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Lord Black of Brentwood
To ask Her Majesty’s Government what action they are taking to improve the diagnosis and management of atrial fibrillation.
Lord Black of Brentwood (Con)
My Lords, I am honoured to have the opportunity to lead a debate on an issue which affects hundreds of thousands of our citizens, and I am grateful to all noble Lords who are taking part.
I have an interest to declare in this subject, but not one you can find in the register. It is that for many years I have had a form of AF known as paroxysmal atrial fibrillation. It is brought on by a significant rush of adrenalin—not the sort, of course, which comes from listening to debates in your Lordships’ House but the sort which comes from sudden exertion. I am lucky, however. A doctor diagnosed AF when I was in the midst of an episode and referred me to a specialist. Regular monitoring and medication ensure that, so long as I am careful, I have no problems. Today’s debate is about those who are not so lucky, either because they are not diagnosed or because they are not getting the right treatment.
Atrial fibrillation is a heart condition that causes an irregular and often unusually fast heartbeat. It happens when abnormal electrical signals fire from the top chambers of the heart in a way which overrides the heart’s natural pacemaker. The causes of AF are not fully understood, but it affects up to 1.5 million people in the UK, including around one in 10 people aged over 65. It often runs alongside other cardiac conditions such as high blood pressure or clogged arteries.
There are various ways to manage the condition, including drug therapy, cardioversion from electric shocks and, if all else fails, ablation, where areas of the heart causing the abnormal heart rate are destroyed by radio frequency pulses. The use of one or all of these methods makes AF a condition that is manageable provided it is diagnosed—and that is a key point for this debate. For while AF can be extremely uncomfortable, producing palpitations, chest pains and dizziness as a result of the heart racing at well over 100 beats a minute, it can present no symptoms at all. That is when it is at its most dangerous. Undiagnosed and untreated, a heart that is not beating regularly can lead to the formation of blood clots inside it which can then enter the general circulation in a way that blocks arteries in the brain; in other words, the cause of a stroke.
Diagnosis of AF is therefore a crucial public health issue, as many people—perhaps up to 750,000 in the UK—are simply not aware they have it, significantly increasing their risk of a stroke. According to NICE, around 7,000 strokes a year, and 2,000 premature deaths, are likely to result from the failure to detect AF and treat it with anticoagulant drugs. As Professor Mark Baker, NICE’s director of clinical practice, said:
“This needs to change if we are to reduce the numbers of people with AF who die needlessly or suffer life-changing disability as a result of avoidable strokes”.
A good deal of progress has been made in recent years in dealing with this problem and I know how seriously the Department of Health and NHS England take it. I was enormously grateful to the former Health Minister, the noble Earl, Lord Howe, who met me to discuss it last year. I know that the Minister will take that work forward, and I look forward to hearing from him this evening what progress has been made in a number of areas, three of which I will highlight.
The first is improving diagnosis. In many ways, this could not be simpler, because it can be done through a plain old manual pulse check at an ordinary GP appointment. The irregular heartbeat is easy to feel; the examination takes seconds to do; and it is of course completely painless—one of those genuine occasions when, when the GP says, “This will not hurt”, it does not.
Given that there is nothing like a practical demonstration, I can even show noble Lords how quick and easy it is. Next Tuesday morning, I shall host a drop-in event in association with AntiCoagulation Europe and Bayer HealthCare, where parliamentarians can come and get their pulse checked by an expert doctor who will be able to talk about this issue and advise on any irregularities in colleagues’ pulses. I hope that there will not be many of them, but it pays to be on the safe side, so I invite noble Lords to come along to Room G between 10 am and l pm to see what I mean.
Given that diagnosis is so easy and effective, why is a manual pulse check not routine, especially for over-65s? The reason is that the UK National Screening Committee, part of Public Health England, recommended in a report in June 2014 that it is,
“uncertain that screening will do more good than harm … because … treatment and care for people with AF is not optimal”.
Given that we are talking about a simple test that saves lives, I do not believe that the quality of existing services—which have been improving but perhaps not rapidly enough—should be cited as a compelling reason not to introduce screening for AF. We need to do what we can, of course, to ensure that care becomes “optimal”, but, in the mean time, we should not endanger people who are unaware that they have this condition by failing to test them. Will the Minister join me in calling on Public Health England and the National Screening Committee to review this recommendation?
