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That this House has considered quality of life for patients with heart failure.
It is an absolute pleasure to serve under your chairmanship, Mr Mundell, and I look forward to this debate. Believe it or not, I applied for it this time last year. It has taken that long for the opportunity to come around. It does not matter that it did not happen in March or April last year; I am pleased that it is happening now. That is the important thing.
I am very pleased to see Members virtually and in person. I look forward to the contribution from the shadow Minister, the hon. Member for Ellesmere Port and Neston (Justin Madders). It is a pleasure to see the Minister. I have already enjoyed her company for an hour and a half, and now I will enjoy it for another period of time. We will see how we get on.
I am delighted to have been granted this important debate and I am particularly pleased to see Members from across the House present to take part in it. Heart failure is a progressive, long-term condition affecting nearly 1 million people across the United Kingdom of Great Britain and Northern Ireland; nearly 20,000 people have been diagnosed with it in Northern Ireland alone. I am my party’s health spokesperson, so I am pleased to present the case, and as we are on the UK mainland, I ask the Minister to respond.
I am pleased to see the hon. Member for Birmingham, Selly Oak (Steve McCabe). He and I had an opportunity to observe an operation at St Thomas’ Hospital. I was telling the shadow Minister about it. I will not go into the details, but the hon. Member for Birmingham, Selly Oak will remember it well. The operation was on someone who was having a stent put it. I thought we were going to have a wee chat, and was not fully aware that we were going to see it. When I got there, I suddenly found out. We were in the blue surgical gowns, had the body armour on and were present as the gentleman had his operation. The hon. Gentleman was more prepared than I was; he survived it, and I just about survived it. So, we have seen that in person, and I am sure the hon. Gentleman will make a valuable contribution later in the debate.
It is a pleasure to see you in the Chair, Mr Mundell.
As chair of the newly formed all-party parliamentary group on heart valve disease, I congratulate the hon. Member for Strangford (Jim Shannon), a co-founder of that new all-party group, on securing the debate. The aim of the all-party group is to increase awareness of heart valve disease in the United Kingdom, and help ensure that patients receive timely diagnoses and the optimal management and treatment of their condition.
Heart valve disease affects approximately 1.5 million people in the UK. As we have heard, patients can experience fatigue, shortness of breath and chest tightness and/or pain. The most common form of heart valve disease is aortic stenosis, which affects about one in eight people over the age of 75. Unfortunately, awareness and knowledge of the condition in the general population is alarmingly low: in a recent survey, only 3.8% of people really knew what aortic stenosis was. People with heart valve disease have poor survival rates without prompt treatment, and longer waiting times inevitably lead to worse outcomes. However, as we have heard, heart valve disease is a very treatable condition, particularly if patients are diagnosed early.
The all-party group receives secretariat support from Heart Valve Voice, with which I have worked closely on several projects. Most recently, I have been working with Wil Woan, its chief executive, on the “100,000 Conversations” initiative, a campaign focused on improving awareness by encouraging people to discuss their condition with friends and relatives, particularly the symptoms, as well as access to diagnosis and treatment. I should perhaps confess that I had open heart surgery for a repair to my mitral valve back in 2012, and so feel very familiar with many of the issues people raise. I recently had the opportunity to hold one of these conversations with the shadow Health Secretary, my right hon. Friend the Member for Leicester South (Jonathan Ashworth), and I know Heart Valve Voice would be delighted if I could persuade the Minister to also take part in one.
I echo the comments just made. I am very grateful to the hon. Member for Strangford (Jim Shannon) for securing this debate and for the comprehensive exposition with which he started it.
A debate on heart health matters to many of our constituents who live with heart conditions. My father died in 1969, when I was 15 months old, of a heart attack in Hamilton where he had been working, collapsing and dying at Hamilton Cross, leaving my mother widowed with eight children. I looked on helplessly as my stepfather collapsed and died in the hallway of our home with a heart attack in 1985, when I was 17 years old. That is something I will never forget.
Sadly, too many of those who have lived with someone with compromised heart health could recount similar experiences. Sadly, in my family the deaths were caused by lifestyle factors, but it is important to remember that the most important factor in such disease and premature deaths is poverty. Ultimately, it is poverty that kills, whatever may be written on the death certificate. We really need to be mindful of that.
About 1 million people across the UK and 48,000 people in Scotland have been diagnosed with heart failure. There are around 200,000 diagnoses of heart failure every year in the UK, with some evidence to suggest that the burden of this terrible condition is increasing and is now similar to the four most common causes of cancer combined, in terms of the scale of the challenge. The British Heart Foundation estimates that around 230,000 people in Scotland have been diagnosed with coronary heart disease, more than 700,000 with hypertension and around 48,000 with heart failure. Heart and circulatory diseases are killing three in every 10 people in Scotland.
Some 98% of those in the UK diagnosed with heart failure live with at least one other long-term condition, such as diabetes or chronic obstructive pulmonary disease. As we have heard this afternoon, the signs of heart failure are there if you know how to recognise them: breathlessness, frequent and excessive tiredness, swollen ankles or legs, perhaps a persistent cough, a fast heart rate and dizziness. If anyone has these symptoms, it is very important that they go to their GP.
It is a pleasure to see you in the Chair this afternoon, Mr Mundell. I want to add my congratulations to those offered to the hon. Member for Strangford (Jim Shannon), on securing the debate and on his persistence in getting it almost a year after he first requested it. It is important to discuss the quality of life for patients with heart failure. I thank the hon. Gentleman for his excellent introduction, and for raising many issues, many of which are similar to those that I want to talk about. I add my thanks to those he expressed to people working in the NHS, for the wonderful care that they provide.
