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NHS Health Checks Local City & Hackney update 2023 Pleasenotetheseslideswillbe madeavailabletoyou. • ClaireLister, GPConfederation,JointDirectorof Operationsclaire.lister@nhs.net • HayleyCarr, GP Confederation,ContractsManager hayley.carr6@nhs.net • Contract queries:nelondonicb.gpcontracts@nhs.net • Luis Rivas, CEG,Primary Care Facilitator– l.o.rivastaquias@qmul.ac.uk(EMISqueries) ➢ Roleof the GPConfederation ➢ Confederationwebsite ➢ Patientsandpayments ➢ KPItargetsandpractice performance ➢ Importance ofNHS HC inCity& Hackney ➢ Supportservicesavailabletoreferandsignpostpatientsto ➢ Patientsidentifiedasbeing“atrisk” ➢ EMIStemplate,alerts,searches,NHS HC riskreport Commissioner: London Borough of Hackney Lead provider: City & HackneyGP Confederation Providers: All 39 City & HackneyGP Practices Role of the GP Confederation: • To ensure 100% populationcoverageacross39 GP practicesin City& Hackney(343,800 patients) • Liaisewith the Commissioner – LondonBoroughof Hackneyto agree service requirementsand review practice activity • Issue guidancedocumentandsupportinginformationto practices(cityandhackneygpconfederation.org.uk) • Provideupdatesand key messages viaweekly Confederationbulletin(Thursday) • Advise practicesof targetsandKey Performance Indicators(KPIs) • Work withClinicalEffectiveness Group(CEG) – EMIS template,searches& quarterlydashboard • Monitorperformance at ConfederationandPractice level– activity,quality • Reportsto, andmeets with,LBH commissioners • Quarterlypaymentsto practicesbasedon CEG dashboarddata • NHSHC trainingSupporting information City & Hackney GP Confederation Website – Members’Zone If you haven’t already signed up to the Members’ Zone, please follow the steps below: 1 - Visit https://cityandhackneygpconfederation.org.uk/ 2 - Click 'Member Login' located in the top right of the page 3 - Click 'Join Us' and enter your email, select your practice, enter your name and create a password (please make a note of this password and keep in a safe place) 4 - You will then receive an email saying your account is pending 5 - Your account will be approved within 48 hours and you will receive an email to confirm thisSupporting information continued The Confederation Website • The Contracts section of our website contains a general contracts section and individual contract sections with the service specifications, guidance, targets and supporting information for each contract Confederation Bulletins • These are published every Thursday, members will receive an email alert • Contract news is in every bulletin ClinicalEffectiveness Group • T o access the CEG dashboards, receive the weekly CEG bulletin, or to request a Microsoft Teams visit from the CEG, please email Luis Rivas, l.o.rivastaquias@qmul.ac.uk, providing your practice, role, name and email address with your queryThe Confederation WebsiteContracts Page Patients and Payments Total patient population: 343,800 Total eligible population for NHS HC: 76,188 (based on 5 year rolling programme) “In year” eligible population for NHS HC: 42,306 2022/23 delivery of NHS HC: 10,963 Quarterly payments to practices for each NHS HC: • Low qrisk (<10%) : £11.65 • Medium qrisk (10-19%) : £27.20 • High qrisk (20% +) : £46.60 • No qrisk calculated (n/a) : £0.00 • Face to face appointments • Can claim for phlebotomy “blood sample taken” • Annual targets for each practice and across allpractices - bonus payments if achieved • Payment for all NHS HC delivered to eligible patients (ie payment not capped) • Monitor performance via quarterly CEG dashboards / EMIS searches Key Performance