Putting a health inequalities focus on the Northern Ireland … · 2018-07-10 · 3.3.6 Heart disease ... 3.4 Overarching learning ... It reinforces the imperative of putting people

Putting a health inequalities focus on the Northern Ireland cardiovascular service frameworkSummary report

Health impact assessmentNorthern Ireland cardiovascular service framework

Table of contents PageForeword.......................................................................................................................................2

Executive summary...............................................................................................................4

1 Cardiovascular disease and its determinants .........................................82 Cardiovascular health and wellbeing service framework........... 133 Health impact assessment.................................................................................. 14 3.1 Cardiovascular health and wellbeing profile for Northern Ireland ............................................................................................ 15 3.2 Links between cardiovascular disease and wider determinants of health................................................................................. 16 3.3 Main findings.................................................................................................... 17 3.3.1 Communicationandparticipationforpatients,clients andcarers........................................................................................... 17 3.3.2 Healthimprovement........................................................................... 18 3.3.3 Hypertension...................................................................................... 19 3.3.4 Familialhyperlipidaemia................................................................... 22 3.3.5 Diabetes.............................................................................................. 22 3.3.6 Heartdisease..................................................................................... 23 3.3.7 Cerebrovasculardisease................................................................. 27 3.3.8 Peripheralvasculardisease............................................................. 29 3.3.9 Renaldisease..................................................................................... 31 3.3.10Palliativecare...................................................................................... 33 3.4 Overarching learning.................................................................................... 34 3.4.1 Healthinequalitiesandhealthandsocialcareequity............... 34 3.4.2 Healthintelligenceforhealthimprovement.................................. 34 3.4.3 Capacitybuildinginlearningorganisations.................................. 35 3.4.4 Participation,partnershipsandnetworks...................................... 35

Appendix 1 Management group and steering group members of the health impact assessment................................................ 36

Appendix 2 Health action plan ................................................................................. 38

List of figures ......................................................................................................................... 66

References................................................................................................................................ 67

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Foreword

The challenge

Cardiovasculardiseaseisamajorhealthburden.Itisalsolargelypreventable.

Eighthundredpeoplestilldieannuallyherefromischaemicheartdisease(IHD)alone.Abouthalfofthesedeathscouldbepreventedthroughbetteruseofavailablehealthpromotionandtreatmentservices.

Ourapproachtopreventingandtreatingcardiovasculardiseasesrecognisesthathealth,disabilityanddeathareinfluencedbymanyfactorsthatlieoutsidetheHealthandSocialCare(HSC)sector.

Cardiovasculardiseasesaffectpeoplelivinginpovertymoreseverelythanothers,buttheyarenotuniqueinthisregard.InNorthernIreland,however,theyremainthemaincontributortoinequalitiesinmortality.

MenlivinginthewealthiestareasinNorthernIrelandliveonaveragealmosteightyearslongerthanmeninthepoorestareas.Forwomen,thegapisfiveyears.Thisgapinlifeexpectancyiswideninganditneedstobeaddressed.

Our response

ThePublicHealthAgency(PHA)hasaleadroleinimplementingthecardiovascularserviceframework(CVSFW).Thiswaslaunchedin2009asthefirstofaprogrammeofserviceframeworks.

Ithas45standardsforgoodpracticeinthepreventionandtreatmentofcardiovasculardiseasesinNorthernIreland.ItsprinciplesincludeequityofaccesstoHSCservicesandreducinghealthinequalities.

OneofthePHA’sorganisationalprioritiesistomakehealthimprovementarealityforallpeoplelivinginNorthernIreland.Inlinewiththisaim,thePHAundertookthishealthimpactassessment(HIA)totestandimprovetheeffectsofimplementingtheCVSFWonhealthinequitiesandinequalities.

Iamdelightedtonowpresenttoyoutheresultsofthiswork.Theseincludealiteraturereview,acardiovascularhealthandwellbeingprofileandafulltechnicalreport.Thisreportisbasedonthesedocuments,whichareavailableasseparatedocuments.

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AparticularstrengthofthisHIAhasbeenitswiderangingconsultationacrossandbeyondHSCorganisations.Thefindingsare,therefore,basedonmanysourcesofinformationandincludesuggestionsonhowtogetthebestfromtheCVSFWandotherserviceframeworks.

The way forward

ThisHIAhasconfirmedthathealthinequitiesandinequalitiesexist.ItunderpinstheimportanceofparticipationofbothserviceprovidersandusersinHSCdesignanddelivery.ItreinforcestheimperativeofputtingpeopleandcommunitiesatthecentreofHSCservicesandaligningthesewithindividuals’lifeexperienceandthepatientjourney.

Italsoidentifiesbarrierstohealthimprovementandwaystoovercomethese.ItstatesthebenefitsthatwillarisefromputtingtheCVSFWintoactionandtellsus,intheformofahealthactionplan,whatweneedtodotomaximiseitsbenefits.

Mythanksgotoallthoseindividualsandorganisationswhohavecontributedtothiswork,whichwillhelptoguideHSCserviceplanning,developmentandcommissioningthroughthepresentandfutureannualcommissioningplans.

MyhopeisthatthelearningfromthisworkwillsupportthePHAandotherorganisationsinoureffortstobuildcapacityforhealthimprovementthroughpartnershipsandnetworkswithin,andbeyond,theHSC.

Dr Eddie Rooney Chief ExecutivePublic Health Agency

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Executive summaryCardiovasculardiseaseisthemaincauseofdeathanddisabilityinNorthernIreland,despitesteadyimprovementsinservicesandreductionsinmorbidityandmortality.

CardiovascularhealthisdeterminednotonlybyaccesstoHSCservicesandlifestylechoices,butalsobythesocialandeconomicconditionsinwhichpeoplelive.Theseincludehousing,employment,transportandaccesstofreshfood.

InNorthernIreland,somepeoplehavebenefittedmorefromimprovementsinservicesandlivingconditionsthanothers.Thishascreateddifferences(inequities)inhowpeoplecanaccessandmakeuseofservices.Theseinequitieshave,inturn,resultedinhigherlevelsofillhealthandprematuredeath(inequalities)insomepopulationgroups.

Forexample,menlivingintheleastdeprivedareasliveonaveragealmosteightyearslongerthanmeninthemostdeprivedareas.Forwomen,thisgapisfiveyears.Thesedifferencesaregettingworse,wideningthegapbetweenthosewhoaremoreaffluentandthosewhoarenot.Cardiovasculardiseaseisnotuniqueinthisregardbut,inNorthernIreland,isthemaincontributortoinequalitiesinmortality.

In2007theDepartmentofHealth,SocialServicesandPublicSafety(DHSSPS)starteddevelopingaseriesofserviceframeworkstosetoutexplicitstandardsforthosedeliveringandreceivingHSCservicesandtosupporttheplanning,developmentandcommissioningofservices.

TheCVSFWwaslaunchedin2009asthefirstoftheseframeworks.Itidentifies45standardsforgoodpracticeinthepreventionandtreatmentofcardiovasculardiseaseinNorthernIreland.ItsprinciplesincludeequityofaccesstoHSCservicesandareductioninhealthinequalities.

ThePHAhasaleadroleinimplementingtheCVSFW.Insupportofthiswork,thePHAhasundertakenthisHIA:

• totesttheeffectsofimplementingtheCVSFWonhealthinequitiesandhealthinequalities;

• toproposeactionstoincreasehealthequityandreducehealthinequalitiesincardiovascularandrelatedservices;

• toharvestthelearningfromthisHIAandapplyittotheimplementationanddevelopmentoftheCVSFWandotherframeworks.

Thisreportsharesthefindingsof,andlessonslearntfrom,theHIA.

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How we conducted the health impact assessment

OurapproachtotheHIAwasbasedoninternationallydevelopedgoodpracticeguidance.ItwassupportedbytheInstituteofPublicHealthinIreland(IPH)andaninternationallyrecognisedexpertinHIA.Wefollowedasystematic,participatoryprocessandgatheredinformationfromarangeofsourcesandstakeholderswithoutneedingtoundertakeoriginalresearch.

Localdataweregatheredtodevelopacommunityprofile,whichprovidesabaselineforcardiovascularhealthacrossNorthernIreland.ThisimprovesourunderstandingofthehealthneedsofthepopulationaffectedbytheCVSFW.

Aliteraturereviewwascarriedouttoidentifyinternationalevidenceoncardiovascularhealthanditsdeterminants.Thereviewoutlinesappropriateandeffectiveinterventions.

Usingworkshopsweconsultedhealthpractitioners,statutoryrepresentatives,patients,carersandthecommunityonthepotentialhealthimpactsassociatedwiththeimplementationoftheCVSFW.Arapidappraisaltoolwasdevelopedforthis,basedonanalysisoftheCVSFWandtestedindesktopappraisalsessionspriortobeingused.

Eachstandardwassubjecttoacomprehensiveassessmentonhowitcouldbeimplementedeffectivelyandefficiently.ParticipantsateachworkshopmadesuggestionsonhowtoenhancethedeliveryandimpactoftheCVSFWstandardstoreducehealthinequalitiesandinequities.

Thesesuggestionshavebeencollatedtoformahealthactionplan.ThishascontributedtotheHealthandSocialCareBoard(HSCB)/PHAcommissioningplan2011–12andwillsupportfutureserviceplanningactivity.

What the health impact assessment found

TheHIAdeterminedthatalmostallstandardsintheCVSFWrelatedtoareasoftheHSCwherehealthinequalitiesandinequitiesalreadyexist.Theseareduemostlytosocioeconomicfactorsandvariableaccesstoservicesmainlyonaccountofgeography,iewhereservicesaredeliveredinrelationtowherepatientslive.

Therearebarrierstotheimplementationofeachstandard.Theyincludethecapacityofsystems,organisationsandstafftofacilitateandsupportchange.

Ontheotherhand,theHIAidentifiedpositiveeffectsonstaffarisingfromtheimplementationofstandardsifadequatelyresourced.Thisincludesincreasedjobsatisfactionfromthedeliveryofimprovedservices.

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Apotentialincreaseindemandforserviceswasidentifiedforjustunderhalfofthe45standards.Thismightresultfromincreasingawarenessamongpotentialserviceprovidersandusers,orincreasedservicecapacitytorespondtopreviouslyunmetneeds.Againstthis,aboutathirdofstandardsarelikelytoreducetheneedforservicesinthefuturethroughgreatereffectivenessinreducingtheburdenofcardiovasculardisease.

Moststandardswereidentifiedasbenefitingindividualandpopulationhealth.However,therecouldbehighopportunitycostsfromusinglimitedresourcesforspecialistservicesandotherlimitations,suchasoverburdeningpatientswithhealthmessagesandcomplexchoicesabouttreatmentoptions.

TheHIAfoundthattheeffectsofstandardimplementationonthewiderdeterminantsofhealthwillbemainlypositive.ThissupportsthehealtheconomicargumentforsustainableinvestmentinHSCservicestoimprovehealthandproductivityofthepopulationinNorthernIreland.

ThisworkalsoshowedthatdespitetheaimoftheCVSFWtoimproveequityofaccessandequalityofoutcomes,onlyaminorityofstandardswerethoughtlikelybyHIAparticipantstoachievethisresult,evenifparticularattentionwaspaidtovulnerablepopulationgroupsandgeographies.

Suggestions for future action

ThisreportconcludeswiththemainfindingsandsuggestionsarisingfromtheHIAintheformofahealthactionplan.ThisispresentedinaformatthatmirrorsthelayoutoftheCVSFWwhichisdividedinto10sections(seeAppendix2).

Learning for health equity

BeyondthesuggestionsandinsightsrelatingtothespecificsectionsandstandardsintheCVSFW,theHIAhasgeneratedotherimportantoutcomes.

ItprovidesaqualitativeandquantitativeanalysisoftheCVSFW’sabilitytoachieveitsstatedaims.Itidentifieswhereactionisneededtoprotectvulnerablepopulationgroupsfromfurtherunintendedinequity,whichcouldotherwiseresultfromCVSFWimplementation.

ThisworkhashighlightedthathealthisnotevenlydistributedinNorthernIreland,noristheabilityofindividualstobenefitfromHSCinterventions.Thisweneedtobemindfulofifwewishtocontributetoreducingthehealthinequalitiesgap.

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Wehighlightthefollowingareasforconsideration:

Health intelligence for health improvementImplementationoftheCVSFWhasthrownupmanychallengesforinformationsystemsanddatamanagementwithintheHSC.WeneedtoworkondatalinkageandinformationsharingacrossagenciestocreatebetterunderstandingofwhatdetermineshealthandwellbeingforpeopleinNorthernIreland.

Capacity building in learning organisationsThisHIAofhealthpolicyimplementationisthefirstofitskindinIreland.Manypeoplehavecontributedtoit,acquiringnewknowledgeandskillsintheprocess.Thiswasenhancedbytheinvolvementofaninternationalexpert.ThiswillbenefitHSCorganisationsintheirendeavourstoimprovehealthequityandreducehealthinequalitiesinthefuture.

Participation, partnerships and networksDevelopment,implementationandtheHIAoftheCVSFWembracetheprinciplesofparticipationanddependoncollaborativeworkingacrossagencies,organisations,communitiesandindividuals.TheHIAhasaddedvaluetoHSCservicesbystrengtheningconnectionsbeyondinstitutionalboundaries.

The future “…education alone is not sufficient… effective

commissioning and service management are also necessary but not sufficient… vital to address whole systems of care, build on networks, not

institutions…”SirMuirGray,NHSAtlasofVariationinHealthcare,

NHSRightCare,Nov2010

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1. Cardiovascular disease and its determinants Despitesignificantimprovementoverrecentdecades,cardiovasculardiseaseremainsthemaincauseofdeathanddisabilityinNorthernIreland.Thiscanbepartlyattributedtoourlifestyle,suchassedentarybehaviour,alongsidepatternsofeating,smokingandalcoholconsumption.1

Healthisdeterminednotonlybyaccesstoqualityhealthcareservicesandlifestylechoices,butalsobythesocialandeconomicconditionsinwhichpeoplelive.2Theseincludemanyfactorswhichlieoutsidethehealthcaresector,suchashousing,employment,transportandaccesstofreshfood(Figure1).

Figure 1: The determinants of health and wellbeing

Smokingremainsoneofthebiggestriskfactorsforcardiovasculardiseasealongsidesedentarylifestylesandalcoholconsumption.Circumstancesexperiencedduringtheearlyyearsalsoinfluencehealthandwellbeingintoadulthood.Breastfeedingcanhelptoprotectagainstobesity.Physicalactivityandeatinghabitsdevelopfromayoungageandoftenformlifelongpatternsofbehaviour.

Livingandworkingconditionsalsoimpactonhealth.Employment,educationandincomearepowerfulinfluencesonhealth.Theenvironmentinwhichweliveneedsto

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provideaccesstoopenandgreenspace,whichplaysanimportantpartinphysicalactivitypatterns,alongsidethetransportoptionsavailableincommunities.

