The evolution of safe & well visits

Fire and rescue services have increasingly focused on fire prevention and household safety in a bid to reduce domestic deaths and injuries in the home. Firefighters and non-operational prevention staff have shifted from conducting household fire safety visits – commonly known as HSFVs – to safe and well visits. Checking on health and wellbeing allows for the development of new partnerships between local health providers and fire and rescue services. In Cheshire, the fire and rescue service did just this and Dr Julian Clarke was asked to evaluate one aspect of the change of approach.

In 2016, Cheshire Fire and Rescue Service was approached by and collaborated with the Cheshire Clinical Commissioning Groups and the NHS Innovation Agency (North West Coast) to add a test for atrial fibrillation as part of a safe and well visit to help save lives, principally amongst at risk older people aged 65 and over.

Atrial fibrillation is a cardiac arrythmia associated with a range of under-diagnosed and under-treated heart conditions, principally the occurrence of stroke. This article is based on a more detailed report published earlier this year that tries to estimate the value created by the addition of the offer of an atrial fibrillation check to safe and well visits carried out by Cheshire Fire and Rescue Service over the period April 2017 to March 2020.  

We look at value in two ways: first, we assess benefits accruing to householders using established proxies (Quality adjusted life year, Value of a Prevented Fatality). Second, we try to assess benefits to the NHS in terms of treatment savings. All calculations are based on a range of assumptions and so any monetary values must be regarded as potential ranges only.

Our analysis is based principally on safe and well visit statistics compiled by Cheshire Fire and Rescue Service. We also sought views on the value of atrial fibrillation tests from frontline staff, fire and rescue service managers and health service partners using questionnaires. Separately, Cheshire Fire and Rescue Service consulted with householders on the desirability of adding health checks to safe and well visits.

Checking for Atrial Fibrillation

Cheshire Fire and Rescue Service is unique in including the offer of a check for atrial fibrillation using a simple and accurate handheld Electrocardiogram device called Mydiagnostick. The Mydiagnostick is an easy to use device that accurately identifies symptoms of atrial fibrillation. It requires no skin electrodes or wires and the user of the device does not require any experience or medical knowledge. Within a minute or two of activation the Mydiagnostick gives an indication of whether a person has atrial fibrillation or not.

As noted above, atrial fibrillation is associated with a range of heart conditions and diseases, principally the occurrence of stroke. Although there are different risk models that predict the likelihood of stroke with atrial fibrillation, it is agreed that there is a causal link (Lip et al 2010, Gage et al 2001). The situation is complicated by the fact there are different types of atrial fibrillation. The check offered by Cheshire Fire and Rescue Service is primarily for silent or asymptomatic atrial fibrillation (Salieva et al. 2000).

Cheshire Fire and Rescue Service offered health checks to householders who were aged 65 or over. Following a brief conversation with the householder, with consent, an atrial fibrillation test using the Mydiagnostick handheld device is conducted as part of the safe and well visit. If atrial fibrillation is detected by the ECG device, recipients were then signposted to visit their GP for confirmation and potential treatment for the condition. The householder was provided with a leaflet that briefly explains the atrial fibrillation condition; the leaflet reaffirms the advice to make a GP appointment

Over the three years from April 2017 to March 2020, Cheshire Fire and Rescue Service carried out more than 120,000 safe and well visits. In over 82.000 cases, householders aged 65 or over agreed to answer the health and wellbeing section of the visit questionnaire. From that group, staff carried out over 8,500 atrial fibrillation checks using the Mydiagnostick device. This resulted in the identification of atrial fibrillation in 362 cases.

Setting up a satisfactory referral pathway system was problematic. It is important to remove any barriers that would prevent householders with a positive result actually visiting their GP for further testing and/or treatment. One way to help this would be to provide the householder with a printout of the reading from the Mydiagnostick device. One possible solution is for the medical equipment industry to innovate and develop a print enabled solution to an attached micro-printer.

