Cardiovascular Disease

Cardiovascular disease (CVD) comprises all heart and circulatory diseases, including coronary heart disease (CHD), angina, heart attack, congenital heart disease, hypertension (high blood pressure), stroke, and vascular dementia. Risk factors such as smoking, obesity, physical inactivity, excessive alcohol consumption, and a poor diet, can all be modified to reduce a person’s risk of developing CVD. Research shows that social isolation is also a risk factor for CVD, due to increased peripheral vascular resistance and elevated blood pressure (Source: PubMed).  

CVD is the leading cause of death worldwide and a leading public health priority in England. CVD causes 1 in 4 deaths, equating to one death every four minutes (Source: Public Health England). “Although there has not been a significant increase in inequality [of mortality rates] in recent years, in 2020 people living in the most deprived areas were still 4 times more likely to die prematurely from cardiovascular disease than people in the least deprived areas” (Source: OHID). OHID now measure this inequality using the slope index of inequality (SII) method. 

The impact of CVD on the health and social care sector is significant. It is estimated that yearly healthcare costs in England related to CVD are estimated at £7.4 billion, with an annual cost to the wider economy of £15.8 billion (Source: PHE, Health Matters: Preventing cardiovascular disease). 

NHS Outcomes Framework and the Public Health Outcome Framework (PHOF) have a range of indicators related to CVD mortality and risk factors, for example, smoking prevalence. 

NHS Long Term Plan – sets out commitments for actions to improve outcomes for major conditions, such as CVD. The Plan ambition is to prevent 150,000 heart attacks, strokes and dementia cases nationally.  

Prevention is Better than Cure – details the government’s vision to: 

• Stop health problems arising in the first place 
• Support people to manage their health problems when they do arise 
• Improve healthy life expectancy by at least 5 extra years by 2035 
• Close the gap between the richest and the poorest 

A collection of case studies provides examples of best practice for preventing the development of health problems. 

Public Health England CVD prevention programme details ambitions for the detection and management of atrial fibrillation, high blood pressure, and high cholesterol for England (for the 10 years to 2029). 

PHE’s Tackling High Blood Pressure outlines how providers and commissioners can reduce the population average blood pressure with improved prevention, detection, and management. It outlines how to address modifiable risk factors such as obesity, excess dietary salt, excess alcohol consumption and lack of physical activity. 

The National Institute for Health and Care Excellence (NICE) publishes a wide range of guidelines, quality standards, and pathways for CVD. 

The Local Government Association (LGA) publishes a wide range of resources to support the delivery of Local Government public health responsibilities. 

The General Medical Service Quality and Outcome Framework+ (QOF) financially rewards general practices for the provision of quality care and helps to standardise improvements in the delivery of primary medical services. Cardiovascular related indicators are used within the QOF. 

The NHS RightCare Commissioning for Value programme aims to improve health outcomes and reduce inequalities in health access and patient experience. 

The Joint Health and Wellbeing Strategy for Lincolnshire informs decisions, commissioning and delivery of health and care services in Lincolnshire. 

The 2019 Global Burden of Disease (GBD) study revealed CVD to be the second highest burden of disease in Lincolnshire, and the number of years of life lost (either in terms of mortality or disability) match national figures. The study identified high blood pressure, diet, high cholesterol and high body mass index as the main risk factors for CVD. 

Premature mortality rate from CVD in Lincolnshire remains higher than the national average but is improving relative to national numbers. CVD mortality rates in Lincoln, East Lindsey and Boston are particularly high compared to the rest of the county, showing potential correlation with deprivation indices and patterns of lifestyle behaviours. Those in the most deprived communities are 30% more likely to have high blood pressure – the number one risk factor for CVD mortality and morbidity in England (Source: Gov.UK). The Wider Determinants of Health Inequality in Lincolnshire report found that levels of premature CVD mortality in the areas with worse overall health outcomes were 3.6 times higher than in the areas with best health outcomes. 

Hypertension is a major risk factor for CVD, the ‘Size of the Prize in Cardiovascular Disease (CVD) prevention’ (2017) report suggests there were 84,100 people Lincolnshire with undiagnosed hypertension, and 6,700 with undiagnosed atrial fibrillation (around 40% of the population is estimated to have each of the conditions). Statins are prescribed to treat roughly half of the population estimated to be at high risk of developing CVD in the next 10 years. 

The prevalence of hypertension, of stroke and of CHD across Lincolnshire have all been consistently higher than nationally, particularly in East Lindsey, West Lindsey and South Holland. Lincoln is the exception, possibly reflecting the younger age profile of the district. Prevalence of Atrial Fibrillation in Lincolnshire is also above the national average.  

