Special Report – NHS Health Checks by The Magazine Production Company

SPECIAL REPORT: PERMANENT CONTRACEPTION

Contents Permanent Foreword Contraception Life Course Approach to Contraceptive Choice:

John Hancock, Editor

Delivering Access for All Women

Mr Ali Kubba, Chairman International Affairs Committee, Faculty of Sexual and Reproductive Healthcare and Community Gynaecologist at Guy’s & St Thomas’ NHS Foundation Trust

Advertising Executives Michael McCarthy Abigail Coombes Production Manager Paul Davies For further information visit: www.globalbusinessmedia.org

Restrictions on Access to Contraceptive Choice Commitment to Access to Contraceptive Choice Across the Life Course Trends in Contraception for Older Age Groups Permanent Contraception – Adoption of the Latest Technology by NHS Conclusion

Why Birth Control?

SPECIAL REPORT: PERMANENT CONTRACEPTION

Contents

Camilla Slade, Staff Writer

The Best Contraceptive is One That is Used Reasons to Delay or Avoid Pregnancy Health Risks Age Related Summary

Foreword

NHS Health Checks Life Course Approach to Contraceptive Choice: Making the Right Choice

Peter Dunwell, Medical Correspondent

What is Contraception? Different Methods Pros and Cons Changing Live: Changing Priorities

John Hancock, Editor

Life Course Approach to Contraceptive Choice: Outcomes and Values 11 Access for All Women John Hancock, Delivering Editor

The opinions and views expressed in the editorial content in this publication are those of the authors alone and do not necessarily represent the views of any organisation with which they may be associated. Material in advertisements and promotional features may be considered to represent the views of the advertisers and promoters. The views and opinions expressed in this publication do not necessarily express the views of the Publishers or the Editor. While every care has been taken in the preparation of this publication, neither the Publishers nor the Editor are responsible for such opinions and views or for any inaccuracies in the articles.

© 2012. The entire contents of this publication are protected by copyright. Full details are Sponsored by All rights reserved. available from the Publishers. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical photocopying, recording or otherwise, without the prior permission of the copyright owner.

Human Benefits Avoiding Unintended Pregnancies Age Issues Health Issues Healthcare System Benefits

Why Birth Control?

Making the Right Choice Outcomes and Values 13

Getting to the Right Answer Camilla Slade, Staff Writer

Getting to the Right Answer Who Can Help Decide? What Works for Each Person? Wants and Needs Where to Go

References

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Delivering Access for All Women

Why Birth Control?

SPECIAL REPORT: NHS HEALTH CHECKS

SPECIAL REPORT:NHS HEALTH CHECKS

Contents

Camilla Slade, Staff Writer

The Best Contraceptive is One That is Used Reasons to Delay or Avoid Pregnancy Health Risks Age Related Summary

Foreword

NHS Health Checks Making the Right Choice

Peter Dunwell, Medical Correspondent

What is Contraception? Different Methods Pros and Cons Changing Live: Changing Priorities

Dr Robert Sykes, Editor

Alere Supports NHS Health Checks

Outcomes and Values

John Hancock, Editor

Implementing Near Patient Testing

Human Benefits Avoiding Unintended Pregnancies Age Issues Health Issues Healthcare System Benefits

Material in advertisements and promotional features may be considered to represent the views of the advertisers and promoters. The views and opinions expressed in this publication do not necessarily express the views of the Publishers or the Editor. While every care has been taken in the preparation of this publication, neither the Publishers nor the Editor are responsible for such opinions and views or for any inaccuracies in the articles.

Who Can Help Decide? What Works for Each Person? Wants and Needs Where to Go

Sponsored by

Contents

Camilla Slade, Staff Writer

The Best Contraceptive is One That is Used Reasons to Delay or Avoid Pregnancy Health Risks Age Related Summary

Mr Ali Kubba, Chairman International Affairs Committee, Faculty of Sexual and Reproductive Healthcare and Community Gynaecologist at Guy’s & St Thomas’ NHS Foundation Trust

The NHS Health Check: Focusing on Cardiovascular Risk

NHStoHealth Getting the RightCheck: Answer

It Just Makes Sense 13

Alere Supports NHS Health Checks

Jayne Lewis, Medical Writer with Special Interest in Point of Care

Camilla Slade, Staff Writer

The Health Check: Patchy Implementation or Great Start?

References

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Reaching the ‘Hard to Reach’ Engaging Social Media Making Every Contact Count Rapid Results for Rapid Diagnosis Many PCTs Are Not Yet Hitting Targets

Implementing Near Patient Testing Requirements of an NPT Device NPT can be Implemented Now

The NHS Health Check: Focusing on Cardiovascular Risk

Production Manager Paul Davies For further information visit: www.globalbusinessmedia.org The opinions and views expressed in the editorial content in this publication are those of the authors alone and do not necessarily represent the views of any organisation with which they may be associated. Material in advertisements and promotional features may be considered to represent the views of the advertisers and promoters. The views and opinions expressed in this publication do not necessarily express the views of the Publishers or the Editor. While every care has been taken in the preparation of this publication, neither the Publishers nor the Editor are responsible for such opinions and views or for any inaccuracies in the articles.

Foreword

Starting an NPT Service

Editor Dr Robert Sykes

Advertising Executives Michael McCarthy Abigail Coombes

Dr Robert Sykes, Editor

Business Development Director Marie-Anne Brooks

Senior Project Manager Steve Banks

Contents

The Bigger Picture

Susan Thomas, Medical Correspondent

Dr Robert Sykes, Editor

Basic Data The Key Data

Alere Supports NHS Health Checks

NHS Health Check: It Just Makes Sense

Implementing Near Patient Testing

John Bushnell, Staff Writer

Risk Management and Lifestyle Interventions

The NHS Health Check: Focusing Supporting Individuals on Cardiovascular Risk Not in the Check but Essential

The Health Check:Check: It Just Makes NHS Health Patchy Implementation or Great Start?

Sense

Jayne Lewis, Medical Writer with Special Interest in Point of Care

The Health Check: Patchy Implementation or Great Start?

Dr Robert Sykes, Editor

Aspirations versus Reality Strong Criticism Is the Future Brighter? Improving Access

References

Alere Supports NHS Health Checks

Published by Global Business Media

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Reaching the ‘Hard to Reach’ Engaging Social Media Making Every Contact Count Rapid Results for Rapid Diagnosis The Bigger Picture Many PCTs Are Not Yet Hitting Targets

Implementing Near Patient Testing Dr Robert Sykes, Editor

Requirements of an NPT Device Starting an NPT Service

Business Development Director Marie-Anne Brooks

NPT can be Implemented Now

Editor Dr Robert Sykes

The NHS Health Check: Focusing on Cardiovascular Risk

Susan Thomas, Medical Correspondent

Basic Data The Key Data

NHS Health Check: It Just Makes Sense

John Bushnell, Staff Writer

Risk Management and Lifestyle Interventions Not in the Check but Essential Supporting Individuals

The Health Check: Patchy Implementation or Great Start?

Dr Robert Sykes, Editor

Aspirations versus Reality Strong Criticism Is the Future Brighter?

