At the heart of better care

Faced with a dual assault from financial constraints and an ageing population, the NHS must co-ordinate its resources to sustain improvements in treating heart disease, writes Martin Barrow


Heart disease affects the lives of millions of people and is one of the largest causes of death and disability in the UK. Although there have been improvements in the prevention and treatment of cardiovascular disease (CVD) over the last decade, comparisons with other countries show that Britain could do better.

There is also evidence that the progress of the past ten years, which owes much to a decline in the number of smokers, is being eroded by current levels of obesity and diabetes. This has raised concern that these improvements will not be sustained unless significant changes are made to the way the health service, in partnership with local authorities, responds to the challenge of CVD.

The scale of this challenge should not be underestimated. According to the British Heart Foundation (BHF), heart and circulatory diseases cause more than 25 per cent of all deaths in the UK, accounting for 159,000 deaths each year. The cost of premature death, lost productivity, hospital treatment and prescriptions is estimated at £19 billion.

Even after recent advances coronary heart disease is the UK’s single biggest killer, responsible for almost 74,000 deaths a year. Almost 2.3 million people live with coronary heart disease and their treatment costs £2 billion a year. There are around 103,000 heart attacks each year and more than 750,000 people live with heart failure, according to the BHF.

Patients are treated by different teams in a disjointed way, resulting in unco-ordinated care, multiple hospital visits and confusing or contradictory information

Although men are still more likely to be affected by heart disease, the gap between men and women is narrowing as a consequence of changes in lifestyles. In an ageing population, obesity and diabetes are emerging as the main causes, affecting men and women in almost equal measure.

Earlier this year, the Department of Health published its strategy for improving outcomes for people with, or at risk of, CVD. Publication, which followed months of consultation with the NHS, Public Health England, local authorities and patients, came at a crucial time, with the health service going through a period of unprecedented reorganisation while having to make billions of pounds in savings.

At its core is an acknowledgement that heart disease would place an intolerable burden on the health service without significant change in the way treatment and care is provided.

Of particular concern is the variation in outcomes that exists in different parts of the country, with the poorest outcomes evident in areas of greatest deprivation. The strategy also highlighted the need to address issues regarding the quality of life of those with heart disease, with many being denied the support to which they are entitled and which is available in other parts of the country.

Key to the success of this latest strategy is the management of CVD as a single family of diseases and conditions linked by common risk factors. These include coronary heart disease, stroke, hypertension, hypercholesterolemia, diabetes, chronic kidney disease, peripheral arterial disease and vascular dementia.

Many people who have one CVD condition commonly suffer from another, and yet opportunities to identify and manage these are often missed. Patients are treated by different teams in a disjointed way, resulting in unco-ordinated care, multiple hospital visits and, in some cases, confusing or contradictory information. This happens both in hospitals and in the community.

NHS England has been asked to develop a standard template that can be used in hospitals and the community to fully assess patients with cardiovascular problems. In addition, the NHS will consider additional incentives to provide good management of people with CVD while the National Institute for Health and Care Excellence (NICE) is to review the relevant quality and outcomes framework indicators to promote primary care liaison with local authorities, charities and Public Heath England.

There is also a need to improve screening. The NHS Health Check, which is now the responsibility of local authorities, covers about 15 million adults, but many people at risk of CVD are not being assessed. The Department of Health wants GPs to do better in identifying at-risk groups, particularly those with a family history of heart problems, with a more targeted approach.

Improvements in acute care have played an important role in reducing premature mortality for CVD. For example, 30-day mortality following a heart attack was above 20 per cent in 1980, but in 2011 was less than 8 per cent.

However, variation across the country persists in some areas of acute care and more could be done to improve CVD outcomes if the highest standard was achieved.

The Department of Health and the NHS will continue to make the case for service reconfiguration, concentrating expertise in a smaller number of specialist units that can provide the best care at all hours.

The aspirations that are at the heart of the government’s CVD strategy are shared by all healthcare professionals, but there is concern that implementation of its recommendations will be immensely challenging at a time of such severe financial constraints and while new health and social care structures are still taking shape. Yet failure to rise to the challenge presented by CVD is not an option for a state-funded health service that faces such an uncertain future.