That this House has considered the prevention of cardiovascular disease.
I do not know where my functionality comes into it, Mr Mundell, but we are doing two debates in a row and it is lovely to serve under your chairship. As I explained in the last debate, I am my party’s health spokesperson. I have a lot of interest in this subject; I also declare an interest as chair of the all-party parliamentary group on respiratory health. Cardiovascular disease is one of the things that the group focuses on.
Back in 2019, the NHS long-term plan defined cardiovascular disease as the single biggest area where the NHS can save lives over the next 10 years. Six years on, that statement still rings true, but I am not sure whether we any closer to arriving at a conclusion. Over 7.6 million people are living with heart and circulatory diseases in the United Kingdom, and CVD is responsible for a quarter of all deaths here every year. It is one of the biggest killers.
I am very pleased to see the hon. Members here, and I thank them for coming. The Parliamentary Private Secretary, the hon. Member for Glasgow South West (Dr Ahmed), is here for the Minister, and I look forward to the Minister’s contribution. I am pleased to see the shadow Minister, the hon. Member for Hinckley and Bosworth (Dr Evans); he and I seem to regularly share debates. I am also pleased to see the Liberal Democrat spokesperson, the hon. Member for Mid Sussex (Alison Bennett).
According to predictions from the British Heart Foundation, by 2030 the prevalence of heart and circulatory conditions in the United Kingdom will have increased by 1 million. By 2040, it will rise by 2 million, due to a growing elderly population, the high prevalence of CVD risk factors and improved survival from major CVD events. Cardiovascular disease care in the United Kingdom is most certainly at a critical juncture. That was starkly illustrated by Lord Darzi’s recent independent investigation into the state of the NHS; I know that we are all aware of some of the key points of that. The investigation set out how nearly 50 years of progress to improve CVD outcomes has begun to reverse in recent years. That must not happen.
I seek reassurance from the Minister that we are out to stop that reversal. The number of people dying before the age of 75 with CVD has risen to its highest level since 2010, while the association between poor CVD outcomes and health inequalities has also increased, with people living in the most deprived parts of the country being twice as likely to die from CVD as those in the least deprived. Something is seriously wrong when those who just happen to live in a deprived area have a bigger risk of dying than those who do not. The slowing of progress is creating an enormous cost for the NHS and society as a whole, including £12 billion in total healthcare costs and £28 billion across the wider economy due to premature death, long-term care, disability and other informal costs.
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A key challenge relates to the high prevalence of CVD risk factors such as high blood pressure, obesity, diabetes, limited physical activity, air pollution and smoking. I declare an interest as I have had type 2 diabetes for almost 20 years. Mine is controlled by medication and I thank God for that, but I understand the impact on others much worse off than I am.
Raised cholesterol is another significant risk factor, associated with one in five deaths from CVD. Just over half of all UK adults are living with raised cholesterol, significantly increasing their risk of heart attack and stroke. However, due to the lack of immediately obvious symptoms, high cholesterol levels often go undetected. There are concerns that without immediate action there could be a further tidal wave of CVD deaths due to the thousands of “missing patients” living with undetected and unmanaged heart and circulatory conditions.
There are similar challenges in Northern Ireland. I always give a Northern Ireland perspective, which I think replicates what happens here on the mainland; that is why I do it. An estimated 225,000 people are living with heart and circulatory diseases in Northern Ireland—remember that we have a population of 1.9 million; that gives you an idea of the proportions. Since the 1960s, significant progress has been made, with CVD death rates falling by three quarters. But that improvement has plateaued in recent years: some 4,227 people died from CVD in Northern Ireland last year, including 1,133 people under age 75. It is not just an elderly person’s disease. That has to be put on the record.
Annual NHS expenditure on CVD in Northern Ireland is some £290 million—a colossal amount—and CVD’s overall cost to the Northern Ireland economy equates to some £740 million each year. Those are massive figures. I know that we should not look at health from a purely financial point of view, but those figures tell us that if we were working better to combat CVD the impact on the economy and health service would be greatly reduced. Northern Ireland faces similar problems when it comes to identification and management of CVD risk factors, with around 400,000 people living with high blood pressure, including 110,000 who are undiagnosed. Some 45% of adults in Northern Ireland are not performing enough daily physical activity.
In my constituency of Strangford, the prevalence of hypertension, coronary heart disease and stroke is significantly higher than in the rest of Northern Ireland. The reason for that could well be that our population is elderly: people tend to retire to my constituency. Despite the dire figures, there are real opportunities, both in Northern Ireland and the United Kingdom as a whole, to reverse the trends and help the UK become a world leader in CVD, as at one stage it was clearly trying to do. To get there, however, we clearly have to start doing things rather differently. Recent years have seen a number of policy commitments from successive Governments, but those have not shifted the needle, focus or direction. Today’s debate is about highlighting that and seeking help to address the situation.
