Question for Short Debate
My Lords, I am most grateful to all noble Lords taking part in this important debate this evening.
Atrial fibrillation is a heart condition which causes an irregular and often unusually fast heart rate as a result of abnormal electrical signals in the heart. Because of the irregular rhythm, diagnosis is straightforward, through a manual pulse check at an ordinary GP appointment. It is easy to detect, the examination takes seconds and a range of effective treatments, including, where appropriate, anticoagulation, can be deployed.
Although sometimes uncomfortable, in itself AF is not fatal, but its sinister mischief is that it can lead to blood clots forming in the heart that can then enter general circulation and block arteries in the brain, causing stroke. As a result, AF is the root cause of one in five strokes in the UK, and people with this condition are five times more likely to suffer one than those with a regular heartbeat.
Strokes which arise from AF also tend to be more severe than other types of stroke and are associated with significant mortality and morbidity. In addition to the enormous human consequences of an AF-related stroke—for the patient as well, of course, as their families —treating and managing strokes places a huge financial burden on the National Health Service. The average health and social care cost of stroke in the first year after onset is estimated at £22,175, with accumulated costs of over £45,000 after five years. AF illnesses overall cost the NHS about £2.2 billion each year.
I have an interest in this subject as a result of personal experience. I was diagnosed 16 years ago with a form of AF, known as paroxysmal atrial fibrillation. It is brought on by sudden exertion such as running, which I therefore avoid. It happens to me but rarely; the last time it occurred was here in the House of Lords, when I was rushing too quickly up the stairs for a vote. Such is my devotion to my noble friend the Chief Whip that I am prepared to risk ill health for him. I am one of the fortunate ones, though, in that I was aware of the problem because it manifested itself with unpleasant symptoms. I received a swift diagnosis and have been on effective treatment ever since. My condition is well managed and monitored but some people are not so fortunate. For some, the condition is symptomless and undiagnosed, which is when it is at its most dangerous. For others, a diagnosis is made but they then receive inadequate treatment; the consequences of that can be cataclysmic. The debate today is about those people and what can be done to ensure that their condition is diagnosed and managed.
At the end of the day, while AF is a common condition with potentially serious consequences—it affects around 2.5% of the population in England—it can, with proactive diagnosis and effective treatment, be dealt with in a way which reduces the risk of stroke and minimises health and social care costs for the taxpayer. It is estimated that appropriate treatment with effective anticoagulation remedies averts one stroke in every 25. That is why clinical guidelines from NICE make it clear that people with AF should have their risk of stroke assessed and be offered anticoagulation remedies to help prevent the formation of potentially lethal blood clots.
We last had a substantive debate on this issue four years ago, I think. Since then we have seen good progress, to the credit of the Government and the NHS. In 2016, a menu of preventive interventions published by Public Health England set out an ambition to increase the optimal management of people with AF from 74% to 89% by 2021. More recently, the NHS Long Term Plan identified cardiovascular diseases as,
“the single biggest area where the NHS can save lives over the next 10 years”,
not least through better detection and treatment of high-risk conditions including AF, high cholesterol and high blood pressure in order to prevent 150,000 strokes.
As part of that process, NHS England and Public Health England have committed to new national goals for AF, the aim being to ensure that 85% of the expected number of people with AF are detected by 2029 and that 90% of those diagnosed with high risk are adequately anticoagulated by then. Those aims are absolutely laudable but as yet we have little clarity on how such ambitions are to be translated into local action within the NHS to improve patient outcomes. Can my noble friend the Minister let us know how the upcoming national implementation framework will support delivery against the cardiovascular disease prevention ambitions for AF, and how NHS England and Public Health England will measure progress against the goals for detection and management, and report on them?
Key to that ambition are two issues: diagnosis and treatment. I should like to say a word about each. First, it is estimated that in England about 1.4 million people suffer from AF, of whom 1.11 million have been diagnosed. That figure has improved significantly since 2015 but it still means that one in five people with a condition that has potentially fatal consequences is unaware of the fact. Ensuring that they are identified and risk-assessed is absolutely fundamental to reducing the number of avoidable strokes. A quick examination can have a huge impact on an individual’s life. In the absence of a national screening programme for AF, we need to ensure that GPs and healthcare professionals take every opportunity to undertake manual pulse checks, especially among at-risk groups such as the elderly. Can my noble friend tell us what steps are being taken to ensure that that happens, and what Public Health England and NHS England are doing systematically to ensure that individuals at risk of AF are diagnosed?
