Circulatory Diseases

Introduction

Cardiovascular disease (CVD) causes nearly a third of all deaths in the UK (about 130,000 deaths in 2011). Cardiovascular disease is a broad term for all diseases affecting the heart and blood vessels. Coronary heart disease (CHD), the leading cause of death in men in the UK, killed 64,000 men and women in the UK in 2012 (ref ONS) and accounts for nearly half (46%) of CVD deaths. Stroke and mini strokes, heart failure (affecting more than 75,000 people in the UK) and arrhythmias (eg atrial fibrillation) are also part of the CVD family (Ref BHF website and Watson and Hughes). Watson and Hughes 2013. Many CVD deaths are preventable: the risk of death is increased by modifiable risk factors such as high blood pressure and lifestyle behaviours such as smoking and poor diet.

There are large inequalities in CVD by gender, geography and ethnicity. It has been long established that there is social gradient i.e. decreased mortality with increasing social class in CHD. This is demonstrated in Haringey.

CVD contributes to more than one third of the life expectancy gap between affluent and least affluent men and 14% of the gap in women across Haringey (PHE London life expectancy segmentation by cause ) (see JSNA chapter on life expectancy gap).

Reducing the risk from CVD and cancer (priority 8) and supporting people with long term conditions eg heart failure (priority 9) are key priorities for Outcome 2 of the Haringey Health and Wellbeing Strategy (HWS): a reduced life expectancy gap.

Key JSNA chapters with more information of relevance to CVD are:

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Key Issues and gaps

  • CVD mortality in Haringey as a whole has reduced by 64.3% since 1995 and is similar to the national rate
  • However there are marked inequalities in CVD prevalence, outcomes and mortality
  • CVD prevalence and outcomes (eg admission rates, mortality) are higher in men than women. The prevalence of CVD increases markedly over 40 years of age
  • There is a strong social gradient nationally and locally with CVD mortality and socio-economic group. The rate increases with deprivation and lower socio-economic group
  • Certain BME groups eg South Asian men for CHD and Black people for stroke have high mortality rates
  • The gap between diagnosed and expected cases (the “prevalence gap”) for each of CHD, stroke and high blood pressure is poor in Haringey compared to England and Wales, suggesting high rates of undiagnosed cases (Watson and Hughes, SEPHO)
  • Haringey has high rates of emergency admissions and this rate has been increasing in Haringey, compared to a slower increase or decrease in London and England
  • Prevention, early intervention and treatment and care programmes are required to reduce inequalities in CVD in Haringey.  It is also important to consider approaches that focus on: population health, personal health/services and community health (Redoubling Efforts, HINST)
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Who is at risk and why

The following risk factors are recognised for CVD (NICE, 2010):

Age: The prevalence of cardiovascular disease increases significantly after the age of 40 years. (SEPHO profile)

Ethnicity:  eg South Asian men are more likely to develop CHD at a younger age, and have higher rates of heart attack.  Black people have the highest stroke mortality rates ( SEPHO profile)

Deprivation or lower socio-economic group: CVD mortality and prevalence is strongly linked to deprivation and socio-economic group nationally and locally

Modifiable risk factors: Smoking and high blood pressure are important risk factors One in five adults in Haringey smoke and this is strongly linked to socio-economic group (see Smoking JSNA). Haringey data suggests that 17.4% of patients on GP registers with long term conditions smoke (SEPHO). 48,478 people in Haringey are estimated to have high blood pressure. Other modifiable risk factors include: high cholesterol, physical inactivity, being overweight or obese and excess alcohol consumption. More information on these factors is found in relevant JSNA chapters on smoking, physical activity, obesity and alcohol misuse.   

