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«MAY 2010 DEPARTMENT OF HEALTH AND CHILDREN Copyright © Minister for Health and Children, 2010 Department of Health and Children Hawkins House ...»

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Changing Cardiovascular Health

National Cardiovascular Health Policy

2010 – 2019

MAY 2010


Copyright © Minister for Health and Children, 2010

Department of Health and Children

Hawkins House

Hawkins Street

Dublin 2

Tel: +353 (0)1 635 4000

Fax: +353 (0)1 635 4001

E-mail: info@health.gov.ie

Web: www.dohc.ie

Published by Government Publications, Dublin

ISBN 0-7557-7639-9

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission in writing of the copyright holder.

For rights of translation or reproduction, applications should be made to the Head of Communications, Department of Health and Children, Hawkins House, Hawkins Street, Dublin 2, Ireland.

CONTENTs Minister’s Foreword vii Acknowledgements ix Membership of the Cardiovascular Health Policy Group x Executive summary 1 Introduction to the Cardiovascular Health Policy (Chapter 1) 2 Cardiovascular Disease – Trends in Ireland (Chapter 2) 2 Prevention and Health Promotion (Chapter 3) 3 Primary Care (Chapter 4) 6 Hospital and Emergency Care Services (Chapter 5) 11 Cardiac and Stroke Rehabilitation and Continuing Care (Chapter 6) 22 Workforce Planning (Chapter 7) 28 National Framework for Quality in Cardiovascular Health (Chapter 8) 31

1. Introduction 35 Cardiovascular Health Policy Group 36 Background 36 A vision for cardiovascular health 37 Structure of report 38

2. Cardiovascular Disease – Trends in Ireland 39 Life expectancy and healthy life years 40 Cardiovascular disease 40 Heart failure 46 Peripheral arterial disease 47 Sudden cardiac death 48 Congenital heart disease and grown-up congenital heart (GUCH) disease 48 Diabetes 48 Cardiova

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Appendix 4: Stroke Networks – Description and Governance 162 MINIsTER’s FOREWORD I am pleased to introduce this new policy framework covering all aspects of cardiovascular health, including stroke. It is now a decade since the first National Cardiovascular Health Strategy, Building Healthier Hearts (1999), was launched. It introduced a wide range of new services and initiatives, which have had a positive impact on reducing the burden of cardiovascular disease through prevention, better diagnosis and treatment. However, given the pace of change in scientific development and medical practices in this area during the last decade, an updated policy was required. Furthermore, any policy on cardiovascular care would be incomplete unless it includes a strategy on stroke.

This new policy, Changing Cardiovascular Health, covering the period 2010-2019, addresses the spectrum of cardiovascular disease and stroke, including prevention and management and how these are integrated to reduce the burden of these conditions. It covers the whole area of prevention, including measures that individuals can take as well as population interventions, and areas in which intersectoral action is necessary. It deals with the clinical management of cardiovascular disease and stroke, and covers all aspects of healthcare – from childhood through old age, from pre-hospital emergency care to rehabilitation and palliative care.

The policy is being launched in a challenging economic climate with little prospect of additional resources. However, the policy covers the period 2010-2019 and much can be done to advance it in tandem with other national strategies and the reorganisation of current resources. The Health Service Executive has been tasked with developing an implementation plan detailing how it intends to arrange services to support the delivery of care.

This policy represents a significant development coming after previous policies on cancer and diabetes, which together will account for the majority of healthcare in this country. The policy will operate alongside and complement existing policies on obesity, alcohol and chronic disease. The review is timely given the considerable changes in health services, the impact of unhealthy lifestyles, the future demand on health services and the scope for substantial improvements in cardiovascular mortality in the years to come. I am confident that this policy paves the way for enhanced prevention and care of cardiovascular disease and stroke in the next decade and will mark a new chapter for service delivery in this area.

