HEALTHY HEARTS IN THE WEST INITIATIVE ~ HHW COMMUNITY PHARMACY PROGRAMMES IMPACT OF THE PROGRAMMES FOR CLIENTS REFERRED TO THEIR GP AND WEIGHT MANAGEMENT CLIENTS May 2014 Healthy Hearts in the West is funded by The Public Health Agency and Belfast Local Commissioning Group HHW COMMUNITY PHARMACY PROGRAMMES IMPACT OF THE PROGRAMMES FOR CLIENTS REFERRED TO THEIR GP AND WEIGHT MANAGEMENT CLIENTS Contents Context 3 Overview of the Two HHW Community Pharmacy Programmes 4 Overview of Clients Referred to the GP following Vascular Risk Screening 6 Feedback from Clients: Vascular Risk Screening GP Referrals 8 Overview of Weight Management Programme Clients Followed Up 10 Feedback from Clients: Weight Management Programme 11 I would like to acknowledge and thank Ashleen Devine, the Community Pharmacy Programme Support Coordinator for her work with clients, following up those who participated in the HHW Community Pharmacy Programmes. Jane Turnbull Evaluator / Researcher Healthy Hearts in the West May 2014 2 CONTEXT The Healthy Hearts in the West Initiative (HHW) was established to mobilise existing resources and assets of communities in West Belfast, and to work with health professionals and other organisations, so that people living in West Belfast experience heart health equivalent to the best in Northern Ireland / Europe. In 2003 the Department of Health highlighted that pharmacists are the biggest untapped resource for health improvement. Pharmacies are located in the ‘heart of communities’, and are well placed to make an important contribution to improving public health and the wider promotion of health. Two Community Pharmacy Programmes, aiming to reduce risk factors to heart health, have been piloted in West Belfast, linking into the Healthy Hearts in the West Initiative. The Vascular Risk Screening and the Weight Management Programme are promoted and delivered by ten Pharmacies in West Belfast. Delivery of the HHW Community Pharmacy Programmes was supported by the Ulster Chemists Association. One of the most effective ways to evaluate the impact of the HHW Community Pharmacy Programmes is to collect data about ‘what happened next’ for those clients who were referred to their GP, and follow-up with clients who participated in the Weight Management Programme. In March 2014 (following a meeting including representation from the Pharmacists, the Ulster Chemists Association, the Public Health Agency, and Healthy Hearts in the West) it was agreed that there would be significant benefit in undertaking follow-up telephone interviews with clients to ascertain the outcome, and therefore personal impact, of the Community Pharmacy Programmes. It was agreed that the focus should be with clients who Pharmacists asked to self-refer to their GP following potentially high risk health check results, and also to talk with clients who completed the Weight Management Programme (and also those who did not complete the six-month Programme to ascertain their reasons for non-completion). This Report presents the feedback from Follow-Up telephone interviews undertaken by the Community pharmacy Programme Support Coordinator in February and March 2014. 3 OVERVIEW OF THE TWO HHW COMMUNITY PHARMACY PROGRAMMES Ten pharmacies engaged in delivery of the HHW Community Pharmacy Programmes, located within the HHW Hub areas as follows: Greater Falls Hub area (five pharmacies) Boots the Chemist James McDonagh Pharmacy McGettigan’s Pharmacy Rockville Pharmacy T A Maguire Pharmacy Upper Falls Hub area (three pharmacies) Doherty’s Pharmacy Ltd McGraths Pharmacy Woodbourne Pharmacy Close to the Upper Falls Hub area (two pharmacies) Laurel Glen Pharmacy Dairy Farm Pharmacy The Pharmacists involved with the HHW Community Pharmacy Programmes were expected to follow the same specification and protocols; they had all purchased the same equipment; and completed comprehensive Client Record Forms (developed in consultation with the Public Health Agency, who also collated data and provided the numerical data analysis for the first fourteen months of the Programmes). Basic criteria were established for those wishing to participate in the Programmes. Vascular Risk Screening is open to all adults aged over 45 years; the Weight Management Programme can be accessed by anyone over 18 years with a BMI of 30 or more. Clients with potentially at-risk health check results were advised by the Pharmacists to make an appointment with their GP. Pharmacists also signposted clients to: The Healthy Hearts Hubs (Lower Falls, Upper Falls and Upper Springfield) The Weight Management Programme (following the Vascular Risk Screening, when the clients BMI measured 30 or greater (ie ‘obese’) Smoking Cessation Programmes Specialist agencies. Pharmacists delivering the Programmes engaged with individuals raising awareness and advice on diet, physical exercise, alcohol, and smoking to support lifestyle change. In 2014 the Pharmacists were given a range of resource materials produced by the British Heart Foundation. 