Towards a National Action Plan for Heart Attack and Stroke

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1 PRE-BUDGET SUBMISSION FEDERAL BUDGET Saving lives Reducing avoidable hospital admissions Towards a National Action Plan for Heart Attack and Stroke Joint policy proposals from the National Heart Foundation of Australia and the National Stroke Foundation January 2013

2 Towards a National Action Plan for Heart Attack and Stroke Executive Summary While there has been significant progress over the past five decades, cardiovascular disease (CVD) - heart, stroke and vascular disease - remains the leading cause of death in Australia, the most expensive disease group in terms of direct healthcare costs and a major cause of avoidable hospital admissions and disability. Despite the immense social and economic costs caused by this leading disease group, there is no funded, national action plan to improve outcomes. A national action plan has the potential to significantly reduce the impact of CVD in Australia, the toll it takes on the Australian people and the health budgets of federal, state and territory governments. This submission on Federal Budget priorities sets out a series of evidence-based policies to drive down the impact of cardiovascular disease on the community. Summary of policy proposals Prevention: stopping disease before it starts 1. Empower Australians to identify and manage their health risk Fund Know your numbers, a community and pharmacy based health check program looking at the risk of heart disease, stroke and diabetes.. 2. Integrated health checks in primary care Introduce an integrated health check in general practice to assess for risk of CVD, type-2 diabetes and chronic kidney disease. 3. Link to Health: Linking patients at high risk of chronic disease with appropriate lifestyle modification programs Link patients at high risk of chronic disease with appropriate lifestyle modification programs. 4. End investment in tobacco companies via Australian Government agencies and investment funds 5. Reform alcohol taxation Reform alcohol taxation measures to reduce the future health costs. Investment $16.5m over three years Potentially cost-saving $2m a year for three years No cost Revenue More than $1,000m a year 6. Supercharge food reformulation Expand the life-saving work of the Australian Government s Food and Health Dialogue to reduce salt, fat and sugar content of the food supply. $2m to $5m a year 7. Renew the Healthy Communities Initiative Renew the two expiring national programs supporting the Healthy Communities Initiative: Heart Foundation Walking and Heartmoves. $0.6m a year 8. Boost participation in walking, cycling and public transport $50m a year 2

3 Clinical care, rehabilitation 9. Increase eligibility for time-critical stroke treatment Fund the FAST social marketing campaign to increase awareness of the signs to increase numbers of people getting hospital quickly for treatment. $6.5m over three years 10. National cardiac procedures register Establish a national cardiac procedures register to improve quality, enable rapid recall for implantable high-risk devices, and enhance outcomes for patients. 11. Stroke care improvement Establish data collection and quality improvement activities that will monitor and improve stroke care in Australia. 12. Boost access to cardiac rehabilitation Improve access to cardiac rehabilitation programs, reducing the chance of heart attack patients having further cardiac events. 13. Close the Gap for Indigenous heart attack patients in hospitals Help close the life expectancy gap by improving in-hospital interventions for Indigenous people suffering heart attacks, achieving this through the development of accountability measures for all hospital services. 14. Stroke Care Improvement Fund Establish a competitive fund to increase access to stroke unit access and to thrombolysis treatment. 15. Providing care and support for stroke survivors Fund a program of follow up and early intervention post discharge to the community to ensure stroke survivors and carers are connected to services, training and information to maintain independence and wellness in the community. $2.5m a year $21m over three years $30m a year $0.9m a year $100m over three years $21m over three years Research, data and monitoring 16. Update burden of disease data for Australia The Australia s Burden of Disease study is almost a decade old and the study needs to be re-done as a priority. 17. Fund research into rehabilitation and emotional and psychological support for stroke survivors $1m a year $33m over three years 3

4 Heart attack and stroke: The facts Cardiovascular disease (CVD) 1 is the leading killer of Australians: 46,000 deaths (31.7% of all deaths) in CVD is the most expensive disease group: $7.9bn or 11% of direct healthcare expenditure a year 3 CVD accounts for a large number of potentially preventable hospitalisations Strokes cost Australia an estimated $2.1bn a year 4 The direct health costs of heart attacks is estimated at $1.1bn a year Total economic cost of CVD is estimated to be $15.5bn a year 5 CVD comprises 18% of the total disease burden in Australia 6 There are an estimated 3.7m Australians with long-term CVD 7 1.4m Australians have a disability associated with CVD 8 Australians will suffer around 50,000 new and recurrent strokes each year 9 CVD death rate in rural/remote areas is 1.4 times higher than in major cities 10 Addressing lifestyle factors can reduce mortality risk by 66% 11 Deaths and disability adjusted life years (DALYs) by disease Deaths DALYs Conditions Number % of total Number % of total Ischaemic heart disease 22, , Stroke 8, , Hypertensive heart disease 1, , Bowel cancer , Breast cancer , Diabetes 1, , All other causes 16, , Total attributable 52, , Source: Vos T, Begg S. (2003) The burden of cardiovascular disease in Australia for the year Heart disease and stroke, together with vascular disease, are collectively known as cardiovascular disease (CVD) 2 Australian Bureau of Statistics (2012) Causes of death Australian Institute of Health and Welfare (2012) Australia s Health Cadilhac D, Dewey H. et al (2005) Investing in Stroke What are the potential cost offsets from the Strokesafe program, National Stroke Research Institute Technical Report (Unpublished) 5 Access Economics (2009) The economic costs of heart attack and chest pain 6 Vos T, Begg S. (2003) The burden of cardiovascular disease in Australia for the year 7 Australian Bureau of Statistics (2012) National Health Survey Australian institute of Health and Welfare (2009) Impact of falling cardiovascular disease death rates: deaths delayed and years of life extended. Bulletin 70 9 Australian Institute of Health and Welfare (2006) How we manage stroke in Australia 10 Australian Institute of Health and Welfare (2011) Cardiovascular Disease Australian Facts Loef M, Walach H. (2012) The combined effects of healthy lifestyle behaviours on all cause mortality: A systematic review and meta-analysis, Preventative Medicine 4