Once AF is diagnosed, it needs effectively to be treated. Some patients with AF need anticoagulation therapy to stop their blood clotting and reduce their risk of an AF-related stroke. Identifying those patients is not always straightforward but has been made much easier by the introduction of a new tool for GP practices called GRASP-AF, which helps identify patients at risk by assisting GPs to interrogate their clinical data. GRASP-AF is being rolled out across England, but data suggest that only about one-third of GP practices are using it. I would be grateful if the Minister could update us on the rollout of this programme and on what his department is doing to ensure that GPs most effectively assess AF patients’ risk of stroke.
My final point relates to the anticoagulant drugs that are used to treat AF where this is judged necessary by a GP or consultant. The most widely used treatment option in this area is warfarin, which has been deployed for over 50 years and has undoubtedly saved many lives. However, as many noble Lords will know, it is not an ideal drug, as it requires regular monitoring and dose adjustments to ensure that it is working properly, usually in a specialist anticoagulation clinic. This is a problem for those in full-time work, and often difficult for elderly or immobile people. My late father was on warfarin for the last few years of his life, and, as he was to all intents and purposes housebound, his regular tests became very complex and stressful for both my parents.
On top of that, many foods can interfere with warfarin or alter its effects, along with alcohol and some medicines. In other words, it is far from ideal. Warfarin is one of the most common causes of drug-related adverse events and is responsible for about 6% of all fatal and severe drug-related incidents. This is a terrible cost in lives and a substantial financial cost to the NHS. Many GPs therefore do not like prescribing it, and I can understand why. As a result, they either do not treat the condition at all—and audit data suggest that 46% of AF patients who should be on treatment to prevent blood clots are not—or they treat it with aspirin, which is not recommended by NICE.
Yet there is an effective alternative to warfarin in the form of novel oral anticoagulants, or NOACs. These drugs were developed specifically to overcome the limitations of warfarin which I have just described and are recommended by NICE as clinically effective for stroke prevention in AF as well as being cost-effective for the taxpayer. Treatment of AF through NOACs significantly improves a patient’s quality of life because it does not require routine monitoring or ongoing dose changes; it does not entail dietary restrictions; and it provides predictable, stable and regular levels of anticoagulation. Against that background, it would be advantageous both for patients and for the taxpayer if the use of NOACs was more widespread. However, at the moment, data from NHS England show that only 11% of anticoagulants prescribed are NOACs—possibly because of lack of clinical awareness and confidence in using them rather than warfarin, or because NICE guidance is being implemented too slowly.
Under the NHS constitution, patients should have access to the full range of treatment options recommended by NICE, but at the moment that does not seem to be the case. Will the Minister tell us what action is being taken to ensure that more patients have access to NOACs, in line with NICE guidance, and to reduce variations in their use across the country? For instance, might he consider providing specific support for clinical commissioning groups with the lowest rate of NOAC use, to ensure that patients in those areas have better access to treatment?
I greatly look forward greatly to the contributions of noble Lords this evening. This is no peripheral health issue, but one of real importance to the lives of hundreds of thousands of individuals and their families. Great progress has been made in recent years, but, thanks to the development of new drugs and new technology, more can be done. This is an occasion when a tiny hand on the tiller by my noble friend could mean significant further advances in diagnosis and treatment, with real public health benefits. I hope that our debate tonight will gently nudge the noble Lord in the direction of that tiller and lead to life-saving changes.
Baroness Murphy (CB)
My Lords, I am delighted to support the noble Lord, Lord Black of Brentwood, in his campaign to get better recognition for the causes and treatment of atrial fibrillation. I am interested because I have spent a good part of my professional life as a psychiatrist working with elderly people suffering the emotional and neuropsychological aftermath of serious stroke. It makes me hopping mad to come across people who still have atrial fibrillation after they have been treated for their stroke and have then come on for further psychiatric treatment. It is a tragedy to recognise that they still have the atrial fibrillation that could be treated to prevent a further stroke.
I am now retired from clinical practice and I understand that things have improved. It is now much more likely that patients will arrive with appropriate treatment. I congratulate this Government, the previous coalition Government and the Government before that, on supporting the major stroke initiative that has led to much better targeted care of people with stroke, from access and recognition of stroke right through to focused centres and better outcomes in mortality and morbidity. We are making good progress, but there is still much more to be done.
Atrial fibrillation is extremely easy to diagnose, as the noble Lord, Lord Black, said. If you are treating a lot of elderly patients every day, it is very nice to sit down and gently feel their pulse, right at the beginning. This breaks the ice and is a very good way of making contact with an elderly patient you might not know very well. We are now getting to the point when we are joining the elderly generation. Some of us are already well into that period of life. The time has come when we are the patients who need to know about atrial fibrillation and know when we have an irregular pulse. We are the ones who need to understand. The population increasingly understands the causes of stroke and what to look for. We can teach people, with education and public information, how to feel their own pulse. Most people already know; it is so easy, so there is no problem there.