Indicators– what are they and how did we do in 2022/23? KK:KeyPerformanc Indicators(KPIs) No. KPI ANNUAL TARGET2022/23 2022/23 ACHIEVEMENT RATIONALE Confederation target 13.8% annual 10,963 NHS HC delivered To improve earlyidentification of 1 13.8% of total eligiblepopulation (~74,000) receivean NHS HC riskfactors and prevent disease 10,200 NHS HC to deliver for 22/23 £11,000 sharedbetween 23 practices 2 Practicetarget 12% annual 100% of practices achieve To ensure equitableaccess tothe 12% of “in year” eligiblepopulation (~42,200) to receivean NHS their target servicefor all registeredpatients HC 5,065 NHS HC to deliver for 22/23 All practices to achievetheir target £11,000 sharedbetween all practices 3 To ensure appropriate targeting of % attended with high qrisk(20% or more) 2.5% 2.1% highestriskgroups 4 To ensure appropriate targeting of % attending who areBlackAfrican / Caribbeanor South Asian 25% 33% highestriskgroups To ensure servicereaches hard to 5 % attending who aremale 53% 48% engagegroups 6 To ensure servicereaches hard to % attending who areunder 50 years 60% 57% engagegroups % with qrisk10% or higher referred to appropriate services for 50% offered 43% offered To improve access tobehavioural 7 support with lifestylechangeorsignpostedto places ifpatients (including referrals made and (of which 24% havereferrals support to reduce risk inthe canself-refer referrals declined) made and 76% declined) population 8 % patients issuedwith anNHS HC riskreport n/a 43% To provide information for each patient Reviewing the quality of the NHS Health Checks delivered AREA RECORDED AVERAGEACROSSALL RANGEDELIVEREDBY PRACTICES PRACTICESFORPERIOD 2022/23 2022/23 DIET %Dietary advicegiven 86% 34%-100% ACTIVITY %Brief intervention forphysicalac83%ity 33%-100% %Currentsmokerswithsmoking 85% 24%-100% SMOKING cessationadvice %Drinking> 1unit per weekgiven 75% 24%-100% alcoholadvice ALCOHOL %Patients issuedwith an NHS risk 43% 3%- 98% RISKREPORT report Qualityassurancetabon CEGdashboard showsthisdata,itis reviewedbytheConfederationandCommissioners It showsthecompletenessofNHSHCbeingundertakenforeach indicatorateachpractice–pleasereviewforyourpractice How is mypractice doing? • Please seethe A3 sheetwhichhas NHS HC data takenfrom theend of year 2022/23 CEG dashboard.See how your practice is doing: o How is your progress comparedtothe City & Hackney average? o What areas are youdoing well in? o What areas could youimprove in? o Please sharethis informationwith your practice team. NHS Health Checks Practice performance 2022-23(1stApril 2022- 31stMarch2023) Source:CEG Dashboard KPIand QualityAsssurancetabs B C D E F G H I J K L M N O P Q R S T ELIGIBLEPATIENTSOFFEREDANDRECEVIEDNHSHC ANDTARGETS KPI's QualityAssurance % NHSHC +QRISK>= % of % of CEG 5-year Confed Practice annual % NHSHCs % NHSHCs 10% +Offered % of patients patients total InYearTotal % of done for Noof lifestyle referral % of patients % of eligible Target eligible Target NHSHC % NHSHC Total no.of targetof Confed done on under50yrs patients advice (Accepted& % of givenBrief whosmoke who patients Listsize population 13.8% of the population 12% of In Offered Offeredin NHSHC NHSHCs Target Male old NHSHC Declined) OR patients Intervention given consume withNHS 5-yeartotal YearTotal deliveredin delivered givendiet smoking alcohol forNHSHC eligible forNHSHC eligible 22/23 22/23 22/23 inQ1 Targetis Targetis withQrisk signpostedto advice forPhysical cessation given HC report @01/04/202 @01/04/2022 13.8% Targetis >=10% services Activity issued 2 population population Targetis 53% 60% advice alcohol 12% advice Targetis50% 17332 2376 328 1413 170 1578 66% 