Joint Strategic Needs Assessment

• Cardiovascular disease (including stroke) is the largest cause of death when all ages are considered, and the second largest cause of death after cancer in people aged under 75 years.
• Coronary heart disease causes 16% of all deaths in both age categories.
• Whilst the rates of premature CVD mortality are declining in Nottingham, the inequality gap between the City and England average remain and the narrowing of the gap has decreased in recent years.
• The CVD mortality rate in the city is significantly higher amongst men than women.
• The recorded prevalence of coronary heart disease in GP practices is significantly less that the national average and that of comparator cities. 
• There is significant variation in the identification of CHD patients in GP practices and between GP recorded prevalence and CHD mortality.
• National data shows that people born in South Asia, the Caribbean or East Africa are more likely to die from CVD than the general England population (CHD for South Asians, stroke for people of African Caribbean ethnicity).
• The increased prevalence of diabetes in the Asian population contributes to the increased risk of CHD.
• Men born in Pakistan, Bangladesh and East African are more likely to die from CHD than women born in the same countries.
• Qualitative research with middle aged men in areas with higher levels of CVD suggest that men can be resigned to a short life expectancy, disinterested in long term benefits, have low aspirations regarding their life, and therefore are unable or unwilling to change.

• A small scale survey with Asian men suggests that long working hours and perceptions that services are not for men are key barriers to accessing commissioned services.
• Patients with severe mental disorders are more at risk of having and dying from CVD than the general population due to increased CVD risk factors, poorer access to healthcare and the effect of antipsychotic medication on their metabolism.
• The CVD and CHD mortality rate is significantly higher in the most deprived than in the least deprived fifth of the city. However this gap has narrowed over the last decade.
• St Anns and Arboretum wards had the highest rates of CVD and CHD mortality in 2008-10. Arboretum was one of the wards with the highest CHD emergency admission rate, but St Anns was not. Arboretum also had the highest heart failure mortality rate, although this was not significantly higher than the city average.
• The prevalence of CHD recorded in Nottingham City GP Practices is significantly less that the national average and in comparable areas, despite the CHD mortality rate being significantly higher than average.
• There is wide variation in the proportion of patients at high risk of CVD who are prescribed statin in Nottingham City GP Practices.
• In the Quality and Outcomes Framework, Nottingham City GP Practices performance well in several CHD, Hypertension and Heart Failure domains. But they are significantly worse than the England average with regard to referral of angina patients for exercise testing, recording of cholesterol amongst CHD patients, and the recording of blood pressure amongst hypertension patients.
• The uptake of Phase III cardiac rehabilitation was lower in the East Midlands than in England. This varied markedly for myocardial infarction (36 to 41%), angioplasty (15 to 29%) and bypass surgery (65 to 76%).  Uptake of NUH hospital cardiac rehabilitation is in line with this but further analysis is required to determine the uptake of cardiac rehabilitation by city patients, and also uptake of the CityCare community cardiac rehabilitation service.
• Angiography rates for city patients are significantly lower than the England average showing lower uptake of this diagnostic technique.

 

• Continue the emphasis on the primary prevention of CVD through the NHS Health Checks programme and CVD Prevention Services.
• Address Practice variation in the management of patients identified as being at high risk of CVD through the Health Checks Programme.
• Continue having performance targets for groups most at risk of CVD in the prevention services commissioned by Public Health. Consider revising the geographical targeting of services using more recent statistics and wards as the unit of geography rather than LSOA.
• Utilise services within the CVD prevention pathway commissioned by Public Health for the secondary prevention and management of CVD as well as primary prevention of CVD and cancer.
• Include similar performance targets for groups most at risk of CVD, in CVD treatment services commissioned by the Clinical Commissioning Group.
• Address Practice variation in the identification of patients with CHD.
• Improve the access to CVD prevention interventions and CHD management and interventions for patients with severe mental health problems. This should include management within primary care.
• Increase identification of patients with atrial fibrillation. Increase referral rates to angiography and increase the uptake of cardiac rehabilitation.

Hypertension

• 13.5% of the GP registered population aged 16 and over in England in 2010/11 have diagnosed hypertension. This represents 44.1% of the estimated prevalence (30.6%).
• Amongst men, Black Caribbean (38%) Indian (33%) and Irish (36%) men had the a prevalence of hypertension higher than the general population (32%). This is from the 2004 Health Survey for England. Amongst women, Black Caribbean (32%) were the only group with a higher prevalence than the general population (29%) (NHS Information Centre, 2004).

 
High Risk of CVD

• QRISK2 is the name of a cardiovascular disease risk calculator derived from an English patient population. It is one of those recommended for use by NICE (NICE, 2008).  
• It has been estimated using QRISK2 that 13.3% (8.6% of women; 18.1% of men) of the population aged 40-74 years are at high risk of CVD (defined as a 20% or greater risk of having a cardiovascular event in the next 10 years) (Hippisley-Cox et al, 2008).
• The proportion of people at high risk of CVD  increases with age and increasing Townsend score (deprivation). Males are at higher risk than females. Men and women of Indian, Pakistani and Bangladeshi origin are at greater risk of CVD.
• Other factors that increase the risk of CVD include: being a current smoker; having type 2 diabetes, treated hypertension, atrial fibrillation, rheumatoid arthritis, renal disease and having a family history of coronary heart disease (Hippisley-Cox et al, 2008).

