Atrial Fibrillation

Viscount Craigavon Excerpts

Tuesday 7th May 2019 Lords Chamber

[Viscount Craigavon (CB)]

My Lords, we should be grateful to the noble Lord, Lord Black of Brentwood, for tabling this important subject for debate and for his tour d’horizon of the facts and circumstances of AF. I have chosen to focus more on the Question, which may be a mistake. I have been a member of the All-Party Parliamentary Group on Atrial Fibrillation for some time, and have tried to support its good work, in which it has the excellent outside help of the AFA—the AF Association.

The direct Question asked by the noble Lord, Lord Black, has been rather overtaken by a more up-to-date report published in February this year, more narrowly focused on CVD—cardiovascular disease—rather than many preventive interventions in the whole of the NHS, which the earlier report covered. That earlier report by Public Health England in 2016 gave a five-year plan to come up with the figure of 89% by 2021. The key words in the Question are “known … patients”, as there are estimated to be an additional huge number, about 300,000 people, who have this condition but are undiagnosed and unaware of it but who nevertheless suffer from it in varying degrees.

As to what is meant by the phrase “appropriate treatment”, if the underlying problem with AF is an irregular heartbeat or activity, this might lead to clots or strokes. When people are offered anticoagulants, that may usefully ameliorate the symptoms, but it is not strictly treating the underlying heart condition itself. When we are talking about treating 89% of patients, that is not treating the underlying cause in the heart, which can be very difficult, but largely dealing with the symptoms, which is nevertheless useful and desirable.

The more recent report, in February, again emanating from Public Health England, focusing solely on CVD, has chosen to launch a new 10-year prediction or ambition, ending in 2029. Again, this covers only known patients, but is obviously aiming also to reduce the number of those unaware of their condition. It is nevertheless useful to have the Minister here to answer how the 2016 prediction for 2019 is presently going and whether the figure of 89% for 2021 is realistic. In all these percentage predictions, it can be asked how useful or valuable it is to create these sorts of targets, especially some time ahead, with so many variables likely to intervene.

One might also ask by what authority such ambitions are arrived at. Like the sustainable development goals, successors to the millennium development goals, many of which failed to reach their expectations, I believe it is better to have common benchmarks, against which some sort of progress can be measured. However, as with the current climate change debate, one can be slightly sceptical about predictions the further away in time they are laid out. I am grateful that we have these Public Health England reports and predictions, and I do not want to seem to be nit-picking about the percentages, all of which I have taken from them. However, the target or ambition in the 2016 report, as in the Question, is that by 2021 89% of known patients should be on appropriate treatment for AF; whereas in the latest report, in February this year, the 10-year target ambition from now—apparently 84%—to 2029 is going to be only 1% higher, at 90%. I realise that in many things the last few percentage points are sometimes the most difficult to achieve, and it may be that the latest report has wisely resisted the temptation to be too optimistic.

To explain where this comes from, I will quote the report itself:

“Progress has already been made”—


to 84%—

“and it has therefore been agreed that the ambition for optimally managing AF should be 90%. There is clinical consensus that a treatment ambition of 90% is appropriate and achievable”.

I emphasise the words “optimally managing AF”. As I said earlier, the Minister might be able to throw some light on these intentions.

As I also said earlier, all the percentages I have quoted so far relate to known cases of AF, but the report I mentioned also deals with the percentages of detection. As the noble Lord, Lord Black, mentioned, that is what percentages of all cases are known and have been identified. That is obviously difficult to estimate, but I earlier gave the round figure of 300,000 for those not detected, which in the 10-year report relates to a starting figure for detection of 79%. That is set against the target in 10 years—for 2029—of 85%. Again, whatever the figure might be, that size of the unknown is very worrying, especially as everyone agrees that AF can be readily diagnosed.

Leaving percentages behind for now, I shall continue on the latest report by Public Health England, of February 2019, on CVD. AF is only one of three aspects of CVD it covers, the others being blood pressure and cholesterol. It is encouraging that this report also addresses some stark health inequalities, committing to publishing data highlighting high-risk conditions and setting goals in future to remedy these. It also usefully raises the aspect of return on investment, which is not just financial but includes lives saved and lived. It also helpfully reminds us that the present direct annual cost to the NHS of CVD is £7.4 billion, and that the wider, non-healthcare costs are at least double that, at £15.8 billion.

I shall focus the rest of my speech on AF amelioration and therapies, where changes have been frustratingly slow. There is a general need to make the public and clinicians aware of and understand the particular connection between AF and prevention of strokes. It is widely accepted that aspirin has no effect on AF, but it is still widely prescribed for known AF patients. That figure might be as high as 20%, when there are so many improved remedies available today. There is a high percentage of patients who have suffered strokes and are known to be AF patients but who are not receiving any effective anticoagulants.

