Written evidence submitted by the British Heart Foundation (PEG0146)

Executive summary

• Medical research charities such as the BHF have played a key role in supporting patients throughout the Covid-19 pandemic and will continue to respond to patients’ concerns beyond this crisis.
• However, the pandemic has significantly affected the BHF's ability to fund life saving research: disruption to our fundraising activities and the closure of large parts of our retail network mean that we expect our budget for investing in new research to halve this year from around £100 million to around £50 million – a sharp drop that could take years to recover from.
• Medical research charities such as the BHF will play an important role in the UK’s economic recovery from the Covid-19 crisis through the research we fund and the contribution our shops make to local economies.
• Charity-funded medical research provides significant return on investment - every £1 of public or charity investment in medical research delivers a return equivalent to around 25p every year, for ever.
• To preserve the distinct contributions of the BHF to the UK’s research base and to harness our role in supporting the UK’s economic recovery from the Covid-19 crisis, the BHF and 151 other charities are calling for the Government to match research spending of medical research charities pound for pound over the next 3-5 years via a Life Sciences-Charity Partnership Fund.
• We are also calling on the Government to ensure the UK remains open to global research talent to support the UK's economic recovery and stimulate sustainable growth. This requires a future immigration system that is agile and enables the recruitment of those possessing skills that are vital to the UK science and innovation sector.
• The UK charity retail sector directly benefits local economies by employing 26,000 people and benefits other local businesses by drawing trade to high streets and filling empty retail units.
• In order to safeguard the contribution of charity shops to local economies across the UK, we are calling on the Government to ensure large charity retailers such as the BHF can maximise use of the Retail, Hospitality and Leisure Grant Fund (RHLGF).

About the British Heart Foundation

1. The British Heart Foundation (BHF) is the largest independent funder of medical research into heart and circulatory diseases in the UK, and our research has helped halve the number of people dying from these conditions since the 1960s. Today, there are more than 7 million people living with heart and circulatory diseases in the UK and these diseases still cause more than a quarter of all UK deaths. Healthcare costs relating to heart and circulatory diseases are estimated at £9bn each year. Our ambition is to beat heartbreak forever, and we work to transform the detection and treatment of heart and circulatory diseases and provide support for people affected by these conditions.

Should the Government prioritise certain sectors within its recovery package?

2. The voluntary sector has been significantly impacted by the Covid-19 outbreak at a time when its services and support are needed the most. For the BHF, this is undoubtedly the greatest challenge we have faced in our 60-year history, one that is impacting our researchers, our work, our people and our mission to deliver better treatment and care for people affected by heart and circulatory diseases. The Covid-19 pandemic will significantly harm our ability to raise vital funds for our research for years to come.

3. This submission outlines the BHF’s role in the UK’s economic recovery from the pandemic and the measures the Government needs to take to guarantee the BHF and other medical research charities can ensure current progress is maintained in tackling the world’s biggest killers. A flourishing civil society will be vital to the UK’s recovery from this crisis and should be prioritised in the Government’s recovery package.

Charity-funded research makes a significant contribution to the UK’s economy

4. The BHF is the largest independent funder of medical research into heart and circulatory diseases in the UK. We awarded £128.2m in life saving medical research grants in 2018/19, and currently support a portfolio of £446 million of research at 47 institutions across the UK. This includes funding the posts of more than 1,700 researchers, hundreds of whom are in the early stages of their scientific career.

5. Charity funded medical research provides significant return on investment - every £1 of public or charity investment in medical research delivers a return equivalent to around 25p every year, for ever – by:

• addressing unmet needs, funding research shaped by patients, carers and the public
• de-risking early stage research so that other funders can deliver new treatments and products
• investing in talent and skills, by funding the salaries of over 17,000 researchers
• funding research across the UK so that research benefits every corner of the country.

6. It has long been recognised that publicly-funded biomedical research in the UK is strongly concentrated in London and in the south and east of the country – the ‘Golden Triangle’ for research and development. However, medical research charities such as the BHF are increasingly funding research in areas outside of this area, enabling those research institutions to attract further investment. For example, the BHF awarded 549 new research grants worth over £180 million to research institutions outside the Golden Triangle between April 2015 and March 2020. In 2018/19, five of the top 10 institutions (in terms of the amount of funding awarded by the BHF) were from outside the Golden Triangle - the University of Leeds, University of Manchester, University of Leicester, University of Edinburgh and University of Glasgow.

7. Charity funding is often leveraged by research institutions to attract additional funding. It is an integral part of the research pipeline in moving academic science into a position where it can attract commercial funding for new diagnostics and treatments. In 2019, researchers leveraged approximately £1.27bn of additional funding from a BHF investment of approximately £476m. The average return on investment from sources other than the BHF was £2.14 per £1 of BHF investment. Most of this additional funding was leveraged from organisations within the UK (82%, ~£1bn), ensuring continued growth of the UK’s research and development base.