CVD is more common among South Asian, and African Caribbean ethnicities, for males, older individuals, and those experiencing severe mental illness (Source: PHE). People with severe and prolonged mental illness are at risk of dying 15 to 20 years earlier on average, than others. Two thirds of these deaths occur from avoidable physical illnesses such as CVD (Source: NHS England). 

Primary prevention of CVD focusses on preventing onset of disease, for example, by supporting the public to make healthier lifestyle choices. Secondary prevention focuses on early diagnosis, treatment, and management, to stop CVD progressing – and reduce the risk of future CVD events. 

• The NHS Health Check Programme is a screening and risk management programme that aims to identify people at risk of CVD and other conditions amongst people aged 40-74 years. 
• The general practice Quality and Outcome Framework (QOF) includes a range of indicators in relation to CVD prevention, for example, atrial fibrillation and hypertension. General practices maintain a register of patients identified with a high risk (based on QRISK calculator) of developing CVD in order to offer clinical reviews and treatment. 
• The NHS Community Pharmacy Blood Pressure Check Service supports detection and prevention of CVD. The service identifies over 40s who have not previously been diagnosed with hypertension, and to refer those with suspected hypertension for appropriate management. 
• The NHS Diabetes Prevention Programme means to reduce incidence of Type 2 diabetes, by reducing blood glucose parameters and reducing weight. For more information about diabetes, see the dedicated JNSA topic. 
• Making Every Contact Count (MECC) is an approach to behavioural change utilising the millions of day-to-day interactions between professionals and the public, to encourage positive health choices and lifestyle behaviours. 
• Local support is given to national campaigns, such as NHS Better Health, to encourage individuals to address the modifiable risk factors of CVD and poor health choices. This is supported by the One You Lincolnshire Integrated Lifestyle Service, which offers evidence based health improvement interventions across Lincolnshire. 
• Local NHS Trusts provide Stroke Services, Cardiology and Cardiac Rehabilitation services. 

Whilst not specific to CVD, lots of engagement takes place with the public, patients and other stakeholders to ascertain views about many issues. 

Healthwatch Lincolnshire carries out work to understand the needs, experiences and concerns of people who use health and social care services. Some areas of work are related to CVD, for example, wanting to hear the views of people who have suffered a stroke. 

Lincolnshire NHS Citizens Panel are residents who volunteer to provide regular feedback and research, allowing residents the opportunity to share opinions and views on health and care services within the county. 

• Excess weight of adults and children is an issue in parts of the county. There are gaps in addressing overweight and obesity across the four-tiered model (Tiers 1-4). For example, there is currently no Tier 3 (specialist) or Tier 4 (surgery) services in Lincolnshire to provide specialist multi-disciplinary obesity services.  There is more information about healthy weight in the dedicated JNSA topic. 
• There are many people with undiagnosed risk factors, or conditions such as atrial fibrillation, high blood pressure or high cholesterol. Public Health England set a 10 year cardiovascular ambition to improve detection and management of these risk factors. 
• Uptake of NHS Health Checks in the 20% most deprived areas of Lincolnshire was much lower than in less deprived areas. There is also a disparity in Health Check uptake between sexes, with men being least likely to attend. 
• NHS RightCare Commissioning for Value shows variation in the detection of CVD risk factors and in the management of patients with CVD conditions across Lincolnshire. 
• There is no cohesive county-wide or system-wide programme of prevention for CVD in Lincolnshire. 

Develop deep and secure data sharing across organisations and map data sources: The wealth of data collected locally is not effectively shared across organisations. Integration of data is essential for understanding, planning, and commissioning effective health services.  We need to develop closer links across health partners (ULHT, LPFT, local authorities, LCC directorates). By understanding the data landscape, and the story it tells, a robust understanding of gaps will develop. 

Explore system wide approaches to tackling CVD: Prevention, management, and treatment. Work taking place for the NHS RightCare CVD National Priority Initiative supports this ambition. 

Co-design systems and processes to assist healthcare professionals explore opportunities for prevention during face to face encounters. 

Implement actions for the priorities and objectives in the JHWS for Lincolnshire, specifically in relation to obesity and physical activity. 

Foster interventions that address health inequalities for CVD and associated risk factors. 

Improve detection and management of high risk conditions; atrial fibrillation, hypertension, and high cholesterol; to contribute to the prevention of CVD. 

Deliver the NHS Health Check programme to identify and manage CVD risk factors. 

Provide people with the knowledge and skills for self-care, to reduce risk of CVD, and manage their CVD risk factors, or an established CVD condition. 

Commission and provide high quality healthcare for people facing CVD risk factors, or established CVD.