Cardiovascular Disease (CVD)

Integrated Strategic Needs Assessment

Local Strategic Review of Cardiovascular Disease (CVD)

Corporate Research Joint Intelligence

Third Floor

Town Hall

Blackburn

BB1 7DY

Version 1.0 - 12th June 2012

Cardiovascular Disease (CVD) 1. Defining the issue Cardiovascular Disease (CVD), or Circulatory Disease, covers the full range of disorders of the circulatory system. Major subcategories include:

 Coronary Heart Disease (CHD), or Ischaemic Heart Disease (IHD), including heart attack and angina;  Cerebrovascular Disease - including stroke, and the less severe Transient Ischaemic Attack or TIA;  Heart Failure – impaired pumping ability, causing reduced blood flow and fluid congestion; and  Problems with the rhythm of the heart, notably Atrial Fibrillation. Much of the burden of cardiovascular disease can be attributed to a build-up of fatty deposits in the arteries, which may have been accumulating for many years before the onset of symptoms. Efforts to mitigate the impact of CVD need to be pursued at three levels 1:  Primary prevention – the attempt to reduce the risk of the disease developing in the first place;  Secondary prevention – the management of established disease to decrease the future risk of a heart attack, stroke or other major event;  Tertiary prevention – rehabilitation to maximise functional capacity and ensure the best possible prognosis and quality of life.

2. Why is this issue highlighted?

CVD in context As highlighted in the influential Marmot report2, CVD incidence and mortality are both disproportionately high among deprived groups. Given its high levels of disadvantage, it is not surprising that Blackburn with Darwen has some of the country’s worst CVD mortality rates (Table 1), and that these are concentrated in its most deprived areas (Figures 11 & 12). Marmot emphasises that long-term solutions will depend on tackling the underlying social determinants (the ‘causes of the causes’), such as worklessness, low income and poor housing. These issues are explored further in the companion document, ‘Integrated Strategic Needs Assessment – Summary Review’.3

CVD Mortality CVD, or indeed CHD on its own, is widely quoted as being the ‘biggest’ cause of death nationally. This rather depends on how other causes of death are grouped together for comparison. What is beyond dispute, however, is that CVD Figure 1 – Deaths from CVD and other causes, 2008-2010, Blackburn with Darwen and England accounted for approximately a third of all deaths in both Blackburn with Darwen and England in 2008-2010 (see Figure 1). 1 Why is this issue highlighted?

The mortality rate from CVD under age 75 is a high-profile indicator, which was until recently the subject of a government target. It is now included in both the new NHS Outcomes Framework4 and the Public Health Outcomes Framework.5 Over the years, the under-75 death rate from CVD in Blackburn with Darwen has declined in line with the national trend, but it has remained higher than average: Figure 2 – Death rate from CVD, Males and Females under 75, 1993-2010

Source: NHS IC Indicator Portal

Source: NHS IC Indicator Portal Like most places, Blackburn with Darwen achieved the target 40% reduction in the under-75 death rate from CVD ahead of schedule.6 However, when its recent death rates are compared with those of the other 150 PCTs in England, it is clear that CVD mortality in the borough is still a major issue: Table 1 - Directly standardised mortality rates, persons, 2008-10 Blackburn with Blackburn with Darwen rank Age-group Cause of death Darwen rate (out of 151 PCTs) (per 100,000) Under-75 CVD 101.82 8th highest All ages CVD 233.41 highest Under-75 CHD only 62.77 5th highest All ages CHD only 125.74 2nd highest Under 75 Stroke 20.63 3rd highest All ages Stroke 59.66 highest Source: NHS IC Indicator Portal As can be seen in Figure 31 (rear of this document), the worst rates for all the above indicators are found in the North West. Figure 3 shows the under-75 CVD mortality rate for every PCT in England. Blackburn with Darwen’s confidence interval does overlap with several other PCTs, but they too are in (or very nearly in) the worst quintile:

Figure 3 - CVD mortality (under-75, persons), by PCT, 2008-10

England

Worst quintile

Source: NHS IC Indicator Portal 2 Why is this issue highlighted?

CVD Morbidity Mortality statistics are only part of the story. Data about those living with CVD is less readily available and less reliable, but the following gives a broad indication of the scale of the problem nationwide:

 Estimates of the number of people living with CVD problems in Britain range from approximately 3 million7 to 5.6 million8.

 It is estimated that one year after a stroke approximately 40% of patients are dependent9.

 About a third of heart attack sufferers will develop depression and anxiety, one fifth become disabled, and a significant proportion (especially among the more deprived) will lose their job as a result10.

 The prevalence of heart failure is increasing as the population ages, and as more people survive the heart attacks or other cardiac problems which can precipitate the condition.11,12 Heart failure patients often have multiple health problems12, and up to a third of them will suffer severe depression.13

 CVD is responsible for one fifth of all hospital admissions14. Heart failure alone accounts for over three- quarters of a million bed-days each year in England13, not counting the large number of patients for whom it is a secondary (rather than the primary) diagnosis.11

Cost of CVD to economy The estimated cost of CVD to the UK economy in 2006 was £30.7bn. 15 This includes not only healthcare costs, but also the productivity lost through mortality and morbidity, and the income foregone by informal carers. The healthcare cost alone of £14.4bn equates to £250 per head of population, or approximately 12% of the country’s entire healthcare expenditure. Figure 4 - Cost of CVD to the UK economy, 2006

Source: http://www.heartstats.org/datapage.asp?id=9075 Policy agenda The importance of the CVD agenda to central government is reflected in the publication in 2000 of its National Service Framework (NSF) for Coronary Heart Disease.16 Spanning the full range of prevention, diagnosis, treatment, rehabilitation and long term care of people with coronary heart disease, the NSF is considered to have had a significant and positive impact, and is widely credited for much of the improvement in mortality which has taken place during its ten-year course.17 One of the major innovations of the NSF was the setting up of Coronary and Stroke Networks, such as the Cardiac and Stroke Networks in Lancashire and Cumbria (CSNLC). CSNLC’s own Cardiac Strategy 2010-15, which embodies NSF principles, directly influences the planning and commissioning of services across the sub-region, including Blackburn with Darwen. 18 3 Why is this issue highlighted?