I agree that there is a problem with the drugs. I went to see an elderly friend of mine who was also a doctor in her time and is now 90. She has a touch of atrial fibrillation and she said, “I will take anything except that rat poison”. I told her that she was taking a bit of a risk but she said, “I have discussed it with my doctor, but my next-door neighbour has just died of a cerebral haemorrhage. Are you really going to subject me to that risk as well?”. There are now four new drugs on the market, some of which have been around for about two years, but the problem is that they do not diminish the risk of haemorrhage. We need to discuss the risk with individual patients, but patients are still having to think through whether or not they really want a drug when the side-effect risks are huge.
I have been speaking for four minutes, so I will shut up, but my final point is that we need to take heart from some of the newer treatments. Left atrial appendage ablation, which is available in the States now, and is coming here, is the way forward for the future.
Lord Rennard (LD)
My Lords, I draw the attention of the House to my entry in the Register of Lords’ Interests. I also congratulate the noble Lord, Lord Black of Brentwood, on securing this important debate. Approximately 900,000 people in England have been diagnosed with atrial fibrillation, or AF, and there are perhaps half a million people here with the condition who have not yet been diagnosed. The condition causes an irregular heartbeat and it is one of the most important risk factors for stroke, contributing to one in five strokes. If left untreated, AF increases the risk of stroke fivefold.
AF-related strokes are often more severe, with higher mortality and greater disability arising from them than from other strokes. The Global Burden of Disease Study in 2013 suggested that atrial fibrillation and atrial flutter resulted in 112,000 deaths in 2013, compared to 29,000 in 1990. So it is a growing problem. Treatment with anticoagulants significantly reduces the risk of stroke in people with AF, but according to the Stroke Association, almost half of all the people in the UK with AF are not receiving the full anticoagulation treatment which significantly reduces the risk of stroke.
The issues for us to consider, and for the Minister to respond to, must therefore begin with the question of whether greater attempts at screening, which could enable early diagnosis, could be justified in terms of lives saved. Patients often do not feel any symptoms when their heart rate changes. There are many causes of this but not all of them are obvious. Can we simply rely on many people turning up at their doctors with other concerns leading to the identification of this condition? For those who are diagnosed, is enough being done to promote these anticoagulation treatments, including those most recently developed?
Surveys suggest that patient access to novel oral anticoagulants is lower than should be expected, highly variable across the country and much lower than in other European countries. The National Institute for Health and Care Excellence produced an excellent atrial fibrillation quality standard in July, which was endorsed by the Department of Health. But there is real doubt over whether that standard is being properly applied uniformly and in a timely fashion. The evidence suggests not.
An NHS Improving Quality report estimates that just over half of people with AF are getting drug treatment in line with the recently updated best practice guidelines. A year ago, it produced a report which suggested that better care of people with AF could help prevent an additional 11,600 strokes and save the NHS as much as £124 million per year. It also suggested that full implementation of new best practice guidelines could prevent almost 28,000 strokes each year and lead to overall savings of £293 million for the NHS in England.
I hope the Minister will respond positively by telling us that there will be rapid progress towards full implementation of these best practice guidelines.
Baroness Masham of Ilton (CB)
My Lords, I thank the noble Lord, Lord Black of Brentwood, for this debate and for his ongoing questions to the Government on atrial fibrillation. Both my late husband and one of my best friends had irregular heartbeats. I used to check their pulses and told them that they must get checked out for atrial fibrillation, but their doctors did not take these abnormalities seriously. This is why I strongly support this debate on improving the diagnosis and management of AF.
I declare an interest as the vice-chair of the All-Party Parliamentary Group on Atrial Fibrillation. I am pleased to tell your Lordships that there is to be a meeting tomorrow in Portcullis House on transformation of AF services following NICE clinical guideline 180 and what it will mean for patients. It is good to have these specialising all-party groups to help to make Parliament aware of the many needs.
My husband had a stroke while watching a cricket match on TV and I knew exactly what was happening. Neglect in the local hospital, bleeds, clots and diabetes followed. It was a nightmare. If strokes can be avoided, that must be a priority. Prevention is much better than cure because so often there is not one. We need to prioritise prevention. Sadly, many people with AF are not diagnosed and many who have been diagnosed do not receive the anticoagulation treatment that they need. It has been estimated that as many as 700,000 people in the UK may be undiagnosed. Improving access to the full range of anticoagulation therapies would bring benefits to patients and the NHS.
