End of Life Care Strategy

Introduction
The Liverpool Care Pathway (LPC) was created in the late 1990’s as an alliance between the Royal Liverpool Hospital and the Liverpool Marie Curie Hospice. Designed as a template model utilizing numerous resource locations such as hospitals, care homes, hospices and patients own homes its fundamental vision was to ensure the greatest quality of care for the dying patient in their last moments. The Liverpool Care Pathway first emerged as a template from the Department of Health in 2006 and was championed to reflect the best practice model available for a person entering their first stages of death. The Department of Health released the “End of Life Strategy” consisting of a three-part strategy of which the Liverpool Care Pathway formed an integral component in 2008 and 2009 (LPC, 2009). Initially, the LCP initiative was directed towards the care of cancer patients however has increasingly been utilized for patients entering their last days of life, irrespective of diagnosis (Nursing Times 2005).
The fundamental objective of the LCP is to improve the care the dying patient encounters in their last days or hours of life (MLPCIL, 2009). In a comprehensive, structured outline it identifies key areas including initial and ongoing assessments and after death care, pinpoints the main elements of care such as the physical, psychological, social and cultural aspects and finally how the organization of such a task should be governed, the implementation of which encompasses clinical decision making, management and leadership, learning and teaching, research and development and governance and risk (LPC, 2010).

Identifying the stage at which patients are entering the dying phase can be hard; however the MDT approach to diagnoses is key in instigating this transition of care. This united approach, utilizing interpersonal and inter-professional communication avoids conflicting information to the family and enhances patient care. This crucial and sensitive diagnosis of dying is reached when the multi-professional team agree on two of the following; the patient is bedbound, the patient is semi-comatose, the patient is can only take sips of fluids, and if the patient is unable to consume tablets (Nursing Times 2005).
In the early part of the decade The National Institute for Clinical Excellence (NICE) put forth recommendations to create a “suitably trained workforce” with the aim of providing support and palliative care to cancer patients, their families and other informal care givers. The LCP has since been championed within the National Institute for Clinical Excellence (NICE) Guidance for Supportive and Palliative Care (2004) and recently within the White Paper “Our Health, Our choice, Our Say” (2006) as a pathway for guaranteeing the needs of patients, their informal carers are identified and addressed (Gambles and Ellershaw, 2006).
However the LCP guidelines are “only as good as the teams using it”, the robust and sustained education of health care professionals par-taking in this scheme therefore needs regular evaluation; involving continuous reflection, challenge, vital senior decision making and clinical ability in working for the best interest of the patient (MLPCIL, 2009)..
The interpersonal multi-professional team including doctors, nurses and social workers developed the LCP. Naturally such a profession and the nature of the Liverpool Care Pathway mean this health care provider will be a main target of utilization (LPC, 2009)(Department of Health, 2007).
LCP – Patients and relatives.
The LCP’s generic version 2008 has a relative carer information leaflet/information section within the core documentation. This information ensures relatives are given a sense of reassurance, a feeling of being part of the overall process LCP 2009 (12). Main points of emphasis within the information sheet for relatives highlight communication between doctors and nurses, updates of the patient’s state, involvement in important decision making with the health care professionals and the MDT which are in control. The main points of emphasis for relatives within the LCP highlight communication between doctors and nurses ensure they receive updates of the patient’s state, and are involved in important decision making within the interpersonal health care team. The LCP ensures that relatives and friends of the patient are un-interrupted during special time, when the patient wishes to be left alone or with the company of only family and friends during what they themselves feel as sensitive moments, something otherwise not available in busy hospitals or crowded hospice environments LCP 2009 (12).
The LCP creates a dignified environment of choice in all setting be it a hospital, nursing home, hospice or home care. Recent results from an independent evaluation carried out in Lincolnshire showed deaths at home to be 42% compared to 19% and hospital deaths down from 63% to 45% (Department of Health, 2007)(NHS, 2010).
