Two cardiovascular disease (CVD) projects delivered in partnership with the Buckinghamshire, Oxfordshire and Berkshire West (BOB) Integrated Care System, both based in primary care and focused on prevention, were shortlisted for the 2022 AHSN Network/NHS Confederation ‘Innovate Awards’ which recognise excellence in health and care innovation.
1 ‘Holistic CVD care through the lens of hypertension’ was a finalist in the Population health management category. This project, led by Dr Heike Veldtman, aimed to address the negative impact of the COVID-19 pandemic on management of hypertension. A number of GP practices across the BOB region put a structured process in place to ensure that patients were having their blood pressure reviewed and to increase the number of people on a home-monitoring pathway. The aim was to develop a simple process, focusing on people aged 65-74 living in the most deprived deciles. Over 7,000 people in the target cohort are now actively monitoring their blood pressure at home, with 74% of these achieving their target. The next phase of this work will be to develop a coherent and cohesive offer for practices for CVD prevention – tackling hypertension, lipid management, atrial fibrillation and heart failure in a joined up way, recognising that a more holistic approach is required for this patient group.
2 ‘Improving health outcomes in diabetes for the Nepalese community’ was nominated in the Reducing health inequalities category. This project, led by Dr Ganesh Sharma and Dr Aparna Balaji, aimed to address the poor diabetic control and outcomes that Nepalese people with type 2 diabetes experience when compared to other patient groups. An innovative group consultation model was developed, led by a GP and a health facilitator who speak Nepalese and are familiar with Nepalese culture and beliefs. This model, which was co-designed with members of the Nepalese community, enabled patients to understand their condition, the treatment options and the importance of self-management. Patient feedback was excellent and there was a reduction in average blood glucose levels after six months.