Hypertension: brief intervention to increase physical activity

Indicators

IND95: The percentage of patients with hypertension aged 16 to 74 years in whom there is an annual assessment of physical activity, using GPPAQ, in the preceding 15 months

IND96: The percentage of patients with hypertension aged 16 to 74 years who score ‘less than active’ on GPPAQ in the preceding 15 months, who also have a record of a brief intervention in the preceding 15 months.

Introduction

This report provides a high-level cost impact assessment for two indicators relating to physical activity piloted for the 2012/13 NICE menu of indicators for QOF. The intent of these indicators is to incentivise an assessment of physical activity in people with hypertension and to encourage physical activity in those people identified as inactive. The indicators aim to promote the link between increased physical activity and improved health outcomes outlined in the recommendations made in ‘Four commonly used methods to increase physical activity’ (NICE public health guidance 2), which take into account the Chief Medical Officer for England’s (CMO’s) recommendation that adults should achieve at least 30 minutes of moderate activity on 5 or more days of the week (Department of Health 2004).

The General Practice Physical Activity Questionnaire (GPPAQ) is a screening tool, validated for use in primary care, to assess physical activity levels in adults aged 16 to 74 years. It is used to help inform a practitioner of when a brief intervention to increase physical activity is appropriate.

Brief interventions in primary care are defined as any intervention involving verbal advice, encouragement, negotiation or discussion with the overall aim of increasing physical activity by a health or exercise professional, with or without written or other support or follow-up. Brief interventions vary from basic advice to increase activity to more extended, individually-focused attempts to identify factors influencing levels of activity, and are delivered by a wide variety of primary care professionals.  

Cost implication

Patient numbers affected

The intent of this indicator is to assess physical activity levels in people with prevalent cases of hypertension. QOF indicator BP1 in the 2011/12 General Medical Services contract provides a register of people with prevalent hypertension. Using the most recent published data (2009/10) for this indicator gives an eligible population for GPPAQ of 7.3 million.

Table 1 Estimated number of people with hypertension in England eligible for the General Practice Physical Activity Questionnaire (NHS Information Centre 2010)

Current indicator	Denominator
BP1: The practice can produce a register of patients with established hypertension	7,321,472

Current care

Data collected during piloting of these indicators demonstrated that the GPPAQ is not being routinely used in primary care.

The NICE costing report for NICE public health guidance 2 (NICE 2006) estimated that brief interventions for physical activity were instigated on an opportunistic basis in 25% of the total appropriate instances, that is, to inactive adults presenting to general practice, with the potential to rise to 50%.

In 2009 the Department of Health launched a new physical activity care pathway called Let's Get Moving (LGM) based on the principles of NICE public health guidance 2. Commissioning of the pathway was expected to further increase the use of brief interventions for physical activity in primary care and to increase the uptake of the GPPAQ tool which is part of the set of resources for the LGM pathway.

The QOF at present does not include dedicated physical activity indicators, although the 2011/12 QOF indicator for primary prevention of cardiovascular disease (PP2) incentivises lifestyle advice on increasing physical activity, smoking cessation, safe alcohol consumption and healthy diet for those newly diagnosed with hypertension. If IND95 and IND96 are negotiated into the QOF, the reference to ‘physical activity’ would be removed from current QOF indicator PP2.

Table 2 National level results for 2009/10 for current QOF indicators (NHS Information Centre 2010)

Current indicator	Numerator	Denominator	Underlying achievement
PP2: The percentage of people diagnosed with hypertension (diagnosed after 1 April 2009) who are given lifestyle advice in the preceding 15 months for: increasing physical activity, smoking cessation, safe alcohol consumption and healthy diet	229,908	272,217	84.6%

Proposed care

GPPAQ takes approximately 30 seconds to fill in and can be completed:

• by patients waiting for appointments
• in disease-specific clinics
• in routine consultations
• in activity clinics.

It then takes a maximum of 1 to 2 minutes to transfer the responses to the electronic template and analyse the result. The template will automatically assign a Physical Activity Index.

The delivery of lifestyle advice on increasing physical activity already forms part of standard care for 2011/12 QOF indicator PP2. This component of PP2 would be removed from the indicator wording of PP2 if NM36 and NM37 are included in the QOF. In practice, the delivery of a brief intervention for physical activity would be indicated in a proportion of those people currently receiving lifestyle advice for physical activity, that is, in those scoring ‘less than active’ using GPPAQ.

Resource impact

While pilot data showed that GPPAQ is not routinely being used in primary care, people with hypertension are in regular contact with their GP for blood pressure checks. In addition, the time required to complete GPPAQ is minimal. There may be a requirement for an additional amount of GP time in some cases, however it would be reasonable to assume that annual assessment of physical activity using GPPAQ could be carried out opportunistically for the majority of people.

