The newly appointed National Clinical Director for Cardiovascular Disease Prevention looks at the challenges ahead:
There is now growing acceptance across the NHS that we have to get serious about prevention.
Why? Because year on year we are seeing a relentless rise in preventable illness that damages lives and threatens to break the NHS bank.
Much of this, of course, is driven by the epidemic of obesity, poor diet, inactivity and other risk factors that come with the 21st century lifestyle. It is estimated that around two thirds of premature deaths – that is deaths before the age of 75 – could be prevented by tackling the major risk factors. And one in four premature deaths is caused by cardiovascular disease (CVD), especially heart attacks and strokes.
What can we do about this in the NHS? Undoubtedly, population level interventions are key to supporting people to live healthily – for example, reducing salt and sugar content in food, banning smoking in public places, local planning and design regulation that makes it easier for people to be physically active, and action to tackle the social determinants of ill health. But in the NHS we must avoid the temptation to side-step prevention as ‘someone else’s business’. We have a responsibility to play our part in preventing ill health and supporting healthy living.
Firstly, we have an opportunity that no one else has. For example, with a million contacts every day, primary care practitioners see at first hand the scale and the personal impact of the health and wellbeing gap – two thirds of our patients are overweight, similar numbers are physically underactive, and one in five smoke.
These one million daily conversations give us the opportunity to support individual behaviour change systematically and at scale – if we have the right resources and systems in place to help us do that.
Secondly, despite having one of the best primary care systems in the world, there are significant gaps in how well we detect and treat the major physical risk factors for CVD – part of the care and quality gap. For example, four in 10 people with hypertension, that’s around 25,000 people in every CCG, are undiagnosed. That means they are unaware of their high risk and are not receiving the lifestyle advice and medical treatment that we know prevents heart attacks and strokes. Similarly, large numbers of people with atrial fibrillation and type 2 diabetes – both conditions that dramatically increase the risk of life-changing CVD – are undiagnosed or under-treated.
So what can we do to ramp up the NHS contribution to preventing cardiovascular disease and other conditions?
At a time of major financial constraint and unprecedented demand on the staff who deliver healthcare at the front line, we will only achieve this by doing things differently and by building new partnerships.
There are 3 key elements to focus on:
- Systematic approaches to improve our role in primary prevention: for example, community wellbeing and social prescribing initiatives can reduce GP workload while providing patients with more systematic and expert support for behaviour change. Innovative wellbeing partnerships linked to practices are springing up across the country, for example in Newcastle, Brighton and Halton.
- Systematic approaches to improve our role in secondary prevention: for example, supporting practices to reduce unwarranted variation in detection and management of high risk conditions such as hypertension, atrial fibrillation, raised cholesterol and diabetes. Bradford and Tower Hamlets have established successful programmes – and their success is very much driven by local primary care leadership. Innovative approaches elsewhere have included greater use of pharmacists, self-monitoring by patients and new technologies. The expanding RightCare programme will support CCGs to identify local opportunities for improvement.
The NHS Health Check and new Diabetes Prevention Programme offer a systematic approach for reaching individuals with undiagnosed risk factors. And the evolving new models of care in the Vanguard sites will provide a real opportunity for innovation to support earlier diagnosis and improved management.
- NHS support for population level approaches to prevention: CCGs and local authorities across the country are now developing their STPs – the long term Sustainability and Transformation Plans. There is a real opportunity for GPs and others in the NHS to offer clinical leadership and support in developing the STPs, to ask challenging questions of local authority and other partners on behalf of patient populations, and to help champion a system-wide approach to building health and wellbeing that will complement our actions in the NHS.
Over the coming months, I will be working closely with the National Clinical Directors for heart disease, stroke and diabetes to see how we can best support the NHS to play its part in preventing cardiovascular disease.