Stockton JSNA

Cardiovascular Disease

1. Summary

2. Introduction

Cardiovascular disease (CVD) refers to a group of related disease and conditions of the heart and blood vessels linked by a common set of risk factors leading to atherosclerosis. Atherosclerosis is the gradual build-up of fatty material ‘atheroma’ in the walls of arteries leading to narrowing and stiffening of the arteries. Cardiovascular conditions includes:

• Coronary heart disease (CHD) is a disease in which the coronary arteries are narrowed by arthrosclerosis or obstructed by blood clots resulting in a reduced or sudden stop of the blood supply to the heart muscle. This leads to angina, heart attack and heart muscle damage.
• Cerebrovascular disease is a disease in which the cerebral arteries are narrowed by arthrosclerosis or obstructed by blood clots resulting in a reduced or sudden stop so the blood supply to the brain. This leads to transient ischaemic attacks (TIA) and stroke.
• Peripheral vascular disease is a disease in which the arteries of the arms and legs are narrowed by arthrosclerosis or obstructed by blood clots resulting in a reduced or sudden stop of the blood supply to arms and legs. This leads to claudication.

More than 7 million people in the UK are estimated to suffer from cardiovascular disease. CVD remains the leading cause of death in the UK and is still the single most common cause of premature death in the UK with significantly higher mortality rates in the most deprived areas compared with the least deprived areas. 

The diagnosis of CVD is a life-changing event for patients and their families and causes considerable demand on health and social care. Healthcare costs relating to heart and circulatory diseases are estimated at £9 billion each year and costs to the UK economy are estimated to be £19 billion each year.

CVD is preventable. CVD mortality and early mortality reduced significantly over the past decades through preventing and managing risk factors as well as better treatment for CVD. To ensure that this trend continues a focus on preventions and collaborative effort to identify and teat early is required.  

3. Data and Intelligence

Risk factors

CVD and the burden it has on individuals, communities, health and social care services are highly preventable through changes to individual behaviour, population measures such as tobacco control and salt and sugar reduction, and individual level interventions such as clinical management of high risk conditions such as high blood pressure, atrial fibrillation (AF) and high cholesterol.

Behavioural risk factors such as smoking, physical inactivity and poor diet resulting in overweight and obesity are common. 15% of the population over 18 are smokers, 62.5% are physically inactive and 65.9% are overweight or obese. Smoking rates have declined significantly over the past decades and the Stockton rate is similar to the national average. 36.7% of the population drinks more than the recommended level compared to 25.7% in England. There are higher rates of physical inactivity and overweight and obesity compared to the national average.

Diagnostic and treatment gap

CVD prevention is being limited by the diagnosis and treatment gap for conditions such as high blood pressure, diabetes and atrial fibrillation, which cause lead to heart attacks and strokes. Not all patients with these conditions are diagnosed and of those who are diagnosed not all receive the best treatment.

Hypertension  

Uncontrolled hypertension can lead to chronic kidney disease and cognitive decline and cause heart attacks and strokes. The proportion of people with hypertension is increasing year on year in England and in Stockton. In 2016/17, 15.4% of all patients in primary care in Stockton-on-Tees had a diagnosis of high blood pressure, compared to a national average of 13.8%.

Public Health England estimates that only 61% of all people with hypertension in Stockton and Hartlepool have been diagnosed. This leaves 14,000 people with hypertension in Stockton and Hartlepool who are not aware of their condition and do not receive treatment. There is significant variation with regards to undiagnosed hypertension and recommended treatment across GP practices.

Atrial Fibrillation

Atrial fibrillation is an abnormal heart rhythm and can lead to the formation of blood clots in the heart. People with atrial fibrillation are at increased risk of having a stroke. The prevalence of atrial fibrillation is increasing year on year in England and in Stockton. 2% of all patients in primary care in Stockton-on-Tees had a diagnosis of atrial fibrillation in 2016/17 compared to a national average of 1.9%.

Public Health England estimates that 2.5% of population are suffering from atrial fibrillation in Stockton and Hartlepool, which means that there are 1,258 people with undiagnosed and untreated atrial fibrillation across the CCG. There is significant variation with regards to undiagnosed atrial fibrillation and recommended treatment across GP practices.