One therapy that can be effective, if properly given, is warfarin, but there are often shortcomings in administering this. While I realise that not all therapies are suitable for everyone, there are the recent additional medicines called DOACs, also referred to as NOACs, which, while they may be more costly, provide much simpler and successful outcomes for most AF patients. I realise that there is something called clinical independence, and that clinicians cannot be forced to prescribe what others might think best, but this is a long-term matter of educating and informing both patients and clinicians. This will continue to be a valuable and worthy process, but at the same time it is frustratingly slow. If anyone has seen the effects of a stroke and thought, often correctly, that it could have been avoided, I hope they might support efforts to make knowledge about AF a more important priority in our health service.

Human Fertilisation and Embryology (Parental Orders) Regulations 2018

Viscount Craigavon Excerpts

Wednesday 12th December 2018 Grand Committee

[Baroness Barker (LD)]

My Lords, I thank the Minister for introducing this debate in the way that he did and giving the background to the instruments before us today. I should declare that I am a member of the All-Party Parliamentary Group on Surrogacy. I have a long-standing interest, fuelled by many a night sitting listening to the noble Lord, Lord Winston, as we went through various bits of legislation but principally by the work done by Surrogacy UK in 2016 when it produced a report. There was a debate in December of that year. Baroness Warnock was no longer a Member of your Lordships’ House, but the noble and learned Lord, Lord Mackay of Clashfern, was. Those of us who had been involved in legislation on this matter from the beginning in the 1980s accepted that the overall legislative framework we now have is not really fit for purpose, not least because of the many scientific advances that have happened in the intervening years. As the noble and learned Lord, Lord Mackay, observed in that debate in 2016, there are now many more ways in which families, as well as children, are created.

The Minister was right that the original stimulus for the legislation was the case of a man who in 2015 had a child by surrogacy abroad, brought the child back and found that the child’s status was incompatible with our law at the time, which stated that parental orders could be made only in respect of a couple. That was two and a half years ago. In the meantime, others have found themselves in similar limbo. The courts have had to make what are essentially temporary orders. Those orders are above all for the welfare of a child: a child is being cared for by somebody who is not their legal parent and has no legal responsibility for them. We should not lose sight of that.

This measure is a welcome step forward which offers a degree of certainty not only to individual parents or intended parents who find themselves in this position but to the children. I am pleased that the Law Commission is now undertaking an extensive review of the legislation. The All-Party Parliamentary Group on Surrogacy is conducting its own hearings on the matter. For just a small all-party group, the hearings have been extremely interesting. We have had a huge number of people give evidence, some with very conflicting views. I think that we will end up with an interesting report that feeds into that work. My guess is that the Law Commission will take about two years to produce a report.

My reason for mentioning all that is that time ticks by for individuals as we debate these matters. I do not suggest for a moment that we should do anything in a rush, but, at the same time, it is incumbent on us to deal with some matters urgently, because to do so is in the interest of individuals.

There are some ways in which a single person applying for a parental order will be still be left outside these remedial orders. I understand that a case is before the courts at the moment of a woman whose relationship with the biological father of a child has broken down. She is now in the position of being a single person who has no biological relationship with the child but nevertheless wishes to have parental responsibility. Another tragic case is before the courts in which one member of a couple has died subsequent to the fertilisation process having taken place.

However long the Law Commission takes to do its work, which it should do extensively and thoroughly, I think that we will continue over the years to have a small number of cases that are intensely important both for intended parents and for children. It is therefore likely that we will find ourselves back in this House making more revisions of regulations of this kind before we get the comprehensive review of surrogacy law that we need so that practitioners, medics, intended parents and children all have a better understanding of where we should be legally in this day and age.

[Viscount Craigavon (CB)]

My Lords, I will say a few words, partly reflecting what the noble Baroness, Lady Barker, said. I spoke on this subject in her debate some time ago.

We should be extremely grateful to the Law Commission for taking on this, in my opinion, very difficult and rather controversial work. Only an organisation like that is going to bring this to some sort of conclusion, but as the noble Baroness, Lady Barker, said, it will take considerable time, and understandably so—we do not want to hurry it. However, one or two problems are going to slip through the net before it reaches its conclusion. The noble Baroness, Lady Barker, mentioned particular problems and some of them might be resolved, as she said, by further orders but some will still be in difficulties because some women simply do not have the time to spare in their reproductive cycles to wait for these problems to be solved.

There is another example, similar to what the noble Lord, Lord Winston, was saying. In rather rare cases of cancer, the treatment disallows women from being able to be genetically connected to the child who is being born. That is another example where we might be in difficulties over the long time period we have. I very much welcome these regulations, and I hope the department will keep an eye on difficult cases that come up. We will be looking after them as well.

