Calls for action on cardiovascular disease

The Care Quality Commission (CQC) has called for a renewed drive to cut numbers of people with cardiovascular disease (CVD), which is responsible for one in three deaths in England. Caused mainly by obesity and smoking, CVD costs the country more than £30 billion a year. It is the nation’s biggest killer, causing more than 200,000 deaths annually and is set to affect even greater numbers of people – with forecasters predicting that 90% of adults will be overweight or obese by 2050. The CQC has therefore published a study on efforts to cut deaths from the disease and to reduce inequalities between those in deprived areas and other parts of the country of which CVD is the biggest cause. The study applauds the decline in England in death rates from the condition, driven by reductions in both smoking and cholesterol levels and points out that the Government has already met its target of cutting total deaths among people under 75 by at least 40% by 2010. It is also on track to meet its target of narrowing the gap between worse-off areas and the country as a whole. However, the CQC says the nation must go further as the UK still has one of the highest CVD rates in Europe. It also highlights the fact that patients get different standards of care in different areas as many primary care services, including GP practices, do not follow proven practice consistently. It calls for measures to improve further performance of GPs and commissioners on statin prescribing, cholesterol management and targeting of poor areas. CQC chair, Barbara Young, said: “This disease is likely to touch every single one of us at some point in our lives. It is good news that the number of deaths has been driven down, but resting on those laurels is really not an option. We cannot accept that more people die here prematurely from CVD than in other countries and we cannot rest while health inequalities exist on the scale that they do. People in the richest area can expect to live up to 23 years longer than people in the poorest. “We have to raise the bar of acceptable performance, upping the level GPs and primary care practitioners are being asked and incentivised to perform to.” CQC’s study looks at statin prescribing, which reduces cholesterol levels, and the provision of NHS stop smoking services, which provide advice, support and nicotinereplacement products. The regulator has, for the first time, collated and analysed data on the performance of some 8,300 GP practices and 152 primary care Trusts responsible for the provision and commissioning of this care. Findings include the following: Tougher goals required: Giving GPs financial incentives to manage cholesterol levels has improved performance and there is now room for more stretching goals. Currently, GPs get maximum payment when they record acceptable cholesterol levels for 70% of patients on the register. While there has been improvement, the report shows this is leveling off. Therefore, CQC recommends increasing the payment threshold. It points out that nearly one in five patients on heart disease registers do not have their cholesterol levels recorded as being acceptable and that GP practices can receive maximum payment without doing this for a third of their patients. CQC adds that the national average masks variation in performance – 5% of GP practices did not reach the maximum payment threshold. Unrecorded CVD in deprived areas: There is still too much unrecorded CVD and this is a particular problem in the most deprived areas of the country. GPs in deprived areas are less likely to record whether someone has CVD. Those not recorded as having the condition may not get access to the services they need. The report estimates that the median (the mid point) unrecorded prevalence across PCTs was 1.1% of the total population. This equates to around 350,000 people in England who would be expected to have CVD but who are not recorded as such. The problem is greater in the most deprived areas where estimates suggest that up to 7% of the population has CVD which is unrecorded. This is particularly worrying as people in the more deprived areas may have more complex health and social needs and may suffer greater burden of disease before seeking help. CQC says PCTs should use outreach programmes to target people at most risk when commissioning primary care practitioners to carry out vascular screening. The NHS is now offering vascular screening to every adult between the ages of 40 to 74. Prescribing of expensive branded statins: Too many GPs prescribe expensive branded statins when equally effective, cheaper non-branded ones are available. Statins are the main medicine for lowering cholesterol. NICE recommends that low-cost statins are prescribed where appropriate in the first instance to all adults over the age of 16 who have clinical evidence of CVD and to all those assessed as being at high risk of CVD, but may currently have no symptoms. The NHS spends more on statins than any other drug, with the total cost doubling to some £500 million in the three years to 2007. The study points to analysis by the best practice and training body, the NHS Institute for Innovation and Improvement, which suggests that 78% of statin prescribing should be for generic rather than branded drugs. Therefore, CQC estimates that the cost saving would be £62.5 m if all GPs prescribed statins in this way. CQC says PCTs should strongly encourage GPs to prescribe non-branded statins, where clinically appropriate, and monitor this systematically. Statin prescribing should be part of an overall care programme that involves lifestyle changes to reduce risk of CVD. PCTs should feed back to GPs any inequalities in prescribing and take action where necessary to ensure prescribing is cost efficient. Poor management of cholesterol levels: Too many GP practices that are not prescribing cost-efficiently also perform less well on managing patients’ cholesterol levels. CQC looked at the overall level of statin prescribing and the overall level of cholesterol management. It found that too many practices were in the lower performing category on both counts. The study shows that around one in four practices (approximately 2,000) were in this group. The report raises concerns that these practices may be managing CVD less well in terms of both keeping costs down and delivering good outcomes for patients. It says this finding underlines CQC’s recommendation that primary care Trusts closely monitor prescribing costs and further improve cholesterol management, commissioning services accordingly. Need to improve smoking cessation: GPs in deprived areas are less likely to prescribe nicotine-replacement products to patients. Smoking is still the biggest single avoidable cause of death, killing some 82,000 people a year. Overall, levels of smoking have fallen from 28% of the population in 1998 to 21% in 2006, although this masks variations across the population. The study shows that, in deprived areas, the prescribing of nicotine replacement products does not increase in line with greater smoking prevalence. This suggests need is not being met. The report says that NICE should recommend extending Quality and Outcomes Framework indicators so that all smokers registered with a GP practice are offered advice or referral to NHS stop-smoking services, as well as medicines that are proven to help. PCTs should monitor how effectively services meet need where it is highest. They should also ensure GPs proactively identify people who live in poorer areas, smoke and at risk of CVD. The Department of Health should collect and publish data on how individual people use services so that performance can be effectively monitored. Stop-smoking services in deprived areas also need to find more innovative ways of helping people stay off cigarettes. At least one in five PCTs failed to meet NICE guidance that they should get 5% of the smoking population to take advantage of these services. There is also too much variation between Trusts in recruitment and quit rates. For example, the proportion of people who quit for four weeks ranges from just 33% in one PCT to more than 80% in another, with quit rates worse in more deprived areas. Data shows that all but one PCT helped at least 35% of people to quit after four weeks, in line with NICE guidance, but this includes people using the service more than once. CQC recommends that NICE increases both the 5% and 35% goals. It suggests having more stretching goals in areas where there are more smokers.