HEALTHY HEARTS IN THE WEST INITIATIVE ~ PHASE ONE

Evaluation Report

Cardiac Rehabilitation Phase 3 Programme

February 2014

Healthy Hearts in the West is funded by

The Public Health Agency and Belfast Local Commissioning Group

HEALTHY HEARTS IN THE WEST

Cardiac Rehabilitation Phase 3 Programme

PHASE ONE: Evaluation Report

Contents

Introduction 3

Context 5

Healthy Hearts in the West Aims and Objectives10

An Overview of Cardiac-Rehabilitation Phase 3 Programmes11

Statistical Patient Data for The Maureen Sheehan CR Unit14

Comparative Patient Data20

Feedback from Patients25

Feedback from the Cardiac Rehabilitation Team

Delivering Phase 3 at The Maureen Sheehan Centre36

Comment38

Annexes

One:Health Inequality and Cardiovascular Disease 39

Two:Northern Ireland Policy Context 44

Three:West Belfast Local Context48

References51

I would like to thank and acknowledge the time and information input to this Report provided by Juanita Cunningham, BHF Cardiac Rehabilitation Nurse, Belfast Health and Social Care Trust; and additional support from Paula Maine(BHF Cardiac Rehabilitation Nurse), Siobhan Doyle BHSCT Physiotherapist and the Heart Healthy Living Centre staff.

Jane Turnbull

HHW Evaluator / Researcher

March 2014

INTRODUCTION

The Healthy Hearts in the West Initiative (HHW) was established to mobilise existing resources and assets of communities in West Belfast, and to work with health professionals and other organisations, so that people living in West Belfast experience heart health equivalent to the best in Northern Ireland / Europe.

In 2011 the Healthy Hearts in the West was initiated in response to the high levels of cardiovascular disease across West Belfast and the need to reduce inequalities in heart health. The Community Planning Officer - Health, employed by West Belfast Partnership Board (WBPB), established a small cross-sectoral working group; with representation from local community groups, the Public Health Agency (PHA), and Belfast Health and Social Services Trust. Key to the development of the HHW initiative was addressing health inequality in West Belfast, focusing on cardiovascular disease – with data showing mortality at an earlier age and higher percentages of the population experiencing heart related illness than the average across the NI population (see section 4). The working group looked at the delivery of the Healthy Choices Project (to tackle obesity) delivered in the Upper Falls; and felt that the cross-sectoral nature of the project could be extended to a community wide approach to addressing health inequality.

The working group ‘tested’ interest in building a community assets approach to health inequalities relating to heart health at a workshop in March 2011, ‘Working Together to Make a Difference’. The workshop was attended by representatives from the community, voluntary, statutory, and private sectors, and the Workshop Report informed the development of the Healthy Hearts in the West proposal.

In September 2011 funding was awarded to develop and deliver HHW from the PHA and Belfast Local Commissioning Group (LCG). Phase One became operational in January 2012, and finished on the 31st March 2013.

Following the Status Report (December 2012), a presentation to the Belfast LCG (January 2013) and a series of meetings with the PHA early in 2013, the Healthy Hearts in the West Initiative Steering Group was informed that there would be further funding for one year; allowing for future planning.

HHW has benefited from a formative evaluation process being built into the Project, with a series of reports contributing to ongoing review and development. It was agreed that comprehensive evaluation reports should be prepared, pulling together the data collected and reports written during the first Phase.

The four Evaluation Reports presenting the development and delivery of the first phase of the Initiative are:

  1. Healthy Hearts in the West Process, Infrastructure, and Partnership: an Overview
  2. Healthy Hearts in the West Hubs and Community Development
  3. Healthy Hearts in the West Community Pharmacy Programmes
  4. Healthy Hearts in the West Cardiac Rehabilitation.

This Evaluation Report presents the Cardiac Rehabilitation Phase 3 Programme, delivered from the Maureen Sheehan Centre from January 2012. It also places cardiovascular disease into context. The Evaluation Report has been informed through the National Audit of Cardiac Rehabilitation data, Patient Follow-Up Questionnaires, discussions with the Cardiac Rehabilitation Nurses, and data provided by the Heart Healthy Living Centre.

