National Health Service: Coronary Heart Disease · 1. Coronary heart disease kills about 180,000...

NATIONAL AUDIT %%‘ICE

Report by the Comptroller and Auditor General

National Health Service: Coronary Heart Disease

Ordered by the House of Commons to be printed 14 February 1989

Her Majesty’s Stationery Office, London E5.50 net 208

NATIONAL HEALTH SERVICE: CORONARY HEART DISEASE

This report has been prepared under Section 6 of the National Audit Act, 1983 for presentation to the House of Commons in accordance with Section 9 of the Act.

John Bourn Comptroller and Auditor General National Audit Office

8 February 1989

The Comptroller and Auditor General is the head of the National Audit Office employing some 900 staff. He, and the NAO, are totally independent of Government. He certifies the accounts of all Government departments and a wide range of other public sector bodies: and he has statutory authority to report to Parliament on the economy, efficiency and effectiveness with which departments and other bodies use their resources.

NATTONAL HEALTH SERVICE: CORONARY HEART DISEASE

Contents

Summary and conclusions

Part 1: Introduction

Part 2: Prevention of Coronary Heart Disease

Part 3: Treatment of Coronary Heart Disease in England

Pages

1

5

9

17


Summary and conclusions

1. Coronary heart disease kills about 180,000 people in Great Britain each year and causes suffering for, perhaps, two million. The cost to the National Health Service (NHS) of treatment is over E500 million a year. Deaths from coronary heart disease in Great Britain have reduced slightly in the last decade. However, in some comparable countries such deaths have declined over a much longer period and at rates four to five times higher than those in Great Britain.

2. The three health departments - the Department of Health in England, the Welsh Office and the Scottish Home and Health Department - have for some years fostered initiatives to raise public awareness of health risk factors and to promote healthier lifestyles. Recently both England and Wales have also introduced heart disease prevention programmes. In the area of treatment the Department of Health have combined high level monitoring of NHS regional arrangements for providing coronary care with two specific initiatives; one to encourage the extended training of ambulance staff in resuscitation techniques for heart attack patients and the other by setting a national target for the provision of coronary artery by-pass graft operations.

3. This report presents the results of an examination by the National Audit Office (NAO) of the roles of the health departments and the NHS in securing a reduction in coronary heart disease mortality and morbidity. The report addresses two main issues:

(a) whether the health departments have effective arrangements for seeking to prevent coronary heart disease (Part 2);

[b) whether there are effective arrangements in England for monitoring the provision of hospital treatment for coronary heart disease (Part 3).

Main findings 4. The NAO found that:

On prevention:

(a) there is no single body with responsibility for minimising the risk of differences between departments’ policies or objectives and government policy on the importance of preventing heart disease, similar to the ministerial committees concerned with AIDS, drugs and alcohol abuse (paragraphs 2.5 to 2.7);

(b) the three health departments have adopted separate approaches to the prevention of coronary heart disease and consider that geographical differences and the need to assess what works best in practice, preclude greater consistency (paragraphs 2.9 and 2.10);

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NATIONAL HEALTH SERVICE: CORONARY KURT DISEASE

(c) national strategies have not, thus far, included departmental guidance for health authorities in developing specific programmes aimed at coronary heart disease prevention (paragraphs 2.11 and 2.12);

(d) comprehensive data relating to morbidity and health indicators, which are a prerequisite for proper planning and oversight of health promotion and disease prevention work, are lacking. Unlike in some other countries, where coronary heart disease shows greater reductions, there are no national systems in England and Scotland for monitoring coronary risk factors (paragraphs 2.13 to 2.16);

(e) the programme to reduce coronary heart disease in Wales, which began in 1985, follows the approach recommended by the World Health Organisation, is well-structured and shows early signs of having an impact on people’s lifestyles (paragraphs 2.18 and 2.19);

(fJ a similar campaign in England, the first phase of which started in 1987 in response to the perceived need to take urgent action, has had some successes, but after more than a year still lacked quantified targets and estimates of the resources needed nationally; the Department of Health and the Health Education Authority carried out a review which highlighted earlier missed opportunities and weaknesses caused in part by staff shortages and, as a result, are developing a long term strategy (paragraphs 2.20 to 2.25);

(g) in Scotland, where the incidence of heart disease is particularly high, the approach is to address health risk factors through an umbrella campaign comprising several programmes, but without explicit references to heart or other diseases; the campaign has increased awareness of the principal risk factors but there are no quantified targets; and the approach to preventing heart disease is being reviewed (paragraphs 2.26 to 2.30);

(h) a small sample of health authorities in England showed an uneven local approach to the prevention of heart disease, although each of the districts visited were tackling associated risk factors to some extent. However, a further analysis of 34 districts revealed that a quarter had failed altogether to mention the issue in their 1988-89 Short Term Programmes (paragraphs 2.31 to 2.35);

(i] information provided by English regions in their 1988-89 plans proved insufficient for the Department of Health’s purpose of assessing the extent of local initiatives being taken and their integration with the national campaign (paragraph 2.36);

On treatment:

(j) although Department of Health policy is to leave questions of the distribution and development of cardiac services to NHS regions, they expect to be consulted about significant changes, and acknowledge a responsibility to act where there is a serious imbalance in the distribution of services affecting patients’ access to treatment (paragraphs 3.7 to 3.9);

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Conclusions

(k) because there are wide regional variations in the size of waiting lists for cardiac care and the length of time to clear them, and in the numbers of cardiologists and cardiothoracic surgeons relative to regional populations, depending on where they live some patients may have markedly better opportunities for treatment than others (paragraphs 3.10 to 3.13);

(1) fundamental reviews of cardiac service provision undertaken by the two regions visited by the NAO revealed scope for the rationalisation and development of services (paragraph 3.14);

(m) the Department of Health are seeking, through the collection and better use of data, to remedy a situation in which demand for heart treatment is probably not being met and, until recently, NHS planning generally lacked an informed assessment of future need (paragraphs 3.14 and 3.15);

(n) in 1984 the Department of Health encouraged health authorities to introduce extended training of ambulance staff in life-saving resuscitation techniques but, because of the devolved nature of management responsibility, they do not routinely monitor the extent of the response by ambulance services (paragraphs 3.17 to 3.21);

(0) the Department of Health, having in 1986 set a target of 300 coronary artery by-pass grafts a year per million population by 1990, currently lack sufficiently reliable information to determine the progress towards achieving the target with any real accuracy, but have taken steps to improve future data (paragraphs 3.25 and 3.26);

(p) there seems little prospect that the overall target for by-pass grafts will be achieved; regionally there are wide variations and some regions would seem to need to increase provision significantly in order to reach the target by 1990 (paragraphs 3.27 to 3.29);

(q) it is unclear whether the development of angioplasty has had an impact on the number of by-pass grafts being performed; the Department of Health are seeking to compile comprehensive data for the extent of its use (paragraphs 3.26 and 3.30);

(I) as the use of by-pass grafts in some other countries continues to increase, and with the Scottish Home and Health Department and the Welsh Office recently setting higher targets, the Department of Health are keeping the target for England under review (paragraphs 3.31 and 3.32);

(s) the Department of Health consider that the evaluation of new developments in treatment is primarily the role of the medical profession, although some health authorities see a need for greater guidance from the Department on the use of new techniques (paragraphs 3.33 to 3.37).