Atrial Fibrillation (AF)

• AF is a known risk factor for stroke and heart failure.
• It is often asymptomatic, but characterised by an irregular pulse rate.
• People with AF have a 2-10% chance each year of suffering a stroke.

 
Coronary heart disease prevalence and hospital admissions

• 5.8% of the GP registered population aged 16 and over  in England were estimated to have coronary heart disease based on 2010/11 data (SEPHO, 2012).
• The directly standardised hospital admission rate for CHD in 2010/11 was 225.9 per 100,000. This rate has decreased by 23.9% since 2003/04.
• Male admission rates (305.3) were significantly higher than in females (153.7).
• Admission rates increase from the least deprived to the most deprived quintile in England.
• Pakistani men (8%) are the only minority ethnic group found to have CHD prevalence higher than the general population (6%) in the 2004 Health Survey for England.
• All minority ethnic groups had a lower prevalence of CHD amongst women than the general population (4%) (NHS Information Centre, 2004).

Heart failure hospital admissions (SEPHO, 2012)

• The directly standardised hospital admission rate for heart failure in 2010/11 was 59.8 per 100,000.  This rate has decreased by 22% since 2003/04.
• Male admission rates (74.8) were significantly higher than in females (47.5).
• Admission rates increase linearly from the least deprived to the most deprived deprivation quintile in England.

Cardiovascular Disease mortality (SEPHO, 2012, unless stated otherwise)

• Cardiovascular disease mortality amongst people aged less than 75 years in England decreased by 56.1% between 1996 and 2010. It is forecast that this will increase to a 61.6% reduction by 2012.  
• Cardiovascular disease accounted for 24.6% of all deaths in England during 2008-10 amongst people aged less than 75 years. The different diseases contributed to CVD mortality in the following proportions: CHD (58.9%), Stroke (27.3%), Other (4.4%).
• Male CVD mortality rates (208.1 per 100,000 in 2008-10) are more than twice as high as female rates (131.9).
• Nationally, CVD mortality rates increase across deprivation quintiles and are 1.8 times higher in the most deprived (229.6) than in the least deprived (129.2).
• People of South Asian origin living in the UK, have a 50% greater risk of dying prematurely from CHD than the general population (Lip et al, 2007).
• CHD accounts for around a quarter of deaths of people born in South Asia (men: 27%, women: 18%) but dying in England and Wales compared with around 15% of deaths of the general population (men: 18%, women: 13%) born in the UK (British Heart Foundation, 2011). 
• Men born in Pakistan, Bangladesh and East Africa are more likely to die from CVD than women born in the same countries (British Heart Foundation, 2011). 
• The rate of stroke mortality is significantly higher amongst men and women born in the Caribbean. This is covered in the stroke JSNA chapter.
• The increased risk of CHD mortality amongst people of South Asian origin is attributable to the increased prevalence of diabetes amongst these groups (BHF, 2010; Tziomalos et al 2007).
• Coronary heart disease is a leading cause of death amongst people with learning disabilities (14%-20%) with rates expected to increase due to increased longevity and lifestyle changes associated with community living. 
• High CHD rates in people with learning disabilities may be attributable to poor diet, low levels of physical activity and higher rates of overweight and obesity, as well as poorer uptake and access to primary care for the management of conditions. Notably, the prevalence of smoking and alcohol consumption is lower in adults with learning disability than the general population. Almost half of all people with Down’s syndrome are affected by congenital heart defects (Emerson & Baines, 2010).
• Patients with severe mental illness (major depression, bipolar disorder and schizophrenia) are at significantly higher risk of morbidity and mortality than the general population. The evidence for the level of this increased risk varies depending on the condition (de Hert et al, 2011).
• The increased risk of CVD amongst patients with severe mental illness is due to increased prevalence of CVD risk factors; the independent effect of antipsychotic drugs in their liability for metabolic side effects; lower levels of treatment with cardiovascular medication and cardiac surgery (de Hert et al, 2011, Department of Health, 2011).

CVD mortality

• CVD is the main cause of death in Nottingham. Of the 2,362 deaths in 2009, it accounted for 32% of deaths - comprising heart disease (16%), other circulatory diseases (8%) and strokes (8%) (NHS Nottingham City, 2011).  
• Whilst cancers are the biggest contributor to death amongst people aged less than 75 years (36%), CVD is the second major cause,  contributing 26% of all deaths (heart disease (16%), other circulatory diseases (6%) and strokes (4%)).
• From 1995 to 2010 CVD mortality decreased by 46% in Nottingham City compared with

54% in England. This represents a 12.1% reduction in the gap since 1995.

