EXECUTIVE SUMMARY

  1.  Coronary heart disease (CHD) is the biggest killer in the UK, and cholesterol is the single greatest risk factor for developing CHD. Cholesterol contributes to almost half of all coronary heart disease related deaths in the UK. High levels of cholesterol, and the associated risk factors including heart disease and stroke, are intrinsically linked to health inequalities. It also contributes to the increased risk of cardiovascular disease associated with diabetes and obesity.

  2.  People on low incomes are at greatest risk of developing cardiovascular disease: the highest levels of cholesterol are evident in areas with greater deprivation, where poor diets, smoking, obesity and inactivity are commonplace. This was illustrated by the results of the Flora "Test the Nations' Hearts" survey (Flora pro.activ, 1996), which found that over half of all adults tested (56%) had cholesterol levels above the recommended level, and identified Glasgow and Huddersfield as the 2 UK cities with the highest cholesterol levels and the highest percentage of residents with above optimal blood pressure. Other cities with high percentages included Sheffield and Middlesbrough.

  3.  H.E.A.R.T. UK, the cholesterol charity, is a nationwide charity that aims to raise awareness about the importance of cholesterol management with both patients and healthcare practitioners. The charity helps families with a high risk of premature cardiovascular disease, particularly those with some form of inherited high cholesterol. However, up to 85% of people with inherited high cholesterol are undiagnosed, and are therefore not undergoing treatment.

  4.  H.E.A.R.T. UK believes that the health service has a vital role to play in tackling the health inequalities associated with high cholesterol, and that a public health campaign on the dangers of cholesterol is needed to tackle this growing problem. This is becoming increasingly important in light of the ageing population, and the Government's desire to keep people in work for longer.

  5.  In order to tackle health inequalities, H.E.A.R.T. UK believes that a long-term Department of Health strategy on public health is required, including a public education campaign on fats, greater awareness of the risks associated with high cholesterol, and wider availability of high quality cardiovascular risk testing including full cholesterol profile. In addition, H.E.A.R.T. UK is calling for the implementation of the latest clinical standards of cardiovascular disease management for high risk groups, and for these to be incorporated in the QOF targets on cholesterol. The charity also supports the need for better training for healthcare professionals in the primary care setting on providing diet and lifestyle advice, in order to empower the patients to take action to improve their heart health. NICE is currently in the early stages of producing guidance on the prevention of cardiovascular disease at the population level. As a registered stakeholder, H.E.A.R.T. UK believes that this guidance must specifically look to address health inequalities.

The extent to which the NHS can contribute to reducing health inequalities, given that many of the causes of inequalities relate to other policy areas eg taxation, employment, housing, education and local government

  6.  If the government is to meet its target of keeping more people in work for longer, it must address the health issues that affect people's capacity to continue working, and to help those most at risk of suffering from ill-health or disablement as a result of deprivation or poverty. For this reason, the NHS has a pivotal role to play in reducing health inequalities.

  7.  A recent report by H.E.A.R.T. UK ("Cholesterol and the ageing population: Avoiding the crisis in health and pension costs", 2007) found that the Government's plans to raise the age of retirement and keep people working longer are under threat as a result of increased ill health and incapacity. The report found that by 2020, CHD disease will be the leading cause of disablement in the UK. The report also highlighted the findings of the 2002 economic study, "The economic burden of coronary heart disease in the UK", which found the annual cost of cardiovascular disease to the UK economy was around £7 billion.

  8.  People on lower incomes are shown to be at greatest risk of developing cardiovascular disease, and it is these people who will be hit hardest by an inability to work as a result of CHD related incapacity. In addition, once diagnosed people on lower incomes may struggle to pay for the long-term treatments recommended to them, leading to low compliance with medication and elevated risk of suffering an event as a result of their condition. H.E.A.R.T. UK believes greater consideration should be given to widening the exemptions for prescription charging.

  9.  A long term strategy on public health is needed, led by the Department of Health. This must include a public education campaign on fats, greater awareness of the risks associated with raised cholesterol and wider availability of high quality cholesterol and heart risk assessment.

  10.  NHS healthcare practitioners are also well placed to tackle health inequalities, particularly in primary care. This is because primary care is often the public face of the health service, and has regular contact with patients. Patients also trust their primary healthcare professionals to help them to make informed choices about their health and to discuss treatment options.

The distribution and quality of GP services and their influence on health inequalities, including 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

  11.  The role of primary care in addressing health inequalities is paramount. As the first point of call for many members of the public who are seeking healthcare advice, primary care is uniquely placed to educate patients about the risks of cardiovascular disease and to assess individuals for their overall risk by measuring blood cholesterol, blood pressure, blood glucose, body mass index, family history, etc. The primary care team is well placed to offer services and support for preventative action and treatment, as necessary, for the majority of patients—only those at highest risk and with complex conditions such as familial cholesterol conditions may require referral to specialist care.

