Meeting of the Parliament

Meeting date: Tuesday, March 6, 2018

Official Report 911KB pdf

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Atrial Fibrillation

The next item of business is a members’ business debate on motion S5M-09376, in the name of Colin Smyth, on atrial fibrillation in Scotland. The debate will be concluded without any question being put.

Motion debated,

That the Parliament welcomes Focus on Atrial Fibrillation in Scotland; A report by the Cross Party Group on Heart Disease and Stroke, which is due to be published on 23 January 2018; recognises that this heart condition, which affects an estimated 145,000 people across the country, including in the South Scotland parliamentary region, increases the risk of stroke by fivefold; welcomes the work that has taken place in compiling the report, and thanks the members of the advisory panel who supported and informed the report and helped formulate the recommendations.

13:20  

I thank all the members from across the chamber who supported my motion and allowed this debate on how we can improve care for those with atrial fibrillation, which is among the most common types of irregular heartbeart, to take place.

What is atrial fibrillation? A normal heart’s pumping action is controlled by regular electrical messages that are produced by the part of our heart that is called the sinus node. Atrial fibrillation occurs when additional, irregular electrical messages are sent from other areas in and around the atria, which is the upper chamber of the heart. Those irregular messages make the atria quiver or twitch, which is known as fibrillation—hence the name atrial fibrillation.

Around 96,000 people in Scotland are currently diagnosed with the condition. It is particularly prevalent among older adults, so rates are expected to rise in line with our ageing population. In fact, international data suggests that AF rates could triple by 2050.

Given the scale of the condition in Scotland, the cross-party group on heart disease and stroke, of which I have the pleasure of being co-convener, decided to carry out an inquiry to examine how to improve detection, treatment and awareness of the condition. The inquiry process, which included more than 250 written consultation responses and four round-table evidence sessions, brought together knowledge from a range of perspectives, and the expertise of those who were involved is clear from the report’s 10 key recommendations.

However, it was the contributions from those who live with the condition that added a real depth of understanding. The voices and the lived realities of those with health conditions are all too often missing in the statistics and the analysis that we use to inform our work on health issues. I am therefore delighted that we were able to incorporate into our inquiry so fully the invaluable insights and experiences of those with AF.

A recurring point that was raised in our inquiry was the difficulty of identifying and diagnosing atrial fibrillation. Gordon, who was a round-table participant with AF, told the inquiry:

“I think the big problem is those who are undiagnosed, who perhaps don’t have many symptoms, aren’t aware that they’ve got AF and their risk of stroke, or heart failure, are very, very much increased”.

That was a very valid point from Gordon. AF increases a person’s risk of stroke by five times. It is associated with heart attacks, and it is thought to be a factor in heart failure.

Ivan, who was another participant, told the inquiry:

“I probably had AF for a long time but didn’t know what it was. To me, the condition was unknown”.

That response is all too common. I said that 96,000 people in Scotland have been diagnosed with AF. However, it has been estimated that 2.6 per cent of the Scottish population—that is, 145,000 people—have the condition. That means that as many as 50,000 people in Scotland are living with undiagnosed AF.

One of the key barriers to early diagnosis is that the condition often exists with very limited symptoms or no symptoms at all. Indeed, as many as 40 per cent of people with AF experience no symptoms at all, and those with paroxysmal AF often struggle to gain a diagnosis at all because of the intermittent nature of their condition. For some people, the first indication that they have AF is when they suffer a stroke. However, with the right treatment—for example, the appropriate use of anticoagulation drugs—the risk of stroke for those with AF reduces by two thirds.

Given that stroke is the third most common cause of death and a leading cause of disability in Scotland, the benefits of early diagnosis of AF cannot be stressed enough. As a result, although our report stops short of advocating national universal screening, we propose

“targeted AF case-finding programmes for those most at risk”,

as well as more investment in proven technologies for AF detection. We also stress the need for the Government to tackle staff shortages—for example, the lack of cardiac physiologists—to improve early diagnosis.

However, diagnosis is not the only issue. Clinical professionals and people with AF alike raised concerns about post-diagnosis pathways and support, and the inquiry revealed the need for more integrated and specialised care for people with AF.

