Ten years of the CHD NSF Professor Roger Boyle CBE National Director for Heart Disease and Stroke Department of Health

Frustration Poor performance Lack of teamwork Inability to innovate – new ideas stifled Poor management –Financial and general Poor results (outcomes) Increasing frustration

Modernising care Networks Improvement programme CHD Partnership CHD Collaborative Heart Improvement Programme NHS Improvement

Standards 1 & 2: Reducing heart disease in the population 1. The NHS and partner agencies should develop, implement and monitor policies that reduce the prevalence of coronary risk factors in the population, and reduce inequalities in risks of developing heart disease. 2. The NHS and partner agencies should contribute to a reduction in the prevalence of smoking in the local population. SMOKING PREVALENCE All adult smoking rates have reduced over the period from 28% in 1998 to 21% in Smoking in the routine & manual groups has reduced from 31% in 2001 to 29% in In 10 years the number of smokers fell by one fifth (2 million fewer smokers).

Standards 1 & 2: Reducing heart disease in the population 1. The NHS and partner agencies should develop, implement and monitor policies that reduce the prevalence of coronary risk factors in the population, and reduce inequalities in risks of developing heart disease. 2. The NHS and partner agencies should contribute to a reduction in the prevalence of smoking in the local population. SMOKING RATES IN CHILDREN Smoking rates in children aged years have reduced from 13% to 6% in the period 1996 to These reductions are well ahead of target. This is encouraging news for the future. IMPACT - SMOKING CESSATION SERVICES There has been an increase in the numbers of people attending Smoking Cessation services & setting a quit date from 361,000 in 2003/04 to 671,000 in 2008/09. Numbers of people successfully stopping have risen from 205,000 in 2003/04 to 337,000 tin 2008/09.

Standards 1 & 2: Reducing heart disease in the population 1. The NHS and partner agencies should develop, implement and monitor policies that reduce the prevalence of coronary risk factors in the population, and reduce inequalities in risks of developing heart disease. 2. The NHS and partner agencies should contribute to a reduction in the prevalence of smoking in the local population. PHYSICAL ACTIVITY – ALL AGE TREND Participation in physical activity which meets recommended levels has risen slowly since It still remain at around one third of people who meet the recommended levels. PHYSICAL ACTIVITY – TREND BY AGE The increasing trend is most evident in the under 35s and those aged There is, however, evidence in the latest Health Survey for England that people are over-optimistic about the duration of self-reported exercise compared with electronic monitoring.

Standards 1 & 2: Reducing heart disease in the population 1. The NHS and partner agencies should develop, implement and monitor policies that reduce the prevalence of coronary risk factors in the population, and reduce inequalities in risks of developing heart disease. 2. The NHS and partner agencies should contribute to a reduction in the prevalence of smoking in the local population. HYPERTENSION There has been a steady but modest increase in the % of males & females who have their hypertension controlled. There has been a steady reduction in the % of males who have their hypertension untreated. HYPERTENSION UNTREATED & UNCONTROLLED People with hypertension untreated & hypertension treated but uncontrolled continue to be at risk. Between 2003 & 2008 –the % of men at risk due to untreated & uncontrolled hypertension reduced from 26.3% to 23.4% –The % of women at risk due to untreated & uncontrolled hypertension reduced from 23.5% to 19.4%. 23.4% of men & 19.4% of women continue to be at risk.

Standards 1 & 2: Reducing heart disease in the population 1. The NHS and partner agencies should develop, implement and monitor policies that reduce the prevalence of coronary risk factors in the population, and reduce inequalities in risks of developing heart disease. 2. The NHS and partner agencies should contribute to a reduction in the prevalence of smoking in the local population. PREVALENCE OF DIABETES Increased diabetes prevalence accounted for 4.8% of the increase in CHD mortality from 1980 to Since then prevalence has increased by 68% for women and 70% for men. PREVALENCE OF CHD All age prevalence reduced from 5.7% in 1998 to 5.2% in There have been similar reductions in the age groups & with a more pronounced reduction in the age group – from 9.6% in 1998 to 7% in Prevalence in the 75 plus age group has risen from 20.3% in 1998 to 22.8% in This is likely to be the result of delayed onset & increasing average age in the 75 plus age group.

Standards 3 & 4: Preventing CHD in high risk patients 3. General practitioners and primary care teams should identify all people with established cardiovascular disease and offer them comprehensive advice and appropriate treatment to reduce their risks. 4. General practitioners and primary health care teams should identify all people at significant risk of cardiovascular disease but who have not developed symptoms and offer them appropriate advice and treatment to reduce their risks. BLOOD PRESSURE – PEOPLE WITH CHD QOF reporting started in 2004/05. QResearch has published earlier trends in BP control for their population of 3.4 million people. The trend for the QResearch sample (01/02-06/7) & the QOF results (04/05- 08/09) shows a steady increase in the % of people on CHD registers with BP<150/90. By 2008/09 QOF reported 89.7% of people with CHD had BP<150/90. CHOLESTEROL – PEOPLE WITH CHD The trend for the QResearch sample (01/02-06/7) & the QOF results (04/05- 08/09) shows a steady increase in the % of people on CHD registers with Cholesterol of 5 mmol/l or less. By 2008/09 QOF reported 82.1% of people with CHD had cholesterol of 5 mmol/l or less.

