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Peripheral Arterial Disease

Volume 506: debated on Tuesday 2 March 2010

It is a great pleasure to serve under your chairmanship, Mr. Jones, for what I think is the first time. It is also a great pleasure to see the Minister here to respond to the debate. I will try to persuade her that we can avoid lower-limb amputations if the national health service works more holistically.

Amputations are in the mind of the general public for the tragic reason that many of our troops are returning home from war theatres—particularly Afghanistan—having undergone not only lower-limb amputations, but amputations of parts of their arms. However, the vast majority of amputations undertaken in the national health service are caused by peripheral arterial disease, diabetes or, quite often, a combination of both. Losing a limb is a tragedy for any patient, and their quality of life afterwards, particularly if they are elderly, can be extremely poor. Only half the patients who undergo a major lower-limb amputation as a result of such diseases live more than another two years. The number of major lower-limb amputations is still rising—there were well over 25,000 major amputations between 2003 and 2008. There is an urgent need to reduce amputation rates and to save more legs. The good news is that that can be done.

Peripheral arterial disease is a form of arterial sclerosis and is closely associated with stroke and coronary heart disease. The condition is caused by a narrowing of the arteries, usually in the legs. A symptom of the disease is intermittent claudication, which is a cramping pain felt in the calf, thigh or buttock during walking or other exercise. It is caused by poor blood flow and affects up to 870,000 people, or 5 per cent. of the population. Without proper blood flow, wounds cannot heal, which leads to infections, ulcerations and, tragically, to amputation in some cases.

I congratulate the hon. Gentleman on bringing this matter to the House. He is going through the disease processes, but does he acknowledge that one of the greatest risk factors after genetics is smoking? Will he therefore welcome no-smoking day on 10 March, which will be run in community halls, schools and shopping centres across the country? Will he try to get the NHS to get more people to stop smoking?

I have been a great advocate of stopping people smoking, including people in my family, and I will refer a little later to smoking as a causative factor of narrowing arteries.

Diabetes is a major cause of peripheral arterial disease. Diabetics have an increased risk of developing the disease and account for up to 70 per cent. of non-traumatic amputations. The relative risk of amputation is 40 times greater for diabetics. Anther pretty stark statistic for right hon. and hon. Members to digest is that a diabetic who smokes runs an approximately 30 per cent. risk of amputation within five years—the point made by the hon. Gentleman.

We all know how the prevalence of diabetes is increasing to worrying proportions as a result of lifestyle and obesity. There are an estimated 3 million people with diabetes in the UK, and large increases in amputation rates are a possible unfortunate consequence of the growing number of diabetics. However, the good news is that, according to the International Diabetes Federation, 85 per cent. of amputations in patients with diabetes can be avoided, and that is the main point of today’s debate.

The impact of amputation on patients is stark and evident. Amputations also cost the country and the NHS large amounts of money. The amputation rate is between 5 and 6 people per 100,000, but the figures range broadly between strategic health authorities. I have just received the latest statistics on the numbers of amputations in England, which are broken down into the different kinds of amputations. The numbers are still rising.

Each surgical procedure costs between £10,000 and £15,000, which means an annual bill to the NHS of between £50 million and £75 million. However, that does not take into account the substantial costs of rehabilitation, the provision of prostheses and social care, and the social and economic impact on society. The wider cost of patients in employment with moderate-to-severe peripheral arterial disease can be measured in terms of working days lost through illness and disability. We should also consider the loss of taxation revenue to the Exchequer and the cost of benefit payments to ill and disabled people, which are likely to amount to hundreds of millions of pounds on the taxation bill.

Some 85 per cent. of amputations are preceded by a foot ulcer. The estimated cost of foot complications alone to the NHS is £256 million per annum. The past 20 years have seen major developments in the healing of foot and/or leg tissue loss, which have been driven by innovations in assessment and treatment, the development of modern wound-care dressing materials and the development of surgical and other, less invasive interventional treatments by vascular specialists. Despite that, the numbers of lower-limb amputations are still high.