8. In 2018/19, as a result of BHF funding:

• BHF award holders reported 19 new instances of funding from 12 private sector sources, worth over £5m
• 12 patents were filed resulting from BHF funded research at 9 different UK universities
• Two spin out companies were created:
• Quell Therapeutics was spun-out of academia to continue the development and commercialisation of T regulatory cell therapy which can help prevent rejection in organ transplantation;
• LUNAC Therapeutics, received a substantial boost from Innovate UK’s Biomedical Catalyst programme. This funding is being used to develop innovative new anticoagulant treatments that have minimal risk of bleeding[1].

9. The BHF also funds high-risk research that attracts and mobilises world-leading scientists, clinicians, innovators and entrepreneurs to tackle cardiovascular health research challenges, significantly increasing the probability of developing solutions.

• The BHF’s Big Beat Challenge (BBC) is a global competition that will culminate in a single research award of up to £30 million. The BHF challenged researchers to form international, multi-disciplinary teams to identify and propose transformative solutions to significant problems in heart and circulatory disease. Shortlisted projects include the use of robotics as an alternative for transplantation in heart failure patients and the development of treatments that target and silence the genes responsible for diseases of the heart muscle[2]. However, the BHF’s ability to fund the BBC is under threat in light of the sudden contraction of BHF’s research budget.
• The BHF-Turing Cardiovascular Data Science Awards promote multi-disciplinary research to generate data science solutions to key cardiovascular problems. In 2019, six awards were made, each co-led by a cardiovascular investigator and a data scientist.

Charity shops help the UK’s high streets to thrive, as well as contributing to a more sustainable society and offering thousands of employment opportunities

10. The BHF is the UK’s largest charity retailer, with around 750 charity shops and stores. We took the decision in mid-March to close all our shops to protect our staff, volunteers and customers from the spread of coronavirus. As of the 15th June, when Government guidance allowed non-essential retail to reopen, our shops had been closed for just over 12 weeks, and in that time, we could not accept or trade any donations. We began a phased reopening on 16th June, with the intention to reopen all our shops by the end of July. However, we anticipate significant disruption beyond this point due to the practical challenges of opening in accordance with social distancing and hygiene guidelines, as well as differing timeframes in the devolved nations.

11. Across the UK, there are 11,200 charity shops operated by around 850 different charity retailers[3]. The charity retail sector directly benefits local economies by employing 26,000 people and making rental payments to local landlords. It also benefits other local businesses by drawing trade to high streets and filling empty retail units. In 2018/19, charity shops contributed £330 million to their parent charities, playing a vital role in supporting their respective charitable causes.

12. The BHF receives 75-80 million items per year from local communities that are processed, checked, cleaned, resold or sold on for re-use. This results in 78,000 tonnes of used goods per annum being diverted from the waste stream. Collectively, charity retailers support sustainability by diverting 339,000 tonnes of textiles from landfill, saving local authorities over £30 million in Landfill Tax alone in 2018/19[4].

13. Full-time staff in charity retail outlets are supported by over 233,000 volunteers. The BHF provides training and development for 10,000 volunteers who join our retail team each year, helping to increase life skills, boost confidence, improve mental health and, in many cases, supporting our volunteers to successfully re-enter the job market.

14. Our shops are also used as a resource centre for people in the UK affected by heart and circulatory disease. They provide access to CPR training sessions and kit loans to the local community and promote awareness of healthy lifestyles and risk factors for heart and circulatory diseases.

Covid-19 has had a devastating impact on fundraising and retail, ultimately halving our ability to fund high-impact research

a)      The impact of Covid-19 on our income

15. The BHF is losing £10m against expected revenues every month of the pandemic due to significant disruption to our fundraising activities and the ongoing closure of large parts of our retail network. This presents a direct threat to our ability to support future research.

16. In addition to the impact on income generated by our shops, our fundraising has also been severely affected by the cancellation of large face to face fundraising events, such as the London Marathon and our flagship London to Brighton bike ride, which last year raised over £2 million. We have also cancelled thousands of volunteer-led community fundraising events, and all street, private site and door-to-door fundraising activities for the foreseeable future. The practical challenges of social distancing and hygiene guidelines, the impact of local lockdowns, as well as differing timeframes in the devolved nations will continue to cause disruption to the reopening of our shops and delivery of face-to-face fundraising events for the foreseeable future.

b)      The impact of Covid-19 on our research

17. The Covid-19 pandemic has caused significant disruption to our research, with clinical research staff being redeployed to support NHS frontline services and clinical trials paused until the appropriate mechanisms can be continued. However, the burden of heart and circulatory disease does not stop for a pandemic. To ensure patients still see the benefits of this research, we have committed to supporting current projects through to successful completion and we are continuing to pay our researchers’ salaries even when research has been paused. To maintain our capacity to fund new grant applications and thereby help to secure the long-term viability of the UK’s outstanding cardiovascular research base, we are encouraging our research community to use no-cost extensions as the primary mechanism for mitigating the impact of the Covid-19 disruption wherever possible.

18. Despite the use of several Government support schemes, we estimate that our budget for investing in new research will halve this year from around £100 million to around £50 million – a sharp drop that could take years to recover from. The same crippling challenges are being faced by research charities across the country. Analysis by the Association of Medical Research Charities (AMRC) forecasts that, given the loss of income experienced by their members, the medical research charity sector’s ability to fund new research over the next 3-5 years will be diminished by at least 40%.