Allofthesefactorsalsoinfluencementalhealthandemotionalwellbeing.Figure2providesanoverviewofthedeterminantsofhealthinrelationtocardiovasculardisease.3

Figure 2: Cardiovascular health and its contributory factors

Health inequalities and inequitiesHealthinequalitiesaredifferencesinhealthandwellbeingexperiencedbyindividualsorgroupsinsociety,suchassocioeconomicgroupsorbetweenmenandwomen.Menlivinginthe20%leastdeprivedareasinNorthernIrelandliveonaveragesevenyearslongerthanmeninthe20%mostdeprivedareas;forwomen,thisgapiseightyears(Figure3).Cardiovasculardiseaseremainsthemaincontributortothisgap.

Local capacity for leadership and

organisingLocal

actions Costs (CVD and non-CVD attributable to risk factors

CVD risk factor prevalence and control• Hypertension• High cholesterol• Diabetes• Smoking• Secondhand smoke• Air pollution exposure

Estimated first-time CVD events• Heart attack• Stroke• Peripheral vascular disease

Utilisation of services• Behavioural change• Social support• Mental health• Preventive health

Nutrition, physical activity, and stress• Eating and activity options• Smoking policies• Socioeconomic conditions• Environmental policies• Health care options• Support service options• Media and events

Local context• Eating and activity options• Smoking policies• Socioeconomic conditions• Environmental policies• Health care options• Support service options• Media and events

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Figure 3: Contribution to the life expectancy gap between the 20% most deprived and 20% least deprived areas in Northern Ireland (2006-08) by cause of death (years)

Source:ProjectSupportAnalysisBranch,DHSSPSNote:Positivenumbersindicatethatdeprivedareashadlowerdeathratesthantheleastdeprivedareas.Conversely,negativenumbersindicatethatdeprivedareashadhigherdeathrates.

Healthinequalitiescanalsooccurwithin,orbetween,geographicalareas.Figure4showsthatpeoplelivinginCookstownandBallymoneyDistrictCouncilareasaremorelikelytodiefromcerebrovascular(CVD=stroke) orIHDthanthosefromotherareasinNorthernIreland.

CoronaryheartdiseaseStroke

OthercirculatoryPneumonia

ChroniclowerrespiratorydisOtherrespiratory

LungcancerBreastcancer

ProstatecancerColorectalcancer

LymphcancerPancreascancer

OthercancersDiabetes

Otherdiabetes/metabolicdisMental/behaviouraldisorders

NervoussystemandsenseorgChronicliverdisease

OtherdigestivediseasesRoadtrafficaccidents

OtheraccidentsSuicide

KidneydisorderOthergenitourinarydis

PerinatalperiodconditionsCongenitaland

chromosomalabnormalOthercauses

-1.4 -1.2 -1.0 -0.8 -0.6 -0.4 -0.2 0.0 0.2Years

Malegap(-7.8years)

Femalegap(-4.9years)

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CarrickfergusNewtownabbey

Antrim

Moyle

Craigavon

Larne

CarrickfergusNewtownabbey

Antrim

Moyle

Craigavon

Larne

Ards

Armagh

Ballymena

Ballymoney

Banbridge

Belfast

Castlereagh

Coleraine

Cookstown

Derry

Down

Dungannon

Fermanagh

Limavady

Lisburn

Magherafelt

Newry and Mourne

North Down

Omagh

Strabane

Figure 4: Comparative death rates for IHD or stroke 2006-08 (Northern Ireland average = 100)

HSCservicesinNorthernIrelandareintendedtobeavailablefairlytoallwhoneedthem,butsomepeoplearelesslikelythanotherstoaskfor,orget,thetreatmenttheyneed.Thishealthinequitymightbetheresultofwheretheyliveorbecausetheyaredisadvantagedbypoverty,disabilityorethnicity.

Inequitiesinhealthareavoidabledifferencesintheopportunitytobehealthy,andintheriskofillnessandprematuredeath,whichcanarisefromanunequaldistributionofservices,resourcesorpower.

Disadvantagedpeopletendtobelesshealthyand,thereforeonaverage,needmoreHSCservicesthanwealthiermembersofsociety.Thereisampleevidenceofinequitableaccesstohealthservicesforpeoplewithcardiovasculardisease.

Figure5showsthat,despitehigherlevelsofillhealth,peoplefromlowersocioeconomicgroupsarelesslikelytobeadmittedtohospitalforelective,ieplannedinvestigationsortreatment,thanthosefromhighersocioeconomicgroups.Instead,theyaremuchmorelikelytocometohospitalforemergencytreatment,whichcarrieshigherrisksofpooreroutcomes.

This material is Crown Copyright and is reproduced with the permission of Land and Property Services under delegated authority from the Controller of Her Majesty’s Stationery Office, © Crown copyright and database rights NIMA ES&LA210.2

Deaths per year of IHD or stroke

122 to 134 (1)110 to 122 (1)98 to 110 (14)86 to 98 (7)74 to 86 (3)


Deaths per year of IHD or stroke

122 to 134 (1)110 to 122 (1)98 to 110 (14)86 to 98 (7)74 to 86 (3)

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Figure 5: Elective and non-elective treatment rates, by economic deprivation decile 2001–02 (per thousand population)

Source:BelfastHSCT,2008

180.0

160.0

140.0

120.0

100.0

80.0

60.0

40.0

20.0

0.01Most

deprived2 3 4 5 6 7 8

Elective Non-elective

9 10Leastdeprived

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2. Cardiovascular health and wellbeing service framework

In2007,theDHSSPSbegantodevelopaprogrammeofserviceframeworkstosetoutexplicitstandardsforhealthandsocialcareforserviceusers,providersandplanners.Serviceframeworksaimtopromoteseamlesscarefrompreventionandhealthpromotion,throughprimaryandhospital,toendoflifecare(Figure6).

Figure 6: Development of service frameworks

ThefirstseriesofserviceframeworksfocusedonthemostsignificantcausesofillhealthanddisabilityinNorthernIreland–cardiovascularhealthandwellbeing;respiratoryhealthandwellbeing;cancerprevention,treatmentandcare;mentalhealthandwellbeing,andlearningdisability.Othersarebeingdevelopedforolderpeople,andchildrenandyoungpeople.

TheCVSFWwaslaunchedin2009asthefirstoftheseframeworks.Ithas45standardsforgoodpracticeincommunication,healthimprovement,hypertension,hyperlipidaemia,diabetes,heartdisease,stroke,peripheralvasculardisease,kidneydiseaseandendoflifecare.

ThePHA,theHSCB,HealthandSocialCareTrusts(HSCTs),primarycareteamsandotherserviceprovidersallhavearesponsibilityforimplementingtheCVSFW’sstandards.

Prevention/promotion/protection/lifestyle

Assessment and diagnosis

Treatment and care

End-of-life care/palliative care

Discharge/completion

of care

Ongoing care/chronic disease management

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3. Health impact assessmentHIAisdefinedas,‘acombinationofprocedures,methodsandtoolsbywhichapolicy,programmeorprojectmaybejudgedastoitspotentialeffectsonthehealthofapopulation,andthedistributionofthoseeffectswithinthepopulation’.4

ThestrategicdecisiontoconductanHIAoftheNorthernIrelandCVSFWwastaken:

• totesttheeffectofimplementingtheCVSFWframeworkonhealthinequalitiesandinequitiesinrelationtocardiovasculardisease;

• tousethelearningfromtheHIAontheCVSFWandapplyittothedevelopmentandimplementationofotherserviceframeworks.

TheHIAwasoverseenbyanHIAsteeringgroup(memberslistedinAppendix1)whoagreedthescopefortheHIAandaworkplanfortheproject.Thetermsofreferenceofthesteeringgroup,HIAscopeandworkplanarecontainedinthefulltechnicalreportavailableonlineatwww.publichealth.hscni.net

AwiderangeofinformationwascollectedtosupportandshapetheresultsoftheHIA.Thisincluded:

• aliteraturereviewoftheinternationalevidenceonwhatworksinreducinginequalitiesandinequitiesincardiovascularhealth,servicesanddeterminants(summarisedonpage16;fulldocumentavailableonlineatwww.publichealth.hscni.net),

• acardiovascularhealthandwellbeingprofileforNorthernIreland,whichbringstogetherlocalinformationtogiveabetterunderstandingofthecardiovascularhealthneedsofpeople(summarisedonpage15;fulldocumentavailableinprintandonlineatwww.publichealth.hscni.net)

• consultationwithserviceusersandprovidersonpotentialeffectsonhealthfromimplementatingtheCVSFW.

ThefollowingconsultationworkshopswereheldwithHSCpractitioners,policymakers,researchers,patients,carersandthewiderpublic:

➢ Communityengagementsessions: MaureenSheehanCentre,Belfast,27May2010 GasyardHealthyLivingCentre,Derry,14June2010 ArdsPeninsulaHealthyLivingCentre,Kirkubbin,20July2010 LoughguileMillenniumCentre,CoAntrim,5August2010

➢ Statutorystakeholderengagementsession: FarsetInternational,Belfast,24June2010

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Theconsultationcoveredissuessuchasexistinghealthinequitiesandinequalitiesinrelationtoindividualstandards,potentialbarrierstoimplementationandimpactsonservices;aswellasimpactsonhealth,inequalitiesandinequities.

Mostimportantly,weaskedforsuggestionsonhowtoenhancepositive,andminimisepotentialnegative,impactsarisingfromimplementatingthe45standardsintheframework.

Thisinformationwasanalysedandthefindingswereprioritised,basedontheirimportancefor,andpotentialimpactson,thehealthandwellbeingofserviceusersandproviders.

Basedonthis,ahealthactionplanwasdevelopedforusebyHSCservicesintheplanninganddeliveryofcardiovascularandrelatedservices.ThisissummarisedinAppendix2.

3.1 Cardiovascular health and wellbeing profile for Northern Ireland

ThefollowinginformationisasummaryofthecardiovascularhealthandwellbeingprofileforNorthernIreland.Itprovidesasnapshotofcardiovascularhealthandtherangeoffactorswhichcontributetoit.1

• Cardiovasculardisease(involvingtheheartandbloodvesselsinthebrainandotherpartsofthebody)remainsthemaincauseofdeath.Thiscanbepartlyattributedtolifestylesincludingsedentarybehaviourandpatternsofeating,smokingandalcoholconsumption.

• Thereisalargegapinlifeexpectancybetweendifferentsocioeconomicgroups.Peoplewholiveinthemostdeprivedareasarealmosttwiceaslikelytodie,beforetheageof75years,astheregionalaverage.

• Coronaryheartdisease(CHD)andstrokeaccountedfor19%ofdeathsinpeopleaged15–74between2001–08.Inthesameperiod,thesediseasesaccountedforthedeathsof30%ofthoseaged75yearsandover.

• WhilelowersocioeconomicgroupsaremorelikelytosufferCHD,theyarelesslikelytobetreatedinaplannedwaybeforehavingaheartattack.

Lifestyle factors contributing to cardiovascular health• Menandwomenfrommanualoccupationshavehigherratesofsmokingthannon-

manualworkers.5• Around60%oftheadultpopulationandapproximately22%ofprimaryschool

children,areeitheroverweightorobese.6,7• Peoplelivinginthemostdeprived20%ofgeographicalareasareoverfourtimesas

likelytodiefrommisuseofalcoholasthoselivinginaffluentareas.8

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Other factors influencing cardiovascular health• In2008,3.6%ofyoungpeopleleftschoolwithnoGCSEs.9

• Olderpeople,especiallythoselivingalone,aremorelikelytoliveinhousesunfitforhumanhabitationthanotherpopulationgroups.10

• Onequarterofallhouseholdsdonothaveaccesstoacarbut,withpublictransportinshortsupply,mostpeoplearedependentoncarsfor travel.11

Thefullcommunityprofileisavailableinprintandonlineatwww.publichealth.hscni.net

3.2 Links between cardiovascular disease and wider determinants of health

ThisisasummaryoftheliteraturereviewundertakenaspartoftheCVSFWHIA.

• Themajorriskfactorsforcardiovasculardiseaseincludesmoking,highbloodpressure,diabetes,obesityandphysicalinactivity.Preventionofcardiovasculardiseasedependsoneffectivereductionoftheseriskfactors,especiallysmoking,physicalinactivityandpooreatinghabits.

• Peoplefromdeprivedareasareathigherriskfromcardiovasculardiseasethanpeoplelivinginmoreaffluentareas.Smokingismoreprevalentinpeoplefromdeprivedareas.Unemployment,jobinsecurityandloweducationlevelsareassociatedwithincreasedriskofcardiovasculardisease.Thequalityofthelivingenvironmentaffectscardiovasculardiseaseriskintermsofopportunitiesforphysicalactivity,communitycohesionandhousingconditions:fuelpovertykills.

• Peoplefromdeprivedareas,women,olderpeople,peoplefromethnicminoritiesandpeoplewithmentalhealthproblemsorlearningdisabilitiesappeartobelesslikelythanotherstogettreatedforcardiovasculardisease.

• Peoplefromdeprivedareasarelesslikelytobenefitfromhealthpromotionandeffortstoimprovelifestyles.Moreaffluentcommunitiesarealsoatriskandhealthimprovementactionsmustreachall,butwithascaleandintensityproportionatetoneed.Population-wideapproachesincludinglegislationtendtobemoreeffectivebecausetheyreacheveryone,donotstigmatiseandcanreducehealthinequalities.

Thefullliteraturereviewisavailableonlineatwww.publichealth.hscni.net

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3.3 Main findings

InthissectionwesummarisethemainfindingsfromtheHIAinrelationtoindividualsectionsandstandardsoftheCVSFW(3.3.1–3.3.10).Thestandardsarenumbered1to45.

Wefirstoutlinetheneedforactionstoimprovehealthequityandreducehealthinequalities.ThehealthactionplanatAppendix2providesmoredetail.

WethendrawgenericconclusionsfromtheHIAprocessfororganisationallearning,capacitybuildinganddevelopment(3.4.1–3.4.4).

3.3.1 Communication and participation for patients, clients and carers (Section 1, Standards 1–2)1.AllpatientsandcarersshouldexpecteffectivecommunicationfromHSCorganisationsasanessentialanduniversalcomponentoftheplanninganddeliveryofHSC.2.Allpatients,carersandthepublicshouldhaveopportunitiestoengageactivelyandmeaningfullywithHSCorganisationsatalllevels.

Healthinequalitiesandinequitiesalreadyexistinrelationtobothofthesestandards,includingforpeoplefromlowersocioeconomic,andblackandethnicminority(BME)groups,thosewithhearingandvisualproblems,andruraldwellers.Therearemanybarriersto,butalsopotentialbenefitsarisingfrom,standardimplementationforbothservicesandstaff.

Demandsonstafftoimprovecommunicationwithserviceusers,anddemandsforservicesasaresultofbetterinformedserviceusers,willincreaseintheshorttomediumterm.

Inthelongerterm,thehealthandwellbeing,notonlyofserviceusers,butalsoserviceproviderswillbeimprovedthroughempowermentandparticipation.Thiswillhavewiderbenefitsonandthroughthedeterminantsofhealth,leadingamongotherthingstoahealthierworkforceandmoreappropriateuseoflimitedHSCresources.

ThemainsuggestionforachievingthebenefitsarisingfromimplementationofStandards1and2isto:

• FacilitateHSCstaffinimprovingcommunicationwith,andparticipationof,serviceusersandthewiderpublicinservicedesignanddelivery.

