HEALTHY HEARTS IN THE WEST INITIATIVE ~ PHASE ONE

EVALUATION REPORTCARDIAC REHABILITATION PHASE 3

PROGRAMME

February 2014

Healthy Hearts in the West is funded byThe Public Health Agency and Belfast Local Commissioning Group

HEALTHY HEARTS IN THE WESTCARDIAC REHABILITATION PHASE 3 PROGRAMME

PHASE ONE: EVALUATION REPORT

Contents

Introduction 3

Context 5

Healthy Hearts in the West Aims and Objectives 10

An Overview of Cardiac-Rehabilitation Phase 3 Programmes 11

Statistical Patient Data for The Maureen Sheehan CR Unit 14

Comparative Patient Data 20

Feedback from Patients 25

Feedback from the Cardiac Rehabilitation Team Delivering Phase 3 at The Maureen Sheehan Centre 36

Comment 38

Annexes

One: Health Inequality and Cardiovascular Disease 39

Two: Northern Ireland Policy Context 44

Three: West Belfast Local Context 48

References 51

I would like to thank and acknowledge the time and information input to this Report provided by Juanita Cunningham, BHF Cardiac Rehabilitation Nurse, Belfast Health and Social Care Trust; and additional support from Paula Maine (BHF Cardiac Rehabilitation Nurse), Siobhan Doyle BHSCT Physiotherapist and the Heart Healthy Living Centre staff.

Jane TurnbullHHW Evaluator / ResearcherMarch 2014

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INTRODUCTION

The Healthy Hearts in the West Initiative (HHW) was established to mobilise existing resources and assets of communities in West Belfast, and to work with health professionals and other organisations, so that people living in West Belfast experience heart health equivalent to the best in Northern Ireland / Europe.

In 2011 the Healthy Hearts in the West was initiated in response to the high levels of cardiovascular disease across West Belfast and the need to reduce inequalities in heart health. The Community Planning Officer - Health, employed by West Belfast Partnership Board (WBPB), established a small cross-sectoral working group; with representation from local community groups, the Public Health Agency (PHA), and Belfast Health and Social Services Trust. Key to the development of the HHW initiative was addressing health inequality in West Belfast, focusing on cardiovascular disease – with data showing mortality at an earlier age and higher percentages of the population experiencing heart related illness than the average across the NI population (see section 4). The working group looked at the delivery of the Healthy Choices Project (to tackle obesity) delivered in the Upper Falls; and felt that the cross-sectoral nature of the project could be extended to a community wide approach to addressing health inequality.

The working group ‘tested’ interest in building a community assets approach to health inequalities relating to heart health at a workshop in March 2011, ‘Working Together to Make a Difference’. The workshop was attended by representatives from the community, voluntary, statutory, and private sectors, and the Workshop Report informed the development of the Healthy Hearts in the West proposal.

In September 2011 funding was awarded to develop and deliver HHW from the PHA and Belfast Local Commissioning Group (LCG). Phase One became operational in January 2012, and finished on the 31st March 2013.

Following the Status Report (December 2012), a presentation to the Belfast LCG (January 2013) and a series of meetings with the PHA early in 2013, the Healthy Hearts in the West Initiative Steering Group was informed that there would be further funding for one year; allowing for future planning.

HHW has benefited from a formative evaluation process being built into the Project, with a series of reports contributing to ongoing review and development. It was agreed that comprehensive evaluation reports should be prepared, pulling together the data collected and reports written during the first Phase.

The four Evaluation Reports presenting the development and delivery of the first phase of the Initiative are:1. Healthy Hearts in the West Process, Infrastructure, and Partnership: an Overview

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2. Healthy Hearts in the West Hubs and Community Development3. Healthy Hearts in the West Community Pharmacy Programmes4. Healthy Hearts in the West Cardiac Rehabilitation.

This Evaluation Report presents the Cardiac Rehabilitation Phase 3 Programme, delivered from the Maureen Sheehan Centre from January 2012. It also places cardiovascular disease into context. The Evaluation Report has been informed through the National Audit of Cardiac Rehabilitation data, Patient Follow-Up Questionnaires, discussions with the Cardiac Rehabilitation Nurses, and data provided by the Heart Healthy Living Centre.

“The benefits to patients completing CR are evident through positive changes, in important clinical outcomes, such as; smoking cessation, physical activity status, anxiety and depression”.

National Audit of Cardiac Rehabilitation, Annual Statistical Report 2013

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CONTEXT

Health Inequality and Cardiovascular Disease

Cardiovascular disease (CVD) is a major cause of death and disability in Northern Ireland. In 2012 more than one in four deaths (27%, 4,001 deaths) in Northern Ireland were due to diseases of the circulatory system (Figure 1).i

28%

27%14%

5%

26%

Figure 1: Proportion (%) of deaths by major cause, 2012p

Cancer (C00-C97)

Circulatory Diseases (I00-I99)

Respiratory Diseases (J00-J99)

External Causes(V01-Y98)

Other Causes(Rem* A00-Y98)

Various factors affect the risk of cardiovascular disease.ii Some factors such as ethnicity, age and gender (men generally develop coronary heart disease earlier than women) cannot be modified. However other risk factors can be modified. The INTEREART study found that over 90% of the risk of heart attack was attributable to nine factors including abnormal lipids, smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, consumption of fruits, vegetables, and alcohol, and insufficient regular physical activity.iii The British Regional Heart Survey (BRHS) also found that at least 80% of major coronary heart disease events in middle-aged men can be attributed to total cholesterol, high blood pressure and smoking. iv

The prevention of cardiovascular disease is dependent on the reduction in major risk factors such as smoking, high blood pressure or diabetes, cholesterol, waist-hip ratio and physical inactivity.v Changes in cardiovascular disease (CVD) risk factors can be brought about through intervention at both an individual level in terms of behaviour change and at population level though development of appropriate policy and legislation.vi Cardiovascular health is also influenced by other social and economic factors such as housing, employment and transport.vii

The relationship between socio-economic disadvantage and cardiovascular disease (CVD) is well established. Men living in the 20% most affluent areas in Northern Ireland live on average 7.6 years longer than men in the 20% most deprived areas; for women, this gap is 4.5 years.viii Cardiovascular disease remains one of the main contributors to the differential in life expectancy.

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Reducing the disease burden of cardiovascular disease presents significant challenges. However, there are effective interventions that can reduce risk, prevalence and deaths from CVD. In addition to medical interventions, these include recommending that people make healthier choices, such as eating healthier foods, using alcohol sensibly, undertaking regular physical activity, stopping smoking, and accessing services promptly.ix

Annex One presents a more detailed overview of heart health inequality in Northern Ireland.

Northern Ireland Policy Context

The Programme for Government (PfG) 2011-15 sets out the strategic context for both the Budget and the Investment Strategy for Northern Ireland.x It identifies the following five Priorities:

1. Growing a Sustainable Economy and Investing in the Future; 2. Creating Opportunities, Tackling Disadvantage and Improving Health and Wellbeing; 3. Protecting Our People, the Environment and Creating Safer Communities;4. Building a Strong and Shared Community; 5. Delivering High Quality and Efficient Public Services.

The Health and Social Care (Commissioning Plan) Direction (Northern Ireland) 2012 sets out the focus for the Regional Board and Regional Agency in the commissioning of health and social care services.xi It provides details of how the services being commissioned by the Regional Board align with the Programme for Government, the Economic Strategy and the Investment Strategy and includes a number of key priorities and targets for delivery. The first priority is to improve and protect health and well-being and reduce inequalities, through a focus on prevention, health promotion and earlier intervention.

The new 10-year public health framework (launched for consultation in July 2011) aims to secure more coherence cross-departmentally with a focus on upstream interventions which will improve health and tackle health inequalities.xii Fit and Well xii recognises that health is determined by factors both within and beyond the control of individuals, families and communities and influenced by social and economic circumstances well beyond the reach of health services. Hence it seeks to improve health and wellbeing along the life course from early to old age by addressing disadvantage through and across a wide spectrum of service provision and support. It also provides strategic direction for work to be taken in support of this at both regional and local levels, with public agencies, local communities and others working in partnership. The framework contributes to achievement of the priorities identified in the Programme for Government.

The service framework for Cardiovascular Health and Wellbeing, launched in 2009 was the first of a series of service frameworks for Northern Ireland.xiii Cardiovascular disease was chosen because of its significance as a cause of ill health and premature death in Northern

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Ireland. The aim of the framework is to improve the health and wellbeing of the population of Northern Ireland, reduce inequalities and improve the quality of care. It sets out 45 standards in relation to the prevention, diagnosis, treatment, care, Rehabilitation and palliative care of individuals and communities at a greater risk of developing cardiovascular disease. Each standard is supported by key performance indicators, which set levels of performance to be achieved over a three-year period (2009-12).

In 2010 a Health Impact Assessment (HIA) was undertaken to test the effects of implementing the framework on health inequities and inequalities in relation to cardiovascular health. The HIA found that almost all of the standards were affected by health inequities and inequality, mainly relating to socioeconomic factors and variable access to services depending on where patients lived. Suggestions on how to enhance the delivery and impact of the cardiovascular standards in reducing health inequalities and inequities were collated in the form of an action plan to inform commissioning of services.

A review of the implementation of the Cardiovascular Service Framework, conducted by the Regulation and Quality Improvement Authority (RQIA) in 2012, found widespread support among stakeholders for the service framework approach and made recommendations for the implementation of future service agreements.xiv The West Belfast Partnership Healthy Hearts Initiative is highlighted as a local project supporting the framework implementation process.

In December 2011, Transforming Your Care (TYC), a review of the provision of Health and Social Care (HSC) Services in Northern Ireland, was published. TYC proposes a future model for Integrated Health and Social Care, identifying twelve major principles for change. It is designed with the individual at the centre and health and social care services built around this, providing support to promote self care and make good health decisions. With people living longer the demand for health and social care services will increase in the future; pointing to the need for more preventative work and improved community based access.

Draft Population Plans, developed by Local Commissioning Groups (LGCs) with input from Health and Social Care Trusts, set out how the evolving health and social care needs and expectations of the population will be met. The plan for Belfast LCG specifically highlights Healthy Hearts under actions being taken to Deliver Service Outcomes relating to Population Health and Wellbeing and Long Term Conditions.xv The consultation ended on the 15th January 2013.

There are four new Integrated Care Partnerships (ICPs) across Belfast, launched in 2013. ICPs are networks which will see doctors, nurses, social workers and other health professionals, and the voluntary and community sector working together to keep people well and make sure they get the care they need, when they need it.xvi The focus of the West Belfast Integrated Care Partnership is Stroke.

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Annex Two presents an overview of the Northern Ireland Policy Context.

“Cardiovascular disease remains the main cause of premature death. Reductions in premature death from stroke and coronary heart disease, which have led to increased life expectancy elsewhere, have not been as marked in areas of deprivation”.

