Improving access to early diagnosis and management of hypertension and high cholesterol for underserved people
Hypertension and high cholesterol are key risks for Cardiovascular Disease. Collaborative projects in Cornwall and Somerset focused on high-risk populations, improving access to Health Checks and innovative therapies in primary care.
Cardiovascular Diseases (CVD) in England affect 6.4 million individuals annually and contribute to 142,690 deaths. Hypertension and high cholesterol are significant modifiable risk factors for CVD, highlighting the importance of improved diagnosis and management to prevent heart attacks and strokes, and reduce the burden on the NHS. Regional disparities, particularly evident in rural and coastal areas of Cornwall and Somerset, are intensified by deprivation, necessitating targeted interventions for high-risk populations.
Health Innovation South West participated in two collaborative initiatives aimed at addressing healthcare inequalities. These initiatives focused on hypertension and high cholesterol management in these regions.
In Cornwall and the Isles Of Scilly, by applying the Index of Multiple Deprivation (IMD), four GP practices prioritised CVD Health Checks for those living in lower IMD areas, streamlining care pathways, and inviting patients by text and telephone, based on clinical need and deprivation level.
A Quality Improvement (QI) approach and designated leads facilitated project support, while future plans emphasise building on existing prevention activities in primary care. Strategies for project continuation include seeking additional funding, sharing insights with other onboarding practices, and addressing information governance challenges.
In Somerset, the focus was addressing inequalities among homeless populations, including expanding access to novel lipid-lowering therapies in four GP practices and prioritising blood-test follow-ups. Despite challenges, such as sustaining changes and evaluating long-term impacts on cardiovascular conditions, the GP practices demonstrated commitment to addressing enduring healthcare issues and funding initiatives for homeless patient support.
Cornwall
- Uptake and Access: 258 Health Checks were conducted across four GP practices for patients at high risk of CVD.
- Patient Experience: Participants found the care pathway generally acceptable and welcomed proactive invitation for the Health Checks.
- New ways of team working appreciating diverse skills and effective teamwork across organisations were key to successful delivery of the project.
Somerset
- Patient Experience:
- Patient feedback around contact was positive from patients who had responded.
- In general staff reported patients were receptive to the follow-up process.
- There was a notable decrease in patients awaiting risk assessment and an increase in percentages of patients treated to target for lipid optimisation across all practices, with a number of them receiving novel injectable therapies.
- Practice trials against background: Comparison of lipid treatment optimisation between intervention practices and broader Somerset practices. Despite starting at a lower baseline, intervention practices showed greater improvement, outpacing intervention practices compared to others in Somerset. Using CVD PREVENT and Somerset CVD dashboard data, ongoing analysis will be conducted for further insights.
- Equity: The decrease in number of people in the blood tests cohort was greater in those in the prioritisation group compared to the other bloods group. At six weeks, the priority group’s need for follow-up decreased by 57% compared to 1% for other patients. By 12 and 24 weeks, while both groups showed reductions, the prioritisation group continued to see greater improvements, especially among vulnerable patients, demonstrating improved access to treatment for underserved people.
Website Links
- CVD Prevention and lipid pathway resources for health care professionals
- Improving lipid management to reduce cardiovascular disease and save lives (NHS)
- Death and deprivation - BHF
- NHS Core20PLUS5 – An approach to reducing health inequalities for children and young people. (2022)
- Rural Services Network: Helping Homeless Rough Sleepers
I think most people were actually really pleasantly surprised that someone looked at their data and then being proactively offered treatment without them having to ask a question. I almost think uptake was better because of that proactive approach. Our experience was very, very positive.
Staff member, Somerset study