More than 90 Cheshire Fire and Rescue Service staff responded to a questionnaire seeking their views about their experience of offering atrial fibrillation checks to householders. The majority were in favour of the addition, although some were unsure. Most thought that the training they had received equipped them to use the Mydiagnostick device and give appropriate advice to householders. Managers in partner organisations who were interviewed were very positive about the relationship with Cheshire Fire and Rescue Service.

Assessing the Value of Atrial Fibrillation Checks

Our work looked in detail at the value of offering the atrial fibrillation check to householders in Cheshire. The benefits of atrial fibrillation checks accrue to three different categories of stakeholder.

Category 1: Beneficiaries of the check

• Clients in who receive the atrial fibrillation check
• Family of the client and other (potential) carers.

The benefit is realised in therapy and the attendant avoidance of illness, costs of care and the potential improvement in older people’s wellbeing.

There are two basic ways of assessing the value of the atrial fibrillation check for Category 1 stakeholders: using the Quality Adjusted Life Year (QALY), which is a measure developed across a range of health services and tested across the European Union (Donaldson 2010) and the Value of a Prevented Fatality, a measure used by the UK Department for Transport.

Quality Adjusted Life Year: It is possible to assign monetary values to health outcomes using a proxy measure. The NHS has used a such measurement called a QALY (quality adjusted life year) to construct the cost-benefit analysis of specific interventions. The current value of a QALY is £60,000 (HM Treasury Green Book 2018). This represents the value of an individual of remaining in good health for a year.

Value of a Prevented Fatality: Department for Transport values for serious injury and fatality were used in previous research on the cost of fire deaths and injuries (DCLG 2008). A fatality is currently valued at £1,958,303, a serious injury at £220,058 and a slight injury at £16,964 (2018 values) (HM Government 2018).

In addition to these methods, there is a third approach that we are interested in using that focuses on improved wellbeing. Wellbeing has increasingly been incorporated into official thinking. Recent work has indicated that we should perhaps add to one of the foregoing calculations a value for improved well-being resulting from diagnosis and treatment. The methodology is suggested in the Treasury Greenbook (HM Treasury 2018).

Estimating the risk of stroke to people with atrial fibrillation is complicated. Risk rises with age and other factors. Research estimates that between one per cent and five per cent of people with atrial fibrillation are likely to have a stroke or other cardiac event (Passman and Bernstein 2016).  

If we take a minimal estimate that 3.62 strokes have been prevented for one year this is worth £217,000 based on a QALY figure of £60,000. If we take the maximal estimate of 18.1 the figure is £1,860,000. These figures do assume that all 362 people consulted their GP and received anticoagulation therapy.

Using the Department for Transport Value of a Prevented Fatality model, an intervention that prevents one death (from stroke) can be valued at nearly £2 million. If that intervention mitigates injury (a stroke survived) it can be valued at over £200k. Multiplying these costs by the likely number of strokes prevented gives a range of over £600k to over £3.6 million if we just assume that the check prevents serious injury. If we were to assume the same range for deaths prevented, then figures would range from a £6.9 million to over £34 million.

This valuation is made plausible by the consultation carried out by Cheshire Fire and Rescue Service. A very large majority of respondents (over 90 per cent) were positive about the addition of health and wellbeing checks to safe and well visits (CFRS 2019). There is also anecdotal support resulting from unsolicited phone calls from individuals that had tested positive reporting that they were now receiving anticoagulation therapy. The calls indicated an addition to the wellbeing of the families concerned and therefore added qualitative benefit and value.

Further research is needed to understand the impact of carrying out atrial fibrillation checks as part of safe and well visits. A starting point may include questions such as:

• What is the wellbeing value for the 362 householders of being directed to anticoagulation therapy?
• What is the wellbeing value for the 8,528 householders who got a negative atrial fibrillation result?
• Is it possible to put a monetary value of receiving news of a negative atrial fibrillation result? Even if we value it at only £100 per person this comes to over £800,000.