At this point, I pay tribute to the work of the Circulation Foundation, the Vascular Society and the British Society of Interventional Radiology, whose members have done, and are still engaged in, excellent work highlighting the need to save people’s legs. Indeed, I recently hosted a parliamentary reception to highlight the subject. Groups such as the Lindsay Leg Club Foundation also do excellent work helping patients with leg and foot tissue loss through direct support and care.

Clinicians are only too well aware of the challenge of rising amputation rates. Put simply, patients are being seen by vascular specialists far too late, when amputation is the only option available. When a patient first goes to their general practitioner with mild symptoms of intermittent claudication, they are correctly advised to change their lifestyle and particularly to cease smoking and undertake some exercise. Medication with aspirin or statins can reduce clot formation and cholesterol levels and can help to limit disease progression. Other cardiovascular risks to which the patient is likely to be subject can be addressed at the same time.

Unfortunately, treatment by a vascular specialist is often seen as a last resort. However, revascularisation through an open surgical procedure or angioplasty, with or without a stent, can bypass or unblock arteries, improving blood flow in the lower extremities. Revascularisation can significantly add to the benefits of lifestyle change. Britain has one of the lowest revascularisation rates for legs in Europe and some of the highest amputation rates, which tells us a lot. If patients were referred to vascular specialists a lot earlier, they could get the appropriate treatment, and we could save a hell of a lot of legs.

We must increase awareness of peripheral arterial disease among health professionals and particularly among GPs. That is what I am trying to do today. A clear referral pathway from primary care to secondary care would help vascular specialists to see patients sooner. Peripheral arterial disease is not, however, a condition that involves just one discipline, which is why I mentioned an holistic approach at the beginning of my speech. A diabetic patient with foot ulcers and advanced intermittent claudication should be seen by a wound care specialist, as well as by a diabetologist and a vascular specialist—either a vascular surgeon or interventional radiologist.

Peripheral arterial disease requires a multidisciplinary approach. There are some great examples here in the UK where that approach is seen to be working and is already saving legs. An 11-year survey of diabetic amputation rates, conducted between 1995 and 2005 at Ipswich hospital, showed a significant decrease in lower-leg amputation rates following the introduction of a multidisciplinary foot team. Over the survey period, the incidence of all amputations fell by a staggering 40 per cent., and among people with diabetes by a more staggering 70 per cent. Similar outcomes have been achieved in Middlesbrough and Southampton, and there are probably other examples of best practice in this country of which I am unaware.

Although I have painted a generally bleak picture, I hope that I have shown hon. Members, and particularly my hon. Friend the Minister, that we can achieve great improvements through a co-ordinated effort and bringing services together. In the end, the improvements in care I suggest would lead to a higher quality of life for many patients and could be cost-effective overall, too. The Government have made great strides in improving survival rates and treatment for patients with coronary heart disease, and we know that the NHS, with a clear strategy, can achieve great things—there have been many examples of that in the past 10 years. Peripheral arterial disease is often seen as a poor relation to stroke and heart disease. I think it is high time that we should focus on peripheral arterial disease as well.

We can save legs and save money, even in an age of austerity. I am confident that, by learning the best practice from our European partners, which do much better than we do, particularly through early referral; by incorporating best practice from the UK; and by bringing into every hospital multidisciplinary collaboration between leading clinicians, we can reduce amputation rates, despite an ageing population and more patients unfortunately being diagnosed with diabetes. That view is shared by many consultants, some of whom I have talked to personally.

Such improvements in care fit perfectly with the drive in the NHS for better quality of patient care and improved productivity but, of course, it is also important to prevent the ever-increasing occurrence of diabetes. We need much more research to find out what is really causing the increasing prevalence of that difficult disease. Prevention is always better than cure, for the patient as well as the NHS. Now could be the right time for a national target to reduce Britain’s rising amputation rates. A national campaign to raise awareness, among not just health professionals—especially GPs—but the general public, seems justified at this time.

