AT A GLANCE
THE CHALLENGE
High levels of deprivation, obesity and smoking were increasing the risk of CVD and life expectancy was lower than the national average. Take-up of NHS Health Checks was half pre-COVID-19 levels and particularly low among the most deprived patients and those from ethnic minorities. Hypertension was the most prevalent diagnosis across the PCN.
Patients with two or more CVD lifestyle risk factors had 5.5 more consultations per year on average than the general adult population. Hypertension was the most prevalent diagnosis across the PCN. Clinical coding, collaboration and sharing of information could be improved across the practices.
WHAT THEY DID
The national CLEAR team gathered local insight from staff across the PCN through site visits. face to face or remote interviews and two focus groups speaking to GPs. nurses. commissioners. a health and wellbeing co-ordinator. outreach worker and pharmacist. Data was analysed relating to 57,000 patients. 1.5 million appointments and 6.1 million consultations. Five themes emerged which included opportunities to improve patient pathways, develop the workforce in CVD care and improve data collection and use.
CLEAR RECOMMENDATIONS
The national CLEAR team recommended that the identification of patients with CVD risk factors could be enhanced by increasing the offer and take up of NHS Health Checks, optimising IT systems and improving booking and screening access, especially for younger patients and ethnic minority groups. Hypertension (blood pressure) reviews could be increased through risk stratification with remote reviews for medium and low risk patients and face-to-face reviews in practices and pharmacies for those at high risk.
The creation of a new CVD personalised care team would help patients change their behaviour and better manage their health.
New roles could be created to provide CVD leadership, engage with the community to reduce health inequalities. optimise coding and reduce workforce costs through the Additional Roles Reimbursement Scheme.
FORECAST IMPACT
A systematic approach to the identification, monitoring and management of patients at risk of CVD would significantly improve both life expectancy and quality of life for people in Hyde.
It’s forecast that up to 19 strokes and heart attacks a year could be avoided saving the NHS around £350,000 with a social return on investment of £1.6 million. The avoidance of disease could free up around 15,000 consultations a year. The cost of the new model of care would be offset by savings from reduced consultations and increased Quality and Outcomes Framework (QOF) revenue with an overall saving of up to 90,000 annually. Workforce diversification and career development opportunities could improve staff morale. Engagement with marginalised groups would improve, health inequalities be reduced and patient satisfaction increase with care tailored to their needs.
