1. Haringey NHS Health Checks Care Pathway November 2014 Review date November 2015 Haringey NHS Health Checks Care Pathway November 2014 Review date November 2015

2. Programme Overview The NHS Health Check programme is a public health programme in England for people aged 40-74 which aims to keep people well for longer. It is a risk assessment and management programme to prevent or delay the onset of diabetes, heart and kidney disease and stroke.

3. Pathway Overview 1. Identification and invitation 2. Risk Assessment Including diabetes and hypertension filters 3. Risk communication 4. Risk management including lifestyle advice and referral 5. Data collection management and sharing 6. Recall

4. 1a. Identification and Invitation NHS Health checks are available for all individuals aged 40-74 years inclusive who have no pre-existing diagnosis/history of diabetes, heart disease, hypertension, atrial fibrillation, heart failure, familial hypercholesterolemia, chronic kidney disease, stroke, peripheral arterial disease or Transient Ischaemic Attack (TIA). There is a systematic call/recall system for health checks: low- risk individuals (10 year CVD risk <20%) are recalled every 5 years, high risk individuals (10 year CVD risk ≥20%) every year. General practices will be responsible for sending out invitation letters and make appointments for the health checks. DH guidance is that individuals should be invited for the check and invitation is the preferred method, however patients can be checked opportunistically. Please record invitations. Sample invitation letter templates are in the standard operating procedure.

5. 1b. Invitation Process It is possible to extract a list of patients who qualify for a NHS health Check on all Primary care clinical systems (Vision and EMIS web). Practices who are participating in the NHS Health Checks need to run an IT search extracting 40 to 74 year olds, excluding those on the relevant disease registers (CHD, Hypertension, Stroke/TIA, Diabetes, CKD and Familial Hypercholesterolemia etc.) and other diagnoses of any cardiovascular diseases and excluding patients who had a health check in the past (READ codes 38B1 or 8BAg) Practices should systematically record which individuals have been invited (READ codes 9mC0, 9mC1, 9mC2, 9mC3, 9mC4, 9m25) Practices are able to individually decide on the best method of invitation (e.g. phone, verbal, letter, SMS, combination of methods) as well as the order in which patients are invited (by age, alphabetically, by postcode or risk factors e.g. smokers) Practices should check their list on a regular basis to identify newly registered patients eligible for the NHS Health checks as well as patients entering the eligible age group

6. 2. Risk Assessment- Minimum Dataset ItemRequired dataComment ConsentInformed consent Name and addressInclude the postcodePostcode used by QRisk to adjust the risk score for deprivation AgeYearsShould be between 40 and 74 inclusive GenderM/FSelf reported Risk ScoreA figure between 1-100%Using Qrisk2 Framingham Family HistoryAny history of coronary heart disease or stroke in a first degree relative under 60 years old Any history of Diabetes Mellitus in a first degree relative Any family history of hypertension Any family History of Chronic Kidney disease First degree relative means father, mother, brother or sister Ethnicityusing ONS categories Smoking statusCurrent smoker, has quit within one year or non-smokerFramingham risk calculation defines smoking as Cigarette smoking or quit within the past year Otherwise (non smoker or quit over a year ago) QRISK defines smoking as: Smoker Non-smoker (incl ex-smoker) DietIntake of fruit and vegetables Diet Oily fish intake Dietary sodium Intake of fruit and vegetables: ≥ or < 5x/wk Diet: low in fat, average high saturated fats Oily fish intake: ≥ or < 2x/week Dietary sodium: low/average/high AlcoholAlcohol consumptionBased on Audit C screening tool Physical activityClassification according to GPPAQhttp://www.dh.gov.uk/en/Publicationsandstatistics/Publicati ons/PublicationsPolicyAndGuidance/DH_063812 Body mass IndexBMI= weight(kg)/ height (m) 2 Cholesterolmeasured in mmol/LRandom plasma cholesterol. If choelsterol has been checked within the past 6 months, this value can be used Blood pressureMeasured in mmHgUsing a validated, calibrated and well maintained blood pressure device. BP can be measured several times initially for an appropriate reading if deemed necessary

