Skip to main content

Coronary Heart Disease

Volume 486: debated on Wednesday 21 January 2009

Motion made, and Question proposed, That this House do now adjourn.—(Ian Lucas.)

I thank you, Mr. Deputy Speaker, and Mr. Speaker for giving me the opportunity this evening to raise this issue, which is of great importance to my constituents.

In the 19th and early 20th centuries, before the advent of vaccination, the most common causes of death and disability in this country were infectious diseases such as smallpox, diphtheria, tetanus, whooping cough, measles and polio. The average life expectancy of a male baby born in 1900 was 45. Edwardian men considered themselves old in their early 40s. Our pursuit of the maxim that prevention is better than cure has been successful: it has changed the structure and quality of our lives, but much more remains to be done. Often, if we solve one set of public health problems, the next challenge looms clearer.

The main cause of death in the UK now is cardiovascular disease and coronary heart disease, with nearly half the deaths caused by the latter. Based on 2005 data, there are some 227,000 heart attacks each year. The British Heart Foundation estimates that 1.5 million men and 1.1 million women are living with CHD. That is an immense residual quantum of personal suffering, but also a burden on the economy. It is reckoned that coronary heart disease costs the UK economy nearly £9 billion a year, and £5.7 billion of it is a result of days lost owing to death and illness and to informal care costs.

What is the best medical handle to bear down on this? Well, we know that high blood cholesterol is the single biggest risk factor. It was from that finding that a strategy began to be put in place to address the problem. In April this year, the Department of Health launched “Putting Prevention First”—a national programme of vascular checks for 40 to 74-year-olds, including risk assessment and management. It is thought that that programme has the potential to prevent up to 9,500 heart attacks and strokes every year and to save no fewer than 2,000 lives.

Running in tandem with that is the key part of the mechanism: the annual reward and incentive programme based on GP practice achievement results. That is the quality and outcomes framework, which began in 2004 and is known as the QOF. The current QOF target is to get 60 per cent. of all identified patients to a target cholesterol level. However, there are elements within the overall control strategy that are not operating optimally—at least not yet. A report by the university of York of June 2007, which I commend to hon. Members, dealt with

“the link between healthcare spending and health outcomes”,

and reads:

“Recent developments in circulatory drug therapy (especially statins) are acknowledged to be highly cost effective",

but we do not make full use of them. Our death rates from cardiovascular disease remain among the highest in western Europe. Tony Hockley, director of the Policy Analysis Centre, reckons that in England alone there are more than 7,000 unnecessary heart attacks a year because we do not diagnose and treat enough people with raised cholesterol levels.

I understand that cholesterol testing in the US is recommended for all adults over 20 every five years, that US targets for cholesterol reduction are significantly more ambitious than in the UK and that, broadly speaking, the hard-headed medical insurance companies in the US are prepared to pay for cholesterol-reducing medications on a preventive basis for those in high-risk groups. What makes sense to commercial ventures in the USA should make sense to a value-for-money-minded Treasury in the UK, too.

The big problem with QOF is that it has not moved with the times. The 2004 measure was based on recommendations made in 2000. There are inconsistencies with the National Institute for Health and Clinical Excellence guidelines of 2008 and the Joint British Societies professional guidelines. The 2008 NICE guidelines on lipid modification and type 2 diabetes recommend a level of cholesterol in the blood 20 per cent. lower than the QOF provides for, but, as yet, the target remains static. That means that the way in which we pay GPs is not incentivising them adequately to treat patients down to ideal serum cholesterol levels. That represents a missed opportunity, and lives lost or blighted.