Improving Access

References 17

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SPECIAL REPORT: NHS HEALTH CHECKS

Foreword T

he NHS has undergone a great deal of change

In the second of our articles, Jayne Lewis, Medical

since its inception in 1948, and the monolith

Writer with Special Interest in Point of Care testing

now casts a massive shadow over the organization

(POCT), writes on behalf of Alere and explores

originally founded by Aneurin Bevan all that

some of the challenges faced by clinicians and

time ago. Most notably, the NHS was originally

commissioners surrounding the NHS Health

established in an era when we sought to cure our

Checks programme, and suggests how the use of

patients, and where health outcomes were clear

point of care diagnostics can help improve success.

cut. We then got very good at treating disease,

Subsequently, and for those whose interest is piqued,

and in increasing life expectancy, resulting in

we review the current guidance relevant to the

the well documented shift from cure to care

successful implementation of POCT.

medicine. Unfortunately, improving secondary

Over the following two articles, the actual meat

prevention produced little improvement in health

of the health check is outlined: what it is, and what

inequalities, and has led to chronic conditions

we can use it for. As the second of these articles

coming to the fore.

clearly intimates, it really does just make sense to

By 2008 the government sought to move us away

do it. However, the continued poor levels of uptake

from this care paradigm, right back to primary

are shocking given the potential benefits such a

prevention. In the two key documents covered in

programme can offer, and the final discussion piece

this report, “Healthy Lives, Healthy People” and

outlines the current poor state of play. This Report

“Putting Prevention First” we see these ideas very

hopes to inform the reader about the health check,

much brought to life in government policy striving

and offers simple, signposting guidance to either

to put public health, and disease prevention, at the

get you started on the path to implementation or to

top of the medical agenda. By April 2013, many of

improve your existing services.

the recommendations of these guidelines are due for full implementation1, and this presents an important challenge for primary care trusts in England.

Robert Sykes Editor

Dr Robert Sykes qualified with a degree in medicine (MBChB Honours) in 2004 from the University of Liverpool where he was awarded the George Holt Medal for high academic achievement, along with commendations for a number of his clinical reviews. As a postgraduate he entered into a GP vocational training scheme before opting to work in a portfolio career, and in 2008, he set up Northern Editing (www.docrob.co.uk/nothernediting) for medical writing and editing. Currently, he is also the Executive Editor for the UK’s only peer support organisation for doctors with mental illness, the Doctors’ Support Network (registered charity 1103741; www.dsn.org.uk).

2 | www.primarycarereports.co.uk

SPECIAL REPORT: NHS HEALTH CHECKS

Alere Supports NHS Health Checks Jayne Lewis, Medical Writer with Special Interest in Point of Care Alere explores some of the challenges for clinicians and commissioners surrounding the NHS Health Checks programme and suggests how the use of point of care diagnostics can help improve success.

Helping you hit your NHS Health Check targets

Afinion™ AS100 Laboratory quality lipids and HbA1c on the same analyser.

• HbA1c • TC/HDL • ACR • CRP

Alere Cholestech LDX®

ince January 2008, when it first announced its intention to shift the focus of the NHS towards empowering patients and preventing illness, the Government has continued to put health and wellness at the top of the healthcare agenda. Its ‘prevention is better than cure’ approach acknowledges the critical need to reduce the increasing burden of preventable disease and its impact on individuals, society and healthcare resources. By keeping more people healthy for longer, the Government hopes to save lives, improve morbidity, address health inequalities and reduce costs. These commitments were reiterated in the 2010 White Paper; “Healthy lives, Healthy people: our strategy for public health in England” which sets out “a bold vision to make wellness central to all we do – in health and across government”. “The vision for an improved public health system is focused on tackling health inequalities and the causes of ill health, helping all the people in England to enjoy longer, healthier lives”. Reducing cardiovascular disease (CVD) – coronary heart disease, stroke, diabetes and

kidney disease – is a major priority. Affecting the lives of more than 4 million people and killing 17,000 every year, CVD is the biggest cause of death in the UK. It also contributes significantly to health inequalities, accounting for more than half of the mortality gap between rich and poor.1 The recent Impact Diabetes2 report projected that NHS spending on diabetes alone will increase from £9.8 billion to £16.9 billion over the next 25 years, a rise that means it would be spending 17% of its entire budget on the condition. Against this backdrop it is clear why the Government’s first national ‘predict and prevent’ initiative is specifically aimed at reducing CVD. First announced in 2008, the NHS Health Checks Scheme (initially known as Vascular Checks), is now mandatory (2012/13) and is directly targeted at the sector of the population most at risk from CVD. Everyone in the country, not already diagnosed with CVD, aged 40 – 74 years should have a Health Check every 5 years. Basic biometric information and lifestyle questionnaires are used to calculate cardiovascular risk and a consultation with a trained health worker provides the perfect forum to discuss lifestyle issues that

Used in over 70 PCTs at more than 2,000 UK sites.

• TC/HDL • ALT/AST • hsCRP

Contact our dedicated Customer Care Team to find out how Alere can help you hit your targets. Tel: 0161 483 5884 Email: ukcustomer@alere.com alere.co.uk © 2012 Alere. All rights reserved. All trademarks referenced are trademarks of their respective owners. REF046 - CLIN - 17/10/12 - NA 1

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SPECIAL REPORT: NHS HEALTH CHECKS

It is the ‘hard to reach’ sections of the population that not only represent the greatest challenge in terms of attendance but also represent the biggest opportunity to use Health Checks to help address health inequalities.

could improve the quality of life and reduce the risk of a developing debilitating disease. Whilst the checks occasionally identify people that need urgent intervention, in the majority of cases the real value of the consultation lies in the opportunity to make people aware of their personal risk and to encourage them to take responsibility for improving their own health. Signposting people to healthy lifestyle schemes such as smoking cessation, weight management, alcohol awareness, healthy eating and activity programmes provide much-needed support to improve the chances of making lasting changes.

Reaching the ‘Hard to Reach’ Whilst people who regularly visit their GP surgery are likely to readily accept the invitation for a health check, it is the ‘hard to reach’ sections of the population that not only represent the greatest challenge in terms of attendance but also represent the biggest opportunity to use Health Checks to help address health inequalities. As the Health Checks Lead at Shropshire County PCT explained; “This is a group of people that represents a major challenge for us; they are not prepared to travel or wait for appointments and are unlikely to re-visit for results or follow up. We therefore recognized that a Health Check needed to fit in with their lifestyle and, with word of mouth being essential for the success of any health awareness campaign, it was crucial that they had a positive experience. On this basis, a ‘one stop shop’ approach, where people could access all of the information they need in a single visit, was identified as our preferred model.” Throughout the country, a range of delivery models has been adopted to ensure easy access and maximum engagement from the target group. Many PCTs have explored ways of taking testing into the community, working with pharmacies, pathology laboratories, outreach groups, charities and third party providers. From health buses that visit popular venues to ‘walkin’ clinics in supermarket car parks, the broad range of case studies detailed on the Alere web site (www.alere.co.uk) shows that innovation and flexibility are key to making the scheme accessible to as many people as possible.

Engaging Social Media However, providing easy access to testing is only half of the battle, and making people aware of the service and encouraging them to come for testing is often an uphill struggle. The starting point for inviting people to attend a Heath Check is usually a personalized letter to patients on the PCT database, but if someone isn’t registered, they can’t be contacted directly. Promotional campaigns including posters, flyers and local advertising vary enormously depending on 4 | www.primarycarereports.co.uk

the services on offer and PCTs need to look for innovative ways to increase participation. Social media is increasingly proving its worth in generating awareness, interest and participation and NHS Shropshire is one of the more pioneering PCTs successfully using YouTube, Facebook and Twitter to help meet its targets.

