The National Institute for Health and Clinical Excellence (NICE) has published new public health guidance on reducing the rate of premature deaths from cardiovascular disease (CVD) and other smoking-related diseases. The guidance is designed to help tackle health inequalities by making recommendations about the best ways to identify and support those most at risk and improve access to services.These recommendations are intended to complement existing initiatives and wider health promoting policies aimed at reducing health inequalities.

The Guidance has been developed specifically for smoking cessation services and the provision of statins and is aimed at general practices, PCTs, community services and local authorities with a remit for tackling health inequalities. Recommendations include:

-- Primary care professionals and those working with communities should use a range of methods to identify adults who are disadvantaged and at high risk of premature death from CVD. Examples include: primary care and general practice registers and appointments; analyses of quality outcomes framework (QOF) data; health sessions run at a range of community and public sites; culturally sensitive education sessions that include a CVD risk assessment and outreach activities provided by community health workers.

-- 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. People who are disadvantaged should be involved in the planning and development of these services.

-- Develop and sustain partnerships with professionals and community workers who are in contact with people who are disadvantaged. Use existing mechanisms such as the joint strategic needs assessments (JSNA) drawn up by the local authority and PCTs outlining the health and wellbeing status of the local community and local area agreements (LAAs) between central and local government which set out priorities for a local area.

-- Ensure practitioners have the skills to identify people who are disadvantaged and can develop services to meet their needs.

Professor Peter Littlejohns, Executive Lead for the guidance, and Clinical and Public Health Director at NICE said: "There are numerous factors contributing to health inequalities in this country, including poor living conditions, lower educational achievement and behaviours which damage health (such as smoking) which can lead to a greater than average risk of premature death, risk of illness and lower life expectancy. With health inequalities so deeply entrenched in today's society, providing improved access to services can only be one element of a broader strategy."

Professor Catherine Law, Chair of the Public Health Interventions Advisory Committee (PHIAC) at NICE and Professor of Public Health and Epidemiology, UCL Institute of Child Health said: "The death rate from coronary heart disease (CHD) is three times higher among unskilled workers than among professionals and similarly deaths from lung cancer are four times higher among unskilled male manual workers of working age than among professional men. Tackling smoking and providing statins, as recommended, should make a significant contribution to reducing inequalities. The guidance has a clear focus on system and structural changes that will ensure effective clinical and public health practice can take place."

Dr David Sloan, PHIAC member at NICE and Retired Director of Public Health said: "The recommendations made in the guidance are focused on two of the most widely used interventions to prevent cancer and CVD, smoking cessation services and the provision of statins. Although both have been shown to be effective, there are many factors preventing them from being fully effective including: lack of available, appropriate and accessible primary care services and the reluctance of many people within vulnerable or at-risk communities to use health services or to follow agreed treatment. This guidance aims to support those in the NHS and other professionals in finding effective ways of identifying at-risk or vulnerable groups and tailoring services to make them accessible and keeping people in the system."

Dr Bobbie Jacobson, Director of the London Health Observatory and Vice Chair of the Association of Public Health Observatories (APHO) said: "We welcome the new guidance as an important addition to the evidence-led armoury for reducing inequity in our society. We hope that it will be used in conjunction with the APHO health inequalities intervention tool, a ready reckoner for every Primary Care Trust and local authority to help understand their health divide and target sustained action on statin prescribing and smoking cessation where it is most needed."

About the guidance

1. The identifying and supporting people most at risk of dying prematurely guidance is available at: nice/PH015.

2. 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.

3. This guidance should be used alongside NICE guidance on smoking cessation, lipids and statins:

Lipid modifications: cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. NICE clinical guideline 67 (2008). Available from: nice/CG067
-- Smoking cessation services in primary care, pharmacies, local authorities and workplaces, particularly for manual working groups, pregnant women and hard to reach communities. NICE public health guidance 10 (2008). Available from: nice/PH010
-- Brief interventions and referral for smoking cessation in primary care and other settings. NICE public health guidance 1 (2006). Available from: nice/PHI001
-- Statins for the prevention of cardiovascular events. NICE technology appraisal 94 (2006). Available from: nice/TA094

4. 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.

. Recommendations aim to support and complement other initiatives that attempt to identify and support those people most at risk of dying prematurely. Existing programmes include the coordinated vascular disease control programme commissioned by the UK National Screening Committee, which seeks to identify and reduce the risk of CVD in the general population and also the Department of Health's vascular checks programme, announced in January 2008, which focuses on everyone aged between 40 and 74.

The Association of Public Health Observatories (APHO) is a network of 12 collaborating public health observatories across the UK and Ireland. The APHO Inequalities Intervention tool was commissioned by the Department of Health and developed by the LHO working with the Yorkshire and Humber and Eastern region PHOs. The tool charts the causes of the life expectancy gap at birth for every local authority in England and predicts the effect of 4 high impact interventions on reducing the gap both between and within local authorities. The tool can be accessed at lho/HEALTH_INEQUALITIES/Health_Inequalities_Tool.aspx. Further information about APHO can be found at www.apho

About NICE

The National Institute for Health and Clinical Excellence (NICE) is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health.

NICE produces guidance in three areas of health:

public health - guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
health technologies - guidance on the use of new and existing medicines, treatments and procedures within the NHS
clinical practice - guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.


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