Getting Serious About CVD Prevention What does this mean for Primary Care?

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1 Getting Serious About CVD Prevention What does this mean for Primary Care? 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

3 Prevention works

4 CVD a principal cause of premature mortality CVD

5 CVD dramatic fall in mortality Total CVD mortality declined by 68% between 1980 and 2013 in the UK Ref: Bhatnagar et al, Heart Online, 2016

6 CVD dramatic rise in primary care management From 1981 to fold increase in CVD prescriptions in England Ref: British Heart Foundation, 2015

7 A population getting older

8 and a population getting bigger 8

9 The burden of cardiovascular disease

10 Global Burden of Disease Study 2013 Leading causes of premature death and disability in England

11 Population level measures have the greatest impact But the NHS has a critical contribution to make Prevention what can the NHS do?

12 Getting serious about prevention What s the role of the NHS? 1. Advocate for population level interventions 2. Support for individual behaviour change 3. Early diagnosis and optimal treatment of the high risk conditions

13 1. Primary prevention population measures National action o Tobacco restrictions, obesity strategy, sugar tax, food reformulation and labelling Local action o Place based approach of STPs o Local Authority, NHS, employers, schools, communities as partners o Planning, licensing, marketing, active transport, healthy workplace, etc Opportunity for NHS leadership through STPs

14 2. Primary Prevention supporting behaviour change One million daily consultations across primary care Multiple opportunities to identify lifestyle risk factors, provide brief interventions and signpost. Systematic support to make this more effective: NHS Health Check Programme Diabetes Prevention Programme One You, All our Health New models of social prescribing and wellbeing hubs linked to practices

15 3. Secondary prevention in high risk conditions 15

16 Secondary Prevention The High Risk Conditions for CVD But late diagnosis and suboptimal treatment are common 16

17 High risk conditions Preventive Treatment is Highly Effective High Blood Pressure Contributes to half of all strokes and heart attacks Every 10mmHg BP reduction reduces risk of CV event by 20% Atrial Fibrillation 5-fold increase in stroke risk and more likely to kill & disable Anticoagulation reduces strokes by two thirds in high risk AF High Cholesterol Progressive increase in risk of heart attacks and strokes Every 1 unit reduction lowers risk of CV event by 25% each year Type 2 Diabetes Doubles risk of heart attacks and strokes Control BP, cholesterol and sugar substantially reduces risk

18 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 (*with wide geographical variation) 1 in 2* 4 in 10*

19 Rule of Halves Preventive treatment before a stroke THIN database 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%

20 Widespread variation shows high level of inequality Percentage of people known to have AF prescribed anticoagulation before their stroke - CCG comparison Across England only a half of people with known AF who then suffer a stroke have been anticoagulated despite the dramatic impact of this treatment on outcomes. But wide variation between CCGs

21 Variation is even greater between practices Hypertension: ratio of recorded to expected prevalence CCG variation 43-58% Practice variation 27-74% 21

22 Plugging the CVD Prevention Gap The size of the prize 1. Improving detection and treatment in high risk conditions such as high BP, high cholesterol and atrial fibrillation would significantly improve outcomes 2. For example, NICE has modelled that if all appropriate patients with AF received anticoagulants, there would be 10,000 fewer strokes in England every year 3. If we only improved treatment in half the eligible patients, that would still prevent 5,000 strokes per year that s 25 strokes in every CCG 22

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24 24 Stow Health Self testing blood pressure New diagnoses Optimising treatment Released 15 hours/month clinician time

25 Dudley Practice pharmacists managing blood pressure 25

26 Lambeth & Southwark Pharmacists manage blood pressure and AF Community pharmacist interventions Results: Improved BP control 1300 new patients anticoagulated Estimated 45 strokes averted in 15 months

27 West Hampshire Systematic support to improve management of AF CCG wide programme: Leadership and education Screening and audit tools, Pharmacist interventions Results: Estimated 52 strokes averted in 20 months

28 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 200 strokes and heart attacks averted in 18 months

29 Improving secondary prevention in CVD The key local ingredients 1. Local clinical leadership GP, nurse, consultant, pharmacist, public health, commissioner, patient 2. Local intelligence how many people have high risk conditions that are undiagnosed or under-treated? 3. Clarity of vision - relentless local focus on the size of the prize - how many strokes and heart attacks could we prevent by doing better? 4. Doing things differently high impact interventions Mobilising the wider system to support general practice Expanded role for pharmacists in diagnosis, management & adherence Self testing and self monitoring Shared decision making eg anticoags and statins New technologies eg AliveCor, WatchBP Boosting NHS Health Check uptake Improvement at scale 29

30 CVD Prevention a must do for NHS sustainability 30 NHS RightCare will work with CCGs: To implement optimal value interventions Deploying audit tools and new models of care Improving detection and management in the High Risk Conditions for CVD

31 Thank