Roundtable discussions identified models in which pharmacy teams are already playing a significant role in both supporting people to stay healthy through prevention and supporting patients with CVD, as well as looking at how more support could be provided or scaled up across the country.
There was felt to be scope for pharmacy teams working within or in collaboration with PCNs to support healthy living and prevention, early detection of cardiovascular disease and treatment of stable chronic illness in primary and community-based settings as part of multidisciplinary teams. Making more specialist medicines optimisation support available in both primary care and in hospitals was also identified as an opportunity.
It became clear that a range of different models of care for people with cardiovascular disease, or to prevent people from getting it, are developing however these are localised innovations and there is variability across England.
What was less clear was the extent to which these models are being integrated into existing services and there was a general view that as services develop they need to link up existing services and optimise the use of pharmacy expertise. This needs to include the development of co-created services that are integrated to support local populations and have defined direct referral pathways to and from pharmacists providing these services.
The question of how best practice is shared across systems was raised and this is considered in section 4 along with other potential enablers.
The group then considered where pharmacy teams can offer support for cardiovascular disease and highlighted some examples of practice.
3.1 Prevention and healthy living
Due to their accessibility and the number of contacts with patients and the public, community pharmacists and their teams have a clear role to play in supporting healthy living and the prevention of cardiovascular disease.
There are already models in place such as Healthy Living Pharmacies that can support people to make the lifestyle changes necessary to prevent the development of cardiovascular disease.
By April 2020 every community pharmacy will need to become accredited as a Healthy Living Pharmacy. This is a model in which health champions deliver opportunistic brief interventions around lifestyle advice (and early detection see 4.2) that supports cardiac health and is a key way in which pharmacy teams could do more. Doing more with Healthy Living Pharmacies could be linked to better use of public health campaigns to include cardiovascular disease.
Ultimately the Healthy Living Pharmacy model could be used to increase pharmacy activity in public health and prevention across a range of areas.
The role of NHS Health Checks as part of the prevention and healthy living agenda was discussed. Currently commissioned by local authorities, the view around the table was that overall the provision of NHS Health Checks is variable and that in order to increase uptake there was an opportunity to better use the multidisciplinary team, increasing access and sharing workload.
The NHS Long Term Plan (NHS England. NHS Long term plan. January 2018), published after the roundtable, acknowledges the need to work with local authorities and Public Health England to improve the effectiveness of approaches such as the NHS Health Check to rapidly identify people with high-risk conditions.
The importance of including pharmacy services as part of an approach of sustained community engagement in healthy living and prevention was discussed. This would include links with public health initiatives, personal health budgets, new support for people to manage their own health in partnership with patient groups and the voluntary sector, and social prescribing.
Case study 1 highlights how pharmacy services can be incorporated into a collaborative community-wide approach to reducing blood pressure.
Case study 1: Public health collaborative supports blood pressure reduction
The Merseyside Pharmacy Local Professional Network has been working with the Champs Public Health Collaborative to influence the Cheshire and Merseyside CVD strategy. The work has focused on better utilisation of Healthy Living Pharmacies (HLPs) for delivery of the strategy.
In 2017, Saving lives: Reducing the pressure was launched in Cheshire and Merseyside and sets out the vision, aims, objectives and high-level action plan for the prevention, detection and management of high blood pressure. The HLPs’ role was recognised in all three areas of prevention (Making Every Contact Count), detection (BP and AF screening) and management (medicines optimisation tools, medicines reviews/NMS).
120 HLPs were recruited in a British Heart Foundation (BHF) funded BP screening pilot with a further 120 due to be recruited in 2019. In two areas another project is being developed to link HLPs with GP pharmacists to also detect and manage new AF patients. The HLPs were automatically included in the Blood Pressure UK’s 2017 Know Your Numbers!® Week that aimed to help increase detection of the estimated 260,000 people in Cheshire and Merseyside who have high blood pressure but don’t know it.
In addition a new BP service funded by local NHS and CCGs is being offered as an expansion for the HLPs in the BHF pilot once they have reached their minimum screening quota that, in addition to screening, offers medicines optimisation opportunities to existing hypertensive patients.
The Champs Public Health Collaborative (www.champspublichealth.com) delivers local priorities agreed in partnership with Public Health England North West and NHS England Cheshire and Merseyside.
