Why is it an issue?Cardiovascular diseases are the main cause of death in the UK causing around 156,800 deaths in England in 2008 (around a third of all deaths). Around 45% of all deaths from CVD are from coronary heart disease (CHD) and more than a quarter from stroke (28%). CHD is the most common cause of death in England and Wales (15% of all deaths).
What’s the local picture and how do we compare?
How do we compare?
What do things look like locally?
- Mortality rates from CVD are significantly higher than the national rate, and have decreased by 48.1% since 1995-7 (CVD Profile, 2011).
- The cost of total statin prescribing relative to the local population with CHD was lower compared to the national picture (CVD Profile, 2011).
- For people having myocardial infarction reperfusion, the median call to treatment time to receive thrombolysis is higher than the national time, but it is higher for angioplasty (CVD Profile, 2011).
- There is a definite correlation between deprivation and CVD Mortality. The priority neighbourhoods have a DSR that is much higher than the Wakefield average (HI Gap Analysis, 2010).
- Levels of CHD appear to be higher on the east of the district, rather than by priority neighbourhoods. Statin prescribing is matching this pattern (HEA, 2010, CHD Equity Audit, 2013).
- Recorded hypertension is relatively equal across the district with high levels in pockets of Knottingley, Fitzwilliam, Featherstone and Normanton. Levels of strokes are also level across the district with pockets in Knottingley, Ackworth and Hemsworth (HEA, 2010).
- The expenditure per head for all circulatory diseases in Wakefield District was £123.70 in 2009/10, £14.20 less than in England and £6.30 less than in Yorkshire & Humber. There has been an increase in expenditure per head in England, but little change in expenditure per head in Yorkshire & Humber between 2004/05 and 2009/10. The expenditure per head for CHD in Wakefield District in 2009/10 was £38.89, £2.20 lower than England and £0.04 higher than Yorkshire & Humber. The expenditure per head for cerebrovascular disease in Wakefield District in 2009/10 was £14.84, £6.71 lower than England and £5.17 lower than Yorkshire & Humber (YHPHO SPOT Analysis, 2010).
- There are a slightly higher proportion of stroke patients under-75 years discharged back to their usual place of residence compared to the national picture (CVD Profile, 2011).
What’s the trend and what can we predict?
- The absolute gap in CVD mortality for persons under 75 years between the most deprived and least deprived local areas has decreased by 20.1% between 2001 and 2009 (CVD Profile, 2011).
- The number of people dying from heart attacks (all age CHD mortality) has slightly reduced from the 2006-08 level of 100.47 per 100,000 to 94.68 per 100,000 in 2007-09 (NCHOD… at a glance, 2010; EOY Trust Board Report, 2011).
- The number of people dying prematurely from heart attacks and strokes (under 75s CVD mortality) has slightly reduced from the 2006-08 level of 90.55 per 100,000 to 85.31 per 100,000 in 2007-09 (NCHOD… at a glance, 2010; EOY Trust Board Report, 2011).
- Total population aged 65 and over predicted to have a longstanding health condition caused by a stroke is expected to rise from 1,200 to 2,000 by 2030, assuming reported stroke in the General Household Survey remains static (POPPI, 2010).
- Using the same methodology, Total population aged 65 and over predicted to have a longstanding health condition caused by a heart attack is expected to rise from 2,650 to 4,200 by 2030, assuming reported cardiac arrest in the General Household Survey remains static (POPPI, 2010).
What are we doing and what can be done differently?
- Wakefield have an excellent history of cost effective prescribing and the Medicines Management team encourage practitioners to use the lowest acquisition cost statins as per NICE guidance, therefore the cost of prescribing statins is lower in Wakefield that the National picture. The costs will continue to stay the same although additional high cost statins patent expire (Atorvastatin), we will continue to identify more high risk clients and offer stain treatment (The NHS Health Check programme-100,000 people in Wakefield are eligible for a health check over a five year period). There will be lives saved and a reduction in morbidity as diseases are diagnosed earlier. (DH 2009).
- Regarding Myocardial perfusion, Thrombolysis in Wakefield (the drug injected to dissolve the blood clot causing the blockage to the heart artery) has been superceded by an alternative treatment called Primary Angioplasty, this is where the patient goes direct to the Leeds Heart Centre and has the clot removed and the artery has a stent inserted to maintain the blood flow to the heart, this is an emergency procedure and a treatment. Prior to this, the procedure was performed in two separate sessions usually 7-10 days apart, (Thrombolysis and Angioplasty). This treatment is not available in every part of the country. Patients where Primary Angioplasty is not appropriate, thrombolysis will be considered, therefore the time to receive this treatment is higher as there has been an unavoidable delay while the best decision for the individual is made. Target time for Angioplasty is 150 minutes from time of calling for help. Target time for Thrombolysis is 60 minutes from call for help. The message is ‘if you think you are having a heart attack, dial 999.’
