Coronary heart disease ten years on

Cardiac services have improved enormously in England, since 1997, driven largely through the impetus of the National Service Framework and the NHS Plan. The challenges now are to complete this journey, as cardiovascular disease becomes more of a chronic condition than just an acute illness or a sudden death. Cardiovascular risk needs to be managed both through improving lifestyle and through better treatment of risk factors – even in asymptomatic people. It is also important to replicate the improvements seen in heart disease, in areas such as stroke and transient ischaemic attack. In March 2000, the National Service Framework (NSF) for coronary heart disease was drawn up, which outlined a number of high level standards that were reinforced and augmented by the NHS Plan. At this time, cardiovascular mortality rates were falling but not as fast as in other West European nations. The plan was to build on this foundation and accelerate the rate of improvement by ensuring better prevention and better, faster treatment.

In fact, there has been a rapid decline, since 1997, so the target of a 40% reduction by 2010 is certain to be reached several years earlier than planned.

TACKLING RISK FACTORS

•A comprehensive tobacco control programme has had a measurable impact on smoking prevalence, while major media and education campaigns have promoted debate over second-hand smoke, in the lead up to a smoking ban in the workplace. The ban on tobacco advertising was accompanied by the development of NHS smoking cessation programmes.

• It is estimated that eating five portions of fruit or vegetables each day could lead to a reduction of up to 20% in overall deaths from diseases such as heart disease, stroke and some cancers. A number of actions are in place to encourage this agenda including the school fruit scheme, Five-a-Day, the school food programme and better liaison with the food industry.

• The Government is engaged in a wide range of projects to promote physical activity, set out in Choosing Activity (2005). These include action through the National Healthy Schools Programme, the Local Exercise Action Pilots, and training primary care professionals in the use of pedometers as a motivational tool.

• It is estimated that 3.4 million people are now taking statins (7% of the population) with the number of prescriptions rising each year by some 30% so that some 9,700 deaths from heart disease are being avoided each year as a result.

• Similar increases in prescriptions of other cardiovascular products has led to substantial improvements in blood pressure levels across England with encouraging trends in average blood pressure in both men and women. The prevalence of untreated hypertension fell from 32% to 24% between 1998 and 2003.

IMPROVING SERVICE

A national programme of modernisation has been developed to ensure that the patient’s experience is improved as far as possible. Thirty-two clinical networks have been developed to ensure that national priorities are delivered at local level, supported by improvement teams. These teams aim to improve the processes of care to provide faster access, better communication and more streamlined care throughout. One project, improving the speed of transfer of patients between hospitals for more complex treatments, saved thousands of bed days – the equivalent to a hospital of 900 beds in one year. The teams have also been active in tackling wider topics such as congenital heart disease, heart failure services, arrhythmias and cardiac rehabilitation.

One of the early priorities in the NSF delivery programme was to improve the speed with which the NHS responded to people suffering acute myocardial infarction or heart attack.

In 2000, only one third of emergency departments were capable of administering thrombolysis and many calls for help were being handled by GPs leading to an additional 40 minutes delay.

A number of initiatives have been established: • Ambulance services are required to respond to 75% of category A calls within 8 minutes.

• Paramedic-based treatment is being introduced.

• Hospitals are required to thrombolyse patients within 30 minutes of arrival.

This required a switch to treating patients in emergency rooms and the appointment of thrombolysis nurses in larger hospitals.

• A national register was devised so that every acute hospital submits data (Myocardial Infarction National Audit Project – MINAP).

The proportion of patients treated within 30 minutes of arrival at hospital has risen from 39% to well over 80%, while 57% of patients receive treatment within 60 minutes of calling for help. This has contributed to substantial reductions in 30-day mortality after heart attack. The audit process has also been effective in improving the uptake of effective therapies on discharge after acute myocardial infarction.

Over the last two years the Government has funded a national pilot testing the feasibility of a primary angioplasty strategy (balloon treatment rather than thrombolysis) in seven health communities covering about one fifth of the English population. It has also sponsored a public access defibrillation scheme. So far, over 100 people resuscitated by lay people working in stations, airports and bus stations have survived long-term.

FASTER SERVICE

In 2000, many patients were waiting more than a year for an outpatient assessment. Now, there is a network of rapid access clinics that ensures that over 95% of newly referred patients are seen within two weeks.

The increased activity in primary care has led to a much larger number of referrals for investigation rising from 66,000 per quarter to 110,000 per quarter. The new clinics, often staffed by specially trained nurses helped cope with this load.

A number of factors have contributed to the falling waiting times:

• There are more staff – including surgeons, cardiologists and nurses.

• £600 million has been invested in new or expanded facilities.

• Greater efficiency has been achieved – there is better management of staff and resources to make efficient use of the capacity.

• Patient choice has increased, allowing patients to travel to wherever they can be treated soonest.

Another bottleneck in the referral pathway was for diagnosis by coronary angiography. Faced with long waits for the procedure and unequal access to investigation, the Department of Health joined forces with the Big Lottery Fund to build and equip over 90 new catheter laboratories across England costing £125 million. Ultimately, with better facilities, more staff and easier access to care, it has been possible to provide safer treatment to a wider range of patients.

REFERENCE

1 Coronary heart disease ten years on – improving heart care, Professor Roger Boyle CBE, National Director for Heart Disease and Stroke (April 2007)