CDV: Skill a National Priority

“CVD: Still a National Priority
Huon Gray
National Clinical Director (Cardiac), NHS England
Consultant Cardiologist, University Hospital of Southampton
Improving the cardiovascular health of people with serious mental illness:
Key learning from the NHS England Sustainable Improvement team pilot site project
Second National Learning Network Event
Wednesday 27th January 2016
Tower Hotel, London

National Service Framework for
Coronary Heart Disease
“This Framework will transform the prevention,
diagnosis and treatment of coronary heart
disease. It will help professionals to give
better, fairer and faster care everywhere, to
everyone who needs it. We want a service
that is amongst the best in the world. Our
people deserve nothing less.”
Alan Milburn
Secretary of State for Health
March 2000

NHS Spending (£ billion)
120% increase
since 2000

BHF Heart Stats (2012) http://www.bhf.org.uk/publications/view-publication.aspx?ps=1002097
CVD Mortality in England (all <75 yrs)

Source: www.statistics.gov.uk/ statbase/Product.asp?vlnk=6725
Causes of Death (England, <75 yrs)
(Source: ‘Living Well for Longer’ [ONS data], 2013)

Causes of Death
(England & Wales, 2013)

Global Burden of Disease Study.
Lancet 2013;381:997-1020
DALYs Attributable to top 20 (of 67) Risk Factors (UK)

March 5th,
2013
https://www.gov.uk/government/publications/improving-cardiovascular-disease-outcomes-strategy

http://www.kingsfund.org.uk/publications/never-again
Nicholas Timmins
July 2012
NHS & Social Care Reform (2010-12)

Government
Dept of Health
Public Health
England (PHE)
4 Regional Offices
27 Local Area Teams (LATs)
211 Clinical Commissioning
Groups (CCGs)
152 Local
Authorities
152 Health &
Wellbeing Boards
National
Specialised
Commissioning
(74 CRGs)
NHS England
GP
15
AHSNs
12 Strategic
Clinical
Networks
12 Clinical
Senates
NHS Improving
Quality (NHSIQ)

Government
Dept of HealthNHS England

“…NHS England is
legally required to
pursue the objectives
and comply with the
requirements in this
document ”

“The Government
and NHS England are
of one mind in
recognising that the
scale of the
ambitions in this
mandate cannot be
achieved through a
culture of command
and control.”

“NHS England’s
objective is to get the
best health outcomes
for patients by
strengthening the
local autonomy of
clinical
commissioning
groups, health and
wellbeing boards,
and local providers of
services.”

October 2014
http://www.england.nhs.uk/wp-
content/uploads/2014/10/5yfv-
web.pdf
http://www.england.nhs.uk/wp-
content/uploads/2014/12/forward-
view-plning.pdf
December 2014
Five Year Forward View
https://www.england.nhs.uk/wp-
content/uploads/2015/12/planning
-guid-16-17-20-21.pdf
December 2015

Word Search
• ‘Cardiovascular’ = 0,
• ‘Cardiac’ = 1
– “Cardiac outcomes are better”
• ‘Heart’ = 3
– “Early deaths from heart disease are down by
over 40%”
– “new biosensor technology” for heart failure
– “congenital heart disease”
• ‘Cancer’ = 51

• Prevention (DPP, Obesity strategy)
• Early detection (NHS Health Checks, BP awareness, AF)
• Integration of services (New Models of Care)
• Better management in, and support for, 10 Care
• Inherited cardiac conditions (FH, ICC)
• Improved survival from Out of Hospital Cardiac Arrest
(Urgent & Emergency Care Review, PAD funding)
• 24 x 7 Services (MI, Stroke, U&E Care Review)
• 7 day working (Cardiac Physiology Review)
• Inequalities (physical & mental health, learning disabilities)
• Information (NCVIN, Clinical Audits, CSQM & MyNHS)
• Research & Innovation
March 2013
October 2014
CVD Priorities

