Cardiovascular disease is a leading cause of mortality in the UK and a major driver of health inequalities. But it is highly preventable – both through changes to lifestyle and by treatment of the high-risk conditions that can lead to heart attacks and strokes.
We have developed CVDACTION to support GP practices to transform the prevention of cardiovascular disease. This smart data tool brings together all the key metrics for CVD prevention in one place, integrating the results of around 85 searches into user friendly, highly actionable dashboards, displaying gaps, opportunities and inequalities in preventive care. The tool mirrors the national audit, CVDprevent, but in addition provides GP practices with patient identifiable information so that clinicians can act on the data to prioritise and optimise care where needed.
CVDACTION is being evaluated by ten Primary Care Networks (PCNs) as part of a pan-London programme and a further five PCNs are implementing the tool outside of London. Before wider roll-out, we are learning from each PCN’s approach.
We spoke to Dr Deep Shah, GP, and Romil Mandvia, Pharmacist & Cardiovascular Disease Lead at Hammersmith & Fulham Partnership to understand how they have implemented CVDACTION and are prioritising and reviewing at-risk patients.
Embedding CVDACTION into local systems
The Hammersmith & Fulham Partnership, has taken a PCN-wide approach, pooling resources across the practices, such as PCN pharmacists and a centralised administrative function, to manage the booking and optimisation of patients identified through CVDACTION.
In North West London, the CVDACTION dashboard has been incorporated into the local Population Health Management system. This allows General Practice staff to access the data easily via a pre-existing data governance structure, ensuring that information is stored and accessed safely.
Before using CVDACTION, the PCN undertook the following to ensure patients identified through the dashboard are optimised and receive wider lifestyle support, in a streamlined way:
Stakeholder engagement & workforce mapping – The project team mapped and met with key stakeholders and workforce across the PCN to ensure all staff were aware of the programme and supportive of it. Engaging with staff was essential throughout the introduction of CVDACTION. This included clearly communicating the benefits for patients and staff, collaboration on process design and listening and acting upon concerns. This has ensured that all staff feel ownership over their work and reacted positively to the introduction of the tool.
We did process planning before we had access to the data. This involved meeting with pharmacists on each site to introduce the CVDACTION dashboard. At a CVD meeting we decided who would be involved in the new processes and how roles and responsibilities would be allocated.
Romil Mandvia, Pharmacist & Cardiovascular Disease Lead
Pathway Design – The programme team took time to review current pathways and map where high-risk patients, identified through the dashboard, would be directed, and where clinicians could receive additional support for more complex patients. The PCN also decided to include an initial desktop review for all patients identified in CVDACTION to streamline the process. Administrators play a key role as they call patients for reviews and therefore it’s important to ensure that the Partnership has sufficient administrative capacity.
At each site we have a CVD Pharmacist who delivers reviews and there is a CVD clinic. We set up pathways so that the CVD Pharmacist always has someone to go to with questions.
Romil Mandvia, Pharmacist & Cardiovascular Disease Lead
Resource management – The PCN anticipated what resources were needed, to effectively deliver holistic care to the high-risk patients. This included for example consultation templates, but also the broader UCLPartners proactive care resources.
Cohort prioritisation – In order to maximise the targeted approach CVDACTION enables, it is important to consider which specific cohorts need to be prioritised. The PCN wanted to tackle high risk hypertension and cholesterol and therefore decided to prioritise those not on therapy and those who had poor control of their condition. This was easy to do as CVDACTION provides a helpful way to select patients who need care early on and offers safety netting for high-risk patients who might otherwise see their care deferred.
The dashboard features a number of CVD indicator bars spanning the high-risk conditions that highlight at-risk groups.
By using CVDACTION we are trying to proactively prevent CVD, which might not have otherwise been done. The tool provides a helpful way to pick out patients who need care early on and offers a safety net for looking after patients.
Romil Mandvia, Pharmacist & Cardiovascular Disease Lead
Next steps
Next steps will see patients booked into pharmacy clinics after their initial desktop review to begin optimisation. Patients will then be followed up by the same pharmacists in as little as two weeks to rapidly monitor progress and ensure they are seeing the expected improvements.
Our top tips
- Prioritise: select which cohorts of patients you intend to start with and deploy staff and resource accordingly.
- Clarity: Make sure you have a clearly communicated escalation policy.
- Engage, engage, engage: Raise awareness amongst staff about the tool at the beginning of implementation and bring them along with you, encouraging a co-designed process.
- Adapt accordingly: Elderly cohorts of patients may need a bit more support. Demographic data can help with this.
- Educate and empower: Enable patients to self-manage.
- Have regular slots: Make time for pharmacists every week which allows you to build in follow ups.