ICS 2012 Report ‘‘Next Monday, you are Minister for Health. Now what?’’

by Edel O’Connell reporting on the Stokes Lecture by Professor Ian Graham.

Professor Ian Trinity Garfield Weston Professor of Cardiovascular Medicine at Trinity College Dublin was well placed to describe changing practices in preventive cardiology in Ireland.

An academic cardiologist and international leader in preventive cardiology Prof Graham spent most of his career as a cardiologist and research director for St Vincents Hospital and for the Irish Heart Foundation. He has been particularly active in medical prevention as chair of the Joint European Societies Cardiovascular Prevention Committee, co-author of its Joint Recommendations, and a leader of prevention demonstrations.  He is also project leader of the Score project and Heartscore.

His main research interests are cardiovascular risk prediction, defining the role of new risk markers and integrating them with the “old” cardiovascular disease risk factors which make him well placed to discuss where the Government is going wrong with regards to the fight against cardiac disease and health reform planning.

However, it is not just the Government but a failure by the medical profession to be active lobbyists for change which is hampering health reform, according to the eminent cardiologist.

His recent survey of European practitioners pointed up the professional, patient, and social factors impeding the effectiveness of medical strategies in cardiovascular disease prevention.

“Cardiovascular disease is increasing not reducing globally and by 2020 it is estimated it will cause 25 million deaths. We know between this and next year’s Stokes Lecture in Ireland the equivalent of the population of a medium sized town will have died from it. In contrast the 250 road traffic accidents we get here each year, although admittedly very tragic, will get the lion’s share of the publicity. We have got something wrong in our balance,” he said.

“We know the cause of disability is chronic disease and we know that chronic diseases share a common substrate, so whatever we do in cardiovascular disease- the major biggest problem- carries substantial added value in health planning in general,” he added.

Prof Graham said that notwithstanding a drop-off in cardiovascular disease in the last three decades medical professionals should ward against complacency and intensify their efforts in light of rising obesity.

“In 1980 cardiovascular disease was half the cause of death, by 2000 it was 42pc, it is now somewhere in the mid thirties but that is a reason for intensifying our efforts rather than reducing our efforts. It is still our biggest cause of death and to get further gains, particularly with what is happening with obesity we need increased efforts,” he said.

“We know the major causes; there is irrefutable evidence that we can reduce it. We know from Simon Capewell’s impact modelling that in general over half of the reductions of cardiovascular disease are as a result of risk factor changes. We know the strategy should be complimentary and we know there is major added value to control virtually all chronic diseases, so why are we so unwilling to truly engage with the problem?” he asked.

Prof Graham went on to praise the joint European Societies Guidelines on cardiovascular prevention in clinical practice saying they represent “a partnership of the major players” and in this respect push us ahead of America in terms of progress.

“However, what happens when you are involved is you get this glow of vanity and precisely nothing happens. It is just another guideline,” he said.

On the issue of European cardiology preventative models Prof Graham described the European Society of Cardiology’s Euroaspire project as the “Rolls Royce order” for people with established cardiovascular disease.

“Over the three Euroaspires cholesterol has gone down but blood pressure control did not improve, despite more medication probably because body weight has gone up. The trouble with Euroaspire is you need to be rich to carry it out. It takes about two hours with each patient at a special clinic, so we asked  would it be possible to complement EuroAspire with a  very simple, quick and  economical audit that might be widely applied and represent practice throughout Europe  and perhaps internationally?” he said

In response Prof Graham devised a new approach to risk factor audits- SURF, the Survey of Risk Factor Management which can be conducted within 60-90 seconds at routine clinic attendances to minimise selection and participation bias and allows for much more widespread use.

“The pilot study was first only to be carried out in Ireland but several other countries asked to join so now we have 1000 in the pilot study. We have now started Phase 1 in 10 European countries and China has also joined,” he said.

With regard to health planning Prof Graham made reference to two documents which could be put to good use by the Government- the report of the cardiovascular health strategy group Building Healthier Hearts and Professor Hannah McGee’s National Cardiovascular Health Policy.

“These are two wonderful reports which are gathering dust- there is also a raft of evidence which supports universal health insurance. There is a very aspirational but very reasonable Government health Strategy, A Programme for Reform so has logic failed us and if so why?” he asked.

Prof Graham purports that the political process is anathema to any kind of health progress.  “Maybe the problem is Ministers for Health simply can’t be effective within the current system. The EU started out as an economic union dedicated to the promotion of tobacco and saturated fats- it was pretty much anathema to health. There was no legislative framework for health. It is only developing a social conscience very late in the day. It has a central control system which separates power from responsibility. It has a political system which renders problem solving practically impossible. There is an endemic lack of trust. Plethora of vested interests and there is no money,” he said.

According to the expert the political system should carry “a health warning”.

“There is a four year cycle which is anathema to any kind of long term health planning. TD’s are elected democratically but there is no requirement to have any kind of appropriate knowledge, training and skills. The system is supposedly based on debate but if you listen to what goes on in the Oireachtas it is simply combat aggression and point scoring and the casualty is truth, and evidenc- based decision making,” he said.

However, Prof Graham holds health professionals equally responsible for the sluggish pace of health reform in this country, saying they have failed to effectively take on the roll of lobbyists and advocates.

“We have failed as lobbyists and advocates in this country. We are the experts. We believe we are caring professionals so why is Royal College of Surgeons, the Royal College of Physicians the Irish Hospital Consultant’s Association, the Irish Medical Council and the Irish Medical Organisation so silent about health reform? Why aren’t we engaging in the project? If we don’t like it, why aren’t we engaging our power we are on very weak ground in criticising the Government if we don’t engage ourselves in the political process,” he said.

“The villain is the system and the public, the profession and even the Department of Health are the victims of the system. There is an ample evidence base for effective and efficient healthcare and very reasonable healthcare reform proposals but these can not be implemented as things are because of a short-term, adversarial political system, an unwilling Health Service Executive, that seems to want power to distance itself from responsibility and a medical professional that fails to lobby or be advocates for better care not to mention the economic woes and problems,” he added.

Prof Graham proposed these issues could only be resolved with an acceptance of the principles of evidence-based healthcare and an understanding of conflict resolution and avoidance.