NHS Islington - A local perspective in primary prevention of cardiovascular disease and diabetes 21 st July 2010 Ian Sandford Public Health Strategist

Background General Practice ◄ 2007 Annual Public Health Report Reducing early deaths from CVD in Islington  Tackling risk factors for CVD  Improving disease registers and quality indicators Putting Prevention First 2008 ► National vascular risk assessment programme for all adults without CVD or diabetes

Islington in Context Eighth most deprived borough in England and fourth most deprived in London 94% of Islington’s 118 LSOAs ( 2 / 3 total population) fall into England’s 20% most deprived LSOAs Stark polarisation in wealth — rich and poor live side-by-side

92% of Islington’s population fall into two of 15 groups: –People renting flats in high- density social housing (46%) –Well-educated city dwellers (46%) No clear geographical pattern to distribution of types Lower income and higher income postcodes side-by-side Unclassified postcodes in the south of Islington – new builds, businesses Distribution of Mosaic™ types in Islington by postcode

NHS Health Checks in GP practices Qrisk2 chosen because of high social deprivation and ethnically diverse community Disappointing experience with third-party risk stratification software Qrisk2 integrated to EMIS – 37/38 Islington practices Qrisk2 estimated for all patients aged with no CVD or diabetes in 37/38 practices

Process in GP practices (1) LES described the NHS Health Check process Facilitators visited all practices to: –Run the QRisk2 batch process from within EMIS –Provide each practice with a list of eligible patients –Extract anonymous data for PCT (for baseline and modelling) Simple practice searches used to identify number of NHS Health Checks done for NHS London –Practices reporting low numbers were visited in February 2010 –In depth data extracted from practices reporting high numbers

Process in GP practices (2) Problems with data –Recording of checks in general practice –Read code used 9OhA (cardiovascular risk assessment done) not exclusive to NHS Health Checks Solutions –Facilitators extracted data from practices (ongoing) –Data analysis NHS Health Checks done but not coded Cardiovascular risk assessments done (but not NHS Health Checks) Quality of data recording: lifestyle etc. Outcomes: diagnoses, prescribing Outputs: 6,800 checks completed in General Practice

Outcomes: Hypertension Hypertension register increased by 0.3% pre-NHS Health Checks LES, and by 1.4% during 1 st year of LES

Outcomes: Diabetes Diabetes register increased by 0.7% pre-NHS Health Checks LES, and by 4.7% during 1 st year of LES

Modelling interventions 8% estimated to be at high risk (≥20%) 17% estimated to be at medium risk (10% to 19%) 75% estimated to be at low risk (1% to 9%)

Outside of General Practice Pharmacy pilot in 2008/09 – 600 NHS Health Checks in most deprived areas –Paper based system – transcription errors, unwieldy –Training issues –Quality assurance But: –Appreciated by patients –Evidence of some case finding

Pharmacy programme 2010/11 PCT purchased 10 computer systems (Telehealth’s Cardiopod), majority of all data transfer is electronic Advised by Clinical Biochemist: Changed POCT device, introduced mandatory EQA Worked with the Royal Free Hampstead NHS Health Trust to train pharmacists – accredited CPD Go Live July 2010

Community NHS Health Checks PCT tendered for a community provider to provide 1,500 checks in the community Awarded to “Health Smart” Re-working of the patient pathway for the diabetes assessment (can’t ask patients to return for fasting glucose in the community) Investigated use of HbA1c with expert clinical support – agreed as solution Go live at Pro-Active festival 19 th June Planned sites around housing estates (Homes for Islington and Circle 33 Housing Association) and various one-off events

Conclusion A mixed approach to primary and secondary prevention Targeted according to need in GP Practice (estimated QRisk2 score) Pharmacies with extended opening located in areas of greatest deprivation targeting patients who find it difficult to access GP Community provision for those who find it difficult to access health care and unregistered population Demonstrated outcomes in terms of case-finding

Questions Contact: Ian Sandford Public health Strategist NHS Islington