Cardiovascular Disease Directed Enhanced Service: views and experiences of General Practices

9. Emerging impact and next steps

This chapter looks first at practices’ decisions to continue into year 2 of the CVD DES and any views on potential involvement beyond the second year if the CVD DES continues. It then goes on to consider whether they are looking, or plan to look at different ways of engaging with patients as a result of participating in the CVD DES. The chapter concludes by summarising survey and interview participants’ overall reflections on the CVD DES and then presents some suggestions for changes going forward made by interviewees.

Year 2 and future plans (interview findings)

Interviewees were asked if they were adopting the same approach in Year 2 of the CVD DES or had any plans to change their approach to targeting and selecting patients to be invited for checks.

Most practices were planning a broadly similar approach to that they had used in Year 1 and expected that approach would be effective in terms of meeting the number of interventions they have been funded to deliver in Year 2. Whether using an opportunistic or more data-driven approach, practices generally anticipated that there would be a sufficient level of interest – including among patients living in the more socio-economically deprived areas covered by their practice – to keep a focus on that patient group. In some cases, practices were planning on reinviting patients who had not taken up the offer in Year 1.

Among practices that had already made or were anticipating making changes to how they target patients, possible options being considered included:

• expanding the target group into those living in their ‘next’ SIMD area; for example, if they had been focusing on SIMD 1 and 2 areas only, potentially starting to look at patients living in SIMD 3 areas
• more individual patient-based targeting, including engaging a broader range of practice staff in identifying patients who might benefit from CVD check
• shifting the balance between the direct targeting and more opportunistic approaches, generally with a focus on picking up a greater proportion of patients through the opportunistic route

From the interviews overall, it was clear that many practices have not only reflected on what has worked or not worked but have also been considering whether their CVD DES-related experience can help inform their approaches to other areas of their work. Survey respondents raised similar themes, including in relation to improved targeting and the use of data-informed approaches to identifying patients at risk of CVD. Practices described making greater use of risk stratification tools, including ASSIGN and diabetes risk tools,^[21] alongside more deliberate identification of higher-risk or less engaged patients.

“The high engagement levels demonstrate the value that careful targeting and a more focused, data‑informed approach can achieve. For any similar project in the future, we would apply the same level of targeted focus in order to help ensure success.” Small practice, serving an urban population and a relatively high proportion of people living in deprived areas

“We have been late starters with this but I think we will definitely reflect on this project and review how we target patients and follow-up them up for recall.” Medium practice, serving a predominantly urban population and a relatively high proportion of people living in deprived areas

Future changes in approach to patient engagement (survey findings)

To note, this question asked about future engagement in general and was not focused specifically on Year 2 of the CVD DES.

Survey question: Do you think you will change your engagement with patients in future as a result of this intervention? If Yes, please specify what change(s) you think you will make

Of 162 practices that responded to the survey, most (69%; n=111) reported that the programme would not change how they will engage with patients in the future. Just under a third reported that it would (31%; n=51). This suggests that, despite the programme’s implementation, approaches to patient engagement were largely expected to remain consistent within practices at the time of the survey.

In response to the question ‘If yes, please specify what change(s) you think you will make’, responses from 51 practices were thematically analysed.

Shift towards more proactive/opportunistic approaches

The most prominent theme was a shift towards more proactive and opportunistic approaches to identifying and engaging patients at risk of CVD. This included placing greater emphasis on opportunistic screening during routine consultations and identifying risk at an earlier stage. For example, practices described plans to ‘be more proactive in looking for potential risks of CVD in younger age group[s]’, be ‘more open minded about doing opportunistic CVD checks’, and ensure that ‘with any patient over 45 [we are] making [an] effort to make sure CVD risk assessments have been done’. Other responses reflected a broader change in mindset, with practices describing becoming ‘more mindful and proactive’ and adopting a ‘screening mindset over [a] reactive mindset’.

