Atrial Fibrillation

Wednesday 12th March 2014 Westminster Hall

11:00

[Mr Barry Sheerman (Huddersfield) (Lab/Co-op)]

I hope that colleagues from Yorkshire who have been listening to the debate on trans-Pennine rail would like to stay for this important debate on atrial fibrillation, but in truth I know that many would ask what on earth atrial fibrillation is. Part of the purpose of the debate, therefore, is to open up our understanding and knowledge of the condition. I am sure that some colleagues at least will know that atrial fibrillation is a disease of the heart—[Interruption.] Excuse me, Mr Turner; I thought that that was the Division bell. Atrial fibrillation is a disease that causes an irregular heartbeat. It can often lead to a stroke and therefore to either a disabling long-term disability or death.

I called for this debate because 750,000 people in this country have atrial fibrillation. We know that because they have been tested for it. They may or may not be receiving treatment, but we know about them. It is estimated that another 750,000 suffer from atrial fibrillation but are undiagnosed, so we do not know where they are, although we have an idea because we can do the stats. If we know the average number of AF sufferers in a given area, we can extrapolate the numbers across the country. Where we see very low diagnosis numbers, we know that the local GPs and health service are not getting to grips with discovering who has AF, checking them out and treating them.

I would like to tell a little fairy story. There is a fantasy world in which a dreadful heart condition affects more than a million people in our country. A great deal of research is carried out, because no one really knows how to tackle it, and then there is an enormous breakthrough: we discover a new class of drugs that can not only help people to avoid having a stroke in the first place, but allow them to live a good, full and healthy life. However, the wicked godmother arrives and says, “Thou shalt not have any of these wonderful drugs, even though the National Institute for Health and Care Excellence says that they are good and should be available.”

I remind Members that the NHS constitution states that patients have a right to

“treatments that have been recommended by NICE”

when they are deemed “clinically appropriate”. That is the right of your constituents, Mr Turner, and mine. However, the fact is that most people with AF in this country are not getting the opportunity to receive such drugs. There is a real problem: we have a new generation of drugs that are recommended by NICE, but they are not available. What is the barrier? The barrier is the clinical commissioning groups and GPs.

If someone is a sufferer of AF—my wife is, which is why I know something about the condition—they are traditionally treated with warfarin, which is a very popular drug in this country. You will not be surprised to hear, Mr Turner, that even on the Isle of Wight GPs know—because they are highly skilled and knowledgeable —that warfarin is very cheap indeed. It is one of the cheapest drugs that can be prescribed.

[Jim Shannon (Strangford) (DUP)]

I thank the hon. Gentleman for bringing such an important matter to the attention of Westminster Hall and of the Minister. Warfarin can be used to treat hyperthyroidism, as well as many other conditions. The issue that comes to my attention is that of GPs and their training, and their ability to administer to atrial fibrillation as required. Does the hon. Gentleman feel that GPs can do more in their own surgeries?

[Mr Sheerman]

The hon. Gentleman is absolutely right. I was going to come on to that issue and I am grateful to him for making that point. The fact of the matter is that a very high percentage of people who are diagnosed with atrial fibrillation are currently either not treated with anti-coagulants, or they are given aspirin. Everyone knows that aspirin is very cheap but not effective as an anti-coagulant.

People with AF may also be given warfarin, which is a good treatment. I can say that from the heart. I have watched a close member of my family—it does not get any closer than one’s wife—undergo treatment that must be evaluated day in, day out. It is quite complicated to ensure that the dosage is right. If someone does not have a home testing kit, they will have to go regularly to the hospital for their blood to be tested and their dosage evaluated. If they have a full-time job or family responsibilities, that is an onerous requirement. As a result, many of the people who are taking warfarin are not taking it in the right dosage and so are not getting the proper, balanced treatment.

It is a scandal that 8.5% of atrial fibrillation patients are not receiving treatment, 35% are receiving aspirin, and only 56.9% are receiving oral anti-coagulation treatment. What is more, we now have three drugs that could be prescribed. We should be saying, “Isn’t it wonderful? We’ve had a breakthrough!” I hope that I can pronounce them properly—they are dabigatran, rivaroxaban and apixaban. However, compared to the 3p that it costs for a dose of warfarin, they are more expensive—I have seen an estimate that treatment would cost around £800 a year.

That might be considered an excessive cost compared to the tiny amount that warfarin costs, but strokes cost this country £2.5 billion a year. If we really want to wreck the national health service, we should not treat people with AF properly. They will have a stroke and end up in long-term care, making great use of hospital beds and highly qualified medical staff. Such a burden on the health service could be avoided.