Patients are transferred to a safer, more comforting environment where they will be the focal point and healthcare professionals who are trained to deal with these sensitive and crucial last moments of life can provide the best healthcare. The LCP takes into consideration all factors the physical aspect of care, psychological, social and spiritual to optimize patient and relative encounters (Constantini and Berraco 2009). Recent quasi-experimental studies looking into how the extent LCP has in improving the quality of communication for patients relatives showed that although it was assessed as the same prior to the intervention of the LCP, the level of bereavement was significantly lower for patient relatives after (Simon and Higginson 2009).A similar study also reflected a similar outcome in the quality of communication however reflected an improvement in both the nurse and relative perspective with the written documentation attributed to death which was seen to increase and the symptoms burdens associated decreases after the LCP was introduced (Veerbeek et al 2008).
Liverpool Care Pathway – community health care professionals.
The responsibility is upon individual organizations to select a “multidisciplinary team” (MDT) of which at the least constitutes a doctor and a nurse however this can be expansive including other healthcare professionals/trained personnel such as community health workers, volunteers and hospice workers. The MDT trained professionals work as part of an organization or are self-employed by numerous types of organizations for example, a charity, or a government entity in providing health care (Gambles and Ellershaw, 2006). Research carried out soon after the LPC implemented and found nurses in the acute hospital setting had a positive opinion of its impact.
The general consensus was that the LCP equated to improvements in symptom control, enhanced nursing care and raised patient and relative profiles (Letter to editor)
A study exploring the perspective of doctors and nurses in the hospice environment towards the LPC also found that the LPC had become an invaluable tool and that they would not consider regressing to a pre-LPC state. The major benefit of the LPC in hospices was that it “streamlined and reduced the documentation of care, allowing them to spend quality time with the patients and relatives during a sensitive phase of care provision. Health care providers within the hospice setting further favored this approach to anything previously due to the ability of the LPC, if adhered to promote consistency through continuous education of the staff (both doctors and nurses) (Gambles and Ellershaw, 2006).
A report published (2009) “Standard Commission of on Carers” which recognized a closer connection had to be formed between plans for the Carers Strategy and other strategy’s related to carers, such and that of the End-of-life Strategy. Methods of identifying and supporting carers within a range of services, including palliative care have emerged as the DoH has created 25 Carers Demonstrator sites (LCP, 2008).
LCP – implementation in other key diagnostic areas.
The implementation of the LCP entering a new environment encompasses a number of fundamental stages, one of which includes the “training of health and social care professionals”. Four key phases have been outlined which reflect the transferable nature of the LCP into other specific diagnostic areas including pediatrics’ neurological conditions, heart failure, advanced chronic kidney disease, intensive care unit and care homes (MLPCIL, 2009).
Giving two examples, pediatrics and heart failure in which the LCP is thought to be a prospective future goal, namely, pediatrics and heart failure, this paper will briefly highlight its implications. The former consists of a multidisciplinary team (MDT) which includes collaborations of the following; a LCP Team UK, an adult hospital specialist palliative care team, a paediatric palliative care team/oncologist and pediatric medical and nursing personnel (LCP, 2008).
A second proposed diagnostic area for the incorporation of the LCP n is laid out in phase 3 – heart failure. Since the introduction of the National Service Framework (NSF) by the Department of Health (DoH) which addresses critical areas of reform concerning the diagnosis, prevention and treatment of coronary heart disease (CHD), the idea of palliative care has gained immense interest from government, statutory bodies and physicians over the past several years (MLPCIL, 2009).
Experts set out to be key in the delivery and execution of the LCP for heart failure and include the following; LCP Central Team UK, Cardiologists, specialist palliative carers, patients and/carers, and the voluntary sector including the British Heart Foundation (BHF) and the National Council for Palliative Care (LCP, 2008).
Benefits of Intensive Palliative care in the form of the LCP.
