The Government stated in its National Service Framework to coronary heart disease (CHD), its commitment to building a new NHS more convenient for patients, to be achieved through a ten year modernisation programme.

The NSF for coronary heart disease sets standards for the prevention, diagnosis and treatment of this disease. It explains how the standards can be delivered, how progress is to be monitored, and it introduces a ten year programme to reduce premature deaths and promote faster, fairer access for all to a high quality service.

 

 

Coronary heart disease accounts for about 3% of all hospital admissions in England. The burden of CHD is higher and has fallen less in the UK than in many other countries. CHD is a common frequently fatal and largely preventable disease. Unskilled working men are three times more likely to die prematurely of CHD than many professional or managerial occupations. In addition, the wives of manual workers have nearly twice the risk compared to wives of non-manual workers. There are also ethnic variations. For people born in the Indian sub-continent, the death rate from heart disease is 38% higher for men and 43% higher for women than rates for this country.

CHD kills more than 110,000 people a year in England.

The health problems caused by CHD in this and other countries have led to a great deal of research in both causes and treatments and there is now better evidence to guide the prevention, the diagnosis and treatment of CHD than there is for most other major diseases. For all these reasons the potential to improve health and reduce unfairness, to tackle inequalities and to improve the service is a priority for the Government and a priority for the NHS. As well as reducing the burden of CHD, this NSF is also intended to reduce the incidence of other arterial diseases, especially stroke.

References to all of this are available on the Internet under http://www.doh.gov.uk/nsf/coronaryexecsum.htm

There is also reference to Foreword by the Secretary of State, Mr Alan Milburn available on: http://www.doh.gov.uk/nsf/coronaryforeword.htm

This NSF established twelve standards for the prevention, diagnosis and treatment of CHD. These standards are intended to remain relevant for ten years or more and aim to reduce heart disease in the population.

 

 

Standard 1
The NHS and all its agencies should develop policies that reduce the prevalence of coronary heart disease in the population and reduce inequalities in the risks of developing heart disease.

Standard 2
The NHS and its agencies should contribute to a reduction in smoking in the population.

Standard 3
General Practitioners and their teams should identify all people with established cardiovascular disease and offer them comprehensive advice and appropriate treatment to reduce their risks.

Standard 4
General Practitioners and their teams should identify all people at significant risk of cardiovascular disease who have not developed symptoms and offer them appropriate advice and treatment to reduce their risks.

Standard 5
People with symptoms of possible heart attack should receive help from an individual equipped and appropriately trained in the use of a defibrillator within eight minutes of calling for help. This is to maximise the benefits of resuscitation should it be necessary.

Standard 6
People thought to be suffering from a heart attack should be assessed professionally and, if indicated, receive aspirin immediately. Thrombolysis i.e. treatment with clot softening drugs should be given within 60 minutes of calling for professional help.

Standard 7
NHS Trusts should put in place agreed protocols and systems of care so that patients admitted to hospital with heart attack are appropriately assessed and offered treatment at proven clinical and cost effectiveness to reduce their risks of disability and death.

Standard 8
Patients with symptoms of angina or suspected angina should receive appropriate investigation and treatment to relieve their pain and reduce their risks of coronary events.

Standard 9
Patients with angina that is increasing in frequency or severity should be referred to a cardiologist urgently or, for those at greatest risk as an emergency.

Standard 10
NHS Trusts should put in place hospital wide systems of care so that patients with suspected or confirmed coronary heart disease receive timely and appropriate investigations, and treatment to relieve their symptoms and reduce their risk of subsequent coronary events.

Standard 11
Doctors should arrange for patients with suspected heart failure to be offered appropriate investigations that will confirm or not confirm the diagnosis. For patients whose heart failure is confirmed its cause should be identified. Treatments most likely to relieve their symptoms and reduce their risk of death should be offered.

Standard 12
NHS Trusts should put in place agreed protocols and systems of care so that prior to leaving hospital, patients suffering from coronary heart disease should have been invited to participate in a multi-disciplinary programme of further prevention and rehabilitation. The aim of this programme is to reduce subsequent cardiac problems after discharge from hospital and to promote their return to full normal life.

 

These standards are set out to reduce heart disease in the population. They include preventing coronary heart disease in high risk patients. They describe the treatment of heart attack and other coronary diseases. They describe the treatment and management of angina. It sets out the surgical treatment or referral for specialist opinions. It sets out the treatment of heart failure and it sets out the treatment of cardiac rehabilitation.

The coronary heart disease NSF was developed with the assistance of expert (external reference groups). These members included heart specialists, cardiologists, cardiac surgeons, general practitioners, emergency care physicians, casualty officers, nurses, public health physicians, scientists, epidemiologists and health service managers. It also included voluntary agencies such as the British Heart Foundation and the National Heart Forum. Most importantly it included patient and carer representation from the British Cardiac Patients Association.

 

The Framework describes a wide range of clinical assessments known as "audit" that relates to the prevention and treatment of coronary heart disease. This audit has been developed with the help of the external reference group and others. However, not all of these clinical audit and performance indicators are available either locally or nationally at present. The NSF sets goals and milestones for each standard and to mark progress for each standard. This is likewise to help the NHS locally to plan and implement the programme. The milestones are intended to foster a process of continuous improvement. Many organisations should be able to reach these milestones well ahead of the dates.

 

 

There are improvements that can and should be achieved quickly. The Government expects rapid improvement in the following areas:

1.       Health Authorities will introduce specialist smoking cessation clinics.

2.       There should be 50 rapid access chest pain clinics to ensure that a specialist can assess people who develop symptoms that their General Practitioner thinks might be due to angina. There should be access to these clinics within two weeks and there should be 100 rapid access clinics available by April 2002.

3.       There should be a reduced call-to-needle time for the administration of thrombolysis (clot thinning drugs) for heart attacks. This means improving ambulance response times and increasing the proportion of Accident and Emergency Departments able to provide such drugs. This should lead to 75% of eligible patients receiving such drugs within 30 minutes of hospital arrival by April 2002, and within 20 minutes by April 2003.

1.       Improving the use of effective medicines after heart attacks so that 80-90% of people discharged from hospital will be prescribed such drugs.

2.       Increasing the total number of revascularisation i.e. coronary artery by-pass surgery procedures available to patients, by 3000 operations.

1.       Beginning to modernise a service for CHD by delivering the first milestones on systematic approaches to delivery of care.

Comprehensive local delivery plans for implementing the framework should be in place and agreed by all the relevant bodies by October 2000. To make this happen:

1.       Local Health Authorities will need to implement the National Standard and Service Arrangement into local delivery plans.

2.       These local delivery plans should spell out what has to be done.

3.       There should be national and regional systems of strategies to support the local implementation.

4.       There will be a national CHD implementation group providing overall leadership for implementation and updating the framework.

5.       The regional offices of the NHS Executive will monitor performance and work with the NHS locally to ensure good progress.

 

The scale of the Government's progress to raise standards across the NHS has been underestimated. The NSF against heart disease is essentially a crusade and a far reaching programme. This programme of excellence can only be financed in a way set out by the Prime Minister himself reasonably by raising the level of investment in health care in Britain as a whole.