4 The Vascular Risk Screening and the Weight Management Programmes were promoted through posters, leaflets, word of mouth (referrals from the community sector and recommendation from family and friends), and through promotional activity at fifteen Health Events. Vascular Risk Screening The Vascular Risk Screening Programme offered a one-to-one consultation with the Pharmacist; and a series of health checks, namely: Blood Pressure, Glucose (Blood Sugar), Cholesterol, Body Mass Index (BMI), and Waist Circumference. 757 people have accessed the Community Pharmacy Vascular Risk Screening 131 people have been referred to their GP with potentially high-risk health check results 253 people were signposted by Pharmacists to community heart health programmes. A number of people referred to their GP took part in a short follow-up survey. A high majority had been prescribed medication, predominantly for high blood pressure, but also due to other at-risk health results. A minority were referred to health specialists (for example, due to diabetes). Weight Management Programme The HHW Weight Management Programme required clients to engage over a six month period. Following the initial one-to-one consultation and health checks, clients were expected to visit the Pharmacy for regular ‘weigh –ins’ using the Keito Machine (which they could personally access); and be able to access advice and support from the Pharmacist (who had all received training in Motivational Interviewing Techniques). 104 people enrolled on the Community Pharmacy Weight Management Programme 76 people have completed the Programme; and the majority who completed, have lost weight. 5 OVERVIEW OF CLIENTS REFERRED TO THE GP FOLLOWING VASCULAR RISK SCREENING As noted above, total of 162 clients were referred to their GP following the health checks. In February and March 2014 the Pharmacy Support Coordinator carried out a series of followup telephone interviews; using a short interview form (adapted from the PHA Farm Families Health Checks Follow-Up model). The Community Pharmacy Vascular Risk Screening and Weight Management Specification states that referral to the GP is required if: Client’s blood pressure exceeds systolic BP 160 mmHg and / or diastolic BP 90 mmHg If the client is known to suffer type 2 diabetes the ‘at-risk’ reading is deemed to be systolic BP 145 mmHg and / or diastolic BP 85 mmHg Total blood cholesterol concentration is 7.00 mmol/L or greater Additionally, Pharmacists referred clients to their GP when their Blood Glucose reading was greater than 8.00 mmol/L (note: this figure was not included in the manual as it was thought that different commissioners might wish to define alternative referral criteria. This is the criterion that is used within the HHW Community Programme health checks, and was detailed to the Pharmacists on the training day). The Pharmacy Support Coordinator sought to contact 51 clients who were referred to their GP by the Pharmacist following the Vascular Risk Screening. The table below shows that contact was made with 26 clients. No. of Clients Referred Pre-April 2013 12 Referred between April 2013 to January 2014 No response after three phone calls (post-March 2013) 14 3 Insufficient contact details (post-March 2013) Total 22 63 The table below presents the Pharmacy that referred the clients to the GP following participation in the HHW Community Pharmacy Vascular Risk Screening Programme. Pharmacy Pre April 2013 Dairy Farm Pharmacy Boots the Chemist Doherty’s Pharmacy Ltd James McDonagh Pharmacy 3 - No. of Clients April 2013 Insufficient to January contact info 2014 6 2 - 2 2 - No response to phone call 6 Pharmacy continued No. of Clients Pre April 2013 April 2013 to January 2014 Insufficient contact info No response to phone call Laurel Glen Pharmacy McGettigan’s Pharmacy 9 - 3 - 2 2 - T A Maguire Pharmacy McGraths Pharmacy - 3 2 2 2 Rockville Pharmacy Woodbourne Pharmacy Total 12 14 2 8 22 1 3 The table below shows the reason for Pharmacist referred the client to their GP (as recorded on the Client Record Form). Reason for Pharmacist Referring the Client to their GP Contact made with the client No. of Clients Insufficient No response contact to phone info call Total No. of clients Cholesterol level Blood Pressure BMI / weight Blood Sugar and BMI Blood Pressure and BMI Blood Sugar Cholesterol level and BMI Blood Sugar & Cholesterol level 6 7 5 4 3 1 2 4 4 3 3 1 4 1 2 1 - 12 11 9 7 4 4 2 2 Unknown Weight, Cholesterol & Blood Sugar - 2 1 - 2 1 As the table shows, the highest numbers of referrals were due to high cholesterol results, followed by blood pressure and BMI readings. The table also shows that 15 clients had two potentially high-risk health check results and 1 had three high-risk health factors. 