I also thank my hon. Friend the Member for Birmingham, Selly Oak (Steve McCabe) for his contribution and congratulate him on the formation of the new all-party parliamentary group on heart valve disease. He spoke about the initiative for 100,000 conversations, which sounds like an excellent way of drawing attention to the issue. Indeed, he brought his own experiences to the fore, which can only help in drawing more attention to the matter.
It is important to discuss heart failure. It is a progressive, potentially life-limiting condition, and there are a number of potential causes; coronary heart disease, high blood pressure and diabetes can all contribute. It can manifest in a number of different ways, including, as we heard, shortness of breath, fatigue and sometimes swelling of the lower limbs. It can occur at any age and the example that the hon. Member for Strangford gave from his constituency was of someone at the lower end of the age bracket. However, heart failure is of course more common in older groups.
As we have heard, there are currently an estimated 920,000 people living with heart failure in the UK, with around 200,000 new diagnoses every year. That is a significant number of people, by any calculation. Nearly all of those people—98%—will also have at least one other long-term health condition. Sadly, about half of all people diagnosed with heart failure die within five years of their diagnosis. Heart failure is a common cause of unplanned hospital admissions, with more than 110,000 of those each year. The rate of such admissions increased by nearly a third in the past five years, and now nearly one in 17 hospital visits in England can include a heart failure diagnosis as either a cause or a contributing factor.
It is a pleasure to serve under your chairmanship, Mr Mundell. I thank the hon. Member for Strangford (Jim Shannon) for securing the debate, and for his tenacity in waiting a year before we could be here to discuss what is an incredibly important subject. He is right: it is vital that we keep this serious disease on the agenda.
I was interested in the comments from the hon. Member for Birmingham, Selly Oak (Steve McCabe), who was also in the Chamber with us for the last debate, about his own experience in 2012. I am glad to see that he is a living testament to how well people can recover from heart incidents with the right treatment and in the way they live their lives.
Although in recent years we have made enormous progress in understanding more about heart disease, I acknowledge that it remains high on the list of the biggest killers in England, and there is still a lot of work to do. I would like the hon. Member for Strangford to extend my good wishes to his constituent Tara, about whom he spoke. Key to improving the quality of life that we want to see for everybody is ensuring that those who are diagnosed younger and who probably do not have the co-morbidities that we have spoken about in others have access to those good services.
We must, in particular, ensure that we intervene earlier, that we have the right care, and that we have the right rehabilitation services and support. I hope to explain what we are doing, and I am more than happy to have further conversations with the hon. Members for Strangford and for Birmingham, Selly Oak in their capacity as chairs of the APPG, and knowing their keen interest in health matters in particular.
I want to extend my thanks to all those on the frontline who have worked so hard, particularly in the area of cardiac services. They did recover, but they have dropped again during this second wave, so we know there is work to do. Heart failure is a key priority for NHS England and Improvement. One ambition in the NHS long-term plan is to raise awareness of the symptoms of heart failure and to ensure early and rapid access to diagnostic tests and treatments. The British Heart Foundation report found that people are still concerned and worried about coming forward, so if anyone is worried about any symptoms, I very much urge them to come forward. The NHS is open and is here to help.
First, I very much thank the hon. Members for North Ayrshire and Arran (Patricia Gibson) and for Birmingham, Selly Oak (Steve McCabe). The hon. Gentleman in particular referred to the APPG which was started up four or five weeks ago. We look forward to working with many others, and we will probably hold an inquiry about providing a better quality of life.
I am quite friendly with the hon. Lady, but I did not know that her father and stepfather both died from heart failure, which is a very personal thing. She also mentioned poverty and socioeconomic status—to which the shadow Minister, the hon. Member for Ellesmere Port and Neston (Justin Madders) and I referred, and the Minister responded—and how that can impact on way of life, affecting us all. She also referred to tackling at source inequality and poverty. We all heard the Minister respond and how she understands that.
I thank the shadow Minister very much for his contribution. He, too, referred to the social and economic backgrounds in which people are severely impacted; to the pandemic’s impact on heart failure; and to late diagnosis, which we all realise is an issue.
In particular, I thank the Minister very much. I always do, but I mean it, because that was a very comprehensive response. We are all heartened by that. You would not have given me the time, Mr Mundell, to go through all the things on which the Minister responded, but what she said was marvellous—quickly, the cardiac rehabilitation input, the community diagnostic hubs, the NT-proBNP community specialists, the primary care network NICE guidelines and the GP surgeries gathering the data. As the Minister, the shadow Minister and we all said, data is very important—with the data, we can focus the strategy on where we want to be.
There are life changes to make and so a role for us all to play, including me. I am a diabetic today, because of my lifestyle. I did not know what I was doing—or I did not know until too late—and it was all that Chinese food, plus two bottles of Coca-Cola. I would not recommend it. My sugar levels were extremely high. Add a bit of stress to that, and all of a sudden, someone becomes a diabetic. I am guilty of that, but I am saying that we all therefore have a role to play.
4:43 pm
Sitting adjourned.
Around 98% of people in this country who have heart failure live with at least one other long-term health condition, and many have complex care needs. Living with heart failure means that the heart cannot pump blood around the body as effectively as it should, and it usually occurs as a result of a heart attack, high blood pressure or congenital heart disease, though there are other causes. As people get older, their bodies get weaker. I hope you are an exception, Mr Mundell. I myself am on a list of tablets, and during the last debate, about pharmacies, I knew my tablets were in my pocket, and I was thinking about them when the Minister was speaking, so I know what it is like to live with a disease. In my case, it is high blood pressure and diabetes, not heart disease.
At present, it is not possible to cure heart failure, as there is no way to repair damaged heart muscle, so people with that condition can live their lives dealing with severe fatigue and shortness of breath, among other symptoms. A young lady called Tara Loughlin from Ballyclare was diagnosed with heart failure at the age of just 41, as the result of a rare heart muscle disorder. Tara had symptoms such as breathlessness and extreme fatigue for years. She visited her doctor multiple times with those symptoms. Only when she felt very unwell one day and was referred for an echocardiogram, which is an ultrasound scan of the heart, did she receive the diagnosis of heart failure.
