Aim statement
Use data to help predict and prevent cardiovascular disease (CVD) and diabetes within the prevalence of QRISK outcomes, such as heart attacks and strokes.
We aimed to reduce CVD prevalence by 10 per cent, and increase the prevalence of diabetes by 10 per cent, as well as identify incidences of pre-diabetes, within the next 12 months.
What we did
- Used EMIS to identify patients at high risk, not already taking statins
- Used the Q-diabetes calculator to identify all patients with a risk of more than 50 per cent of developing diabetes
- Invited patients to health check clinics on a Saturday and in the evening
- Reviewed our aim and made changes at the mid-way point
- Saw a 600 per cent increase in chronic kidney disease (CKD), a 533 per cent increase in diabetes and a 314 per cent increase in pre-diabetes, plus a 500 per cent increase in fatty liver disease
- Had 300-plus more patients attending for checks, and made 200-plus more diagnoses compared to the previous year
- Recognised the importance of using tools to support the stratification of patients into suitably convenient clinics
- Patients appreciated the choice of convenient appointments at weekends or in the evening, at a selection of locations
- Empowered patients to manage their conditions through early identification
- Broadened the outcome for patients and supported better health benefits
How the proactive and personalised care programme helped
- Allowed us to have protected thinking time
- Learned how to use new tools to support the visualisation of our project
- Developed a focused project plan, driver diagram, and highlighted where problems might occur and how to combat them
- Helped the PCN to focus when we found we were stumbling
- Useful and inspirational networking with other PCNs
- Devoted senior clinical time away from practice to focus on quality improvement (QI) and problem-solving
- Additional support from a proactive Advanced Clinical Practitioner and the project senior team, as well as Clinical Director (Senior GP partner)
Next steps
We want to continue to build on the success of the project and develop multiple clear projects for all practices in the PCN, enabling this tried and tested approach to become ‘best practice’ and business-as-usual for us.
We believe keeping wider stakeholders informed, celebrating our successes and having the right ethos will help focus our PCN plans for neighbourhood planning and population health management for the year ahead.
We will continue to review our data on a monthly basis, and support our staff and patients to improve health outcomes.