Making Every Contact Count The Health Check also provides a perfect opportunity to discuss wider health issues, as recommended by the Department of Health’s ‘Make Every Contact Count’ (MECC) campaign, which encourages all NHS workers to “use every opportunity to promote health and wellbeing.” NHS employees are being encouraged to develop the knowledge, skills and confidence they need to support patients in making healthier life choices – a strategy that fits closely with the Health Checks scheme. By enabling a range of diagnostic tests to be performed whilst the patient is having their consultation and providing immediate results, point of care testing also plays a key role in both Health Checks and MECC. On-the-spot testing eliminates the need for repeat visits, which is more convenient for the patient and more efficient for the health provider. It also supports immediate interventions and signposting, significantly increasing the level of engagement and minimising the risk of attendees being ‘lost to follow up’ – a particular problem with ‘hard to reach’ groups.

Rapid Results for Rapid Diagnosis Whilst point of care testing offers immediate advantages in terms of patient engagement and convenience, it is only of real value if health providers can treat and manage the patients on the basis of the results. Screening tests that require a referral to the laboratory for confirmation simply add further steps into the patient pathway and increase the chances of the patient failing to return to discuss the results. This was a key finding at NHS Cambridgeshire, where an initial evaluation of Health Checks highlighted concerns that some patients have missed their follow up as they were “reluctant to turn up for a second visit.” As a result of the findings, a ‘one stop’ approach utilizing near patient testing was recommended by participating GPs to minimize loss to follow up. Alere, one of the world’s leading diagnostic companies, specialises in point of care testing and its extensive range of lab-accurate products delivers rapid, reliable results for diagnosis and monitoring. Its scope is not limited to a role in CVD risk assessment, with easy to use devices and tests that play a key role in the diagnosis and management of heart disease

SPECIAL REPORT: NHS HEALTH CHECKS

A Patient self-testing using the Alere INRatio 2 PT/INR Monitor – The Alere INRatio 2 combines reliable ®

results with practical convenience, making it an optimal solution for anticoagulation management

Helping you hit your NHS Health Check targets

which are widely used in Health Checks for cholesterol, lipid profiles and HbA1c, is well documented. Their high quality results and ease of use have proved hugely beneficial in community or clinic situations. Alere provides extensive after sales support including on-site

Afinion™ AS100 Laboratory quality lipids and HbA1c on the same analyser.

• HbA1c • TC/HDL • ACR • CRP

The Alere Triage® MeterPro is a multiparameter analyser, combining sophisticated technology with user-friendly ergonomics, to deliver highperformance testing at the point of care. It offers the largest immunoassay menu available in a POC platform, including BNP, NTproBNP,

Alere Cholestech LDX®

D-dimer, Cardiac markers, NGAL and toxicology

(BNP/NTproBNP ), diabetes (HbA1c), kidney disease (ACR/NGAL), venous thromboembolism (D-Dimer), anticoagulation monitoring (INR) and COPD (blood gases). Alere’s expansive range of point of care devices also includes products for sexual health, infectious diseases and women’s health and toxicology. The robust devices are small, portable and designed for use wherever the patient is, thereby ensuring minimal inconvenience for the patient and clinician. Innovative connectivity solutions are also available to ensure rapid and accurate exchange of data.

Afinion™ AS100 Analyser – designed to enable accurate and fast on-the-spot testing and deliver accurate results during patient consultations for improved patient management.

• TC/HDL

Tests available include HbA1c, Lipids, ACR and CRP

• ALT/AST • hsCRP

Contact our dedicated Customer Care Team to find out how Alere can help you hit your targets.

The Bigger Picture Health Checks don’t exist in a silo but are part of the ‘bigger picture’ of preventative healthcare provision. The accessibility, range and performance of Alere’s point of care tests mean that the company can play an important role in the wider prevention agenda, helping health practitioners to monitor the progress of patients as they make lifestyle changes. The excellent performance of the Alere Cholestech LDX® and Afinion™AS100 analysers,

Used in over 70 PCTs at more than 2,000 UK sites.

Alere Cholestech LDX® – used in over 70 PCTs at more than 2,000 UK sites, the Alere Cholestech LDX® offers rapid and economical point of care for lipids, ALT/AST and hsCRP

training, standard operating procedures (SOPs), 24/7 technical support, quality assurance and a wealth of experience to reassure and support health workers delivering checks. The company

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SPECIAL REPORT: NHS HEALTH CHECKS

The Government estimates that the Health Checks programme could, each year, prevent 1,600 heart attacks, prevent 4,000 people from developing

Patient receiving a Health Check using the Alere Cholestech LDX®

diabetes, detect at

also has a number of high quality partners that can provide additional services, allowing delivery of a complete Health Checks service when other resources are unavailable.

least 20,000 cases

Many PCTs Are Not Yet Hitting Targets

of diabetes or kidney disease earlier and save at least 650 lives.

6 | www.primarycarereports.co.uk

Whilst NHS Health Checks are now mandatory, it is clear from the latest figures that many areas are failing to reach the national targets of seeing 20% of their cohort every year. Department of Health data covering the period April 2011 to March 2012 (published May 2012)3 show that of the 15.8 million people eligible for a Health Check, only 2.2 million (13.9%) were offered one. This is significantly below the 20% annual target. Of these only 1.1 million received an assessment, an uptake rate of around 50%, with large variations in numbers of offered and received checks around the country. Many PCTs have not yet implemented the scheme and some health providers have raised questions about the relatively small number of individuals in their area that will benefit from the service by making significant lifestyle changes. However, Health Checks is a national scheme and even small changes (4 -5%) at the population level can make a very significant impact. The Government estimates that the Health Checks programme could, each year, prevent 1,600 heart attacks, prevent 4,000 people from developing diabetes, detect at least 20,000 cases of diabetes or kidney disease earlier and save at least 650 lives.1 Healthy Lives, Healthy People proposes that local authorities, supported by a new integrated public health service, will “drive delivery of improved outcomes in health and wellbeing”, and the responsibility for providing NHS Health Checks is likely to gradually transition to Local Authorities by April 2013.

Looking ahead, the NHS Health Check is a national performance measure in the Operating Framework for the NHS for next year. This will provide an essential lever to boost activity and to position the programme strongly as it moves over to Local Authorities. The NHS Health Check programme is one of only two specific public health functions contained within the NHS Operating Framework which articulates the expectation that public health is prioritised by PCTs. Alere is well placed to help commissioners and providers to develop and implement effective Health Checks programmes and support the ongoing management of the risks identified.