Generally, a key aspect, which is detrimental to issues surrounding palliative care, is the initiation of diagnosing death. Professionals are reluctant to diagnose dying due to lack of adequate training; the effect is reflected in the transfer of patients to a side-room which can be viewed as a physical and more importantly emotional withdrawal from the patient and family members – an event which predominantly occurs in the hospital setting (Ellershaw and Ward, 2003).
The hospice model of intensive palliative care at this point should in an ideal scenario come into motion and provide psychological, social and spiritual care for all involved, the patient, relatives involved and the health care providers (Ellershaw and Ward, 2003). The LCP pathway should provide health care professionals with the confidence and training to be able to identity and deal with such difficult situations.
LCP – possible areas of concern and areas of improvement.
Problems with the integration of LCP into Pediatric involve the relative inexperience of health care professionals and their in-exposure to caring for the dying child and their families. This inexperience and lack of knowledge in knowing how to deal with circumstances of near death in children result in feelings of apprehension and discomfort in coping mechanisms faced by community health care professionals working in this intense emotional setting surrounding dying child patients (Sahler et al, 2000).
Possible ways of addressing these issues involve investing in training health care students, both doctors and nurses, to manage the adverse feelings and emotions associated with the death of a child. This training can be achieved through preparing professionals for possible negative outcomes and encouragement in incorporating palliative care into their delivery approach adhering to guidelines set out in the LPC. These measures will enable and ensure health care providers are more competent and empowered to deal with the burdens of death in the emotionally charged pediatric environment (Sahler et al, 2000) (MLPCIL, 2009).
As nurses are essential in the implementation of the LCP, the problem of nurse shortages in the UK is an important concern. An ageing population, advances in technology and the expectations of having to deliver exceptional patient care have caused difficulties in recruitment and pose a burden on those already working within the community health service (Ingleton et al, 2009).
Nurses are faced with a difficult decision as most opt to work with healthy patients, or those who will recover. Palliative nurses requires a different ethical approach, one that tests personal abilities of those involved, and also means they must undergo intensive education. This poses a challenge for nurses working to implement the LCP, as they also have to balance their professional life with family responsibilities, the stress of having to continuous insecurity of finding funding post qualifying professional qualifications for specialist areas of nursing such as that of palliative care. In essence it is the nurses that are present at the bedside delivering the LCP intervention which affect the care aimed at the patients and family (Ingleton et al., 2009)(Nursing Times 2010a).
A key issue concerning the LCP is also the identification of patients nearing end of life by acute sector workers. A strategy in the form of the AMBER (Assessment, Management, Bets practice, Engagement of patients and carers, for patients whose Recovery is uncertain) has been developed by St Thomas’ Hospital and is currently being modeled in four NHS trusts (Glasper 2010).
A recent Dutch study has surfaced weaknesses in the selection criteria and suggests patients such as those suffering from chronic illnesses such as dementia would technically be eligible, and these are individuals most at risk at being put on such pathways without palliative care advice. (Reitjens et al, 2008). This study has certainly highlighted the immense importance surrounding the decision making of the MDT concerning the diagnosis of death and with the area already being one of controversy, i.e. as mentioned earlier the reluctance of health professional to diagnose death, can further be detrimental to the advancement of the LCP into the other diagnostic fields. However it will no doubt ensure a greater degree of communication, education and contemplation will take place in these environments.
Another area of concern comes with the research surrounding palliative care as only a finite number of studies have been carried out to assess the effectiveness of end of life care pathways, on symptom severity and quality of life for those dying and the family members. It is an area which lacks any randomized control trials and therefore it is essential future study designs aim towards assessing and evaluating if and how clinical pathways are effective to the outcome for end of life care (Nursing Times 2010a).
Conclusion
The Liverpool care pathway has had immense implications on the health care profession, in particular those, which deal with patients in a sensitive environment where the last days of life are managed in a more structured, positive way.
Since its advent few experimental studies into the effectiveness of the pathway have found it to be to productive and the overall success or areas of improvement has so related to creating a more peaceful, efficient and positive environment for all those involved in the process (Constantini and Berraco, 2009).
