The lessons learned Sam Rice May 2011

The ‘up and under’

‘To work in partnership to develop a systematic approach for primary prevention of diabetes and cardiovascular disease within workplace settings in Carmarthenshire’ Project Aim

Diabetes in Wales 3.2 million people With diagnosed diabetes: –Around 160,000 Prevalence of 5.0% Probably 65,000 with undiagnosed diabetes Probably 400,000 with IGR (x 2.5 the number with diabetes?)

Mortality in Carmarthenshire Carmarthenshire Deaths: N=2,267

Cardiovascular disease is the commonest cause of death in western countries Risk factors for developing diabetes and cardiovascular disease include: smoking lipid abnormalities impaired glucose regulation hypertension obesity The risk of developing cardiovascular disease can be predicted at least 10 years before symptoms occur long before Correcting the above risk factors can reduce risk of developing diabetes and cardiovascular disease Rationale for Prosiect Sir Gar

How Prosiect Sir Gâr supports the Chronic Conditions Management Framework The general population, for whom health promotion, primary prevention, early detection and assessment will maintain good health throughout life Prosiect Sir Gâr People with chronic conditions who can be optimally cared for in the community People with chronic conditions who are at high risk of residential care / hospitalisation People with chronic conditions and complex needs who frequently use hospitals

The Partnership Hywel Dda Health Board (Carmarthenshire Division) Tata Steelworks Primary care The Commercial Sector Public Health Wales The School of Medicine, Swansea University Carmarthenshire County Council The Voluntary Sector Project management approach

Why the workplace setting Working people are a “hard to reach” group The workplace environment has the potential of peer support Improving the health of the workforce increases work productivity Good employers are keen to improve workplace health standards: corporate awards

Risk Assessment Standard Operating Procedure Near Patient testing for Cholesterol and HbA1C QRISK2* General Practice Physical Activity Questionnaire Height Weight BMI Waist circumference Blood pressure Pulse Family history Smoking status

Data set from January 2011 NHS StaffTata Steel Workers Total number Mean age5048 Male19%98% Female81%2%

Data set from January 2011 NHS StaffTata Steel Workers BMI >3023%32% Chol:HDL ratio>64.6%21.2% BP >140 systolic15%14% HbA1c >6%3.5%7.8% Current smoker9.8%12.4% GPPAQ Active Moderately active Inactive Moderately inactive 16% 44% 4.0% 33% 62% 35% 0% 3%

Data set from January 2011 NHS StaffTata Steel Workers QRISK2 >20%0.9%6.7% QRISK %11.6%7.9%

Cardiovascular risk projection to age 60: Steelworkers

Diabetes risk projection to age 60: Steelworkers

Staff feedback 94% staff strongly agreed they were satisfied with the health check 93% strongly agreed to recommend the service to others ‘Convenient to have in the workplace’ ‘It was a wake up call, makes you take stock’ ‘It was reassuring to have the tests and to know what action was necessary to improve my fitness levels’ ‘Excellent view point on existing health condition. Worthwhile attending and now have a baseline for future monitoring’

Prosiect Sir Gar Lifestyle Intervention Service Structure RISK SRCEENING FOR CARDIOVASCULAR DISEASE AND TYPE 2 DIABETES INTERMRDIATE RISK OF CVD (10-20%) HIGH RISK OF CVD (≥20%) IMPAIRED GLUCOSE REGULATION OBESITY DIETETIC ASSESSMENT CLINIC ONE TO ONE INTENSIVE PHASE 8 SESSIONS GROUPS INTENSIVE PHASE 8 SESSIONS APRAISAL WITH DIETITIAN MAINTENANCE PHASE 4 SESSIONS (1 x month) MAINTENANCE PHASE 7 SESSIONS (1 x 6 weeks) TOTAL SESSIONS 13 OVER 1 YEAR TOTAL SESSIONS 16 OVER 1 YEAR

Project Income Provider: Total Shering-Plough (Swansea University) 16,667 Sanofi-Aventus (Swansea University) 48,000 Carmarthenshire LHB (Swansea University Fund) 16,000 Carmarthenshire County Council 3,000 Lilly 24,5608,18632,746 Pfizer 5,000 Diabetes Charitable Fund 10,000 Takeda 5,000 Tumble Surgery 115 Corus 40,000 Yearly income88,782 79,5608,186176,528

Next steps Secure longer term funding Adoption by the Health Board as a priority Assess the clinical and cost effectiveness of this approach

The Lifestyle Intervention Programme (Intensive Phase) Eight 75 minute sessions are delivered once weekly by a dietitian (7 sessions) and an exercise specialist (1 session) with an emphasis on education and motivation for behavioural change. Weight, BMI, waist circumference, and a health and lifestyle questionnaire score are collected at programme commencement and completion. Participant satisfaction is also captured. All employees have an appraisal (one to one session with dietitian) post intervention plus follow up every 4-6 weeks up to one year.

Results of the Pilot Phase To date, six 8-week programmes have been evaluated and 21 participants have completed. Fifteen participants demonstrated weight reduction post-LIP with mean BMI 35.2 ± 3.4 kg/m² pre-LIP and mean BMI 34.3 ± 3.3 kg/m² post-LIP, respectively. Among the fifteen participants mean percentage weight loss was 2.7 ± 2% post-LIP. Among these weight reducers, 2 participants had a raised waist circumference (WC) post-LIP however mean reduction in WC was 4.9 ± 3.2 cm.

Results continued: Sixteen participants completed the HLQ of which, 15 demonstrated improved scores. Observations from the post pilot phase at 3 months indicates ongoing weight loss in a cohort of 6 participants where data was taken from CVD risk screening, with a mean percentage weight loss of 6.5 ± 2.6%.

Economic Aspects Costs of the programme –Staff costs (direct and indirect); consumables; travel –Treatment costs; concerns about diagnosed conditions –Opportunity costs – loss of production; cover for absences Benefits of the programme –Years of life gained –Quality of life gained –Enhanced production –Enhanced corporate reputation

QOF Changes and New Indicators for 2009/10 Cardio Vascular Disease CVD – Primary Prevention (13 points) PP 1: In those patients with a new diagnosis of hypertension (excluding those with pre- existing CHD, diabetes, stroke and/or TIA) recorded between the preceding 1 April to 31 March: the percentage of patients who have had a face to face cardiovascular risk assessment at the outset of diagnosis using an agreed risk assessment treatment tool (8 points; thresholds 40 – 70%). For the purposes of QOF measurement, ‘at the outset of diagnosis’ is defined as within three months of the initial diagnosis. PP 2: The percentage of people diagnosed with hypertension diagnosed after 1 April 2009 who are given lifestyle advice in the last 15 months for: increasing physical activity, smoking cessation, safe alcohol consumption and healthy diet (5 points; thresholds 40 – 70%).