5 Towards a national action plan for heart attack and stroke Heart, stroke and vascular disease collectively known as cardiovascular disease (CVD) remains the leading killer of Australians. While mortality rates have been in decline for several decades, CVD still causes one-third of all deaths (31.7%), is a leading cause of the total burden of disease in Australia (18%), and imposes massive social and economic costs, comprising 11% of total direct healthcare expenditure. The number of people with CVD is set to increase as the population grows, ages, becomes increasingly overweight and obese and some risk factors, such as poor nutrition, lack of physical activity, high blood cholesterol and high blood pressure, continue at alarmingly high rates. Common risk factors for selected chronic diseases and conditions 14 Conditions Tobacco smoking Behavioural Physical activity Alcohol misuse Nutrition Obesity Biomedical High blood pressure High blood cholesterol Ischaemic heart disease Stroke Type 2 diabetes Kidney disease Arthritis (A) (B) (B) Osteoporosis Lung cancer Colorectal cancer Chronic obstructive pulmonary disease Asthma Depression Oral health (A) Relates to rheumatoid arthritis (B) Relates to osteoarthritis Importantly, much of the burden of cardiovascular disease is avoidable around 80% in the case of coronary heart disease. Many of the risk factors can also be prevented, including high blood pressure, high blood cholesterol, lack of physical activity, smoking, overweight/obesity and poor nutrition. A comprehensive series of measures has the potential to save lives, reduce costs and curb avoidable hospital admissions. The need to better tackle CVD was acknowledged when it was designated as a national health priority area in Subsequently, all health ministers agreed to a National Service Improvement Framework for Heart, Stroke and Vascular Disease in This was a key part of the national approach to improve health services for chronic disease under the National Chronic Disease Strategy. 12 Australian Bureau of Statistics (2012) Causes of death Vos, T & Begg, S. (2003) The burden of cardiovascular disease in Australia for the year 2003, Centre for Burden and Costeffectiveness, University of Queensland School of Population Health 14 Australian Government (2010) Taking Preventative Action, A Response to Australia: The healthiest country by 2020, A report of the National Preventative Health Taskforce 15 Vos, T & Begg, S. (2003) The burden of cardiovascular disease in Australia for the year 2003, Centre for Burden and Costeffectiveness, University of Queensland School of Population Health 16 Australian Institute of Health and Welfare (2009) Impact of falling cardiovascular disease death rates: deaths delayed and years of life extended 5

6 While the CVD Framework sets out critical intervention points and priority areas to address CVD, no implementation plan was developed and no funding provided to ensure the proposed outcomes could be achieved. Implementation was left to state and territory governments. Eight years after the CVD Framework was agreed, there is still no funded national action plan to reduce risk, improve early intervention and drive improvements in outcomes for patients. Such a plan would also help contain future costs for governments. It will also help address significant gaps in the current approach to CVD. These gaps occur in current approaches to prevention, treatment and care of people with, or at high risk of developing CVD. Addressing these gaps will reduce the number of people who have heart attacks and strokes and who die prematurely from these acute events. Better quality and access to care will improve health outcomes, reduce costs and ease the pressure on our hospitals. While there is no funded action plan for CVD, other national health priority areas have received attention by federal governments over the past few years. As the table below shows, targeted funding for CVD programs, above and beyond MBS/PBS, hospital payments and research, remains alarmingly low. National Health Priority Area Program funding 17 Burden of disease 18 Total deaths to Cardiovascular disease $0.0086bn 18.0% 31.7% Cancer $2.5bn 19.0% 30.2% Mental health $1.4bn 13.0% 4.9% Diabetes $1.6bn 5.0% 2.7% The concept of a national action plan already has strong support from stakeholders including state and territory governments. The Review of Cardiovascular Disease Programs (Birch Review) commissioned by the Federal Department of Health and Ageing and released in 2011, found: There is strong support across jurisdictional and non-government stakeholders for the formulation of a national action plan for CVD. The need for action plans at the national, state/territory and local level was also spelled out in the current National Chronic Disease Strategy, endorsed by health ministers in In many ways, cardiovascular disease can be considered Australia s most costly disease. It costs more lives than any other disease and has the greatest level of health expenditure. Australian Government s commitment to address NCDs In 2011, the Australian Government became party to the declaration of the UN High Level Meeting on Non-Communicable (chronic) Disease. This declaration focused the attention of member states on the need for action to tackle four leading killers - cardiovascular disease, cancer, diabetes and lung disease. 17 Commonwealth of Australia Department of Health & Ageing, Senate Estimates answers, October Australian Institute of Health and Welfare (2012) Australia s Health Australian Bureau of Statistics (2012) Causes of death

7 The declaration called for all states to develop national action plans on these four major disease groups. The declaration states: Promote, establish or support and strengthen, by 2013, as appropriate, multi-sectoral national policies and plans for the prevention and control of non-communicable diseases, taking into account, as appropriate, the WHO Action Plan for the Global Strategy for the Prevention and Control of Non-communicable Diseases, and the objectives contained therein and take steps to implement such policies and plans. 20 Bangladesh, North Korea and Papua New Guinea are among 84 nations across the globe that have plans or programs that specifically target CVD. 21 While Australia does well in some aspects of its response to cardiovascular disease, we still lack a funded national action plan to drive comprehensive improvements in patient care. Nor do we include CVD in a funded, national program to address chronic disease. This is a glaring omission that could be addressed by adopting a funded national action plan embracing cost-effective, or cost-saving measures outlined in this submission. Reducing avoidable hospital admissions Cardiovascular disease - including heart attack, stroke, heart failure, angina, vascular disease and hypertension - is a major cause, if not the leading cause, of potentially preventable hospitalisations. The Atlas of Avoidable Hospitalisations in Australia (2007) examined admissions in resulting from ambulatory care-sensitive (ACS) conditions - excluding heart attack and stroke, but including angina, hypertension and heart failure. 22 It showed: 552,000 admissions were potentially avoidable (8.7% of all admissions) Almost two-thirds of hospital admissions for ACS conditions are attributable to chronic conditions, just over one-third to acute conditions and a small proportion (3.0%) to vaccine-preventable conditions. Admissions for chronic conditions as % of all avoidable hospitalisations CVD and respiratory conditions 34.0% Complications of diabetes 25.6% Chronic obstructive pulmonary disease 9.9% Angina 9.0% Congestive heart failure 7.7% Asthma 7.4% If heart attack and stroke were to be included in this definition, particularly those cases deemed preventable through population health interventions as well as those that are ambulatory care sensitive, (ie avoidable through better management in primary care) the results are likely to show that CVD would be the single largest cause of avoidable admissions. 20 UN General Assembly (2011) Political Declaration of the High-Level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases 21 World Health Organisation (2011) NCD country profiles 22 Page A, Ambrose S, Glover J, Hetzel D. (2007) Atlas of avoidable hospitalisations in Australia: ambulatory care-sensitive conditions, University of Adelaide 7