Proposed changes in the divergence of the LCP into other areas will begin to emphasize the need for excellent communication within those who encompass the MDT. It will also require adaptability in an otherwise un-structured area of palliative care giving. It is envisaged this transfer of practice from settings such as that of hospices and hospitals to other more comforting settings such as the patient’s own home for all patients including non-cancer patients will be a major challenge and a prospective area for development (Ellershaw and Ward 2003). Worrying a recent article (Nursing Times 2010 (b))has revealed that only 25% of funds that were given to primary care trusts by the government were spent on direct nursing provision for patient care at homes. This was raised as a major concern by the head of Macmillan Cancer Support, who also said that 8% of money which was directed towards 24 hour services was unsubstantial. The National End of Life Care Network, showed a geographical inconsistency with the proportion of care patients receive around the United Kingdom, describing it as “disease lottery”. This is an obvious flaw and should not be projected onto the future if this pathway is to achieve is optimum effectiveness across the country.
It is difficult therefore to assess such a measure, which is only in its infancy, it shall take a number of years to conclude the impact the LPC has had and is having on the community health care works. The key areas of the LPC have been highlighted, with the emphasis on the main aspects of the LPC, patients, relatives and most importantly those that at the forefront in proving this care being explored. With LPC moving into other areas, including neurology and cardiology the future for community health care professionals shall be very diverse and interesting. It remains to be seen if the LCP continues to be a success and what amendments shall be introduced affecting all encompassed within the framework.
References (part a)
Constantini M., Berraco (2009), Health Services Research on End-of-life Care, Current Opinion in Supportive and Palliative Care, p. 194.
Department of Health (2007), LPC Generic Version
Dept of Health, (2009), New Version LPC, Version 12,
Department of Health, NHS, (2010), End of Life Care Strategy, Second Annual Report.
Ellershaw. J and Ward, C. (2003) Care of the dying patient: the last hours or days of life, BMJ, pp. 30–34
Gambles, M., Stirzaker. S, Jack B. A., Ellershaw. The Liverpool Care Pathway in Hospices: an explanatory Study of Doctor and Nurse Perceptions, International Journal of Palliative Nursing, 2006;No 9, pp. 414-421.
Glasper. A. The Governments eight-point plan for improving end-of-life care. British Journal of Nursing, 2010; Vol. 19, No 18. P 1194-1196.
Ingleton. C, Gott. M., Kirk. S. Editorial: The beginning of the End (of Life Care Strategy), Journal of Clinical Nursing, 2009; Vol. 18, pp. 935-937.
LCP, (2006), The Liverpool care Path in hospices: an explanatory study of doctors and nurses perceptions
LCP, (2010), What is the Liverpool Care Pathway for the Dying patient (LCP), Information for healthcare professionals, Marie Curie Palliative Care Institute: Liverpool
LCP, (2008), End of Life decision making for cancer patients in different clinical settings and the impact of the LCP. Palliative Medicine, 22 (2), pp. 145-51
LCP 2009 (12) – Liverpool care pathway for the dying patient (LCP) supporting care in the last hours or days of life. LCP Generic version 12, December 2009.
Letter to Editor. Liverpool care pathways carers’ survey. Palliative Medicine 2009; 00: 10-2.
MLPCIL, Marie Curie Palliative Care Institute: Liverpool (2009), LCP transferability into specific diagnostic groups. Briefing Paper, Marie Curie Palliative Care Institute: Liverpool.
