Coronary Heart Disease National Service Framework Summary

Standards 1 & 2

Reducing heart disease in the population

• The NHS and partner agencies should develop, implement and monitor policies that reduce the prevalence of coronary risk factors in the population, and reduce inequalities in risks of developing heart disease

• The NHS and partner agencies should contribute to a reduction in the prevalence of smoking in the local population

Standards 3 & 4

Preventing CHD in high-risk patients

• General practitioners and primary care teams should identify all people with established cardiovascular disease and offer them comprehensive advice and appropriate treatment to reduce their risks

• General practitioners and primary health care teams should identify all people at significant risk of cardiovascular disease but who have not developed symptoms and offer them appropriate advice and treatment to reduce their risk

Standards 5,6 & 7

Heart attack & other acute coronary syndromes

• People with symptoms of a possible heart attack should receive help from an individual equipped with and appropriately trained in the use of a defibrillator within 8 minutes of calling for help, to maximise the benefits of resuscitation should it be necessary

• People thought to be suffering from a heart attack should be assessed professionally and, if indicated, receive aspirin. Thrombolysis should be given within 60 minutes of calling for professional help

• NHS Trusts should put in place agreed protocols/systems of care so that people admitted to hospital with proven heart attack are appropriately assessed and offered treatments of proven clinical and cost effectiveness to reduce their risk of disability and death

Standard 8

Stable angina

• People with symptoms of angina or suspected angina should receive appropriate investigation and treatment to relieve their pain and reduce their risk of coronary events

Standards 9 & 10

Revascularisation

• People with angina that is increasing in frequency or severity should be referred to a cardiologist urgently or, for those at greatest risk, as an emergency

• NHS Trusts should put in place hospital-wide systems of care so that patients with suspected or confirmed coronary heart disease (CHD) receive timely and appropriate investigation and treatment to relieve their symptoms and reduce their risk of subsequent coronary events

Standard 11

Heart failure

• Doctors should arrange for people with suspected heart failure to be offered appropriate investigations (e.g. electrocardiography, echocardiography) that will confirm or refute the diagnosis. For those in whom heart failure is confirmed, its cause should be identified – treatments most likely to both relieve their symptoms and reduce their risk of death should be offered

Standard 12

Cardiac rehabilitation

• NHS Trusts should put in place agreed protocols/systems of care so that, prior to leaving hospital, people admitted to hospital suffering from CHD have been invited to participate in a multidisciplinary programme of secondary prevention and cardiac rehabilitation. The aim of the programme will be to reduce their risk of subsequent cardiac problems and to promote their return to a full and normal life

• Clinical teams should meet as a team at least once every quarter to plan and discuss the effects of clinical audit and, generally, to discuss clinical issues

• PCGs/PCTs and hospitals that together form a local network of cardiac care should have effective means for agreeing an integrated system for quality assessment and quality improvement

• All medical records and hospital correspondence must be held in a way that allows them to be retrieved readily in date order

• Appropriate medical records must contain easily discernible drug therapy lists for patients on long-term therapy

• A systematically developed and maintained practice-based CHD register is in place and actively used to provide structured care to people with CHD

• A protocol describing systematic assessment, treatment, and follow-up has been agreed locally and is used to provide structured care

• Clinical audit data no more than 12 months old are available that describe use of relevant effective interventions as outlined in the NSF document

NSF goals

• Every practice should offer advice about each of the specified goals by clinical interventions to those in whom they are indicated, demonstrated by clinical audit data no more than 12 months old

• Every primary care team should ensure that all those with heart failure are receiving a full package of appropriate investigation and treatment, demonstrated by clinical audit data no more than 12 months old

• HAs, LAs, PCGs/PCTs, and NHS Trusts will:
• have actively participated in the development of Health Improvement Programmes (HImPs)
• have agreed their responsibilities for and contributions to specific projects identified in HImPs
• have agreed a mechanism for being held to account for the actions they have agreed to deliver as part of the HImP
• have agreed a mechanism for ensuring that progress on health promotion policies is reported to and reviewed by the Board
• have identified a link person to be a point of contact for partner agencies

• HAs, LAs, PCGs/PCTs, and NHS Trusts will:
• have agreed and be contributing to the delivery of the local programme of effective policies on:
  • reducing smoking
  • promoting healthy eating
  • increasing physical activity
  • reducing overweight and obesity
• have a mechanism for ensuring all new policies and all existing policies subject to review can be screened for health impacts
• as an employer, have implemented a policy on smoking
• be able to refer clients/service users to specialist smoking cessation services, including clinics
• have produced an equity profile and set local equity targets

• HAs, LAs, PCGs/PCTs, and NHS Trusts will:
• have quantitative data no more than 12 months old about the implementation of the policies on:
  • reducing the prevalence of smoking
  • promoting healthy eating
  • promoting physical activity
  • reducing overweight and obesity
• as an employer, have developed 'green' transport plans and taken steps to implement employee-friendly policies

