UK lags behind rest of Europe with latest heart treatments

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.

Moving slowly

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.

Cardiovascular treatments

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.