References 1. NHS Information Centre for Health and Social Reform. www.ic.nhs.uk 2. H ex, N Bartlett, C Wright, D Taylor, M Varley, D. (2012). Estimating the current and future costs of Type 1 and Type 2 diabetes in the United Kingdom, including direct health costs and indirect societal and productivity costs (York Health Economics Consortium Ltd, University of York, United Kingdom). 3. D epartment of Health: Unify2 data collection – IPMR_1

Contact Details Alere Limited Pepper Road Hazel Grove Stockport Cheshire, SK7 5BW 0161 483 5884 Tel 0161 483 5778 Fax ukcustomer@alere.com www.alere.co.uk

SPECIAL REPORT: NHS HEALTH CHECKS

Implementing Near Patient Testing Dr Robert Sykes, Editor

he use of Near Patient Testing (NPT), also known as POCT, is something that all of us will be familiar with to some degree or another. NPT is any analytical test performed for an individual outside the laboratory setting. From the ubiquitous urine dipstick and blood glucose monitor, to bench top analysers, we are presented with NPT devices on an almost daily basis. The reasons for this are obvious: good NPT is convenient for the patient and for healthcare professionals alike. They can reduce the need for excessive follow up and travel, and rapid results improve the likelihood of immediate diagnosis and therefore treatment, without the concerns of patients being lost to follow up. Indeed, these ideas are very much at the heart of the governments reforms in “Healthy Lives, Healthy People1” to make consultations more patient centred and convenient3, and, therefore, to make every contact count (MECC)4. This move was further supported in January 2012 when the Future Forums 5 stated that “... healthcare professionals in England now need to do a lot more to question patients about their lifestyle… at every meeting” broadly supported by the BMA6. The 2008 “next steps” document7 for vascular health checks first proposed the inclusion of NPT as a valid way of implementing these new requirements to front line NHS practice, requiring that a lot more be achieved in fewer consultations. The use of NPT, of course, has distinct advantages in this area: results and lifestyle advice can be provided for a person in one appointment, potentially increasing the uptake and motivation to make meaningful lifestyle changes. NPT will continue to be an essential component of these encounters, and will play an important role in the NHS health check2. In this article we look at some of the

Table 1: Identifying a need – questions to consider8,9 •W hich group(s) of patients need testing and what test(s) need to be performed?

Helping you hit your NHS Health Check targets

•H ow is the service currently provided, and does it adequately meet the clinical need?

Afinion™ AS100

• I f clinical need has not been met, what has been done to try to rectify the problem?

Laboratory quality lipids and HbA1c on the same analyser.

• I s access to a laboratory service difficult for patients with conditions requiring frequent monitoring? Has this been discussed with the laboratory?

• HbA1c • TC/HDL

•W ill POCT enable more rapid/effective diagnosis or treatment?

• ACR • CRP

•C an you provide evidence that POCT will provide a measurable clinical and economic benefit? •W ill POCT provide a cost-effective alterative to laboratory testing?

Alere Cholestech LDX® Used in over 70 PCTs at more than 2,000 UK sites.

practical considerations that need to be made when implementing NPT.

Requirements of an NPT Device The Medical Devices Agency (MDA) has published guidelines establishing the key factors related to the implementation of NPT (detailed in Tables 1 & 2)8,9. Furthermore, the Department of Health’s (DoH) guidance for primary care trusts (PCTs) provides advice for PCTs using, or planning to use, NPT to support their NHS Health Check programme2,7, offering a host of useful information under the sections on NPT. The requirement for NPT technology to be properly evaluated before being put into routine use and for operators to be aware that results may not be interchangeable with laboratory results, is also stressed

• TC/HDL • ALT/AST • hsCRP

Calculated from 2011 Department of Health Data

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SPECIAL REPORT: NHS HEALTH CHECKS

The use of NPT, of course, has distinct advantages in this area: results and lifestyle

throughout the documents. The Medicines and Healthcare Regulatory Agency (MHRA) also provide a range of useful documents on NPT, specifically urine dipstick, blood glucose and cholesterol NPT, that are available for reference10,11,12.

Table 2: What equipment will meet your needs – questions to consider8,9 • What is the expected workload? • Who is going to use the equipment?

advice can be provided for a person in one appointment, potentially increasing the uptake and motivation to

•W hat level of analytical accuracy and imprecision is required for the service? •W here will the equipment and consumables be sited? •D o you have adequate space in which to carry out POCT? •A re appropriate services available e.g. power, water, refrigeration? •H as the equipment been evaluated by an external professional organisation e.g. MDA? •A re the results comparable to those of the local hospital pathology laboratory? • What are the limitations of the equipment?

make meaningful

•W ill the POCT service work with existing data handling systems and IT infrastructure?

lifestyle changes.

•H ave Health and Safety issues been considered e.g. safe disposal of clinical waste and sharps?

Starting an NPT Service The use of NPT looks like it is here to stay, and over the last decade, guidelines have been published, first in 2002/38 and then in 20109, by the MHRA. These guidelines offer essential advice and guidance on the management, use and implementation of NPT as a new service. The major change between the 2002/3 and 2010 documents was the paragraph “POCT may be performed... in the community

8 | www.primarycarereports.co.uk

and primary care. POCT must be performed by staff whose training and competence has been established and recorded. The reason for this is to protect the patient, and ensure the quality of the service is appropriate to the clinical setting. This is applicable to all providers of POCT services”. The other key points made are: •A clinical need must be identified for a POCT service. •Y ou should consider involving the local hospital laboratory. • There should be clear lines of accountability. •C linical governance requires POCT service managers must be aware of their responsibilities. •A dverse incidents must be reported to the MHRA. •C lear, comprehensive record keeping/ documentation is vital. •A rrangements for training, management, quality assurance and quality control (QC), and standard operating procedures must be made, and reviewed periodically. Finally, the United Kingdom Accreditation Service (UKAS) accredits organisations which provide point of care testing against ISO 22870: 200613 applied in conjunction with ISO 15189: 201214. This accreditation is an important element in establishing and maintaining confidence in any NPT service.

NPT can be Implemented Now In terms of the NHS health check, the clinical need for POCT has clearly been identified at a national level by Government, and has been encouraged in the various documents referenced throughout this text. The DoH, MDA, UKAS and MHRA have established clear guidance on its safe implementation. Clearly, everyone involved in NPT should know what to do in the event of any abnormal result or unsatisfactory QC result, or have easy access to that knowledge. Also, close collaboration with a local hospital can be a very useful tool to help ensure the accuracy

SPECIAL REPORT: NHS HEALTH CHECKS

Table 3 – Top Ten Tips: Point Of Care Testing15 • I nvolve your local hospital laboratory: Your local hospital pathology laboratory can play a supportive role in providing advice on a range of issues including the purchase of devices, training, interpretation of results, troubleshooting, quality control, and health and safety. •M anagement: Many people will be involved in the creation, implementation and management of a POCT service. It is vital that an appropriate POCT coordinator is identified and a POCT committee established. •H ealth and safety: Be aware of the potential hazards associated with the handling and disposal of body fluids, sharps and waste reagents outside of a laboratory setting. • Training: Training must be provided for staff who use POCT devices. Only staff whose training and competence has been established and recorded should be permitted to carry out POCT.

“POCT may be performed ... in the community and primary care. POCT must be performed by staff whose training and competence has been established and recorded.

Afinion™ AS100 Laboratory quality lipids and HbA1c on the same analyser.

The reason for this is to

• HbA1c

protect the patient, and

• TC/HDL • ACR

•A lways read the instructions!... and be particularly aware of situations when the device should not be used.

ensure the quality of the

•S tandard operating procedures (SOPs): SOPs must include the manufacturer’s instructions for use.

service is appropriate to

•A ssuring quality: The analysis of quality control (QC) material can provide assurance that the system is working correctly.

Helping you hit your NHS Health Check targets

• CRP

Alere Cholestech LDX®

the clinical setting. This is

Used in over 70 PCTs at more than 2,000 UK sites.

applicable to all providers • TC/HDL

of the service, and to maintain clear lines of accountability. A complementary document “Top Ten Tips (for) Point Of Care Testing” provides a summary list of the key needs for good NPT15, and they are summarized in table 3. When implementing the NHS Health Checks, the use of NPT offers a highly efficient way forward.