5. The health departments have been aware for several years of the heavy burden on NHS resources resulting from the very high incidence of coronary heart disease in Great Britain. They have also seen how other similar countries have managed to reduce significantly the impact of the disease. The departments’ response has been slow to develop and is not co-ordinated in the same way as for Aids and drug and alcohol abuse, where ministerial committees have been established.

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6. The national programmes directed at public Information and exhortation show some encouraging signs of early progress but no targets have been set in England and Scotland against which this can be measured. Furthermore, in England, government departments and the NHS, as employers, have given little support to the programme; and locally funded activity within the NHS is patchy and not well integrated with the national programme. If Great Britain is to emulate the achievements of others in the field of prevention, much remains to be done.

7. There is evidence from NHS regions to support the contention that opportunities exist for rationalising and developing cardiac treatment services. The wide regional variations in the level of service provision proportional to population suggests there is scope for the Department of Health to exercise their acknowledged responsibility to remedy a situation in which patients living in different parts of England have access to widely different opportunities for treatment.

8. The Department of Health have recognised the need to increase the number of coronary artery by-pass grafts being undertaken by setting a national target. The Department’s subsequent monitoring has been hampered by the poor quality of the information coming from regions, which the Department are seeking to remedy. It seems improbable, on the basis of existing information, that a number of regions will reach the target set for 1990.

9. If the best use is to be made of scarce resources, the Department of Health need to develop significantly the collection of basic data for monitoring the appropriateness of the levels of cardiac services generally and of by-pass grafts in particular. Meanwhile, the timely development of newer and more economical treatments may call for earlier and more positive intervention by the Department than is presently the case.

4


Part 1: Introduction

1.1 About 180,000 people die from coronary heart disease in Great Britain each year - equivalent to one person every three minutes. This disabling disease also causes suffering for some two million more people. The incidence of coronary heart disease has increased greatly in Great Britain over the last half-century. It is now the largest single recorded cause of death, accounting for 27 per cent of all deaths in 1986 [Figure 1). In scale it is similar to the major diseases of the past, such as cholera, typhoid and smallpox.

1.2 The health departments are unable to estimate the extent of expenditure on the prevention of coronary heart disease because of the notoriously difficult problem of costing health promotion activities. However, excluding spending specific to risk factors such as smoking and diet and the unquantifiable costs of advice given to people by general practitioners, total expenditure is of the order of El0 million a year. Annual expenditure on treating patients suffering from the disease is about f500

million. But there are also broader economic costs. Coronary heart disease accounts for about 10 per cent of all working days lost due to illness (35 million), and in 198&85 resulted in sickness benefits which, according to one estimate, amounted to more than E250 million. There is also the cost of productivity lost through sickness and premature death.

Coronary heart disease

1.3 Coronary heart disease is caused by fatty deposits which contain cholesterol silting up the coronary arteries. If these arteries get too narrow the blood supply to the heart muscle can become restricted, or even completely blocked, thus weakening it and reducing the heart’s efficiency as a pump. The disease manifests itself in several ways - including sudden death, acute heart attack, angina and heart failure. Between 30 and 40 per cent of all major heart attacks prove fatal, with half of those deaths occurring within two hours of the onset of symptoms.

Figure 1

Total deaths in Great Britain analysed by cause

Coronarv heart disease

Accident & violence (21,700)

Respiratory diseases (70,500)

SOUrCe: Annual Abstract of Statistics, 1986 data

Other (140,200)

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NATIONAL HSALTH SERVICE: CORONARY HEART DISEASE

Figure 2

Coronary heart disease mortality Males: aged 40 - 69

7501 -. -. ,- ,-

‘\ ‘\ 700- -=.*’ .\______ 700- -=.*’ .\______ -._* -._*

_---_ _---_ ‘\ ‘\

450- 450-

400- 400-

350- 350-

300 300

01 ” E ” 1 ” 1 ” 1 ” 1 ‘a 01 ” E ” 1 ” 1 ” 1 ” 1 ‘a 1968 1971 1974 1977 1980 1983 1985

year

Coronary heart disease mortality Females: aged 40 - 69

1968 1971 1974 1977 1980 1983 1985 Yea

Source: WHO statistics Cardiovascular Epidemiology Unit Dundee

Scotland

Finland

England &Wales

Australia USA Canada

Scotland

England & Wales USA Finland Australia Canada

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1.4 In recent years there have been significant advances in the treatment of coronary heart disease. However, the scope for making significant reductions in morbidity [ill health) and mortality, and for reducing the higher burden on NHS resources, lies in the area of health promotion and disease prevention. It is now widely recognised that the premature onset of coronary heart disease could be reduced significantly if people adopted healthier lifestyles (for example, by avoiding smoking).

1.5 Historically, Great Britain has not been alone among developed countries in experiencing a rising trend in deaths from coronary heart disease. Although the position has improved slightly in recent years, Great Britain has not matched the large reductions achieved in some other countries (Figure 2). Since the late 1960% for example, Great Britain’s standardised mortality rates [aged 4&69) have declined by only some 10 per cent for males and some two per cent for females, while Canada and the United States of

Figure 3

America have achieved reductions for both sexes of some 40 and 50 per cent respectively. Although these broad figures mask some marked improvements within narrower age bands (see Table 2) it remains the case that overall mortality rates in Great Britain remain among the highest in the world (Figure 3).

Roles of the health departments and the NHS

1.6 The role of the three health departments - the Department of Health in England, the Welsh Office and the Scottish Home and Health Department - in the prevention, diagnosis and treatment of illness is mainly strategic. They determine national policies and priorities, or targets, and monitor the performance of health authorities and boards under planning and review arrangements. Generally it is for health authorities and boards to decide how services should be implemented and developed within this framework to meet local needs and priorities. To

Coronary heart disease mortality in some developed economies

Sweden

Scotland

England & Wales

Finland

USA*

Germany

Australia*

Canada*

Netherlands

0 75 150 225 300 375 450 Mortality (per 100,000 population)

Notes: 1. Countries selected on basis of GNP per capita (World Bank) 2. Mortality data from 1986 WHO Statistics (except *1985)

q Females

Males

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NATIONALHEALTHSER"KE:CORONARYHEARTDISEASE

facilitate the promotion of good health the Government has established national education bodies - the Health Education Authority in England, the Welsh Health Promotion Authority, both preceded by the Health Education Council until 1987, and the Scottish Health Education Group.

Departmental initiatives

1.7 The health departments have for some years fostered initiatives aimed at raising public awareness of general health risk factors and the promotion of he&bier lifestyles. In recent years England and Wales have additionally introduced national prevention programmes aimed at heart disease. Health authorities, and health boards in Scotland, also operate health education and prevention campaigns and programmes, scnne of which are specific to heart health.

1.8 Most patients with chronic coronary heart disease are cared for on a continuing basis by their general medical practitioners. Those requiring nmre specialised care are treated in hospital. Hospital costs account for about half of the total NHS expenditure on this disease (paragraph 1.2). While the pattern of treatment is determined by the medical profession the Department of Health have sought to influence the volume and pattern of care in two main ways. In 1984:

- they encouraged health authorities to introduce extended training of ambulance staff in resuscitation techniques appropriate to the victims of heart attacks; - they made the provision of coronary artery by-pass graft operations a priority.