For many years, I have felt that basic first aid should be taught in all schools to pupils above a certain age. Taking the pulse manually should be commonplace. I have been amazed that so many people cannot take their pulse. With so much talk about self-management and self-care, surely it is time to show everyone the way with basic training. Does the Minister think that all GPs have read the NICE guidelines on AF? If they have, why are they still prescribing aspirin?
I congratulate the Stroke Association on all that it is doing to help with AF. If all the estimated 1.4 million people with AF in England were detected and adequately treated, an estimated 16,000 strokes could be prevented every year. In addition to reducing mortality and severe disability, additional health and social care costs could be avoided. The NHS alone could save £130 million with appropriate detection and treatment of AF. I hope that the Minister will give us some encouragement. It is a very important issue.
Baroness Gardner of Parkes (Con)
My Lords, I suppose I should declare an interest. Some years ago I was told that I had mild atrial fibrillation—it might have been named intermittent. Now, it is clearly stated that I have permanent atrial fibrillation. I am aware of this diagnosis and the fact that it means my heart is less efficient. Noble Lords have heard everything from everyone else about that. I take Warfarin daily to keep my international normalised ratio within appropriate levels recommended by my cardiologist. It seems to be effective, but regular monitoring through blood tests is required to ensure that my INR remains as it should. The test is straightforward and involves a finger prick to obtain a blood sample, which is put into a reading system that provides the answer. The dosage of tablets is then increased or decreased to correct an unsuitable reading. It is the sort of test that people with diabetes—particularly type 2—need to carry out several times a day.
Yesterday, I discussed this with a distinguished Member of your Lordships’ House who has been in exactly this position—as a type 2 diabetic—for some years. He said he gets warnings: when he feels that he is getting muddled, that means that his blood sugar is low and it is time for another test. If he is feeling slothful and lethargic, his blood sugar is high. He has to do this test up to five times a day and carries out these procedures himself; he has no problems with this. Why is it that individuals requiring very similar blood tests for atrial fibrillation are not able to do their own tests in this same way?
Over the years, I have raised this question, especially with my noble friend Lord Howe. In his days as Health Minister, he told me that it would be logical for those who wished to self-test to do so. I was informed that this would help to reduce National Health Service workload, and sure enough, the INR clinics are always very busy and in demand in most of the major hospitals and in many general practices. The NHS supported self-help, according to my noble friend. In that case, why is there not more self-monitoring for atrial fibrillation? Is this still the case?
For some years, manufacturers of self-test appliances have provided demonstrations in the House of the simplicity and effectiveness of the process. There would be considerable savings for the NHS if patients bought their own machines—I believe that many would—and the NHS provided the small disposable items needed for the tests, such as finger-prickers and solutions. At present, different areas of the NHS provide others with different items. In some areas, the situation is very unsatisfactory for those who feel they should have access to these items. If there were just one system and all the patients therefore had the same choices, there would be a considerable saving.
Mention has been made of the drugs that could be taken instead of Warfarin. My cardiologist said, “Don’t do that”, because the good thing about Warfarin is that its effects are reversible if you suddenly find that your reading is much too high or too low. However, the effects of these new tablets—which have been referred to as NOACs—are not reversible. You have to wait until the body gets rid of them, so there is a time-lag and the situation could become quite dangerous.
In Australia, children born with heart conditions have such machines loaned to them, so that all the treatment can be administered at home. Again, that is very important. My noble friend Lord Black mentioned the difficulty a lot of people face in getting to a hospital. I hope the Minister will support the view that there should be access to self-monitoring.
Lord Rea (Lab)
My Lords, I congratulate the noble Lord, Lord Black: he has done us all a service by bringing atrial fibrillation before us. It is not the first time it has been debated in the House, but it is very relevant. Like him, I suffer from the condition of paroxysmal atrial fibrillation. What he and many other people have said more or less follows what I have prepared; I agree with nearly everything that has been said so far. Atrial fibrillation is on the increase and is a really serious problem, in that it can cause a stroke.
It is also relevant that I am a former GP who has treated a number of people with atrial fibrillation, but that was some years ago and we did not have the tools and medications—the drugs—that we have now. Some of my information, therefore, has been gained through reading rather than practice.