“The benefits to patients completing CR are evident through positive changes, in important clinical outcomes, such as; smoking cessation, physical activity status, anxiety and depression”.
National Audit of Cardiac Rehabilitation, Annual Statistical Report 2013

CONTEXT

Health Inequality and Cardiovascular Disease

Cardiovascular disease (CVD) is a major cause of death and disability in Northern Ireland. In 2012 more than one in four deaths (27%, 4,001 deaths) in Northern Ireland were due to diseases of the circulatory system (Figure 1).[i]

Various factors affect the risk of cardiovascular disease.[ii] Some factors such as ethnicity, age and gender (men generally develop coronary heart disease earlier than women) cannot be modified. However other risk factors can be modified. The INTEREART study found that over 90% of the risk of heart attack was attributable to nine factors including abnormal lipids, smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, consumption of fruits, vegetables, and alcohol, and insufficient regular physical activity.[iii] The British Regional Heart Survey (BRHS) also found that at least 80% of major coronary heart disease events in middle-aged men can be attributed to total cholesterol, high blood pressure and smoking.[iv]

The prevention of cardiovascular disease is dependent on the reduction in major risk factors such as smoking, high blood pressure or diabetes, cholesterol, waist-hip ratio and physical inactivity.[v] Changes in cardiovascular disease (CVD) risk factors can be brought about through intervention at both an individual level in terms of behaviour change and at population level though development of appropriate policy and legislation.[vi] Cardiovascular health is also influenced by other social and economic factors such as housing, employment and transport.[vii]

The relationship between socio-economic disadvantage and cardiovascular disease (CVD) is well established. Men living in the 20% most affluent areas in Northern Ireland live on average 7.6 years longer than men in the 20% most deprived areas; for women, this gap is 4.5 years.[viii] Cardiovascular disease remains one of the main contributors to the differential in life expectancy.

Reducing the disease burden of cardiovascular disease presents significant challenges. However, there are effective interventions that can reduce risk, prevalence and deaths from CVD. In addition to medical interventions, these include recommending that people make healthier choices, such as eating healthier foods, using alcohol sensibly, undertaking regular physical activity, stopping smoking, and accessing services promptly.[ix]

Annex One presents a more detailed overview of heart health inequality in Northern Ireland.

Northern Ireland Policy Context

The Programme for Government (PfG) 2011-15 sets out the strategic context for both the Budget and the Investment Strategy for Northern Ireland.[x] It identifies the following five Priorities:

  1. Growing a Sustainable Economy and Investing in the Future;
  2. Creating Opportunities, Tackling Disadvantage and Improving Health and Wellbeing;
  3. Protecting Our People, the Environment and Creating Safer Communities;
  4. Building a Strong and Shared Community;
  5. Delivering High Quality and Efficient Public Services.

The Health and Social Care (Commissioning Plan) Direction (Northern Ireland) 2012 sets out the focus for the Regional Board and Regional Agency in the commissioning of health and social care services.[xi] It provides details of how the services being commissioned by the Regional Board align with the Programme for Government, the Economic Strategy and the Investment Strategy and includes a number of key priorities and targets for delivery. The first priority is to improve and protect health and well-being and reduce inequalities, through a focus on prevention, health promotion and earlier intervention.

The new 10-year public health framework (launched for consultation in July 2011) aims to secure more coherence cross-departmentally with a focus on upstream interventions which will improve health and tackle health inequalities.[xii]Fit and Well xii recognises that health is determined by factors both within and beyond the control of individuals, families and communities and influenced by social and economic circumstances well beyond the reach of health services. Hence it seeks to improve health and wellbeing along the life course from early to old age by addressing disadvantage through and across a wide spectrum of service provision and support. It also provides strategic direction for work to be taken in support of this at both regional and local levels, with public agencies, local communities and others working in partnership. The framework contributes to achievement of the priorities identified in the Programme for Government.

