Addressing Health Inequalities is one of our two overarching objectives as Frimley Health and Care ICS:
(1) Reducing Health Inequalities for all of our residents who experience unwarranted variation in their outcomes or experience
(2) Increasing Healthy Life Expectancy for our whole population, ensuring an improvement not just in length of life but in the quality of those years as well.
Our Medicines Optimisation Team felt it was important to focus on individuals in Core 20 Plus 5 groups during 2023/24. This would help Frimley ICS move forward with these two objectives. One of the areas identified for accelerated efforts in the Core 20 Plus 5 initiative in cardiovascular prevention. This was also an area where performance in Frimley ICS had declined during the pandemic.
In addition, both lipid and hypertension management are National Medicines Optimisation Opportunities, as guided by NHS England. Therefore, we decided to focus on CVD prevention.
In Frimley ICS, we have a shared patient record system called Connected Care. This record also allows a highly granular level of data and population stratification to be undertaken. For the first time, our Medicines Optimisation Team worked with Connected Care Team to identify people in Core 20 Plus groups in our area who were on sub-optimal lipid modifying therapy. Those identified were then offered improvements in therapy in primary care through shared decision making.
3572 people were identified with cardiovascular disease and not on a high intensity statin and living in the 20% most deprived postcodes of our ICS or who were in one of the following “Plus” groups agreed for our ICS: homeless, LD, ex-military, refugee, released from prison, social isolation, need support to communicate.
Practices who took part in the project contacted individuals from this group and offered them high intensity statins .The impact achieved was as follows:- In practices undertaking active work under this project – reduction from 1991 to 1696 (295 people, 14.82%) in people in Core 20 Plus groups who had a history of CVD and were not on a high intensity statin.- (Compared group of those practices who did not participate – reduction from 1581 to 1520 (61 people, 3.86%))This is against a background of a new QOF target focussed on lipid modification. So all practices would have been working on lipids. Nevertheless, the increase in the Core 20 Plus group in the practices not taking part in the project was small.The project has demonstrated that specifically identifying and sending communication to individuals in Core 20 Plus groups does increase their access to improved lipid modifying therapies (3-4 fold). It correlates with data showing these groups find it harder to access health services.