…NHS England’s
objective is to make
significant progress in
supporting the earlier
diagnosis of illness,
particularly through
appropriate use of primary
care, and tackling risk
factors such as high
blood pressure and
cholesterol. This includes
working with Public
Health England to support
local government in the
roll out of NHS Health
Checks

NHS Outcome Indicators
22
3
Overarching indicators
Improvement areas
Helping people to recover from episodes of ill health or
following injury
3a Emergency admissions for acute conditions that should not usually require
hospital admission
3b Emergency readmissions within 30 days of discharge from hospital* (PHOF 4.11)
Improving outcomes from planned treatments
3.1 Total health gain as assessed by patients for elective procedures
i Hip replacement ii Knee replacement iii Groin hernia iv Varicose veins
v Psychological therapies
Preventing lower respiratory tract infections (LRTI) in children from becoming
serious
3.2 Emergency admissions for children with LRTI
Improving recovery from injuries and trauma
3.3 Proportion of people who recover from major trauma
Improving recovery from stroke
3.4 Proportion of stroke patients reporting an improvement in activity/lifestyle on the
Modified Rankin Scale at 6 months
Improving recovery from fragility fractures
3.5 Proportion of patients recovering to their previous levels of mobility/walking ability
at i 30 and ii 120 days
Helping older people to recover their independence after illness or injury
3.6 i Proportion of older people (65 and over) who were still at home 91 days
after discharge from hospital into reablement/ rehabilitation service***
(ASCOF 2B)
ii Proportion offered rehabilitation following discharge from acute or
community hospital
Enhancing quality of life for people with long-term
conditions2
Overarching indicator
2 Health-related quality of life for people with long-term conditions** (ASCOF 1A)
Improvement areas
Ensuring people feel supported to manage their condition
2.1 Proportion of people feeling supported to manage their condition**
Improving functional ability in people with long-term conditions
2.2 Employment of people with long-term conditions** * (ASCOF 1E PHOF 1.8)
Reducing time spent in hospital by people with long-term conditions
2.3 i Unplanned hospitalisation for chronic ambulatory care sensitive
conditions (adults)
ii Unplanned hospitalisation for asthma, diabetes and epilepsy in under
19s
Enhancing quality of life for carers
2.4 Health-related quality of life for carers** (ASCOF 1D)
Enhancing quality of life for people with mental illness
2.5 Employment of people with mental illness **** (ASCOF 1F & PHOF 1.8)
Enhancing quality of life for people with dementia
2.6 i Estimated diagnosis rate for people with dementia* (PHOF 4.16)
ii A measure of the effectiveness of post-diagnosis care in sustaining
independence and improving quality of life*** (ASCOF 2F)
Preventing people from dying prematurely1
1a Potential Years of Life Lost (PYLL) from causes considered amenable to
healthcare
i Adults ii Children and young people
1b Life expectancy at 75
i Males ii Females
Improvement areas
Reducing premature death in people with serious mental illness
1.5 Excess under 75 mortality rate in adults with serious mental illness* (PHOF 4.9)
Reducing deaths in babies and young children
1.6 i Infant mortality* (PHOF 4.1)
ii Neonatal mortality and stillbirths
iii Five year survival from all cancers in children
Reducing premature mortality from the major causes of death
1.1 Under 75 mortality rate from cardiovascular disease* (PHOF 4.4)
1.2 Under 75 mortality rate from respiratory disease* (PHOF 4.7)
1.3 Under 75 mortality rate from liver disease* (PHOF 4.6)
1.4 Under 75 mortality rate from cancer* (PHOF 4.5)
i One- and ii Five-year survival from all cancers
iii One- and iv Five-year survival from breast, lung and colorectal cancer
Reducing premature death in people with a learning disability
1.7 Excess under 60 mortality rate in adults with a learning disability
4
Ensuring that people have a positive experience of care
4a Patient experience of primary care
i GP services
ii GP Out of Hours services
iii NHS Dental Services
4b Patient experience of hospital care
4c Friends and family test
Improvement areas
Improving people’s experience of outpatient care
4.1 Patient experience of outpatient services
Improving hospitals’ responsiveness to personal needs
4.2 Responsiveness to in-patients’ personal needs
Improving access to primary care services
4.4 Access to i GP services and ii NHS dental services
Improving women and their families’ experience of maternity services
4.5 Women’s experience of maternity services
Improving the experience of care for people at the end of their lives
4.6 Bereaved carers’ views on the quality of care in the last 3 months of life
Improving experience of healthcare for people with mental illness
4.7 Patient experience of community mental health services
Improving children and young people’s experience of healthcare
4.8 An indicator is under development
Improving people’s experience of accident and emergency services
4.3 Patient experience of A&E services
Improving people’s experience of integrated care
4.9 An indicator is under development *** (ASCOF 3E)
Reducing the incidence of avoidable harm
5.1 Incidence of hospital-related venous thromboembolism (VTE)
5.2 Incidence of healthcare associated infection (HCAI)
i MRSA
ii C. difficile
5.3 Incidence of newly-acquired category 2, 3 and 4 pressure ulcers
5.4 Incidence of medication errors causing serious harm
Improving the safety of maternity services
5.5 Admission of full-term babies to neonatal care
Delivering safe care to children in acute settings
5.6 Incidence of harm to children due to ‘failure to monitor’
Treating and caring for people in a safe environment and
protect them from avoidable harm5
5a Patient safety incidents reported
5b Safety incidents involving severe harm or death
5c Hospital deaths attributable to problems in care
Improvement areas
NHS Outcomes
Framework 2013/14
at a glance
Alignment across the Health and Social Care System
* Indicator shared with Public Health Outcomes Framework (PHOF)
** Indicator complementary with Adult Social Care Outcomes
Framework (ASCOF)
*** Indicator shared with Adult Social Care Outcomes Framework
**** Indicator complementary with Adult Social Care Outcomes
Framework and Public Health Outcomes Framework
Indicators in italics are placeholders, pending development or identification

