This article describes how high performance in cardiovascular disease (CVD) management, in a relatively deprived population with a high level of cardiovascular disease and a shortage of GPs, was achieved.
Outcome – In brief
More of the residents with cardiovascular disease in Thurrock have their conditions well managed (as measured by the Quality outcomes Framework) in primary care compared to the rest of the Mid and South Essex Integrated Care System’s area, and England:
- Blood pressure control in adults and older adults, both generally and for those with diagnosed hypertension, coronary heart disease (CHD), and stroke.
- Management of heart failure.
- Assessment of patients with atrial fibrillation.
- Recording of smoking status.
In addition, the quality of care in Thurrock is the best in the mid and south Essex area and it’s in the 20 per cent nationally measured by:
- 45+ year olds with a blood pressure check in the last five years
- Management of (CHD) patients with aspirin, APT and APC (drugs for treating CHD)
- Ensuring smoking cessation support is offered to patients with CVD conditions (over the last 24 months)
Thurrock also has the lowest proportion of hypertension that has not been diagnosed in mid and south Essex.
Cardiovascular disease (CVD) affects 7.6 million people in the UK, with those in disadvantaged communities experiencing higher rates of CVD and reduced life expectancy. Of all diseases CVD causes the highest levels of premature death and is a leading cause of inequalities in health outcomes. In Thurrock it was decided to undertake some focused work to address CVD, with General Practices and the Public Health Team, by starting a CVD data-driven programme of work. This has resulted in the borough now having the best-managed hypertension and other CVD conditions in England, as shown by recently released data (source: Hypertension and Risk factor statistics, Coronary Heart Disease Management Statistics, Stroke Management statistics and Population Health Management Health Inequalities profiles).
The case for tackling CVD in Thurrock
The 2016 Annual Public Health Report for Thurrock Council set out a vision and plans for a sustainable adult health and social care system in the Borough. This extensive report highlighted several issues including:
- Variable access to primary care within the Borough.
- Differences in the quality of care between practices (affecting both the detection and management of CVD conditions).
- Impact on patients of having differing quality of care, with resulting changes in their health status and consequent hospital admissions.
The report suggested ways that the health and care could be improved for Thurrock’s residents while delivering better value for money.
Uncovering undiagnosed CVD in Thurrock
Case finding strategies designed to improve the detection and management of long-term conditions, including cardiovascular disease, were piloted with a view to uncovering thousands of missing people with undiagnosed conditions. Blood pressure monitors were introduced into GP waiting areas, pharmacies and other care settings, alongside training for staff, to identify unmet need and refer patients to a clinician or emergency care if required
Improving the care of diagnosed CVD
A successful enhanced quality standards programme was run between 2017 and 2022. The Public Health Team worked with local clinical leads, practice managers and administrative partners to drive up the percentage of people with a diagnosis who were managed ‘to clinical threshold’, i.e., the threshold that effectively reduces an individual’s risk.
In addition, six training sessions were provided by a cardiology consultant to ensure the best quality and most up-to-date care was provided to all residents with a diagnosis of CVD, including diabetes, atrial fibrillation, and stroke.
These differing interventions resulted in Thurrock having the highest number of people in England with hypertension whose condition is well-managed. It is anticipated that the early reductions seen in associated hospital admissions observed in 2019/20, before the pandemic, will continue.
Holistic CVD care in the community
Following the successful enhanced quality standards programme, the next step was to create a holistic approach to care and improve the health and wellbeing of patients with a CVD condition. This aimed to further reduce the risk of a major health event or issue, and so reduce reliance on hospital or social care services in the future.
Risk assessment and population health management techniques identified a group of residents with two or more long-term conditions related to CVD e.g., high blood pressure or cholesterol, and Type 2 Diabetes. They applied the UCLP Proactive care frameworks, to identify people where a preventative approach might reduce the risk of their health becoming worse.
This group represents 25% percent of people in Thurrock with two or more long-term conditions, which equates to 2.4% percent of the entire population over 18 years in Thurrock.
They were from the following PCNs:ASOP (Aveley South Ockendon & Purfleet-on-Thames) Stanford-le-Hope and Corringham Tilbury & Chadwell Grays
The PCNs and Thurrock Public Health designed a new holistic approach to care, setting up and designing their own multiple morbidity clinics and interventions focused on cardio-vascular diseases, supporting the management of existing conditions and lifestyle support services.
The clinics are overseen by an advanced nurse practitioner and include social prescribers, community pharmacy, as well as Thurrock Healthy Lifestyle Service for smoking cessation, and weight management.
Building better heart health for Thurrock’s residents – what next?
Engagement and development of the programme has taken place throughout 2022 and early 2023. The clinics were established and trialled at three PCNs for six weeks, with 10% of the total group reviewed during this time. The group made improvements in the majority of clinical areas during this time, which helped identify areas of focus and development for 2023/24.
It is hoped that by the end of 2023/24 we’ll see improvements for this group in CVD risk factors, including blood pressure management and control, stroke risk assessment and anticoagulation. In addition, the group will have increased levels of flu vaccination, referral to stop smoking and weight management services, where indicated, as well as mental health assessments and any relevant onward treatment, through invitation and review at a clinic.
PCNs are committed to working together and using what they have learned to create a more personalised approach when developing services. They also will provide key measures and evaluation plans to provide insight into the patient journey through the service and allow improvements and changes as a result of the feedback. Quarterly feedback is being provided to PCNs, to inform service development with full results available to review in 2024.
It is also planned to increase focus on finding more residents who may have a cardiovascular condition but are not currently aware of it so that they too can receive this excellent level of care.Read the full report here
A range of services are available locally to help you improve your health and wellbeing. Click on the link below to find out more and access your local service.Lifestyle Services