Health Promotion in
Primary Care
Dr Lola Savage
15th February 2012
AIM
• To increase awareness of health promotion
in General practice
• Case presentation
• NHS health Check
• Questions-Single best Answer
GP Curriculum
• Healthy people: promoting health and
preventing disease
Definition
• WHO: Health promotion is a process
of enabling people to increase control
over and to improve their health
Prevention
• Health Professionals-we aim to prevent diseases
in our patients
• Prevention can be classified into the following:
• Primary prevention
• Secondary prevention
• Tertiary prevention
• Which of the above categories do we spend most
of our time doing?
Primary prevention
• What health promotion activities do
we currently advocate in primary
care?
Primary Prevention
• New Patients
• Well woman and well man clinics
• Immunisations
• Travel advice
• Screening programmes- cervical/mammogram/STI
New patients health
check
•
•
•
•
•
•
•
•
•
Urinalysis
BMI
Blood pressure
Smoking status
Exercise
Alcohol screen-Audit C
Family hx
Ethnicity
Health ed- diet/ exercise-recorded
• Well woman/men check:
•
Smear status
• How do we as GP registrars
incorporate primary prevention into
our practice?
How can we incorporate health
promotion into our
consultations
•
Medication review-review summary records- alcohol
intake/BMI/cholesterol/renal function
•
Pill check-promote LARC
•
Adhere to prompts for QOF- e.g smoking/ blood pressure reading
•
Pregnant patients-folic acid/blood
pressure/alcohol/smoking/diet/vit D/refer to community midwife
•
? Promote NHS health checks
Case Presentation
• 53 man who presented with a 12 week history of Left foot
pain following a car going over his foot in a motorcycle
event. X-ray left foot-NAD
• PMH- Essential Hypertension
• DHx-Amlodipine 5mg od (last issued may 2010)
• SHx- Runs his own company. Doesn’t smoke
• What should I do next?
Case Presentation
• Took brief hx of the pain/ex his left foot and
decided to refer him for physiotherapy
• Establish a rapport with him and explored his
ideas about his medical hx and non compliance
with medications
• Clinic blood pressure readings: 174/85, 162/93
Case Presentation
•
•
Arrange for him to do home readings for a week and to review
again
Average home readings-156/90
•
•
•
Reviewed risk- bloods- cholesterol/renal function/glucose
Q-risk- 9.5%
Nice guidelines- ACEI- ramipril
•
Reviewed in 1/12- bp 130/86
•
Follow up- pt applied for health insurance- declined-previous hx of
non-compliance to meds
NHS health check
• Background
• Heart disease/ Stroke /Diabetes and kidney disease are
the biggest cause of death in the UK
• 4 million of people in the UK affected
• 170,000 people die each year in England from these
conditions
• Health inequalities in deprived areas and in certain ethnic
groups
• 2008-DoH published ‘Putting Prevention First’ –sets out a
systematic and integrated approach to assess individuals
between 40-74
• This National Screening Programme is known as Health
Checks- due to be rolled out by PCTs in 2012/2013
NHS health check
• Invites patients ages 40-74 who are
not known to have DM/CVD/TIA/
MI/HT once every 5 years
• Fixed factors-Age/ Gender/Ethnicity
NHS health checks
• Aims
•
To identify patients at risk of developing
MI/CVA/TIA/Diabetes/HT
•
To sustain increase in life expectancy
•
To reduce premature death associated with obesity/sedentary life
•
Reduce health inequalities
•
Reduce the cost of long term ill health on the NHS
What does it look like?
NHS Health Checks – Summary Flow Chart
Cardiovascular Risk Assessment
Data requirements:
Family History of CHD
Smoking Status (Current/ Non
(inc. ex))
Medical History (Rheumatoid
arthritis or Atrial fiibrilation)
Townsend score/ postcode
Cholesterol
Diabetes Risk
Assessment
Data requirements:
BMI
Ethnicity
Blood Pressure
Gender (M/F)
Age (yrs)
Ethnicity
Blood Pressure
BMI
QRISK 2
>20%
Provide lifestyle advice on
reducing risk.
Statins are recommended
for primary prevention in
individuals with 10 year risk
>20%.
>10% but <20%
Explain risk to
individual and
provide lifestyle
advice on lifestyle
modification and
risk reduction.