“The performance of the UK in terms of premature
mortality….is below the mean of the EU15+…….further
progress will require improved public health, prevention,
early intervention and treatment activities……and
deserves an integrated and strategic response”

“…NHS England is
under specific legal
duties in relation to
tackling health
inequalities and
advancing equality.”

Richmond Group of Charities
November 2014

Lancet 2015 Published online September 15, 2015 http://dx.doi.org/10.1016/S0140-6736(15)00195-6

Age-standardised years of life lost (YLLs) relative to the deprivation levels
in the nine English regions for both sexes combined in 2013
England
Average

England
Average

Interpretation
“Health in England is improving although substantial opportunities
exist for further reductions in the burden of preventable disease.
The gap in mortality rates between men and women has
reduced, but marked health inequalities between the least
deprived and most deprived areas remain. Declines in
mortality have not been matched by similar declines in
morbidity, resulting in people living longer with diseases.
Health policies must therefore address the causes of ill health as
well as those of premature mortality. Systematic action locally and
nationally is needed to reduce risk exposures, support healthy
behaviours, alleviate the severity of chronic disabling disorders,
and mitigate the effects of socioeconomic deprivation.”

Long Term Conditions: Heart
Failure Prevalence
Men Women Men Women Men Women Men Women Men Women
0-44 45-54 55-64 65-74 75 plus
England 0.0% 0.0% 0.2% 0.1% 0.9% 0.4% 3.1% 1.6% 13.7% 12.5%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
PrevalenceofHeartFailure(%)
England – Heart Failure – Prevalence (%) by Age & Sex - 2009
General Practice Research Database 2010
Source: General Practice Research Database 2010, reported in British Heart Foundation
Coronary Heart Disease Statistics . 2010 Edition