In 1986 the Department set an annual target for coronary artery bypass graft operations to be achieved by 1990.

Review of coronary heart disease

1.9 Several key reports on coronary heart disease were published during the eighties. In 1982 the World Health Organisation, which is supported by the British Government, published a report which recommended a national preventive approach for countries with a high incidence of heart disease. This approach was supported by the Canterbury Conference (19841, which was sponsored by the health departments and other professional groups, to consider practical ways of implementing the World Health Organisation’s recommendations in the United Kingdom.

1.10 Other important reports have included the Report of the Committee on Medical Aspects of Food

Policy: Diet and Cardiovascular Disease (COMA) in 1984 and the recent report of the National Forum for Coronary Heart Disease Prevention. This body, partly funded by the Health Education Authority, coordinates smne 30 national organisations with an interest in the disease. On treatment, key reports have included those by the British Cardiac Society and Joint Cardiology Committees of the Royal Colleges of Surgeons and Physicians.

Scope of NAO examination

1.11 Against this background, the NAO set out to consider the role of the health departments and the NHS in securing a reduction in coronary heart disease mortality and morbidity. The study concentrated on those aspects of prevention and treatment over which health departments exert most influence. Two main issues were examined:

[a) whether the health departments have effective arrangements for seeking to prevent coronary heart disease [Part 2);

(b) whether there are effective arrangements in England for monitoring the provision of hospital treatment for coronary heart disease (Part 3).

1.12 The NAO examination largely focussed on England but, in recognition of the different approaches to prevention in Wales and Scotland, that issue was also covered at department level in these countries. Because of the likely impact on the primary care sector of the White Paper “Promoting Better Health” (Cm 249), published in November 1987, the role of general practitioners was excluded from the study. Nevertheless the key role played by them in coronary heart disease prevention is recognised and needs to be taken into account. In addition to enquiries within the three health departments and their health education authorities, NAO staff visited two Regional Health Authorities and four District Health Authorities in England as follows:

South East Thames Lewisham and North Southwark Dartford and Gravesham

North Western South Manchester T&ford

The NAO also made enquiries at the London Ambulance Service, which is accountable to the South West Thames Regional Health Authority.

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Part 2: Prevention of Coronary Heart Disease

2.1 Prevention of coronary heart disease is complex, 2.2 The extent of morbidity and mortality associated as the disease arises from a multiplicity of factors. with coronary heart disease and the considerable cost Some of these such as heredity, sex and age are of beating it are powerful arguments for action by the unavoidable; others are not (Table 1). And there is no health departments and the NHS aimed at preventing complete consensus on the relative importance of the disease. Over the last decade Government policy some of the avoidable factors. However, for a number increasingly has been to ensure that health promotion of years there has been agreement amongst doctors and prevention is given more attention. Given the and scientists internationally that the rate of relationship between the main causes of morbidity premature deaths and illness from coronary heart and mortality and personal lifestyles, a major theme disease can be lowered by attention to the three has been to encourage the public to accept greater principal coronary risk factors of smoking, blood responsibility for their own health. The policy was pressure and cholesterol levels. This requires changes most recently restated (in the context of primary in lifestyles, affecting diet and physical exercise. health care) in the Government’s 1987 White Paper Greater evidence on the importance of physical “Promoting Better Health”, (paragraph 1.12). Under exercise has been the main development since 1981, this policy the health departments and their health when Table 1 was published. education bodies have for some years undertaken a

Table 1

Risk factors for coronary heart disease (Note: In most cases of coronary heart disease it is likely that more than one factor is present. Only the first three characteristics given below have been shown to operate as risk factors independently of others. A combination of factors is likely to increase the risk).

Principal risk factors Smoking (cigarettes] The greater the amount smoked currently, the greater the risk

Blood pressure The higher the pressure the greater the risk

Blood cholesterol The greater the concentration the greater the risk

Diabetes

Family history

People with diabetes have a higher risk

The longer parents live, the less the risk for their children

Obesity Being overweight may increase the risk (unproven]

StrBS

Pl3SOdi~

Physical activity

Hardness of tap water

Stress may increase the risk (unproven)

Some types may be more prone than others (unproven)

The less exercise customarily taken, the greater may be the risk (unproven)

The softer the tap water the greater may be the risk (unproven)

Source: Avoiding Heart Attacks, DHSS, 1981.

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Table 2

Percentage changes in mortality rates due to coronary heart disease: 1975-1985

Male

England & Wales -30 -27 -24 -11 -5 -9 -13

Scotland -22 -29 -18 -16 -2 -7 -12

Female

England & Wales -37 -27 -13 -5 +2 -6 -6

Scotland -17 -40 -14 -5 c3 +4 -3

Source: WHO Mortality Statistics from Cardiovascular Epidemiology Unit, Dundee.

wide variety of initiatives designed to encourage people to lead healthier lives by making changes in their lifestyles. These initiatives will have contributed to the evident improvements in coronary heart disease mortality rates since 1975. For example, between 1975 and 1985 the standardised mortality rate for men aged 40-69 fell by 13 per cent in England and Wales and by 12 per cent in Scotland. These figures reflect marked improvements in scane narrower age bands for both men and women (Table 2).

2.3 However, aware of the substantial achievements of other countries, such as the USA and Canada, in reducing their death rates from heart disease (paragraph 1.5), and encouraged by the 1982 Report of the World Health Organisation (paragraph 1.91, departments have more recently introduced prevention campaigns. The Welsh Office and Department of Health programmes are aimed specifically at the disease. In Scotland a number of programmes at national level address, not the disease, but individual health risk factors which are common to heart and other diseases. In addition acme health authorities and health boards have local campaigns which specifically address heart disease.

2.4 NAO examined the following issues: (a] whether the health departments, and other departments whose responsibilities impact upon the nation’s health, have a co-ordinated and consistent approach to the prevention of coronary heart disease; (b) whether there are sound, relevant and effective national strategies and programmes for prevention; (c) in England, whether local initiatives are soundly planned and implemented, and supported by firm and effective departmental oversight.

Co-ordination and consistency of approach across government

2.5 The World Health Organisation’s Report (paragraph 1.9) noted that, although decisions regarding health care are taken by health departments of member countries, other decisions which profoundly influence the underlying causes of heart disease, (for example, in the areas of agriculture and taxation) are often taken by other government departments and agencies. The Report therefore emphasised the importance of individual government departments acting in a co-ordinated manner to prevent heart disease, and to minimise the possibility of interdepartmental differences.

2.6 Although there is considerable co-operation between government departments, there is no single body with responsibility for ensuring that, in formulating their policies, objectives and priorities, government departments take account of the need to prevent coronary heart disease. This contrasts with the position on AIDS, drugs and alcohol abuse where, although fewer deaths and lass ill health are involved, a ministerial committee has been established in each case to co-ordinate government action across departments. However, because the prevention of coronary heart disease involves every aspect of life, the health departments consider that the creation of such a committee would not achieve more than is already achieved under current inter-dep.&mental arrangements.