Nursing times 2005 – “Improving practice with the Liverpool Care Pathway”: http://www.nursingtimes.net/nursing-practice-clinical-research/improving-practice-with-the-liverpool-care-pathway/203693.article
Nursing Times 2010 (a) – “Do end of life care pathways improve symptoms and quality of life for patients and family” – http://www.nursingtimes.net/nursing-practice-clinical-research/clinical-subjects/palliative-care/-do-end-of-life-care-pathways-improve-symptoms-and-quality-of-life-for-patients-and-families/5016161.article
Nursing Times 2010 (b) – End of life care is compromised as “crucial” services are denied funds. http://www.nursingtimes.net/whats-new-in-nursing/primary-care/end-of-life-care-is-compromised-as-crucial-services-are-denied-funds/5018738.article
Rreitjens. J, van Delden. J, Onwuteaka-Philipsen. B, Buiting. H, van der Maas. P, van der Heide. A. Continuous deep sedation for patients nearing death in the Netherlands: descriptive study. British Medical Journal 2008; 336:810-1.
Sahler et al, (2000), Medical Education about the end-of-life care in the paediatric setting. Principles, challenges and opportunities, Paediatric, pp. 575-584
Simon. S and Higginson. IJ. Evaluation of hospital palliative care teams: strengths and weaknesses of the before-after study design and strategies to improve it. Palliative Medicine 2009; 23-28.
Veerbeek. L. Van der Heide. A, de Vogel-Voogt E et al. Using the LCP: bereaved relatives’ assessment of communication and bereavement. Am Journal Hospital Palliative Care 2008; 25: 207-214.
b) Discuss how effective UK policy has been in meeting long-term needs of patients with coronary heart disease.
Introduction

This essay shall focus on three major points to address this issue, coronary heart disease, cardiac rehabilitation both in the UK and briefly will touch upon progress made in Europe of which the UK is affiliated and UK policy concerning the long term care of patient with Coronary Heart Disease. Coronary heart disease (CHD) accounts for the largest cause of morbidity and mortality in the UK and the majority of nations within Europe (Khunti et al., 2007) (Mera, 1997).
CHD along with stroke is one of the principle causes of cardiovascular disease (CVD), latest figures show CVD cause over an estimated 190,000 deaths within the United Kingdom, of which CHD is accountable for almost 46%. Singularly CHD is the most frequent cause of death, with statistics from 2008 showing 1 in 5 male deaths and 1 in 8 female deaths totaled 88,000 deaths in the UK. Recent data also shows CHD presents as the most common source of premature deaths in the UK, causing over 28,00 deaths. Statistics collated by the British Heart Foundation data also reflect regional, national and socioeconomic variances, a primary concern when attempting to address this fatal disease (British Heart Foundation, 2010). CHD culminates as results of the pathological conditions known as atherosclerosis and thrombosis (Medline, 2010).

Coronary heart disease (CHD)
Pathology
Atherosclerosis is most often initiated with endothelial damage due to high blood pressure of inflammation, which goes on to affect plasma lipoproteins levels (high and low density lipoproteins (HDP/LDL’s) and their inclination for oxidation. Atherosclerosis causes vasoconstriction of blood vessels, which supply the heart and occur when fibrofatty plaques accumulate in the intimal layer of the arterial wall, known as “atherosclerotic plaques/atheroma” causing them to both thicken and harden, frequently becoming calcified and protrude into the arterial lumen. This fibrofatty plaque build-up adversely affects the luminal radius, by narrowing it this leads to such conditions as angina, dyspnoea, acute myocardial infarction, heart failure and other related cardio-respiratory symptoms (Mera, 1997)(Medline, 2010). The secondary process of thrombosis arises as result of the atherosclerotic plaque, which becomes partially disconnected due to high blood pressure breaking from within the endothelium of the arterial vessel associating itself directly with the blood flow. This thrombus may go onto to further occlude the artery due to its unsmooth surface allowing for nearby blood platelets to adhere resulting in fibrin deposit, which entraps red blood cells forming the “thrombus/clot” or is transported via the bloodstream into the arterial network in the form of an embolus (Mera, 1997)(Hall, 2006).

