The Size of the Prize Doing Things Differently To Prevent Heart Attacks and Strokes at Scale

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1 The Size of the Prize Doing Things Differently To Prevent Heart Attacks and Strokes at Scale Dr Matt Kearney GP and National Clinical Director for Cardiovascular Disease Prevention NHS England and Public Health England

2 The NHS needs a radical upgrade in prevention if it is to be sustainable 5 year Forward View 2014

3 NHS Prevention Board The NHS Prevention Board endorses CVD prevention as a priority for the Health and Social Care systems January 2017

4 Presentation title - edit in Header and Footer The Burden of Cardiovascular Disease

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6 National Action on CVD Prevention Childhood obesity: a plan for action Smoke Free NHS campaign NHS Healthy Workforce Programme - CQIN Action on sugar sweetened beverages in NHS NHS Health Check Diabetes Prevention Programme Menu of Preventive Interventions Evidence reviews Alcohol control policies CVD prevention actions Intelligence CVD profiles, prevalence models, intel packs Return on Investment tool NHS Health Check data extraction Health marketing campaigns Tobacco alcohol Digital support for behaviour change Heart Age Food Smart ActiveTen

7 Presentation 7 title - edit in Header and Footer NHS Health Check Evidence synthesis Cambridge University/Rand Europe Detection of undiagnosed conditions Hypertension 1:20-33 Diabetes 1:76 2. Health inequalities uptake higher in lowest deprivation quintile 3. Uptake suboptimal 48% 4. Communication of risk suboptimal 5. Variation in risk factor management lifestyle and clinical

8 Presentation 8 title - edit in Header and Footer Diabetes Prevention Programme Early indicators 1. Coverage 75% England 2. On target to enrol 100,000 by Take up 49% 44% male 80% under 75 More from deprived and BAME communities 4. Retention TBC

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10 Secondary prevention in Primary Care The High Risk Conditions for CVD 10

11 High Risk Conditions: opportunity for improvement High Blood Pressure Diagnosed Controlled to 140/90 6 in 10 6 in 10 Atrial Fibrillation Known AF and on anticoagulant at time of stroke 1 in 2 High Cholesterol 10 year CVD risk above 20% and on statins 1 in 2 Type 2 Diabetes All 8 care processes All 3 treatment targets 1 in 2 4 in 10

12 Rule of Halves 2017 Preventive treatment before a stroke THIN Database of GP records 29,000 patients at first ever stroke/tia 17,700 had one or more preventive drugs indicated Clinically indicated prevention drugs not prescribed Statin 49% Anticoagulant 52% Anti-BP 25%

13 Are we all doing the same thing?

14 Detecting Hypertension Practice detection rates (excluding outliers) Vary 45% 65%

15 Treating Hypertension Practice achievement rates 150/90 (excluding outliers) Vary 65% 95%

16 Anticoagulation in Atrial Fibrillation Practice stroke prevention rates (excluding outliers) Vary 60% - 95%

17 Stroke Prevention in Atrial Fibrillation CCG stroke prevention rates (excluding outliers) Vary 25% - 95%

18 How much does it matter?

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23 Why does the Rule of Halves persist? Why do we struggle to implement evidence based care? The ask is simple Routine pulse checks Frequent BP testing Frequent monitoring anticoagulant dosing, drug adherence In depth conversations/shared decision making - lifestyle, statins, anticoagulants General practice is complex Asymptomatic conditions or states Patients have multiple priorities Clinicians have multiple priorities Consultations are high pressure and complex

24 British Journal of General Practice October 2017 Matt Kearney, Julian Treadwell, Martin Marshall

25 What can we do to improve care and outcomes? More of the same is not likely to resolve the Rule of Halves that has been entrenched for decades We have no capacity to work harder We will only drive improvement by doing things differently

26 CVD Prevention a must do for NHS sustainability NHS RightCare will work with CCGs and STPs to improve detection and management in the high-risk conditions for CVD Implementing high impact interventions Mobilising the wider primary care to do things differently 26

27 NHS RightCare CVD Prevention Pathway Solutions for quality improvement at scale to support General Practice

28 High Impact Interventions Resources: Atrial Fibrillation High Blood Pressure 28

29 Practical solutions that support general practice Doing things differently new models of care and pathways 1. Expanded role for pharmacists Diagnosis and management BP and anticoagulant Supporting behaviour change Shared decision making anticoagulants, statins Supporting adherence BP, statins 2. Expanded role for patients Self-monitoring BP, TTR 3. New technologies Eg. AliveCor, WatchBP, Heart Age tool, SDM tools 4. Mobilising communities Increased uptake of NHS Health Check Widespread availability of BP testing 5. Systematic audit real time intelligence

30 What are people doing differently? Some examples

31 Stow Health Self testing blood pressure New diagnoses Optimising treatment Released 15 hours/month clinician time

32 Dudley Practice pharmacists managing blood pressure

33 Presentation title - edit in Header and Footer Bradford Systematic improvement at scale and pace Multiple interventions Shared approach across practices Results 21,000 Rx optimisations (BP, AF, Cholesterol) 200 strokes and heart attacks averted in 18 months

34 Summary Opportunity to prevent heart attacks, strokes and other vascular events AT SCALE Substantially improving outcomes for our communities We now have opportunity to do things differently o Clinical improvement: mobilising the wider primary care to support general practice We will need intelligence and innovation, creative partnerships and professional leadership to make this happen

35 Thank