Health in Scotland 2001
CHAPTER 2: FOCUSING ON PRIORITY HEALTH TOPICS
SCOTLAND'S MAJOR HEALTHCARE PROBLEMS: THE DOUBLE BURDEN OF DISEASE
Scotland faces a double burden of disease at the start of the 21st century. One element is the growing burden of chronic disease. The other is that of new and re-emerging infections diseases. The first part of this chapter focuses on the growing burden of disease from:
The second part of the chapter focuses on protection of health from:
Coronary Heart Disease, Stroke and Cancer
Deaths from Coronary Heart Disease (CHD), Stroke and Cancer account for around 60% of all deaths in Scotland every year. Much of the work to improve lifestyles described in Chapter 1 is focussed on prevention of CHD, Stroke and Cancer with action targeted at:
This chapter reinforces aspects of prevention but focuses on health care for CHD, stroke, cancer and other priority health topics.
CORONARY HEART DISEASE/STROKE
The Size of the Problem
Coronary Heart Disease
In Scotland, an estimated half a million people have coronary heart disease (CHD), of whom 180,000 are symptomatic. Over the past 10-15 years the proportion of deaths in Scotland caused by CHD has fallen from 29% to 23%. Table 2.1 illustrates standardised CHD mortality by NHS Board of residence, from 1992-2000, and shows a steady decline year on year.
Table 2.1 CHD mortality - directly standardised rate (2) 1992-2000, by NHS Board
Argyll & Clyde
Ayrshire & Arran
Dumfries & Galloway
(1) From January 2000, deaths in Scotland have been coded using ICD10. Note that any apparent change in trend between 1999 and 2000 may be due to the move to ICD10 rather than a real change. The trend over this period should be treated with caution.
(2) Rates age standardised using the European standard population.
However, approximately 12,500 Scots continue to die each year from CHD, many prematurely. The burden of CHD falls most heavily on older people, with 81% of all CHD deaths occurring in people aged 65 and over. While mortality has fallen by around 50% in the under 65s, there has only been a 28% reduction in the over 75s. Table 2.2 clearly illustrates that the over 65 age group have the highest GP consultation rate for CHD per 1,000 practice population and these rates have remained fairly steady over the past several years.
Table 2.2 GP consultation rate for CHD per 1,000 practice population by age group 1996-2000
All Ages (1)
Source: ISD Continuous Morbidity Recording (CMR)
(1) Includes small numbers of patients under 25.
Similarly, stroke is an illness predominantly affecting older people. Annually around 1,500 Scots suffer their first stroke, of whom 75% are aged 65 or more. The annual incidence is estimated at approximately 3 per 1,000 population. Demographic trends in Scotland mean that the prevalence of both CHD and stroke will increase in subsequent decades as the proportion of the population aged 65 and over increases.
The year 2000 target for coronary heart disease, which has been met, was to reduce mortality among people under 65 by 40% between 1990 and 2000. The new target is to reduce rates by 50% in people under 75 between 1995 and 2010.
Coronary Heart Disease and Deprivation
There is a clear gradient of increasing incidence and mortality from coronary heart disease (CHD) with increasing deprivation. The correlation is most marked in those aged under 65. All groups of the population have enjoyed falling death rates from CHD over the 1990s (Figure 2.1). The absolute fall in numbers has been greatest in those from the most deprived areas. However, the percentage fall has been greater in those from the less deprived areas and the ratio of deaths between the most and least deprived has increased. This point is emphasised further in the section on the Coronary Heart Disease/Stroke Task Force.
Fig. 2.1 Trends in death rates from coronary heart disease in under 65s
Coronary Heart Disease/Stroke Task Force
September 2001 saw the publication of the final report of the Coronary Heart Disease/Stroke Task Force, chaired by Professor Ross Lorimer. The Task Force was established in response to a recommendation in the Report of the Acute Services Review (1998), with the primary aim of developing a clinical network of cardiac services throughout Scotland. The Task Force's formal remit can be summarised as follows:
to investigate and quantify the scope for increased intervention rates within the four current cardiac centres in Scotland, and to address known inequity of access. Waiting list issues will be addressed
to build on existing work to develop a national database, in conjunction with ISD
to provide advice on the strategic direction for organisation of adult cardiology services, with particular emphasis on coronary heart disease (CHD)
to ensure implementation and audit of relevant SIGN guidelines
to examine existing, new and developing cardiological procedures
to advise on the future direction of stroke services in Scotland.