Unfortunately, a significant delay between identifying symptoms and a diagnosis of heart failure is common for many people with the condition. I will speak about that more as we go forward. Life changed forever for Tara, who is a keen runner and loves nothing more than walking her dogs or working up a sweat in Zumba classes. People might think that Tara looks well from the outside, but in fact she battles extreme fatigue and wakes up exhausted and breathless. She gets severe fluid build-up in her hands and legs, to the point where she cannot wear jeans. Tara says this gets her down. Before, she loved clothes and going out, but she is now forced to wear looser clothing and stay home. She said she has still not come to terms with her diagnosis, and the same is applicable to many other patients across the United Kingdom.
Sadly, around half of people diagnosed with heart failure in the UK will die within five years of the diagnosis, but that can be improved; we can do better. With early diagnosis and access to the right treatment, care and support, people can manage their symptoms. Perhaps the Minister will tell us something about that in her response—I look forward to hearing what those things might be. They can have a better quality of life and live longer, which has to be good news.
That, however, has not been a reality for many people with heart failure, which is why the debate is being held —to look at those people who might not be getting what they need. At the end of my speech, the Minister will have heard the four questions that we are asking, and I hope she will be able to respond. We might ask a few more on the way; we do not want to let her off with just four, if we can help it.
As we all know, health services across the country are under unprecedented pressure, and I express my deep gratitude to all frontline staff who work tirelessly to provide care to people who urgently need it. It is vital that we do not lose sight of people with heart failure who may not be able to access the care and support they need at this time, and who may become more unwell as a result. The same is true of other things—for example, cancer has been a big issue, and the Minister understands that disease better than most—but I seek clarifications and reassurance on heart failure.
In 2016, the all-party parliamentary group on heart disease made 10 recommendations to improve heart failure care in England. Its inquiry highlighted issues and opportunities across the patient pathway, including the need to raise awareness of heart failure among generalist medical professionals, so that they understand it. I know that they are experts, but they deal with lots of problems. It would also be good to improve the information given to patients at the point of diagnosis, and to ensure that all patients can access the specialist care needed from a multidisciplinary team. They should also be able to access rehabilitation services and timely palliative care.
Unfortunately, insight gathered by the British Heart Foundation and others suggests that progress has been slow in realising the recommendations. Perhaps the Minister will reassure us about the 10 recommendations made by the APPG in 2016. Services are still not always joined up or consistently addressing the needs of people with heart failure across the patient pathway. That variation starts at diagnosis.
We always say that diagnosis is so important—it is critical—but many people are still diagnosed late and in inappropriate settings. Research shows that although 40% of heart failure patients display symptoms that should trigger an assessment in primary care, as many as 80% of heart failure cases in England are diagnosed in hospital. That can lead to worse outcomes and higher mortality rates. Why has that happened? That is one of the questions that we want to ask.
Staffing shortages and variable access to echocardio- graphy—a key tool for diagnosing heart failure—in primary care and the community are just some of the reasons for late diagnosis. Again, we seek from the Minister some assurance that such issues are being addressed. N-terminal pro B-type natriuretic peptide testing—a blood test that helps in the diagnosis of heart failure—is another key tool, but it is still not routinely available or appropriately used in primary or secondary care settings across the country.
Heart failure can also be challenging to diagnose. What is happening on that? Are we seeing an improvement? I look forward to the Minister’s response. I know her well, and I am quite convinced that we will get the answers we seek, which will help to alleviate some of our fears and concerns. Symptoms are variable and can be confused with those of other conditions, meaning that it is easy for those without specialist expertise to miss the signs of heart failure. I sometimes wonder how that can happen, but it can, because of the system that we have. Better training of generalist healthcare professionals and improved access to key diagnostics will be critical to improving outcomes, while early intervention allows people with heart failure to live with a better quality of life for longer. I gave an example of that earlier. Their quality of life can be better, and they can live longer as well.
There is also significant regional variation in the quality of care patients receive following admission to hospital; the percentage of patients seen by a specialist is reported to be 100% in some hospitals in England and Wales but less than 40% in others. Why the variation? Specialist input during admission is key, because it increases the likelihood that patients receive the drugs and referral to ongoing support that they need. It is important to note that the audit does not include data from hospitals in Northern Ireland, as this is obviously a devolved matter, although the National Institute for Cardiovascular Outcomes Research seeks the participation of our hospitals back home for future reports. I intend to follow up on that, and I will replicate every question I ask the Minister here to the Minister who has responsibility for this in Northern Ireland.
Regardless of where a person is diagnosed, National Institute for Health and Care Excellence guidance recommends that heart failure be managed by a multidisciplinary team with relevant expertise to optimise medications, provide the necessary information about heart failure and its treatment, and refer patients to other services, such as rehabilitation and palliative care, as needed. Again, it would be helpful to know from the Minister exactly where the multidisciplinary team plays its role.
Hospital data shows that, in 2018-19, only 41% of patients discharged from hospitals in England and Wales were recorded as having relevant follow-up with a member of the multidisciplinary team within two weeks of discharge. That figure concerns me. We need reassurance that that shortfall is being addressed, and that, in the long term, a much larger number of patients will have that treatment and this problem will no longer occur. Access to multidisciplinary team-led care is vital for improving outcomes for people with heart failure. As well as treating the acute episodes that bring someone with heart failure into hospital, it is really important that healthcare services treat each person as someone living with a long-term condition, giving them the tools to self-manage and access routine care in community settings.
