Hearts and Minds programme run by Bright Ideas Nottingham
Hearts and Minds is a programme, initially funded by the British Heart Foundation (BHF), and developed by Bright Ideas in Nottingham. It aims to identify approaches that work in relation to promoting heart health in Nottingham’s visible and non-visible diverse Black and minority ethnic communities. The programme has included an annual conference, the development of community action researchers and “the Love Hearts”, a team of volunteers that work on the project to improve the Heart Health of African Caribbean Communities. The programme is currently being evaluated. The BHF are also evaluating other programmes they have supported, including an integrated care (so-called ‘house of care’) pilot in Hardwick CCG (Derbyshire), running for two years to May 2017, which will be evaluated. The BHF also produce a range of best-practice and training materials for professionals.
NHS Health Checks commissioned by public health
The aim of NHS Health Check programme in Nottingham City is to prevent heart disease, stroke, diabetes and kidney disease through offering a ‘midlife MOT’ to anyone without a pre-existing condition aged 40-74. Everyone eligible should be invited for a health check every five years – 20% of the relevant population should therefore be invited each year. Patients will be invited for an NHS Health Check once every 5 years, therefore around one-fifth of the eligible population should be offered a check each year. Pre-existing conditions that are excluded from the programme are coronary heart disease, chronic kidney disease, diabetes, hypertension, atrial fibrillation, transient ischaemic attack, hypercholesterolaemia, heart failure, peripheral arterial disease and stroke. In addition, people who are prescribed statins are also excluded, as are any people who have previously been identified as having a 20% or higher risk of developing cardiovascular disease over the next ten years.
The check includes a blood test to check cholesterol and blood glucose, measurements of blood pressure, BMI (height and weight) and questions around demographics, family history and lifestyle (e.g. smoking status, alcohol, physical activity, etc.). Patients found to be at high risk of cardiovascular disease, and those who are diagnosed with a condition as a result of the Health Check, are managed according to normal pathways.
GPs (currently 61 practices in Nottingham city) are the principal providers and are commissioned to identify, prioritise and invite their eligible population for NHS Health Checks, as well as deliver the Health Check itself. There has also been some limited alternative provision through local pharmacies, although this has not proved to be particularly successful and has recently been phased out.
The effectiveness of general health checks in reducing morbidity and mortality has been debated in the published literature (Braillon et al., 2015), but remains supported by the UK government, and is a statutory duty of local government.
According to nationally published data (from http://www.healthcheck.nhs.uk) in 2013/14 the eligible population in Nottingham city was 73,583, of whom 12,636 were offered a health check during the year, which equates to 17.17% of the eligible population, compared to 18.42% across all of England in the same period. The number of appointments received in Nottingham in 2013/14 was reported by healthcheck.nhs.uk as 6,295, representing 8.55% of the eligible population, which compares with 9.03% nationally (England).
5,063 NHS Health Checks were completed
157 patients were found to be high risk as result of their Health Check
273 patients were prescribed statins within two months of their Health Check
46 patients were newly diagnosed with Type 2 Diabetes as a result of the Health Check (defined as diagnosed within 90 days of the Health Check), 4 patients were diagnosed with Chronic Kidney Disease, 111 were diagnosed with hypertension and 4 were diagnosed with atrial fibrillation (TCR DH outcomes report [accessed 16/11/15])
There is a wide variation in the proportion of high risk patients treated with a statin to control cholesterol levels by general practices locally.