Once that crucial diagnosis is made, the next hurdle is effective treatment through anticoagulation, particularly for those at the highest risk of stroke. The enormous benefits of anticoagulation are well recognised and clinical guidelines underline its importance. NICE recommends that people with AF at risk of stroke should be offered either warfarin or a non-vitamin K oral anticoagulant—a NOAC. All treatment options should be available to patients where clinically appropriate, but the terrible truth is that many high-risk patients are not receiving adequate treatment because they are getting no medication at all or an ineffective treatment such as aspirin. That has profound consequences.
National clinical audit data for stroke shows that in England in 2017-18 nearly 16,000 people were admitted to hospital with potentially avoidable AF-related strokes. Many of these incidents arose because there had been no diagnosis. Tragically, however, over 40% of these strokes affected people who had been diagnosed with AF but were not receiving an appropriate therapy at the time of their admission to hospital. This means that in the space of 12 months there were 6,703 AF-related strokes that were potentially preventable. Just think for a moment of the shocking human consequences of that failure. The data shows that of those potentially avoidable strokes, because of a failure to anticoagulate, one quarter—1,723 souls—died in hospital. Another 46%, or 3,077 people, were discharged with a severe or moderate disability of a kind which will have changed their lives, and those of the loved ones who care for them, for ever.
To address what is, I believe, an extremely grave issue of undertreatment, the national clinical directors for stroke and cardiovascular disease have made it clear that failure to prescribe an important treatment such as an anticoagulant needs to be seen as an error as serious as prescribing the wrong treatment. What consideration has been given by NHS Improvement to classifying stroke cases that occur in patients with diagnosed AF who were not receiving an appropriate treatment as a “Never event” that requires further investigation? Ensuring increased accountability and transparency in this area could be a vital step in addressing the problem of undertreatment.
My final point relates to the sub-optimal treatment of patients who have been diagnosed and are on an appropriate treatment. Regrettably, strokes among this group can, and still do, occur as a result of poor-quality anticoagulation control and poor adherence to medication. At the moment, warfarin continues to be the most commonly prescribed therapy for AF: some two-thirds of patients are treated with it, compared to around one-third for NOACs. Whereas treatment of AF through a NOAC significantly improves a patient’s quality of life because it does not require routine monitoring or ongoing dose changes, treatment with warfarin—alongside a risk of bleeding—can be unpredictable and unstable if not carefully monitored.
Estimates suggest that even well-monitored warfarin patients are outside the therapeutic range which gives them effective protection about one-third of the time, meaning that they are then at risk of stroke. Indeed, a report by Anticoagulation UK last year showed that 37,000 patients in England are known to have sub-optimal warfarin control. We know that is a problem but we do not know enough about it because of a lack of data. We need to remedy that. Will my noble friend say what steps are being taken to enable local NHS services to identify those whose AF treatment is sub-optimally managed? Will she engage with NHS England and Public Health England with a view to putting in place a system for the routine collection and publication of INR and therapeutic range data to measure the effectiveness of anticoagulation management and to inform quality improvement strategies?
I am conscious that I have sought to cover a lot of ground today but this is a big issue which impacts on many hundreds of thousands of people, and is one where we can make a real difference. I look forward to contributions from other noble Lords, and to hearing from the Minister.
My Lords, we should be grateful to the noble Lord, Lord Black of Brentwood, for tabling this important subject for debate and for his tour d’horizon of the facts and circumstances of AF. I have chosen to focus more on the Question, which may be a mistake. I have been a member of the All-Party Parliamentary Group on Atrial Fibrillation for some time, and have tried to support its good work, in which it has the excellent outside help of the AFA—the AF Association.
The direct Question asked by the noble Lord, Lord Black, has been rather overtaken by a more up-to-date report published in February this year, more narrowly focused on CVD—cardiovascular disease—rather than many preventive interventions in the whole of the NHS, which the earlier report covered. That earlier report by Public Health England in 2016 gave a five-year plan to come up with the figure of 89% by 2021. The key words in the Question are “known … patients”, as there are estimated to be an additional huge number, about 300,000 people, who have this condition but are undiagnosed and unaware of it but who nevertheless suffer from it in varying degrees.
