Atrial Fibrillation

Baroness Blackwood of North Oxford Excerpts

Tuesday 7th May 2019 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Blackwood of North Oxford) (Con)]

My Lords, I thank my noble friend Lord Black for giving us all this opportunity to discuss what is not just an important issue but one that must be of incredible importance to him personally, and for sharing his story to date. As noble Lords are aware, and as we have discussed, although briefly, AF is a common heart rhythm disorder associated with debilitating consequences including heart failure, stroke, poor mental health—which we have not yet discussed—reduced quality of life, and death.

As my noble friend rightly said and others repeated, anticoagulation is an effective therapy for managing people with AF who are at risk of stroke. It can reduce the risk of stroke by up to 66%. AF increases the likelihood of stroke by five times; on average, there are 40 AF-related strokes every day in England. As my noble friend rightly indicated, PHE has been working alongside key partners to increase the proportion of patients with AF offered appropriate treatment from 74% to 89% by 2021. I will come on to the questions asked about surveillance and data.

My noble friend and other noble Lords are absolutely right that, although we have made progress on treatment, regional variation remains in the detection of AF and appropriate treatment. For that reason, a national programme was established in 2017 by NHS England and Public Health England to tackle the issue of AF-related strokes. Through this work, the 15 academic health science networks across England made it a priority to “detect, protect and perfect”—that is quite challenging to say in one sentence—AF services.

In response to questions from my noble friend Lord Black and the noble Viscount, Lord Craigavon, regarding the importance of accurately monitoring progress, a number of quality and outcomes frameworks—QOFs—measure the diagnosis and management of patients with AF. I am pleased that, based on the captured data, we can say accurately that progress has been made and that, as of last year, 84% of people with AF were appropriately managed with anticoagulation treatment; however, as the noble Viscount said, those people are only those who have been identified. It has therefore been agreed that the ambition for optimally managing AF should be increased to 90%; there is clinical consensus that this revised ambition is appropriate and achievable.

As the noble Baroness, Lady Wheeler, rightly identified, there is a role for technology to aid self-management and prevention. That is why, in July 2015, AliveCor’s KardiaMobile ECG mobile heart monitor, which allows individuals to detect, monitor and manage heart arrhythmia, joined the NHS Innovation Accelerator. Currently, 33 NHS organisations, including GP practices and acute trusts in all 15 academic health science networks, now use it with the aim to reduce the prevalence gap in AF to ensure that more people are treated appropriately to prevent AF-related strokes.

As has been mentioned, The NHS Long Term Plan, published in January 2019, sets out the ambition to prevent 150,000 heart attacks, strokes and dementia cases over the next 10 years. It includes commitments to developing and implementing an AF patient optimisation demonstrator programme, helping to case-find and optimise treatment for people with known cardiovascular disease. That is important because it will include practice pharmacists being trained in shared decision-making skills to utilise when having conversations with patients about their treatment options, which answers some of the questions asked by the noble Lord, Lord Rennard. It will also give health professionals the opportunity to work together with patients to decide on a patient’s treatment and care. SDM has been shown to improve patient experience and increase adherence to medication—a crucial issue raised by the noble Viscount, Lord Craigavon.

Clinical pharmacists, anticoagulant nurses or other appropriately qualified clinical staff will also carry out case-finding in GP records to find people with untreated AF as part of this programme, which is an encouraging part of the commitment made in the long-term plan. The programme launched on 7 May was developed in collaboration with Public Health England, the British Heart Foundation, the academic health science networks and NHS RightCare, as mentioned by the noble Baroness, Lady Wheeler. Through the programme, NHS England will invest £9 million over 18 months to case-find patients in GP records who have been diagnosed with AF but are not receiving optimal treatment. Twenty-three CCGs across England have already begun implementing the programme.

Of course, stroke prevention and treatment is a priority for the NHS. NHSE has been working closely with the Stroke Association to develop a national stroke programme to be delivered within the timeframe of the long-term plan. As the noble Baroness knows, the implementation plan will be published shortly. The programme will build on the successes of the Department of Health’s national stroke strategy and look at how to improve stroke care across the whole pathway, addressing the challenges of prevention—in this case, secondary prevention—service reconfiguration, optimising rehabilitation services, workforce development and transformative data. NHS England has engaged with cross-sector partners to support Health Education England in the development of workforce modelling for strokes. Health Education England is also looking carefully at the various components of the proposed stroke pathway and undertaking workforce modelling to articulate which workforce will be required; that will be engaged in the discussions on the spending review, as we have discussed previously in Questions. It has worked with arm’s-length bodies, charities, professional associations and academics to ensure that the required workforce is achievable over the period of the long-term plan.

The long-term plan also outlines commitments to improving vital stroke rehabilitation services. The recently established Stroke Programme Delivery Board also aims to place a strong focus on rehabilitation. Campaigns to increase awareness of stroke onset have been in place since 2009; of course, that is essential because early response is vital in avoiding disability. Public Health England has run the “Act FAST” national campaign, of which I know your Lordships will be aware. It has helped to reduce the amount of time between someone having a stroke and arriving at hospital, helping those eligible for thrombolysis and thrombectomy to access treatment in a timely way. As a result, 5,365 fewer people have become disabled due to stroke since 2009—an outcome we can all be pleased about.

I will answer some of the questions asked by the noble Baroness, Lady Wheeler, and the noble Lord, Lord Rennard, regarding regional variation. Quality of care varies greatly depending on geographic location, the day of the week and even the time of day that a patient is admitted. The NHS is working with providers to share best practice through initiatives such as that mentioned by the noble Baroness: the RightCare programme, which sets out optimal pathways for the care of stroke patients and AF patients through the collection of data in the Sentinel Stroke National Audit Programme.

My noble friend Lord Black, the noble Viscount, Lord Craigavon, and the noble Lord, Lord Rennard, all rightly linked surveillance, training and optimal treatment. CVDprevent will be the national primary care audit tool, and has been referred to by a number of noble Lords. It will automatically extract routinely held GP data covering the diagnosis and management of six high-risk conditions that cause stroke, heart attack and dementia. It will be implemented from March 2020, in response to a question asked by the noble Baroness, Lady Wheeler. The outputs will include regular national data extraction for a professionally led national audit programme which will be limited to routinely recorded primary care data. They will require no input from GPs. Analysis and reporting will identify achievement, gaps, variations, opportunity and treatment. They will also support systematic quality improvements to reduce health inequalities, a point mentioned by a number of noble Lords. They aim to improve outcomes for individuals and populations.

I also point to the primary care networks, which will be required to deliver a set of seven national service specifications. Five will start in April 2020: structured medication reviews, enhanced health in care homes, anticipatory care with community services, personalised care, and supporting early cancer diagnosis. The remaining two, which will start by 2021, comprise cardiovascular disease case finding and locally agreed action to tackle inequalities. All these will go towards answering the questions that have been raised in the debate.

I am conscious there were some questions that I have not been able to answer, and I will be happy to write on those. I hope that I have demonstrated in my response the NHS’s commitment to improving outcomes not only for people living with AF in this country but for the many more who are at risk of suffering from stroke. I cannot think of a more fitting way to close this debate than by repeating the excellent point from the CVD report referred to by the noble Viscount, Lord Craigavon: the return on investment of getting this right will be measured not just in a better quality of life for patients, important though that is, but in lives saved and life-changing disabilities averted. That is something which we must all work together to achieve.