Additionally, widespread concerns were raised about the lack of information for those diagnosed with the condition. Indeed, 15 per cent of respondents to our inquiry said that they had received no information at all about their condition, and only 33 per cent said that they had received a detailed explanation.

A number of consultation respondents reported that their treatment options were not fully explained to them. One stated:

“l would have been happier if it had been explained to me why other treatments were not for me.”

Similarly, Richard, who took part in one of our round-table discussions, told the inquiry that

“atrial fibrillation is unique to the individual so each case must be carefully considered to determine the correct course of treatment. It would be good if someone could give an idea of what treatments are available, and which are likely to work in each particular situation.”

It was clear from our inquiry that more needs to be done to ensure that patients with AF are adequately informed and actively involved in decisions about their care.

The importance of information extends to the wider public, and a number of responses to the inquiry highlighted the need for a public awareness campaign and the importance of raising awareness of AF among healthcare professionals.

Respondents to our inquiry also reported differences in how often their condition and treatment are reviewed. One stated that they

“would have liked a check-up programme”

but that they

“had little success in asking about drug changes and risks of current drugs.”

Integrated, multidisciplinary care can allow more opportunities for AF patients to receive appropriate reviews of their condition, provided by a variety of health care professionals. For example, community pharmacy could have a particular role to play through regular medication reviews for people with AF.

Our inquiry highlights the need to re-examine how we identify and ultimately treat atrial fibrillation, and I very much commend our 10 recommendations to the Scottish Government. If implemented, they would drive forward positive change and act as a catalyst that would improve the outcomes and experience of people with the condition.

I appreciate the efforts of everyone who was involved in our inquiry. I extend our gratitude to those who were kind enough to share their personal experiences of living with atrial fibrillation. I also thank the members of the advisory panel to the inquiry: Jim Bruce and Paul Hodson, who were our patient representatives; Wendy Armitage from Chest Heart & Stroke Scotland, Morven Dunn from the British Heart Foundation and Colin Oliver from Stroke Association Scotland, who were our third sector representatives; and Dr Neil Grubb from NHS Lothian, Professor Lis Neubeck from Edinburgh Napier University and Dr Terry Quinn from the University of Glasgow, who were our academic and clinical advisors. They all provided invaluable advice, for which we are very grateful.

I particularly thank Kylie Barclay from the British Heart Foundation, who invested a huge amount of time and effort in supporting the inquiry and developing the excellent final report that is before us today. I hope that everyone who was involved in the report is proud of it. It is a positive example of the work of a cross-party group.

Creating our report is only the first step. I am the co-convener of the cross-party group on heart disease and stroke. My fellow co-convener is Alexander Stewart, who continues the excellent work of his predecessor Maree Todd. We are determined, along with all members of the CPG and the advisory panel, to build on the momentum that I hope our report has created.

We are committed to working collaboratively with the Scottish Government and NHS Scotland to deliver our recommendations and, ultimately, to make a positive difference to the lives of people living with atrial fibrillation, their families and their carers.

We move to the open debate. We are really pushed for time today, so speeches of less than four minutes would be much appreciated.

13:28  

I am delighted to be able to participate in today’s members’ business debate, and I congratulate Colin Smyth on securing it.

As we have heard, atrial fibrillation is one of the most common forms of abnormal heart rhythm and a major cause of stroke in the United Kingdom. AF is an abnormal heart rhythm in the heart’s upper chambers, and we have heard about its consequences. More than 96,000 people in Scotland alone have the condition. We are also aware that 50,000 people remain undiagnosed, which is a massive number of individuals who are not aware of a condition that they might have to deal with at any time. Therefore, it is very important that we are aware of the condition and get out the message that we are trying to put across today.

In my Mid Scotland and Fife region, 12,188 people have been diagnosed with AF. They will undoubtedly be aware that the condition increases the risk of stroke by up to five times. Stroke is also the third most common cause of death and a leading cause of disability, with more than 15,000 people in Scotland having had a stroke in the past year.