Sustaining changes beyond the DES

A second key theme related to sustaining changes beyond the DES. Some practices indicated that elements of the programme would be sustained or embedded into routine practice. This included continuing activity beyond funding thresholds, with practices reporting that they were ‘continuing to assess suitable patients even though we reached our target for funding’ and would continue to ‘offer patients within the age bracket the option to have the blood tests completed’. Other responses described integrating elements of the CVD DES into chronic disease management, including incorporating ‘the structure of the CVD DES consultation’ into existing processes and using ‘waist measurements as routine and diabetic risk scoring’. Practices also reported establishing ongoing recall and monitoring systems, for example having ‘created a 5-year CVD risk recall for those at risk’ and introducing ‘annual reviews for pre-diabetics and increased referrals to the pre-diabetic clinic’.

Broader prevention and health promotion activity

A number of practices described broader prevention and health promotion activity arising from the programme. This included increasing opportunities for ‘well person checks’, updating patient information materials, and identifying previously undiagnosed conditions such as diabetes. For example, one practice noted that the programme had helped identify ‘patients with a new diagnosis of diabetes… [where] health promotion was proactive rather than reactive’. These responses suggest that some practices perceived wider benefits beyond CVD risk assessment, particularly in relation to prevention, early identification and health promotion.

Conditional changes

Finally, a small number of practices highlighted workload and resource considerations as factors influencing future implementation. Responses suggested that the sustainability of some approaches was contingent on available funding and staff capacity. For example, one practice indicated that continuation of activities would depend on ongoing resourcing, stating that ‘if there was an ongoing DES we would continue… without a DES we won’t do this as it increases workload’. Another reflected on the time-intensive nature of telephone outreach, noting that ‘…we won’t phone patients or make repeated attempts to engage, rather than moving on to the next person as we have a large cohort to select from’. These responses suggest that, for some practices, decisions about future delivery would be influenced by considerations of workload, capacity and available resources.

Taken together, the responses suggest that the CVD DES may have influenced future thinking and practice among some practices, particularly in relation to proactive identification of CVD risk, targeted patient engagement and the use of digital communication methods. Several practices described plans to sustain or embed aspects of the programme into routine care, while others identified opportunities to refine existing approaches through greater use of risk stratification and preventive activity. However, a small number of practices highlighted that the extent to which changes could be maintained in the longer term would depend on factors such as workload, staffing capacity and ongoing resources.

Reflections on the CVD DES overall (survey findings)

In their further comments, many survey respondents described the CVD DES in positive terms, emphasising its preventative value, benefits for patient care and benefits for the practice itself:

“This DES has been very enthusiastically adopted by both patients and staff alike. We feel it is a very positive use of resources for public health and are keen that it will continue.”

“This is an excellent health screening opportunity which has been taken up by our patients. I hope to see this expand.”

“Very positive step the government is taking in primary prevention and also paying GP practices for services rendered!”

“Fantastic DES for our high area of deprivation.”

However, even among practices who were broadly positive about the DES, some caveats were raised, particularly in relation to workload, funding and the longer-term sustainability of the programme. Some practices also highlighted concerns about aspects of the eligibility criteria and their potential impact on participation. These responses suggest that positive perceptions of the programme were sometimes tempered by practical considerations regarding implementation and resourcing.

“This is potentially a really valuable DES and I think it should be continued. But you need to fund it. You also need to look at your exclusion criteria because you are currently preventing some people taking part for no good reason (i.e. they had 1 high BP recorded when they were unwell 2 years ago but have not had any other screening).” Medium practice, serving a predominantly urban population with relatively low levels of deprivation

A minor theme among survey respondents related to negative overall assessments of the programme. Although relatively few practices expressed these views, those that did often reported strong concerns about the balance between the resources required to deliver the CVD DES and the benefits achieved. Practices described the programme as time-consuming, administratively burdensome and challenging to implement, particularly where patient engagement was low. Some also questioned whether the outcomes generated justified the level of effort involved.