Only 13% of patients admitted to hospital were referred to cardiac rehabilitation services at the point of discharge. Many of these services have been severely depleted by the pandemic. I understand the pressures that the Minister and the Government are under, and I know how hard they work to try to address these issues, but that really is a small number, so we need reassurance on that. I found evidence that some people are even disappearing, and others are moving online. Perhaps the follow-up is just not done in the way that it should be.
Rehabilitation services offer a range of support for patients, including exercise to improve cardiac function, advice on living healthier, and psychological and peer support. How important is peer support? It should be there, if at all possible. It is the family around the patient who give them the help that they need. Many people with heart failure who have been referred to rehabilitation services describe them as having a major positive impact on their wellbeing. Many rely on these services to help them exercise safely and to provide the emotional, psychological and physical support needed.
Very few people with heart failure are referred to palliative or hospice support, or are referred late. This is partly due to the disease trajectory of heart failure. Many patients can experience several acute episodes, after which they recover, making it hard to know when they are truly at the end of their life. This means that end of life care decisions may be made late for many heart failure patients, which limits the time for advanced care planning, and increases the chance that professionals without the necessary palliative care skills will deliver inappropriate care at the end of patients’ lives. I find that disturbing—we all do—but it tells us that we have to look at this issue. This reduces the chances of patients having their wishes around their end of life treatment being met.
Although these statistics are not published by nation, it is concerning to see that referrals to cardiac rehabilitation services are low, and that conversations about end of life care are not starting as early as possible during a patient’s heart failure journey. This disrupts their chances of receiving the care they need and of their wishes being met at this critical time. To avoid this, we must stop treating each healthcare touchpoint in isolation. By focusing on the person and taking a full pathway approach, we can avoid disjointed care and better address all care needs, including psychological support and end of life care. Clear leadership across the whole pathway is vital.
Strong leadership in heart failure services has led to significant improvements in care in Scotland. I often look to the Scottish health system with a purpose, because it is always good to share. They have some advantages and have taken good steps—I welcome that. The Scottish Heart Failure Hub is working to raise the profile of heart failure among decision makers and spread best advice across the nation. This has allowed it to respond quickly to the impact of coronavirus. Health services across Northern Ireland, England and Wales must follow suit, identify strong leaders of heart failure services, and give the resources needed to drive change across the pathway, both nationally and regionally.
Despite improvements in heart failure therapies over the past two decades, the risk of premature mortality remains high among heart failure patients. There are inequalities linked to characteristics including age, ethnicity and gender, and details such as geographical location and socioeconomic status. The variability in mortality can be linked to how quickly someone is diagnosed with heart failure and the severity of their condition at diagnosis, the number of times that they are readmitted to hospital, and whether they receive support following discharge.
Socioeconomically deprived groups have consistently worse outcomes than the most affluent. They face a 20% higher risk of hospitalisation, even after adjustment for other factors. This inequality has persisted for several decades. Again, I ask the Minister, what has been done to address this continual problem? Access to important services, such as rehabilitation and other relevant recovery and support services in primary care and the community, can also vary as a result of demographic factors, geographical location and socioeconomic status. It is vital that comprehensive demographic data be collected, so that we can better understand the inequalities in access to care and healthcare outcomes. This will help those with worse outcomes to receive better care. Government, and the Minister in particular, must act to ensure that no one is receiving substandard care just because of their age, ethnicity, or gender, where they live, or their economic status.
It is likely that the coronavirus pandemic has exacerbated all the issues that I have talked about—we all know that. Little did we know this time last year, when we were coming into the covid-19 episode, that we would still be in it a year later. I certainly did not. We all thought that the summertime would be better, but that was not the case. The Government’s strategy and response, here and in the devolved Administrations, together with the vaccine roll-out, has enabled us to look forward with positivity. I give the Government credit for this: there is no doubt in my mind that the Government pushed that and made it happen. From the regional point of view, we in Northern Ireland thank them. Over 600,000 of our people from Northern Ireland have had their covid-19 jab. On Monday coming, at 20 minutes to 5 in the afternoon in the Ulster Hospital, I will have my covid-19 jab. I will go and get the other one about eight weeks later.
While the NHS has rightly prioritised providing urgent and emergency care, the redeployment of clinical staff, combined with the need to maintain social distancing, has resulted in a significant amount of routine care and treatment being postponed. I understand that, but the question is: how do we address the problems that are being caused even now?
The postponed care and treatment include routine appointments that allow for review, opportunities for medication optimisation and access to treatments to prevent the exacerbation of conditions. These are the interventions that enable people with heart failure to maintain a good quality of life, and without them we risk patients becoming more unwell, adding to urgent and emergency care needs, and to a rapidly growing backlog of people for health services to deal with as we come out of the pandemic. That is being seen not just with delays to treatment, but with delays to diagnosis. Again, the issues are very clear.
Although we do not have figures for Northern Ireland, figures from NHS England show that completion of echocardiograms—as I mentioned before, these are scans that can detect heart failure, so it is very important for people to have them—fell by around two thirds, or 67%, in April and May 2020, compared with February 2020. While I understand that there was some improvement throughout the rest of 2020, for which I give credit, can the Minister say whether we have caught up yet and matched the figure from before the pandemic?
The use of echocardiograms has struggled to return to pre-pandemic activity levels, meaning that waiting lists have remained long—perhaps even longer than they should have been. As a result, thousands of heart failure diagnoses are likely to be delayed or even missed, with potential implications for people’s long-term health and quality of life.
The fall in the number of people presenting to hospital with heart failure has also been dramatic, dropping by 41% in England as we entered the second wave of the pandemic. I believe that there is limited information about how these missing patients may or may not have accessed care and support during this period. It seems that many people with heart failure have fallen through the cracks since the pandemic began, adding to the picture of disrupted and fragmented care. Again, I seek an answer to this question: has the Minister any figures or statistics that can identify these missing patients?
