CPR: surviving beyond 2020

Save a Life Scotland BHF Roundtable - credit Holyrood/Alistair Kerr

Around 70 people in Scotland have an out of hospital cardiac arrest (OHCA) every week. Only about one in 20 survives. 

In 2015 the Scottish Government launched a five-year strategy with two central aims: increase that survival rate by 10 per cent through an improvement programme and “equip an additional 500,000 people with CPR skills by 2020”. 

This second ambition recognises the fact that if a bystander acts quickly, the likelihood of survival increases by two or three times. 

But what does “equip” mean? A public-facing campaign, Save a Life Scotland, was launched to encourage people to train in CPR skills so they can make that difference. 

Like the formation of the strategy itself, Save a Life Scotland involved the major stakeholders in cardiac arrest, including the Scottish Ambulance Service, Scottish Fire and Rescue Service, Police Scotland, St Andrew’s First Aid, British Red Cross, British Heart Foundation, Chest Heart and Stroke Scotland and the British Association for Immediate Care. 

Most of these bodies were present at Holyrood’s recent roundtable to discuss the progress of the strategy and what legacy and further work is needed to keep the momentum going beyond 2020. 
James Cant, director of the British Heart Foundation in Scotland, said the fact the strategy came out of collaboration between government, services and the third sector was, in itself, ground-breaking. 

“This is what co-creation looks like,” he said. 

Lisa MacInnes, programme lead for Save a Life Scotland, said how much CPR training people actually need to make a difference is secondary to the cultural change needed to encourage people to intervene if they witness a cardiac arrest.

“Scotland is not very good at stepping up and doing CPR if it’s needed,” she said. “People stand back so they are, essentially, bystanders. We stand back and wait for somebody who is better to step up and take that role.” 

Although cultural change is hard to measure, she added, the important thing to aim for is to increase the number of people willing to intervene. 

Dr Gareth Clegg, who chairs the strategy delivery group, said the Scottish strategy was more focused on “the front part of the chain” than the more cardiology-focused UK-wide framework. 

“It’s very easy to be seduced by science and kit, the high-tech stuff doctors love to play with, but I think the constituency round this table really emphasises the fact we believe that if we want to save more lives, the biggest bang for your buck is to get more CPR going on.” 

An important initiative has been the way 999 calls are now handled. To begin with, the question is: “is the patient breathing”, said Dr Jim Ward, medical director of the Scottish Ambulance Service, so that the call handler can quickly talk the bystander through CPR. “We’re optimising that pathway every way we can,” he said. 

The ambulance service has also recruited over 1,500 volunteers in communities to train and engage people with CPR, added paramedic Dave Bywater. 

Scottish Fire and Rescue, too, has played an active role, hosting CPR training kits donated by the BHF in every fire station. 

Project manager Garry MacKay hailed the service’s privileged access to the public during home safety visits. 

“I think for us there’s now a recognition in the service that where we can make the biggest difference is around awareness and development, and that’s not to the detriment of what we do in response, which is of course hugely important.” 

Police Scotland trains 17,000 of its own officers and 600 volunteer special constables in CPR, but the force’s national lead for first aid, Murdo MacLeod, said they had been “bogged down” in quality assurance at an early stage. 

“There was that kind of hang up in the early stages of the strategy but I think we’ve moved away from that and it’s all about engagement because you don’t need highly qualified people to deliver CPR. It’s moving away from that mindset.” 

Indeed, the notion that CPR is difficult and best left for those more qualified is a global problem, said Canadian expert, Steve Brooks, who sits on the International Liaison Committee on Resuscitation. 

“We have to demystify CPR, to de-medicalise CPR for the public, and that’s not going to happen overnight,” he said. 

“You may not be excellent at it without practice and a little instruction, but watching a 90-second video can give you that little bit of knowledge you need when you talk to the 999 operator who’s going to talk you through. 

“It’s those sorts of efforts that are trying to put CPR into the hands of the people, take it out of the doctors’ ivory tower and put it on the street.” 

One solution mooted was to introduce CPR training in primary schools, something which is recognised to have made a difference in Denmark. MacInnes pointed out there are 400,000 children in primary school across Scotland who could then go on to influence their own families at home. 

Schools in many parts of Scotland already have kits provided by the BHF, Cant added. 

Freddy Lippert, chief executive of Denmark’s Emergency Medical Services in Copenhagen, said making CPR compulsory in schools had taken ten years and been grown from a grassroots level in individual schools. 

“We thought it would be a good idea to distribute new ‘CPR anywhere in 30 minutes’ tools to schools. We did so, and then it grew up,” he said. 

Teachers were reluctant to begin with, he said, but eventually advocated the idea to government. 

“So in the end, it was easy for the politicians to make the decision to say, of course it should be mandatory, because there was an ongoing grassroots thing from the very beginning.” 

Could something similar happen in Scotland? MacKay said making being CPR aware “a cultural norm” would be the most effective route, so that it becomes “almost a civic duty”. 

“Bystander CPR, to my mind, actually straddles between prevent and respond, because it’s about saying, innate in people’s mindset, we can make a difference as a society.” 

