Organisations launch a three-phase project to reduce number of people affected by cardiovascular disease, leading to identification of 18,000 patients with undiagnosed hypertension

Synopsis

The West Yorkshire & Harrogate Health and Care Partnership has commissioned Yorkshire & Humber AHSN to deliver a Healthy Hearts project on behalf of the nine local NHS Clinical Commissioning Groups.

This is a large scale quality improvement project, across a population of 2.6 million people. The aim is to reduce the number of people affected by CVD by 10%, consisting of an estimated reduction of 800 heart attacks and 350 strokes over the course of the project by addressing the risk factors of hypertension, cholesterol and diabetes.

Ambition

In February 2018, West Yorkshire & Harrogate Health and Care Partnership’s Clinical Forum (WY8eH HCP) confirmed support for a region-wide quality improvement programme focused on improving outcomes for people with CVD and Diabetes. This followed a review of NHS RightCare data that showed CVD and diabetes were clinical areas where the combined West Yorkshire and Harrogate CCGs had significant opportunities for improvement.

The decision was ratified by the WY&H HCP Joint Committee of CCGs which supported a three-phase project focusing on improvement management of Hypertension, Cholesterol and Diabetes.

The work supports the Hep’s ambition to reduce cardio-vascular disease incidents including heart attacks and strokes by over 10% by 2021, delivering an estimated reduction of 350 strokes and 800 heart attacks with estimated savings to the health and care economy of over £12 million.

The project aims to improve care by utilising existing primary care resources and maximising clinicians’ engagement with a large-scale improvement project. A central project management team is providing additional delivery capacity that allows the nine CCGs to maximise resources and the potential Impact of the project.

This project, which had its roots in work previously developed by Bradford Districts CCG (Bradford Healthy Hearts), has already started to see some excellent early results (see Outcome section).

Bradford Healthy Hearts switched 6,000 patients on to more effective statins and put a further 7,000 on to a statin who were not currently taking one to prevent future CVD risk. 2,500 additional patients were identified as hypertensive and 6,400 treated to achieve safe blood pressure targets.

The WYH Healthy Hearts project was launched to clinical leads and key stakeholders, who were briefed on the benefits and outcomes of the Bradford Healthy Hearts project and had the opportunity to ask questions and shape the approach to be adopted.

Each CCG then worked with its respective clinical stakeholders including; the Local Medical Council and Primary Care and Secondary Care colleagues to gain strategic sign up to the project.

Since its launch, a number of strategic events have been organised with the Clinical Leads and key stakeholders, in which the strategic direction has been agreed and supporting resources scoped. This has been conducted within the context and review of UK and International best practice, in order to develop a project that is evidence based, but that is suitable for local implementation.

Outcome

The WYH Healthy Hearts project has three phases, the first of which is focused on hypertension.

The resources developed as part of the project including simplified clinical searches and treatment guidance (see supporting document - section 3) have supported GPs to identify and treat approximately 18,000 patients with undiagnosed hypertension across the region and a further estimated 40,000 existing hypertension patients that may benefit from improvements to their existing medication or lifestyle.

The project has recently had its second quarter hypertension results and has seen nearly 3,500 additional patients having their blood pressure controlled to 140/90, and an extra 4,500 additional patients added to hypertension registers. Because of this, over the next five years, an estimated 28 people will avoid an early death, 52 people will not have a stroke and 35 people will not have a heart attack.

This excludes those additional patients who have recently been added to the hypertension register, who once controlled, will increase these outcomes significantly.

Public Health England’s Size of the Prize analysis shows that by optimising the treatment of all those with diagnosed hypertension across the WY&H HCP (69,700 people) could avert, within three years, 420 heart attacks saving of up to £3.1 million and 620 strokes saving of up to £8.8 million. For Cholesterol, the estimated adult population across WY8 (H with a 10-year CVD risk greater than 20% is 175,000 and of those 89,250 aren’t treated with statins. The Healthy Hearts project aims to identify and treat 10% of these leading to an estimated 400 CVD events prevented over five years saving around £4million.

These economic assumptions are verified by the University of Sheffield and Public Health England (CVD Return on Investment) based on work by the School for Public Health Research (SPHR) funded by the National Institute for Health Research (NIHR).

By approaching this as a WY81H region wide quality improvement project, it creates economies of scale and value for money in terms of implementation. The objective is to do once and share the learning. Resources are created centrally following extensive engagement and feedback from stakeholders and front-line staff, and then shared with the CCGs.

Resources, including treatment guidance, clinical information and communication materials, have created a strong brand and consistency of message that supports buy-in and delivery (see Supporting Document - section 3)

Spread

Fundamental to the success of the project are the resources that have been created and sharing the early results with key stakeholders, in order to demonstrate impact, gain buy in and keep momentum on delivery.

All the resources have been disseminated to GPs and health professionals including; treatment guidance, briefing presentations, the case for change and clinical background documents. Attendance at clinical protected time learning events for both Primary Care and Community Pharmacy have been successful for the spread of resources, and key project messages. These events continue to be supported and attendance at further events is planned for 2020.

Other methods of spreading resources include a joint CVD webinar with Public Health England which had good uptake and feedback from Primary Care. The webinar covered the rationale for creating local treatment guidance, how to find various useful CVD resources and counted towards Continual Professional Development for those joining the webinar.

