Written evidence submitted by The British Heart (RTR0137)

About the British Heart Foundation

The British Heart Foundation (BHF) is the largest independent funder of medical research into heart and circulatory diseases in the UK and research we fund has helped halve the number of people dying from these conditions since the 1960s. Our vision is a world free from the fear of heart and circulatory disease, and we work to transform the detection and treatment of heart and circulatory diseases and provide trusted information for people affected by these conditions.  

About our representation   

We welcome the opportunity to respond to this important inquiry on the future of the health and social care workforce. Our response will focus on the cardiovascular disease workforce in England.  Should you require any further information about anything in this response, please contact Lisa Plotkin, Policy Manager, at plotkinl@bhf.org.uk

Introduction

1. Today, there are more than 7 million people living with cardiovascular disease (CVD) in the UK – more than twice as many people as cancer and Alzheimer’s combined. CVD causes around a quarter of all UK deaths annually, on average one death every three minutes.  CVD is responsible for the largest gap in healthy life expectancy, with those in the most deprived 10 per cent of the population almost twice as likely to die due to CVD than those in the least deprived 10 per cent.  The NHS England Long Term Plan identified CVD as the single biggest area where the NHS can save lives over the next ten years.

2. Prior to the pandemic, cardiovascular services were already under immense pressure, with significant unwarranted variation across the patient pathway, from primary care to cardiac rehabilitation. The pandemic has exacerbated those pre-existing issues in the health system and undermined the progress services were making on national ambitions for CVD.  Millions have now been unable to access care, over 280,000 are on an NHS waiting list for a heart test or procedure[i], and in the first year of the pandemic alone there were 5,800 ‘excess’ deaths due to heart and circulatory disease.[ii] We are now at a point where six decades of progress against death and disability from heart disease could start to reverse unless decisive action is taken now to prioritise CVD in the Covid-recovery – starting with investing in the cardiovascular workforce.

Key challenges for the CVD workforce

3. Throughout their care and treatment, people at risk of or living with CVD are supported by a diverse range of health and care professionals. What is considered the ‘core heart team’ includes cardiologists, specialist cardiac nurses, advanced clinical practitioners (ACPs), radiographers, and cardiac physiologists. They are supplemented by the wider team of GPs, pharmacists, and others based in primary and community care. This wider team works with their local populations to prevent the onset of CVD from developing, detecting those at highest risk, and helping patients to manage their condition in the long-term so that it doesn’t deteriorate and require specialist support.
4. In the wake of the pandemic, the cardiovascular disease workforce faces four key challenges that must be addressed if the NHS Long Term Plan CVD commitments and the Government’s recovery aspirations are to be met[iii]:

1. Gaps in the CVD workforce must be addressed

Health Education England (HEE) analysis from 2021 shows widespread capacity issues across a variety of cardiac roles and significant shortages in certain areas, like cardiac physiology. The Getting it Right the First Time (GIRFT) cardiology report (2021) estimates that the NHS is short almost 100 consultant cardiologist posts, needs 760 new cardiac physiologists to meet demand over the next decade, and has greatly underestimated the number of heart failure specialist nurses or ACPs that are required to deliver the NHS Long Term Plan.[iv] These calculations do not even consider the full extent of the Covid backlogs and national recovery targets, meaning the shortages are most likely even more pronounced.

2. We must do a better job retaining the specialist CVD workforce

Prior to the pandemic, retention was already a significant issue for the NHS workforce, as highlighted in the NHS People Plan for 2020/21.[v]  The pressures of delivering care during a pandemic has resulted in a concerning rise in NHS staff experiencing work-related stress or burnout, compounding pre-existing retention issues. There is now credible concern that the NHS could be facing a workplace exodus in the coming years, with more than two per cent of the entire NHS workforce (27,000 medics) voluntarily leaving the NHS in the third quarter of last year alone – the highest number on record.[vi] Strong data on how this will specifically affect the CVD workforce is not readily available, but insight from healthcare professionals suggests that many are considering moving organisations or retiring in the next five years.