BMI ≥ 30 or ≥ 27.5 in Indian, Pakistani,
Bangladeshi, Other Asian or Chinese
OR
Blood Pressure ≥140/90mmHg or SBP
≥140 or DBP ≥90mmHg
If YES
Recall for
fasting blood
glucose test
<10%
Exit for
routine
recall in 5
years
If NO
Exit for routine
recall in 5 yrs
≥ 6 to 7 mmol/l
OR ≥ 7mmol/l
and asymptomatic
If OGTT
confirms
diabetes –
follow LES for
diabetes
<6mmol/l
Provide brief
intervention
Exit for routine
recall in 5 yrs
If OGTT does not confirm diabetes –
give advice on symptoms and lifestyle.
Recall annually for follow up OGTT
Physical Activity Assessment – Everyone attending for a vascular check should have their current levels of physical
activity assessed using the GP Physical Activity Questionnaire (GPPAQ). This classifies individuals into active,
moderately active, moderately inactive and inactive. Any individual identified as less than active should receive a brief
intervention advising them to aim for 30 minutes physical activity on at least 5 days of the week.
Data requirements:
Blood Pressure
Data requirements:
Blood Pressure
If YES
Carry out serum
creatinine test and
recall for
assessment by
GP practice team
Oral Glucose Tolerance Test
Diabetic –
follow LES
for diabetes
Hypertension
Risk Assessment
Blood Pressure
≥140/90mmHg or SBP
≥140 or DBP ≥90mmHg
FBG results
≥ 7mmol/l
and symptomatic
Chronic Kidney
Disease Risk
Assessment
Blood Pressure
≥140/90mmHg or
SBP ≥140 or DBP
≥90mmHg
If NO
Exit for routine
recall in 5 yrs
If eGFR
2
<60ml/min/1.73m
Manage and assess
for CKD including
urine
albumin:creatinine
ratio (ACR). Follow
up inline with NICE
guidance 73
If eGFR
>60ml/min/1.7
2
3m provide
lifestyle
advice
Exit for
routine recall
in 5 yrs
If Hypertension diagnosed
place on GP hypertension
register and follow up
appropriately
If NO
Exit for
routine
recall in
5yrs
If YES
Discuss links
between BP
and lifestyle. To
identify
hypertension
recall for at
least two further
appointments,
checking BP
twice on each
occasion.
If not hypertensive
repeat lifestyle
advice and exit for
routine recall in 5
yrs
• Questions-Single best Answer
1
Which of the following statements does not apply to the Cardiovascular Disease Screening
Programme?
a) Cardiovascular disease screening will identify risk factors that will contribute to
vascular disease
b) Early intervention can reduce the onset of vascular disease
c) Cardiovascular Disease screening will support patients who have had a heart attack.
d) Cardiovascular Disease screening can prevent and in some circumstances reverse the
onset
of vascular disease
2
For what age group is the National Cardiovascular Disease screening programme
recommended?
a) 20yrs- 40yrs
b) 30yrs- 64yrs
c) 35yrs- 65yrs
d) 40yrs- 74yrs
3
Which of the following blood pressure measurements would you refer your client to their
GP?
a) 130/75
b) 130/85
c) 140/85
d) Above 140/90
4 Which of the following risk factors can be modified or potentially reversed in the
Cardiovascular Disease Screening process?
a) Age
b) High Blood pressure
c) Ethnicity
d) Family History Cardiovascular disease
5 Which of the following conditions will not affect a patient’s Cardiovascular Disease risk
calculation?
a) Smoking
b) Elevated BP
c) Diabetes
d) Alcohol
6
Why would a 45 year old male who smokes, has a blood pressure of 160/90, Total
Cholesterol/ HDL ratio of 6.0 and a BMI of 27.7 have a low CVD QRISK Risk Score of 8%?
a) They drink above the recommended 21 units of alcohol per week
b) They have Asthma
c) Because he is 45yrs old
d) Because he has Diabetes
7
Lifestyle advice/or referral as part of the NHS Health Check is important because….
a) Fresh air is good for everyone
b) It offers patients the opportunity to make lifestyle changes that will improve their
health
c) It looks good for the practice
d) The government thinks it’s a good idea.
8
When should a patient be sent for a fasting blood glucose test for assessment of Diabetes
through NHS Health Checks?
a) BMI is in the obese range >30
b) Blood pressure is at or above 140/90, or where the SBP or DBP exceeds 140 or 90
respectively.
c) The patient has a BMI >27.5 and is either Indian, Pakistani, Bangladeshi, Other Asian or
Chinese
d) All the above
Summary
• Increase awareness of health
promotion in primary practice
• Case presentation
• NHS health checks
Any questions?
Thank you
References
• www.doh.gov.uk. Putting prevention
first. Vascular checks: risk
assessment and management
• Oxford handbook of GP