Associate feature: Shocking heart care back to good health

For the first time in 30 years, deaths from cardiovascular disease are on the rise.

Meanwhile, predictions indicate more people will develop risk factors for heart and circulatory problems in the next few decades.

Add an ageing population and the unknown impact of COVID-19, and it looks like a poor prognosis for Scotland’s heart health.

This is the backdrop against which British Heart Foundation (BHF) Scotland has been consulting on a new cardiac strategy.

The Scottish Government’s Better Heart Disease and Stroke Care Action Plan was published in 2009, with a short update released in 2014 to “ensure that the priorities remain current”.

The BHF believes a new plan must be a priority for the next Scottish Government.

It is proposing three priority areas: preventing heart disease by managing risk factors; equitable access to care; and improved data.

Prevention has been something of a buzzword in healthcare recently.

It’s understandable – improving the general health of the population by promoting healthy lifestyles reduces the risk of myriad chronic conditions.

That’s why various public health strategies and policies are already in place, from reducing obesity to minimum pricing for alcohol.

But prevention for heart disease is also about catching risk factors and getting them under control early.

Dr David Murdoch, a consultant cardiologist and chair of the National Advisory Committee for Heart Disease, explained: “The strategy is going to focus mainly on things like atrial fibrillation (that’s an irregular heartbeat), hypertension and cholesterol.

“Those things are mostly dealt with within primary care.

“Now that QOF [Quality & Outcomes Framework] has gone, we don’t really have a handle on how good we are at dealing with that, so that fits into one of the other priorities which is collecting data.”

He added: “The new SPIRE software GPs have will be able to pull data from GP records on how good we are at treating hypertension and cholesterol problems and picking up patients with atrial fibrillation.

“I think we are good at that – but because we think we’re good at it, doesn’t necessarily mean we are. The data will tell us one way or another.”

There is also the question of how to improve detection. High blood pressure, high cholesterol and atrial fibrillation do not normally have symptoms, so a person may be living with increased risk of heart problems without knowing it.

A cardiovascular health awareness programme in Canada has adopted a community care approach to identify people with high blood pressure and support them in managing the condition.

It led to a reduction in hospital admissions for stroke, heart attack and heart failure. The BHF is supportive of a similar programme for Scotland to test blood pressure and cholesterol.

Meanwhile, a Cambridge University study is currently investigating the potential for atrial fibrillation screening.

Retired cardiologist Professor Stuart Pringle, who also chairs the BHF’s strategy development group, said proper diagnosis and management of these conditions would help increase healthy life expectancy in Scotland, which currently compares unfavourably to England and other European countries.

He said: “Instead of people having heart problems in their 40s, 50s or 60s, they may have it in their 70s, 80s and 90s – that in itself is an achievement, giving people as long as possible with a heart disease-free life or with heart disease that is well controlled and managed.”

In addition to improving community care, Pringle also emphasised the need for national leadership.

He said: “I think, on the basis that a lot of these strategies are individual doctors or services or multi-disciplinary teams working on things, they need an overseeing body to make sure that it’s all coordinated and happening.

“I’m sure the government would see that as their role too.”

This national oversight is also embedded within the BHF’s recommendations on improving access to diagnosis, treatment and care.

The forthcoming strategy will recommend the creation of national pathways which set out key interventions, timeframes and outcomes. How does this differ from the clinical pathways already in place?

“That’s a very good question, actually. The answer is: nothing really,” said Pringle.

“I don’t think the plan would be to have a new national pathway for care because there are already clinical pathways for almost every branch of cardiology care.

“The idea of a national perspective is to make sure they all reach similar standards.”

He added: “Every health department locally has their own strengths and weaknesses, so they tend to adapt the clinical pathways appropriate to what facilities they’ve got.

“If you’re in the centre of Glasgow [or] the centre of Edinburgh, you’ve a very different healthcare service than if you’re in the Western Isles or Borders.

“Scotland’s unique challenge in that regard is the geographical and population dispersion of people. It’s a huge area to manage.

“We would be talking about locally developed guidelines for all heart conditions, and then they would be overseen by a national committee of some form – either the national advisory committee as exists or another committee, just to make sure the local pathways meet the national standards that would be set out.

“If they don’t, then advice and resources are given to make sure that everyone, wherever they access their care, gets the same standard of care.”

The experience of the COVID pandemic could provide some helpful insight into how new technologies could drive forward some change in this area.

The shift away from face-to-face appointments and instead having to rely on telephone consultations and even patient self-management apps may be a framework for managing the differences across the country.

Pringle said: “There’s no doubt about it, you can do a lot of the clinical interface without actually being directly in contact with a patient. COVID has made that a necessity.

“What we mustn’t do is lose the best bits of all that when we go back to the new normal afterwards.”

Of course, technology is not the only answer. There would need to be staff in place to utilise it and the leadership to support it.

Murdoch said: “I think leadership is about resource, but it’s also about creating a culture where we sustain a workforce, we sustain a system where we think this is the excellence that we want to achieve going forward for the patient journey. It’s just about getting that culture going, getting that mindset.”

Underpinning these two priority areas is data. There needs to be a better understanding of where the risk factors are, who needs access to healthcare interventions, which health boards are struggling to recruit and where the bottlenecks are in treatment.

Professor Lis Neubeck, head of cardiovascular health at Edinburgh Napier University, said: “Investment in data is clear and highlighted within the strategy.

“We know that we should have world leading data and having that data allows us to identify areas which are not meeting targets.

“But in fact in practice it’s very difficult to get the data at the right time in a way that’s useful to inform care.”

Explaining the benefits, she added: “We can use it for a whole range of things. We can use it on the individual level to ensure people are getting the right sorts of care at the right time, bearing in mind that most cardiac patients have more than one chronic condition so they are likely to be seeing a range of healthcare providers.

“On an individual level the data can give us common insight. It can also be used to help support patients to self-manage.

“On a broader level, we can gain so many insights into areas of higher need, we can make cases for provision of services, we can look at how markers of inequity are being borne out in the population.

“We can use data for a whole range of things, and I think data will help us achieve some of that work around prevention [and] tackling risk factors.”

Much of the data is already collected at patient level, but there is a problem with aggregating it to create a clearer picture of cardiovascular care.

There was a similar issue with cancer data a few years ago, leading to the creation of the National Cancer Intelligence Platform. Having a corresponding platform for heart disease would be a big improvement.

Taken together, these three priority areas of prevention, equity of care and data could help resolve problems facing cardiovascular health, provided resources are made available.

Neubeck said: “There are opportunities now to really futureproof the system by creating an adaptive service that meets the needs of every individual in Scotland with a long-term condition.

“And investment is needed in order to prevent having to deal with a rising number of people with cardiovascular complications.”

Senior policy and public affairs manager at BHF Scotland, David McColgan, agreed: “The prospect of a newly defined heart and circulatory disease plan in Scotland is great.

“However, the Scottish Government and political parties must ensure it is adequately resourced.

“We stand at a point in time where deaths from heart and circulatory disease are on the rise again after a 30-year decline.

“Tackling the social, demographic and systemic challenges that contribute to this will require real resource and national leadership.

“A successor document to the 2014 heart disease improvement plan can provide this leadership, but without meaningful resource it is being set up to fail.”

This article was sponsored by the British Heart Foundation