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3.3.2 Health improvement (Section 2, Standards 3–9)3. TheHSCshouldworkincooperationwithvoluntary,education,youthandcommunityorganisationstopreventtherecruitmentofyoungpeopletosmoking.

4. AllHSCprofessionalsshouldidentifypeoplewhosmoke,makethemawareofthedangersofsmoking,advisethemtostopandprovideinformation,andthensignposttothewelldevelopedspecialistcessationservicesavailable.

5. HSCprofessionalsshouldidentifyinactive*individualsand,whereappropriate,providethemwithadviceandsupporttoaccumulateaminimumof30minutesofmoderateactivity**onfivedaysoftheweekormore.

6. Allpeopleshouldbeprovidedwithhealthyeatingsupportandadvice,appropriatetotheirneeds,inarangeofsettings.

7. HSCprofessionalsshouldworkwithearlyyearssettings,schools,workplacesandcommunitiesinthepromotionandsupportofbreastfeeding,healthyeatingandphysicalactivitytopreventobesity.

8. Primarycareprofessionalsshouldidentifypeoplewhoconsumehazardous/harmfulamountsofalcohol,makethemawareofthedangers,advisethemtoreduceorstopandprovideinformationandsignpostingtospecialistservices,ifappropriate.

9. HSCprofessionalsshouldworkwithschools,workplacesandcommunitiestoraiseawarenessof,andaccessto,emergencylifesupportskills.

TheHIAidentifiedhealthinequitiesandinequalitieslikeage,genderanddisabilityinaccesstoservices,especiallyforruraldwellers,aswellasmanybarrierstoimplementationofeachstandardinthehealthimprovementsection.Standard8(managementofalcoholmisuseinprimarycare)hasthehighestnumberofidentifiedinequalitiesrelatedtoitinthewholeCVSFWHIA.

Thesocioeconomicgradientinhealthylifestylebehaviours,andcapabilityforchange,isalreadywellrecognisedandhasagainbeendemonstratedinthisHIA.Investmentinhealthimprovementinterventionscantaketimetogenerateidentifiablereturns,andevaluationofhealthoutcomescanbechallengingbecauseofthis;aswellasthecomplexityofmodellingormeasuringthem.

ThisisborneoutbytheHIAfindings,whichrecognisethatimplementationofStandards3–9willinitiallyincreasedemandforrelevantservicesbut,inthelongertermthroughimprovedhealthofpeople,decreasetheirneedforsuchservices.

*nophysicalactivitybeyondwhathappensduringnormalactivitiesofdailyliving**activitythatgetspeopleoutofbreathandmakestheirheartbeaterfasterwithoutpushingthemtotheirphysicallimits

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Theriskofincreasingexistinghealthinequitiesandinequalitiesamongsocioeconomicallydisadvantagedpeopleishigh,withhealthimprovementinterventionslikethoseintheCVSFWwhichareaimedatchangingindividuals’lifestylesandbehaviours.Thosemostinneedareleastlikelytobeabletomakethenecessarylifestylechangesbecauseofothercompetingpriorities(inversecarelaw).

Itisthereforeofcriticalimportanceforthesuccessofhealthimprovementinterventions,aimedatindividualriskfactorreduction,thattheyaredesignedanddeliveredinwaysthatmakethemeffectiveforallpeoplewhoneedthem.

Therecommendationsfromthehealthactionplanrecognisethisandseektoshapehealthimprovementinterventionsinwaysthatmakethemeffectiveforallmembersofsociety:

• Integratehealthimprovementactivitiesacrosstopics,settingsandsectorsby: – coordinatingbriefinterventiontrainingforallHSCstafftosupportbehaviour changeandselfmanagement;

– supportingcollaborationbetweenHSCorganisations,communitiesandlocal governmentincreatinghealthierenvironments;

– creatingsynergybetweencommunities,voluntaryorganisationsandHSC providersincludingpharmaciesandprimarycareproviders.

• Implementanobesitypreventionstrategicframeworkonaninteragencybasis totakeaccountofthedeterminantsofhealth.

• Developaregionalemergencylifesupportbusinesscase,strategy,policyand implementationplan.

• Advocateforsaltreductioninfood.

3.3.3 Hypertension (Section 3, Standards 10–11)10. Alladultsshouldbeofferedlifestyleadviceastothepreventionofhypertensionandhavetheirbloodpressuremeasuredandrecordedusingstandardisedtechniqueseveryfiveyearsfromage45years.

11. Allpatientsshouldbeoffereddrugtherapyiftheyhave(a)persistentbloodpressureof160/100mm/Hgormoreand/or(b)raisedcardiovascularrisk(10yearriskofcardiovasculardiseaseof20%orexistingcardiovasculardisease/targetorgandamage)withpersistentbloodpressureof140/90mm/Hg.

20

Figures7and8showmapsofGPpracticeswhichmeasurebloodpressureinunder85%ofeligiblepatientsandthosepracticeswhodosoinover95%ofeligiblepatients.

Therearehealthinequalitiesandinequitiesassociatedwiththesestandards,butnotallaresocioeconomicallypatterned.TherearedifferencesintheperformanceofGPpracticesacrossNorthernIrelandinidentifyingandmanaginghypertension,butthesedifferencesarenotrelatedtodeprivation.

Interventionstoimproveimplementationofthesestandardsinprimarycarethereforeneedtobetargetedatindividualpracticesregardlessoflocation,ratherthanfocusingondeprivedareas.

Figure 7 Northern Ireland GP practice performance in measuring blood pressure in patients aged 45 years and over

Standard 10 -‐ KPI 10a -‐ % of pa2ents aged >45 yrs who have had a recorded BP on their GP record within the past 5 years. Target is 70%


NIMDM 2010 Ranks of Deprivation - Ward LevelThe darker the shading the more deprived the w ard

465 to 582 (116)340 to 465 (116)220 to 340 (116)98 to 220 (117)0 to 98 (117)

Health & Social Care Trust boundary

GP Practices scoring within bottom 20%

GP Practices scoring within top 20%




465 to 582 (116)340 to 465 (116)220 to 340 (116)98 to 220 (117)0 to 98 (117)







465 to 582 (116)340 to 465 (116)220 to 340 (116)98 to 220 (117)0 to 98 (117)




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Figure 8 Belfast Health and Social Care Trust GP practice performance in measuring blood pressure in patients aged 45 years and over

Onceidentified,itisimportanttoensurethatallpatientswithhypertensionaretreatedeffectively.Thisismorechallenginginpatientswithotherchronicillnesses,likediabetes.However,Figure9showslittlevariationindiabeticbloodpressurecontrolbasedoninformationfromtheprimarycarequalityandoutcomesframework(QOF)lookedatbydeprivationareas.

Figure 9: Diabetic blood pressure control by deprivation decile

Forstaffdeliveringtheseservicesinprimarycare,therewilllikelybefurtherincreasesinworkloadsthroughhigherserviceactivityandeffortstoreachallinneedoftreatment.Theseseeminglyadverseeffectsarelikelytobebalancedinthelongertermthroughimprovedpopulationhealthandlessneedforhealthservicesinprimaryandsecondarycare.

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%1 2 3 4 5 6 7 8 9 10 NI


Belfast Trust Standard 10 -‐ KPI 10a -‐ % of pa8ents aged >45 yrs who have had a recorded BP on their GP record within the past 5 years. Target is 70%


465 to 582 (116)340 to 465 (116)220 to 340 (116)98 to 220 (117)0 to 98 (117)

Health & Social Care Trust Boundary






465 to 582 (116)340 to 465 (116)220 to 340 (116)98 to 220 (117)0 to 98 (117)







465 to 582 (116)340 to 465 (116)220 to 340 (116)98 to 220 (117)0 to 98 (117)




Source: QOF

22

Intheshortterm,patientsmightfeel‘medicalised’bybeingofferedtreatmentforaconditionwhichinitselfisnotcausingthemanysymptoms.Thiscanhaveadverseeffectsonmentalhealthandphysicalwellbeing.

Inlightofthis,theHIAmakesrecommendationsto:

• Addressvariationinprimarycareperformance.

• Integratehealthimprovementworkaimedatreducinghypertensionwiththewiderhealthimprovementactivitiesdiscussedin3.3.2.

3.3.4 Familial hyperlipidaemia (Section 4, Standard 12)12.Allpeoplewithfamilialhypercholesterolaemiashouldbeidentifiedandtreatedandtheirnamesenteredonaregionalregistersothatotherfamilymemberscanbeidentifiedinorderformeasurestobeintroducedtopreventthedevelopmentofcardiovasculardisease.

Thisstandardreferstoanestimated3,500peopleinNorthernIrelandlivingwithaninheriteddisorderthatresultsinahighlevelofcholesterolintheirblood.Thisputsthemathigherriskofcardiovasculardiseasethanothers.Justover500ofthispatientgrouphavebeenidentifiedtodateandarereceivingspecialisttreatment.Therefore,manypeoplewhohavetheconditionareunawareofitandarenotreceivingthetreatmenttheyneedtoreducetheirriskofcardiovasculardisease.ThissituationisnotuniquetoNorthernIrelandandexistsinotherpartsoftheUK.Toaddressthis,weneedto:

• Pursuefundingandimplementationofabusinesscaseforexpansionofaregionalhyperlipidaemiaserviceandestablishmentofaregionaldatabaseandgeneticsupportoutreachservice.

3.3.5 Diabetes (Section 5, Standards 13–15)13.Allpeoplewithdiabetesshouldhaveanaccuratediagnosismade.

14.Allpatientswithdiabeteshaveaccesstoeducationprogrammesandemotional/psychologicalsupport.Serviceswillencouragepartnershipindecisionmaking,supportinmanagingtheirdiabetesandhelptoadoptandmaintainahealthylifestyle.

15.Allpatientswithdiabetesshouldhaveaccessto,ataminimum,anannualreviewtoadefinedstandardbyanappropriatemulti-disciplinaryteam.

Therearewelldocumentedhealthinequalitiesandinequitiesforpeoplelivingwithdiabetes,andthesehavebeenconfirmedintheHIA.Theseincludesocioeconomicdisadvantage,ethnicity,ageanddisability.

23

Standard14(accesstostructuredpatienteducationprogrammesincludingpsychoemotionalsupport)wasfoundbytheHIAtobebesetbythelargestnumberofhealthinequitieswithintheCVSFW.ThisisbecauseofthepatchyavailabilityofsuchprogrammesacrossNorthernIreland.

TheHIAalsoidentifiedmanybarrierstostandardimplementationandpotentialnegativeeffectsonstaffthroughanincreaseindemandforservicesintheshorttomediumterm.Improvedandmoreequitableserviceprovisionontheotherhandwasthoughttobegoodforstaffmorale.

Fromaserviceuserperspective,theeffectsofstandardimplementationwereconsideredtobelargelybeneficialbothforpopulationandindividualhealth.Cautionwillbeneededtomeetpatientexpectationsforimprovedservicesandensurethatallpatientsgetthesupporttheyasindividuals,andtheirfamiliesorcarers,needtobenefitfrompatienteducationandselfmanagementprogrammes.

Thereareapproximately60,000peoplewithdiabeteslivinginNorthernIrelandandthisfigureissettoincreasesharplyunlesstheobesityepidemiccanbehaltedandreversed.

ItisthereforecriticalforthehealthandwellbeingofpeopleinNorthernIreland,andthesustainabilityofHSCservicesaswellasthewidereconomy,thatimprovementsinthepreventionandmanagementofdiabetesareachieved.

Inlightofthischallenge,theHIArecommendsthatastronginfrastructureisestablishedtodrivetheseimprovements:

• Establishregionalandlocalnetworkstofacilitateserviceimprovementincludingequitableaccesstostructuredpatienteducation(SPE).

3.3.6 Heart disease (Section 6, Standards 16–28) Congenitalheartdisease(ConHD)16.Allpregnantwomenshouldhaveappropriateantenatalscreeningforcongenitalheartdisease(ConHD),withspecialistservicesavailabletothoseinwhomadiagnosisof ConHD is made.

17.Allchildrenwithsuspectedmajorcongenitalandacquiredheartdiseaseshould have access to prompt diagnosis and appropriate management in line withministerialtargets.

18. All patients with suspected inherited cardiac disease should have accesstoaconsultant-ledservicespecificallydesignedtomeettheirneeds.

19.Alladultswithmajorcongenitalheartdiseaseshouldhaveaccesstoaspecialistconsultant-ledservicespecificallydesignedtomeettheirneeds.

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Thefirstfourstandardsintheheartdiseasesectionrefertoinbornandinheritedheartdisease,aswellaschildrenwhodevelopheartdisease.Theseconditionsdonotfollowasocioeconomicdistributionpattern.Lifeexpectancyinthisnumericallysmallbutgrowinggroupofpatientshasimprovedduetobettertreatmentoverrecentdecades.Whilesomeinvestmentshavebeenmade,moreisneeded.DetailedrecommendationsarisingfromtheHIArelatingtothesestandardsarecontainedinthehealthactionplan.SeeAppendix2.

Cardiacarrhythmia(irregularheartbeat)20.Allpatientswithadiagnosisofnonatrialfibrillationarrhythmiashouldreceivetimelyassessment,treatmentandsupportbasedonindividualneed.

21.Allpatientswithadiagnosisofatrialfibrillationshouldreceivetimelyassessment,treatmentandsupportbasedonindividualneed.

Heartfailure22.AllpatientswithaclinicalsuspicionofheartfailureshouldhaveaccesstoECGandBNP(abloodtest)forfirstlevelruleoutinaprimarycaresetting.

23.Allpatientswithadiagnosisofheartfailureshouldbeprescribedevidence-basedmedicationasappropriate,undertheguidanceofthemultidisciplinaryspecialistteam.

Myocardialinfarction24.AlleligiblepatientssufferinganacutemyocardialinfarctionwithST-segmentelevationheartattackshouldreceivethrombolysiswithinonehourofcallingforprofessionalhelp.

Cardiacrehabilitation25.Allpatientsidentifiedasrequiringcardiacrehabilitation,inlinewiththeregionalguidelines,shouldbeofferedthisservice.

Angina26.AllpatientswhodevelopnewonsetchestpainsuggestiveofanginashouldbereviewedatarapidaccesschestpainclinicwithintwocalendarweeksofreferralbytheGP/appropriateclinician.

27.AllhighriskpatientspresentingwithnonSTelevationacutecoronarysyndromesshouldundergoangiography/revascularisationwithin72hoursofdiagnosisinaccordancewithclinicalneed.

25

Pulmonaryhypertension28.Allpatientswithsuspectedpulmonaryarterialhypertensionshouldbemanagedinatimelyfashionbyaspecialistmultidisciplinaryteaminlinewithnationalspecialistcardiacassessmentgroups.

Heartdisease,withtheexceptionofitsinbornforms,tendstoaffectpeoplefromdisadvantagedbackgroundsmorecommonlyandmoreseverelythanothers,butthereisnoevidencefromprimarycareQOFdatathattreatmentvarieswithdeprivation.Figures10and11showmapsofGPpracticeswhichtreatatrialfibrillationinlinewithrecommendationsforbestpracticeinlessthan90%ofpatients,andthosewhodosoinover95%ofpatients.