Looking ahead CVD prevalence The percentage (and number) of people living with CVD is widely expected to increase in the years ahead, as the population ages and becomes more obese, more people survive acute CVD events, and improvements in secondary and tertiary prevention take effect.7,19 The sharpest rises may be expected in the conditions particularly associated with old age, such as atrial fibrillation (predicted to rise by two and a half times by 2050 across Europe43), and heart failure.20 CVD mortality Although it is considered likely that age-standardised mortality rates from CVD will continue to fall, it is quite possible that the number of CVD deaths may rise in future, entirely due to the ageing of the population.7,50 Hospital admissions for heart failure Even though there is good reason to believe that the prevalence of heart failure will rise, one widely-quoted prediction of the impact this will have on hospital admissions may need to be treated with caution: Any search of the literature on heart failure will soon come across the statement that: “Hospital admissions for heart failure are projected to increase by 50% over the next 25 years” This prediction can be found in sources ranging from a British Heart Foundation ‘Heart Failure Supplement’ of 200221, to the latest NICE guidance issued in 2010.22 If any attribution is given, it will lead to a paper by Gnani and Ellis, which appeared in Health Statistics Quarterly in 2002.23 The first point to make is that the predictions made in that paper extended to 2026-27, a period which could then be described as ‘the next 25 years’, but no longer can. They were produced by the very simple method of taking the age-specific admission rates for 1999-2000, and applying them to the (then) ONS population projections for the years ahead. In fact the exercise was confined to the 45+ age-group, but this includes the vast majority of heart failure admissions. Actual admissions in recent years (red line in Figure 5) have been well below the projected level, even when all ages are included: Figure 5 - Actual and predicted number of hospital admissions for heart failure (England)

Sources: Actual and projected admissions age 45+ - Gnani and Ellis23 Actual admissions all ages – www.hesonline.nhs.uk

4 Why is this issue highlighted?

3. Who is at risk and why? Figure 6 - Risk factors for CVD

Collectively account for 90% of heart attack risk7,24,25

Stroke risk 6 times higher9, CHD risk 2 to 5 times higher7

Jointly explain 80% to 90% of CHD in UK7

Switching to an active lifestyle can reduce CHD risk by 30% 7

Can quadruple risk of stroke9 70% of cases of heart failure start with high blood pressure13

Obese people have 2-3 times higher risk of CHD and stroke than those of normal BMI26

Doubles risk of stroke.9,27 CHD risk 2-3 times higher.7,27 Accounts for 10% of CVD deaths in developed countries.27

Heavy drinkers have 3x risk of stroke.9 CVD death rate more than 2.5x higher in most v. least deprived 20th of areas.28 Average age on admission with heart failure 5yrs younger in most deprived v. least deprived quintile of areas11

CVD risks double each decade of lifespan7 Heart failure more than 100 times commoner in over-85s than under- 55s13

Men tend to get CHD approx 10yrs younger7 Men admitted to hospital with heart failure on average 5yrs younger 11

South Asian death rates from CVD approx 50% higher than average8 5 Who is at risk and why?

Modifiable risk factors The precipitating factors which we can (arguably) do something about are known as modifiable risk factors. A widely-quoted international research study in 200424 found that approximately 90% of the risk of a first heart attack could be attributed to a combination of nine modifiable risk factors, listed in Figure 6. (The factor labelled here as ‘Stress/Deprivation’ was referred to as ‘Psychosocial factors’ in the original paper.) It may seem surprising that another report claims that 80%-90% of CHD in the UK can be explained by smoking, cholesterol and hypertension alone.7 However, this is not necessarily a contradiction, as some of the nine risk factors in the full list impact upon each other and/or ‘cluster together’, so that for example people who smoke are also more likely to have a poor diet and exercise less.8 Obesity The best-known obesity predictions, from the Government’s Foresight programme29, have now been updated by the National Heart Forum using more recent data from the Health Survey for England. 30 The researchers have also estimated the impact upon conditions such as CVD, for which increasing Body Mass Index (BMI) is a risk factor. They simulated two scenarios – one which allows for the ageing of the population and the predicted rise in obesity, and one which holds obesity levels constant and reflects the effect of ageing alone. They then divided one set of rates by the other, to obtain the predicted percentage increase in disease prevalence due to rising BMI, over and above the effect of the ageing population (Figure 7).

Figure 7 - Increase in age-and gender-standardised prevalence of diseases attributable to rising BMI levels Deprivation The British Heart Foundation’s report on Regional and social differences in Coronary Heart Disease 200828 presents a wealth of data BwD BwD on the relationship between deprivation and CVD, demonstrating that the highest mortality rates are concentrated in the most deprived areas of the country. This gradient can be seen in Figure 8, but mortality in Blackburn with Darwen tends to be above the line – i.e. higher than average even after allowing for BwD deprivation. There is also evidence that CVD BwD has a worse effect on the quality of life of people in lower socioeconomic groups.31,32

Figure 8 - Age Standardised Mortality Rate by PCT (2008-2010) v. Average Score on Index of Multiple Deprivation (IMD 2010) Many lifestyle-related risk factors, such as smoking, physical inactivity and obesity, themselves have a strong social gradient. Although it is no ‘quick fix’, Marmot stresses the importance of looking beyond these health behaviours and addressing the social and economic inequalities which underlie them (the ‘causes of the causes’).2 6 Who is at risk and why?

