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Hello, my name is Michaela Nuttle and I'm a cardiovascular nurse and I'm here today to talk to you a little bit more about NHS Health Checks. This is an introduction to NHS Health Checks and certainly isn't intended to replace any training that you should be going on. But I really just wanted to spend about 20 to 30 minutes giving you a basic outline of what NHS health checks are and why it's really important to do them properly. Now, before I get started, I just want to tell you a little bit about us. So my name, as I said, is Michaela, I'm from Smart Health Solutions and we're a training center for NHS Health Checks and we're a center for the Royal Society of Public Health and we're supported by Heart UK. And if you want to get involved in any social media, here, it all is. There's uh lovely people that work in the background making it all happen. So we're linkedin Twitter, Facebook and um Instagram. So there you go. But this session for the next, as I said, about 30 minutes, what I'm gonna try and persuade you is that health checks are really complex. I often hear people saying, oh yes, they're really straightforward. Anyone can do them. Well, the answer I think is no, not anybody can do them, the right people and the competent people can do it. And there is way more to NHS health checks than just ticking boxes. And you might be using a template that's feeling very big with lots of boxes to tick. But remembering that a template is capturing what you're doing. It shouldn't be the only things that we do. So with death, more to it about them ticking boxes and by being skilled in delivering health checks, that means being confident to having the knowledge, the skills and the expertise will really help the program to achieve the outcomes that we know it can deliver. So what are NHS health checks? Well, it's a national program for people in England. And um it's really about trying to help prevent people developing diabetes, heart disease, chronic kidney disease, stroke and dementia in the future. That's a key part of it. But actually, there's more to health checks than just that. For me, it's also about early detection of other conditions like hypertension and diabetes and other conditions that we're starting to look at. We're also going to calculate somebody's cardiovascular risk, that's their chance of having a heart attack or stroke in the next 10 years as well as trying to get people to make a behavior change. Now, for anybody who is interested in delivering health checks who are already delivering health checks. I hope you've had a look at this document. So this is produced by Public Health England. Um It will be reproduced by the Office for Health Improvement and disparities in the future as you know, as many of you know, there's been that transition over but the documentation still stands and this is the NHS health health checks competency framework. And for anybody, I'm a believer for anybody who's going to do something, they should know why they're doing it, how to do it and how to explain those results that makes you competent. And often what we do is we get taught how to do something. This is how to measure a BP, this is how to do a height and weight, this is how to do venipuncture, but we don't often get taught why and how to explain them. And that is all about being competent. Now, these uh what this health check competency framework and the learner workbook is available nationally on the NHS health Check website or you can follow us at some point and we've already got at some point. Gosh, that sounds awful, doesn't it? But you know what I mean? Um We will also have for anybody that watches this on demand, you will be able to have access to these uh this framework. We upload it already for you. So as I said before, there is a lot more to NHS health checks and I'm just going to touch on the competencies that are there. Um, it's gonna be a whistle stop tour. It's not about getting you to be competent by watching this wee video for a bit of time. It's about giving you a flavor of what it's all about. So you can see the new guidance and I say you, it's been around for quite some years now. That's that old blue and white one. And the older guidance is the stuff that's with the green and the cog man. And that was when the program was called putting prevention first. So remember three main things early detection. So when we're doing a health check, early detection of those long term conditions, hypertension, diabetes, chronic kidney disease, atrial fibrillation, and familial hypercholesterolemia, along with the calculation of somebody's chance of having a heart attack or stroke in the next 10 years and behavior change. There are three real biggies. Now, what are we trying to prevent though? And I like to really get us to think about what is going on inside people's bodies. And this is an artery arteries are really powerful blood vessels that take blood away from the heart and they're under very high pressure. They're fantastic creatures that can expand and contract a little bit. They produce chemicals, the endothelium produces chemicals. It, it's a very um yeah, it's a fantastic bit of our body. Veins are very different. Veins are floppy. Old creatures that just let blood come back. Now, these arteries have a really special lining called the endothelium and that's beautiful and smooth when we're born, then the life that we lead, do we smoke? Are we overweight? Do we exercise along with what's our age, gender, ethnicity, family history? All of these risk factors that are there cause us to, to create, to move along this process, creating blockages at different rates. So if you look at the image here, we start off with relatively smooth arteries