Policy responses and statements

Name of organisation:: The Scottish Government
Name of policy document:: Better Coronary Heart Disease and Stroke Care
Deadline for response:: 31 October 2008

Background: Better Health, Better Care, Scotland's action plan for health and wellbeing, confirmed that both Coronary Heart Disease (CHD) and stroke remain national clinical priorities in Scotland and committed the Scottish Government to refreshing the national clinical strategy for these conditions.

CHD is a disease of the heart and coronary arteries caused by the build up of fatty materials in the blood vessels that supply the heart with oxygen. This can cause a heart attack, chest pain or angina. Stroke is a "brain attack", caused by a disturbance to the blood supply to the brain. Both CHD and stroke are classed as types of cardiovascular disease (CVD).

The Scottish Government's objective for a Healthier Scotland is to "help people to sustain and improve their health, especially in disadvantaged communities, ensuring better, local and faster access to healthcare". This strategy examines the implications of this objective for the way in which we tackle CHD and stroke across Scotland. It sets out a series of potential approaches in order to improve people's experience of care, tackle health inequalities, embed services to a greater extent in local communities and ensure that high quality services are planned and delivered efficiently.

In developing this draft strategy, the Scottish Government has worked closely with key voluntary sector organisations such as the British Heart Foundation Scotland and Chest, Heart and Stroke Scotland (CHSS). The Government now hopes to build further on these relationships, as this draft is discussed more widely and we agree a shared vision and action plan for CHD and stroke in Scotland.

COMMENTS ON

THE SCOTTISH GOVERNMENT

BETTER CORONARY HEART DISEASE AND STROKE CARE

The Royal College of Physicians of Edinburgh is pleased to respond to the Scottish Government on Better Coronary Heart Disease and Stroke Care.

Scope and Remit

The College broadly supports this document but has a number of observations.

There is some doubt about the wisdom of considering CHD and stroke together for anything other than primary prevention, since the management of CHD and stroke are so different. The more generic ‘vascular disease’ is preferred to the potentially confusing ‘cardiovascular disease’.

The College would advise limiting the remit strictly to CHD and stroke at a national level, thereby omitting any reference to other cardiac conditions (arrythmias, cardiomyopathy, pulmonary vascular disease and congenital heart disease) and is also concerned about the detailed description of the contribution of one hospital (the Golden Jubilee National Hospital) to regional services.

The project title in Para 7.6 ‘Hearty voices’ again seems inappropriate for stroke patients.

The document and the revised strategy in due course would benefit from a more focussed approach on good practice, specific local and national recommendations and targets (identifying which will attract new funding).

What further actions should we take to encourage healthy choices that can reduce the risk of CHD, stroke and cardiovascular disease more generally?

It would be helpful to reproduce the key learning points from the “Have a Heart Paisley” project, given the resources allocated to this project and the wish to prioritise future actions and share these lessons widely.

Paragraph 3.4 (action against childhood obesity) is crucial to primary prevention of CHD and stroke and the eventual strategy should include explicit references to avoiding conflict with other governmental policies, e.g. the removal of school playing fields versus encouraging participation in exercise at school.

The document would benefit from some revision on various points relating to healthy living, CHD and stroke, namely:

Discussion of key risk factors in the foreword (paragraph 4) fails to mention hypertension, cholesterol, diabetes and atrial fibrillation.

The explanation of the harmful effects of smoking, which include inflammation, platelet activation and fibrinolysis, is too simplistic. Para 3.2 should be revised. A relevant additional publication for the new strategy for CHD would be Professor Jill Pell’s report of the benefit of smoke free legislation in Scotland (N Engl J Med. 2008 Jul 31,; 359(5): 482-91)

Para 3.3 takes a overly simplistic approach to the effect of alcohol on CHD and should be revised to take account of the effects of higher levels of consumption on hypertension and stroke but not CHD.

Paragraph 3.4 (action against childhood obesity) is crucial to primary prevention of CHD and stroke and the eventual strategy should include explicit references to avoiding conflict in governmental policies, e.g. the removal of school playing fields versus encouraging participation in exercise at school.

What further actions should we take to tackle the impact of inequalities in CHD and stroke?

The College wishes to highlight the wider socio-economic framework required to tackle health inequalities by strengthening the economy and improving employment, housing and education

Ref para 4.9 -is the ASSIGN score validated on a Scottish population? The College understands that the Framingham score on which it is based does not work well.

The College accepts that the morbidity data in the West are particularly dramatic but is concerned about the balance of attention to the West of Scotland and the Golden Jubilee National Hospital in what is intended to be a national strategic document on CHD. This should be balanced with examples of good practice from other parts of Scotland.

What further actions should we take to improve the range and quality of CHD services in Scotland and how should these actions be prioritised?

