Skip navigation

Tackling IHD prevention and management in primary care


Developing a community approach to cardiac care in Finchingfield, Essex.


Why was the initiative launched?

In the mid 90s there was growing concern about the increase in cardiovascular morbidity and potentially avoidable deaths in people under 65. Changes to the GP health promotion contract had been introduced to allow practices to develop their own health promotion strategies providing these were compatible with Health of the Nation objectives.

The prevalence of IHD in the Freshford practice in rural Essex was comparable to that in GP practices participating in the fourth national study of morbidity statistics 1991/92. The practice served a geographically discrete, rural population (6,000) from a new (1993) purpose built health centre. There was a growing consensus locally that improvements should be possible. They thought it was timely to look for ways to promote cardiovascular health not only by sticking to clinically accepted standards of care, but also by promoting a population approach to risk reduction.

Making the ideas a reality.

The challenge was to engage all the agencies supporting the practice population: staff in the practice, at the health authority, in local NHS Trusts and at the district council. An effective local partnership that crossed agency boundaries was needed. The first steps were to create a project team who could guide the work: members came from all the main agencies. The team's initial task was to determine the objectives, success criteria, cost implications and timescale of the project.

The project objectives:

To reduce the risk of CHD by increasing awareness of lifestyle factors

To facilitate timely and effective diagnosis, treatment and care.

To engage members of the community in systems to monitor progress.

From the outset, the project was seen as an opportunity to promote cardiovascular health in a variety of ways. The team was determined not to adopt the traditional approach of concentrating on better care for patients who had proven heart disease. They wanted to give as much effort to promoting a healthy lifestyle.

Their first task was to get a good picture of the current situation. They assembled a wide range of information, included collating and comparing practice, district and national morbidity and mortality data, understanding existing service provision and allied initiatives and assembling literature on clinical and cost-effectiveness, comparable community projects and current policy/guidelines. This mapping exercise demonstrated the many activities that were already taking place. What was lacking was co-ordination.

Working with the Community

Some of the examples of activities promoted by the team were:

Local pubs and restaurants were encouraged to sign up to the heart beat award initiative which ensured healthy menu options and smoke free eating zones. They were also encouraged to ban smoking in dining areas and gain entry to the smoke-free directory being compiled by the Health Promotion department.

The four local primary schools in the area were encouraged to formulate their own school nutrition action group, agree to a policy of healthy snacks only at break times and join in specific initiatives to promote exercise facilitated by the local leisure centre. One school ran half hour activity sessions for the whole school, three days a week, prior to the start of the day's lessons. School nurses have promoted cardiovascular health through interactive workshops and encouraging children to represent their messages and views in poster form as part of a local competition.

The local District council is introducing a bodycare programme for year 6 promoting cardiovascular health through a variety of activities over 5 two hour sessions. The health centre has hosted a healthy heart zone initiative with the aid of all members of the working group to further heighten awareness amongst the primary school children of all aspects of cardiovascular health.

Practice staff ran public health awareness evenings, covering a variety of topics including coronary heart disease and stroke, managing the menopause, alternative therapies and basic CPR.

Better care for patients

Progress to improve the management of patients with IHD and related risk factors has proved to be difficult. The team has literally run into a few brick walls. Information is the basic building block to any attempt to identify and monitor the progress of patients. Creating and managing this process is not straightforward. It requires agreement on coding practice, data entry, use of computer systems, risk factor definition and treatment protocols. The team has engaged in many debates and discussions over the last three years but progress has been slow. There have been moments of despair.

Has it made a difference?

The initiative seeks to promote awareness amongst the general population, and especially amongst primary school age children, of the importance of a healthy lifestyle. It is unlikely therefore that the benefits of some endeavors will be seen for many years to come. Despite the difficulties in measuring and proving the effectiveness of many aspects of the work the team believes that a population approach to reducing morbidity and mortality caused by IHD is the right way forward.

Measuring progress

Nevertheless some progress has been achieved and this was recognised when the Project was awarded Beacon Status in 1999. A repeat audit in January 2000 of risk factor management and treatment of patients post-operatively and those with IHD has shown encouraging progress (see Tables 1 and 2). All patients with a diagnosis of IHD are now recalled to see their GP every year, with visits to the cardiac specialist nurse in between GP visits. Gradually, over time, a more reliable database of patients with risk factors or CHD is evolving.


Table 1: Percentage of IHD patients with risk factors monitored

Risk Factor

January 1994 to December 1996

January 1997 to December 1999

(n=177)

(n= 186)

Blood cholesterol

63

49

Blood Pressure

53

58

BMI

22

23

Smoking status

2

18

Alcohol consumption

15

20

Physical activity

7

18

Pulse

-

7

Glucose

-

65

Aspirin prescribed

-

55

Aspirin over the counter

-

>1

Warfarin

-

<1

Dietary advice

-

<1


Table 2: Percentage of post cardiac operation patients with risk factors monitored

Risk Factor

January 1994 to December 1996

January 1997 to December 1999

 

(n=12)

(n= 7)

Blood cholesterol

75

71

Blood Pressure

92

100

BMI

42

100

Smoking status

83

85

Alcohol consumption

58

43

Physical activity

58

85

Pulse

-

-

Glucose

75

100

Aspirin prescribed

42

85

Aspirin over the counter

-

-

Warfarin

-

-

Dietary advice

-

-


Practice guidelines have been produced which build on national recommendations and evidence. A practice nurse is developing specialist knowledge and skill in the management of patients with IHD (similar to asthma and diabetic nurse specialists). Practice staff training in CPR has already taken place but will be provided henceforth on an annual basis. A journal club is now a regular event as are multidisciplinary training sessions.

Expert Patients Panel

One of the most encouraging symbols of progress has been the creation, in autumn 2000, of an Expert Patients Group that involves 17 heart patients from the practice: patients who have angina, heart attacks or heart surgery. The group is facilitated by Cathy Lowenhoff a health visitor at the Freshwell Health Centre but is slowly starting to develop its own identity and work programme. For example to develop a network of local health walks, to make better us of local facilities and run their own rehabilitation courses.

Tips for Success


To find out more, contact:


Cathy Lowenhoff Project Co-ordinator
Freshwell Health Centre Wethersfield Road
Finchingfield Essex CM7 4BQ.
Telephone 01371 810328
Fax: 01371 811269

ImpAct bottom line

Appreciate that Rome wasn't built in a day and that even the tortoise got there in the end!