4 Prevention is better than cure
4.2 The National Service Framework
National Service Frameworks are long-term strategies for tackling major health issues and important diseases, especially improving specific areas of care, e.g. coronary heart disease, cancer and diabetes. They set measurable goals within set timeframes. The National Service Framework for coronary heart disease in England, published in March 2000 (Department of Health, 2000), sets out a strategy to modernise coronary heart disease services over 10 years. It details 12 standards (see Table 3) for improved prevention, diagnosis and treatment, for rehabilitation goals, and to secure fair access to high-quality services.
Table 3: The 12 standards that make up the National Service Framework for coronary heart disease in England (NHS, National Health Service)
|Reducing heart disease in the population||1||The NHS and partner agencies should develop, implement and monitor policies that reduce the prevalence of coronary risk factors in the population, and reduce inequalities in risks of developing heart disease.|
|2||The NHS and partner agencies should contribute to a reduction in the prevalence of smoking in the local population.|
|Preventing CHD in high-risk patients||3||General practitioners and primary care teams should identify all people with established cardiovascular disease and offer them comprehensive advice and appropriate treatment to reduce their risks.|
|4||General practitioners and primary health care teams should identify all people at significant risk of cardiovascular disease but who have not developed symptoms and offer them appropriate advice and treatment to reduce their risks.|
|Heart attack and other acute coronary syndromes||5||People with symptoms of a possible heart attack should receive help from an individual equipped with and appropriately trained in the use of a defibrillator within 8 minutes of calling for help, to maximise the benefits of resuscitation should it be necessary.|
|6||People thought to be suffering from a heart attack should be assessed professionally and, if indicated, receive aspirin. Thrombolysis should be given within 60 minutes of calling for professional help.|
|7||NHS Trusts should put in place agreed protocols/systems of care so that people admitted to hospital with proven heart attack are appropriately assessed and offered treatments of proven clinical and cost-effectiveness to reduce their risk of disability and death.|
|Stable angina||8||People with symptoms of angina or suspected angina should receive appropriate investigation and treatment to relieve their pain and reduce their risk of coronary events.|
|Revascularisation||9||People with angina that is increasing in frequency or severity should be referred to a cardiologist urgently or, for those at greatest risk, as an emergency.|
|10||NHS Trusts should put in place hospital-wide systems of care so that patients with suspected or confirmed coronary heart disease receive timely and appropriate investigation and treatment to relieve their symptoms and reduce their risk of subsequent coronary events.|
|Heart failure||11||Doctors should arrange for people with suspected heart failure to be offered appropriate investigations (e.g. electrocardiography, echocardiography) that will confirm or refute the diagnosis. For those in whom heart failure is confirmed, its cause should be identified – treatments most likely to both relieve their symptoms and reduce their risk of death should be offered.|
|Cardiac rehabilitation||12||NHS Trusts should put in place agreed protocols/systems of care so that, prior to leaving hospital, people admitted to hospital suffering from coronary heart disease have been invited to participate in a multidisciplinary programme of secondary prevention and cardiac rehabilitation. The aim of the programme will be to reduce their risk of subsequent cardiac problems and to promote their return to a full and normal life.|
The 2006 progress report for England states that:
We continue to make good progress towards our Public Service Agreement mortality target for cardiovascular disease (CVD) with a 35.9% reduction, against a target of 40% by 2010.
A similar framework was published for Wales in July 2001 (The National Assembly for Wales, 2001) and outlined five standards. Other countries worldwide are likely to have or be developing their equivalent National Service Framework for coronary heart disease and other cardiovascular diseases and be at various stages of implementation.
In Section 1.5 the substantial economic costs of cardiovascular diseases were introduced. Box 3 reports the success of physicians in the USA in lowering the national average blood pressure values to slightly below those in some Western European countries. They have achieved this with more interventions and drug treatment. This presumably also has higher cost implications, at least initially – as is currently being experienced with the National Service Framework for coronary heart disease in England. The obvious question that follows is to ask whether prevention would be cheaper than intervention. If so, how can it be done at different levels: globally, nationally, individually? In Sections 4.3, 4.4 and 4.5 we will start to consider some of these issues.
Box 3: Keeping the blood pressure of nations under control
A recent study reveals that people living in the USA have lower blood pressure than some of their Western European counterparts (in the UK, France, Germany, Spain and Italy; Wang et al., 2007).
US doctors administer hypertension treatment earlier and more aggressively than doctors in Western Europe. By doing this, they say they can reduce the cost of health care for patients by decreasing their chances of developing cardiovascular diseases (mainly MIs and strokes).
The US patients in this study had an average blood pressure slightly lower than the combined blood pressure average of Western Europeans. Of the 21 000 US patients with hypertension, 63 per cent had their blood pressure under control and met the recommended blood pressure target of 140/90 mmHg. This was a significantly larger percentage than the other countries featured in the study. Furthermore, 32 per cent of US patients with inadequately controlled hypertension received increased doses of medication, compared with only 14 to 26 per cent of Western European patients.