Stress and the workplace Much of the research associating CVD with stress has focused on Coronary Heart Disease, and on stress in the workplace. The ‘Whitehall’ studies33, led by Sir Michael Marmot, were first to dispel the myth that the risk of CHD was greatest among those in high status jobs. They found instead that the key factor was low job control, especially when combined with high demands (producing so-called ‘job strain’). This is typically a characteristic of low status jobs, and thus contributes to the social gradient in CHD.34,35 CVD modifiable risk factors and dementia NICE recognises the existence of a link between CVD and dementia8, and NHS Evidence states that the modifiable risk factors for CVD potentially apply to dementia too. The evidence is strong enough for reduced risk of dementia to be mentioned as a possible added benefit when encouraging people to reduce their cardiovascular risk.36 Unmodifiable risk factors Unmodifiable risk factors are those which are essentially biological, such as age, gender and ethnicity. However, these are often accompanied by behavioural factors and attitudes which complicate the picture. Ethnicity At the national level, a general picture emerges of higher levels of CVD in South Asian heritage populations. Some of these conclusions are based on country of birth, due to inadequate recording of ethnic group37:  CHD accounts for 25% of deaths in those born in South Asia, versus 15% for those born in the UK37;  South Asians of both sexes have an above-average incidence of heart attacks37;  South Asian people experience a CHD event on average 10 years younger than white people38;  CHD prevalence is highest among Indian and Pakistani men37;  Inequalities in CVD mortality between South Asians and the general population appear to be widening7. A recent study estimated that over 20% of the excess CHD mortality in the South Asian group could be explained by lack of exercise.38 Other factors may include diet, smoking, and the fact that nearly 45% of ethnic minority people in England live in the most deprived 20% of areas.37 Much of the excess CHD mortality occurs in people with diabetes, which is itself four to six times more common among those of South Asian heritage than in the white population, and occurs five to ten years earlier.39 It is also possible that health promotion messages about risk factors, and about how to react in an emergency, are failing to meet the needs and perspectives of BME communities. A recent research project by Dr Foster Intelligence explores how the ‘Act F.A.S.T.’ stroke awareness campaign (http://www.nhs.uk/actfast/Pages/stroke.aspx) has been received by Black and Asian communities in the North West, and makes recommendations as to how it could engage these audiences more effectively.40 An NHS document on Heart disease and South Asians provides a comprehensive overview of the issues.41 Existing CVD as a risk factor Future life expectancy after a first CVD event is less than half that of a healthy individual, with a median survival time after a first heart attack or stroke of approximately eight years.7 Heart failure is closely intertwined with other forms of CVD: it often develops as a result of a heart attack, CHD or hypertension; may itself increase the risk of a stroke; and can be either a cause or a consequence of atrial fibrillation.13 Some of the milder forms of CVD are now recognised as a potential warning sign for more serious events. A transient ischaemic attack (TIA) only produces temporary symptoms, but a sixth of patients will go on to have a full stroke within three months.42 Patients with atrial fibrillation (AF) may have no symptoms at all, but the condition increases the annual risk of a stroke by five or six times, and such strokes are also more severe and 50% more likely to leave the patient disabled.43

7 Who is at risk and why?

4. Level of need in the population

CVD Mortality Mortality trends Figure 9 depicts the generally declining trend in mortality from CVD and its major sub-categories. Stroke mortality in Blackburn with Darwen involves quite small numbers (e.g. 26 deaths under age 75 in 2010), but for 2008-2010 combined, all these death rates in BwD were significantly above the England average. BwD Figure 9 - Directly Standardised Death Rate per 100,000 Persons, 1993 thru 2010 England

Source: NHS IC Indicator Portal

Inequalities within Blackburn with Darwen CVD mortality varies with deprivation not only between PCTs or local authorities, but also within them. Blackburn with Darwen’s 2010 Public Health Annual Report10 draws attention to the gap in premature CVD mortality between the borough’s most and least deprived areas (Figure 10). It estimates that if the rate across the borough could be reduced to that of its least deprived local quintile (the ‘Levelling up’ target), approximately 40 premature deaths would be saved each year.

Figure 10 –Mortality from CVD below age 75 in Blackburn with Darwen by level of deprivation, 2007-2009 8 Level of need in the population

To assist with needs assessment, the Association of Public Health Observatories (APHO) has issued CVD mortality figures by Middle Super Output Area (MSOA). Blackburn with Darwen has eighteen of these areas, each roughly the size of a ward. The death rate for each MSOA is expressed as a Standardised Mortality Ratio (SMR), which would come to 100 if its mortality was typical of England. For example, an SMR of 150 implies a death rate which is half as bad again as the England average. Figure 11 summarises the results of these calculations for CVD overall, and separately for CHD and Stroke. Any small area is bound to experience random fluctuations in mortality, but the pink shading denotes an SMR which is significantly above 100 – i.e. where we are 95% sure the difference is not due to mere chance. Similarly, the red shading denotes an SMR significantly above 150. There were no instances of an SMR significantly below 100. Figure 11 - BwD Standardised Mortality Ratios (SMRs) at Middle Super Output Area (MSOA) level, 2006-10

Source: Association of Public Health Observatories (APHO), www.apho.org.uk

There is an obvious similarity with the pattern of deprivation (Figure 12). This map has been shaded at the smaller Lower Super Output Area (LSOA) level, but overlaid with ward boundaries. It depicts national quintiles, so the darker shades are over-represented in Blackburn with Darwen. In fact, over half of LSOAs in BwD have the darkest shading, with only five (out of 91) in the least deprived quintile.

Figure 12 - Index of Multiple Deprivation 2010 (national quintiles)

9 Level of need in the population Source: DCLG

CVD Prevalence Recorded prevalence (QOF) GPs are incentivised under the Quality and Outcomes Framework (QOF) to keep a register of patients with various conditions, including CHD, Stroke, Hypertension, Heart Failure and Atrial Fibrillation. Figure 13 shows the latest recorded QOF prevalences as crude rates, which do not take the age profile of the population into account. A low value could mean effective prevention, and/or low underlying risk (e.g. because of a young population), but it could also mean that cases are being missed: Figure 13 - Recorded (QOF) Prevalence of CHD, Stroke, Hypertension, Heart Failure and AF, 2010-11

