1 Recommendations

This document constitutes the Institute's formal guidance on what works in finding and supporting those most at risk of early death and improving their access to services.

The evidence statements that underpin the recommendations are listed in appendix C.

Definitions of adults who are disadvantaged and of what constitutes a disadvantaged area and a high risk of cardiovascular disease (CVD) are given below, along with a brief explanation of why there was a focus on smoking cessation and statin interventions.

Definitions

  • Adults who are disadvantaged include (but are not limited to):

    • those on a low income (or who are members of a low-income family)

    • those on benefits

    • those living in public or social housing

    • some members of black and minority ethnic groups

    • those with a mental health problem

    • those with a learning disability

    • those who are institutionalised (including those serving a custodial sentence)

    • those who are homeless.

  • Local agencies (such as local authorities and primary care trusts [PCTs]) define disadvantaged areas in a variety of ways. An example is the Index of Multiple Deprivation 2007 (ID 2007). This combines indicators on economic, social and housing issues to produce a single deprivation score.

  • According to NICE guidance, if someone has a 20% or higher risk of a first cardiovascular event in the next 10 years they are deemed at high risk of CVD (see NICE clinical guideline 67 on lipid modification).

Smoking cessation and statins

Smoking cessation and statin interventions were used as the basis of the recommendations because:

  • Methods of identifying and supporting adults and improving their access to services need to be assessed using interventions which have already been established as effective and cost effective. Smoking cessation services and the provision of statins are both generally agreed to be effective and cost effective.

  • Epidemiological data show a clear socioeconomic gradient for smoking and CVD. Tackling smoking and providing statins, as recommended, should make a significant contribution to reducing health inequalities.

This guidance should be used alongside NICE guidance on smoking cessation, lipids and statins (see list of publications in section 7: 'Related NICE guidance').

Cost effectiveness

Smoking cessation interventions are generally cost effective, irrespective of the target audience, the methods used to identify and recruit adults or the type of service offered. It is also cost effective to identify adults in secondary care who are disadvantaged and need statins (and then prescribe these drugs). In primary care, the cost effectiveness of identifying people at risk of CVD and providing them with statins is determined by the number at risk of CVD in the baseline population. (The more people at risk, the more cost effective it becomes to identify them and provide them with statins.)

Tackling health inequalities

Health inequalities are so deeply entrenched that providing disadvantaged groups or areas with better services – and better access to those services – can only be one element of a broader strategy to address the distribution of the wider determinants of health. All activities need to be developed and sustained on a long-term basis.

The recommendations focus on system and structural changes to ensure effective clinical and public health practice can take place. This requires a comprehensive approach at all levels of the health system (for example, involving both practitioners and commissioners) and in partnership with others in the wider public, community and voluntary sectors. The recommendations are not aimed at clinical practice itself as the relevant advice is found in other NICE guidance (see above).

Effective implementation of the recommendations will require:

  • an appropriate infrastructure and resources for commissioners, planners and service providers

  • policy initiatives which prioritise health inequalities and ensure action to tackle them are included in PCT plans and local area agreements.

Recommendation 1: identifying adults at risk

Who is the target population?

Adults who are disadvantaged:

  • who smoke and/or

  • who are eligible for statins and/or

  • who are at high risk of CVD due to other factors.

Who should take action?

Service providers and commissioners (for example, general practices, PCTs, community services, local authorities and others with a remit for tackling health inequalities).

What action should they take?

  • Primary care professionals should use a range of methods to identify adults who are disadvantaged and at high risk of premature death from CVD. These include:

    • primary care and general practice registers (for example, to identify adults who smoke; who are from particular minority ethnic groups; or who have family members who have had premature coronary heart disease)

    • primary care appointments (for example, during routine visits and screening)

    • systematic searches in pre-identified areas or with specific populations (for example, using direct mail or telephone)

    • analyses of quality outcomes framework (QOF) data.

  • Those working with communities should use a range of methods to identify adults who are disadvantaged and at high risk of CVD. Methods to use include:

    • health sessions run at a range of community and public sites, including post offices, charity shops, supermarkets, community pharmacies, homeless centres, workplaces, prisons and long-stay psychiatric institutions. (Lifestyle factors such as smoking or other indicators, such as blood pressure, could be used to identify those at risk)

    • culturally sensitive education sessions that include a CVD risk assessment and which take place in black and minority ethnic community settings (including places of worship)

    • outreach activities provided by community health workers (including health trainers).

  • Service providers should monitor these methods and adjust them according to local needs.

  • Service providers should encourage everyone who is disadvantaged to register with a general practice.

Recommendation 2: improving services for adults and retaining them

Who is the target population?

Adults who are disadvantaged:

  • who smoke and/or

  • who are eligible for statins and/or

  • who are at high risk of CVD due to other factors.

Who should take action?

Service providers (for example, PCTs, general practices, community services, local authorities and other organisations with a remit for tackling health inequalities).

What action should they take?

  • Provide flexible, coordinated services that meet the needs of individuals who are disadvantaged. For example, this could include providing drop-in or community-based services, outreach and out-of-hours services, advice and help in the workplace and single-sex sessions.

  • Involve people who are disadvantaged in the planning and development of services. Seek feedback from the target groups on whether the services are accessible, appropriate and meeting their needs.