19. This crisis imperils more than just our research budget – it could endanger the future of UK cardiovascular research. The BHF currently supports a research portfolio of around £450 million at 47 institutions across the UK, directly funding the salaries of more than 1,700 researchers and supporting the research of many others[5]. If this funding is reduced, patients and the public will suffer as the discovery and development of new ways of preventing, diagnosing and treating heart and circulatory diseases will slow. We could potentially lose a generation of cardiovascular researchers because of the reduction in our funding, impacting the research ecosystem for years to come.

20. To preserve the distinct contributions of the BHF to the UK’s research base and to harness our role in supporting the UK’s economic recovery from the Covid-19 crisis, the BHF and 151 other charities are calling for the Government to match research spending of medical research charities pound for pound over the next 3-5 years via a Life Sciences-Charity Partnership Fund[6]. The Fund could be used as a tool to leverage further R&D investment by providing an opportunity for industry partners, investors and philanthropists to invest in research designed around patient needs, capitalising on the attractiveness of the UK’s unique medical research charity sector. It could also contribute to government’s central ambition to invest unprecedented levels in R&D and for the UK to be a global hub for life sciences.

Covid-19 has had a significant impact on people affected by heart and circulatory diseases and the services they use

21. We know that people with heart and circulatory diseases are at increased risk of complications and death when infected with Covid-19. A study of UK patients who were hospitalised with Covid-19 found that 29% had known chronic heart disease[7]. Heart and circulatory disease risk factors, including obesity, high blood pressure (hypertension) and diabetes, also raise the risk of severe illness from the virus. Official mortality statistics in England, Scotland and Wales from the Office of National Statistics (ONS) shows that coronary heart disease is one of the most common pre-existing health conditions in people who have died with Covid-19 in England and Wales[8]. This has understandably increased anxiety among people living with heart and circulatory diseases, prompting us to increase support through our Heart Helpline and online resources. We received around 400 calls per day to our Helpline during the peak of the pandemic and our coronavirus web pages have been visited by 1.3 million times since March.

22. In response to the increase in demand for support, the BHF has significantly expanded our patient offer, providing comprehensive information and support to people impacted by Covid-19. This includes:

• Increasing the times and staffing levels of our Heart Helpline, including an option to live chat with our cardiac nurses.
• Creating a dedicated content hub containing information and tools for patients and carers, regularly updated as new guidance is issued.
• Developing support materials for people to engage in an online cardiac rehabilitation offer.
• Maximising our peer support networks, such as Health Unlocked, an online support network and community for people with long term conditions, as well as Teen Heart and One Beat, which are BHF-led communities of young people with heart and circulatory diseases.

23. Difficulties in accessing routine care in hospitals during the pandemic has had a profound impact on people with heart and circulatory diseases. A BHF survey of people with heart and circulatory conditions conducted during the peak of the pandemic, found that around half of patients had found it harder to get medical treatment since the pandemic began[9]. Of this cohort, 41% said that they had a planned test, surgery or procedure postponed or cancelled. We also know that access to specialist cardiac care in the community has been severely depleted in many areas due to redeployment of staff. Cardiac rehabilitation services have also been substantially reduced during this time, meaning many people have lost the support they need to live well and remain out of hospital. Rehabilitation services, and access to care in the community play a significant role in reducing burden on hospitals and overall costs.

24. We also know that attendance at A&E with symptoms of heart attacks and strokes dropped significantly since the beginning of the lockdown. The number of people attending emergency departments in England with symptoms of a possible heart attack halved between the beginning and end of March[10]. A BHF survey of cardiologists from across the UK largely attributed this decrease to people avoiding hospital due to fear of infection with Covid-19 or out of a desire not to burden the NHS[11]. The BHF has been working closely with NHS England to urge people who experience heart attack symptoms to seek medical help immediately. Delays to urgent treatment could lead to patients becoming more unwell, placing greater pressure on the NHS in the long term.

25. Covid-19 has also exacerbated variation in access to heart failure services. These have been caused by an inconsistent reduction in services for heart failure patients, due to redeployment of staff. Insight about changes to heart failure services were the most frequently collected by our Health Service Engagement team (more than half of 172 discrete pieces of insight) and nearly two thirds of this insight described a loss of or decrease in services[12]. Such services are not only vital for the health and wellbeing of heart and circulatory disease patients but are also key to relieving pressure on the NHS by keeping people out of hospital. This impact has been confirmed by the increase in calls to our helpline from patients who are struggling to access support in the usual way.

26. Since the Prime Minister’s announcement on easing the lockdown, we have also seen an increase in calls to our Heart Helpline from people feeling unsafe to return to work due to the lack of guidance around reasonable protections for those who cannot work safely. As we move through the phases of the Government’s Covid-19 recovery strategy and lockdown measures are relaxed, sectors are unlocked and more people return to work, there needs to be clearer guidance for those who are in the clinically vulnerable group[13]. This must include clarity around travelling to and from work, as well as how people will be able to maintain social distancing measures at work. There must also be protections in place for those who are unable to return to work safely – people need to be confident they won’t lose their jobs if they cannot go back to work due to their health condition. Unless these safeguards are in place, there is a real risk that people will need to choose between their jobs and protecting their health. This could have a considerable impact on unemployment and the UK’s long-term recovery from the pandemic. All of these add up to a complex landscape for patients and significant unmet need.