2.7 Examples of actions which are not supportive of government policy on the importance of prevention (see paragraph 2.2) include:

(a) health education in schools: the COMA Report in 1984 (paragraph 1.10) emphasised that educating the public in eating and exercise

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2.8

habits should begin at school. The health departments told the NAO that health education is an element 01‘ theme within a wide range of relevant subjects. However, in England and Wales it is not a core subject in the national curriculum for children aged five to sixteen years, although its place within the curriculum as a whole is currently being examined;

(b) school meals: since 1980, where education authorities provide school meals, they are not statutorily obliged to ensure they are nutritionally balanced, and in England and Scotland there are no national guidelines in this important area. However, a large number of individual education authorities are actively involved in promoting healthy eating;

(c) tobacco duty: as the price of tobacco significantly influences the level of sales, increases in tobacco duty represent an efficient way of controlling smoking. However, despite large increases in duty over the period 1984-86, more recently increases have not kept pace with inflation. The health departments regularly pass on their views to the Treasury on the health hazards of smoking, but they accept that final decisions about tobacco duty are for the Chancellor to take.

The NAO noted the following examples of bilateral co-operation between the health departments and others in the fields of health education and disease prevention:

(a) on smoking: the health departments and the Department of the Environment have reached voluntary agreements with the tobacco industry which restrict advertising and sports sponsorship, give greater prominence to the Government’s health warnings and reduce the tar and nicotine yields of cigarettes. Legislation has been introduced to tighten the law on tobacco sales to those under sixteen years old;

(b) on exercise: the national Sports Councils in conjunction with the health education bodies, and with other non-governmental bodies, organised an international conference on Exercise-Heart-Health in 1987, provide support to local authority leisure services, and have each published advisory booklets on exercise. The English Sports Council is to carry out a national exercise, health and fitness survey in 1989-91;

(c] on diet: following publication of the COMA Report81984 (paragraph 1.10) the Ministry of Agriculture, Fisheries and Food adjusted the Beef and Sheep Variable Premium Schemes to exclude the fatter animals. The Ministry have also issued voluntary guidelines on nutrition

labelling which, among other things, would help consumers to compare the fat content of foods and to reduce their fat intake.

National strategies for the prevention of coronary heart disease General

2.9 The 1982 report of the World Health Organisation (paragraph 1.9) recommended that, as the main causal factors of coronary heart disease in high incidence countries were to be found in the population as a whole, only a community based approach would help such countries to reduce the disease. The Organisation stressed that such an apprv~h needed to be cu-ordinated in a comprehensive national disease surveillance, prevention and health promotion stragegy involving the formulation of plans with clear objectives and time based goals; the identification of the extent of the disease and the resources required to address it; and specific programmes directed at the main risk factors.

2.10 The health departments in England, Wales and Scotland have each adopted their own national approach to the prevention of coronary heart disease. The departments consider that, whilst the principal risk factors (Table 1) are addressed in each country, geographical variations in their relative importance justified different approaches. Furthermore there is unlikely to be a case for greater consistency of approach until, through their current efforts, they have assessed what works and what does not.

2.11 While the departments afford a high priority to coronary heart disease prevention, their strategies have not so far included the provision of guidance to assist health authorities in developing specific programmes. However, in England, as a result of identifying deficiencies in regions’ health promotion plans, the Department of Health asked health authorities in July 1988 (HC(88)43) to develop district profiles that identify the preventive needs generally of their populations. The Department are also preparing guidance on health promotion programmes, including those for coronary heart disease. This will be issued for the next strategic planning round in 1989.

2.12 The Welsh Office intend to consider the need for guidance on coronary heart disease programmes in the light of the achievements of the present programme and further developments in corporate management and strategic planning. In June 1988, the Scottish Health Service Planning Council set up a working group to advise on prevention and health promotion.

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NATIONALHEALTHSERVKXCORONARYHEARTDISRASE

Data for planning and monitoring

2.13 For the planning and oversight of health promotion and prevention work to be effective, departments and the NHS need systematic data covering, for example, the changing incidence of mortality and morbidity. However changes in mortality levels are only discernible in the long term. But trends in the levels of risk factors do provide an indicator, although not a conclusive one, of the effectiveness of prevention work and, hence, of the likely incidence of the disease in the population.

2.14 The NAO noted that, whilst the Office of Population Censuses and Surveys and the Registrar General for Scotland provide the health departments with annual data on deaths from coronary heart disease, the departments do not routinely collect comprehensive data on the nature, extent and distribution of morbidity from the disease. This contrasts with the position on cancer where, since 1962, a registration scheme has operated throughout Great Britain. The resulting data is used in the planning of health care and to monitor changes in the incidence of the disease. The Department of Health believe that it is reasonable to assume that the relationship between morbidity and mortality is roughly constant. Therefore, they do not consider it necessary for health districts to establish expensive case register systems.

2.15 What information the health departments have on the incidence of morbidity mainly comes from:

(a] hospital inpatient statistics which cover deaths and discharges from hospital of heati disease patients. Although useful for hospital planning pm-poses, they measure current levels of treatment rather than need, and count episodes of care rather than patients;

(b] the National Survey of Morbidity in General Practice provides information at ten-yearly intervals on the incidence of coronary heart disease horn the primary care perspective. The most recent survey is based on 1981-82 data;

(c) research studies covering specific aspects.

These sources fall short of providing a comprehensive picture of the morbidity of heart disease, which makes it difficult to assess either changes in incidence rates or the effectiveness of control measures.

2.16 As regards the monitoring of risk factors the health departments are able to identify national

smoking and dietary trends using the General Household Survey and the National Food Survey. The Government, in 1987, also commissioned the first national survey of adults’ eating patterns. When fully analysed, this will also provide some information on blood pressure, cholesterol levels and body weight. Further studies in changes in risk factor levels are planned. However, the NAO noted that, with the exception of Wales and Glasgow (see paragraphs 2.17 [a) and (c)) little up to date or comprehensive information is currently available about trends in blood Pressure, cholesterol levels and body weight. This contrasts with the position in the United States of America and Australia where national systems to monitor major coronary risk factors exist.

2.17 Nevertheless, progress towards improving the data base on coronary heart disease is, with departmental funding, being made in some areas:

(a) a study by the Cardiovascular Epidemiology Unit at Dundee, as part of a major international monitoring programme by the World Health Organisation, will provide information over the decade to 1994 on the relationship of risk factors to the incidence of coronary heart disease in Glasgow and the effect of various types of medical care. Much of the design and quality control of the international programme has been lad from the Dundee Unit;

(b) a second study carried out by the Unit between 1984-86, the Scottish Heart-Health Study, measured the risk factors in a representative sample of 12,000 Scottish people. A number of Health Boards have based prevention programmes on data from the Study;

(c) the Welsh Heart Health Survey, which started in 1985, involves a study of 22,000 Welsh people and aims to assess changes in lifestyles. It includes a clinical survey to monitor trends in blood pressure, cholesterol levels and body weight:

(d) the British Regional Heart Study, which started in 1969, aims to explain the marked regional variations in coronary heart disease and provide information about the causal factors.

In March 1988, the Government announced a study was to be undertaken to consider the feasibility of setting up a portfolio of health indicators, which might include indicators for high blood pressure and cholesterol levels. Work on developing this is continuing.

