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

Objectives

Develop an integrated national cardiovascular health strategy to reduce avoidable death and illness, improve cardiovascular health, and provide equitable, effective, efficient and high-quality services across prevention, acute care, rehabilitation and long-term management.[1]The strategy is founded on equity, quality, accountability, health and social gain, regional decision-making, performance measurement and responsiveness to service users.[2][3]

• Reduce cardiovascular disease mortality among people aged under 65 by 30% over ten years.[2][3]
• Reduce mortality from ischaemic heart disease and stroke 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]
• Prevent cardiovascular disease through population health promotion, supportive environments, healthier public policy, community action, personal skills and reoriented health services.[4][5]
• Address smoking, diet, physical inactivity, obesity, alcohol consumption, raised blood pressure, cholesterol and diabetes, while recognising socioeconomic, psychosocial, genetic and developmental influences on risk.[6][2][7]
• Identify and manage people at high cardiovascular risk, provide secondary prevention for people with established disease, and improve survival and quality of life after acute events.[6][8][9]
• Ensure access based on need rather than income, ability to pay, residence, gender or age, including access to health promotion, primary prevention, emergency care, cardiac investigation, intervention, surgery, rehabilitation and secondary prevention.[3]
• Strengthen pre-hospital care, acute coronary treatment, cardiac diagnostics, interventional cardiology, heart-failure care, cardiac surgery and rehabilitation through evidence-based standards.[10][11][12][13]
• Reduce inequalities affecting disadvantaged communities, women, older people, children, people with disabilities and patients with congenital, inherited or childhood-onset cardiac conditions.[14][15][16]

Implementation

Implement the strategy through nationally coordinated, cross-sectoral action delivered locally by health boards, hospitals, primary-care teams, community organisations, schools, workplaces and voluntary bodies.[1][5][14]An Implementation Group within the Department of Health and Children, convened by the Secretary General, was established to support planning and reduce delay between publication and implementation.[2]

• Coordinate national policy through the Department of Health and Children, relevant government departments, the Department of Education, Science and Technology, the Food Safety Authority of Ireland, health-board health-promotion departments and voluntary organisations including the Irish Heart Foundation.[1][14]
• Use health boards to develop and implement programmes responsive to local need, supported by strategic plans and annual service plans.[14]
• Establish regional cardiovascular committees to oversee cardiology provision, coordinate rehabilitation, formalise hospital relationships and link regions with tertiary referral centres.[17]
• Develop regional self-sufficiency for appropriate services while concentrating cardiac surgery, transplantation, specialist electrophysiology and other highly specialised services in supra-regional or national centres.[3][13][18]
• Deliver population prevention through settings-based programmes in communities, schools, workplaces, primary care, hospitals and mass media, adapting interventions to local settings and integrating successful programmes into routine activity.[19][5][20]
• Strengthen tobacco control through fiscal policy, legislation, cessation counselling, school education, smoke-control policy audits and targeted action to prevent uptake among young people and support cessation.[21][22]
• Improve nutrition through food policy, media and community education, healthy catering standards, community dietitians, school and health-service food provision, and Food Safety Authority of Ireland oversight.[23][24]
• Promote physical activity through health-board, school, workplace, community and sports-sector initiatives, including support for girls, young people with disabilities and less-active groups.[25][26]
• Develop general practice as the principal setting for ongoing prevention and secondary prevention, using agreed investigation, referral, treatment and shared-care protocols with hospitals.[8][27]
• Implement a high-risk primary-care pilot involving at least 10% of general practitioners across urban and rural settings, then extend nationally using lessons from the pilot.[28]
• Support participating practices with contracts, targets, training, computerised patient registers, practice nurses, dietitians, smoking-cessation services and referral pathways to specialist risk-management clinics.[28][29]
• Provide structured follow-up for people with cardiovascular disease, including counselling, risk-factor management, medicines, rehabilitation and computerised information systems; support payment arrangements for General Medical Services Scheme patients and reimbursement options for others.[30][31]
• Strengthen emergency care through prioritised ambulance dispatch, standard patient report forms, first-responder schemes, cardiopulmonary resuscitation training, automated external defibrillators, advanced cardiac life support and pre-hospital thrombolysis where distance from hospital warrants it.[32][33][34][35]
• Establish rapid-access chest-pain assessment, fast-track acute myocardial infarction pathways, prompt aspirin and thrombolysis, and coronary care capacity with trained staff, monitoring and resuscitation facilities.[36][37][38][39]
• Expand equitable access to echocardiography, coronary angiography, angioplasty, pacemaker services, cardiac surgery and regional diagnostic facilities, with formal referral arrangements where services are unavailable locally.[39][40][13]
• Provide multidisciplinary cardiac rehabilitation in every hospital treating heart-disease patients, including exercise, education, smoking cessation, nutrition, psychological support, vocational support and long-term maintenance.[41][42][43]
• Strengthen the rehabilitation workforce through trained co-ordinators, cardiologist or physician oversight and multidisciplinary teams, while addressing reported staffing, funding and space barriers.[44][45][42]
• Use mortality, hospital, prescription, survey, register and audit data to monitor disease burden, service use, risk factors, inequalities, treatment outcomes and progress towards targets.[46][47][48]
• Develop the Public Health Information System, strengthen Hospital In-Patient Enquiry coverage, establish cardiovascular registers and undertake regular health examination and interview surveys.[46][49][50][48]
• Apply clinical audit against agreed standards, review implementation in subsequent cycles and use findings to identify remedial action and improve quality.[48][51]