Source: Information Centre (www.ic.nhs.uk) Modelled prevalence (APHO) The Association of Public Health Observatories (APHO) has used the relationship between disease prevalence and factors such as age, sex, ethnicity, smoking and deprivation to model CHD, stroke and hypertension prevalence at the practice and PCT level.44 These modelled estimates attempt to capture the ‘true’ prevalence of both diagnosed and undiagnosed disease. Figure 14 - Recorded (QOF) versus modelled (APHO) Recorded versus modelled prevalence prevalence ratios, 2010/11 Given that the APHO models are the nearest thing we have to a ‘true’ prevalence, it is desirable for the ratio of recorded (QOF) prevalence to APHO prevalence to be as high as possible - ideally close to 1. When the latest APHO models are compared to the latest QOF results, the proportion of expected cases being duly recorded in Blackburn with Darwen is similar to the Source: North West and England average (Figure 14). APHO and QOF Prevalence of hypertension By far the biggest shortfall in Figure 14 is for hypertension, where recorded cases are well below the modelled estimates for every PCT. This is because the Health Survey for England, on which the model is based, actually measured respondents’ blood pressure. It therefore found many ‘hidden’ cases of hypertension - perhaps too many, as it relied on only one reading, whereas a GP would normally take three.45 In August 2011 NICE issued updated guidance on the diagnosis of hypertension, advocating a shift from clinical blood pressure measurement to the use of 24hr ambulatory blood pressure monitoring. This is expected to reduce the incidence of newly diagnosed hypertension by 28%46, leading in time to lower QOF prevalences, which suggests that the APHO model will also need to adapt to the new definition.

10 Level of need in the population

5. Good practice

Factors contributing to improved mortality Figure 15 - Explaining the fall in CHD Improvements prior to 2000 deaths in England & Wales 1981-2000 It is estimated that the reduction in CHD mortality between 1981 and 2000 is almost 60% attributable to improvements in modifiable risk factors, and only 40% to improved treatments (Figure 15).10, 48 The biggest single contribution was from the reduction in smoking levels, along with improving blood pressure and cholesterol, and a slight reduction in deprivation. Risk factors which moved in the wrong direction are obesity, diabetes and physical activity. 47

Source: McPherson 201048, re-drawn by Green 201049 One of the researchers behind Figure 15 gives the following encouraging message: “…population-wide changes in lifestyle and diet could reduce mortality with surprising rapidity, increasing its appeal to policy makers who need to solve problems within short time frames”50 Improvements since 2000 The death rate from heart attacks in England has continued to fall since 2000, roughly halving between 2002 and 2010. A recent paper in the BMJ has found that just over half of this reduction is explained by there being fewer heart attacks in the first place, and the remainder by better survival after a heart attack. The declining incidence points to the success of primary and secondary prevention measures, and improved survival is at least partly accounted for by advances in acute treatment. However, prevention strategies may also be helping to improve survival prospects, by reducing disease severity even in patients who do suffer a heart attack.51,52

Prevention strategies CVD prevention at the population level NICE guidelines53 on the prevention of CVD contain wide-ranging recommendations, aimed at policy-makers from the EU level downward. Local agencies would have a role to play in implementing several of these:

 Measures to reduce intake of salt, saturated fats and ‘trans fats’;  Protection of children from marketing which encourages an unhealthy diet;  Health impact assessment of policies which could impinge on CVD;  Policies to encourage physically active travel (walking, cycling etc.);  Improved nutritional standards in public sector catering;  Planning control of fast-food outlets. The guidance also explains how to develop a multi-component local or regional CVD prevention programme, sustainable for at least five years, which is properly planned, led, resourced and evaluated.

11 Good practice

Secondary prevention - TIA The ‘ABCD’ score was devised in 2005 by a team at Oxford as a simple way of identifying those patients whose TIA put them at high risk of having a stroke in the next seven days54. It has since become the ‘ABCD2’ score, and any TIA patient scoring 4 or more on it is deemed to be at high risk of an early stroke55: 2 Such high-risk patients are the subject of an NHS Vital Figure 16 – ‘ABCD ’ Scoring System for TIA Sign (indicator CV11), which states that they should be A — age: 60 years of age or older, 1 point. fully investigated and treated within 24 hours. This should B — blood pressure at presentation: have been achieved in 60% of cases by April 2011. 140/90 mmHg or greater, 1 point. Blackburn with Darwen’s performance against this target C — clinical features: unilateral weakness, is discussed in Section 6. According to the National Audit 2 points; speech disturbance without weakness, 1 point. Office, the costs of dealing promptly with high-risk TIA D — duration of symptoms: 60 minutes or cases are outweighed by the potential savings from longer, 2 points; 10–59 minutes, 1 point. strokes averted, to the tune of around £600 per patient D — presence of diabetes: 1 point. assessed and treated.42 Secondary prevention – Atrial Fibrillation Atrial fibrillation, with its 5-6 fold increase in stroke risk, affects approximately 600,000 people in England and is strongly associated with increasing age. Approximately a third of those with AF have no symptoms, so GPs are encouraged to check older patients’ pulses opportunistically, for example at flu clinics, looking for any signs of irregularity. An ECG can then be offered to establish whether the patient does indeed have AF.43,56 The Quality and Outcomes Framework (QOF) contains indicators covering the keeping of a register of AF patients, and the percentage whose AF has been diagnosed with an ECG or by a specialist. It also records the percentage who are on anticoagulation therapy (such as Warfarin) or antiplatelet therapy (such as Aspirin): Figure 17 - Percentage AF patients on therapy 2010-11 (QOF indicator AF3)

However, indicator AF3 does not indicate a preference for one therapy over the other. There is discussion as to whether it should be replaced by one which favours Warfarin for the highest-risk AF patients.57,58 A report from NHS Improvement59 argues that Warfarin gives greater stroke protection to this group and saves money compared with the cost of an average stroke due to AF, which is £11,900 in the first year alone. A software tool called GRASP- AF (http://www.improvement.nhs.uk/graspaf/) has been released to help GPs identify patients on their systems whose records show that they have AF, and are at high risk of stroke, but are not on Warfarin. Tertiary prevention – cardiac rehabilitation In their Cardiac Strategy for 2010-1518, the Cardiac and Stroke Networks in Lancashire & Cumbria (CSNLC) endorse the commitment to cardiac rehabilitation made in the National Service Framework16, and quote evidence of its efficacy at reducing mortality. Cardiac rehabilitation also offers a high return on investment18 and is generally perceived in a positive light by those that attend.17,18 The fact that cardiac rehabilitation was chosen as the subject of DH’s first ever commissioning pack is an indication of the importance placed upon it.60 Although it has traditionally been triggered by acute CHD events or surgical interventions, cardiac rehabilitation can also improve the functional capacity and quality of life of patients with heart failure or angina13, and the CSNLC Strategy urges the extension of provision to patients with these conditions. 12 Good practice

6. Current services / initiatives

Secondary prevention Figure 18 - BwD's Health Check logo NHS Health Checks In 2008, the Department of Health introduced ‘NHS Health Checks’ (http://www.healthcheck.nhs.uk/), available to everybody aged 40-74 who has not already been diagnosed with heart disease, stroke, diabetes or kidney disease. If the check uncovers previously undetected disease, or a high risk of CVD, appropriate treatment and/or prevention can be offered.

