Cardiovascular disease (CVD) is a largely preventable illness, which causes a quarter of all deaths in the UK (Bhatnagar et al, 2015). During the pandemic, CVD claimed more lives than COVID-19 and affected minority ethnic groups and those from deprived communities at an increased rate (Ahmad, 2021). CVD is the single biggest condition where, with early intervention, lives could be saved (NHS England, 2019). Due to the impact that CVD has on minority and deprived communities, it has become a national priority. Hypertension optimisation features as one of the Core20Plus5 key clinical areas for health inequalities (NHS England, 2021).
Hypertension (high blood pressure) is one of the leading causes of heart attacks and strokes (Stamler et al, 1993), which are the most common cause of premature death (Bhatnagar et al, 2015). It accounts for a 25% life expectancy gap between the most affluent and the most deprived communities (UK Health Security Agency (UKHSA), 2021). Treatment that aims to lower blood pressure is highly effective at preventing these life-changing events, reducing demand on hospital services as well as health and social care costs. Primary care services are best placed to facilitate preventative interventions on these patients as they serve populations of 30 000–50 000 individuals and can provide opportunistic assessments of CVD risk (Gillespie and Kearney, 2019).
UCLPartners Proactive Care Frameworks: an opportunity for improvement
The COVID-19 pandemic demonstrated the effects of disrupting treatment for patients with hypertension. Data from the Quality Outcomes Framework from 2020–21 showed that optimisation rates for patients with hypertension have deteriorated substantially during the pandemic as patients’ access to healthcare has been disrupted. There is a backlog of patients with long-term illnesses that had difficulty accessing their routine primary care services. UCLPartners Academic Health Science Network (AHSN) responded to this challenge in 2020 by working with primary care colleagues and patients to develop the Proactive Care Frameworks (Kearney, 2021). NHS England has recently commissioned England's 15 AHSNs, led by UCLPartners, to deliver the Blood Pressure Optimisation Programme using the Proactive Care Frameworks to support the primary care workforce to deliver improvement at scale (Kearney, 2022).
Blood pressure optimisation and awareness
To support awareness of the need for treatment optimisation for hypertensive patients, UCLPartners developed The Size of the Prize, which identifies the impact of COVID-19 in disrupting treatment for people with hypertension, and the opportunity for improvement. For every Integrated Care System, the Size of the Prize shows on a single slide (Figure 1):
- The impact of COVID: in disrupting treatment for people with hypertension. On average the proportion of people with optimally controlled blood pressure has fallen from 70% to under 50%
- The risk: how many strokes and heart attacks might result if that disruption is not rapidly corrected. Across England this number exceeds 27 000 in 3 years
- The ambition: how many additional heart attacks and strokes can be prevented in 3 years and what savings can be generated if more people have their treatment optimised: with three levels of ambition.
See Resources for more information on how to review and download The Size of the Prize for your region.
Developing a tool to support primary care
The UCLPartners Proactive Care Framework for hypertension was developed in collaboration between UCLPartners and primary care clinicians, with additional feedback from patients and the public. The resources are free, recommended by the Royal College of General Practitioners and support is available locally for implementation in primary care.
Proactive care involves listening, asking questions, providing information and intervening early to prevent deterioration and promote continuous care (Rawaf, 2018). The Frameworks were created to help GP practices to prioritise and focus resources on optimising care in patients with CVD, reducing the effects of the pandemic on this population. It allows the wider workforce to implement interventions, reducing physician workload and increasing availability for the patient.
The UCLPartners Proactive Care Frameworks are based on a three-step approach:
- Stratification: run the free search to stratify patients who have hypertension into priority groups according to clinical criteria
- Prioritisation: review patients in clinical priority order to optimise management
- Proactive care intervention: use the wider workforce (staff such as healthcare assistants) to provide broader proactive care, supported by the protocols, conversation guides and other resources in the Frameworks.
The Frameworks help teams to:
- Identify who do we need to see now and who can we safely phase for later review?
- Support patients to access home blood pressure monitors either through local programmes or recommending monitors and teaching how to submit accurate readings
- Support patient education, self-management and lifestyle change
- Training and identifying other resources to support patient activation and self-management in the home setting.
‘The UCLPartners Proactive Care Frameworks provide a much-needed resource that support GP practices in recovering to pre-pandemic levels. By using the wider workforce there are opportunities for practice nurses and their teams to develop their skills in behavioural interviewing, clinical assessment and diagnosis to support their GP practice and patients.’ Helen Williams, National Speciality Advisor for CVD Prevention, NHS England
What are the opportunities for nurses in primary care?
Much long-term condition management in primary care is led by nurses. The UCLPartners Proactive Care Framework for hypertension will help nurses and other clinicians to manage their capacity and improve care for patients. The search tools stratify and prioritise patients by clinical need, identifying those who need to be seen more urgently and those whose follow up can be safely phased to later. The wider Framework resources can be used to deploy staff such as healthcare assistants to deliver structured support for education, self-management and behaviour change – improving care to patients and freeing up clinician time.
Key takeaways
- CVD is a leading cause of premature mortality and disability
- CVD is a major driver of health inequalities
- The UCLPartners Proactive Care Frameworks are supporting primary care to recover and transform care post-pandemic
- The Frameworks support nurses and other clinicians to risk stratify and prioritise patients, and to use the wider workforce to improve proactive care for patients and release clinician capacity
- Nurses are at the heart of long-term condition management, and the UCLPartners Frameworks, nominated for a HSJ award 2022, are being adopted nationally and provide opportunities for professional development and leadership.
Resources
- Download The Size of the Prize for your region: uclpartners.com/work/size-of-the-prize-for-high-blood-pressure-preventing-heart-attacks-and-strokes-at-scale/
- Review and download the hypertension Framework: uclpartners.com/proactive-care/
How can I find out more and support the programme?
For more information about the national Blood Pressure Optimisation Programme and UCLPartners Proactive Care Frameworks, visit uclpartners.com/proactive-care/. The UCLPartners team can introduce you to your local Academic Health Science Network for practical help and advice, contact primarycare@uclpartners.com for details.
Who are UCLPartners and the Academic Health Science Network?
UCLPartners is 1 of 15 regional Academic Health Science Networks (AHSN). The AHSNs are funded by the NHS to deliver health innovation at pace and scale into practice. The goal of AHSNs is to focus on regional issues that affect health equity and create solutions to address these in collaboration with NHS trusts, higher education institutions and the commercial sector. Your local AHSN will be actively supporting improvement work in general practice, visit https://www.ahsnnetwork.com/ for further details and training opportunities.