Existing Government support schemes will not provide long term solutions

27. Where possible, the BHF is making use of the available support announced by Government so far, including furloughing around 80% of our internal BHF staff through the Coronavirus Job Retention Scheme (CJRS) and encouraging universities to make use of the scheme for their staff funded on our grants in instances where research cannot continue. We welcome the extension of the furlough scheme until 31st October and the additional flexibility from August. However, we call for clarity for research funders from the Department of Health and Social Care and NHS England around the issue of recouping salary costs of seconded research staff from the NHS.

28. The Government’s £750m support package for charities, announced in April, was an important first step in mitigating some of the most extreme effects of the crisis on the sector. However, this falls far short of the £4bn stabilisation fund that the National Council for Voluntary Organisations (NCVO) and the wider sector had been calling for[14]. More recent research has shown that there will be a £12.4bn shortfall in income across the sector this year, which further highlights the gap between the impact and the support measures announced to date[15]. The BHF, like many other medical research funders, does not fit the eligibility criteria for the Government support package because we are not a front-line service provider or a small, community-based charity – despite us swiftly and significantly increasing our patient support services. The same can be said for the additional £150m unlocked from dormant funds that was announced in May[16].

29. There are no clear-cut support mechanisms for medical research charities within the Government’s existing support schemes, including the recent university stabilisation package which focused on bolstering university-funded research[17]. Despite the significant value medical research charities add to science, society and the economy, there appears to be no clear recognition of the impact that loss of charitable funding could have on the research ecosystem. At present it is not clear to us that the university stabilisation package will provide a long-term solution for charity-funded medical research and we are uncertain if it can protect the UK from losing the huge contribution charities make to talent and skills. Without bespoke support for the medical research charity sector, the BHF is deeply concerned progress will be stalled in making the life saving discoveries in cardiovascular research we urgently need.

30. We welcome some of the measures available for charity retailers, such as 100% retail relief until 2021 and temporary measures to protect high street shops from aggressive rent collection. But there are gaps in the support that is available. For example, owing to the Government’s application of State Aid rules to the Retail, Hospitality and Leisure Grant Fund (RHLGF), large charity retailers have been unable to maximise support from the fund. The RHLGF allows retailers to claim up to £25,000 per eligible retail outlet, which could be a significant factor in protecting the future of charity retail networks. However, the application of State Aid rules in relation to charity retail means this is capped at €800,000 (just over £700,000) for any one organisation.

31. Due to this application of State Aid rules, the BHF can only claim for around 30 grants on an estate of 550 qualifying shops, which on average equates to around £1,300 per shop – far less than our projected losses. Based on there being no second peak of Covid-19 with subsequent reimplementation of lockdown measures, current estimates are that BHF shops eligible for the RHLGF will lose approximately 40% of sales this year (25% from lockdown and 15% from the remainder of the year). This equates to £40m, which is an average of £72,000 per shop.

32. The Charity Tax Group and Charity Retail Association estimate that the cost of lifting State Aid rules conditionality for the charity retail sector would be around £150 million. This could be easily absorbed within the budget currently set out for retail grant schemes, which as of 8 July had almost £1.7 billion of unspent funds. Taking this approach would also retain the key social purpose of supporting the high street and smaller retailer outlets, given there would remain a cap of £51,000 on the rateable value of applicant outlets.

33. Without the full support available from the RHLGF, more than a third of our shops will incur an operating loss despite the support from extended rates relief, furlough support and the limited grant aid currently available.

34. Although the Government has made some efforts to engage with charities during this crisis, the overall response so far has not been agile and has not met the needs of the sector. We urge the Government to work with charities to carefully assess the needs of the sector and how we can be supported during and beyond the crisis.

How can the Government best retain key skills and reskill and upskill the UK workforce to support the recovery and sustainable growth?

The UK must remain open to global research talent

35. The BHF, along with others within the medical research sector, has taken a great interest in the development of a new immigration system for the UK once it leaves the EU. We believe it is vital that a new system protects the international connections that have delivered substantial benefits for UK-based researchers and the research community. People from outside the UK bring skills and expertise that enrich our research and innovation workforce. They promote international research collaborations, attract inward investment and become informal ambassadors, strengthening the UK’s trade, research and diplomatic links. The UK must stay open to the world, so that skilled scientists want to come and work here and are able to do so. The system must enable research talent at all levels, from technician to professor, to contribute to the UK’s reputation as a world-leader in research and innovation.

36. To support research and innovation in all its settings, the UK should develop an effective and internationally competitive immigration system that builds public confidence, grows UK skills and attracts global talent. The following features will be key:

• Government must not allow costly visas to be a barrier to boosting UK R&D. The Global Talent fast-track visa announced earlier this year, is a positive step towards an immigration system that works for science[18]. This is an attractive visa route that will encourage talented researchers and specialists from all over the world to choose to work in the UK. However, the costs of obtaining a visa for study or work in the UK are not in line with international competitors and stand in opposition to the Government’s ambition to boost the UK’s status as a science superpower[19]. If our visa system remains one of the most expensive in the world, we risk deterring global talent and devaluing the Government’s significant historic and future investment in research. We therefore urge the Government to conduct an urgent review of the UK’s visa costs.  

