West Yorkshire and Harrogate Healthy Hearts Project set to stop 1,200 heart attacks and strokes
GPs are using new data analysis techniques to find patients on their lists who have had raised blood pressure but not been offered any monitoring and invite them for routine blood pressure checks – known to save lives.
Healthy Hearts started in Bradford in 70 GP surgeries and now, thanks to the developed relationships in the Integrated Care System (ICS) between the Yorkshire & Humber Academic Health Science Network, GPs, data analysts, hospitals and many others has been scaled up across 316 surgeries across West Yorkshire and Harrogate. It’s expanded from checking the 600,000 people in Bradford to being scaled up across the 2.7m population.
Since 2019:
- 22,000 more people have their blood pressure controlled to target numbers;
- 6,900 have been added to the hypertension register ensuring they get at least an annual BP check;
- 6,300 patients have had a change to a more effective statin; and
- 2,400 patients who are at risk of CVD have been offered a statin.
Healthy Hearts has made a huge difference to people’s lives in the area and as a GP I feel very satisfied that we’re now able to proactively seek people out who need our services. Instead of being a very reactive system we can identify people who have warning signs such as high blood pressure then take simple steps to protect their health and prevent needless deaths. Working in the Integrated Care System has been key to this because we’ve been able to roll it out across a much wider area instead of it being just a local project.
Heart and circulatory disease, also known as cardiovascular disease (CVD), is the biggest cause of death and disability in England with 1 death every 4 minutes, but often it can be prevented by leading a healthy lifestyle.
'Support people into a healthier lifestyle'
GPs across the region receive a toolkit and resources to help them identify the patients most at risk. This could include people who have a family history of ischaemic heart disease but have not had a BP check for a while. It could be someone who has been to the doctor for something else, had multiple slightly high BPs but not been offered any further intervention. People in the past often attended the GP for other reasons and have their BP checked but without follow-up.
Once identified the patient will receive a letter inviting them to come for a BP check. This could be at the GP surgery, at the chronic disease clinic or with the nurse or even do it yourself on the BP machine in the waiting room. The results are fed back to the GP and follow-up given where needed. This could be to attend for medication such as statins – much of the work here is to ensure people are on the right dose as this gives the highest benefits. It could also be to support people into a healthier lifestyle.
'Access relevant services'
Social prescribers working across multiple GP surgeries also help more patients who may have additional issues preventing them from accessing health services or remembering to take medication. They can spend more time with the person and help them access relevant services including weight management, mental health, or issues with housing or employment.