578 40.9% 24.3% 47% 54% 94 13% 89% 87% 80% 77% 5% 8631 922 127 542 65 844 92% 124 22.9% 13.4% 40% 57% 22 59% 95% 97% 100% 89% 24% 15375 3006 415 1558 187 2035 68% 367 23.6% 12.2% 56% 63% 45 47% 97% 97% 85% 76% 89% 12215 2682 370 1294 155 1803 67% 317 24.5% 11.8% 54% 59% 62 52% 96% 89% 76% 54% 52% 5192 1094 151 672 81 1075 98% 169 25.1% 15.4% 49% 45% 33 6% 93% 94% 93% 93% 87% 4964 1079 149 470 56 1127 104% 224 47.7% 20.8% 50% 63% 36 47% 95% 90% 94% 24% 41% 6247 933 129 206 25 357 38% 148 71.8% 15.9% 49% 76% 14 36% 78% 73% 57% 58% 74% 3071 798 110 495 59 463 58% 155 31.3% 19.4% 43% 54% 32 88% 92% 84% 100% 97% 52% 1840 380 52 127 15 67 18% 52 40.9% 13.7% 46% 54% 11 100% 100% 100% 100% 100% 98% 5720 1197 165 540 65 354 30% 126 23.3% 10.5% 46% 48% 27 41% 93% 92% 96% 81% 28% 8033 1844 254 854 102 1118 61% 240 28.1% 13.0% 41% 56% 47 15% 95% 96% 96% 97% 34% 8479 2351 324 1392 167 1503 64% 269 19.3% 11.4% 42% 42% 69 33% 81% 76% 82% 68% 30% 12311 2790 385 1671 201 513 18% 407 24.4% 14.6% 38% 53% 65 69% 84% 85% 100% 90% 49% 6025 1003 138 553 66 772 77% 137 24.8% 13.7% 50% 65% 18 33% 83% 86% 76% 81% 85% 12097 3807 525 2127 255 775 20% 585 27.5% 15.4% 42% 43% 123 33% 82% 79% 90% 74% 33% 11952 3058 422 1839 221 853 28% 461 25.1% 15.1% 49% 52% 84 56% 96% 93% 99% 95% 70% 6672 1273 176 709 85 541 42% 263 37.1% 20.7% 49% 67% 20 30% 91% 88% 100% 94% 14% 4724 908 125 478 57 173 19% 128 26.8% 14.1% 45% 70% 8 88% 92% 93% 90% 90% 33% 14906 3647 503 2137 256 328 9% 300 14.0% 8.2% 44% 52% 35 40% 89% 87% 100% 92% 10% 5358 1022 141 547 66 138 14% 131 23.9% 12.8% 40% 53% 19 79% 73% 52% 92% 52% 49% 4857 1201 166 713 86 900 75% 220 30.9% 18.3% 51% 48% 41 80% 84% 80% 95% 84% 56% 11854 2826 390 1423 171 1458 52% 472 33.2% 16.7% 45% 63% 48 88% 97% 95% 90% 94% 7% 5242 1335 184 598 72 138 10% 121 20.2% 9.1% 34% 57% 15 40% 69% 68% 100% 92% 42% 14466 3668 506 2220 266 1452 40% 662 29.8% 18.0% 46% 62% 81 37% 90% 89% 83% 78% 29% 7177 1829 252 1174 141 822 45% 219 18.7% 12.0% 47% 53% 39 23% 97% 94% 96% 90% 29% 7750 1651 228 1023 123 607 37% 231 22.6% 14.0% 49% 49% 36 58% 87% 85% 24% 91% 85% 1244 485 67 242 29 307 63% 101 41.7% 20.8% 80% 59% 21 43% 53% 56% 84% 35% 14% 7945 1451 200 939 113 1161 80% 300 31.9% 20.7% 48% 71% 25 40% 83% 83% 73% 74% 18% 11037 2729 377 1639 197 308 11% 244 14.9% 8.9% 50% 61% 34 18% 89% 84% 67% 78% 76% 18253 2282 315 1418 170 1341 59% 414 29.2% 18.1% 55% 63% 63 27% 88% 89% 95% 83% 34% 3897 857 118 344 41 337 39% 201 58.4% 23.5% 41% 52% 32 53% 34% 33% 95% 79% 24% 6094 1354 187 588 71 261 19% 234 39.8% 17.3% 63% 71% 31 71% 94% 95% 95% 93% 70% 10837 2743 379 1741 209 364 13% 220 12.6% 8.0% 46% 57% 34 32% 52% 52% 70% 49% 3% 4519 945 130 479 57 574 61% 212 44.3% 22.4% 55% 52% 47 19% 95% 92% 95% 43% 9% 9717 2947 407 2000 240 1418 48% 280 14.0% 9.5% 58% 35% 73 92% 96% 96% 72% 89% 90% 12336 2740 378 1905 229 1590 58% 513 26.9% 18.7% 47% 70% 47 47% 77% 75% 77% 55% 84% 15593 3222 445 1772 213 3189 99% 621 35.0% 19.3% 50% 51% 116 34% 82% 82% 75% 47% 34% 9200 2036 281 1418 170 1441 71% 355 25.0% 17.4% 46% 57% 61 21% 77% 53% 84% 41% 46% 9173 1477 204 940 113 237 16% 162 17.2% 11.0% 43% 54% 26 27% 78% 82% 77% 88% 44% 342335 73948 10203 42200 5065 34322 46% 10963 12.0% 13.8% 48% 57% 1734 38% 86% 3% 85% 73% 43% Importanceof NHS Health Checksin City & Hackney • Higher rates of smokingacrossC&H • Populations with much higher rates of hypertension/ CHD/ strokeand diabetes • Manypractices with higher rates of obesity and diabetes • Multi-morbidity happens 10-15years earlier in deprived communitiessuch as Hackney You can make a changeto these patients’chances of developing these problems. An important part of this is to