I would like to take this opportunity to thank the members of the Cardiovascular Health Policy Group, who gave freely of their time and expertise in order to develop this framework, and especially Professor Hannah McGee, Professor of Health Psychology at the Royal College of Surgeons in Ireland, who worked tirelessly on this project.


Mary Harney, TD Minister for Health and Children vii ACkNOWLEDGEMENTs This National Cardiovascular Health Policy was commissioned by the Minister for Health and Children.

Its aim is to provide an integrated and quality-assured policy framework for the prevention, detection and treatment of cardiovascular disease, including stroke and peripheral arterial disease. The policy comes a decade after the important first National Cardiovascular Health Strategy in Ireland (Building Healthier Hearts, 1999) and is a timely successor. Since Building Healthier Hearts, we as a country have improved our evidence base on population health and on service delivery and cardiovascular outcomes, although there is much still to do to ensure our information collection methods are systematised to deliver evidence in a dependable periodic manner.

I am very grateful to the hard-working and enthusiastic Working Group who developed this policy.

The similarity of the professional challenges of working in the traditionally separate areas of cardiac and stroke care, and the opportunity to work together to develop a common approach to the variety of presentations of cardiovascular disease (from prevention through emergency care to early rehabilitation and lifelong chronic disease management), was an important stimulus to work to achieve an integrated vision for the coming decade in the management of cardiovascular disease.

While all of the Working Group provided their unique perspectives to make a comprehensive final product, I know that members will concur with me in particularly thanking Dr. Brian Maurer who combined his lifelong career expertise from cardiology and his advocacy role from the Irish Heart Foundation to bring wisdom and a sense of responsibility to our deliberations. It was a pleasure to be part of the developmental processes of the Working Group.

Thanks are extended to many people outside of the core Working Group for their support. It is not possible to individually list all who provided some assistance. We thank Dr. Kathleen Bennett and Dr.

Tom O’Hara, Department of Pharmacology & Therapeutics, Trinity College Dublin, for biostatistical support, and we acknowledge their Department head and mentor – Professor John Feely, Chair of the HeartWatch Implementation Committee, whose untimely death during this period deprived the academic and clinical cardiovascular community in Ireland of one of its inspiring contributors. We thank the HSE staff for data and advice (Professor Joe Barry, Ms. Deirdre Carey, Dr. Nazih Eldin, Dr. Catherine Hayes, Dr. Fenton Howell, Dr. Maria Lordan-Dunphy and Ms. Fionnuala O’Brien); and Royal College of Surgeons in Ireland staff for research and administrative support (Dr. Karen Morgan, Dr. Anne Hickey, Mr. Mark Ward, Ms. Deirdre Holly, Ms. Helen Burke, Ms. Carole Caetano and Ms. Shani Rushin). Thanks also to Dr. John Billings, Health Information and Quality Authority; Mr. Martin Feeley, Irish Association of Vascular Surgeons; Mr. Tom Horton and Mr. Aonghas Horgan, Office of Social Inclusion; and staff at the Grown Up Congenital Heart Services, Mater Misericordiae University Hospital Dublin; the Food Safety Authority of Ireland; and the National Treatment Purchase Fund. Thanks to the many staff in the Department of Health and Children who provided support throughout the work of the Group – in particular Dr. John Devlin, Deputy Chief Medical Officer, who was the ongoing contact for the Group.

All of these efforts have been towards delivering a new policy for a new era in cardiovascular care – where the goal will be to prevent, to treat and to manage in an environment that is both more challenged economically, but also more enabled by the many scientific, professional and societal achievements of the last decade in this area. The title of the new policy conveys the impetus – Changing Cardiovascular Health: the challenge is to make change rather than to observe change.

We trust this policy will empower policy-makers, service providers and service users to work to change our cardiovascular health in the coming decade.