“This has been the most time consuming, labour intensive DES with very little response from the “missing”. They do not want to engage and we have spent a great deal of time chasing people who in the end, officially opted out of this initiative... The time and effort invested in this DES has been monumentally inordinate to any positive outcomes. If we had been aware of how fruitless this exercise was at the outset, we would have thought twice before opting in...” Large practice, serving a predominantly urban population with relatively low levels of deprivation

This suggests that, for a small number of practices, the CVD DES was perceived as placing substantial demands on staff and practice resources, with limited perceived return in terms of patient outcomes or service benefit.

Taken together, the additional feedback highlights the diverse experiences of practices implementing the DES. While practices frequently identified positive outcomes, including successful case finding and opportunities for prevention and early intervention, many also highlighted operational challenges relating to workload, funding, administrative burden and patient engagement. The findings suggest that practices generally supported the aims of the programme, but that experiences of implementation were shaped by local capacity, systems, and the extent to which programme requirements aligned with routine practice. These factors appear to have influenced both perceptions of the programme and its delivery across responding practices.

Potential adaptions to the CVD DES (interview findings)

As noted earlier, the practices of all of the interviewees had decided to take part in year 2 of the CVD DES, and all also reported that they had made the right decision to sign up to participate in the CVD DES in the first instance. Setting aside the availability of resources, practices’ initial and ongoing support for a focus on prevention was clear.

In terms of the particular clinical focus on the CVD DES, most were of the view that the CVD focus was reasonable and supported by the evidence of prevalence of CVD in Scotland. However, there were also suggestions that broadening out the scope, to the more general health focus of preventative work in the past, should be considered. It was also noted that, relative to the scale of the health problem, the potential impact of the CVD DES in terms of longer-term health outcomes is inevitably limited, and that even at current levels it will be further constrained by recent changes to clinical assessment tools, and particularly ASSIGN, and the point at which follow up treatment is recommended.

Connected to reflections on the potentially limited impact of the CVD DES was an appetite from many practices to potentially deliver a higher number of interventions, especially among practices who had been funded to see fewer patients because of the age and/or socio-economic profile of their list.

However, for others the current number of places for which they have funding was seen as a more workable option going forward. This view tended to be linked to resourcing within the practice but also, on occasion, to a continued focus on those living in more deprived areas and the ‘missing’. With a continued focus on this patient group, some practices thought they would find it difficult to find higher numbers of patients who were interested in taking part.

Although, as noted earlier, there tended to be support for an ongoing focus on patients living in areas of higher deprivation, there was less of consensus around the focus on ‘missingness’. This was in no way to suggest that practices did not see value in looking to engage with this group of patients, but they were not always convinced that the CVD DES is an appropriate or effective vehicle for doing so. Instead, it was suggested, the Scottish Government may wish to consider an additional and focused piece of work that looks at innovative practice around engaging with this patient cohort.

Summary findings

From survey:

• most responding practices reported that the programme would not change future patient engagement approaches
• respondents that did expect to change their approach were most likely to foresee a shift towards more proactive and opportunistic approaches
• while many survey respondents described the CVD DES in positive terms, emphasising its preventative value, benefits for patient care and benefits for the practice itself, many also highlighted operational challenges relating to workload, funding, administrative burden and patient engagement

From interviews:

• all of the interviewees had decided to take part in year 2 of the CVD DES, and all reported that they had made the right decision to sign up to participate in the first place. Setting aside the availability of resources, practices’ initial and ongoing support for a focus on prevention was clear
• although most considered the CVD focus reasonable in view of the prevalence of CVD in Scotland, it was noted that impact of the programme on longer-term health outcomes will be limited relative to the scale of the problem, and some practices felt they would be able to deliver a higher number of interventions if given funding to do so
• while in no way suggesting they did not see value in seeking to engage with the ‘missing’ group of patients, some interviewees were not convinced that the CVD DES is an appropriate or effective vehicle for doing so