Patients with Heart Failure

Justin Madders Excerpts

Thursday 11th March 2021 Westminster Hall

[Justin Madders (Ellesmere Port and Neston) (Lab)]

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.

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?