Figure 10 Northern Ireland GP practice performance in treating atrial fibrillation


465 to 582 (116)340 to 465 (116)220 to 340 (116)98 to 220 (117)0 to 98 (117)




Standard 21 – KPI 21a -‐ % of pa3ents with AF who are currently treated with an3-‐coagula3on drug therapy or an an3-‐platelet therapy. Target is 90%.



465 to 582 (116)340 to 465 (116)220 to 340 (116)98 to 220 (117)0 to 98 (117)







465 to 582 (116)340 to 465 (116)220 to 340 (116)98 to 220 (117)0 to 98 (117)





This material is Crown Copyright and is reproduced with the permission of Land and Property Services under delegated authority from the Controller of Her Majesty’s Stationery Office, © Crown copyright and database rights NIMA ES&LA210.2 Source: QOF

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Figure 11 Belfast Health and Social Care Trust GP practice performance in treating atrial fibrillation

TheHIAconfirmedhealthinequalities,aswellasinequitiesinaccesstohospitalbasedcardiovascularservices.Thelatteraremostlyduetogeography,eitherbecausesomeservicesareonlyavailableincertaincentrallocationsordifficulttoaccessinruralareas.

IncommonwithothersectionsoftheCVSFW,theHIAidentifiedbarrierstoimplementationofstandardsandimpactsonstaffarisingfromincreasingdemandsforservicesintheshorttomediumterm.Itisimportanttomanagetheseadditionaldemandscarefullyandactivelyinsupportivewaysthatbuildsustainableservicecapacity.

Withanticipatedimprovementsinpopulationandindividualhealth,needforcardiacsurgeryandcardiologyservicesshouldreduceinthelongerterm,butdemandon,andneed for, community-based services is likely to increase as patients seek managementoflongtermillhealtharisingfromcardiovasculardiseaseclosertohome.

Recommendations arising from the HIA have been referred to the Northern IrelandCardiacNetworkforactionandinclude:

• Increase investment in congenital and inherited heart disease services to meet theneedsofagrowingpatientpopulation.


465 to 582 (116)340 to 465 (116)220 to 340 (116)98 to 220 (117)0 to 98 (117)





Standard 21 – KPI 21a -‐ % of pa3ents with AF who are currently treated with an3-‐coagula3on drug therapy or an an3-‐platelet therapy


465 to 582 (116)340 to 465 (116)220 to 340 (116)98 to 220 (117)0 to 98 (117)







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Source: QOF

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• Increaseinvestmentinthepreventionofatrialfibrillation.

• Supportpatientsintheiradherencetotreatment.

• Establishselfhelpgroupsforpatientswithheartfailure.

• Identifykeyworkersforpatientswithheartfailure.

• Introduceprogrammebudgetingandmarginalanalysistofacilitateallocationofresourcestothemanagementoflongtermconditions,includingheartfailure.

• Improvecommunication,throughdatalinkage,betweenprimaryandsecondarycareforpatientsneedingcardiacrehabilitation.

• Streamlinereferralsforpatientswithacutechestpainfromprimarytosecondarycarebyimprovingpatientpathways.

3.3.7 Cerebrovascular disease (Section 7, Standards 29–32)29.Allpatientswithsuspectedtransientischaemicattack(TIA)shouldhaverapidspecialistassessmentandinvestigationtoconfirmthediagnosisandshouldhaveamanagementplanurgentlyputinplacetoreduceshorttermandlongtermcardiovascularcomplications(seealsoStandard35).

30.Allpatientswithsuspectedacutestrokeshouldhaverapidaccesstospecialistassessment,appropriatebrainimagingandemergencytreatment,includingthrombolysis.

31.Allpatientswhohavehadastrokeshouldhavetheirrehabilitationdeliveredbyaspecialiststrokerehabilitationteaminastrokeunit,startingimmediatelyafteradmissiontohospital.

32.AllpatientswhohavehadastrokeorTIAarereviewedpostdischargebyprimarycareservicesatsixweeks,sixmonths,andannually.Strokepatientswithpersistingdisabilityatsixmonthsshouldbereviewedbyamemberofaspecialistteamtodeterminetheneedforafurthertargetedperiodofrehabilitation.Aspartofongoingreview,referraltoneuropsychologyservicesshouldbeconsideredwhereappropriate.

TheHIAconfirmedmanyhealthinequalitiesincerebrovasculardiseaseincludingsocioeconomicdeprivationandmembershipofanethnicminoritygroup.

RecentGPdatashowapicturethatisdifferentfromthesocioeconomicgradientusuallyassociatedwithcirculatorydiseases.Theleastdeprivedwardshavethehighestratesofstroke/TIAcomparedwiththeNorthernIreIandaverage.Themostdeprivedwardshavethesecondhighestrates(Figure12).

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Figure 12 Prevalence of stroke/TIA by population deprivation deciles, using NISRA or GP list information

Increasedprevalenceisreportedfromthe leastdeprivedareas,butthismayreflecttheolderageprofileofpeoplelivinginthoseareas,sinceprimarycareQOFdataarenotageadjusted.Thesedataneedtobeinterpretedwithcaution;inaddition,areaofresidenceisbeingusedasproxyforindividuals’socioeconomicstatusintheabsenceofeasilyavailablealternatives.

ThevariationbetweenGPlistbasedrates,andthosebasedonNorthernIrelandStatisticalandResearchAgency(NISRA)populationestimates,ismostnoticableinthemoredeprivedareas.Thisisconsistantwithotherwork,whichhashighlightedvariationbetweenGPlistdataandNISRApopulationestimates,especiallyinareasofgreaterBelfastwherethereisageographicalconcentrationofdeprivedareascomparedtotheremainderofNorthernIreland.

DuringtheHIA,concernsaboutinequitiesinaccesstoservicesandreferraltospecialistservicesforstrokepatientswereindentifiedforseveralstandardsinthissection.TherearemanybarrierstoimplementingtheCVSFWstandards,buttheHIAfindingsemphasisehowimprovedserviceswillleadtobetterstaffmoraleandmoreefficientuseofresourcesinthemediumtolongerterm.

Theeffectonstandardimplementationwillbemainlypositiveforpopulationhealthandthatofindividuals,theirfamiliesandcarers.Healthinequalitiesmightbereducedultimatelyifequityinservicedistributionandaccessforallpopulationgroupscanbeachieved.

20

15

10

5

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NISRArate GPrate

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e pe

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Manypositiveimpactsthroughimprovedcerebrovascularhealthandwiderdeterminantsofhealthwereidentified,includinglifestyleandpersonalcircumstances,socialandeconomicfactors.

ThemainsuggestionsfromtheHIAtotheregionalstrokestrategyimplementationgroupinclude:

• Implementagreedreferralpathways.

• Establisharegionallyavailable24/7thrombolysisservice.

• Sharegoodpracticebetweenserviceprovidersandusersthrougheffectivemechanisms,ienetworks.

3.3.8 Peripheral vascular disease (Section 8, Standards 33–38)Thestandardsforperipheralvasculardisease(PVD)refertodistinctconditionsandthereforeneedtobeconsideredseparately.Theyallcarryhealthinequalitiesandinequitiesinaccesstoservices,aswellasbarrierstoimplementationcommontootherserviceimprovementinitiatives,butvaryintheirimpactonhealthserviceprovidersandusers.Deprivationandbeingasmoker,olderpersonormalewereconfirmedintheHIAtopredisposetoPVD.

Peripheralvasculardisease33.AllpeoplewithahighriskofdevelopingPVDsuchaspatientswithdiabetes,chronickidneydisease,smokersandtheelderlyshouldhaveaccessibleandtimelycaredeliveredbyappropriatemembersofthemulti-disciplinaryfootcareteam.

36.Patientswithlegpainonexertion,suggestiveofperipheralarterialdisease,shouldhaveananklebrachialpressureindex(ABPI)testperformedinprimarycare.

Thesetwostandardsrefertoprimarycareservicesforpeopleeitheratriskof,orpresentingwith,PVD.

Theirimplementationwillimproveservicequalityforpatientsandthereforeimpactpositivelyontheir,andpotentiallyalsopopulation,health;butwillincreaseworkloadsinprimarycare.

Likeotherinterventionsaimedatriskfactorreductionandtreatmentofsymptomaticpeople,implementationofthesestandardsislikelytoincreasehealthinequalitiesbecauseofinequitableprovisionanduptakeofprimarycareservices.

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ThemainrecommendationsarisingfromtheHIAtothevascularnetworkare:

• Providesupporttoprimarycareteamsforparticipationin,anddeliveryof,PVDdirectenhancedservice(DES).

• ProvidealternativestoGPservicesthroughcommunitybasedprovision,especiallyindeprivedareas.

Aorticdisease34.Allpatientswithabdominalaorticaneurysm(AAA)shouldhavetheirmedicaltherapyoptimised,particularlyallpatientsshouldbeonstatintherapy.Aneurysmrepairshouldbeconsideredinpatientswhoseaneurysmexceeds5.5cmindiameter.Patientsshouldbeofferedopenorendovascularrepairifpossible.Allmenaged65shouldbeofferedAAAscreeninginlinewithnationalscreeningcommitteerecommendations.

37.Allpatientspresentingwithfeaturesofthoracicaorticdissectionshouldbeassessedandreferredimmediatelytoanappropriatemanagementcentre.

Thesetwostandardscovermanyaspectsofservicequalityimprovementforpeoplewithaorticdisease,fromscreening,todiagnosis,tosurgicaltreatmentandrehabilitation.

EarlyidentificationofAAAthroughscreeningreducesmortalityinmenandwillreducetheneedforemergencytreatment,whichhaspooreroutcomesthanplannedsurgery.Incommonwithotherscreeningprogrammes,AAAscreeningwill:increasetheworkloadforhealthserviceproviders;resultinanxietyandpotentialharmforpatientsfromdiscoveryandtreatmentofanotherwiseunknownhealthproblem;increasehealthinequalitiesandinequitiesifsomepeoplearemorelikelythanotherstoavailof,orbenefitfrom,screening.

AAAscreeningisonlyrecommendedformen,becausetheygetthediseasemoreoftenandatanearlieragethanwomen.

RecommendationsfromtheHIAtostaffresponsibleforvascularservicesinclude:

• IdentifyandaddressbarriersforpatientsinmakinginformedchoicesabouttreatmentforAAA.

• Raiseawarenessandimprovemanagementofthoracicaorticdissectionamongthepublicandprofessionals.

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Lymphoedema38.Allpatientswhoareatriskof,orwhohavedevelopedlymphoedema,shouldhaveaccesstotimelyinformation,diagnosisandtreatmentwithintheLymphoedemaNetworkinNorthernIrelandinaccordancewiththeCRESTlymphoedemaguidelines.

Thisstandardreferstothemanagementofaconditionthatcan,amongothers,complicatecancertreatment.Awarenessandavailabilityofimprovedserviceswillincreasedemandinitiallywheretherehasbeenunmetneed.Earlierandmoreproactivetreatment,ontheotherhand,willultimatelyreduceneedforservices.

Theimpactonstaff,arisingfromstandardimplementation,isthoughttobepositiveasaresultofimprovedsatisfactionthatcomeswithdeliveringbetterservicesdespiteincreasesinworkload.

Individualandpopulationhealthwillimprovequicklywithbettertreatmentofadisablingcondition,becauseitwillimprovepatients’qualityoflifeinrelationtoseveraldeterminantsofhealth,egbyallowingthemtoreturntowork.Healthinequalitiesandinequitieswillbereducedasservicecapacityincreasestomatchneed.

TheHIArecommendationstothelymphoedemanetworkcentreon:

• Providingawareness-raisingandtrainingtoserviceusersandprovidersinidentificationandmanagementoflymphoedema.

Cerebrovasculardisease35.AllpatientswhoexperienceananteriorcirculationTIAandcarotidarterystenosisof70–99%shouldbereferredtoavascularsurgeon,beinvestigatedandhavetheircarotidsurgerywithintwoweeksoftheevent.Thelongtermgoalshouldincludecarotidinterventionwithin48hours(seeStandard29,Section7onCVD,whichitissimilar).

3.3.9 Renal disease (Section 9, Standards 39–42)39.Allpatientswithadiagnosisofchronickidneydisease(CKD)shouldreceivetimely,appropriateandeffectiveinvestigation,treatmentandfollow-uptoreducetheriskofprogressionandcomplications.

40.Renalservicesaretoensurethedeliveryofhighquality,safeandeffectivedialysiscare,whichisdesignedaroundtheindividual’sneedsandpreferencesandareavailabletoallpatientsofallages.Thisshouldbedeliveredbyahighlyskilledmultiprofessionalworkforcetomaximisedialysiscapacity,improvequalityoflifeandreducecomplications.

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41.Allchildren,youngpeopleandadultslikelytobenefitfromakidneytransplantshouldreceiveahighqualityservice,whichsupportstheminmanagingtheirtransplantandenablesthemtoachievethebestpossiblequalityoflife.

42.Allpeopleatriskof,orsufferingfrom,acutekidneyinjury(AKI)acuterenalfailureshouldbeidentifiedpromptly,withhospitalservicesdeliveringhighquality,clinicallyappropriatecareinpartnershipwithspecialisedrenalteams.PreventionofAKIshouldbeapriorityforallcliniciansinbothprimaryandsecondarycare.

TherenalstandardsrefertobothAKIandCKDinthecommunity(Standards39and42)andthespecialisttreatmentofkidneyfailurewithdialysisandkidneytransplant(Standards40and41).

TheHIAidentifiedinequitiesinaccesstoservicesandservicequalityaswellasbarrierstoimplementationforallfourstandards,buthealthinequalitiesonlyforStandards39–40andpossiblyfor41,namelysocioeconomicdisadvantageandimpactsarisingfromthedifferentapproachesacrossNorthernIrelandtoprovidingvascularaccessfordialysis.

ImprovedserviceswereconsideredintheHIAtoincreaseworkloadsforcertainstaffbymovingpreferencesfromoneinterventiontoanother,butalsoleadtoincreasedsatisfactionamongserviceprovidersthatcomeswithdeliveringbetterservicesforpatients.Patientandpopulationhealthoutcomeswillultimatelyimproveasaresultofstandardimplementation,butearlieridentificationofCKDcouldworrysomepatients.

Healthinequalitiesandinequitiescouldbereducedifstandardscanbeimplementedfullytoreachallpopulationgroupsequitably,butespeciallywithStandard39(managementofCKDinprimarycare)andStandard40(accesstoevidence-baseddialysis services) health inequities might increase through differential access to andcompliancewithtreatment.

Impact on quality of life and wider determinants of health including lifestyle, personalcircumstances,socialandeconomicactivityislikelytobemainlypositive.

HIA recommendations to the regional renal implementation group included:

• Supportpatients,especiallythosefrommarginalisedgroups,inmanagingpsychosocial(anxietyandadherencetotreatment)aspectsofCKDidentificationandtreatment.

• Considerhomevisitsforhardtoreachpatients.

• Ensuregeographicalequityofvascularaccessfordialysisserviceprovision,inlinewithevidenceforbestpracticeacrossNorthernIreland.

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3.3.10 Palliative care (Section 10, Standards 43–45)43.HSCprofessionals,inconsultationwiththepatient,willidentify,assessandcommunicatetheuniquesupportive,palliativeandendoflifecareneedsofthatperson,theircaregiver/sandfamily.

