1. CVD Secondary Prevention plans within Thames Valley
Gita Sundareshwar
Network Quality Improvement Lead
18/09/2018

2. CVD UK Key Facts- BHF

3. Information from size of the prize - PHE
The diagnosis and treatment gap in 2015/16 for the Thames Valley region
Frimley health
Buckinghamshire, Oxfordshire and Berkshire West
Estimated adult population with Hypertension
161,900
390,200
Estimated adult population with undiagnosed hypertension
69,200
166,200
GP registered hypertensives not treated to 150/90 mm/Hg target
19,500
45,200
GP registered population with Atrial Fibrillation (AF)
11,200
29,600
Estimated GP registered population with undiagnosed Atrial Fibrillation
5,700
13,100
GP registered high risk AF patients (CHA2DS2VASc >=2) not anticoagulated
2,300
5,000
Estimated adult population 30 to 85 years with 10 year CVD risk >20%
52,700
121,300
Estimated percentage of people with CVD risk ≥20% treated with statins
49%
The burden: first ever CVD events, 2015/16
Frimley Health
Buckinghamshire, Oxfordshire and Berkshire West
Coronary Heart disease
1,700
3,000
Stroke
750
1,750
Heart Failure
550
1,150

4. Information from size of the prize - PHE
The opportunity: potential events averted and savings over 3 years by optimising treatment in hypertension, 2015/16 – info from size of the prize for STPs
Buckinghamshire, Oxfordshire and Berkshire West STP
270 heart attacks
Up to
£2.00 million saved
400 strokes
£5.40 million saved
Frimley health STP
120 heart attacks
£0.90 million saved
170 strokes
£2.50 million saved
Optimally treating high risk AF patients averts within 3 years
£6.60 million saved
180 strokes
£3.10 million saved

5. Thames Valley Strategic Clinical Network (TVSCN) plans in progress
The TV SCN:-
1. Is establishing a core group of CVD clinical leads to complement STP prevention groups.
This group will-
provide strategic direction and leadership across the system
set a clear ambition, targets and trajectories for improvement of the cardiovascular health for the TV population by focussing on increasing earlier detection and better management of cardiovascular diseases with reduced variation between practices, resulting in the reduction of CVD incidents and improved patient outcomes.
determine the scope of work
2. Has produced an example case for change. Offering each locality a detailed analysis of the CVD outcomes, and current and projected burden of the different CVD events. In addition practice level data highlighting variation and the sharing good practice initiatives to improve patient outcomes and reduce the cost burden.
3. Is scoping local initiatives to provide a comprehensive picture across TV for the clinical leads with potential collaboration between network, Year of Care and a small number of GP practices testing out the application of Care and Support Planning approach in a group based setting for people diagnosed with hypertension.
4. Is working with key partners- British heart Foundation (BHF), AHSN, BoB and Frimley STP prevention boards

6. Proposed Thames valley Ambitions and Target

7. My email address: Sangeetha.sundareshwar@nhs.net