Pilot data showed that 52% of people assessed using GPPAQ scored ‘less than active’ and would therefore be eligible for a brief intervention. Evidence suggests that brief interventions for physical activity are instigated on an opportunistic basis in 25% to 50% of cases in primary care. In addition, the delivery of lifestyle advice on increasing physical activity already forms part of standard care for 2011/12 QOF indicator PP2, and 2009/10 achievement for this indicator shows an average national achievement of 84.6%. Pilot data suggest the delivery of brief intervention by GPs or practice nurses involved a 1 to 2 minute discussion at the end of a consultation.

Assuming that 50% of people who are identified as ‘less than active’ will require a brief intervention by a GP or practice nurse at the end of a consultation, the potential costs of this indicator are outlined below.

Table 3 Estimated cost of delivery of brief interventions in those people scoring ‘less than active’ on GPPAQ

-	BP1
Number of people eligible for GPPAQ	7,321,472
% of people scoring ‘less than active’	52%
Number of people eligible for brief intervention	3,804,551
Expected uptake	90%
% of people currently receiving a brief intervention	50%
Number of people requiring a brief intervention	1,712,048
Cost of a brief intervention by a GP	£5
Cost of a brief intervention by a practice nurse	£1.16
Estimated cost if carried out 50/50 by a GP/practice nurse	£4,846,200

Note: Costs of a brief intervention by a GP or practice nurse assume a 1.5 minute discussion following a consultation based on £36 per 12 minute GP consultation and £12 per 15.5 minute nurse consultation.

Sensitivity analysis

Estimates of cost have been provided for varying uptake levels from 50% up to a maximum of 100%.

Table 4 Estimated cost of delivery of brief interventions in those people scoring ‘less than active’ using GPPAQ based on various uptake levels

Denominator	50%	60%	70%	80%	90%	100%
BP1	£2,692,333	£3,230,800	£3,769,266	£4,307,733	£5,798,872	£4,846,200

Unquantifiable costs

There is a potential for further additional costs if, after the brief intervention, people are referred on to other services, for example, exercise classes. However, feedback from the pilot suggested that these services were not routinely available. In addition there are a number of methods to increase physical activity without occurring costs, for example using free outdoor gyms provided in some areas by local councils.

Providing written information to people about the benefits of activity and the local opportunities to be active and follow-up appointments, as recommended in the NICE public health guidance 2, may also have an impact on resources, however these costs are difficult to quantify. In addition, these activities are not specified in the new indicators and therefore would not be directly attributable to implementation of this indicator.

Potential savings

There is a clear link between physical inactivity and ill health. A study into the burden of physical activity-related ill health in the UK for just five conditions
(post-menopausal breast cancer, lower gastrointestinal cancer, cerebrovascular disease, cardiovascular disease and type 2 diabetes) estimated that the related ill health caused 3.1% of morbidity and mortality in the UK contributing to a direct cost to the NHS of £1.06 billion per year (Allendar et al. 2007).

People who are physically active reduce their risk of developing major chronic diseases such as coronary heart disease, stroke and type 2 diabetes by up to 50%, and reduce the risk of premature death by about 20% to 30% (Department of Health 2004). Implementation of these indicators may therefore result in financial savings to the wider NHS through a reduction in ill health associated with inactivity.

Conclusions

Annual assessment of physical activity using GPPAQ could be carried out opportunistically for the majority of people included in the proposed indicators IND95 and IND96. Evidence suggests that brief interventions for physical activity are instigated on an opportunistic basis in up to 50% of cases. In addition, the delivery of lifestyle advice on increasing physical activity already forms part of standard care for 2011/12 QOF indicator PP2.

Based on an uptake of 90% the expected cost of implementing the proposed indicators for physical activity is estimated to be £4.8million in opportunistic costs to GP practices. This is assuming that consultation length increases by 1 to 2 minutes for a proportion of patients.

There may be additional costs to commissioners if services such as exercise classes are provided locally. However evidence suggests limited availability of these services.

There is the potential for implementation of these indicators to result in
financial savings to the wider NHS through a reduction in ill health associated
with inactivity.

References

Allender S, Foster C, Scarborough P, Rayner M (2007) The burden of physical activity-related ill health in the UK. Journal of Epidemiology Community Health 61: 344–348.

Curtis L (2010) Unit costs of health and social care 2010. Personal Social Services Research Unit: The University of Kent.

Department of Health (2004) At least five a week. Evidence on the impact of physical activity and its relationship to health: a report from the Chief Medical Officer. London: Department of Health.

Department of Health (2006; updated 2009) The General Practice Physical Activity Questionnaire: A screening tool to assess adult physical activity levels, within primary care.

Department of Health (modified April 2010) Let’s Get Moving – introducing a new physical activity care pathway [online].

National Institute for Health and Clinical Excellence (2006) Four commonly used methods to increase physical activity. National costing report. Implementing NICE public health intervention guidance 2. London: National Institute for Health and Clinical Excellence.

NHS Information Centre (2010) QOF 2009/10 results: England level QOF tables 2009/10 – clinical tables 2009/10 [online].