• However, the rate of premature CVD mortality was 28% higher than the England average in 2010 and this gap has not decreased since 2006.
• There is also a large inequality gap in premature mortality between the most deprived and least deprived fifth of areas in Nottingham for CVD (2007-2009). The gap has narrowed since 2001-2003 (NHS Nottingham City, 2011).
• The CVD mortality rate is significantly higher amongst men than women.
• During 2008-2010 the 4 wards with the highest under 75 CVD mortality rate were Arboretum (highest), St Anns, Bilborough and Bridge. St Anns and Arboretum were the two wards with statistically significantly higher under 75 CVD mortality rates compared to the city average. All other wards had a rate that was not statistically different to the city average with the exception of Wollaton West that had a rate significantly lower than the city average. St Anns also had the highest rate in the previous two years.

Figure 1 Premature (under 75 years) mortality from cardiovascular disease 1996-2012

People at risk of CVD

• Local modelling estimates that there are 12,000 people at high risk of CVD in Nottingham City (Hird, 2008).
• 6,456 people were identified as high risk through CVD risk assessments since October 2005; 58% of all patients identified as high risk and still aged 40-74 were managed (i.e. prescribed a statin and/or referred to a CVD prevention service) between October 2010 and September 2011.
• The proportion of people found to be at high risk of CVD is expected to increase with increasing deprivation. Analysis suggests that while this may be the case among women in Nottingham, the percentage of men found to be high risk has been fairly consistent across deprivation quintiles.  However, this may be due to the targeted approach of only inviting those patients estimated to be high risk.

Coronary Heart Disease

• The CHD mortality rate is significantly higher in the most deprived fifth of the city compared with the least deprived fifth (2007-2009). The gap has narrowed since 2001-2003 (NHS Nottingham City, 2011).
• Arboretum had the highest CHD mortality rate during 2008-2010 followed by St Anns, but no ward had a statistically higher CHD mortality rate than the city average. However Wollaton West did have a significantly lower rate than the city average.
• The below maps identifies a disparity between deaths from CHD amongst people aged under 75 years (figure 2 - map on the left) and estimates of ward level CHD prevalence based on GP practice Quality and Outcomes Framework data (figure 3 – map on the right).
• This is particularly apparent for Berridge, Arboretum, St Anns, Bridge and Dunkirk & Lenton wards which have higher death rates but lower prevalence of CHD when the Quality and Outcomes Framework data is used.
• The prevalence of CHD recorded in Nottingham City practices (2.8%) is significantly less that the national average and that of the Centres with Industry comparator areas (3.4%). 
• There is a wide prevalence range by practice from 5.5% (Bulwell Practice) to (0.1%, University student practice). 12 practices were statistical outliers for unusually low prevalence rates .  This may be due to patient demographics, natural random variation or lower than expected diagnosis. There is also wide variation amongst GP practices in the proportion of patients identified with CHD compared to the expected prevalence using Quality and Outcome Framework data (figure 4). This does not seem to correlate with hospital CHD emergency admission rates by GP practice.

Figure 2. CHD mortality rates (under 75), 2007-2009 vs estimates of CHD prevalence based on QOF  09/10 

Figure 3. Nottingham City GP Practice identified CHD prevalence as a percentage of expected prevalence (QOF) vs CVD hospital admission in people aged less than 75 years

• The emergency admission rate for CHD in the city decreased by 22.5% between 2003/04 and 2010/11. This is a smaller decrease than in England (23.9%), but greater than for comparable areas (Centres with Industry 15.5%) (SEPHO, 2012).
• In 2010/11 the emergency admission rate for CHD, all persons, in Nottingham City was 270.6 per 100,000 (781 admissions). This is significantly higher than England (225.9 per 100,000) but lower than Centres with Industry (272.8 per 100,000).
• Emergency admission rates for CHD are significantly higher in the most deprived fifth of the city compared to the least deprived fifth (SEPHO, 2012).
• During 2008-10 the wards with the highest CHD admission rate were Bilborough (highest), Bridge, Arboretum and Dales. Bilborough, Bridge and Arboretum had rates significantly higher than the city average and Mapperley (lowest), Bullwell Forest, Basford and Wollaton West significantly lower. This ranking was the same for CHD admissions for people aged less than 75 years. St Anns with the highest CHD mortality rate had the 10th highest admission rate.

Heart Failure

• During 2008-2010 Arboretum had the highest all age heart failure mortality rate, followed by Leen Valley, Bestwood and Dunkirk & Lenton. However, no ward had a rate significantly higher than the city average. Wollaton East & Lenton Abbey and Dales had significantly lower rates.
• In 2010/11 there was no statistically significant difference between the prevalence of patients diagnosed with heart failure between the city and comparator areas and the England average.
• The emergency admission rate for heart failure was significantly higher than the England average, but lower than the Centres with Industry group. (SEPHO, 2012)
• The admission rate in the most deprived fifth was 1.8 times that in the least deprived (SEPHO, 2012).
• During 2008-2010 all age heart failure admissions were highest in St Anns (highest), Bulwell, Aspley and Bestwood. They were lowest in Wollaton West, (lowest) Wollaton East and Lenton Abbey, Sherwood and Bulwell Forest which had significantly lower rates than the city average. St Anns and Bulwell had rates significantly higher than the city average.
• The ward distribution was slightly different for under 75 admission rates, with Radford and Park rather than Bestwood having the 4th highest admission rate and Wollaton East and Lenton Abbey having the lest rate. St Anns was the only ward with a rate significantly higher than the city average.