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Wales

2.18 In March 1985 the Health Education Council, the body then responsible for health education in England and Wales (and Northern Ireland], launched “Heartbeat Wales” in conjunction with the Welsh Office. It was launched as a pilot project from which other parts of the United Kingdom would be able to benefit. Wales was chosen as the project area because of the high incidence of heart disease, its size and its strong national identity which it was felt would help a community based programme. The project aims to develop and evaluate a regional strategy to reduce coronary heart disease mortality and morbidity by tackling the associated risk factors and involving all interested sections of society. The Welsh Health Promotion Authority is now responsible for the programme’s continuing development, monitoring and evaluation. In 1987-88 the programme cost about E700,OOO (25 pence a head).

2.19 The “Heartbeat Wales” programme closely follows the approach recommended by the World Health Organisation. In particular:

(a) the programme has set measurable goals, objectives and outcome targets (for example, to reduce by at least five per cent, by 1990, the proportion of those aged 18-64 who smoke cigarettes); (b) the programme is based on an extensive survey of the lifestyles and risk factors of the Welsh population (paragraph 2.17(c)). Interim surveys in 1987 and 1988 have revealed promising changes in peoples’ smoking, dietary and exercise habits, as well as an increase in the number of people having their blood pressure checked; [c) the programme started with a structured plan of action for the achievement of each risk factor target. The NAO noted however that, because of the need to consult with a wide range of organisations, these plans had only recently been prioritised; (d) the programme has established effective links with a large number of outside agencies which have led to many health promotion initiatives, including lean meat merchandising schemes developed with the Meat and Livestock Commission, food labelling and education programmes involving major Welsh supermarket chains, an extensive community first aid training programme, exercise “trim trails” and a special programme for primary school children; (e) the programme team within the Welsh Health Promotion Authority embraces some 25 staff who are able to provide close support to health authorities.

England

2.20 The “Look After Your Heart” campaign was launched by the Demwtment of Health and the Health Education Authority in April 1987. They decided to do this before the Walsh pilot study had been completed, due to the size of the problem and the urgent need for action. As the English campaign encompasses 47 million people in 14 Regions with no strong single national identity such as that in Wales, they decided that they had to adopt a somewhat different approach. However, aspects of the Welsh programme have been incorporated in it.

2.21 The campaign aims to increase awareness of the risk factors associated with coronary heart disease and, in due course, to offer practical guidelines for healthier living. It is to be the first phase of a continuing programme to reduce the incidence of the disease and to co-ordinate health promotion activities in this area. It seeks to involve all relevant sections of society, including the NHS, industry, voluntary bodies and the media, and to assist local initiatives through community grants. The Authority’s overall expenditure on the campaign in 1987-88 was some g5 million (11 pence a head). The Department told the NAO that the marked difference in expenditure per head of population between the Welsh and English programmes (paragraph 2.18) reflected the former’s status as a pilot project.

2.22 “Look After Your Heart” is broadly consistent with the approach recommended by the World Health Organisation. However, the NAO noted that the campaign strategy lacks quantified targets and estimates of the resources and funding needed to meet its objectives.

2.23 In preparing the campaign, the Department commissioned a survey of awareness of, and attitudes towards, coronary heart disease which found a reasonable level of awareness of the disease and the associated risk factors. These findings were subsequently confirmed by advertising and public relations studies. However, a continuing high level of awareness is known to be needed to bring about changes in lifestyles.

2.24 After the first year of the campaign the Health Education Authority undertook a review of progress which indicated that a promising start had been made. For example, the campaign had been highly successful in the workplace (74 major employers covering two million employees had been recruited) and had achieved widespread local support through its community grants. But, the review also identified some missed opportunities:

NATIONALHRALTHSERVICE:CORONARYKMRTDISEASE

(a) although nearly 500 companies expressed an interest in the campaign, in most cases follow up action could not be taken because the campaign team of three was too small. This had also led to failure to exploit opportunities to promote the campaign through the commercial sector;

(b] only three government departments (Health, Social Security, and the Land Registry) and 18 of the 205 regional and district health authorities had joined the campaign as employers. (The number had increased to 42 by January 1989.);

and, weaknesses in the quality of the campaign:

(c) both awareness and media coverage had, so far, been lower than cheaper events, such as the National No Smoking Day:

(d) the initial advertising campaign had not resulted in a sustained increase in awareness.

2.25 The Department of Health and the Authority concluded that, in order to address these points and to build on campaign successes, they needed to develop a comprehensive long term strategy. This would involve clarifying the campaign’s objectives by setting quantified targets and priorities, the provision of extra campaign staff, further awareness raising advertising and improved management arrangements. At the time of the NAO examination the Authority, together with the Department, were finalising the details of a proposed long term programme strategy.

Scotland

2.26 The Scottish Home and Health Department recognise that the death rate from coronary heart disease is higher in Scotland than in England and Wales (Figure 2). However, they have not mounted a specific campaign or programme against the disease on the grounds that the associated risk factors also relate to a wide range of other diseases. Instead, the Department prefer to take a positive approach which broadly encourages healthy lifestyles, whilst allowing individual health boards to determine their own approaches according to circumstances in their areas.

2.27 Thus, since 1984, the Scottish Home and Health Department through the Scottish Health Education Group have brought together separate programmes addressing health risk factors under the umbrella campaign “Be All You Can Be”. This approach avoids concentrating on particular diseases because research commissioned by the Group revealed that initiatives exhorting the “avoidance” of poor health were viewed negatively by adults in Scotland. In 1987-88, the Group, wholly funded by

the Department, spent about s700,OOO (14 pence a head) on programmes which had a bearing on the prevention of coronary heart disease. Since the programmes were not exclusively concerned with the disease this figure cannot be compared with expenditure levels in England and Wales (paragraphs 2.18 and 2.21).

2.28 The programmes encompassed by “Be All You Can Be” address the main risk factors associated with coronary heart disease. However, the NAO noted that the Scottish Home and Health Department had not set quantified targets for the programmes and that the Health Education Group considers that their impact on behaviour cannot be measured. The Group, however, undertakes periodic tracking surveys to establish public awareness of the programmes. These show that adults’ awareness of the seriousness of coronary heart disease and the principal risk factors had increased substantially since 1984.

2.29 The Scottish Health Education Co-ordinating Committee, in a report in 1988, drew attention to the modest reduction in mortality rates for man in Scotland over the past 20 years, the increased incidence of coronary heart disease in social classes C2, D and E compared with classes A and B, and the striking local variations in mortality rates. The Committee recommended the introduction of a national programme directed specifically towards the prevention of heart disease, and that health boards should be asked to review their commitment in this area.

2.30 Subsequently, the Scottish Home and Health Department asked the Working Group on Prevention (see paragraph 2.12) to review issues relating to the prevention of coronary heart disease as its first task. The Group met for the first time in October 1988.

Local initiatives in England and Departmental oversight

2.31 The success of strategies to prevent coronary heaxr disease depends ultimately on health promotion work locally. However, because of the length of time before preventive measures have a discernible impact on mortality and morbidity, it is important that the health departments exercise firm and effective oversight of local initiatives. The NAO therefore examined the planning, implementation and monitoring of local initiatives at a small number of health authorities in England (two Regional Health Authorities and four of their districts). They also looked at the extent of Departmental oversight.