3.2 Early detection
Early detection and treatment of cardiovascular disease can help people live longer, healthier lives. Many people are still living with undetected, high-risk conditions such as atrial fibrillation (up to 500, 000 people) (British Heart Foundation), high blood pressure (one in 10 people (British Heart Foundation)) and raised cholesterol.
Community pharmacists and their teams, and pharmacists in PCNs can, and in some parts of the country already do, provide opportunities for the early detection, case-finding, and treatment of these high-risk conditions.
Early detection of atrial fibrillation by community pharmacy teams and PCN pharmacists was highlighted as a key area where care and patient outcomes could be improved. Strokes related to atrial fibrillation have worse patient outcomes (British Heart Foundation).
It is clear from discussions at the roundtable that this is an area across England where different service models are being developed and piloted often with specialist input from secondary care hospital pharmacy teams. The importance of developing a sustainable model as part of a PCN with defined referral pathways that include pharmacy services was stressed (see case study 2). This is now being considered as part of the Community Pharmacy Contractual Framework and a fundamental part of the PCN CVD prevention and diagnosis network enhanced service.
Case study 2: Surrey Heartlands Integrated Care System model
Surrey Heartlands Health and Care Partnership is a developing Integrated Care System (ICS) with a devolution agreement between Surrey Heartlands, NHS England and NHS Improvement.
One of the key priorities identified by the ICS was prevention and planned care, with a strong focus on Cardiovascular disease. In Surrey Heartlands coronary heart disease and cerebrovascular disease are the second and third largest contributors respectively to premature mortality. Two-thirds of deaths could be avoided through improved prevention, earlier detection of factors such as hypertension and diabetes and improved treatment in primary care.
Throughout 2018 work began to develop and operate under one Surrey Heartlands cardiovascular operating model, to deliver a cardiology service across the region.
Committed to the Surrey Heartlands citizen-led co-design communications and engagement initiative, discussions involved clinicians GPs, consultants, community pharmacists and specialist nurses as well as members of the public to understand the population needs; investigate optimal pathways and agree a collaboratively developed work programme.
Working with the Kent, Surrey and Sussex Academic Health Science Network the programme will distribute over 100 mobile ECG devices to a range of settings including community pharmacies, GP practices, community nurses, patients’ homes and community hospitals.
These units can be used to carry out opportunistic pulse rhythm checks and identify people who have atrial fibrillation (AF) so that appropriate care can be provided. The devices have been shown to be an effective, low-cost solution for identifying new AF and reducing the risk of AF-related strokes.
A key theme of the citizen-led co-design was the role community pharmacy could play in the prevention and wellbeing agenda, which has led to Surrey Heartlands ICS partnering with Community Pharmacy Surrey and Sussex (the Local Pharmaceutical Committee) to develop the community pharmacy element, offering blood pressure and atrial fibrillation (AF) checks alongside healthcare advice to manage these conditions.
The service is to be developed by the LPC service development and support pharmacist, funded by Surrey Heartlands ICS. The service is expected to be launched later in 2019.
As well as opportunistic interventions (see case study 3), the need for a strategic approach to case finding was also highlighted (see case studies 4 and 5).
Atrial fibrillation has been a part of the innovations programme for the Academic Health Science Networks and there have been a range of initiatives across the networks to improve early detection as well as treatment of atrial fibrillation (www.ahsnnetwork.com/about-academic-health-science-networks/national-programmes-priorities). Many of these initiatives have looked at how community pharmacists can play a role.
Case study 3: Early detection of Atrial Fibrillation through community pharmacies
Objectives of the service are; to improve the detection and treatment of undiagnosed atrial fibrillation, to improve anticoagulation prescribing inpatients with diagnosed AF, to:
- Facilitate early referral to a specialist centre, and
- To improve adherence to anticoagulation using the New Medicines Service.
30 community pharmacists from the Hillingdon area were recruited and trained; ten in 2016 for the pilot study and a further 20 when the project was scaled up in 2018/19. Patients were selected by community pharmacists as eligible (≥65 years old with AF associated risk factors) for a specially designed AF medicines review.
A handheld Kardia ECG (NICE approved technology) was used to detect AF. Patients are referred directly to the Arrhythmia Care Team (ACT) at the Royal Brompton and Harefield Hospital. Once diagnosis is confirmed anticoagulation is started and the patient is referred to their community pharmacist for the New Medicines Service to help support adherence.
The need for a strategic approach to case finding was also highlighted as an important part of early detection and treatment (see 3.3 below).