44.Allpatients,carersandfamiliesshouldhaveaccesstoresponsive,integratedservices,whicharecoordinatedbyanidentifiedteammemberaccordingtoanagreedplanofcare,basedontheirneeds.

45.Allpeoplewithadvancedprogressiveconditions,theircaregiversandfamilies,willbeinformedaboutthechoicesavailabletothem,byanidentifiedteammember,andhavetheirdignityprotectedthroughthemanagementofsymptomsandprovisionofcomfortinendoflifecare.

Healthinequalitiesandinequitiesexistinrelationtothestandardsforpalliativecarewhich,likethecommunication,participationandhealthimprovementstandards,aregenericandsharedacrossserviceframeworks.Theseincludesocioeconomicdisadvantage,age,disabilityandlowliteracyoreducationalattainmentlevels,whichmitigateagainsthealthequalities.Variableavailabilityofservicescurrentlycreateshealthinequity.

Therearemanybarrierstoimplementationaswouldbeexpectedwithcomplexandmultifacetedserviceimprovementinterventions.TheeffectsonHSCproviderswillalsobevariable–encompassingbothpositiveimpactsarisingfrombetterandmoreintegratedserviceprovision,andnegativeconsequencesresultingfromincreasedworkloadsandthedemandsthatchangebringswithit.

Implementationofallstandardsisexpectedtoincreasebothdemand,duetohigherlevelsofawarenessamongserviceusers,andneedasaresultofbroadeningthescopeofpalliativecareservicestoincludelife-limitingconditionsotherthancancer.

Therewillbeimprovementstoindividualwellbeingandpopulationhealth,butresourcesareneededforexpansionofpalliativecareservices.

Also,therecouldbebothpositiveandnegativeeffectsonhealthinequalitiesandinequitiesarisingfromstandardimplementationifaccessto,andavailabilityof,palliativecare services is not evenly distributed among population groups, disease groups andgeographicalareas.

The positive effects of standard implementation on individual and population health willinpartcomefromimprovementsinthewiderdeterminantsofhealth,includingbetterlifestyleandpersonalcircumstances,economicandsocialfactors.

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ThesuggestionsfromtheHIAtotheregionalpalliativecarestrategyimplementationboardinclude:

• Increasehealthliteracythroughcommunitydevelopmentapproaches(whichwillbenefitotherHSCserviceareasalso).

• Engageespeciallywithvulnerable,andpotentiallymarginalised,populationgroupstoreducehealthinequities.

3.4 Overarching learning

BeyondtherecommendationsandinsightsrelatingtospecificsectionsandstandardsoftheCVSFWcontainedinthisreport,theHIAhasalsogeneratedsomelesstangible,butequallyimportantoutcomes.

3.4.1 Health inequalities and health and social care equityLikeanyotherhealthpolicyorstrategy,theCVSFWisintendedtoimprovehealthandwellbeingandtodosofairlyandsustainably.

TheHIAprovidesaqualitativeandquantitativeanalysisoftheCVSFW’sabilitytoachieveitsstatedaimsofimprovingaccesstoHSCservicesequitably,andultimatelycontributetoareductioninhealthinequalities.Itgivesclearunderstandingwhereadditionalstepsneedtobetakentoprotectvulnerablepopulationgroupsfromunintendedharms(increasedinequalitiesgap),whichcouldotherwiseresultfromimplementationoftheCVSFW.

HealthisnotevenlydistributedinNorthernIreland,noristheabilityofindividualswithinitspopulationtobenefitfromHSCinterventions.Weneedtobemindfulofthisifwewishtocontributetoreducingthehealthinequalitiesgap.

3.4.2 Health intelligence for health improvementImplementationoftheCVSFWhasthrownupmanychallengesforinformationsystemsanddatamanagementwithinHSCorganisations.TheHIAhasbroughttheseintosharpfocusbecauseitreinforcestheimportanceofmeasuringHSCperformanceandpopulationhealthoutcomes,beyondgeographicalareas,atthelevelofindividualsandinwaysthatlinktheinterplayoffactorswhichinfluencehealthandwellbeingforpeoplefromdifferentbackgrounds.

Thisposeschallengesforallsectors,shouldtheybegovernmental,statutory,voluntary,communityorprivateorganisationswithaninterestinhealthandsustainability,toworkondatalinkageandinformationsharing–withintheconfinesofdataprotectionlegislation–tocreateabetterunderstandingofhealthandwellbeinginNorthernIreland.

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Thislearninghasalreadybeensharedingovernmentalforumssothatitmaybenefitthedevelopmentofotherserviceframeworks,andultimatelyICTstrategicapproachesandoperationalsystemdevelopments.

3.4.3 Capacity building in learning organisationsThisHIAofhealthpolicyimplementationisthefirstofitskindontheislandofIreland.Manypeoplehavecontributed,learningnewknowledgeandskillsintheprocess.ThiswasenhancedbytheinvolvementofaninternationalexpertinHIA.ThiswillbenefitandstrengthenHSCorganisationsintheirendeavourstoimprovehealthandreducehealthinequitiesinthefuture.

Alreadymanyparticipants,includingmembersofthepublic,haveexpressedtheirappreciationforabetterunderstandingofhealth,itsdeterminantsanddistributionacrossNorthernIrelandandwhatthismeansforserviceprovidersandusers.

ThedisseminationstrategyfortheHIAincludesprintedandwebbasedpublications,apubliclaunchevent,speakingengagementsatnationalandinternationalconferencesandtrainingevents,aswellasotherscientificpublications.

Therewillbeanevaluationinearly2012toreviewprogress.

3.4.4 Participation, partnerships and networksDevelopment,implementationandtheHIAoftheCVSFWbynecessityanddesignembracetheprinciplesofparticipationanddependoncollaborativeworkingacrossagencies,organisations,communitiesandindividuals.

TheHIAhasaddedvaluetoHSCservicesbystrengtheningitsconnectionsbeyondinstitutionalboundaries.

Boththeprojectstructure,withitslargeanddiversesteeringgroup,andthewiderangingconsultativeprocesshavecreatedopportunitiesforfurtherinnovation.Theseincludecommunitydevelopmentapproachestoriskfactorreductionforcardiovasculardiseases,andstrongerlinkswiththevoluntaryandcommunitysectortosupportadvocacyforcardiovascularhealthimprovement.

36

Appendix 1

Management group and steering group members of the health impact assessment

HIA management group

Name Organisation

ChristineMcMaster(Chair) PublicHealthAgency

DianeAnderson PublicHealthAgency

LeslieBoydell BelfastHealthandSocialCareTrust

AvrilCraig PublicHealthAgency/PatientClientCouncil

FfionaDunbar HealthandSocialCareBoard

LouiseHerron PublicHealthAgency

ClaireHiggins InstituteofPublicHealthinIreland

EricaIson IndependentHIAPractitioner

SineadMalone StrokeServiceDevelopmentTeamNorthern IrelandChestHeartandStrokeAssociation

ElaineO’Doherty PublicHealthAgency

37

HIA steering group

Name Organisation

AdrianMairs(Chair) PublicHealthDirectorate,PublicHealthAgency

LoraineAdair CardiovascularServiceNurseManager,

SouthernHealthandSocialCareTrust

DianeAnderson HealthIntelligenceDepartment,PublicHealthAgency

LeslieBoydell BelfastHealthandSocialCareTrust

AvrilCraig BusinessSupportDirectorate,PublicHealthAgency(until

July2010);PatientandClientCouncil

IainDeboys BelfastLocalCommissioningGroup,

HealthandSocialCareBoard

FfionaDunbar InformationManagement,PublicHealthAgency(untilApril

2010);PerformanceManagementandService

ImprovementandDevelopment,HSCB

VeronicaGillen DepartmentofHealth,SocialServicesandPublicSafety

(untilApril2010)

MarkHarbinson ConsultantCardiologist,BelfastHealthandSocialCare

TrustandQueen’sUniversityBelfast

BrendanHeaney DiabetesUK

LouiseHerron PublicHealthDirectorate,PublicHealthAgency

ClaireHiggins InstituteofPublicHealthinIreland

EricaIson IndependentHIAPractitioner

StephanieLeckey BritishHeartFoundation

JimLivingstone DepartmentofHealth,SocialServicesandPublicSafety

HoustonMagee GeneralPractitioner,HealthandSocialCareBoard

SineadMalone NorthernIrelandChestHeartandStrokeAssociation

SheelinMcKeagney ChairofSouthernAreaLocalCommissioningGroup

ChristineMcMaster PublicHealthDirectorate,PublicHealthAgency

LizMcShane MaureenSheehanHealthyLivingCentre,WestBelfast

LornaNevin NorthernIrelandCancerNetwork

ElaineO’Doherty HealthImprovementDivision,PublicHealthAgency

JillianPatchett NorthernIrelandChestHeartandStrokeAssociation

EmmaQuinn PrescribingAdvisor,HealthandSocialCareBoard

JohnYarnell Queen’sUniversityBelfast(untilSeptember2010)

38

Appendix 2

Health Action Plan

Communication; standards 1-2

CVSFW Standard

1Allpatientsandcarersshouldexpecteffectivecommunicationwiththembyhealthandsocialcareorganisationsasanessentialanduniversalcomponentoftheplanninganddeliveryofhealthandsocialcare

HIA Suggestions

Ensurethathealthcareprofessionalsaccordappropriateprioritytoeffective,timelycommunicationwithpatientsandcarersandareprovidedtheopportunitytoreflectonanddiscussappropriateandeffectivemethodsofpatientengagement

Developandauditcommunicationpracticesandprocedures,whichencouragefeedbackfrompatientsandcarerstofacilitatedialogueandhelpunderstanding.

Communicationpracticesshouldensurethatwritteninformationisunderstandableandtailoredtotheneedsofdifferentpopulationgroupssuchasyoungpeople,vulnerable,disadvantagedormarginalisedgroups.Considercommunicationsneedsindifferentsettingandhowtoengagepeoplewithliteracydifficulties.Takeintoaccountthatdifferentpeoplepreferdifferentlevelsofengagement,andincorporateascertainingwhatlevelofengagementpeoplewantintotheprocessandgivethemachoice,subjecttowideconsultationwithappropriaterepresentationfromvariousgroups.

Developproceduresandmechanismstoensuregoodcommunicationamongallpartnersinvolvedinimplementationofthestandardandencouragehealthcareprofessionalsandcommunitygroupstolinkupandinformeachotheroftheopportunitiesavailableforinvolvementandengagement.Thiscanbeachievedbyprovidingpatientadviceservicese.g.withinHealthyLivingCentres(HLCs).

Stakeholders(Lead agency underlined)

HSCT,PHA,PCCGPs–NIMDTA,NMC,Professionaltrainingcourses,RQIA

PCC,HSCTasleadandRQIAtomonitorPHA,PCC,GPs–NIMDTANMC,Professionaltrainingcourses,GAINVoluntaryusergroupstoensurewritteninformationisunderstandable.

PCC,HSCTPHAHLCsUserGroups

Possible links or existing implementation opportunities

HSCTs–asregionalleadinareawouldhavealreadycommencedplanofworkinthisarea.

39

CVSFW Standard

2Allpatients,carersandthepublicshouldhaveopportunitiestoengageactivelyandmeaningfullywithhealthandsocialcareorganisationsatalllevels

HIA Suggestions

HealthcareorganisationsneedtoconductconsultationsaboutPublicandPatientInvolvementinawaythatmembersofthegeneralpublicandserviceuserscanrespondtoeasilyandeffectively.

DuringthedevelopmentofPatientandPublicInvolvementstrategies,andinanyinformationproduced,makecleartheopportunitiesavailabletoserviceuserstobecomeinvolvedandactivelyengaged.


Noleadasneedstobeelementofallhealthcareorganisations,includingHSCT,PCC,PHAthroughregionalPPIGroup

PHAAllhealthcareorganisationshavePPIconsultationschemesinplace


40

Health Improvement: standards 3-9

CVSFW Standard

3Healthandsocialcareshouldworkincooperationwithvoluntary,education,youthandcommunityorganisationstopreventtherecruitmentofyoungpeopletosmoking

HIA Suggestions

Develop,inacoherentway,aholisticevidence-basedprogrammewiththepartnersmentionedinthestandard

Increasesupport(staffandresources)forsmokingcessationfortheorganisationsmentionedinthestandard;ensurethesupportissustainableandimplementationisnotsimplyaone-offactivity

Undertakeindividualarea-basedneedsassessmentsandevaluationstoensurethattheprogrammesimplementedareeffectiveforthelocalpopulation

Ensureallstaffinvolvedfromallorganisationsarecommunicatingthesamemessagetoserviceusersaboutsmoking

Providetrainingforstaffinbriefinterventions,butensurethetrainingprovidedisappropriatetoeachorganisation

Developandestablishamentoringschemethatcanbeimplementedatalocallevel.

Developeducationprogrammesforparentstomakethemawareofthekeymessagesaboutsmoking

Implementabanonsmokinginopenspaces,incars,andinthepresenceofyoungpeople


PHA,HSCT,Voluntary/communityorgs,ELBs,DE

DHSSPS,PHA,ELB,HSCT,Voluntary/communityorgs,(UCF)

PHA,LCG,HLCVoluntary/communityorgs

PHA,LCG,HLC,Primarycare(PC),Voluntary/communityorgs,HSCT

HSCT,Voluntary/communityorgs,PHAresponsibilitytoCommission,PC

PHA–tocommissionandresourceHSCT,Voluntary/communityorgs,UCF

PHA,DE,HSCTVoluntary/communityorgs,Surestart

PHA,DHSSPSVoluntary/communityorgs,Localgovernment,NILGA


PHAcurrentlydevelopingTobaccoActionPlan/Strategy(detailsnotfullyknown).PHAhasbeenidentifiedasleadformajorityofsuggestionsinthissectionandcouldthereforeformacorecomponentofthiswork.

41

CVSFW Standard

4Allhealthandsocialcareprofessionalsshouldidentifypeoplewhosmoke,makethemawareofthedangersofsmoking,advisethemtostopandprovideinformationandthentosignposttothewelldevelopedspecialistcessationservicesavailable

HIA Suggestions

Ifthestandardappliesto“allstaff”,insertthestandardintomanagementobjectivesascorebusinessandincludeinstaffpersonaldevelopmentplans

Provideappropriatetrainingforhealthandsocialcareprofessionalstoensurestaffcanidentifywhetherpeoplearereadytostopsmoking,andbeclearontheirroleonadvisingpeople(e.g.opportunisticchatandsignpostingtoservices)

ImplementthestandardbyfocussingontargetgroupsandtargetsettingsasidentifiedintheNICEGuidance,whichneedstobeincorporatedintothestandard;ensurethatolderpeopleareconsideredasoneofthetargetgroups

Providesmokingcessationservicesatalocallevel,andaddresstheneedsofthelocalpopulation,e.g.needfortravel,andneedforchildcare


HSCT,HSCB,PHA,PCRQIA–toinspect

HSCT,HSCB,PHA,NIMDTA,Nursingtraining

PHA–asleadbutfocusisonrangeoforganisationstotakeforwardPC,Pharmacies,Localauthorities,Workplaces

Voluntary/communityorgs,PHA,HSCTPrimaryCare


Allorganisationshavetoinitiateandimplementthereforenoleadisidentified.

