What is the challenge your project is going to address and how does it connect to the theme of 'How can we improve across system boundaries?​

Challenge:
Of Bradford’s neighbourhoods, 34% fall within the most deprived 10% in England and Bradford has the country’s 12th highest premature mortality rate – 105 deaths per 100,000 from cardiovascular disease (CVD), higher than the national average and which positively correlates with deprivation. Data from Connected Bradford (a pseudonymised linked dataset) indicates a higher prevalence of CVD deaths in men from minority ethnic backgrounds at a younger age than in other ethnic groups, corroborated by anecdotal evidence from clinicians and community members.

Project:
Using Connected Bradford and partnering with the Primary Care Network, Voluntary Community Sector, and community groups we will conduct health checks targeting high-risk groups in community settings – at an accessible time and location. Furthermore, we will offer social prescribing and support individual’s in taking control of their health. Feedback from previous events:
“Good initiative, Helps prevent health crisis.”
“Good opportunity to come and get a health check.”

What does your project aim to achieve?

Aims:

• Support the identification and optimisation of CVD risk factors (hypertension, type 2 diabetes, and chronic kidney disease) in known high-risk groups.
• Increase awareness of risk factors and empower people in managing their condition.
• Support access to treatment by updating the GP record.
• Delivering long-term improvements in people’s heart health.

Objectives:

• Provide cardiovascular health checks in local community settings, targeting at risk populations as defined by the Core20PLUS5 criteria.
• Deliver brief interventions and signpost to lifestyle interventions and advice from local community organisations.
• Facilitate connections to primary care services, by uploading results to a patient’s GP record.
• Through partnership working, effectively mobilise community assets to enhance quality and delivery of the health checks , identifying opportunities for community collaboration, e.g., awareness work through social media.
• Evaluation of the impact and effectiveness of the health checks using quantitative and qualitative data.
• Understand priorities within the community to support development of future initiatives.

How will the project be delivered?

Building on learning from previous events we will deliver 10 events, providing a health check to approximately 600 people (BP, weight, height, HbA1c, lipid profile, and renal function). We have established relationships with the following to support the events:

• Living Well
• PCN 4 (5 GP practices)
• Bradford Council
• Diabetes UK
• Community Partnership 6
• Girlington Community Centre
• Milat Islamia Masjid
• Park Lane Centre

We will collect participant feedback to improve and adapt events using our experience in implementation science and quality improvement.

At a recent health check event 41% (32/78) had an abnormal BP. Given that 1 in 4 residents in Bradford describe themselves as South Asian, 40% of these may have an abnormal blood pressure, this equates to 200,000 people. Another 3 were newly diagnosed with type 2 diabetes. A health event of 100 people brings 0.3 QALYs, which is £10,000 benefit for a low-risk group (Crossan et al., 2017); targeting a higher risk group increases this to approximately £20,000.

How is your project going to share learning?

Data will be analysed using Stanford Lightning Report methodology, to share learnings with stakeholders within a week of events. This will enable us to adapt and develop the delivery approach for subsequent events – in line with quality improvement methodology.

We will develop a framework to support wider spread and adoption of the model and use existing Q networks to gather support and share learning as it emerges to help others working in this space. We will also provide our expertise in quality improvement and implementation science to support the spread, adoption, and evaluation of the model across other regions.

Feedback will also be co-developed with community groups to share with attendees so they can see the impact and contribute their personal stories regarding the benefit of attending the events. This will build on existing feedback, where people have been newly diagnosed or had medication amended from attending.