Building Healthier Hearts: The Report of the Cardiovascular Health Strategy Group

Objectives

Ireland’s cardiovascular health strategy seeks to reduce avoidable death and illness from cardiovascular disease through an integrated approach spanning population prevention, early identification of high-risk people, acute and chronic clinical care, secondary prevention and rehabilitation. It prioritises equity of access, quality, effectiveness, efficiency, service co-ordination and improved health-related quality of life across primary, secondary and tertiary care.[1][2][3]

• Reduce cardiovascular mortality among people under 65 by 30% over ten years.[2][3]
• Reduce ischaemic heart disease and stroke mortality among people aged 65 to 74 by at least 15%, from 1,142 per 100,000 in 1995 to no more than 971 per 100,000 by 2005.[2][3]
• Address tobacco use, unhealthy diet, physical inactivity, overweight and obesity, excessive alcohol consumption, raised blood pressure, high cholesterol and diabetes, while recognising social, biological, genetic and psychosocial influences on risk.[4][2][5][6]
• Promote healthier environments and choices through health promotion in communities, schools, workplaces, primary care and health services, with particular attention to young people, women, older people and disadvantaged groups.[7][8][9][10]
• Strengthen prevention and continuing management for people with established coronary heart disease, other atherosclerotic disease and diabetes, including risk-factor control, lifestyle support, appropriate medication and cardiac rehabilitation.[11][12][13][14]
• Improve the chain of survival for cardiac emergencies through early emergency access, cardiopulmonary resuscitation, defibrillation and advanced cardiac life support, alongside timely thrombolysis and acute coronary care.[15][16][17]
• Expand equitable access to assessment, diagnostic services, interventional cardiology, cardiac surgery, rehabilitation and specialist services, while providing regional self-sufficiency where safe and appropriate and national or supra-regional provision for highly specialised care.[3][18][19][20]

Implementation

Implementation is conceived as a cross-sectoral, multidisciplinary national programme, led through the Department of Health and Children and translated through health boards, hospitals, primary care, public-health and health-promotion services, voluntary organisations, local authorities and other government sectors.[1][2][7][21]An Implementation Group within the Department, convened by its Secretary General, was intended to prepare for delivery and shorten the interval between the strategy report and implementation.[2]

• Coordinate national and regional action through health-board health-promotion departments, regional cardiovascular committees and formal links between acute hospitals, tertiary centres, general practice and rehabilitation services.[1][22][23]
• Deliver population prevention through settings-based programmes in schools, workplaces, communities and health services, supported by mass-media activity, community participation, supportive environments and policies affecting tobacco, food, alcohol, transport and physical activity.[7][6][9][24]
• Strengthen tobacco control through taxation, legislation, smoking-control audits, school education, health-professional counselling and cessation support, including nicotine replacement where appropriate.[25]
• Develop systematic cardiovascular risk assessment and management in general practice, using opportunistic and structured case finding, computerised patient registers, practice nurses, agreed risk-assessment methods, lifestyle counselling and referral to dietetic, smoking-cessation or specialist services.[26][27][28]
• Implement a general-practice high-risk pilot involving at least 10% of general practitioners across urban and rural areas, evaluate it after one year, and extend it nationally only after incorporating learning from the pilot.[27]
• Establish shared-care protocols and locally adapted clinical guidelines for chronic cardiovascular disease, secondary prevention, acute myocardial infarction, stroke and heart failure, with clear responsibilities for general practitioners, ambulance services, emergency departments, coronary care units and hospital specialists.[29][30][22]
• Standardise pre-hospital emergency care through national patient-report forms, prioritised dispatch, medical advisers, protocols, ambulance training, automated external defibrillators, community cardiopulmonary-resuscitation schemes and audit of response times and outcomes.[16][31][32]
• Develop acute hospital capacity through coronary care and intensive monitoring, rapid-access chest-pain assessment, cardiac investigation areas, angiography pathways, regional diagnostic centres and appropriate staffing, equipment and referral arrangements.[33][34][18]
• Organise cardiac rehabilitation as a multidisciplinary, phased service linking inpatient care, early post-discharge support, outpatient programmes and long-term community maintenance, under cardiology oversight and with trained rehabilitation co-ordinators.[14][35][23]
• Build surveillance and quality improvement from mortality records, hospital-discharge data, prescription information, health surveys, clinical audits and care, investigation and intervention registers.[36][37][38]
• Monitor progress through explicit mortality and risk-factor targets, repeated health and lifestyle surveys, clinical audit cycles, service-performance measures and evaluation of health-promotion programmes.[5][6][39]
• Address resource constraints through additional personnel, facilities, information systems, training, audit capacity and rehabilitation space; however, the supplied material does not provide a comprehensive costed implementation budget or financing plan for the overall strategy.[40][41][42]