While some parts of the country lost heart failure services altogether during the first wave, due to redeployment of heart failure specialist teams to the initial covid-19 response, other parts maintained a skeleton service. The impact on services, combined with the continuing reduction in capacity to deliver face-to-face care, has meant that many people with heart failure have struggled to access the support that they need.
Organisations such as the British Heart Foundation—I work quite closely with it; indeed, I think it works quite closely with everyone—have stepped in to provide information, for example through the BHF’s heart failure online hub and heart helpline. It is vital that people can access the health and care services they need to live well during, and indeed beyond, the pandemic.
The BHF has highlighted in its report, “Heart failure: a blueprint for change”, that one of the main problems is that there is a lack of co-ordinated data outside hospital settings, and particularly in primary and community settings. This has meant that a significant proportion of the heart failure community has been largely invisible to the system during the pandemic, and opportunities to drive real system change have been lost. Again, the information and statistics that the BHF has been able to gather show that many people with heart problems went missing during the pandemic.
The covid-19 pandemic has clearly exposed the huge inequalities in care that people have been experiencing for years. I believe that now is the time for stakeholders across the health service and the Government, and parliamentarians, to come together and seize the opportunity to build back better. I want to ensure that each and every one of the 860 people diagnosed with heart failure in Strangford in the last year, and the thousands more across the United Kingdom of Great Britain and Northern Ireland who have received a similar diagnosis, has the opportunity to live a better quality of life, and that we all have an opportunity to create better outcomes for everyone living with this condition.
I have four asks—indeed, I made a few asks throughout my speech and I know that the Minister has been writing them down. However, there are four key asks that I hope the Minister will respond to at the end of the debate. I will conclude with them.
First, system leaders must take a full pathway approach to improving services. By focusing on the person and taking a full pathway approach, we can avoid disjointed care and provide better support for patients, including addressing their psychological and emotional needs, from diagnosis to end of life.
Secondly, we must stop just treating the acute episodes that bring someone with heart failure into hospital, and instead treat each person as someone living with a long-term condition, providing them with the tools to manage their condition and access routine care in community settings.
Thirdly, leadership across the pathway will be vital. Recruiting heart failure champions at regional and national levels—it is really important that we do this—will help to strengthen leadership and accountability for services, and lead to significant improvements in care.
Fourthly, collecting more reliable, comprehensive and timely data across the whole pathway could break down the barriers to improving heart failure services and drive real system change. I do not know how many debates the Minister and I have been at, but the issue of data comes up continuously. That data will prove where we need to focus the attention, and I think that is what we are likely to do.
In conclusion, for too long people with heart failure have not been given the chance to live well with their condition, and the pandemic has disrupted opportunities to make that a reality for more people. I believe we owe it to those people to finally address this issue and give everyone the opportunity to live well for longer. I thank those who are going to speak for their participation, and look forward very much to the Minister’s response.
We are also working on a campaign called “Just Treat Us”, which concentrates on encouraging patients to see their doctor if they are experiencing symptoms such as breathlessness, dizziness or fatigue, as well as encouraging care centres to treat patients, especially as the country starts to move out of lockdown. A simple stethoscope test is often all that is needed to identify a heart valve problem. Delaying treatment leads to worse outcomes, but with timely treatment, people can go back to a good—or even a better—quality of life.
As we have heard from the hon. Member for Strangford, covid-19 has had a significant impact on the investigation and care of people with heart valve disease, as with many other conditions. It has been reported that 100,000 fewer heart operations were carried out in 2020 compared with 2019. It has also been reported that 45,000 cardiac procedures have been cancelled.
When I had my mitral valve repaired, I was in an operating theatre for over seven hours. I was in intensive care for three days and spent another two weeks in hospital, and it took me approximately six months to fully recover. Transcatheter aortic valve implantation—TAVI— has been introduced as an alternative therapy to replace damaged aortic valves in patients who are considered high risk for traditional open-heart surgery. The procedure is less invasive, and patients can be discharged from hospital in a short period, allowing them to return to normal life while also saving hospital resources. As the hon. Member for Strangford said, he and I once witnessed a transcatheter procedure carried out on an 85-year-old gentleman at St Thomas’s. He had a local anaesthetic and was largely alert during the procedure. He was able to return home and was working on his allotment within three weeks of the procedure.
The “Valve for Life” initiative, run by the European Association of Percutaneous Cardiovascular Interventions, aims to promote transcatheter valve interventions, which could be crucial in rapidly reducing the waiting list that has been built up during the covid-19 crisis. It has four main goals: to raise awareness of valvular heart disease; to facilitate access to new therapies, such as TAVI; to increase educational standards; and to reduce obstacles to therapy and discrimination in access to care. The overall objectives of “Valve for Life” are to address inequalities in patient access and the disparities between countries in Europe, as well as to inform Government officials, healthcare administrators and healthcare providers about the clinical and economic value of transcatheter heart valve therapies in the management of valvular heart disease.
The UK has the second lowest rate of TAVI procedures per million people in Europe. Even within the UK, there is a large geographical disparity regarding access to treatment, as I think we heard earlier. We are very lucky in this country to have Dr Daniel Blackman, one of our leading interventional cardiologists, spearheading the campaign to raise the volume of transcatheter procedures. As we learn the lessons from the pandemic, I hope this is one area where we might be willing to entertain new thinking.
Heart valve disease is extremely common among older people and will obviously continue to place huge demands on our health service, but with early diagnosis and increased use of TAVI procedures, it need not be a killer. Indeed, it need not impair the quality of life. I hope that in the months and years ahead we can work to increase the use of new treatments and interventions, so that those suffering with heart disease can, in large part, look forward to a long and productive life following timely treatment and prompt rehabilitation support. Once again, I thank the hon. Member for Strangford for securing the debate and for making such an informed contribution.