Category 2: Beneficiaries of budgetary/cost saving action

• NHS delivery organisations
  • Clinical commissioning groups
  • Hospital trusts
• Local authority public health teams.

The benefit is realised as the potential to avoid the costs of stroke treatment, aftercare and hospital bed occupancy.

Taking Category 2 stakeholders, we can use the same stroke occurrence estimates to calculate potential savings to the NHS and social care delivery organisations. For each stroke avoided there is a potential saving of £45,409 (Stroke Association, 2015).

Assuming the potential prevention of between 3.62 and 18.1 strokes the gross savings to the NHS and care providers range between a lower estimate of more than £164,000 and an upper estimate of over £820,000.

Category 3: Reputational/organisational/funding beneficiaries

• Cheshire Fire and Rescue Service
  • Management and administration
  • Frontline delivery officers and advocates
• Innovation Agency (Academic Health Science Network for the North West Coast in terms of public funding).

Benefits for this category of stakeholders are entirely dependent on achieving demonstrable benefits for categories 1 and 2. These benefits may be realised as enhanced reputation (as successful innovators and contributors to public service efficiency) and consequent sustained or increased funding.

The cash value of benefits to Category 3 stakeholders is difficult to calculate and would follow from the benefits calculated for Category 1 and 2 stakeholders. The immediate benefits will be reputational and developmental. For Category 1 stakeholders this will be assessed in terms of increased value to and satisfaction of service users (a potential measure of increased wellbeing). For Category 2 stakeholders the principal value will be in terms of budgetary savings.

Any additional cost to Cheshire Fire and Rescue Service and NHS in management time is outweighed by savings to treatment costs. The safe and well visits target the same potentially vulnerable group who are at higher risk of stroke and hard to reach by traditional health services.  By conducting atrial fibrillation checks the service has enabled an outreach to this group which can lead to early identification of potential cardiac illness.

Conclusion

The offer of an atrial fibrillation check during Cheshire Fire and Rescue Service safe and well visits is of public value. It provides a low-cost addition in the community to the preventative work of the NHS. They provide an assessable (subject to the recognition of a range of assumptions) cost benefit to three categories of stakeholders and probably provides wellbeing benefits to those that have had the atrial fibrillation check.

Reviewing the outcomes of our work, Professor Gregory Lip, Cardiovascular Medicine and Director of the Liverpool Centre for Cardiovascular Science, University of Liverpool, said: “The findings of the Cheshire FRS research show that a non-medical agency, such as a fire and rescue service, with appropriate training and provision of basic ECG devices, can successfully screen people for atrial fibrillation in their own homes. Addressing cardiovascular disease (CVD) is a priority for NHS England and Public Health England across Cheshire and Merseyside. This research report is evidence that Cheshire Fire and Rescue Service, through safe and well visits, has made a positive contribution to the local CVD agenda.”

Acknowledgements

Thanks to Mike Larking, Dan Taylor, Dr Julia Reynolds and Professor Gregory Lip for support and critical comments. This article is based on a much more detailed report (including full references) produced for Cheshire Fire and Rescue Service, which can be accessed from:

www.cheshirefire.gov.uk/Assets/1/200611%20%20SAW%20research%20master%20-%20formatted.pdf

About the Author Julian Clarke has a social sciences background including a PhD in social anthropology. Teaching and research originally focused on ethnicity, race, migration and equality policy. This led to work with the Commission for Racial Equality and the Local Government Association. He was a member of a team that developed the Equality Standard for Local Government and a subsequent assessment programme. A number of fire and rescue services took up the Standard and were assessed against the framework. A research interest in FRS management grew out of this work, which has focused on public service partnerships and the creation of public value. He has published work on the Migrants Impact Fund, fire and rescue services and equality management, fire and rescue services assessment of vulnerability and fire and rescue service accountability to citizens. He retired from full-time university work in 2017.