There are no secrets in cardiovascular care, no magic treatments that doctors or hospitals keep to themselves and deny to others. Everything that works is published, promoted and shared. But the speed with which national health care systems adopt the best care varies hugely, with the UK all too often lagging behind the rest.
Much has been made of the improvement in heart attack survival in the UK, but a study last year put it into perspective. Compared with Sweden, a third more UK patients died within a month of having a heart attack. More than 11,000 deaths could have been prevented between 2004 and 2010 if UK care standards had been as good as Sweden’s.
Why? In a nutshell, the NHS does slowly what others do fast. Professor Harry Hemingway from University College London, who led the study published in The Lancet, says: “The uptake and use of new technologies and effective treatments recommended in guidelines has been far quicker in Sweden. This has contributed to large differences in the management and outcomes of patients.”
The waves of innovation that carry others on almost always leave the NHS disconsolately paddling in their wake
In this case, the key may have been the speed with which the two countries adopted angioplasty – opening up constricted coronary arteries – as an emergency treatment. In Sweden, 59 per cent of patients had this treatment; in the UK it was 22 per cent.
The same pattern can be discerned across the board, with almost every new innovation taking longer to be adopted here than abroad. By the end of the study, the gap had narrowed, but this is a small consolation because by then we had failed to adopt lots of other new technologies. The waves of innovation that carry others on almost always leave the NHS disconsolately paddling in their wake.
The treatment of heart rhythm disturbances is a textbook example. In drugs, surgical treatments and even in its public health response, the UK lags. Nor is this a small unimportant corner. “Sudden cardiac arrest is the number-one killer in the UK and in Western Europe,” says Trudie Lobban, founder of the Arrhythmia Alliance. “It kills 100,000 people in the UK every year, more than breast cancer, lung cancer and Aids combined.”
The commonest cause of cardiac arrest is atrial fibrillation (AF), a heart rhythm disturbance. Audits show that UK patients are less likely to get treatment for such conditions than they would in other comparable counties. Pacemaker implants here are well below the European average and have been consistently so for more than a decade, according to the 2013-14 national audit of cardiac rhythm management devices. The rate for implantable cardiac defibrillators is much lower and has been falling further behind in recent years. There are no clinical reasons why the need for either device should be lower here than in Europe, the audit reports.
Exactly the same is true of transcatheter aortic valve implantation (TAVI) in which heart valves are replaced through a catheter, a procedure suited to elderly and infirm patient too ill to risk open-heart operations. In 2011, one study showed, 36 per cent of suitable patients in Germany were treated by TAVI, compared with 9 per cent in the UK.
Catheter ablation, a technique for treating and usually curing heart rhythm disturbances using fine electrodes threaded into the heart through veins, shows a parallel pattern. “Sadly, we lag behind Europe,” says Ms Lobban. She’s right: the rate for the procedure in the UK is at the bottom of the Western European average. Denmark performs nearly three times as many ablations for AF, Switzerland almost twice as many, Germany 44 per cent more.
The uptake of new drugs tells the same tale. New medicines to thin the blood and reduce the risk of strokes in AF patients have been on the market for several years, are approved by the National Institute for Health and Care Excellence (NICE), but are little used. Audits show uptake much lower than NICE expected.
In the House of Commons last November, MP Barry Sheerman, whose wife has AF, asked: “What is the good of innovation if we do not use it? For the one million people who suffer from atrial fibrillation, these three new NICE-approved drugs are a life-saver; they make life worth living. But only about 6.5 to 7 per cent of people have been prescribed the new drugs, as they are being blocked by clinical commissioning groups and GPs. What will the minister do about that?”
Calling for change
Life sciences minister George Freeman replied that he had launched a review, now called the Accelerated Access Review and chaired by Sir Hugh Taylor, a former permanent secretary at the Department of Health. It aims to identify how regulation, payments systems and uptake could be reformed to speed the process. Don’t hold your breath: in 2011 the NHS launched Innovation, Health and Wealth, a strategy designed “to make innovation and its spread central to what we do”. Three years later the Medical Technology Group found that it had made very little difference.
Barbara Harpham, chair of the group and also director of Heart Research UK, blames conservatism and the operation of a tariff system for some of the delays. She points out that one intervention that is now widely used in the NHS is stenting – opening up clogged arteries and introducing a tiny expandable cage to keep them open.
Lengthy regulatory processes are another cause of delay, most commonly for drugs that need both evidence of effectiveness and cost effectiveness
“Stents are a cash cow,” she says. “Patients are in and out in a day. You can do ten stents in a day and it’s easier than a TAVI. Hospitals are more likely to do the procedures that get easy money.”
Proposed cuts to the tariff – the payment to a hospital for each procedure carried out – could make things worse. “NHS England is proposing tariff cuts of between 17 and 45 per cent,” says Ms Lobban of the Arrhythmia Alliance. “What will happen if these go through is that the UK won’t be able to implant the latest technology – it will be like implanting an old mobile phone rather than an iPhone 6. Some of the newer devices last ten to eleven years, while the older ones last three to four years, so in the long term it will cost the NHS more.” UK specialists have signed a letter opposing the changes.
Lengthy regulatory processes are another cause of delay, most commonly for drugs that need both evidence of effectiveness (a licence) and cost effectiveness (approval by NICE). A new cholesterol-lowering drug, Amgen’s Repatha, has recently won a licence for use in the UK, but its high price compared with statins is likely to mean NICE will approve it for very few patients.
Much more encouraging is the Early Access to Medicines scheme, which aims to fast track promising drugs and make them available before they are licensed. In September, the first non-cancer drug was accepted on this scheme, Novartis’ LCZ696 (sacubitril valsartan) for heart failure. “Based on what we’ve seen so far, access to this new medicine will help patients live longer and keep them out of hospital, compared to currently available treatment,” says Iain Squire, Professor of cardiovascular medicine at Leicester. Heart failure affects 550,000 people in the UK and costs the NHS £2.3 billion a year.
But this is just a small thread of optimism in a canvas woven in sombre colours. If you are going to suffer any heart disease, the UK is not the best place to choose.