Atrial fibrillation increases with age, so it is not surprising that a number of your Lordships suffer from it. Some of us may not even be aware of it, as has been said, since it gives rise to quite mild symptoms and sometimes none. Sometimes it is continuous, but sometimes it is episodic or paroxysmal. Treatment consists of measures to detect and, as far as possible, correct any conditions that might underlie the atrial fibrillation—and there are quite a few—and then to restore normal rhythm, if possible, with drugs, electrical cardioversion, or surgical ablation, as has been mentioned. Most important is the prescription of suitable anticoagulants to minimise the formation in the left atrium of clots, which can be carried around the body, block an artery and deprive an area of the brain of its blood supply, leading to an ischaemic stroke. A stroke caused by atrial fibrillation is often more serious than one from other causes, so it is particularly important to detect it as soon as possible and start treatment with effective anticoagulation. Until recently, this was not emphasised adequately by clinicians and the standard drug used was inadequate—low-dose aspirin.
Trials have shown that more powerful anticoagulants have a measurably better effect than aspirin in reducing embolic stroke. The first of these, as has been said, is Warfarin—rat poison—which inhibits vitamin k action, an essential part of the clotting process. It is remarkably cheap, and its cost is amply repaid by the savings incurred by the National Health Service that it gives rise to through stopping atrial fibrillation-related stroke. I take warfarin, like the noble Baroness, Lady Gardner. My condition is under control, but having to be tested from time to time is a nuisance. I thoroughly agree with the suggestion that self-monitoring should be made available. The instruments cost about £200.
The main trouble with warfarin is that it takes some time for its effects to cease, and it can cause internal bleeding. If such bleeding occurs and cannot be brought down quickly, that is a worry. Despite what the noble Baroness, Lady Masham, said, NOACs allow the clotting time to increase quite rapidly after stopping taking them, so they are safer than warfarin.
On detection, it is very important, as has been said, to find the cases that do not have much in the way of symptoms. I will say a few words on that. Sadly, detection has been woefully inadequate up to now. That may be simply because the doctor or nurse has failed to take the patient’s pulse.
Lord Colwyn (Con)
My Lords, everything that could be said probably has been. I declare an interest as a member of both the AF APPG and the stroke APPG. We have meetings tomorrow, as we have heard. I also have personal experience of living with AF for many years.
Atrial fibrillation is the most common sustained cardiac arrhythmia and estimates suggest that its prevalence is increasing. If left untreated, atrial fibrillation is a significant risk factor for stroke and other morbidities. Men are more commonly affected than women and prevalence increases with age.
It has been suggested that AF can be detected by a simple pulse check. I have found that a pulse check should be verified with an oximeter. It is difficult to self-diagnose irregular cardiac rhythms that are often in excess of 150 beats per minute without the use of an oximeter. Perhaps that is what the GRASP machine is; I had not heard of it before. AF affects around 1 million people in the UK. Sometimes the condition does not cause any symptoms and a person with it may not be aware that their heart rate is irregular. It is important that AF is diagnosed so that medical practitioners can decide when active treatment is needed.
The aim of treatment is to prevent complications, particularly stroke, and to alleviate symptoms. Drug treatments include anticoagulants, to reduce the risk of stroke, and antiarrhythmics, to restore or maintain the normal heart rhythm or to slow the heart rate in people who remain in atrial fibrillation. Non-pharmacological management includes electrical cardioversion, which may be used to shock the heart back to its normal rhythm, and catheter or surgical ablation to create lesions to stop the normal electrical impulses that cause atrial fibrillation. I have had both of these techniques.
There are also new updated guidelines that address several clinical areas in which new evidence has become available, including stroke and bleeding risk stratification, the role of new antithrombotic agents, and ablation strategies. The recommendations apply to adults—those aged 18 years or older—with atrial fibrillation, including paroxysmal, persistent and permanent atrial fibrillation, and atrial flutter. They do not apply to people with congenital heart disease precipitating atrial fibrillation.
Sadly, many people with AF are not diagnosed and many who have been diagnosed do not receive the anticoagulation treatment that they need. Between April 2014 and March 2015 only 38% of patients with diagnosed AF who were admitted to hospital with a stroke were being treated with anticoagulants. It has been estimated that as many as 700,000 people in the UK may have undiagnosed AF.
In recent years several anticoagulants, known collectively as non-vitamin K antagonists, have been recommended by NICE. Under the NHS constitution, patients should have access to the full range of treatment options recommended by NICE. However, data from NHS England reveal that only 11% of patients being prescribed anticoagulation are receiving these treatments. Improving access to the full range of anticoagulation therapies would bring benefits to patients and the NHS. The Government have estimated that up to 7,100 AF-related strokes could be prevented annually if everyone with AF were appropriately managed.
Since 2012 four novel oral anticoagulants have been recommended by NICE as both clinically effective and cost-effective for the prevention of strokes in patients with AF. These treatments should now be available to all patients whose doctors wish to prescribe them. Their use is increasing, but it is lower than expected. All healthcare professionals caring for people on anticoagulation therapy should be familiar with the full range of treatment options. Despite having a NICE recommendation as being clinically effective and cost-effective, many GPs appear to lack confidence in the use of NOACs to prevent AF-related strokes.
