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

Dr Matt KearneyGP and National Clinical Director for Cardiovascular Disease PreventionNHS England and Public Health England

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• “The NHS needs a radical upgrade in prevention if it is to be sustainable”

• 5 year Forward View 2014

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NHS Prevention Board

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

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The Burden ofCardiovascular Disease

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Childhood obesity: a plan for actionSmoke Free NHS campaignNHS Healthy Workforce Programme - CQINAction on sugar sweetened beverages in NHS

Evidence reviewsAlcohol control policiesCVD prevention actions

IntelligenceCVD profiles, prevalence models, intel packsReturn on Investment toolNHS Health Check data extraction

NHS Health CheckDiabetes Prevention ProgrammeMenu of Preventive Interventions

Health marketing campaignsTobaccoalcohol

Digital support for behaviour changeHeart AgeFood SmartActiveTen

National Action on CVD Prevention

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NHS Health Check Evidence synthesis – Cambridge University/Rand Europe 2017

1. Detection of undiagnosed conditions• Hypertension 1:20-33• Diabetes 1:76

2. Health inequalities – uptake higher in lowest deprivation quintile3. Uptake suboptimal 48%4. Communication of risk suboptimal5. Variation in risk factor management – lifestyle and clinical

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Diabetes Prevention Programme – Early indicators

1. Coverage 75% England2. On target to enrol 100,000 by 20203. Take up 49%

• 44% male• 80% under 75• More from deprived and BAME communities

4. Retention – TBC

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Secondary prevention in Primary CareThe High Risk Conditions for CVD

High Blood PressureDiagnosed

Controlled to 140/90

Known AF and on anticoagulant at time of stroke

Atrial Fibrillation

High Cholesterol10 year CVD risk above 20% and

on statins

6 in 106 in 10

1 in 2

1 in 2

High Risk Conditions: opportunity for improvement

Type 2 DiabetesAll 8 care processes

All 3 treatment targets1 in 24 in 10

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Rule of Halves 2017Preventive 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%

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Are we all doing the same thing?

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Detecting Hypertension

Practice detection rates (excluding outliers)

Vary 45% – 65%

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Treating Hypertension

Practice achievement rates 150/90 (excluding outliers)

Vary 65% – 95%

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Anticoagulation in Atrial Fibrillation

Practice stroke prevention rates (excluding outliers)

Vary 60% - 95%

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Stroke Prevention in Atrial Fibrillation

CCG stroke prevention rates(excluding outliers)

Vary 25% - 95%

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How much does it matter?

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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

Why does the Rule of Halves persist?Why do we struggle to implement evidence based care?

General practice is complex• Asymptomatic conditions or states• Patients have multiple priorities• Clinicians have multiple priorities• Consultations are high pressure and complex

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

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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

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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

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NHS RightCare CVD Prevention Pathway

Solutions for quality improvement at scale to support General Practice

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High Impact Interventions

Resources:• Atrial Fibrillation• High Blood Pressure

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Practical solutions that support general practiceDoing things differently … new models of care and pathways1. 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

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What are people doing differently?Some examples

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New diagnosesOptimising treatmentReleased 15 hours/month clinician time

Stow HealthSelf testing blood pressure

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DudleyPractice pharmacists managing blood pressure

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BradfordSystematic improvement at scale and pace

Multiple interventionsShared approach across practices

Results• 21,000 Rx optimisations

(BP, AF, Cholesterol)• 200 strokes and heart attacks

averted in 18 months

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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

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Thank YouMatt.Kearney@nhs.net

@DrMattKearney