Standards 5,6 & 7: Heart attack and other acute coronary syndromes 5. People with symptoms of a possible heart attack should receive help from an individual equipped with and appropriately trained in the use of a defibrillator within 8 minutes of calling for help, to maximise the benefits of resuscitation should it be necessary. PHASE 1 - SAVING LIVES – OUR HEALTHIER NATION The White Paper Saving Lives: Our Healthier Nation was launched in 1999 £2m invested in installing 681 automated external defibrillators (AEDs) in busy public places (airports, stations, shopping centres) From February 2005 all 681 AEDs were handed over to 21 Ambulance Services & financial allocations made to each Trust to ensure programme continuity. All AEDs managed as core NHS activity. PHASE 2 - THE NHS PLAN The NHS Plan (July 2000) 3,000 automated external defibrillators (AEDs) in public places. £6m was awarded to the BHF Community Defibrillation Officers appointed A further 2,300 AEDs were funded – based on bids received from Ambulance Trusts Over 100 survivors to hospital discharge

Standards 5,6 & 7: Heart attack and other acute coronary syndromes 6. People thought to be suffering from a heart attack should be assessed professionally and, if indicated, receive aspirin. Thrombolysis should be given within 60 minutes of calling for professional help. THROMBOLYSIS FOR STEMI Thrombolysis for STEMI was implemented soon after the publication of the NSF. The % of patients with Call to Needle within 60 minutes reached 70% in Q4 2007/08. The % of patients with Door to Needle within 30 minutes reached 80% plus from Q2 2003/04. In many parts of the country pre-hospital thrombolysis was implemented & by % of thrombolysis was being given before arrival at the hospital. THROMBOLYSIS & PRIMARY PCI From 2003 Primary PCI started to be adopted as a more effective alternative. The National Infarct Angioplasty Project (NIAP) evaluated implementation at pilot sites. DH guidance (2008) recommended the roll- out of PPCI to areas where 120 call to balloon times could be delivered. Thrombolysis now accounts for 40% of post STEMI treatment & PPCI accounts for 60%.

How are heart attacks being managed? %

Standards 5,6 & 7: Heart attack and other acute coronary syndromes 7. NHS Trusts should put in place agreed protocols/systems of care so that people admitted to hospital with proven heart attack are appropriately assessed and offered treatments of proven clinical and cost effectiveness to reduce their risk of disability and death. PRIMARY PCI – RESPONSE TIMES Door to Balloon (DTB) The national mean time reduced from 61.7 minutes in 2007 to 53.8 minutes in 2008 In 2008 – 81.3% were less than 90 minutes Call to Balloon The national mean time Call to Balloon was minutes in 2008 In % were less than 150 minutes. OUTCOMES FOR PATIENTS WITH ACS While 30 day mortality after nSTEMI has been falling, outcomes for patients with ACS (nSTEMI) remain of concern. The immediate diagnosis & treatment of nSTEMI has lagged behind that for STEMI. NICE GUIDANCE – MARCH 2010 NICE is preparing clinical guidance on –The management of ACS - published March 2010 Future improvements in management & treatment to be based on guidance issued.

Falling mortality rates – MINAP data STEMIs 30 days

Falling mortality rates – MINAP data Non STEMIs 30 days

Standard 8: Stable angina 8. People with symptoms of angina or suspected angina should receive appropriate investigation and treatment to relieve their pain and reduce their risk of coronary events. RAPID ACCESS CHEST PAIN CLINICS Central funding enabled Rapid Access Chest Pain Clinics to be developed across the country Since 2002/03 referrals have been running at over 25,000 in each quarter Over the period since their introduction there has been an upward trend in referrals nationally – so no let up in symptomatic presentation. In each of the last 5 quarters to June 2009 there have been over 30,000 referrals. SPEED OF ACCESS & % CARDIAC IN ORIGIN Since % of referrals have been made within 24 hrs of GP decision to refer. Over 95% of referrals have been seen within 14 days (97% in the quarter to June 2009) Over the first year of their introduction specificity of referral increased & over 40% of referrals have been cardiac in origin (43% in the quarter to June 2009)

Standards 9 & 10: Revascularisation 9. People with angina that is increasing in frequency or severity should be referred to a cardiologist urgently or, for those at greatest risk, as an emergency. 10. NHS Trusts should put in place hospital-wide systems of care so that patients with suspected or confirmed coronary heart disease receive timely and appropriate investigation and treatment to relieve their symptoms and reduce their risk of subsequent coronary events. ANGIOGRAPHY – GROWTH IN ACCESS Access to angiography has improved substantially The number of angiograms increased by 66% between 2000/01 & 2007/08. ANGIOGRAPHY – SPEED OF ACCESS Speed of response has improved markedly. Since April 2004 Total waiters have reduced by over 15,000 - down 66% In April % of people waited a month or less By December 2009 – 82% of people waited a month or less.

