Cardiovascular disease

In Calderdale an estimated 9.3% of the population have CVD: (National General Practice Profiles).

All age and premature mortality rates from CVD are higher in Calderdale than both the regional and national rates. The under 75 CVD mortality rate in Calderdale is 87.9 deaths per 100,000 (Directly Standardised Rate (DSR)) compared to 84.7 in Yorkshire and Humber and 75.7 in England: (Public Health Outcomes Framework: Overarching indicators).

Premature CVD mortality rates are influenced by gender. The Calderdale under 75 CVD mortality rate in men is 121.7 per 100,000 (DSR) compared to 55.6 in women. Again both these figures are higher than the regional (119.6 and 51.6) and national (106.2 & 46.9) rates: (Public Health Outcomes Framework: Overarching indicators)

Deaths from circulatory diseases under the age of 75 years are higher in the more deprived wards of Calderdale than in the more affluent areas. Standardised mortality rates are highest in the wards of Illingworth and Mixenden (196.4), Park (179.9) and Ovenden (173.9) which are the three wards with the highest levels of deprivation in Calderdale: (Local Health)

Following the national picture, premature CVD mortality rates continue to fall in Calderdale year on year, however they have now remained significantly higher than the England average since 2007: (Public Health Outcomes Framework: Overarching indicators)

Under 75 mortality rate from all cardiovascular diseases (Persons) - Calderdale

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Calderdale levels are worse than those for Yorkshire & Humber and England as a whole for many of the common risk factors that are recognised as increasing the likelihood of individuals developing CVD:

• Smoking;
• Physical Inactivity;
• Overweight and Obesity;
• Alcohol;
• Diabetes;
• High Blood Pressure (Hypertension).

In 2014 there were 29,218 people on GP lists in Calderdale with diagnosed hypertension. This equates to 13.6% of the population registered with a GP. However, it was estimated the expected prevalence of hypertension in Calderdale was 24.9%, meaning that 11.4%, or approximately 24,000 adults could have hypertension that has not been diagnosed: (Cardiovascular disease profile)

Prevention:

The NHS Health Check is a systematic approach to identifying local people at high risk of CVD, offering behaviour change support and early detection of disease. The checks are delivered by all 26 GP practices in Calderdale for their eligible population. Modelling suggests that a 75% uptake rate will lead to substantial reductions in premature mortality; uptake rates in Calderdale in 2014-15 stood at 58.4%. Work is being undertaken to improve the uptake and quality of the service being delivered in Calderdale, and to ensure that it is accessible to those most at risk of CVD.

Since April 2015 Calderdale’s Better Living Service have been commissioned to advise and support individuals and families to adopt healthier lifestyles and address some of the lifestyle related risk factors that can lead to the development of CVD eg weight management, healthy eating, physical activity. Referrals into the service come from many avenues including the NHS Health Check programme.

Yorkshire Smokefree Calderdale have also been commissioned to reduce the level of smoking in the Calderdale population and the Food For Life Partnership are tasked with promoting healthy food behaviours in certain community settings.

These services, along with whole population level programmes of work, aim to tackle some of the major risk factors associated with the development of CVD.

CVD is a clinical priority for Calderdale Clinical Commissioning Group (CCG), and in particular Heart Failure and Atrial Fibrillation leading to an increased risk of stroke.  The CVD programme will deliver a safe and effective service through early identification and assessment in primary care, providing efficient diagnosis and treatment including appropriate and timely referral to secondary care services. Where people are admitted to hospital our aim is to ensure they are treated effectively and discharged back to community services for ongoing support and the promotion of self-care to manage their condition.

Engagement for the Care Closer to Home programme included CVD. We know that local people want to see services improved. Whilst we know some things work well there are a number of areas which require improvement. Feedback from our recent engagement activity has told us that we need to improve access to our services and ensure people receive more services in a community setting. Current services are not responding fully to this request and we need to ensure we can develop future services with this in mind.