Hypercholesterolaemia (High blood fats)

Six out of ten adults in England have high cholesterol, with many completely unaware of it. High cholesterol itself does not usually cause any symptoms, but increases the risk of developing arteriosclerosis and cardiovascular events.

Diabetes

Diabetes is a major cause of premature death and greatly increases the risk of developing heart disease, kidney disease and stroke. The prevalence of diagnosed diabetes is increasing each year in England and in Stockton. 6.4 % of all patients in primary care in Stockton-on-Tees had a diagnosis of diabetes in 2016/17 compared to a national average of 6.5%. Public Health England estimates that there are a further 1.8% (2850 people) of the population with undiagnosed diabetes. In total there are about 13,000 people with diabetes living in Stockton. There is significant variation with regards to undiagnosed diabetes across GP practices.

In addition to this another 10.9% of the population (n=17,000 people) have a higher than normal blood sugar and are at risk of developing diabetes. 

There is significant variation in the provision of the recommended standard of care across GP practices.

People with diabetes have a significantly higher risk of developing renal failure leading to dialysis, angina, heart failure, heart attack and stroke compared to people without diabetes.

Chronic kidney disease (CKD)

Chronic Kidney Disease is common and can progress to kidney failure and it substantially increases the risk of heart attack and stroke. 9160 people across Stockton and Hartlepool (CCG) have been diagnosed with CKD. Public Health England estimates that only 64% of CVD has been diagnosed which means that a further 5050 people with CKD remain undiagnosed. There is significant variation with regards to undiagnosed CKD and recommended treatment across GP practices.

The mortality rate from CKD in Stockton is significantly above the England average.

Coronary Heart Disease (CHD)

4% (n= 11,816) of the population of Stockton-on-Tees had a diagnosis of CHD recorded on GP systems compared to 3.2% in England. CHD has been decreasing slowly at local and national level

In 2016/17 there were 1632 hospital admissions for CHD for Hartlepool and Stockton CCG. Hospital admissions for coronary heart disease have also declined but have been significantly higher in Stockton for most years since 2002/3.

Early mortality from coronary heart disease across Stockton and Hartlepool (CCG) has decreased over the last decades and moved closer to the England average remains significantly higher than the national average.   

Stroke

In 2016/17 a history of stroke or transient ischemic attack was recorded for 2.1% (n= 6,089) of the population of Stockton-on-Tees compared to 1.8 % in England.

Hospital admissions for coronary heart disease have been significantly higher in Stockton compared to England. In 2016/17 there were 1632 hospital admissions for stroke for Hartlepool and Stockton CCG.

Early mortality from stroke across Stockton and Hartlepool (HAST CCG) has decreased over the last decade and moved closer to the England average.    

Cardiovascular disease (CVD)

Early mortality (<75) from CVD in Stockton has reduced significantly over the last decades at local and national level, although the decrease has slowed down since 2008. The early mortality rate for Stockton is not significantly higher than the England average.

Public Health England states that premature death rates from cardiovascular disease in the most deprived 10% of the population were almost twice as high as the least deprived 10% of the population in 2013-15 in England.

NHS Health Check

The NHS Health Check is a systematic method to identify patients who are unaware their high risk   of developing cardiovascular disease. In 2017/18 over 5300 people in Stockton received an NHS Health Check. 20% of patients had an increased or higher risk score of developing CVD.

6.7% of those who had an NHS health check in 2016/17 had an increased blood pressure reading, 3% had higher than normal blood fats (cholesterol ratio), 3.8% had a higher than normal blood sugar and 0.7% an irregular (arrhythmic) pulse which is indicative of atrial fibrillation.

4. Which population groups are at risk and why?

5. Consultation and engagement

6. Strategic issues

7. Evidence base

8. What needs to be done and why?

Prevention

Local authority, NHS and Voluntary, Community and Social Enterprise (VCSE) organisations are key providers of:

• Transport and planning initiatives.
• Active lifestyle and leisure facilities.
• Exercise and weight management services including commissioning of NHS health checks and supporting physical activities in both work and school environments.
• Stop smoking services
• Social prescribing programmes

Stockton-on-Tees Borough Council promotes active transport to encourage physical activity in children and adults. This includes improvements to walking and cycling networks and cycle to work schemes as well as cycling and pedestrian training in primary schools.