As to what is meant by the phrase “appropriate treatment”, if the underlying problem with AF is an irregular heartbeat or activity, this might lead to clots or strokes. When people are offered anticoagulants, that may usefully ameliorate the symptoms, but it is not strictly treating the underlying heart condition itself. When we are talking about treating 89% of patients, that is not treating the underlying cause in the heart, which can be very difficult, but largely dealing with the symptoms, which is nevertheless useful and desirable.
The more recent report, in February, again emanating from Public Health England, focusing solely on CVD, has chosen to launch a new 10-year prediction or ambition, ending in 2029. Again, this covers only known patients, but is obviously aiming also to reduce the number of those unaware of their condition. It is nevertheless useful to have the Minister here to answer how the 2016 prediction for 2019 is presently going and whether the figure of 89% for 2021 is realistic. In all these percentage predictions, it can be asked how useful or valuable it is to create these sorts of targets, especially some time ahead, with so many variables likely to intervene.
One might also ask by what authority such ambitions are arrived at. Like the sustainable development goals, successors to the millennium development goals, many of which failed to reach their expectations, I believe it is better to have common benchmarks, against which some sort of progress can be measured. However, as with the current climate change debate, one can be slightly sceptical about predictions the further away in time they are laid out. I am grateful that we have these Public Health England reports and predictions, and I do not want to seem to be nit-picking about the percentages, all of which I have taken from them. However, the target or ambition in the 2016 report, as in the Question, is that by 2021 89% of known patients should be on appropriate treatment for AF; whereas in the latest report, in February this year, the 10-year target ambition from now—apparently 84%—to 2029 is going to be only 1% higher, at 90%. I realise that in many things the last few percentage points are sometimes the most difficult to achieve, and it may be that the latest report has wisely resisted the temptation to be too optimistic.
To explain where this comes from, I will quote the report itself:
“Progress has already been made”—
“and it has therefore been agreed that the ambition for optimally managing AF should be 90%. There is clinical consensus that a treatment ambition of 90% is appropriate and achievable”.
I emphasise the words “optimally managing AF”. As I said earlier, the Minister might be able to throw some light on these intentions.
As I also said earlier, all the percentages I have quoted so far relate to known cases of AF, but the report I mentioned also deals with the percentages of detection. As the noble Lord, Lord Black, mentioned, that is what percentages of all cases are known and have been identified. That is obviously difficult to estimate, but I earlier gave the round figure of 300,000 for those not detected, which in the 10-year report relates to a starting figure for detection of 79%. That is set against the target in 10 years—for 2029—of 85%. Again, whatever the figure might be, that size of the unknown is very worrying, especially as everyone agrees that AF can be readily diagnosed.
Leaving percentages behind for now, I shall continue on the latest report by Public Health England, of February 2019, on CVD. AF is only one of three aspects of CVD it covers, the others being blood pressure and cholesterol. It is encouraging that this report also addresses some stark health inequalities, committing to publishing data highlighting high-risk conditions and setting goals in future to remedy these. It also usefully raises the aspect of return on investment, which is not just financial but includes lives saved and lived. It also helpfully reminds us that the present direct annual cost to the NHS of CVD is £7.4 billion, and that the wider, non-healthcare costs are at least double that, at £15.8 billion.
I shall focus the rest of my speech on AF amelioration and therapies, where changes have been frustratingly slow. There is a general need to make the public and clinicians aware of and understand the particular connection between AF and prevention of strokes. It is widely accepted that aspirin has no effect on AF, but it is still widely prescribed for known AF patients. That figure might be as high as 20%, when there are so many improved remedies available today. There is a high percentage of patients who have suffered strokes and are known to be AF patients but who are not receiving any effective anticoagulants.
One therapy that can be effective, if properly given, is warfarin, but there are often shortcomings in administering this. While I realise that not all therapies are suitable for everyone, there are the recent additional medicines called DOACs, also referred to as NOACs, which, while they may be more costly, provide much simpler and successful outcomes for most AF patients. I realise that there is something called clinical independence, and that clinicians cannot be forced to prescribe what others might think best, but this is a long-term matter of educating and informing both patients and clinicians. This will continue to be a valuable and worthy process, but at the same time it is frustratingly slow. If anyone has seen the effects of a stroke and thought, often correctly, that it could have been avoided, I hope they might support efforts to make knowledge about AF a more important priority in our health service.