Standard 11: Heart failure 11. Doctors should arrange for people with suspected heart failure to be offered appropriate investigations (e.g electrocardiography, echocardiography) that will confirm or refute the diagnosis. For those in whom heart failure is confirmed, its cause should be identified – treatments most likely to both relieve their symptoms and reduce their risk of death should be offered. ECHOCARDIOGRAPHY – SPEED OF ACCESS Diagnostic waiting times have reduced as part of achieving 18 weeks For echocardiography – in March 2009 –88% of people waited less than 4 weeks –99% of people waited less than 6 weeks.

Standard 11: Heart failure 11. Doctors should arrange for people with suspected heart failure to be offered appropriate investigations (e.g electrocardiography, echocardiography) that will confirm or refute the diagnosis. For those in whom heart failure is confirmed, its cause should be identified – treatments most likely to both relieve their symptoms and reduce their risk of death should be offered. HEART FAILURE - MORTALITY There is some evidence that mortality among newly diagnosed cases of heart failure has decreased (South East England Hillingdon/Bromley 1995/97 & Hillingdon/ Hastings 2004/05).

England – Heart Failure – Hospital Finished Consultant Episodes & Admissions – By Specific Diagnosis /9-2008/9 Left Ventricular Failure - Admissions & FCEs have reduced FCEs by 35% since 1998/99 & by 30% since 2000/01 Admissions by 49% since 1998/99 & by 43% since 2000/01

Receipt of cardiac rehabilitation

% of patients with MI, CABG and PCI receiving cardiac rehabilitation

England MICABG PCI

Wales MI CABGPCI

Reasons for rejection

Uptake by ethnicity

Quality requirement two: Diagnosis and Treatment People presenting with arrhythmias, in both emergency and elective settings, receive timely assessment by an appropriate clinician to ensure accurate diagnosis and effective treatment and rehabilitation.. Heart Rhythm Devices – UK National Surveys Annual surveys & reports Tracking progress – nationally & by Network & PCT Compare observed with expected 2009 Report due July 2010 Overall mapping shows improved access rates between 2006 & 2008 for –Pacemakers –ICD –CRT Source: Cunningham et al, Heart Rhythm Devices UK National Survey, 2008

Outcomes – CHD Mortality CHD MORTALITY UNDER 75 Between 1995/97 & 2005/07 average annual deaths from all causes reduced from 202,061 to 159,921 Deaths from CHD reduced from 46,615 to 24,495 Deaths from Other Circulatory Diseases reduced from 27,610 to 18,557. Between 1995/97 & 2005/07 - mortality rates from All Causes reduced from 397 per 100,000 to 302 per 100,000 – down 24% Mortality rates from CHD reduced from 89 to 45 per 100,000 – down 50% Mortality rates from Other Circulatory Disease reduced from 52 to 34 per 100,000 – down 35%

Outcomes – CVD Mortality CVD MORTALITY UNDER 75 As a result of these reductions there has been a reduction of 47% in death rates from circulatory disease. The Public Service Agreement target was to achieve a 40% reduction by The target has been achieved 5 years ahead of schedule. INEQUALITIES In addition, the aim is to reduce the absolute gap between the worst fifth of areas in the country for health & deprivation (the spearhead PCTs) & the national average by 40% by The absolute gap has reduced by 38.4% between 1996 and 2007 – well on the way to achieving that target.

Outcomes – CHD Mortality CHD MORTALITY UNDER 75 However, comparison of the changing rates between Local Authorities – grouped into deprivation quintiles (using the Index of Multiple Deprivation) shows a different picture. In , there was a large overlap in the mortality rates between the local authorities in the 1 st (least deprived) and 5 th (most deprived) quintiles. By , the gap had widened & the overlap had almost disappeared. However, the variation in mortality rates within the 1 st & 5 th deprivation quintiles has narrowed AND In both the 1 st & 5 th quintiles the highest (worst) mortality rates in are lower (better) than the lowest (best) mortality rates in

Next ten years! ?

How it looked 10 years ago

How it looks now

How it might look 10 years from now - the next 50% 34,000 fewer deaths each year cf

Challenges for hospital care Maintaining quality during current economic climate Driving up efficiency –Reducing LOS –Reducing admissions/readmissions –Reducing follow-ups Working primary care to improve CV care and referral patterns

What is left for primary care to do? Further optimise secondary prevention Get upstream – Health Checks –Prevent CVD and diabetes Identify and manage people with AF –Prevent about 5,000 strokes Identify people with FH –Entirely treatable condition once diagnosed Run the NHS!