Belfast Local Commissioning Plan 2012-2013

West Belfast Local Context

West Belfast is the most deprived geographical area in Northern Ireland. Approximately three quarters (76%, 71,709 people) of the West Belfast (AA2008) population live in one of the 20% most deprived Super Output Areas in Northern Ireland.xvii

People living in deprived areas are at higher risk from cardiovascular disease than those living in more affluent areas. In 2011, an estimated 93,986 people lived in West Belfast.xviii West Belfast has a higher proportion of children aged 0 to 15 years (23.0% compared to 20.9%) and a lower proportion of older people aged 60+(17% compared to 19.8%) (Figure 2) compared to the Northern Ireland population.

0-15 16-44 45-59 60+0

5

10

15

20

25

30

35

40

45

20.9

40.1

19.2 19.823.0

41.4

18.617.0

Figure 2: West Befast (AA) population age profile, 2011 Census

Northern IrelandBelfast West

% o

f tot

al p

opul

atio

n

Those living in West Belfast have the lowest life expectancy in Northern Ireland (average life expectancy for males 72.5 years v Northern Ireland average 77.1 years; for females 78.4 years v Northern Ireland average 81.5 years).xix CVD is a major contributor to the gap in life expectancy.xx Between 1997-2001 and 2006-2010 CVD mortality decreased across the geographical area of the Belfast Health and Social Care Trust (BHSCT). However, the decline in mortality in the most deprived areas stopped in 2003-2007 and as a result the inequality gap within BHSCT increased from 57% to 67%.xxi

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In 2011 there were 191 deaths due to CVD in West Belfast. Figures for 2006-2010, show that age standardised mortality rates for circulatory disease were the highest in West Belfast with 129 deaths per 100,000 compared to the Northern Ireland average of 81 deaths per 100,000.xxii Deaths due to CVD tend to occur at an earlier age in West Belfast compared to Northern Ireland. Figure Three highlights in more detail the discrepancy for males and females of older working age, with death rates in this age group 1.5 times higher in West Belfast compared to Northern Ireland.

Males 40-64 years Female 40-59 years0

5

10

15

20

25

30

Figure 3: Circulatory disease deaths (per 1,000 population), 2001-2010

Northern IrelandWest Belfast (AA1998)

Deat

hs p

er 1

,000

pop

ulati

on

In March 2013 there was a higher prevalence of heart disease, stroke, chronic obstructive pulmonary disease, mental health, asthma, peripheral vascular disease, and epilepsy amongst patients whose GP practice is located in the Belfast West area compared to the average for all GP practices across Northern Ireland.xxiii

Annex Three presents the West Belfast Context in greater detail.

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HEALTHY HEARTS IN THE WEST AIMS AND OBJECTIVES

Vision

The vision promoted through the Healthy Hearts in the West Initiative is “that people living in West Belfast experience heart health equivalent to the best in Northern Ireland / Europe”.

Aim

The overarching aim of the Healthy Hearts in the West Initiative (HHW) is “to mobilise existing resources and assets of communities in West Belfast, and to work with health professionals and other organisations, so that people living in West Belfast experience improved heart health equivalent to the best in Northern Ireland/Europe”.

Objectives

The Initiative has six core objectives: 1. Raise awareness about the risk factors contributing to heart disease.2. Raise awareness about how to achieve a healthy lifestyle through local programmes.3. Strengthen partnerships between community, statutory, voluntary and private sectors to

improve heart health.4. Improve access to preventative, diagnostic, treatment and rehabilitation services.5. Promote self-management for those with cardiovascular disease.6. Create care pathways that enable delivery of integrated services for cardiovascular

disease.

Core Elements

There is a three-fold approach to delivering the Healthy Hearts Initiative: Community wide programmes, activities and events supporting Healthy Hearts. The Pharmacists Programme: Cardio-Vascular Screening and Weight Management Local provision of Cardiac Rehabilitation programmes (Phase 3 and Phase 4) and

promotion of opportunities for progression.

The third strand of the Healthy Hearts in the West Initiative, Local provision of Cardiac Rehabilitation programmes (Phase 3 and Phase 4) and promotion of opportunities for progression, links directly to the delivery of the Belfast health and Social Care Trust (BHSCT) Phase 3 Programme from the Maureen Sheehan Centre. Consequently evaluation of this Programme was included within the remit of the HHW Evaluator / Researcher.

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AN OVERVIEW OF CARDIAC REHABILITATION PHASE 3 PROGRAMMES

There is robust evidence that comprehensive Cardiac Rehabilitation is associated with a reduction in both cardiac and total mortality. Effective Cardiac Rehabilitation results in improved outcomes for patients with heart disease and reduces unplanned readmissions. Cardiac Rehabilitation improves patients’ functional capacity and their perceived quality of life, whilst also supporting early return to work and development of self-management skills.

Cardiac Rehabilitation Phases

There are four Phases to Cardiac Rehabilitation. These are described below in the context of care provision in West Belfast:

In-hospital In order to maximise service uptake, initial assessment is performed by a member of the Cardiac Rehabilitation team as part of in-patient care. All patients at the Royal Victoria Hospital should receive comprehensive discharge information, both in written and DVD format.

Early Contact Post-Discharge Patients are contacted by phone within two weeks of discharge to determine whether they are willing and /or clinically ready to attend an assessment (two attempts are made to contact the patient by phone. If unsuccessful, a letter is mailed asking the patient to contact Cardiac Rehabilitation). Priority at the Royal Victoria Hospital will be given to those patients who have not been seen by the Cardiac Rehabilitation nurse prior to discharge and patients following Primary Percutaneous Coronary Intervention (PPCI).

The pre-assessment appointment includes an individual clinical assessment of the patients’ anxieties, abilities and risk factors. Based on findings and patient goals a tailored programme is prescribed that may encompass, management of psychological and social needs, smoking cessation, diet, weight management, physical activity, individual medication, and long term management. Collaboration at this stage, with community services predominantly based at the Maureen Sheehan Healthy Living Centre (HLC) are integral from this point onward in optimising uptake of phase 3 and providing individualised care.

Delivery of the Cardiac Rehabilitation Programme The Programme adopts a biopsychosocial evidence-based approach which is culturally appropriate and sensitive to individual needs and preferences. Core components include:

Health behaviour change and education Lifestyle risk factor management

o Physical activity and exerciseo Dieto Smoking cessation

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Psychosocial health Medical risk factor management Cardioprotective therapies Longterm management Audit and evaluation

Patients are offered a rolling programme and the average course is eight weeks. Programme completion is defined by completion of formal assessment, at the end of the programme, of lifestyle risk factors, psychosocial health status, medical risk factors and use of cardioprotective therapies, together with patient satisfaction. A mechanism of re-offer and re-entry is in place where patients initially decline or drop out. A full summary of the patient’s journey through Rehabilitation is forwarded to the cardiologist, GP & practice nurse to ensure continuity of care.

By the end of the programme patients will have been encouraged to develop self-management skills and so be empowered and better prepared to take ownership of their own responsibility to pursue a healthy lifestyle. To facilitate this patients and their families are signposted and encouraged to join:

Phase 4 Cardiac Rehabilitation Local heart support groups Community dietetic and weight management services Smoking cessation services.

Cardiac Rehabilitation Phase 3 Programme delivery across the BHSCT area

The Cardiac Rehabilitation Phase 3 Programme is currently delivered from four centres in Belfast (ie within the Belfast Health and Social Care (BHSCT) area), as shown in Table 1.

Table 1: Cardiac Rehabilitation Phase 3 Centres in the BHSCT area

CR Phase 3 Centre Hospital patients predominantly admitted to

Number of Programmes (weekly)

Musgrave Belfast City Hospital 2 programmesMaureen Sheehan Royal Victoria Hospital 2 programmesGrove Health and Wellbeing Mater Hospital 1 programmeMater Hospital Mater Hospital 1 programme

Delivery of the Cardiac Rehabilitation service at the Maureen Sheehan Healthy Living Centre started on the 15th January 2012. The Maureen Sheehan Centre is located in the heart of the Greater Falls (Albert Street); included in the Centre is the Heart Healthy Living Centre, a Pharmacy, Clan Mór Sure Start, and a GP surgery.

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The Cardiac Rehabilitation Phase 3 Programme is delivered by a team of three specialist nurses and one dedicated physiotherapist from Belfast Health and Social Care Trust.

The core rationale for delivery of the Cardiac Rehabilitation Phase 3 Programme from the Maureen Sheehan Centre was due to concerns that patients living in West Belfast were not taking up the opportunity to attend Phase 3 Programmes due to the distance they had to travel, and (prior to 2012) that the Programme was not delivered in their own community.

The Cardiac Rehabilitation Phase 3 Programme is delivered by a team of three specialist nurses and one dedicated physiotherapist from Belfast Health and Social Care Trust (BHSCT). It involves other members of the multi professional team as required. The majority of the Cardiac Rehabilitation nurses are independent nurse prescribers.

If referred by the Cardiac Phase 3 nurses, people can also attend the Cardiac Rehabilitation Phase 4 Programme which is delivered by the Heart Healthy Living Centre at the Maureen Sheehan Centre.

“I felt I was not left alone after the heart attack and that I was still being cared for after hospital. It was great to be given a one to one helping hand and tailor-made support”.

CR Phase 3 Programme Patient

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STATISTICAL PATIENT DATA FOR THE MAUREEN SHEEHAN CR UNIT

The Department of Health, Social Services and Public Safety Northern Ireland Statistics provided aggregated data on people discharged alive after having a MI, PCI and CABG in any diagnostic/treatment category. The National Audit of Cardiac Rehabilitation (NACR), located at the University of York, is funded by the British Heart Foundation and hosted in conjunction with the Health and Social Care Information Centre (HSCIC). The role of the audit is to:1. Map the extent of Cardiac Rehabilitation provision across the UK2. Assess uptake and clinical outcome3. Highlight inequalities in provision and outcome4. Aid clinical decision making locally and within regional networks5. Disseminate audit findings to service providers and the public6. Inform clinical guidance, policy makers, commissioners and practice standards7. Drive up quality and facilitate service improvement locally, regionally and nationally.

The National Database is a programme that has been developed to support the submission of data to the NACR. Data presented in this section and the following section have been accessed from the National Database.

The data presented are in relation to the period 1st January 2012 (ie when delivery of the Cardiac Rehabilitation Phase 3 Programme started at the Maureen Sheehan Centre) to 31st March 2013 (ie the end of the first Phase of HHW).

Patients eligible to participate in the Cardiac Rehabilitation Phase 3 Programme

1131 patients had an initiating event between the 1st January 2012 and the 31st March 2013. Of these patients, 283 (25%) live in one of the three West Belfast postcode areas (BT11, BT12, and BT13). Initiating events include acute coronary syndrome, angina, aortic valve disease, arrhythmia, cardiac arrest, Myocardial Infarction, acute coronary syndrome, angina, coronary bypass grafting, aortic or mitral valve replacement and heart failure.

Table 2 below shows the ages of those admitted to the Royal Victoria Hospital due to an initiating event.

Table 2: Patients admitted to the Royal Victoria Hospital by age

Age < 30 30–39 40–59 50–59 60–69 70–79 80-89 90 + TotalPatients No. 10 14 96 258 297 337 106 12 1130

% 0.9% 1.2% 8.5% 22.8% 26.3% 29.8% 9.4% 1.1% 99.9%

The age of one patient was not recorded.

