Coronary heart disease (CHD) is a major cause of death in Derby, England. Rates of CHD in Derby are higher than the national average and are significantly impacted by socioeconomic factors. Local policies aim to address CHD through the "Livewell" program, which provides personalized support to improve lifestyle behaviors and access to health resources. The program focuses on high-risk areas and bringing services directly to communities. National policies also target CVD through initiatives aimed at early detection, treatment, and prevention across demographic groups.

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B743SG – Coronary Heart
Disease in the Derby City
Centre
24456
Word Count = 2997

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Coronary Heart Disease and it’s impact on the
Community health of Derby City Centre
Public Health Profiling is an invaluable tool in today’s NHS. It allows a detailed
snapshot of the current health of a local or national population over time, allows a
comparison between local, regional and national health and can be used to help
efficient allocation of resources to target areas. Further, it takes into account the
many different factors that can affect health – socioeconomic, environmental,
educational etc.
Since the devolution of Public Health from the central NHS to local authorities,
Public Health profiling is more important and invaluable than ever and is utilised
on a continuous basis to try ensure the best possible care can be provided.
In England, Public Health is developed and implemented on a regional level,
which marked a decisive change from national policy. This change occurred in
2012, marking the end of thirty eight years of national policy where Public Health
was decided upon by one central body.
Derby City and Public Health
The community area I was placed in was Derby, a city consisting of
approximately 248,000 inhabitants, of which 24.7% are from an ethnic minority
group, an increase of 10% in ten years. (ONS Census 2011) It is important to
take into the account the ethnic diversity of this area – for example there is
evidence to suggest an increased risk of diabetes and CVD in Asian communities
and potential barriers to accessing services (BHF 2007)

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Derby City is the capitol city of Derbyshire, and it falls short on many key
indicators of health in England. The standard of public health differs vastly across
the region and, most importantly, socio-economic groups – a 12 year life
expectancy gap exists between the central and outer areas of the city, where
total income comes into play greatest (PHE 2014)
It is estimated that 24.3 % of children in the city live in poverty, and in 2012,
24.3% of adults where classified as obese. (PHE & ONS 2014) The rate of alcohol
related harm hospital stays was 1,701 stays per year, which was worse than the
average for England. The number of smoking related deaths was 368 per year.
(ONS 2014) The rate of sexually transmitted infections is also worse than
average.
Derby itself is classed as ‘relatively deprived’ (JSNA 2011), and this deprivation
can be associated with health limiting activities – smoking, excessive drinking etc.
One-quarter of all adults in Derby smoke - significantly higher than the England
average, over one-fifth (22.4%) of Derby’s population binge-drink, Derby has
comparatively high rates of alcohol-related hospital
admission and alcohol-attributable crime. (ONS 2014 & PHE 2014)
There are around 2,000 problematic drug users in Derby – around 70% of which
are in treatment.
Around one-quarter (24.2%) of adults in Derby are obese – similar to the
national average, almost three-quarters (72.9%) of adults do not eat healthy
diets and just 13.6% of adults take part in moderate exercise per week. (ONS
2014 & PHE 2014)

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Coronary Heart Disease in Derby City Centre
The condition I have chosen to examine, and the surrounding policies and
initiatives concerning it is Coronary Heart Disease.
Coronary Heart Disease (CHD) remains one of the biggest causes of death in
Derby and the UK in general, with 13.9% of deaths attributed to the condition
(ONS 2014), with local services treating almost 50,000 patients with heart
disease conditions/symptoms every year (ONS 2014).
As can be seen below, Derby is significantly worse than the England average for
cases of CHD
What causes CHD?
CHD is usually caused by a build-up of fatty deposits in the coronary arteries,
called atheroma, and are made up of cholesterol and other waste substances.
The build-up of atheroma on the walls of the coronary arteries makes the arteries
narrower and restricts the flow of blood to the heart muscle (atherosclerosis.)