7 FEEDBACK FROM CLIENTS: VASCULAR RISK SCREENING GP REFERRALS All 26 clients who were referred to their GP following the Vascular Risk Assessment, with whom contact was made, were asked whether they took the referral advice of the Pharmacist and made an appointment to see their GP. Client reported that they made an appointment and saw their GP Referred Pre-April 2013 Referred between April 2013 to January 2014 Total No. of Clients Male Female 3 4 7 4 4 8 Therefore, of the 26 clients who were referred to the GP 15 saw their GP and 11 did not (4 males and 7 females). Some clients explained why they had not made an appointment with their GP: Started Weight Watchers – already on prescription drugs for cholesterol (reason for referral) Has regular appointments with the GP and now feels the healthiest he has been for a year; also started running Too scared to go to the GP; takes painkillers, and believes blood pressure is alright (Pharmacist reported it as very low) Did not go because her husband died Has lost some weight; also went to the Royal Victoria Hospital and checked weight there, advised by the Nurse that the weight was ok Already on medication for blood pressure (referred due to high blood pressure reading) and has regular appointments with the GPHas porridge in the morning now (referred because of cholesterol levels) Plans to attend (referred in December 2013); but intends to go back to the Pharmacist first to recheck health results (referred because of cholesterol levels). The table below provides an overview of the outcome of the 15 clients who saw their GP Outcome of GP Appointment Referred to Specialist Service Review /Commencement of Medication Health Promotion Advice Given No action taken by GP No. of clients 1 8 10 5 Clients gave additional information about the outcome of their appointment with the GP. This has been categorised as no action taken by GP, action taken by GP in relation to medication, and lifestyle changes. 8 No action taken by GP The Doctor said that blood pressure and cholesterol health results (reasons for referral) were fine x 2 responses Blood pressure is fine and has remained fine (referred with high blood pressure) Referred because of blood sugar and BMI results – already taking tablets for cholesterol. Sees GP regularly because suffers from depression Action taken by GP in relation to Medication Taken off Beta-Blockers (blood pressure was low and falls) Started medication for blood pressure (Penndopril, 2mg and statins – client only has one kidney) has lost 18.5 kilograms Put on medication for blood pressure and cholesterol (Simvastatin) Was given tablets for cholesterol; but forgets to take them and doesn’t go back to the GP; has not stopped smoking Started on statins (referred because of cholesterol level) and has a review with the GP later in the month Changes in Lifestyle Doesn’t want to start medication (referred because of cholesterol health check result); instead has changed diet, including no butter and no chips Everything fine; no medication. Has started going to the gym. Some clients also engaged with the Healthy Hearts Hubs, and made lifestyle changes; examples given included Seeking advice from the Healthy Hearts Hub Coordinator Joining a HHW walking club Starting physical exercise programme Taking part in a healthy eating programme Going to the Leisure Centre (circuits, spin class During the telephone interviews the Pharmacy Community programme Support Worker gave clients advice. This included: Clients advised to make an appointment to see the GP Discussion with clients about opportunities to engage in physical exercise Signposted clients to smoking cessation programme Gave clients Healthy Hearts Hub Coordinator details Signposted clients to healthy eating programme. 