at the beginning. And then you can see that whole process of athera along with endothelial dysfunction, that's that special lining being damaged, forming with a blockage. Now, that blockage gets lots of different names. We call it plaque, a fibrous plaque, athera, atherosclerosis and atherosclerotic plaque, lots of different names. It means that blockage and we can get that blockage all over our bodies. It could happen in the arteries in our heart. It can happen in the arteries in our neck, in our, in our kidneys, in our legs. And if I had a penis in my penis, my uh penile arteries could get those blockages. And really, that's what we're trying to do in a health check. We're trying to help slow down this progression and this, it's partly because, you know, we get these blockages because we weren't designed to live this long. We were for the majority of time that humans have been around and remember we've all got different um beliefs on how we got here. But for the majority of time that humans have been around, we lived for about 20 to 30 years. Some of the, you know, maybe the, the kings and queens would live a lot longer. But for the general population, we didn't live very long. I meant we didn't grow old enough to have heart attacks, grow old enough to have strokes. And it's only since the advent of farming, modern medicine, all of those things that will keep us alive for longer that we have started to live. So use our bodies for much longer than they were designed to be used, which is fantastic in one way. So our life expectancy is growing, but we are now gathering other conditions along the way. So, you know, 100s of thousands of years ago, we probably died from childbirth, blood loss infections. You know, we died from different things. Nowadays, we die from heart attacks, strokes, cancers. So our bodies weren't designed to last this long. But equally, they are complicated machines with lots of different working parts. And if we don't use a machine, the way it was designed to be used, well, it's not gonna work as well either. So no cell in our body was ever designed to take in tobacco, no cell in our body. So if you ever see somebody that's a smoker or an ex smoker, then they will have been growing those blockages faster than they should have been. Secondly, we were designed as hunter gatherers. That's how we lived as humans for the majority of the time that we've been around and we would move around gathering nuts and berries and seeds and green leafy vegetables and eating them. And any leftover fuel from that energy we were putting in, our bodies would store as fat cells for when there's harsh winters ahead and no nuts and berries on those trees. Now, this is not nuts and berries. We are surrounded by an abundance of high fat, high salt, high sugar, eat readily available, ultra processed foods. So we are putting the wrong fuels in our bodies. Thirdly, most of us are lucky enough to be born with a couple of working legs and they have a job to do and that job is moving around following the seasons, ok? Following the seasons, looking for food, we are really not moving so that all leads to the UK today and in particular, the England today, which is where we're at for NHS health checks and we are a very unhealthy nation. Now, there is something worse than the UK of today and that is the future and Children do not figure in the health check program. I'll tell you in a moment, the age range we have, but pretty much anyone that comes in for health check will have Children, grandchildren, siblings, nieces, nephews, cousins, and we know you know that actually getting people to make lifestyle changes with, for alongside their Children, they will be much more likely to make and maintain those changes. So we know that cardiovascular disease remains our biggest death um in the, in England, one in every four deaths, which equates to one every four minutes. And we know that um inequalities has a massive role to play play. So if you live in the most deprived areas, you are four times more likely to die than those who are living in the least deprived areas. And our ethnicity makes a difference too. So this study here, which was local to me, this was just based down in Lambeth, I think. Um and this was looking at both for men and women comparing white Europeans with people who are South Asian, with people who are Africa Caribbean. And when you can see here is whether it's men or women. When we're looking at heart disease, we see that the people who have the most heart disease are South Asian men and South Asian women and the people that have the least amount of heart attacks are Afro Carribean men and Afro Carribbean men. But then and women, sorry. But then when we start to look at strokes, we see something different. So we can see in the context of strokes, more South Asian men and more South Asian women than their white European counterparts will have strokes. But men and women who are a Carribean have the most amount of strokes. So when you're doing your health checks and you're looking at your patients, think about who is that person in front of me, what should I be looking for? And a little note when we're looking at the prediction of heart attacks or strokes in the next 10 years for Q risk, then it's predominantly looking at ischemic heart disease. We're looking for heart attacks there more than strokes. So that can surprise you. Sometimes men have more heart attacks than women. Ok. That's quite well recognized. However, most of what we know about heart attacks is on research in men. And for many women, their symptoms go unrecognized. They often thought we're protected by our hormones and in, in some ways we are, but we can have premenopausal women having heart attacks. There's something out there about