The report describes the current position in relation to mortality from CHD and stroke in Scotland. The Task Force report covers all aspects of coronary heart disease, from primary prevention through to cardiac rehabilitation and makes specific recommendations in each area. It draws attention to issues of equity of access and particularly the effect of deprivation on the incidence and outcome from CHD.
As already stated, socio-economic deprivation has a profound effect on the risk of having a first acute myocardial infarction (AMI) and the chances of surviving it. Figures 2.2a and b illustrate the much higher incidence in mortality from AMI in both men and women in socio-economically deprived groups (DEPCAT 5-7) than the more affluent groups (DEPCAT 1-2). The Task Force recommended that NHS Boards give particular attention to the needs of more deprived communities when planning services for CHD.
Fig. 2.2a AMI directly standardised rates per 100,000 by DEPCAT group, males 15-64, Scotland 1990-2000
Fig. 2.2b AMI directly standardised rates per 100,000 by DEPCAT group, females 15-64, Scotland 1990-2000
The report describes the concept of Managed Clinical Networks for cardiac services, the aim being to set up local networks linking primary and secondary care across Scotland which relate to each other. The local networks would in turn link to a high level intervention network undertaking coronary artery bypass grafting and angioplasty. The experience in Dumfries and Galloway of establishing a local network for cardiac services is described opposite.
Pilot Managed Clinical Network for Cardiac Services
July 2001 saw the official launch of the pilot Managed Clinical Network (MCN) for cardiac services in Dumfries and Galloway. Funded by the Scottish Executive Health Department it had three main objectives:
to implement a local MCN for CHD in Dumfries and Galloway
to address generic issues relevant to all MCNs, including clinical governance arrangements, finance and administrative support, public involvement and reporting arrangements
to evaluate the impact of a local MCN on health outcomes.
The lead clinician for the Network, Dr Chris Baker, was also a member of the CHD/Stroke Task Force. The pilot MCN has already produced interim generic recommendations in the areas outlined above, and specific outputs relating to CHD patients including the development of:
care pathways and protocols for patient management
clinical governance protocols
standard referral letters
patient information leaflets
patient held records.
The pilot MCN has agreed clinical standards with the Clinical Standards Board for Scotland (CSBS) and is providing locally based training for patients and the public involved in the MCN. It has been successful in securing NHS Board funding for previously neglected areas of CHD health care and has also secured charitable funding for specialist nurses and money from the publishing industry for "how to do it" manuals. The MCN is clearly acting as a lever for change locally and has demonstrated that strategic thinking and decision making about resource allocation can move from a closed process at NHS Board level to a more open process fully involving clinicians and patients. This has had an undoubted positive impact on morale locally and on how the future of cardiac services is viewed. The next step is to roll out the generic and specific lessons emerging from this pilot MCN across Scotland.
Coronary Heart Disease and Older People
As the Expert Group on Healthcare of Older People (EGHOP) identified, about 80% of all CHD deaths occur in people aged 65 and over. There is a concern that interventional treatments such as coronary artery bypass grafting or percutaneous transluminal coronary angioplasty are under used in older people. Heart failure is commonly caused by coronary heart disease, affects 20% of older people and is one of the commonest reasons for which they contact their GPs. Drug treatment is increasingly effective but there is again concern older patients with heart failure are less likely to be investigated and to fully receive some of the most effective treatment.
As outlined earlier and emphasised by EGHOP, mortality from acute myocardial infarction
has been falling in Scotland over the past decade. There has been a reduction of about 50%
in people under 65 but only of around 28% in the over 75s. Older people can gain benefit
from multi-professional rehabilitation programmes after a heart attack. EGHOP recommended that older people with coronary heart disease should have full access to the developments that will follow from implementation of the CHD/Stroke Task Force Report. Some self help groups such as the Braveheart Project in Falkirk, provide mentoring service to their peers with coronary heart disease.
The Coronary Heart Disease and Stroke Task Force report points to the significant amount of previous work undertaken in the area of stroke, including that of SIGN and CRAG. The Task Force recommends that, as for CHD, Managed Clinical Networks be established, proactively supported by NHS Boards. Such Managed Clinical Networks should include a dedicated stroke unit serving a specific geographical area and pay particular attention to the issue of integrated discharge planning and co-ordinated stroke rehabilitation. The report also recommends that NHS Boards review current provision of "one stop clinics" for assessment of transient ischaemic attacks (TIAs), but acknowledges that currently this will not be feasible in all parts of Scotland.
