Transcript Slide 1

How to develop a national strategy to
prevent cardiovascular disease?
Prof. Sir Roger Boyle
National Director for Heart Disease and Stroke
Department of Health
London
Tuesday 20th January 2009
“The NHS belongs to the people. It is there to
improve our health, supporting us to keep
mentally and physically well, to get better
when we are ill and, when we cannot fully
recover, to stay as well as we can. It works at
the limits of science – bringing the highest
levels of human knowledge and skill to save
lives and improve health. It touches our lives
at times of basic human need, when care and
compassion are what matter most.”
The NHS Constitution
The English NHS is a large
complex system
Population 55 million
1,400,000 employees
1,000,000 patients every 24 hrs
Primary & secondary care
Mental health
Dentists, Opticians, Pharmacies
Ambulance services
10 regional Strategic Health Authorities
Each with a population between
2.5 and 7 million
Similar in population to Ireland,
Norway, Finland & Denmark,
Change in philosophy in the NHS
Focus on quality of care
– Setting standards
• National Institute for Clinical Excellence (NICE)
• National Service Frameworks (NSFs)
– Coronary Heart Disease
– Cancer
– Implementing standards
• Local clinical governance
– Monitoring standards
• Independent regulator
• National Patient and User Surveys
Satisfaction with the NHS is
increasing
Primary Care 89%
Clinics 87%
ER 79%
NHS overall 73%
Spending on Health, 1980–2007
Average spending on health
per capita ($US PPP)
Total expenditures on health
as percent of GDP
$2,454
Note: $US PPP = purchasing power parity.
Source: Organization for Economic Cooperation and Development, OECD Health Data, 2009 (Paris: OECD, Nov. 2009).
Efficiency scores
Overall ranking
Total expenditure
on health as % of
GDP
% of national
health expenditure
spent on
administration
Patient time spent
on paperwork and
billing disputes
AUS
CAN
GER
NETH
NZ
UK
US
2
6
5
3
4
1
7
2
5
6
4
3
1
7
1
3
5
4
7
2
6
2
3
5
7
4
1
6
Commonwealth Fund using OECD data
Age-standardised CHD mortality
England and Wales (1924 – 1998)
185,000 men dying
each year in 1959
British Heart Journal
1959 – 6/65 articles on CHD
1964 – 7/85 articles on CHD
National Service Framework for
Coronary Heart Disease
This Framework will transform the prevention,
diagnosis and treatment of coronary heart
disease.
It will help professionals to give better, fairer
and faster care everywhere, to everyone who
needs it.
We want a service that is amongst the best in
the world. Our people deserve nothing less.
March 2000
Alan Milburn
Secretary of State for Health
Process
• Setting up of an independent expert group
to review the evidence and make
recommendations on the basis of best
evidence
• Included patients and carers as well as
various clinicians, public health experts
and epidemiologists
Modernising care
Clinical networks
CHD Collaborative
Heart Improvement
Programme
NHS Improvement
National audits and registries
Public portal
Public portal
Congenital
Pacing
& ICDs
Register
Of
Deaths
(ONS)
Cardiac
Rehab &
QOL
Cardiac
surgery
Central
Cardiac
Database
Electrophysiology
Ambulance
Care
Angioplasty
Heart
attack
Heart
Failure
Developing
Published
outcomes
Heart programme
Twin track approach
• Better prevention
– Primary
– Secondary
• Better treatment
– Faster
– Better outcomes
– More equity
1. Ban on advertising
2. Advertising campaigns
3. Pack health warnings
4. Price increases (serial)
5. Smoking cessation clinics
6. Ban on smoking in the
workplace & public places
7. Increasing the minimum legal
age for buying cigarettes
Advertising campaign
against fat
Cholesterol levels
212
210
208
206
Mean total 204
cholesterol 202
(mg/dL) 200
198
196
194
192
212
212
204
202
199
England
Scotland US White US Black
Mexican
American
NHANES (1999-2002), Health Surveys of England and Scotland (2003)
England – Statin Prescribing – Total Statins (Proprietary & Generic)
