Cardiovascular disease (CVD), which covers a wide range of conditions, such as coronary heart disease, heart valve disease (HVD) and strokes, is responsible for a quarter of all deaths in the UK.
The NHS’ Long Term Plan, which identifies CVD as the single biggest area where the NHS can save lives over the next ten years, highlights the importance of tackling lifestyle-related risks such as obesity, smoking and poor diet.
Improving the detection and management of high-risk conditions, such as high blood pressure, high cholesterol and atrial fibrillation (AF) that can cause CVD, as well as many cases of dementia, is also a key part of the strategy.
Identifying people at risk
Most CVD is regarded as preventable or capable of being reduced since many of the risk factors – such as smoking, obesity, high cholesterol, high blood pressure, poor diet and physical inactivity – can be avoided.
The Long Term Plan – which calls on the NHS to help prevent up to 150,000 heart attacks, strokes and dementia cases over the next ten years – pledges to take further action on problems such as obesity, alcohol and smoking.
It also highlights the progress that other countries have made in ensuring that people routinely know their ‘ABC’ – AF, blood pressure and cholesterol – and the possibility of replicating this approach.
In line with this, it was recently announced that pharmacists are set to offer rapid detection and help in respect of killer conditions, such as heart disease, as part of a major revamp of high street pharmacy services. Pharmacists’ work would be supported by GPs, providing for holistic care, as part of Primary Care Networks’ (PCNs) prevention strategy.
NHS England has said that, as part of a new £13-billion, five-year contract, from October 31 community pharmacists will start to develop and test an early detection service to identify people who may have undiagnosed high-risk conditions like high blood pressure for referral for further testing and treatment. If successful it could be rolled out to all community pharmacies by 2021/22.
Work to identify and treat people with high blood pressure and AF has already been tried successfully in Lambeth and Southwark, Dudley and West Hampshire, where there has been substantial improvement in rates of diagnosis and optimal treatment. The scheme has also freed up clinical time for GPs.
Another area of focus in identifying people at risk is genome mapping, particularly around rarer conditions. The Long Term Plan says that expanding access to genetic testing for Familial Hypercholesterolaemia (FH), which causes early heart attacks and affects at least 150,000 people in England, will enable it to diagnose and treat those at genetic risk of sudden cardiac death.
Currently only 7% of those with FH have been identified but the NHS aims to improve that to at least 25% in the next five years through the NHS genomics programme. Two NICE-approved treatments for FH have also been designated for accelerated access via the NHS.
The role of tech
Technology is key to enabling improvements across the NHS, particularly in early diagnosis and disease prevention. Improving the effectiveness of approaches – such as the NHS Health Check, which is currently offered to everyone aged between 40 and 74 to spot the early signs of major conditions that cause premature death – is a CVD-related objective in the Long Term Plan.
Following on from this, the government recently announced a review of the NHS Health Check service to explore how analytics and data-driven technologies can deliver personalised health advice to patients. The idea is that new, intelligent, predictive checks could enable the NHS to take issues such age, risk factors and lifestyle into account when offering tests. So, for example, 70 to 74-year-olds could be specifically targeted with advice on how to reduce their blood pressure.
Primary Care Networks
CVD prevention and diagnosis is one of the seven national service specifications of the new PCN Directed Enhanced Service (DES) Contract for GPs. In line with this, many CVD services will be delivered in PCNs by community teams that are likely to include physician associates, clinical pharmacists, specialist heart failure nurses and possibly consultants.
There will be a big focus on identifying relevant cohorts of patients and offering timely interventions. As well as medications, interventions could include advice on lifestyle improvements, particularly weight management, as well as social prescribing. The use of technology, such as community echocardiograms for HVD detection, will be very important.
This work will be supported by a new national CVD prevention audit which will extract routinely recorded but anonymised GP data, making it easier for PCNs and other NHS organisations to determine what needs to be done to improve outcomes for their patients and populations.
Integrated Care Systems
Integrated Care Systems (ICSs) will look at the whole CVD strategy to ensure a co-ordinated approach at each level of integrated care. This will cover everything from identifying the right patients to target, to providing proactive screening and treatment for lipid lowering.
When engaging with ICSs, pharma needs to be aware that for every part of the CVD pathway, there will be a focus on primary prevention, detection of at-risk populations, management of existing conditions, secondary prevention and better management of hospitalised patients.
It is also important to note that elsewhere, in specialist care, there will be a major structural change in stroke services, where hyper- acute specialist stroke centres with new clot-busting technology will be replacing existing stroke-receiving units.
Implications for pharma
As the NHS continues to embrace ICSs, reducing costs across the whole system is expected to become increasingly important. In line with this, annual contracts are likely to move to multi-year contracts of between five and 15 years.
This will help ICSs to consider technologies and drugs that support service transformation and improve outcomes over time without increasing overall costs in the entire patient journey.
Key players in the anticoagulant market have already managed to successfully engage with the NHS on the long-term cost-saving benefits of these products for stroke prevention.
Given the current focus on ABC, industry needs to do the same for lipid-lowering drugs, paying particular attention to how cost-efficiency messages for these products translate over a long period of time.
For example, pharma needs to consider the impact that its drugs could have from a workforce perspective, as it becomes increasingly difficult to recruit staff for the NHS, and also as the NHS aims to move more care out of hospitals and into the community.
So, if a product has proven to be really effective in reducing failure rates, then it could be argued that this will have a significant impact on the workforce because it will reduce the number of times a patient needs to be reassessed.
Similarly, if a drug has been proven to be effective in reducing emergency admissions, then the associated cost savings will have an impact across the whole joined-up system.
To provide this type of evidence, pharma’s short-term clinical trial data needs to be backed up with longer-term real-world evidence on how a product is performing and where it can help the NHS to derive greater benefits in the long term and across whole care systems.
Given the NHS’ focus on place-based care, pharma also needs to gather other supporting population health data relevant to specific areas, such as the number of previous hospital admissions for stroke in a given region, or the cost of managing comorbidity issues in a relevant cohort of patients.
Conclusion
Prevention and early intervention are key to tackling CVD, and the Long Term Plan makes it clear that the NHS must take a multifaceted approach from addressing lifestyle-related issues to identifying high-risk conditions. This does, however, reinforce the opportunities for joint-working with pharma.
New multidisciplinary teams in PCNs will be instrumental in helping the NHS to achieve its goals by utilising technology and integrated care systems to identify cohorts of patients who are at risk and ensure timely interventions.
Pharma needs to keep abreast of local plans for CVD prevention and management, which will be published as part of ICS and Sustainability and Transformation Partnership (STP) plans by the end of 2019. Industry also needs to ensure that its propositions are built on a solid understanding of the NHS’ goals for CVD and the integrated, population-based approach that underpins it.