7. Individuals with an initial BP measurement of 140/90 or more will also require further blood pressure investigations, as described in NICE clinical guidance 127. Creatinine and blood sugar measurements should not be delayed while blood pressure investigations are being undertakenNICE clinical guidance 127 Individuals with an initial BP measurement of 140/90 or more will also require further blood pressure investigations, as described in NICE clinical guidance 127. Creatinine and blood sugar measurements should not be delayed while blood pressure investigations are being undertakenNICE clinical guidance 127 2a and 2b. Applying Diabetes & Hypertension Filters Is BMI >30 (>27.5 for South Asian or Chinese descent) YesNo Is the systolic BP ≥ 140 mmHg OR The diastolic BP ≥ 90mmHg Yes Test blood glucose and serum creatinine (to calculate eGFR) No Test blood glucose No further investigation for diabetes or hypertension

8. 2a Diabetes Screen All individuals with a BMI>30 (27.5 for individuals of South Asian or Chinese descent) or a BP ≥ 140/90 mmHg will need a fasting plasma blood glucose or an HbA1c/IFCC measurement. A fasting plasma glucose <6 mmol/L or a Hba1c < 6% (IFCC<42/mmol/mol) excludes diabetes and healthy lifestyle advice should be provided A plasma fasting glucose ≥ 7 mmol/L or a Hba1c ≥ 6.5% (IFCC ≥48 mmol/mol) in asymptomatic patients will require a second Hba1c test. A second Hba1c ≥ 6.5% (IFCC ≥48 mmol/mol) is diagnostic of diabetes. A second Hba1c ≥ 6% (IFCC ≥42 mmol/mol) and <6.5% (IFCC <48 mmol/mol) will require an OGTT. A plasma fasting glucose between 6-6.9 mmol/L or a Hba1c ≥ 6% (IFCC ≥42 mmol/mol) and <6.5% (IFCC <48 mmol/mol) will require dietary advice and a second HbA1c/IFCC after 3 months. If the Hba1c ≥ 6% (IFCC ≥42 mmol/mol) but <6.5%, then an OGGTT is required. Patients with a second Hba1c ≥ 6.5% (IFCC ≥48 mmol/mol) or FPG ≥7 mmol/L should be added to the diabetes register and managed accordingly. The OGTT will determine if the individual has diabetes or impaired glucose tolerance, and appropriate management should follow according to diabetes guidelines Patients with a fasting plasma glucose ≥ 7mmol/L or a HbA1c ≥6.5% (IFCC ≥48 mmol/mol) and symptoms of diabetes should be treated as newly diagnosed diabetics without the need for an OGTT If point of care testing is being used, a value of less than 5.5mmol/L is considered normal and healthy lifestyle advice should be dispensed. A value above 5.5mmol/L would require venous blood sample for laboratory testing.

9. Checking for Diabetes Risk

10. An eGFR calculator can be found at http://www.renal.org/eGFRcalc/http://www.renal.org/eGFRcalc/ NICE guidelines on chronic kidney disease can be found at http://www.nice.org.uk/CG73http://www.nice.org.uk/CG73 Individual with no prior history of hypertension or chronic kidney disease has blood pressure ≥ 140/90 mmHg Check patient’s creatinine Calculate estimated glomerular filtration rate (eGFR) from creatinine result If eGFR ≥ 60ml/min/1.73m 2 No further renal assessment is required If eGFR < 60ml/min/1.73m2 Management and assessment for chronic Kidney disease required inline with NICE clinical guideline 73 2b. Hypertension/Serum Creatinine Screen

11. 3. Risk Assessment and Communication QRISK2 risk calculator is the preferred risk calculator in Haringey. This should be available in GP IT systems e.g. EMIS web, Vision and ISoft Torex. Levels of risk, and what it means for individual should be clearly explained. Patients should be provided with a written copy of their results and their calculated CVD risk. Nice clinical guidelines 181 “Lipid modification: cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease” provide some pointers on communicating the risk of cardiovascular disease.“Lipid modification: cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease” The use of a risk engine to calculate the individuals’ risk of developing cardiovascular disease in the next ten years is required, and everyone who undergoes a NHS Health Check must have their cardiovascular risk score communicated to them.

