New strategy may end up gathering dust if funding is not made available to implement it, writes DR MUIRIS HOUSTON
CARDIOVASCULAR DISEASE remains one of the most common causes of death in the Republic, accounting for one-third of all fatalities and one in five premature deaths. So the publication of a new cardiovascular health strategy by the Department of Health last week is an opportunity to assess progress made under the last “Building Healthier Hearts” strategy as well as assessing the challenges that lie ahead.
Substantial progress has been made, with death rates from heart attack, stroke and other vascular diseases here down by two-thirds in the past 30 years. However, with improvements also occurring in other countries, we still rank below the EU-15 average for life expectancy. And when it comes to funding, we also lag behind our European neighbours: we spend just 6 per cent of our health budget on cardiovascular health compared with an EU average spend of 10 per cent.
Which brings us to the first challenge faced by the new strategy, “Changing Cardiovascular Health”. For all its finely argued rhetoric and scientific logic, Minister for Health Mary Harney said at the launch that no additional funding would be forthcoming to implement the strategy’s proposals. And with current services for patients with cardiac disease and stroke suffering from major budget cutbacks, there is a real risk of the strategy gathering dust on the department’s shelves.
Already the axe is falling on programmes aimed at preventing heart disease.
Prevention is seen as the Cinderella of the health service; as soon as budgetary constraints kick in, it is first up for the chopping block. It means that services for those known to be at risk of developing cardiovascular disease have been curtailed, while any chance of developing meaningful long-term interventions to reduce risk factors in the community are poor this side of a sustained economic recovery.
Without additional funding, strategy targets to reduce obesity levels in adults from 23 per cent to 18 per cent by 2019 and to decrease the percentage of children who are overweight from 11 to 7 per cent will be difficult to meet.
Despite the success of the HeartWatch programme in general practice, which targets people with existing heart disease in order to prevent a future cardiac event such as a heart attack, the section on primary care makes no reference to the need to update it or to extend it to cover the whole population.
Instead, we have the recommendation: “Develop structured clinical care, which includes prevention of cardiovascular disease, in clinical practice . . . a risk assessment programme – similar to the HeartWatch programme, but incorporating ‘high-risk’ individuals – should be piloted and implemented . . . ”
At the risk of being cynical, this sounds like a stalling mechanism, given the data already out there proving the success of such programmes.
It’s a woolliness of language not found in the sections of the strategy dealing with acute cardiac care. At least in the case of cardiac rehabilitation – the care of patients after a heart attack or bypass procedure – there is an acknowledgement that “services are overstretched and many eligible patients cannot avail of rehabilitation, while others wait longer than desirable to commence outpatient programmes after hospital discharge”.
And highlighting the disparity between public and private care in the area of cardiac rehab is welcome: in an unusual case of inverted equity, the report acknowledges that such care is not available to patients in most private hospitals.
If heart health was the success story of the last cardiovascular strategy, it is the turn of stroke services to play catch-up.
But, as the Irish Heart Foundation has pointed out, this will be difficult without extra funding. We are way behind the UK when it comes to adequate stroke care, a recent audit found.
The strategy calls for fully staffed stroke units in every acute hospital in the Republic. “Each stroke unit should have sufficient capacity to admit patients directly from the emergency department and the rapid access TIA [mini-stroke] clinic, to accept transfers from other hospitals within the stroke network when required, and to provide care for all stroke/TIA patients for their hospital stay,” it states.
However, its assertion that because many of the required staff are already in place, it should be possible to implement stroke unit care “even in economically challenging times”, sounds optimistic.
The commitment by Dr Barry White, director of quality and clinical care with the Health Service Executive, to deliver heart failure and stroke initiatives closer to where patients live, is welcome.
Pointing out that some 70 per cent of morbidity and mortality occur in six chronic disease groups, including heart disease, he said the management of these needs to be standardised throughout the country.
Because it is a 10-year strategy, there is some hope of it achieving success in the long term. But not before cardiovascular services retreat in the short term, under severe pressure from a minimum €3 billion cut in public service funding.