It is often the case that the underlying causes of heart failure are heavily influenced by lifestyle factors, which can cause heart disease and high blood pressure, although we have to be aware of genetic inheritance and the fact that some people are born, unfortunately, with congenital heart difficulties. While treatment is available, there is no real cure, but the important thing for us all to do is to do the best we can to live as healthy a lifestyle as possible. However, as we have heard, the scale of this illness is significant and demands our attention.
Those living with heart failure can find their lives limited in ways that detrimentally impact their quality of life. They may experience various physical and emotional symptoms, such as dyspnoea, fatigue, oedema, sleeping difficulties, depression and chest pain. These symptoms limit the daily physical and social activities of those living with heart failure and result in a poor quality of life. That, in turn, often corresponds with high hospitalisation and mortality rates.
I am pleased that the Scottish Government are taking action to tackle heart health problems and will publish an updated heart disease improvement plan later this spring, which will make sure that there is equitable access to diagnostic tests, treatment and care for people with heart disease in a timely manner. This must remain a national priority. In addition, £1 million has been invested in the heart disease improvement plan, supporting important work such as that led by the Heart Failure Hub and the cardiac rehabilitation champion. The recent publication of the British Heart Foundation Scotland strategy document has been welcomed by the Scottish Government, who are keen to work with the British Heart Foundation.
As we begin to hope that we can emerge from this health pandemic, we cannot forget the stark health inequalities that were exposed and exacerbated by covid-19. The disproportionate harm caused by covid-19 to a number of groups in our communities, including those with cardiovascular disease, has highlighted new vulnerabilities and underscored existing health inequalities. That is why the Scottish Government in their recent Budget delivered an increase of more than £800 million on health spending, bringing overall health funding to a total of £16 billion, with an additional investment of more than £1 billion to address pressures related to covid-19. A significant proportion of those resources will be spent on caring for those with heart disease. I urge the UK Government to match Scottish Government spending per capita on health and social care.
I shall end where I began, by saying that the answer to many of our health problems, and even our social problems, is to do all we can to build a more equitable society. If we can do that, fewer adults will develop heart failure and other serious life-limiting conditions. There will be fewer folk whose health prevents them from being economically active. We will have children who can reach their full potential if the chains of poverty and poor health outcomes can be broken. Health outcomes are driven by poverty and our health is the key to the kinds of lives that each of us can live, the kinds of opportunities that we can create for ourselves, and the kinds of paths that we can follow. As with so many things, we could make much greater inroads into this and other health inequalities if we were to tackle at source, with more vigour and determination, inequality born of poverty. As we begin to emerge from the pandemic, I hope that the Minister will reflect on the fact that there is no better time than right now to look afresh at how our society works, to make it better for everyone.
That of course means that the issue puts a considerable burden on the NHS. The Lancet reports that
“the burden of heart failure in the UK…is now similar to the four most common causes of cancer combined.”
It accounts for 2% of the total NHS budget, and around 70% of those costs are due to hospitalisation. I should add the caveat that that clearly does not include covid, which we hope will not be something we must deal with on an annual basis at the level we have had to for the past 12 months.
The British Heart Foundation says that, despite improvements in heart failure therapies over the last two decades, the risk of mortality for patients with heart failure remains high, with the inequalities that we have heard about linked to age, ethnicity, gender, socio-economic status and geographical location. Those inequalities can affect the entire patient pathway, from how quickly someone is diagnosed, which of course, as we have discussed, has an impact on the severity of their condition, to the number of times they are readmitted to hospital and whether they receive the correct support in the community following their discharge from hospital.
For example, while the National Institute for Health and Care Excellence reports the average age of diagnosis as 77, according to the British Heart Foundation it falls to the age of 69 for people from black and minority ethnic groups, and to the low 60s for people from the most economically and socially deprived backgrounds. In 2021, that is simply unacceptable.
Looking more closely at diagnosis, as with many serious health conditions, early diagnosis can of course save lives, yet sadly it is still too often the case that patients are diagnosed late. In a hospital setting, that means they are more likely to have advanced disease, and therefore face poorer outcomes. Research from Imperial College shows that eight in 10 diagnoses of heart failure in England are actually made in hospital—for example, when a patient is admitted with a life-threatening episode of breathlessness—despite four in 10 people presenting with potential symptoms, such as fluid retention or breathlessness, to their own GP. That could have triggered an early assessment or diagnosis in a different care setting.
NICE guidelines for diagnosis and management have been in place for over a decade now, but the British Heart Foundation reports that they have not been universally implemented, meaning that heart failure services remain variable across the country. When there are national guidelines in place, it really should not be something that we have to address, and we need to do better.
Moving on to admission, we know that specialist input during admission is vital to ensuring that patients receive the care that they need. It leads to fewer deaths in hospital and fewer deaths after discharge. Heart failure cannot be cured, but there are treatments that can keep symptoms under control, such as healthy lifestyle changes, medication or devices implanted in a person’s chest. Those treatments not only prolong life, as we have heard, but can improve quality of life, relieving symptoms and improving overall enjoyment and participation in life. Some of the most common symptoms of heart failure—breathlessness, fatigue and fluid retention—really matter on a day-to-day basis for people’s quality of life.
Some treatments can limit physical function, leading to withdrawal from activities and social contact. They can cause psychological problems. Being aware of our own mortality obviously can have an impact, leading to sleep disturbance, depression and anxiety. Many things flow from such a diagnosis that cannot be underestimated. It is therefore vital that we look at all of the pathway in terms of a patient’s journey, so that they receive the best possible specialist care and treatment throughout, to ensure that their quality of life can get better following a diagnosis.