Nursingtrainingformotivationalinterviewingalreadyinplace.Notalwayseasytoimplemente.g.smokingoutsidedoorsathospitals.

42

CVSFW Standard

5Healthandsocialcareprofessionalsshouldidentifyinactive*individualsand,whereappropriate,providethemwithadviceandsupporttoaccumulatea minimumof30minutesofmoderateactivity**on5daysoftheweekormore

HIA Suggestions

Includethisstandardinthecorporateobjectivesoftheresponsibleorganisations,andamendstaffremitsaccordingly

Needtobespecificaboutwhich“healthprofessionals”aretobeinvolvedintheimplementationof/takeresponsibilityforthisstandard–isitallhealthworkersintheHPSSorjustadefinedgroup?

Needtoidentifymorepreciselyhowandwhenitisappropriatetoidentifyinactiveindividualsandprovidethemwithadviceandsupport,forinstance:whatismeantbytheuseof“support”inthewordingofthestandard;needtoincludechildrenandyoungpeopleintheidentificationof“inactiveindividuals”.ThereisalsoaneedtoensurethatappropriateagenciessuchasthePlanningServiceandlocalauthoritiesareinvolvedinrelationtoplanningopportunitiesforactivitysuchasopenspaceprovisionandgoodqualityfootpathsinruralareastosupportinactiveindividuals

Toascertainwhethertheimplementationofthisstandardisaffectingpeople’shealthstatus,amechanismforregularreviewneedstobeestablishedandakeyperformanceindicatordefined


DHSSPS–directionoftravel,PHACommunity/Voluntaryorgs,HSCTs,HSCBClinicalAdvisoryGroupinCardiacRehabilitation

DHSSPS-ServiceFrameworkInformaticsWorkingGroupPHA,HSCT,HSCB

DHSSPS,PHA,HSCT,HSCBLocalgovernmentDEDoEPlanningService

PHADHSSPS–SFWForumandinformaticsworkinggroupHSCB


UndertakinginPHABusinessPlantosupportimplementationoftheCVSFW(codeAmber)

TheNationalAuditandCardiacRehabilitationDatabasecontainshealthbehaviourinformationinrelationtopeoplewhohavehadangioplastiesorcardiacsurgery

InformaticsGroupalreadysetup–theycouldaddresshowinformationsystemscanbemodifiedtorecordstaffactivity.Itcouldworkinprimarycarebutprobablynotsecondary

JointWorkingArrangementsbetweenPHAandlocalgovernment–clustersfocusonobesityandphysicalactivity.

ObesityFrameworkisoutforconsultation–thiscouldbeusedtodefinegreaterdetailwithrespecttothisintervention,andtotakeforwardsomeofthesuggestionsfromtheHIAoftheCVSFW

Systemneedstobeputinplacetoenablethissuggestion/actiontohappen(see5.2);NorthernIrelandHealthSurveywillbeyearlyfrom2010andgathersinformationonself-reportedlevelsofphysicalactivity–couldalsoaskwhetherpeoplehadreceivedadvice

43

CVSFW Standard

5Healthandsocialcareprofessionalsshouldidentifyinactive*individualsand,whereappropriate,providethemwithadviceandsupporttoaccumulateaminimumof30minutesofmoderateactivity**on5daysoftheweekormore

HIA Suggestions

Developatrainingprogrammeonbriefinterventions.PHAneedstodevelopatrainingresourcethattakesaholisticapproachtobriefinterventionstopromotehealthylifestylechoices(notdevelopseparatetrainingprogrammesforeachdifferentlifestylefactor,e.g.diet,physicalactivity,alcoholconsumption).HSCstaffallneedtobetrainedsystematicallysothataconsistentmessageandapplicationaretheresult.FocusonearlyyearsandcontinuityacrossHSCsectors,incl.primaryandcommunitycare

Workinpartnershipwithlocalcouncils,privatesector,educationandvoluntarysectortoincorporateintotheimplementationofthisstandard,theneedtoincreasepeople’saccesstogreeninfrastructureandphysicalactivity.Concessionsforpeople/familiesinlow-incomegroupsneedstobeconsideredalongsidesupportinginactiveindividualsthroughworkplaceactivitiesandencouraginguseofactivetravele.g.provisionofbicycleracksandshowers


DHSSPS,PHA,HSCTrustsHSCBLCGsPrimaryCareDEandschools

PHA,HSCT,HSE?Localgovernment,includingChamberofCommerce,Community/Voluntarysector,includingSustrans,DE,DoEPlanningService,DRDRoadsServiceRuraltransportnetworks


LoughboroughmayhaveatrainingprogrammeonphysicalactivityandEatWellPlate.UseresultsfromHIAofNICVSFWtoinfluenceimplementationofObesityPreventionStrategicFramework

JointworkingarrangementsbetweenPHAandlocalgovernment

ImplementationofObesityPreventionStrategicFramework

CycletoworkschemeforPHA

CVSFW Standard

6Allpeopleshouldbeprovidedwithhealthyeatingsupportandadvice,appropriatetotheirneeds,inarangeofsettings

HIA Suggestions

Provideinformationindifferentlanguagestoreflectthoseusedbylocalpopulation.

Encouragepeopletogrowtheirownfruitandvegetables(whichwillalsoincreasetheirlevelofphysicalactivity).


HSCT

PHA–lead,DARDLocalgovernment


Section75oftheNorthernIrelandAct1998

Communityandvoluntarysectorprojects.Allotments

44

CVSFW Standard

7Healthandsocialcareprofessionalsshouldworkwithearlyyearssettings,schools,workplacesandcommunitiesinthepromotionandsupportofbreastfeeding,healthyeatingandphysicalactivitytopreventobesity

HIA Suggestions

SupporttheimplementationofthisstandardthroughthePrioritiesforActiontargetssetbytheDHSSPS

Identifythebarriersanddevelopappropriateinterventionsforactiveculturalchangewithinhealthandsocialcareservicestoenhancetheeffectivenessoftheimplementationofthisstandard,forexampleprovidetrainingforstafftoaddressthelackofcapacity

Encouragepeopletotakephysicalactivityoutdoors,e.g.workonanallotment


PHA


ThroughimplementationofObesityPreventionStrategicFramework‘AFitterFutureforAll’

45

CVSFW Standard

8Primarycareprofessionalsshouldidentifypeoplewhoconsumehazardous/harmfulamountsofalcohol,makethemawareofthedangers,advisethemtoreduceorstopandprovideinformationandsignpostingtospecialistservicesifappropriate

HIA Suggestions

Buildcapacitywithinprimarycaretoidentifyandsupportpeopleconsuminghazardousorharmfulamountsofalcoholtoreducetheirintake

Establishagreaternumberofcentrestosupportpeoplewhoconsumehazardousamountsofalcoholtoimprovesystemsofdeliveryofspecialistalcoholservices

Encourageparentsandcarerstospendtimewiththeirchildrensothatyoungpeopledonotstarttoconsumeharmfulamountsofalcoholfromanearlyage

Increasethelevelofeducationinschoolsabouttheharmsassociatedwithconsuminghazardousamountsofalcohol

Healthandsocialcarestaffincludingaccidentandemergencydepartmentstaffshouldworkwithcommunitygroupsasonewaytoreachpeoplewhoarehazardousorharmfuldrinkers,especiallythosewhoaredisadvantagedorexperiencinghealthinequalities


Primarycaretraining–NIMDTA,HSCTsupportstaff,HSCB,PHA,LCGsCommunitypharmacy

HLCs,HSCBVoluntary/CommunityorgsEDACT,DACT,FASA,CODAetcLCGsascommissioningagents

Surestart,HSCT,PHAParentingprogrammesinVoluntary/Communityorgs

DE,ELBs,PHA,HSCTLocalgovernment

A&Estaff–littlecapacityGPs–throughreferralfromA&E,Voluntary/Communityorgs,HSCT


LinkintoDrugsandAlcoholworkcurrentlyhappeningacrossNorthernIreland

Note–thisismoreasignpostingsuggestionduetonatureofA&Ework.

CVSFW Standard

9Healthandsocialcareprofessionalsshouldworkwithschools,workplacesandcommunitiestoraiseawarenessofandaccesstoemergencylifesupport(ELS)skills

HIA Suggestions

UsecommunitygroupstodeliverELS


PHA,BHF,HSCTs,LTCCommissioningGroup


Regionalbusinesscaseunderdevelopmenttofeedinto2011/12serviceplan

46

Hypertension: standards 10-11

CVSFW Standard

10Alladultsshouldbeofferedlifestyleadviceastothepreventionofhypertensionandhavetheirbloodpressuremeasuredandrecordedusingstandardisedtechniqueseveryfiveyearsfromage45years

11Allpatientsshouldbeoffereddrugtherapyiftheyhave(a)persistentbloodpressureof160/100mmHgormoreand/or(b)raisedcardiovascularrisk(10yearriskofcardiovasculardiseaseof20%orexistingcardiovasculardisease/targetorgandamage)withpersistentbloodpressureof140/90mm/Hg

HIA Suggestions

Advocateareductionintheamountofsaltinfood

Promoteworkplacehealthinitiatives,includingbloodpressuremeasurementandlifestyleadvice

Coordinateandstrengthenongoingworkincommunityandvoluntaryorganisations,outreachservices,communitypharmacyandprimarycareservicesinidentifyingandmanaginghypertensionandunhealthylifestylesthrough,amongstothers,casefindingandbriefinterventions

Involvepatientsinselfmanagement,i.e.bytrainingstaffinwaysofmaximisingconcordancewithdrugregimes

Workwithpharmaciestoimprovelevelsofcompliancewithdrugregimensthroughevidencebasedinterventions


PHA,NICHSA,Safefood,DHSSPS:MGPH

PHA,HSCT,NICHSA,BHFDETI

Pharmacies,PHAVoluntary/CommunityorgsPCstaff,LCGs/PCPsHSCTs,DHSSPS-longtermconditionsstrategy,HSCB(prescribingadvisors)


Healthinallpolicies!

DevelopsynergybetweendisparatehealthimprovementinitiativesaimedatpreventinglongtermconditionsincommunityandworkplacesettingsbyaligninghealthimprovementfunctionsofPHA,HSCB(primaryandcommunitycareincludingpharmacy),communityandvoluntaryorganisationsandpolicymakers.

47

Hyperlipidaemia: standards 12

CVSFW Standard

12Allpeoplewithgeneticallylinkedhighcholesterol(familialhypercholesterolaemia)shouldbeidentifiedandtreatedandtheirnamesenteredonaregionalregistersothatotherfamilymemberscanbeidentifiedinorderthatmeasurescanbeintroducedtopreventthedevelopmentofcardiovasculardisease

HIA Suggestions

Raiseawarenessofhyperlipidaemiainthegeneralpopulation

Providetrainingtoprimarycareteamsforeffectiveidentificationandmanagementofpeoplewithhyperlipidaemia

Providesupporttoidentifiedindexpatientsandfamilymembers,i.e.throughsupportgroups


HealthpromotionPCstaff

PCstaffCommunity/voluntaryorgswithaninterestincardiovasculardisease


Includeinawarenesscampaign

Progressbusinesscasefordevelopmentofregionalfamilialhyperlipidaemiaservice

Diabetes: standards 13-15

CVSFW Standard

13Allpeoplewithdiabetesshouldhaveanaccuratediagnosismade

HIA Suggestions

Raiseawarenessamongmembersofthepublicabouttheriskfactorsforandsymptomsofdiabetes,withstrategiesforreachingpeopleinhard-to-reachgroups,includingraisingthelevelofcommunity-basedawareness

Developcapacitythroughtrainingandskillsdevelopmentforidentificationandmanagementofdiabetes,especiallyinprimarycareandwithafocusontheprovisionofStructuredPatientEducation(SEP)

Improvecommunication,sharingofinformationandperformancemanagementbetweenprimaryandsecondarycarefromdiagnosisthroughcreationofpatientpathwaystosystemsofcaredevelopment


PHA,Community/Voluntaryorgs

PHA,HSCBPCstaff

PHA,HSCB,PCstaffSecondarycarestaff


Includeinawarenesscampaignforpreventionoflongtermconditions

Progressthroughdevelopmentofdiabetesnetworkandlongtermconditionscommissioninggroup

48

CVSFW Standard

16Allpregnantwomenshouldhaveappropriateantenatalscreeningforcongenitalheartdisease(ConHD),withspecialistservicesavailabletothoseinwhoma diagnosisofConHDismade

17AllchildrenwithsuspectedmajorcongenitalandacquiredheartdiseaseshouldhaveaccesstopromptdiagnosisandappropriatemanagementinlinewithMinisterialtargets

Heart Disease: standards 16-28The following suggestions have been presented to the Cardiac Network for consideration

HIA Suggestions

Increaseinvestmentinservicedeliveryforcongenitalheartdisease,includingtrainingforhealthcareprofessionals,andinequipment

Improvethequalityofinvestigationforcongenitalheartdisease,especiallyinareahospitals

Increasetheefficiencyoftheserviceinprocessingtheresultsofinvestigationforcongenitalheartdisease

EnsurethecapacityisavailableintheBelfastRegionalCentretomeettheincreaseddemandasaresultoftheimplementationofthisstandard

Developaclearlydefinedreferralpathwayforcongenitalheartdisease

Conductoutcomesevaluation,andongoingauditofscreeninganddiagnosisofcongenitalheartdisease

Undertakehealtheconomic/outcomesassessmenttocontroltheopportunitycostsofcongenitalheartdisease

Increaseinvestmentinequipmentandinservicedeliveryforchildrenwithcongenitalheartdiseaseandacquiredheartdisease,includingtrainingforhealthcareprofessionals

Increaseawarenessamonghealthcareprofessionalsoftheneedsofchildrenwithcongenitalheartdiseaseandacquiredheartdiseaseexperiencinghealthinequalitiesandinequities

Providepost-natalsupporttochildrenandtheirfamiliesand/orcarers,especiallyforchildrenfromlowersocio-economicgroupsorwhoarefromvulnerableormarginalisedgroupsinsociety

Considerthedevelopmentofcross-borderservicesforthetreatmentofchildrenwithcongenitalheartdiseaseandacquiredheartdiseaseinordertoobtaintheappropriatelevelofskillsintheoperator(surgeon)

Conductoutcomesevaluation,andongoingauditofthetreatmentofchildrenwithcongenitalheartdiseaseandacquiredheartdisease

Increasetheefficiencyoftheserviceinprocessingtheresultsofinvestigationsforcongenitalheartdiseaseandacquiredheartdiseaseinchildren

Undertakehealtheconomic/outcomesassessmenttocontroltheopportunitycostsoftreatingchildrenwithcongenitalheartdiseaseandacquiredheartdisease

49

CVSFW Standard

18Allpatientswithsuspectedinheritedcardiacdiseaseshouldhaveaccesstoaconsultantledservicespecificallydesignedtomeettheirneeds

HIA Suggestions

Reviewthecurrentprovisionofservicesforpeoplewithsuspectedinheritedcardiacdisease,andconsiderincreasinginvestmentinservicedelivery,includingtrainingforhealthcareprofessionals,andinequipment

Providesupporttoindividualswithinheritedcardiacdiseaseandtheirfamiliesand/orcarers,especiallyforthosefromlowersocio-economicgroupsorwhoarefromvulnerableormarginalisedgroupsinsociety

Increaseawarenessamonghealthcareprofessionalsofthespecialistservicesavailableforpeoplewithsuspectedinheritedcardiacdisease

Increasetheefficiencyoftheserviceinprocessingtheresultsofinvestigationforsuspectedinheritedcardiacdisease

Conductoutcomesevaluation,andongoingauditoftreatmentandaccesstoservicesforinheritedcardiacdisease

50

CVSFW Standard

19Alladultswithmajorcongenitalheartdiseaseshouldhaveaccesstoa specialistconsultantledservicespecificallydesignedtomeettheirneeds

HIA Suggestions

Increaseawarenessinsecondaryandtertiarycareoftheneedsofpatientswithadultcongenitalheartdisease

Increaseinvestmentinequipmentandinservicedeliveryforpatientswithadultcongenitalheartdisease,includingtrainingforhealthcareprofessionals

Ensurethereissufficientcapacityinadultcongenitalheartdiseaseservicestoprovidecareforanincreasingpopulation,including:• Investigations(echocardiographyandMRI);• Interventions;• Cardiacsurgery.