I have been a member of the all-party group on atrial fibrillation for some time now, and I know that its chair, the hon. Member for Montgomeryshire (Glyn Davies), is going to speak after me. We served together on the Education and Skills Committee, Mr Turner—do you remember when we had a very good Clerk working for us? I think he is sitting on your left-hand side. When we were on that Select Committee, you will have heard me articulate many times the watchwords, “I like evidence-based policy.” The atrial fibrillation campaign is the one, against all others, for which the evidence shows that if we have a drug that can sort out the condition, it should be used.

NICE says that we should use it, and it is clear that it is the right of patients to have it. The people getting in the way are GPs—not because they are malign, but because the cost means that they are leant on by their practices about prescribing it. Also, a very substantial population of GPs do not understand the treatments and their effectiveness—which treatments work and which do not. It is a scandal that people suffering from AF are prescribed either nothing or aspirin by their doctors. That is a very serious problem for the profession, and we have been taking it up with the Royal College of General Practitioners.

There is a second barrier, which is that even with the cheapest of the drugs—warfarin—the sophistication of the treatment and the monitoring are very difficult for very large numbers of our population to deal with. My constituents and your constituents, Mr Turner, find it very difficult to get the right dosage and to maintain the quality of treatment.

The third barrier is the clinical commissioning groups. There is no doubt that the clinical commissioning groups are a barrier to this spending. These are relatively new drugs. They were approved by NICE about 18 months ago—I am looking at the chair of the all-party group in case that is not correct—and NICE said that by now it would expect about 20% of AF sufferers to be on the new anti-coagulants, but only 3.4% of sufferers are on them. Even NICE, projecting forward, thought that the figure would already be 20%.

I do not want to talk for too long, because other hon. Members want to speak, but it is a national scandal that people are dying today, are dying every day and are having incapacitating strokes, and that that is costing the national health service an enormous amount of money and requiring the use of an enormous amount of expertise. It is a burden on the national health service that should not be there.

There is an easy resolution. It is based on science, based on research, based on evidence. It is about time that the ministerial team took the lead on this matter, that GPs woke up, and that clinical commissioning groups heard the hard words that we will not allow our constituents unnecessarily to die or suffer long-term disability just because of the inactivity of the system. We are seeing this short-term saving, this mean-minded pettiness of saving a bit of money on the balance sheet of a CCG today, when the real cost to the health service is a generic one right across our country.

This is the beginning of a campaign. We have been campaigning for a long time, but it is at a new level. We are not going to let this issue go away. This is not party political. We will chase the Minister, chase the Secretary of State and chase the Prime Minister, because this issue is important and we cannot allow this injustice to continue any longer.

11:12

[Glyn Davies (Montgomeryshire) (Con)]

I am grateful to have the opportunity to speak in a debate that is hugely important to me on a personal level. I agree with every word of the speech by the hon. Member for Huddersfield (Mr Sheerman).

Soon after I was elected as a Member of Parliament in 2010, I was selected for Question 1 at Prime Minister’s questions. I immediately thought that that was going to be my great occasion. One knows that one is on national television and everyone is watching. It is a chance to support the thrust of the Prime Minister’s argument and I was really looking forward to it, but on the Monday morning I called my GP, because I had been suffering a bit of breathlessness, and I was rushed into hospital because he thought that I was having a heart attack. This is what influenced me greatly. I then spent three days in the assessment unit of the Royal Shrewsbury hospital, and it was probably the most expensive bed in the hospital.

As I said, I was there for three days with a supposed heart attack. No one was telling me what was happening. It was only because I became so angry that I almost had a heart attack that I had some reasonable treatment, and I was told that I was probably suffering from atrial fibrillation. I had never heard of this; I did not know what it was, but as I got to know a little more about it, I learned how, in many cases, it is very easy to put right. I was given electric shock treatment—cardioversion—which reversed the fibrillation on the first attempt, and I made a full recovery, but I learned quite a lot about the condition and I realised the sheer lack of awareness that there is of it. Then I understood what the hon. Member for Huddersfield has been telling us. The issue is not so much the atrial fibrillation itself—although it can be quite difficult for many people—but what it causes. It multiplies the chance of a stroke by about five times. That is a massive cost to the NHS, but it also completely destroys people’s lives in a way that AF does not necessarily do. There are several other diseases associated with it, but the key issue is the implications of the cost of a stroke.

