Written Evidence Submitted by Bob Blackman MP

(CLL0056)

Foreword

On 24 November, a group of leading medical experts in the NHS, patient charities, patient representatives and parliamentarians gathered for a webinar titled Coronavirus lessons learnt: rethinking heart disease care in pursuit of healthy ageing, hosted by Bob Blackman MP. The meeting aimed to reflect on issues faced by the NHS and heart disease patients through COVID-19, during which participants agreed on a suite of recommendations to rethink heart disease care and enable healthy ageing based on the commitments made in the NHS Long Term Plan in (2019) and the UK’s Industrial Strategy Grand Challenges (2019).

Participants agreed to share the discussion findings with the Health and Social Care Committee and Science and Technology Committee by contributing to the joint inquiry into lessons to be learnt from the coronavirus pandemic. They wish for the recommendations to be considered in the final report, informing the Government and the management of the NHS on how they can better support elderly heart disease patients in the next phases of the pandemic and in the long-term.

Medical experts: Prof Phil MacCarthy (King's College London), Dr Clare Appleby (Liverpool Heart and Chest Hospital), Dr Laura Dobson (Wythenshawe Hospital Manchester), Dr Dan Blackman (Leeds General Infirmary), Dr John de Verteuil (Northwest Surrey West Byfleet Clinic), and Nicola Bowers (Buckinghamshire Wycombe Hospital).

Stakeholders who participated in the webinar: Livvy, a patient waiting for surgery, British Cardiovascular Intervention Society, British Heart Valve Society, British Society of Echocardiography, British Association for Nursing for Cardiovascular Care, Heart Valve Voice, Positive Ageing London - AGE UK, BHF Data Science Centre, and NHS Digital.

Lessons learnt on the provision of heart disease care through COVID-19
 

Participants noted that the COVID-19 pandemic has seen a different scale of test for the NHS, going far beyond anything the sector has previously experienced. Recent data reported a 23-25% increase of men dying from heart disease at home in England and Wales since the advent of the pandemic[1], and since the pause of GP’s face-to-face appointments, many patients have remained undiagnosed.

Medical experts agreed that patients with heart conditions were more vulnerable and at increased risk of developing COVID-19 and of poor outcomes of COVID-19, such as admission to hospital or intensive care, or of dying.

Participants noted the onus was placed on patients to self-diagnose, but that patients often lacked the requisite knowledge to identify heart disease symptoms, often masked by natural signs of ageing. The consensus was reached that many of these patients are older people with multimorbidity who were unable to test deteriorating symptoms and struggle to access timely referral and adequate diagnosis during England’s lockdown.

Livvy, a patient from Southampton highlighted the obstacles in receiving heart valve treatment which has been delayed by 12 months due to COVID-19. The delay has had a tremendous impact on her working and family life which led to the worsening of her condition.

To address the disruption in diagnostic services, increased uptake in telemedicine maintained the provision of albeit limited primary care. Webinar participants cautioned around the more comprehensive roll-out of telemedicine, highlighting the difficulty in conveying symptoms to practitioners via telephone consultation, as well as the inability to provide on-the-spot diagnostic assessment using a stethoscope, or performing other tests such as echocardiography or electrocardiography.

Through the pandemic, the treatment of heart diseases was severely curtailed by the disruptive impact of COVID-19 on the NHS. In the webinar, the clinicians working in hospitals across England noted that at the beginning of the pandemic, they witnessed a 45 percent reduction in patients accessing healthcare with heart attacks[2], for example, and a pervasive cautiousness among the public around accessing healthcare services for fear of contracting COVID-19 or burdening an already overwhelmed NHS.

The biggest challenge in cardiac care was the continuation of elective diagnostics and procedures. The NHS already had a huge backlog of patients waiting for these appointments before the pandemic and there was a great fear that due to COVID-19 many patients would have remained undiagnosed, unreferred and untreated. Aortic stenosis (AS) was highlighted as an example as it requires timely intervention to avoid rapid progression and death. Severe AS has a prevalence of 3.4 percent in over 75s[3] and a mortality of 3.7 percent at just one month[4], and a lack of timely diagnosis leads to up to 5,000 premature deaths in England each year.

In other parts of the country, the clinicians noted their success in triaging patients for cardiac intervention, a large proportion of whom were heart valve disease patients. In hospitals in London in particular, cardiac care was broadly able to continue as certain hospitals, without A&E departments, were designated specialist centres for non-COVID-19 care as part of the Pan-London Emergency Cardiac Surgery Service. 140 transcatheter aortic valve implantation (TAVI) procedures were undertaken in the private London Bridge Hospital, for example, with no patients contracting COVID-19. This highlights the inequality across the country in providing heart valve treatment.

Recommendations for building back better heart disease care in light of COVID-19

Building on the issues encountered as the pandemic evolved, and following from the NHS Long Term Plan commitments on improving primary care detection of heart failure and heart valve disease, the webinar participants agreed on a suite of recommendations to rethink heart disease care to enable healthy ageing.

1. To address the prevailing issue in a lack of awareness of the forms and prognosis of heart diseases, including heart valve diseases, participants agreed on the need for a public awareness campaign directed at the general public to recognise symptoms of all heart conditions, next to the most commonly known risk symptoms of cardiovascular conditions (AF, blood pressure and cholesterol).
2. The NHS LTP commitment to better detection in primary care, must be supported by other healthcare professions such as community pharmacists and primary care professionals. Stethoscope checks should be required for all older patients over 65s and GPs should be encouraged to use digital solutions such as digital stethoscopes and symptom trackers through future lockdowns and future health shocks.
3. The increased uptake in digital health solutions must be supported with appropriate infrastructure and education to bridge the digital divide, especially among elderly patients and other disadvantaged groups.
4. Blood tests for heart disease should be used more often across primary care settings for the over 65s to diagnose heart conditions such as heart failure more accurately and rapidly.
5. Minimally invasive treatment options such as trans-catheter aortic valve implantation and trans-catheter mitral valve leaflet repair reduce exposure to COVID-19 and minimise critical care occupancy and must be encouraged to ensure cardiac care can be maintained, particularly for older patients unsuitable for more invasive types of surgery.
6. Treatments that enable healthy ageing and reduce the social care burden must be recognized, encouraged and made more accessible as they help to reduce vulnerability and avoid spikes in community mortality observed through COVID-19.
7. In view of its prevalence and prognosis, heart valve disease must be reprioritised nationally as a key priority treatment area and clinicians must be supported in ensuring that critical cardiac diagnosis and treatment can continue through future lockdowns and health shocks, as well as to reduce unwarranted geographical inequities in care provision among CCGs.
8. The UK must remain at the forefront of research – and facilitate the use of population-level data – into the risks of COVID-19 and heart valve diseases to understand the impact of the pandemic on people’s long-term health and the burden on society.

Recommendations endorsed by

Bob Blackman MP, Virendra Sharma MP, Steve McCabe MP, Henry Smith MP, Jim Shannon MP, Baroness Greengross, Baroness Jolly

(November 2020)