The NHS long-term plan has highlighted cardiovascular disease prevention as a national priority. It sets out an ambitious 10-year commitment to prevent 150,000 heart attacks, strokes and cases of dementia, by improving the detection and management of the high-risk conditions – atrial fibrillation, high blood pressure and high cholesterol.
A clinical urgency
The burden of CVD is huge. It is responsible for 25 per cent of deaths under the age of 75 and is a major contributor to health inequalities, accounting for a quarter of the life expectancy gap between rich and poor. Many of these deaths could be prevented by optimising care in the high-risk conditions.
For example, people with AF have a five-fold increase in risk of stroke – a risk that is reduced by up to two thirds by treatment with anticoagulants. Despite this, large numbers of people with AF remain undiagnosed, and even when detected many do not receive potentially life-saving anticoagulant treatment.
The CVD Prevention Size of the Prize in 2017 estimated that if we anticoagulated all people with known AF who are currently untreated this would prevent 14,200 strokes in England every three years.
Newly released Quality Outcome Framework data shows that we are making progress. For example, across North Central and North East London Sustainability and Transformation Partnerships, anticoagulation rates have risen significantly from 80.5 per cent to 82.7 per cent between April 2018 and March 2019.
This equates to 3,050 people with AF who have been started on anticoagulants. This is expected to prevent an additional 80 life-changing strokes in these communities this year and every year in the future.
Preventing heart attacks and strokes at scale will require primary care transformation, with new pathways for diagnosis and treatment that improve care and outcomes
Over the last three years, AF has been a clinical priority for all Academic Health Science Networks, working with primary care to drive system level action to find and treat more people with AF.
This has included business case support and quality improvement tools, pharmacist-led virtual clinics, treatment guidelines, education and training for staff, distribution of 6,000 handheld ECG devices to primary and community care settings, public awareness raising and pulse testing events, and patient self-management support.
To achieve the huge ambition for CVD prevention set out in the long-term plan, primary care will need to do things differently and at scale. Under-diagnosis and under-treatment of the high-risk conditions has been with us for a long time.
Indeed, there has been little change to the rule of halves for hypertension that I was taught as a medical student over 30 years ago (“half the people with high blood pressure are not known, half of those known are not treated, and half of those treated are not controlled”).
This is because apparently simple clinical tasks that we expect to happen in routine care – checking pulse and blood pressure – are often difficult to do in complex, time-pressured general practice consultations where multimorbidity and multiple clinical priorities are the norm.
Preventing heart attacks and strokes at scale will require primary care transformation, with new pathways for diagnosis and treatment that improve care and outcomes while reducing burden on GPs. The long-term plan and the new GP contract lay the groundwork for this transformation:
- CVDPREVENT, the new national primary care audit expected to launch in early 2020, will automatically extract routinely recorded GP data every three months showing the achievement, gaps and opportunities in the management of AF, blood pressure and cholesterol (as well as diabetes, pre-diabetes and chronic kidney disease). This will provide GPs with an essential tool for professionally-led quality improvement, allowing practices and networks to quantify patients who are sub-optimally treated or potentially undiagnosed.
- The thousands of new practice pharmacists being deployed to Primary Care Networks will provide an expanded clinical workforce that can support practices to systematically case find and optimise care in patients who are not treated to target, using the data outputs from CVDPREVENT.
- The Primary Care Network CVD Prevention contract, due to commence in April 2021, will resource networks and practices to case find and optimise treatment.
- A QOF Quality Improvement module on CVD prevention, developed with Royal College of General Practioners and the National Institue for Health and Care Excellence, is expected to come on stream in 2021.
STPs and Integrated Care Systems are now developing their operational plans and reflecting the long-term plan they are all expected to prioritise CVD prevention through the optimisation of AF, blood pressure and cholesterol treatment.
AHSNs will be key partners in this. In each of the six STPs served by the UCLPartners, a core priority to drive system transformation is to mobilise wider partnerships that include primary and secondary care clinicians, NICE, RightCare, Public Health, British Heart Foundation, the Stroke Association, and industry.
In addition, we will focus on building local clinical leadership through professional networks, communities of practice and leadership training; supporting quality improvement and adoption of new models of care; innovation in analytical tools that help transform data into action; and developing new community diagnostic pathways including more access to blood pressure testing in non-clinical settings.
It is now time to consign our tolerance of the rule of halves to history, and grasp the huge opportunity that the long-term plan brings to transform our management of the high risk conditions and prevent tens of thousands of heart attacks, stroke and dementia across the country.
This article was first published in the HSJ on 19 December 2019.