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Health: Atrial Fibrillation and Stroke

Volume 787: debated on Tuesday 12 December 2017


Asked by

To ask Her Majesty’s Government how many people with a diagnosis of atrial fibrillation who were admitted to hospital with a stroke in 2016-17 were not on an appropriate anti-coagulation therapy prior to admission.

My Lords, audit data shows that around half of patients with known atrial fibrillation who have a stroke have not received anti-coagulation treatment before their stroke. Figures for last year show that this varies from 25% in some clinical commissioning group areas to almost 100% in others. More than 300,000 people in England have undiagnosed atrial fibrillation.

I thank my noble friend for that Answer. As he knows, atrial fibrillation is a significant cause of stroke but it is also avoidable, because it is easily diagnosable and easily treatable with anti-coagulant medication. Yet as the figures he just gave us show, more than 7,000 people in England who were admitted to hospital with a stroke last year were known to have AF but were not receiving proper therapy. Is my noble friend aware that the National Clinical Directors for cardiovascular disease prevention and stroke recently stated:

“Failure to prescribe an important treatment”,

such as this,

“needs to be seen as an error that is equally as serious as prescribing the wrong treatment”?

What action can the Government take to ensure that all eligible patients with AF are prescribed anti-coagulation to help protect them from stroke and the devastating consequences that flow from that for them and their families?

I thank my noble friend for making that point. He is quite right that atrial fibrillation is easily diagnosable and treatable. In the end, it has to be a clinical judgment on what kind of medicine is appropriate for any given patient, but the variation in the prescription of anti-coagulants demonstrates that there is not uniform understanding of the options. There are a number of things I could point my noble friend to, such as the NICE guideline which promotes not only self-monitoring systems, which are typically what we have had, but encourage patient choice for the new types of anti-coagulants which have a lower risk of bleeding and are much more popular with patients.

My Lords, will the Minister say why the national stroke strategy has not been updated or renewed? We had outstanding success in London in concentrating hyperacute services in a small number of centres, which improved outcomes and mortality rates. Why on earth has the NHS been allowed to stop proposals in other parts of the country taking that forward so that outcomes there are higher?

On the stroke strategy, a follow-on plan is being developed by NHS England and its partners, including the Stroke Association, which will take forward that approach. The noble Lord will also be pleased to know that it is an integrated-service approach including ambulances, community care and secondary care. On the point about reorganisation, he is quite right that London has seen excellent success through the specialisation and concentration of services, and we certainly encourage the rest of the country to do that too.

My Lords, during the House of Lords Select Committee inquiry on the long-term sustainability of the NHS we heard a great deal of evidence demonstrating the great variations in care, in the treatment not only of atrial fibrillation but of other conditions. Is it not time that we made the NICE guidelines, which are very clear about the management of patients with atrial fibrillation, mandatory to reduce the variation in care and improve outcomes?

As the noble Lord will know better than anyone, making them mandatory is a challenge because of the importance of clinical autonomy. What we can make mandatory is an understanding of those guidelines and that they inform every treatment pathway. That is part of what the NHS RightCare programme, which is now rolled out across the country, is doing. It is introducing new things such as stroke pathways so that there is clarity about the options available. Patient choice is at the centre of that decision.

My Lords, I have this condition but I had never heard of it until I was diagnosed about seven years ago. I urge my noble friend to try to ensure that greater publicity is given to it. Could we start by making sure that every Member of your Lordships’ House has the opportunity to be tested for it?

I like my noble friend’s idea of putting on a special clinic. I hope he is getting excellent care with his own AF. The idea of publicity is an important one, and I draw attention again to the role that the Stroke Association is playing within the development of the new plan, because clearly it has fantastic reach to patients and is a trusted voice. It has a key role in making sure that there is that understanding among both patients and the clinical community.

My Lords, regular checks of the pulse rate can help indicate whether someone has atrial fibrillation. These should be carried out at the five-yearly general health check that GPs offer to those aged between 40 and 74. Could the Minister tell the House how many GP practices routinely call patients for this health check, whether they are paid to do so and how many patients take up the opportunity? I declare an interest as I am in this age range and have never been offered a health check.

I too am in that age range. I am afraid I cannot tell the noble Baroness what the global figures are, but I shall write to her to do so.

My Lords, a couple of years ago I attended a clinic in this House where there was a device, on which you placed your hand, which diagnosed whether you had atrial fibrillation. The idea was that these would be rolled out into doctors’ surgeries, where people could test themselves while in the waiting rooms. How is that progressing?

The noble Lord is quite right that this is a very easily diagnosable condition through checking pulses. The device that he described and other ones are doing that. They are in every GP surgery and form part of the health checks that the noble Baroness talked about. As I said, I do not have the figures for just how many of those are taking place, but we know that 300,000 people are undiagnosed with this condition. Many of them will be in regular contact with the health service, and this is about making sure that GPs use the opportunity to carry out those tests, which will inform the treatment that follows.

My Lords, could the Government undertake to ascertain from NHS England why the commissioning of day-case ablation for the treatment of atrial fibrillation is way below the European average, given that it is shown to be safe and effective, and to improve symptoms and the rate of return to work? It also almost certainly, although this is not yet completely proven, decreases the incidence of strokes, so it can be a preventive measure.

Yes, I shall certainly write to NHS England to find that out, and I will write to the noble Baroness with that information.

My Lords, it is quite clear that many people do not receive the anti-coagulants that they need, and my noble friend has reminded us of the figures relating to those suffering from this problem. Since 2012, four novel oral anti-coagulants—NOACs—have been recommended by NICE as both clinically and cost effective for the prevention of stroke in patients with AF. Their use is increasing but is lower than expected. Can my noble friend explain why access to the full range of anti-coagulation therapies is not acceptable to many GPs, who appear to lack confidence in their use of NOACs, and why some patients are still being given aspirin to prevent AF-related stroke? I should declare my interest as an officer of both the Arrhythmia Alliance and the Atrial Fibrillation Association.

My noble friend is quite right to highlight the benefits that come from new treatments. We clearly have a long way to go, as half the people presenting with strokes have not had those anti-coagulants, but there has been an increase in the number of pre-stroke patients receiving anti-coagulants, up from 38% to 53%, so it is an improving picture. The NICE guideline recommends the use of anti-coagulants and, critically, encourages patient choice for the new breed of NOACs and DOACs. There is very clear guidance within the system. It is getting better, but there is some way to go.