Other risk factors are:

  • Family history
  • Co-morbidities with other diseases. For example, diabetes increases cardiovascular risk and also shares many of the risk factors associated with CVD (Healthcare for London, 2009)
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The level of need in the population

Prevalence

  • About 1 in 20 (5.3%) of people in Haringey are estimated to have CHD, 2.5% living with stroke and more than 1 in 4 (26.8%) have high blood pressure
  • GPs record information on whether their patients have CHD, stroke and hypertension (Quality Outcomes Framework data). The actual numbers recorded by GPs is then compared to the number estimated to be living with that condition within the relevant catchment area. The observed prevalence compared to estimated prevalence is lower in Haringey for all three disease areas, although they are significantly worse for CHD than the others.  This suggests high number of cases may be undiagnosed in Haringey. (SEPHO profile)

Admissions

  • Emergency admission rates are significantly higher in Haringey than in London and England
  • Emergency admission rates are significantly higher for men than for women for CHD, heart failure and stroke. For CHD and Heart Failure this gender difference is greater than London or England (SEPHO profile)
  • There is a poor trend for emergency admissions in Haringey compared to London and England: The emergency admission rate for CHD in Haringey has decreased by 5.0% between 2004/5 and 2011/12. However this does not compare favourably with England which has decreased its emergency admissions rate by 23.1% and in London by 23.4%. In addition emergency admission rates for heart failure have risen by 61.1% in the same period, although they have fallen in both London and England. Stroke admission rates have risen by 19% in Haringey but only by 10.6% and 3% in London and England respectively (see Figure 1)

Fig. 1 Changes in emergency admission rates between 2004/5 and 2011/2

  • There is a clear social gradient for emergency admissions for CHD, stroke and heart failure by quintile of deprivation in Haringey.  The gradient is particularly strong for CHD (SEPHO profile)
  • Emergency readmission rates for patients with stroke are significantly higher in Haringey than in London and England
  • Haringey stroke patients under 75 years are less likely to be discharged back to their usual place of residence compared to the national picture

Mortality Rates

  • CVD mortality rate (165.7 per 100,000, directly standardised, 2009-11) in Haringey is higher than England and significantly higher than London (see Figure 2 below)
  • Male CVD mortality rates in Haringey are significantly higher than female CVD mortality rates (SEPHO profile) (see Figure 2 below)

Fig 2 CVD Mortality Rates by gender 2009-2011

  • Mortality rates from circulatory disease tend to be higher in more deprived areas. This is true for Haringey where CVD mortality is 1.7 times greater for those living in the most deprived areas compared to the least deprived areas. There is a social gradient with a graded increase in mortality rate from the most affluent to most deprived quintiles.  (SEPHO profile)
  • In the past (2003-7) under 75s CVD mortality rate by electoral ward has shown a picture very similar to high deprivation and low life expectancy with a clear divide between the east and west of Haringey. It would be good to repeat this analysis (Cross Party Working Group paper on life expectancy gap for HWS)
  • The trend in under 75 CVD mortality has been downwards in Haringey since 1995, reducing by a broadly similar rate to London and England (SEPHO profile)

Risk factors

Key risk factors for CVD are outlined in the section above.  Further information is available in relevant JSNA chapters for population profile, smoking, physical activity, obesity, alcohol misuse and diabetes.

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Current services in relation to need

Prevention Services and CVD Awareness

(Details on smoking cessation, physical activity and adult obesity can be found in other sections).

A number of preventative programmes are provided within Haringey that help reduce the risk of CVD and other long-term conditions. As the evidence has highlighted above, people living in the areas of highest deprivation have higher rates of CVD mortality and morbidity. These programmes are all aimed at reducing the health gap between the average for the population and the poorest in the population. These include:

  • The NHS Health Check programme aims to help prevent heart disease, stroke, diabetes and kidney disease. Everyone between the ages of 40 and 74, who have not already been diagnosed with one of these conditions or have certain risk factors, will be invited once every five years to have a check to assess their risk of the above conditions and will be given support and advice to help them reduce or manage that risk. Provision of the programme is mandatory for local authorities. The programme is being rolled out across east Haringey (the area of highest <75 mortality from CVD causes) through GP surgeries and community venues. Since 2010 over 15,000 health checks have been delivered in Haringey
  • Stop Smoking Service: NHS Stop smoking Service (external link) - supports people in stopping smoking and offers brief intervention training to staff (see Smoking JSNA chapter)
  • The Haringey Community Sport and Physical Activity Network (CSPAN) (external link) works with partners from the NHS, council, Smarter Travel and voluntary and community providers to ensure people of all ages and abilities have the opportunity to participate in high quality physical activity (see JSNA physical activity section)
  • Physical activity programmes include: Three council owned leisure centres, leisure provision by a number of voluntary and community sector partners, and 600 acres of parks and open spaces. The ‘Active for Life’ exercise GP Referral Scheme focuses on those people with long term conditions who are among the least active.
  • Weight management support: vouchers from slimming world or weight watchers obtained via the health trainer service and a men only weight watchers programme (see JSNA Obesity Section)
  • NHS Health Trainers are a key workforce drawn from local communities in the east of the borough; they are trained to help people make positive lifestyle changes, including stopping smoking. This scheme is being expanded and re-commissioned this year
  • Ongoing training is provided to staff on delivering effective brief interventions (motivational interviewing). Sessions will be offered in 2013/14 for all staff in the local authority and NHS who are involved in supporting people to improve their health through lifestyle changes, with additional sessions in 2014/15
  • The work to tackle alcohol-related harm is informed by Haringey’s annual Alcohol Action Plan. This includes commissioning services for adults and young people with substance misuse problems and services for their friends and family. The services provide both harm reduction advice and interventions i.e. needle exchange and treatment aimed at recovery for substance misuse

Stroke

  • Stroke can have a lasting and profound impact on how people move, see, speak, feel or understand their world. Stroke is a medical emergency in which time is critical; the faster someone reaches expert help, the greater their chances of making a full recovery or reducing the risk of long term disability. Patients who are left with residual disability need timely, high quality services and longer term support in many aspects of their lives
  • TIA clinics provide rapid diagnostic assessment and access to a specialist within 24 hours for high- risk patients and 7 days for low-risk patients. There are 8 Hyper-acute stroke units (HASUs) in London – location of HASU was dependent on ensuring every patient in London should have access to a HASU within a 30 minute ambulance journey. UCLH is the main HASU for Haringey residents. Stroke Units provide multi-therapy rehabilitation and ongoing medical supervision following a patient’s hyper-acute stabilisation. The Haringey Stroke Clubs (external link) are run by Age UK and are affiliated to the Stroke Association. They offer a social opportunity for those affected by stroke. Different Strokes provides a service for people of working age who have suffered a stroke. It is run by stroke survivors and offers free help, advice, information and support

CHD

Cardiac Rehabilitation is a structured set of services that enables people with CHD to have the best possible help (physical, psychological and social) to preserve or resume their optimal functioning in society. It is divided into 4 phases. Phases 1-3 are provided by the local hospital trusts and phase 4 is provided through the Active-4-life service commissioned by Public Health Directorate. A review is underway. In Haringey, phases 1-3 are provided by North Middlesex and Whittington Hospitals. They have slightly different models for delivering their cardiac rehabilitation service. There is a ‘gold standard’ of cardiac rehabilitation set by the BACPR Cardiovascular Disease Prevention and Rehabilitation 2012, and a recent analysis by NHS Improvement indicates that achieving a 65% uptake of a ‘gold standard’ cardiac rehabilitation would result in a 30% reduction in unplanned cardiac readmissions.  Haringey CCG is working towards achieving this goal

  • The CCG is currently looking into the quality of the current cardiac rehabilitation provision. It aims to ensure that all areas of the British Heart Foundation and BACPR gold standard3 are being delivered and any gaps will be addressed

Heart Failure

  • In light of the data highlighting the high rate of emergency admissions for heart failure, a new pathway for patients with newly diagnosed heart failure has been developed. It offers a unified entry point to newly diagnosed heart failure patients and those in need of chronic heart failure care and offer each patient service’s that suit their clinical condition and personal circumstances. Its aim is to improve the quality of care for patients and align their care with best practice
  • Haringey CCG is currently modelling the impact of the pathway, considering the contracting framework and negotiating it into contracts in 2014/15

