Heart disease: policy context
From their peak in the 1970s, incidence rates of coronary heart disease (CHD) have tended to decline in Scotland, but not at the pace of neighbouring northern European countries. CHD will remain a major public health problem in Scotland for several decades to come.
A target of a 50% reduction between 1995 and 2010 in the age-standardised death rate from CHD for people aged under 75 was set in the 1999 white paper Towards a healthier Scotland. The Scottish Government increased the target to a 60% reduction in their 2009 action plan. This target was achieved in 2010.
In light of Scotland's poor record on heart disease and stroke, the Scottish Executive published the CHD and stroke strategy for Scotland in October 2002, following the publication of the CHD/Stroke Task Force report a year earlier. The strategy represents the culmination of 4 years' work, based upon extensive consultation with patients, clinicians and managers.
Progress of the strategy was reviewed in a supplementary report, Coronary heart disease and stroke in Scotland - Strategy update 2004, published in December 2004. One of the strategy recommendations was for all health boards to have managed clinical networks (MCNs) for CHD services, and these have been established.
In Delivering for Health (2005) , the section on heart disease looked at targets for reducing both premature deaths from CHD and CHD deaths in disadvantaged communities as well as the role of MCNs in reducing CHD incidence by their prevention stategies.
In Better Health, Better Care - action plan (2007) , the section pertaining to heart disease focussed on reducing mortality in deprived areas and agreed reductions in hospital admission rates.
Following consultation (Better Coronary Heart Disease and Stroke Care: a consultation document (2008)), in 2009 the Scottish Government published an updated strategy in the Better Heart Disease and Stroke Care Action Plan which broadened its remit to include other forms of heart disease (e.g. familial hypercholesterolaemia).
The aim of reducing mortality from CHD among the under 75s in deprived areas is included as part of one of the five high level purpose targets and as a specific national indicator set out by the Scottish Government in Scotland Performs:
- National Indicator 26: "Reduce mortality from coronary heart disease among the under 75s in deprived areas" (defined as the 15% most deprived data zones in Scotland, based on the Scottish Index of Multiple Deprivation (SIMD)).
Scottish Government policy on reducing health inequalities includes Equally well, the 2008 report of the Ministerial Task Force on Health Inequalities. This set out a series of recommendations addressing the social determinants of health - including education, poverty and employment - and health and wellbeing in the early years. It also called for analysis to support long-term monitoring of inequalities in a number of high level indicators, of which coronary heart disease was one. The 2008 Long-term monitoring of health inequalities: first report on headline indicators and the latest 2013 update presented data on: CHD - first ever hospital admission for heart attack aged under 75 years; and CHD - deaths aged 45-74 years.
There have been a number of SIGN guidelines on CHD and stroke, and Guideline 97 'Risk estimation and the prevention of cardiovascular disease' was published in February 2007. These guidelines, drawn from a contemporary evidence base and best practice to meet the needs of the patients, has lead to a publication of Clinical Standards for Heart Disease by NHS QIS Clinical standards for Heart Disease.
The most recent policy document has been the Heart Disease Improvement Plan (2014) . This set out 6 priorities and actions to deliver improved prevention treatment and care for people in scotland affected by heart disease. The priorities include:
(1) prevention of cardiovascular disease by looking at inequalities among people at high risk of developing heart disease
(2) improving mental health and well-being for those with heart disease
(3) ensuring patients are receiving the right investigation and treatment in secondary and tertiary care cardiology
(4) helping patients live longer, healthier and independent lives through heart disease management and rehabilitation
(5) & (6) improving the journey of care by developing a whole systems approach to patients with heart failure and arrhythmias