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Eligibility to progress to the Cardiac Rehabilitation Phase 3 Programme

Some patients are not eligible for referral to the Cardiac Rehabilitation Phase 3 Programme. Reasons for ineligibility include: Ongoing investigations of the patient Physical incapacity of the patient Patient too ill Rehabilitation not needed / not appropriate for the patient Mental incapacity Death of the patient.

Of the 1131 patients who were admitted to the Royal Victoria Hospital, 634 are recorded as ‘elsewhere on the NACR database. This would be because they fall outside the BHSCT Geographical area. Of the remaining 497 patients, 170 were not eligible to progress to the Phase 3 Programme delivered from a Cardiac Rehabilitation Centre (see non-eligibility list above). Patients may be offered alternative support: of the total cohort (1131), 49 patients (4.3%) received a home visit to support their Rehabilitation after they were discharged from the Hospital.

Of the remaining 278 eligible patients 141 chose not to not attend the Phase 3 Programme. Reasons recorded included ‘not interested’ or ‘refused’, ‘no transport’, ‘returned to work’, and ‘language barrier’.

During the 1st January 2012 and the 31st March 2013 a total of 137 patients participated in the Phase 3 Programme at the Maureen Sheehan Centre. Therefore, of the 278 eligible patients, there was a 49.3% uptake onto the Programme. There has been an 11% increase in uptake of eligible patients to the Programme from the previous year. Further detail is given in the section below, providing comparative data prior to and following the involvement of the Maureen Sheehan Centre and HHW.

Patient Profile

Of the 137 patients who attended the Cardiac Rehabilitation Phase 3 Programme at the Maureen Sheehan Centre during Phase 1 of HHW, 95 were male and 42 were female.

63% of patients on the Programme reside within a West Belfast Postcode area.

29 patients were aged 49 years or less (2 were aged between 30 and 39). Table 3 presents the full age range.

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Table 3: Age of patients who engaged with the Cardiac Rehabilitation Phase 3 Programme

Age 31–40 years

old

41–50years

old

51–60years

old

61–70years

old

71–80years

old

81 + years

old

Total

Patients Number 2 27 37 32 35 4 137Percentage 1.5% 20% 27% 23% 25.5% 3% 100%

52 patients who completed Phase 3 were referred to and started the Cardiac Rehabilitation Phase 4 Programme.

Impact on patient clinical measurements

At the individual Pre- and Post-Assessment of patients undertaken by the Cardiac Rehabilitation Nurses (approximately 12 weeks between the pre-assessment and the post-assessment) a number of clinical checks are taken , and measurements are recorded for each patient. The table below shows the change in measurements between the Pre-Assessment and the Post-Assessment.

Table 4: Clinical measurements Pre and Post-Assessment

Clinical measurements Pre and Post-Assessment

No. of patients

with both values

Assessment 1 Assessment 2 Change

N % N % % point

BMI <30 88 53 60.2 54 61.4 1.2

Exercise5x30 mins sessions/week

8020 25.0 46 57.5 32.5

Smokers 77 11 14.3 8 10.4 -3.9

BP systolic<130 mm Hg and diastolic <80 mm Hg

8643 50.0 46 53.5 3.5

Total cholesterol <4 mmol/l 73 32 43.8 37 50.7 6.9Cholesterol LDL <2 mmol/l 66 31 47.0 34 51.5 3.7

Waist <102cm (men or <88cm (women)

7947 59.5 44 55.7 -3.8

It is noted that the Blood Pressure limits (systolic<130 mm Hg and diastolic <80 mm Hg) are used in line with the Joint British Society (JBS) guidance on prevention of cardiovascular

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disease in clinical practice (also prescribed by NICE). These guidelines are different than those used in other medical guidance, for example during risk assessment screening. Table 4 shows that following participation in the Cardiac Rehabilitation Phase 3 Programme: 26 patients increased their level of exercise to within the government recommended

guidelines 5 patients’ total cholesterol level reduced 3 patients stopped smoking (it is noted that new guidelines for pre- and post-assessment

now capture data about when patients stopped smoking – ie before or after the event) 3 patients waist measurements reduced to falling within the recommended range The BMI of 1 patient fell below the BMI obese range The waist circumference of 3 patients increased – whilst data is not available to explain

this increase the CR Nurses suggest this might include patients who have stopped smoking and put on weight.

Health Related Quality of Life and Mental Health Data

At the Pre- and Post-Assessment (approximately 12 weeks between the pre-assessment and the post-assessment) two questionnaires are used to measure patients’ clinical, behavioural, health and psychological domains. Two standardised questionnaires are used within the National Service Framework: Hospital Anxiety and Depression Scale (HADS)and Dartmouth COOP - Quality of Life.

The HADS questionnaire is used to determine the levels of anxiety and depression that a patient is experiencing. The HADS is a fourteen item scale that generates ordinal data. Seven of the items relate to anxiety and seven relate to depression.  Each item on the questionnaire is scored from 0-3 and this means that a person can score between 0 and 21 for either anxiety or depressionxxiv. 

Table 5: HADS assessment for patients on the Cardiac Rehabilitation Phase 3 Programme at the Maureen Sheehan Centre

HADS Assessment – CR patients at the Maureen Sheehan

Centre

No. of patients

with both values

Assessment 1 Assessment 2 Change

N % N % % point

HADS AnxietyNormal

BorderlineClinically Anxious

80392219

48.827.523.8

481616

60.020.020.0

11.2-7.5-3.8

HADS DepressionNormal

BorderlineClinically Depressed

80551015

68.812.518.8

63107

78.812.58.8

10.00

-10.0

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Table 5 shows that following participation in the Cardiac Rehabilitation Phase 3 Programme, there was an increase of 9 patients falling within the ‘normal’ anxiety level and a reduction of 3 patients assessed as ‘clinically anxious’. It also shows an increase of 8 patients with a ‘normal’ depression rating; and a decrease of 8 people assessed as ‘clinically depressed’.

The Dartmouth Primary Care Cooperative Information Project designed the Quality of Life Questionnaire as a practical way of assessing patients’ functional status. The Questionnaire sets out to produce reliable, accurate, easily interpretable, and clinically useful data on a core set of functional dimensions. A patient’s functional status is measured for physical endurance, emotional health, role function, and social function; overall well-being is assessed through questions relating to overall health, change in health, and level of pain; and quality of life is specifically measured in relation to overall quality of life, and social resources/supportxxv.

Table 6: Quality of Life assessment for patients on the Cardiac Rehabilitation Phase 3 Programme at the Maureen Sheehan Centre

Quality of Life Assessment - CR

patients at the Maureen Sheehan

Centre

No. of patients

with both values

Assessment 1% normal

score

Assessment 2% normal

score

Change

N % N % % point

Physical Fitness 70 25 35.7 45 64.3 28.6Daily Activities 72 56 77.8 67 93.1 15.3Social Activities 75 57 76.0 68 90.7 14.7Pain 75 47 62.7 57 76.0 13.3Overall Health 75 47 62.7 56 74.7 12.0Feelings 72 53 73.6 58 80.6 7.0Quality of life 72 67 93.1 68 94.4 1.3Social Support 72 64 88.9 53 73.6 -15.3

Table 6 shows the greatest change for patients following participation in the Cardiac Rehabilitation Phase 3 Programme is in the ‘normal’ scores assessed for physical fitness. With the exception of the ‘social support’ assessment, all domains showed a positive increase at the Post-Programme Assessment. The latter may be due to the fact that the pre-assessment would have taken place when patient’s family and friends were providing additional support following discharge from hospital; whereas this support naturally decreases over time.

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Counselling and Complementary Therapies

One of the advantages of this Phase 3 Programme being located in the Maureen Sheehan Centre is that the Cardiac Rehabilitation Nurses can refer patients on the Programme to the on-site Counsellor and Complementary Therapist (both of whom work for the Heart Healthy Living Centre). 30 patients on the Cardiac Rehabilitation Phase 3 Programme have been referred to the Counsellor and 53 patients referred to the Complementary Therapist to access additional support. Feedback from the patients and the Nurses (see sections below) report that these interventions have been beneficial to the patients.

“I was referred to a Counsellor [by the CR Nurses] because I was depressed. I was agitated and anxious. The Counsellor suggested that I see the Complementary Therapist. I had acupuncture and was also given treatment to help with my breathing. I went to the Complementary Therapist for six weeks and the Counsellor for two weeks. I was also referred to another organisation about my alcohol consumption. As a result of this my alcohol consumption has reduced. I had never heard of the Maureen Sheehan Centre before and was given great help here. I have learnt to relax. I have stopped cigarettes and got the drinking under control; and now the plan is to get a wee bit fitter.”

CR Phase 3 Programme Patient

Cardiac Rehabilitation Phase 4 Programme

The Heart Healthy Living Centre employs two people who have qualified in the delivery of the Cardiac Rehabilitation Phase 4 Programme. This is delivered in the small gym located within the Maureen Sheehan Centre.

An advantage of this is that patients can meet the Cardiac Rehabilitation Phase 4 Programme coaches whilst attending the Phase 3 Programme; and for those referred on to Phase 4 the transition is seamless; and the programme is delivered within an environment that people are familiar with.

During the Healthy Hearts Initiative 96 people enrolled on the Cardiac Rehabilitation Phase 4 Programme, delivered at the Maureen Sheehan Centre (through the Heart Healthy Living Centre), following Cardiac Rehabilitation Phase 3.

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COMPARATIVE PATIENT DATA

Using the NACR data this section presents comparative data for: Take up of the Cardiac Rehabilitation Phase 3 Programme by eligible patients at the

Grove Health and Wellbeing Centre and the Maureen Sheehan Centre The Maureen Sheehan data and Northern Ireland data The Maureen Sheehan Centre, Northern Ireland, and England and Wales.

Take up of CR Phase 3 in 2011 and January 2012 to March 2013

Prior to the delivery of the Cardiac Rehabilitation Phase 3 Programme from the Maureen Sheehan Centre, people living in West Belfast tended to attend the Phase 3 Programme at the Grove Health and Wellbeing Centre (in North Belfast). Patient feedback during 2011 suggested that this was a challenging option for some. Apart from public transport issues, people were going away from their own community; after the Programme they found it more difficult to maintain progress as they had not met with local people experiencing similar circumstances.

In 2011, when patients living in West Belfast predominantly attended the Cardiac Rehabilitation Phase 3 Programme at the Grove Health and Wellbeing Centre, 322 patients were eligible to participate in the Programme. Of these 141 enrolled on the Programme, ie an uptake of 44%. This data was derived from the NACR data for the period 1st January 2011 to 31st .December 2011 for take-up of eligible patients to the Phase 3 Programme at the Grove Health and Wellbeing Centre. The same eligibility criteria were applied as for those eligible to attend the Programme at the Maureen Sheehan Centre. It is noted that although the data in relation for delivery of the Cardiac Rehabilitation Phase 3 Programme at the Maureen Sheehan Centre is over a period of 15 months, compared to 12 months, these are percentage figures (not referring to individuals) and therefore the data are valid for comparative purposes.