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Local planning

2.32 The NAO found that:

(a) the North Western Regional He&b Authority had issued a clear he&h promotion strategy to its districts in 1985. The strateE!y identified quantified goals for the reducti& of heart disease mortality and each of the associated risk factors, suggested areas for action, and gave relevant baseline data for the region. Of the two districts visited Trafford had already set some targets and had made some progress towards establishing local incidence data;

(b) the South East Thames Regional Health Authority had no clearly stated health promotion strategy, although one was being developed at the time of the NAO visit. Whilst prevention of circulatory disease generally is one of the Region’s major goals, its policy is to encourage positive choices towards healthy lifestyles and to address risk factors generally, without their being associated with particular diseases. Hence, the Region has not encouraged districts to take up “Look After Your Heart”. Nor has it required districts to prioritise and set targets for their promotional activities on the basis of assessments of local needs. Such an approach has, nevertheless, been adopted by one District (Lewisham and North Southwark], but not by the other (Dartford and Gravesham).

2.33 The NAO found that while all the districts visited were tackling, to varying degrees, the risk

areas associated with heart disease their response to “Look After Your Heart” had been mixed. Two of the districts (D&ford and Gravesham, Lewisham and North Southwark) had not integrated the campaign with existing promotional activity (as required by the Department), while South Manchester’s progress had been limited. Only one district (T&ford) had platformed any existing schemes under the campaign banner, or were actively using the campaign logo. Of the health authorities visited, only North Western Region had signed up to take an active part in the campaign as employers (see also paragraph 2.24(b)).

2.34 The NAO were unable to identify the level of support given to promotional activities associated with heart disease, but noted considerable variations in expenditure and staffing levels on health promotion generally [Table 3). An analysis of the 1988-89 Short Term Programmes produced by each of the 34 districts within the two regions visited showed that eight of the 34 did not refer to the issue of coronary heart disease prevention either directly, or indirectly through measures to tackle the risk factors associated with the disease.

Local monitoring

2.35 Generally, the NAO found little evidence of monitoring of the effectiveness of health promotion activities to determine whether there was increased awareness and avoidance of coronary heart disease risk factors by the local populations.

Table 3

Expenditure In 1987-88 (~000) 200 27 69 108

Proportion of total revenue budget (per cent) 0.16 0.06 0.08 0.39

Staff (1987-88) Health education officers (whole time equivalents): Regional Target* 7.5 5.5 4.5 5.5 Actual 7 1 3 6

* One health education officer for 50,000 population.

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Departmental oversight

2.36 Health promotion generally has featured in the regional review process for the past two years. In May 1987 the Department of Health, in the light of “Look After Your Heart”, additionally asked regions to provide information in their 1988-89 operational plans on initiatives on coronary heart disease prevention. The NAO reviewed the Department’s analysis of the first 10 plans to be received (out of 14). This showed that the Department considered that the plans generally did not contain sufficient

information to enable them to assess the extent of initiatives being undertake and their integration with “Look After Your Heart”. The Department’s analysis also confirmed the NAO’s local findings of wide variations in districts’ expenditure levels and staffing proposals for health promotion generally (paragraph 2.33). The Department intend that the responses given by Regions will be taken into account in the next round of Regional Reviews, which will also be highlighting those Regions and Districts that have not yet signed to the “Look After Your Heart” campaign as employers.


Part 3: Treatment of Coronary Heart Disease in England

3.1 It will be several years before the increased impetus being given to the prevention of coronary heart disease in England has an impact on morbidity. Until then the likelihood is that the demand for treatment will remain high, and even increase as better cardiac techniques become available.

3.2 Treatment of coronary heart disease involves a range of medical, paramedical and surgical services. The nature of such treatments is determined by the medical profession. The role of the Department of Health in the provision of treatment services is essentially strategic. However, since 1984, the Department have introduced two specific initiatives to improve coronary care (paragraph 1.8).

3.3 The Department’s policy on cardiac matters is based on advice received both formally and informally from a number of sources. The primary sources are the Royal Colleges of Physicians and Surgeons which provide formal advice either spontaneously or by invitation. Professional societies and learned bodies are often consulted. From time to time advice is sought from the Standing Medical Advisory Committee which includes the Presidents of the medical Royal Colleges and Faculties, the Chairman of the Council of the British Medical Association and other members appointed by the Secretary of State. It provides impartial advice to the Secretary of State on clinical medical matters. There is also the Cardiology Liaison Committee, a forum for departmental officials to meet informally with leading cardiologists and surgeons. The Department also keep abreast of current issues by reviewing the medical press and attending conferences.

3.4 Hospital services, which account for about half of the total NHS cost (i500 million) of treating coronary heart disease (paragraph 1.8), are usually provided on a tiered basis. They range from non- surgical investigation and treatment provided, usually at district level, by cardiologists or general physicians specialising in cardiology, to open heart surgery provided by cardiac surgeons on a regional basis and heart transplants provided supra-regionally. The paramedical service also has an important role in cardiac care because of the need for prompt treatment of heart attack victims (paragraph 1.3).

3.5 Recent years have seen important advances in the treatment of cardiac patients, including the

development of the coronary artery by-pass graft procedure. This surgical technique is designed primarily to relieve cardiac pain and in some cases may prolong life in some patients. It involves the use of a section of vein or artery from elsewhere in the patient’s body to by-pass the obstructed section of the coronary artery (paragraph 1.3). First introduced into Great Britain in 1969, it has since become internationally recognised as a low risk procedure. Each operation costs some s4,OOO. Newer developments are:

angioplasty: involves passing a catheter through the restricted arteries to clear them. This non- surgical procedure is suitable for about 10 to 15 per cent of patients who might otherwise receive by-pass grafts and costs about a third less;

intravenous thrombolytic therapy: involves administering a drug intravenously to heart attack patients to dissolve the blockage which caused the attack. Recent international trials have shown that, if this procedure is administered in hospital within 4 to 6 hours of the onset of symptoms, mortality is reduced by 20 to 30 per cent.

These developments have important implications for the relief of suffering and saving lives, and for the use of NHS resources.

3.6 Against this background the NAO set out to examine:

[a) the effectiveness of the Department’s oversight of coronary heart disease treatment generally;

(b) the progress of the Department’s initiatives to improve coronary care services; and

(c) the role of the Department in fostering new developments in treating the disease.

Departmental oversight of coronary heart disease treatment

3.7 The Department of Health monitor the provision of health care by the NHS through planning and review procedures under which Regional Health Authorities prepare and submit for approval long term (strategic] plans and short term (operational) programmes. Subsequently, regions account to the

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Department through a system of annual performance reviews. Similar planning and review arrangements exist between regions and districts.

3.8 The Department’s policy is that the distribution and development of cardiac services, like any other acute service such as cancer, is essentially a matter for regions and the medical profession to determine. Therefore, they do not routinely attempt to monitor the adequacy of the level of service being provided for particular specialties. Exceptionally, however, they do monitor regional progress against the national target for by-pass grafts (paragraphs 3.22 to 3.30). In monitoring service provision in the acute sector as a whole, the Department examine the coherence of regional plans in terms of activity, finance and manpower; and progress towards improved efficiency, measured by such performance indicators as throughput, length of stay, and bed usage.

3.9 Nevertheless, the Department expect to be consulted by regions on proposals which would significantly affect service provision for the treatment of coronary heart disease. Equally, they acknowledge a responsibility to act in the event of a serious lbalance in the distribution of services affecting patients’ access to treatment.

3.10 Performance indicators, although they must be interpreted with caution, show wide variations in the provision of treatment for coronary heart disease. [Table 4).