Atrial Fibrillation (AF)

• The prevalence of diagnosed AF on GP registers locally was 3,391 persons with AF or 0.99% of the population (QOF 2010/11), which is considerably less than the national average (1.43%). This suggests that there may be as many as 1,500 undetected cases of AF in the population.

Notable changes since JSNA April 11

The JSNA has been significantly updated particularly with comparisons to England from the CVD profile for Nottingham (SEPHO, 2012) and ward level comparisons.

 

Decade Of Better Health Programme
The programme run by the Health Promotion team in NHS Nottingham City Public Health, includes engaging with and working with local communities and volunteers to raise awareness and develop solutions for health improvement in relation to the Nottingham Plan priorities including CVD risk factors of diet, physical activity and smoking. A specific activity is engaging individuals to make pledges. Of the 10,000 city pledges made since 2010, 7% were for reducing or stopping smoking, 26% related to losing weight, 26% being more physically active, 18% reducing alcohol and 23% improving mental wellbeing.

Change Makers
Change Makers is part of the Decade of Better Health Programme. Change Maker volunteers use innovative methods such as community theatre to raise awareness of risk factors and signs and symptoms of CVD. Some of the activities that the Health Promotion team have facilitated with Change Maker volunteers include:

• Putting up display in community service centers and other community venues to raise awareness of the NHS Health Checks and a signs and symptoms of cancer and CVD.
• Community Link Work in partnership with Nottingham University – volunteers from black and minority communities working with individuals to raise awareness of diabetes and prevention through walking and weight management.
• Volunteers involved with consultation around the low uptake of the Slimming World on Referral Scheme amongst the Asian female community
• Volunteers taking part in a Healthy Ramadan campaign promoting healthy lifestyle changes and better health management during this time.
• Volunteers working in partnership with local pharmacies to take Health Checks out into the community and promote awareness of preventative measures.
• Volunteers involved in the design of resources such as banners and promotional items that promote health messages to reduce CVD.

Hearts and Minds programme run by Bright Ideas Nottingham
Hearts and Minds is a programmed funded by the British Heart Foundation and developed by Bright Ideas in Nottingham. It aims to identify approaches that work in relation to promoting heart health in Nottingham’s visible and non-visible diverse Black and minority ethnic communities. The programmed has included an annual conference, the development of community action researchers and “the Love Hearts”, a team of volunteers that work on the project to improve the Heart Health of African Caribbean Communities.

NHS Health Checks commissioned by public health
The NHS Health Check programme in Nottingham City is delivered by all 63 GP practices and 12 community pharmacies.  It aims to identify patients at high risk of cardiovascular disease and those who have undiagnosed conditions as well as identifying lifestyle risk factors and encouraging patients to make positive changes. 

Patients will be invited for an NHS Health Check once every 5 years, therefore around one-fifth of the eligible population should be offered a check each year.  The check includes a blood test to check cholesterol and blood glucose, measurements of blood pressure, BMI (height and weight) and questions around demographics, family history and lifestyle (e.g. smoking status, alcohol, physical activity, etc).  Patients found to be at high risk of cardiovascular disease, and those who are diagnosed with a condition as a result of the Health Check, are managed according to normal pathways, including referral to Healthy Change if appropriate.

In 2011/12:

• 4,765 NHS Health Checks were completed
• 1,218 patients were found to be high risk as  result of their Health Check
• 1,022 patients were prescribed statins
• 48 patients were newly diagnosed with Type 2 Diabetes as a result of the Health Check (defined as diagnosed within 90 days of the Health Check), 4 patients were diagnosed with Chronic Kidney Disease, 144 were diagnosed with hypertension and 5 were diagnosed with atrial fibrillation
• 1,788 patients were given general lifestyle advice
• 820 patients were given stop smoking information and advice and 137 were referred to a stop smoking service
• 2,958 patients were given a brief intervention in physical activity and 296 were referred to physical activity services
• 2,951 patients were given health education on diet/dietary advice, 1,942 were given weight management information and advice and 120 referred to weight management services
• 2,203 patients had their alcohol use assessed using AUDIT-C, 1,543 were given alcohol information and advice and 18 were referred to alcohol treatment services (100 declined an alcohol intervention). (TCR DH outcomes report [accessed 02/07/12])

There is a wide variation in the proportion of high risk patients treated with a statin to control cholesterol levels by general practices locally.