We know from the heart failure audit carried out by the National Institute for Cardiovascular Outcomes Research in 2018-19 that the percentage of patients seen by a specialist ranges from as little as 40% in some hospitals to 100% in others. That can continue following discharge, when many patients are unable to access or are not offered the care and support, such as rehabilitation and relevant recovery and support services in primary care in the community, that they need in order to continue to live well.
Again, unfortunately that is particularly true for those in socially and economically deprived groups, who have consistently worse outcomes than those in more affluent groups and are 20% more likely to be hospitalised. According to a population-based study by The Lancet, that has not changed in decades. We should be ashamed that we are still talking about it today.
This is before we even start to consider the impact that covid has had on such vital services, which, as we would expect, has been significant. NHS England data shows that during the first wave of the pandemic the number of echocardiograms fell by around two thirds in April and May of last year, compared with February 2020, and it has since struggled to return to pre-pandemic levels. During the second wave, the number of people presenting to hospital with heart failure also fell dramatically—by some 41% from the beginning of October to mid-November.
We should be worried about that, because we know that late diagnosis has long-term implications for health and quality of life, but also because we do not know whether these missing patients have accessed care and support during this period or whether they have simply fallen through the cracks. Then there are the indirect effects on patients who are already in the system who face reduced access or delays because their care has struggled to meet what we would normally expect in a non-pandemic situation.
We know the reasons for that: staff had been redeployed; there is a need to maintain social distancing in clinical settings; there have been changes to the way services operate; and a significant amount of routine care and treatment for heart failure patients has been postponed, including routine appointments just to review their condition and their treatment or medication to ensure that they are able to live well. The backlog has come about for a number of reasons. We know that services across the board were already severely strained before covid-19 hit us. The shutdown of non-covid services, combined with drastic changes in patient behaviour, means the NHS is now facing a large backlog of non-covid-19 cases.
We also know that stricter infection control measures mean that, as we hopefully move out of the pandemic, there will still be a reduction in the number of patients able to go through hospital. That backlog could actually take longer to work through than we would otherwise expect it to. All this matters because we know that diagnosing people with heart failure earlier and getting them into the specialist care as soon as possible not only cuts emergency admissions, but relieves overall pressure on the NHS. It also improves the quality of those individuals’ lives, giving them the opportunity to live well for longer.
We are thankfully past the peak of the virus, we hope, although we know the pressure that the NHS is still under. We know the number of patients in England waiting over a year for routine hospital care is now 130 times higher than before the pandemic, and there are now 4.5 million people waiting for NHS treatment. This could take years to address, and of course, as we have discussed many times in the past few weeks, our healthcare workers are exhausted. They are struggling with the long-term consequences of giving care during the pandemic, with one in four doctors having sought mental health support during the pandemic. The staff survey that was released today gave some alarming statistics about how our NHS workforce are feeling at the moment.
It is vital that we come up with a realistic plan to tackle the backlog in non-covid care, which is something we have called for. I hope the Minister can set out how the NHS, and heart failure services in particular, will be able to recover from the pandemic, now that hospitalisations for covid are beginning to decrease. We know that the long-term plan already identifies cardiovascular disease as a clinical priority and commits to supporting people with heart failure better through improved rapid access to heart failure nurses, so that more patients with heart failure who are not on a cardiology ward will receive specialist care and advice. It is welcome that the Minister has confirmed that these are priorities from the number of written questions we have seen her answer recently.
We know that there are shortages across the NHS workforce. The 2018 audit of heart failure nurses showed that the biggest concern was the significant case load that they are having to manage, with demand on services increasing without further resources being provided. Can I ask the Minister to set out in her response what steps she will take to increase the number of heart failure nurses to meet this commitment? Could she also update us on the number of heart failure patients who actually have access to a specialist heart failure nurse?
The Minister will be aware that a report from the Public Accounts Committee in September was highly critical of the Government’s approach, finding that a long-term plan was not supported by a detailed workforce plan to ensure the numbers and types of nurses that are needed across the board. It also found that the removal of the NHS bursary in 2017 failed to see the increase in student numbers that we would have liked to see and that the Government had said would occur.
We are also still waiting for publication of the substantive long-term workforce plan, which we all want to see deliver a lasting solution to recruitment and retention in the workforce, ensuring that there are enough skilled staff to provide the care that we all want to see. Again, I would be grateful if the Minister updated us on when we might see that plan. The long-term plan also commits to greater access to echocardiography in primary care to improve early detection. Will the Minister update us on what steps have been taken to improve that access?
I will say a few words on data, which the hon. Member for Strangford mentioned. The only nationally available mandated dataset for heart failure is the heart failure audit, which collects data about hospital admissions, symptoms, demographics, access to diagnostics, specialist input, types of treatment, and mortality. Unfortunately, that data is not linked to primary community data, and local systems struggle to get their own data back out of the audit to inform their local decision making. We need a comprehensive dataset that is accessible and useable for clinicians in a timely manner. It should include the comprehensive demographic data that we need to understand inequalities in access to care and in outcomes, as well as an expanded range of data to include primary community care, allowing clinicians and system leaders to get hold of the analysis that I think we all want to have. Will the Minister tell us a little more about what is happening on the adequacy of data collection, and whether there are any plans to expand the collection of data across primary community care settings?
As we know, many medical research charities have made dramatic cuts to their research budgets because of fundraising shortfalls in the last year. The Minister will be aware that the medical research charities reacted with some disappointment to the comprehensive spending review, which committed to £14.6 billion in research funding, but failed to ring-fence any of that for medical research charities and did not provide any long-term assurances of funding for the sector. The British Heart Foundation, whose research all Members appreciate and rely on, has had to reduce its spending by half in the last year. Are there plans to support those medical research charities in meeting the shortfall that they will have to find after the last 12 months?