8 One New Zealand study of avoidable admissions at Christchurch Hospital found that CVD was by far the largest category of potentially avoidable hospitalisations, comprising 47% - or nearly half - of avoidable admissions in the study period (2003). 23 Heart failure has high rates of readmissions, with one recent US study showing that readmission rates for congestive heart failure ranged from 11% to 32%. 24 There are significant quick wins to be gained through measures to reduce avoidable CVD admissions, including: establishing a national cardiac procedures register introduce a community and pharmacy based health check program looking at the risk of heart disease, stroke and diabetes introducing an integrated health check in general practice to detect and manage people at high risk of developing heart, stroke and kidney disease and type-2 diabetes increasing the number of patients accessing cardiac rehabilitation programs. Achieving change through national partnership agreements Federal, state and territory governments are increasingly working together to drive reform in specific health areas through National Partnership Agreements. These harness federal funds to provide facilitation and reward payments against agreed milestones and targets to address specific reform priorities, such as bowel cancer screening, sub-acute care and hospital admission times. National Partnership Agreements - either bilateral or multilateral - could be used to address serious gaps in cardiovascular services, improve health outcomes and reduce avoidable hospital admissions. Areas in which partnership agreements could be used to improve quality and better manage costs include: Cardiac rehabilitation improving low access and completion rates Multi-disciplinary heart failure programs improving quality and access Reducing time to treatment for people suffering heart attack and stroke Stroke units ensuring all hospitals that should have a stroke unit, actually have them. 23 Sheerin I, Allen G, Henare M, Craig K. (2006) Avoidable hospitalisations: potential for primary and public health initiatives in Canterbury, New Zealand, New Zealand Medical Journal 24 Epstein A, et al (2011) The relationship between hospital admission rates and rehospitalisations, The New England Journal of Medicine 8

9 Areas for future action The Heart and Stroke Foundations while not advancing specific proposals at this stage call on the Australian Government to prepare to take action and develop policies to address three specific issues, including: extending the Close the Gap initiative for Indigenous health beyond current commitments facilitating the extension of universal ambulance cover beyond Queensland and Tasmania to cover all Australians preparing for the second phase of the two-step increase in tobacco taxation, as proposed by the Heart Foundation and Cancer Council in their joint submission to the Henry Tax Review. Continued funding to Close the Gap in Indigenous Health The Australian Government deserves high praise for its leadership and commitment to closing the life expectancy gap between Indigenous and non-indigenous Australians. This includes measures advocated by the Heart Foundation, such as substantial funding for Indigenous tobacco control programs, a strategy to address acute rheumatic fever/rheumatic heart disease, expansion of the Medical Specialist Outreach Assistance Program and support for chronic disease management and prevention. If Australia is to successfully and quickly close the gap in life expectancy between the Indigenous and non-indigenous populations, it must concentrate on areas where the biggest gains can be made. These must include the continuation of specific measures to improve prevention of chronic disease and the management and care of people with cardiovascular disease. Funding for the Indigenous Chronic Disease Package, in particular tackling chronic disease risk factors like smoking, poor nutrition and lack of exercise needs to continue beyond June Tackling smoking in one area that substantial gains can be made. The Australian Government has displayed outstanding leadership in the way it has allocated significant funding to address disturbingly high smoking rates among Aboriginal and Torres Strait Islander people. As the Government has acknowledged, tobacco makes a major contribution to the life-expectancy gap. Aboriginal and Torres Strait Islander people are 2.2 times as likely to smoke tobacco than non-indigenous Australians. 25 New policy initiatives (including tackling high rates of smoking) further demonstrates [the Government s] commitment to closing the life expectancy gap between Indigenous and non-indigenous people within a generation. Joint media release: Prime Minister Kevin Rudd, Minister for Health Nicola Roxon, and Minister for Indigenous Affairs, Jenny Macklin, March 20, 2008 The Heart Foundation calls on the Australian Government to ensure its financial commitment to close the life expectancy gap is maintained and strengthened in real terms over the forward estimates. Heart attack and universal ambulance cover In Australia, more than 50% of heart attack deaths occur out of hospital and about 25% of people who have a heart attack die within one hour of their first ever symptom. 25 Australian Institute of Health and Welfare (2012) Australia s Health

10 Too many people lose their lives to heart attack because they take too long to call Triple Zero (000) for an ambulance. Getting to hospital quickly can reduce the damage to heart muscle and increase the chance of survival. Patient delay time - that is, the time from the onset of heart attack warning signs to when a patient decides to seek medical assistance - remains the principal cause of delay to receiving early treatment for heart attack in Australia. 26 The median patient delay time in Australia is between three and four hours, with about 30% of patients presenting to hospital with chest pain more than eight hours after the onset of symptoms. 27 Stroke is always a medical emergency and treatment is time critical. Yet data from the National Stroke Foundation 2011 Clinical Audit shows only 66% of people present to hospital by ambulance. Those who are not transported by ambulance are less likely to present quickly. Half of those who experience stroke symptoms delay calling an ambulance; many individuals hope symptoms will alleviate, or will elect to speak to friends, family or their GP. The Heart and Stroke Foundations support the introduction of universal ambulance cover (UAC) because it removes one reason for patient delay concern over the cost of calling an ambulance. Two states already have universal ambulance cover, Queensland and Tasmania. A Heart Foundation analysis found that a higher number of patients with time-critical emergencies, such as heart attack, arrive at hospital in an ambulance in these states than those without universal ambulance cover. 28 Achieving a national and universal ambulance system will require the Australian Government to be at least partly responsible for funding ambulance care. Funding ambulance services from a centralised national mechanism would: provide all Australians with cover for appropriate ambulance care reduce funding inefficiencies, and acknowledge paramedics and ambulance services as an integral part of the health care system. The Heart and Stroke Foundations call on all governments to consider options to achieve universal ambulance cover. Tobacco tax: second phase of tobacco excise increase The Australian Government announced a 25% increase in tobacco excise in April 2010, the first increase in excise in real terms in a decade. The increase was in line with the first of a two-step increase in tobacco excise recommended by the Heart Foundation and Cancer Council in submissions to the Australian Government and the Henry Tax Review. 26 Taylor DM, Garewal D, Carter M, et al. (2005) Factors that impact upon the time to hospital presentation following the onset of chest pain, Emergency Medicine Australasia 27 National Heart Foundation of Australia ( ) Warning Signs: sentinel site data analysis 28 Australian Institute of Health & Welfare (2011) Analysis of the Hospital Statistics data

