Secondary prevention NHS SoTW

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Secondary prevention NHS SoTW

• Dr Jackie Gray

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Bridging the Gap

• Extending the measured length of life,
• Improving the measured quality of life,
• Reducing health inequalities in terms of the
  measured health differential between SoTW and
  England and Wales, and between small areas within
  the patch.

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• NHS SoTW
• S Tyneside
• Gateshead
• Sunderland

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The CVD mortality gap
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Risk Factor differences
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Reducing the Gap in Life Expectancy Mortality
(Health Inequalities Intervention Tool )
Identifying Managing hypertension
Prescribing statins Expanding smoking cessation
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NHS SoTW Commissioning Executive
NHS SoTW Bridging the Gap CVD strategy group
Practice Based Commissioning
Cardiac Network
Arrhythmia Task Group
Stroke Task Group
Vascular Risk Task Group
Heart Failure Task Group
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Strategic priorities

• Take an overview of the development and
  commissioning of CVD services as a programme.
• Ensure that PBC and PCT commissioning and
  development of CVD services is co-ordinated..
• To ensure an appropriate balance between the
  commissioning of prevention, treatment and care
  in the reduction of mortality from CVD.
• Expansion of lifestyle services - 12M investment
  
• Lead on needs assessment, equity audit,
  performance management, an outcomes and
  evaluation framework.
• Act as a local part of the regional cardiac
  network.

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PVD
CKD
CVA
CHD
DM
Obesity
Lipids
Risk factor modification
Smoking
Hypertension
Risk assessment
Population health improvement
Public and patient engagement and empowerment
Clinical leadership, engagement workforce
development
Health needs assessment, risk Knowledge
management
Partnership working to mobilise community
resources
Procurement, contract management investment
Improving / assuring clinical quality outcomes

Performance management
Communications
Evaluation
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Task groups priorities

• Vascular risk
• Stroke
• Heart failure
• Arrhythmia

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NHS SoTW Workstreams

• Partnership working to mobilise community
  resources
• Health needs assessment, risk knowledge
  management
• Improving assuring clinical quality outcomes
• Clinical leadership, engagement workforce
  development
• Public patient engagement empowerment
• Procurement, contract management investment

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Vascular Risk task Group

• Systematic vascular risk identification
  measurement and management within primary care
  supported by community services
• Risk estimation LES
• Social Marketing
• IT systems
• Service models

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Participation and coverage
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What proportion of the population are at risk?
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How do actual risks relate to predictions?
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Prevalence of risk across SoTW
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Heart Failure

• Map out the whole patient pathway and develop a
  standard heart failure pathway for SoTW
• Review current service provision against the
  standard SoTW pathway to identify gaps in the
  service, areas for development and improvement
  and make recommendations for commissioning to
  improve and develop services
• Review all local heart failure guidelines and
  protocols to ensure they comply with national
  heart failure guidance develop a standard heart
  failure guidelines for the SoTW area
• Develop competencies for delivery of heart
  failure service in primary care, review training
  for primary care clinicians to support the Les
  and make recommendations
• Review current heart failure rehabilitation
  services and identify areas for service
  improvement and development
• Review current palliative care services for
  patients with heart failure and identify areas
  for improvement and development

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Arrhythmia

• Map out ideal arrhythmia pathway
• Review current services against the pathway, and
  develop recommendations for future commissioning
  service improvement development

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CVA - Early Work Planned

• Development of a local model of provision of TIA
  services to reduce stroke incidence
• Assessment of stroke rehabilitation needs
• Work with the Cardiovascular Network to raise
  awareness of stroke in our local populations
• Build on initial equity audit to gain an
  understanding of health inequalities in relation
  to stroke and develop approaches to address these