recognizing symptoms differently in women. There's always a thought they, they, they look very different, sometimes they do, sometimes they don't. But actually the challenge will come in about that diagnosis. Things like angiograms, the troponins are less uh are less um effective. So our troponin levels are lower when we're having heart attacks and angiograms don't pick it up in, in quite the same way. And we know that risk factors are stronger in women than in men. Now, that is about that sort of global look at cardiovascular disease and it's not something that our risk engines really pick up in the same way. Now, why are we dying from cardiovascular disease? And this is from the 2013 g BD analysis and this looks at cardiovascular disease. That's the Blue bar. And I'm just trying to persuade you that really, what we're doing is really, really makes a difference. So what we put in our mouths, whether that's food or tobacco causes the most amount of cardiovascular disease deaths followed by physical inactivity. And this all translates into high BP, high BMI high cholesterol, uh diabetes and chronic kidney disease. And this is all the stuff that we're really looking for in the health check program. So that's a really big introduction into why it's really important to do health checks and why it's important to do it right for the next 15 minutes or so. I'm going to whip us through some more of the competencies to really entice you to want to learn more about NHS health checks. So, competency number two is looking at information governance and data flow cos data does move around the Health Jet program. So it's really important that people understand where data goes and how it's moved and how it's moved safely as well as understanding when to consent. People for their data moving. Sometimes it doesn't affect people in the same ways depending where health checks are delivered. And this is all the different from this is my little interpretation of all the different places that health checks happen that are involved in data movement. So we have, oops, let me just change that slide. We have community NHS health check services and there are people out and about in outside of general practice. So that might be a pharmacy, it might be a pop up, it might be a community venue. Now, wherever that health check happens, the information from the health check needs to end back up in primary care in that patient's data. So that means it has to be identifiable. Now, sometimes primary care refers people to lifestyle services and sometimes the community providers refer people to lifestyle services that has to be identifiable. But then you go below the line and that's all non II, that's the only bit that identifiable data moves below there. We have submissions to public health departments. We have sometimes the federations get involved and ultimately everything gets sent to. Oh I the offers health improvement and disparities now not everything gets sent. It's the culmination of everything which gets distilled down and pretty much two numbers, how many health checks were offered and how mental health checks were done and that's looking at our uptake, that's there. So what do we mean by offered? Well, that's that invitation process and that's for people aged 40 to 74 without preexisting conditions that you can see here on the left of the screen to be invited in for a health check every five years. Then we get to what we call what we call assessment and results. So this is competency three and four. And I'm gonna take us to a very big flow chart now, which um may be hard for you to see, but you can get it from the best practice guidance and I'm just going to walk us through it. So you've got your patients, they've turned up for their NHS health check. It's really important to make sure that you're using the right template for it. Cos that will have the right way of data being coded to find out where it's at. And we can see the minimum amount of information that should be on your template. That's age, gender, ethnicity, family history, body mass index, smoking status, physical activity, cholesterol, BP measurement, the alcohol use a diabetes risk tool and dementia awareness and sign posting. So there is a lot to be done in health checks and that's where it can start to really feel like this tick box because you have templates that go on and on and on and that's down to your skill as a healthcare professional or a clinician to make it not feel like a tick box. This should be a moment in time, 20 to 30 minutes where you have got protected time with your patients or with your client to be able to really not just ask the information but also give them the results back to be able to communicate back. Now within here, we have um the, what I call the, the, the. So what ifs the filters and that's where it drops down and goes to the green boxes. And we're going to look at those green boxes in a moment. You can see the risk assessment. That's the big red triangle. That is the key risk. And the little yellow boxes is what do we do depending on that key risk result. And then finally, on the right hand side is the risk management and that is all around the lifestyle services that will or will not be available to you depending where you're working. And the best place to always find out your latest information on lifestyle services is looking is finding out from your local authority, your Public Health Commission as they will tell you what is available. What's the easiest way to refer in? You might have um very clickable links in your templates or you can get people off to weight management or diabetes prevention programs. And the bottom right corner is if anyone gets diagnosed with any of these other health conditions, then they leave that health