11 The Australian Government should consider timing of the second tobacco excise increase, as recommended by the Heart Foundation and Cancer Council. 29 Price increases have a two-fold effect. They provide a real incentive for smokers to quit. And they discourage young people from starting in the first place. Tobacco kills 15,500 Australians every year costing the health system and the economy $31.5bn annually. 30 Tobacco is Australia s leading preventable cause of death and injury and is a major cause of cardiovascular disease, including heart attack, peripheral vascular disease and stroke. Research conducted internationally and in Australia, shows that when a tax increase occurs, the number of people quitting and seeking help to quit increases. Studies also show that people from lower socio-economic groups may be more likely to quit as a result of tax increases. Tobacco use is significantly higher among disadvantaged groups. Increases in tobacco taxation are strongly supported by the Australian community. Opinion polls and surveys conducted over the past 20 years show majority support for tobacco tax increases, especially if the revenue is diverted into smoking cessation and health initiatives. A Newspoll survey in 2008 suggested 88% of Australians supported an increase in tobacco tax if the revenues supported health programs. 29 National Heart Foundation of Australia and Cancer Council Australia (2009) Taxation reform and tobacco excise: best practice for a sustainable future Joint submission to the Australian Government review of Australia's tax system 30 Australian Institute of Health and Welfare (2012) Australia s Health

12 POLICY PROPOSALS Prevention: Stopping disease before it starts 1. EMPOWER AUSTRALIANS TO IDENTIFY AND MANAGE THEIR HEALTH RISK Fund Know your numbers, a community and pharmacy based health check program looking at the risk of heart disease, stroke and diabetes to enable Australians at risk of chronic disease to better understand and take action to reduce their risk and support development of consumer education and self-management tools. Measure: Investment: Early detection, prevention $16.5m over three years Awareness Raising Know your numbers High blood pressure, or hypertension, is a leading cause of CVD and the single most significant risk factor for stroke. The Australian Health Survey shows in just over 3.1 million people (21.5%) aged 18 years and over had measured high blood pressure. The recently released Victorian Health Monitor report has also shown high rates of hypertension (between a third and two-thirds of over 45s) and alarming rates going untreated, particularly amongst men (more than one in five year olds and almost a third of year olds). There is strong and comprehensive evidence that community pharmacy-based early detection of risk factors such as high blood pressure can significantly reduce the burden of CVD and incidence of stroke through improved access to assessment and treatment. Current Australian Government funded health checks are not identifying those at risk primarily because of low access rates. Less than a quarter of those over 75 years, and only 6% of those aged are accessing regular health checks. The Know your numbers program provides opportunistic, standardised blood pressure, type 2 diabetes and CVD risk checks in community settings. Health check locations are identified through partnerships with the Pharmacy Guild of Australia, some community health centres, Rotary International, YMCA, workplaces and other organisations. As an evidence-based intervention, it has proven successful in enabling Australians at risk of chronic disease to better understand and take action to reduce their risk. By so doing, the program contributes to improvements in the identification and aversion of stroke and other CVD risk through early detection and appropriate assessment and management. Each Know your numbers station is run by a trained operator who conducts blood pressure checks and gathers data on participant CVD and type 2 diabetes risk factors to provide information and recommendations for subsequent action. This includes a recommendation they visit their GP for a full risk assessment for those who are identified as potentially at highrisk of CVD or type 2 diabetes. The National Stroke Foundation has run Know your numbers since 2007 and results demonstrate a comprehensive national service can be provided. Program numbers to date have proven: 12

13 For every 100,000 people checked at a pressure station, more than 18,000 will visit their GP. For every 100,000 people checked at a pressure station, between 57 and 191 strokes can be averted (depending on treatment levels). Data collected to evaluate the effectiveness of Know your numbers and to inform ongoing program improvement has demonstrated: 47% of participants checked registered a high blood pressure reading and 50% were at high risk of developing Type 2 diabetes in the next five years. Of those, 70% were referred to their GP for further assessment. Among participants who were at risk, almost 20% had an AUSDRISK score of 20+ indicating a one in three chance of type 2 diabetes within the next five years. Among those identified as high risk, 69% didn t know they were at risk of diabetes. A three-month follow up of participants in Know your numbers showed increased knowledge about the health risk of high blood pressure and 100% of follow up participants reported at least one action to address their health: Around one-in-ten stopped or reduced smoking Almost 30% had lost weight The program directly supports desired Australian Government healthcare outcomes including early detection, management and prevention of chronic diseases. The Know your numbers program also supports and helps to leverage the Pharmacy Guild of Australia Quality Assurance Program (QCPP). By partnering in the delivery of Know your numbers health checks, community pharmacy is able to meet its community service obligations under the Fifth Pharmacy Agreement, thereby increasing the efficiency of existing government investment. The National Stroke Foundation is currently delivering Know your numbers with the support of state governments in New South Wales and Queensland. It is recommended the Australian Government provide funding to rollout the program to all states and territories delivering an intensive month long campaign through partnership with community pharmacies and in other community settings. Fully-funded, the Know your numbers program has the potential to check 570,000 people a year, referring 105,000 people to GPs for full health assessments and averting between 325 and 1,089 strokes each year 31 as well as additional events associated with diabetes, heart disease and kidney disease. The proposed option presents a low risk, cost effective model that delivers significant outcomes for the Australian community with a cost offset of between $22.2m and $74m. 32 This is a conservative estimate as it includes only the cost offsets associated with stroke and not savings associated with other forms of CVD. Support for consumer risk self-management There is also scope to develop and introduce new tools designed to assist consumers to better understand their risk and involve them in the process of decision making about treatment and care. We recommend investment of $1.5m over three years to develop new tools. 31 National Stroke Foundation (2010) Business Case for Know your numbers 32 National Stroke Foundation (2010) Business Case for Know your numbers 13