3. The development and upskilling of the multidisciplinary (MDT) heart team must be improved

The GIRFT review into cardiology services found considerable variation in how the cardiology workforce is being deployed and the competency that staff were working at. For example, in the 63 trusts surveyed for the GIRFT analysis, specialist cardiac nurses were only able to prescribe in 23 and there was great variation in the extent to which they were being deployed independently to run heart failure, chest pain, and other clinics.[vii] The development of extended roles and upskilling the whole heart team is essential to delivering high quality and integrated services, enabling the workforce to operate more effectively. It is also critical for achieving the vision outlined in HEE’s Future Doctor programme for a more flexible, adaptable, and multidisciplinary workforce.[viii]

4. The lack of diversity in cardiac leadership, clinical research, and consultant level roles must be tackled

The NHS People Plan expects the NHS to take action to improve the diversity of the workforce, helping ensure that their staffing reflects the diversity of their community. Cardiology faces its own unique set of challenges in this regard, notably when it comes to the proportion of women in clinical and leadership roles. Despite making up over half of medical students in the UK, recent data shows that women represent only 28 per cent of cardiology trainees and only 13 per cent of cardiology consultants.[ix] The disparities are most marked in interventional specialties and academic cardiology. Given the burden of cardiovascular disease on women, the academic and clinical cardiovascular workforce needs to be drawn from the widest pool of talent and the status quo is not acceptable.

Spotlight on the cardiac physiology and heart failure specialist nurse workforces

Cardiac physiologists

5. Cardiac physiologists are the workforce responsible for delivering many cardiac diagnostic tests, such as echocardiograms (echos) and electrocardiograms (ECGs). In some cases, they are also responsible for the long-term monitoring of patients with certain heart conditions, such as heart valve disease. Clinical standards as they relate to cardiology require echocardiography to be available every day of the week, with urgent tests needed to be conducted within a 12-hour time frame.

6. Prior to the pandemic, there was a long standing and significant deficit in cardiac physiologists to support the expansion of echocardiography. Reasons for this are multifactorial, including a lack of trainees coming through the national training scheme and poor rates of retention, most likely due to a lack of career progression and losses to agencies, overseas employment, and industry. The chronic shortage has led the National School for Healthcare Science to highlight the need for echocardiographers on the Migration Advisory Committee (MAC) Shortage Occupation List.[x]

7. Access to echo and ECG for diagnosing heart failure and other conditions is varied throughout the UK. With many clinical cardiac physiology staff redeployed during the pandemic’s peaks, waiting lists for echocardiography have dramatically increased. At the end of November 2021, there were almost 150,000 people waiting for an echo – which stands in stark contrast to the pre-pandemic monthly average of 55,000 people.[xi] It is also notable that by the end of November 2021, only 58 per cent of patients met the six-week diagnostic waiting time standard.

8. These delays have been due to a variety of factors that committee members will be familiar with, including the need to implement Covid infection control measures and staff redeployment. However, echocardiography has been hit particularly hard due to the pre-existing shortages in the specialism. GIRFT analysis states that “around 760 new cardiac physiologists are needed to meet demand over the next ten years, of whom 460 should be in echocardiography”.[xii] The NHS won’t be able to meet its target of delivering 20 per cent more diagnostic activity compared to pre-pandemic levels in 2022/23 if these shortages aren’t addressed.[xiii]

9. Long waits for key heart tests, such as echos, have contributed to the growing backlog of heart care for potentially life-saving procedures. At the end of November 2021, there were over 280,000 people on an NHS cardiac waiting list, with 3,589 people waiting over a year.[xiv] Such long waits for the treatment of conditions like coronary heart disease increase the risk of someone becoming more unwell or even dying while they wait for care.

Heart failure specialist nurses

10. There are nearly one million people living with heart failure in the UK today, a life limiting condition that often causes emergency hospital admissions, poor quality of life, and ultimately premature death.  While incurable, there are several treatments that, combined with lifestyle changes and holistic care and support, can allow many people with heart failure to live well for longer.

11. Heart failure specialist nurses (HFSN) play a vital role in delivering the high-quality care these patients require. They often fulfil extended roles and have a range of responsibilities, including triaging patients, providing care across the heart failure pathway, supporting clinics and ward rounds, and prescribing.

