Risk Assessment and Management in CVD: An English Approach

Elizabeth Lynam Branch Head, Vascular Programme Department of Health

• Established in 1948, the NHS celebrated its 60th anniversary in 2008 • Provides high-quality healthcare, free at the point of need, according

to clinical need • taxpayer-funded healthcare accounted for 7.8% of UK GDP in

2007/8 • Provides healthcare in a variety of settings and at various stages in

the care pathway of patients: – primary care: through pharmacists, General Practitioners,

dentists, – opticians and walk in centres – community care: through health visitors, district nurses,

community hospitals – secondary care: through ambulance services, acute hospitals,

mental health services, and social care services

Structure of the NHS in England

• England is organised into 10 SHAs

• A network of 152 Primary Care Trusts holds the NHS budget and commissions services on behalf of local populations

• NHS annual budget is £103 billion for 2009 - 10

Lifestyle Risk Factors

• lifestyle challenges such as smoking, obesity and alcohol misuse, cost the NHS approx € 10bn annually, society approx € 40bn annually and cause 140,000 preventable deaths each year.

• though rates are dropping, 10million (21%) of the general population smoke; half of these are routine and manual workers

• 62% of the adult population are overweight or obese

• only 39% of men and 29% of women meet the recommended daily amount of physical activity

Our Approach

1. Informing and supporting people to make healthier and more responsible choices

2. Creating an environment in which the healthier and more responsible choice is the easier choice

3. Identifying, advising and treating those at risk

Impact of Cardiovascular Disease in England

• Second biggest area of spend for the NHS by disease programme

• CVD is the leading cause of premature mortality

• Stroke is the leading cause of adult disability

• Diabetes is the leading cause of adult blindness and lower limb amputations

Health Inequalities

In England, people who live in least affluent areas have worse health outcomes, including higher rates of premature death.

• CVD is leading cause of premature death

Also, certain groups in English society experience higher rates of CHD:

• mortality rates from CHD is 46% higher for men and 51% higher for women of South Asian origin than in the non-Asian population

• occurrence of diabetes in individuals of South Asian origin is twice that of the general population

Vascular diseases: the strategic approach

Good progress tackling vascular

conditions so far:

• 40% fewer cardiovascular deaths

• planned reduction achieved early

Existing policies: • Coronary Heart Disease NSF (2000)

• Diabetes NSF (2001)

• Renal Services NSF (2004)

• National Stroke Strategy (2007)

All highlight the need for prevention

but set out individual approaches

CVD and Diabetes Prevention – the Case for Risk Assessment

UK National Screening Committee – proposed diabetes screening for targeted groups within the context of broader CVD risk assessment

Department of Health’s Vascular Programme Board – with major Screening Committee input developed an outline proposal for a vascular risk assessment and management programme

‘

Vascular disease risk factors Same risk factors:

‘Fixed factors’

• age

• gender

• ethnicity

‘Modifiable factors’

• smoking

• physical inactivity

• obesity

• blood pressure

• blood fats

Having one disease increases the risk of

developing another

Vascular Risk Assessment and Management Programme

Role of the National Programme

• A population-based approach based on public health principles

• About risk assessment (and management) – not principally a disease finding programme

• Systematic and universal (for populations within specified age bands)

• Will standardise the approach to vascular risk assessment and management already being undertaken piecemeal across the country – ensuring that diabetes and kidney disease are included

The National Offer

• NHS Health Check detailed in Best Practice Guidance (April, 2009)

• Everyone aged between 40 – 74 not on an existing disease register

• Call and recall every 5 years

Clinically and cost effective

DH economic modelling showed that, each year the NHS Health Check programme could prevent at least:

• 1,600 heart attacks and strokes

• 650 cardiovascular deaths

• 4000 people developing diabetes

Prevention figures are cautious estimates based only on known effective management applied to those at high risk.

The check

• Face to face check

• Assess risk of: • heart disease • stroke • diabetes • kidney disease

• Explanation of vascular risk

• Tailored lifestyle advice

• Referral to other investigations and interventions as appropriate

Strategic Fit with National Health Policy

Primary Care Led NHS ����

Prevention ����

Tackling Health Inequalities ����

Greater Role for Pharmacy ����

Health Promotion Strategies ����

Reaching those at highest risk

• Check suitable for a variety of settings

• Some PCTs using outreach services – examples on the NHS Improvement website

• Targeting those with greatest risk/need first

• National communications materials tested with those at highest risk.

• Tailored and translated of the leaflet being made available – plus DVD

Early Challenges Encountered

• Rolling out a standardised programme in a devolved healthcare system

• Will take several years to reach full coverage

• Overcoming scepticism from some of the people who will need to provide this

• Achieving good rates of take up

• Having enough services to support lifestyle interventions

Further information

www.improvement.nhs.uk/nhs healthcheck

www.dh.gov.uk/nhshealthcheck

e-mail: nhshealthcheck@dh.gsi.gov.uk