- The NHS Health Checks programme has increased the identification of patients with hypertension (the biggest risk factor for stroke), across the District. The Older Peoples Health and Well being staff and the Health Trainers in Wakefield have been very active in the communities. They have had training in cardiovascular risk assessment and blood pressure measurement, to enable them to identify clients who may have hypertension or at high risk of cardiovascular disease and signpost them to their doctors for investigations and treatment. The Health Trainers and Older Peoples Health and Well being staff offer lifestyle interventions and support for clients in the community. The aim is to reduce their risk and improve their life chances.
- The population is living longer and heart disease has not been prevented in this group it has been delayed. There is improved emergency treatment for heart attacks, more people are surviving their first heart attack; more people are living longer with heart disease as there are systematic pathways of care, rehabilitation and improved uptake of secondary prevention drugs, (Aspirin, Statins, Beta Blockers and ACE Inhibitors). We need to continue with this programme and at the same time increase our efforts to promote healthier lifestyles to prevent heart disease in the future
- There have been new services for Wakefield residents, in September 2010, the cardiology department commenced a Percutaneous Coronary Intervention (PCI or Angioplasty) service, previously patients were admitted to Mid Yorkshire Hospitals Trust (MYHT) with Chest pain and had a diagnostic angiogram, if required the patient would then be transferred to Leeds Teaching Hospital for an angioplasty (stent to widen the artery), this wait could be 7-10 days. This has been reduced to 5 days as the procedure is done in one operation at MYHT and the patient remains at MYHT until fit for discharge home.
- MYHT have appointed additional consultant cardiologists with a special interest in heart failure and implanting heart failure pacemakers to improve the hearts function, these services are available locally for Wakefield residents. There are heart Failure Specialist Nurses that work in the Hospital and the community supporting patients with heart failure to improve their quality of life. The additional heart failure services and resources are an indication of the future trend of more people surviving a heart attack, and living longer, but requiring more interventions and support to improve the quality of their lives. Heart Failure Rehabilitation reduces hospital admissions and improves quality of life, this service is being piloted for Wakefield patients, the evaluation is being considered for implementation into mainstream services.
- Community Cardiology services are new services available in the community for patients with symptoms of palpitation and heart murmurs. The service is closely linked to MYHT to ensure there are no delays if patients require further treatment following the investigations in the community. The service enables shorter wait times and more convenience for the patient.
Stroke & Transient Ischaemic Attacks
- The Mid Yorkshire Hospitals NHS Trust (MYHT) Hyperacute Stroke and TIA business case for the Acute Stroke Pathway was approved at the beginning of July 2011. This was developed by MYHT due to a need to bring the current stroke and TIA services in line with the regional Stroke Assurance Framework Indicators. The business case predominantly allowed the recruitment of 6 wte, Band 6 Stroke Assessment Nurses (SANs) to be available on a 24/7 basis. The role is to assess a suspected stroke patient in the emergency department, and take them through the hyperacute phase of the stroke pathway (imaging, thrombolysis and stroke unit). A limited service (12 hours, 5 days) has been in operation for around 12 months and has demonstrated a significant improvement in the quality of service patients experience when the SANs are on duty.
- All the new nurses have now been recruited, and are undergoing a process of induction and training. A 7 day, 8am to 8pm service will start on November 1st, leading to a 24/7 stroke assessment service (including thrombolysis for eligible patients) from January, 2012. Additional therapy and radiology resources have also been identified to support the stroke pathway. In addition, the business case allows streamlining of the transient ischaemic attack (TIA) service over seven days to support a more rapid response to the higher risk patients.
- MYHT stroke services will undergo an accreditation process as part of the Y&H Stroke Assurance Framework. The visit will take place at Pinderfields Hospital on December 12th, 2011. Accreditation is an important assurance process and will enable local stroke services to take part in regional telemedicine rotas for out of hours hyperacute and thrombolysis decision support.
- There is now a stroke Early Supported Discharge Service within the Community Therapy team. This aims to take around 40% of stroke patients (those in the mild to moderate category) to continue their rehabilitation within their home environment. Evidence is clear that the medium and long term outcomes for this group of patients are better if they rehabilitate at home.
- NHS Wakefield and Wakefield WMDC Family Services are currently working on a joint commission of services from the Stroke Association. This will provide support for patient and carer from hospital discharge, and will enable the achievement of identified patient goals in terms of community integration or return to work.
- A pilot of an approach to the 6 month review of stroke survivors is underway in Wakefield, as part of a Y&H regional project to develop a template in SystmOne. The results of the pilot are expected towards the end of November, 2011 and roll out across the district is then anticipated.
- The stroke prevention workstream is to engage with all GP practices in Wakefield around the stroke prevention agenda with particular emphasis on atrial fibrillation (AF) and transient ischaemic attack (TIA) and to implement the GRASP AF Tool in conjunction with offering information, support and education. This will in turn enable improved detection and increased awareness in AF and Warfarin management, supporting a reduction in the number of AF related Strokes in Wakefield District.
- The workstream will also enable a targeted approach to increasing awareness of the signs and symptoms of TIA/Stroke amongst health care professionals and members of the public in Wakefield. Ultimately, the need is to ensure commissioning of an effective and evidence based service for TIA patients.