• The future UK immigration system must be agile and enable the recruitment of those possessing skills that are vital to the UK science and innovation sector. Salary is not the best proxy for skill, and the system must not negatively impact technical roles that are necessary to support cutting-edge research in the UK.

• The UK must be an attractive place to undertake and to lead research, hence the system must minimise cost and bureaucracy, as well as considering researchers’ needs in terms of family and career development[20].

37. The Government must make access to EU funding schemes a priority for future relationship negotiations. The BHF strongly supports the UK’s association with Horizon Europe and has joined more than 100 researchers and organisations in supporting a statement that sets out how negotiations could secure an agreement on UK participation[21]. Without continued access to EU funding schemes and resulting collaboration opportunities, the Global Talent visa will not be sufficient to attract researchers to the UK, and the Government’s vision to cement the UK as a science superpower will not be realised. 

Is the Industrial Strategy still a relevant and appropriate vehicle through which to deliver post pandemic growth?

38. The BHF is committed to playing a key role in driving forward the ambitions outlined in the Industrial Strategy through its Grand Challenges on artificial intelligence and clean growth as well as our participation in the Life Sciences Sector Deal. We particularly welcomed the Strategy’s emphasis on the use of data to revolutionise the delivery of healthcare and improve patient outcomes.

Using big data and artificial intelligence to transform the delivery of healthcare

39. The BHF is committed to maximising the use of our health data resources, including through our support and funding for Health Data Research UK (HDR UK) to deliver a step change in the UK’s biomedical data capabilities and address research challenges that require a depth and scale of data that cannot be achieved through individual research programmes. HDR UK is a key partner in the BHF’s Data Science Centre, which seeks to enable more efficient, cost-effective, data-driven research that will benefit the public’s cardiovascular health and improve outcomes for patients[22]. The Data Science Centre is part of a network of Digital Innovation Hubs which are formal collaborations between NHS, academic organisations, patients, charities and industry, bringing  their collective expertise together to maximise the value of health data research and potentially benefiting millions of people across the country[23]. The Data Science Centre has been critical in the UK’s early response to the pandemic in sharing data with SAGE. It is also supporting the BHF’s partnership with the National Institute for Health Research (NIHR) to develop large-scale projects that will help address many important questions regarding Covid-19 and heart and circulatory diseases.

40. However, much work still needs to be done to ensure that the revolutionary potential of patient data can be realised, particularly around building public trust and striking the right balance between data security and confidentiality, and ease of access for research. Government must take action to realise the opportunities of patient data; difficulties with recording, linking and sharing data across the NHS could hinder improvements in patient care and the ability to conduct world-class research. Public confidence in how health data is used is vital. As data and technology capabilities develop, it is important there is an ongoing dialogue with the public about the benefits of collecting, storing and sharing data for research and care. The BHF has a role to play in communicating the benefits of data sharing for these purposes, but charities alone cannot build trust.

41. The BHF also welcomed the Government’s ambition to make the UK a world leader in the use of artificial intelligence to help transform the diagnosis and treatment of chronic diseases through the AI Grand Challenge. Accelerating research using health data and artificial intelligence will build on the UK’s reputation for cutting-edge science, and lead to transformative improvements in treating patients within the NHS. The BHF’s research, including through initiatives like UK Biobank, is already showing the huge potential of data science to transform care for the millions of people living with heart and circulatory disease in the UK[24]. For example, there is promising evidence that using artificial intelligence to analyse CT scans could spot early signs of heart disease which may be missed by current techniques. This could lead to a quicker diagnosis with more personalised treatment that could ultimately save lives. Since 2017, the BHF has also partnered with the Alan Turing Institute to fund research in this area — bringing together data scientists and cardiovascular researchers to find solutions to important health problems.

Clean growth

42. The Industrial Strategy’s focus on clean growth could be a vehicle for the delivery of a ‘green recovery.’ It could provide an opportunity to drive forward the Government’s ambitions to tackle air pollution, as articulated in the Government’s 2019 Clean Air Strategy[25]. Research funded by the BHF has highlighted the significant impact of toxic air to the heart and circulatory system. These studies have found that particulate matter (PM2.5), can damage the heart and circulatory system, increasing the risk of a heart attack or stroke in people with vascular disease. Exposure to high levels of air pollution has also been shown to increase the risk of heart failure hospitalisations and deaths. Up to 11,000 deaths from heart and circulatory diseases are attributable to air pollution in the UK each year. According to Public Health England (PHE) the cumulative health and social care costs of air pollution in England could reach £5.3 billion by 2035 unless action is taken[26]. They calculate that a relatively small reduction in the population’s exposure to the most harmful pollutants could lead to a significant reduction in costs.

43. While the evidence exploring the relationship between Covid-19 and air pollution is in a nascent phase, the evidence on the damage that air pollution does to overall health is not. Years of research demonstrate that air pollution leads to increased risk of heart and circulatory diseases,   which are known to result in worse outcomes from Covid-19. A relationship between long-term air pollution exposure and worse Covid-19 outcomes may be likely and needs to be explored further.