12. 4. Risk Management-Lifestyle Every person receiving an NHS health check should receive individually tailored lifestyle advice, regardless of their risk of vascular disease. This should be delivered using a patient- centred approach such as motivational interviewing. A number of risk management and lifestyle interventions can support individuals to help manage their risk of developing vascular disease: 4a Smoking 4b Physical activity 4c Weight management 4d Alcohol 4e NHS Mid-life LifeCheck 4f Health trainers More information can be found in the healthy lifestyles information pack found on the CCG intranet.

13. 4a. Smoking All smoking cessation interventions should be delivered in accordance with NICE public health guidance on Brief interventions and referral for smoking cessation in primary careNICE public health guidance on Brief interventions and referral for smoking cessation in primary care Information on local smoking cessation services can be found on the Smokefreelife Haringey website: http://www.smokefreelifeharingey.co.ukSmokefreelife Haringey website http://www.smokefreelifeharingey.co.uk

14. 4b. Physical Activity –The physical activity status of all patients should be assessed using the General Practice Physical Activity Questionnaire (GPPAQ), a validated screening tool. GPPAQ can be found at: https://www.gov.uk/government/publications/general-practice-physical-activity-questionnaire-gppaq https://www.gov.uk/government/publications/general-practice-physical-activity-questionnaire-gppaq –The GPPAQ provides a simple, 4-level Physical Activity Index (PAI) categorizing patients as Active, Moderately Active, Moderately Inactive, and Inactive that is correlated to CVD risk. –It is used to help inform a practitioner of when a brief intervention to increase physical activity is appropriate. All patients who receive a score less than ‘Active’ should be offered a brief intervention supporting behavior change to increase physical activity. –When providing physical activity advice, primary care practitioners should take into account the individual’s needs, preferences and circumstances. –They should also provide written information about the benefits of activity and the local opportunities to be active. –Where appropriate, offer a referral into the ‘Active for Life’ physical activity on referral programme. –For those with a CVD risk of greater than 30% over ten years, GPPAQ should be completed annually. –Details on local physical activity programmes are detailed in the Healthy Lifestyle Information Resource Pack.

15. 4c. Weight Management ClassificationBMISuggested Action Healthy weight18.5-24.9 Healthy eating and physical activity advice Overweight25.0-29.9 General advice on losing weight, healthy eating and physical activity (DH - Why Weight Matters card); Offer follow-up appointment Obesity I30.0-34.9 Diet and physical activity Obesity II35.0-39.9 Diet and physical activity; consider drug treatment Obesity III>40.0 Diet and physical activity; consider drug treatment; consider surgery if BMI>50 or >45 with co-morbidities and all alternatives have been considered There are a number of opportunities for HARINGEY residents to participate in community based weight management programmes. These are detailed in the Healthy Lifestyle Information Resource Pack There are a number of opportunities for Haringey residents to participate in physical activity. These are detailed in the Healthy Lifestyle Information Resource Pack on the CCG intranet. The North Central London Adult obesity care pathway and resource pack advises on diet and physical activity interventions and referral to specialist services. Further details on weight management can be found in the NICE clinical guideline 43: Obesity: http://www.nice.org.uk/CG43http://www.nice.org.uk/CG43

