Focus on CVD

Despite the successes in fighting cardiovascular disease, the NHS is still to tackle the inequalities gap that can be responsible, says Victoria Hoban

At first glance, cardiovascular disease appears to be one of the success stories of the NHS in recent decades. Mortality rates for people under 75 have fallen by an impressive 38 per cent in the past 10 years, according to British Heart Foundation (BHF) statistics.

What is proving harder to improve, however, is the gap in inequalities. Since the 1970s, a threefold gap has widened up in premature death rates from coronary heart disease between professional and unskilled men and South Asians living in the UK have 50 per cent higher premature death rate from CHD than average.

But although medication, such as over-the-counter availability of statins, has played an crucial role in lower CVD rates, controlling existing risk factors and implementing lifestyle changes remain the two most important factors. Lower socio-economic groups, for example, have much higher rates of smoking and high cholesterol, people of Afro-Caribbean origin have a genetic predisposition to hypertension, as do the South Asian population to type 2 diabetes - both risk factors of CVD.

'There is evidence-based research that shows a high correlation between BME communities and poor health,' says Adrian Mayers, head of partnership at Hammersmith & Fulham PCT. 'We have a high concentration of BME communities in the north of the borough and they are also the most deprived areas.'

Ironically, it is the areas of the UK such as Scotland, Liverpool and the Midlands with high levels of deprivation - and therefore of CVD - that now have the most knowledge and experience to share with the rest of the country.

Walsall PCT has one of the highest rates of heart disease in the UK. Over the past five years, however, it has achieved year-on-year reductions in mortality from CHD. In 2000 the PCT recorded 620 deaths from CHD. By 2004 this was down to 467, the target being 400 by 2010.

Phil Griffin, associate director for primary care commissioning at the trust, says commissioning evidence-based services in line with the National Service Framework for CHD has been key to success. 'Our work has improved life expectancy for the borough as a whole, but there is still a 10-year difference in life expectancy between East and West Walsall,' he says.

'Our priority is to reduce this gap by at least three years within the next two years. The NSF itself described the services that should be commissioned at each stage of the pathway and standards that should be achieved. Primary prevention is the key and Walsall has a proud record.'

BHF statistics state that 80 per cent of CHD is preventable. Whereas much has already been done to tackle the effects of the disease and reduce waiting times, the National Service Framework for CHD (2001) and more recently the Choosing Health white paper (2004) place a greater focus on primary and secondary prevention.

However, prevention is complex. How do you reach those who you most need to reach, but who are the hardest to reach?

Collecting better data is one way. 'The NHS is an expert in so many things, but so far hasn't used tools like marketing research to its advantage,' says Martin Machray, programme lead at Dr Foster Intelligence, which brings together existing geographical data, hospital admissions data, smoking cessation rates, population data and plots a 'risk of conditions' for PCTs.

'We bring in other data from marketing and research and map risk against stereotypes and lifestyle habits such as media or shopping habits. That has never really been available to PCTs before - they have relied more on mortality and morbidity rates and longitudinal studies.'

For Waltham Forrest PCT, the company has collected data on five areas where they already have neighbourhood management to address high multiple deprivation indices.

'We map the area to street level, so you can find out if you are better off targeting street A or street B. In this way we have doubled the number of people attending smoking cessation clinics.'

This allows PCTs to make money available for personnel such as community matrons in very specific areas. The government aims to have 3,000 community matrons in post by March 2007. In the GP practice of primary care tsar David Colin-Thome, community matrons have cut emergency hospital admissions by 16 per cent and cut length of stay by a third, saving£1m.

Another best practice intervention is the Primary Care Collaborative. Both the NSF CHD and the GMS contract state that practitioners should develop a register of CHD patients, to enable medication to be reviewed and regular lifestyle advice to be given to those patients most at risk. The result of the collaboration has been a significant rise, up to 50 per cent, in the amount of aspirin, beta blockers and statins prescribed. In Waves I and II, (June 2000-02 and Jan 2001-03) the reduction in death rates in participating areas was four times greater than in those not taking part. Such an improvement would save 6,000 lives a year across England.

At Wallasey Heart Centre in Merseyside a local service was set up, easily accessible to residents in an area with CHD rates, high unemployment, and a large reliance on public transport. Services include an exercise and lifestyle service for those with pre-existing risk factors as well as specialist GP cardiology assessments and a cardiac rehabilitation service. The result? Only 9 per cent of patients in three years have been referred on to secondary care.

'It is post-diagnosis where - at the moment - there is widespread inequality,' says Anita Trotman-Beasty, cardiac rehabilitation professional/service manager at East Yorkshire PCT. 'Treatment for MI is good, but there were no secondary prevention programmes.'

She believes multi-agency working is crucial to redressing this. 'We work with BHF, local government and sports and leisure services and that partnership is increasing the uptake of cardiac rehabilitation. The council wants people to get back to work and start paying taxes and be less likely to visit their GP or go back into hospital,' she says. 'We see local government as a major stakeholder in improving cardiac rehabilitation.'

But she warns that good leadership is crucial, something the Healthcare Commission and NSF for CHD also endorse. 'It is easy for cardiac programmes to be disjointed as they span the PCT, acute trust and secondary prevention - it is important to have leadership. We have been able to develop in a way that brought stakeholders together to allow us to develop further.'

But finding innovative ways to engage and reach high-risk individuals in deprived populations is by far the single most important element to success - and the biggest challenge.

Dr Sam Ramariah, director of public health at Walsall PCT says: 'The South Asian community is large in Walsall. Our work has been around getting people on board. We have had particular success at lowering smoking rates among Bangladeshi men.

'We have done this by working with places of worship. Having religious leaders telling them smoking is bad is much more effective. We are currently using Ramadan as an opportunity to get that across.'

The trust has also employed local people as health trainers, who provide outreach support on the doorstep of deprived communities. 'We are the only PCT in the West Midlands which is investing in health trainers. We see them as &Quot;barefoot doctors&Quot; - people from the same communities who understand what needs to be done.'