Like the Pope being against sin, the need to effectively target CVD prevention is pretty much a given. However, as with sin, there are conflicting views as to the best way of targeting it. This was evident in a lively debate at The National Institute for Preventive Cardiology (NIPC) National Prevention Conference 2015 in Galway. This was the second such conference organised by the NIPC, which was set up in 2014 by the cardiac foundation Croi, which has pioneered community-based CVD prevention programmes.

At the conference, an expert panel, chaired by broadcaster and historian John Bowman, debated the best way forward for CVD prevention. The debate heard some conflicting views on, among other things, the role of primary care versus hospital and other types of care, the integration of the different components of the health system and the best means of education, health promotion and regulation in the battle to keep Ireland heart-healthy. A key theme pervading the panel debate and the conference as a whole was how difficult it is to push the prevention agenda when the ‘sexier’ concepts of high-tech interventional techniques tend to grab the headlines.

Dr Orlaith O’Reilly, the HSE’s national clinical adviser and programme lead for health and wellbeing, said she found that the prevention message was a ‘very hard sell’ when it came to clinicians, particularly hospital clinicians, who tended to be more interested in high-tech developments. Dr O’Reilly pointed out that prevention initiatives were ‘low-tech’. She said prevention programmes should be centred in general practice, supported by health and wellbeing and preventive initiatives in the community and by specialist care.

Cardiologist and member of the Board of the European Society of Cardiology, Prof Ian Graham, stressed the need for co-ordination between many disciplines when it came to prevention. He felt doctors have over-medicalised and over-controlled prevention, and there was a serious problem in communicating with the public, particularly to children, to make them more responsible for their own health. 

Prof Kieran Daly, national clinical lead with the HSE’s Acute Coronary Syndrome Programme, and a founding member of Croi, spoke on the need to focus on prevention and rehabilitation to complement initiatives being taken by clinical programmes to improve hospital treatment services.

The need to keep the message simple and persistent was stressed by Prof Joe Harbison, joint lead of the HSE Stroke Programme. According to Prof Harbison: “What we know about education is that it works while it is being received, so you need to keep the information going all the time.” He cited the memorable FAST campaign to alert people to the need to act on stroke symptoms, which was organised by the Irish Heart Foundation. However, while initially successful, the effects of this campaign had now almost completely disappeared, because the resources were simply not there to keep the campaign going, he said. 

Prof Harbison pointed out, incidentally, that the level of VAT charged on media advertising, which would be charged on broadcast media health promotion campaigns, was higher than the level of VAT currently charged on fast food. What was needed, he said, was to keep the prevention message out there. This could include more prominent information on the salt content of food products.

Dr Ronan Canavan, clinical lead for the Diabetes Programme, highlighted the need to develop integrated care, and to link prevention and intervention.

Dr Nazih Eldin, national obesity adviser with the Department of Health, stressed the need for a whole Government and whole society approach to promoting healthier living.

Prevention in primary care

When the debate was thrown open to the floor, Andrew Murphy, professor of general practice at NUI Galway, praised Croi for the work it has done; however he noted the significance of there being no primary care representatives on the expert panel. He said a significant challenge would be how primary care is embraced when prevention strategies are being planned. “Basing services in primary care is not the same as integrating services with primary care and unless primary care is embraced, what we are trying to do (with prevention) will be noble and worthy but ultimately futile,” said Prof Murphy. 

He then argued that primary care needed to be included in initiatives. He pointed out that there are 20 million patient contacts each year in Irish general practice. In response, Prof Harbison spoke about the recent atrial fibrillation screening programme (through GP pulse-checking) in the west of Ireland that was organised by the HSE. This showed that this screening worked very well.

Prof Murphy said it had already been well shown that this type of preventive screening was successful; “We don’t need more small trials in Ireland; we need implementation of what research is already out there,” he said.

Prof Harbison, defending the west of Ireland AF trial, said trying to co-ordinate prevention initiatives across multiple different GP practices around the country was a big challenge. He said trying to implement change into primary care in Ireland was very difficult. For instance, in the Dublin hospital in which he works, GPs often queried why patients were being brought into hospital for warfarin checking when they say they can do that themselves in general practice.

Prof Harbison said not all GPs, however, might do warfarin testing. “The secondary care system sometimes has to cater for the least capable element of primary care because there is no unanimity in the system.” He felt that initiatives whereby there would be more universal screening programmes (eg. warfarin testing) in general practice could form part of the new GP contract.  

Dr O’Reilly said a lot of the future of prevention and health promotion would depend on what was in the new GP contract. “All of this costs GPs time and money, so unless it’s a contractual arrangement it’s not going to be mainstreamed.”  

Prof David Wood, cardiologist and president-elect of the World Heart Federation, who was a guest speaker at the NIPC conference, felt it was completely wrong to state the solution lies in general practice, and there was a third way outside hospitals and general practice. “Primary care is overwhelmed by the sick. There is not sufficient interest in prevention and I don’t think the types of programmes we are talking about can realistically be effectively operated in primary care.” He said healthy living programmes should be put into the community, led by nurses and other health workers. 

Prof Daly agreed with this and pointed to the work done to date in terms of community prevention by Croi. He said if you can develop programmes in community centres, GAA halls etc and get people to attend these sessions, it is a much easier ‘sell’. The only downside of that, he said, is you will get some ‘worried well’ attendees and you may miss the real at-risk people. However, he said community initiatives working with general practice would provide a very good solution.

Prof Harbison pointed out that what Prof Wood was suggesting actually constituted primary care, even though it would not be done in GP practices. “It all depends on how you define primary care. People think that primary care is only general practice but primary care is everywhere; it’s the public health nurse going out to see your patient; it’s the community physiotherapist; it’s screening in the community, it’s all primary care.”

Prof Murphy pointed to the need for co-ordination between the different sectors. Setting up ‘silos’ was not the solution, he said, as these would not take the totality of the patient into account.

Dr Martin O’Flaherty of the University of Liverpool said CVD prevention should actually happen in supermarkets, where the healthiest food option was usually not the cheapest or most accessible option. Dr Eldin agreed. He pointed to modern lifestyles leading to people taking less exercise, and to the fact that the popularity of convenience foods and fast foods have led people to become ‘deskilled’ from cooking healthier foods for themselves. The reason healthier food tended to be dearer than less healthy food was simply market forces, which needed to be changed.

The problems of getting the healthy lifestyle message across to those in lower socio-economic groups was stressed by Prof Graham, who decried the largely middle-class approach that is taken to prevention. Public health specialist Dr Siobhan Jennings said it was a challenge for healthcare professionals to engender the same public excitement into prevention that currently existed with new medical technologies. 

The need to ‘make every consultation count’ was referred to by Prof Daly. For example, to ask a patient whether they have had their blood pressure checked recently when they are attending for a vaccination or for warfarin testing. The difficulty was, however, in reaching out to the general population when it came to prevention programmes.

Legislation and tax

An Irish-born cardiologist working in London, Dr Susan Connolly, said legislation was the key to changing lifestyle behaviour. She said Ireland had led the way with its smoking ban and should lead the way in Europe with proper taxation of unhealthy foods. She pointed out there had been public resistance to fat and sugar taxes in other countries, “but governments need to be brave on this.”

Dr Eldin said Health Minister Leo Varadkar had proposed to the government the introduction of a 20% tax on sugar-added drinks in the recent Budget; however, mainly for technical reasons this was not implemented. He said we need such a sugar tax in Ireland. Tackling the food industry was not as easy as people might think but it still needed to be worked on.

The message from the panel debate was that progress on effective prevention was painfully slow, but progress was nonetheless being made.