44. The BHF recognises that there is no silver bullet to tackling air pollution. For the Clean Air Strategy to achieve success, air quality must be a priority across Government, and activity must be joined up across departments with responsibility for the environment, health, transport, energy and industry. To drive this action, we must also see an ambitious and far-reaching commitment from Government in the form of an update to our air quality laws in the Environment Bill. The Bill outlines a framework for setting a legal limit for PM2.5. This limit must be set with reference to the vast body of evidence on the harmful effects of air pollution and with the involvement of health experts. The BHF is calling for the Government to adopt the World Health Organization (WHO) limit for PM2.5, which sets an annual average concentration of 10 µg/m3 across all parts of the UK. This is the level at which the WHO states that the harms to health can be minimised, although it is important to note that there is no safe level of PM2.5. Efforts should therefore be focused on reducing population-level exposure, and all interventions should be developed and evaluated based on the impact on health.

45. For the Industrial Strategy to succeed and be used as a vehicle through which to deliver post pandemic economic growth, it must capitalise on the UK’s status as a world leader in the use of health data and take bold action to sustain potential improvements to air quality during the pandemic. Its success also requires an environment that fully supports charity funded medical research during and beyond the pandemic. It is important that the Strategy is used as an opportunity to think far ahead and make a long-term investment in the life sciences sector. Medical research requires foresight, stability and confidence to flourish. At a time of increased uncertainty, the Government should use the Life Sciences Industrial Strategy to reassure medical research charities and demonstrate a long-term commitment to its stability and growth.

What lessons should the Government learn from the pandemic about actions required to improve the UK’s resilience to future external shocks (including – but not limited to – health, financial, domestic and global supply chains and climate crises)?

Creating a healthier and more resilient nation

46. Tackling the risk factors that place certain populations at greater risk of poor outcomes from Covid-19 will be crucial to ensuring the UK is more resilient to the effects of a future pandemic. Emerging evidence has linked risk factors such as obesity to greater risk of poor outcomes [27] [28] [29] [30] [31]. A recent evidence review by PHE states that excess weight is associated with an increased risk of hospitalisation, admission to intensive care and death. The risks seem to increase progressively with increasing BMI above the healthy weight range, even after adjustment for potential confounding factors, including demographic and socio-economic factors[32].

47. Latest figures show that, the majority of adults in the UK have obesity or excess weight; 67% of men and  59% of women - 26% of men and 29% of women have obesity (measured by body mass index), while one in six children in the UK has a weight defined as obese [33]. There are also stark inequalities in prevalence between the lowest and highest socio-economic groups[34]. Children with obesity are more likely to become adults with obesity, putting them at increased risk of developing heart and circulatory diseases and their risk factors, such as type 2 diabetes and high blood pressure, later in life. Obesity is estimated to cost the UK economy around £27 billion per year[35].

48. The Government’s renewed focus on the prevention and treatment of obesity is a welcome step towards securing an environment that supports health[36]. We were particularly pleased to see pledges to:

• Introduce a 9pm watershed on advertising of high salt, fat and sugar (HFSS) products on television and online, with further consultation on a total online ban
• Mandate calorie labelling on menus across large businesses in the out-of-home sector, and to encourage smaller businesses to do the same to help reduce calorie consumption[37].
• Restrict multi-buy and location-based promotion of HFSS products in retail and out of home settings.

We look forward to seeing further detail on these pledges in forthcoming consultation responses and urge Government to implement these policies swiftly and fully, so that they truly create an environment that supports health.

49. Public Health England’s reformulation programme, which sets targets to reduce the amount of sugar, calories and salt in our everyday foods will play a crucial role in the Government’s overall ambition to tackle obesity. However, voluntary programmes have so far seen mixed progress. The latest evaluation of the sugar reduction programme, which seeks a 20% reduction in the sugar content of certain foods and drinks by 2020, found that, since 2015, there has only been an overall 2.9% reduction in the sugar content of retailer own brand and manufacturer-branded foods[38]. This contrasts with the mandatory Soft Drinks Industry Levy (SDIL), which has achieved a 28.8% reduction in sugar per 100ml across products[39], and removed 30,133 tonnes of sugar without depleting soft drinks sales[40]. Should final evaluation of the sugar reduction programme find that the voluntary programme has not achieved its aim, then the Government should explore possible mandatory measures to encourage industry to play its full part, outlining a timeline for sanctions for non-compliance by industry.

50. The BHF was pleased to see the Government’s prevention green paper outline plans to ‘publish revised salt reduction targets in 2020’ to drive salt consumption down to 7g a day[41]. Sustained high salt intakes contribute to high blood pressure. An estimated 28% (15 million) of adults in the UK have high blood pressure[42] which has been linked to poor Covid-19 outcomes[43]. Progress on salt reduction against industry targets set in 2014 was mixed, with just over half (52%) of all the average salt reduction targets met by the in-home sector by 2017, and higher salt levels in foods sold in the out-of-home sector[44]. The latest population urinary salt analysis found that there were no statistically significant changes in salt intake between 2014 and 2018/19[45], indicating that reformulation programmes are necessary to drive change. The new salt reduction programme must be ambitious and comprehensive, ensuring that industry across the in- and out-of-home sectors takes responsibility for reformulating the content of everyday foods seriously. The programme must monitor and report on progress annually and ensure regular evaluation of the effect on population-level salt consumption via urinary sodium analysis.