I am privileged to be, along with Colin Smyth, co-convener of the cross-party group in the Scottish Parliament on heart disease and stroke. I was actively involved in the group before I stepped up to that role when Maree Todd moved on, and I am thrilled that we have achieved so much already. I pay tribute to everyone who has participated in the group.

I was delighted to host the British Heart Foundation’s social science event in the Parliament on the first evening in February. The event highlighted the charity’s fantastic research into AF.

The cross-party group held an inquiry into the diagnosis and treatment of people in Scotland who live with AF. The launch of our report was a fantastic opportunity to make the case for what the cross-party group is trying to achieve, and the group is doing everything that it can to move things forward.

The group heard from two of the British Heart Foundation’s hugely knowledgeable scientists. Professor Jesse Dawson and Professor Tony Workman gave fascinating insights into what they are doing to break down barriers through their fantastic work, which includes studying single heart cells taken from individuals who are managing chronic illness and identifying research that will ensure that every individual gets the best chance. Their work is improving our understanding of AF.

As Colin Smyth said, the round-table discussion with individuals who live with AF was useful in enabling us all to gain an understanding of the symptoms and hear people’s views about the condition and what needs to be done. The scientists’ contribution was vital, too.

I pay tribute to all who are working so hard to pioneer new treatments for AF, to everyone who is participating in a study and to everyone who helped to produce the recent publication.

The report is, without question, a major achievement, which shows us in the best light—working together at local and national levels. Such an approach enables us to support the work of the British Heart Foundation and provides a platform from which to promote the scientists and volunteers, so that the message goes out loud and clear.

We are here to fight alongside the British Heart Foundation, hand in hand, to support the charity in its drive to raise awareness and improve outcomes for people who live with AF.

I am delighted to provide assistance and support whenever I can and to play my part in standing up for improved awareness of atrial fibrillation.

13:32  

I congratulate Colin Smyth on securing this important debate, and I remind members that I am a registered nurse.

Colin Smyth’s motion says that there are 145,000 people in Scotland who are at risk from stroke due to atrial fibrillation. Some 50,000 of those people have not been found yet. I want to focus on detection and diagnosis.

The report of the cross-party group on heart disease and stroke, “A Focus on Atrial Fibrillation in Scotland”, discusses detection and diagnosis, which are important in the prevention of stroke in the first instance—that is primary prevention—and in the prevention of a further stroke, which is secondary prevention.

Most folk’s hearts beat in a steady, regular rhythm—“like a ticking clock”, as it says in the report—of 60 to 80 beats per minute at rest. AF is a heartbeat that is not regular—an arrhythmia. The most common method for detecting an arrhythmia is traditionally to use the radial pulse and check for 60 seconds, by putting one’s hands on the patient’s wrist, feeling for the radial pulse—the pulse at the thumb side of the wrist, where the radial artery is—and counting the beats for a full minute. Feeling the pulse for a full minute allows the trained individual, whether they are a doctor, a nurse, a healthcare support worker or an allied health professional such as a physio or dietician, to determine whether the rate is regular. An irregular heart rate triggers a further test: a diagnostic electrocardiogram, or ECG.

The current vital signs chart—the national early warning score, or NEWS chart—is where temperature, pulse or heart rate, blood pressure and respiration rate and other vital signs such as blood glucose and urine output are recorded. The NEWS documentation now includes a box to prompt those who obtain and record vital signs to say whether a pulse is regular or irregular. If an irregularity is detected, there is further diagnostic practice.

The NHS Dumfries and Galloway stroke nurse specialist I contacted last week—Christine Cartner—said that if an irregular heart rate is detected, it is often at the time of admission to hospital. However, by that time, people might already be experiencing a stroke event. Christine said that the main issue is detecting and diagnosing AF prior to a stroke happening and outside of hospital. The new technology that is emerging to detect AF is interesting. A simple electronic test can be used to validate regularity or arrhythmia by using a single-lead electrocardiograph.

The cross-party group made 10 recommendations in its report, but I will not be able to review all 10 in the time that I have today. Recommendation 1 said that

“targeted AF case-finding programmes for those most at risk”

should be considered. Those groups include those aged over 65 years and “those with previous stroke”. I support the potential to use technology.

