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1. Introduction
It is now accepted that heart
attacks, stroke, and other preventable cardiovascular diseases are responsible
for the majority of premature deaths in the
Progression of cardiovascular
disease results in a reduced quality of life and an increasing financial and
resource burden to the NHS. This is strongly reflected in
Evidence shows that it is possible
to identify the risk factors for CVD, such as diet and lifestyle and also to
act to change them. Early intervention to reduce risk can prevent, delay, and,
in some circumstances, reverse the onset of cardiovascular disease.
Therefore, Berkshire East Healthy
Hearts (BEHH), using the MyAction strategy, was created as a screening and
intervention programme in cardiovascular disease. Our mission is to improve
mortality and morbidity rates for cardiovascular disease.
This programme
is in line with the National drivers such
as
- Health profile of England 2007
(Slough Health Profile 2007)
- Operational plans
2008/09-2010/11( DoH)
- The Operating Framework for the
NHS in England 2008/9, 2009/10 (DoH)
- High Quality care for All. Next
Stage Review final report (Lord Darzi 2008)
- 10 High Impact Changes for
Service Improvement and Delivery, No 8 and No 10
(NHS modernisation Sept 2004)
- Putting Prevention First
Vascular checks: risk assessment and management (DoH 2008)
- Key Performer Indicators
NI 121 - Mortality rate for all circulatory diseases at ages under 75
NI 8 - Adult
participation in sport and active recreation
NI 123 - 16 plus current smoking
rates
NI 124 (Local) - People with LTC supported to be independent
2. What
are the unique features of BEHH?
- The programme is family centred
and both the patient and their partner participate in the entire programme
together.
- BEHH has the ability to treat
as well as provide early intervention.
- Run by a multidisciplinary
team; all aspects of lifestyle and clinical prevention are covered. The
team consists of a prescribing nurse manager, a dietitian, a physical
activity specialist and an administrator.
- Based at a leisure centre, the
programme is easily accessible to the community and reduces patient fear
of a hospital setting.
- Exercise classes are performed
and encouraged in a clinically safe environment and may often be a
patient’s first exercise in many years.
- All patients and partners
participate in weekly workshops for up to 16 weeks which helps to build
good relationships with the team, further motivating them to make lasting
improvements to their lifestyle.
- Emphasis is placed on working
with the patients to implement and maintain lifestyle changes, rather than
just suggesting them.
- In contrast to cardiac
rehabilitation, this programme is designed for patients at risk of
developing cardiovascular disease as well as coronary patients. In the
long term, this can be more cost-effective to the NHS.
- By being able to provide
intensive support, BEHH ensures medication changes are complied with. This
is particularly relevant in slough, where some ethnicities may not comply
with Western-medicine if side effects occur.
- BEHH has sought to increase
awareness of local government to the impact of cardiovascular disease on
the
3. Background
to BEHH
The BEHH
programme is underpinned by extensive evidence obtained by large, cross
This
approach was shown to be more effective than usual care (i.e. general practice
and general hospital) as it combines lifestyle intervention with cardio
protective drugs which together reduced cardiovascular events.
BEHH is one
of the first sites in the country to run this programme with professional
support and all resources provided by the MyAction team at
4 How
does the BEHH programme work?
4.1 Our
Overall Goals:
- Work collaboratively with
partners
- Engage with the community
- Screen for early disease
- Offer early intervention and
promote health
- Reduce health inequalities
These goals
are further elaborated below
4.1.1 Work collaboratively with partners
Eleven GP
surgeries have been visited in the
The team also receives referrals from the
community matron, stroke coordinator, Slough Borough Council and the Leisure
Centre. The team also refers patients to other services such as the diabetes
clinic The nurse and dietitian are members of the Slough Public Health Working
Group, this facilitates good working relationships with other health
professionals in
4.1.2 Engage with the community
The team
also visited community groups such as the Slough Senior Citizens group, Slough
Mental health group, Mars Pensioners Club, Age concern and attended a road show
to raise awareness with local people and encourage uptake. We also explored other
ways of engaging the diverse ethnic community of
4.1.3 Screen for early disease
Patients at
risk of CVD are identified via their GP records and then sent a letter
describing BEHH in simple terms and inviting them for an assessment. Members of
the community can also self refer by simply ringing the office to make an
appointment for an initial assessment. At the initial assessment information is
gathered to gain a risk score based on the JBS2 guidelines. Any patient scoring
≥20% is accepted on to the programme. This process contributes to the
national vascular health checks screening targets via the monthly PEC report.
Patients scoring £ 20% are invited to join the ‘StayActive’
exercise class.
4.1.4 Offer early intervention and
promote health
This is
achieved by Comprehensive assessments, workshops and follow-up as outlined
below.
Comprehensive
assessments
Once accepted
on to the programme, patients and their partners are invited for a thorough
assessment with the team. An in depth analysis of diet and alcohol intake is
undertaken with the dietitian. The physical activity specialist conducts a physical
test to assess fitness, current activity levels and patient limitations. The
nurse investigates medical history, blood pressure, cholesterol, glucose, medication
concordance, smoking and psychosocial health status. Each patient sets targets
with each member of the team at the end of their assessment.
Workshops
Once
assessed all patients and their partners are invited to participate in up to 16
weeks of workshops, one workshop per week. At these 3 hourly sessions the
participants are reviewed by one of the team to check their blood pressure,
weight as appropriate, medication concordance and whether they are meeting
their lifestyle change targets.