In addition the public want agencies to work together, including how information is shared and providing information once. Investment in staff training and new technology is part of the public response to seeing how we can achieve improvements. Supported self-managed care is also a major focus for the public including how we develop information and systems to support people to be able to do this.

Specific work with CVD stakeholders told us they wanted:

• Improved diagnosis and access to treatment close to home;
• Reduced variation in diagnosis and treatment across primary care;
• Increased understanding of their condition, including medication, to inform better self-care and how to access services and support.

The fact that gender, ethnic and socio-economic inequality gaps persist in Calderdale for the prevalence of and mortality rates from CVD and for the prevalence of the major risk factors associated with the development of CVD indicates that further targeted work is required to close these gaps.

Further work is also required to engage with those who are likely to be at higher risk of developing CVD, but who have not taken up the offer of an NHS Health Check and who do not routinely engage with primary care or lifestyles services.

Whilst the Better Living Service is commissioned to support type 2 diabetics to adopt healthier lifestyles and therefore reduce their risk of going on to develop CVD, there is currently no lifestyle service in Calderdale to support individuals with non-diabetic hyperglycaemia (high blood sugar) in order to prevent them developing diabetes.

As age is a key factor in cardiovascular disease and the prevalence of CVD increases significantly after the age of 40 years, an aging population, including those who have not addressed modifiable health risks, is likely to result in a sizeable increase in CVD.

In England, currently 24.9% of adults aged 16 years and over are obese. The prevalence of overweight and obesity is increasing and by 2050 it is predicted that 60% of adult men and 50% of adult women will be obese. Because of the impact of obesity on type 2 diabetes, the rising prevalence of obesity has led, and will continue to lead, to a rise in the prevalence of diabetes. In 2013, 2.7 million or 6% of the adult population had diagnosed diabetes in England. The total number of adults with diabetes is projected to rise to 4.6 million or 9.5% of the adult population by 2030. Any increase in obesity or diabetes is likely to result in a rise in the prevalence of CVD.

The National Institute for Health and Care Excellence (NICE) Guidance CG181 “Cardiovascular disease: risk assessment and reduction, including lipid modification”  provides recommendations on

• Identifying and assessing CVD risk;
• Lifestyle modifications for the primary and secondary prevention of CVD (including diet, physical activity, weight management, alcohol use, smoking);
• Lipid modification therapy for the primary and secondary prevention of CVD.

NICE Guidance PH25 “ Cardiovascular disease prevention” states that changes in CVD risk factors can be brought about by intervening at the population level (eg national or regional policy and legislation) and at the individual level, such as establishing interventions focused on changing an individual’s behaviour. The guidance goes on to give 24 recommendations on policy and practice and makes the case that CVD is a major public health problem.

NICE guidance CMG45 (2012) ‘Services for the prevention of cardiovascular disease’ recommends that commissioners consider the following components of a high-quality service:

• Population-wide and community-level approaches;
• Assessing an individual's risk of cardiovascular disease, including commissioning the NHS Health Check programme and Making Every Contact Counts;
• Behaviour change and lifestyle interventions;
• Medical interventions.

The following areas need to be considered in future work to address CVD risk:

• Improved lifestyle services which address modifiable lifestyle factors and aim to prevent cardiovascular disease;
• Earlier detection and better management by general practice of people with cardiovascular disease;
• Work with vulnerable and high-risk groups to reduce inequalities, specifically people living in the most deprived areas and South Asian populations;
• Improved self-care support, leading to a reduction in complications and repeat admissions from cardiovascular disease.

References

• NICE: Improving the treatment of cardiovascular disease.
• PHE: National General Practice Profiles.
• PHE: Public Health Outcomes Framework: Overarching indicators.
• PHE: Local Health.
• PHE, 2015: Cardiovascular disease profile.
• PHE, 2014: Adult obesity and type 2 diabetes.
• NICE CG181, July 2014:  Cardiovascular disease: risk assessment and reduction, including lipid modification.
• NICE PH25, June 2010: Cardiovascular disease prevention.