Bridging the survival divide

When First Minister John Swinney announced £2.5m of funding for over 1,000 defibrillators at the end of February he said the investment was being made with the specific aim of saving lives. Surviving a cardiac arrest depends, he said, “on what happens in the minutes before an ambulance arrives” and the government was providing the funding to “strengthen local response networks and ensure more people have the skills and confidence to act”.

For David McColgan, the head of British Heart Foundation Scotland, it was a vindication of the work the organisation has been doing around highlighting the key role defibrillators play in  increasing an individual’s chances of surviving an out-of-hospital cardiac arrest (OHCA). 

“This is a wonderful announcement for Scotland,” McColgan says. “It represents a 10 per cent increase in publicly available defibrillators across the nation and is a clear sign that the Scottish Government is taking the issue seriously. Compared to the rest of the UK, Scotland is now leading with a strategic investment in a data-driven approach to defibrillators. There will be countries across the world now looking to Scotland and this programme and seeing how it can be replicated.”

In his announcement the first minister said the aim of the government is to ensure there is a defibrillator within reach any time a cardiac arrest occurs, adding that evidence will be used to “identify the best locations and modes of delivery”. 

What he didn’t say was that BHF Scotland has already done important work on that, with a report issued earlier this year – Bridging the Survival Divide: Strategically Improving OHCA Outcomes – not only identifying that the OHCA survival rate remains low, but that disadvantaged communities are disproportionately affected. 

There will be countries across the world now looking to Scotland and this programme and seeing how it can be replicated

“The government published its first cardiac arrest policy back in 2015, which was a big moment,” McColgan says. “It was a big recognition that we had a challenge to improve OCHA survival rates. At that time Scotland was lagging behind the rest of the UK and other global leaders – we had a survival rate of one in 20 when in countries like Norway and Denmark it was one in four. What the data from Copenhagen and Stavanger showed was that when you have a young, mobile population trained in CPR you have really good survival rates so there was a big focus on CPR training here and it made a big improvement to survival rates, bringing them to one in 10.”

That first OHCA strategy, delivered CPR training to 640,000 people, with a refresh in 2021 aiming to equip one million people with CPR skills and make defibrillators as accessible as possible. Now that that second phase has bedded in, BHF Scotland is keen for the intent of the policy to shift again, this time taking account of what the data is telling us about the way in which existing defibrillators have been used. The data collated, McColgan says, will help ensure the new machines being funded by the Scottish Government are placed where they are needed most.

“We’re coming to a point where the strategy is starting to be reviewed again in Scotland and we’re looking at what strategy 3.0 will look like,” he says. “For us, that’s where the thinking came around our latest report. A lot has changed in the past 10 years. One of the biggest changes between 2015 and now is the creation of The Circuit – the UK’s national defibrillator network – which was created in partnership between the British Heart Foundation and Microsoft. The Circuit is an online database of registered defibrillators that the Scottish Ambulance Service has full access to so when a 999 call comes in to say there’s been a cardiac arrest the call handler can instantly identify the nearest defibrillator and direct someone to go and get it.

“Last year we passed the 10,000 registered defibrillator mark in Scotland and what that’s given us is a really unique snapshot of availability across the country. There was a study from Stockholm many years ago showing that 60 per cent of defibrillators were placed in city centres while 90 per cent of cardiac arrests happen in the home. The Circuit has given us a really unique insight into defibrillator locations and when you map that with SIMD [Scottish Index of Multiple Deprivation] data and cardiac arrest data from the ambulance service you start to get a view of Scotland that shows where you should be putting defibrillators to be more useful or where you shouldn’t be putting them because there’s overprovision in that area already.”

In one sense the data has confirmed what was already known – that people from the most affluent areas are more likely to survive a cardiac arrest than those from the most deprived, while those in less affluent areas experience cardiac arrest at an earlier age but are less likely to receive CPR when that happens. Despite this, the data has highlighted that there are fewer defibrillators located in more deprived communities than in wealthier ones, giving clear evidence of a glaring health inequality that needs to be addressed. 

Scotland’s rural communities also face challenges in defibrillator access, the report highlighting that static defibrillators in unlocked cabinets are less effective in remote locations. Longer travel times and sparse coverage means that an ambulance may arrive before a defibrillator can be retrieved, so different solutions are needed. 

McColgan says the main reason defibrillators are unevenly distributed across the country is that until now they’ve been purchased for on a case-by-case, often through community fundraising. That has led to device clustering as well as areas disproportionately lacking defibrillators. What the BHF Scotland report has done is highlight the importance of placing publicly funded devices where they are likely to be needed most.

“Defibrillators cost about £1,200 each and the historical model has been community activism for provision, for example if someone at a rugby club has a cardiac arrest the club will fundraise for one and that’s where it will be sited,” McColgan says. “Some communities will fundraise for them because they are rural and really far from an ambulance station but recently I was driving though rural Fife and in one town the main street was about a mile long – at one end there were two churches and both had fundraised for defibrillator and both had sited them right outside.”

The mapping of defibrillator-location data with cardiac-arrest data was undertaken by the University of Edinburgh in a project known as PADmap. McColgan says the Scottish Government should use that resource to best inform where the latest batch of defibrillators should be located.

“PADmap is a really interesting project because it takes the data from The Circuit and the data from Scottish Ambulance Service and maps the two on top of each other to calculate the best place to put them,” he says. “It does that at local authority level and by postcode too, mapping where the gaps are. Our Bridging the Survival Divide report is about supporting people to be more informed about where to put defibrillators. If you’re a community group and want to fundraise that’s great, we’d love you to do that, but maybe you don’t need to put it on your building.

“People tend to put defibrillators in a place where there’s been an incident but one of our conclusions is that it’s very clear from the emerging data that if you left the placements unchecked you’d see the survival divide get greater. You’d still see affluent areas want to fundraise and you’d still see them placing them in their communities or areas of attachment, but you’d still see people in more deprived areas not know how to fundraise or where to put them.

“The British Heart Foundation has a programme where people can apply for help and St John Ambulance does that too, but that relies on communities having to apply. If we’re really serious about tackling the inequality that exists around surviving out-of-hospital cardiac arrests the Scottish Government needs to provide defibrillators to communities that are most in need – we now know where those communities are because of the data – and it needs to provide some capacity for community resilience because you can’t just stick defibrillators anywhere. They require a guardian to look after them, checking that their batteries work every three months, and there needs to be training and awareness. Where that all comes together there’s a huge opportunity.”

The Scottish Government has clearly been paying attention. It has vowed to use the data to work out where to place the new machines it is funding and has said the money will also support the creation of new Cardiac Arrest Rescue Zones to strengthen community responses, with the areas facing the greatest inequalities set to be prioritised. Indeed, when Swinney announced the £2.5m funding package he said the aim is to “build a Scotland where everyone, regardless of where they live, has the best possible chance of surviving a cardiac arrest and can live healthier, longer lives”. BHF Scotland aims to hold him to that. 

This article was sponsored by BHF Scotland.