A proposal for a vascular disease risk factor assessment and management programme was submitted to the NHS National Screening Committee in November 2005. It recommended the introduction of a vascular risk management programme, in which the whole population (aged over 40 years) would be offered risk assessment that could include measurement of risk factors such as blood pressure, cholesterol and glucose.
PSNC identified vascular risk assessment (VRA) as a target service for community pharmacy provision in 2006 and has been lobbying the Department of Health (DH) and other key influencers to ensure inclusion of pharmacy within government plans.
In January 2008, the Prime Minister announced the government's intention to shift the focus of the NHS towards empowering patients and preventing illness. As part of this, he set out his ambitions to dramatically extend the availability of 'predict and prevent' checks to give people information about their health, support lifestyle changes and, in some cases, offer earlier interventions. In a speech he said:
"...there will soon be check-ups on offer to monitor for heart disease, strokes, diabetes and kidney disease - conditions which affect the lives of 6.2 million people, cause 200,000 deaths each year and account for a fifth of all hospital admissions."
In April 2008 the DH published Putting Prevention First: Vascular checks - risk assessment and management, which announced the development of a VRA service across England. Two days later the DH published its pharmacy White Paper, Pharmacy in England: Building on strengths, delivering the future, which highlighted the role of community pharmacy in the provision of VRA.
It will be clear to pharmacists that there is a great potential for community pharmacy to play a significant part in the delivery and success of this programme. Indeed many community pharmacies have offered similar services to patients on a private basis for a number of years.
The aim of the programme
The aim of the VRA programme is to offer a straightforward risk assessment for diseases affecting the vascular system, including diabetes and chronic kidney disease, to everyone between 40-74 years of age. It is expected that once fully implemented, the programme will prevent on average 1,600 heart attacks and strokes, and save at least 650 lives each year.
The longer-term aims of the VRA programme are to:
- Reduce premature death from related vascular conditions including coronary heart disease, chronic kidney disease, diabetes mellitus, stroke, transient ischaemic attacks and peripheral arterial disease;
- Reduce the incidence of these related vascular conditions;
- Narrow inequalities in premature death from these related vascular conditions.
When will it start?
The programme will be introduced by PCTs from 1 April 2009, using a local commissioning approach; all PCTs must 'show some evidence of participation' with the programme during 2009.
The DH has determined that implementation of the service will be phased over five years; however, some PCTs may choose to move to full implementation more quickly (particularly the spearhead PCTs).
The phased approach to implementation allows the gradual development of capacity to support and manage people who are found to be at moderate and high risk. It will also assist PCTs in managing the cost pressures that this extra activity, including prescribing, will have on budgets. Many PCTs are already piloting the service and a small number have fully implemented a VRA.
The DH has secured additional funding (in the region of £250m) from HM Treasury to fund rollout of the service). This funding will start being added to PCTs' baseline funding in 2009/10.
The VRA programme, where delivered sensitively, has the potential to substantially contribute to key delivery targets for PCTs. It provides an opportunity to strengthen and improve performance in the following areas:
- Reducing health inequalities (Public Service Agreement 18.2);
- Improving life expectancy (Public Service Agreement 18.1);
- Reducing mortality from circulatory diseases (SR 2004 Public Service Agreement 1.1 and 6.1).
Not only are these DH priorities for action, they are also key Local Area Agreement indicators that many Local Strategic Partnerships have agreed to focus on, particularly in areas of deprivation.
The VRA programme is underpinned by three National Service Frameworks (NSFs) - Coronary Heart Disease, Diabetes and Renal Disease - as well as the National Stroke Strategy, which was launched in December 2007.
It offers a tool to provide shared primary prevention elements from the NSFs and the Stroke Strategy. The programme will strengthen work across all four disease areas by drawing together common elements and existing activity, specifically on risk assessment and management.
The VRA service is a set of processes that are designed to determine a person's 'risk' or likelihood of developing a number of chronic conditions that affect the vascular system i.e. veins, arteries, capillaries and organs of the circulatory system. These vascular diseases include:
- Coronary heart disease (heart attacks and angina);
- Kidney disease.
These diseases all affect the body in different ways. However, they are linked by a common set of risk factors:
- Physical inactivity;
- High blood pressure;
- Disordered blood fat levels (dyslipidaemia);
- Impaired glucose regulation (higher than normal blood glucose levels, but not as high as in diabetes).
Having one vascular condition increases the likelihood of an individual suffering others.
It is useful to view this new service as three separate stages:
Stage 1 - Identification of individuals eligible for VRA
The DH is developing a national 'call and recall' system that will operate in a similar way to the National Breast Cancer Screening programme, which uses a database of all women in the target age group to remind them when a mammogram is due. This system is unlikely to be in operation before 2011 so alternative approaches to identifying patients need to be used in the interim period.
Using GP records to target individuals at increased risk of vascular disease is likely to be used in some areas. GP records may also be used as the basis of a local call and recall system, prior to the national system being implemented. A pharmacy-based VRA service could be an assessment option that is offered to people targeted by a local call and recall system.
A further option is opportunistic assessment in pharmacies for people in the target group, using local marketing to encourage use of the pharmacy service. Community pharmacy could also facilitate mass 'screening' e.g. at local sporting events.
PCTs that have commissioned the service from community pharmacy so far have tended to use the opportunistic approach, but it appears that many are now likely to prefer a more targeted approach to VRA using a local call and recall system. This approach allows risk stratification techniques to be applied, targeting higher-risk groups first.
Stage 2 - Risk assessment
The DH wants the service to be as inclusive as possible, both in term of providers and users. Community pharmacy will have to compete with other providers to supply this service. The testing element is made up of data collection from the patient and a number of clinical measurements described in Figure 1.
Stage 3 - Intervention: advice, signposting and patient management
Stages 1 and 2 take the patient up to the point of having completed a test. Stage 3 involves any subsequent intervention, including healthcare advice, signposting, formal referral, lifestyle interventions and disease management. This stage is where the majority of the cost of the programme will be spent.
The success of the VRA programme is dependent on effective interventions following the testing and risk assessment process. There is significant potential for community pharmacy to play a part in Stage 3 of the programme using existing enhanced services and new services commissioned to complement the VRA programme. Service examples include:
- Stop smoking service;
- Weight management service;
- Basic healthy living and exercise interventions;
- Disease management programmes e.g. diabetes management.
VRA presents a major opportunity for community pharmacy to become more involved in supporting wellness and making public health interventions.
The location of community pharmacies makes them an ideal venue from which to provide the service and there is an emerging evidence base that suggests that pharmacies can effectively target hard to access groups that use GPs services very infrequently.
PSNC has developed detailed guidance on VRA for Local Pharmaceutical Committees and ran a series of LPC seminars in February 2009 (www.psnc.org.uk/vascularchecks). A template service specification has been written and PSNC is in the process of getting this agreed by the DH.
- Putting Prevention First: Vascular checks - risk assessment and management: 'Next Steps' guidance for primary care trusts (www.dh.gov.uk/vascularchecks).
- University of Leicester. The Handbook for Vascular Risk Assessment, Risk Reduction and Risk Management (www.screening.nhs.uk).
- A selection of case studies is available on the NHS Improvement website (www.improvement.nhs.uk/vascularchecks).
- The PSNC services database contains details of a number of pharmacy-based VRA services (www.psnc.org.uk/database).
Alastair Buxton is Head of NHS Services at the Pharmaceutical Services Negotiating Committee.