• ALT/AST

of POCT services.”

• hsCRP

Calculated from 2011 Department of Health Data

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SPECIAL REPORT: NHS HEALTH CHECKS

The NHS Health Check: Focusing on Cardiovascular Risk Susan Thomas, Medical Correspondent

Broadly speaking, the NHS health check is a vascular risk assessment that breaks down risk using these validated tools in order to identify targets for both primary and secondary prevention and intervention, specifically in the areas of CVD, hypertensive, diabetic and chronic kidney disease (CKD) risk.

10 | www.primarycarereports.co.uk

isk assessment in cardiovascular disease (CVD) has been a massive area of study over the last 60 years. The Framingham Heart Study16 for example published 2,346 studies between 1950 and 201117 alone. It is not surprising then, that the risk assessment stage of the NHS Health Check 2 uses the Framingham tool, taking its lead from the National Institute for Health and Clinical Excellence (NICE), which recommended that it be used to calculate risk in its lipid modification guidance18. Recently, an alternative tool called QRISK219,20, has been developed requiring additional data 21. Although there are differences between the two, the health check uses both. Broadly speaking, the NHS health check is a vascular risk assessment2 that breaks down risk using these validated tools in order to identify targets for both primary and secondary prevention and intervention, specifically in the areas of CVD, hypertensive, diabetic and chronic kidney disease (CKD) risk. Here we outline the main data that is collected when determining vascular risk and that is used to stimulate prevention. A

diagrammatic overview of the program can be seen in [see Figure 1 on page 4 of â&#x20AC;&#x201C; http://bit.ly/aqb9MW]3 and is the reference point.

Basic Data Age, gender, ethnicity, Family History, and smoking history are all self-reported requirements of the Framingham and QRISK2 scores. The age requirement spans 40 to 74 years whilst gender is recorded as male or female. Ethnicity is important for both the tools, and where possible should be recorded using standard categories22. QRISK2 additionally records a family history of coronary heart disease in a first-degree relative under 60 years. Smoking status is needed too, and presents a perfect opportunity to offer health advice and support. Therefore, any smoker who wants to quit should be offered either very brief advice23 or a referral for the support of an NHS Stop Smoking Service24.

The Key Data Assessments of Body Mass Index (BMI), cholesterol, and blood pressure (BP), together

SPECIAL REPORT: NHS HEALTH CHECKS

Helping you hit your NHS Health Check targets

Afinion™ AS100 Laboratory quality lipids and HbA1c on

It is acknowledged

the same analyser.

that implementation

• HbA1c • TC/HDL • ACR

of the health check

• CRP

may therefore identify with blood glucose testing, and kidney function (estimated glomerular filtration rate; eGFR) are all necessary. These are each assessed individually, but further investigation may also be triggered by each other. Assessing a patients BMI is essential and is used, in part, to identify those at high risk of developing diabetes, or who may have existing undiagnosed diabetes (figure 1)2. A blood glucose check is needed where the individual is in the obese range for their ethnic group. However, the assessment of diabetic risk is the most complicated component of the health check. Although random tests are still used, they are too heavily influenced by food and the guidance advises against their use. Neverthe-less, near patient testing (NPT) may have a limited role in identifying or rationalising those in need of further testing12, particularly where lab facilities are limited or the patient refuses. Either fasting blood glucose or an HbA1c are the preferred route to definitive diagnosis2 [see Figure 2 on page 20 of – http://bit.ly/aqb9MW]. There is no specific threshold for cholesterol levels in the health check2, although the two risk tools require it17,20. The guidance is however

Alere Cholestech LDX®

people with previously

Used in over 70 PCTs at more than 2,000 UK sites.

unidentified but • TC/HDL

established disease,

• ALT/AST • hsCRP

although it is hoped that they will benefit from that early diagnosis and treatment.

Calculated from 2011 Department of Health Data

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Near patient testing

(NPT) may have a limited

role in identifying or

rationalising those in

need of further testing,

particularly where lab

facilities are limited or

the patient refuses.

12 | www.primarycarereports.co.uk

clear, that if an individualâ&#x20AC;&#x2122;s total cholesterol is >7.5 mmol/l you should consider familial hypercholesterolemia25. A random cholesterol test is considered acceptable in order to maximise take-up2 which opens up the possibility for NPT13,26. However, before lipid modification therapy is offered, a fasting cholesterol test would be needed3,12. In contrast, the assessments of BP and CKD use clearly defined parameters. If either the systolic or diastolic BP exceeds 140mmHg or 90mmHg respectively, the individual requires further assessment with fasting plasma glucose or HbA1c and an assessment for CKD27,28. CKD itself is primarily monitored through serum creatinine, which is then used to calculate the estimated glomerular filtration rate (eGFR), and therefore kidney function. A threshold eGFR level of 60ml/min/1.73m 2 is used in line with national guidance29, and active management should be stimulated when it falls below this level.

The risk engines often require additional information to support decisions on appropriate lifestyle interventions. Framingham, for example, requires that any previous diagnosis of left ventricular hypertrophy or diabetes is recorded; whilst the QRISK2 requires the Townsend deprivation score and specific past medical history (treated hypertension, rheumatoid arthritis, CKD, atrial fibrillation or diabetes). It is acknowledged that implementation of the health check may therefore identify people with previously unidentified but established disease, although it is hoped that they will benefit from that early diagnosis and treatment. In potentially short consultations, the health check can work its way through the QRISK2 and Framingham tools to highlight patients that may benefit from either primary or secondary prevention. Furthermore, it can highlight previously unmet need, resulting in intervention and a reduction in the long term consequences of that risk.

SPECIAL REPORT: NHS HEALTH CHECKS

NHS Health Check: It Just Makes Sense John Bushnell, Staff Writer

he health check programme is of course not just about collecting data on risk; it is a preventative programme intended to help people stay healthier for longer. The check requires that everyone entering it, regardless of their risk score, be given appropriate lifestyle advice to help them manage and reduce their risk 2. This just makes sense, since we have a captive audience and clearly evidenced interventions. By encouraging patients to engage at these opportunities, the government hopes that General Practice can be at the forefront of implementing a massive health and wellbeing push1,2,3. Therefore, unless clinically unsafe to do so, everyone having the check should be provided with individually tailored advice on risk and risk management to help motivate them and support the necessary lifestyle changes that may be required2.

Risk Management and Lifestyle Interventions The best practice guidance for the health check recommends using a simple behavior modification tool as a focus for discussions. The preferred “change tool” is the “NHS Life Check31”, an online health assessment tool that requires baseline data on age, gender, height, weight and alcohol consumption. It offers an interactive, user-friendly interface that presents detailed feedback and offers ideas, information and support for lifestyle change. NICE also provides some useful pointers on how advice can be effectively delivered in terms of cardiovascular risk18, and other examples of best practice are available at the NHS Improvement website (www.improvement.nhs.uk). The key areas that you should cover at each opportunity are as follows. Smoking Advice: Anyone who is a smoker and wants to quit should be offered the support of a local NHS Stop Smoking Service24. As detailed elsewhere, the DoH advocates very brief advice23 (Table 4). Physical Activity: NICE advocate the GP Physical Activity Questionnaire (GPPAQ) based on validated correlations between inactivity and CVD risk32. The 2006 NICE physical

activity guidance recommends that primary care practitioners should take the opportunity, whenever possible, to identify inactive adults and advise them to aim for 30 minutes of moderate activity on five days of the week (or more), and to offer adults who are less than active a Brief Intervention in Physical Activity (Table 4)33. A brief intervention is usually all that is required, although supervised sessions should be considered via an exercise referral or a condition-specific exercise programme if there is additional risk34.