The service framework for Cardiovascular Health and Wellbeing, launched in 2009 was the first of a series of service frameworks for Northern Ireland.[xiii] Cardiovascular disease was chosen because of its significance as a cause of ill health and premature death in Northern Ireland. The aim of the framework is to improve the health and wellbeing of the population of Northern Ireland, reduce inequalities and improve the quality of care. It sets out 45 standards in relation to the prevention, diagnosis, treatment, care, Rehabilitation and palliative care of individuals and communities at a greater risk of developing cardiovascular disease. Each standard is supported by key performance indicators, which set levels of performance to be achieved over a three-year period (2009-12).

In 2010 a Health Impact Assessment (HIA) was undertaken to test the effects of implementing the framework on health inequities and inequalities in relation to cardiovascular health. The HIA found that almost all of the standards were affected by health inequities and inequality, mainly relating to socioeconomic factors and variable access to services depending on where patients lived. Suggestions on how to enhance the delivery and impact of the cardiovascular standards in reducing health inequalities and inequities were collated in the form of an action plan to inform commissioning of services.

A review of the implementation of the Cardiovascular Service Framework, conducted by the Regulation and Quality Improvement Authority (RQIA) in 2012, found widespread support among stakeholders for the service framework approach and made recommendations for the implementation of future service agreements.[xiv] The West Belfast Partnership Healthy Hearts Initiative is highlighted as a local project supporting the framework implementation process.

In December 2011, Transforming Your Care (TYC), a review of the provision of Health and Social Care (HSC) Services in Northern Ireland, was published. TYC proposes a future model for Integrated Health and Social Care, identifying twelve major principles for change. It is designed with the individual at the centre and health and social care services built around this, providing support to promote self care and make good health decisions. With people living longer the demand for health and social care services will increase in the future; pointing to the need for more preventative work and improved community based access.

Draft Population Plans, developed by Local Commissioning Groups (LGCs) with input from Health and Social Care Trusts, set out how the evolving health and social care needs and expectations of the population will be met. The plan for Belfast LCG specifically highlights Healthy Hearts under actions being taken to Deliver Service Outcomes relating to Population Health and Wellbeing and Long Term Conditions.[xv] The consultation ended on the 15th January 2013.

There are four new Integrated Care Partnerships (ICPs) across Belfast, launched in 2013. ICPs are networks which will see doctors, nurses, social workers and other health professionals, and the voluntary and community sector working together to keep people well and make sure they get the care they need, when they need it.[xvi] The focus of the West Belfast Integrated Care Partnership is Stroke.

Annex Two presents an overview of the Northern Ireland Policy Context.

“Cardiovascular disease remains the main cause of premature death. Reductions in premature death from stroke and coronary heart disease, which have led to increased life expectancy elsewhere, have not been as marked in areas of deprivation”.
Belfast Local Commissioning Plan 2012-2013

West Belfast Local Context

West Belfast is the most deprived geographical area in Northern Ireland. Approximately three quarters (76%, 71,709 people) of the West Belfast (AA2008) population live in one of the 20% most deprived Super Output Areas in Northern Ireland.[xvii]

People living in deprived areas are at higher risk from cardiovascular disease than those living in more affluent areas. In 2011, an estimated 93,986 people lived in West Belfast.[xviii] West Belfast has a higher proportion of children aged 0 to 15 years (23.0% compared to 20.9%) and a lower proportion of older people aged 60+(17% compared to 19.8%) (Figure 2) compared to the Northern Ireland population.