Increasing uptake in Nottingham such that it exceeds the national average may be one way of reducing the health inequality due to CVD between Nottingham and England. However, a local intra-city analysis of inequality within Nottingham itself is also important, in order to ensure that there is not a local unintended effect of prioritising the worried well over the sick and needy, and increasing health inequality within the city, even if the overall effect is to decrease inequality at the national level. Health Equity Audits have been carried out to examine how far Health Checks are focussed on those in greatest need (Hawley, 2015). The key findings of the first audit were: firstly, that the invited population was significantly different from the uninvited and that this appeared to show that CVD risk was being used as a means of prioritising invitations; and, secondly, that those with higher CVD risk, particularly as represented by age, deprivation and smoking status, were less likely to take up their invitation. The second audit also found that a risk stratified approach is being adopted with respect to invitations issued for health checks, and that this is being successful with respect to the take-up of the service by patients with a higher calculated risk score. It also found, however, that there is evidence that the reach of the service is inequitably distributed with respect to other characteristics, and that in some cases this may be attributable to invitation strategy as well as patient propensity to take up the service. In particular:
Although men are more likely to be invited because of their higher risk, they are less likely to take-up the invitation;
The position is similar for current smokers, who are more likely to be invited, reflecting their higher risk profile, but less likely to be assessed. Some of this is likely to be explained by the fact that more men are current smokers, but may also reflect a greater reluctance to seek medical help amongst smokers generally (Chen et al., 2012);
With respect to ethnicity, there is inequity between White British and aggregated other ethnicities for probability of being invited and attending. When disaggregated to individual ethnic groups, there is some considerable variation in this respect, with some ethnicities appearing to be significantly better than White British and some significantly worse. With respect to the latter, the underrepresentation within the Pakistani community may be worthy of further investigation.
The national and local NHS Health Check programme is, in principle, a universal service, with the aim being to reach 100% of the eligible population every five years. Achieving 100% uptake would obviously ensure that the programme is delivered equitably. In reality such a position is unattainable, and the current performance target is set at 60%. It seems likely that the lower the proportion of uptake that is achieved, the greater the likelihood for perverse outcomes in terms of equity of access to the service. One approach might therefore be to seek a higher overall target for uptake. An alternative strategy might be to incentivise uptake within specific groups identified as deficient. In particular, it might be that greater uptake from men and from smokers could be sort by setting differential uptake targets for those groups. In addition, the apparent underrepresentation from the Pakistani community warrants further attention, particularly in light of the higher risk of diabetes associated with people of South Asian origin.
Adult healthy lifestyle service to prevent long-term conditions and services commissioned by public health
The adult healthy lifestyle service enables adult patients with one or more lifestyle risk factors for CVD to access behavioural change support to improve risk factors. These risk factors are common to other conditions such as certain cancers, and therefore the pathway contributes to the prevention of other chronic/long term conditions as well. These services are currently subject to a commissioning review, with the intention that revised services will be commissioned from April 2017.
The pathway utilises the proportionate universalism concept advocated in the Marmot Review. All of the commissioned services are available to Nottingham City residents and patients aged 18 years and over. In addition, all of the commissioned services are targeted towards the most socially-deprived ten electoral wards in the City (Figure 4).
Supporting people with CVD
Management of hypertension, CHD and heart failure in primary care
The Quality and Outcomes Framework (QOF) includes a number of indicators for practices, CCGs and the country about the management of cardiovascular disease, including high blood pressure, atrial fibrillation, cardiovascular risk, stroke, heart failure, and peripheral vascular disease. The latest data relate to 2014/15 (QOF, 2014/15). In general, detection rates (reflected in the registers of people diagnosed with each risk or condition) are below the local and national average for these conditions. The published figures do not, however, allow us to assess the extent to which this might be explained by genuinely lower prevalence rates, because of the younger age profile of the City’s population (most of these conditions are more common among older people). In addition, indicators of good treatment are very slightly below neighbouring areas, although this is often very marginal. In addition, relative to other areas, our position has not generally improved from the figures in the last JSNA, which were for 2010/11.
Heart Failure nurses in the community currently support patients with one type of heart failure (left-sided), there is an outstanding need for a service for those with right heart failure.
Chest pain services
NICE Guidance now recommends a more complex pathway for the investigation of suspected stable angina (chest pain on exertion caused by ischaemic heart disease). Simply, a wider range of tests may be used, depending on the initial estimation of the probability that the patient has angina. A pathway has been developed, though there have been issues with maintaining short waiting times.
The CVD profile (SEPHO, 2012) contains a range of information on cardiac procedures. Key issues include:
Angiography rates and significantly were lower than the England average and Centres with Industry. Rates have decreased in the city since 2003/4, whereas they have increased in England and Centres with Industry. These lower levels of angiography may be an indication of lower levels of reporting of heart disease symptoms in primary care or investigation, and may contribute to the higher levels of revascularisation in the city.