check program. A common question I get asked is what about the blood tests? Now, everybody who has a health check should have a blood test and we need a cholesterol to be able to calculate risk. Ok? To be able to do that red triangle that everybody has to have done. We need a cholesterol result. It can be a random result. Ok? It can be a random result. There's no need to do fasting. So some people are doing point of care. That's the finger prick test. That's random. We do it on the day and there you'll get your total cholesterol, your HDL and your ratio. If you're not doing the point of care on the day, then the recommendation is you do the venous sample before the check. So that when your patient's there, when the patients are in front of you, you've got the result to be able to do the cue, risk some areas as a result of COVID are doing sort of blended versions of part ones, part twos or bring people in and do a cholesterol and follow them up. Yeah, that's not ideal. I have to say not ideal, particularly when we're sending out letters for follow up, you know, explaining people's queue is on a piece of paper really doesn't work. So I would always recommend if you're doing a venous test, do it before and if you're doing, you're doing your total cholesterol HDL and ratio rather than having to repeat another blood test and throw in your HBA1C and possibly your using these, which helps to look for um for, for creatinine to look for our EG fr if you're doing the point of care on the day, sometimes people have got the HBA1C machine as well. Great. If you can do that. If not, you do your venous sample for those patients that there. And this is where that localization comes in. OK? It's where that real localization comes in for what to do. So really finding out from your service specification by your commissioner is knowing exactly what blood test should be done when now if the BP you see, so these are all filters, the green bit that we saw before, if that BP is greater than 1 40/90. And remember that's three different readings over that one minute apart with the right bit of kit and everything. So if that patient has a BP of either 140 or 90 then that patient needs to be assessed for hypertension, assessed for diabetes and assessed for kidney disease. And this is something you do all the time. Ok? You do all the time. It's bread and butter work out in primary care. What about that check for diabetes? Um, again, this is looking a little blurry. I'm very sorry. I took it from the best practice guidance. You can find that it'll all be uploaded for when you've done any of any, any evaluations and got your certificates for having a little look at this. But also, um, it's readily available on the best on the from the Best Practice Guidance on the NHS health check website. And there's probably something like this in your service specification. And this is really saying not only do we use the BP of 1 40/90 to look for diabetes. Then we also look for people's BMI. So that's a BMI of 30 or 27.5. And that gets us the HBA1C test for anybody whose BP is greater than 100 and 40. Over 90. What we should be doing is looking for their e looking at their eeg fr so venous sample upfront, you can put that one in. If you're doing a point of care, then you do your venous sample uh on the day or they can follow them back up. And as you would do normally and following a peg fr s, if it's less than 60 then you're going to repeat and also do an acr the thing we pick up slightly less well, would be our cholesterol levels. And what we should be doing if we ever see anybody whose cholesterol is greater than 7.5 then really what we're thinking there is, that's very high. What might it be? So we want to eliminate other reasons first. So we get a full lipid profile. That's a fasting one. And then we check thyroid liver kidneys and we check for diabetes. And if all of those are ok, there's nothing that might be altering that cholesterol, then really we should be thinking about. Is this an inherited high cholesterol condition? Is this familial hypercholesterolemia? That's all the filters that come through the health check program. Now, if I just go back for a moment to the BP. One, when you're doing a BP, remember always to palpate a pulse before you do a BP. It's very important. Now, the Q risk and I would say Q risk for me is one of the most complicated bits of NHS health checks. And I thought long and hard about this session. I thought, I it's too much to try and squeeze into something like this. It's very complicated and it's very complex and it takes a long time to, um, I think, learn to understand it ourselves before we can even communicate it well with patients. But if I just tell you the process, sort of the pathways that would happen. So if people's Q risk is less than 10% they stay in the health check program and have a health check every five years. If their Q risk is greater than 20% then they leave the health check program and they're going to have annual reviews and offered a statin and hopefully taking that statin cos we know that will really make a difference if their Q risk is somewhere between 10 to 19%. Well, that's really about offering them a statin. And if they want to take that statin or then they leave the health check program because a statin is an exclusion criteria and we're gonna see them more frequently. And if they don't want that statin, then we don't exclude them from the program, we keep them in the program and we see them every five years and that's just when people come back or take a stat in them. But everybody should be offered lifestyle, whatever lifestyle is available out there. The real challenge for me is communication of risk, that chance of having a heart attack or stroke in the next 10 years. And