I congratulate my hon. Friend the Member for Bolton, South-East (Dr. Iddon)on securing this important debate and commend him for his excellent work in the all-party group on diabetes, which is a sign of his commitment to reducing vascular disease. He said that he was seeking to persuade me, and as always the points he made were persuasive and well-informed. They shone a light on something that perhaps few have drawn attention to.

My hon. Friend has raised an issue that perfectly illustrates the challenge the NHS must meet in the coming years. His speech reminded me of a quotation. At the turn of the last century, George Bernard Shaw despaired of a society that

“will pay a surgeon to remove a leg, but nothing to save it”.

In this century, the NHS has changed and continues to change: it is not just a service for treating illness, but a national health service for the promotion of good health. Specifically, it is true that we must do more to save more people from the terrible tragedy of limb amputation. As my hon. Friend says, although peripheral arterial disease can have devastating consequences and affects a significant number of people, it is not often in the public eye. That is why I particularly welcome the debate and am grateful to him for drawing attention to the matter.

To give a wider context, under our five-year plan “From good to great”, the NHS must do three things: take a more preventive approach, stopping more people developing serious illness, as we have discussed; be more people-centred, organising services around the individual, and in particular managing long-term conditions in more effective ways; and put quality at the heart of everything it does—improving diagnosis, treatment and management of disease, and building stronger multidisciplinary teams to improve the care that a patient receives.

I absolutely agree with my hon. Friend that peripheral arterial disease is a clear case in point. We must get better at preventing and diagnosing it and managing it at primary care level, and get better at joining up primary and secondary care, so that fewer patients end up facing limb amputation.

As to awareness, it is an unfortunate fact that by the time many of us get to 50, we will have some fatty build-up in our arteries, which can lead to peripheral arterial disease, or indeed to heart disease or stroke. A typical candidate for peripheral arterial disease might be over the age of 50 and would probably be a smoker—often male—and perhaps would have diabetes. Many GPs therefore come across cases fairly regularly, and in the early stages of the disease can treat it themselves with advice about blood pressure and the means to lower cholesterol levels. However, I accept the points that my hon. Friend raised about awareness. It is always good to ensure that GPs are brought into contact with the latest thinking about diagnosis and treatment.

I would like to add to the Minister’s list obesity, poor diet and lack of exercise, which are also causal factors.

I thank the hon. Gentleman for that intervention. I will come on to the contribution that obesity can make, which my hon. Friend the Member for Bolton, South-East has already referred to.

The responsibility for the content of GPs’ continuous professional development lies with the royal colleges, as my hon. Friend knows. I confirm that, as a result of the debate taking place, I plan to write to them, raising his concerns and seeking their assurance that peripheral arterial disease features on the curriculum. I am sure he will welcome that.

As to improving the way that people live and their health, the sensible points that my hon. Friend made reminded me of the importance of reducing smoking and encouraging healthier lifestyles. We know that that is vital for reducing cardiovascular disease and diabetes. I was therefore very encouraged recently to hear that, as a result of our Change4Life campaign, more parents—indeed, we estimate that it is a million more mums—are shopping more healthily, putting better food on the table and encouraging their children, like themselves, to move forward. In other words, they are thinking more about their children’s diet and exercise, putting them on the road to better vascular health later in life.

My hon. Friend rightly mentioned that the biggest risk factor in peripheral arterial disease is smoking. More than 90 per cent. of people with the disease are smokers—a shocking figure. It is clear that quitting smoking can not only prevent peripheral arterial disease, but can improve and stabilise the condition once it is established. Our ambition to halve smoking rates through the tobacco control strategy that we recently presented will therefore help to reduce peripheral arterial disease, as more people seek to quit and more people do not take up smoking in the first place.

My hon. Friend is right to make those links as, after all, many people would be shocked to hear that by smoking they could ultimately find themselves facing limb amputation, if peripheral arterial disease sets in.