14 Decision aids are an example of a tool used by health practitioners to involve patients in the decision making process about things such as potential medical treatment and lifestyle modification. Ranging from story board style tools to increasingly sophisticated Smartphone technology, decision aids are demonstrating potential to be a useful and effective communication tool. The use of decision aids with patients has been shown to significantly increase knowledge as well as accuracy of risk perception 33. Patients are reported to have greater satisfaction with the decision making process, have more realistic expectations and are more likely to be decisive with fewer patients left undecided about their treatment 34. As a specific example, for patients with atrial fibrillation who had participated in a major clinical trial, the use of an audiobooklet improved their understanding of the benefits and risks associated with different treatment options and helped them make definitive choices about therapies 35. To quote from a literature review on shared decision making and decision aids: better aids are those in which the information is personalised to the individual patient. Therefore, web based or computer programs can have an advantage. They can be programmed to enhance interactivity and contain the potential for personalising information such as individual risk factors based on each patient s risk profile There is also potential for technology to be used in conjunction with the rollout of the e-health record. 33 Stacey D, Bennett CL, Barry MJ, Col NF, Eden KB, Holmes-Rovner M, Llewellyn-Thomas H, Lyddiatt A, Légaré F, Thomson R. Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews 2011, Issue 10. Art. No.: CD DOI: / CD pub3. 34 Thistlethwaite, Jill, Evans, Rebecca, Nan Tie, Rodney, and Heal, Clare (2006) Shared decision making and decision aids. Australian Family Physician, 35 (7). pp Man-Son-Hing M, Laupacis A, O Connor AM, et al. A patient decision aid regarding antithrombotic therapy for stroke prevention in atrial fibrillation: a randomised controlled trial. JAMA 1999;282: Shared decision making and decision aids, A literature review, Jill Thistlethwaite BSc, MBBS, MMEd, FRCGP, FRACGP, DRCOG. 37 Edwards A, Elwyn G. The potential benefits of decision aids in clinical medicine. JAMA 1999;282:

15 2. INTEGRATED HEALTH CHECKS IN PRIMARY CARE Introduce an integrated health check in general practice to assess for risk of cardiovascular disease (CVD), type-2 diabetes and chronic kidney disease with coordinated management of those diagnosed with chronic disease through Medicare Locals. This is a joint Heart Foundation, Stroke Foundation and Kidney Health Australia proposal and has the support of the Australian Medicare Locals Alliance. Measure: Early detection, prevention Investment: potentially cost-saving Cardiovascular disease (CVD) is Australia s largest killer, causing more than 46,000 deaths each year, almost one-in-three deaths. 38 It accounts for 18% of the overall burden of disease in Australia and is the most expensive disease group in terms of direct healthcare costs, at $7.9bn a year or 11% of recurrent expenditure. 39 CVD also has a strong relationship with other significant chronic diseases, in particular type 2 diabetes and chronic kidney disease. Because they share risk factors, underlying causes and disease mechanisms, these major chronic diseases often occur together. For example, it is estimated that more than 400,000 Australians have both CVD and diabetes. Importantly, effective prevention and management of one condition can lead to reduction in the risk of related diseases. 40 Unfortunately, too many people are at high risk of developing these disease, or living with them, go unrecognised, leading to avoidable premature death and disease at significant social and economic costs to the nation. Early detection and ongoing management of these chronic diseases is the key to reducing the number of CVD events (such as heart attacks and stroke) occurring each year while also reducing the incidence of diabetes and chronic kidney disease. But the current suite of government-funded health checks are not effectively identifying those at risk primarily because of low access rates, non-integrated approaches to CVD risk assessment and the absence of a national program to support better management of risks for CVD and related diseases like type 2 diabetes and kidney disease. In 2009, the Australian Institute of Health and Welfare published a framework for monitoring the prevention of vascular and related disease. 41 The framework cited evidence that existing vascular and related disease assessment and management programs had limited uptake and were not well integrated or promoted as part of a national preventative health system. It revealed that less than a quarter of those over 75 years and only 6% of those aged were accessing regular health checks Australian Institute of Health and Welfare (2010) Australia s Health Australian Institute of Health and Welfare (2010) Australia s Health Australian Institute of Health and Welfare (2009) Prevention of cardiovascular disease, diabetes and chronic kidney disease: targeting risk factors 41 Australian Institute of Health and Welfare (2009) Prevention of cardiovascular disease, diabetes and chronic kidney disease: targeting risk factors 42 Australian Institute of Health and Welfare (2009) data summarised in National Vascular Disease Prevention Alliance Position Paper, May 2011, Risk awareness raising, assessment and management for the prevention of vascular and related diseases 15

16 These figures are alarming, especially given the high prevalence of a number of significant risk factors in the community, including overweight/obesity, high blood cholesterol and high blood pressure. Recent data shows that while some risk factors, such as tobacco smoking, are in decline (though still highly prevalent), other risk factors are becoming increasingly prevalent or remain at very high levels. The Australian Health Survey ( ) reveals that 63% of Australian adults are overweight or obese, up from 56% in More than 60% of men had a waist circumference that put them at an increased risk of developing chronic disease, while 67% of women had an increased level of risk. 43 The survey also shows that just over three million adults had measured high blood pressure. 44 A coordinated approach is required to increase awareness of individual vascular and related disease risk, to provide high quality assessment of individual risk and to provide appropriate interventions to support risk management. The way forward The Heart Foundation, Stroke Foundation and Kidney Health Australia with the support of the Australian Medicare Locals Alliance propose a high quality assessment of disease risk through the collection of data on major risk factors through simple questions, tests and measurements. Comprehensive vascular and related disease risk assessments and ongoing preventative care for those people identified to be at higher risk should occur in a primary care setting, including that of general practice and Aboriginal medical services. The assessment should include recognised measures to assess risk including: A CVD risk assessment (an absolute risk assessment where appropriate and consideration as high risk if clinically indicated) AUSDRISK (+/- blood glucose tests) Serum creatinine and urinary albumin Assessment and classification of moderate and high-risk individuals should result in provision of medical interventions to reduce individual risk and referral to quality-assured lifestyle modification programs. GPs would prescribe necessary medication and refer people at risk to lifestyle interventions that could be delivered through a range of community settings. Medical interventions could include drug treatments for high blood pressure and high blood cholesterol. Lifestyle interventions could include: smoking cessation services; weight management or exercise and behaviour change programs. Lifestyle modification programs incorporating weight reduction, healthy eating and physical activity (eg Life! in Victoria, Get Healthy in NSW) are currently available for people at high risk of type 2 diabetes and could be broadened to include people who may be at increased risk of vascular diseases. Establishment of a systematic process for identification of risk of CVD, diabetes and kidney disease will increase referrals to such programs, increasing their efficiency. 43 Australian Bureau of Statistics (2012) Australian Health Survey: First Results, Australian Bureau of Statistics (2012) Australian Health Survey: First Results,

