Prevention in Primary Care

Short-term delivery of two targeted initiatives which support local and national programmes of work relating to prevention, specifically to CVD. Activity must be delivered between 1st March 2026 - 31st December 2026. A rising prevalence of cardiovascular disease (CVD), diabetes, chronic kidney disease (CKD), and obesity in Surrey Heartlands, with significant health inequalities affecting deprived and high-risk groups. There is a growing number of people living with major illness, projected to increase by over a third by 2040. The working-age population (20-69 years) is particularly affected, with poor treatment-to-target rates for CVD and related conditions. Early identification and intervention are needed to reduce acute healthcare demand and improve long-term health outcomes, especially among underserved and priority groups to support a reduction in health inequalities. Service outcomes: * Improved early detection and management of CVD, diabetes, and CKD * Reduction in modifiable risk factors (smoking, poor diet, inactivity). * Improved health outcomes and reduced health inequalities. * Increased treatment-to-target rates for CVD and cholesterol * Enhanced quality of life for patients with CVD, diabetes and obesity, measured through patient-reported outcome measures. * Cost savings through reduced hospital admissions and improved disease management. * Positive return on investment for preventative interventions Service Element 1: Healthchecks Healthchecks to be carried out on registered patients who are; - Aged 25-39 living in one of the Surrey Heartlands five priority neighbourhoods - Aged 18-24 in Higher Education who are from minority ethnic communities and in one of the Surrey Heartlands five priority areas Service Element 2: CVD Prevention Additional Enhanced access clinics to be established to specifically target the working age population who are not currently treated to target for cholesterol management (CVDP003). Payment: Service Element 1: Healthchecks Clinics in Under 40's: PS40 per health check Service Element 2: CVD Treatment to Target Clinics: PS369.56 / 2hr Session or PS739.12 per 4-hour session. There will be no additional payments for activity over the stated thresholds. This Service should be provided to all eligible patients defined within the service specification including any registered patients who are housebound and requiring treatment. Funding includes work associated with home visits or community events Aims: * To deliver targeted health checks and preventative interventions for CVD, diabetes, and obesity. * To support primary care in improving access, outcomes and experience for high-risk and underserved populations. Objectives: * Expand health checks to adults aged 25-39 (or 18-24 in higher education, from minority ethnic communities) in priority neighbourhoods, focusing on early detection and intervention. * Support GP Federations or PCNs with financial resource to run targeted clinics for the working-age population (18-59) to improve treatment-to-target rates. * Address health inequalities by targeting interventions to groups at greater risk due to socio-economic factors, age, or geography. Priority Neighbourhoods: Hooley, Merstham & Netherne; Westborough; Bellfields and Slyfield; Canalside; Stanwell North The targeted work will be defined by specific time and volume parameters, to identify service gaps and needs. It will assess the benefits of large-scale models to inform the future design of Surrey's prevention services. The project requires access to GP practice patient lists, existing collaborative relationships, and established financial pathways to support its implementation. Exclusion criteria and thresholds * Healthchecks in smokers Under 40 where there is currently a funded project being delivered by Public Health * The payments for this work are to support the setup of clinics and delivery of Healthchecks and does not duplicate payments paid out for QOF or Public Health for achievement. Additional information: PSR Key Criteria requirements: Quality & Innovation 20% Compliance with national standards: IPC (NIPCM for England, National Standards of Healthcare Cleanliness 2021, NICE CG139/QS61), chaperone/consent guidance (GMC/CQC), serious-incident reporting, safeguarding (Pan-Surrey procedures; CQC Reg 13), medicines alignment to APC/PAD, equipment standards (e.g., ECG 60601-2-25), premises suitability. Innovation in delivery such a novel clinic formats (e.g., targeted extended-access sessions, community events), digital outreach, continuous feedback loops, measurable treatment-to-target improvement. Value 10% Delivery against payment model (e.g., PS40 per Health Check; PS369.56 / 2-hr CVD session), activity thresholds/timeframes (Mar-Dec 2026), avoidance of duplication, credible Return on Investment (ROI) case through reduced hospital demand/ improved outcomes. Integration, collaboration and service sustainability 25% Ability to deliver the service within system frameworks, collaboratively, sustainably, and in a way that supports ICS-wide priorities. Place-based delivery model: Operating model with GP federations/PCNs/practices that does not duplicate Public Health funded work (e.g., smokers under 40) and clarifies interdependencies with QOF/Public Health. Clinical systems & data: Access to patient list, use of Ardens templates in EMIS/SystmOne; correct SNOMED coding; data-sharing routes for referrals/escalations; quarterly monitoring forms Sustainability & continuity: Workforce plan, training via Surrey Training Hub as needed; subcontracting/collaboration arrangements; equitable coverage across federations; contingency for session delivery. Improving Access, reducing health inequalities and facilitating choice 35% Surrey primary care specific knowledge Comprehensive understanding of the local population and their needs Ability to ensure services are equitable across different federations and localities Demonstrated capability to identify, engage, and book eligible patients in the five priority neighbourhoods (25-39s and 18-24s in HE from minority ethnic communities), including multilingual/culturally appropriate outreach Evidence of reducing non-attendance and increasing uptake. Choice & accessibility: Offer women-friendly/community-friendly slots, home visits for housebound patients, reasonable wait times (<=2 weeks), and accessible venues compliant with dignity/privacy standards. Inequalities focus: Clear plan to reduce risk factors and improve treatment-to-target in working-age adults Ability to track improvements by deprivation/ethnicity/age cohort. Social Value 10% Local social impact: Plans to employ locally, develop health champions/volunteers, support community cohesion and confidence, and contribute to long-term wellbeing in priority neighbourhoods Alignment to NHSE expectations on social value. Basic Selection Criteria: 1. Ability to deliver the required CQC-regulated activities through appropriate CQC-registered entities and robust governance ensuring compliance with CQC requirements 2. Premises & equipment suitability (CQC-registered premises or appropriate venue; equipment meeting standards, e.g., ECG 60601-2-25; calibration/servicing arrangements). 3. Clinical systems capability (access to EMIS/SystmOne and ability to use Ardens templates and required SNOMED codes). 4. Information Governance (IG standards met; data-sharing and reporting as specified; quarterly forms with no patient identifiable information) 5. Safeguarding compliance (Adults/Children/LAC; Pan-Surrey procedures; CQC Reg. 13; training). 6. IPC competence (NIPCM; National Standards of Cleanliness 2021; NICE CG139/QS61; education framework level for IPC leads). 7. Medicines governance (alignment to APC PAD decisions/pathways). 8. Workforce/training (evidence of suitably trained/credentialed staff; access to Surrey Training Hub). 9. Home-visiting capacity for eligible housebound patients. 10. Coverage and capacity to deliver clinics across the five priority neighbourhoods within timeframes and activity thresholds. 11. Interdependencies/QOF/Public Health alignment (no duplication with PH smokers under 40; clarity on how activity sits "over and above" extended access).