Risk factors
The risk factors for atherosclerosis of which CHD is the most common manifestation come in various categories consisting of non-modifiable, partially modifiable and modifiable. Non-modifiable risk factors include; age, gender, race, a genetic predisposition in the form of familial hypercholesterolemia, familial mixed hyperlipidaemia, familial type III hyperlipoproteinaemia, familial lipoprotein lipase deficiency and familial apo-CII deficiency. Partially modifiable risk factors encompass the some of the following; secondary hyperlipidaemia, diabetes, hypothyroidism, chronic renal failure, obesity, hypertension and personality type and behavior. The final category of modifiable risk factors amongst which include; cigarette smoking, physical exercise and diet (Mera, 1997).
Diagnosis
Numerous tests are available to diagnose CHD, such test include a variety of imaging techniques such as ultrasound (intravascular ultrasonography), magnetic resonance imaging (MRI)-angiography, computerised tomography (CT) angiography. Echocardiography is utilized to hear sound waves reflected as images of the heart, electrocardiography (ECG), Angiography, a common diagnostic tool in which a contrast medium in injected via a catheter, usually into the femoral artery to display continuous images of the beating heart and blood flow by X-ray fluoroscopy. Other tools used are testing for biochemical markers; these are enzymes specific to certain time periods and reflecting certain pathologies such as the release of creatine kinase and lactate dehydrogenase from dying cardiac muscle (Medline, 2010)(Hall, 2006).
Treatment of CHD
The uses of lipid lowering drugs, which aim to reduce LDL cholesterol levels to 100mg/dL or less and possibly lower in some, affected patients in order to slow down the buildup of atheromas (Mera, 1997). Surgical procedures are employed in advanced cases of angina and include bypass surgery, coronary artery angioplasty and coronary stenting (British Heart Foundation, 2010). The first line therapy for angina is the administration of nitrates. Myocardial infarction is treated with the mina objective to restore myocardial perfusion and include some of the following interventions; coronary angioplasty is the immediate choice closely followed by thrombolytic treatment, aspirin therapy and anticoagulation therapy and combinations of other drug therapies are commonly utilized as a long-term aid. Finally diuretics and vasodilators are the chief treatment options for heart failure (Mera, 1997) (Medline, 2010).
An important area of treatment distinguishable from primary intervention is known as “secondary prevention/cardiac rehabilitation (CR)” and will be discussed in great depth in the following sections. (Mera, 1997).
Cardiac Rehabilitation –UK measures.
For this purpose of this paper, the terms “secondary prevention” and “cardiac rehabilitation (CR)” are synonymous terms, the latter (CR) shall be used in the remaining sections. Cardiac rehabilitation refers to a process through which patients suffering from ischemic heart disease are encouraged to develop their maximum physical, emotional, social, vocational an economic condition. This outcome is usually achieved through a multidisciplinary teamwork usually led by a medical director; via a combination the best services available (World Health Organization, 1993). Comprehensive CR is thought to be the most effective method in reducing cardiovascular risk and is the most attractive long-term care of cardiac patients and patients who display numerous coronary risk factors (Giannuzzi et al., 2003). CR is divided into a three-part strategy as laid out by the WHO; (I) the acute phase (II) the reconditioning phase and (III) the maintenance phase. It is the second phase which following the acute heart attack, which sees the integration of the multidisciplinary program that collates knowledge and skills from medical treatment, patient education, exercise training and counselling for CHD patients (Vanhees et al., 2000).
Since the British Cardiac Societies report in 1987, significant amounts of research within the field of cardiovascular research, has identified numerous benefits of lifestyle changes and secondary interventions in the control of coronary risk factors (Aspire, 1996). This was championed by the British Heart Foundation (BHF), which as a result provided financial investments to generate new cardiac rehabilitation programmes. In 1999/2000 64 applications were put forth and of which 11 awards were given to fund new innovative projects, since 1989-1999 approximately 133 awards have been approved at a cost of an estimated ?3.5 million (Fearnside et al., 1999).