Statin Type (All) Prescribed Items (000s) & Net Ingredient Costs (£000s)
800,000
60,000
NSF
CHD
700,000
50,000
500,000
400,000
40,000
30,000
300,000
20,000
200,000
Statins – Net Ingredient
Cost (£000s)
Statins – Prescribed
Items (000s)
10,000
100,000
Year
08/09
07/08
06/07
05/06
04/05
03/04
02/03
01/02
00/01
99/00
98/99
97/98
96/97
95/96
94/95
93/94
0
92/93
0
Prescribed Items (000s)
Total Statins
Between 2000/01 & 2008/09
-Net Ingredient Cost - up 38%
-Prescribed Items - up 388%
91/92
Net Ingredient Cost (000s)
600,000
Data
Trend in prescriptions
for CV drugs
Number of items prescribed in
primary care (millions)
50% increase over five years
70
60
50
40
30
20
10
0
Q2
2002/3
Q4
Q2
Q4
2003/4
Q2
Q4
2004/5
Q2
Q4
2005/6
Q2
2006/7
Q4
Q2
2007/8
England – QOF % of People with CHD with BP <150/90 – 2001/02 – 2008/09
QResearch Population & National QOF Results
100%
QOF Reported
BP<150/90
90%
QOF Reported
BP<150/90
as % of
CHD Register
70%
60%
50%
40%
QResearch BP<150/90
Pre-introduction of QOF
30%
20%
10%
0%
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
% of People with CHD
80%
2001/02
2002/03
2003/04
2004/05
2005/06
Year Quarter
2006/07
2007/08
2008/09
Data
QR BP <150/90
QOF BP<150/90
REG BP<150/90
England – QOF % of People with CHD with Cholesterol 5mmol/l or less –
2001/02 – 2008/09 - QResearch Population & National QOF Results
100%
QOF Reported
Chol <5mmol/l
90%
70%
QOF Reported
Chol <5 mmol/l
as % of
CHD Register
60%
50%
40%
30%
QResearch Chol <5mmol/l
Pre-introduction of QOF
20%
10%
0%
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
% of People with CHD
80%
2001/02
2002/03
2003/04
2004/05
2005/06
Year Quarter
2006/07
2007/08
2008/09
Data
QR Chol <5 mmol/l
QOF Chol <5 mmol/l
Reg Chol <5 mmol/l
Rapid access chest pain clinics
(National network – every hospital)
Percentage seen within two weeks
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Hospitals
New onset, stable angina
Thrombolysis rates for acute myocardial
infarction, England 2001-2008
90
80
% patients
70
% of patients
thrombolysed within
30 minutes of arrival
60
50
% of patients
thrombolysed within
60 minutes of calling
for help
40
30
20
10
0
2001 2002 2003 2004 2005 2006 2007 2008
Source: Royal College of Physicians, MINAP
Proportion of patients discharged on
secondary prevention medication,
2002 -2007
100
90
% patients
80
70
60
Aspirin
Statins
Beta blockers
50
40
30
20
10
0
2002-3
2003-4
2004-5
2005-6
2006-7
Source: Royal College of Physicians, MINAP
Falling mortality rates – MINAP data
STEMIs
30 days
Falling mortality rates – MINAP data
Non STEMIs
30 days
SAVING LIVES
Circulatory Disease Mortality Target
Death rates from All Circulatory Disease in England 1993-2006 and target
Persons under 75
Death rate per 100,000 population
160
140
Progress since baseline:
A fall of 44% over 10 years
Target achieved
five years
ahead of
schedule
141.0
120
Target:
40%
100
80
84.2
84.6
60
minimum
reduction
from
1995-97
baseline
rate
Immortality
guaranteed by 2026
40
20
0
1993/4/5
1995/6/7
baseline
1997/8/9
1999/2000/1 2001/2/3
2003/4/5
3 year average
Progress
Rates are calculated using the European Standard Population to take account of differences in age structure.
ICD9 data for 1993 to 1998 and 2000 have been adjusted to be comparable with ICD10 data for 1999 and 2001 onwards.
Source: ONS (ICD9 390-459; ICD10 I00-I99)
2005/6/7
2007/8/9
2009/10/11
target
Mortality from all circulatory diseases
2002- 4 according to social deprivation
Deprivation
Standardised mortality
Mortality
Index of deprivation
CV Deaths averted
0
-20,000
-40,000
-60,000
Redrawn from Capewell et al
-80,000
1980
2000
Risk factors worse
Obesity
Diabetes
Less physical activity
+13%
+3.5%
+4.8%
+4.4%
Risk factors better
Smoking
Cholesterol
Popul’n BP fall
Deprivation
Other factors
-71%
-41%
-9%
-9%
-3%
-8%
Treatments
AMI treatments
Secondary prevention
Heart failure
Angina: CABG/PCI
Angina: drugs
BP treatment
-42%
-8%
-11%
-12%
-4%
-5%
-3%