Reducing the inequalities of life expectancy – targets for a new NHS/public compact in November.

2 Cardiovascular conditions

A few weeks ago I commented on an article examining the successful English health inequalities strategy 2003-2010. The article concluded

“The English health inequalities strategy was associated with a decline in geographical inequalities in life expectancy, reversing a previously increasing trend. Since the strategy ended, inequalities have started to increase again. The strategy may have reduced geographical health inequalities in life expectancy, and future approaches should learn from this experience.”

This strategy successfully increased survival rates, and therefore life expectancy, in some of the poorest local authorities in England. This in turn resulted in life expectancy numbers for poorer areas beginning to catch up with the average for the country. The business end of this policy ensures that the NHS works with people in poorer areas by providing for four interventions,

– Support for people to give up smoking
– Control of blood pressure
– Control of Cholesterol levels
– Interventions to reduce infant mortality

Yesterday I outlined that by 2017, when compared to ten years earlier, we knew more about how to help people give up smoking. By targeting our interventions around motivation and concrete support for poorer people in poorer areas we could help those that want to give up smoking succeed.

Today I want to extend this thinking to other areas of intervention – specifically control of blood pressure and cholesterol levels. Just to reiterate, the purpose of this policy and practice it is not to control blood pressure and cholesterol for their own sake, it is to do it in poorer areas so that we keep people alive for more years and by doing so decrease the inequalities of life expectancy.

Of course there is some overlap here with outcomes from stopping smoking. 26% of all deaths are caused by cardiovascular disease (CVD) and, whilst high blood pressure and high cholesterol are major indicators of possible future problems with CVD, so is smoking. Helping people to give up smoking would have a big impact on these deaths – but so would bringing blood pressure and cholesterol under control.

As we saw yesterday with smoking a major reason for the unequal response between the rich and the poor in their ability to take action to improve their hypertension is the difficulty poorer people have in taking control of their lives – and their bodies. Things can happen to people that have little control over their life – and one of these is high blood pressure. Saying to those many people who have little say over their jobs, income or housing, that they can control their blood pressure sounds like fantasy.

On July 1st one of the NHS’s most famous GPs, Julian Tudor Hart,  died in his 90s. In his GP surgery in South Wales he built strong relationships with pit men and their families who had little control over their life over the decades. Day by day, week after week he worked with his patients to provide them with a greater say over their health. He was famous for his anticipatory care. He knew that people who smoked and were overweight would have more strokes and heart attacks and spent time and effort helping them change their lives. He didn’t tell them to change how they lived – but he spent hour upon hour supporting them in making those life changes.

He, and his practice, were exceptional and whilst we cannot plan the future of the NHS solely on the practice of exceptional people we can learn from them.

Hart helped people gain control of aspects of their health by empathising rather than ignoring their lack of control over their lives. This approach requires strong support but that doesn’t have to come from the GP themselves. It can be provided by others at the doctor’s suggestion. It could come from other patients, or from health trainers – the only essential is that it comes from those who understand how hard it is to gain control.

This requires much greater development of screening programmes. In Dudley for example they knew that there was a large gap between the numbers of people reporting hypertension and the numbers that should be expected. They developed a local pathway based on NICE guidance and in 2 years had diagnosed over 1000 new cases of hypertension. They estimate that for every 1000 people diagnosed that keep to their prescribed treatment 16 strokes and 12 heart attacks are stopped every year.

To underline the point, if we want to increase life expectancy in poorer areas and we diagnose an extra 1000 people then in that year 28 very bad cardiovascular events do not happen. We really do know how to do this – we can save more lives in poorer areas. But it isn’t happening.

Having diagnosed people we need to do something about it. In the last 12 months, less than 9% of those with hypertension have been assessed for physical activity. To put this another way more than 9 out of 10 people who have hypertension have not been asked about their physical activity. This is really awful. Effectively we are saying, “We know you have hypertension, and we know it’s a good idea for you to get a bit more active – but we are not assessing that.”

What might be achieved if in poorer areas assessment was 100% and patients could join a group of a similar individuals to develop their levels of activity?

To return to my main point.  Referring people who don’t feel in charge of their lives to a walking group is going to have less impact than referring those who do. If it wants to save the lives of those who have little control of their lives the NHS needs to be much more active than simply referring people. It needs to actively support them. As we are learning to do with social prescribing.

The purpose of these two posts has been to try and explain why it seems harder to get people who have little control over their lives, to gain control of their smoking habit or their blood pressure.

We know how to do this. For every month that we fail to act we can calculate the price of our failure so to do.