Written evidence from the British Heart Foundation (LTC 06)
Summary
- The BHF is currently providing support for projects aimed at treating more patients outside hospital.
- Cardiac rehabilitation is a model of long-term condition management that needs to be fully funded across the UK. Every patient who is suitable and wishes to take part should be offered a cardiac rehabilitation programme.
- Every person living with a long-term condition should be guaranteed a holistic needs assessment, a written care plan encompassing health, social and preventative care and the right to access a named care co-coordinator of their choice.
- To ensure that patients benefit from all the latest developments, Health Education England should recognise the importance of continuing professional development of specialist nurses and other healthcare professionals.
- Every person with a long-term condition should be treated for their physical and psychological needs in equal measure.
- A number of measures are needed to tackle obesity and create an environment that helps people to make healthier choices on food and increase levels of physical activity.
- We believe the Committee should also separately consider the contributing role of tobacco as major contributing factor to the development of long-term conditions.
1.1 The British Heart Foundation (BHF) is the nation's leading heart charity. We are working to achieve our mission of a world in which no-one dies prematurely of heart disease. There are 2.3 million people in the UK living with coronary heart disease and in the fight for every heartbeat we want to ensure they have all the support they need to manage the impact of their condition of all aspects of their everyday lives.
1.2 We welcome the opportunity to respond to the Committee’s inquiry on how the NHS and social care system in England supports people with long-term conditions such as heart disease. It is disappointing that after seeking views on the development of a new long-term conditions strategy last year the Department of Health has opted not to publish a strategy. While NHS England now has the responsibility to take this forward, we believe that strong recommendations from the Health Committee may help to ensure that making tangible improvements for people with long-term conditions is prioritised.
1.3 The Department of Health originally set up a cross government group to develop the strategy, in recognition of the many different areas of people’s lives that may be affected by having a long-term condition. While NHS England takes this work forward alongside relevant organisations in the new commissioning landscape, it is important that cross-government involvement continues.
1.4 We are pleased to see the Committee review as part of the inquiry services provided for patients with diabetes as having diabetes, especially if it’s undiagnosed or poorly controlled, can significantly raise your risk of having a heart attack. While the Committee has also asked for evidence on obesity as a contributing factor to long-term conditions, we believe the Committee should also separately consider the contributing role of tobacco – which is responsible for around 25,000 deaths from cardiovascular disease each year.[1]
Treating people with long-term conditions in a community setting
2.1 The Committee has asked for comments on varying the current mix of service responsibilities so that more people are treated outside hospital. The BHF is currently providing support for projects aimed at treating more patients outside hospital. For example, we are currently funding a two-year pilot programme to assess safe and effective ways for specialist nursing teams to administer intravenous (IV) diuretics to people at home, or in a day care setting, with the view to preventing costly hospital admissions.
2.2 People with heart failure often experience breathlessness and as the condition worsens, fluid accumulates in the lower limbs, and eventually in the abdomen. Diuretic tablets help reduce fluid retention, but as the disease progresses, oral diuretics are not enough to control symptoms. To relieve symptoms at this stage, the patient is currently admitted to hospital and treated with IV diuretics.
2.3 The BHF pilot supports heart failure specialist nurses at twelve NHS sites in the UK, and help them develop and introduce community based IV diuretic services as part of existing heart failure services. Following guidelines developed by a BHF-led steering group and expert panel, specialist nurse teams are trained to administer the IV medication safely and effectively out of hospital, to closely monitor the patients’ response to treatment, and adjust dose as necessary.
2.4 Challenges during the development of the project have included gaining support from other parts of the healthcare system, securing backfill staffing for the project lead and providing a seven day and out of hours service.
2.5 In addition to the twelve funded projects, there are six extra sites that are not part of the award but are participating in the on-going, independent evaluation of the project. Every site will deliver care to heart failure patients slightly differently, by integrating this new aspect of patient care into existing local services. The evaluation will report on the effectiveness of each service and a final evaluation will be available in late 2013. The interim report has already been published and is already demonstrating impacts and outcomes.[2]
2.6 If successful, this project will allow the specialist teams to develop new best practice guidelines and protocols for community-based IV diuretic treatments that can be rolled out on a wider scale. Administering IV diuretics in community settings should help increase patients’ quality of life and reduce hospital admissions.
