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Coronary Heart Disease and Stroke: STRATEGY FOR SCOTLAND
2 Prevention
11. If Scotland is to be successful in tackling CHD and stroke, we must look to prevent or at least delay the onset of symptomatic disease (primary prevention) and manage those with existing disease so as to reduce their risk of suffering further acute events (secondary prevention).
12. The Reference Group is aware that the Scottish Executive's overall approach to public health improvement is encapsulated in the 1999 White Paper,
Towards a Healthier Scotland. With an overarching aim of tackling health inequalities, it involves a far-reaching programme aimed at:
enhancing life circumstances;
improving lifestyles; and
targeting priority topics.
13. To support the delivery of this programme, in 2000 the Scottish Executive established a new Health Improvement Fund, which is investing an additional 100m over an initial 4-year period in public health improvement.
Life Circumstances
14. Like so much ill-health, CHD and stroke afflict the socially disadvantaged - those experiencing relatively poor life circumstances - to a much greater extent than they do the more affluent. At UK, Scottish and local levels, work has been put in hand to bring about improvements in key areas like housing, employment, education, welfare benefits, childcare, community care, crime and the environment.
The Scottish Executive's Social Justice agenda offers an important focus for this work, and CHD mortality rates have been designated as key milestones against which progress will be assessed.
Lifestyles
Smoking
15. Smoking is a major preventable cause of CHD and stroke. Targets for reductions in adult smoking are: to reduce the rate of smoking from an average of 35% to 33% between 1995 and 2005 and to an average of 31% by 2010. While it appears that the 2005 target has already been met, it is too early to say whether this trend will be maintained. A wide range of work is in hand to achieve these targets, and the situation will continue to be monitored through the Scottish Health Survey.
Diet
16. Dietary factors may be responsible for significant amounts of CHD and stroke. Scots eat too much fat, salt and sugar, and do not eat enough fruit, vegetables and complex carbohydrates such as starches. The National Diet Action Co-ordinator is taking forward implementation of the Diet Action Plan (1996), with a particular focus on supporting primary producers, manufacturers, retailers (particularly the supermarkets) and the catering sector to realise their full potential in contributing to the implementation of the Diet Action Plan's recommendations.
Physical Activity
17. Physical inactivity is a major independent risk factor for CHD. Physical activity also has a positive effect on other risk factors for CHD including reducing blood pressure in people with hypertension, improving blood lipid profiles and improving insulin sensitivity. Inactive people have double the risk of dying from CHD as active people. A National Physical Activity Task Force has developed proposals aimed at raising levels of regular physical activity amongst all age groups in Scotland. These are currently subject to consultation, and a National Physical Activity Co-ordinator has been appointed.
Priority Topics
18. CHD/stroke is one of the priority topics identified in
Towards a Healthier Scotland; which also established challenging targets for reducing associated premature deaths by 2010. A key commitment in the White Paper was that a demonstration project would be established to develop an inter-sectoral community-based approach to the prevention of heart disease, recognising that many of the measures will also help to avoid stroke and, indeed, diabetes and cancer. With 6m funding from the Scottish Executive, the project - known as 'Have a Heart Paisley' - commenced in October 2000. It is testing the hypothesis that effective interventions will bring about a step change in the health of the population of Paisley, with the potential for disseminating the lessons learned throughout the whole of Scotland. Further information about the project is given in
Appendix 2 and on the website
www.show.scot.nhs.uk/demonstrationprojects
19. 'Have a Heart Paisley' is not the only innovative community-based initiative focusing on the prevention of CHD and stroke. Other examples include 'In Fine Fettle' in the Scottish Borders, the Grampian Heart Campaign and 'Braveheart' in Lanarkshire.They are complemented by the extended public health function of community nursing staff and Local Health Care Co-operatives and the Health Promoting Health Service framework, developed by the Health Education Board for Scotland, which is being piloted in various parts of the country.
20. Other priority topics are likely to be relevant and beneficial. For example, child health is fundamentally important, not just for its own sake but also for the influence that it has on health in later life. Work to support child health, including another of the demonstration projects, Glasgow's 'Starting Well', can be expected to yield longer-term benefits in a range of areas, including CHD and stroke.
21. Foundations are now in place for the development of a CHD National Learning Network. The aim of the Network, being developed by the Public Health Institute of Scotland in collaboration with key interests, is to take lessons from the National Demonstration Project 'Have a Heart Paisley' and other local, national and international projects, and use them to inform the CHD evidence base and future policy and practice across Scotland. The Network will complement and support existing initiatives and will have a focus on the prevention of CHD. Further information is available on
www.show.scot.nhs.uk/phis The Reference Group believes that the Learning Network will help inform the health promotion component of local MCNs for both cardiac and stroke services.
22. Individually-targeted primary prevention is appropriate where an individual is known to be at very high risk. Such high-risk individuals include those known to have diabetes, hypertension, hypercholesterolaemia or other conditions such as peripheral vascular disease. The findings of the recently-published 'Heart Protection Study' and other research uphold the value of appropriately targeted preventative measures such as the prescription of statins to a wider group of at-risk individuals than was previously recognised.
RECOMMENDATION
23.
All NHS Boards should, through their local MCNs, develop explicit CHD and stroke prevention strategies by December 2004. These should link to, and may be an integral part of, more general strategies for primary/secondary prevention/health improvement, such as Joint Health Improvement Plans and local health plans. The strategies should adopt a 'population approach' to improving the health of the communities that they serve, complemented by 'high risk groups approach' targeted at certain key groups, such as those with hypertension, hypercholesterolaemia or diabetes, as well as the most socially disadvantaged groups within the population. These strategies, as well as the more general health improvement strategies, must be kept under scrutiny, to take account of new evidence on prevention as it emerges.
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