People living in Stockton-on-Tees have access to several leisure centres and other offers to become more physically active such as walking and cycling activities and events.

The ‘Lite 4 life’ weight management programme is a group based intervention to support people to reduce weight and become more active.

The Active Health Exercise Referral scheme is a progressive exercise programme to help patients to manage their medical condition.

The NHS Diabetes Prevention Programme offers a structured behavioural and weight management programme for patients identified with an elevated blood sugar level.

The Better Health at Work Award Programme promotes healthy lifestyle advice and interventions including healthy diet and healthy weight to employees of participating organisations.

The Stockton and Hartlepool Specialist Stop Smoking Service provides stop smoking drop-in clinics. Clinics are offered in a variety of community locations (in the areas of most need).    

Pharmacies in Stockton-on-Tees provide support, advice and nicotine replacement treatment. The scheme improves access to stop smoking service through extended opening hours and increasing convenience and choice of stop smoking services.

VCSE organisation such as Middlesbrough and Stockton MIND and CGL offer targeted stop smoking programmes to their clients.

Risk and disease identification

The NHS health check aims to prevent heart disease stroke, diabetes, kidney disease and certain types of dementia through early detection, behaviour change and referral for further identification and management of risk factors and conditions which can lead to the development of CVD. NHS health checks in Stockton focus on reducing health inequalities through prioritising and incentivising health checks for the eligible population in the most deprived areas.

Patients with hypertension, high blood cholesterol, diabetes, atrial fibrillation, chronic kidney disease, CHD and Stoke are mostly identified and treated in primary care. GP practices offer clinics for the management of cardiovascular disease and following cardiovascular events.   

Secondary care service for the population of Stockton-on-Tees are provided by the University Hospital of North Tees, University Hospital of Hartlepool and the James Cook University Hospital.

The cardiology department at North Tees and Hartlepool NHS Foundation Trust offers a full range of services including consultant-led cardiology clinics offering general cardiology and specialist clinics for heart failure, structural heart disease and arrhythmia. Cardiology services South Tees offers most tertiary care services.  

The Stroke Service at North Tees and Hartlepool NHS Foundation Trust offers:

• Assessment clinics for TIA and stroke
• Thrombolysis to those eligible for treatment
• Physiotherapy, speech and language and occupational therapists are involved early in treatment and care to support recovery whilst at hospital.

A community stoke team of physiotherapists, occupational therapists, speech and language therapists, dietitians, psychologist, rehabilitation assistants, specialist nurses and Stroke Association family and care support officer supports patients at home during the weeks and months following discharge. 

9. What needs are unmet?

10. What needs to be done and why?

11. What additional needs assessment is required?

Further engagement and consultation with service users and other interested stakeholders in Stockton-on-Tees is required to gather views and opinions in order to improve CVD prevention and care in the borough.

12. Key contact

Name: Ruby Poppleton / Dr Tanja Braun

Job title: Health Improvement Specialist / Consultant in Public Health

Organisation: Stockton-on-Tees Borough Council

Phone number: 01642 526697

Contributor/s:

Claire Wong, Commissioning and Delivery Manager, NECS

Dr Helen Murray, GP, Hartlepool and Stockton CCG  

Dr Vineet Wadehra, Consultant Cardiologist & Specialty lead for Cardiology, NTUH

Sara Dalton, Health and Wellbeing Programme Manager, Catalyst

13. References

PHE Cardiovascular Disease Profile

https://fingertips.phe.org.uk/profile/cardiovascular/data#page/0/gid/1938133106/pat/46/par/E39000039/ati/153/are/E38000075/iid/219/age/1/sex/4

PHE Local Authority Profile

NHS RightCare Commissioning for Value Focus Pack: Cardiovascular Disease (NHS England 2016)

CVD: Primary Care Intelligence Pack – NHS Hartlepool and Stockton-on-Tees CCG (PHE 2017)

CVD Prevention: Supporting data for Durham, Darlington, Teesside, Hambleton, Richmondshire and Whitby (PHE 2018)

Email: ruby.poppleton@stockton.gov.uk / tanja.braun@stockton.gov.uk