There is an additional anomaly. GPs can still qualify for their QOF incentives even if significant numbers of patients are excluded from the calculations under the exception reporting rules. That is fair up to a point. Practices should not necessarily be penalised if, for example, patients do not attend for review, or if a medication cannot be prescribed because of contra-indications. However, the exception reporting rate for cholesterol control varies widely in primary care trusts, from 5 to 15 per cent. Worse, 14 of the 40 PCTs with exception reporting rates above 10 per cent. are also meant to be “spearhead PCTs”, and therefore to be leading a drive to tackle public health problems such as smoking, obesity and poor diet in some of England’s most deprived areas. My own PCTs, Blackburn with Darwen and East Lancashire Teaching, have an exception reporting rate of 12.8 per cent. and 11 per cent. respectively. We are left with more than a suspicion that the exception reporting rules are being used in a way that preserves GP income but does not maximise health service delivery, not least in the most deprived areas of the country.

The message is clear: the mechanism by which we incentivise GPs to deliver health improvement is outdated. It needs review, not least in bearing down on high exception reporting rates. As a nation, we invest a great deal in the NHS and we have a right to expect value for money and achievable goals in driving down rates of the main killer disease in Britain today.

I thank the Minister for attending today. She has previously expressed an interest in this topic in answer to parliamentary questions, and I look forward to hearing her response.

I congratulate my hon. Friend the Member for Rossendale and Darwen (Janet Anderson) on securing this important debate. Heart disease is exceptionally important for all of us who work in health, because the advances in addressing it have been overwhelming, as my hon. Friend described at the beginning of her contribution. My father died of coronary heart disease at the age of 57 some 30-odd years ago, and possibly he would be alive today if there had been the advances then that we now see so regularly in our NHS.

Appropriate and targeted services for the treatment of coronary heart disease are, of course, vital. I am advised that in the Blackburn with Darwen primary care trust area, which covers part of my hon. Friend’s constituency, mortality under the age of 75 from all circulatory diseases was significantly higher than the England and Wales average during 2005-07. Despite falls in circulatory disease mortality under the age of 75, it remains a leading cause of premature death both nationally and locally. In Blackburn with Darwen it accounted for more than one in three premature deaths in men and almost one in four in women in 2007. In the Lancashire area, which also covers my hon. Friend’s constituency, there has been a decrease in the early death rate from heart disease and stroke, but it still remains above the England average.

Nationally, coronary heart disease is the biggest cause of death in England, responsible for more than 110,000 deaths every year, and it costs the economy more than £7 billion annually. But the cost to the families involved—the mums, dads, daughters and sons—cannot be counted. In most instances we are talking about sudden death, and no one can say that people can recover from such a thing happening in their family. As a former nurse, I have often had to break bad news to relatives in this situation, and I have sometimes tried and failed to save someone’s life.

It is vital that frameworks are put in place both nationally and locally to address the financial and personal burden of cardiovascular disease. We have made tremendous progress in tackling the challenges of heart disease over the past 10 years. The national service framework for coronary heart disease set a 10-year framework for action to prevent disease, tackle inequalities, save more lives and improve the quality of life for people with heart disease. It set a framework to deliver quality services that are responsive to the needs and choices of patients.

I am pleased to report that the target set out in Our Healthier Nation to reduce the number of deaths from cardiovascular disease in people under 75 by 40 per cent. by 2010 was met five years early. Furthermore, the mortality rate fell by 44 per cent. between 2005 and 2007, compared with the 1995 to 1997 baseline. I pay tribute to all in the national health service who have achieved that target so many years in advance; it was met in 2008, rather than in 2010. That is something to be proud of when celebrating 60 years of the NHS.

One example of an initiative that has saved lives is the installation of 681 defibrillators in busy public places across the country, saving the lives of at least 93 heart attack patients. Indeed, my colleague in the Department of Health, Lord Ara Darzi, practised saving lives very successfully some time ago by using a defibrillator in the other place when a Member of the House of Lords was taken ill. These improvements have required significant investment in the prevention and treatment of coronary heart disease. Some £613 million has been spent nationally on providing new or expanded heart surgery hospitals across the country, and £122 million has been invested in improved diagnostic and treatment facilities. The investment supports the building and equipping of 90 new or replacement catheterisation laboratories—I have had the pleasure of visiting such units at Harefield, King’s College and St. Peter’s in Chertsey in the past few months—and that has met a real need to act fast not only when chest pain arrives, but when coronary arteries are diseased and that is shown through the angiogram process.