Delivery of the Cardiac Rehabilitation Phase 3 Programme started at the Maureen Sheehan centre on the 15th January 2012. From 15th January 2012 to 31st March 2013, 278 patients were eligible to participate in the Programme. Of these 137 enrolled on the Cardiac Rehabilitation Phase 3 Programme, ie an uptake of 49.3%. This represents an 11% increased take up of the opportunity to engage with the Cardiac Rehabilitation Phase 3 Programme by eligible patients.

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Numbers and percentages of people who have had an MI, PCI or CABG attending Cardiac Rehabilitation Phase 3 Programmes in 2011-12

The tables below show the number of patients receiving Cardiac Rehabilitation in Northern Ireland by initiating event, and in England and Wales. It is noted that the NACR data list 15 Cardiac Rehabilitation Centres in Northern Ireland, but there are in fact 16.

Table 7: Initiating event prior to attending a Cardiac Rehabilitation Phase 3 Programme in Northern Ireland

Data from the 15 NI CR Centres2011 - 2012

No. of patients Receiving CR % Uptake

MI 2221 1109 50PCI 2309 428 19CABG 568 405 68Total 5128 1942 38

Table 8: Uptake of patients attending a Cardiac Rehabilitation Phase 3 Programme in Northern Ireland, England and Wales

2011 – 2012

NI % Uptake England % Uptake

Wales % Uptake

MI 50 46 40PCI 19 29 15CABG 68 70 68Total 38 43 38

12 week outcomes

Basic health checks are carried out during the initial clinical assessment, ie prior to a patient starting on the Cardiac Rehabilitation Phase 3 Programme, and again on completion of the programme at the final assessment.

Table 9 below presents the percentage point change for patients completing the Maureen Sheehan Centre Programme (where known) between the 1st January 2012 and the 31st March 2013, and for patients completing the Phase 3 Programme at all Centres (for whom data have been uploaded) across Northern Ireland, England and Wales recorded in the NACR Annual Statistics for 2011 – 2012.

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Table 9: Twelve week outcomes: patient clinical domains recorded for the Maureen Sheehan Centre and Northern Ireland, England and Wales

Twelve week outcomes for patients following the CR Phase 3 Programme

Maureen Sheehan CR Programme:No. of patients

with both values

Maureen Sheehan Centre:

Change2012 - 2013

NI, England and Wales:

Change2011 - 2012

% point

BMI <30 88 1.2 0

Exercise5x30 min sessions / week

80 32.5 23

Smokers 77 -3.9 5

BP systolic<130mm Hg and diastolic <80mm Hg

86 3.5 3

Total cholesterol <4mmol/l 73 6.9 21Cholesterol LDL <2mmol/l 66 3.7 18

Waist <102cm (men or <88cm (women)

79 -3.8 2

Total Numbers for NI, England and Wales = 15,967

Note: negative values show a reduction in the number of patients who smoke; and an increase in waist measurement.

The data show that patients who attended the Cardiac Rehabilitation Phase 3 Programme at the Maureen Sheehan Centre had above average outcomes in relation to reduced BMI, increased exercise, reduced number of smokers and reduced blood pressure (within the guidelines for people following hospital admission due to a heart related event).

HADS Questionnaire

As noted in the previous section, the Hospital Anxiety and Depression Scale (HADS) Questionnaire is administered to patients at the initial assessment and again at the end of the Programme. The percentage of patients with a ‘normal’ (non-case) score at Assessment 1 and Assessment 2 is recorded on the NACR database.

Table 10 shows the percentage point change between the first HADS Questionnaire assessment and the second HADS Questionnaire assessment for patients who completed

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the Cardiac Rehabilitation Phase 3 at the Maureen Sheehan Centre, and all those who completed the Programmes delivered across Northern Ireland, England and Wales.

Table 10: HAD assessments recorded for patients attending the Maureen Sheehan Centre and patients attending centres across Northern Ireland, England and Wales.

HAD Assessments: Comparative Data

Maureen Sheehan CR Programme:

Change2012 - 2013

NI, England and Wales:Change

2011 - 2012

% point

HADS AnxietyNormal

BorderlineClinically Anxious

11.2-7.5-3.8

6-2-4

HADS DepressionNormal

BorderlineClinically Depressed

10.00

-10.0

5-3-2

N for Maureen Sheehan Centre CR Phase 3 Programme = 80 patients with both valuesN for NI, England and Wales = 13,771

The data show that patients who attended the Cardiac Rehabilitation Phase 3 Programme at the Maureen Sheehan Centre had above average outcomes in relation to anxiety and depression following participation in the Cardiac Rehabilitation Phase 3 Programme.

Dartmouth COOP - Quality of Life Questionnaire

As noted in the section above, the Quality of Life Questionnaire is administered to patients at the initial assessment and again at the end of the Programme. The percentage of patients with a ‘normal’ score at Assessment 1 and Assessment 2 is recorded on the NACR database.

The table below shows the percentage point change between the first Quality of Life Questionnaire assessment and the second Quality of Life Questionnaire assessment for patients who completed the Cardiac Rehabilitation Phase 3 at the Maureen Sheehan Centre, and all those who completed the Programmes delivered across Northern Ireland, England and Wales.

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Table 11: HAD assessments recorded for patients attending the Maureen Sheehan Centre and patients attending centres across Northern Ireland, England and Wales

Maureen Sheehan Programme

No. of patients with both values

Maureen Sheehan CR Programme:

Change2012 - 2013

NI, England and Wales:Change

2011 - 2012% point

Physical Fitness 70 28.6 30Feelings 72 7.0 6Daily Activities 72 15.3 10Social Activities 75 14.7 12Pain 75 13.3 6Overall Health 75 12.0 13Social Support 72 -15.3 -3Quality of life 72 1.3 2

N for NI, England and Wales = 12,135

The data show that patients who attended the Cardiac Rehabilitation Phase 3 Programme at the Maureen Sheehan Centre had above average outcomes in relation to reduced pain, increased daily and social activities, and positive feelings. With the exception of ‘social support’ (previously explained), the data for patients across the other domains are similar to those for patients across NI, England and Wales.

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FEEDBACK FROM PATIENTS

Context

Following discussions with the Cardiac Rehabilitation (CR) Nurses it was agreed that it would be beneficial to carry out a formal follow-up with patients once they have completed (or left) the Cardiac Rehabilitation Phase 3 Programme delivered at the Maureen Sheehan Centre. The aim was to gather feedback about the provision of the Programme within the community setting.

The CR Nurses asked ten patients who had participated in the Cardiac Rehabilitation Phase 3 Programme to participate in a telephone interview with the HHW Evaluator / Researcher. Eight telephone interviews were completed, each lasting approximately thirty minutes. It was agreed that the feedback received was valuable; and that the responses from the telephone interviews provided a valuable baseline from which to draft a Patient Follow-Up Satisfaction Questionnaire. This would be less time-consuming to administer than telephone interviews; and it would also meet one of the CR Standards listed within the Cardiovascular Service Framework.

The Follow-Up Patient Questionnaire was drafted (based on other Cardiac Rehabilitation questionnaires used in the UK and on the eight telephone interviews); and first administered in July 2012. Copies of the Follow-Up Satisfaction Questionnaire were posted to those who had completed the Programme at the Maureen Sheehan Centre earlier in the year; and since the end of July 2012, all patients leaving the Programme are asked to complete the Questionnaire.

The Follow-Up Patient Satisfaction Questionnaire developed through HHW has been taken up by Cardiac Rehabilitation Centres at regional level in NI.

67 Follow Up Patient Satisfaction Questionnaires have been completed and returned for the period 15th January 2012 to 31st March 2013, representing a 52.8% return (67/137 and excluding the 10 patients who were asked to participate in the telephone interviews). This Report presents the data collected from the Questionnaires.

In addition, six case studies have taken place involving people who were on the Cardiac Rehabilitation Phase 3 Programme (including those who were referred by the CR Nurses to either the Counsellor or the Complementary Therapist for additional support). The Counsellor and Complementary Therapist work within the Heart Healthy Living Centre and respond to the Cardiac Rehabilitation referrals. These individual experiences have also been included within this Report (in text boxes).

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Patient respondent’s profile

The profile of the patient’s who completed and returned the Questionnaire with respect to gender and age is presented in the table below.

Table 12: Cardiac Rehabilitation Phase 3 Programme Patient Profile

31 – 40 years old

41 – 50years old

51 – 60years old

61 – 70years old

71 – 80years old

Age unknown

Male 1 11 15 7 13 -Female 1 5 3 4 5 -Total 2 16 18 11 18 2

None of the patients who completed and returned the Questionnaire were under 30 years old or over 80. As the table shows, more men than women completed and returned the Questionnaire. This is unsurprising, as more men than women participated in the Cardiac Rehabilitation Phase 3 Programme at the Maureen Sheehan Centre (see page 16).

Accessing the CR Phase 3 Programme

Patients completing the Questionnaire were asked: What date were you discharged from hospital? When did you start the CR Phase 3 Programme? When did you finish the CR Phase 3 Programme

This enabled calculations to be made about the length of time between hospital discharge and starting the CR Phase 3 Programme; which is shown in table 13 below.

Table13: Length of time from hospital discharge to commencing the Cardiac Rehabilitation Phase 3 Programme

Less than five

weeks

5 to 6 weeks

7 to 8 weeks

9 to 12 weeks

More than 12 weeks

Unknown

Time between hospital discharge and starting the CR Phase 3 Programme

10 14 9 6 18 10

It also enabled a further calculation to be made as to how many weeks the patients who responded to the Questionnaire attended the CR Programme (although this may not directly

26

equate to how many sessions they attended, as the CR Nurses report that occasionally individuals do not attend on consecutive weeks due to other commitments).

Table 14: Number of weeks patients attended the Cardiac Rehabilitation Phase 3 Programme

Number of Weeks Patients attended the CR Phase 3 Programme4 5 6 7 8 9 10 11 12 13 14 19 Unknown2 4 12 10 13 6 4 1 2 2 2 1 7

“I believe that I am better equipped to manage having gone through the Cardiac Rehabilitation Programme. I went on to the Phase 4 Programme as well. I’m fairly resilient anyway; but it’s the fact that the Programme happened in the immediate aftermath; I couldn’t emphasise enough how much it has helped. I know a lot of it is down to me; but it is having the good guidelines and the good foundation that has helped so much. And the Nurses are still only a phone call away if I need them”.

CR Phase 3 Programme Patient

Prior to starting the Cardiac Rehabilitation Phase 3 Programme

The CR Phase 3 Programme Follow-Up Questionnaire asked how patients heard about the Programme; as shown in the table below. The majority heard about the Programme whilst in hospital (CR Phase 1). This information is presented in Table 15.

Table 15: How Patients learnt about the Cardiac Rehabilitation Phase 3 Programme

When Patients were told about the CR Phase 3 Programme No. of responsesWhen in hospital 45In a telephone call from the Cardiac Rehabilitation Nurse 21In a letter from the Cardiac Rehabilitation Nurse 14From my doctor 2

“I was in the ward and thought to myself ‘I need to change my ways’ – I realised that much for myself. I was there because of poor lifestyle choices. I thought I would have to do my own research and had made an appointment with the Nutritionist in the Royal. I was all set to go off and do this. Then the CR Nurse called in to see me when I was still on the ward, and introduced herself; to my delight she told me about the CR Phase 3 Programme. She left me some leaflets and phoned a couple of weeks later and confirmed that I was interested. I started the Programme within two months after I was discharged”.