In Blackburn with Darwen, the scheme has been extended to cover the 35-74 age-group. An independent evaluation of its early operation found that respondents were generally highly satisfied with the service, and 90% would recommend it to others.61 By March 2011, over 19000 people had been screened, of whom 20.7% were found to be at high (i.e. 20% or greater) risk of suffering a cardiovascular event within ten years. 62 The full average cost of each Health Check in BwD, including follow-on tests and overheads, was found to be £36.12, which is not far removed from the Department of Health’s estimate of £33.50. At the beginning of 2010, the average cost in a sample of 25 PCTs was found to be approximately twice this much.63 Atrial fibrillation All practices in BwD have now used the GRASP-AF tool (http://www.improvement.nhs.uk/graspaf/) to identify patients whose records show that they have atrial fibrillation, and are at high risk of stroke, but who are not on Warfarin. This exercise identified 1900 AF patients, all of whom have had their case notes reviewed by NHS Blackburn with Darwen’s CHD facilitator. Almost 700 were identified as needing to be reviewed by their GP. Practices found this quite demanding, so the PCT provided additional support to manage the extra workload. Even so, the acceptability to patients with known AF of being converted onto Warfarin has been lower than expected. The emphasis is now on identifying new patients with AF and increasing the proportion started on anticoagulation when diagnosed. Stroke Awareness and Telestroke The F.A.S.T. campaign was launched by the Department of Health in February 2009, and succeeded in achieving over 80% awareness nationally. This quickly tailed off when the campaign was off the air, particularly among high-risk BME groups, so the advertisements were re-screened for three weeks in March 2011.64 Blackburn with Darwen recruited a F.A.S.T. coordinator earlier in 2011 to promote awareness locally, especially among South Asian residents. A major incentive for fast response to stroke is that clot-busting drugs Figure 19 - the F.A.S.T. logo (‘thrombolysis’), which can reduce mortality and disability, can only be administered in the first 4½ hours. This treatment saves the NHS an estimated £30,000 per stroke survivor, but is not suitable for all patients, and can only be authorised by a senior stroke physician. Hospitals in Lancashire and Cumbria have limited cover at this level, but the new Telestroke service (http://tinyurl.com/44xeg5k), which went live in July 2011, means that an on-call consultant at home can provide a fully-informed face-to-face assessment at any hour of the day or night. Patients at Royal Blackburn Hospital are already benefiting from the new service (http://www.elht.nhs.uk/index.php/inside/332/). 13 Current services / initiatives

Transitional Ischaemic Attack (TIA) Figure 20 - Percentage of high-risk TIA NHS Vital Sign CV11 states that TIA patients at high risk of an patients treated within 24 hours early stroke should be fully investigated and treated within 24 hours, with 60% compliance by April 2011. In May 2009, the Lancashire Telegraph drew attention to the generally poor performance on this indicator across East Lancashire65. The 2010 NHS Atlas of Variation66 identified that in 2009/10, Blackburn with Darwen came 20th equal lowest in England, on 10.3%. At the other end of the scale, 11 PCTs achieved 100%. Measures were put in place locally to remedy this situation, including a move from 5-day to 6-day working at the TIA clinic at the beginning of 2011. These have taken rapid effect, and since May 2011 Blackburn with Darwen has not only met the target, but overtaken the England average (Figure 20).67 Unfortunately the new (2011) Atlas of Variation68 quotes the 2010-11 Q4 figure, when Blackburn with Darwen was still in the lowest quintile.

Cardiac care in the community The Specialist Heart Failure Team serving Blackburn with Darwen and East Lancashire were winners of the 2010 “Nursing in Practice” Cardiac Care Award. From exercises such as the register validation project to help identify at-risk patients, right through to end-of-life care and bereavement support, the service is involved at every stage of the heart failure pathway. It provides care and education through home visiting, nurse-led clinics and ‘in-reach’ work in hospitals. Building upon this success, the team is now being transformed into a comprehensive Community Cardiac Service, covering not only heart failure but arrhythmia, and delivering person-centred care in an environment of the patient’s choice. The new service was designed and will run in close collaboration with the Cardiac Rehabilitation Service, ensuring that this group of patients benefits from rehabilitation options appropriate to their needs.

The Specialist Heart Failure Team also works closely with the East Lancashire-based charity “Pumping Marvellous”, with its distinctive and user-friendly website

Figure 21 - logo of the 'Pumping Marvellous' website (www.pumpingmarvellous.com)

Rehabilitation Cardiac Rehabilitation Although the National Service Framework (NSF) for Coronary Heart Disease is credited with transforming many services, cardiac rehabilitation is generally regarded as having missed out somewhat.16 Although popular with those that receive it, and proven to be highly cost-effective, it has struggled to attract funding and raise its profile with both consultants and patients, who do not always appreciate its importance. Studies have shown particularly low uptake among BME communities, suggesting that standard rehabilitation services may not be meeting the individual needs of a diverse population.17 14 Current services / initiatives