Figure 4. Percentage of high risk patients prescribed a statin by practice (October 2010 - June 2011)

CVD Prevention Pathway and services commissioned by public health
The CVD Prevention Pathway enables adult patients with one or more CVD risk factors to access behavioural change support to improve risk factors.  These risk factors are common to other conditions such as certain cancers, and therefore the pathway contributes to the prevention of other chronic/long term conditions as well.

The pathway utilises the proportionate universalism concept advocated in the Marmot Review. All of the commissioned services are available to Nottingham City residents and patients aged 18 years and over. In addition, all of the commissioned services have targets to meet for the number of clients from the following groups living in areas of the city (defined by lower superoutput areas) with the highest CVD mortality and some neighbouring LSOA that were in the most deprived LSOA quintile:

• People aged over 40 years
• Men aged over 40 years
• People aged over 40 years from black and minority ethnic communities

This strategy was developed through the planning of the Health Floor Target Action Plan for the City in 2006 and then reviewed in 2007 which was subsequently used to inform the NHS Nottingham City 5 Year Strategy.

Incorporation of these health inequalities targets have enabled commissioners and service providers to monitor performance in relation to engaging  people who are most at risk of developing CVD in the services. However the areas of the city with the highest CVD mortality have changed slightly since 2008 (figure 6).

Figure 5. Current CVD priority areas for commissioned services (left) and more recent map of  40% of city LSOA with highest under 75 CVD mortality (right)

However some of this change may be attributable to population movement and change in the demographics of people living in the small areas defined by LSOA. The commissioners of these services may therefore wish to consider moving to ward based priority areas such as the 8 wards with the highest CVD mortality – 2008-10 (figure 6).

Figure 6. Nottingham City wards ranked by under 75 CVD  mortality quintile 2008-10

The pathway (below) can be described in three stages:

• Identification, Assessment and Referral

People enter the pathway in one of three ways:

• Making a pledge through the Decade of Better Health Programme.
• Referral by a health professional in primary care, community services or secondary care.
• Self-referral to Healthy Change or other commissioned CVD prevention service.

• Referral Hub and Goal Setting

Healthy Change is a telephone-based lifestyle referral hub commissioned by NHS Nottingham City and provided by NHS Direct. Healthy Change employs Health Trainers who provide behaviour change support to clients over the telephone using the methods advocated in the Health Trainer Handbook. This involves goal setting and onward referral to the other prevention services. Healthy Change aims to see 2800 clients a year of which 2000 are from CVD priority groups.

• Prevention Services

Clients access the prevention services either after contact with Healthy Change or for some services, by direct self referral following advertising or outreach work. All services have targets to achieve a proportion of their clients from CVD priority areas and groups. 

Service	Target Activity (2011/12)	Description
Stop Smoking (see smoking chapter for more detail)
New Leaf Stop Smoking Service (CityCare Partnership)	5,514 clients 2,767 4-week quitters	Free local NHS stop smoking service for smokers who live or work in Nottingham.
Physical activity & healthy eating (see physical activity and diet& nutrition chapters for more details)
Active for Life Physical Activity Referral Service (Notts YMCA)	840 completing 12 week programme from priority groups + 360 not from priority groups	12 week programme of physical activity tailored to health condition with goal setting to increase physical activity.
Be Fit (Partnership between Nottingham City Council Leisure Services and Health Equality)	240 starting programme from priority groups + 920 not from priority groups	Access to 3 city council leisure centre facilities at specified times of the day for adults in receipt of specified benefits and those accessing the Active for Life scheme.
Best Foot Forward Walks (age UK Notts)	150 starting programme from priority groups + 60 not from priority groups	Free short guided health walks around open spaces in Nottingham.
Cycling for Health (Ridewise)	80 completing 4 hours cycling training from priority groups + 60 not from priority groups	Free cycle training, aiming to motivate people to cycle more.
Food for Thought (Citycare Partnership)	160 benefiting from healthy eating sessions. 70 not in target areas.	Six week course of nutrition education and food preparation skills and knowledge.
3)  Obesity (see adult obesity chapter for more details)
Slimming World on referral (Slimming World)	1,000 accessing Slimming World 330 loosing 5% body weight	12 week weight management programmethrough existing Slimming World groups.
Motivate men’s weight management (Notts County Football in the community)	1,000 accessing Slimming World 330 loosing 5% body weight	12 week weight management programme marketed at men.

For details of alcohol support and treatment services please refer to the Alcohol JSNA chapter

Supporting people with CVD
Management of hypertension, CHD and heart failure in primary care
The QOF contains a range of indicators relating to the care of patients with hypertension (2 indicators), coronary heart disease (9 indicators) and heart failure (2 indicators). Performance relating to the following indicators was either statistically significantly better (green) or worse (red) than the England average. The two heart failure indicators were not significantly different to the England average. These results from the SEPHO CVD profile also contain a comparison to the Centres with Industry for which the Nottingham City performance was similar.  