complete and code the EMIS RP NHS Health Checks template in full, including knowing where and howto refer and signpostpatientsto local services. Find Support services: City& Hackney lifestylesupportservices https://hackney.gov.uk/find-support-services Inactive Overweight Highalcohol Hypertension Nutrition Pre-diabetic Smoking obese consumption / Diabetes If eligible, refer to: If eligible, refer to: If eligible, refer to: If eligible, refer to: If eligible, refer to: If eligible, refer to: Refer to: • Hackney Healthier • Hackney Healthier • Homerton Adult • Healthier You • Turning Point (high • Smokefree City & • Hackney Diabetes Together for Together for Community National Diabetes risk) Hackney Centre (diagnosis of physical activity on weight Dietetic Service. Prevention • PCN Health & • PCN Health & diabetes) referral. Exclusion management See different Programme (NDPP):. Wellbeing coaches Wellbeing coaches • NHS Digital Weight criteria here. programme (obese pathways for (hba1c 42-47 (if available) (if available) Management (BMI • Fusion exercise on or overweight eligibility here. >30 / >27.5 for referral (City based on BMI). mmol/mol, 6.2-6.4% minority groups and in the last 12 months) patients only) Exclusion criteria diagnosis of diabetes • PCN Health & well- here. and/or hypertension) being coaches (if • Fusion weight available) management programme (City patients only) Signpost to a community exercise group / healthy eating resource: Signpost to: Signpost to: Signpost to: • Love Hackney • HackneyVolunteer Centre: • HealthierFamilies • Alcohol advice • NHS Quit Smoking • MyType1Diabetes TogetherBetteractivitiesin leaflet app online resource • Walking Groups onlineresource • Alcohol and • Healthy Living for • New Age Games(forover 50s) practice (if available) • NHS FoodScanner mental health People with Type 2 • ShoreditchTrust The Sharp • BetterHealthonlineresource app advice leaflet diabetes online End • Physicalactivityguide(foradults) • Eatwellguide • Swimming • MyDrinkAware resource • Core Sport (mental health website • NHS WeightLossapp • ShoreditchTrust,Madein • MyDrinkAware app • NHS GetActive:Couchto 5K and Hackneyand Bagsof Taste Pleasenote, not all PCNs haveHealth & Wellbeingcoaches,andnot all PCNs haveTogether Active10apps (online)healthycookingclasses Better activities available. Updated: June 2023 Practice pathways as a resultof diagnosis made due toan NHS Health Check • If you find someonewithraised BP/ HbA1c/ cholesterolor patientswith concerns about memory,speak tothe lead nurse or GP and follow practice protocols. • Don’tforgetto codepeople whoare at: • High risk of cardiovasculardisease – Qrisk 20% or more • High risk of diabetes – HbA1c42-47 mmol/mol(6.0 - 6.4%) Thesepatients will thenbe reviewed annually.Any questions?CEG supporttools NHSHealth Checks Luis Rivas – CEG Primary Care FacilitatorNHS HC SupportT ools on EMIS Web •Clinicalemplate •Risk Report •Searches •CEG AlertsAccessing the Clinical T emplate RP NHS Health Checks City and Hackney CEGNHS Health Check risk report https://www.youtube.com/watch?v=RxFYNImgb8wUsingthe Risk Report 6 easystepsto maximiseyourhealthcheck… 1. Fill in the NHSHealth Check EMIStemplate 2. Save thetemplateand also save the consultation 3. ‘Createletter’, searchfor “NHS Health CheckRisk Report” ( latest) 4. Usethe risk report tosupportdiscussionswith thepatient 5. Ybe saved once finishedwithannotateddirectly in EMIS. Either way, it needs to 6. Once discussed,either sendto thepatient(via email/post) or give a printoutto the patient Note,oncesaved, this automatically codes itRisk ReportSearchesNeeds Invited Invite Under50Any Questions