The promotion of early results is essential to demonstrate the hard work that is taking place. A Healthy Hearts dashboard has been created which shows at a region, CCG and practice level (and soon Primary Care Network level) the impact of the project. This dashboard has been created to help identify areas of good practice and to identify areas where more support may be needed.

Regular highlight reports and communication materials are routinely disseminated to stakeholders to ensure key messages and progress updates are shared. These communications always include acknowledgements, which help to build relationships and trust through recognition of individual and organisational contributions to this large-scale quality improvement project.

Other areas have requested further information on how the project is being delivered and we are keen to share our learning. Areas interested in our work include:

• Greater Manchester
• Humber Coast and Vale
• Lancashire and South Cumbria
• Cumbria and North East
• Cheshire and Merseyside
• West Hampshire

The original Bradford Healthy Hearts website has been purchased by NHS RightCare, making it freely available to health economies across the country, allowing each area to develop and localise their own website.

The WYH Healthy Hearts website contains resources and information linked to the project and locally, CCGs have used much of the content to populate their own website landing pages. This gives a strong brand identity, which is important when promoting the work regionally.

The Healthy Hearts project has been put forward nationally as a potential AHSN innovation delivery model for CVD.

Value

We have developed resources to support GP practices to identify patients likely to require further investigation and management. These are simple, non-time consuming to implement and include:

• Clinical searches to facilitate identification of patients who need to improve their hypertension / cholesterol control
• Locally developed hypertension / cholesterol treatment guidance
• WYH Healthy Hearts website with resources for healthcare professionals, patients and public
• Dashboards showing areas of improvement and where further support is needed
• Hypertension / Cholesterol Implementation Resource with information and a checklist to help support GP practices.

Feedback from GP engagement events has been positive:

• Lots of useful info on the website. We can pick and choose what we really need.’
• ‘Really like the simplicity of the treatment guidance and it’s so good to have something that’s been created locally.’
• ‘These targeted searches will help us find patients a lot easier, especially when we’re all really busy.’
• ‘A good, clear protocol, nice and simple, which is really important.’
• ‘The advice on lifestyle and behaviour change, on the Healthy Hearts website, will be really helpful for staff at our practice.’
• ‘As a GP the searches are going to make my working day easier.’

We continue to capture feedback and have engaged directly with over 500 GP, health professionals and Community Pharmacists at education events across the region.

The Yorkshire & Humber AHSN project team includes a dedicated Communications and Marketing Manager, allowing us to create content and ensure messages are heard across the busy Primary Care landscape. The initial six months has seen over 2,400 profile views on our social media account, over 650,000 impressions of our Twitter campaign and over 9,000 views by over 2,000 users on our Healthy Hearts website.

A centralised approach to developing communication resources has ensured economies of scale are maximised providing value for money to the HCP by removing the need for individual CCGs to create resources. The HCP monitors delivery via routine reporting to relevant committees, including highlight reports, delivery dashboards showing data down to individual practice level and regular steering group and project meetings.

Yorkshire & Humber AHSN has added value to this project through relationship building and knowledge of NHS systems and this impact is seen in the supporting testimonials (Supporting Document - section 1) Our partners talk positively about the benefits we bring including; flexibility, building relationships, stakeholder engagement, drive and passion, helping to deliver early results and strong project management.

Involvement

The CCGs within the WY&H HCP have passionately committed to tackling CVD. This is seen through excellent attendance at our monthly implementation meetings and our stakeholder planning workshops.

To ensure we maximise success, we actively engage with a range of stakeholders: CCGs, primary and secondary care, as well as strategic partners from Public Health England, British Heart Foundation and the Local Pharmacy Committees. The engagement on our local treatment guidance for hypertension undertook extensive consultation over a three-month period gaining feedback from 40 different groups, organisations and committees including local Area Prescribing Committees, Local Medical Committees, and Consultants and Medical Directors from our local acute providers.

This led to strategic West Yorkshire and Harrogate sign-off of the hypertension treatment guidance at the Joint Committee of Clinical Commissioning Groups in March 2019. This process was replicated for the Cholesterol treatment guidance, which was signed off by the WY&H Joint Committee of CCGs on 1st October 2019. Supporting document - section 2 - provides details of all the stakeholders involved in the creation of the hypertension and cholesterol treatment guidance.

Patient and the public engagement on our phase two plans for cholesterol management has successfully captured the views of over 200 individuals with over 250 individual comments and will form a “you said; we did” action plan. Through the patient and public consultation wanted to understand where patients go for self-care /lifestyle advice, by understanding this we can develop support resources and information which would allow them to make lifestyle changes which could improve their condition and overall wellbeing.

The responses and comments were received through an online questionnaire and 15 patient focus groups. Feedback from respondents covered 50 out of 78 postcodes within the West Yorkshire and Harrogate area and nearly a quarter of responses were from those of black and Asian minority ethnic group. Almost 90% of those who completed the questionnaire felt the second phase of the project would benefit local people and around 75% felt the information, that we gained their opinion on, was clear.

We have used the feedback to revise patient letters which will be used as part of implementation. Based on this feedback the language was altered and taken through patient user reader groups. This gives the project a high degree of confidence that the information which will be used in our second phase of the project is of the highest quality.