Lord Plant of Highfield (Lab)
My Lords, most of what needed to be said has been said. I echo everything that noble Lords have said about the initiative by the noble Lord, Lord Black, and I am very pleased that he called for this debate. Like other noble Lords, I have had AF for a very long time—20 years or more—and I have been taking warfarin every day, along with a low-dose aspirin, for 20 years. This medication was changed recently and I was rather nervous about it. The aspirin was replaced by clopidogrel. So far no adverse effects have been detected, but it is a bit of a big thing when you move from one medication to another.
I am pleased that in its guidance NICE says that there should be proper consultation between the patient and the cardiologist about any sort of medication. I wonder whether an organisation such as the British Heart Foundation could produce one of its short pamphlets explaining the action—the function—of these drugs in a fairly straightforward way. I hope that I am a person of at least moderate intelligence, but I did find parts of the NICE guidelines completely incomprehensible. It would be worth having a leaflet setting out the pros and cons of different kinds of therapy.
Given that a lot of people—most people, probably—will stay on warfarin for the foreseeable future, I am worried by its prescription into quite old age and the risk of falling. If you fall and your blood is very thin, the chances of having some kind of bad event are quite strong. I remember—as will many members of this House—our friend Donald Dewar, the former Secretary of State for Scotland, who fell over in a frosty street in Edinburgh and died as a result of a brain haemorrhage. He was on warfarin: it was a contributing factor. So it is important that we consider knocking off warfarin for elderly people and perhaps replacing it with some of these NOAC drugs, so long as they do not have the same sorts of risks. Perhaps they do.
There is another thing that happened to me recently that perhaps the Minister could think about, although not necessarily today. It is where you have atrial fibrillation and you have a stroke. I had a stroke in November 2014, which badly affected the sight in my right eye, and almost immediately after the stroke, which was caused by AF—they knew that because I was in hospital at the time and my heart was in atrial fibrillation when I had the stroke—I had a carotid artery endarterectomy. That was a slightly alarming operation, to put it mildly, but it seems to have helped things along. How routine is offering carotid artery surgery to otherwise fit patients who have had an AF-induced stroke? It would be useful to know whether it is pretty routine or an exceptional thing.
I have been fortunate since I have had all this trouble to have lived in Oxford, where there is an exceptional cardiology department, and now Southampton, where there is a regional centre for cardiology. I just wonder how far the ease with which my symptoms and the carotid artery operation were dealt with was due to the fact that Southampton is a regional centre, or whether you could get that kind of treatment in a much smaller hospital. It would be useful to have some indication of that. If the Minister could write about that, I would be very pleased.
Baroness Wheeler (Lab)
My Lords, I, too, congratulate the noble Lord, Lord Black, on securing this debate and pay tribute to his work highlighting the importance of early detection and effective management of AF. I also very much welcome the important walk-in clinic initiative he is promoting within Parliament, with AntiCoagulation Europe providing pulse checks to help prevent strokes and blood clots for people with AF, and hope that as many MPs, noble Lords and Parliamentary staff—if they are included—as possible will go along on 10 November.
I am also very grateful for today’s debate because it sets the scene for my own debate on 18 November on the updating of the now eight year-old national stroke strategy. The strategy runs out in April 2017 and today’s focus on AF underlines the priority it needs to have in the future strategy for preventing stroke and reducing the number of people who have strokes that could have been avoided.
As a vice-chair of the All-Party Group on Stroke, as well as being the carer of a disabled partner who had a major brain haemorrhage stroke in 2008, I am sure that noble Lords will understand why most of my remarks on AF will focus on stroke-related aspects. Better diagnosis and treatment through early detection and effective management of AF with an anticoagulant would result in the prevention of more than 4,500 strokes and 3,000 deaths across England each year. Untreated AF is a contributing factor in 20% of strokes in England, Wales and Northern Ireland, and, as we have heard, more complex disability can result from AF-related strokes.
We have heard a number of figures about the scale of the problem. The Stroke Association’s figure, cited by the noble Baroness, Lady Masham, is that an estimated 16,000 strokes could be prevented every year. The association hears many accounts from stroke recoverers about the devastating consequences of poor detection of AF, so it is worth putting on the record just two of those case histories.
