If the government wants to make good on its ambition to shift the focus of the health system from treating illness to preventing sickness, then cardiovascular disease (CVD) absolutely has to be central to their strategy.
At present, CVD, a basket of conditions that includes things like heart attacks and strokes, causes around a quarter of all premature deaths (under the age of 75) per year in the UK – that’s 38,000 deaths in England alone. Shockingly though, or hearteningly, depending on how you want to look at it, up to 80% of these deaths are preventable.
“Tackling CVD represents an enormous prize”
For this reason, tackling CVD represents an enormous prize for a government looking to boost prevention. It causes a massive strain on the NHS and burdens the UK economy to the tune of £29bn annually by taking people out of the workforce. Most importantly, it also devastates the lives of patients and their loved ones. And yet preventing it, to an enormous extent, is already in our power. We know what works – but as with so much in healthcare, a key challenge is delivery.
Clearly, getting this right will mean a whole range of measures in terms of public health, with bold action needed to tackle obesity and smoking and create environments that are conducive to the kind of wider determinants of health that prevent people from being at risk of developing CVD in the first place.
It will also mean a huge amount of work in secondary prevention in terms of treating patients with CVD or CVD risk factors, which will, to a very significant extent, need to be delivered by our primary care infrastructure. However, in our recent King’s Fund report, supported by the British Heart Foundation, what we found on the state of CVD prevention across primary care was a mixed picture.
Across the country, we found evidence that Integrated Care Systems (ICSs) are for the most part bought into the idea that CVD prevention represents a major opportunity and imperative, and are actively working on secondary prevention in particular. What this looks like in practice, typically, is a focus on using data analytics to identify segments of populations that have an elevated risk of CVD, and then implementing various types of case finding approaches to go and find people with conditions like high blood pressure, high cholesterol, atrial fibrillation or undiagnosed CVD.
At the same time, work is being done to improve and optimise the care that people receive once they are found by the system – supporting people in primary care settings to adopt best practice, and to stay up to date with the latest medications and approaches.
All of these activities are positive – as far as they go.
“Initiatives were often stuck in a cycle of ‘pilot’ phases”
However, a major issue that we found during our work was that these kinds of initiatives were often relatively small in scale, or stuck in a cycle of ‘pilot’ phases. Major barriers were emerging in a number of areas, including around a lack of operational management support from Integrated Care Boards (ICBs) to enable those engaged in actual delivery, often GP practices, with the practical nuts and bolts of working at scale. There were also barriers around funding, with money often being short term or highly ring-fenced, meaning that CVD, and broader, prevention work was rarely on a sustainable long-term footing.
This meant that the work was happening in fits and starts, and was inconsistent geographically, with variable levels of clinical engagement and interest in CVD among primary care staff also having an impact here.
Addressing these issues will be vital if we are to seize the opportunity that CVD prevention represents. ICBs are undergoing significant changes at present, and we need to ensure that whatever new form they take is one that enables them to overcome challenges around consistent funding streams and make them able to support primary care in building the capacity and capability needed to shift to prevention.
In our report, we make a number of recommendations on how to do this. These include: national bodies helping local systems to strengthen their capabilities around operational management, place-based leadership and analytic expertise; and ICBs working proactively with GP practices and primary care networks (PCNs) to ensure that they have the training and technical assistance they need to transform pathways and act on available data sources for CVD, including CVDPREVENT.
“Let’s hope the opportunities this strategic shake up creates can be taken”
If this can be done – and flexible, sustainable funding streams can be created to enable primary care to take on and deliver secondary CVD prevention at scale – then the health and economic benefit for the country is enormous. If the NHS wants to deliver the government’s laudable aim of shifting the system from treatment to prevention, it has to start here. There are some encouraging signs in the newly published 10 Year Plan for Health which talks both about the importance of CVD and about the need to move away from short term fixes and short-term funding, so let’s hope the opportunities that this strategic shake up creates can be taken – sooner rather than later.
