Different approaches to tackle health inequalities

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Different approaches to tackle health inequalities: cardiovascular disease prevention

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How can local systems drive better detection and management of high cholesterol to drive CVD outcomes?

This article is part 2 of a series looking at how local systems and their providers can improve CVD prevention within their local populations, and ultimately lead to better CVD outcomes. In the last article, we introduced five inherent challenges that local systems face, offering some strategic aims that could help underpin real improvements.

In this post I will delve into the first of these challenges: that CVD-related deaths and prevalence are higher in deprived and often less engaged communities, and that consequently 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.

The vicious cycle of CVD and inequality

When it comes to CVD, and also many other lifestyle driven diseases, there are two important, interlinked points that you need to consider:

1. Many of the main determinants of CVD, such as diet and smoking, are factors that are often higher in more deprived parts of our community, or certain geographic areas.

2. That CVD is in itself is among the largest drivers of health inequalities and low levels of population health.

So if we add the fact that CVD is largely preventable, if we can find ways to target those in more deprived areas, and help them avoid getting CVD, then we can also reduce a direct driver of health inequalities.

This is likely why the NHS Long Term plan describes CVD prevention as “the single biggest area where the NHS can save lives over the next 10 years.” 

However, if we can’t achieve this then what we may have is a vicious cycle of inequality. So it stands to reason that generally all improvements in CVD prevention are necessary, but addressing those who are the most deprived, hardest to reach and least likely to seek preventative support is critical for local health systems.

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Targeting preventative support in deprived areas

In every local area both the prevention of CVD, and tackling local inequalities, will be highest on the list of priorities. and in response to national strategy objectives, such as the NHS Long Term Plan. So all of the above will be well known.

However, as I covered in the last article, CVD outcomes are going in the wrong direction nationally, and there are significant levels of variation in activities in different localities. Much more needs to be done in terms of how preventative activities take place, and where they take place.

This raises a big strategic question around whether the objective should be to focus on increasing uptake of existing services, or whether different approaches or services should be designed around the needs of these specific groups. The answer is probably both, and ‘it’s complex’ because deprivation affects different groups in different ways, but what we do know is that deprivation has a direct impact on levels of access.

In 2016, a study on socioeconomic inequalities in Health Care in England found:
“Poorer and more socially disadvantaged people tend to consume more health care at any given age, in terms of both volume and cost, because they are sicker.Richer and more socially advantaged people tend to present to health care providers at an earlier stage of illness and to consume more preventive care.”

Similarly, a recent review by the Kings Fund summarised that “poverty makes it harder for people to access services, and services do not always reach those in poverty. This lack of access means people living in poverty are getting sicker and accessing services later”. 

The report argued that “The NHS needs to do more to deliver services that people living in poverty are more easily able to access and navigate”, suggesting that in high priority areas of prevention, such as CVD, we need the tools and versatility in how we design services, and what ‘access’ looks like.

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Prevention is about much more than intervention

To this point I have been using the singular term of ‘prevention’, but if we’re going to design different approaches and services to drive this objective, we need to know what exactly we mean when we say prevention.

Unsurprisingly there are different ways to answer this question.

Firstly there are different stages of progression that prevention can take place, including public health measures (also called primordial prevention), primary (supporting the at risk population) and secondary (stopping or delaying the progress of conditions) prevention.

Another approach to prevention that deeply resonates with the work we do at PocDoc is the principles of population health management. This relatively recent methodology, strongly supported by NHS England, considers the stages and approaches that can use data to drive improvements in care, by strategically segmenting local populations by identified need, to understand and stratify risk, and then taking action through designing and delivering proactive, personalised, and preventative care models to meet the range of needs identified.

As we’ll explore in the next edition of this article series, we believe that to achieve this level of proactivity, personalisation and ultimately prevention, local teams will need better, more versatile tools to access those who are less likely to proactively engage, or be more difficult to access as a system, and also that the answer will be in community embeddedness, reaching out in ways that would have previously not been possible, but are now becoming essential. Last year’s Major Conditions Strategy offers a real insight into how this mindset is shifting in relation to prevention, embedded within the wider frame of care.

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Piloting CVD prevention activities in harder to reach areas

Over the last couple of years myself, Kiran,Vlad and the wider team at PocDoc have had the opportunity to work closely within two of the Integrated Care Systems with the highest prevalence of CVD within the population, and who would benefit the most from improvements in prevention, particularly in areas of high deprivation.

In exploring how and where alternative models of CVD testing can be deployed, we have had the opportunity to learn about engaging different, often deprived, hard to reach groups. I would like to share some examples of the lessons we learned:

Firstly, we’ve really learned how complex inequalities can be, and how much needs to be factored into improving engagements, especially considering behavioural, societal and cultural elements that may factor in. We’ve found the CORE20PLUS5 used as part of NHS England’s Innovation for Healthcare Inequalities Programme (InHIP) to be really helpful when considering how we can support enablement in new areas. These include:

1. Cultural distrust of HCPs; reliance on community leaders for trusted information.

2. Lack of female HCP support means female minorities reducing primary service engagement.

3. Shift working and/or family commitments affecting engagement.

4. Language is a barrier to making and attending appointments.

5. Specific forms of dietary intake in minority cultures and communities.

6. Lack of awareness of cardiovascular disease and the importance of prevention.

Some real successes we’ve seen in our own pilots is how much understanding more community embedded groups (or assets) have of these factors in their locality, and are able to not just deliver the NHS Health checks but also connect individuals to culturally appropriate specialist support, and spend time talking about relevant lifestyle changes that could be made.

Another example we’re taking real pride in supporting is targeted women’s health initiatives. For example we have worked with a number of Women’s Groups to run health screenings in community centres in areas with high ethnic minority populations.

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Another big factor that can feed into inequality is in areas of high rurality. We have been running screenings in Farmers Marts to provide an easy means for people living in rural areas to check their health. This has the added bonus of being an easy way for the farming workforce, who typically don’t engage with primary healthcare, to check their health.

Finally, with the cost of living crisis over the last few years, we’ve seen that with more people having to take on more shifts and work longer hours to pay the bills, locating screening in workplaces especially large employers with shift workers such as the Police Force, offer a receptive cohort who struggle to access services when working patterns are unpredictable or at inconvenient times.

These are just a few of the examples, but in each of these examples the driving factors can vary hugely, and require different solutions that often are hard to support in busy general practice settings.

In the next article, I will be looking at how local systems can think about alleviating pressure on primary care sites and make better use of the community when undergoing CVD prevention.

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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 Cardiovascular, Metabolic, and Renal Diseases.

These diseases affect 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.

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