Figure 7.  General Practice Quality and Outcomes Framework 2010/11 CHD and Hypertension indicators that are significantly different to the England average

Indicator	Nottingham City	Centres With Industry	England
Coronary Heart Disease
% newly diagnosed angina patients referred for exercise testing or assessment	93.2	93.9	94.6
% CHD patients in whom last blood pressure reading was 150/90 or less	90.8	89.8	90.2
% CHD patients with a record of total cholesterol in last 15 months	93.0	93.6	93.7
Hypertension
% hypertension patients with record of blood pressure in last 9 months	91.1	91.6	91.6

Cardiac surgery
The CVD profile (SEPHO, 2012) contains a range of information on cardiac procedures. Key issues include:

• Angiography rates and significantly were lower than the England average and Centres with Industry. Rates have decreased in the city since 2003/4, whereas they have increased in England and Centres with Industry. These lower levels of angiography may be an indication of lower levels of reporting of heart disease symptoms in primary care or investigation, and may contribute to the higher levels of revascularisation in the city.
• Angioplasty rates are significantly higher in the city than the England average and Centres with Industry.
• Coronary Artery Bypass Graft (CABG) rates are significantly lower than the England average and Centres with Industry.
• Revascularisation rates are higher in the most deprived quintile in the city than the least deprived, but the gradient is less than in England and Centres with Industry.
• Survival rates for cardiac surgery (98.3%) at NUH are higher than required for UK standards (Care Quality Commission, 2010).

Cardiac rehabilitation
The national audit of cardiac rehabilitation (British Heart Foundation, 2011), found that uptake of cardiac rehabilitation was lower in the East Midlands than in England. This varied from 36 to 41%, 15 to 29%, and 65 to 76% for MI, angioplasty and bypass surgery patients, respectively. The East Midlands had the 7th, 9th and 10th lowest proportion of eligible patients accessing the services amongst the 10 English regions, for MI, angioplasty and bypass, respectively.

Service	Activity (annual)	Description
Hospital based community cardiac rehabilitation service provided by Nottingham University Hospitals Trust	In 2010  2774 referrals from all PCT areas (Nottm City, part of Notts County, Derbys County) Overall uptake of the service ranges from 30-60% depending on the reason for referral.	Multi-disciplinary cardiac rehabilitation covering preoperative & Phase I-III of cardiac rehabilitation across the NUH catchment area. Phase III is delivered in the community and includes exercise provision. Plus referral to phase IV. Heart failure patients are not currently eligible.
Community cardiac rehabilitation service provided by CityCare and commissioned by Nottingham City Clinical Commissioning Group	373 people Overall uptake of 83%.	Community nurse-led, case management service with a focus on secondary prevention, lifestyle management and education for city patient. Provides secondary prevention support to patients who have had recent cardiac event (heart attack and Acute Coronary Syndrome) and cardiac surgery.
Phase IV cardiac rehabilitation exercise sessions commissioned by NHS Nottingham City and provided by Nottinghamshire YMCA		Phase IV exercise is provided as part of the Active for Life Physical Activity on Referral service. In 2010/11 there were 186 clients and the number that completed was 81.
Community Heart failure service  provided by CityCare and commissioned by Nottingham City Clinical Commissioning Group	210 people per year	A community focussed specialist service to monitor and support people with diagnosed Left ventricular systolic dysfunction.

Notable changes since JSNA April 11

• The Nottingham City NHS Health Check programme has been expanded to cover all eligible 40-74 year olds instead of targeting only those with an estimated risk score of 15% or more.
• Redesign of the CVD Prevention pathway and commissioning of the Healthy Change Service and the Physical Activity Referral Service.
• Commissioning of the Be Fit Service.

Commissioning of the Motivate Men’s Weight management Service

 

Outcomes  - CVD mortality

The trajectory in the Nottingham City premature (under 75 years) CVD mortality has been calculated using the trend data from 1995 up to 2010. This shows that if the current trend continues the rate of premature CVD mortality will continue to decrease up to 2015 and the gap between the England rate and the Nottingham rate will continue to decrease.

Year	Trajectory England DSR (per 100,000)	Trajectory Nottingham DSR (per 100,000)	Gap (%)
2010	63.0	88.1	25.1
2011	57.2	81.5	24.4
2012	51.4	75.0	23.7
2013	45.5	68.5	23.0
2014	39.7	62.0	22.3
2015	33.9	55.5	21.6

In the longer term, prevention and earlier identification of CVD-related conditions through the Health Checks programme should reduce cardiovascular events and complications.  National modelling has shown that most of the longer term savings of the programme will come from earlier identification and prevention of diabetes.

