Prof Ian Graham believes a ‘walk in my shoes’ approach needs to be taken before addressing the almost intractable problem of why the CVD prevention message has had relatively limited success.

“My initial premise about the problems in implementing CVD prevention policies would be: ‘So you are starting tomorrow as Minister for Health. What can you do about CVD prevention?’ 

“While there are no simple solutions, we can get to understand the barriers to the implementation of effective CVD prevention policies, whether it be primary or secondary prevention, and use this as a basis for planning more effective action.

“Everybody worries, for example, about patient compliance. For example, only half of the people who are started on statin therapy are taking the drug a year later. But then, if you don’t feel particularly ill it is very difficult to get motivated to take a tablet aimed at lowering your cholesterol. Also, older people may be on 10 tablets at a time, which makes compliance with any specific drug therapy a problem.”

Prof Graham, who is chair of the Irish Heart Foundation Council on CVD Prevention, says health professionals face considerable barriers in trying to promote better CVD health.

“Doctors will say they don’t have time to engage effectively in preventive healthcare, as they are too busy actually treating acute and chronic illness. They will also point out, particularly in the primary care sector, that they need to be properly resourced to provide this type of service. In other words, they get paid to treat sickness but not to keep people healthy.

“The GP contract in the UK has incentives to partake in prevention, with specific payments related to screening targets, for example. This is something that should be looked at here in the context of a new GP contract.”

As someone who has helped draw up management guidelines, Prof Graham accepts that there is a feeling among doctors that the guidelines are sometimes seen as too complex and that they don’t always fit individual patient profiles.

Another problem is that government health policy often does not facilitate preventive healthcare, particularly in the cardiovascular area. This is not a deliberate policy, but is reflective of the transient nature of governments and variations in priorities according to political changes Prof Graham contends.

“It’s worth noting that in Ireland, we have one person and an organisation in charge of cancer care, whereas we don’t have any one person with overall responsibility for heart health.”

“I think it would certainly help prevention to have a co-ordinating State policy body for heart health, along the same lines as the cancer control programme. I think with the HSE’s existing clinical programmes, too many of them are in silos – there is a stroke programme and  separate heart failure and diabetes programmes. Some of these focus on management  rather than recognising that they share a substrate of common risk factors.

“The stroke programme is concentrating on areas like thrombolysis and rehabilitation, which is great, but the fact that people have stroke is often due to a failure of prevention – in simple terms, checking blood pressure and the pulse for atrial fibrillation – and this needs to be addressed.

“The extent of the problems with implementing prevention properly can be seen from studies that have looked at how risk factors are being dealt with. There is a consistent pattern here. Year after year cholesterol control gets slightly better, and blood pressure control improves slightly. However, body weight increases  and activity gets less so that obesity increases, smoking stays more or less static. Around one in five patients who have had heart attacks still smokes afterwards.

“That said, we have been very proactive in this country on smoking policy. Plain packaging is a good idea and the workplace smoking ban was very progressive, and our smoking rates have declined over the past decade.”

To a great extent, says Prof Graham, talking about adherence or compliance is in many ways very judgemental. 

“There’s something here that we are just not getting as a profession about encouraging exercise and combating overweight. For a start we need to help our patients to find exercise that they actually enjoy. In terms of doctors trying to encourage healthy food choices and to avoid tobacco, they are up against big vested interested such as the food and tobacco industries. Snack food portion sizes have seen a marked increase in recent years. Much of our processed food is very dense in fat, salt and sugar.

“And then there is relentless marketing of junk food to young people. Cinemas make very little out of admission charges, but their big profits come from selling large and expensive portions of fast food and snacks. And usually, you buy your ticket at the food counter, and the food and drink is placed at a level that is visible and accessible to children. But we have to face it that we are not going to stop people eating convenience foods, but that doesn’t mean we can’t concentrate on getting the message across about moderate consumption of them, and particularly stressing the benefits of choosing fresh, unprocessed foods. There’s no such thing as a ‘bad’ food, it’s a question of how much of these foods you eat.”

Encouraging exercise, says Prof Graham, comes with its own specific issues. “If you can’t recommend some type of exercise that people enjoy, it won’t work. People join gyms in January and often quit going in February. You need to identify something that people will enjoy; it doesn’t have to be very strenuous but will provide enough exercise to improve physical health, eg. walking, cycling or hiking. And if people are encouraged to do this exercise with friends they will be encouraged more to keep it up as they won’t want to let the other person down.”