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CHD can be caused by multiple issues, such as Hypertension, high cholesterol,
lack of regular exercise, Diabetes and Obesity (NHS Choices 2012)
There is some link to genetic factors– the risk is increased if there is a male
relative with CHD under the age of 55 or a female relative under 65.
Age is another key factor in CHD, with increased significantly increased
prevalence over the age of 40 - The percentage of the population aged 40 or over
in Derby is expected to remain unchanged at 21.8% for males and decrease from
23.7% to 23.1% for females between 2011 and 2021.
In Derby, early mortality (under 75 years) rates from CHD are similar to the
national rate, and have decreased by 59.5% since 1995, and emergency
admission rates for both CHD and stroke are similar to the national rate. (SEPHO
2013)
Local and National Implications
Overall, cardiovascular diseases such as CHD cost the NHS over thirty billion
pounds a year, and deaths are higher than most other developed countries (only
Finland and Ireland having higher rates). (JSNA 2011) There is also a significant
difference across socioeconomic areas in the UK - for instance, premature death
rates from CVD are up to six times higher among lower socioeconomic groups
than among more affluent groups (O'Flaherty et al. 2009). In addition, death
rates from CVD related conditions are approximately 50% higher than average
among South Asian groups (Allender et al. 2007).

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The higher incidence of CVD related conditions is a major reason why people
living in areas with the worst health and deprivation indicators have a lower life
expectancy compared with those living elsewhere in England. For males, it
accounts for 35% of this gap in life expectancy (of that, approximately 25% is
due to CHD and 10% due to other forms of CVD). Among females, it accounts for
30% of the gap (DOH 2008).
In 2009/10 the emergency admission rate for CHD in Derby was 214.8 per
100,000 (675 admissions). This is higher than England (205.3 per 100,000) and
higher than East Midlands (201.9 per 100,000). Male CHD emergency admission
rates are significantly higher than female CHD emergency admission rates. The
emergency admission rate for CHD in Derby City has decreased by 33.6%
between 2003/04 and 2009/10. In England it has decreased by 24.2% and in
East Midlands it has decreased by 27.5% (JSNA 2011)
The emergency admission rate for CHD in 2009/10 for persons who live in the
most deprived areas of Derby City was 307.6. This is more than two (2.2) times
greater than the emergency admission rates for persons who live in the least
deprived areas of the city (149.3). The gap in CHD emergency admission rates
between the most and least deprived areas in Derby City was 158.4 in 2009/10.
This has decreased from 332.5 since 2003/04 (JSNA 2011)

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Local Policy
As CHD is a condition which is part of the Cardiovascular Disease (CVD)
collection, there are many treatments – medications, lifestyle changes – and
policies in place to combat this.
Previous to the devolution of Public Health to local boroughs, Derby’s health
services where performing well on an individual basis, but research showed the
approach was fragmented and the approach wasn’t holistic. £1.5 million was then
allocated from multiple funding areas into one area, from which the ‘Livewell’
programme was created.
Livewell is person-centred and based around individuals’ priorities and aspirations
for improving their own health. For example, smoking may be the major health
risk for an individual, but they where more concerned about weight loss, then this
would be the central approach of the program, with a sub focus on the smoking.
A large part of the success of the programme is a result of the service assessing
patients at referral and working with those who show a true readiness to change.
Initially, Livewell consultants work with users providing intense support and
guidance, and this support is lessened and lessened as the program progresses.

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Further, the programme is carried out in a range of community venues such as
children’s centres, community centres, libraries and leisure centres with a specific
focus on venues in deprived areas of the city, essentially bringing the service to
the front door of users.
There are plans in the future to utilize Derby’s Velodrome, and figures show a
97% utilization of sports facilities for the first time by those involved in the
program. (Derby Public Health 2014)
The programme is continuing to grow, with a newly developed children and young
people’s component. This targets children between the ages of seven and
seventeen who are overweight or obese, through a whole family approach. This is
aimed to encourage change within the entire family, rather than the single
individual.
The programme has changed since the pilot; referrals have been widened beyond
GPs to include self referral, midwives, school nurses, clinicians from the acute
sector and mental health services to target people who may have high levels of
need, for instance as a potential alternative to weight-loss surgery.
Further, Derby utilizes it’s status as a ‘Heart City’ (In association with the British
Heart Foundation) to provide access to a number of key resources and
information to help the communities across the demographic area, in line with it’s
Livewell policy and the wider Derbyshire Public Health plan.
Derby’s ‘Heart City’ status also gives access to online support and communities,
giving advice from both professionals and those being treated/have been treated
for CVD previously.