Helping you hit your NHS Health Check targets

Afinion™ AS100 Laboratory quality lipids and HbA1c on the same analyser.

Table 4: Brief Intervention Approach

• HbA1c

Smoking cessation

• ACR

Brief advice consists of:

• CRP

• TC/HDL

• recording smoking status • advising of the health benefits of stopping • acting on the patient’s response. Physical Activity

Alere Cholestech LDX®

If the GPPAQ32 identifies individuals as less than active, brief intervention33 in physical activity should:

Used in over 70 PCTs at more than 2,000 UK sites.

•C onsider the individual’s needs, preferences and circumstances

• TC/HDL

• Offer specific targets and goals

• ALT/AST

•P rovide written information about the benefits of activity together with any local opportunities to be active (a specific leaflet may facilitate this) •C onsider referral to a condition-specific or exercise referral programme34, if available. •O ffer follow up at appropriate intervals over a 3-6 month period. Alcohol Use The aim of the brief intervention38 is to increase a patients understanding of:

• hsCRP

Contact our dedicated Customer Care Team to find out how Alere can help you hit your targets.

• Alcohol units

Tel: 0161 483 5884 Email: ukcustomer@alere.com alere.co.uk

•C onsumption risk levels and knowing where they sit on the risk scale.

The benefit of cutting down (and tips for doing so).

REF046 - CLIN - 17/10/12 - NA 1

Calculated from 2011 Department of Health Data

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SPECIAL REPORT: NHS HEALTH CHECKS

The best practice guidance for the health check recommends using a simple behavior modification tool as a focus for discussions. Weight Management: Preventing and managing weight gain is complex. However, NICE has well established guidelines on this issue35, and when it presents as a significant risk factor, advice and onward referral is mandated. Where the individual’s weight status is not a risk factor though, this does not mean that the issue can be neglected. It is for example, an opportunity to reinforce the benefits of being physically active and of eating healthily. With the latter, it has been reported that this is an ideal opportunity to challenge commonly cited barriers to dietary change, such as healthy eating being more expensive36. When providing advice around weight management or referring individuals on to more sustained interventions, it will be important to take a personalised approach (looking at how ready the person is to commit to change, their life stage as well as cultural factors), and develop local pathways to ensure targeted intervention is available. A specific DH tool kit exists to help PCTs and local authorities “plan, coordinate and implement comprehensive strategies to prevent and manage overweight and obesity37.”

Not in the Check but Essential Cholesterol: This usually arises as part of any discussion of appropriate diet. The health check itself does not specifically review cholesterol management, and unless a patient is diagnosed with either diabetes, hypertension or CKD, those with elevated cholesterol should continue to be included in the programme. However, intervention should still exist in line with other lifestyle modifiers according to local and national policies. The specific reduction measures taken (lifestyle or

14 | www.primarycarereports.co.uk

medication) will of course depend on the overall risk score of the individual. If the 10-year risk is 20% or greater, statin therapy should be offered following NICE guidance18. Alcohol Use: Also not a specific requirement of the health check, an individual’s alcohol intake could be considered both independently (highlighting links between alcohol intake and liver disease) and as part of any discussion about energy intake (obesity). It is also mentioned specifically in the NICE guidance on lifestyle interventions in hypertension27,28. It is advised that practitioners deliver brief alcohol advice in primary care38, similar to that offered with activity and smoking cessation (Table 4). Although the current recommendations of 3-4 units/day for men and 2-3 units/day for women are recommended, someone identified to have problem drinking, or to be experiencing difficulty in stopping, should be considered for referral to specialist services using locally agreed pathways39.

Supporting Individuals Supporting individuals to help them manage their risk of developing CVD is a critical part of the health check programme. Consequently, PCTs need to consider how to commission individually tailored lifestyle advice for everyone having a check, regardless of their risk. Encouraging the necessary behavioural change is a complex and unique process to an individual patient. Clearer discussion and agreement of goals and specific changes will help patients make more progress, and can be achieved with brief intervention strategies (table 4), and the “NHS Life Check31”. We know that these tools can help; it now makes sense to implement them wholeheartedly.

SPECIAL REPORT: NHS HEALTH CHECKS

The Health Check: Patchy Implementation or Great Start? Dr Robert Sykes, Editor

he past few years have seen the government increasingly strive to move healthcare toward a more patient centered approach whilst focusing increasingly on prevention. The April 2008 document on putting prevention first40 was heralded as one such step on the path to that realisation. Subsequently, make every contact count4 (MECC) and “Healthy Lives, Healthy People1” have strengthened this focus. In recognition of the difficulties inherent to such goals, the Marmot Review (2010) identified that “while on the whole we are living longer than ever before, people’s health and wellbeing varies significantly across England … and that there is a social gradient of health – the lower a person’s social position, the worse his or her health”41. Unfortunately, it already appears that the uptake of the health check may indeed be reduced in socially deprived areas42. From April 2013, PCTs must implement the health check in a minimum of 20% of their eligible population per year1, although it seems increasingly unlikely that this will happen. If health checks are not implemented, it represents more than a failure to implement the latest government dictate, but the deeper failure by us all to close these health inequalities.

Aspirations versus Reality The September 2010 update for the health check reported what it considered positive results43 following the first year’s full implementation of the NHS health check. At this stage, early data for 2009/10 indicated that around 1 million people were offered an NHS Health Check with nearly 800,000 checks being delivered. This data was an estimate based on a 70% take up rate that several SHAs had indicated to be the average achieved in their areas. The statistical returns for 2011/12 were not much better, although since the first year’s data were estimated, it is probably unwise to draw any strong comparisons44. Nevertheless, the data published in February 2012 for quarter 3 revealed that a mere 1.5 million offers were

sent out, with only 760,000 NHS Health Checks actually being performed. The end of year data was just as poor, showing that of the 15.8 million potential candidates, only around 2.2 million were offered the check with around 1.1 million actually receiving it, meaning that only 13.9% of eligible people received it45. Uptake amongst trusts is remarkably variable too, with some managing to get this figure close to 37%, whilst others languish on zero percent45. Although the Department of Health feels that significant progress has been made, it is clear that we still have a long way to go to meet its now mandated target of 20% universally.

Helping you hit your NHS Health Check targets

Afinion™ AS100 Laboratory quality lipids and HbA1c on the same analyser.

• HbA1c • TC/HDL • ACR • CRP

Strong Criticism So, things are not all rosy with the NHS health check, and there is growing criticism. According to the report ‘Let’s Get it Right’ by Diabetes UK46, “thousands of people with type 2 diabetes (T2D) in England are missing out on being diagnosed because of the failure to properly implement the NHS Health Check programme.” A key component of the health check programme was to detect people with T2D and to identify those at high risk. Diabetes UK states that it is disappointed that so far, this potential has not been realised, noting that implementation of the programme has been poor and patchy at best47. Furthermore Barbara Young, Chief Executive of Diabetes UK, has attacked the lack of progress considering that T2D is a condition that costs the NHS over £10 billion a year, but where 80 per cent of those costs are spent on complications that are potentially avoidable48. She outlines that a key aspect of tackling the rise in T2D and its devastating and costly complications, is to bridge the gap between the anticipated prevalence and those actually diagnosed, suggesting that this may be as many as 850,000. Indeed, the 2011/12 data for the health check found that several PCTs failed to offer a single person an NHS Health Check, that two thirds (64%) failed to provide enough checks to meet the programmes 20% target mark (for percentage of eligible people

Alere Cholestech LDX® Used in over 70 PCTs at more than 2,000 UK sites.