Politics of preventive health

He feels the politics of preventive health is another barrier to successful implementation of policy. 

“We are awash with reports of working groups and other bodies on heart health. We don’t need any more. We know what to do, it’s a question of working out how to do it.

“This is really difficult, however, with a four-to-five-year political cycle, as preventive health policy is a long-term strategy. You then ask yourself, is it impossible to have a democratic system that is based on problem-solving and long-term strategy instead of persistent political point-scoring? I honestly don’t know the answer to that. The political system seems to make it very difficult to implement effective health policy.”

Also, he says, when you look at the structure of the health system, we see a bureaucratic monster of central control that separates power from responsibility and does not appear to have the confidence to delegate.

“There’s an inherent lack of trust in the system as well, both from the public and even among those working in it. Then of course you have vested interests at many levels paying lip service to, but reluctant or unable to actually effect change.”

Prof Graham says we have three fundamental problems in terms of implementing effective CVD prevention policies. With health professionals, it is a question of lack of time and resources. For people, it is a question of knowledge and motivation in the face of societal and marketing factors, and the health system militates against reform due to bureaucratic stagnation and the transient and fickle political process.

“As regards motivating people, I think we need a much stronger sense of social conscience from school onwards. There is a health-promoting schools network, but it needs to be saying, not just  ‘thou shalt not do this or that’, but giving children both the information and the skills  to make healthy choices

“And we need to be thinking outside the box as regards facilitating healthier lifestyles. For example, they’ve started building ‘adult playgrounds’ in Australia and we are beginning to see these here, so that not just kids but adults can exercise anywhere. The concept of joining a gym is still pretty middle-class, and membership can be too expensive for some people, so this could overcome that barrier.”

He wonders too, while admitting that it might not necessarily be politically correct, about schools perhaps being too understanding nowadays about excusing children from doing physical activity or sports. “Sports and gym at school used to be a compulsory part of the curriculum, so perhaps the education system should be doing more to encourage physical exercise at an early age, instead of looking for reasons not to do it.

“But positive things are happening in schools. Lunches are getting better and banning fast food and drink vending machines is a positive step. Also, the government, while it has made progress in areas like tobacco control, could do more in terms of taxing sugary drinks and curtailing trans fatty acids.”

The European Society of Cardiology (of which he is currently a board member) has been proactive in getting countries, including Ireland, to appoint co-ordinators to assist in the strategic implementation of guidelines. In this regard, he paid tribute to the work of the Irish National Co-ordinators, Dr Angie Browne and Siobhan Jennings.

“Without a defined implementation strategy”, says Prof Graham, “publishing guidelines is just a waste of paper or computer space”. Patient empowerment and involvement is important, he stresses.

“The ESC, in an attempt to overcome barriers to implementation of CVD policy, is getting patients more involved in its activities, and we are building relationships with patient organisations around Europe.”

On the effectiveness of treatment guidelines implementation, research shows that there are very wide variations round Europe in terms of compliance. Most health professionals, he says, would in general think guidelines are a good thing but the extent to which they are used is quite variable.

Risk factor control

Prof Graham says when you examine the main drivers of improvements in CVD mortality in recent years, it’s really 50-70% down to risk factor control, with the remainder due to effective drug therapies and procedures. Against this, however, there is the growing issue of obesity, which has the potential to reverse this rate of progress.

“There has to be a worry that CVD mortality levels that have been decreasing over the past two decades will start to increase again because of the explosion in obesity and diabetes. A key issue is to tackle overweight and obesity among lower income groups. Social deprivation has been shown conclusively to be a major factor in poor health and mortality.

“I think targeting prevention to specific social groups is a challenge. My experience with promoting prevention is that too often you are talking to the same middle-class audience; you’re essentially preaching to the converted. We really need to look very hard at the school curriculum, so that not only can the child be educated about healthy living but can educate the parent as well.”

Another issue here, he says, is health literacy. People are often not getting the message because they don’t understand how it’s being presented. 

“. And regardless of literacy levels, when you have a cardiac problem, you are naturally anxious and may be unable to hear the detail of what’s being said to you in these circumstances.

“All the information leaflets and booklets we produced that we thought were very good were having no effect because people didn’t completely understand them. We had to simplify the language. So how we deliver the prevention message is very important.”

“So looking at the issues around CVD prevention, they can only be resolved in an atmosphere of truth and generosity with regard to motives, and an acceptance of the principles of evidence-based healthcare, coupled with an understanding of conflict resolution and avoidance.”