Table 4

Coronary heart disease ixatment indicators regional variations in England

Cardiology

Waiting list (per 100,000 population) 0.2 11.7 30.0

Notional time to clear waiting list (weeks) 4.0 10.0 24.0

Cardiothoracic surgery* Waiting list (per

100,000 population) 4.3 Notional time to clear

waiting list (weeks) 6.0

12.6 20.0

12.2 47.0

Source: Hospital In-patient Waiting Lists for England at 31 March 1988.

*Cardiac and other procedures within the chest cavity.

3.11 Recent developments in the diagnosis and treatment of coronary heart disease have underlined the key role of the cardiologist in the initial screening and referral of patients for cardiac surgery. There is a close relationship between their work and that of the surgeons. The NAO therefore examined relevant staffing data.

3.12 They found wide variations in the numbers of experienced cardiologists in post, ranging from 1.8 per million population in South Western Region to 7.2 per million in South East Thames Region (Figure 4). Furthermore, London regions have more experienced cardiologists than regions in the North, which in turn have more than those in the South outside the London area. This suggests that patients with coronary heart disease living in some parts of the country may have less chance of being referred for necessary treatment than those living elsewhere. However, to the extent that cardiology services are provided by general physicians with an interest in cardiology, these figures may under-estimate the service available.

3.13 Figure 4 also illustrates wide variations in the number of cardiothoracic surgeons ranging from 0.5 [Oxford) to 5.7 (South East Thames) per million population. However, as access to cardiac surgery is more dependent on the number of consultants, and the number of consultants practising cardiac surgery within the specialty is not known, the NAO were unable to draw firm conclusions as to the levels of accessibility for cardiac surgery in the regions.

3.14 The Department of Health have not sought through the review process to encourage directly regional health authorities to review and develop their existing service provision for coronary heart disease, except where they have seen evidence of the need to do so. However, both the authorities visited by the NAO had carried out a fundamental review of their cardiac services as a basis for drawing up regional strategies. Both reviews identified scope for rationalisation and development of existing services, thereby demonstrating the value of examining service provision in a comprehensive way. For example, North Western Region:

(a) found wide variations among districts in the number of their patients being referred to the regional centres for those procedures provided on a regional basis. Distict referral rates to the regional cardiology centres varied from 0.57 per 1,000 population in Blackburn to 2.51 in South Manchester; and to the regional cardiothoracic

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Figure 4

Regional variation in the numbers of experienced doctors (consultants, senior registrars and registrars)

8

. Cardologists

q Cardiothoracic surgeons

Source: DHSS Hospital Statistics, Sept 1986 (whole time equivalent)

surgery centres, from 0.36 per 1,000 population in Lancaster to 1.76 in Trafford. The Region considered that such variations were caused by some districts being further than others from regional centres and by the differing number of out-patient clinics in districts;

(b) recognised the need for a clear definition of the geographical catchment areas for individual centres and to redraw the boundaries between regional specialty and district acute work in cardiology;

(c) estimated a 60 per cent increase in the caseload for regional cardiology by 1993 (ix from 5,400 to 8,600);

(d) identified a potential need for some 1,300 new pacemaker inplants a year, double the current regional workload.

North Western Region’s review concluded that implementation of a regional cardiac strategy would be likely to uncover a large amount of hitherto unmet demand.

3.15 The Department recognise that the demand for heart treatment is probably not being met and that, until recently, NHS planning was incremental, based

on historical demand rather than on an informed assessment of future need. In July 1988 they advised health authorities that service planning generally should be based on a clear identification of the future health needs of their particular populations (HC(88]43). The Department consider that the proposed portfolio of health indicators [paragraph 2.17) might help to assess the need for treatment services. They also recognised in the Primary Care White Paper (paragraph 1.12) that there is scope for making greater use of Family Practitioner Committee patient registration data in health service planning.

Department of Health initiatives

3.16 The two specific initiatives introduced by the Department of Health since 1984 designed to secure improvements in the provision of cardiac services (paragraph 3.2) involve the extended training of ambulance staff and the setting of a target for cbronary artery by-pass grafts. The NAO examined the progress of these initiatives and the extent of the Department’s influence over them.

Extended training of ambulance staff

3.17 Half of all deaths from heart attacks occur within two hours of the onset of medical symptoms

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and some 30,000 such deaths occur outside hospital every year in Britain. Early resuscitation care at the scene of the emergency and prompt admission to hospital can increase the chances of survival, and better enable the specialised resources of cardiac care units to be used to their full potential, particularly with the advent of thrombolytic therapy (paragraph 3.5).

3.18 Recognising the role of ambulance staff in this key area, the Department of Health commissioned research in the early eighties into the costs and benefits of giving extended training to ambulance staff in advanced resuscitation techniques. Although the Department felt that the results of the review were somewhat tentative they concluded that such training would be beneficial to patients. In June 1984, therefore, they encouraged health authorities, in the light of their local circumstances, to consider introducing extended training of ambulance staff in various resuscitation techniques. These included the use of defibrillators (equipment which uses an electric shock to restore the heart’s normal rhythm). The training was to be provided from within planned resources. Subsequently, the NHS Training Authority introduced a comprehensive training package in January 1987.

3.19 The NHS Training Authority monitors the adequacy of the training facilities and procedures of those ambulance services in England and Wales that have chosen to adopt its extended training package. The NAO noted that, as at September 1988, some 18 training centres (broadly corresponding to 40 per cent of ambulance services in England) were using the Authority’s package. Because management of ambulance services is devolved to health authorities neither the Training Authority nor the Department of Health routinely monitor the number of ambulance staff undergoing, or who have completed, training.

3.20 The ambulance services at the two regions visited by the NAO (that is, the London Ambulance Service, and the Greater Manchester and the Lancashire Ambulance Services which cover North Western Region) introduced their own particular concept of extended training prior to the issue of the Training Authority’s package in 1987 (paragraph 3.18). The NAO found that, by mid 1988, the London Ambulance Service had fully trained about 20 per cent of its emergency staff, while in North Western Region about 55 per cent of ambulance staff had completed the first (defibrillation) module of a three- module training package.

3.21 However, the NAO noted that in the London Service the distribution of trained staff varied from 13 per cent of ambulance staff in South East Division to

7.8 per cent in South West Division. This was due to the pace of training being determined by the acquisition of defibrillation equipment, which in turn depended on the success of voluntary fund-raising activity in the different sectors.

The coronary artery by-pass sraft target

3.22 In 1983 the Department of Health, with expert advice, estimated that the need for coronary artery by-pass grafts probably lay in the range 200 to 700 per million population. This was considerably higher than the then current rate (86 procedures per million population in 1980). They concluded that 300 procedures per million population might represent a reasonable provisional target for by-pass grafts.

3.23 Following the advice of the Standing Medical Advisory Committee [paragraph 3.3), the Department decided to instruct health authorities iu January 1984 to develop coronary artery surgery as an NHS priority, but without setting a target. Subsequently, in October 1986, in order to increase the number of procedures performed, the Secretary of State announced an annual target of 300 coronary artery by-pass graft operations per million population, to be achieved in England by 1990 from within planned resources.

3.24 The NAO therefore set out to examine the adequacy of the Department’s data base for monitoring purposes, NHS progress towards the target and whether the target is still appropriate.