There was the NHS long-term plan of 2019, which set out ambitions to prevent 150,000 heart attacks, strokes and dementia cases over the following 10 years. Unfortunately, in my constituency and elsewhere there are high levels of dementia cases, strokes and heart attacks. In Northern Ireland the figures are unfortunately incredibly high.
Successive versions of the NHS annual planning guidance have encouraged local systems to prioritise CVD and address the significant inequalities associated with it. Although the previous Government’s major conditions strategy was not fully implemented, it set out a series of robust principles to improve CVD care, including personalised prevention, early diagnosis, effective management of multiple conditions, integration of physical and mental health services, and services tailored to individual needs. The previous Government’s strategy was clear. I think this Government’s strategy is equally clear, but we need to address some of the issues that I will come to as I go through my speech.
We are lacking a deeply embedded, system-wide approach to CVD prevention that moves care upstream, is backed by sustainable, long-term funding and deploys the latest technologies and innovations. The National Audit Office’s recent report, “Progress in preventing cardiovascular disease”, provided stark evidence that such an approach has been lacking. It focused on the delivery of the NHS health check, which is one of our main tools for enabling early intervention on heart disease. It concluded:
“there is currently no effective system for commissioning Health Checks, despite it being a statutory responsibility on local authorities. DHSC and local government have weak levers to encourage primary care or other services to deliver Health Checks.”
That will be one of my asks of the Minister, who I am pleased to see in his place. I wish him well, and I know I will not be disappointed by his response to our requests.
In 2023-24, only half of the eligible population attended a health check, and only 3% of local authorities covered their entire eligible populations. We have to change that, so my request is that local authorities, which have statutory responsibility, primary care and other services that deliver health checks increase the number of people who get checked.
We need an action plan. The NAO report said:
“This is not a satisfactory basis for delivering an important and potentially life-saving and money-saving contribution to population health.”
Major improvements are needed, and the Government must embed them in a policy environment that promotes prevention rather than treatment. I have always been a believer in prevention rather than treatment. We must diagnose early and prevent disease at an early stage to stop the whole thing going further.
The current approaches do not sufficiently take account of genetics and the role of inherited familial conditions such as familial hypercholesterolaemia and cardiomyopathy in increasing CVD risk. Children are not routinely screened, GPs often fail to take account of people’s family history, and many patients report difficulties in accessing genetic screening.
Patients and doctors need to be empowered to access genetic testing, secure diagnosis and take preventive measures, which will ensure better health for the future and save money in the NHS. I am pleased that the Government have committed an extra £26 billion to the NHS, because right across this great United Kingdom of Great Britain and Northern Ireland, we will all benefit from that.
Up to 80% of premature deaths from CVD are preventable—we cannot ignore that figure. Preventing those deaths must be our goal, so the importance of this issue cannot be overstated. The evidence shows that CVD prevention pays. Analysis from HEART UK estimates that merely improving the management of cholesterol, triglycerides and other lipids through increased uptake of NHS health checks and, by extension, increasing the number of patients on lipid-lowering therapies, could deliver more than £2 billion in annual savings for the NHS and wider society.
I will focus on lipid-lowering therapies, because that is a solution that I am keen to see the Government take on board. Although prevention spending is often deprioritised in favour of meeting short-term measures, that is the kind of investment that we need if we are to deliver on the Government’s pledge to shift from sickness to prevention. I welcome the Government’s commitment to do that; that is what my party and I want.
In recent discussions I have had with stakeholders on this area, they have agreed a number of key themes that will be crucial to delivering progress on CVD prevention. Those include securing dedicated and ringfenced funding for CVD prevention, to enable targeted prioritisation of preventive approaches; identifying at-risk patients through early detection and risk assessment strategies, including testing from birth and family cascade testing; developing comprehensive public awareness campaigns that empower patients to self-monitor—if we can have patients’ participation in this as we go forward, that will be much welcomed; increasing access to prevention services by moving them closer to home, including by delivering more community-based diagnostic services; and ensuring timely implementation and consistent application of evidence-based clinical guidelines.
There is growing recognition of the potentially transformative opportunity that can be realised through wider awareness and recognition of another key CVD risk factor: lipoprotein(a), or Lp(a), which is a large lipoprotein made by the liver. Lipoproteins are parcels made of fat and protein. Their job is to carry fats around the body in the blood. Elevated levels of Lp(a) in the blood are an independent, inherited and causal risk factor for CVD, due to its pro-atherogenic, pro-inflammatory and pro-thrombotic effects.