17 Consolidating the current existing primary health care approaches into an integrated health check will help GPs determine a person s absolute risk of a cardiovascular event and the most appropriate preventive measure for people who are at risk, but not yet showing symptoms, of disease. This will have potentially significant benefits to those at risk as well as to the healthcare system. The direct health cost of CVD (currently $7.9bn a year) could be contained with early identification and management of those at high risk before they develop disease, particularly for those aged over 45. Anticipated benefits include systemic efficiencies, substantial cost savings and reduction in chronic disease related hospitalisations. In addition, the proposal supports a number of priority areas within the National Primary Health Care Strategy The need to develop an integrated health check has been recognised in the UK, where the British Government s Putting Prevention First program (commenced in 2009) is based on vascular checks for people in middle-age. The UK Health Department estimated that the vascular health check program could: 45 prevent at least 9,500 heart attacks and strokes a year (2,000 of which would be fatal) prevent at least 4,000 people a year from developing diabetes detect at least 25,000 people a year earlier with diabetes or kidney disease. Recommendation The Australian Government should fund an integrated heath assessment program linking assessment, prevention, coordinated care and management which encompasses the following elements: 1. Assessment: Assessment of risk factors, including kidney function, diabetes status (using AusDrisk or blood glucose testing in high risk individuals), and the calculation of an absolute risk score assessment for stroke and heart attack risk. 2. Prevention: Prevention for those at high risk of type 2 diabetes or with high absolute cardiovascular disease risk or high kidney disease risk. Those identified at high risk of chronic disease in the assessment phase are referred to appropriate community-based lifestyle modification programs. It is proposed that chronic disease care coordinators should be funded to assist with care coordination and provision of self-management support. There is good evidence that this coordination role has a positive impact on patient outcomes, is best performed by a non-gp care coordinator and leads to a significantly lower use of health services. 46 To enhance the capacity of the chronic disease care coordinators to deliver the range of activities required, a primary health care provider network should be established to support the coordinators and other primary health care providers to promote interdisciplinary communication, networking and collaborative practice. 3. Management and treatment: Pharmacotherapy and lifestyle advice are among the management and treatment tools for those at high risk of developing cardiovascular and related diseases. 45 UK Department of Health (2008) Putting prevention first - vascular checks: risk assessment and management 46 Productivity Commission (2005) Australia s Health Workforce: Productivity Commission research report 17

18 3. LINK TO HEALTH: LINKING PATIENTS AT HIGH RISK OF CHRONIC DISEASE WITH APPROPRIATE LIFESTYLE MODIFICATION PROGRAMS Fund a pilot a program that ensures patients identified at high risk of chronic disease access appropriate community-based lifestyle modification programs through a structured telephone counselling service. This proposal is supported by the Australian Medicare Local Alliance. Measure: Investment: Primary/community care $2m a year for three years Cardiovascular disease represents a significant challenge for the community and government, causing almost one-in-three deaths and 18% of the total burden of disease and injury in Australia. It is also the most expensive disease group in terms of direct healthcare expenditure costing $7.9bn a year. Risk factors for cardiovascular disease (CVD) are highly prevalent in the Australian community with 92% of adults having at least one modifiable risk factor and 25% have three or more modifiable risk factors. There is enormous potential to improve early detection of people at high risk of developing CVD, referring them to appropriate lifestyle modification programs and reducing avoidable hospital admissions. This proposal addresses gaps in the current approach, with clear breakdowns between identification of people at high risk of major chronic disease and seamless referral pathways into appropriate lifestyle programs with high retention rates. Primary health care services, including general practice, are at the frontline for the prevention of CVD. The use of an absolute risk approach to CVD prevention, rather than the traditional focus on single risk factors, is well established internationally and is the recommended approach to CVD prevention in Australia. Using an absolute risk based approach in primary health care has recently been identified as a highly cost effective way to addressing CVD prevention in Australia. Despite its strong evidence base and demonstrated cost-effectiveness, systematic use of absolute cardiovascular disease risk identification and management in primary health care is not usual practice in Australia. While general practice plays a key role in CVD prevention, it alone cannot provide the level of support required for the lifestyle change that is recommended for people at high risk of CVD. Fostering dynamic, and sustained linkages between the health and community sectors, is a potentially effective strategy for improving population prevention outcomes. There is a need for major shifts in practice for all involved in the prevention continuum if systematic and effective assessment and management of individuals at risk of cardiovascular disease is to be achieved. The Pilot The Link to Health pilot aims to achieve evidence-based practice for CVD risk reduction. The pilot will use systems-thinking to build the capacity of the primary health care sector. Specifically, the aims of the pilot are to: 18

19 Identify individuals aged between years (or over 35 if Aboriginal or Torres Strait Islander) considered to be at high risk of CVD and reduce their risk. Deliver a brief health behaviour change intervention and provide a pathway into locally delivered, but nationally coordinated, lifestyle modification programs (eg. Heartmoves and Heart Foundation Walking). Develop and support linkages between the health sector and community based lifestyle services and programs. Activate and coordinate the existing resources of Medicare Locals, health professionals and the community sector to achieve measurable outcomes in CVD risk reduction. Increase knowledge and skills in relation to the absolute risk for CVD assessment and management guidelines across the diverse workforces of the CVD prevention continuum. Develop an effective framework that will inform activities in other priority health issues in primary health care. Link to Health process Identifiation of patients at high absolute risk (>15%) Systematic recall for high risk for CVD patients Opportunistic identification of high risk for CVD patients Medicare local staff work with practices to improve data quality and information systems to enable identification of high risk patients. Clinical Management and actviation for llifestyle change in General Practice. Provide guidelines based clinical management and establish relevant cycle of care for each patient. Refer to allied health professionals as required. Provided brief health behaviour change support to increase motivation for lifestyle change and participation in the "Link to Health" program. Fax or referal to the "Link to Health" phone service. Lifestyle change support and referal by Heart Foundation Heart Information Service (HIS) Provide health behaviour change support by qualified staff. This would be a 45min-1hour session focused on issue identification and goal setting. Relevant support literature sent to patient. Patient refered to local providers of nationally coordinated lifestyle modification programs/services, eg. Heart Foundation Walking, Heartmoves or Quitline. Community based lifestyle modification support Local providers of national lifestyle modification programs contact the patient and engage them in the relevant activity and refer to other programs if required. Medicare Local works with their lifestyle program and service providers to develop and grow these services. Local CVD prevention community networks developed. The Link to Health pilot will support the sustainability of the national lifestyle modification programs funded under the Healthy Communities Initiative by creating an ongoing referral pathway to these programs. While Link to Health is an intervention for high risk individuals it will achieve systems improvements that will over time achieve population health outcomes. By providing a flexible multi-risk factor intervention model that is able to meet the needs of a wide range of people across Australia. The Link to Health pilot will demonstrate national and local level collaboration between health and community sectors in line with primary health care principles and the vision of the Australian Government National Primary Health Care Strategy and Medicare Locals. 19