• TC/HDL • ALT/AST • hsCRP

Calculated from 2011 Department of Health Data

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SPECIAL REPORT: NHS HEALTH CHECKS

According to the report ‘Let’s Get it Right’ by Diabetes UK, “thousands of people with type 2 diabetes (T2D) in England are missing out on being diagnosed because of the failure to properly implement the NHS Health Check programme.”

16 | www.primarycarereports.co.uk

receiving an NHS Health Check) and that no single Strategic Health Authority (SHA) reached that level overall45. Further still, according to 118 trusts responding to a request under the Freedom of Information Act, a fifth (21%) admitted they will fail mandatory DoH targets for 2012/13 despite being given three years to prepare49. Although some of these people will be caught in other programmes or routine consultations, and their health needs may be met there, it is obvious that a significant opportunity is being missed. The move to shift responsibility for commissioning the programme to local authorities by April 20131 could further impact the future sustainability of the programme and worsen, not improve its implementation48.

Is the Future Brighter? Overall, it appears that the current state of play with the NHS health check is poor. Worse still, significant postcode lotteries exist between areas of England as the full programme of checks gets under way. Three PCTs did not provide a single check in 2011/12, with another providing just four, demonstrating just how stark this is. Equally, the forecast for full implementation by April 2013 looks poor. Indeed, the Government’s own data suggest that between 2010/11 and 2011/12 patient uptake fell by around 6%43,45. However, for 2012/13 the NHS Health Check became a national performance measure with the aim that this would boost activity and position the programme strongly as it moves over to Local Authorities in April 201344. This means much greater scrutiny of plans for NHS Health Checks submitted by PCTs, with only the most credible plans being signed off. Although this offers promise, it fails to tackle the central issue that we currently face. Considering that trusts have not taken up the programme so far, and with health budgets under increasing pressure, there is no guarantee that government

targets will be met, or that the existing health inequalities will be bridged. The time is now for trusts to turn their attention to full implementation of the NHS health check. Until this happens, “making every contact count”, “Healthy Lives, Healthy People” and other similar phrases, will be consigned to a long list of meaningless slogans.

Improving Access The way forward for improving inequalities may lie in improving access. A common failing of the system is often that the service is ‘one size fits all’. Developing tailored options for customer access could make a considerable impact on inequalities in access and outcomes . Indeed, it is increasingly being suggested that deficiencies in access are due to the accessibility of the service and system, and are not patient related51,52. Primary care is in a unique position to be more innovative in the way it tackles these inequalities. NPT/POCT as detailed in this report is one such way, as are the brief interventions that can be applied in the context of a detailed consultation (table 4). Equally, working with the local authority and Local Strategic Partnerships, implementing collaborations with the voluntary sector53, and even the private sector where health checks in retail environments have proved successful54, may all be required. Finally, it has been suggested52 that the Quality and Outcomes Framework and the health checks themselves lead to a degree of positive discrimination with a privileging of treatment to people with certain conditions. It is crucial to remain vigilant to these potential threats to equality, and to focus on universally improving the outcomes of patients at each and every encounter, through whatever opportunities are available [see Figure on page 1 of – http://bit.ly/RUTVDW]50. It is not simply about sticking to the letter of the policy as outlined in this Report, but rather the spirit of it.

SPECIAL REPORT: NHS HEALTH CHECKS

References: 1

H M Government. “Healthy Lives, Healthy People: Our strategy to public health in England”. 30th November 2010. Available: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_127424.pdf)

Department of Health. “Putting Prevention First: The NHS Health Check. Vascular Risk Assessment and Management. Best Practice Guidance.” 3rd April 2009. Available: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_098410.pdf

Department of Health. “Equity and Excellence – Liberating the NHS”. 12th July 2010. Available: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_117353

M Murfin, E Varley. “An Implementation Guide and Toolkit for Making Every Contact Count.” East Midlands Health Trainer Hub. Available: http://learning.nhslocal.nhs.uk/sites/default/files/mecc_booklet.pdf

NHS Future Forums. “NHS Future Forum. Summary Report: Second Stage.” January 2012. Available: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_132085.pdf

Helen Mooney. “Doctors are told to “make every contact count” to reduce costs of poor lifestyles.” BMJ 2012;344:e319. (Published 10 January 2012). Available: http://www.bmj.com/content/344/bmj.e319

Department of Health. “Next Steps’ Guidance for Primary Care Trusts.” 13 November 2008 (www.dh.gov.uk/vascularchecks, Gateway reference 10729). Available: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_090278.pdf

Medicines and Healthcare products Regulatory Agency (MHRA). “Device Bulletin:Management and Use of IVD Point of Care Test Devices.” DB2010(02) February 2010. Available: http://www.mhra.gov.uk/home/groups/dts-bi/documents/publication/con071105.pdf

Medical Devices Agency (MDA). “Device Bulletin: Management and Use of IVD Point of Care Test Devices.” DB(NI)2002/03 June 2002. Available: http://www.dhsspsni.gov.uk/hea-db(ni)2002-03.pdf

Medicines and Healthcare products Regulatory Agency. Point of Care Testing leaflet – Urine Dipsticks. 2010. Available: http://www.mhra.gov.uk/Publications/Postersandleaflets/CON2023434

Medicines and Healthcare products Regulatory Agency. Point of Care Testing leaflet – Blood Glucose Meters. August 2010. Available: http://www.mhra.gov.uk/Publications/Postersandleaflets/CON2015499

Medicines and Healthcare products Regulatory Agency. Point of Care Testing leaflet – Cholesterol Testing. 2011. Available: http://www.mhra.gov.uk/Publications/Postersandleaflets/CON2015501 Point of Care Testing – particular requirements for quality and competence. 2010. Available: http://www.nliah.com/portal/microsites/Uploads/Resources/iL82WywvC.pdf ISO. Medical Laboratories – particular requirements for quality and competence. 2012. Available: http://www.iso.org/iso/catalogue_detail.htm?csnumber=56115 Medicines and Healthcare products Regulatory Agency. Top Ten Tips (for) Point Of Care Testing. December 2005. Available: http://www.mhra.gov.uk/home/groups/dts-bi/documents/publication/con008384.pdf

Framingham Heart Study. http://www.framinghamheartstudy.org/index.html

Framingham Heart Study (Bibliography). Available: http://www.framinghamheartstudy.org/biblio/index.html

National Institute for Clinical Excellence. “Lipid modification: Cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease”. NICE clinical guideline 67. May 2008. Available: http://www.nice.org.uk/CG067

Hippisley-Cox et al. “Predicting cardiovascular risk in England and Wales: prospective derivation and validation of QRISK2.” BMJ 2008;336:a332 doi:10.1136/bmj.39609.449676.25. QRISK. Available: http://www.qrisk.org/BMJ-QRISK2.pdf