Patient who was on the CR Phase 3 Programme

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Sixty patients thought they had received enough information about the Programme before they started the Cardiac Rehabilitation Phase 3 Programme; 5 people were not sure; and 2 people said they did not receive enough information beforehand.

Three patients gave examples of additional information that would have been useful. These included: A leaflet outlining the structure and purpose of the Programme Explanation of how long the Programme would run for Meet and Greet before the Programme started

12 patients said that they had some concerns before they started the CR Phase 3 Programme. These are presented in Table 16 below.

Table 16: Patient concerns before the Cardiac Rehabilitation Phase 3 Programme

Concerns Prior to Starting the CR Phase 3 Programme No. of responsesNervous / apprehensive 5About the level of physical exercise [was it safe to do?] 3That I could not do it 2That I didn’t know anyone 1Chest healing 1

62 of the 67 patients responding said that the Maureen Sheehan Centre was their first choice of venue for the Cardiac Rehabilitation Phase 3 Programme. Reasons for the Maureen Sheehan Centre being the first choice are given in Table 17 below.

Table 17: Patients’ reasons for choosing to go to the Maureen Sheehan Centre

Reason for Choosing The Maureen Sheehan Centre No. of responsesThe location is convenient to get to 53The Centre is based in my community 14I did not want to attend the Programme in a hospital environment 6To meet up with local people 4

As the table shows, the most frequently given reason for choosing to attend the CR Phase 3 Programme at The Maureen Sheehan Centre is that it is convenient to get to, and is located in the community.

“When I came out of hospital, I didn’t know what to do, what way I was supposed to be feeling, I didn’t know if the pain was meant to be as bad as it was. When I came to the Maureen Sheehan Centre I was able to meet people who had gone through the same thing and I wasn’t on my own. If you needed to talk to somebody you could get on to the Cardiac Rehabilitation team. Getting to know

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the staff made me feel more secure and safe. Every week there was a presentation about aspects of the heart and I learned about healthy eating and the medication that I take. I enjoyed all parts of the programme. You go where the help is available and then I found that there was more going on at the Maureen Sheehan Centre than I ever expected. The longer I‘ve been coming to the Centre the more I learn; I am not on my own, there is help here and it is ongoing”.

Patient who was on the CR Phase 3 Programme

Three patients gave other reasons for wanting to attend the CR Phase 3 Programme at the Maureen Sheehan Centre: I wanted to start as soon as possible and was told that the Maureen Sheehan Centre

could accommodate me My Doctor’s surgery is in the Maureen Sheehan Centre Suitable for transport

Patient feedback about the Cardiac Rehabilitation Phase 3 Programme content

Patients were asked how useful they found the different elements of the Programme; feedback is shown in the table below.

Usefulness of the Different Elements of the CR Phase 3 Programme

Very useful Somewhat useful

Not useful

Not relevant

Exercise sessions 62 2 1 -Information on heart disease 61 1 - 1Information on medication 60 4 1 -Advice about diet 59 4 1 1Advice about alcohol 53 6 1 3Access to the fitness suite 52 3 - 6Help to cope with anxiety about heart disease

50 9 4 3

Advice on work or employment 33 3 3 18Help to stop smoking 31 2 - 24

As the data presented in the table show 75% of the patients found almost all the elements of the Programme ‘very useful’. The two elements receiving the lower scores, ie ‘advice on work or employment’ and ‘help to stop smoking’ were not relevant to 27% and 36% of the patients respectfully.

“From the word go, it was all good, I did enjoy it all. I appreciated being able to discuss my concerns, worries and fears with the Nurses. I felt comfortable chatting to the nurses and was able to ask questions. They allayed my fears and also advised me to go to my GP when I thought I needed to. Before the Programme I thought the

29

problems were insurmountable, but the Nurses put it in black and white for me, it was a big help. I have stopped smoking, I was a smoker for over 50 years. I would definitely recommend this Programme to other people in a similar situation. Although I have a great family support group, I needed something outside of that”.

Patient who was on the CR Phase 3 Programme

The Follow Up Patient Satisfaction Questionnaire presented a series of statements and asked the patients to say whether they agreed or disagreed with each statement. Feedback is presented below.

Statements about the Programme Agree Not sure DisagreeExercise classes were well supervised 64 - -I felt safe at all times 64 - -Staff were considerate and understanding 64 - -The written information provided was useful 64 - -I enjoyed the Programme 64 - -I felt able to ask questions or raise concerns 63 1 -I received enough written information 62 - 2Educational material was presented clearly 61 2 1I felt that exercise was tailored to my needs 59 3 -

62 of the 67 patients who returned the Questionnaire said they attended all the sessions they were advised to attend; 5 said that they didn’t attend all the sessions. Of those who did not attend all the sessions they were advised to 3 said that they had been unable to attend due to illness.

In response to the question about whether or not they received additional support whilst attending the Cardiac Rehabilitation Phase 3 Programme, 10 patients said they were referred to and attended sessions with the Counsellor at the Maureen Sheehan Centre (through the Heart Healthy Living Centre); and 9 were referred to and attended sessions with the Complementary Therapist (also through the Heart Healthy Living Centre).

All 17 patients who received additional support said that it was useful. No one said that the Counselling or Complementary Therapy support was not useful.

Five patients described how the Counselling was useful for them: Allowed me to come to terms with my heart attack Got to be with other people with the same condition as myself Helped me cope with stress and family / personal problems In each of the six sessions the Counsellor came up with useful advice or insights Helped me regain self-confidence and more control in my life

“The Nurses thought it would be beneficial if I spoke with the Counsellor. He is

30

very affable and easy to talk to and communicate with. He is also sensible, with a sensible head on. I could run different things by him each week and he came up with some good suggestions about the issues we were talking about and talking a different perspective or angle on things. I found it very useful and took on board what we discussed. The heart attack was six months ago, and I’m still sort of in shock. Being able to talk about it helped a lot. I have been looking after another member of the family the last year; but it is fairly bleak at home and it was useful to be offered a different perspective and talking about how to deal with death without being overwhelmed. Without the CR Nurse I wouldn’t have accessed the counselling. I think there is probably a connection between the fact that I got so much from the Phase 3 Programme and was attending the Counselling at the same time”.

CR Phase 3 Programme Patient

Three patients described how the Complementary Therapy was useful for them: Still attending relaxation classes and finding it very helpful It left me knowing all that was good for my body and eating habits Helped me about what way to sit and bend with my sore back

“I was referred to the Complementary Therapist and attended sessions for six weeks. I felt the Complementary Therapy and the Therapy was very good. He chatted away and was really able to put things into perspective for me about how I was dealing with things. I really benefitted from the conversations with him. I had acupuncture which was beneficial in relaxing me and helped me tremendously.”

CR Phase 3 Programme Patient

“I was referred to the Complementary Therapist because I couldn’t get motivated to do anything, I wasn’t sleeping and I was depressed. The sessions helped me to be able to sleep and also helped to overcome fears that I had about the pains I was having”

CR Phase 3 Programme Patient

Patient Feedback after the Cardiac Rehabilitation Phase 3 Programme

The Follow Up Patient Satisfaction Questionnaire asked respondents how they feel now compared to when they started the Programme; their feedback is shown in the table below.

How Patients Feel Having Completed the Programme

Much better

Better Not changed

Worse Much worse

My energy levels are … 37 21 9 - -My general health is … 33 22 8 1 -My overall quality of life is … 32 17 6 2 -

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My independence levels are … 32 14 18 - -My self-confidence levels are … 32 17 18 - -My ability to manage stress is … 26 23 18 - -

The data show that 86% of the patients who completed the Questionnaire felt ‘much better’ or ‘better’ in terms of energy levels, general health, and overall quality of life on completion of the Cardiac Rehabilitation Phase 3 Programme. 73% felt their level of independence, self-confidence and ability to manage stress is ‘much better’ or ‘better’.

The Questionnaire asked whether, as a result of the Programme, patients have made any lifestyle changes; their responses are shown below.

Lifestyle Changes Yes No Not relevantImproved diet and eating habits 59 6 1Lost weight 32 18 4Given up smoking 16 7 24Reduced alcohol intake 39 5 11Exercise more regularly 50 8 2Go to the Leisure Centre or Gym 19 29 -Joined a sports club 9 30 -

Overall value and assessment of the Cardiac Rehabilitation Phase 3 Programme

The Follow-Up Patient Satisfaction Questionnaire asked what patients found most useful during the CR Phase 3 Programme. The table below summarises their responses to this open question.

Most Useful Part of the Programme No. of responsesExercise sessions 20Opportunity to ask the Nurses for information and advice 8Everything 8Information on exercise / keeping fit 7Talks / information 7Support / friendliness / reassurance from the Nurses 5Meeting / talking with people who have had a similar life changing event 4Information / facts about heart disease 4Information on diet 2Helped me to understand / deal with my life 1Emotional support 1Working to correct pulse rate 1Walking 1

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The activities and advice was easy to understand 1Availability 1Relaxation sessions at the end of each class 1Information on my medication 1The confidence boost 1Professionalism of the staff 1

The table shows the value of the exercise sessions for the patients attending the Programme. It also highlights the accessibility and empathy offered by the Cardiac Rehabilitation Nurses.

“One of the things I liked and appreciated was that everything was next door to each other. The Gym is very well equipped. The joined up, holistic approach to the situation for people recovering from a heart attack is excellent”.

CR Phase 3 Programme Patient

7 patients responded to the open question about that they found ‘least useful’ about the Programme. 60 people said that this was ‘not applicable’, a number wrote that ‘everything was useful’, and some left it blank. The table below shows the elements that patients found least useful.

What Patients Found Least Useful During the Programme No. of responsesRelaxation session at the end of class 3As I don’t smoke or drink the information about these 1I was not able to join all (my fault) 1Exercise 1Sometimes it stretched a bit long 1

The Questionnaire asked whether patients had any suggestions as to how the CR Phase 3 Programme could be improved. Eight patients gave suggestions for improvements that could be made to the Programme.

Two patients would be happier if the Programme was longer: More – another eight weeks I would have been delighted to continue with the Programme for another month or more

Two patients had other comments to make about the timing of the Programme: A bit more time for one-to-one sessions, if possible Less time [for each session], more days instead of once a week

Four other suggestions were given: Additional recall programmes from time to time

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More equipment More information on other courses available in the Centre. The facilities were not made

known – a tour of the Centre would be useful I found that the sound in the hall was somewhat low

63 patients answered the question about whether or not they would recommend the Cardiac Rehabilitation Phase 3 Programme to others who were offered the opportunity to enrol; 60 said that they would recommend the Programme to other people, 1 said they would not recommend the Programme, and two said they were ‘not sure’.

The table below presents the reasons given by the patients who completed the Questionnaire as to why they would recommend the CR Phase 3 Programme to other people offered the same opportunity.