• HAs, LAs, PCGs/PCTs, and NHS Trusts will:
• have implemented plans to evaluate progress against national targets associated with Saving Lives: Our Healthier Nation and local targets

• The NSF will:
• contribute to the target reduction in deaths from circulatory diseases as outlined in Saving Lives: Our Healthier Nation of up to 200 000 lives in total

• Begin to modernise services for CHD by delivering the first milestones of the NSF on systematic approaches to delivery of care

• Reduce the call-to-needle time for thrombolysis for heart attacks (i.e. the time from when the initial call is made until clot-dissolving thrombolytic therapy begins). This involves:
• improving ambulance response times so that 75% of category A calls receive a response within 8 minutes
• increasing, to at least 75%, the proportion of A&E departments able to provide thrombolysis
• This leads to further thrombolysis targets by April 2002 and April 2003 (see below)
• HAs will introduce specialist smoking clinics, helping 150 000 people

• There should be 50 rapid-access chest pain clinics, to help ensure that people who develop new symptoms that their GP thinks might be due to angina can be assessed by a specialist within 2 weeks of referral

• Improve the use of effective medicines after heart attack (especially use of aspirin, beta-blockers and statins) so that 80–90% of people discharged from hospital following a heart attack will be prescribed these drugs

• 75% of eligible patients to receive thrombolysis within 30 minutes of hospital arrival

• Increase the total number of revascularisation procedures, providing an extra 3000*

• There should be 100 rapid-access chest pain clinics, and nationwide roll-out thereafter

• 75% of eligible patients to receive thrombolysis within 20 minutes of hospital arrival

*This target was revised in The NHS Plan, which states that extra money announced in The NHS Plan will ‘enable the NHS to achieve the 3000 target ahead of time, and to bring on stream at least a further 3000 operations on top of this by 2003’

• CHD mortality rates* by HA (annually from existing Public Health Common Data Set)

• 10 yearly mortality rates by socio-economic class in England and each region (from existing National Census data)

• Additional indicators of lifestyle:
• annual smoking prevalence by age and sex in England and each region (from existing General Household Survey data)
• prevalence of physical activity (from existing Health Survey for England data

• Number and % of smokers using smoking cessation services

• Number of smokers provided with free nicotine replacement therapy

• Number of smoking cessation services (i.e. specialist smoking cessation clinics and 'intermediate interventions')

• Number of smokers using smoking cessation services who are still not smoking 4 weeks after quit date

• Number and % of practices in a PCG/PCT with a systematic approach to following up people with CHD. New collection from 2001/2002

• Number and proportion** of people aged 35–74 years with recognised CHD whose records document advice about use of aspirin

• Number and % of patients eligible for thrombolysis receiving it within 60 minutes of call for professional help (call-to-needle time)

• Rates* of coronary artery bypass graft (CABG), percutaneous transluminal coronary angioplasty (PTCA) and angiography per million population by HA and PCG/PCT (annually from existing Hospital Episode Statistics [HES] data)

• Number and proportion** of people aged 35–74 years with recognised CHD whose records document advice about use of aspirin

• Number and % of PCGs/PCTs in a region with PCG/PCT-wide protocols for specialist care agreed with local cardiologists

• Admission rates* for heart failure by HA and PCG/PCT (from existing HES data)

• Number and % of patients discharged from hospital after coronary revascularisation or with a primary diagnosis of acute myocardial infarction (AMI) with documentation of arrangements for cardiac rehabilitation in discharge communication to GP (new collection from 2001/2002)

• Cost per one-month-quitter of smoking cessation service by type of service

• Reference costs for:
• AMI (HRG codes E11 and E12)
• chest pain (E35 and E36)
• cardiac arrest (E28)
• pacemaker implant for AMI, heart failure or shock (E07)

• Reference costs (annually from existing Trust unit costs data) for:
• angina (HRG codes E33 and E34)
• angiography (E13 and E14)
• coronary atherosclerosis (E22 and E23)
• CABG (E04)
• PTCA (E15 and E16)

• Reference costs for:
• heart failure (HRG codes E18 and E19)
• pacemaker implant (E07)
• arrhythmia (E29 and E30)
• cardiac valve procedures (E03)

• Indicator from National CHD Survey of NHS Patients

• Rate* of cardiovascular events in people with a prior diagnosis of CHD, peripheral vascular disease, transient ischaemic attack or occlusive stroke

• Proportion* of people aged 35–74 years in a PCG/PCT and HA area with a diagnosis of AMI who die during their index admission to hospital (from existing HES data**)

• Proportion* of people aged 35–74 years in a PCG/PCT and HA area with a diagnosis of AMI who die in hospital within 30 days of their infarct**