Written evidence submitted by Edwards Lifesciences (RTR0108)
Edwards Lifesciences is a leading medical devices company providing lifechanging technologies to people with structural heart conditions and providing best-in-class monitoring technology in the operating room and intensive care units. Our heart treatment technologies provide curative and restorative treatment to people suffering from heart valve disease (HVD).
HVD affects an estimated 1.5 million people in the UK, becoming more prevalent with age; with demographic ageing, this figure is set to double by 2046.[i] If left untreated, severe aortic stenosis, a form of HVD, has a critical prognosis, with a two-year survival rate of around 50 per cent and a five-year survival rate of just 20 per cent.
Edwards Lifesciences produces devices for heart valve disease that are minimally invasive and are an alternate treatment option to open heart surgery - particularly necessary for elderly and fragile patients.
Minimally invasive surgery options, such as the Transcatheter Aortic Valve Implantation (TAVI), are cost- and time-effective treatments that can help drive efficiency and mitigate key workforce and capacity issues. Such options can require shorter hospital stays and lead to less hospital-based follow-up care – while recovery from open heart surgery may take several weeks, after TAVI patients can typically be released home after 48 hours, relieving nursing and support staff for other duties. With cross-training of staff made easier with minimally invasive treatment options, more practitioners can provide treatments, mitigating workforce capacity issues.
Below we outline why and how the NHS workforce can be supported to enable the benefits of minimally invasive surgery to be realised, both now and in the future.
Relevant term of reference
“Are there specific roles, and/or geographical locations, where recruitment and retention are a particular problem and what could be done to address this?”
Recommendation: That the echocardiography workforce is expanded through both increased recruitment of new staff and the retraining of existing staff.
Heart diseases are currently mostly diagnosed in hospitals despite 40% of patients having symptoms which should have triggered an earlier assessment.[ii] The earlier HVD is detected, the sooner it can be diagnosed and treated. The early detection of murmurs characteristic of HVD is essential to ensure timely treatment. The primary and community care workforce trained in the use of cardiac monitoring technologies such as digital stethoscopes must be expanded to ensure timely detection.
A lack of specialist echocardiographers can delay HVD diagnosis, worsening patient outcomes. The expansion of echocardiography services is essential to reduce delays in diagnosis following initial detection. The services could be expanded in two ways; first, through the recruitment of more specialist echocardiographers, or alternatively through the adoption of newly available hand-held echo devices that can be used by other staff. This would also then require the improved training of GPs and nurses.
Recommendation: That further staff in regions where there is currently low access to quality treatment are trained to use minimally invasive technologies.
Geographically, there are often inequities in access to the new innovative treatments due to workforce shortfalls.
For example, South West England has poor TAVI availability, with just one cardiac centre providing this treatment option. Many elderly and particularly fragile patients unable to undergo traditional open heart surgery are often required to travel for treatment, with referral pathways stretching even to London.
Staff must be trained across regions to support the development of services to address regional shortfalls in care. The wider adoption of minimally invasive treatment options such as TAVI can enable more staff to provide treatment. Ensuring access to a multidisciplinary team for care, with care along the pathway overseen by a heart valve disease nurse coordinator, can ensure HVD patients access treatment more efficiently.
Relevant term of reference
“What changes could be made to the initial and ongoing training of staff in the health and social care sectors in order to help increase the number of staff working in these sectors?”
Specifically, “Do the curriculums for training doctors, nurses, and allied health professionals need updating to ensure that staff have the right mix of skills?”
Recommendation: Training is undertaken to support primary and community professionals with screening and patient monitoring to identify symptoms of treatable, but unpreventable, conditions such as heart valve disease that can often be misdescribed as general signs of ageing.
In primary care, professionals are often unaware of the symptoms of diseases and illnesses which contributes to missed diagnoses.
This issue is acute in heart valve disease care, which shares many similar symptoms – such as breathlessness – to common signs of ageing. Due to the poor use of stethoscopes in GP appointments and other health checks, approximately half of patients with HVD are not diagnosed until significant valve disease has developed and detection occurs in a hospital setting.
Training and upskilling different professionals across the workforce, to support the creation of multidisciplinary teams, is key to meeting growing demand for HVD care. Training should be offered to nurses and associates to upskill the workforce in HVD detection, diagnosis, management and the use of TAVI technology. Cardiac physiologists and specialist nurses should be supported in extending their skillset to fill various functions such as echocardiography and cardiac surveillance, addressing the national shortage in accredited echocardiographers.[iii]
By improving training in the primary and community setting to include the proper and timely use of stethoscopes, HVD and other heart diseases may be detected much sooner. Further training of staff in primary care to improve both awareness of symptoms and detection of common diseases is needed to improve detection.
Recommendation: Training programmes for minimally invasive surgery options be prioritised to ensure that all patients across England can access the best quality of care and not be restricted by geographical location.
As above, a minimally invasive approach has been found to be more cost-effective as it often requires a shorter hospital stay, decreased amounts of imaging and laboratory tests and reduced numbers of required readmissions and follow-up costs.
Minimally invasive surgery options can thus be particularly useful in helping to relieve workforce issues as they can often be performed by a wider pool of staff, releasing the capacity of nursing staff and doctors post-operation.
The equipment for TAVI is already available in many hospitals, and the increased utilisation of this could support addressing the backlog of care by decreasing waiting and recovery times for patients with HVD, and releasing much-needed capacity and resources. This surgery is often restricted to certain staff, contributing to wide variation in the rate of TAVI provision across trusts, with less efficient TAVI units providing over 50% fewer TAVIs in a clinical day.[iv]
We recommend that training programmes for these innovative technologies and techniques be prioritised in both the short and long term as they are cost effective and provide positive outcomes for patients, as well as releasing much needed capacity and resources.
Recommendation: Better utilise diagnostic hubs by ensuring the workforce are trained in using stethoscopes or new digital diagnostic devices.
We welcome the Government’s commitment to the development of around 100 new community diagnostic hubs across England and recognise that they could improve patients’ movement through the care pathway.
Utilising the new community diagnostic hubs by improving integration with other diagnostic services, such as new community diagnostic networks, and upskilling the primary care workforce so that all primary care workers (GPs, pharmacists, social care nurses etc.) are trained to properly use stethoscopes and hand-held echo machines, could ensure that patients are treated sooner and more efficiently. This would allow many more people to receive regular health checks and help to address the backlog caused by the pandemic.
[i] BHF (July 2018). Heart valve disease facing diagnosis crisis over next 40 years.
[ii] NHS Long Term Plan, p. 62. Bottle, A., Kim, D., Aylin, P., Cowie, M., Majeed, A. & Hayhoe, B. (2018) Routes to diagnosis of heart failure: observational study using linked data in England. Heart. 104 (7), 600-605.
[iii] GIRFT, February 2021, p. 44.
[iv] Getting it Right First Time (GIRFT) (February 2021). Cardiology. GIRFT Programme National Specialty Report. P. 52.