In the second part of the keynote address at Issues & Answers 2018 Professor Huon Gray (National Clinical Director [Cardiac] NHS England) provided a strategic update on the national priorities and ‘levers’ that are helping to improve practice in cardiovascular disease.
A huge amount of work in tackling cardiovascular disease has been carried out since the publication of the CVD Outcomes Strategy in 2013. Although not mentioned specifically in the 2014 Five Year Forward View, cardiovascular disease remains a national priority with a range of organisations working to promote change and encourage best practice in the NHS. Professor Gray summarised the wide range of work taking place in cardiovascular medicine over the past 5 years.
In 2016 Public Health England (PHE) published ‘Getting Serious about Prevention’ which provided excellent infographics and statistics to highlight the importance of cardiovascular disease prevention.
In addition, a recently published PHE Return on Investment tool will help commissioners to calculate the health benefits and cost savings in different cardiovascular prevention strategy to manage hypertension, atrial fibrillation, diabetes, hyperglycaemia, chronic kidney and disease and high cholesterol.
Early detection and risk
There has been increased focus on identifying at-risk patients. The NHS Health Check is having measurable success in this alongside the work of regional Academic Health Science Networks (particularly in atrial fibrillation and familial hypercholesterolaemia [FH]), QOF, the Heart Age tool and other strategies. There is growing evidence that a proportion of people who use the various assessment tools then move onto using additional resources (such as obesity management and smoking cessation support) to help them manage their conditions.
The NHS Health Check targets the top 7 causes of preventable mortality
- High blood pressure
- High cholesterol
- Poor diet
- Physical inactivity
- Excess alcohol consumption
Integration of services
The CVD Outcomes Strategy and the Forward View emphasized the importance of integration of services. NHS England has been pioneering new models of care which led onto Sustainability and Transformation Partnerships (STPs) which all produce plans for improved cardiovascular prevention services. Overall, there is a growing move to work in integrated care systems with networks expected to grow over coming years to further connect primary and secondary care.
Inherited cardiac conditions
There has been an increased effort to find people with undiagnosed FH and a recent 2017 addendum to NICE Clinical Guideline CG71 on FH management highlighted the need to systematically search primary care records to identify people 30 years and older with a total cholesterol (TC) level >9.0 mmol/L and those younger than 30 years of age with a TC of >7.5 mmol/L as these are the people who are at greatest risk of FH.
An FH Implementation Guide was published in August 2018 to provide a summary of the recent updates to the NICE guideline, an outline of national and European policy documents and best practice case studies to help healthcare professionals improve the identification and management of people with FH.
There have been encouraging signs of increased rates of FH diagnosis over recent years with a five-fold increase in diagnosis since 2010. This has been driven by the introduction of FH nurses funded by the British Heart Foundation and now 50% of England and Wales is covered by an FH nurse. However, much remains to be done as only 8000 new cases have been identified out of the estimated 150-200,000 undiagnosed cases in the country.
There has been an increased focus on genomics, with the recent identification of 7 Genomics testing hubs around the country to form a single national testing service for a variety of diseases including many CV genetic disorders. As of October 2018 all genetic testing for FH is commissioned by NHS Specialised Commissioning so funding is now available for all potential FH patients and their families to be tested.
NHS RightCare provides data so CCGs can compare their performance and costs with other similar regions to cut down variation in service provision. The agency also provides pathways of best practice and CV disease was the first pathway that was defined. All these efforts are helping to improve outcomes and practice in both primary and secondary care.
NHS RightCare: a programme committed to reducing unwarranted variation, to improve people’s health & outcomes, and reduce inequalities in health access, experience and outcomes”
Professor Gray also described the work in a number of other areas where developments are taking place in cardiovascular medicine:
- Specialised Commissioning – the Specialised Cardiac Improvement Programme has been launched to ensure best value for money in specialized cardiac medicine which mainly takes place in secondary care.
- Congenital Heart Disease Review – the NHS Board has approved Quality Standards for the delivery of services for congenital heart disease and work is ongoing to implement these standards.
- 7-day working – the limited availability of Cardiac Physiologists in hospitals and primary care continues to be a significant challenge.
- Improved survival from Out of Hospital Cardiac Arrest – the Resuscitation to Recovery document sets out a pathway for improved out-of-hospital care for people having a cardiac arrest. Also there is ongoing work between the British Heart Foundation and Microsoft to produce a database of public access defibrillators.
- 24 x 7 Services – in a range of urgent and emergency care networks for myocardial infarction, stroke and vascular medicine
- Inequalities – to improve access for different people groups including those with mental health issues, learning disabilities, and older people
- Diagnostics – improvements in diagnostic techniques including BNP, Echo, CT and MRI scanning
- Information – ensuring that healthcare professionals have the best access to clinical and statistical information.
Professor Gray concluded his presentation with some issues that could continue to disrupt progress in the management of cardiovascular disease including:
- The impact of deprivation – people in the most deprived quintile are 3 times more likely to die from CV disease than those in the least deprived quintile which results in a reduction in average lifespan of between 6.8 years for women and 9.2 years for men.
- Projected population figures show the increasing proportion of elderly patients who will require cardiovascular services with a smaller number of young people available to pay for these services.
- Growing pressure on the NHS drugs bill due to increased longevity and more complex and expensive medicines being developed.
- Long-term NHS funding issues
However, the inclusion of cardiovascular disease as one of the five NHS priorities in the recent NHS England draft Long-term Plan is welcome and will bring further collaborative opportunities to further improve cardiovascular care in the future.