The data base on by-pass grafts

3.25 The NAO noted that the Department of Health have had difficulty in establishing fully accurate and up to date information about the number of by-pass grafts being performed. Until 1986, the Department relied upon data relating to the United Kingdom as a whole collected by the Society of Cardiothoracic Surgeons. However, for 1986-87 following the introduction of the target they asked regions to report the number of by-pass graft procedures performed. But the Department found that the information they received was unreliable and only broadly indicative of the general trend. For example, it was not always clear whether regions had used a common measure of population, distinguishing between residents and non-residents, when calculating regional rates for the procedure. Also, some regional returns failed to distinguish between coronary artery by-pass g&s and other open heart procedures. Furthermore, the periods covered by the data varied (for example, four regions provided only 1985 data).

.

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3.28 Therefore, in April 1988, as part of the final guidance to health authorities on the compilation of outturn reports for 1987-88 and plans for 1988-89, the Department issued revised instructions intended to remedy these shortcomings. They also asked regions to report on the development of angioplasty. However, the NAO noted that they did not seek information on waiting lists for by-pass grafts, or on the split between elective and emergency operations. As at September 1988, 9 of the 14 regions had supplied the above reports and plans. However, the extent of the data on by-pass grafts and angioplasties varied, as follows:

198748 1988-89 outturn planned

By-pass grafts 9 9 Angioplasties 6 3

Progress towards the national target

3.27 Figure 5 shows how the annual by-pass graft rate in the United Kingdom increased from 51 per million population in 1977 to 208 per million in 1985. The Department told the NAO that it was likely that rates in England had increased in a similar way during this period. Provisional data indicate that the number of procedures performed in the United Kingdom fell slightly in 1986. However, for 1987-88 the Department’s own data, about which there are some reservations [paragraph 3.25), suggest that up to 223 procedures per million population may have been carried out in England.

3.28 Nevertheless, to reach the target rate of 300 procedures per million population by 1990 would still demand a further increase of some 35 per cent from 1988. Prospects for success seem low. NAO examination of the nine regional plans (paragraph 3.26) revealed planning for only marginal increases in 1988-89. One region (Trent) aims only to achieve a rate of 239 by 1991.

3.29 Departmental policy is that the national target should apply to all regions on the grounds that their population statistics are broadly similar. Every region is expected to make proper provision for its population, using facilities within the region or by agreement with other health authorities. Thus London hospitals managed by Special Health Authorities perform up to 20 per cent of by-pass grafts in England, and the South East Thames Regional Health Authority is believed to import up to 30 per cant of

its cases. There are also other cross boundary flows. These factors make it difficult to interpret the information obtained by the Department (paragraph 3.26) which, as Figure 6 shows, suggest wide variations in regional achievements. Oxford and South Western Regions for example, would seem to have to increase the number of procedures several fold to meet the target, but the Department told the NAO that these Regions refer large numbers of patients to London hospitals.

3.30 One factor which may have reduced the rate of growth of by-pass grafting is the gradual introduction since the early 198Os, of angioplasty as an alternative and cheaper procedure for certain patients (paragraph 3.5). The Department of Health have yet to compile comprehensive data for the extent of its use (paragraph 3.26). Preliminary indications suggest that current usage may be about 50 per million population. One region visited by the NAO (South East Thames) considered that the demand for angioplasty could be as high as 300 per million population.

Appropriateness of the by-pass graft target

3.31 The Department of Health based their target for by-pass grafts on the numbers being performed in England and overseas in 1980 (paragraph 3.22). Since then the procedure has become increasingly routine, with demand growing as its value has been demonstrated. For example, the NAO noted how the use of by-pass graft had increased in some other countries:

1980 1983 1985

USA 500 900 1,000 Australia 300 - 600

The Department pointed out that any comparison between the United Kingdom and the USA has to be made with caution because medical opinion concerning the selection of patients for by-pass grafting differs between the two counties. The national totals also include differing proportions of repeat operations.

3.32 The NAO also noted that, following reviews of cardiac surgery provision in Scotland and in Wales in 1988, the Scottish Home and Health Department adopted a by-pass graft rate of 350 per million population, and the Welsh Office recommended a rate of 400-500. This latter rate is in line with advice from

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Figure 5 Coronary artery bypass grafts performed in the United Kingdom

300

250

t3 ‘3 m 200 2 ZL E 150 ;= 1 E Es 100 a,

50

c

S0llXe: Annual No. of CABGs: Cardiac Surgery Register Population - OPCS Annual Abstract of Statistics, 1988

Figure 6

208 202

1985 1986

Regional variations in Mortality and coronary artery bypass graft rates

SE Thames *

NE Thames

N Western SW Thames

E Anglia

Yorkshire

Northernt

Trent NW Thames

0 50 100 150 200 250 300 350 400 CABGs per million population/Mortality per 100,000 population

Mersey

Wessex

W Midlands s Western

Oxford *

CABGs

q Mortality

Source: Mortality: Broken Hearts, Dept of Health Bypass graft rates: 1987-88 Outturn Statements

(except t1987,*1986-87)

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the Royal Colleges of Physicians and Surgeons in 1985. Meanwhile, the Department of Health are keeping their target rate under review in the light of experience elsewhere and the development of angioplasty.

Fostering new developments

3.33 In addition to angioplasty and intravenous thrombolytic therapy (paragraph 3.5), there are a number of other advanced surgical and investigative techniques, such as laser angioplasty and magnetic resonance imaging, whose impact on coronary heart disease has yet to be felt. Such developments have the potential to relieve suffering and, in some cases, to save additional lives, as well as having important resource implications for the NHS. The NAO therefore considered the role of the Department of Health in fostering new developments in treatment methods.

3.34 The NAO examination confirmed that the Department’s network of advisory mechanisms (paragraph 3.3) has provided them with regular advice on emerging developments in the treatment of heart disease. For example, in March 1986 the Cardiology Liaison Committee advised the Department that angioplasty had potential for great advance. While the procedure was still to be widely adopted in the United Kingdom [see paragraph 3.30) its u$e had increased rapidly in other countries like Germany and the USA. The Committee therefore recommended that the Department should identify angioplosty ns n priority along with coronary artcry surgery. Subsequently, in January 1988, in response

to a request from the British Heart Foundation, the Department agreed to fund jointly with the Foundation a study by the British Cardiac Society which will compare coronary artery by-pass grafts with angioplasty. However, the NAO noted that the results of the trial will not be available until 1994.

3.35 At local level, the NAO noted that both the Regions they visited made funds available for local research and the development of clinical practice generally. The results of such work are usually published in the medical journals, but there is no onus on the NHS to inform the Department of promising developments.

3.36 The Department of Health consider that the evaluation of new developments is primarily the responsibility of the medical profession and that their role is confined to facilitating this process (for example, see paragraph 3.34). However, the Department acknowledge that much remains to be done to ensure that new treatment methods are properly evaluated. Thus, they established a Health Technology Assessment Group in 1986 to provide them with advice on the need to evaluate new and established medical treatments.

3.37 The Department also consider that it is the role of the medical professions to disseminate advice on new developments in treatment methods. Nevertheless, two of the four District Health Authorities visited by the NAO (South Manchester, and Lewisham and North Southwark) felt there was a need for the Department to issue guidance on the use of new dcvclopments such as angioplasty and intravenous thrombolytic therapy.

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