Pharmaceutical Services Negotiating Committee (PSNC)
[pic]
Service Specification for Check it Out 2
(Vascular Screening Assessment via Community pharmacy)
Pilot project September 2010
Contents:
1. Purpose of this Service Specification
2. Scope of Service to be provided
3. Background; Cardiovascular Disease (CVD) and its prevention
4. Aims and Objectives
5. Target population
6. Service model
7. Patient Pathway including follow up
8. Workforce requirements
9. Values and principles
10. Integrated Governance
11. Equipment specification
12. Professional competency, education and training
13. Patient, Public and Staff Safety
14. Information management
15. Clinical audit and review
16. Patient and Public Involvement and partnership working
17. Equality and Human Rights
18. Managing complaints
19. Quality and performance
20. Funding and volume of activity
21. Financial details
1. Purpose of this Service Specification
The purpose is
• to equip commissioners, pharmacy team members and practitioners with the necessary background knowledge, service and implementation details to safely deliver a targeted, high quality, vascular checks service in primary care and the wider community setting.
• to improve the health and quality of life for people aged 40-74 by providing patient-centred, systematic vascular risk assessment.
The Service to be provided will be underpinned by the values and principles detailed in the following documents:
• Putting Prevention First (DOH, March 2008)
• The Handbook for Vascular Risk Assessment, Risk Reduction and Risk Management (UK National Screening Committee, March 2008)
2. Scope of Service to be provided
This service is open to targeted men and women aged 40-74 years of age.
The service is primarily a preventative one; it is not intended for those people who already have vascular disease.
3. Background; Cardiovascular Disease (CVD) and its prevention
Targeting prevention of CVD is one of the six High Impact Public Health changes to which Manchester PCT is committed.
CVD is the leading cause of death in England and Wales with the prevalence rising in people over the age of 50 years. In 2005, 33.7% of deaths in Manchester were attributable to CVD. CVD is the greatest cause of inequality in life expectancy between Manchester and the rest of the UK.
CVD includes:–
• coronary heart disease (heart attacks and angina);
• stroke;
• diabetes;
• peripheral vascular disease
• chronic kidney disease.
These diseases all affect the body in different ways. However, they are all linked by a common set of risk factors. Obesity, physical inactivity, smoking, high blood pressure, abnormal cholesterol levels (dyslipidaemia) and impaired glucose regulation (higher than normal blood glucose levels, but not as high as in diabetes) all raise the risk of vascular disease. Having one vascular condition increases the likelihood of the individual suffering others.
Damage to the vascular system increases with age, and progresses faster in men than women, in those with a family history of vascular disease and in some ethnic groups. These are called ‘fixed factors’ because they can’t be changed. Importantly, however, the rate at which vascular damage progresses is also determined by ‘modifiable factors’, which can be altered. Changing these can greatly reduce the probability that vascular disease will strike early, bringing premature death or disability. These modifiable factors are:
• smoking;
• physical inactivity and a sedentary lifestyle;
• high blood pressure;
• raised cholesterol levels
• obesity.
The combined effects of these factors lead to a build-up of atheroma; fatty deposits on the walls of the arteries. In the coronary arteries of the heart, this causes heart attacks and angina. In the arteries of the brain, atheroma and high blood pressure can lead to strokes or transient ischaemic attacks. In the arteries of the kidneys and small blood vessels that make up the filters of the kidneys, the result is the commonest form of chronic kidney disease. This in turn, increases the risk of heart attacks and may lead to kidney failure. Obesity and physical inactivity may lead to the most prevalent form of diabetes, which, if unrecognised or poorly controlled, itself damages blood vessels and increases the risk of atheroma and therefore other vascular disease.
Taking action to reduce these risk factors can make a difference to how fast these diseases progress, or whether they happen at all, and so reduce the risk of vascular disease.
It is well known that people living in deprived circumstances have poorer health than the rest of the population. This is strongly reflected in vascular diseases, where people in lower socio-economic groups tend to suffer earlier and more severe disease. In addition, vascular disease in some ethnic groups makes a significant contribution to premature death. In the UK, mortality from coronary heart disease is currently 46% higher for men and 51% higher for women of South Asian origin than in the non-Asian population. The occurrence of diabetes in individuals of South Asian origin is twice that of the general population and the occurrence of chronic kidney disease is six times the rest of the population.
To identify individuals at a high risk of CVD, predictive risk registers are being compiled in all GP surgeries in Manchester. The success of these registers in identifying and managing individuals at risk of developing CVD is dependent upon the availability of accurate and up to date information about risk factors. There are gaps in the patient information currently available and a number of individuals have insufficient information recorded to enable a calculation of risk to be made. Therefore NHS Manchester wishes to commission a targeted pilot vascular checks programme to be delivered to specific GP practices across the city to determine a model of best practice, for the future management of CVD risk calculation for patients.
The Department of Health have stipulated that PCTs will begin the roll out of a National Vascular Checks Programme for adults aged between 40-74 years from April 2005 and this roll out to be completed by 2012. Repeat checks will then be offered every five years. A national call and recall system is planned within 5 years.