One in five people are estimated to have raised levels of Lp(a) in their blood. That equates to some 13,400,000 people in the United Kingdom—equivalent to filling every seat in Wembley stadium about 150 times. Lp(a) is associated with an increased risk of several life-threatening events and conditions, such as myocardial infarction, heart attack, stroke, coronary artery disease, peripheral arterial disease and heart failure. Sadly, those events are often premature, so we need a way of diagnosing, doing early prevention and doing things better. My ultimate request to the Minister will be that that happens.
In severe cases, which applies to about 12% of the population, raised Lp(a) contributes to a two to four times higher risk of heart attack, stroke and heart disease. The prevalence of raised Lp(a) is typically greater among African and south Asian populations—a trend that is likely exacerbating existing health inequalities even further.
Despite the huge numbers at risk, few people know that they have a raised level of Lp(a). If they did, preventive measures might be taken: they could get a diagnosis, and we could ensure that their lives were better and longer, as well as reducing the cost to the NHS. The awareness of the role of Lp(a) in contributing to CVD risk is low among the general public and healthcare professionals, so there is a need to raise awareness. With that significant burden comes a huge opportunity to improve outcomes for a so far largely untreated and unserved patient population.
I want to mention my constituent, Dr Paul Hamilton, and also Gary Roulston. They are consultant chemical pathologists at Queen’s University Belfast and Belfast health and social care trust. They are leading pioneering work to proactively measure Lp(a) levels in patients who are at risk of CVD. I am always amazed—I always like to say this about Queen’s University, and it is right to do so—that when it comes to research and development, it is at the forefront, including on Lp(a). I encourage the Minister to interact with Queen’s University. The recent audit of its testing programme has revealed that early measuring of Lp(a) levels leads to a change in CVD management for a large number of patients. That demonstrates that Lp(a) testing and management can be implemented to improve population health and reduce the risk of CVD.
When we look at those things, we see something that can be done even better. Although there are currently no specific therapies for lowering Lp(a) levels, the taskforce believes that there is a clear and growing case for taking action now to incorporate Lp(a) testing and management within mainstream CVD prevention strategies. Several new therapies to lower Lp(a) are currently undergoing late-stage clinical trials, and could well be available in the near future, pending the outcome of those trials. That is a really exciting way forward, and an exciting way to save and improve lives. It is therefore vital that steps are taken to enable system readiness for those therapies and to ensure that the NHS is in the best possible position to maximise their anticipated benefits.
In the interim, there is a growing clinical consensus about the value of identifying patients with elevated Lp(a). In particular, knowing an individual’s Lp(a) can inform more intensive management of other cardiovascular risk factors, including blood pressure, lipids and glucose, and empower people to make a lifestyle change to reduce their overall CVD risk. It can also support cascade screening of family and close relatives—again, a positive way forward —given the genetic status of Lp(a). There is clearly a way to use technology and innovation to test more and to do more good for people. Tangible progress in that area could play a key role in supporting many of the key principles that have been identified as crucial to guaranteeing the future sustainability of the NHS, such as reducing pressure in the acute sector, delivering more personalised care and precision medicine, and capitalising on the pioneering innovation led by the UK’s life science sector.
More broadly, Lp(a) testing can support the Government’s ambitions right here in Westminster to get people back into work, by reducing the incidence of major CVD events, which can prevent people from participating in the labour market. Diagnosis and prevention can support people. To be fair, most people want to work; they want to have a normal life. The ones I speak to are not seeking benefits for any reason other than that they are unable to work.
Without formal recognition of Lp(a) in national policy, the only Lp(a) testing that takes place will be reliant on the work of proactive local clinicians. We need to make it the norm; we need to make it acceptable and the way forward. The regional variations are also not acceptable, and local systems need clear direction from the centre to encourage them to start thinking proactively about how Lp(a) testing and management could be incorporated into their local CVD prevention pathways.
What are we seeking? We are looking for a review of current CVD prevention and treatment pathways, for an assessment of where Lp(a) testing could be incorporated to deliver tangible benefits now—not later, but now—and to maximise the benefits of therapies that lower Lp(a), when those become available. We are also looking for engagement with local specialist lipid clinics and clinical laboratories to assess current levels of Lp(a) testing and whether it aligns with agreed best practice and to consider what will be needed to upscale activity in the coming years. We want to encourage local CVD champions to start thinking about the role of Lp(a) in contributing to CVD risk and to disseminate information about Lp(a) within their local networks.
