Atrial Fibrillation

Baroness Wheeler Excerpts

Tuesday 7th May 2019 Lords Chamber

[Baroness Wheeler (Lab)]

My Lords, I too congratulate the noble Lord on securing this important debate and welcome the time we have had to look in more detail—albeit we will not use it—at this issue, which is so vital to addressing premature death or severe disability arising from heart disease and stroke. I also commend the noble Lord’s work and campaigning on AF, in particular on the need to reach the estimated 425,000 people who have yet to be identified and treated. Following our last debate on AF in 2015, the noble Lord and I had a helpful follow-up meeting with the then Minister, the noble Lord, Lord O’Shaughnessy, particularly on the need to step up routine health checks of at-risk groups in GP surgeries and community settings, including pharmacies. The inclusion of heart disease and stroke in the better care for major health conditions action plan in the NHS Long Term Plan is welcome.

We recognise the good progress made since PHE’s setting in 2016 of the ambition in the Menu of Preventative Interventions of increasing the optimal management of people with AF from 74% to 89% over five years. The figure for 2017-18 was 84%, and there is strong clinical consensus that the PHE target of 89% is both appropriate and achievable. PHE estimates that if the ambition was achieved within three years, at least 49,000 strokes and 32,000 heart attacks could be prevented, which shows what can be achieved if the current barriers are overcome. PHE also shows that reductions in other events averted, including heart failure, TIAs, vascular dementia and angina, would achieve 81,000 life years gained and avoid 9,000 mortality cases. As we have heard, the NHS long-term plan sets an additional, less focused target of preventing up to 150,000 heart attacks, strokes and dementia cases over the next decade.

I would welcome the Minister explaining how the NHS and PHE ambitions are to interact and be brought together into a coherent long-term implementation plan. When the NHS long-term plan was published in January, noble Lords underlined the need for a clear implementation plan setting out what is to be achieved, how the plans are to be implemented, and how the outcomes are to be funded, measured and evaluated. Can the Minister update the House on the work being undertaken, the consultation taking place on its development, and tell us when any plan is due to be published?

We also pay tribute to the work of the AF Association, the Stroke Association, the British Heart Foundation and other key health organisations which have been instrumental in raising awareness among patients, the general public and policymakers of the importance of identifying and treating people with AF. We welcome the collaboration between NHS England, PHE and the key health charities, and the February launch of the action plan for improving the detection and treatment of the ABC causes of heart disease—AF, high blood pressure and high cholesterol—and promoting free health checks for those high-risk diseases. As the Stroke Association put it at the time, in England alone there are 5.5 million people with undiagnosed high blood pressure who are ticking time bombs for stroke. Tackling this and AF would see the biggest drop in the number of strokes each year.

As the carer of my disabled partner who had a major brain haemorrhage stroke in 2008, I am sure that noble Lords will understand me focusing on stroke. As we have heard, AF contributes to one in five of all strokes in the UK and, if we do not act now, the number of strokes is set to increase by 44% in the next 20 years.

The excellent call to action in last year’s white paper from the AF Association on the inequalities and unmet needs in detecting AF and therapies to prevent AF-related stroke has been referred to. Its call to action in four areas—supporting patient education, adapting clinical practice to enhance AF detection, strengthening clinical and professional training in AF and promoting awareness and accountability among decision-makers for effective AF-related stroke policies—have been raised, and I look forward to the Minister’s response to those important issues.

NHS England’s national stroke programme, which de facto replaces the national stroke strategy that ran out in 2017, underpins the NHS Long Term Plan. I understand that there are five work streams under the programme, including prevention, and this feeds into wider CVD respiratory diseases. Four aspects of the AF-related work under the programme refer to: consideration of a new national CVD to support clinical improvement; targeted awareness-raising, particularly in at-risk communities, such as some BAME communities; promoting the NHS RightCare CVD pathways, which have had significant impact when they have been effectively used; and improving the use of genetic testing when detecting and diagnosing CVD conditions. Can the Minister update the House on those developments? I was unable to find any specific data on AF conditions in BAME communities or any specific programmes to raise awareness or treatment levels, and I should be grateful if the Minister could advise the House of the work being done on that important issue. Is there, for example, any national information on CCG work to date on this?

The NHS plan commits to supporting GPs, pharmacists, nurses and the voluntary sector in primary care settings to case-find and treat people with high-risk health conditions. It is vital that diagnosis and treatment is provided before patients have a stroke and are hospitalised. The AFA white paper makes for concerning reading on the awareness of AF as a stroke risk factor among staff outside specialist cardiology settings, and calls for tailored guidelines for non-specialists to be drawn up to help to embed simple AF awareness practices and treatment in everyday care settings. Can the Minister advise what work is being done to address this issue?

Worryingly, the White Paper also refers to uncertainty among health professionals over how to deal with anticoagulation therapy, particularly for patients with complex conditions. Problems in using and interpreting risk assessment scores and the difficulty in AF detection associated with the complexity of symptoms is also identified. Moreover, healthcare professionals are often not passing to patients guidance on awareness-raising developed by patient organisations, which of course have first-hand experience, which would really help to raise patient awareness action. What guidelines and decision-making tools are being developed, particularly to support GPs?

Noble Lords have highlighted the role that new technology is increasingly paying in opportunistic clinical and community settings for AF, such as mobile ECG devices and ECG patches. The AFA white paper praises the pilot scheme in England enabling community pharmacies to refer people with an abnormal heart rhythm to a one-stop AF clinic after first testing them with a handheld device, which has speeded up diagnosis of AF and access to appropriate anticoagulant therapy within two to three weeks, compared with the national average of 12 weeks. These developments need to become routine in every CCG area. Following on from the successful scheme of virtual clinics run across south London in Lambeth and Southwark CCG in 2016, we welcome today’s announcement of funding for specialist clinical pharmacists in 23 areas with high levels of deprivation and/or high levels of untreated AF.

An NHS England press release draws attention to the fact that people who are poorer, who are from black and ethnic minority backgrounds or other disadvantaged groups are more likely to be among those who go undiagnosed and untreated. Following on from my earlier question, can the Minister provide further information on how those areas are to be evaluated and documented so that we can begin to develop a countrywide assessment of how the problems in hard-to-reach communities can be addressed?

Still on the subject of new technologies, smartphone apps and smart watches can help patients uncover AF symptoms, but what steps can be taken to ensure that they are fully integrated into the care pathway, so that people with suspected AF receive adequate follow-up care?

On research for future treatments, I was very interested to hear about the British Heart Foundation study, again at the University of Birmingham, on biomarkers. They are measurable indicators of a biological state or condition which could pave the way towards better detection of people with AF and more targeted treatment. Two biomarkers identified in the study—brain natriurertic peptide, and fibrogrowth factor 23—have the potential to be used in a blood test in community settings, such as GP practices, to simplify patient selection for ECG screening, leading to speedier diagnosis. Is there any further information on this and other developments that could help in the detection and treatment of people with AF?

Finally, with the progress being made in identifying and treating people with AF, can the Minister provide the House with a timeframe by which we would hope to see routine pulse checks become normal procedure, fully integrated into everyday primary care practice?