What's in this Article: 

• Lets consider the cardiovascular disease statistics
• What needs to be addressed to turn the tide?
• Population and Operational Challenges 
• How could these translate into local strategic intentions around CVD prevention?

Cardiovascular Disease Prevention: "Unfinished Business"

Everyone agrees that better prevention of Cardiovascular Disease (CVD) is a ‘must do’ for any modern health system, and as one of the big ticket items on national and local priorities it’s one of the few areas that people need convincing that we need to do more on.

Let’s consider the stats:

• In England alone it’s estimated that nearly 7 million people are living with CVD, and almost 100,000 people have a stroke each year while two-thirds of stroke survivors leave hospital with a disability.

• CVD is also one of the largest contributors to health inequalities, accounting for one-fifth of the life expectancy gap between most and least deprived communities; people from South Asian and Black groups have the highest risk of CVD.

• When considering the overall pressure this creates on an NHS that is facing huge challenges, it is estimated that CVD accounts for around 1 million hospital admissions, leading to 5.5 million bed days.

• In terms of cost CVD is estimated to cost the NHS £7.4 billion each year and the economy an estimated £15.8 billion a year. If we take social care into account, the estimated social care costs to the UK economy for stroke survivors are estimated at £5.2 billion annually.

• The good news is that CVD is largely preventable (est. 80% of cases), and that it has long been a high priority across the NHS, with national policies emerging in the late 90s, and the introduction of the NHS Health Check in 2009.

So, presumably, we’ve seen an improvement in CVD outcomes over the last 15 years?

• Yes and no. While some improvements were made against the rising tide of lifestyle diseases, research from the British Heart Foundation, profiled in the BMJ this January, found that ” early deaths from cardiovascular disease have reached a 14-year high in England.” 

• The BHF described this as the “worst heart care crisis in living memory” and “a tragic loss of hard-won progress”.

What needs to be addressed to turn the tide?

CVD should never be considered in isolation, and there are numerous factors that play into the prevalence and outcomes of CVD beyond interventions, such as social and economic factors, and the stretched nature of the NHS. But from a health system perspective, given that CVD is largely preventable, the question naturally turns to whether the current approach to prevention is optimal.

• Whilst the implementation of the NHS Health Check, funded by Local Authorities and largely delivered by General Practices, has been successful in many ways, the level of uptake is hugely variable, with the percentage of eligible people receiving an NHS Health as low as 10.2% in some areas . 

• The government has since sought to evolve and improve the NHS Health Check, with a growing emphasis on where digital can play a role and also how alternative delivery models within communities can play a part, perhaps most strongly outlined in the recent Major Conditions Strategy published by DHSC last year.

• From both the literature and our own experiences in working within the field of innovation around CVD prevention, we believe there are five critical issues that need to be understood and addressed within the contemporary NHS landscape.

The first two issues are population challenges where unaddressed priority cohorts are hard to find, engage and reach, and the following three issues represent operational challenges, where the current service configuration lacks versatility and community embeddedness.

These challenges are outlined in more detail below:

Population Challenge 1 - CVD-related deaths and prevalence are higher in deprived and often less engaged communities. 

• The average CVD emergency admission rate, and age-standardised death rates (ASDRs), are consistently higher (nationally) in our deprived communities. For a range of reasons these communities can often be the hardest to engage, activate and support in primary prevention activities.

Population Challenge 2 -We’re reliant on patient finding, testing and activation to drive behaviour change. 

• Prevention, particularly primary prevention, relies on services in local areas being able to actively target and screen as many patients as possible for their risk of CVD (QRISK scoring) in order to intervene and drive behaviour change. The current proactive approaches, whilst improving, can be easy to ignore, easy to miss or challenging to engage with.

Operational Challenge 1 - Existing initiatives can’t fully reach. 

• The current approach to testing within primary prevention of CVD requires patients to engage with a limited number of brick and mortar sites, primarily general practices. There are few options available to deploy testing activities and engage parts of the population with low uptake of CVD screening, such as workplaces, events, places of congregation, high footfall and at home. A low number of community pharmacies can easily support this activity.

Operational Challenge 2 - Limited access to primary care. 

• As is well known, access to primary care locally is an ongoing challenge, and continuing pressure on general practice is impacting proactive and preventative quality focused initiatives in a number of ways. Beyond direct figures around performance, and variation, of practices delivering Health Checks, busy practices being more inflexible and difficult to engage is likely to impact our ability to engage those harder to reach parts of the community.

Operational Challenge 3 - System bottlenecks. 

• The current reliance on lab-based testing creates delays in obtaining test results and often requires patients to go back to a physical location for second or even third appointment in some cases to discuss the results. This delay not only hampers timely interventions but also results in ‘lost patients’ who might not engage at a later date as and when prevention is required. Delays and multiple steps when there is not a direct symptom to be addressed will again be felt more by those in our more deprived areas.

How could these translate into local strategic intentions around CVD prevention?

1. Local systems need to drive better detection and management of high cholesterol to avoid lower population health and higher health system costs in the future.

2. Local systems need to alleviate pressure on primary care sites, and to make better use of the community, especially in population health management and prevention.

3. Local systems need to be accessible in the places where testing and detection would be most effective (workplaces, pharmacies, places of congregation, shopping centres), rather than solely through practices.

4. Local systems need to shift away from practice driven lab based testing as the sole route, utilising new testing methods that are trustworthy, accurate and usable in different parts of the community.

• Over the next few years, local systems will be expected by NHS England to support testing at home. Preparedness is necessary.

5. Local systems need routes that will allow results, follow up and advice to go to the right people and the right places when intervention is required, including the patients themselves.

Additionally, as is the case in most NHS priorities, it would be logical to explore where and how technologies and digital innovations can provide the means to improve preventative activities, as recommended within the recent national conclusions when reviewing the NHS Health Check.

It is also logical (perhaps necessary) to discuss the metabolic and renal diseases that overlap heavily with cardiovascular disease - namely Type 2 Diabetes and Chronic Kidney Disease.

Prevention of any lifestyle driven disease is highly complex and multifaceted, and naturally the devil would be in the detail of how the five are approached, individually and collectively.So in the following weeks and months we will further explore these five issues and recommended priorities in greater detail, to support efforts and thinking around how innovation in CVD prevention could help once again lead to better outcomes.

About Steve Roest

Steve Roest is the Co-Founder and CEO of PocDoc, which combines proprietary microfluidic assay technology and its AI-driven HUESnap© digital diagnostic pipeline within the cloud based PocDocOS© ecosystem to deliver end to end digital pathways for the assessment, diagnosis and treatment of major diseases - starting with Cardio, Metabolic and Renal Diseases.

These diseases affected the most patients, cost the most to treat, have the highest barriers to screening and are the most preventable of any major disease - that’s why PocDoc is focused on them first.