David had a stroke at 62 which had a considerable impact on his life. He now has reduced mobility and this impacts on his job as an electrical engineer. David was not diagnosed with AF until after he had the stroke, and when discussing how to reduce the risk of having another stroke caused by AF, his GP seemed keen for him to take aspirin rather than an anticoagulant; that is, clot-reducing medication. However, David conducted his own research and then pressurised his GP into prescribing an anticoagulant drug.
Another stroke recoverer, Brenda, suffered a stroke thought to be caused by AF. She initially had a mini-stroke and was told by the hospital she was taken to that she had had an arrhythmia; there was no mention of AF. She went on to have a stroke 18 months later. Often AF is discovered only after patients are admitted to hospital with a stroke, and obviously by then it is too late. The Sentinel Stroke National Audit Programme found that only 28% of stroke patients known to have AF when admitted to hospital were on the anticoagulant medication they should have been on. The noble Lord, Lord Colwyn, gave this figure as 38%, I noticed.
Significant underdiagnosis and undertreatment remain, despite the incentives mentioned by noble Lords in the quality and outcomes framework, last year’s reissued NICE guidelines and the new quality standard on AF. It is imperative to address the low level of knowledge among GPs of the importance of early detection and the appropriate treatment of AF. The toolkit AF: How Can We Do Better?, developed by the Stroke Association for GPs and others in primary care, is one of a number of key actions that would lead to the increased awareness and understanding that are needed, particularly about the link between AF and stroke. Government support for NHS Improving Quality’s new GRASP-AF guidance on AF risk assessment and stroke prevention within GP practices would also make a significant difference.
How will the Government be supporting these initiatives? Does the Minister acknowledge that if swift and routine pulse checks were included as part of every GP visit, huge progress could be made and thousands of lives saved? Does he agree that the current low levels of awareness among health professionals are not conducive to developing better understanding among the public? Finally, I support the inclusion of indicators on detection and treatment of AF in the public health outcomes framework. Local health trusts need to be assessed on the efforts they are undertaking to prevent strokes and other major conditions that can arise from AF to ensure that vital opportunities to save lives are not missed.
The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)
My Lords, I thank my noble friend Lord Black for initiating this debate. It has been very interesting for me. I did not know anything about atrial fibrillation until I researched it for this debate. What always strikes me is the extraordinary depth of the contributions noble Lords make to these debates.
I shall draw out four themes that we often come across in these debates before I respond in detail. The first is how expert patients or carers of patients have become and what a contribution they can make to helping NHS England and clinical commissioning groups in structuring the right kind of care pathways for these serious illnesses. The second point is the variation around the country, from GP to GP, from CCG to CCG and from one region to another, every time we debate almost any disease in this Chamber. The third point, which was made strongly by the noble Lord, Lord Rennard, is the correlation always between quality and cost. We often think of them as separate and in opposition to each other, but good quality is usually also achieved at lower cost. The fourth point is the growing role of self-care. My noble friend Lady Gardner and others mentioned that as technology develops self-care will become an increasing part of how we deliver care. On education, the noble Baroness, Lady Masham, talked about basic first aid, such as learning to take your pulse at school. It is so obvious that you would not think it needed saying, but I have never done a first aid course and I am not proud of that fact.
I start with diagnosis of AF. Around 18% of cases of AF remain undetected. That means a lot more needs to be done. NHS England is encouraging clinical commissioning groups to work with local practices to target people at risk of AF. In addition, the NHS Health Check programme’s best practice guidance recommends that a pulse check is carried out as part of the process of taking a blood pressure reading. People found to have an irregular pulse rhythm should then be referred to their GP for further investigation. Other innovative approaches are being used to identify AF in older people, such as pulse testing at flu clinics and by some dentists.
There is also research under way. The National Institute for Health Research is funding a study into how a hand-held device can be used in primary care to provide an automatic diagnosis of atrial fibrillation. The National Institute for Health and Care Excellence—NICE—published an updated guideline on AF in June 2014 which includes recommendations on diagnosis. I looked at the care guideline before I came here. I did not find it as complicated as the noble Lord opposite but no doubt it could be simplified.
My noble friend Lord Black stressed the importance of screening. I do not think I have a very good answer. I have a response here on screening but I am not sure it will satisfy him—it did not entirely satisfy me. There are calls for screening for AF, as we have heard today. Ministers are advised by the UK National Screening Committee. In 2014, it recommended that a systematic population screening programme for people aged 65 and over should not be offered. This is because, based on the evidence in the review, the committee was not convinced that such a programme would bring more good than harm to the population offered screening. This position will be reviewed in 2017-18, or earlier if new evidence emerges. I am very happy to meet the noble Lord, Lord Black—or any other noble Lord—and the people from Public Health England responsible for the decision if he would like to understand more fully the reasons why. I am not saying they are wrong—they may well be right—but I should like to understand in more detail the reasons they believe that screening is not appropriate. I think the noble Baroness, Lady Murphy, suggested a reason in her speech. Maybe we should depend more on people taking responsibility for themselves and less on a screening programme, although I am not sure whether that was the point she was making. In any event, it is an issue that I would like to explore further with the national screening programme people.