A rehabilitation service has been available in Pennine Lancashire since 1996, with uptake levels similar to the regional and national average, but a review by the Health Inequalities National Support Team suggested that a modern, more tailored approach was needed. This year has seen the launch of a new rehabilitation (or ‘Cardiovascular Disease Improvement’) service across Blackburn with Darwen and East Lancashire, with a mission to expand access for all, especially those in deprived areas or hard-to-reach groups. The new service is nurse-led, and delivered mainly in the home, but also via community facilities and by telephone. The rehabilitation team works closely with the community service for heart failure and arrhythmia, to ensure that cardiac rehabilitation is made available to as wide a range of patients as possible. Historically, heart failure patients have not routinely been offered this service, accounting for only about 1% of those undergoing rehabilitation. However, the Cumbria and Lancashire Cardiac Strategy spells out the advantages of cardiac rehabilitation for these patients18, and the two Pennine Lancashire teams have worked together to devise a specialist programme suited to their particular needs. Stroke Rehabilitation The rehabilitation service provided by Blackburn with Darwen’s multidisciplinary Community Stroke Team (CST) has been commended both by the National Audit Office69 (NAO) and by NHS Improvement.70 A brief introduction, including a video, is available at http://tinyurl.com/6z2wwpc. The Community Stroke Team’s approach involves working with other local services to help individuals lead a more socially integrated lifestyle. For example, once the Team has taught an individual how to get on and off a bus, the local ‘dial a bus’ service will collect them and take them to a local exercise class. The service is committed to learning from its users, through feedback mechanisms such as the Patient Experience Survey.71 One of the key strengths of the Blackburn with Darwen service is that it is information-led. Patients are assigned to one of four pathways of care, according to their degree of dependency. The CST has its own purpose-designed database, on which patient progress is continuously monitored. This allows patients to be easily re-directed to a different pathway as required, and has also enabled the service to demonstrate improvements in average levels of dependency, mobility, balance, and activities of daily living.69 Figure 22 – It is estimated that the reduced dependency resulting from the Team’s NHS Blackburn with interventions lowers care costs across the borough by a total of Darwen approach to £93,600pa.70 Their involvement in discharge management stroke rehabilitation has also helped to reduce average length of hospital stay for stroke from 31 days in 2005 to 21.5 days in 2009.70 In 2009/10, 95.7% of stroke patients aged 75+ in Blackburn with Darwen were discharged to their own home or usual place of residence, which is the Source: second highest proportion in England.6,* The CST database has NHS Improvement70 allowed the service to effectively evaluate and demonstrate its achievements, and make the case for further investment. In January 2011, Blackburn with Darwen’s stroke aftercare services were awarded a ‘Best Performing’ rating by the Care Quality Commission72. This is reserved for services which score high marks across eight or nine of the fifteen scored indicators, and low marks in only one or two.

* According to the underlying data (http://www.sepho.org.uk/NationalCVD/docs/Strokemgmt.xls), this statistic has a wider confidence interval than depicted in the CVD Profile itself6, but is still significantly above the England average. 15 Current services / initiatives

Data validation Heart failure register validation Nationally, most of the disease prevalences recorded on QOF registers are suspected of being too low, and heart failure prevalence is no exception. A more complete register can help to ensure that patients with heart failure receive optimal care and treatment, increase practice revenue through the QOF incentives paid for providing that care, and better inform the planning and commissioning of services.73 Figure 23 - Recorded (QOF) prevalence of Heart Failure in Blackburn with Darwen, April 2010-March 2011 To this end, NHS Blackburn with Darwen and NHS East Lancashire piloted a manual process of searching GP records for patients who potentially had heart failure, but had not been allocated the correct code for inclusion in the register. It soon became clear that there was a large number of such patients, and the work was taken over and automated by the Cardiac and Stroke Networks (CSNLC), and rolled out over the whole of Lancashire and Cumbria. The steepest rise in prevalence over one year was seen in Blackburn with Darwen (Figure 23).

7. Gaps

Secondary prevention NHS Health Checks Although the Blackburn with Darwen scheme has screened over 19000 people, the number attending in 2010-11 was well down on the year before (5844 compared with 9005), and the proportion found to be at high risk has also been falling year-on-year. Recommended improvements based on the earlier independent evaluation of the scheme were endorsed by NHS Blackburn with Darwen Transformational Commissioning Board in March 2011, and are already being acted upon. These include making health checks available outside of working hours, carrying them out in workplaces, jobcentres, mosques and sports venues, and engaging community and faith leaders to promote the scheme. It is hoped that these measures will both arrest the decline in uptake, and help to focus the screening effort upon potentially high-risk groups, such as people of Pakistani heritage or those living in deprived areas.

16 Gaps

8. Value for money

Programme Budgeting data ‘Programme Budgeting’ data from DH allows us to compare expenditure on 23 major ‘programmes’ of NHS activity. In Figure 24, Blackburn with Darwen’s expenditure on Circulatory Disease is compared with England and with a ‘cluster’ of 19 similar PCTs called ‘Centres with Industry’. Spending is expressed per head of Unified Weighted Population, an artificial headcount, scaled up or down to reflect local need. Figure 24 - Expenditure per head on CVD after adjusting for need (Programme Budgeting data 2010/11)

It can be seen that Blackburn with Darwen’s spend per head on circulatory diseases is lower than average. If the highest spending PCT is ranked ‘1’, then Blackburn with Darwen comes 131st out of 151 (after adjusting for need). Caveat Changes to the way the 2010/11 programme budgeting data is collected mean that it cannot be compared with previous years, and must be treated with greater than usual caution. Although Figure 24 presents a breakdown into four subcategories (CHD, Stroke, Rhythm and Other), this can only be regarded as very approximate. For instance, most PCTs cannot produce this split for outpatient activity, so they were all instructed to classify their entire outpatient CVD expenditure as ‘Other’ (even those that knew better). Care settings A new feature of the Programme Budgeting data is that they are broken down into twelve ‘care settings’ (see Figure 25). Compared with England, proportionally more of Blackburn with Darwen’s CVD expenditure goes on ‘Inpatient Elective and Daycase’ care, and proportionately less on Figure 25 - CVD Expenditure split by Care Setting † ‘Outpatient’ and ‘Other secondary’ care. (England v. BwD, Programme Budgeting data 2010/11)

† ‘Other Secondary Care’ covers a miscellany of services which are costed differently from mainstream inpatient and outpatient care. An example in this context might be hospital-based stroke rehabilitation. 17 Value for money

Activity and spending in relation to QOF Figure 26 - Percentage rate of CHD admissions of prevalence people on QOF CHD register (2005/06-2010/11) The Unified Weighted Population reflects the overall health need of the locality, but may not be the best choice of denominator when focusing on one particular disease. A better alternative might be the number of patients on the QOF register for the disease in question. In the case of CHD, admissions per 100 patients on the register has fluctuated more in Blackburn with Darwen than regionally or nationally, but the latest rate is close to average (Figure 26 on right):

Source: NHS Comparators

Figure 27 breaks the 2010/11 figures down into elective and emergency admissions, and also examines their cost. Blackburn with Darwen has above-average elective activity per 100 CHD patients on the register, and spends correspondingly more per patient on these admissions.