My Lords, the noble Lord, Lord Black of Brentwood, is to be congratulated on securing this debate and on his personal tenacity in pursuing this issue through many other debates and questions and through the activities of the all-party parliamentary group. I have been pleased to take part in some of these, including the one to which he referred, in 2015, which focused on detection of AF. His Question today refers to the Menu of Preventative Interventions published by Public Health England in 2016. This communicated an ambition to increase optimal management of people with atrial fibrillation from 74% to 89% over the five years to 2021.
As the noble Lord said, AF is the root cause of one in five strokes, and people with the condition are five to six times more likely to suffer a stroke than those with a regular heartbeat. Aside from the human cost and many indirect costs, strokes directly cost the NHS more than £2.2 billion each year, but the risk of an AF-related stroke can be substantially reduced by providing effective anticoagulation therapy to prevent the formation of clots. Too often, however, AF remains underdiagnosed and undertreated. In 2014, NICE estimated that around 250,000 people in the UK have undiagnosed atrial fibrillation, and the King’s Fund says that a huge proportion of those who have been diagnosed with AF are not receiving the correct anticoagulation medicine to prevent stroke.
Better diagnosis and treatment could prevent around 7,000 strokes, prevent more than 2,000 people suffering severe disability and prevent 2,000 premature deaths each year. With an ageing population, AF prevalence is likely to grow, so why are we not identifying the condition and treating it as effectively as we might? Much of the problem is that there are significant gaps and inequalities in our health system, as shown by the rates of AF detection and access to therapies and treatment for stroke. Cardiovascular disease is one of the conditions most strongly associated with health inequalities, and if you live in England’s most deprived areas you are almost four times more likely to die prematurely than someone in the least deprived. Cardiovascular disease is also more common where a person is male, older, has a severe mental illness or is south Asian or African-Caribbean in ethnicity.
Action to address health inequalities, as proposed in the recent NHS Long Term Plan, is of course very welcome. The plan states:
“Early detection and treatment of CVD can help patients live longer, healthier lives. Too many people are still living with undetected, high-risk conditions such as high blood pressure, raised cholesterol, and atrial fibrillation”.
A new return on investment tool confirms that savings can be made from better identification and management of patients. This suggests that more than 14,000 heart attacks and strokes could be prevented each year through earlier identification, diagnosis and effective management of AF. However, we are not doing what we could because suboptimal treatment of AF is widespread, particularly through the prescribing of aspirin monotherapy.
The National Institute for Health and Care Excellence recommends that people with AF who are at risk of stroke should be offered either warfarin or a non-vitamin K oral anticoagulant, known as a NOAC. NICE also makes explicit that people with AF should not be prescribed aspirin on its own for preventing stroke, as the bleeding risks outweigh the clinical benefits. This is reiterated in the NICE AF quality standard, QS93:
“Adults with atrial fibrillation are not prescribed aspirin as monotherapy for stroke prevention”.
But some healthcare professionals still believe that aspirin is an effective alternative to other NICE-recommended therapies. This practice puts a significant number of patients at unnecessary increased risk of stroke. The most recent national audit for stroke reveals the extent of suboptimal treatment with aspirin monotherapy and the impact on patient outcomes. In 2017-18, approximately 2,400, or 14%, of AF-related stroke patients were being prescribed aspirin on its own when they were admitted to hospital. This issue can be addressed with better education for healthcare professionals, particularly in primary care, to prevent aspirin on its own being prescribed when new cases of AF are diagnosed. Just as importantly, local GP practices and the new primary care networks can take proactive steps to ensure that existing AF patients are appropriately anticoagulated by identifying and reviewing those currently prescribed aspirin alone for AF-stroke prevention, as a priority.
At a population health level, addressing inappropriate treatment in individuals whose clinical risk factors are suboptimally managed provides the opportunity for every health economy to improve AF-stroke prevention at scale in a short timeframe. This can be achieved by undertaking a systematic audit of primary care data to identify AF patients being treated with aspirin monotherapy, and offering them more effective long-term treatment with a NICE-approved anticoagulant therapy such as warfarin or a NOAC. The new NHS Long Term Plan included a commitment to support the creation of CVDprevent, a new national cardiovascular disease prevention audit, to support healthcare professionals in primary care to improve the identification and management of patients with high-risk CVD conditions, including AF. It is critical that this system incorporates metrics to systematically identify patients with AF currently treated with aspirin monotherapy.
