Optimising treatment of high-risk conditions

LTP Priority: Prevention Cardiovascular Disease (CVD)

Population Intervention Triangle: Segments (link to Section 1 PHE PBA): Service

Type of Interventions: Optimising treatment of high-risk conditions (AF, BP, statins)

Major driver of health inequalities in your area of work

Cardiovascular disease is one of the health conditions most strongly associated with health inequalities.  If you live in England’s most deprived areas, you are almost four times as likely to die prematurely than those in the least deprived. CVD is also more common where a person is male, older, has a severe mental illness, or ethnicity is South Asian or African Caribbean.  CVD accounts for more than a quarter of deaths (> 124,000) in England and drives the life expectancy gap as the largest cause of premature mortality in areas of deprivation with 40% of all amenable deaths in CVD in the three most deprived deciles.

CVD causes heart attacks and strokes as well as dementia, kidney failure and limb amputations. Black people are almost twice as likely to have a stroke than white people.  African and African Caribbean people have their strokes on average 10 years younger than the Caucasian population. Evidence shows and increased stroke incidence among those living in more disadvantaged neighbourhoods and survival after stroke is lower in patients from the lower socioeconomic groups.

Atrial fibrillation increases stroke risk by a factor of five. High blood pressure and high cholesterol substantially increase risk of stroke, heart attack and dementia. Treatment of these conditions is very effective at preventing CVD. Despite this, many people are undiagnosed, untreated or under treated, with marked geographical variation. Optimising treatment of these conditions while targeting interventions in populations where the care gap is greatest, will have a significant and early effect in reducing health inequalities due to CVD.

Target groups

Deprivation. Protected characteristics.

Intervention

Optimising treatment of high-risk conditions (AF, BP, statins)

Making health inequalities a central theme of the CVD prevention programme

Health inequalities are a central theme in the CVD prevention programme: prioritising action on the three high risk conditions and targeting areas with the greatest prevalence and treatment gaps will deliver improvement and reduction of inequalities at scale.

The intervention will scale up optimising treatment in the under treated (AF, BP, statins) using new models and pathways that minimise burden on general practice utilising wider skills and capabilities of pharmacists and advanced practice nurses to systematically case find under treated patients across primary care networks (PCNs) and then optimising care.

CVDprevent, the new national primary care audit for CVD prevention will under pin this programme by providing real time data to spotlight gaps, inequalities and opportunities for improvement, and to monitor improvement and impact on inequalities.

There are plans to maximise contractual levers through the development of the service specification for CVD prevention informed by the PCN test bed programme and the AF demonstrator programme.

Evidence

Tackling inequalities in detection and management of the clinical risk factors and smoking will bring much earlier return on investment than action on other lifestyle factors e.g. obesity, diet, physical activity etc.

Modelling shows that 150,000 heart attacks, strokes and cases of dementia can be prevented over 10 years by optimising treatment of the high-risk conditions.

The biggest opportunities for CVD are through improved management of high-risk conditions such as AF and high blood pressure. Based on modelling for the interventions set out in the Long Term Plan, optimisation of blood pressure management alone could prevent up to 4,822 heart attacks and 7,197 strokes within five years, saving £149m.

Similarly, treatment of high-risk patients with AF could prevent a further 5,995 strokes and 1,437 deaths, saving over £69m within five years.

Public Health England, Chapter 5: Inequality in Health, 13 July 2017. 

Wang, Y., Rudd, A.G., Wolfe, C.D., Age and ethnic disparities in incidence of stroke over time: the South London Stroke Register, Stroke, 2013 Dec; 44 (12), 3298-204

Public Health England, Guidance: Using the world leading NHS Health Check programme to prevent CVD, 24 January 2018. 

Howard VJ, McClure LA, Kleindorfer DO, et al. Neighbourhood socioeconomic index and stroke incidence in a national cohort of blacks and whites.Neurology 2016; 87: 2340–47.