This service is intended to be a pilot prior to the roll out of a wider scale vascular checks service in line with the National guidance.
This document outlines the service specification for the delivery of targeted vascular checks in community pharmacy.
4. Aims and Objectives
The aims of the Targeted Vascular Checks Pilot Programme are:
• to identify asymptomatic individuals at high risk of developing CVD, and individuals with no prior diagnosis of CVD but who demonstrate symptoms of disease;
• to ensure that such individuals are entered into the appropriate care pathway;
• to facilitate the compilation of accurate CVD registers in General Practice.
The specific objectives of the pilot are:
• To offer targeted vascular checks in an easily accessible community setting at appropriate times of the day;
• To accurately test and record specific anthropometric and lifestyle information in order to calculate a personalised estimated level of CVD risk using a Framingham based score, adjusted to take into account ethnicity;
• To communicate this risk to the individual and signpost accordingly;
• To accurately and promptly report information to General Practice.
5. Target Population
Individuals meeting the following criteria:
• Individuals registered with a Manchester PCT GP
• Men and women aged between 40-74 years (inclusive) at date of assessment
• Within this group, individuals who report that they have not had their blood pressure measured in the past year
Exclusion criteria:
Individuals who:
• do not meet the registration
• criteria detailed above
• have previously had a vascular check (in the past year) by a pharmacy team member acting on behalf of the NHS (not including Biobank)
• report that they have had their Blood Pressure measured within the last year
• have a pre-existing condition such as diabetes, stroke, coronary heart disease
6. Service Model
Community pharmacists will be providing the following elements of the service:
• Risk factor-based vascular checks and calculation of estimated individual 10 year CVD risk;
• Communication of risk, discussion of lifestyle modification, stop smoking support and signposting to health improving opportunities to all individuals, according to assessment of risk factors;
• Communication of the detail and outcome of the vascular check with the individual’s General Practitioner; (NB the patient will have already been identified as having a predictive CVD risk of >20%)
• Systematic and appropriate onward referral, according to local pathways, for individuals who present with symptoms of other pre-existing disease that may require further investigation or treatment.
Pharmacy team members will be expected to demonstrate the Service is:
• targeted appropriately and reduces, rather than widens, existing health inequalities;
• proactive, creative and effective engages with the target population(s) to systematically assess CVD risk;
• available at times which maximise uptake in populations at highest risk;
• being provided to a minimum number of patients specified by the PCT (average of five per week) and communicate the audit information to the PCT on a monthly basis. Failure to meet this specification may result in the PCT withdrawing the service and commissioning with another pharmacy.
The Pharmacy team member will be expected to gain informed written consent from the individual for assessment and communication of the content and outcome of such with their General Practitioner, prior to a vascular check taking place.
The Joint British Society (JBS) CVD Risk Prediction Chart based on Framingham data can be used to estimate total risk of developing CVD over a period of 10 years based on 5 key factors:
• Age
• Gender
• Smoking habit
• Systolic Blood Pressure
• Ratio of total cholesterol (TC) to High Density Lipoprotein (HDL) (as measured by random cholesterol test using approved, calibrated equipment)
Therefore, the above factors must be measured and used to calculate the estimated risk. (Diabetes status must be recorded and should result in the client being eliminated from the assessment).
Therefore, the above factors must be measured and used in order to calculate estimated risk.
In addition, the assessment will also record:
• Body Mass Index (BMI)
• Waist measurement
• Diastolic Blood Pressure
• Physical Activity level
• Glucose level measurement
• Unit of alcohol consumed per week
• Pulse(for atrial fibrillation)
The Pharmacy team member will document the measurements and assessed level of CVD risk using the PCT recording form which will be collected by a member of the health inequalities team for the data to be transferred to the GP practice, in order to inform the predictive risk registers in General Practice and the individual’s subsequent medical management. The pharmacy team member will communicate the results of the Vascular Check to the patient and supply them with a copy of their results form.
The Pharmacy team member will be expected to demonstrate a clear understanding of the services available locally to individuals to support healthier lifestyles and communicate this information to the appropriate individuals.
The pharmacy team member will also provide the individual with a pack of information, devised by the PCT, including various health promotional items. These materials will not be used for other purposes and it is the pharmacy team member’s responsibility to ensure that they have ordered an appropriate number of packs for their client base.
The pharmacy should refer an individual whose lifestyle may increase their CVD risk into the appropriate pathway, eg stop smoking service, exercise programme etc.
The appropriate referral paperwork is included in the PCT information folder provided to each pharmacy.
The pharmacy lead will demonstrate that the Vascular checks are performed by a suitably trained and competent healthcare professional who has completed the PCT training and accreditation programme.
The pharmacy lead will be expected to work in collaboration with a nominated Project Manager from NHS Manchester to ensure that this occurs in a timely manner and in accordance with guidelines.
The pharmacy team will work within the standards identified in the NHS Manchester Infection Control policies with particular reference to the hand hygiene, body substance and use of personal protective equipment, cleaning and disinfection of the environment and patient care equipment policy to ensure safe clean practise and that all reusable equipment is decontaminated between patient use to prevent the spread of infections.