There are a number of questions to consider. How close are we to having regular systematic audits in every GP practice? The guidance on risk assessment and stroke prevention for atrial fibrillation, known as the GRASP-AF tool, can help to identify people at risk who are not anticoagulated or who are suboptimally anticoagulated. How far is this tool being used to help GPs assess the risk of AF-related stroke and provide for effective management of AF in patients? Can the Minister tell us what new measures are being taken to ensure that new and existing patients with AF are not prescribed aspirin monotherapy for preventing stroke, in line with NICE clinical guidelines? In addition, can we know the timelines for implementing the CVDprevent primary care audit programme?
We look forward to hearing what steps are being taken to enable local NHS services to identify AF patients who are being suboptimally managed, and then supporting them to obtain the right treatment. We would like to know how local NHS clinical commissioning groups and providers are using the national audit for stroke to improve atrial fibrillation management. For example, what training is being made available to medical personnel and health staff, including pharmacists, to encourage pulse checks in routine check-ups, and in non-clinical settings, to detect AF?
Finally, I draw attention to how researchers at the University of Birmingham have developed two apps that help patients and clinicians manage atrial fibrillation more effectively. Funding for this research came in part from Horizon 2020, the EU framework programme for research and innovation. Will this kind of funding be guaranteed in future?
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?
My Lords, I thank my noble friend Lord Black for giving us all this opportunity to discuss what is not just an important issue but one that must be of incredible importance to him personally, and for sharing his story to date. As noble Lords are aware, and as we have discussed, although briefly, AF is a common heart rhythm disorder associated with debilitating consequences including heart failure, stroke, poor mental health—which we have not yet discussed—reduced quality of life, and death.
As my noble friend rightly said and others repeated, anticoagulation is an effective therapy for managing people with AF who are at risk of stroke. It can reduce the risk of stroke by up to 66%. AF increases the likelihood of stroke by five times; on average, there are 40 AF-related strokes every day in England. As my noble friend rightly indicated, PHE has been working alongside key partners to increase the proportion of patients with AF offered appropriate treatment from 74% to 89% by 2021. I will come on to the questions asked about surveillance and data.
My noble friend and other noble Lords are absolutely right that, although we have made progress on treatment, regional variation remains in the detection of AF and appropriate treatment. For that reason, a national programme was established in 2017 by NHS England and Public Health England to tackle the issue of AF-related strokes. Through this work, the 15 academic health science networks across England made it a priority to “detect, protect and perfect”—that is quite challenging to say in one sentence—AF services.
In response to questions from my noble friend Lord Black and the noble Viscount, Lord Craigavon, regarding the importance of accurately monitoring progress, a number of quality and outcomes frameworks—QOFs—measure the diagnosis and management of patients with AF. I am pleased that, based on the captured data, we can say accurately that progress has been made and that, as of last year, 84% of people with AF were appropriately managed with anticoagulation treatment; however, as the noble Viscount said, those people are only those who have been identified. It has therefore been agreed that the ambition for optimally managing AF should be increased to 90%; there is clinical consensus that this revised ambition is appropriate and achievable.
As the noble Baroness, Lady Wheeler, rightly identified, there is a role for technology to aid self-management and prevention. That is why, in July 2015, AliveCor’s KardiaMobile ECG mobile heart monitor, which allows individuals to detect, monitor and manage heart arrhythmia, joined the NHS Innovation Accelerator. Currently, 33 NHS organisations, including GP practices and acute trusts in all 15 academic health science networks, now use it with the aim to reduce the prevalence gap in AF to ensure that more people are treated appropriately to prevent AF-related strokes.
As has been mentioned, The NHS Long Term Plan, published in January 2019, sets out the ambition to prevent 150,000 heart attacks, strokes and dementia cases over the next 10 years. It includes commitments to developing and implementing an AF patient optimisation demonstrator programme, helping to case-find and optimise treatment for people with known cardiovascular disease. That is important because it will include practice pharmacists being trained in shared decision-making skills to utilise when having conversations with patients about their treatment options, which answers some of the questions asked by the noble Lord, Lord Rennard. It will also give health professionals the opportunity to work together with patients to decide on a patient’s treatment and care. SDM has been shown to improve patient experience and increase adherence to medication—a crucial issue raised by the noble Viscount, Lord Craigavon.