Why Patients Would Recommend the Programme No. of responsesConfidence / makes you feel better within yourself 11Informative / educational 10Information about suitable exercise to meet personal needs 9Useful 6Staff are very helpful and caring 5Opportunity to talk to the Nurses about your recovery 4Very helpful 4Changing lifestyle quality 3Emotional and physical benefits 3Meeting people in the same situation as myself 2Tips about diet 2Helps you cope with heart disease and prevent further cardiac events 2Well presented and structured 2Enjoyable 1People are properly and medically supervised 1Helps one get back to norm faster 1Motivates people 1

None of the patients who completed and returned the Follow-Up Questionnaire gave any reasons for not recommending the CR Phase 3 Programme.

“The reason why I would recommend the CR Phase 3 Programme to others in a similar situation is very simple: it helps to instil confidence in people and lessens the sense of vulnerability and fear. I found the reassurance I received most useful. The whole staff team were very helpful and personable; but business like too”.

CR Phase 3 Programme Patient

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The Follow-Up Questionnaire asked patients to give an overall, rating to the Cardiac Rehabilitation they received. 49 patients rated the Programme as ‘excellent, 14 rated it ‘very good’ and 2 patients gave a rating of ‘good’. No patient ticked the other two options of ‘fair’ or ‘poor’.

29 patients took the opportunity to give additional comments; these are presented in full below: How understanding and knowledgeable the Nurses were, they made me come to terms

with my condition Keep the Programme going – it was/is excellent Good to meet others who had the same problems Highly worthwhile. I would recommend the Programme to anyone with heart disease I enjoyed it and the Nurses are very nice and pleasant and helpful The staff are very good and educational to anyone attending Keep up the good work! The staff were most professional in what they do Continue with this exercise I found the programme very easy to follow, and the Nurses and Physiotherapist were

terrific Everyone involved in the Programme was considerate to the needs of all attending the

Programme The Nurses were brilliant It was good to meet people who had been through the same of similar procedures The whole staff were very helpful and personable; but business like too I really enjoyed going each Thursday to the classes The girls were brilliant While everyone is different, it would be useful to have a typical timetable outlining the

key stages of recovery – eg healing of wounds, driving, travel, typical time period for resumption of everyday activities, and particular types of exercise

Enjoyed meeting others on the Programme I found all the staff very sympathetic and helpful to my needs and my welfare I would recommend the Programme to anyone in a similar situation It was too short; make it longer next time The staff were very helpful and I felt I benefitted from doing the Programme I enjoyed it The staff helped you to understand how and why you have heart disease and how it

reduces stress It made me feel alive again I enjoyed the Programme, and the staff’s kindness, immensely Company one day a week (I live on my own) The staff made it all happen – they were first class The staff are approachable and informative

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FEEDBACK FROM THE CARDIAC REHABILITATION TEAM DELIVERING PHASE 3 AT THE MAUREEN SHEEHAN CENTRE

The Cardiac Rehabilitation Nurses, who deliver the Phase 3 Programme at The Maureen Sheehan Centre, were asked about the advantages and disadvantages of delivering the Programme in this community setting.

The Nurses believe that collaboration with community services which are predominantly based at the Maureen Sheehan HLC are integral in optimising uptake of phase 3 and providing individualised care.

Of most benefit to the CR Phase 3 Programme to date are the counselling services and complementary therapies. These opportunities can help facilitate achievement of patient goals and in some cases have been instrumental in improving patient engagement and completion of Cardiac Rehabilitation. The ‘rapid response’ approach available at the Centre provides significantly greater impact for a patient; if there is a wait of several weeks, the additional support will not happen in parallel with the Phase 3 Programme, so that some patients do not get the maximum benefit from Phase 3).

However, there are a limited number of funded and voluntary Counselling and Complementary Therapy sessions available; and currently it is increasingly likely that patients will go on a waiting list, rather than be seen immediately. Timely intervention is crucial with patients post-Cardiac Event.

Examples of the ways in which patients have benefited from Complementary Therapies include withdrawal from cigarettes or other addictions; anxiety control; and insomnia or poor sleep patterns. The Nurses report seeing a real difference in patients after two or three sessions with either a Counsellor or a Complementary Therapist. The patient’s GP and Cardiologist are informed if they are referred to additional support.

The nurses believe that being based in The Maureen Sheehan Centre works very well, providing an integrated package of Primary and Secondary shared care. They see it as a shared partnership, whereby each person respects the role that others bring; and being based in the Centre offers a one-stop-shop for patients. This partnership has the potential to diminish everyone’s workload in Primary Care; with the triage during and at the end of Phase 3 ensuring that the patient is referred to the most appropriate next step – whether this is Phase 4 in the community; a referral to a Counsellor or Complementary Therapist; linkages to the GP; or referral to specialist medical support.

Phase 3 is a patient focused programme; seeking to empower the patient to be fully functioning in society after their cardiac event. It supports patients moving on to Phase 4, allowing the continuation of links with people they have already met whilst on the Phase 3 Programme.

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The Nurses have not identified any disadvantages to delivering Phase 3 at The Maureen Sheehan Centre; which they believe is unique in offering a community based full practice of integrated care. The only issues at present, are current waiting times for patients being able to start the Phase 3 Programmes (due in part to finding times for the Pre-Assessment) and increasing waiting times for counselling and complementary therapy.

It was also noted that there are concerns initially about ‘adverse Incidents’ happening in a community setting for Phase 3 programmes; which could be more effectively and immediately responded to if the Programme was taking place on a hospital site. To date there have been no Adverse Incidents that have not been effectively dealt with, and ambulances have responded promptly when called.

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COMMENT

The National Audit of Cardiac Rehabilitation statistical data, feedback from the patients, and feedback from the Cardiac Rehabilitation nurses all provide evidence that delivering the Cardiac Rehabilitation Phase 3 Programme from the Maureen Sheehan community setting has been a success.

Factors contributing to this success include: The Maureen Sheehan Centre is convenient and easy to access The Maureen Sheehan Centre is based in the community (not in a hospital/medical

environment) The CR Nurses are able to refer patients to the Counsellor and Complementary

Therapist who work with the Heart Healthy Living Centre (located in The Maureen Sheehan Centre). The Nurses report that this additional support helps facilitate achievement of patient goals and in some cases has been instrumental in improving patient engagement and completion of Cardiac Rehabilitation.

If referred by the Cardiac Phase 3 nurses, people can also attend the Cardiac Rehabilitation Phase 4 Programme delivered by the Heart Healthy Living Centre at the Maureen Sheehan Centre (an environment that they know). Heart Healthy Living Centre also organises weekly swimming and walking groups, which some people have joined as a progression from the Cardiac Rehabilitation Phase 3 Programme.

It is noted that the overall Healthy Hearts in the West Initiative was ‘highly recommended’ on the National Institute for Health and Care Excellence (NICE) Shared Learning Awards (2014). This was in relation to the Initiative using the Public Health Guideline for Behaviour Change at individual, local and community level (PH6). One of the Cardiac Rehabilitation Nurses was shortlisted for the Integrated Care British Heart Foundation Healthcare Professional Award (following a nomination through HHW).

The legacy from the Healthy Hearts in the West Initiative is that the Cardiac Rehabilitation Phase 3 Programme will continue to be delivered from the Maureen Sheehan Centre. Furthermore, the Follow-Up Patient Satisfaction Questionnaire developed through HHW continues to be used by Cardiac Rehabilitation Centres at regional level.

The challenge for the Cardiac Rehabilitation Team is how funds might be accessed to continue being able to refer patients to the Counsellor and Complementary Therapist at the Maureen Sheehan Centre (as HHW has provided funding to support these additional interventions).

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ANNEX ONEHEALTH INEQUALITY AND CARDIOVASCULAR DISEASE

Cardiovascular disease (CVD) is a major cause of death and disability in Northern Ireland. In 2012 more than one in four deaths (27%, 4,001 deaths) in Northern Ireland were due to diseases of the circulatory system (Figure A).xxvi

28%

27%14%

5%

26%

Figure A: Proportion (%) of deaths by major cause, 2012p

Cancer (C00-C97)

Circulatory Diseases (I00-I99)

Respiratory Diseases (J00-J99)

External Causes(V01-Y98)

Other Causes(Rem* A00-Y98)

The main types of CVD are: ischaemic heart disease, stroke and peripheral vascular disease.xxvii (Note: Cardiovascular disease is also known as circulatory disease and the terms are interchangeable). Deaths are mostly accounted for by ischaemic heart disease (1,975 deaths, 13%) and stroke (1,077 deaths, 7%).xxviii The number of male deaths from ischaemic heart disease exceeds the number of female deaths, while female deaths from strokes exceed the number of male deaths.

Over the last three decades the number of deaths due to diseases of the circulatory system, fell by more than half (54%) from 8,655 in 1981 to 4,001 in 2012 (Figure B).

19811983

19851987

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0100020003000400050006000700080009000

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Figure B: Deaths by cause (1981 to 2012P)

Cancer (C00-C97)

Respiratory Diseases (J00-J99)

Circulatory Diseases (I00-I99)

External Causes(V01-Y98)

Other Causes(Rem* V01-Y98)

Num

ber

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Various factors affect the risk of cardiovascular disease.xxix Some factors such as ethnicity, age and gender (men generally develop coronary heart disease earlier than women) cannot be modified. However other risk factors can be modified. The INTEREART study found that over 90% of the risk of heart attack was attributable to nine factors including abnormal lipids, smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, consumption of fruits, vegetables, and alcohol, and regular physical activity.xxx The British Regional Heart Survey (BRHS) also found that at least 80% of major coronary heart disease events in middle-aged men can be attributed to total cholesterol, high blood pressure and smoking. xxxi

The prevention of cardiovascular disease is dependent on the reduction in major risk factors such as smoking, high blood pressure or diabetes, cholesterol, waist-hip ratio and physical inactivity.xxxii Changes in cardiovascular disease (CVD) risk factors can be brought about through intervention at both an individual level in terms of behaviour change and at population level though development of appropriate policy and legislation.xxxiii As illustrated in Figure C below, cardiovascular health is also influenced by other social and economic factors such as housing, employment and transport.xxxiv

Figure C:

Source: Putting a health inequalities focus on the Northern Ireland cardiovascular service framework summary report. Health impact assessment Northern Ireland cardiovascular service framework. Belfast: Public Health Agency, 2011.

The relationship between socio-economic disadvantage and cardiovascular disease (CVD) is well established. Men living in the 20% most affluent areas in Northern Ireland live on

40

average 7.6 years longer than men in the 20% most deprived areas; for women, this gap is 4.5 years.xxxv Cardiovascular disease remains one of the main contributors to the differential in life expectancy (Figure D).xxxvi

Figure D:

Between 1997-01 and 2006-10 mortality due to circulatory disease (CHD, stroke and other cardiovascular diseases) in Northern Ireland reduced from 133.5 to 76.4 deaths per 100,000 (Figure E).xxxvii However, the most deprived areas saw a smaller reduction. This has resulted in an increase in the inequality gap, with the rate of deaths in the most deprived areas increasing from double in 1997-01 to almost two and a half times that of the least deprived areas in 2006-10.