"Where 100 people with AF are identified and receive anticoagulation medication, an average of four strokes are averted, preventing serious disability or even death.”
- NHS Long Term Plan
3.3 Primary Care Network management of cardiovascular disease by pharmacists
Case finding and better management of cardiovascular care in primary care was identified as an area where pockets of innovation exist. Examples the group heard about included GP practice pharmacists increasingly managing cardiovascular patients (see case study 4).
We would expect that community pharmacy is included in the formation of the national service specification for CVD as they can play a significant role in ensuring delivery.
Case study 4: Pharmacist led CVD clinic in general practice
Churchdown Surgery in Gloucestershire (14,000 patients) developed a new cardiovascular pathway in 2016. The aim of the new pathway was to improve patient experience and cardiovascular outcomes whilst easing the burden on GP appointments for initiation or titration of blood pressure medications/statins and medication reviews.
Nurse-led hypertension and CVD monitoring clinics did not have sufficient capacity with the nursing team, GP reviews were opportunistic and the practice had to put on extra clinics at end of year to meet quality and outcome framework targets. The full-time appointment of a GP practice pharmacist with an independent prescribing qualification presented an opportunity to introduce a more robust system of monitoring.
The new pathway utilises the skills of the pharmacist and healthcare assistants and includes the annual recall of patients with known hypertension and cardiovascular disease, in addition to patients presenting with a newly raised blood pressure. The clinic includes all patients currently on the hypertension, coronary heart disease, peripheral arterial disease (PAD), or stroke/TIA registers.
As an independent prescriber, the pharmacist can diagnose and manage hypertension and can start/amend/stop medications for other conditions if needed. The pharmacist also undertakes frailty/polypharmacy reviews and routine medication reviews at the same time, saving repeat appointments for the patient.
The pharmacist-led pathway has led to lower average blood pressures and an increase in the proportion of patients taking statins which will reduce the risk of cardiovascular events over the next 10 years.
The patient satisfaction questionnaire results show satisfaction in the care provided by the pharmacist. This pathway was one of a number of changes the practice made which meant the GPs could extend their appointment times from 10 to 15 minutes.
As well as pharmacists working in general practice, the group heard about virtual clinics running in primary care that are accessing the medicines expertise of specialist or consultant cardiovascular pharmacists based in hospitals to provide both direct patient care in primary care and as a teaching model for primary care (see case study 5).
Case study 5: Virtual anticoagulation clinics with specialist pharmacists
A ‘virtual clinic’ approach targeting AF patients on GP registers who were not receiving anticoagulation, initially led by Lambeth and Southwark CCGs and King’s College Hospital, is now being rolled out by a number of Academic Health Science Networks and across 23 CCGs between December 2018 – March 2020.
In this model, specialist anticoagulation pharmacists systematically searched GP records to case-find patients who had been diagnosed with AF, but were not receiving optimal management and treatment. Patients who were not being optimally managed were then discussed in a ‘virtual clinic’ between the specialist anticoagulation pharmacist and a GP, to recommend an optimal course of treatment.
The ‘virtual clinics’ are so-called, as they can be carried out remotely, via telephone, Skype or videoconference. Following the virtual clinic, the GP meets with the patient to discuss and agree on a course of treatment.
The pilot in Lambeth and Southwark was carried out between October 2015 – December 2016, and reviewed the 1,340 patients and anticoagulated an additional 1,292 patients. It is estimated that this pilot prevented approximately 65 strokes per annum across the two CCGs.
It has been estimated that scaling up this local pharmacist-led model across England, could prevent an estimated 3,000 AF-related strokes and save 750 lives.
Care home residents are increasingly seeing the care they are offered through the NHS improved in line with the Enhanced Health in Care Homes model developed through the NHS England vanguards programme. This includes regular pharmacist-led medicine reviews where needed and provides the opportunity to optimise cardiovascular medicines in frail and elderly people (NHS England. NHS Long term plan. January 2018).
Building on NHS England’s Medicines Optimisation in Care Homes Programme, Primary Care Networks must enable care homes to be supported by a multi-disciplinary team of healthcare professionals including pharmacists and pharmacy technicians.
