CVD, Hypertension and Atrial Fibrillation

blood pressure .jpgPurpose

The overall scope of Hounslow Borough Based Partnership (BBP) work on cardiovascular disease (CVD) prevention and management is based on the priorities set out in the NHS Long Term Plan (2019).  Across NWL ICB- including across the Hounslow BBP- we aim to deliver the Pan London vision for CVD:

  • Prevention of heart attacks, strokes and dementia
  • Empower local residents to take control of their health 
  • Engage with borough-based partners including the local authority, primary care, community and secondary care partners and the voluntary and community sector in identifying the populations at risk of the four conditions- hypertension, high cholesterol, atrial fibrillation, and heart failure
  • Engage with stakeholders to identify gaps which exist in the prevention, detection and treatment of CVD conditions and changes which might be necessary to service pathways
  • Deliver proactive management of CVD patients including particularly BAME patients with co-morbidities such as diabetes and other groups/sub-cohorts in need of preventative health checks and disease management. 

The local CVD Prevention and Management Project has the following objectives:

  • To identify communities at risk of cardio -vascular ill-health through stakeholder engagement 
  • To draw from evidence-based sources, design and implement local intervention programmes and evaluate their impact  
  • To improve health outcomes of population cohorts at risk through engagement and collaborative, tailored initiatives with NWL and other local programmes including local health and council services and the VCS
  • To support at risk cohorts and those with a CVD condition to take responsibility for their own health & wellbeing, to build up their resilience and independence and use their learning/ experience to make prevention and early intervention the basis for reducing avoidable demand on the health and care system
  • To reduce health inequalities in the Hounslow population so that fewer residents miss life opportunities because of avoidable long-term health conditions.

 The 2022-23 Blood Pressure @ home monitoring project was completed successfully in April this year. It has been embedded in the three PCNs' - Chiswick, Hounslow Heath and Feltham & Bedfont as business as usual activity. A copy of the project report can be accessed in the Resource Centre on this website.

The BBP's 2023-24 CVD Delivery Plan was agreed last month. The priorities set out in the plan align with NHS priorities & planning objectives including NHSE DES objectives and NWL ICB's CVD programme. Hounslow BBP aim to:

  • Increase the percentage of patients with hypertension treated to NICE guidance to 77% by March 2024.

  • Increase the percentage of patients aged between 25 and 84 years with a CVD risk score greater than 20 percent on lipid lowering therapies to 60%.

It is expected that the plan, encompassing health inequalities and outcome targets, would deliver improved diagnosis and follow up of hypertension, improved identification of those at risk of familial hypercholesterolaemia, atrial fibrillation and heart failure in two phases as follows:

  • Phase one between September 2023 and January 2024 focusing on hypertension and high cholesterol detection, prevention and management.

  • Phase two between February 2024 and April 2024 focusing on atrial fibrillation and heart failure management.

The CVD project 2023-24 also consists of three other workstreams which support the delivery targets in the plan as follows:

1. A workstream focusing on adult carers at risk of developing CVD and those with a CVD with /without other long term conditions. It aims  to: 

  • Identify how well existing adult carers with a CVD condition or those who are at risk of developing CVD are accessing services - both clinical and non-clinical.

  • Detect from the existing carers population cohort those with a CVD or at high risk of developing a CVD condition and ensure they are signposted to the relevant services.

  • Increase health promotion for this cohort.

2. A workstream focusing on community outreach work with black and other mixed ethnic groups. It aims to:

  • Engage with this population cohort to improve awareness of hypertension and its impact on health and well-being.

  • Identify barriers to accessing health services, including primary care and the factors which can promote better access.

  • Offer opportunities for blood pressure and other health checks in support of case-finding.

3. A workstream focusing on improving the impact of the community pharmacy blood pressure checks. It aims to engage with a group of community pharmacists to identify the gaps in communications with primary care services and co-create possible solutions for improving communications with GPs and enhance the detection of hypertension.


Next steps

Plans are being developed  to implement the workstreams outlined above. A progress report will be available at the end of each Quarter. 


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