Effective management of long-term conditions
3.1 Cardiac rehabilitation has been defined as the sum of interventions needed to ensure the best possible physical, psychological and social conditions for heart patients. Most heart patients need support to help them live with their condition and to prevent a further major heart event.[3] Recent developments in the treatment of heart disease, such as thrombolysis and primary angioplasty, have changed the experiences of heart patients and dramatically reduced their residual cardiac impairment. Consequently some patients do not perceive themselves to be in need of further help and support. For most patients with heart disease, the focus of cardiac rehabilitation programmes now is therefore on helping people living with heart disease to manage their condition and to prevent that condition from deteriorating. Cardiac rehabilitation is therefore a model of long-term condition management.
3.2 Cardiac rehabilitation can take place in hospital as an outpatient, in a community setting such as a GP practice or sports centre or in the patient’s own home. Some patients like a group-based programme but others do not and prefer to carry out their rehabilitation at a time and place that suits them and their family. There is evidence that offering a home-based self-management programme as an option can substantially improve uptake and that outcomes from these programmes are the same as those from traditional group-based programmes.[4],[5],[6] Importantly, offering patients a choice may increase take-up of services especially amongst groups who are currently under-represented as they may face practical problems accessing centre-based programmes.[7]
3.3 NHS Improvement commissioned a short study[8] in 2013 that modelled the relationship between uptake of cardiac rehabilitation and unplanned cardiac readmission rates both nationally and at commissioner level. This aimed to examine the Quality, Innovation, Productivity and Prevention (QIPP) potential of cardiac rehabilitation and to establish whether the benefits of cardiac rehabilitation outweigh the costs in terms of the potential impact on readmissions alone.
3.4 The results suggested that increasing the uptake of ’gold standard’ cardiac rehabilitation has the potential to reduce cardiac-related readmissions and deliver significant financial savings. Achieving an uptake rate for cardiac rehabilitation of 65 per cent in England among all eligible patients could reduce admissions by over 28,000 – releasing over £30 million per year in overall savings nationally which could be reinvested in rehabilitation and re-ablement.
3.5 Cardiac rehabilitation has been identified by national governments, the health service and NICE as an important part of the care that should be provided for people with heart disease, yet provision and take-up remains patchy across the UK. This is in spite of it being a cost effective programme, costing around £550 per patient to deliver.[9] According to the latest figures from the 2012 National Audit for cardiac rehabilitation just 44 per cent of heart patients in England took part.[10] Cardiac rehabilitation services need to be fully funded across the UK. Every patient who is suitable and wishes to take part should be offered a cardiac rehabilitation programme.
3.6 The Department of Health in England published a new Cardiovascular Disease Outcomes Strategy in March 2013. The Strategy has highlighted that care providers should carry out a holistic assessment of the patient’s need for rehabilitation and long-term support, which should consider the physical, psychological and social care needs. A specific action in the Strategy is therefore for NHS Improving Quality (which from April 2013 replaced NHS Improvement) to work with the new Strategic Clinical Networks in England to develop, evaluate and disseminate approaches to assessment and care planning for CVD patients – including the full cardiovascular assessment. This would be strengthened further through a long-term conditions outcome strategy produced by NHS England, which would reiterate the importance of rehabilitation, and call on commissioners to ensure that cardiac rehabilitation is available to all heart patients who choose to take part.
Patient-centred integrated care
4.1 People with long term conditions, such as heart disease, often have numerous, confusing and uncoordinated interactions with the health system and social care systems. Typical problems include dealing with a range of different healthcare professionals who do not have access to existing medical records or other information, poorly scheduled appointments and a lack of clarity about who to contact for advice and support.[11]
4.2 We have included in appendices 1 and 2 the health care journeys of two patients that have shared their experiences of how they have interacted with different services related to their care (anonymised for this submission). They illustrate the complexity of different services that patients are required to navigate. These ‘webs of care’ suggests a system that has not been built around the patient.
4.3 To effectively provide for the integration of health and social care in the management of long-term conditions, every person living with a long-term condition should be guaranteed a holistic needs assessment, a written care plan encompassing health, social and preventative care and the right to access a named care co-coordinator of their choice. The process of developing the care plan should help people understand the care and support that they are receiving and be confident about who should be approached if they need support. Further information is detailed in the report From vision to action, produced by the Richmond Group of Charities – a coalition of ten of the leading health and social care organisations in the voluntary sector.[12]
4.4 The BHF is a member of the Care and Support Alliance, a group of over 70 organisations who support and represent older and disabled people, those with long-term conditions and their families. We believe that the social care system is in crisis – unable to cope with a rapidly ageing population and people living longer with illness and disability. Urgent reform and additional funding are therefore essential.