51. Although the evidence on the relationship between smoking and Covid-19 is emerging, it is known that smoking can increase the risk and severity of respiratory infections, potentially increasing the risk of Covid-19 infection[46]. We know that smoking is a well-established risk factor for heart and circulatory and respiratory diseases, which are known to lead to poorer outcomes from Covid-19. Therefore, damage to people’s overall health caused by smoking, could, in turn, lead to increased severity of and worse outcomes from Covid-19.

52. Public Health England (PHE) and others including Action on Smoking and Health (ASH) have therefore encouraged people to quit smoking during the pandemic, not only to reduce their immediate risk from the virus, but to safeguard their overall health and to reduce pressure on the health service[47]. According to analysis by ASH and University College London, over a million people have quit smoking during the pandemic[48].

53. We welcome findings from a survey conducted by ASH across English local authorities which found that the vast majority (96%) of local authorities are providing support for smokers from trained advisors, either by telephone, video conferencing, email or text message or through an app[49]. However, local authorities reported variability in communication and outreach activities directing people to these services, which may feed into differences in footfall experienced by different services- 24% of local authorities surveyed reported an increase in access to services. Evaluation of public health messaging and innovation within stop smoking services during the pandemic will be key to driving further progress on smoking as we look to recovery.

54. The Government’s 2017 Tobacco Control Plan for England estimated that the cost to the economy of smoking is over £11 billion per year, £2.5 billion of which falls to the NHS[50]. The prevention green paper published in July 2019, pledged action to achieve a Smokefree England (defined as a smoking rate of 5% or less) by 2030. As a member of the Smokefree Action Coalition (SFAC), the BHF endorses the Roadmap to a Smokefree 2030 set out by the SFAC[51].

55. Investment in the prevention of ill health is crucial. Local authorities deliver many preventative services, including weight management and smoking cessation support. The ring-fenced public health grant has seen successive and devastating cuts since 2014/15 , totalling approximately £850 million to 2019/20[52] and leading to erosion of services. While a £145 million uplift announced in 2019 was welcome, the King’s Fund and Health Foundation estimated in June 2019 that the grant required a £1 billion restoration[53]. Moreover, this funding must be delivered in a sustainable and equitable way. The largest cuts have been experienced by local authorities with the biggest socio-economic deprivation, deepening inequalities[54].

56. The UK Government will need to take bold action if it is to halt and reverse the rise in risk factors for heart and circulatory diseases that also lead to poorer outcomes for people with Covid-19. A renewed focus on the prevention of ill health requires a far-reaching and ambitious prevention strategy that sits across all Government departments and is seen as a priority for decision-makers. Such a strategy must articulate a responsibility framework and make available adequate resource for all actors across national and local government, civil society and the health service to play their full part in this agenda. The BHF looks forward to working with the Government and NHS to ensure the proposals in its prevention green paper can be taken forward with the necessary ambition and urgency as we move beyond the pandemic[55].

Ensuring the NHS is equipped to deal with future pandemics

57. Although many patients with heart and circulatory diseases have struggled to access care during the Covid-19 pandemic, some health and care services across England have adapted rapidly to cope with the surge in demand caused by Covid-19. Innovations that would typically take months or years to develop, have been achieved in weeks and days, such as implementation of virtual consultations and the development of online options for rehabilitation and management of long-term conditions. As the infection rate slows and we consider how we transition to a ‘new normal’, we welcome the opportunity to set out what lessons the Government should learn from the pandemic about the actions required to improve the resilience of health and care services to future external shocks, including consequent waves of coronavirus and other pandemics. Enacting the following will help health and care services to deal with the consequences of the coronavirus pandemic and prepare for future shocks of this kind:

58. The NHS must ensure extra capacity is available to respond to future waves of Covid-19 while clearing the backlog of care. Increased capacity for safe and socially distant care will mitigate the effect of future pandemics on routine care and hopefully reduce the size of associated backlogs. Data suggests that approximately 30,000 inpatient elective procedures for heart and circulatory diseases have been deferred as part of the response to Covid-19, leaving a backlog of patients requiring treatment and support, which will only increase as the lockdown continues until services are fully restored. In addition, we estimate that around 190,000 fewer heart ultrasound tests were carried out in England after lockdown began. Moreover, a recent report from the Department of Health and Social Care has forecast that over time as many as 190,000 people could die from the indirect impact of this year’s lockdown, including delays to treatment[56]. Additional capacity in the health service is crucial if this scale of deaths is to be avoided in future pandemics[57].