Developaneffectivereferralpathwayintospecialistservicesforadultswithcongenitalheartdisease

Increasetheefficiencyoftheserviceinprocessingtheresultsofinvestigationforadultcongenitalheartdisease

Ensuredirectaccesstoservicesviaaspecialistnurse

Developnurse-ledtransitionservicesforyoungpeopleaged14-16years

Provideclinicalpsychologysupportandpalliativecareservices

Providesupporttopatientsandtheirfamiliesand/orcarers,especiallyforpatientsfromlowersocio-economicgroupsorwhoarefromvulnerableormarginalisedgroupsinsociety

Conductoutcomesevaluation,andongoingauditoftreatmentofandaccesstoservicesforadultcongenitalheartdisease

DevelopanetworkwithotherservicesforadultswithcongenitalheartdiseaseintheUK

Undertakehealtheconomic/outcomesassessmenttocontroltheopportunitycostsofadultcongenitalheartdisease

51

CVSFW Standard

20Allpatientswitha diagnosisofnon-atrialfibrillationarrhythmiashouldreceivetimelyassessment,treatmentandsupportbasedonindividualneed

21Allpatientswitha diagnosisofatrialfibrillationshouldreceivetimelyassessment,treatmentandsupportbasedonindividualneed

HIA Suggestions

Investinincreasingaccesstoservicesfornon-atrialfibrillationarrhythmia

Investinstafftraining

Developtheappropriateskillsmixinservicesforpatientswithnon-atrialfibrillationarrhythmia

Developasharedcareprotocolbetweenprimaryandsecondarycare

Supportpatientsinthedevelopmentofself-managementskillsthroughgood-qualitypatienteducation

Ensureallpatientswithnon-atrialfibrillationarrhythmiaarefollowedupbyHSCservices

Monitorandevaluatetheoutcomesofservicesforpatientswithnon-atrialfibrillationarrhythmia

Conductacost-effectivenessassessmentofservicesforpatientswithnon-atrialfibrillationarrhythmia

Establishmechanismsforpatientfeedbackonservicesfornon-atrialfibrillationarrhythmia

Conductongoingqualityimprovementinservicesfornon-atrialfibrillationarrhythmia

Considerconductingopportunisticscreening/casefindingwhilepatientsareinhospitalforotherreasons,e.g.forpre-operativework-uporwhenhospitalisedwithanothercondition

Increaseinvestmentinthepreventionofatrialfibrillation

Increasetheamountofresourcesforfrontlinestaffintheidentificationandmanagementofpeoplewithatrialfibrillation

Identifyandensuretheappropriateskillsmixfortheidentificationandmanagementofpeoplewithatrialfibrillation

Targethighriskgroupsforidentificationofatrialfibrillation,e.g.peoplewithhypertension

Undertakeincidentalfindinginveryfrailelderlypeople–sometreatmentriskinthisgroup

Undertakeregularreviewsofpatientmedication

Increasepatientadherencetotreatment

Introducechangemanagementandqualityimprovementinitiativestoreducehealthinequities

Includekeyperformanceindicatorsthataddressthediagnosisandassessmentofpatientswithatrialfibrillation

52

CVSFW Standard

22AllpatientswithaclinicalsuspicionofheartfailureshouldhaveaccesstoECGandBNPforfirstlevelruleoutinaprimarycaresetting

HIA Suggestions

Runtrainingcoursesandprovideregularupdatesforprimarycareteamsintheappropriateuseofdiagnostictest(BNPandECG)

Increasetheuseofpatientpathwaysinthemanagementofpeoplewithheartfailure

Increasetheuseofreferralsystems(electronic)inthemanagementofpeoplewithheartfailure,includingupdatingprimarycareteamsonappropriatereferral

Workwithandtrainpracticenursesinthemanagementofshortnessofbreath

Establishself-helpgroupsforpeopleheartfailure

Undertakeregularreviewsofpatientmedicationforheartfailure

Eitherre-wordthestandardoraltertheKPI–thestandardconcernsrulingoutheartfailureinaprimarycaresetting,andtheKPImeasuresthepercentageofpatientsreferredtoaspecialistheartfailureservices

Definea“specialistheartfailureservice”(mentionedinKPI)

53

CVSFW Standard

23Allpatientswithdiagnosisofheartfailureshouldbeprescribedevidence-basedmedicationasappropriate,undertheguidanceofthemultidisciplinaryspecialistteam

HIA Suggestions

Enhancethecapacityofmultidisciplinaryteams

Encourageandmonitortheregionalstandardisationoftheserviceprovidedbymultidisciplinaryteams

Ensuretheoverallclinicalleadershipforthemanagementofheartfailurepatientsismadeclearineachcase

Considertheuseofnurseprescribersinthemanagementofpatientswithheartfailure

Considerwaysofensuringcontinuityofcareforpatientswhenseveralhealthcareprofessionalsareinvolvedintheirmanagement,e.g.identifyingakeyworkerforpatients

Considertheprovisionofa24/7serviceforpatientswithheartfailure

Ensurethereiscapacityintheservicetosupportqualityimprovement,andthenecessarychangemanagementprocesses

Developacoherentplanforthemanagementoflocalapproachestocommissioninghealthcareservices(LocalCommissioningGroups)

Considerwaystoredistributefundingequitablyfromthevoluntarysectortohealthandsocialcaretrusts

Monitorexpenditureonandinvestmentinheartfailureservices

Reviewthefundingandresourcesforheartfailureservices

Considertheintroductionofprogrammebudgetingandmarginalanalysistofacilitatetheallocationofresourcesforheartfailureservices

Establishacentralpointofcontacttoimprovecommunicationbetweenprimaryandsecondarycareaboutpatientswithheartfailure

Setupandmaintainastrategiccentralservertocollectweb-baseddatatosupportthemanagementofpatientswithheartfailure

54

CVSFW Standard

25Allpatientsidentifiedasrequiringcardiacrehabilitation,inlinewiththeregionalguidelines,shouldbeofferedthisservice

26Allpatientswhodevelopnewonsetchestpain,suggestiveofanginashouldbereviewedatarapidaccesschestpainclinic(RACPC)within2calendarweeksofreferralbytheGP/appropriateclinician

27AllhighriskpatientspresentingwithnonSTelevationacutecoronarysyndromesshouldundergoangiography/revascularisationwithin72hoursofdiagnosisinaccordancewithclinicalneed

28AllpatientswithsuspectedpulmonaryarterialhypertensionshouldbemanagedinatimelyfashionbyaspecialistmultidisciplinaryteaminlinewithNSCAGcentres

HIA Suggestions

Increasecapacitytodeliverrehabilitationservices,e.g.bytrainingthetrainers

Identifymechanismsofcollaborationbetweenprimaryandsecondarycare

Setupdatalinkagesystemsbetweenprimaryandsecondarycare

ImprovethemonitoringoftheKPI

Considerthedevelopmentofapatientmanualofcardiacrehabilitationservices

EstablishastructuredreferralprocessforGPs

Auditinappropriatereferrals,andusetheresultstoimprovepracticesinreferral

Consideranincreaseinthenumberofclinicsabletoofferchestpainservices

Toachieveequity,considerdifferentmodelsofprovidingchestpainservices

ImplementNICErecommendationsforthemanagementofchestpain

Providetrainingandeducationforhealthcareprofessionals,includingteam-buildingskills

Undertakemonitoringandevaluationoftheserviceprovided

Providefeedbackonperformancetostaff,e.g.throughuseofanelectronicwhiteboard

AuditservicesagainstEuropeanstandardstoimproveunderstandingofoutcomes

Reviewthecarepathwaysforsuspectedpulmonaryarterialhypertension

IntroduceeffectivechangemanagementforserviceprovidersnotcomplyingwithNSCAGrequirements

Providefeedbackonperformanceinthemanagementofpulmonaryarterialhypertension

55

CVSFW Standard

29Allpatientswithsuspectedtransientischaemicattack(TIA)shouldhaverapidspecialistassessmentandinvestigationtoconfirmthediagnosisandshouldhaveamanagementplanurgentlyputinplacetoreduceshorttermandlongtermcardiovascularcomplications.(SeealsoStandard35)

HIA Suggestions

EnsuretheimplementationofNICEguidance

ConductanauditofcompliancewithNICEguidance

Ensurethereisafocusonsecondarypreventionthroughouttheservice

ConductaprogrammetoraiseawarenessamongprimaryandsecondarycarestaffofthesymptomsandsignsofsuspectedTIA,includinginformationonreferralandcarepathways

EnsurethereiscapacityinTIAclinicstoprovideanequitableservice

Establishanagreedreferralpathwayforpeoplerequiringcarotidendarterectomy

Providetrainingintheuseoftheagreedreferralpathway,andprovideGPswithaccesstoimmediatespecialistadviceonTIAsymptoms,toavoidinappropriatereferrals

EstablishlinksbetweentheTIAserviceandotherrelevantservicessuchasthediabetesserviceandthecardiacservice

EmployspecialistnursesforTIAandstroke

Increaseaccesstourgentscanningthroughtheinvestmentofresourcesorthroughre-organisationoftheservice

Cerebrovascular Disease: standards 29-32The following suggestions have been presented to the Stroke Strategy Implementation Group for consideration

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CVSFW Standard

30Allpatientswithsuspectedacutestrokeshouldhaverapidaccesstospecialistassessment,appropriatebrainimagingandemergencytreatment,includingthrombolysis

31AllpatientswhohavehadastrokeshouldhavetheirrehabilitationdeliveredbyaSpecialistStrokeRehabilitationTeaminaStrokeUnit,startingimmediatelyafteradmissiontohospital.Specialiststrokerehabilitationfocusesonassessingtheindividualneedsofpatientsand,inconsultationwiththepatientandtheirfamily/carer(s),addressingtheminthemosteffectiveway.Ongoingspecialistrehabilitationneeds,asdefinedbytheTeam,shouldcontinuetobedeliveredbyaSpecialistStrokeRehabilitationTeam

HIA Suggestions

Conductaprogrammetoraiseawarenessamongprimaryandsecondarycarestaffofthesymptomsandsignsofsuspectedacutestroke,includinginformationonreferralandcarepathways

Auditthecarepathwayforstroke

Establisharegionalthrombolysisservicethatisavailable24/7

Developanappropriateservicemodeltotakeaccountofhealthinequities,whichisalsopracticalsopeoplearenotputatrisk

Obtaininformedconsentfrompatientswiththeprovisionofgood-qualityinformation

Setupmechanismsforsharingbestpractice

Establishmentoringschemestoimprovestaffcompetencies

Provideappropriatetrainingtohealthcareprofessionalstoensurethattheyareabletodelivertheservicedescribedinstandard30

Ensurearegionalcoordinatedandnetworkedapproachtotheprovisionofstrokeservices

EnsureacoordinatedapproachtostrokecareacrossNorthernIreland

Conductauditsofrehabilitationservicesforstrokepatients

Improveteam-workingbetweenrehabilitationteamsworkingintheacutesectorandthoseworkinginthecommunity

stablishmechanismsbywhichhealthcareprofessionalscansharegoodpracticeintheprovisionofstrokerehabilitationservices

Provideaskillsdevelopmentprogrammetoincreasestaffcompetenciesintherehabilitationofpeoplewithstroke

Introduceasystemforring-fencingbedsforpeoplewithstrokewhoneedrehabilitation

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CVSFW Standard

32AllpatientswhohavehadastrokeorTIAarereviewedpostdischargebyprimarycareservicesat6weeks,6months,andannually.Strokepatientswithpersistingdisabilityat6monthsshouldbereviewedbyamemberofaspecialistteamtodeterminetheneedforafurthertargetedperiodofrehabilitation.Aspartofongoingreviewreferraltoneuropsychologyservicesshouldbeconsideredwhereappropriate

HIA Suggestions

Establishasystematicapproachtothefollow-upofpeoplewithstrokethatwillensureallpatientsarefollowedupregardlessoflocationorlevelofsocialsupport

Providetrainingforprimarycarestafftoenablethemtocarryoutreviewseffectively,aswellaspromotinglifestylechangesforhealthimprovement,e.g.smokingcessation

Ensurethatreviewsareholistic,patient-centred,andareconductedbyamultidisciplinaryteam

Establisheffectivemechanismsforcommunicationandcoordinationbetweenprimaryandsecondarycare,especiallywithrespecttocommunicatingtheresultsofreviews

Providepeoplewithstrokewithinformationontherelevantvoluntarysectororganisationswhichcanprovidesupport

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CVSFW Standard

33AllpeoplewithahighriskofdevelopingPVDsuchaspatientswithdiabetes,chronickidneydisease,smokersandtheelderlyshouldhaveaccessibleandtimelycaredeliveredbytheappropriatemembersofthemulti-disciplinaryfootcareteam

34Allpatientswithabdominalaorticaneurysm(AAA)shouldhavetheirmedicaltherapyoptimised,particularly,allpatientsshouldbeonstatintherapy.Aneurysmrepairshouldbeconsideredinpatientswhoseaneurysmexceeds5.5cmindiameter.Patientsshouldbeofferedopenorendovascularrepairifpossible.Allmenaged65shouldbeofferedAAAscreeninginlinewithNationalScreeningCommitteerecommendations.

35AllpatientswhoexperienceananteriorcirculationTIAandcarotidarterystenosisof70-99%shouldbereferredtoavascularsurgeon,investigatedandhavetheircarotidsurgerywithin2weeksoftheevent.Thelongtermgoalshouldincludecarotidinterventionwithin48hours(SeealsoStandard29)

HIA Suggestions

EncourageallGPpracticestoparticipateintheperipheralvasculardiseaseDES

Provideongoingtrainingforprimarycarestaff

AdviseGPstouseopportunisticapproacheswithmenwhodonotattendtheservice

Engagewithmen’shealthgroupstoprovidealternativecommunity-basedservicesinareasofdeprivation

EnsuretheequitablegeographicalprovisionofAAAscreeningservicesacrossNorthernIreland.