16. 4d. Alcohol This pathway is based on AUDIT-C, a shortened alcohol screening questionnaire. Information on brief intervention for alcohol is available at: www.alcohollearningcentre.org.uk The full version of the alcohol screening tool can be found on the HAGA website: http://www.haga.co.uk/Tools.htm Ask 3 AUDIT-C questions using 2-sided Haringey Screening Tool. AUDIT Score 8 -15 AUDIT Score 16-19 AUDIT Score 20+ Congratulate and reinforce benefits of lower risk drinking. Deliver 5 mins Brief Advice using 2-sided Haringey Brief Advice Tool &/or book for 20-30 min follow-up session of Extended Brief Advice using 2- sided Extended Brief Advice Tool. Deliver 5 mins Brief Advice using 2-sided Haringey Brief Advice Tool. With patient consent, refer to Haringey Advisory Group on Alcohol for specialist assessment and a range of treatment options offered through HAGA, including community/ residential detoxification, counselling, one-to-one support, family work and access to structured aftercare. Refer via FAX with the completed AUDIT, individual’s contact details and proof of consent for referral to 0208 802 0081. Phone: 020 8800 6999 590 Seven Sisters Road, Tottenham, N15 6HR AUDIT Score 0-7 Where individual scores 5+, ask further 7 AUDIT screening questions using 2- sided Haringey Screening Tool. Where individual scores below 5, no further action required. Where individual requires further Brief Advice or Extended Brief Advice sessions (i.e. does not reduce their drinking), arrange up to 5 further sessions. Please note: most people require 1-3 sessions. Where 6 sessions do not result in reduced drinking, consider referral to HAGA or other options. Call HAGA for advice 020 8800 6999.

17. 4e. Health Trainers The NHS health trainers initiative is a local programme. Health trainers are drawn from the communities within which they work or are knowledgeable about the community. They support local people at a greater risk of poor health and are trained to use evidence based techniques to help people change behaviours known to cause ill health. (Smoking, alcohol, physical activity and weight management). Local health trainers can be contacted on 0208 3795269. More information can be found on the Haringey council website: http://www.haringey.gov.uk/healthtrainerservice and the Healthy Lifestyle Information Resource Pack http://www.haringey.gov.uk/healthtrainerserviceHealthy Lifestyle Information Resource Pack

18. 5. Risk Management- Medical When diabetes, hypercholesterolemia, chronic kidney disease or hypertension are newly diagnosed as a result of the NHS health check, relevant care pathways should be followed. The management of these conditions is outlined in individual care pathways and summarised in the following pages of this document. All care pathways are consistent with NHS Haringey approved care pathways and North Central London Cardiac and Stroke Network guidelines.

19. 5a. Lipid Modification A cholesterol test is compulsory for the NHS Health Check. Statins should be considered for primary prevention in people with a calculated CVD risk of ≥20%, using clinical judgment and alongside lifestyle changes, regardless of plasma cholesterol Initial therapy should be simvastatin 40mg daily. See Nice clinical guidance 181 for detailsNice clinical guidance 181 There is no target total cholesterol or LDL for primary prevention All persons with a total cholesterol >7.5mmol/L and/or LDL > 4.9mmol/L should be assessed for familial hypercholesterolaemia (FH) and statin therapy

20. 5b. Hypertension Management An initial BP≥ 140/90 should trigger a further BP measurement using ambulatory blood pressure monitoring or home blood pressure monitoring. If the average recorded blood pressure remains over 135/85 mmHg, it should be treated pharmacologically if the 10 year CVD risk is ≥20%, otherwise the relevant lifestyle advice should be given. If blood pressure is ≥ 160/100 mmHg, it should be treated pharmacologically regardless of the 10 year CVD risk An initial blood pressure ≥ 180/110 should be treated immediately Further details on the management of hypertension in primary care can be found in the NICE clinical guidance 127: http://guidance.nice.org.uk/CG127http://guidance.nice.org.uk/CG127