Angioplasty rates are significantly higher in the city than the England average and Centres with Industry.
Coronary Artery Bypass Graft (CABG) rates are significantly lower than the England average and Centres with Industry.
Revascularisation rates are higher in the most deprived quintile in the city than the least deprived, but the gradient is less marked than in England and Centres with Industry.
Survival rates for cardiac surgery (98.3%) at NUH are higher than required for UK standards (Care Quality Commission, 2010).
The national audit of cardiac rehabilitation (NICOR, 2012/13), found:
Waiting times for cardiac rehabilitation in the East Midlands do not meet the national target (42 days) for patients with myocardial infarction or heart surgery, although assessments are carried out much more quickly and faster than in most regions.
A basic minimum of 56 days rehabilitation is proposed. On average, most regions, including the East Midlands (42-50 days, depending upon indication), were not meeting this target.
Only 3% of patients stopped smoking during cardiac rehabilitation in the East Midlands; this is the lowest proportion of any region.
Exercise levels at the start (9%) and completion (17%) of rehabilitation were the lowest in the country, with the smallest improvement, at 8%.
In contrast, the proportion of patients with a BMI<30 increased by 2% during rehabilitation in the Easy Midlands. Though modest, this is the highest increase in the country.
There were reasonable reductions by patients following rehabilitation in anxiety and depression they experienced. In addition, quality of life overall improved well during rehabilitation.
The audit report recommended:
1. CR programmes are treating more patients than ever but more needs to be done to recruit and refer a greater percentage of patients from the eligible groups. This is particularly the case for medically managed post MI patients and elective PCI patients.
2. There is an urgent need for CR services not meeting the minimum standards to redesign their services to align with national guidance and evidence-based practice. Specifically this means that those programmes not adhering fully to clinical and national guidance should:
i. Start CR earlier for all patient groups
ii. Carry out pre CR assessment early and use this data to tailor the intervention
iii. Ensure that the duration of CR is aligned with national guidance
iv. Complete and record an end of CR assessment (post CR)
v. Submit data on CR delivery and patient outcomes to the national audit.
Abdominal Aortic Aneurysm Screening
An abdominal aortic aneurysm (AAA) is a weakening and expansion of the main blood vessel (the aorta) in the abdomen. Such aneurysms can expand and even burst, usually resulting in death. An ultrasound scan of the abdomen is the easiest way to check whether someone has an AAA. As AAA is most common in men aged 65 and over, the national screening programme offers a screening ultrasound test to men as they attain the age of 65 years. Men over that age can also refer themselves for a screening test. The National Screening Programme aims to reduce mortality by up to 50% by detecting and effectively treating suitable aneurysms.
In general, the Nottinghamshire Screening Programme performs very well (The Nottinghamshire Abdominal Aortic Aneurysm Screening Programme
Annual Report 2014-15). In 2014/15:
Of those invited to be screened (5,407 men), some 4,297 (79.5%, c.f. 79.3% nationally) accepted.
40 aneurysms were detected (0.93%, c.f. 1.19% nationally).
The programme achieved almost all standards, except those where the standard is not being achieved nationally and may be reviewed.
Patient satisfaction levels were high (97.3% rated their experience as good or excellent).
The main exception is for the rate of non-visualisations (where the aorta is not seen adequately on the screening scan), where 3.69% of Nottinghamshire scans were non-visualised (c.f. 1.12% nationally). This has, however, improved dramatically over the three years of screening (from 8.17% in 2012/13, and 5.33% in 2013/14). Achievement is expected by 2015/16 or 2016/17.
The outcomes of surgery cannot currently be reported, as the number of operations is very small and publication of the actual figures would constitute a risk to patient confidentiality.
From the perspective of Nottingham City CCG, however, uptake was lower, at 72.3%, than for the other CCGs served by the programme, and no publicity to increase uptake could be undertaken by the programme due to a lack of staff capacity, which should be rectified. Nottingham City’s representatives on the committee overseeing the local programme should influence the programme to increase uptake in the City, particularly amongst BME communities, and to reduce the rate of non-visualisation at screening.