Atrial Fibrillation

Diagnosing and detecting atrial fibrillation can prevent stroke, transient ischaemic attacks and other CVD conditions.  Work is underway to increase prompt diagnosis and treatment of Atrial Fibrillation

Improvement in CVD services for the north and east London region

  • Given the number of early deaths from CVD in this part of London there are plans to develop a single integrated cardiovascular centre at St Bartholomew’s Hospital and the Royal Free Hospital will remain as a second heart attack centre. This would lead to the following benefits: improved patient experience and outcomes, prompt access to treatment, and reduce waiting times, greater access to new diagnostics and equipment, same access for patients no matter where they live  
  • These plans will be further developed in 2014
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Service users and carers opinion

Some examples from stroke services are:

  • Stroke survivors and carers comprise 50% of the stroke performance monitoring group membership
  • Several questionnaires and focus groups have been undertaken with stroke survivors and carers around issues faced on re-integrating back to meaningful life roles. The main issues identified were the need for improved psychological support and the provision of a wide range of information and advice
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Expert opinion and evidence base

Strategic guidance (local and national):

  • Redoubling Efforts to achieve the 2010 National Health Inequalities Life Expectancy Target. Resource Pack. Department of Health, March 2010
  • Tackling the Life Expectancy Gap: briefing paper for the cross party working group. Haringey Council, 2011 (available from Haringey Public Health Department)

See also life expectancy JSNA

National guidance on CVD commissioning and management

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Projected service use in 3-5 years and 5-10 years

There has been a downward trend in CVD mortality in Haringey and London and England since 1995.

Data projections show that prevalence of CHD and Hypertension is likely to increase but will remain static for stroke. Thus service demands for these two areas are likely to increase in the future, and service planning needs to ensure that future needs are met.

Updated future projections are not yet available.

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Unmet needs and service gaps

The information above demonstrates stark inequalities in CVD prevalence and outcomes by gender (males) and deprivation in particular.  Risk factors for CVD show a similar pattern.  Service recommendations are outlined in the recommendations for commissioning below.  Key unmet needs are:

  • Although CVD mortality in Haringey has reduced since 1995 CVD mortality in Haringey is higher than London and England
  • There are marked inequalities in CVD prevalence, outcomes and mortality
  • CVD prevalence and outcomes (eg admission rates, mortality) are higher in men than women. The prevalence of CVD increases markedly over 40 years of age
  • There is a strong social gradient nationally and locally with CVD mortality and socio-economic group. The rate increases with deprivation and lower socio-economic group
  • Nationally certain BME groups eg South Asian men for CHD and Black people for stroke have high mortality rates
  • The gap between diagnosed and expected cases (the “prevalence gap”) for each of CHD, stroke and high blood pressure is poor in Haringey compared to England and Wales, suggesting high rates of undiagnosed cases (Ref Watson and Hughes, SEPHO)
  • Haringey has high rates of emergency admissions and this rate has been increasing in Haringey, compared to a slower increase or decrease in London and England. Emergency admissions show a social gradient with increasing admissions for more deprived populations, particularly for CHD
  • Service users identify the key gaps for service gaps for stroke patients as a lack of neuro psychological support for stroke survivors and access to a wide range of information and advice
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Recommendations for Commissioning

The approach to improving CVD outcomes and inequalities outlined in the HWS and delivery plans and encompasses prevention, early intervention and treatment and care (Ref cross party working group on life expectancy gap and Haringey HWS).  National guidance also suggests ensuring that three areas are considered to systematically address inequalities these are: population health, personal health/services and community health (Ref redoubling efforts for 2010 target). The recommendations below can inform the refreshed HWS delivery plans for outcome 2 priority 8 (reducing CVD and cancer risk) and priority 9 (supporting people with long term conditions) as well as CCG and social care plans and strategies.

