Matt Kearney reflects on a joint NHS England/Public Health England initiative to help Sustainability and Transformation Partnerships (STPs) deliver at-scale improvement in the secondary prevention of cardiovascular disease.
The Size of the Prize for Cardiovascular disease (CVD) was announced jointly last week by Bruce Keogh and Duncan Selbie. The one-page graphic for each STP shows how many people in the STP area have undiagnosed high blood pressure or atrial fibrillation (AF) and how many have under-treated high blood pressure or AF. And it draws on published evidence to calculate how many strokes and heart attacks could be averted if treatment were optimised in those who are under-treated. The numbers are compelling.
For every STP it amounts to thousands of people with undetected or under treated conditions and hundreds of life changing events avoided. Aggregating these numbers across England over 3 years, optimising blood pressure treatment could prevent up to 9 000 heart attacks and 14 000 strokes and save £270 million, and optimising AF treatment could prevent 14,000 strokes and save £240 million.
AF and high blood pressure (along with cholesterol, diabetes and chronic kidney disease) are high-risk conditions that multiply the risk of cardiovascular events such as stroke, heart attack and dementia. Treatment is highly effective at preventing these events, and the success of general practice in providing secondary prevention has been one of the key reasons that early deaths from CVD have fallen so dramatically in recent years.
However, the rule of halves still broadly applies in these conditions. For example 40 per cent of people with high blood pressure are undiagnosed, 40 per cent of people with treated high blood pressure do not achieve the NICE target of 140/90, and 50 per cent of people with known AF who suffer a stroke are not treated with anticoagulants before their stroke. A major reason for this is that these are largely silent conditions. People often have no symptoms and without testing they are unaware of their level of risk.
The Size of the Prize shows the scale of opportunity in each STP area. But it is important to acknowledge that we are not going to realise this opportunity just by doing more of the same, relying solely on visits to the doctor to identify the high-risk conditions. The new relationships in STPs between NHS and Local Authority will allow us to do things differently and at scale, mobilising community interest and increasing access to routine testing, making it as normal to know your pulse and blood pressure as it is to know your weight and height. Many areas in the country are beginning to do this.
Examples include mobile blood pressure units in shops and community centres, automated self-testing machines in workplaces and leisure centres, and training a wide range of people to add blood pressure testing to their routine encounters with people – for example local authority and voluntary community workers, fire officers, opticians and pharmacy technicians. And of course, maximising uptake of the NHS Health Check which is currently reaching only 50 per cent of eligible people.
STPs can also act at scale to optimise the treatment of people with the high-risk conditions by maximising the roll out of the NHS RightCare CVD Prevention programme. RightCare delivery partners are now beginning to work with every CCG to improve the management of high blood pressure and AF – achieving this by mobilising the wider primary care system and organising services differently to support general practice and ensure patients get proven treatments.
Examples of this approach include:
- In Dudley, practice based pharmacists took over routine diagnosis and management of high blood pressure. In one year 27,800 new patients were detected with undiagnosed hypertension, and there was a substantial increase in numbers controlled to the NICE target of 140/90.
- In West Hampshire a mix of GP education, diagnostic devices for AF and pharmacist-run anticoagulation services resulted in an estimated 52 strokes being averted in 20 months.
- In Lambeth and Southwark, pharmacists were commissioned to manage blood pressure and AF. Over 15 months, an estimated 45 strokes were averted.
- Bradford Districts CCG has used at-scale methods to transform primary care pathways, optimising treatment in 21,000 patients with minimal added burden on GPs. This has delivered improved population-level control in blood pressure, cholesterol and AF, and substantial reduction in heart attacks and strokes (over 200 in 15 months).
Primary prevention is of course key to preventing CVD in the longer term, and the place based focus of STP partnerships will allow them to do this in a more creative and joined up way. The Size of the Prize casts a spotlight on scale of the opportunity to do better in secondary prevention, doing things differently and at scale across the STP, to avert large numbers of strokes and heart attacks in the relatively short term and deliver substantial financial savings.