NHS Reset: Cardiac prevention in secondary care must evolve to address health inequalities | Dr Zarrin Shaikh

Dr Zarrin Shaikh

 NHS Reset is an NHS Confederation campaign to help shape what the health and care system should look like in the aftermath of the pandemic.

In this blog, part of a series of comment pieces from NHS Confederation members and partners, Dr Zarrin Shaikh observes that despite great advances in cardiology, cardiac disease continues to negatively affect the more marginalised in society. Here, she details her thoughts on how to better tailor cardiology services to benefit all patients, regardless of class or ethnicity.

The last few decades have seen immense progress within the field of cardiology. Innovations in the treatment of heart attacks, heart failure and rhythm disorders have, until recently, paved the way for a year-on-year drop in mortality. Our toolkit of preventative medications and interventions has expanded to enable us to optimise risk factors.

However, while we have witnessed decreases in mortality, much more work remains ahead. Heart and circulatory diseases still cause approximately 27 per cent of all UK deaths. Furthermore, 7.4 million people are living with cardiac disease and it unfavourably affects the most marginalised among us. The causes of this unequal distribution are complex, involving an interplay between social, ethnic, political, economic, psychological and environmental factors.

The coronavirus pandemic has magnified these health inequalities. COVID-19 has disproportionately affected deprived socioeconomic groups and members of the black, Asian and minority ethnic community. A Public Health England review into disparities in the risk and outcomes of COVID-19 cited contributory factors including housing, occupation, jobs and language barriers. With the country poised for another recession, these gaps in health will widen unless we take a coordinated, research-based and multidisciplinary approach tailored for communities particularly at risk.

Prevention should be the foundation of our strategies

Prevention requires broad, multi-stakeholder initiatives with action on multiple fronts. The wider discussion about health equity can seem out of the control of hospital doctors. Issues such as housing, income, transport and education are not within our remit. We can, however, offer part of the solution. At a time of great change and technological development within the NHS, a unique opportunity is unfolding to improve prevention services in secondary care. Health equity must be at the forefront of this improvement.

How can we best tailor cardiology services to benefit all patients, regardless of class or ethnicity?

  1. Self-reflection offers a good first step. We all have unconscious bias that can influence decisions. Asking questions about our own hidden prejudices identifies unrecognised bias. This is uncomfortable but necessary to enable equitable care delivery.
  2. As hospital medics, we often discuss lifestyle factors with our patients. It is well known that good nutrition, exercise, smoking cessation and stress reduction prevent many non-communicable diseases. In my experience, broad brush lifestyle advice does little to accommodate socioeconomics, environmental factors, physical ability, ethnicity or culture. Discussions often result in a feeling of blame; the resulting shame is never an effective prevention tool. Using a compassionate and non-judgemental approach sensitive to individual patient’s social circumstance is key. How can we coordinate such a personalised approach?
  3. The prescription of preventative medications is another key area in which we are involved. The 2019 Myocardial Ischaemia National Audit Project report demonstrated excellent prescription rates of 90.4 per cent for secondary prevention medications after a heart attack. Data on adherence is less favourable, particularly among those with depression or lower health literacy. How can we develop tailored approaches to improve compliance?
  4. One could argue that the most effective secondary preventative measure is cardiac rehabilitation (CR), which reduces mortality, hospitalisation and improves functional capacity. Uptake of CR programmes is low, with only 50 per cent of eligible patients taking up the offer. Additionally, patients attending CR are predominantly white-British males. How can we organise CR around jobs and childcare while ensuring it is inclusive to different ethnic groups?

There are many excellent prevention strategies already being employed that we can build on. It is vital that we continue to learn from successful initiatives, audit current interventions and research new ideas, with particular emphasis on marginalised groups.

We can improve connection of secondary care with local public health and primary care networks, community groups, social prescribers, charities and social enterprises. This enhances our ability to refer high-risk patients to services already available. Harnessing the use of technology offers an exciting opportunity to tailor programmes around work commitments using language and culture specific approaches. Improved awareness of current technological resources can aid in signposting relevant patients towards them.

To ensure progress in disease prevention, we need support. We require time within job plans, workforce allocation and funding. The global COVID-19 pandemic has accelerated many advances in technology and care delivery. Within hospitals, at an immensely stressful time, collective teamwork facilitated rapid, radical changes to working environments, patient flows, ward areas and staff rotas which have all succeeded in continuing to manage COVID-19. The need was urgent and the response was impressive.

Going forward, the need to address health inequality must also be tackled with the same urgency and with disease prevention at the heart of the strategy.

Dr Zarrin Shaikh is locum consultant cardiologist at Ashford and St Peter's Hospitals. Follow her on Twitter @freshheartdoc

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