Clinical pharmacists, anticoagulant nurses or other appropriately qualified clinical staff will also carry out case-finding in GP records to find people with untreated AF as part of this programme, which is an encouraging part of the commitment made in the long-term plan. The programme launched on 7 May was developed in collaboration with Public Health England, the British Heart Foundation, the academic health science networks and NHS RightCare, as mentioned by the noble Baroness, Lady Wheeler. Through the programme, NHS England will invest £9 million over 18 months to case-find patients in GP records who have been diagnosed with AF but are not receiving optimal treatment. Twenty-three CCGs across England have already begun implementing the programme.
Of course, stroke prevention and treatment is a priority for the NHS. NHSE has been working closely with the Stroke Association to develop a national stroke programme to be delivered within the timeframe of the long-term plan. As the noble Baroness knows, the implementation plan will be published shortly. The programme will build on the successes of the Department of Health’s national stroke strategy and look at how to improve stroke care across the whole pathway, addressing the challenges of prevention—in this case, secondary prevention—service reconfiguration, optimising rehabilitation services, workforce development and transformative data. NHS England has engaged with cross-sector partners to support Health Education England in the development of workforce modelling for strokes. Health Education England is also looking carefully at the various components of the proposed stroke pathway and undertaking workforce modelling to articulate which workforce will be required; that will be engaged in the discussions on the spending review, as we have discussed previously in Questions. It has worked with arm’s-length bodies, charities, professional associations and academics to ensure that the required workforce is achievable over the period of the long-term plan.
The long-term plan also outlines commitments to improving vital stroke rehabilitation services. The recently established Stroke Programme Delivery Board also aims to place a strong focus on rehabilitation. Campaigns to increase awareness of stroke onset have been in place since 2009; of course, that is essential because early response is vital in avoiding disability. Public Health England has run the “Act FAST” national campaign, of which I know your Lordships will be aware. It has helped to reduce the amount of time between someone having a stroke and arriving at hospital, helping those eligible for thrombolysis and thrombectomy to access treatment in a timely way. As a result, 5,365 fewer people have become disabled due to stroke since 2009—an outcome we can all be pleased about.
I will answer some of the questions asked by the noble Baroness, Lady Wheeler, and the noble Lord, Lord Rennard, regarding regional variation. Quality of care varies greatly depending on geographic location, the day of the week and even the time of day that a patient is admitted. The NHS is working with providers to share best practice through initiatives such as that mentioned by the noble Baroness: the RightCare programme, which sets out optimal pathways for the care of stroke patients and AF patients through the collection of data in the Sentinel Stroke National Audit Programme.
My noble friend Lord Black, the noble Viscount, Lord Craigavon, and the noble Lord, Lord Rennard, all rightly linked surveillance, training and optimal treatment. CVDprevent will be the national primary care audit tool, and has been referred to by a number of noble Lords. It will automatically extract routinely held GP data covering the diagnosis and management of six high-risk conditions that cause stroke, heart attack and dementia. It will be implemented from March 2020, in response to a question asked by the noble Baroness, Lady Wheeler. The outputs will include regular national data extraction for a professionally led national audit programme which will be limited to routinely recorded primary care data. They will require no input from GPs. Analysis and reporting will identify achievement, gaps, variations, opportunity and treatment. They will also support systematic quality improvements to reduce health inequalities, a point mentioned by a number of noble Lords. They aim to improve outcomes for individuals and populations.
I also point to the primary care networks, which will be required to deliver a set of seven national service specifications. Five will start in April 2020: structured medication reviews, enhanced health in care homes, anticipatory care with community services, personalised care, and supporting early cancer diagnosis. The remaining two, which will start by 2021, comprise cardiovascular disease case finding and locally agreed action to tackle inequalities. All these will go towards answering the questions that have been raised in the debate.
I am conscious there were some questions that I have not been able to answer, and I will be happy to write on those. I hope that I have demonstrated in my response the NHS’s commitment to improving outcomes not only for people living with AF in this country but for the many more who are at risk of suffering from stroke. I cannot think of a more fitting way to close this debate than by repeating the excellent point from the CVD report referred to by the noble Viscount, Lord Craigavon: the return on investment of getting this right will be measured not just in a better quality of life for patients, important though that is, but in lives saved and life-changing disabilities averted. That is something which we must all work together to achieve.