 

NICE Guidance
Below is a list of the NICE clinical guidance documents related to primary prevention of cardiovascular disease and the management of hypertension and cardiac disease:
CG36 (2006) – Management of atrial fibrillation
CG34 (2006) – Management of hypertension in adults in primary care
CG48 (2007) -  Secondary prevention of myocardial infarction
CG67 (2008) – Lipid modification and risk assessment
CG71 (2008) -  Identification and management of familial hypercholesterolaemia
CG94 (2010) -  Unstable angina and NSTEMI
CG108 (2010) -  Chronic heart failure
CG95 (2010) - Chest pain of recent onset
CG107 (2010) - Hypertension in pregnancy
CG127 (2011) - Hypertension
CG126 (2011) - Management of stable angina

The NICE public health guidance documents below have been published for the prevention of cardiovascular disease:
PH15 (2008) -  Identifying and supporting people most at risk of dying prematurely: guidance
PH25 (2010) - Prevention of cardiovascular disease: guidance

DEPARTMENT OF HEALTH Guidance
Putting Prevention First - NHS Health Check: Vascular Risk Assessment and Management, Best Practice Guidance (2008)

For NICE guidance on CVD risk factors please refer to the NICE website or the relevant Nottingham JSNA chapters.

NHS Health Checks
NHS Nottingham City piloted cardiovascular health checks through the Happy Hearts pilot in 2009-2008. As part of this various means were used to develop customer insight which informed the service approach, and informed our subsequent NHS Health Checks service.
Market research was commissioned, which included 16 in-depth one-to-one interviews of patients who had been invited for a consultation. The aim was to ascertain what had either prevented them from responding or attending an assessment, or for those who had attended, what had motivated them to do so. Patients who had attended were also asked about their perceptions of the service and their experiences of the programme. This information was invaluable in designing the way in which people were invited.
Other methods to ensure an accessible service included: pre-testing leaflets with local residents within the target age range, and scripted phone calls to invite people who had not yet attended their GP surgery to attend specific community events on a Saturday.

Evaluation of CVD prevention services
The views of service users have been obtained as part of the evaluation of the Healthy Change, Be Fit and Physical Activity Referral Service conducted by MEL Research for NHS Nottingham City. This will be published later in 2012.

Improving CVD Prevention Services to Engage Men in Nottingham City – Insight Project
Qualitative interviews were commissioned in 2011 to provide insight into developing healthy living interventions aimed at men aged 40 and over who were overweight (DH Insight, 2011). Amongst 39 participants some of the key findings in the report were :

The main barriers to interviewees potentially accessing services were:

• A lack of motivation.
• A lack of interest in specific activities.
• A perception that they did not need to change.
• A lack of confidence in going into new situations.
• Feeling that they would not fit in with other people attending such activities.
• A perception that activities would cost money.
• A lack of disposable income.
• A lack of time.
• Not wanting to travel out of their neighbourhood.
• A lack of knowledge regarding what kind of activities might be available and appropriate for them.
• Many interviewees admitted to being somewhat lazy and enjoying an easy life; they felt that this would have to change if they were to have a healthier lifestyle and were not prepared to do so.
• For some interviewees, the fear of failure or lack of self confidence meant that they were not prepared to attempt to make changes in case they were unable to do this successfully.
• There was a strong view that eating healthily meant that interviewees would have to give up the food that they enjoyed and start eating food that was bland, ‘worthy’ and unpalatable.
•  Resigned themselves to a short life expectancy, therefore disinterested in long term benefits.
• Low aspirations regarding their life, therefore unable or unwilling to change.
• Coping with the impact of specific life events such as divorce, bereavement or redundancy.
• Acceptance of a certain amount of vices such as smoking or not taking much exercise.
• Dislike of authority and being told how to live their lives.
• The impact of working long shifts and the perception that physical jobs provided enough exercise.
• The importance of creating a more structured life after a period of homelessness taking precedence over healthy living (for a minority).
• The responsibilities of being a father and/or partner and the desire to spend leisure time in the home. This view was particularly strong within the Asian men’s focus group.

Awareness and engagement in Prevention Services by Asian men
A survey of 106 Asian men (mainly Pakistani) was conducted in the Sneinton area for the Muslim Community Organisation (Muslim Community Organisation, 2012). Key finding included:

• 46.46% of respondents were aware of health and wellbeing services on offer in the area with 24.43% expressing an interest in receiving help and assistance from these services.
• Over 30% sited not enough time and or working long unsocialable hours as a main reason for not using these services followed by 27.7% feeling they were not for men, 23.4% felt they cost too much and 21.3% felt they had no one to go with.
• 60.2% would like the MCO to assist them to make positive lifestyle changes and improve their
• health & wellbeing;

The most popular activities 47.6% Exercise/gym visits, 47.6% Exercise/gym visits, healthy diet classes, 29.1% swimming classes and 16.5% requesting assistance with weight loss programmes

 

• The Equality Impact Assessment of the CVD Prevention Programme presented evidence that patients with a major mental health diagnosis have an increased risk of CVD and diabetes – this needs to be taken into account in the development of services

Management of CVD in patients with severe mental health problems

1. Continue the emphasis on the primary prevention of CVD through the NHS Health Checks programme and CVD Prevention Services.
2. Address Practice variation in the management of patients identified as being at high risk of CVD through the Health Checks Programme.
3. Continue having performance targets for groups most at risk of CVD in the prevention services commissioned by Public Health. Consider revising the geographical targeting of services using more recent statistics and wards as the unit of geography rather than LSOA.
4. Utilise the services within the CVD prevention pathway commissioned by Public Health for the secondary prevention and management of CVD as well as primary prevention of CVD and cancer.
5. Include similar performance targets for groups most at risk of CVD, in CVD treatment services commissioned by the Clinical Commissioning Group.
6. Address Practice variation in the identification of patients with CHD.
7. Improve the access to CVD prevention interventions and CHD management and interventions for patients with severe mental health problems. This should include management within primary care.
8. Increase identification of patients with atrial fibrillation.
9. Increase referral rates to Angiography.
10. Increase the uptake of cardiac rehabilitation.