9 OVERVIEW OF WEIGHT MANAGEMENT PROGRAMME CLIENTS FOLLOWED UP In addition to the clients contacted (or with whom contact was attempted to be made) because the Pharmacist referred them to their GP; a further 9 clients who had participated in the HHW Community Pharmacy Weight Management Programme were included in the follow-up telephone contact process. Contact was made with 8 of the 9 clients. All 9 clients had participated in the Weight Management Programme at T A Maguire Pharmacy. The table below shows the client’s initial weight, final recorded weight, weight loss, and whether or not they engaged in the Programme for the recommended six months. Weights recorded in stones and pounds were converted into kilograms in order to present similar data). The last client in the table is the person with whom contact was not made. 1 2 3 4 5 6 7 8 9 Male Female Male Male Male Male Female Female Female Initial weight recorded 115.9kg 84.5kg 92.9kg 111.0kg 112.0kg 101.6kg 66.0kg 97.8kg 98.4kg Final weight recorded 106.8kg 86.0kg 81.2kg 104.2kg 106.0kg 93.9kg 66.0kg 93.5kg 89.4kg Total weight loss - 9.1kg + 1.5kg - 12.7kg - 6.8kg - 6.0kg - 7.7kg No change - 4.3kg - 9.1kg Engaged for six months Yes Yes Yes Yes Yes Yes No Yes Unknown As the table shows: 5 clients were male and 4 were female 7 clients completed the six month Programme; 1 client left before the recommended six months, and it is unknown whether the client with whom contact was not made completed the Weight Management Programme 7 clients lost weight; 1 client gained weight, and for 1 client there was no change in weight (this client did not complete the Programme. Additional data provided records that the client who did not complete the Programme, and for whom there was no weight change was referred to her GP by the Pharmacist due to high Blood Sugar level results. She was subsequently diagnosed with diabetes; which she felt was more of a priority to address at the time than losing weight. 10 FEEDBACK FROM CLIENTS: WEIGHT MANAGEMENT PROGRAMME The 8 clients interviewed who had engaged with the Weight Management Programme were asked whether they attained their goal in terms of weight loss. As the table below shows; half of them felt they had achieved their goal, and the other half said they did not achieve their goal. No one said that they had exceeded their goal in relation to weight loss. Clients Attained Goal in terms of Weight Loss Yes exactly Yes exceeded No 4 - 4 One client said that it was “motivation” that helped them to achieve their goal. The clients were asked whether they had an future plans in terms of weight loss, and were given three options in relation to exercise, diet and nutrition, and wishing to lose more weight. Client feedback is given in the table below. Future Plans Yes No u/k Do you plan to carry on taking exercise? 4 3 1 Do you plan to watch what you eat? 7 - 1 Do you want to lose any more weight? 5 1 2 In what way? Walking Running Eating fruit and vegetables Joined Weight Watchers Joined Weight Watchers 4 clients reported that the GP referred them to their GP: Cholesterol level high – reduced by changing diet Cholesterol and blood sugar health check results high; diagnosed as a diabetic and on Simvastan for cholesterol (which has now reduced) Referred because of high blood pressure and cholesterol level; but these have both reduced with weight loss – 12.7 kilograms Put on medication for blood pressure and high cholesterol (Co-amitozide, bendro and statin) – also had a TIA Pharmacists had referred 6 of the people interviewed to the Healthy Hearts in the West Community Hub. 3 of them made contact with the Hub Coordinator. 3 engaged in diet, nutrition, or healthy eating programmes 2 engaged in physical activity programmes Clients gave feedback about lifestyle changes they had made following advice given by the Pharmacist. This included: Changed diet (no bread, no potatoes, no sandwiches, increased fruit and vegetable intake, eating fibre and wholemeal, homemade soups, stopped eating chocolate, diet coke, no salt in diet Taking more exercise (walking, gym 11 Gave up smoking Weigh self at home now Reduced alcohol intake Additional comments recorded during the interviews included: “I am still conscientious and eat breakfast, lunch and dinner, with fruit as a snack” “Although I lost 7.7 kilograms, I have put almost 4.5 kilograms back on six months after I stopped the Programme” “I was told about the Hubs; but have made changes for myself. I watch what I eat, no fatty foods, cut potatoes out, eat everything in moderation, and eat lots of fruit and vegetables (more than five portions a day)” “I reduced my cholesterol level by changing my diet”. “The Weight Management Programme gave me the incentive and I put more effort into losing weight”. 12