ASPIRE

To reflect the important nature and incorporate academic findings into clinical practice a workshop took place in the UK with the aim to highlight strategies beyond symptom relief with medical treatment and revascularisation in order to decrease the risk of (re) infarction and enhance survival, this committee was termed “ASPIRE” (Action on Secondary Prevention through Intervention to Reduce Events). Four main aims were the focal point of this committee; a) to measure the number of coronary patients in the UK, eligible for secondary preventative measures, b) determine what major risk factors are recorded in patients medical history notes, such as cigarette smoking, obesity, hyperlipidemia, c) to interview patients within at least months post hospital admission to measure their risk factors and describe risk management and finally d) to determine if other family members, where suitable have been properly advised for coronary risk factor screening The outcome of this survey indentified key areas of improvement and in attempts to reduce further and consequent incidences of morbidity and mortality (Fearnside et al., 1999). .
UK: Department of Health – Frameworks put in place
The National Service Framework (NSF) for Coronary Heart Disease (CHD) was laid out in 2000 by the Department of Health (DoH) and established clear standards for the prevention and treatment of CHD to improve quality and access to care. Cardiac rehabilitation was a key area addressed, emphasizing the need to initiate CR as soon as the patient is admitted to hospital from Phase I through to Phase III and even extend to a long-term maintenance Phase IIII. Three milestones were laid out in the NSF (i) By October 2000, every hospital should have an “effective means for setting hospital-wide clinical standard…”(ii) by April 2001, every hospital should have “an agreed hospital-wide protocol for the identification, assessment and management of people likely to benefit from CR” and (iii) by April 2002, every hospital should have “clinical audit data no more than 12 months old describing all items listed in bold in paragraph 60”, (page 12, paragraph 60 in bold)” (Department of Health, 2000). The NFS was further enhanced with the advent of the NHS Improvement Plan in 2000 with the aim to further reform and invest in transforming the NHS with dramatic improvement in key areas including CVD treatment/rehabilitation. This UK policy is set to be achieved through the collaborated efforts of the Primary care trusts (PCTs), NHS Trusts (including ambulance an tertiary centers), and local networks of cardiac care. Since the NFS began, every year amendment have been addressed the current available NSF is 2009 and available for the DoH (Department of Health, 2004)(Department of Health, 2000).
Other UK policy frameworks have also complimented the improvement in long-term care for patients with CHD, included the Quality of Outcomes Framework (QOF) set up in 2004, which aims to gather information in order r the NHS Board to organize serviced which revolve around patients needs. With the emerging evidence that patient management with long-term conditions can prevent future adverse events and reduce hospital admissions the government is investing a lot of energy into providing the best service (NHS, 2004).
Cardiac Rehabilitation – cost effectiveness
In the mid 90’s in England and Wales the cost of CR was estimated to be per patient- session at around ?47 and at ?370- per patient per programme, this figure was much favored over the costs of hospital re-admission for patients with acute MI or an ischemic heart episode which were close to or in excess of ?2000, this cost effectiveness continued into 2000 (Department of Health, 2000) (Gray, 1997).
As part of the CR programme and evidence that cardiac liaison nurses, who can further improve patients lives can provide an essential bridge between primary and secondary care, the BHF also funded almost 50 new cardiac liaison nurses entering 2000, a certain aide to enhancing long term-term available care for CHD sufferers (Fearnside et al., 1999).

Improvements to long term care for CHD Patients as result of UK Policies.
There has been a decrease seen mortality rates since the 1970’s in the UK, with CVD mortality rates for individuals under 75 years, falling by 44% within the last decade. This has been attributed to the effectiveness of cardiological treatments and risk factor trends accounting for the decline in CHD mortality in England and Wales between 1981-2000. 58% of this mortality rate decline in Britain was suggested to be as result of reductions in the main risk factors, which primarily involved smoking. Treatment of patients with secondary prevention (i.e. CR) was the cause of the remaining 42% decrease in mortality rate. Within Europe the UK has one of the fastest rates of mortality decline in CVD (British Heart Foundation, 2010).