20 4. END INVESTMENT IN TOBACCO COMPANIES VIA AUSTRALIAN GOVERNMENT AGENCIES AND INVESTMENT FUNDS Introduce an Australian Government policy and amend legislation regulating government investment funds, including the Future Fund, to specifically exclude the funds from investing either directly or indirectly in tobacco companies. Measure: Investment: Tobacco control No cost The Australian Government is a world leader in tobacco control and deserves strong praise for action taken over the past five years to reduce death and suffering caused by smoking. This reputation is somewhat tarnished, however, by continued investment of public funds in tobacco companies, through the Australian Government s Future Fund. In 2012 the Government through the Future Fund alone invests around $210m in tobacco companies. 47 The Australian Government should take immediate action to implement a government-wide policy to exclude investment in tobacco companies. The government should also take immediate action to end Future Fund investment in tobacco companies whether directly or indirectly by amending the Future Fund legislation. Tobacco is responsible for 15,500 deaths a year and if it were to be invented today it would not be a legal product. 48 Investment in tobacco companies is in direct conflict with measures taken by the Australian Government over several decades to reduce lives lost from smoking, much of it through cardiovascular disease including heart attack, stroke and peripheral vascular disease. The health effects of tobacco use and exposure to second-hand smoke are well established, and new evidence continues to emerge on the mechanism and extent of the cardiovascular harm they cause. There is simply no safe use of tobacco, whether smoked, chewed, sniffed or dissolved. In 2012, all governments through the Standing Council on Health, approved the National Tobacco Strategy (NTS), which gives priority to the protection of tobacco control policies from tobacco industry interference. The NTS refers to the World Health Organisation Framework Convention on Tobacco Control (FCTC) Article 5.3 Guidelines and recommendations include the following: 4.6: Parties should require government officials to declare and divest themselves of direct interests in the tobacco industry. 4.7: industry, unless they are responsible for managing a party s ownership interest in a state-owned tobacco industry. Government institutions and their bodies should not have any financial interest in the tobacco The Australian Government is a signatory to the FCTC and therefore should follow through with their commitment to the Articles within the Convention. In addition, the Australian 47 Commonwealth of Australia Department of Health and Ageing (2012) Senate Estimates 48 Australian Institute of Health and Welfare (2012) Australia s Health

21 Government should follow the lead of state governments that have implemented a government wide policy to not invest in tobacco companies. While there is a need to maximise returns for government investment funds, investment in tobacco companies operating in low and middle income nations (where tobacco control laws may be embryonic or poorly enforced) will only support the growth of smoking rates. For example, the Future Fund has invested in a tobacco company in Indonesia, where the number of children aged 10 to 14 who smoke has grown from an estimated 71,000 in 1995 to at least 426,000 in In Australia, smoking contributes to more hospitalisations than drug and alcohol use and it is estimated to cost the Australian community $31.5bn a year ( ). This cost includes health care, reduced workplace productivity and fires started by discarded cigarettes. 49 The Heart Foundation calls on the Australian Government to make its policies clear on tobacco company investment and amend relevant legislation, including the Future Fund Act 2006 to prohibit investment in tobacco companies. 49 Australian Institute of Health and Welfare (2011) Cardiovascular Disease Australian Facts

22 5. REFORM ALCOHOL TAXATION Reform alcohol taxation measures to reduce the future health costs imposed by alcohol misuse. Measure: Revenue: Taxation More than $1,000m a year Consumption of large amounts of alcohol, both on a single occasion and habitually, can adversely lead to disturbance of the heart rhythm, heart failure and heart attack. Excessive alcohol consumption is a major risk factor for morbidity and mortality generally. In Australia, it has been estimated that harm from alcohol caused 3.8% of the burden of disease for males and 0.7% for females ranking it sixth out of 14 major risk factors. 50 While the costs from alcohol misuse are substantial, many of these costs can be minimised by investing in population level public policies with the proven ability to reduce harmful alcohol consumption. In order to address alcohol misuse, the National Alliance for Action on Alcohol (NAAA) and the Foundation for Alcohol Research and Education (FARE) argue that there is a real need to address the gross inequities in the current alcohol taxation system. Evidence clearly shows that low alcohol prices result in higher consumption, and lower prices result in lower consumption. 51 Consequently an increase in alcohol prices results in a decrease in harms, as outlined in the recent Australian National Preventive Health Agency (ANPHA) Draft Report Exploring the public interest case for a minimum price. 52 The Heart Foundation calls on the Australian Government to consider the submissions of both NAAA and FARE, which can be found at: NAAA: FARE: 50 Australian Institute of Health and Welfare (2007) Burden of Disease Report 51 World Health Organisation (2012) Addressing the harmful use of alcohol : a guide to developing effective alcohol legislation 52 Australian National Preventive Health Agency (2012) DRAFT REPORT Exploring the Public Interest Case for a Minimum (floor) for Alcohol 22

23 6. SUPERCHARGE FOOD REFORMULATION Expand the life-saving work of the Australian Government s Food and Health Dialogue to reduce salt, fat and sugar content of the food supply. Better align, coordinate and prioritise government food and health activities into a more coherent, single strategy. Measure: Investment: Prevention food supply $2m to $5m a year The potential population health gains from food reformulation are enormous They can be achieved at low cost to government Current funding commitment to reformulation ends in 2013 Modest additional investment will be a cost-saving measure There is a need to better coordinate, align and prioritise current food and health activities across government Food reformulation working with industry to reduce salt, saturated fat and sugar in processed food while boosting good nutrients, such as fibre is one of the most cost-effective public health measures available to government and is being increasingly used worldwide to prevent premature death from diseases such as heart disease, stroke, diabetes and some cancers. Following Heart Foundation recommendations, the Australian Government embarked on a food reformulation initiative, establishing the Food and Health Dialogue in 2009 bringing together government, industry and NGOs with public health expertise. The Dialogue has established important salt reduction targets for eight priority food categories so far, and is currently working on setting targets for another three. The first two categories, Bread and Breakfast Cereals, will be revisited from the second half of 2013 when achievements on the initial agreed reformulation targets is required. In the UK they have targets set for more than 80 categories and subcategories. Australia only has eight to date. This number needs to increase markedly if there is to be a significant impact on the health outcomes of Australians. It s time to act. The Dialogue has also been charged with seeking to standardise and establish appropriate portion sizes and undertake consumer awareness activities that promote healthy eating patterns and food choices. It is also charged with closely monitoring the progress of industry towards achieving agreed targets. This is an ambitious agenda with enormous potential to improve the health of the entire population. If this agenda is to be achieved, additional resources are needed to support the work of the Dialogue. To date, the Dialogue has received only modest funding to support its work and the Heart Foundation is concerned that funding for the Dialogue terminates in June