Improvements to staffing
5.1 It is vital that the right workforce is in place to best meet the needs of people living with long-term conditions. In particular, there needs to be adequate investment in specialist nurses. The value of these posts has been demonstrated in recent years, including through the BHF’s investment in specialist cardiac nursing. Between April 2009 and March 2011, BHF heart failure nurses reported that they were responsible for avoiding 19,555 unplanned hospital admissions. This saved the NHS around £34.5 million.[13]
5.2 Where specialist nurses are in post, they need the resources and capacity to be able to train and support other healthcare professionals in their locality to meet the needs of patients in the community. It is likely that a significant number of patients will be seen by generalist community health professionals, given the prevalence of cardiovascular disease. The BHF currently funds innovative new roles to increase levels of education in primary care. Our Improving Knowledge, Improving Care project specifically aims to optimise care and outcomes for patients who have had a heart attack and those with heart failure, in order to reduce regional disparities in standards of care and management of treatment. This will be achieved through delivering education to primary and community-based healthcare professionals, including GPs and practice nurses, in six pilot regions.
5.3 Specialist nurses are an important part of the infrastructure to support people living with long-term conditions like heart disease. Generalist health professionals need appropriate training and support to ensure that they are also able to best meet the needs of these patients. To ensure that patients benefit from all the latest developments, Health Education England should recognise the importance of continuing professional development of specialist nurses and other healthcare professionals.
Mental health
6.1 People with long-term conditions also have significant psychological and social needs. Long-term conditions coupled with depression are a significant and growing challenge for health and social care services. People with long term conditions are twice to three times more likely to experience depression and estimates suggest that 20 per cent of people with long term conditions have depression.[14]
6.2 Depression is two to three times more common in a range of cardiovascular diseases and studies indicate that depression can increase the cost of managing long-term conditions by between 33-169 per cent. Every person with a long-term condition should be treated for their physical and psychological needs in equal measure.
Tackling obesity
7.1 The Committee has asked for evidence on how to address obesity. As highlighted by recent policy reports in the UK, obesity remains a serious and pressing issue that requires wide-ranging measures to tackle in full.[15],[16] According to the Health Survey for England 2009-11, one quarter of men and women are obese (BMI over 30) and two thirds of adults are obese or overweight (BMI over 25). Getting and keeping to a healthy weight can reduce your risk of not only heart disease but a number of other health problems, such as diabetes, some cancers and arthritis.
7.2 A healthy diet is one factor that can help to ensure fewer excess calories in addition to other measures such as regular physical activity. But in order to make healthy choices on what we eat, we need an environment that helps people to make healthier choices. We are encouraged by recent progress on food labelling, and are hopeful that the Department of Health will soon recommend a single front-of-pack traffic light scheme that will be adopted by all major retailers, helping people to make healthier at-a-glance choices based on the nutritional content of the food they are buying. We also believe that more needs to be done to address the variability and growth of food portion sizes and plan to publish a report on this issue in the summer.
7.3 Obese children are more likely to become obese adults, and we believe a number of measures are necessary reduce their exposure to promotions for processed foods and drinks high in fat, saturated fat, sugar, and salt. We need a system that truly protects our children and young people from sophisticated marketing campaigns and believe the Government should move to:
- end to junk food marketing before 9pm
- better protect children from the influence of non-broadcast junk food marketing
7.4 A BHF report produced in 2011 reveals the tactics companies are using to market to our children online and assesses how brands bombard kids online in a bid to push products that are high in fat, salt and sugar.[17]
7.5 Evidence shows that children who are physically active have a better chance of becoming healthy adults, yet a significant proportion of children are not reaching recommended levels of activity.[18] Regular activity reduces the risk of obesity in adulthood and reduces the likelihood of risk factors for chronic diseases, such as heart disease and type 2 diabetes, developing early in life.[19] Only one in ten children in England can correctly recall the need for 60 minutes of daily physical activity and half of UK parents underestimate how much physical activity their child needs to maintain a healthy lifestyle. Sustained communication at population and individual level is needed to improve understanding.
7.6 Schools also need to maximise the opportunities for children to take part in physical activity during and around the school day in a positive and inclusive environment. Children should be encouraged to participate in extracurricular physical activities, to be physically active at break-times and to walk and cycle to school.
7.7 With the transfer of responsibility for public health issues in England to local government, local authorities are now well placed to ensure that decisions regarding planning, transport and education support increases in physical activity. Public Health England also needs to lead this approach strategically.
May 2013