The third recommendation was:

“Invest in the proven technologies within clinical practice to detect AF.”

I like the idea of a single-lead ECG to diagnose AF, as there is certainly difficulty in achieving a 12-lead ECG with accurate lead placement and exposure of the patient’s chest, and the discomfort or embarrassment of the 12-lead process.

I am sure that my colleagues will mention other issues that were raised in the report. I welcome the report and continued evidence-based information to develop the best guidelines to detect, diagnose and treat the 50,000 folk with AF whom we have not yet found.

13:36  

I am pleased to speak in support of the motion from my colleague, Colin Smyth, and the important issues that are raised in “A Focus on Atrial Fibrillation in Scotland”. I congratulate Colin Smyth and all the individuals and organisations that are involved with the CPG and the report. They have done a service for all of us in the Parliament and beyond.

Atrial fibrillation is one of the country’s most common conditions, affecting as it does around 100,000 people in Scotland who have been diagnosed with the condition. It is feared that as many as 50,000 people are currently living with the condition, but have not been diagnosed. The condition has serious implications—patients are five times more likely to be at risk of a stroke, and those stokes are likely to be more severe.

Briefly, I want to recognise the work that all Governments have done. It is important to stress that there is cross-party consensus on moving forward and focusing on strokes as one of Scotland’s three main killers, alongside cancer and heart disease. Strokes are the third most common cause of death and one of the leading causes of disability, so it is right that we give the issue focus and priority.

I will focus my comments and suggestions briefly on three areas, the first of which is the shortage of cardiac physiologists in Scotland. The Cabinet Secretary for Health and Sport, the Minister for Public Health and Sport and I have sparred many times across the chamber on the need for a proper workforce plan, the need to address acute shortages in clinical staff and the need to address the large number of consultant vacancies. Perhaps the minister might want to address those issues as they relate to the report.

The second area is how we can work to improve detection and diagnosis. The use of new technology in detection and diagnosis can play a key role in a more accurate diagnosis. Indeed, the diagnosis could be carried out using new technology in settings outwith a hospital or general practitioner practice—particularly in pharmacies or community settings—which could help relieve some of the stress and strains in the acute sector.

Diagnostic practices also need to be consistent across the country. There is variability across the country in diagnostic services for atrial fibrillation. Addressing the staff shortages, along with the wider availability of new technology, would play a big part in addressing some of the geographic differences in diagnosis. I would welcome the minister’s comments on how we can ensure a more consistent approach across Scotland, how we can learn from best practice in other parts of the country and how that can be replicated across the whole of Scotland.

Thirdly, I want to consider the care pathway on which patients travel. We know that atrial fibrillation requires a long-term care management plan. That plan requires the integration of many members of the healthcare team, including cardiologists, nurses, GPs, pharmacists and social care staff. There are good examples of best practice across the country, for example in Tayside and Lanarkshire. Everyone should benefit from the good practice that is developed by colleagues in other parts of the country. Again, I hope that the minister will take the opportunity to set out that her department will ensure parity of service, no matter which health board an individual happens to reside under.

I will close, because I realise that we are short of time. The Government has a key role to play, and I look forward to working with the minister and the wider Government, to hearing what she has to say and to working directly with the cross-party group and all the organisations that are represented on it to progress the recommendations in the report so that we can deliver a first-class service for every patient across Scotland that can serve as an example to the rest of the United Kingdom. [Applause.]

I ask those in the gallery not to show appreciation or otherwise. That does not mean that nobody will appreciate Rachael Hamilton. [Laughter.]

13:40  

Wow! I have never had a welcome like that before.

I welcome today’s important debate, and I congratulate Colin Smyth on securing it. I declare an interest as a new member of the cross-party group on heart disease and stroke. I look forward to contributing to the group’s work and to helping it to build its momentum in the future.