IdentifyandaddressbarrierstopatientsbeingabletomakeaninformedchoiceabouttreatmentforAAA

UndertakequalityimprovementoftheAAAservicewithatargetofreducingmortalitytonationalstandards

EstablishacontinuouscarepathwayforpeoplewithananteriorcirculationTIAandacarotidarterystenosisof70-99%thatisclearandcanbeaccessedeasily

Peripheral Vascular Disease: standards 33-38The following suggestions have been presented to the Vascular Network for consideration

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CVSFW Standard

36Patientswithlegpainonexertion,suggestiveofperipheralarterialdiseaseshouldhaveananklebrachialpressureindex(ABPI)testperformedinprimarycare

37Allpatientspresentingwithfeaturesofthoracicaorticdissectionshouldbeassessedandreferredimmediatelytoanappropriatemanagementcentre

38Allpatientswhoareatriskof,orwhohavedevelopedlymphoedema,shouldhaveaccesstotimelyinformation,diagnosisandtreatmentwithintheNorthernIrelandLymphoedemaNetworkinaccordancewiththeCRESTLymphoedemaGuidelines

HIA Suggestions

EncourageallGPpracticestoparticipateintheperipheralvasculardiseaseDirectEnhancedService

Provideongoingtrainingforprimarycarestaff

Developagreedreferralguidelinesbetweenprimarycareandthevascularservice

Raiseawarenessofthoracicaorticdissectionamongthepublicandhealthandsocialcareprofessionals

ProvidetrainingintheidentificationandmanagementofthoracicaorticdissectionforGPs

Providetrainingintheidentificationandmanagementofthoracicaorticdissectionforclinicians,especiallythoseincardiologyservicesandtheemergencydepartment

Developguidancegoverningthereferralandmanagementofthoracicaorticdissection

Raiseawarenessoflymphoedemaamongpatientsandclinicians

Providetrainingintheidentificationandmanagementoflymphoedematoclinicians

ProvideadequateresourcestotheLymphoedemaNetwork,inparticulartoenabletimelydataentryontotheLymphDatITSystem

Identifyandenhancemethodsforthepreventionoflymphoedema

Ensureequitablegeographicalaccesstolymphoedemaservices

Developandprovidepatientinformationonlymphoedemaanditseffectivepreventionandmanagement

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CVSFW Standard

39Allpatientswithadiagnosisofchronickidneydisease(CKD)shouldreceivetimely,appropriateandeffectiveinvestigation,treatmentandfollow-uptoreducetheriskofprogressionandcomplications

40Renalservicesaretoensureadeliveryofhighquality,safeandeffectivedialysiscarewhichisdesignedaroundtheindividual’sneedsandpreferencesandareavailabletoallpatientsofallages.Thisshouldbedeliveredbyahighlyskilledmulti-professionalworkforcetomaximisedialysiscapacity,improvequalityoflifeandreducecomplications

41Allchildren,youngpeopleandadultslikelytobenefitfromakidneytransplantshouldreceiveahighqualityservicewhichsupportstheminmanagingtheirtransplantandenablesthemtoachievethebestpossiblequalityoflife

HIA Suggestions

Developmechanismsforthepro-activefollow-upbyprimarycareofpeopleatrisk

Ensuretheavailabilityofspecialistnephrologyadvice

Providetrainingforprimarycarestaffinthemanagementof

chronickidneydisease

Identifywaystoincreasecompliancewithtreatment,particularly

inpeoplefromvulnerable,disadvantagedormarginalisedgroups

Providetailoredsupportpackagesforhard-to-reachgroups,e.g.

homevisits

Developpracticestomanagepatientanxiety

IdentifyadatasourceofinformationforKPI39d,anddevelopan

appropriateinformationsystem

Ensuregeographicalavailabilityofdialysisservicesacross

NorthernIreland

Increasetheinputofvascularsurgeonstotheprovisionof

vascularaccess

Identifywaystoreducesurgicalrisk

Resourceanddevelopasustainablerenaltransplantation

service

Developappropriatemechanismstoobtaindonorconsent,and

toprovidesupporttothedonor’sfamilyand/orcarers

Renal Disease: standards 39-42The following suggestions have been presented to the Renal Sub-group for consideration

61

CVSFW Standard

42Allpeopleatriskof,orsufferingfrom,acutekidneyinjury/acuterenalfailureshouldbeidentifiedpromptly,withhospitalservicesdeliveringhighquality,clinicallyappropriatecareinpartnershipwithspecialisedrenalteams.PreventionofAKIshouldbeapriorityforallcliniciansinbothprimaryandsecondarycare

HIA Suggestions

Ensureappropriatedisseminationofguidance

Ensureimplementationoftheguidance

Audittheimplementationoftheguidance

IncorporateguidanceintotheNorthernIrelandCardiovascularServiceFramework

Ensurethatthemanagementofacutekidneyinjuryisincludedintrainingforbothundergraduateandpostgraduateclinicalstudentsandstaff

Providetrainingforhealthcareprofessionalsinvolvedintheidentificationandmanagementofpeoplewithacutekidneyinjury

62

CVSFW Standard

43Healthandsocialcareprofessionals,inconsultationwiththepatient,willidentify,assessandcommunicatetheuniquesupportive,palliativeandendoflifecareneedsofthatperson,theircaregiver/sandfamily

44Allpatients,carersandfamiliesshouldhaveaccesstoresponsive,integratedserviceswhicharecoordinatedbyanidentifiedteammemberaccordingtoanagreedplanofcare,basedontheirneeds

45Allpeoplewithadvancedprogressiveconditions,theircaregiversandfamilies,willbeinformedaboutthechoicesavailabletothem,byanidentifiedteammember,andhavetheirdignityprotectedthroughthemanagementofsymptomsandprovisionofcomfortinendoflifecare

HIA Suggestions

Consideridentifyingabudgetforpalliativeandend-of-lifecareacrossallrelevantprogrammesofcare(andnotjustcancer),therebydevelopingafundingstreamforeachconditionand/orserviceframeworkEstablishsupportnetworksfortrainingandeducationinpalliativeandend-of-lifecare

Defineclearlytherolesandresponsibilitiesofhealthcareprofessionalsinrelationtotheprovisionofpalliativeandend-of-lifecare

Conductqualitativeresearchonpalliativeandend-of-lifecareserviceswithindividualsreceivingcareandtheirfamilies,andensurerepresentationofthepopulationacrossNorthernIreland

Monitorandevaluatetheeffectsoftheimplementationonhealthinequalitiesandhealthinequities

Ensurethereareappropriateprotocolsinplacetomanagepalliativeandend-of-lifecare

ReviewwhetherstaffinglevelsareappropriatefortheimplementationofStandard44

Reviewtheinvestmentrequiredtosupportchoiceforindividualsduringpalliativeandend-of-lifecare

DefinetheroleofthePatientClientCouncilinrelationtopalliativeandend-of-lifecare

Developaprogrammewiththevoluntarysectortoincreasehealthliteracyaboutpalliativeandend-of-lifecare,usingacommunitydevelopmentapproach

Engagewithvulnerable,disadvantagedandmarginalisedgroupsinordertodefinetheirneedsforandincreasetheiraccesstopalliativeandend-of-lifecare

Palliative Care: standards 43-45The following suggestions have been presented to the Palliative Care Implementation Board for consideration

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CVSFW Standard

3Healthandsocialcareshouldworkincooperationwithvoluntary,education,youthandcommunityorganisationstopreventtherecruitmentofyoungpeopletosmoking

5Healthandsocialcareprofessionalsshouldidentifyinactiveindividualsand,whereappropriate,providethemwithadviceandsupporttoaccumulateaminimumof30minutesofmoderateactivity

24AlleligiblepatientssufferinganacutemyocardialinfarctionwithST-segmentelevationheartattackshouldreceivethrombolysiswithinonehourofcallingforprofessionalhelp.

29Allpatientswithsuspectedtransientischaemicattackshouldhaverapidspecialistassessmentandinvestigationtoconfirmthediagnosisandshouldhaveamanagementplanurgentlyputinplacetoreduceshorttermandlongtermcardiovascularcomplications.(SeealsoStandard35)

30Allpatientswithsuspectedacutestrokeshouldhaverapidaccesstospecialistassessment,appropriatebrainimagingandemergencytreatment,includingthrombolysis

HIA Suggestions

Developpublicitymaterialforallorganisationsandindividualstrainedinserviceprovisionatalocallevel

Communicateandpromotethepositiveoutcomesofstandardimplementation,especiallytostaffsotheycanseethebenefitsoftheirwork

Increasethenumberofhealthpromotioninformation“films”onthetelevision

Increasepublicawarenessofthemainmessage,“Phone999”,whenpeoplearehavingaheartattack,includingthroughtheuseofadvertising

Conductapublicawarenesscampaignaboutthesymptomsandsignsoftransientischaemicattack(TIA),includingwhattodoandwheretogo;ensurethecampaignisabletoreachpeoplewhoarevulnerable,disadvantagedormarginalised

Conductapublicawarenesscampaignaboutthesymptomsandsignsofstroke,includingwhattodoandwheretogo;ensurethecampaignisabletoreachpeoplewhoarevulnerable,disadvantagedormarginalised

The remaining HIA suggestions represent those which refer to public awareness campaigns. These are listed below for considered by the Public Health Agency

64

CVSFW Standard

31AllpatientswhohavehadastrokeshouldhavetheirrehabilitationdeliveredbyaSpecialistStrokeRehabilitationTeaminaStrokeUnit,startingimmediatelyafteradmissiontohospital.Specialiststrokerehabilitationfocusesonassessingtheindividualneedsofpatientsand,inconsultationwiththepatientandtheirfamily/carer(s),addressingtheminthemosteffectiveway.Ongoingspecialistrehabilitationneeds,asdefinedbytheTeam,shouldcontinuetobedeliveredbyaSpecialistStrokeRehabilitationTeam

39Allpatientswithadiagnosisofchronickidneydisease(CKD)shouldreceivetimely,appropriateandeffectiveinvestigation,treatmentandfollow-uptoreducetheriskofprogressionandcomplications

41Allchildren,youngpeopleandadultslikelytobenefitfromakidneytransplantshouldreceiveahighqualityservicewhichsupportstheminmanagingtheirtransplantandenablesthemtoachievethebestpossiblequalityoflife

43Healthandsocialcareprofessionals,inconsultationwiththepatient,willidentify,assessandcommunicatetheuniquesupportive,palliativeandendoflifecareneedsofthatperson,theircaregiver/sandfamily

HIA Suggestions

Increaseawarenessofthesignsandsymptomsofstroke,anditsappropriatetreatment

Raisepublicawarenessofthesymptomsandsignsofchronickidneydisease,andwhattodoaboutit

Conductapublicinformationcampaignandlaunchitafterdevelopingtherenaltransplantationservice

Conductapublicawarenesscampaignaboutpalliativeandend-of-lifecare

65

Health action plan abbreviations

BHFBritishHeartFoundation

CODACommunityDrugAwareness

DACTDrugsandAlcoholCoordinationTeamDEDepartmentofEducationDESDirectEnhancedServiceDETIDepartmentofEnterprise,TradeandInvestmentDoEDepartmentoftheEnvironment

DRDDepartmentforRegionalDevelopment

EDACTEasternDrugsandAlcoholCoordinationTeamELBEducationandLibraryBoard

FASAForumforActiononSubstanceAbuseandSuicideAwareness

GAINGuidelinesandAuditImplementationNetwork

HSCBHealthandSocialCareBoardHSCTHealthandSocialCareTrust

LCGLocalCommissioningGroup

MGPHMinisterialGrouponPublicHealth

NACRNationalAuditandCardiacRehabilitationNICHSANorthernIrelandChestHeartandStrokeAssociationNILGANorthernIrelandLocalGovernmentAssociationNIMDTANorthernIrelandMedicalandDentalTrainingAgencyNMCNursingandMidwiferyCouncilNSCAGNationalSpecialistCommissioningGroup

PCPrimaryCarePCCPatientandClientCouncilPHAPublicHealthAgencyPPIPublicandPatientInvolvement

RQIARegulationandQualityImprovementAuthority

SFWServiceFramework

UCFUlsterCancerFoundation

66

List of figuresFigure1: Thedeterminantsofhealthandwellbeing.

Figure2: Cardiovascularhealthanditscontributoryfactors.

Figure3: Contributiontothelifeexpectancygapbetweenthe20%mostdeprivedand20%least deprivedareasinNorthernIreland(2006-08)bycauseofdeath(years).

Figure4: ComparativedeathratesforIHDorstroke2006-08(NorthernIrelandaverage=100).

Figure5: Electiveandnon-electivetreatmentrates,byeconomicdeprivationdecile2001–02(per thousandpopulation).

Figure6: Developmentofserviceframeworks.

Figure7: NorthernIrelandGPpracticeperformanceinmeasuringbloodpressureinpatientsaged 45yearsandover.

Figure8: BelfastHealthandSocialCareTrustGPpracticeperformanceinmeasuringblood pressureinpatientsaged45yearsandover.

Figure9: Diabeticbloodpressurecontrolbydeprivationdecile.

Figure10: NorthernIrelandGPpracticeperformanceintreatingatrialfibrillation.

Figure11: BelfastHealthandSocialCareTrustGPpracticeperformanceintreatingatrialfibrillation.

Figure12: Prevalenceofstroke/TIAbypopulationdeprivationdeciles,usingNISRAorGPlist information.

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References 1. DepartmentofHealth,SocialServicesandPublicSafety.Cardiovascularhealthandwellbeing

serviceframework.Belfast:DHSSPS,2009.

2. BartonH,GrantM.Ahealthmapforthelocalhumanhabitat.TheJournaloftheRoyalSocietyforthePromotionofHealth2006;126(6):252-53.

3. HomerJ,MilsteinB,WileK,PratibhuP,FarrisR,OrensteinD.Modelingthelocaldynamicsofcardiovascularhealth:riskfactors,context,andcapacity.PrevChronicDis2008;5(2).Availableatwww.cdc.gov/pcd/issues/2008/apr/07_0230.htmLastaccessed28Sept2010.

4. WHORegionalOfficeforEurope.Gothenbergconsensuspaper:healthimpactassessment;mainconceptsandsuggestedapproach.Brussels:EuropeanCentreforHealthPolicy,1999.

5. NorthernIrelandStatisticsandResearchAgency.RegistrarGeneralannualreport.Belfast:NISRA,2008.

6. HealthIntelligenceUnit,PublicHealthAgency,2010.

7. DepartmentofHealth,SocialServicesandPublicSafety.Projectsupportanalysisbranch.Belfast:DHSSPS,2010.

8. NorthernIrelandHealthInequalitiesMonitoringSystemviaHealthIntelligenceUnit,PublicHealthAgency,2010.

9. DepartmentofEducationandLearning.Schoolleaverssurvey2008.NorthernIrelandNeighbourhoodInformationSystem.Belfast:NorthernIrelandStatisticsandResearchAgency,2010.

10.NorthernIrelandHousingExecutive.Houseconditionsurvey:mainreport.Belfast:NIHE,2006.

11.DepartmentforRegionalDevelopment.TravelsurveyforNorthernIreland2006-2008.Belfast:DRD,2009.

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Public Health Agency, Ormeau Avenue Unit, 18 Ormeau Avenue, Belfast, BT2 8HS. Tel: 028 9031 1611. Textphone/Text Relay: 18001 028 9031 1611. www.publichealth.hscni.net

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