  • Gain the trust of adults who are disadvantaged. Offer them proactive support. This could include helplines, brochures and invitations to attend services. It could also include providing GPs with postal prompts to remind them to monitor people who are disadvantaged and who have had an acute coronary event.

  • Develop and deliver non-judgemental programmes to tackle social and psychological barriers to change. These should be tailored to people's needs. For example, they could make use of social marketing techniques. (Social marketing involves using marketing and related techniques to achieve specific behavioural goals.)

  • Ensure services are sensitive to culture, gender and age. For example, provide multi-lingual literature in a culturally acceptable style and involve community, religious and lay groups in its production. Where appropriate, offer translation and interpretation facilities. Promote services using culturally relevant local and national media, as well as representatives of different ethnic groups. Consider providing information in video or web-based format.

  • Provide services in places that are easily accessible to people who are disadvantaged (such as community pharmacies and shopping centres) and at times to suit them.

  • Provide support to ensure people who are disadvantaged can attend appointments (for example, this may include help with transport, postal prompts and offering home visits).

  • Encourage and support people who are disadvantaged to follow the treatment that they have agreed to. For example, encourage them to use self-management techniques (based on an individual assessment) to solve problems and set goals. It could also involve providing vouchers for treatments (such as nicotine replacement therapy [NRT]). (For recommendations on the principles of behaviour change, see : 'Behaviour change at population, community and individual levels' [NICE public health guidance 6].

  • Routinely search GP databases (and other electronic medical records) to generate lists of patients who have not collected repeat prescriptions or attended follow-up appointments. Make contact with them.

  • Address factors that prevent people who are disadvantaged from using services (for example, they may have a fear of failure or of being judged, or they might not know what services and treatments are available).

  • Support the development and implementation of regional and national strategies to tackle health inequalities by delivering local activities which are proven to be effective.

  • Use health equity audits to determine if services are reaching people who are disadvantaged and whether they are effective[1]. (For example, by matching the postcodes of service users to deprivation indicators and smoking prevalence.)

Recommendation 3: system incentives

Who is the target population?

Service providers (for example, PCTs, community services, local authorities and others with a remit for tackling health inequalities) and practice-based commissioning (PBC) groups.

Who should take action?

Policy makers, planners and commissioners.

What action should they take?

  • Support and sustain activities aimed at improving the health of people who are disadvantaged by:

    • using relevant indicators to measure progress and compare performance across areas or organisations

    • ensuring, wherever possible, that all targets aim to tackle health inequalities – and do not increase them

    • ensuring exception-reporting does not increase health inequalities: PCTs should be provided with additional levers and tools to monitor and benchmark exception-reporting and to reduce persistent rates of exception coding

    • considering the provision of comparative performance data to encourage providers to meet targets

    • using local enhanced services to encourage providers and practitioners to identify and continue to support those who are at risk of premature death from CVD and other smoking-related diseases.

  • Provide incentives for local projects that improve the health of people who are disadvantaged, specifically those who smoke or are at high risk of CVD from other causes or are eligible for statins. Ensure the projects are evaluated and, if effective, ensure they continue.

Recommendation 4: partnership working

Who is the target population?

Adults who are disadvantaged:

  • who smoke and/or

  • who are eligible for statins and/or

  • who are at high risk of CVD due to other factors.

Who should take action?

Planners, commissioners and service providers with a remit for tackling health inequalities. This includes PCTs, general practices, community services, PBC groups, local strategic partnerships, local authorities (including education and social services), the criminal justice system and members of the voluntary and business sectors.

What action should they take?

  • Develop and sustain partnerships with professionals and community workers who are in contact with people who are disadvantaged. Use joint strategic needs assessments, local area agreements, local strategic partnerships, the GP contract, world class commissioning and other mechanisms. (For recommendations on community engagement see 'Community engagement to improve health' [NICE public health guidance 9].)

  • Establish relationships between primary care practitioners and the community to understand how best to identify and help adults who are disadvantaged to adopt healthier lifestyles. For example, they should jointly determine how best to support health initiatives delivered as part of a local neighbourhood renewal strategy.

  • Establish relationships with secondary care professionals (for example, those working in respiratory medicine and CVD clinics) to help identify patients at high risk of further cardiovascular events. Offer these patients support or refer them on, where appropriate.

  • Develop and maintain a database of local initiatives that aim to reduce health inequalities by improving the health of people who are disadvantaged.

  • Develop and sustain local and national networks for sharing local experiences. Ensure mechanisms are in place to evaluate and learn from these activities on a continuing, systematic basis.

  • Ensure those working in the healthcare, community and voluntary sectors coordinate their efforts to identify people who need help.

Recommendation 5: training and capacity

Who is the target population?

Service providers (for example, general practices, PCTs, local authorities, community and lay workers and others with a remit for tackling health inequalities).

Who should take action?

Commissioners and service providers (for example, PCTs, community services, local authorities and others with a remit for tackling health inequalities).

What action should they take?



[1] Health equity audits typically consist of six steps: 1) Agreeing partners and issues for the audit 2) Undertaking an equity profile 3) Identifying high-impact local action to narrow key inequities identified 4) Agreeing priorities for action 5) Securing changes in investment and service delivery 6. Reviewing progress and assessing impact. DH (2004) Health equity audit: a self-assessment tool. London: DH.