[Richard Graham (Gloucester) (Con)]

My hon. Friend is making a powerful point on an important issue. Those of us who work right next door to him are delighted that he made a full recovery at that time. Does he agree with me that part of making people more aware of atrial fibrillation and what can be done to help sufferers is providing defibrillators? Some very good work has been done across the country, but particularly in my constituency of Gloucester by the Rotary club, which has funded and installed a defibrillator in Gloucester cathedral; and I pay tribute especially to the Hickman family, who have raised huge amounts of money for the Cystic Fibrosis Trust, which is also doing good work in this area.

[Glyn Davies]

I certainly do agree with that. Defibrillators are being installed, through voluntary efforts and fundraising, in many parts of the country. That is not only a good thing in itself, but the way it leads the community to work together is also a very good thing.

I want to return to today’s issue, because I am aware of the time. Today’s issue is the uptake of novel oral anti-coagulants. Warfarin was my treatment and it was fine; it worked very well. However, there is a problem because of the number of occasions I have to visit a hospital. It was once or twice a week in the early stages. That is very difficult. In London, I happen to live next door to St Thomas’s and I could pop in as I was going to work in the morning, so it worked out quite well.

However, there is an issue with warfarin, for two reasons. One is that it is not as effective as the new anti-coagulants that have been approved by NICE and come on stream. Also, there is a negativity about warfarin because it is, in many people’s minds, a rat poison. I remember seeing a headline in a national newspaper, which could have been the Daily Mail, with a huge picture of rat poison—warfarin. The standard way of dealing with atrial fibrillation is still to ask people to take warfarin regularly, and there it was, being promoted as a rat poison. Nothing could be more damaging to the health of the nation than that campaign. I thought it was a disgrace.

I can understand in a way, because of short-termism—the way in which things are often done in Britain today—that there are financial reasons for the use of warfarin. Clearly, there is an extra cost associated with the new products. Warfarin is as cheap as chips. I dismiss aspirin because it does not have any effect anyway, and it is a bit of a disgrace that aspirin is still being recommended. As I said, warfarin is as cheap as chips, but of course it is not as effective. There may be a short-term gain, but there is a long-term cost. I understand the financial pressures. There are financial pressures on every organisation and service. I understand those, but I think that what is happening is wrong. However, the lack of understanding and knowledge of the new products—the lack of awareness—is what we really have to challenge.

There is a risk element. We know that there is a risk. There is a small risk, if one s thinning the blood, of an internal bleed, but there is a very large risk, in not doing it, of causing some heart-related illness. The balance of risk is just not clearly understood. We need a genuine campaign, with Government support and the NHS organisations’ full support, to move towards use of the novel oral anti-coagulants. There would be a long-term saving from that; I accept that it is not short term. It would remove the element of suspicion and of risk that is associated with the standard use of warfarin.

We have to deal with AF, because the numbers of people suffering from it and the implications of it are huge. I hope that my hon. Friend the Minister will take from today’s debate, which is part of a campaign, the message that we need to move forward as quickly as possible on the best treatments for atrial fibrillation.

11:19

[The Parliamentary Under-Secretary of State for Health (Dr Daniel Poulter)]

It is a pleasure to serve under your chairmanship for the second time, Mr Turner. It is also a pleasure to congratulate the hon. Member for Huddersfield (Mr Sheerman) on securing the debate, and to thank my hon. Friend the Member for Montgomeryshire (Glyn Davies) for his important contribution about his own experiences of atrial fibrillation and its consequences. Although he spoke about the cardioversion treatment he received for sudden onset AF, much of the debate today has been about those who have chronic AF, which is often undiagnosed. The debate provides a good opportunity to raise such issues and ensure that those who are listening—in particular, bodies such as the Royal College of General Practitioners —take away messages about what more they can do to support GPs in earlier detection and diagnosis, where that is possible, and to make sure that the right treatment pathways and proper medications are provided to patients.

It may be useful if I talk briefly about the condition. The heart is not my area of medical expertise, but as a junior doctor I looked after several patients with AF, some of whom came through the front door of the hospital in a similar condition to that described by my hon. Friend the Member for Montgomeryshire, so I have seen it at first hand. AF is the most common sustained heart rhythm disturbance, and it occurs as a result of rapid, disorganised electrical activity in the heart’s upper chambers—known as the atria, hence atrial fibrillation—which results in an irregular heart rhythm. As we have heard, AF is a major predisposing factor for stroke and it accounts for approximately 14% of all strokes.

[Mr Sheerman]

On that point, would it not be a fine idea for the Minister or one of his colleagues to write to every Member of Parliament with the statistics? In the Calderdale and Huddersfield NHS Foundation Trust in my constituency, liaison between hospitals and GPs is not as good as it should be. When someone such as the hon. Member for Montgomeryshire (Glyn Davies) comes out of hospital after having an episode, there is no linkage of treatment between the hospital and the GP. Would it not be a fine idea to send a letter to every Member of Parliament giving them the statistics and urging them to talk to their clinical commissioning groups and GPs about the matter?