[Baroness Thornton (Lab)]

My Lords, on this occasion I thought I would let the experts go first—it is called delegation. Like all other noble Lords, I welcome these regulations. I think it is my first experience of a remedial order. As a bit of an anorak in these matters, with 20 years in your Lordships’ House, it is very exciting when you find yourself with a parliamentary procedure that you have not come across before. It is also interesting that the remedial order has then led to the statutory instrument that flows from it. We have also made all the right authorities happy.

I welcome the fact that the Law Commission is reviewing surrogacy. It is a three-year project, so the noble Baroness, Lady Barker, is right in what she said. In the time that I have been involved in doing health work in your Lordships’ House, every year or so we come back to some or other tweak, which is either down to medical science having advanced or, as my noble friend Lord Winston has said, technology having advanced. When my noble friend was speaking, I was reflecting on the fact that you can use the myheritage.com website to track down your genetic relatives from all over the world. If they are there, they will pop up. I suspect that will happen—not that we can legislate for that—and I suspect that the noble Baroness, Lady Barker, is right when she says that we will probably be back before the Law Commission has finished its work and certainly before the results of its work have been considered by the Government—whichever Government it is by then—brought forward and put into legislation.

NHS: Death at Home

Viscount Craigavon Excerpts

Thursday 8th November 2012 Lords Chamber

[Viscount Craigavon]

I am pleased to support the arguments made by the noble Lord, Lord Warner, and I am grateful to him for giving us the chance of this debate.

This is a very difficult area in which to bring about change or certainty, and one of the themes of what I say will be its complexity and confusion. I hope it is not too unrealistic to say that we should be aiming, perhaps in the long term, for simplicity and honesty. Despite that, I believe considerable progress has been made recently with, among other things, the Liverpool care pathway. We have heard about the scale on which it has been adopted to massively positive effect, but with some few negative instances and, as the Times editorial said recently, some mischievous controversy.

Research shows that poor communication around the LCP is not the norm. National Care of the Dying Audit – Hospitals assessed the LCP and found that 94% of relatives and carers were given a full explanation of it and that healthcare professionals discussed it with 56% of dying people. The LCP is a helpful process to minimise suffering at the end of life.

We should be grateful for what Marie Curie Cancer Care has done in this field, particularly in terms of highlighting the timing and cost of hospital in-patient care versus home care. Even with the clear cost advantage of home care, it is known to be quite difficult to set up all the elements satisfactorily, particularly for a patient or family already under stress. We have been given figures on the shortfall between those wishing to die at home and those actually able to do so: 60% want to, but only 21% achieve their wish. According to the National Audit Office, 40% of end-of-life patients had no medical need to be in hospital. In that respect, the message of this debate should be clear. On the NHS Constitution, while I broadly support the recent firming-up of some wording, it might be providing another level of complexity in shared decision-making.

How patients become active and equal partners with their clinicians about their care is still hard to define in any great detail, but that might be the direction in which we should be going. In complex cases, it may be that consultants might be too frightened of being sued to give advice or take action. We have heard tell of what might be called the Shipman effect seeming to inhibit common sense action. Maybe until recently there was a problem of nurses or health workers giving any response to patients who wanted what you might call a normal conversation or guidance on end-of-life matters. The LCP would seem to open the door to some sensible discussion, but it might be difficult for a passing nurse to know the medical status of the person who is asking questions. On the particular matter of assisted dying, I understand that the Royal College of Nursing has given some guidelines in a booklet, but they are understandably not exhaustive. Similarly the GMC has produced useful written guidelines to treatment and care towards the end of life. In understanding and researching this subject, as I said at the beginning, I am struck by the confusing multiplicity of differing sources of advice in this field. It is encouraging that discussion and dialogue are taking place but, for an individual trying to understand what options are available, choices are indeed complex.

In recording and co-ordinating patients’ wishes, we learn that there is something called advanced decisions, lasting power of attorney, advance statements and advance care planning. We learn that in the primary care field, care can be centred on the gold-standard framework, which sounds desirable. There are electronic palliative care co-ordination systems—recording a patient's wishes, one example of which is Coordinate My Care, which is being apparently implemented in London, and is available in addition to about half of ambulance trusts.

With some of this available, and most highly commendable, it is understandable that research shows that patients' misunderstanding and confusion is widespread, as to what their real choices are. I believe, however, that we are moving along with the NHS Constitution, in the right direction. It may be that in advancing the debate and options in this difficult area, such imperfect language and choices are bound to be complex and confusing. Finally, one of the welcome new additions to the NHS Constitution, apparently from April, is what is called the “duty of candour”; meaning that staff must be open and honest if things go wrong or mistakes are made. I hope that this candour might eventually spill over to a more general honesty in end-of-life discussions about achieving a good death.