The 2016 NIPC National Prevention Conference in Galway heard presentations giving both a global and national perspective on where we currently stand on policy-making when it comes to chronic disease, and in particular CVD prevention. 

David Wood, UK cardiologist and World Heart Federation president-elect, provided a global perspective on CVD prevention. He said there is now a clearly defined global strategy in place for prevention of non-communicable diseases. The most recent initiative has been the WHO Global Hearts 2016 project, which carries recommendations as part of a technical package for CVD management in primary care. This has followed on from the WHO’s nine voluntary global targets for non-communicable diseases (NCDs) to be achieved by 2025, including the overall target of reducing premature mortality from NCDs by 25% by 2025. 

The WHO has stressed that if current trends continue, most regions of the world will see increases in deaths from CVD. However, if all the global risk factor targets are achieved, at least two million premature deaths could be averted each year, with most of the benefits seen in low and middle-income countries.

Global Hearts initiative

With this initiative, WHO has entered into a partnership with the World Heart Federation, representing national heart, stroke and hypertension bodies. There are six elements to this new WHO strategy aimed at implementing CVD primary and secondary prevention goals: Healthy lifestyles; evidence-based treatment protocols; access to essential medicines and technology; risk-based management; team care and systems for monitoring.

Global Hearts, said Prof Wood, places great emphasis on healthy lifestyle, so counselling on tobacco cessation, diet, physical activity, alcohol use and self-care are emphasised.

The component parts of this comprise simplified protocols for lifestyle counselling based on a behavioural approach. The guidelines also prioritise the training of healthcare providers including non-health workers to deliver lifestyle counselling and educational material to improve knowledge of CVD and promote self-care.

The WHO initiative also stresses the need for access to affordable drugs and technologies, although at present there is huge variation between regions of the world in terms of access to and availability of same.

Thresholds for assessment

   Prof Wood said total cardiovascular risk assessment has been the centrepiece of prevention guidelines since the early 1990s. The Global Hearts package provides thresholds for CVD risk assessment and management. For example, a threshold of greater than 30% of the high CVD risk population receiving statins and/or antihypertensives based on new CVD risk stratification has been chosen.

   Team care and task-sharing, essentially shifting some prevention tasks from eg. doctors to nurses, is an important part of the Global Hearts initiative, Prof Wood said. 

As part of the systems monitoring process, there is an emphasis on electronic data collection in order to measure outcomes.

Focus on primary care

   The Global Hearts initiative, Prof Wood said, is intended to intensify the investment in prevention of heart attacks and strokes and is focused specifically on primary care and on risk screening assessment and management using nurses and other healthcare workers as the frontline staff. (www.who.int)

He said the CROI MyAction community-based approach to secondary prevention was an exemplar on the optimal way of achieving prevention goals, in line with the WHO initiative. MyAction, said Prof Wood, had demonstrated impressive outcomes in terms of lifestyle change, risk factor control and adherence to medication. Recent research had shown that the Croi initiative was also cost-effective, and its success was clearly evidence-based.

Prof Wood said there was a need for a scaling up of such programmes across Ireland, and this would require leadership at a national level.

Government’s healthcare policy

Dr Stephanie O’Keeffe, national director for health and wellbeing at the Department of Health, updated the meeting on the progress of the government’s healthcare policy.

Dr O’Keeffe said there is rising demand for health services against a background of an ageing population that is living longer, but with a greater level of chronic disease.

“This means we really have to radically transform how we provide services, with a significant focus on prevention, early detection, self-care and self-management.” 

She pointed out that our population is ageing more quickly than in other European countries.

Dr O’Keeffe said there were opportunities for people to live well at home, meaning that we need to transform our models of care with regard to older people and to change how care is delivered outside hospitals as people age.

Addressing multimorbidity and its challenges, Dr O’Keeffe said from the recent TILDA survey we know that half of people over the age of 50 have one chronic disease and 18% have more than one.

This, coupled with the ageing population profile, will impact health services in terms of cost and in terms of how we plan our models of care.

Dr O’Keeffe said looking at obesity, which is a major determinant of future health status, much of this had to do with individual behaviour, but there were also environmental and policy determinants, many of them outside the health area, from housing, to transport, to education. 

“The risks are systemic but the solutions also have to be systemic.”

She said a longer-term approach to planning health services was required, and this was recognised by the recent establishment of an Oireachtas committee which is to devise a 10-year plan for the future of health services. There was also a recognition that improving health and wellbeing is a cross-Government and cross-sectoral agenda.

Current health service priorities

On current health service priorities, Dr O’Keeffe outlined progress on the Government’s 2013 Healthy Ireland strategy(health.gov.ie/healthy-ireland/). Important components of this are health service reform; effective chronic disease management; and workforce health and wellbeing.

Among the health service reforms are changes whereby there is a move to activity-based funding; there will be a move from block hospital allocations to activity-related funding, and there is a need to incentivise prevention and patient outcomes. Dr O’Keeffe said there was a need for significant investment in IT, and she cited in particular a need to develop an electronic health record – a business case had been made for this.

Dr O’Keeffe said there were a series of actions in Healthy Ireland around chronic disease management, from healthier lifestyle initiatives to sexual health and positive ageing. 

She said a lot of work is being done on developing integrated programmes for chronic disease management. The vision here is that most people will receive most chronic disease services in a primary care setting, that care will be integrated and timely in accordance with the needs of the individual, that healthcare professionals will be supported by multidisciplinary teams and specialists when needed and that resources will be used effectively, with standardised pathways of care.

Dr O’Keeffe said the planned new GP contract for primary care will be essential in dealing with the future management and prevention of chronic disease. 

Implementation of Healthy Ireland

With regard to the implementation of Healthy Ireland within the health services Dr O’Keeffe said all the hospital groups bar one have a Healthy Ireland lead sitting on their senior management team, as well as project officers working on developing Healthy Ireland implementation plans for hospitals. 

Tangible political actions

She said within the new HSE community health organisations (CHOs), which are responsible for non-acute care on a regional basis, there is a lead for health and wellbeing along with representatives of healthcare groups. The above will help foster an integrated approach to prevention and management of chronic disease.

Dr O’Keeffe said the emphasis now was on creating connections between people around a common vision and a common agenda with some tangible practical actions that everybody can do to make a difference.

For the Healthy Ireland agenda to be acted on effectively, it must not just happen at health service level but cross-sectorally, tackling issues such as poverty, education and the environment that are not just confined to the health area, she stressed.

She ended by quoting Martin Luther King: “…all life is inter-related…(we) are caught in an inescapable network of mutuality tied in a single garment of destiny. Whatever affects one directly, affects all directly.”