A member of
the team gives a health promotion presentation on different aspects of
cardiovascular health each week. Patients’ participation is optimized by doing group
work. Each session is post-evaluated to check patient understanding and
presentations are reviewed regularly in the light of patient feedback. Ultimately
this aids patient satisfaction and some comments from patients are given in
Appendix 1.
An hour of
physical activity is conducted by the team, lead by the physical activity
specialist. Each participant is allocated to an appropriate level of exercise
for their fitness. Disabled patients are encouraged to participate.
Follow up
After 8
weeks each participant’s overall progress is reviewed by the multidisciplinary
team taking into consideration lifestyle
changes, BP control, lipid profile, weight, diabetes control and medication
concordance. If targets are being met participants are booked for an exit
assessment, if not, they continue on the programme until improvements are
observed.
At the exit
assessment, the participants are thoroughly reviewed to ascertain all
improvements to their lifestyle and their risk of cardiovascular disease.
A report is
then sent to the GP detailing their achievements and continuing goals.
One year
after they start on the programme, participants are invited back for a yearly
follow up.
4.1.5. Reducing health inequalities
Initially
GPs practices where health inequalities are more prevalent were visited and
patients with high CVD risk were invited to the programme. Leaflets were also
given to the surgery to encourage self referrals for screening.
5. New
Exercise Class - Stay Active
In response
to feedback from participants, a new exercise class, funded by Slough Borough
Council, is to be launched on
6. Challenges
A number of
challenges have arisen some of which are common among NHS services in
- Language barrier. Some patients
do not speak English. This reflects the ethnic makeup of
- Some patients are requesting
single sex workshops, in part due to the ethnic makeup of
- We now have participants with
reduced mobility who require one to one supervision when exercising. This
is a challenge as we only have three members of staff to run the exercise
class with about 20 participants
- The programme was originally
set up in three locations across
7. Key results areas
Number of Participants seen
Blood
Pressure
Average
Blood pressure before = 152/85
Average
blood pressure after = 138/79
81% of
people reduced their blood pressure, of those, the average fall was 19/11
Range:
systolic 2 – 49, diastolic 1-30.
Blood
Cholesterol
Average
blood cholesterol before = 5.5mmol/L
Average
blood cholesterol after = 5.1 mmol/L
78% of
people reduced their blood cholesterol, of those, the average fall was 0.89
mmol/L.
Range: 0.1
– 5.6.
Blood
Glucose
Average
blood glucose before = 5.8mmol/L
Average
blood glucose after = 5.4 mmol/L
56% of
people reduced their blood glucose, of those, the average fall was 1.0mmol/L.
Range: 0.1
– 9.3.
Weight
Average
weight before = 84kg
Average
weight after = 78kg
71% of
people reduced their weight, of those, the average fall was 2kg.
Range: 0.1
– 10.4kg.
Waist
Average
waist circumference before = 98cm
Average
waist circumference after = 96cm
69% of
people reduced their waist circumference, of those, the average fall was 3cm
Range: 0.1
– 10.5cm.
BMI
Average BMI
before = 29
Average BMI
after = 28
44% of
people reduced their BMI, of those, the average fall was 0.7.
Range: 1 -
4.
38% of
participants had a BMI over 30.
Mediterranean
score
This is a
validated dietary assessment tool to determine the quality of the participant’s
diet in relation to cardio protective elements. 14 is the highest potential
score (though vegetarians and non drinkers will not be able to achieve this). A
score of over 9 is desirable, For every 2 point increase, CVD risk is reduced.
Average
Mediterranean score before = 6
Average
Mediterranean score after = 9
92% of
people improved their Mediterranean score, of those, the average increase was
2.3 points.
Range: 1 -
7.
The
This is a
validated fitness tool to determine cardio-respiratory fitness. The patient
continues to step at gradually increased rates for a maximum of 10 minutes or
until they reach 80% of their maximum heart rate/or report a moderately
vigorous level of exertion.
Average
duration of test before = 5.3 minutes
Average
duration of test after = 6.9 minutes
82% of
people improved their
Range: 1 -
4.
METS are a
measure of physical activity intensity
Light = 1.5
METS
Moderate =
4 METS
Hard = 6
METS
Very hard =
10 METS
Average
METS before = 5.4
Average
METS after = 6.2
59% of
people improved their METS score, of those, the average increase was 0.9.
Range: 0.5
- 4.
8. Conclusions
As an early
intervention programme, BEHH:
- BEHH is the only family centred
early intervention programme that screens as well as reduces
cardiovascular risk in Berkshire East, no other program exist
- makes significant inroads into
cardiovascular health inequalities, including socio-economic and ethnic
inequalities in
- Reduces the resources required
for both short and long term care of participants on the BEHH course
- Reduces the cost to the NHS
caused by cardiovascular disease progression.
- Focuses on the highest risk
sections of society thereby additionally reducing unnecessary screening
costs
- Provides treatment as well as
early diagnosis
- Promotes and monitors patient
compliance to prescribed medicine and also monitored for side-effects and effectiveness of prescribed medication
- Has identified cases of
vascular disease where it has so far gone undetected, particularly
diabetes. This group of participants have benefited from an immediate
start of treatment for their condition preventing adverse complications
- By early diagnosis of medical
conditions, BEHH has helped reduce hospital admissions
- BEHH does not just suggest
lifestyle changes, but instead works to implement and maintain them
- Has provided excellent patients
satisfaction (Appendix 1)
- Patient recruitment and early
intervention is progressing very well, thereby supporting the continuation
of the BEHH programme.
Some comments from participants in the
Bringing priority patient
groups together
The Team
