IT Systems to support the NHS Health Check

Introduction

In 2009, at the start of the NHS Health Check programme the Barnsley PRIMIS+ team was asked to write a validation programme to demonstrate that GP practices had carried out complete Health Checks. This was to support the Local Enhanced Service (LES).  We set out to create software which would support practices as they delivered Health Checks to the Barnsley population and at the same time to help the PCT ensure that the LES only paid for complete Checks.

There are two Barnsley Health Checks programmes, an Invitation programme and a Monitoring programme.  The programmes use Miquest queries to extract data from GP systems and the Miquest reports are automatically loaded into Excel programmes to produce lists of patients for practices to work on and a summary report. They have been run successfully on EMIS LV, EMIS PCS, EMIS Web, TPP SystmOne, Vision, hosted Vision, and iSoft systems. The programmes are run in GP practices although it is possible to run queries centrally on hosted systems with the necessary agreements.

Read codes

We have tried to collect all relevant Read codes, being aware that many alternatives exist and are in use. We have developed a Barnsley Health Check data entry template but are aware that different PCTs use different codes and we aim to be inclusive with the Miquest queries. Different pathology labs use alternative Read codes for blood results which are used for calculating CVD risk scores. The programmes have now been run in three PCTs and each time we have expanded the Read code set to include all variations. The data collected has evolved over the last three years to reflect changes in national guidance, most recently to incorporate Read codes necessary to support the national dataset, where these are available.

The Invitation Programme

The Summary shows practice population statistics including the size of the population eligible for NHS Health Checks and the numbers required to achieve the national roll out target. The Eligible group is those aged 40-74 as defined by the DH to the best of our understanding, given that we still await published Read codes.

The programme calculates an estimated CVD risk score for all eligible people, using information from the patient record where available and substituting estimated values for required fields where it is not available.

There are two lists of people who are eligible for a Health Check but have not had one in the past five years. One list shows people who have not had a CVD risk score in the past five years, the other list shows people who have (but have not had a Health Check code entered). Both lists are sorted so that people with the highest (estimated) CVD risk score are at the top.

The Miquest queries collect all Read coded invitations and these are shown for each patient so the lists can be used to manage second and third invitations, using drop down filters to produce priority lists.

There are sheets with additional patient lists showing people who are in the eligible population but excluded from the invitation lists:

• People aged 39 or 75 (on the cusp of being eligible)

• People excluded only because they are on statins

• People with a Health Check code recorded in the past five years

The Monitoring Programme

The scope of the Miquest queries is anyone who has had a Health Check / Vascular Check code in the past five years or a CVD risk score after the start of the year prior to the current year. The queries collect all relevant Health Check information about each individual, including all available Read codes that support the national dataset.

The Summary sheet shows:

• How many Invitations and Health Checks have been delivered in the reporting period. It reports all information required for Vital Signs / SQU27 reporting

• The number of CVD diagnoses made within six months of a Health Check

• Statin and anti-hypertensive prescribing

• Age/sex breakdown of those receiving a Health Check

• Age/sex breakdown of those with CVD risk score >=20%

• Ethnicity breakdown

• Deprivation quintile breakdown (requires a postcode look up table)

Other worksheets include lists of patients with:

• Complete Health Checks. A minimum of six items are required to have been completed after the Health Check code (or an earlier alternative) has been recorded or within a selected time period. This is similar to how the national data collection will work

• Incomplete Health Checks, showing the missing or out of date items. This is the sheet most used by practices

• People who have declined

• People who have not had complete diabetic screening, including follow up screening

• People with eGFR readings <45 without a CKD diagnosis (for further investigation if appropriate)

• People diagnosed CKD with eGFR readings >60

• People with raised cholesterol not on statins

• People with completed Health Checks but with abnormal blood pressure, blood sugar, eGFR or cholesterol who may require further investigation or diagnosis

Export spreadsheet

The Monitoring workbook contains a lot of patient information and remains in the practice, but as the programme runs it produces a two sheet export spreadsheet for the practice to email to the PCT. This contains the Summary sheet and anonymised information about people with completed checks, similar to the information which will be collected by the national reporting system. The PCT can use the summary information for LES payment and SQU 27 quarterly reporting.

Data Quality

The monitoring programme requires relevant data to be recorded within an appropriate time frame. Without this Checks are not counted as complete (and the practice does not get paid within the LES). It is surprising how many incomplete Health Checks are identified when the programme is run for the first time in a practice. This tends to be met with disbelief at first and then frequently leads to the discovery that different clinicians are doing the checks in different ways, using different templates, not completing the template etc. Practices frequently change protocols in the light of what they discover. This leads to patients receiving a more thorough and consistent Health Check and to more data being recorded to the patient record.

Performance Monitoring

Practices are required to send the export file to the PCT quarterly. It provides proof that the work has been done, with an Audit trail at the practice. All the practice emails are in the same format so they can be collated automatically into a PCT wide spreadsheet. This supports a LES management programme which allows commissioners to monitor quarterly practice performance. LES payment is linked to the amount of checks performed as a percentage of target and is calculated by the summarising programme. Practice payment is now objectively measured and proportionate.

Practice support

The Miquest queries and Excel spreadsheet are run in practices, mostly by practice staff but with PRIMIS+ training and support, with some practices requiring more support than others. The advantage of the Miquest queries is that all practice systems can be supported but a disadvantage is that they require a fair degree of IT literacy. This can be a problem in smaller practices. The queries and Excel programme need to be installed with an appropriate filing structure in each practice and this is a significant workload for an Information Facilitator to roll out across a PCT. Annual updates are required, which can be emailed to practices.

Achievement

44 out of 45 Barnsley GP practices participate in the NHS Health Check incentive scheme. By 30/6/2011 over half of the Barnsley eligible population had been invited for a NHS Health Check and 36% had received one. 85% of these were delivered to people who had not had a CVD risk score in the previous five years. The main ingredients for success have probably been:

• The Incentive scheme has been adequately financed.

• Performance has been objectively measured, incentive payment has been proportional to the number of Checks completed.

• Practices have been helped both to identify patients for invitation and by highlighting incomplete checks.

Summary

Barnsley is a spearhead authority with high levels of deprivation. The NHS Health Check gives us an opportunity to screen a large proportion of the population and these IT systems help GP practices to identify people who can benefit from primary prevention or diagnosis. Automating practice reporting allows commissioners to concentrate on managing practice performance and monitoring expenditure.

Philip Crabtree
Chris Grove
Julie Fenton
Part of the NHS Barnsley PRIMIS+ team