–  –  –

* Represented by Mr. John Billings and Dr. Deirdre Mulholland ** Replaced by Ms. Patricia Lee x ExECuTIvE suMMARY ExECuTIvE suMMARY


The Cardiovascular Health Policy Group was established with the following terms of reference:

Having regard to the audit of the implementation of the cardiovascular health strategy, Building Healthier Hearts, and the audit of stroke services, Irish National Audit of Stroke Care, and consistent with developments in relation to the management of chronic diseases and the Primary Care Strategy, to develop a policy framework for the prevention, detection and treatment of cardiovascular disease, including stroke and peripheral arterial disease, which will ensure an integrated and quality-assured approach in their management.

This new cardiovascular policy, Changing Cardiovascular Health covering the period 2010-2019, comes a decade after the first national cardiovascular health strategy, entitled Building Healthier Hearts, was published by the Department of Health in 1999. The new policy is timely given the pace of scientific discovery and related changes in medical practice, changes in health service structures, and patterns and influences on population health behaviours in Ireland over the decade. Cardiovascular health and its maintenance is a microcosm of health more generally. A policy that can improve cardiovascular health and cardiovascular disease management will have beneficial effects for the whole healthcare system and population.

CARDIOvAsCuLAR DIsEAsE – TRENDs IN IRELAND (CHAPTER 2) Cardiovascular disease remains the most common cause of death in Ireland, currently accounting for one-third of all deaths and one in five premature deaths. However, there has been substantial progress. Age-standardised death rates from cardiovascular disease have decreased by two-thirds over the past 30 years. Despite improvements, Ireland still ranks below the EU15 average for life expectancy for both men and women. As mortality rates have reduced, demand on health services has intensified.

Without changes in prevalence and practice, hospital bed use can be expected to increase substantially over the next decade as the number of people aged over 65 in Ireland is predicted to increase by 41%. In primary care, prescriptions for cardiovascular medication have increased two- to four-fold. At population level, the current lifestyle-related risk factor profile of the Irish population is a major concern: levels of smoking have not changed in the last 5 years, while levels of obesity and physical inactivity have increased (see Chapter 3). If these patterns continue, they threaten to reverse the declining trend in cardiovascular disease mortality of recent decades. There is thus considerable scope for improvement. This challenge is an intersectoral one – involving and being driven by those responsible for health and healthcare, but supported and enabled by sectors such as education, transport and agriculture.

Apart from the human cost, the cost of cardiovascular disease to the Irish economy – which includes the costs of healthcare, loss in productivity and informal care – is a significant burden. Spending on cardiovascular health, while substantial, accounts for only 6% of the Irish healthcare budget – lower than the EU27 average of 10%. A much greater level of analysis of the costs of cardiovascular disease is needed to inform discussions about service investments and value for investment over the 10-year timeframe of this new policy.

Executive Summary


Cardiovascular disease must be addressed through a combination of population-based approaches, which target the entire population, and high-risk approaches, which focus on individuals in contact with health services. The burden of cardiovascular diseases and the lifestyle factors that contribute to them is borne disproportionately by those in lower socio-economic groups. Evidence suggests these differentials may be increasing. Given the documented inequity in cardiovascular health and risk factor profiles, measures to increase population health must permeate across all socio-economic groups, but with a specific focus on reducing inequity.

The individual determinants of cardiovascular health and disease are similar to those relating to overall disease burden – smoking, raised blood pressure, raised blood cholesterol, physical inactivity, obesity and diabetes mellitus. The current health behaviour profile of the Irish population, and resultant cardiovascular risk, means that a major effort is needed to change these patterns.

This policy proposes a series of 10-year targets for health behaviours influencing cardiovascularrelated population health (see Recommendation 3.1).

RECOMMENDATION 3.1 The Department of Health and Children should prioritise actions that promote the health behaviour profiles underpinning cardiovascular health, with specific targets to actively pursue and achieve within a 10-year period.

The prioritised areas are:

• maintaining a healthy body weight;

• healthy eating and physical activity;

• reducing salt intake;

• refraining from or quitting smoking;

• consuming alcohol responsibly.

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