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Figure E:

Research conducted to investigate the reduction in coronary heart disease mortality in Northern Ireland found that 65% of this decrease was as a result of reductions in the cardiovascular risk factors of cholesterol (40%), smoking (24%) and blood pressure (40%). However, it also raised concerns about the future impact of the growing trends in diabetes, physical inactivity and obesity on the cardiovascular disease burden.xxxviii

Results from the Health Survey Northern Ireland 2011/12 found that respondents from the 20% most deprived areas were more likely to be current smokers (39% vs 18%), to live sedentary lifestyles (33% vs 22%), and show signs of a possible mental health problem (27% vs 16%) compared to those from the 20% least deprived areas. Overall, those living in the 20% most deprived areas were also more likely to be overweight or obese compared to those from the least deprived areas (63% vs 55%). However, while females in the most deprived areas were more likely to be obese (26% vs 17%) than those in the least deprived areas; similar proportions of males in the most deprived (22%) and least deprived areas (23%) were obese.xxxix The survey also found that respondents from the most deprived areas were less likely to think that they have a great deal of influence on their own health (49% vs 59%).

Access to cardiovascular services may be reduced for people living in deprived areas. Those living in deprived areas are more likely to be admitted into hospital for emergency treatment, which carries higher risks for poorer outcomes, because complications are more common in such situations for example, figures for Northern Ireland show that in 2010/11 there were 5,838 emergency admissions per 100,000 for those living in the least deprived areas compared to 10,494 per 100,000 among those in the most deprived areas (Figure F).xl.

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Figure F;

Source: The Health and Social Care (Commissioning Plan) Direction (Northern Ireland) 2012.

Reducing the disease burden of cardiovascular disease presents significant challenges. However, there are effective interventions that can reduce risk, prevalence and deaths from CVD. In addition to medical interventions, these include recommending that people make healthier choices, such as eating healthier foods, using alcohol sensibly, undertaking regular physical activity, stopping smoking, and accessing services promptly.xli

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ANNEX TWONorthern Ireland Policy Context

The Programme for Government (PfG) 2011-15 sets out the strategic context for both the Budget and the Investment Strategy for Northern Ireland.xlii It identifies the following five Priorities:

1. Growing a Sustainable Economy and Investing in the Future; 2. Creating Opportunities, Tackling Disadvantage and Improving Health and

Wellbeing; 3. Protecting Our People, the Environment and Creating Safer Communities;4. Building a Strong and Shared Community; 5. Delivering High Quality and Efficient Public Services.

PfG highlights the key commitments and milestones for achievement under each Priority. It requires that all departments of government work together to produce policies, plans and strategies consistent with the Priorities with a focus on delivery. It also outlines that Government must act collaboratively with partners in the private, community and voluntary sectors to assure, and positively maximise impacts. An Equality Impact Assessment (EQIA) was conducted in parallel with development of the PfG to ensure that policies and programmes are designed to support inclusion and equality of opportunity. The need to promote healthy lifestyles and address inequalities in health has been a theme in successive PfGs.

The Health and Social Care (Commissioning Plan) Direction (Northern Ireland) 2012 sets out the focus for the Regional Board and Regional Agency in the commissioning of health and social care services.xliii It provides details of how the services being commissioned by the Regional Board align with the Programme for Government, the Economic Strategy and the Investment Strategy and includes a number of key priorities and targets for delivery. The first priority is to improve and protect health and well-being and reduce inequalities, through a focus on prevention, health promotion and earlier intervention.

The Northern Ireland public health strategy ‘Investing for Health’ was published in 2002. The strategy aimed to improve health and reduce health inequalities by focusing on the wider determinants of health and included a framework for action based on multi-sectoral partnership working across government, public bodies, local communities, voluntary bodies, district council and social partners.

In July 2011, a proposed new 10-year public health framework, Fit and Well – Changing Lives was launched for consultation. The new 10-year public health framework aims to secure more coherence cross-departmentally with a focus on upstream interventions which will improve health and tackle health inequalities.xliv Fit and Well recognises that health is determined by factors both within and beyond the control of individuals, families and communities and influenced by social and economic circumstances well beyond the reach of

44

health services. Hence it seeks to improve health and wellbeing along the life course from early to old age by addressing disadvantage through and across a wide spectrum of service provision and support. It also provides strategic direction for work to be taken in support of this at both regional and local levels, with public agencies, local communities and others working in partnership. The framework contributes to achievement of the priorities identified in the Programme for Government.

Published in 2004, ‘A Healthier Future’, the regional strategy for health and wellbeing, presents a vision for health and wellbeing in Northern Ireland until 2025. It places a strong emphasis on promoting public health and engagement with people and communities to improve health and wellbeing.xlv

The service framework for Cardiovascular Health and Wellbeing was launched in 2009 as the first of a series of service frameworks for Northern Ireland.xlvi Cardiovascular disease was chosen because of its significance as a cause of ill health and premature death in Northern Ireland. The aim of the framework is to improve the health and wellbeing of the population of Northern Ireland, reduce inequalities and improve the quality of care. It sets out 45 standards in relation to the prevention, diagnosis, treatment, care, Rehabilitation and palliative care of individuals and communities at a greater risk of developing cardiovascular disease. Each standard is supported by key performance indicators, which set levels of performance to be achieved over a three-year period 2009-12.

In 2010 a Health Impact Assessment (HIA) was undertaken to test the effects of implementing the framework on health inequities and inequalities in relation to cardiovascular health. The HIA found that almost all of the standards were affected by health inequities and inequality, mainly relating to socioeconomic factors and variable access to services depending on where patients live. Suggestions on how to enhance the delivery and impact of the cardiovascular standards in reducing health inequalities and inequities were collated in the form of an action plan to inform commissioning of services.

A review of the implementation of the Cardiovascular Service Framework, conducted by the Regulation and Quality Improvement Authority (RQIA) in 2012, found widespread support among stakeholders for the service framework approach and made recommendations for the implementation of future service agreements.xlvii The framework was considered to have facilitated service improvement and development with key examples including the introduction of a screening programme for abdominal aortic aneurysms and expansion of arrangements for fast tracking of thrombolysis for stroke. West Belfast Partnership Healthy Hearts Project is highlighted as a local initiative to support the framework implementation process.

In December 2011, Transforming Your Care (TYC), a review of the provision of Health and Social Care (HSC) Services in Northern Ireland, was published. TYC proposed a future model for Integrated Health and Social Care (presented in Figure I below), designed with the

45

individual at the centre and health and social care services built around this, providing support to promote self care and make good health decisions. With people living longer the demand for health and social care services will increase in the future; pointing to the need for more preventative work and improved community based access.

Figure I:

Source: Transforming Your Care, December 2011

TYC identifies twelve major principles for change, which should underpin the shape of the future model proposed for health and social care.

1. Placing the individual at the centre of any model by promoting a better outcome for the service user, carer and their family.

2. Using outcomes and quality evidence to shape services.3. Providing the right care in the right place at the right time.4. Population-based planning of services.5. A focus on prevention and tackling inequalities.6. Integrated care – working together.7. Promoting independence and personalisation of care.8. Safeguarding the most vulnerable.9. Ensuring sustainability of service provision.

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10. Realising value for money.11. Maximising the use of technology.12. Incentivising innovation at a local level.

On 9th October 2012 the Minister launched a public consultation on ‘Transforming Your Care: Vision to Action’ which summarises key proposals for change set out in TYC.xlviii Draft Population Plans, developed by Local Commissioning Groups (LGCs) with input from Health and Social Care Trusts, set out how the evolving health and social care needs and expectations of the population will be met. The plan for Belfast LCG specifically highlights Healthy Hearts under actions being taken to Deliver Service Outcomes relating to Population Health and Wellbeing and Long Term Conditions.xlix The consultation ended on the 15th January 2013.

There are four new Integrated Care Partnerships (ICPs) across Belfast, launched in 2013. ICPs are networks which will see doctors, nurses, social workers and other health professionals, and the voluntary and community sector working together to keep people well and make sure they get the care they need, when they need itl. The focus of the West Belfast Integrated Care Partnership is Stroke.

“Cardiovascular disease remains the main cause of premature death. Reductions in premature death from stroke and coronary heart disease, which have led to increased life expectancy elsewhere, have not been as marked in areas of deprivation”.

Belfast Local Commissioning Plan 2012-2013

47

ANNEX THREEWEST BELFAST LOCAL CONTEXT

West Belfast is the most deprived geographical area in Northern Ireland. Approximately three quarters (76%, 71,709 people) of the West Belfast (AA2008) population live in one of the 20% most deprived Super Output Areas in Northern Ireland.li

People living in deprived areas are at higher risk from cardiovascular disease than those living in more affluent areas. In 2011, an estimated 93,986 people lived in West Belfast.lii West Belfast has a higher proportion of children aged 0 to 15 years (23.0% compared to 20.9%) and a lower proportion of older people aged 60+(17% compared to 19.8%) (Figure i.) compared to the Northern Ireland population.

0-15 16-44 45-59 60+0

5

10

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20

25

30

35

40

45

20.9

40.1

19.2 19.823.0

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18.617.0

Figure i.: West Befast (AA) population age profile, 2011 Census

Northern IrelandBelfast West

% o

f tot

al p

opul

atio

n

West Belfast Assembly Area (AA) has the highest rate of unemployment in Northern Ireland, with 9.4% (5,481) of the working age population (16-64 years) claiming unemployment-related benefits compared to the Northern Ireland average of 5.4% in 2012.liii Levels of income are also lower with 36,480 (52.6%) of the population aged 16 and over claiming at least one of the main benefits. The highest proportions are concentrated in the wards of Whiterock (70.8%, 2,640 claimants), Falls (67.0%, 2,530) and Clonard (66.7%, 2,280 claimants).liv

Lower levels of education have also been associated with increased risk of death from stroke and cardiovascular disease.lv, lvi In 2010 a lower proportion of school leavers in West Belfast (AA) achieved at least five GCSEs at grades A*-C compared to the Northern Ireland average (69.2% compared to 73.2%); in 2011 this gap decreased, with figures for West Belfast (AA) 75.6% compared to the Northern Ireland average of 76.5%.

Those living in West Belfast have the lowest life expectancy in Northern Ireland (average life expectancy for males 72.5 years v Northern Ireland average 77.1 years; for females 78.4

48

years v Northern Ireland average 81.5 years).lvii CVD is a major contributor to the gap in life expectancy.lviii Between 1997-2001 and 2006-2010 CVD mortality decreased across the geographical area of the Belfast Health and Social Care Trust (BHSCT). However, the decline in mortality in the most deprived areas stopped in 2003-2007 and as a result the inequality gap within BHSCT increased from 57% to 67%.lix

In 2011 there were 191 deaths due to CVD in West Belfast. Figures for 2006-2010, show that age standardised mortality rates for circulatory disease were the highest in West Belfast with 129 deaths per 100,000 compared to the Northern Ireland average of 81 deaths per 100,000 (Table i.).lx

Table i.: Age standardised mortality rates (per 100,000; 0-74 years) for cancer, circulatory disease and respiratory disease, West Belfast (AA) and Northern Ireland, 2006-2010

Cancer Circulatory disease Respiratory diseaseAll Male Femal All Male Femal All Male Femal

West Belfast 194 227 166 129 169 94 47 59 37

Northern Ireland 125 137 114 81 108 55 28 31 25

Source: NINIS

Deaths due to CVD tend to occur at an earlier age in West Belfast compared to Northern Ireland. Figure ii. compares the percentage of deaths from circulatory disease by age in West Belfast and Northern Ireland and shows that deaths in West Belfast occur at an earlier age.

