Atrial Fibrillation

Lord Prior of Brampton Excerpts

Wednesday 4th November 2015 Lords Chamber

[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.