Ward and MacInnes raised inequality as an important factor, when people in deprived areas are both more likely to have a cardiac arrest and less likely to get CPR from a bystander if they live in poor parts of Scotland. 

If you live in a poor area, Clegg said, “you’re twice as a likely to have a cardiac arrest, you’re eight years younger when you have the cardiac arrest, 30 per cent less likely to leave hospital alive after your cardiac arrest, and linked to that is this reduced likelihood of getting bystander CPR”. 

Mark Ballard of Chest, Heart and Stroke Scotland said lived experience could help bring it up the agenda, but MacInnes pointed out in some areas, the possibility of dying from a cardiac arrest in your forties or fifties is just accepted. 

“It’s about breaking that culture of it being the norm, the acceptance they’ll just die anyway, to recognise ‘I could be part of that change’,” she said. 

“That’s the different tack we need to take in these communities. It’s empowering them, it’s making them feel they can give something back, more than in other parts of Scotland.” 

Save A Life Scotland, she said, has been able to offer teachers concerned about time and class management “a fun event” which includes the partners from the emergency services. 

“People say, ‘I love it when a fireman comes in’, ‘I love seeing a paramedic’ and ‘even the coppers are friendly’,” she laughed. 

There has also been the opportunity to tie in with other public health services like smoking cessation and other local projects which talk to children about safety.

St Andrew’s First Aid’s ‘BandAge’ project in the east end of Glasgow, for example, focuses on reducing the risk of violence and what to do in the event of a stabbing. It also includes CPR. 

But could educating people on CPR be a tough ask when many people do not understand the difference between a cardiac arrest and a heart attack? While the latter can cause massive damage over hours or even days, a cardiac arrest is a sudden electrical malfunction which leads to unconsciousness and a lack of pulse within seconds, and death within minutes. 

Cant said the fact the terms are interchanged is a “perennial challenge” for the BHF. 

But Ballard suggested a focus on the science would not help to demystify a procedure people can be talked through, and Ward said semantics were “cut through” via the changes to the operational response in guiding people through CPR.

Lippert said the focus should be on social responsibility, and that anyone who is encouraged to do CPR after phoning 999 will go and tell their friends and family about it. 

“It might just be the simple message of ‘if you find someone who is not well, phone 999. Don’t be scared’,” said MacInnes. 

Save a Life Scotland will need to be resourced effectively to get such messages out, it was agreed. 

Ballard said there could be better alignment with the messages of other campaigns, such as FAST action on stroke, which also encourages people to understand symptoms and call 999. 

And culture change is helped by public figures, said Lippert, who cited the examples of the crown prince and crown princess of Denmark doing CPR training. 

Colin Smyth MSP said he’d be happy to host an event in parliament which would see cross-party politicians receive CPR training. 

“In a simple thing like training in the parliament, you’ll get ‘x’ number of MSPs coming along, that’s 50 or 60 local newspapers who will run bizarre pictures of MSPs looking strange, they love that. That’s a story straight away in every local newspaper across Scotland.”

But what about the Scottish Government itself? 

“When you think about how government can make this sustainable and impactful, it’s measurement, accountability and messaging,” said Brooks.

“We do need to get better at the outcomes we measure,” suggested Ward.

Clegg said Scotland was well placed to provide the data necessary for a registry because of “amazing” data infrastructure in the Information Services Division and the Farr Institute. 

“We can take an ambulance journey, we can connect it to what happens to a patient all the way through their entire connection to the health service via the community health index number,” he said. 

“It’s the envy of everyone else we talk to about this and it’s been used effectively to look at cancer, it’s used effectively to look at rare diseases. 

“My pitch to the government would be a double decker bus-worth of patients in Scotland every week has an out of hospital arrest, can we leverage that for the structure to look at cardiac arrest? We’re currently doing it on the back of an envelope with a piece of string and Blu-tack.” 

Data would also help with the messaging, said MacInnes, if people could see the difference they’d made. Clegg said effective social marketing could be “the real legacy” of the current strategy. 
After that ends in 2020, though, how can Scotland maintain its momentum, and what can the Scottish Government do to help? 

Ward suggested a review of “how we describe success”. 

Resources will need to be a part of the solution too, whether that be for community work by the emergency services or for the continuation of Save a Life Scotland. 

Macleod suggested defibrillators should be in every police vehicle in Scotland. 

Mackay said the fire and rescue service needed support to play a greater role in health and social care. 

“Scotland’s government and stakeholder relationship is a very unique position to be in,” said Brooks. 

“This is a unique opportunity, so my ‘ask’ would be to consider cardiac arrest as a public health issue, work with us to create sustainable systems of measurement, reporting and accountability.” 
“I think we’ve got something exceptionally special,” said MacInnes. 

“Most days, I wake up feeling blessed to be sitting around the table with these groups, but I know that won’t last forever. This is a special time, and the time is now. We have to be as creative as we possibly can. 

“Please, take this seriously. Cardiac arrest is non-discriminate. It’s not old people, it’s not poor people, it’s anybody in Scotland, so take this seriously in the policies you make. Also, be role models. Lead, help us save lives and take people back to their families.”