Monitoring & Evaluation

The strategy establishes monitoring, evaluation, audit and research as integral mechanisms for measuring health gain, tracking progress towards cardiovascular targets, identifying remedial action, and improving the quality and equity of services.[1][48][51]It combines population surveillance, service data, clinical audit, registers and targeted evaluations, although a single consolidated indicator framework, reporting timetable and formal accountability structure are not fully specified.[46][47][48]

• Monitor national mortality targets, including a 30% reduction in cardiovascular mortality among people under 65 over ten years and at least a 15% reduction in ischaemic heart disease and stroke mortality among people aged 65 to 74 by 2005.[2][3][52]
• Track risk factors and health behaviours through repeated health and lifestyle surveys, including smoking, diet, physical activity, body weight, blood pressure, cholesterol and alcohol consumption.[53][54][52][55]
• Develop national and regional cardiovascular indicators through the Public Health Information System, using mortality, hospital discharge, prescription, prevalence-survey and register data.[46][47]
• Strengthen Hospital In-Patient Enquiry data for monitoring acute-hospital activity, diagnoses, procedures, length of stay and service use, while recognising incomplete private-hospital coverage and limitations in distinguishing first from recurrent events.[47]
• Establish a population-based coronary heart disease and stroke register in a defined geographic area, alongside coronary-care, angiography, angioplasty and cardiac-surgery registers.[49][50]
• Monitor secondary prevention in general practice using methods compatible with the European Action on Secondary Prevention through Intervention to Reduce Events protocol, supported by computerised patient information and systematic follow-up.[47][49][31]
• Use clinical audit against agreed standards to assess care quality, service volume, outcomes, implementation of recommendations and variation between providers, with subsequent audit cycles reviewing improvement.[48]
• Assess emergency cardiac care through quarterly response-time recording, standard patient report forms, clinical audit, national pre-hospital databases and treatment-time standards, including a 90-minute call-to-needle benchmark for thrombolysis.[32][34][35][56]
• Evaluate health-promotion interventions through setting-specific process and outcome evaluation, including participation, satisfaction, behavioural change, risk-factor change and feasibility of integration into routine services.[5][20][15]
• Monitor rehabilitation access, participation, waiting time, attendance, drop-out, smoking cessation, exercise and patient satisfaction; existing evidence indicates that programme coverage was limited and poorly measured in many hospitals.[45][42]
• Use health-board strategic plans and annual service plans for local health-promotion activity, with proposed oversight through policy-impact monitoring, health-impact assessment, tobacco-control mechanisms and independent auditing of health-behaviour progress.[14][57]

Costing & Financing

No comprehensive costed implementation plan, cardiovascular programme budget, financing timetable, quantified funding gap or economic model is specified.[1][2][3]The strategy nevertheless identifies substantial resource requirements for workforce expansion, cardiology facilities, primary-care prevention, rehabilitation, information systems, surveillance, evaluation and emergency care.[10][58][13][59]

• Increase health-promotion investment, as the 1998 public-sector health-promotion budget represented 0.19% of overall health-services funding and was judged inadequate; personnel and financial capacity in the Health Promotion Unit was also considered insufficient.[57]
• Provide additional funding and skilled personnel for monitoring and evaluation within the Health Promotion Unit and health boards.[60][61]
• Resource primary-care prevention through practice nursing, administration, training, information systems, counselling, dietetic services and follow-up arrangements, including reimbursement and incentives associated with General Medical Services patients and computerised follow-up.[58][62][30][31]
• Fund cardiac rehabilitation staffing, co-ordinator training, facilities and equipment, addressing documented barriers of inadequate funding, staffing and space.[63][44][45][42]
• Fund cardiology personnel, diagnostic and intervention facilities, hospital information systems, clinical audit and regional service capacity through the Department of Health and Children, although no amounts are specified.[13][17][59]
• Recognise surveillance and research constraints: regional survey samples carry major cost implications, national or general-practice population registers are considered expensive and complex, and cardiovascular research funding is reported as low by international standards.[49][48][51]
• Use tobacco taxation as a public-health policy lever despite the potential reduction in tax receipts from lower consumption; tobacco revenue presents a tension between fiscal income and smoking-reduction objectives.[21][22]
• Note that prescription expenditure on cardiovascular medicines, health-promotion funding and Health Research Board funding are the principal quantified financial information provided.[64][65][57][51]