NHS0017

Written evidence submitted by the Heart Valve Voice

Introduction

Heart Valve Voice (HVV) is the UK’s dedicated heart valve disease charity. We work with patients and clinicians to help increase the awareness of heart valve disease in the UK and improve diagnosis and treatment. Heart valve disease affects over 1.5 million people over the age of 65 in the UK and while there have been many advancements in the treatment of this disease the unfortunate fact is that far too many people are not being diagnosed and treated early enough. Since our formation in 2014, our aim has been to ensure that more of the population is aware of the importance of having their heart checked for heart valve disease, which can often be detected through a simple stethoscope check.
Many heart valve disease patients have been impacted during the pandemic in not being able to access primary care, and therefore vital secondary referrals for these patients have not been made. This has led to worse outcomes for many patients, with many patients being treated sicker and needed more complex procedures, and also resulted an increase in demand on already stretched NHS services. For example, a recent survey by HVV showed that 73% of cardiac clinicians saw a reduction in primary care referrals for heart valve disease.[i]
We therefore welcome the opportunity to submit evidence to this important inquiry and hope that, in the wake of the COVID-19 pandemic, this submission can help many more heart valve disease patients get the timely treatment they need to go on to live full and happy lives.

The impact of COVID-19 on heart valve disease diagnosis

A recent survey by HVV indicated that 96% of clinicians have seen a drop in the number of patients referred for echocardiography during the pandemic.[ii] This is significant, as some types of undiagnosed and untreated symptomatic heart valve disease have a two-year survival rate. To put this into perspective, new guidance [iii] produced by the National Institute for Health and Care Excellence (NICE) recommends that if heart valve disease is suspected in a patient based on; a heart murmur; family/medical history; or age, they should be offered an ‘urgent’ specialist assessment within two weeks in the form of an echocardiogram. HVV welcomes this, and despite the short-term pressures it could place on staffing, diagnosing more cases sooner will create less of a financial burden on the NHS in the future.
The COVID-19 pandemic allowed the NHS to foster the use of novel ways of working. Specifically, telemedicine, which has been highlighted as an innovation that had been of real benefit to the patient community by allowing consultations to occur without the risk of visiting a healthcare setting. However, respondents from a Heart Valve Voice consultation [iv] also expressed the view that telemedicine should not be exclusively used across the patient pathway as certain milestones, such as a new or a change in diagnosis, should occur via an in-person appointment where possible. Telemedicine, while innovative, had an unintended consequence of suppressing incidental diagnoses, as the lack of face-to-face interaction reduces a clinician’s ability to detect a heart murmur through an in-person stethoscope check.
Recent figures from NHS England and NHS Improvement [v] have shown that the average wait time for an echocardiogram in September 2021 was five weeks. The number of patients in the same period waiting for a test at the end of September 2021 stood at 149,050 (a 27% increase in from September 2020), 44 per cent of which waiting six weeks or more. This is twenty times the figure of those waiting for a test before the pandemic.[vi] A recent study by the IPPR also estimated that this backlog has led to 23,000 missed diagnoses of heart failure more generally in England during the pandemic.[vii] Therefore, it is crucial that waiting times come down in line with NICE guidelines, as it greatly increases the propensity of cases being caught earlier. At the very height of the COVID-19 outbreak, HVV surveyed [viii] UK cardiac clinicians to understand how they had responded to the pressures placed on them by the pandemic. The survey revealed that in many centres, anything other than very urgent cases had been put on hold, while staff were deployed to other areas. Two-thirds of respondents reported increased waiting times for an echocardiogram, while nine out of ten responding clinicians saw a reduction in the number of echocardiograms conducted per month. This is consistent with the findings of a report from the Institute for Public Policy Research (IPPR), which found that the total number of echocardiograms undertaken in 2020 decreased by 44% compared to 2019 [ix]. As the COVID-19 pandemic subsides, the backlog of heart valve disease patients should be treated as an issue of urgency. Early intervention returns older patients to a good quality of life in optimal time and is also cost-effective for the NHS.
As the UK’s population ages, the risk of heart valve disease becoming more prevalent in the elderly is higher. Strong surveillance through echocardiography is pivotal in ensuring that more cases are caught earlier. Before the pandemic, the NHS experienced pre-existing issues with administrating echocardiography due to resource shortages. A 2016 report by the APPG on Heart Disease noted that an acute shortage of echocardiographers in the United Kingdom – with only 44 individuals trained in 2016, and severe delays for many patients waiting for an echocardiogram.[x] The COVID-19 pandemic has only made this worse. Patient outcomes, however, should continue to remain a priority – through more and faster echocardiography. Heart Valve Voice therefore welcomes the recent publication of the NICE guidelines, which recommended a two month waiting time for an echocardiogram.

The impact of COVID-19 on heart valve disease treatment

We know that the COVID-19 pandemic has affected the care of patients nationwide, but also that the NHS has made great strides to pivot its practices and continue to facilitate optimal outcomes for patients.

However, treatment for heart valve disease has been affected, with more than 2/3 of responding clinicians having recommended a patient delay treatment until after the pandemic and only 31% reported to have continued to treat patients in line with standard practices [xi]. Out of the clinicians that HVV surveyed, all observed a drop in the number of heart surgeries taking place throughout the pandemic, with some noting a decrease of more than 40%.[xii]
Findings published by the British Heart Foundation (BHF) in July 2021, revealed that 242,181 people were waiting for invasive heart procedures, including heart surgery, at the end of May – the highest number for May on record. Of those waiting, 52,484 had been waiting over 18 weeks – this is more than one in five (22 per cent) of all patients waiting for heart surgery or another invasive procedure at the end of May 2021 [xiii]. This represents an unprecedented backlog in the care of CVD patients.
Furthermore, 73% of cardiac clinicians saw a reduction in primary care referrals for heart valve disease [xiv]. Of those asked, 93% of clinicians attributed this to patients not presenting due to fear of COVID-19. Again, this is concerning, as, for patients with heart valve disease, early diagnosis and treatment is vital. The lack of presentations to primary care and the consequent lack of secondary referrals indicated bigger issues being stored up, potentially leading to worse patient outcomes and future additional costs and resource impacts on an already stretched NHS.
As a result, a group of untreated heart valve disease patients joined together in a statement urging healthcare providers to retain treatment capacity during the second-wave of COVID-19. They highlighted that according to Hospital Episode Data [xv] , aortic valve replacements (AVR), the most common form of valve disease treatment, fell by 29% vs LY (Last Year) (April - September 2020). This equated to 1,635 lost treatments, creating an ever-increasing backlog of patients in the system. HVV estimated that if the second wave of COVID-19 had a similar impact, the NHS could lose as many as 1,162 AVR treatments from October 20 to March 21, taking the total lost treatments in 12 months to 2,817.

[iii] NICE. Heart valve disease presenting in adults: investigation and management. 2021.

[vii] IPPR, State of health and care: the NHS Long Term Plan after Covid-19, 2021

[x] Cowie, M. R. (2017). The heart failure epidemic: a UK perspective, Echo Research and Practice, 4(1), R15-R20. Retrieved Jun 3, 2021

from https://erp.bioscientifica.com/view/journals/echo/4/1/R15.xml [Accessed: June 2021]