More than 16 million people in England are diagnosed with a long-term physical health condition, and one in three of this group will experience a mental health problem. Pharmacists and their teams need to be aware that the diagnosis of a long term condition such as cardiovascular disease is a trigger point for the development of a mental health problem. Signposting people to help and support for a mental health issue needs to be a generalist skill for all pharmacists (Royal Pharmaceutical Society. No health without mental health: How can pharmacy support people with mental health problems? June 2018). Pharmacy team members can train as mental health champions to support mental wellbeing in people with CVD.
3.4 Acute hospital-based care
In the hospital setting specialist pharmacists are key members of the multidisciplinary team and have a pivotal role to play in supporting people with cardiovascular disease. The group heard about pharmacists working as members of an inpatient heart failure team with a focus on identifying people admitted with undiagnosed heart failure across the trust and initiation of treatment (see case study 6).
We also heard about pharmacists running pre-operative surgery clinics to ensure medicines were optimised, medicines optimisation outpatient clinics focused on up titrating medicines, and reviewing and/or changing medicines.
Hospital pharmacists have an ideal opportunity to support people with lifestyle and health promotion advice (e.g. smoking cessation, increasing physical activity, reducing alcohol intake) when patients are admitted to hospital, especially those with a new diagnosis of CVD. They can also signpost to local services and social care link workers whether based in community pharmacies or through other community providers such as third sector organisations.
Case study 6: Heart Failure Pharmacist
City Hospitals Sunderland incorporates the specialist pharmacist into the multi-disciplinary team. The Heart Failure Pharmacist is a permanent member of the Inpatient Heart Failure Team which consists of a consultant cardiologist, a geriatrician and a heart failure nurse.
The objectives for the heart failure service are to comply with the national heart failure audit, to achieve NICE quality standards, co-ordinate care between cardiology and other specialities, improve outcomes for patients and to provide effective management for patients transferring to primary care.
The heart failure pharmacist’s inpatient role includes identification of heart failure patients regardless of the reason for admission, as well as initiating and monitoring treatment, referral, medication review and ensuring follow up on discharge. The outpatient role includes diagnosis, monitoring stability after discharge, up titration of medicines and communication with primary care colleagues.
Overall the service provides patients with early and continued input from a dedicated multidisciplinary Heart Failure team, aids in the up titration of medicines during hospital admission and after discharge, provides patient counselling and lifestyle advice, provides early follow up after discharge (within 2 weeks) and offers specialist heart failure advice to other health care professionals.
Having a pharmacist as a core member of the team provides an additional area of expertise around medicines that is of particular use in people with complex multiple conditions, taking a large number of medicines and/or with ageing pharmacokinetics.
Specialist and consultant pharmacists in cardiovascular disease also have a key leadership role to play in supporting medicines and the development of pharmacists (and other healthcare professionals) across primary and secondary care, especially as care shifts toward being delivered more in community settings as part of Integrated Care Systems (ICSs). However, there was an acknowledgement that there is a shortage of consultant pharmacists and specialist pharmacists with the skills necessary to train colleagues and support this shift (see enablers section 4). With key drivers such as the Get It Right First Time (GIRFT) programme, we would expect pharmacists in hospitals to have a key role to play in helping reduce unwarranted variations across all speciality areas including cardiology and place a vital role as part of hospital specialist multidisciplinary teams.
Further reading: “Heart failure care: pharmacists poised for key role in multidisciplinary future”
3.5 Integrated pathways across sectors
The group discussed where services might develop in the future. It was felt that as care moves out of hospital that there was a need to develop medicines optimisation services in primary care settings that meet all the needs of patients. Ideally this will be facilitated by a systems approach to medicines optimisation across ICSs and PCNs. Each ICS will be responsible for developing services that fit their local populations needs so approaches will differ. However, as services develop, there needs to be integration of pharmacy teams into referral pathways in a way which promotes cross-boundary working, delivered through a mix of local and national commissioning by the NHS and local government.
Defined discharge pathways from secondary care are needed to ensure medicines optimisation in primary care after cardiovascular events. For example, for people coming home after a myocardial infarction there is a need to up titrate doses of ACE inhibitors and beta blockers as this is often not possible prior to discharge.
Equally when some cardiovascular patients leave hospital they require additional support taking their prescribed medicines. This may be because their medicines have changed or they need help taking their medicines safely and effectively. Pathways may vary from locality to locality, but where services such as the community pharmacy New Medicines Service exist these can be utilised. There is also a need to join these up with social care pathways and pharmacists and their teams can play a role in supporting social care teams.
Further reading: A Systems Approach to Medicines Optimisation and Pharmacy