Figure 27 - CHD admissions and associated cost (2010/11) relative to number of patients on CHD register Source: NHS Comparators

A further major component of expenditure on CHD is prescribing costs, where Blackburn with Darwen stands out as the lowest spending PCT in the North West (Figure 28a). This is partly due to its high performance on the ‘Better Care, Better Value’ indicator encouraging the prescribing of low-cost statins (Figure 28b).

Figure 28 - NW PCTs 2010/11 - (a) Expenditure on CHD prescribing per patient on CHD register (b) % low cost statins prescribed (a) (b)

18 Value for money Sources: QOF; NHS Comparators

9. Involvement

Accelerated Delivery Planning workshop By early 2010, BwD was in danger of missing several of the previous government’s public health targets, and a process of Accelerated Delivery Planning (ADP) was put in place to bring them back on track. CVD was one of the subject areas chosen for a facilitated ADP workshop, involving a range of stakeholders from across the Local Strategic Partnership (LSP). Priorities emerging from the CVD workshop were:

 To develop an effective healthy workplace and employment strategy across the LSP;  To undertake an equity audit of ‘lifestyle change’ services;  To improve CVD prevention in people with mental health problems and learning disabilities;  To engage disadvantaged groups in the design and commissioning of lifestyle support services; and  To establish referral mechanisms from partner organisations to the Vascular Screening programme.

‘Heart of the Game’ project Dragon’s Apprentice is a partnership initiative between NHS Figure 29 - the Dragon's Apprentice logo Blackburn with Darwen and Blackburn with Darwen Borough Council, under which community groups can apply for funding for projects which promote the ‘self-care’ agenda. A particularly innovative example was the ‘Heart of the Game’ project74, undertaken by Blackburn Rovers Community Trust in October/November 2011.

‘Heart of the Game’ involved 175 children from Figure 30 – a Heart of the Game 'storyboard' in preparation Years 5/6 of six primary schools in wards with particularly high levels of deprivation and heart disease. After discussing the key elements of a ‘heart healthy’ lifestyle in the classroom, they enjoyed a creative day at Ewood Park, working in groups to form ‘storyboards’ using their own words and characters, and then utilising the latest ICT and video facilities in the stadium’s media studio to turn their message into a state-of-the-art animation. They were able to take their work home on DVD to share with older members of their families, in the hope of persuading them to think more carefully about the changes they could make to improve their heart health. The event was received with great enthusiasm by pupils and teachers, and it is hoped that it can be repeated in future.

Heart Town Community heart health in Blackburn with Darwen received a boost in February 2012 when the Borough became one of the British Heart Foundation’s 50 Heart Towns (http://www.bhf.org.uk/get-involved/in-your-area/heart- towns.aspx). This opens up new opportunities to raise awareness of heart disease, bring the community together in fundraising and volunteering, and offer support and resources to residents, schools and workplaces.

19 Involvement

10. Recommendations

1. To contribute to narrowing the significant life expectancy gap between Blackburn with Darwen and both the region and the country as a whole, reduction of CVD mortality should remain a major priority for Blackburn with Darwen’s Health and Wellbeing Board (HWB) and Clinical Commissioning Group (CCG). 2. To contribute to increased healthy life expectancy of the population of Blackburn with Darwen, and to achieve more sustainable healthcare, greater emphasis is needed on primary, secondary and tertiary prevention of CVD: a. Primary prevention – reducing the risk of the disease developing in the first place; b. Secondary prevention – management of established disease to decrease the future risk of a heart attack or other major event; c. Tertiary prevention – rehabilitation to maximise functional capacity and ensure the best possible prognosis and quality of life. 3. Action to reduce the current high levels of CVD in Blackburn with Darwen should target population groups and areas in which modifiable risk factors are concentrated and are strongly related to deprivation and disadvantage. Examples include: a. targeting screening and support for behaviour change across the social gradient; b. increasing the scale and intensity of provision in more deprived areas; and c. developing prevention services that are effective and accessible for particular high risk groups, such as people out of work or people with mental health problems or learning disabilities. 4. Stress, particularly in the workplace, is a major risk factor for CVD that particularly contributes to inequality. It has not previously been the focus of local strategies to prevent CVD, and so should now be prioritised. Opportunities include: a. stress management (e.g. by implementing the Health and Safety Executive guidance on management standards75); b. the effective promotion of physical and mental wellbeing at work. 5. Reducing tobacco and alcohol consumption and improving the diet and levels of physical activity in the population could lead to rapid reductions in deaths from CVD. It would also have positive, longer term effects on the risk of many other major long-term conditions, including cancer and dementia. Achieving this change should be prioritised and will require a sustainable, properly planned, led, resourced and evaluated multi-sectoral programme, using policy and planning to focus on the places where people live and work to create environments where healthy choices are easier. 6. Following an acute cardiovascular event such as a heart attack, TIA or stroke, we must ensure that our services achieve outcomes for patients comparable with the best in the country; this could also have a significant impact on levels of premature death and disability in the population. 7. Continuing priority should be given to developing local rehabilitation services. Rehabilitation should: a. be available for all CVD conditions in which it is cost-effective; b. be accessible to all patients who could derive benefit, particularly those from BME communities, deprived areas and hard-to-reach groups; c. take a holistic bio-psycho-social approach, which is the most effective model.