Cardiac rehabilitation – European measures
Bases on the UK ASPIRE study, the rest of Europe soon followed this initiative and in 1995-6 the European counterpart survey known as “EUROASPIRE 1” was carried out in nine of the European countries, which included; Czech Republic, Finland, France, Germany, Hungary, Italy, the Netherland, Slovenia and Spain. This work was as result of the collaboration of three of the major societies within Europe; European society of cardiology (ESC), European Atherosclerosis Society (EAC) and the European society of Hypertension (ESH) (Euroaspire, 1997).
Since the establishment of this survey the advent of EUROASPIRE II has evolved including UK, Greece, Ireland and Poland totaling 15 countries. Participating centres within UK included ones in Hull (Castle Hill and Hull Royal Infirmary) and London (Charing Cross Hosp, Hammersmith Hosp, Central Middlesex Hosp and West Middlesex Hosp). This study in 1999-2000, showed the UK centres reported the following statistics on risk factor history on admission and measurements of risk factors seen in patients; Smoking 97%, hypertension 87.9%, hyperlipidemia 69.2%, diabetes 87.7 %, weight 71.4 %, height 47.7%, blood pressure 98%, total cholesterol 65.1 % HDL-cholesterol 22.6% and triglycerides at 48.7%. The reported lifestyle advice given to patients in the UK to reduce risks of CHD and to take part in CR were as follows; stop smoking 63.5%, lose weight 50.3% special dieting to reduce blood pressure 8.6%, special diet to reduce blood cholesterol 32.7%, exercise 34.3 % and cardiac rehabilitation recommendations 35.4% (Euroaspire, 2001).

CVD – UK principle targets for the future
To summarize the main targets remain in England, Wales Scotland and Northern Ireland:
England, to “reduce CHD in patients less than 75 years by at least 2/5 by 2010, saving 200,000 lives and to reduce inequality gaps in death rates for CHD, stroke and related diseases between the fifth of areas with worst health and deprivation indicators and overall population in people under 75 years by 40% in 2010 (British Heart Foundation, 2010).
Wales – “reduce CHD mortality rates in 65-74 year olds for every 600/100,000 in 2002 to 400 per 100,000 in 2012 and to improve CHD mortality in all socioeconomic groups simultaneously for a more rapid improvement in neglected areas (British Heart Foundation, 2010).
Scotland- the aim is to “reduce mortality rates form CHD patients under 75 years by 60% between 1995 and 2010 and to reduce death rate from CHD in those aged under 75 years located in the most deprived regions. Finally no targets for Northern Ireland (British Heart Foundation, 2010)

Conclusion
It is evident to suggest that UK policy over the years since the mid 1980’s have reflected in studies carried out suggesting the huge benefit of secondary prevention/cardiac rehabilitation in the long term care of patients with CHD. Financial investments from the Department of health alongside the British Heart Foundation over the past three decades had resulted in a decline in the mortality and morbidity of one of the leading causes of death worldwide. As the UK are integrated into the European standard of care, UK policy not only has the benefit of Cardiology Societies within the UK but also benefits from knowledge, information and data analysis’s across the rest of Europe with the aim to further improve patients quality of life. There has been encouraging steps, improvement and refinement seen in the form of the NSF and the QOF, not only in ensuring the reduction of mortality rates but also to maintain a fair socioeconomic climate treating all CHD patients across the UK to the best and most effective care available. This paper hopes to have highlighted a positive outlook, based on the abundant evidence of UK policy reflected in statistical data in its attempts to alleviate mortality and to improve, assist and enhance long-term prospects for patients suffering from CHD.
References (part b)
Aspire, (1996), A British and Cardiac Society survey of the potential for the secondary prevention of coronary disease: Action on secondary prevention through intervention to reduce events, Heart, vol. 75, pp 334-342
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Euroaspire, (1997), A European Society of Cardiology survey of secondary prevention of coronary heart disease, European Heart Journal, vol. 75, pp. 334-42.
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