Hippisley-Cox et al. “Derivation and validation of QRISK, a new cardiovascular disease risk score for the United Kingdom: prospective open cohort study.” doi:10.1136/bmj.39261.471806.55 BMJ ONLINE FIRST. July 2007. Available: http://www.qrisk.org/BMJ-QRISK1.pdf

QRISK. Available: http://www.qresearch.org/SitePages/qriskInformationforClinicians.aspx

A practical guide to ethnic monitoring in the NHS and social care. DH/Health and Social Care Information Centre/NHS Employers. 29 July 2005. Gateway reference: 5227. Available: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/ DH_4116839

Smokefree Resource Centre. “Very brief advice (AAA) guide (7000CU).” January 2009. Available: http://smokefree.nhs.uk/resources/resources/ product-list/detail.php?code=1353118458

National Institute for Clinical Excellence. “Brief interventions and referral for smoking cessation in primary care and other settings.” NICE Public Health Intervention Guidance 1. March 2006. Available: www.nice.org.uk/PHI001

National Institute for Clinical Excellence. “Identification and management of familial hypercholesterolaemia.” NICE clinical guideline 71. August 2008. Available: http://www.nice.org.uk/nicemedia/pdf/CG071FullGuideline.pdf

Medical Devices Agency. “Management and Use of IVD Point of Care Test Devices.” Device Bulletin 2002(03). March 2002. Available: http://www.mhra.gov.uk/Publications/Safetyguidance/DeviceBulletins/CON071082

National Institute for Clinical Excellence. “Hypertension: management of hypertension in adults in primary care. NICE clinical guideline CG34: quick reference guide. June 2006. Available: http://www.nice.org.uk/nicemedia/pdf/cg034quickrefguide.pdf

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National Institute for Clinical Excellence. “Hypertension: Management of hypertension in adults in primary care.” NICE clinical guideline 34. June 2006. Available: http://www.nice.org.uk/CG034

National Institute for Clinical Excellence. “Chronic kidney disease: National clinical guideline for early identification and management in adults in primary and secondary care.” NICE clinical guideline 73. 24 September 2008. Available: http://www.nice.org.uk/Guidance/CG73/Guidance/pdf/English

Health and deprivation: inequalities and the north. Townsend, P, Phillimore, P and Beattie, A. Croom Helm, 1988. [ISBN 0-7099-4352-0]

Department of Health. “Developing the NHS Life Chek”. DH/HIPD/SM&HRB/NHS LifeCheck. 26 Nov 2008. Available: http://www.nhs.uk/aboutNHSChoices/professionals/life-checkers/about-us/Documents/nhs-lifecheck-evidence-base-final.pdf. The lifecheck can be found at: http://www.nhs.uk/Tools/Pages/Lifecheck.aspx

Department of Health. “General Practice Physical Activity Questionnaire.” 4th Dec 2006. Available: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_063812

NICE Public Health Intervention Guidance PHI002. “Four commonly used methods to increase physical activity: brief interventions in primary care, exercise referral schemes, pedometers and community-based exercise programmes for walking and cycling”. March 2006. Available: www.nice.org.uk/PHI002

Department of Health. “DH Statement on Exercise Referral”. DH. March 2007. Available: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_072689

National Institute of Clinical Excellence. “Obesity: guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children.” NICE guideline CG43. December 2006. Available: www.nice.org.uk/nicemedia/pdf/CG43NICEGuideline.pdf

RCGP News. “A healthy diet can cost less than junk food says new research.” 15 December 2011. Available: http://www.rcgp.org.uk/news/2011/december/a-healthy-diet-can-cost-less-than-junk-food-says-new-research.aspx

National Heart Forum et al. “Healthy Weight, Healthy Lives: A toolkit for developing local strategies”. October 2008. Available: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_088967.pdf

Alcohol Learning Centre. “Alcohol Identification and Brief Advice e-Learning course.”. Available: http://www.alcohollearningcentre.org.uk/eLearning/IBA/

NHS. “Primary Care Service Framework: Alcohol Services in Primary Care.” NHS. May 2008. www.pcc.nhs.uk/204.php

Department Of Health. “Putting Prevention First: Vascular Chesk: Risk assessment and management”. April 2008. Available: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_083823.pdf

Marmot, M. (2010) Fair Society, Healthy Lives: Strategic Review of Health Inequalities in England post 2010, www.marmotreview.org

Dalton et al. “Uptake of the NHS Health Checks programme in a deprived, culturally diverse setting: cross-sectional study.” J Public Health (2011) doi: 10.1093/pubmed/fdr034. First published online: May 5, 2011. Available: http://jpubhealth.oxfordjournals.org/content/early/2011/05/04/pubmed.fdr034.full

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Department of Health Update (online edition). March 2012. Available: http://www.nhshealthcheck.nhs.uk/default.aspx?iID=4&aID=24&st=statistics

Department of Health. “NHS Health Checks Q4 2011-12.” available as XLS document: http://www.dh.gov.uk/en/Publicationsandstatistics/Statistics/Performancedataandstatistics/Integratedperfomancemeasuresmonitoring/DH_129481

Diabetes UK. “THE NHS HEALT H CHECK PROGRAMME: LET’S GET IT RIGHT.” September 2012. Available:http://www.diabetes.org.uk/Documents/Reports/nhs-health-check-lets-get-it-right-0912.pdf

Wan, Y. “Diabetes UK report finds poor and patchy implementation of NHS Health Check programme.” 20th September 2012. NeLM news service http:// www.nelm.nhs.uk/en/NeLM-Area/News/2012---September/20/Diabetes-UK-report-finds-poor-and-patchy-implementation-of-NHS-Health-Check-programme/?id=773695

Young, B. “Reports and statistics. The NHS Health Check Programme – Let’s Get It Right (Sept 12).” Online Comment by Diabetes UK. Available:http://www.diabetes.org.uk/Professionals/Publications-reports-and-resources/Reports-statistics-and-case-studies/Reports/The-NHS-Health-Check-Programme--Lets-Get-It-Right-Sept-12/

Robinson, S. “Exclusive: PCTs missing health check targets.” 15 August 2012. Available: http://www.gponline.com/News/article/1144897

Department of Health, National Support Teams. “Customer access strategies: developing targeted services to increase accessibility.” 5th March 2010. Available: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_115104.pdf

Dixon-Woods, M. et al. Vulnerable Groups and Access to Healthcare: a critical interpretive review. Report from the National Co-ordinating Centre for NHS Service Delivery and Organisation R & D (NCCSDO, London)

Baker, M. “Strategic Review of Health Inequalities in England Post 2010 (Marmot Review): An RCGP paper on the role of primary care in the reduction of health Inequalities.” Royal College Of General Practitioners. 7th September 2009. Available: http://www.rcgp.org.uk/policy/rcgp-policy-areas/~/media/Files/Policy/A-Z%20policy/Sept%2008%20Marmot%20Review%20Paper%20_-%20for%20web%20gkm.ashx

Ali, A et al. “Addressing Health Inequalities: A guide for general practitioners.” Royal College of General Practitioners. 2008. http://www.rcgp.org.uk/policy/rcgp-policy-areas/~/media/Files/Policy/A-Z%20policy/Health%20Inequalities%20Text%20FINAL.ashx

Dachsel, M. “Opportunistic Health Checks in a Retail Environment .” London Journal of Primary Care. 14 April 2011. Available: http://www.selondon.nhs.uk/documents/3260.pdf

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