When I first met the British Heart Foundation in 2016, it became clear that atrial fibrillation is, despite the fact that it is all too common, not well known. The condition occurs when additional irregular electrical messages are sent from places in and around the atria, which provokes the atria to quiver or twitch—what is known as a fibrillation—and has been diagnosed in 96,376 people in Scotland. Symptoms include palpitations, breathlessness, dizziness, fainting and fatigue, but 40 per cent of people with AF do not experience any symptoms at all. AF might therefore affect thousands more people but remains undiagnosed as a result of the condition not being known about. From the information that has been gathered, we believe that the actual number of people with the condition could be as high as 145,000.

As we have heard, atrial fibrillation can increase fivefold the chances of stroke—the most common cause of death and the leading cause of disability in Scotland—so it can be a life-changing and potentially deadly condition. A number of risk factors are associated with AF, including increasing age, high blood pressure, heart failure, valvular heart disease, previous heart attack, thyroid disease, obesity, diabetes, chronic lung disease, sleep apnoea, kidney disease, smoking and excessive alcohol consumption.

In January, I welcomed the British Heart Foundation’s call for more support to help people who suffer from the condition, of whom there are some 1,724 in the Scottish Borders. I welcome the initiative that encourages the implementation of specialised AF services to facilitate accurate diagnosis and to raise awareness. I also welcome the excellent work that has been done by Colin Smyth and all the members of the CPG, and I welcome the group’s 10 recommendations to the Scottish Government. It is no mean feat for a CPG to gather evidence from carefully selected advisory panels, so we thank everyone who helped to formulate the recommendations in the report.

I fully support the calls to encourage targeted AF case-finding programmes for people who are most at risk—people who are aged over 65, those who have previously had a stroke and those with cardiovascular risk factors. As we know, Scotland and the Scottish Borders have an ageing population, so it is essential that people who are at risk get the support that is required.

In line with that, the Scottish Government should actively promote, and support health boards to implement, specialised AF services in order to facilitate accurate diagnosis, to ensure prompt appropriate anticoagulation and to provide patient-centred management. It was only recently that the Scottish Borders received pulmonary rehabilitation services to help people who suffer from chronic obstructive pulmonary disease. Before that, NHS Borders was the only health board in Scotland without such a service. There should not be such inequality among health boards, so we must ensure that when a service is rolled out to help people with AF, it is rolled out to all health boards. I am sure that that will be the case, but if it is not, I will help to ensure that it is.

I again thank Colin Smyth for securing the debate, and I thank the CPG and the British Heart Foundation for their work on the published report. The Scottish Government has much to do to support the 145,000 AF sufferers, but I am sure that its efforts will be supported by all of us in Parliament.

13:44  

As other members have done, I congratulate Colin Smyth on bringing the motion for debate. I am glad that we have finally got the chance to do so after the weather postponed play last week.

I also congratulate all the members who were involved in the inquiry and the report. A considerable amount of work went into the inquiry from experts, but as Colin Smyth articulated, it is important that the voice of people with experience of atrial fibrillation was also heard.

I applaud Colin Smyth and Alexander Stewart for their passion about and knowledge of AF. I agree with Alexander Stewart that the work on the inquiry and report shows Parliament and its cross-party groups in the best light.

I welcome the opportunity to discuss atrial fibrillation and the Government’s work to improve AF diagnosis, treatment and care. That work is being done by the Scottish Government, NHS Scotland and our third sector partners, including the British Heart Foundation, Chest Heart & Stroke Scotland and the Stroke Association.

As the motion notes, AF is a common and serious heart condition that is associated with a fivefold increase in the risk of stroke. Although most people who have the condition are diagnosed and provided with appropriate treatment, data suggests that 50,000 people with AF in Scotland are undiagnosed. That point has been raised by other members—certainly, by Colin Smyth and Rachael Hamilton. That it is why our national advisory committees for heart disease and for stroke, which include third sector partners, have developed our AF work plan, which aims to support improvement in AF diagnosis, treatment and care. I appreciate also the authoritative and detailed contribution to the debate by Emma Harper, who brought her nursing expertise to bear on how we tackle diagnosis and treatment of AF.