[Dr Poulter]

The hon. Gentleman is absolutely right about the importance of raising awareness of AF. He is also right to point out that co-ordination between primary and secondary care is not always as strong as it could be, not only in this area but throughout the NHS. Part of the reason the Government are investing in the £3.8 billion integrated health fund is to ensure that health and social care are better joined up, to achieve a more co-ordinated and holistic approach that is about individuals’ needs.

If someone has been diagnosed in hospital, it is important that they are given the right support in general practice and in the community. There is a lot of good practice out there, and there are a lot of good and well informed GPs. NICE is producing new guidelines and new draft recommendations on treatment—it has been looking at issues such as the use of anti-coagulants—and it is important that that information is disseminated quickly and effectively. My commitment to the hon. Member for Huddersfield is that I am happy to write to NHS England, which oversees CCGs, to raise the matter and ask it to disseminate NICE guidelines to CCGs and ensure that they are mindful of them.

[Mr Sheerman]

That is excellent news, but as someone with medical training, is the Minister not shocked that 36% of those with AF are being prescribed nothing or aspirin? Was he shocked to find out that rather than the 20% that NICE expected, only 3.4% of sufferers were on the new anti-coagulants?

[Dr Poulter]

The statistics that I am aware of are slightly less positive than those that the hon. Gentleman has cited. It is not for us in this place to micromanage medical professionals or to do their jobs for them. However, it is our job to raise legitimate concerns about care for AF or any other health conditions. We must do our best, as stewards of the health system, to push for good local commissioning that is mindful of best practice. I have undertaken to write to NHS England about that, and I will be happy to share the reply that I receive with the hon. Member for Huddersfield and other hon. Members and hon. Friends.

The exact causes of AF are unclear, but it is important to get the diagnosis right and to diagnose the condition as quickly as possible. We believe that some 18% of cases of AF are undetected, so there is more work to be done. NHS England has recognised that, and has suggested that CCGs should work with local practices to target people who are at risk from AF. The issue is already on NHS England’s radar, but I will write to obtain further assurances that it is being taken as seriously as it should be; I am sure that that is the case.

Research is under way into the condition. The National Institute for Health Research is funding a study into automatic diagnosis of AF in primary care using a hand-held device, which may help identify more patients who have AF and reduce the number of related strokes. If someone does not know that they have the condition, they do not know that they need to see a GP to get help. We must do as much as we can to support people to recognise that they have a medical condition and that help and treatment are available. I hope that the research into that technology provides better early detection of AF, and that that comes forward in a rapid and timely manner.

[Glyn Davies]

I thank the Minister for giving way and allowing me to correct an omission in my contribution. Does he agree that the excellent work of the Atrial Fibrillation Association in promoting knowledge of the disease has had a hugely positive impact, which we should all appreciate?

[Dr Poulter]

My hon. Friend is absolutely right to highlight that work. When NICE draws up guidelines, it consults best practice and tries to engage with key stakeholders. In addition, the Royal College of Physicians has developed some national clinical guidelines for stroke with the objective of encouraging higher levels of anti-coagulation. That is directly linked to some of the things we have debated today.

It is a testament to the work of groups such as the Atrial Fibrillation Association that we are helping to raise the profile of the condition and to get early support and help for people. There is clearly more to do, and NICE must continue to develop strong guidelines to support understanding of the best care and pathways for people who have AF. NICE is updating guidelines at the moment and developing a quality standard on AF, which will set out what a high-quality AF service should look like and drive improvement locally by helping local commissioners and CCGs understand what good looks like in AF care.

[Mr Sheerman]

Before the Minister, who is uniquely qualified to have an opinion, sits down, does he agree that more people should be on the new generation of drugs that will keep them alive and prevent them from having strokes?

[Dr Poulter]

It is not my medical specialty, but if new medication is developed, we need to evaluate it. The priority must be to give treatment according to clinical need. I, as a doctor, the Government and hon. Members on both sides of the House believe that it is right to treat patients according to clinical need and clinical priority. It is for CCGs to work with national guidelines, and we look forward to seeing the NICE quality standard on AF, which I hope will put CCGs in a much better position. I have already committed to writing to NHS England to ensure that it puts the matter high on its priority list, and that it supports and encourages all clinical commissioning groups to take AF seriously and make it a priority across the country.

11:30

Sitting suspended.