21. 5c. Chronic Kidney Disease P atients without diabetes and an eGFR <60ml/min/1.73 m 2 should have the result confirmed by a repeat test within 14 days and their albumin:creatinine ratio (ACR) or protein:creatinine ratio (PCR) tested Blood results (ml/min/1.73 m 2 ) eGFR 30-59eGFR<30 Confirmed by a repeat test within 14 days Urine results (mg/mmol) ACR<30 or PCR<50See NICE clinical guideline 182 for more detailsNICE clinical guideline 182 Consider referral for specialist opinion; See NICE clinical guideline 182 for more detailsNICE clinical guideline 182 ACR 30–69 or PCR 50–99 confirmed on early morning sample No haematuria Haematuria ACR ≥ 70 or PCR ≥ 100Consider referral for specialist opinion. See NICE clinical guideline 182 for more details NICE clinical guideline 182 The management for patients with diabetes differs. Details can be found in the NICE clinical guidance 73 NICE clinical guidance 73: Early identification and management of chronic kidney disease in adults in primary and secondary care can be found at http://www.nice.org.uk/guidance/cg182http://www.nice.org.uk/guidance/cg182

22. 6. Data Collection, Management and Sharing The Health Checks template should be used for data entry if Emis web template is not available. (this can be sent out on request). Interventions given and outcomes should be recorded. Appropriate clinical coding should be used. A register of people found to be at high risk of vascular disease should be kept (i.e. ≥20% risk over 10 years). The health check data must be returned to Haringey public health team on a monthly basis. Practices should record and report back on how many individuals have been invited. Data should be shared with Haringey Public Health for monitoring purposes as required (See the Standard Operating Procedure for more details).

23. 7. Recall Patients with a risk score ≥ 20% should be recalled annually. Patients with a risk score <20% should be recalled every 5 years. To recall patients, a search will need to be run to extract the recall dates attached to the read codes (38B1 or 8BAg) which were entered at the health checks consultation, then the patients can be invited on the relevant recall dates throughout the year. Practices should record when patients have been recalled. Practices are expected to individually decide on the best method of recall(e.g. phone, verbal, letter, combination of methods) Patients diagnosed with vascular disease (Diabetes mellitus, Chronic Kidney Disease, Cardiovascular disease or hypertension) following further investigations should be placed on the appropriate disease register and will not be eligible for further NHS Health Checks

24. 5 yearly invitation Risk assessment 10 CVD risk based on age, gender, smoking status, physical activity, alcohol family history, ethnicity, BMI, Blood pressure Individual Lifestyle Advice Tailored to risk* Further BP assessment Blood Sugar DIABETES REGISTER HYPERTENSION REGISTER CKD REGISTER HIGH RISK ANNUAL REVIEW BP ≥ 140/90 Fasting plasma glucose ≥ 7 or HbA1c ≥ 6.5% (IFCC ≥48) OGTT BP ≥ 160/100 BP ≥ 135/85 BMI >30 (or 27.5 in Asians) or BP ≥ 140/90 Regardless of risk Serum creatinine 2 hr glucose between 7.8 and 11: IGT BP ≥ 180/110 10y CVD risk ≥ 20% 10y CVD risk < 20% eGFR>60 10y CVD risk ≥ 20% : consider lipid modification therapy 10y CVD risk < 20% *Includes behaviour change tool, smoking cessation, weight management, alcohol, physical activity, IFG/IGT advice †diabetes pathway may be further changed 2hr glucose ≥ 11.1 eGFR<60 Haringey NHS Health checks: summary † Fasting plasma glucose < 6 or HbA1c < 6 % (IFCC<42) 6 ≤Fasting Plasma Glucose <7 or 6% ≤ HbA1c < 6.5% (42 ≤ IFCC<48) Further HbA1c (IFCC) symptomatic asymptomatic ≥6.5% (IFCC ≥48) 6≤HbA1c<6.5% (IFCC <48) HbA1c < 6 % (IFCC<42) Repeat Serum creatinine eGFR<60 eGFR>60