I am pleased that the work plan’s actions and priorities echo the recommendations in the CPG’s report. I welcome that concord and was pleased to contribute to the parliamentary reception celebrating the report’s publication in order to share our perspective on, and our work to improve, AF issues. I pay tribute to the people who contributed to that event, including those with lived experience of AF whose voices added colour to the report’s findings. It was a pleasure to meet many people who contributed to the inquiry, to hear from people with AF and to reflect on our shared commitment—which is ambitious and consensual—to improve diagnosis and treatment of AF and care of those who are affected by AF.

I was pleased to note that the progress in delivering our heart disease and stroke improvement plan’s commitments on AF is acknowledged in the inquiry’s report. That includes development of AF e-learning in the heart education awareness resource and training through e-learning—HEARTe—resource, and the stroke training and awareness resources, or STARs, project. Those have both been produced by Chest Heart & Stroke Scotland. Those resources were funded by the Scottish Government, as was a project that tested using smartphone apps in primary care to identify AF, which is another example of using modern technology to help advance treatment options.

The progress on the improvement plan commitments on AF galvanised our national advisory committees for heart disease and stroke to work with partners to improve further AF provision across the healthcare system. They produced our AF work plan, the core of which is to improve pathways for AF detection and treatment in primary and secondary care—specifically, supporting AF case finding in primary care, effective follow-up in secondary care and identifying AF in people who have had a stroke in order to reduce the risk of further stroke.

To respond to some of the issues that Anas Sarwar raised, I note that the report and our work plan provide opportunities to drive forward the improvement that I think he is seeking, and to introduce far more consistency across the country in AF treatment, diagnosis and care.

On the points that Anas Sarwar and Colin Smyth raised about physiologists, we are aware of the UK shortage of cardiac physiologists, so the Scottish Government is considering a formal request to add cardiac physiologists to the shortage occupation lists for tier 2 visas, which would ensure that NHS Scotland can maximise use of overseas recruitment options.

In reflecting on some of the points around care for individuals, I say that one of realistic medicine’s main aims is shared decision-making by patients and healthcare professionals, informed by discussion of treatment options. That and the AF work plan seek to ensure that the benefits of clinical interventions and technologies are maximised. The person-centred plan also includes aims such as raising awareness among the people who are at most risk of AF, enhancing patient engagement and, in time, using data to measure progress and inform our next steps to improve AF diagnosis, treatment and care.

It is important to empower people. Colin Smyth and others referred to ensuring that people are at the centre of the care in order to help them to cope with their condition, and that they have active input into what that care looks like.

I acknowledge all those who contributed to the development of the AF work plan, and I note that many people were also actively involved in the cross-party group’s AF inquiry. Joint work across boundaries and portfolios—such as that to deliver our AF work plan—will achieve the aims of our health and social care delivery plan. We want a health and social care system that is integrated and works together, that is focused on the principles of anticipating people’s health needs, that provides the best standards of quality and safety, and which always puts people at the centre of decisions about their care.

Our vision for primary care is at the heart of improvement in AF diagnosis, treatment and care. We are working with general practitioners, the British Medical Association, integration authorities and health boards to implement the agreed priorities for transformative service redesign in primary care. Key to that is the new general medical services contract, under which general practitioners will become more involved influencers in the wider system in order to improve local communities’ population health, with GP clusters working to improve continuously the quality of patient care. The refocusing of GPs’ role as expert medical generalists will in the future result in some of their current tasks being carried out by wider primary care multidisciplinary teams, where it is safe and appropriate to do so.

AF should also be set within the context of our wider efforts to drive forward improvement at population health level. Heart disease and stroke mortality and incidence rates have decreased over the past decade, which shows that our strategies deliver real improvements, but we want to do more to prevent heart disease and stroke. We are taking decisive action to address alcohol consumption, reduce smoking rates and encourage healthy eating and active living, and we are investing to improve mental health services to help to support people to live healthier lives. Aligned with that is our work to ensure that we can reduce the health inequalities that we all want to see being reduced.

I welcome the inquiry report and its alignment with the priorities in our AF work plan. The two reports and sets of actions give us a blueprint for Scotland to drive forward the improvement and consistency that we seek to have in AF diagnosis and treatment. I again pay tribute to the work of the cross-party group and everyone who was involved in making the inquiry and the report so authoritative. It allows us to work together to make the improvements that we need.