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National Policies
The Cardiovascular Disease (CVD) Health Profile, developed by the South East
Public Health Observatory (now part of Public Health England) brought together a
wide range of data on cardiovascular disease in each upper tier local authority in
England and in associated Strategic Clinical Networks. Its aim was to provide
information to health care professionals, commissioners and other interested
parties about CVD issues in their local community, as an aid to planning and
development.
This tool allows comparison of areas across multiple aspec ts such as detection,
diagnosis, standard treatment, outcomes of care, discharges etc, as is shown in
the table below, comparing national outcomes of treatments comparing Derby to
the East Midlands and England.
Further, The NHS Health Check programme was formally introduced in April 2009
as a key policy to reduce health inequalities and increase life expectancy from
preventable CVD conditions.
Based on pre CCG (Primary Care Trust) performance data submitted in 2011-
2012, there were 78,650 local authority residents in Derby who were eligible to
be invited for an NHS Health Check (SEPHO 2013) Local authorities are expected
to offer the programme to 100% of their eligible population over a five year

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period from April 2013 onwards. During 2011-2012, 19.1% of eligible residents
were invited to attend the programme, with 53.78% of those invited attending
(SEPHO 2013)
Local authorities can access a 'Ready Reckoner' that allows them to identify the
potential service implications, benefits and cost savings resulting from
implementing NHS Health Checks across a variety of conditions.

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National Service Framework (NSF 2000)
The National Service Framework for CHD was published in 2000 to set out the
NHS’ plan for the next decade concerning CHD, it’s causes and treatments. The
NSF recognized that changing the approach to CHD would not happen quickly but
rather needed a long term strategy, so several standards where created.
Below is the list of standards created for CHD.

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Out of these twelve standards, seven key areas have been covered by the NSF -
1. Reducing heart disease in the population (standards one and two)
2. Preventing CHD in high risk patients (standards three and four)
3. Heart attack and other acute coronary syndromes (standards five, six and
seven)
4. Stable angina (standard eight)
5. Revascularisation (standards nine and ten)
6. Heart failure (standard eleven)
7. Cardiac rehabilitation (standard twelve).
The most important standards that are applicable for treating/reducing CHD are
standard 1 and 2 which are explained in more detail below.
For standard 1, the following was recommended for implementation over the next
decade -
The development and implementation of a comprehensive local programme of
effective policies for reducing smoking, promoting healthy eating and physical
activity, and for reducing obesity.
The importance of public health bodies publishing up to date information on levels
of CHD and the issues around it, the implementation of stop smoking services
and ensuring training and support is offered, and ensuring the establishment of
community support teams to help reach the most deprived areas.
For standard 2, the following was recommended for implementation over the next
decade:

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Ensuring that a plan was developed in partnership with local and national services
to provide effective support for those with CHD and related conditions, and that
constant evaluation and development of policies and treatments was present.
A community development approach should be developed to help communities to
make their own decisions about how to achieve better health for themselves,
their families and the wider community. The NSF recommended that each area
marked as ‘deprived’ should have one community team in place for CHD, and that
further funding be made available for Health visitors to help this be facilitated.
The interventions that patients at high risk of/suffering from CHD are both
medication and lifestyle based.
People with diagnosed CHD should be offered advice about how to stop smoking,
and information about other risk factors and advice about how they can be
reduced (including advice about physical activity, diet, alcohol consumption,
weight and diabetes)
They should also have constant blood pressure monitoring and advice on reducing
blood pressure.
Medication such as low dose aspirin, statins and dietary advice to lower
cholesterol, ACE inhibitors for people who also have left ventricular dysfunction,
beta-blockers for people who also have had a previous heart attack, warfarin or
aspirin for people over 60 years old who also have atrial fibrillation, and very
tight control for those with diabetes.

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Evaluation of interventions and potential developments
The approach adopted by Derby City Council and it’s Livewell scheme is similar to
the direction the NHS chose to lead nearly a decade ago in it’s white paper
‘Equity and Excellence – Liberating the NHS’ (2010). The many different studies
and sources of evidence showing support for such a model has gained attention,
and patient’s are now taking active leads in their care and conditions. Further, the
treatment of a collection of conditions with similar co-morbidities not only saves
valuable resources, it helps patient’s take an active lead in developing their care.
Livewell’s effectiveness can be transferred to a number of conditions (beyond
what it currently covers – smoking, exercise, diet etc) and provides a sturdy
model from which not only care can be provided to those in need and wanting,
but can also penetrate harder to reach, more socioeconomically deprived areas
where a single person/group can influence local communities.
However, Livewell is not without it’s downfalls, the biggest of which being
patient’s wanting to be involved in their care from the outset – ‘the programme is
only as successful as those wishing to be involved’ (Derby City Council 2010). A
lack of education about facilities and programmes available can still greatly affect
those taking it up, and lack of reach into deprived areas (of which there are
several in the Derby City area).
Further education and funding of the programme (of which is secured for the next
two years guaranteed) is necessary to ensure more people can benefit from the
programme.
It’s impact on CHD is hard to measure as a singular condition, however it’s
multiple co-morbidities shared with other conditions are apparent and are all
treated in tandem using the Livewell program.

