1.  We write with reference to the Health Select Committee which has launched an inquiry into how the NHS can reduce health inequalities. We wish to address one area of focus—"how the Quality and Outcomes Framework and Practice based Commissioning might be used to improve the quality and distribution of GP services to reduce health inequalities". We submit this evidence as members of the medical profession who regularly deal with patients afflicted by Peripheral arterial disease (PAD).

  2.  PAD is a narrowing of the arteries that supplies blood to the legs. The narrowed arteries cannot carry enough blood, which may cause patients to experience pain in the legs when walking. This is called intermittent claudication (IC). It not only affects a person's ability to walk -it is essentially a manifestation of widespread hardening of the arteries (atherosclerosis) and these patients are at huge risk of events elsewhere eg Stroke and Heart Attack.

  3.  Stroke, Heart attack and PAD are all the same disorder ie atherosclerosis. Our contention is that patients with PAD are being treated unequally compared to these other vascular disease groups. This is true for both the management of risk of future heart attacks and strokes, and in the treatment of PAD symptoms. PAD is highly prevalent and although associated with a significant risk of future heart attack and stroke it remains under diagnosed and under treated in the UK. It is more common in those who smoke and those who are elderly, and in those who are socially disadvantaged. Thus improved treatment of PAD in the population as a whole will help to reduce inequalities. It is a common disorder, affecting approximately 1in 8 patients over the age of 55 in the UK.

  4.  To reiterate—a direct analogy can be draw with our understanding of diabetes where it is not the presenting disease (diabetes) that is accountable for death but the associated cardiovascular risk factors. Unfortunately, patients with PAD often do not receive proper care until the associated devastating heart or brain attack occurs. Aggressive risk factor management, (blood fat (cholesterol), high blood pressure, diabetes, sticky blood cells (platelets)) and smoking cessation counselling in patients with PAD will prevent many premature deaths and much unnecessary suffering. PAD is a major marker for future events (more than chronic stable angina!). As a result, 60% of PAD patients die from heart attack and 12% from stroke. Furthermore, patients with symptomatic PAD have significantly reduced mobility and poor quality of life, equating to some cancers. Symptomtatic treatment is infrequently given to these patients. PAD needs to be included in the GMS contract and other health initiatives, so that doctors are informed and motivated to provide appropriate care for these patients.

  5.  Proven preventative treatments are readily available. Many large scale international studies have provided clear evidence that managing these risk factors prevents heart attack, stroke and death in these PAD patients. In particular, the Heart Protection Study addresses the value of cholesterol control, and the CAPRIE study and others the value of anti-platelet agents.

  6.  If the GMS contract is to achieve its aim of improving healthcare and reducing death from Cardiovascular disease, it cannot continue to ignore a substantial subgroup of patients with such a disorder ie patients with PAD. The case that PAD should be treated as an equivalent to coronary disease is beyond doubt and we are convinced that the addition of PAD to the GMS contract should be brought about as speedily as possible. Our position is that PAD needs to have an appropriate allocation of points from the 152 points currently given to cardiovascular conditions. A simple mechanism would be to change coronary heart disease (CHD) to cardiovascular disease (CVD) and thus PAD Patients would be included in the current assessment programme! We would urge all those involved in assessing inequalities in health care to actively support this alternative as a proposed, and probably successful, method of reducing Cardiovascular mortality in line with Government targets.

Professor Jill JF Belch, MBChB, FRCP, MD, FAcadMed Sci

(Professor of Vascular Medicine, Head of the Institute of Cardiovascular Research, University of Dundee, Consultant Vascular Physician, Ninewells Hospital, Dundee, Co-Chair TARGET PAD group and Past-President and current Secretary of the Section of Vascular Medicine, Royal Society of Medicine, London).

Professor Gerry Stansby, MChir, FRCS

(Professor of Vascular Surgery, University of Newcastle, Consultant Vascular Surgeon Northern Vascular Unit, Co-Chair TARGET-PAD group and Council Member of The Vascular Society of Great Britain and Ireland).

Mr Michael Gough, MB, ChB, ChM, FRCS.

(Consultant Vascular Surgeon, Leeds Vascular Institute and President of the Vascular Society of Great Britain and Ireland).

Mr Jonothan Earnshaw, MB, BS, DM, FRCS.

(Consultant Vascular Surgeon, Gloucestershire Royal Hospital, and Secretary of the Vascular Society of Great Britain and Ireland).

Professor Cliff Shearman, BSc, MB, BS, MS, FRCS.

(Professor of Vascular Surgery, University of Southampton, Consultant Vascular Surgeon, Southampton General Hospital, Council Member of the Vascular Society of Great Britain and Ireland, member of the TARGET-PAD group).

Professor Gerry Fowkes, MBChB, PhD, FRCPE, FFPH

(Professor of Epidemiology, Public Health Sciences, University of Edinburgh and Chair of Scottish Intercollegiate Guidelines Network (SIGN) Guidelines Group on PAD).

January 2008