Long Term Conditions: Heart
Failure - Future Prevalence
2012 2017 2022
45 Plus
Women 371,156 398,461 453,129
Men 344,728 387,815 450,342
0
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000
900,000
1,000,000
EstimatedPrevalentCasesofHeartFailure
Women
Men
England – Heart Failure – Prevalence Cases – Projected Numbers
to 2022 – Based on General Practice Research Database 2010
Source: General Practice Research Database 2010, reported in British Heart Foundation Coronary Heart Disease Statistics . 2010 Edition
Heart Failure rates by Age/Sex applied to ONS Population Projections.
Up 10%
Over 2012
Up 26%
Over 2012715,884
786,276
903,470

CVD Risk: Ageing Population
England – Population Projections (Principal) –
% Growth to 2012, 2017 & 2022
1% 1%
2%
7%
3%
6%
2%
5%
2%
6%
20%
10%
22%
6%
10%
4%
7%
21%
31%
44%
10%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
0-19 20-44 45-64 65-74 75-84 85 plus All Ages
Projected%IncreaseinPopulation
2010-2012 % Increase
Source: ONS Population Projections. 2010-Based
65-74 to grow
By 20% 2010-2017
85 plus to grow
By 44% 2010-2022

Recommended Actions
Integration

Vascular Disease – One Event Leads to Another
(REACH Registry; 69,000 patients, 44 countries)
Original Event = Stroke
MI Risk
• 2-3 x greater risk2*
Stroke Risk
• 9 x greater risk3
Original Condition = PAD
MI Risk
• 4 x greater risk4**
Stroke Risk
• 2-3 x greater risk3++
Original Event = MI
MI Risk
• 5-7 x greater risk1+
Stroke Risk
• 3-4 x greater risk2++
Diabetes
(type 2)
Because of the
increased risk
associated with
diabetes, it
should be
considered a
cardiovascular
risk equivalent to
a non-diabetic
patient with
previous MI
*Includes angina and sudden death. Sudden death defined as death documented within 1 hour and attributed to coronary heart
disease (CHD) **Includes only fatal heart attack and other CHD death; does not include non-fatal heart attack,
+ Includes death ++Includes TIA
1. Adult Treatment Panel II. Circulation 1994; 89:1333–63. 2. Kannel WB. J Cardiovasc Risk 1994; 1: 333–9.
3. Wilterdink JI, Easton JD. Arch Neurol1992; 49: 857–63. 4. Criqui MH et al. N Engl J Med 1992; 326: 381–6.
Data is increased risk vs general population (%)
CKD
MI Risk
• 2 x greater
risk
Stroke risk
• Up 50%

http://www.jbs3risk.com
Heart 2014;100:ii1-ii67

Example 1
Young female with significant risk factors
Effect of intensive risk factor modification
• 35-year-old female smoker
• Systolic BP of 160mmHg
• TC of 7.0mmol/L, HDL of 1.4mmol/L
(non-HDL of 5.6mmol/L)
• Family history of premature CVD

Estimated average
survival without a
CV event

Effect of intensive risk factor modification

Conclusions
• Falling CVD premature mortality is welcome
• Risk of reversal, consequences of ageing population
• CVDOS (2013) priorities are aligned to NHS Mandate,
5 Year Forward View, & Business Plans of NHSE & PHE
• Prevention is a high priority, Parity of Esteem emphasised
• Importance of CVD priorities could be better articulated
• CVD (& its risk factors) and SMI are closely associated
• QRISK (10 year risk) and JBS3 (lifetime risk) are both useful
– JBS3 may be better for communicating longer term risk to younger
people
• Change must be driven locally, supported nationally
• Financial pressures considerable

John Appleby, Chief Economist, King’s Fund 20th January 2016
Total Healthcare Spending as % of GDP
OECD average
= 9.1%

NHS Spending (UK) to match EU-15 by 2020/21

“The question is increasingly not so much
whether it is sustainable to spend more – after
all, many countries already manage that and
have done for decades. Rather, it is whether it
is sustainable for our spending to remain so
comparatively low, given the improvements in
the quality of care and outcomes we want and
expect from our health services.”

CDV: Skill a National Priority

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CDV: Skill a National Priority