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0-4

5-9

10-

14

15-

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Figure ii.: Deaths from circulatory disease (%) by age, 1986-2011

West Belfast (AA1998)Northern Ireland

Perc

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Figure iii. highlights in more detail the discrepancy for males and females of older working age, with death rates in this age group 1.5 times higher in West Belfast compared to Northern Ireland.

Males 40-64 years Female 40-59 years0

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Figure iii.: Circulatory disease deaths (per 1,000 population), 2001-2010

Northern IrelandWest Belfast (AA1998)

Deat

hs p

er 1

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on

In March 2013 there was a higher prevalence of heart disease, stroke, chronic obstructive pulmonary disease, mental health, asthma, peripheral vascular disease, and epilepsy amongst patients whose GP practice is located in the Belfast West area compared to the average for all GP practices across Northern Ireland (Table ii.).lxi

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Table ii.: Selected disease prevalence (raw prevalence per 1,000 patients) for West Belfast compared to Northern Ireland, 2013

Registered list size

Heart disease

Stroke Chronic Obstructive Pulmonary

Mental Health

Asthma Peripheral Arterial Disease

Epilepsy (18+)

NI 1,909,338 39.10 17.53 18.08 8.44 60.43 7.23 10.24

West Belfast

122,381 40.52 17.83 24.86 9.58 66.06 7.97 13.16

Source: NINIS (Quality Outcomes Framework)

Information on hospital admissions for circulatory disease and deprivation is available for Belfast Health and Social Care Trust (BHSCT).lxii Figure iv. shows that over the period from 2000/01 to 2010/11, the standardised admission rates (SAR) due to circulatory disease decreased across all areas. The most deprived Belfast Trust areas fell by 9% which compared with declines of 7% and 5% for the overall Belfast Trust and all NI respectively. The Trust inequality gap narrowed from 29% in 2001/03 to 26% in 2009/11.

51

REFERENCES

52

i Northern Ireland Statistics and Research Agency. Deaths in Northern Ireland 2012. Belfast: NISRA, 2013. ii Service framework for cardiovascular health and wellbeing. Belfast: Department of Health, Social Service and Public Safety (DHSSPS), 2009. iii Yusuf S et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): care-control study. Lancet 2004; 364(9438): 937-52.iv Emberson JR et al. Re-assessing the contribution of serum total cholesterol, blood pressure and cigarette smoking to the aetiology of coronary heart disease: impact of regression dilution bias. European Heart Journal 2003; 24(19): 1719-26.v Cardiovascular health and wellbeing in Northern Ireland Literature review. Health impact assessment Northern Ireland cardiovascular service framework. Belfast: Public Health Agency, 2011.vi Prevention of cardiovascular disease at population level. Public health guidance 25. London: National Institute for Health and Clinical Excellence, 2010.vii Homer J, Milstein B, Wile K, Pratibhu P, Farris R, Orenstein D. Modelling the local dynamics of cardiovascular health: risk factors, context, and capacity. Preventing Chronic Disease 2008; 5(2). viii NI Health & Social Care Inequalities Monitoring System. Fourth update bulletin 2012. Belfast: DHSSPS, 2012.ix Closing the gap. Tackling cardiovascular disease and health inequalities by prescribing statins and stop smoking services. Belfast: Care Quality Commission, 2009.x Programme for Government 2011-15 building a better future. Belfast: Northern Ireland Executive, 2011.xi The Health and Social Care (Commissioning Plan) Direction (Northern Ireland) 2012.xii Fit and Well Changing Lives - 2012-2022. Belfast: Department of Health, Social Service and Public Safety (DHSSPS), 2012xiii Service framework for cardiovascular health and wellbeing. Belfast: Department of Health, Social Service and Public Safety (DHSSPS), 2009.xiv Independent Review of the Implementation of the Cardiovascular Service Framework. Belfast: The Regulation and Quality Improvement Authority, 2012. xv Belfast Local Commissioning Group Locality: Draft Population Plan 2012-15. xvi http://www.transformingyourcare.hscni.net/integrated-care-partnership-progress-welcomed-by-gps/; accessed 21.11.13xvii Based on Census 2011 Usual Resident Population data SOA and MDM 2010 xviii Census 2011. Age Structure: KS102NI (administrative geographies) Neighbourhood Statistics for Northern Ireland (NINIS).xix Life Expectancy (administrative geographies) (AA),2008-2010. Neighbourhood Statistics for Northern Ireland (NINIS).xx NI Health & Social Care Inequalities Monitoring System. Life Expectancy Decomposition An overview of changes in Northern Ireland life expectancy 2001-03 to 2008-10. Belfast: DHSSPS, 2013.xxi Northern Ireland Health and Social Care Inequalities Monitoring System Sub-regional Inequalities – HSC Trusts 2012. Belfast: Department of Health, Social Services and Public Safety, 2012.xxii Standardised Death Rate due to Circulatory Disease (administrative geographies) (AA) 2006-2010, Neighbourhood Statistics for Northern Ireland (NINIS).

xxiii Disease Prevalence (administrative geographies) (AA) 2013, Neighbourhood Statistics for Northern Ireland (NINIS). xxiv http://www.sandbachgps.nhs.uk/uploaded_files/files/ashfields/HADS.pdfxxv http://www.dartmouthcoopproject.org/coopcharts_overview.htmlxxvi Northern Ireland Statistics and Research Agency. Deaths in Northern Ireland 2012. Belfast: NISRA, 2013. xxvii Cardio and Vascular Coalition. Modelling the UK burden of cardiovascular disease to 2020. London: British Heart Foundation, 2008.xxviii Northern Ireland Statistics and Research Agency. Deaths in Northern Ireland 2012. Belfast: NISRA, 2013. xxix Service framework for cardiovascular health and wellbeing. Belfast: Department of Health, Social Service and Public Safety (DHSSPS), 2009. xxx Yusuf S et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): care-control study. Lancet 2004; 364(9438): 937-52.xxxi Emberson JR et al. Re-assessing the contribution of serum total cholesterol, blood pressure and cigarette smoking to the aetiology of coronary heart disease: impact of regression dilution bias. European Heart Journal 2003; 24(19): 1719-26.xxxii Cardiovascular health and wellbeing in Northern Ireland Literature review. Health impact assessment Northern Ireland cardiovascular service framework. Belfast: Public Health Agency, 2011.xxxiii Prevention of cardiovascular disease at population level. Public health guidance 25. London: National Institute for Health and Clinical Excellence, 2010.xxxiv Homer J, Milstein B, Wile K, Pratibhu P, Farris R, Orenstein D. Modelling the local dynamics of cardiovascular health: risk factors, context, and capacity. Preventing Chronic Disease 2008; 5(2). xxxv NI Health & Social Care Inequalities Monitoring System. Fourth update bulletin 2012. Belfast: DHSSPS, 2012.xxxvi NI Health & Social Care Inequalities Monitoring System. Life Expectancy Decomposition An overview of changes in Northern Ireland life expectancy 2001-03 to 2008-10. Belfast: DHSSPS, 2013.xxxvii NI Health & Social Care Inequalities Monitoring System. Fourth update bulletin 2012. Belfast: DHSSPS, 2012.xxxviii Hughes J et al. Explaining the decline in coronary heart disease mortality in Northern Ireland between 1987 and 2007. Journal of Epidemiology and Community Health 2010; 64(Suppl 1).xxxix Health Survey Northern Ireland 20110/12: Analysis of results by deprivation. Belfast: DHSSPS, 2013. xl NI Health & Social Care Inequalities Monitoring System. Fourth update bulletin 2012. Belfast: DHSSPS, 2012.xli Closing the gap. Tackling cardiovascular disease and health inequalities by prescribing statins and stop smoking services. Belfast: Care Quality Commission, 2009.xlii Programme for Government 2011-15 building a better future. Belfast: Northern Ireland Executive, 2011.xliii The Health and Social Care (Commissioning Plan) Direction (Northern Ireland) 2012.xliv Fit and Well Changing Lives - 2012-2022. Belfast: Department of Health, Social Service and Public Safety (DHSSPS), 2012

xlv A healthier future. A Twenty Year Vision for Health and Wellbeing in Northern Ireland 2005 – 2025. Belfast: DHSSPS, 2005.xlvi Service framework for cardiovascular health and wellbeing. Belfast: Department of Health, Social Service and Public Safety (DHSSPS), 2009.xlvii Independent Review of the Implementation of the Cardiovascular Service Framework. Belfast: The Regulation and Quality Improvement Authority, 2012. xlviii Transforming your care. Vision to action. A consultation document 9 October 2012 – 15 January 2013. Belfast: DHSSPS, 2012.xlix Belfast Local Commissioning Group Locality: Draft Population Plan 2012-15. l http://www.transformingyourcare.hscni.net/integrated-care-partnership-progress-welcomed-by-gps/; accessed 21.11.13li Based on Census 2011 Usual Resident Population data SOA and MDM 2010 lii Census 2011. Age Structure: KS102NI (administrative geographies) Neighbourhood Statistics for Northern Ireland (NINIS).liii Claimant Count Annual Averages (administrative geographies) (AA) 2012. Neighbourhood Statistics for Northern Ireland (NINIS).liv Constituency profile Belfast West. Belfast: Northern Ireland Assembly, 2012. lv Avendano M et al. Educational level and stroke mortality: a comparison of 10 European populations during the 1990s. Stroke 2004; 35: 432-37.lvi Huisman M et al. Educational inequalities in cause-specific mortality in middle-aged and older men and women in eight western European populations. The Lancet 2005; 365: 493-500.lvii Life Expectancy (administrative geographies) (AA),2008-2010. Neighbourhood Statistics for Northern Ireland (NINIS).lviii NI Health & Social Care Inequalities Monitoring System. Life Expectancy Decomposition An overview of changes in Northern Ireland life expectancy 2001-03 to 2008-10. Belfast: DHSSPS, 2013.lix Northern Ireland Health and Social Care Inequalities Monitoring System Sub-regional Inequalities – HSC Trusts 2012. Belfast: Department of Health, Social Services and Public Safety, 2012.lx Standardised Death Rate due to Circulatory Disease (administrative geographies) (AA) 2006-2010, Neighbourhood Statistics for Northern Ireland (NINIS).lxi Disease Prevalence (administrative geographies) (AA) 2013, Neighbourhood Statistics for Northern Ireland (NINIS). lxii Northern Ireland Health and Social Care Inequalities Monitoring System Sub-regional Inequalities – HSC Trusts First update bulletin 2012. Belfast: Department of Health, Social Services and Public Safety, 2012.