20 Recommendations

11. Existing strategies, plans and policies  NICE (2010). Prevention of cardiovascular disease at the population level. Available from http://guidance.nice.org.uk/PH25

 Department of Health (2007). National Stroke Strategy. Available from http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_081 062 - see points 2 & 4 of ‘ten-point plan for action’.

 Cardiac & Stroke Networks in Lancashire & Cumbria: Cardiac Strategy 2010-2015. Available from http://www.lsccardiacnetwork.nhs.uk/uploads/files/cardiac/Cardiac_and_Stroke_Networks_in_Lancashir e_and_Cumbria_Cardiac_Strategy.pdf

 Cardio & Vascular Coalition (2009). Destination 2020 – A Plan for Cardiac and Vascular Health – The voluntary sector vision for change. Available from http://www.bhf.org.uk/publications/view- publication.aspx?ps=1000855

12. Where to find out more

 British Heart Foundation statistics website: http://www.heartstats.org/homepage.asp, including: o Coronary Heart Disease Statistics (2010) http://www.heartstats.org/datapage.asp?id=9075 o Stroke Statistics (2009) http://www.heartstats.org/datapage.asp?id=8615 o Ethnic differences in cardiovascular disease (2010) http://www.heartstats.org/datapage.asp?id=8854  Cardiovascular disease health profiles: The Blackburn with Darwen profile can be downloaded from http://www.sepho.org.uk/NationalCVD/NationalCVDProfiles.aspx (also contains a link to ‘CVD data and atlases’).  The Health Foundation (2009). Healthcare delivery models for the prevention of CVD. Available from http://www.health.org.uk/publications/healthcare-delivery-models-for-the-prevention-of-cvd/

 Lancashire and Cumbria Cardiac & Stroke Networks: http://www.csnlc.nhs.uk/  University of Liverpool. Heart Disease: an overview of key epidemiological ideas. Flash presentation, available from http://www.healthimpact.org.uk/Home/ResourceViewer/Heart_Disease_An_Overview  Cardio & Vascular Coalition: http://www.bhf.org.uk/CVC/default.aspx. The CVC is a national coalition of 41 voluntary and professional organisations with an interest in promoting and protecting cardiac and vascular health in England.

21 Where to find out more

13. Key Indicators

Figure 31 - Summary Spine Chart

Source: NCHOD (www.nchod.nhs.uk)

22 Key Indicators

14. References

1 Hull, M (2007). Opportunistic/preventive care and health promotion. In Charlton, R (Ed): Learning to Consult. Radcliffe Publishing, Oxford. Available from http://tinyurl.com/2uul6vn 2 Marmot, M (2010). Fair Society, Heathy Lives – The Marmot Review. Available from http://www.marmotreview.org/ 3 Blackburn with Darwen (2012). Integrated Strategic Needs Assessment – Summary Review. 4 DH (2011). NHS Outcomes Framework 2012/12. Available from http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_131700 5 DH (2012). A public health outcomes framework for England, 2013-2016. Available from http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_132358 6 SEPHO (2011). Cardiovascular disease health profile – Blackburn with Darwen. Available from http://www.sepho.org.uk/NationalCVD/docs/5CC_CVD%20Profile.pdf 7 Cardio & Vascular Coalition (2008). Modelling the UK burden of Cardiovascular Disease to 2020. Available from http://www.bhf.org.uk/plugins/PublicationsSearchResults/DownloadFile.aspx?docid=ad18e5a0-7da6- 4c7c-8142-f68f27cde451&version=- 1&title=Modelling+the+Burden+of+Cardiovascular+Disease+to+2020&resource=Z154 8 NICE (2010). Prevention of cardiovascular disease at population level. Available from http://www.nice.org.uk/nicemedia/live/13024/49273/49273.pdf 9 Leatherman et al (2008). Bridging the quality gap – Stroke. QUIPP (The Health Foundation). Available from http://www.health.org.uk/public/cms/75/76/313/549/Bridging%20the%20quality%20gap.pdf?realName=0 LXBwh.pdf 10 NHS Blackburn with Darwen (2010). Public Health Annual Report / Integrated Strategic NeedsAssessment Stocktake - Equal life chances for all in a generation. Available from http://www.bwd.nhs.uk/public- health/public-health-report-2010/ 11 NHS Information Centre (2010). National Heart Failure Audit 2010. Available from http://www.ic.nhs.uk/services/national-clinical-audit-support-programme-ncasp/audit-reports/heart- disease 12 NHS Improvement (2010). End of life care in heart failure – a framework for implementation. Available from http://www.improvement.nhs.uk/LinkClick.aspx?fileticket=KBUUEsR0mms%3d&tabid=56 13 Sutherland, K (2010). Bridging the quality gap: Heart failure. Available from http://www.health.org.uk/publications/bridging-the-quality-gap-heart-failure/ 14 Department of Health (2008). Putting prevention first – Vascular checks: risk assessment and management. Quoted in: NICE (2010): Prevention of cardiovascular disease – Costing report, available from http://guidance.nice.org.uk/PH25/CostingReport/pdf/English 15 British Heart Foundation (2010). Coronary Heart Disease Statistics. Available from http://www.heartstats.org/datapage.asp?id=9075 16 DH (2000). National Service Framework for Coronary Heart Disease. Available from http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4094274 17 Ipsos Mori (2010). Coronary Heart Disease National Service Framework – an evaluative review among key stakeholders. Available from http://www.dh.gov.uk/en/FreedomOfInformation /Freedomofinformationpublicationschemefeedback/FOIreleases/DH_126679 18 Cardiac and Stroke Networks in Lancashire & Cumbria (2009). Cardiac Strategy 2010-15. Available from http://atrialfibrillation.org.uk/app/webroot/files/file/Care%20Pathways/Cardiac%20Strategy%202010- 2015%20Lancs%20and%20Cumb.pdf 19 Cardio & Vascular Coalition (2009). Destination 2020 – a plan for cardiac and vascular health. Available from http://www.bhf.org.uk/publications/view_publication.aspx?ps=1000855

23 References

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25 References

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26 References