5 - Local Service Specification

• NHS Primary Care Contracting Primary Care Framework • PSNC service specification• Other examples on services database• Customisation of service specifications to meet local

needs may include:– prioritisation of the targeting of certain population groups;– local social marketing provisions;– defining equipment standards; and– service monitoring requirements and criteria concerning

outcomes measures

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Step 6 - Generating local support

• If necessary, try to establish the reasons for non-inclusion of pharmacy contractors in the PCT plans

• Discuss the value of a pharmacy service with key individuals at the PCT (and PBC groups if active in your area), including the Chairman, CEO, Director of Public Health and PEC members

• Talk to the SHA• Brief local councillors / Local Authority health

overview and scrutiny committee on the pharmacy proposals

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Step 6 - Generating local support

• Brief the local MP on the proposals• Talk to the LMC and influential local GPs - discuss

interface issues, e.g. data transfer protocols and QOF issues

• Work with local patient groups and charities to raise the profile of pharmacy and VRA services

• Undertake an assessment of the public’s views on the best location for VRA using a questionnaire (template questionnaire)

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Step 7 – Obtaining local health data

• PCT websites• Annual report of the Director of Public Health• www.healthprofiles.info• www.neigbourhood.statistics.gov.uk• DH vascular checks toolkit for PCTs

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Step 8 - Preparing the bid• Use the local business case / plan template• Establishing the need based on local data and

PCT requirements– Pharmaceutical needs assessment– Wider service assessments– PCT and national targets– PCT underperformance– Patient demand

• Selling the benefits of pharmacy – providing solutions not problems– Use existing service examples and key selling points

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Elements of a successful business plan

A business plan should clearly identify:• The reasons for the service• Potential risks• Expected clinical outcomes• Improvement in patient care• Benefits for the commissioners

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Elements of a successful business plan

Detail to be included:• Contact details• Outline of proposed new service or

change• Target population or patient group

including numbers• Patient benefit/anticipated health gains• Evidence base for clinical effectiveness

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Elements of a successful business plan

• Patient support – consultation?• Stakeholder support – consultation?• Estimated cost implications• Estimated freed up resources and timescales• Links and impact on national or local

objectives• Clinical governance and quality

arrangements• Risk assessment

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Table discussion

Table 1- How do we engage with stakeholders and integrate the pharmacy service with GPs?

Table 2- How do we overcome commissioner objections?

Table 3 - How do we get and maintain contractor buy in?