In the taskforce’s call to action, it identified several system barriers that are holding back progress in this area; these are also applicable to the success of other health prevention strategies. They include National Institute for Health and Care Excellence procedures and methodology. NICE’s guideline methodology needs to take account of wider evidence criteria beyond the ones that apply to a specific treatment. In the case of Lp(a), although specific therapies to lower Lp(a) are not currently available, the taskforce believes that there is none the less a strong case for taking action now to proactively incorporate recommendations on Lp(a) testing and management in NICE guidance. If replicated across other disease areas, that more proactive and anticipatory approach from NICE would help to improve NHS system readiness for new innovations and treatments, encourage healthcare professionals to think more proactively about how a specific risk factor may be contributing to overall risk, and embed a more preventive mindset across the health system, reflecting the significant role of NICE in driving clinical behaviour. If it is possible to make those improvements—it is cost-effective, and early diagnosis will make things preventable—we really need to look at that.
Barriers also include the accuracy of health risk assessments. Risk assessment tools, particularly in CVD, play a crucial role in supporting health prevention strategies. An accurate assessment of an individual’s risk of experiencing a major CVD event can inform the most appropriate action to proactively manage and reduce that risk through a combination of treatment interventions and lifestyle changes—each of, us individually, has to play a part.
Going forward, it is vital that existing CVD risk assessment tools are updated to take account of Lp(a) and its known association with a range of life-threatening or life-changing cardiovascular events and conditions. That recognition will be essential to delivering a truly holistic assessment of an individual’s cardiovascular risk profile.
It is important to look at the standardisation of testing and reporting. The success of health prevention strategies also depends on the accuracy and consistency of diagnostic processes. In the case of Lp(a), testing should be conducted according to the best practice principles set out by HEART UK. Has the Minister had a chance to talk to HEART UK, which has some great ideas and positive ways forward? It is important to work in partnership to deliver therapies, diagnoses and prevention.
On emerging therapies, in particular, it is vital that there is a focus on encouraging greater diagnostic standardisation from the outset. Clinicians often get used to the numbers they first use, and it is important that they do not become entrenched in using the wrong, or indeed superseded, units. Without action in these areas, Lp(a) testing and management risks becoming another promising area of health innovation where the UK falls behind comparative systems.
We need to look further afield and to work with other countries; I met the shadow Minister, the hon. Member for Hinckley and Bosworth, this morning and said the same thing to him. Prominent European and American guidelines, such as those from the American Heart Association, the National Lipid Association and the European Atherosclerosis Society, have set out the importance of considering Lp(a) screening as part of CVD prevention approaches. Some countries are even thinking practically about how universal Lp(a) screening could be introduced. The present approach therefore puts us at risk of missing a rare opportunity to save lives that may be cut short by CVD, and will be increasingly out of line with the Government’s focus on transforming prevention across the NHS.
The Lp(a) taskforce is a coalition of experts from across the cardiovascular, lipid and laboratory community, with members from all four nations of the United Kingdom. They have come together to help tackle the lack of awareness and to set out the value of testing for Lp(a) in routine clinical practice to improve CVD management. Chaired by HEART UK, the group published its calls for action in August 2023, and it has since been working with key stakeholders to set out the potentially transformative role that Lp(a) could play in the future and, more broadly, to help renew the UK’s status as a world leader. We can be the world leader in CVD prevention and care.
I have some questions for the Minister. Is there a willingness to meet me and representatives from the Lp(a) taskforce, as well as other Members here with an interest in the subject, to discuss the essential steps that need to be taken to ensure that the UK is in the best possible position to integrate Lp(a) testing and management as a core part of CVD prevention strategies? Further, will he commit to engaging with key system partners such as NICE, NHS England and the devolved Administrations to address policy barriers that could hold back progress? I am ever mindful that the Lp(a) taskforce already comprises the four nations of the United Kingdom.
The Government must take wider action through their forthcoming 10-year health plan to secure renewed focus on CVD prevention, underpinned by ringfenced funding, enhanced early detection, expanding community diagnostic capacity, the timely implementation of evidence-based guidelines, and comprehensive public awareness and patient empowerment programmes. Will the Minister explore the scope to develop a dedicated national strategy for cardiovascular disease? We had that in 2019; I believe we need it in 2025.
Reversing these worrying trends in CVD is one of the great healthcare challenges that we face in this Parliament, and it must be approached with the necessary focus and attention. The UK must be able to capitalise on new and emerging areas such as Lp(a), which will be crucial if it is to renew its status as a world leader in CVD prevention and care. Just as with cancer, one in two people in this Chamber today are likely to develop heart and circulatory conditions in their lifetime. Just like the cancer community, the CVD community would welcome a commitment from the Minister to publish a dedicated national CVD strategy. At the end of the day, that is what I am asking for.