As for the treatment of atrial fibrillation, NHS England has identified the improved management of AF as a priority for reducing premature mortality. NICE’s updated guidance suggests the use of anticoagulants unless there is a reason not to do so. I know there are concerns—they have been mentioned this evening—that aspirin is still being prescribed instead of anticoagulants, but NICE makes absolutely clear that aspirin on its own should not be used for stroke prevention in people with AF. There is NICE technology appraisal guidance recommending the use of newer anticoagulants for some people, which a number of noble Lords have mentioned this evening. NICE also published a quality standard on AF in July 2015, which sets out what a high-quality AF service should look like and will help drive improvement locally. The QOF contains indicators for the management of AF which cover the use of anticoagulation therapy. That provides a further incentive for doctors to ensure that AF patients receive anticoagulation where appropriate to manage their stroke risk. These actions should help ensure that people receive the anticoagulation treatment that is right for them.
I know there are concerns that some people with AF are not able to access the newer anticoagulants that NICE has approved for certain patients. There is a legal requirement on commissioners to provide funding for treatments and drugs recommended in NICE technology appraisal guidance within three months of that guidance being published. This is enshrined in the NHS constitution. The need to reduce variation and to strengthen compliance with and the uptake of NICE technology appraisals was identified in Innovation Health and Wealth, published in December 2011. In response, NHS England and the Health and Social Care Information Centre have developed an innovation scorecard, published on a monthly basis, to enable commissioners to benchmark their own position and increase transparency to patients and the public. This will assist the NHS in the identification of variation and the adoption of treatments such as NOACs that are recommended in NICE technology appraisals.
Some progress is being made. The uptake of newer anticoagulants—the NOACs—across England in 2014-15 was more than double that in 2013-14. In 2013-14, the figure was 45,708 per 100,000 of the resident population; that had risen to 126,845 in 2014-15. In addition, NHS IQ is promoting the use of GRASP-AF within GP practices in England. This audit tool, which was mentioned by the noble Lord, Lord Black, and other noble Lords this evening, simplifies the process of identifying patients with AF who are not receiving the right management to help reduce their risk of stroke. NHS IQ continues to support the use and rollout of this audit tool. In answer to the noble Lord’s question, I understand that, to date, 2,938 GP practices across the country have used the tool and have voluntarily uploaded their data to the online database. The database now contains information on the management of more than 327,000 patients with AF.
As to self-monitoring, when patients are taking warfarin, they need to have regular blood tests to monitor their internal normalisation ratio—their INR—which measures how fast blood clots. It is important that this remains in the correct range. Understandably, some patients find having to make regular trips for blood tests to monitor their INR disruptive. I am running out of time but it is worth just saying that NICE has recently recommended two point-of-care devices in diagnostics guidance for people taking long-term anticoagulation therapy who have AF or heart valve disease, if they prefer to use this type of monitoring.
To conclude, I hope that some of what I have said reassures noble Lords that we and the NHS take this illness extremely seriously. I am pleased that we are coming back to talk about stroke in more detail later in November and I reiterate my offer to have a meeting with the national screening people if noble Lords would like to find out more about their reasoning behind the decision not to screen for AF.
I am told I have three minutes; I thought I had to finish. I apologise. Having concluded, it is rather difficult to start again. At the beginning of the debate the noble Baroness opposite talked about stroke. I think we are coming back on 18 November to talk about stroke care in more detail. There have been enormous improvements over the past five years in the way that stroke has been treated in this country, in part because of the work done in London to concentrate stroke care in a smaller number of hyperacute hospitals where they can provide thrombolysis—clot-busting drugs—much more quickly. Certainly, in the hospital I was involved with in Norfolk we have seen a huge change in the quality of stroke care in the past three or four years. Before that, stroke had been a very poor relation compared to heart attacks or cancer, for example. In many parts of the country, if you had a stroke after 5 pm on a Friday your care was very poor. We are able now to provide stroke care on a much better basis.
It is hard to start again when you have finished, but my 12 minutes are up. The noble Lord, Lord Black, said that he is supervising a walk-in session on Tuesday for people who would like to have their pulse taken to see whether they suffer from AF. Sadly, I will not be able to make that walk-in session, but I encourage noble Lords to do so.