Health targets are a set of national measures designed to improve the performance of health services. They focus on population health objectives and on reducing inequities.
The More heart and diabetes checks health target began in 2012 and includes a cardiovascular risk assessment (CVDRA) and a blood test for diabetes (HbA1c) delivered in primary care settings.
The goal was for 90 percent of people in specified age and ethnicity cohorts to have had their risk assessed in the past five years. A budget included national funding, and incentives and sanctions for district health boards (DHBs) and primary health organisations (PHOs) to achieve the target.
The evaluation used mixed methods for data collection and was framed around five evaluation questions.
- How well was the health target implemented?
- What difference did the health target make for health practices/service providers and for those whose risk was assessed?
- What have been the economic implications of the health target and is it likely that the programme provides good value for money?
- To what extent are any gains made through the health target likely to continue?
- What should the Ministry of Health do to support CVD and diabetes risk assessment?
The evaluation findings for each of the questions is presented in this summary.
1. How well was the health target implemented?
This represents more than one million CVD and diabetes risk assessments reported since 2012.
The national coverage goal was achieved, but later than initially specified
The coverage rate increased from 49 to 90 percent of the population cohort reaching the coverage goal in September 2016. It is a considerable achievement that the national coverage goal was reached, albeit later than originally specified (June 2014). Four DHBs achieved 90 percent coverage in the originally specified timeframe; with a further 11 DHBs achieving the coverage goal by December 2015.
There were challenges to increasing coverage
The aspirational aim of 90 percent coverage set up a considerable challenge which was often referred to by nurses as ‘the hump’. Getting ‘over the hump’ was an important milestone, achieved through effective leadership, and IT developments, which collectively resulted in considerable buy-in and goodwill from the nurses.
The need for blood tests proved a challenge
Outreach activities were vital to engage with people who infrequently attend a GP. There was widespread evidence of novel and successful out-reach approaches, but the effort and cost required was sometimes considerable, with clinicians commenting that it took considerable resource to expand coverage beyond 80 percent.
Equity of coverage was not achieved but is improving
The gap in the coverage rate between Māori and non-Māori initially grew over the implementation period, but more recently this gap has been closing. This may in part be explained by the inverse equity hypothesis, where the ‘low hanging fruit’ is gathered earlier than that which is ‘harder to reach’. Further, the predecessor health target (2007 to 2012) focused more specifically on diabetes checks, which may have resulted in a high proportion of the Māori population being assessed before 2013.
2. What difference did the Checks health target make for health practices/service providers and for those whose risk was assessed?
The health target has clearly resulted in many more CVD and diabetes risk assessments being made and it seems that this has resulted in more people being aware of their risk and some making changes to reduce that risk. There are many challenges including health literacy problems, the best ways to communicate risk and how to help people make lifestyle changes, but the programme has increased attention to these issues.
Clinical leadership was important. Sometimes this was in the form of a single influential and vocal clinician who championed the programme – sometimes it was support from a broader team of clinical leaders.
Sector buy-in was important. It seems likely that the aims of the programme were not well communicated initially but buy-in increased over time. Importantly, a number of nurses expressed their increased awareness, developed through the programme, of their potential to make a difference to population health.
Motivation to improve patient health, a sound clinical imperative, and funding to support implementation were all important factors to achieving sector buy-in to the programme.
The assessments identified people with previously undiagnosed diabetes, and others were diagnosed as pre-diabetic. It is likely that this new information has led to long-term benefits for some if not all of these people. Evaluation participants, both practitioners and patients, reported lifestyle changes and medical treatment as a result of risk assessments, but this evaluation encountered no hard evidence to support a claim of improved health outcomes at a population level.
Support processes and systems
The programme contributed to improvements to front- and back-office support processes and systems, such as producing lists of patients due for assessment. These ‘patient lists’ were important to progressing coverage gains, and the capability to produce such lists has the potential to support the delivery of other population health programmes.
Increasing public understanding
The best indicator of increased understanding was when the patient returned for follow-up appointments and was found to have reduced their risk through the uptake of lifestyle changes or was using medications as prescribed.
The greater attention on CVD and diabetes risk, and communication of that risk to individuals, has helped to make the public more aware of their CVD risk and how to manage it. However, the evaluation found that communicating CVD risk well is difficult and time consuming, it is not always well-understood by consumers, the advice given is not always acted upon, and lifestyle changes were infrequently sustained over time by consumers who reported their actions through the patient perspectives survey.
3. What have been the economic implications of the health target and is it likely that the programme provides good value for money?
The health target is providing good value for money, but more evidence is needed on the programme’s benefits in terms of health outcomes: evidence that can be expected to become apparent in health statistics over time.
The same result would probably not have been achieved for less
The evaluation found that financial incentives adequately impacted coverage gains. For many people the incentives signalled CVD and diabetes risk assessment as a priority and helped to focus attention. For others the financial incentives were not a key motivator.
There were mixed views about whether or not resources have been efficiently used
Whilst health system resources were largely used efficiently, participants reported that compliance/administrative costs associated with implementing the programme, such as collecting and reporting data, were not insignificant and affected overall programme efficiency.
4. To what extent are any gains made through the health target likely to continue?
The assessments appear to be quite well embedded into most practices, but clinicians nevertheless consider it is likely that coverage will decline over time without the prompt of a national programme. The establishment of processes and systems, and the integration of these into broader work programmes, has been critical to making CVD and diabetes risk assessments part of routine practice.
5. What should the Ministry of Health do to support CVD and diabetes risk assessment?
- Continue to monitor and report risk assessment coverage, under the System Level Measures Framework.
- Complement the focus on risk assessment with greater attention on the management of elevated risk of CVD, stroke and diabetes.