24 The potential health gains from food reformulation are enormous. Reducing intake of sodium from processed food by 15-25% in Australia would avert 5,800-9,700 heart attacks and 4,900-8,200 strokes within ten years. 53 The UK believes that major health gains can be made through food reformulation, including: Reducing daily UK salt intake to 6g a day could result in 20,000 fewer premature deaths each year; and Cutting saturated fat intake from 13.5% to 11% of daily energy intake could result in 3,500 fewer diet related deaths each year. 54 A 2007 study published in the British Medical Journal suggests that a reduction in salt intake of 25% to 30% could lead to a dramatic reduction in heart attacks and strokes by 20% or more. 55 Poor diet is known to influence the risk of cancer, heart disease and other conditions. Around 70,000 fewer people would die prematurely each year in the UK if diets matched the nutritional guidelines on fruit and vegetable consumption, and saturated fat, added sugar and salt intake. There are social inequalities within diet-related ill health that demand attention. And alongside the social impacts, the economic burdens of diet-related ill health are huge perhaps 6 billion in additional NHS costs alone each year. Food Matters: Towards a strategy for the 21 st century: UK Cabinet Office, July 2008 A US study published in 2010 suggests that collaboration with industry that decreases mean population salt intake by 9.5% (as achieved in the UK) would avert, over the lifetime of adults aged 40 and over: 514,000 strokes 480,000 heart attacks $32.1bn in medical costs 56 While regulation would be the most effective means of achieving food reformulation, the voluntary engagement of industry through firm government leadership has proven to be effective in the UK and elsewhere. The Australian initiative is off to a good, though slow start, and now needs to be strengthened and accelerated. Additional funding is required to provide expert advice and additional support to the Dialogue as well as strengthen the capacity of the initiative to deliver on the stated objectives of promoting consumer awareness and monitoring industry progress. Improving capacity of the secretariat serving the Dialogue will be increasingly important as the reformulation of future food categories will be complex and require more significant innovations/recipe variations to achieve reformulation targets (eg reducing the saturated fat content of pastry products without reducing flakiness ). The workload of the Dialogue secretariat has the potential to expand significantly over the coming years as new food categories are added and previous food categories are monitored and then re-visited to negotiate second-round reformulation targets. 53 Goodal S, Gallego G. (2008) Scenario modelling of potential health benefits subsequent to the introduction of the proposed standard for nutrition, health and related claims, Sydney: Centre for Health Economics Research and Evaluation 54 UK Cabinet Office (2008) Food Matters: Towards a strategy for the 21 st century 55 Cook N, et al (2007) Long term effects of dietary sodium reduction on CVD outcomes, British Medical Journal 56 Smith-Spangler C, et al (2010) Population strategies to decrease sodium intake and the burden of cardiovascular disease: A cost-effectiveness analysis, Annals of Internal Medicine 24

25 The Heart Foundation calls for: More categories to be added each year to keep the profile of the strategy high and keep the pressure on industry to achieve public health benefits A significant increase in funding to support data collection and modelling to inform future food category selection and determine the impacts of reformulation on population intakes of targeted nutrients A dedicated reformulation unit, drawing on expertise from CSIRO (a funded position) and with links to industry and appropriate non-government organisations with expertise in this area, such as the Heart Foundation Funding for future food reformulation workshops with industry Additional expert and administrative staff Funding for data collection and modelling to build the evidence base Ongoing funding for communication and media activities, including web-based resources and electronic newsletters to keep stakeholders engaged Funding for social marketing (leveraging off the key messages contained in the revised Dietary Guidelines) to support the reformulation agenda Leadership across agencies and a coordinated approach to food reformulation activities Creation of a cross agency departmental working group to align all activities addressing food and nutrition policy Currently there are at least 26 different Australian Government activities related to food supply and health. These span at least seven different agencies and have comparatively poor linkages. These activities would benefit from a much greater degree of coordination and priority setting against a well-defined food and health strategy. The Heart Foundation recommends that a cross-agency group be established to better coordinate food and health activities and connect them with key strategic themes in food reformulation. This group should create linkages with the Minister and Parliamentary Secretary, partnerships across governments, industry and the health and consumer sectors. Coordination and dissemination of data, evidence through this group will help inform policy development and drive innovation. 25

26 7. RENEW THE HEALTHY COMMUNITIES INITIATIVE Renew the two expiring national programs supporting the Healthy Communities Initiative: Heart Foundation Walking and Heartmoves. Measure: Investment: Prevention physical activity $0.6m a year The Australian Government s Healthy Communities Initiative (HCI) is successfully delivering lifestyle modification programs to communities in local government areas with lower socio-economic profiles across Australia. Communities have embraced two programs in particular, Heart Foundation Walking and Heartmoves programs. Heart Foundation Walking programs operate in 87 of the 92 local government areas participating in the Initiative. Altogether, Heart Foundation Walking groups operate in a total of 308 local government areas. Heart Foundation Walking is a free national walking group program, underpinned by a model that facilitates the development of walking groups in communities by partnering with local providers such as health services, workplaces and local government. The Heart Foundation Walking model also builds community capacity by up-skilling local staff and volunteers and increases community connectedness by working towards a common goal. Heart Foundation Walking: A snapshot 1,350 separate walking groups across Australia 20,000 active walkers Heartmoves is a gentle exercise program for older people, either living with or at risk of developing a vascular or related chronic disease. The program is delivered in community halls, local gyms and residential aged care. It is cost effective and suitable for anyone who hasn't undertaken any exercise for some time. Heartmoves is designed to be safe for people with stable long-term health conditions such as heart disease, diabetes or obesity, helping to improve their health and confidence. In 2010, the Heart Foundation successfully bid for two of the six national grants to support lifestyle modification programs across participating local government authorities with lower SES profiles. The Australian government provided $2.3m over three years to deliver Heart Foundation Walking and Heartmoves. However, funding for Heart Foundation Walking and Heartmoves expires in June Funding is sought to help continue both programs beyond June. Physical inactivity is a major risk factor for chronic disease and is responsible for an estimated 16,000 premature deaths a year. 57 Being active can reduce the risk for leading chronic diseases, extend years of active independent life, reduce disability and improve quality of life. 57 Medibank Private, Econtech and KPMG (2008) Cost of Physical Inactivity, 2 nd Report 26

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