59. Access to specialist care in the community must be improved. System leaders should prioritise increasing capacity to support people with chronic conditions such as heart failure, whether this is through returning support in the community, outreach from secondary care or increasing support for primary care services. This will play a crucial role in improving outcomes for patients, as well as providing the support needed to keep patients out of hospital. Where possible these services should be delivered remotely, but where face to face interaction is needed, systems should be in place to separate patients needing Covid-19 care from those that do not, to decrease the risk of Covid-19 transmission and increase patients’ confidence in safely accessing care. Such services will help mitigate a surge in demand on secondary care from patients who have been unwilling or unable to access care for their condition during lockdown.

60. Access to recovery and support services must be improved. We know these services play an important role both in keeping people out of hospital and rehabilitating them after a significant health event. For example, access to cardiac rehab services reduces risk of death from heart and circulatory diseases on average by 26% and decreases hospital admissions by 18%[58]. Uptake of cardiac rehab prior to Covid-19 was just 50% and was particularly poor among certain groups (including women, people with BAME backgrounds, those on low incomes)[59]. Rehabilitation services have been very fast to respond to the pandemic, with many initiating online services to maintain support for some patients. Going forward it will be important to maintain digital offerings alongside face to face forms of rehabilitation to improve choice for patients and help increase uptake of services, particularly among poorly represented groups.

61. Digital health solutions should be expanded going forward to improve patient choice but also in preparation for future external shocks that may make face-to-face consultations more difficult. It is important however, that digital solutions do not completely replace in-person services. Health and care providers must define and develop ways of ensuring that digitally excluded people are still able to access the care they need to ensure that existing and future digital health policy does not exacerbate existing inequalities.

62. The expansion of digital health solutions necessitates changes to the way the health and care services collect and uses patient data. Linking up different data sets and pooling data across regions and countries could bring tremendous benefits, but there are currently numerous barriers to effective data sharing, including: regulatory boundaries; a lack of standardised data collection, quality and annotation; technical limitations; proprietary considerations; and privacy issues, among others. The significant – but fragmented – digital innovations seen during the Covid-19 pandemic must now be implemented systematically so that patient data can be accessed across all parts of the system. This will be important for bringing to light the impact of changes in areas that are sometimes invisible to the system due to a lack of community-based data, for example in heart failure, which will help to ensure that these conditions are not overlooked in surge planning for future pandemics.

63. Consistent minimum standards of care must be achieved both now and for the future. Covid-19 has exacerbated existing variation in health and care across the country, and clear guidance will be necessary to ensure minimum standards of care are maintained throughout the pandemic and as we move into a new normal. Relevant clinical bodies, such as condition specific societies and royal colleges should work with NHS England and NHS Improvement clinical leads (including health and care professionals across primary, secondary and community care) to define minimum standards of care across the range of heart and circulatory diseases across the lifespan. These standards should then be used to inform local systems while prioritising changes to, and reintroduction of, services. These could include defining the minimum standards of service expected across a range of scenarios based on current and future levels of service capacity due to Covid-19 (including a second wave), winter pressures and the backlog of care and support for heart and circulatory conditions. This should include routine care as well as the reintroduction of elective procedures based on local capacity and need. Developing clear standards with strong clinical leadership will allow local teams to build services around the needs of their patients, while ensuring consistent standards of care across the country and serve as a template for future pandemics.

64. New models of identifying and supporting those at risk of heart and circulatory diseases should be explored. As the impacts of Covid-19 on society become increasingly long-term, including prolonged social distancing and a digital-first approach to delivering services, developing new models for identifying and managing risk factors for heart and circulatory disease will be important for reducing the burden of heart and circulatory disease in the UK. Technological solutions should also be explored and evaluated for identifying those at risk of atrial fibrillation[60] at home, allowing services to better target support to those who need it most. For example, four acute trusts in the south west of England are trialling the use of ZIO patches for remote screening of potential arrhythmias. The patch is stuck on the person's left upper chest and can record a continuous beat-to-beat ECG for up to 14 days. After the monitoring period ends, the wearer sends the patch back to the company by post and the recordings are analysed using machine learned algorithms. The full ECG data can be sent to the clinician on request[61].

65. The Government should also accelerate its review of the NHS health check programme, to see how the programme can be adapted to identify and support those at risk of heart and circulatory diseases while social distancing is still enforced. The Government and health and care services should seek to prioritise prevention messaging that seeks to reduce the burden of heart and circulatory diseases, including providing advice about eating and living well and resources to ensure people are remaining physically active. Initiatives to tackle smoking and obesity should also be bolstered in this time. This should consider the higher burden on deprived communities and those from BAME backgrounds, who we know are at higher risk of complications and death from Covid-19.

66. Delivering the Long Term Plan: NHS England’s Long Term Plan is an important vehicle for saving lives and improving outcomes for people with heart and circulatory conditions. The plan, published in 2019, will shape the direction of the health service for the next ten years and identifies heart and circulatory diseases as the single biggest area where lives can be saved. In light of Covid-19 these ambitions have not changed and tackling the burden of heart and circulatory disease and its risk factors are more important than ever. However, the implementation of the plan will need to adapt to the new normal, including finding new ways of diagnosing and managing conditions, and ensuring new models of services do not create or exacerbate inequalities. This will require the full support of government, including ensuring sufficient funding is in place for the NHS and the wider health and care system to deliver on the ambitions in the plan.

August 2020