Prevention and raising awareness

  • Continue to strengthen preventative programmes aimed to: reduce smoking, increase physical activity, encourage sensible drinking and build the newly re-commissioned Active for Life and Health Trainer programmes. (see Smoking, Physical activity, Alcohol sections)
  • Strengthen links between preventative programmes and between integrated health and social care and prevention programmes. Ensure key pathways include prevention elements and referral to prevention services, scale up brief intervention training for all front line staff to give support to lifestyle change

Early Intervention

  • CCG and partners  (including public health) strengthen the work with primary care to improve numbers of patients on the CHD register to bring our observed compared to estimated prevalence rates at least in line with London and England averages
  • Public awareness and patient education of signs and symptoms to recognise disease and avoid admission. This may include social marketing targeting men, deprived communities and BME groups.  It also includes continuing to strengthen the community health champions programme (who raise awareness of disease)
  • Continue to support the NHS Health Check programme to achieve the objectives of inviting 20% of the eligible population by 2018, and ensuring that the programme is achieving the quality standards set by PHE

Treatment and Care

  • Continue the review of the cardiac rehabilitation provision to identify areas for improvement of the cardiac rehab service. Include consideration of access and outcomes by men, over 40s, BME and deprived communities
  • Explore the provision of a wide range of information and advice that is appropriate and accessible to stroke survivors and commission stroke navigator to provide support to stroke survivors across the stroke pathway
  • Encourage the development of services to support self management for CVD and other long term conditions eg diabetes
  • Continue to strengthen the atrial fibrillation (AF) pathway, including early identification of AF

Health Intelligence:

  • An investigation of the emergency admissions related to all areas of circulatory disease to understand the causes of the high rates of emergency admissions for CHD, stroke and heart failure in Haringey and high readmissions for stroke patients compared with London and England. These need to be explored in relation to deprivation, gender, BME and age
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Recommendations for further needs assessments

Nil at this time.

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Key Contacts

References

  • British Heart Foundation (2012) Cardiovascular Disease Prevention and Rehabilitation
  • Commissioning Support for London, (2009a). ‘Stroke acute commissioning and tariff guidance, London.
  • Commissioning Support for London, (2009b). ‘Stroke rehabilitation guide: supporting London commissioners to commission quality services in 2010/11’, London.
  • Commissioning Support for London, (2010). ‘Life after stroke: commissioning guide’, London.
  • Department of Health, (2000). ‘National Service Framework for Coronary Heart Disease’, London.
  • Department of Health, (2001). ‘National Service Framework for Older Adults’, London.
  • Department of Health, (2005). ‘National Service Framework for Limiting Long Term Conditions’, London.
  • Department of Health, (2007). ‘National Stroke Strategy’, London.
  • Department of Health, (2008). ‘National End of Life Care Strategy’, London.
  • Healthcare for London (2009). ‘Diabetes Guide for London' (PDF, 5.51MB - external link).
  • Improving specialist cancer and cardiovascular services in north and east London (2013) NHS England.
  • NAO, (2005). ‘Reducing brain damage: faster access to better stroke care’, DH.
  • NICE, (2010). ‘Prevention of cardiovascular disease at population level’, NICE public health guidance 25.
  • NICE, (2011). ‘Quality standards programme – stroke’.
  • Rothwell, PM and Johnston, SC, (2006). ‘Transient Ischaemic Attacks – stratifying risk’, Stroke, 37: 320-322
  • Watson, K. and Hughes, A. (2013). ‘Cardiovascular disease Local Authority health profile – Haringey’, SEPHO.
  • Redoubling Efforts to achieve the 2010 National Health Inequalities Life Expectancy Target. Resource Pack. Department of Health, March 2010
  • Independent inquiry into inequalities in health (The Acheson Report). Department of Health, 1998 (external link)
  • Tackling the Life Expectancy Gap: briefing paper for the cross party working group. Haringey Council, 2011 (available from Haringey Public Health Department)
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