Monitoring & Evaluation

The strategy proposes a national cardiovascular monitoring and accountability system combining population surveillance, service information, clinical audit, programme evaluation and research. It identifies inadequate baseline data and variation in service standards as major weaknesses, while setting mortality and risk-factor targets to guide progress.[43][1][2][36]

• Monitor progress against mortality targets, including a 30% reduction in cardiovascular mortality among people under 65 over ten years and a reduction in ischaemic heart disease and stroke mortality among people aged 65 to 74 to no more than 971 per 100,000 by 2005.[2][3]
• Track health-promotion targets relating to smoking, diet, overweight, physical activity, blood pressure, cholesterol and alcohol knowledge or misuse, and evaluate mass-media campaigns for coverage, impact and social-group reach.[5][6]
• Use repeated health examination surveys approximately every five years and health interview surveys at least every two years, with common questions and definitions to enable comparisons over time and between populations.[39]
• Strengthen surveillance through mortality records, Hospital In-patient Enquiry data, prescription data, prevalence surveys, public-health information systems and registers of coronary care, investigations and interventions.[36][37]
• Improve data completeness by expanding private-hospital participation, developing registers, linking risk-factor information with morbidity and medication data, and addressing the limitations of hospital data for measuring incidence, recurrence and community-managed disease.[37][39]
• Establish population-based coronary heart disease and stroke registration in a defined area, alongside hospital-based care, investigation and intervention registers, to measure incidence, treatment, outcomes, demographic inequalities and service demand.[44][38]
• Apply clinical audit as a recurring cycle of review against agreed standards, improvement action and reassessment, supported by better patient data, staff training, national coordination, multidisciplinary participation and consumer involvement.[39]
• Assess service performance through measures such as emergency response times, call-to-needle time, thrombolysis use, access by sex and location, rehabilitation coverage, risk-factor control, patient outcomes and quality of life.[16][45][30][42]
• Require quarterly monitoring of ambulance response times using standard patient report forms, medical-adviser audit and clinical audit against national pre-hospital protocols.[16]
• Evaluate the general-practice high-risk pilot after one year before national extension, monitoring identification methods, risk factors, treatment effects, behaviour change, follow-up and long-term care.[27][28]
• Develop a national set of indicators for cardiovascular targets, including adequate representation of disadvantaged populations in surveys, and provide additional skilled personnel for health-promotion evaluation and practice audit.[46][47]
• Clarify accountability by identifying organisations responsible for preventive and clinical services, using regional decision-making and performance measurement, and establishing regional cardiovascular committees to coordinate service development.[2][48][22]

Several components remain unspecified, including a consolidated national reporting timetable, a complete cross-programme indicator framework and a single independent accountability body.[47][39][49]

Costing & Financing

The material identifies substantial workforce, infrastructure, information-system and evaluation needs, but does not provide a costed implementation plan for the overall cardiovascular strategy. Resource allocation is intended to balance immediate clinical benefit with longer-term prevention, guided by assessed need and evidence of likely benefit.[3][48][28]

• Allocate resources for additional clinical, nursing, technical, paramedical and administrative staff; cardiac facilities; rehabilitation programmes; diagnostic equipment; information systems; audit; research; and professional training.[40][50][41][51]
• Address inadequate staffing, funding and space for cardiac rehabilitation, which constrained programme establishment and led some trained personnel to return to ward duties.[42]
• Provide additional funding for monitoring and evaluation through the Health Promotion Unit of the Department of Health and Children, although no amount or funding source is specified.[47]
• Recognise that regionally representative health surveys have major cost implications and that research funding remained insufficient despite increased support.[39][49]
• Use existing public-health funding: overall public-sector health expenditure was £3.18 billion in 1998, while the total public-sector health-promotion budget was £6.19 million, comprising £3.16 million for the Health Promotion Unit and £3.03 million for eight health boards.[8]
• Supplement health-promotion resources through National Lottery funding of £500,000 and an Irish Heart Foundation health-promotion budget of £0.33 million in 1998; the Foundation received a substantial subvention from the Health Promotion Unit.[8]
• Recognise tobacco taxation as both a public-revenue source and a health-policy instrument: excise duty yielded £572.6 million and estimated Value Added Tax yielded £149 million in 1997, while smoking-cessation counselling with or without nicotine replacement was considered cost-effective.[25]
• Use targeted financing mechanisms proposed for high-risk primary care, including payment or reimbursement for follow-up and financial incentives for general practitioners implementing systematic patient information systems.[11][12]
• Consider service-specific economic evidence, including higher upfront costs but possible overall cost-effectiveness for primary angioplasty, and the need to assess costs of an out-of-hours angioplasty service.[52][53]

The source does not specify an overall programme budget, future funding target, funding-gap estimate, allocation formula or detailed resource-mobilisation plan for implementation.[1][2][49]