• Impact on the NHS Health Checks on the commissioned CVD prevention services.
• Low uptake of cardiac rehabilitation by city patients.
• Reasons for the lower prevalence of CHD in primary care.
• Low uptake of angiography.

Dawn Jameson, Nottingham City Clinical Commissioning Group, dawn.jameson@nottinghamcity.nhs.uk
John Wilcox, Nottingham City Public Health, john.wilcox@nottinghamcity.nhs.uk

Andrew Lee, Nottingham City Public Health, andrew.lee@nottinghamcity.nhs.uk

APHO (2007) Health Inequalities Intervention Toolkit (2007 version). Department of Health / Association of Public Health Observatories. Available at http://www.lho.org.uk/LHO_Topics/Analytic_Tools/HealthInequalitiesTool.aspx

APHO (2009) Health Inequalities Toolkit (2009 version). Department of Health / Association of Public Health Observatories. Available at http://www.lho.org.uk/LHO_Topics/Analytic_Tools/HealthInequalitiesTool.aspx

British Heart Foundation (2011). The National Audit of Cardiac Rehabilitation. Annual Statistics Report 2011. Available at: http://www.cardiacrehabilitation.org.uk/nacr/. [Accessed 26th April, 2012].

Care Quality Commission (2010). Heart Surgery in the UK. Survival rates. Available at: http://heartsurgery.cqc.org.uk/Survival.aspx [Accessed 26th June, 2012]

Collins, G.C. & Altman, D. G. (2010) An independent and external validation of QRISK2 cardiovascular disease risk score: a prospective open cohort study. British Medical Journal 340, 2442.

De Hert, M. et al (2011). Physical illness in patients with severe mental disorders. 1. Prevalence, impact of medications and disparities in healthcare.

Department of Health (2000). National Service Framework for Coronary Heart Disease. Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4094275 [Accessed 27th April, 2012]

Department of Health (2005) Tackling Health Inequalities – what works. Health Inequalities National Support Team, Department of Health

Department of Health (2008) Putting prevention first- vascular checks: risk assessment and management - next steps guidance for primary care trusts. Department of Health

Department of Health (2009) Achieving the 2010 Life Expectancy Target: Modelling required mortality reductions and potential deaths averted through evidence-based interventions. Health Inequalities National Support Team, Department of Health

Department of Health (2011). Quality and outcomes framework guidance for GMS contract 2011/12: Mental Health.

Emerson, E. & Baines, S. (2010). Health Inequalities & People with Learning Disabilities in the UK: 2010. Department of Health.

Hippersley-Cox et al. (2008). Predicting cardiovascular risk in England and Wales: prospective derivation and validation of QRISK2. British Medical Journal 2008;336:1475-82

APHO (2011) Hypertension prevalence estimates and projections. available at http://www.apho.org.uk/resource/item.aspx?RID=111119 [Accessed 12th June 2012]

Lip G.Y.H et al (2007). Ethnicity and cardiovascular disease prevention in the United Kingdom: a practical approach to management. Journal of Human Hypertension. 21, 183-211.

Muslim Community Organisation (2012). MCO Health & Wellbeing. Survey Report January 2012.

NCHOD (2007) Mortality from all circulatory diseases, under 75. National Centre for Healthcare Outcomes Database, available at http://nww.nchod.nhs.uk/

Nottingham City PCT (2006) Black and Minority Ethnic Health Needs Assessment. Nottingham City PCT.
NHS Nottingham City (2011).  NHS Nottingham City Public Health Annual Report 2010 Technical Appendix. Available at: http://www.nottinghamcity.nhs.uk/images/stories/ANNUAL_REPORTSetc/Technical%20appendix.pdf [Accessed 12th June 2012].

NICE (2008). Lipid modification. Cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. (Reissued March 2010). Available at: http://guidance.nice.org.uk/CG67/NICEGuidance/pdf/English . [Accessed 16th July 2012]

NICE (2011). Commissioning Guide 40. Cardiac rehabilitation services.

SEPHO (South East Public Health Observatory) (2012). Cardiovascular Disease PCT Profile for Nottingham City. Available at: http://www.sepho.org.uk/NationalCVD/docs/5EM_CVD%20Profile.pdf [Accessed 30th April 2012].

Tziomalos et al (2007). Vascular risk factors in South Asians. International Journal of Cardiology. 128 (1). 5-16.