7. Patient Pathway including follow up
The patient pathway is
GP practice identify a patient with a predictive CVD risk greater than 20% using the PCT software, Primary Prevention Analysis Tool 2 (CVD PPAT2)
GP practice send invitation letter to a patient with the option to visit ¾ of the nearby pharmacies
Patient attends pharmacy for assessment
Pharmacy undertake assessment, identify risk level and communicate to patient
Pharmacy provide tailored specific health advice to patient and referral if necessary for lifestyle management
Pharmacy team to advise patient to attend GP practice if necessary
Health inequalities team collect CVD risk profomas from the pharmacy and take to the GP practice.
In the event of a measurement that causes concern, then the pharmacy team are advised to follow the pathway detailed below.
|Reason for Appointment |Threshold |Action |Time |
|Blood Glucose | |See GP practice for fasting |approximately 1 week |
| | |glucose | |
| | | | |
| |7.0 – 11 mmols | | |
| | |See GP Practice |within 2 working days |
| |>11.1 mmols | | |
| |>6.0 mmols |Provide lifestyle advice and | |
|Total Cholesterol | |discuss with pharmacist | |
|Blood Pressure | |See GP Practice | |
| |140 – 159 systolic | |approximately 2 weeks |
| | | | |
| |100 – 110 diastolic | | |
| | |See GP Practice |approximately 1 week |
| |160 – 179 systolic | | |
| | | | |
| |>110 diastolic | | |
| | | |within 2 days |
| |> 179 systolic |See GP Practice | |
|Any other clinical problem | |
| |At the discretion of the Pharmacist/Pharmacy team member |
8. Workforce Requirements
The pharmacy lead will:
• Ensure that its staff meet the training, registration and competence requirements
• Be able to guarantee an adequate and stable workforce at all times to meet the potential demand.
9. Values and Principles
The values and principles that underpin this Service Specification are detailed below and it is expected that the Pharmacy lead makes special provision to ensure that their staff are aware of the principles and also demonstrate this in their service delivery (proven by performance data and audit).
Equal access to the service will be provided for all people who meet the inclusion criteria and the pharmacy team member will be able to demonstrate this with monitoring information about race, disability, age, gender, sexual orientation and religion or belief. Patients will not be excluded on the grounds of race, disability, gender in line with Race Relation (Amendment) Act 2000; Disability Discrimination Duty 2005; Equality Act 2006 (Gender Duty). The service will not engage in any discriminatory practices, this includes dealings with the general public and recruitment of staff.
All staff have a responsibility to work with partners to develop, improve and deliver the service. Individuals will be empowered to exercise their rights to choose and given sufficient information which enables them to make informed decisions about their health.
Patients are to be treated with dignity and respect as individuals; these will be given high priority at all points of service delivery. This is a key priority for the NHS measured by the healthcare commission. The practice will have regard to safeguarding issues for Children and Vulnerable adults including referral processes and the sharing of information, where appropriate.
The service pharmacy team member will ensure that patient views are incorporated into development of future services. There will be effective communication and information sharing between agencies involved in the provision of care and with service users and their carers.
Information and records will be kept confidential and in accordance with the data protection legislation and Caldicott principles. Record keeping, information and confidentiality policies which follow NHS standards must be available and adhered to by all staff.
The staff will be appropriately trained to perform related CVD checks and interpret the results. Staff will also have a clear understanding of the specific pathways that patients can access based upon the outcome of their CVD checks.
The service will strive for continuous improvement and provide evidence of progress in line with their contract performance monitoring arrangements.
10. Integrated Governance
Any commissioned service must meet all national standards of service quality and clinical governance including those set out in Standards for Better Health (updated April 2006 .uk). These core and developmental standards of provision are designed to cover the full spectrum of health care as defined in the Health and Social Care (Community Health and Standards) Act 2003. The seven domains are safety, clinical and cost effectiveness, governance, patient focus, accessible and responsive care, the care environment and public health.
11. Equipment Specification
The Pharmacy team member will use the following equipment to undertake the health checks:
|Indication |Equipment specification |Measuring range |
|Blood glucose |LDX Cholestech |2.78 – 27.75mmol/l |
|Total cholesterol |LDX Cholestech |2.58 – 12.92mmol/l |
|HDL cholesterol |LDX Cholestech |0.39 – 2.59mmol/l |
|Blood pressure |OMRON 7051T (BHS validated) see guidance table below for information on cuff | |
| |size | |
|Weight |Seca 884 Class III Floor Scales (or equivalent) |160kg |
|Height |Seca Leicester portable height measure (or equivalent) |0 -2.07metres |
|BMI |BMI calculator wheel |various |
|Clinical waste disposal |Sharps box |N/A |
|Waist measurement |Tape measure |Inches and cms |
Blood Pressure machine cuff specification
|Indication |Width(cm)*= |Length(cm)*= |BHS Guidelines Bladder width & |Arm circ.(cm)* |
| | | |length (cms)* | |
|Standard Adult |12 – 13 |23 – 35 |12 x 26 | ................
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