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The NSF, developed in 2000, has had several evaluations up to 2010, where since
there hasn’t been any major evaluation of services, which could be in relation to
the excellent success the NSF had on CHD.
In 1997, the UK had some of the highest levels of CHD in the developed word
(WHO 1998), despite leading the way. Extensive waiting lists, lack of specialists
and low uptake of services where many of the contributing factors of this. Despite
extensive evidence about the impact of life style on heart health, public health
measures did little to impact on behaviours and attitudes.
A number of key measures as a result of the NSF have come to affect the public
health of the UK and it’s levels of CHD, to the extent that there where less than
40% people with CHD in 2010 than in 2000 (WHO 2010)
It’s estimated that 3.4 million people are now taking statins (7% of the
population) with the number of prescriptions rising each year by some 30% so
that some 9,700 deaths from heart disease are being avoided each year as a
result (WHO 2010)
Similar increases in prescriptions of other cardiovascular products has led to
substantial improvements in blood pressure levels across England with
encouraging trends in average blood pressure in both men and women wit h the
prevalence of untreated hypertension falling from 32% to 24% between 1998 and
2003.
A development of specialist clinics ensured that waiting times where slashed to
under two weeks for those with suspected CHD, and new techniques and
development of existing ones (such as the coronary angiography) have ensured
survival rates have risen greatly.

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The NSF showed the success that can happen when several areas of the NHS and
local and national government work together, and this has since been
implemented in other areas and conditions. However, the extensive funding that
has been allocated to this original NSF is no longer economically feasible in an
NHS that is facing a deficit of nearly half a billion pounds.
This, coupled with rising obesity levels and their impact on the CHD disease
group, brings new challenges for the NHS to face, and a new NSF development
for CHD and other conditions is needed for the next decade and for a new NHS to
surmount.
Overall, the last decade has shown vast improvements to CHD, both detection
and treatment, and the devolution of powers to local authorities will undoubtedly
continue this trend. A new NSF is necessary, not only for due to the old one
reaching it’s timetable, but to cater for the coming years of uncertainty in the
NHS. Further, with the success of the Livewell programme, it would be
encouraging to see other areas adopt similar programmes and then potentially a
nationwide rollout, similar to the Change4Life programme.

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Bibliography
NHS (2000) National Service Framework for Coronary Heart Disease, NHS
Boyle, Professor R CBE (2010),Coronary Heart Disease Ten Years On: Improving
Heart Care, National Centre for Heart Disease and Stroke
NHS White Paper (2013) Putting Patients First – The NHS England business plan
for 2013 – 2016, NHS
South East Public Health Observatory (2013) Cardiovascular disease - Local
Authority Health Profile for Derby City, SEPHO/PHE
The Coronary Heart Disease National Service Framework Building on excellence,
maintaining progress - Progress report for 2008
http://www.bhf.org.uk/heart-health/conditions/coronary-heart-disease.aspx
http://www.bupa.co.uk/health-information/directory/c/coronary-heart-disease
http://www.nhs.uk/Conditions/Coronary-heart-disease/Pages/Treatment.aspx
http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.
uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_096556.
pdf
British Heart Foundation (2010) Coronary heart disease statistics, BNF Publishing

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References
NHS (2000) National Service Framework for Coronary Heart Disease, NHS
Boyle, Professor R CBE (2010),Coronary Heart Disease Ten Years On: Improving
Heart Care, National Centre for Heart Disease and Stroke
NHS White Paper (2013) Putting Patients First – The NHS England business plan
for 2013 – 2016, NHS
South East Public Health Observatory (2013) Cardiovascular disease - Local
Authority Health Profile for Derby City, SEPHO/PHE
The Coronary Heart Disease National Service Framework Building on excellence,
maintaining progress - Progress report for 2008
http://www.bhf.org.uk/heart-health/conditions/coronary-heart-disease.aspx
http://www.bupa.co.uk/health-information/directory/c/coronary-heart-disease
http://www.nhs.uk/Conditions/Coronary-heart-disease/Pages/Treatment.aspx
http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.
uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_096556.
pdf
British Heart Foundation (2010) Coronary heart disease statistics, BNF Publishing