Stopping smoking is perhaps the single biggest prevention measure for vascular disease, but there are other prevention strategies, particularly those linked with the coronary heart disease national service framework and the national service framework for diabetes, which will help to reduce the risk of peripheral arterial disease. The national service framework for diabetes helps to increase the rate of diagnosis, and with diagnosis comes better management of the condition.

I am glad to say that we can point to real progress in reducing vascular disease overall. The Government met their 2010 target on reducing mortality rates for cardiovascular disease five years early, and we have nearly halved death rates compared to the 1995-97 baseline, saving more than 34,000 lives in 2008 alone. The other important development is the NHS health check programme, which was launched last year. It is thought to be one of the most ambitious public health programmes in the world, with around 15 million 40 to 75-year-olds eligible for universal screening and assessment of their risk of developing vascular disease.

The programme will not only spot potential candidates for peripheral arterial disease earlier on—which, as we have heard, is crucial—but will help GPs and other health professionals to talk to patients about risk factors, helping them to adapt their lifestyles early on and prevent the disease.

Clearly, if people develop peripheral arterial disease, it is vital that they get fast access to the treatment that they need, as my hon. Friend said. I was glad to hear the compliments rightly given about the dramatic improvements we have seen in places such as Ipswich, Middlesbrough and Southampton, and I congratulate all the staff who have made that possible. We would like to see the same results across the national health service.

Last June, the Department of Health commissioned a primary care service framework for peripheral arterial disease, which is about giving primary care trusts support and guidance to improve the commissioning of services to diagnose and manage the disease. The National Institute for Health and Clinical Excellence is developing a new specific guideline on peripheral arterial disease, which I hope my hon. Friend will welcome.

My hon. Friend emphasised the connection with diabetes, and he will therefore know that there is best practice guidance on improving the range and quality of hospital foot care services. That is vital for reducing the number of amputations linked to diabetes, including those brought about by peripheral arterial disease. There is also a considerable amount of work under way to improve support for people living with long-term conditions, which includes delivering more personalised care to help them to manage their own conditions more effectively, and wider use of personal health budgets.

We want to give patients flexibility and control over their treatment. By empowering patients, we will drive up the quality of care, encourage better integration across clinical teams and ensure that patients get the multidisciplinary treatment that my hon. Friend referred to as the best practice. Those are all good points that he rightly made on peripheral arterial disease.

Quality draws all this together. We have embarked on an ambitious quality and productivity programme, and over the next year the national health service will put huge energy into identifying the most effective and efficient, and the safest, treatment across the system. The leadership will be provided by the National Quality Board, whose role it will be to take decisions on prioritisation in relation to specific conditions, if that should prove necessary.

My hon. Friend made a call for a specific target to reduce lower limb amputations, and I absolutely understand why he has done so. In recent years, we have tried to move to a position in which we are improving quality throughout the NHS and making quality the organising principle. Linked to that, we have to set service-wide ambitions, such as our commitment to an 18-week maximum wait between GP and operating theatre, the new commitment to one-week cancer diagnosis and the commitment to a maximum four-hour wait in accident and emergency.

All those commitments are crucial to continuing the excellence of health care for patients and what they should rightly have, which should, of course, achieve improvements for everybody. We believe that the approach of setting more service-wide ambitions will ultimately be rather more effective than setting ever more, and ever more condition-specific, targets.

The conditions are right for the NHS to build on the work that has been done over the past decade to reduce and contain all forms of vascular disease and diabetes. It is clear, I agree, that we have to improve the treatment of symptomatic peripheral arterial disease, as my hon. Friend so clearly and rightly described. Above all, we have to do everything we can to prevent more people from developing the condition in the first place. That is where our primary focus will be, and it is why we continue to devote so much effort to programmes such as Change4Life and the NHS stop smoking services. We will, however, continue to take heed of the points that my hon. Friend has made, and I look forward to continuing improvements and a lessening of the number of limb amputations.

Question put and agreed to.

Sitting adjourned.