  12.  In recent years, there have been some significant advances in treating high blood cholesterol in the primary care setting, including the introduction of the GP contract and an increased prescribing of cholesterol lowering statin drugs. However, the potential for the Quality and Outcomes Framework to prevent CVD is compromised as a result of the outdated target value for cholesterol included in the current contract. The latest clinical guidance from the Joint British Societies (JBS2) and the Scottish Intercollegiate Guideline Network recommended a significantly lower target of blood cholesterol to be introduced for high risk groups. Currently high risk patients are being treated to a target of 5mmol/l of cholesterol and 3mmol/l of LDL cholesterol. However, the JBS2 guidance recommended that these targets should be revised to 4mmol/l of cholesterol and 2mmol/l of LDL cholesterol. Failure to update the guidance has also compounded the "treatment gap", where the number of people currently being prescribed cholesterol lowering drugs is considerably less than the number who could benefit from treatment, and the target level for those receiving the drugs is usually well below the cholesterol level actually achieved. It is estimated that more than 7,000 heart attacks a year are attributable to the treatment gap. Therefore the QOF must be allowed to evolve in order to reflect evidence based best practice care and to improve the care provided to the patients.

  13.  In addition, we understand anecdotally from our discussions with patients that the provision of care varies considerably between GP practices. It is our understanding that few practices will provide cholesterol tests to patients if the patient is not considered to be "at risk". Many of the pharmacies that offer testing also charge a small fee, making it more difficult for the people with the greatest need (ie those with lower incomes) to access their risk. The JBS2 guidelines recommends opportunistic testing should be introduced, including regular testing for people over the age of 40—funded by the GP contract—to allow patients, regardless of their background, to be made aware of their cholesterol levels. NICE is also in the process of developing a clinical guideline on lipid modification, which is due to be published this year. This will include guidance on identifying people at risk of CVD through primary care.

  14.  There is some evidence of innovative practice, including practitioners taking testing into the community by testing people in pubs and community centres to reach at risk groups. However, such practices are not widespread. In order to lower cholesterol levels, the first line of action should always be through diet and lifestyle, by reducing the intake of saturated fat, stopping smoking and taking more exercise. Every healthcare professional within the primary care setting has an important role to play here, including practice nurses who are now trained with skills in lifestyle modification, and specialist advice from dietitians and health visitors. The doctors should take responsibility to ensure that their practice has mechanisms in place to provide diet and lifestyle advice, and to appoint all members of the practice with a specific role. In the long term, such action within primary care can improve patient health by empowering the patient to make the right choices about their own health, as well as significantly reducing the burden on secondary care.

The effectiveness of public health services at reducing inequalities by targeting key causes such as smoking and obesity, including whether some public health interventions may lead to increases in health inequalities; and which interventions are most cost effective

  15.  Despite clear signals from the Government that it was seeking to improve public health, including the publication of the 2004 White Paper, "Choosing Health, Making Healthy Choices Easier", implementation of the recommendations has been slow and patchy.

  16.  H.E.A.R.T. UK's 2007 report concluded that the UK's public health policies were making very little impact on reducing health inequalities, and were actually widening the gap between the North and South of England. This was also recognised in the 2006 Department of Health report "Health Profile of England". A report by the London Health Observatory in November 2006 ("London Health Inequalities Forecast") found that the inequalities gap in deaths from heart disease and stroke in London was widening, and concluded that the Government's targets on reducing health inequalities would not be met unless the Spearhead PCTs in London provided services such as the detection of high blood pressure and cholesterol.

  17.  In the UK, the Government's public health policies have fallen well short of their targets. However, evidence from overseas clearly demonstrates that Government-led campaigns can be very successful in helping to tackle public health issues including CHD.

  18.  In the 1960's, Finland suffered from the highest death rate from CHD in Europe. The North Karelia project was launched in 1972 as a collaborative project driven by community initiatives and led by the national Government in order to address this issue. As part of the scheme, which started in the province of North Karelia, a number of activities were established including programmes in the workplace to lose weight; cholesterol lowering competitions between villages; a national television series to chart the progress of volunteers to lead a healthier lifestyle; collaborative action with food manufacturers and supermarkets to encourage dietary changes; and educating key community leaders to encourage them to pay attention to health related issues.

