How this PCN developed pathways for CVD prevention

The population of Central and West Warrington PCN was at high risk of cardiovascular disease yet there was a lack of patient engagement with existing preventative strategies. Here’s how the PCN turned that around. 

Cardiovascular disease (CVD) is a major cause of death and disability in the UK, so it is unsurprising that it is a focus for NHS England. As part of this, Central and West Warrington (CWW) PCN was sponsored by NHS England to participate in a 26-week national initiative for CVD prevention in primary care.

The project called Living Well is part of the national Clinically-Led workforceE and Activity Redesign (CLEAR) programme, which trains and enables clinicians to use a combination of data analysis and modelling tools alongside qualitative techniques to deliver new models of care and workforce. It is hosted by East Lancashire NHS Trust and delivered by the trust and 33n, a team comprising NHS clinicians, education specialists and data analysts. 

For CWW PCN, this meant investment in transformation skills for two PCN staff members who were seconded to the programme as project associates.

Aims of Living Well

Comprehensive analysis of data across the six practices in CWW PCN showed that the local population (around 56,000 people) was at high risk of CVD, with clear evidence of health inequalities and a lack of patient engagement with CVD preventative strategies. There was low uptake of NHS health checks and low referrals to local lifestyle management services, such as weight management, social prescribers, dietitians and smoking cessation support.

To address this, a new PCN NHS health check hub was created, staffed by a multi-disciplinary team. The ambition was to provide a new and improved pathway to complement the existing health check services available at no additional cost to the PCN by using the existing additional roles reimbursement scheme (ARRS) workforce and PCN estates.

Staff trained in CVD prevention and management could increase the number of checks in line with the ambitions of the NHS Long Term Plan. This team could also provide health checks in community settings to reach patients in more deprived areas and minority ethnic groups.

The existing service was expanded to offer an enhanced health check, regardless of age, to those at greatest risk of CVD due to a BMI greater than 30 (or 27.5 for the South Asian community). They would be recalled every two years to assess their risk of CVD and encourage healthier lifestyles.

Another key recommendation was for the team to carry out enhanced pre-diabetes reviews, giving the opportunity to conduct a mini-health check at the same time. A CVD champion could be nominated at each practice who would link with prevention services and work with Warrington Voluntary Action to plan visits to community groups.

Developing a new model of care

Dr Laura Mount, clinical director for CWW PCN and executive sponsor of the Living Well project, says the service was ‘designed to empower and support patients to take control of their health and reduce their risk of developing many diseases’.

Supported by the PCN management team, care coordinators and GP assistants began implementing the programme in February 2024 with the national CLEAR team providing mentoring, coaching and project management guidance throughout the process.

Implementation began with a focus on skills-based competencies rather than specific job roles so that patients can be referred to other services without the need for GP advice. New governance and standard operating procedures (SOP) were developed, which removed some of the burden of prescribing and reviewing bloods from the GP. Having received training and by following the SOP, a GP assistant now reviews most bloods, with the doctor involved in only a limited number, and pharmacists completed a prescribing course so that they could issue relevant prescriptions for statins and antihypertensives.

Staff across the PCN completed motivational interviewing training. The care coordinators ensure regular debriefs and completed ‘plan, do, study, act’ (PDSA) cycles to continually improve the model and track key performance indicators.

The PCN had observed a lower-than-expected prevalence of obesity, so to understand the scale of the obesity cohort, patients with no BMI recorded in the previous 24 months were sent a text survey to complete height and weight. A total of 22,405 text messages were sent out, and 5,999 replies were received – a 27% reply rate.

Implementation of Living Well

At first, one practice was used to test the model and to make any necessary adjustments. Then, the Living Well system was rolled out, with the team focussing on delivering health checks for one practice at a time over a three-week period before moving on to the next practice’s list of eligible patients. This means that the team does not have to switch between clinical systems and appointment books.

Eligible patients are contacted by text message in the first instance. If the patient is a non-responder or has no mobile number, a care coordinator makes a phone call to them.

Patients are invited to a health check review with a GP assistant – either the NHS health check or an enhanced health check if their BMI is greater than 30 and they are outside the age range of 40-74. The enhanced health check assesses the patient’s cardiovascular risk and increases proactive case finding of CVD co-morbidities.

Patients are offered Wednesday and Saturday appointments. Wednesday appointments are at the PCN Hub in the community, which also provides leisure and lifestyle services and is familiar to patients as a Covid vaccine site. Saturday appointments are offered at one of the PCN surgeries, which also houses the PCN enhanced access service.

A total of 40 additional health check review appointments are offered each week (32 on a Wednesday and eight on a Saturday).

Emily Benbow, care coordinator at the PCN, said the hub was ‘a great success with patients pleased with the service and referrals being made to support the patients’ long-term health goals’. 

Outcomes

In the first 18 weeks of the Living Well initiative, an estimated 850 appointments have been delivered away from a general practice estate, while 47 appointments that normally would have been provided by the GP have been provided by a pharmacist. Once the health check reviews are delivered at the desired scale, moving suitable prescribing activity from GPs to pharmacists could release over 35 hours of GP time per year. 

Engagement has increased with hard-to-reach communities and populations at higher risk through health inequalities, particularly those with an Asian background. Attendance from those with a South Asian background has increased from the baseline of 2% to 4.6%, while the attendance rate of those with an East Asian background has increased from 2% baseline to 3.3%. Attendance from those with an ethnic background described as ‘other’ has also increased from 2% to 4.2%.

There has been a significant increase in attendance at local lifestyle management services to promote good health and wellbeing – these have increased from 1% to 14% of the cohort. Early analysis also suggests that the case finding of prediabetes is high, increasing from 3% to 6.4% prevalence in the new models.

Case finding in hypertension, atrial fibrillation, and chronic kidney disease is lower than baseline figures. However, this is expected to increase as time goes on and patients have further investigations and diagnoses confirmed in clinical coding. 

Living Well has also seen the PCN obesity register increase to 15,207 – a 56% increase since the start of the campaign.

Future

In addition to improving patient care, the PCN has increased the offer for NHS health checks at no additional cost or estate demand and successfully removed workload from GPs and nurses.

Comparative modelling of the pathway before and after the introduction of the new model of care suggests the workforce cost has been reduced by £4 per appointment by utilising a predominantly ARRS workforce to deliver the majority of activities within the NHS health check pathway.

Working at current levels and seeing just under 1,000 patients per annum, the projected return on investment (ROI) is just over 1:2. Once working at full capacity, workforce modelling suggests an annual cost of just under £12,000 per year and a potential ROI of just over 1:3.

The PCN aims to deliver NHS health checks to 75% of its eligible population. To meet that target, it needs to conduct 28 NHS health checks per week. Currently, 19 health checks are delivered per week, though the PCN anticipates this will increase as clinical teams become more proficient at delivering the service and delivery is scaled up.

Dr Mount said the Living Well project had been a success.

‘Working with CLEAR gave us the data and taught us how to make changes that will have meaningful long-term health benefits for our patients,’ she said

The PCN plans to use the same approach of a community hub model with a different workforce to scale up the offer to include other cohorts, such as identifying and managing atrial fibrillation.

The project has also given the PCN team the confidence to explore other ways of offering proactive care and working with partners to deliver this. A Living Well toolkit is in development, which will be available nationally in October to support other PCNs in addressing CVD prevention.