The Report of the Expert Group on Healthcare for Older People (EGHOP), Adding Life to Years, emphasised that good multi-disciplinary care improves the outcome in terms of survival and reducing disability. After discharge, patients and their carers should receive the professional support they need and should be put in contact with supportive organisations such as chest, heart and stroke clubs.
Looking to the Future: Coronary Heart Disease and Stroke Reference Group
The consultation period for the Task Force report ended on 31 December 2001, and the vast majority of the comments received have been supportive of its recommendations. The CHD/Stroke Reference Group has now been established under the chairmanship of Dr Nick Boon, Consultant Cardiologist, Edinburgh, and includes other cardiologists, stroke physicians, cardiac surgeons, general practitioners and representation from public health and professions allied to medicine. The Reference Group will produce a national strategy for CHD and stroke, based on the Task Force report and comments received on it. This work is expected to be completed by late summer 2002.
Have a Heart Paisley: A multi-agency partnership approach
The national demonstration project for prevention of coronary heart disease Have a Heart Paisley takes a multi-agency partnership approach to the prevention of coronary heart disease. During 2001 the project made good progress in its five main strands of work:
call to action
opportunities, environments and lifestyle
developments in health care and health information
learning and development.
The aim is to weave these strands together to create a new "Paisley Pattern" of better health. It is particularly appropriate that funding for this initiative of 6 million for a 3 year period starting in October 2000 was awarded to Paisley. Paisley has a significantly higher rate of CHD mortality than Scotland overall and has marked health inequalities within it. The overall CHD death rate in Paisley is 13% higher than it is in Scotland as a whole. Although the project is focused on this one area, which might be described as "Scotland in microcosm", Have a Heart Paisley is acting as a test bed to help inform and stimulate effective action across Scotland as a whole in the field of CHD prevention.
Have a Heart Paisley builds on the experiences of other projects internationally and in particular the North Karelia Project in Finland. The project aims to change the lives and perspectives of every citizen of Paisley by impacting on life circumstances, lifestyles
and specific cardiovascular issues. It also aims to prevent heart disease from developing and to delay the progression of existing heart disease, as well as ensuring access to appropriate care once the symptoms of heart disease are present. The objectives of the original project have been redefined in the past year to improve their focus as follows:
to increase the number of people adopting healthy lifestyles
to help community members and representatives, volunteers and professionals gain the motivation, self-confidence, knowledge and skills they need to play their parts in preventing CHD
to influence policies and encourage environments that make healthy lifestyles easier to achieve, promote good health and protect against CHD
to encourage and enable community involvement and participation
to improve partnership working
to strengthen primary and secondary prevention of CHD in healthcare settings
to promote the recovery of people after an acute episode of CHD
to establish a risk factor database and disease register for CHD
to reduce inequalities in health, primarily relating to CHD.
The expectation is that, as in Finland in relation to the North Karelia Project, the lessons from Have A Heart Paisley will be rolled out across Scotland as and when they emerge, so that other areas can benefit and avoid duplication of effort in the battle to prevent CHD.
Forth Valley: "Braveheart" project: Supporting older people who have had heart attacks
The Braveheart Project is an innovative Ageing Well Health Demonstration Project which has looked at the feasibility and effect of training non-medical senior members of the local community to run mentoring groups to educate, support and empower patients aged 60 years and over with ischaemic heart disease. Over 150 participants have now benefited from this service which has been managed by a project team representing the main partners including Age Concern Scotland, Health Education Board for Scotland, Forth Valley Acute Hospitals Trust, Forth Valley NHS Board and Merck, Sharp and Dohme Ltd. New developments this year have seen the project move from its acute base to the Forth Valley South LHCC with the support of the Scottish Executive and the original partners.
In its first 3 years the Project was run as a randomised controlled trial comparing the outcomes in the participants in the mentoring groups with a similar group of patients who received standard care only. Final results are awaiting publication.
There was a very high satisfaction rating from participants. The model of support appears inclusive of all socio-economic groups and encourages healthy alliances. Mentoring complemented existing secondary prevention and health promotion strategies. The intervention seems to be practical, relatively inexpensive, safe and promotes positive lifestyle changes in older people with coronary artery disease.