NHSE has a programme of work to support the ambition, overseen by clinical professionals from across the country. It remained a priority during the covid-19 pandemic. We know that cardiac rehabilitation saves lives. It improves the quality of life and reduces, as several Members have said, the hospital admissions that occur when people do not access services. In scaling up and improving the promotion and awareness of cardiac rehabilitation, we aim to improve quality of life and to reduce hospital admissions.
In the long-term plan we set out steps to ensure that by 2028 the proportion of patients accessing cardiac rehabilitation would be among the best in Europe, with 85% of those eligible accessing care. It is a long way from where we are now and will need a lot of hard work in the intervening years. We estimate, however, that this will prevent up to 23,000 premature deaths and 50,000 acute admissions over a 10-year period. NHS England and NHS Improvement is developing cardiac networks that will support the regional delivery of the long-term plan ambitions and address the regional variations in health inequalities that the hon. Member for Strangford alluded to throughout his speech.
The long-term plan also commits to improving rapid access to heart failure nurses so that more patients with heart failure who are not on a cardiology ward can receive specialist care and advice. Better personalised planning for patients will reduce nights spent in hospital and also reduce drugs spend. NHSE is accelerating some of the positive lessons learnt from the pandemic, such as the enhanced use of digital technology for cardiac rehabilitation and the greater application of remote consultations, enabling us to bring forward the delivery of some of the ambitions for patients with heart disease.
NHSE is working with Health Education England to develop a new e-learning for health course, which aims to support healthcare professionals in learning more about heart failure and heart valve disease so that they can better recognise the symptoms of heart failure and diagnose, manage and support patients further. We anticipate this will be made available on digital platforms in late summer this year, so they are working at pace.
We are also establishing community diagnostic hubs to more rapidly diagnose heart failure patients, which will include echocardiograms, blood tests and NT-proBNP testing, making sure that that NT-proBNP testing is available to all general practices.
Hon. Members will be aware that high blood pressure can often be a component factor of heart failure. To increase support for people at greater risk, NHSE plans to increase the number of people who have access to remote blood pressure monitoring and management. The NHS @home programme remains committed to addressing health inequalities, and we have introduced targeted blood pressure monitoring systems for patients who are clinically extremely vulnerable and have high blood pressure, including individuals from black, Asian or ethnic minority backgrounds in areas of high deprivation. We are making sure that we target communities who are worst affected because, as we know, the statistics are often worse in areas that are socially and economically deprived and where health inequalities are greater.
We are also targeting those aged over 65 because age is a large component here. This intervention will allow people to monitor their blood pressure from their home, which is something that we know they prefer, and to avoid trips to their general practice by communicating results to their primary care clinician via a digital platform or, for those who may not have access, a phone call to the practice. From April 2021, a further 198,000 blood pressure monitors will be available for primary care.
The NHS @home scheme is a self-management scheme to enable patients with heart failure and heart valve disease to look after themselves in their own home. However, they will work with a specialist clinician, and patients will be supported to understand their medications, how to reduce their salt intake, and how to monitor and record their daily weight and blood pressure, as we know that fluid retention is associated with the disease. They will also be helped to recognise—this is really important—symptoms if their condition is deteriorating, so that they seek help in a timely manner. We know that many people wait too long before they reach out for help and services.
Where patients have suffered heart failure, doctors, nurses, the valuable pharmacists who we spent the previous debate talking about, and allied health professionals can provide support to patients in the multidisciplinary teams that the hon. Member for Strangford spoke about. It is anticipated that this will lead to a reduction in hospital admissions and increased quality of life, which is a key component, with better patient and carer knowledge about how to manage their condition. It will also improve primary, community and specialist team communication.
From 1 July 2019, all patients in England have been covered by a primary care network, and the development of the primary care network directed enhanced service for cardiovascular disease prevention and diagnosis is ongoing, with the phased implementation of new PCN services expected in 2021-22. This emphasises the importance of early diagnosis in the management of patients with heart failure and heart valve disease in primary care, in line with the published NICE guidance.
The quality outcomes framework—QOF—is an annual reward and incentive programme for general practice surgeries in England. Although the specific requirements were stepped down in 2021 to release general practice capacity in order to support the pandemic response, I am pleased that the QOF will be returning later in 2021. This will include the updates that were previously agreed to support moves towards earlier diagnosis and management. GP surgeries are asked to capture data in order to evidence that they have fulfilled the QOF requirements, which encourage the earlier confirmation of heart failure diagnosis and improve pharmacological management.
As several Members have said, data is absolutely key in this space for making sure that we know where patients are and that they are being managed. I am pleased to say that this update also means that patients with heart failure can have an annual review in order to enable better management of their care, which goes to the point about making sure there is sufficient contact. NHS England has had sight of the British Heart Foundation report and thanks it for sharing it, and I have been assured that the national medical director has written back on the matters that were included.
I hope that I have demonstrated that the Government, the long-term plan and the workforce have a key ambition to improve the lives and health outcomes of people living with heart failure in this country. Everybody has to play a part, including the individual. As the hon. Member for North Ayrshire and Arran (Patricia Gibson) said, lifestyle plays an important part, so making changes that can help prevent heart failure—healthier eating, reducing salt intake and exercising more—is particularly important. As several hon. Members have said, it is often a disease with comorbidities, and many of those changes will help health overall.
We can all agree that this agenda really matters. Once again, I thank the hon. Member for Strangford for highlighting this important issue. If we continue to make an impact on the lives of people with heart failure, there will be significant benefits for the NHS and, mostly, enormous benefits for those who are affected. To conclude, I say to people that, if they have any of the signs—breathlessness and so on—or any worries at all, they should come forward to seek help.
I thank everyone for their contribution, you for your patience, Mr Mundell, and the Minister in particular for a comprehensive and helpful response. We appreciate it.
Question put and agreed to.
Resolved,
That this House has considered quality of life for patients with heart failure.