The College emphasises the importance of regional planning for CHD services including the development of subspecialty electrophysiology and interventional services through regional networks.

The College wishes to champion the benefits of cardiac specialist nurses. The difficulties recruiting cardiac physiologists could be addressed by NHS Education Scotland promoting a degree course in cardiac physiology in Scotland.

The management of CHD relies on rapidly advancing technology. There is a need for a better, more streamlined approach to evaluating new devices and technologies in Scotland, to fulfil the role that the Scottish Medicines Consortium carries out for new drugs. Scotland was a late adopter of drug eluting stent technology and cardiac resynchronisation therapy for heart failure.

What further actions should we take to improve the range and quality of stroke services in Scotland and how should these actions be prioritised?

All stroke and TIA patients should have very early access to specialist inpatient and outpatient care since evidence shows that other standards of care (e.g. early imaging, aspirin, better information giving) are much more likely to be delivered by these services. There should be high profile public campaigns, both nationally and regionally, to increase awareness and ensure that many more people know how to react quickly to symptoms of stroke. Surveys need to be carried out to monitor public awareness and could form the basis of targets i.e. 75% of adults to know the 3 commonest stroke symptoms requiring immediate help.

Thrombolysis for acute ischaemic stroke should be available as early as possible to all patients who are likely to benefit. This will require close working between SAS, NHS 24, the acute hospitals and the voluntary sector supported by the Scottish centre for teleHealth. [By 2010 all MCNs should have developed a patient pathway to allow all suitable patients to receive thrombolysis]. The national audit should monitor the numbers of patients receiving thrombolysis and targets should be set for proportions of patients getting this treatment. There should also be targets for reducing delays to treatment e.g. door to needle times for hospitals.

Regional planning is important for stroke services, involving MCNs between regional and local DGH centres. NHS24 and Scottish Ambulance Service need to work together to provide a coordinated and appropriate response to possible stroke symptoms. They need to work with stroke MCNs to ensure that protocols reflect the capabilities of local stroke services and plans are in place for longer journey times to a regional centre.

Patients with stroke should have access to services which will allow them to leave hospital as early as is practical (e.g. effective inpatient rehabilitation, early supported discharge, liaison nurses and community based rehabilitation). [By 2013 all hospital based stroke units should have access to early supported discharge, liaison nurses and community based rehabilitation]. It is important that such services have sufficient capacity to firstly ensure they do not delay discharge (i.e. waiting for community rehab) and secondly to offer patients the choice of whether they complete their rehabilitation in hospital or at home.

There needs to be continued development of education and training for staff working in stroke services. By 2013 all HEIs responsible for training Doctors, Nurses and AHPs should ensure that their basic training includes the stroke core competencies. All staff working within stroke services should have access to continued professional development. Web based resources covering all key aspects of stroke care should be freely available to all staff. NHS IT services should ensure there are no technical bars to their staff accessing approved on line training resources. CPD relevant to stroke should be included within the annual review of all staff working in stroke services

Ref Para 6.17 – the College believes it is a serious omission to exclude specialist physicians (neurologists and stroke physicians) from the team listed for these further interventions.

What further action should we take to improve the patient experience of care for both CHD and stroke?

See also responses to the previous two questions.

We need to ensure that stroke patients and their families have access to services which can deal with the longer term consequences of stroke and have a way back into stroke specific services

There needs to be an expansion in the numbers of healthcare staff in both hospital and community stroke services to ensure that stroke services can meet the National Standards whilst ensuring their staff work within the relevant working time directive.

The College believes that further development and training of cardiac nurses and technicians will improve access times for many patients whether for diagnostic tests or post event rehabilitation.

What further actions should we take to develop the IT infrastructure that is needed to support CHD and stroke services?

The College wishes to emphasise the need for accurate data collection and audit, and the requirement for adequate IT infrastructure.

We would make a plea to participate in established UK-wide audit e.g. MINAP (Myocardial Infarction National Audit Programme) rather than a purely Scotland-based approach. It is important to compare performance beyond Scotland.

All services should participate in the National Audit of Stroke Services including both admitted and non admitted patients. The National Stroke Audit should continue to collect data in all hospitals until at least 2013.

There should be continued investment in the development of, and the widespread implementation of electronic patient records and other technologies. By 2013 all stroke units and neurovascular clinics should use an EPR to collect baseline data, to help guide initial management and to reduce the need to retrospectively capture audit data.

The importance of improved IT infrastructure to assist clinical research, particularly in areas of coronary heart disease and stroke, should also be highlighted.

Other comments

Several of the figures, particularly 3-6, are difficult to read or include confusing legends.

The comments on advanced heart failure (para 5.18 to 5.20) should be included in the Heart Failure section (5.4 to 5.9).

There is no research network for CHD across the UK and this omission may merit attention

Copies of this response are available from:

Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.

Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939

[24 October 2008]