Furthermore, we now have 61 per cent. more cardiologists and 46 per cent. more cardiothoracic surgeons than in 1999. In the north-west region, the Lancashire cardiac centre was a £52 million capital development project, commissioned to serve the residents of Lancashire and south Cumbria. The centre includes three cardiac theatres, three catheter laboratories, eight ward beds and 14 intensive care unit beds. About 3 million people are receiving statins—my hon. Friend mentioned those cholesterol-lowering drugs—and that has saved an estimated 10,000 lives every year. Statins are now also available over the counter, rather than solely by prescription, thus enabling more people to benefit.

I am so proud that the NHS and Department of Health have narrowed by 32 per cent. the gap in coronary heart disease between the most deprived areas and the national average. We remain on track to meet the 2010 target of at least a 40 per cent. reduction. When the quality and outcomes framework—QOF—was introduced as part of the new GP contract in 2004, it was a pioneering approach to improving quality of care by rewarding GP practices for how well they care for patients, not just how many patients they have on their list. The Commonwealth Fund Survey published in November 2006 found that GPs in the UK are leading the world in the efficient management of chronic disease and the uptake of financial incentives to improve the quality of services.

The latest figures for the QOF show that practices have continued to deliver improvements in services for patients. We are also making real progress in addressing health inequalities between affluent and more deprived areas. We want the QOF to continue to support GP practices in delivering outcomes for patients that are among the best in the world. This is key to the vision developed in the primary and community care strategy, working closely with leading GPs and other health care professionals, as part of the NHS next stage review. That will be possible only if the QOF is continuously reviewed to reflect up-to-date evidence of best practice.

The Department is therefore asking the National Institute for Health and Clinical Excellence to lead a new independent and transparent process for developing and reviewing the evidence base for QOF indicators from April 2009, as part of its role in providing guidance to the NHS based on evidence of clinical and cost effectiveness. A consultation document was published on 30 October 2008 with the aim of consulting widely with patients, carers, NHS professionals and commissioners on how the new process should work. The consultation process is due to close soon, on 2 February.

My hon. Friend mentioned concerns about exception reporting. The overall exception rate for England reduced from 5.83 per cent. in 2006-07 to 5.26 per cent. in 2007-08. Independent research shows that practices in deprived areas are slightly more likely to exception-report patients than practices in affluent areas—I believe that the difference is less than 1 per cent. The research concludes that GPs in deprived areas achieved high QOF scores without high rates of exception reporting, and the differences in scores between affluent and deprived areas are small and of relatively little clinical significance.

Our proposals for a new independent and transparent process for reviewing QOF indicators are intended to build on the QOF’s ability to help reduce health inequalities and respond to the needs of our diverse society. There is evidence from research that some practices, whether in deprived or more affluent areas, may be using exception reporting inappropriately. Manipulating QOF data in order to increase rewards without delivering the required level of quality for patients is clearly unacceptable, and also unfair on the majority of practices, which comply with QOF requirements.

PCTs are responsible in England for verifying evidence for QOF achievement. They should analyse exception rates as part of this, investigating any outliers, correcting QOF payments where necessary and taking action if they uncover any actual fraud. I stress that fraud is the exception. We have provided guidance and training for PCTs on examining exception reporting as part of QOF assessment and verification.

The past 10 years have seen significant and tangible progress in cardiac services nationally, and I am keen for them to continue to improve. Our smoke-free policies have made a huge difference, but it is critical that we start early, with our young children and teenagers, in emphasising the need for a healthy lifestyle. I thank my hon. Friend for bringing this important issue to the attention of the House today, and I am glad to have been able to give her such a positive response.

Question put and agreed to.

House adjourned.