I often get a lot of people say, oh, yeah, I feel quite confident with it. I just, you know, I explained to them it's 12%. And that's because Xy and Z and I think that, that to me is not explaining what risk is, that's telling them a number, it's not really communicating it. So if you can get yourself trained up um on a course and multiple course, I've been working in this for years and I still keep learning new things. It's really important because for us, we need to be able to understand it before we can communicate it and get people towards behavior change, which leads us to competency six. And again, this is a whole big fantastic area you can go into if you ever get the chance to attend er, motivational interviewing courses, er, making every contact count courses. All of this about behavior change really is really, is invaluable. So get yourself out there and find some of that and the final competency is about communication back with primary care. Now, if you're out, if you're one of those community providers or pharmacy that will all happen, you will, you will have to be part of that. And it's for you knowing how that happens, working with your local commissioner to understand those processes. And then also for primary care to understand data might be coming back towards them. There are three other elements within the health check program that I'm going to touch on in the last couple of minutes and one is around the dementia aspect and that's really about the messaging of what's good for the heart is good for the brain. And it's really important to know what it's about. It's not there to diagnose, we're not there to screen, we're not there to assess and the health check, we're there to raise awareness. And what we can do is reduce people's chances of developing dementia. What we can't do is ever stop it. So introducing dementia awareness into the health check program is a great idea. GPA is part of the health check program and this stands for the GP physical activity questionnaire. And this is a sort of systematic way, a systematic approach to trying to sort of work out how much somebody's moving um consistently across the country. But our, our way for this is trying to encourage people to move more, that's where we want to get to. And the GPA is a series of questions which will give you ultimately one of these answers anywhere from a to inactive the challenge we have with this is that if we go and ask, you know, 100 people on the high street, what would you see yourself as pretty active? And what they mean is I'm quite busy and this isn't a business questionnaire. This is actually an exercise questionnaire. Now, the G pack along with the next one, which is uh not the next one I had this extra bit in. Sorry, I threw an extra slide in is thinking about the benefits of physical activity. Remembering it's so important that all of us become more active. So whilst we're talking about their physical activity, what's good for the heart? What's good for the brain? Remember, we're going to prevent hip fractures, depression, type two diabetes, colon cancer, breast cancer, a sort of element of health checks. It's not an element of health checks. It's not AF and pulse taking and pulse taking itself isn't a systematic part of the NHS health check. You won't see it in our flow chart. But what you will have to do is as anybody knows if you're going to do a BP, particularly with the automated machines, we should always be palpating the pulse beforehand. That is how we will detect AF in the program. GPA along with audit C which I'm going to talk about. Now in the last moment or two are the two things that we do least. Well in the health check program least. Well, OK. These are the things that happen less frequently. I would say communication of risk is probably the worst thing. But the one that we know that's been captured, er, has not been done so so consistently across is this audit thing. An audit c is another systematic way of trying to find out how hazardous somebody's drinking is. And we do that by asking a series of questions and depending on those results, we ask another set of questions and those schools will get it added up. And then that defines what advice and where we might signpost patients to. So health checks is quite big. There is so much to health checks and people should be given the right amount of time for it and the right amount of training. And so for me, in summary, I hope that listening to me today has really made you think a little bit differently about health checks and it actually is a really complex program. Ok? It's really complex. There's so many elements to it. It's not just doing a height and a weight and asking some cholesterol, doing a cholesterol and asking some questions. There is so much more to it and for it to be effective, it's way more than ticking boxes. It's that moment in time. It's that consultation, it's, it's a protected 20 to 30 minutes that you should be having with your patient to achieve those outcomes. And it's only by understanding those two bits by having the right amount of time, having the right template and you being competent will really help us to achieve the outcomes that the program we know can achieve. So, thank you for watching. I hopefully, uh you found that useful and enticed you to want to go and learn more about health checks. I think we're making this on demand so that you can watch it as many times as you want to and also you get the opportunity to give us some feedback and I might be able to do so more on other things. So go out there find yourself if you haven't already some behavior change training, learning more about BP, maybe a health check course, a communication of risk course, be the best health checker. You can be. Thanks a lot.