Those living in West Belfast have the lowest life expectancy in Northern Ireland (average life expectancy for males 72.5 years v Northern Ireland average 77.1 years; for females 78.4 years v Northern Ireland average 81.5 years).[xix] CVD is a major contributor to the gap in life expectancy.[xx] Between 1997-2001 and 2006-2010 CVD mortality decreased across the geographical area of the Belfast Health and Social Care Trust (BHSCT). However, the decline in mortality in the most deprived areas stopped in 2003-2007 and as a result the inequality gap within BHSCT increased from 57% to 67%.[xxi]

In 2011 there were 191 deaths due to CVD in West Belfast. Figures for 2006-2010, show that age standardised mortality rates for circulatory disease were the highest in West Belfast with 129 deaths per 100,000 compared to the Northern Ireland average of 81 deaths per 100,000.[xxii] Deaths due to CVD tend to occur at an earlier age in West Belfast compared to Northern Ireland. Figure Three highlights in more detail the discrepancy for males and females of older working age, with death rates in this age group 1.5 times higher in West Belfast compared to Northern Ireland.

In March 2013 there was a higher prevalence of heart disease, stroke, chronic obstructive pulmonary disease, mental health, asthma, peripheral vascular disease, and epilepsy amongst patients whose GP practice is located in the Belfast West area compared to the average for all GP practices across Northern Ireland.[xxiii]

Annex Three presents the West Belfast Context in greater detail.

HEALTHY HEARTS IN THE WEST AIMS AND OBJECTIVES

Vision

The vision promoted through the Healthy Hearts in the West Initiative is “that people living in West Belfast experience heart health equivalent to the best in Northern Ireland / Europe”.

Aim

The overarching aim of the Healthy Hearts in the West Initiative (HHW) is “to mobilise existing resources and assets of communities in West Belfast, and to work with health professionals and other organisations, so that people living in West Belfast experience improved heart health equivalent to the best in Northern Ireland/Europe”.

Objectives

The Initiative has six core objectives:

  1. Raise awareness about the risk factors contributing to heart disease.
  2. Raise awareness about how to achieve a healthy lifestyle through local programmes.
  3. Strengthen partnerships between community, statutory, voluntary and private sectors to improve heart health.
  4. Improve access to preventative, diagnostic, treatment and rehabilitation services.
  5. Promote self-management for those with cardiovascular disease.
  6. Create care pathways that enable delivery of integrated services for cardiovascular disease.

Core Elements

There is a three-fold approach to delivering the Healthy Hearts Initiative:

  • Community wide programmes, activities and events supporting Healthy Hearts.
  • The Pharmacists Programme: Cardio-Vascular Screening and Weight Management
  • Local provision of CardiacRehabilitation programmes (Phase 3 and Phase 4) and promotion of opportunities for progression.

The third strand of the Healthy Hearts in the West Initiative, Local provision of Cardiac Rehabilitation programmes (Phase 3 and Phase 4) and promotion of opportunities for progression, links directly to the delivery of the Belfast health and Social Care Trust (BHSCT) Phase 3 Programme from the Maureen Sheehan Centre. Consequently evaluation of this Programme was included within the remit of the HHW Evaluator / Researcher.

AN OVERVIEW OF CARDIAC REHABILITATION PHASE 3 PROGRAMMES

There is robust evidence that comprehensive Cardiac Rehabilitation is associated with a reduction in both cardiac and total mortality. Effective Cardiac Rehabilitation results in improved outcomes for patients with heart disease and reduces unplanned readmissions. Cardiac Rehabilitation improves patients’ functional capacity and their perceived quality of life, whilst also supporting early return to work and development of self-management skills.

Cardiac Rehabilitation Phases

There are four Phases to Cardiac Rehabilitation. These are described below in the context of care provision in West Belfast:

In-hospital In order to maximise service uptake, initial assessment is performed by a member of the Cardiac Rehabilitation team as part of in-patient care. All patients at the Royal Victoria Hospital should receive comprehensive discharge information, both in written and DVD format.

Early Contact Post-Discharge Patients are contacted by phone within two weeks of discharge to determine whether they are willing and /or clinically ready to attend an assessment (two attempts are made to contact the patient by phone. If unsuccessful, a letter is mailed asking the patient to contact Cardiac Rehabilitation). Priority at the Royal Victoria Hospital will be given to those patients who have not been seen by the Cardiac Rehabilitation nurse prior to discharge and patients following Primary Percutaneous Coronary Intervention (PPCI).