12. Although HFSN services are well established in many areas of the UK, there is significant regional variation in their provision – something that the pandemic has further exacerbated. While redeployment has affected a wide range of specialist heart and circulatory services across primary, secondary, and community care, the BHF has confirmed a significant impact on services needed to support those with heart failure in the community. [xv] 

13. Alongside the disruption, and in some cases complete disappearance, of heart failure services in the community, we also saw a dramatic fall (22 per cent in England) in people presenting to hospitals with heart failure between January and September 2020.[xvi] An analysis of National Heart Failure Audit Data suggests that more people died in the community from heart failure during the pandemic than ever recorded (280 excess deaths over a four-month period) because they hadn’t been treated in an acute setting.[xvii]

14. We are also predicting a rising number of heart failure patients in the future as people with suspected heart attacks are having to wait longer for potentially life saving urgent and emergency care due to extreme delays in that part of the pathway.

15. To meet demand and NHS Long Term Plan aspirations, GIRFT estimates that the number of heart failure specialist nurses should be doubled or in some cases quadrupled – from 1 per 100,000 population to 2-4 per 100,000.[xviii]

16. In order for effective heart failure patient pathways to be developed, the BHF’s Heart Failure: a Blueprint for Change strongly suggests upskilling of all healthcare professionals across the heart failure pathway.[xix]

Recommendations for future action

Workforce planning

17. The Government and NHS must deliver a fully funded long-term workforce plan to grow and support the cardiovascular disease workforce. This should include expansion of the number of cardiac nurses, cardiac physiologists, radiographers, and radiologists with interest in heart disease, cardiologists, and other specialist roles to deliver the expert care needed for patients and to support new allied health professional roles. The plan should be informed by demand at cardiac network and ICS level to deliver multidisciplinary team (MDT)-led cardiovascular care.

18. We remain concerned that the 2021 Spending Review settlement provided no clarity on HEE’s budget beyond a commitment to dedicate ‘hundreds of thousands of pounds’ to achieve unspecified training objectives. With the recent announcement that HEE is to be absorbed into NHSE (pending legislation), we urgently need clarification about whether NHS workforce training and development costs will be met from current NHSE operational budgets or whether additional ring-fenced funding for this purpose will be forthcoming.

19. We urge the Government to take the opportunity that has arisen during the Health and Care Bill’s progression through Parliament, and accept a cross-party amendment to the Bill that would place a duty on the Secretary of State to publish independent assessments of current and future workforce need across the NHS, social care, and public health every two years, strengthening the existing legislation. Ensuring a collective national picture of the health and care staff numbers needed now and, in the future, to meet patient need will provide strong foundations to take long-term strategic decisions about funding, regional and speciality shortages (including CVD workforce shortages), and skill mix.

A new People Plan for the NHS must include:

20. We support this Committee’s recent recommendation that the NHS should publish a refreshed People Plan to cover the financial year 2022/23 as soon as is feasible.[xx]  The refreshed plan should:

• Invest in support services for NHS staff facing burnout and requiring psychological support as they recover from the pandemic
• Outline how the workforce will be enabled to work more flexibly in the future in order to improve job satisfaction and staff retention rates
• Ensure that staff are able to access the training needed to expand their roles and skills to support in delivering improvements set out in the NHS Long Term Plan. A commitment to developing multidisciplinary teams must be embedded throughout.
• Commitments to encourage and support women to enter the cardiovascular disease workforce at all levels

The Messenger Leadership Review – actions for the Delivery Plan

21. A key recommendation from the BHF’s Untold Heartbreak report into the impact of Covid on CVD care was to develop clear cardiovascular leadership roles across the health and care system. This means:

• There must be clear and identifiable leadership for CVD in integrated care systems (ICSs) once they are (pending legislation) fully operational as well as a CVD lead in every primary care network (PCN).  ICS and PCN leadership should work closely with cardiac networks and patient in their local population to co-create and develop services that address backlogs and improves care quality.

• Cardiac networks, which hold the potential for playing a key role in helping to address the cardiovascular care backlog, should be resourced and held accountable for driving improvements and outcomes for CVD patients and reducing unwarranted variation in care across regions

Jan 2022

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