  19.  The results of this project were remarkable. Cardiovascular mortality rates for men aged between 35 and 64 decreased 57% from 1970 to 1992; the number of people using butter on their bread fell from 90% in 1972 to just 15% in 1992 whilst the consumption of whole milk fell from 70% to 14%; and annual fruit and vegetable consumption increased from about 20kg per person in 1972 to around 50kg in 1992. Moreover, in 1972 just 28% of men and 42% of women reported having their blood pressure measured in the previous 6 months. By 1993, over 98% of the population had had their blood pressure measured.

  20.  Other international examples of note include the successful Australian Heart Foundation Tick Programme Campaign, where food products and meals eaten out of the home received a tick if they met the healthy heart criteria. This campaign helped to inform the public about the importance of a healthy heart diet.

  21.  The US National Cholesterol Education Programme (NCEP) is a further example of how public health policies can successfully address management of risk factors with beneficial outcomes. NCEP started in 1985 to help to tackle CHD by reducing the number of Americans with high blood cholesterol. The NCEP has successfully highlighted a broad range of risk factors and provided comprehensive management guidelines for both the public and healthcare professionals. This resulted in a 23% increase in the number of people screened for cholesterol in the US between 1991 and 2003. If a similar scheme was introduced in the UK it could lead to widespread changes in health behaviour by making people aware of the risks associated with high cholesterol and poor diet. It could further result in increased intervention for those at risk.

  22.  In the UK the Food Standards Agency has recently consulted on a draft saturated fat and energy intake programme, which H.E.A.R.T. UK responded to. H.E.A.R.T. UK believes that this strategy must take into account health inequalities, and actively seek to address the issue as part of the programme. It is anticipated that the programme will be rolled out during the course of this year.

  23.  Despite action by the UK Government to raise awareness about the dangers of heart disease, many people are still unaware about the importance of low blood cholesterol. Indeed, an estimated 85% of people with some form of inherited high cholesterol remain undiagnosed and untreated. In 2004 Cholesterol UK— a joint initiative of H.E.A.R.T. UK and the British Cardiac Patients Association—carried out a survey in which less than 5% of respondents identified cholesterol as the highest risk factor for CHD, but 90% said they would be fairly or very concerned to learn that their blood cholesterol was too high. This clearly demonstrates a need for a focused public health campaign from government to raise awareness of this issue, to ensure that those in need of treatment are receiving it and that people are taking appropriate action to ensure their cholesterol levels remain low. Any such campaign should be implemented in partnership with charities and community initiatives etc to ensure that it is far reaching.

Whether specific interventions designed to tackle health inequalities such as Sure Start and Health Action Zones, have proved effective and cost effective

  24.  H.E.A.R.T. UK supports specific action to tackle health inequalities and the diseases readily associated with this. As identified in the answer above, we believe that a public health campaign to raise awareness of cholesterol is needed in order to tackle CHD.

  25.  H.E.A.R.T. UK's 2007 report, "Cholesterol and the Ageing Population" also identified 3 other areas of immediate activity for the government, including greater access to cholesterol testing as part of the NHS heart risk assessment to help people understand their own heart health; implementation of latest clinical standards on cardiovascular disease management or high risk groups; and better training for health professionals in the primary care setting on diet, public health measures and prevention of heart disease. H.E.A.R.T. UK believes that these measures are the most effective way of increasing public awareness about cholesterol and CHD, and consequently tackling health inequalities.

The success of NHS organisations at coordinating activities with other organisations, for example local authorities, education and housing providers, to tackle inequalities, and what incentives can be provided to ensure these organisations improve care

  26.  At a local level greater coordination with local authorities, education and housing providers would be of significant benefit to the population. However, as recognised in H.E.A.R.T. UK's 2007 report, "Cholesterol and the ageing population", frequent reports about PCTs across the country suggest that the organisations are more inclined to divert money away from such activities in order to reduce waiting lists or deficits. Indeed, the GUM clinic spending report on Sexual Health & HIV, published July 2006, revealed that just 15% of PCTs were spending money as allocated to them by the Government to implement the 2004 White Paper, "Choosing Health".

CONCLUSIONS

  27.  A long-term Department of Health strategy on public health is needed to tackle health inequalities. This must include a public education campaign on fats; greater awareness of the risks associated with raised cholesterol; and wider availability of high quality cholesterol and heart risk assessment. Comparisons from overseas clearly demonstrate the positive impact that government-led public health campaigns can have on helping to address this issue.

  28.  QOF has the potential to make significant improvements to the care of patients at risk of CVD, but only if the targets reflect evidence based best practice care for patients, and not outdated targets that compound the treatment gap.

  29.  In addition, better training of healthcare professionals in the primary care setting to provide diet and lifestyle advice to patients is required. GPs, practice nurses, dietitians and health visitors all have an important role to play here, and it would empower the patients to make positive choices to improve their own health.

January 2008