Health CommitteeWritten evidence from Lifeblood: The Thrombosis Charity (ETWP 31)

Summary

Lifeblood: The Thrombosis Charity is responding to this consultation with a focus on the need for improved, consistent and high quality education for healthcare undergraduates and professionals on the prevention of venous thromboembolism (VTE) in hospital patients—a national clinical priority for the NHS—and on the diagnosis and management of VTE in the community and in hospital.

In 2005, the then Health Select Committee conducted an inquiry into the prevention of VTE in hospitalised patients. The inquiry recognised the scale of the problem of hospital acquired VTE alongside the cost effectiveness of preventing rather than managing VTE. Recommendation six centred on the need to improve health professionals’ education about VTE given that professional awareness was low.

While national best practice and policy exists to support the implementation of best practice in the prevention of VTE, evidence collected by Lifeblood and the All-Party Parliamentary Thrombosis Group indicates that VTE education remains disparate and poor nationally and across the disciplines. The result is low awareness amongst health professionals about VTE prevention, diagnosis and management, leading to many unnecessary and avoidable deaths from the condition.

Given the accepted clinical and financial significance of VTE to the NHS, Lifeblood recommends that the Health Select Committee investigates how a core education syllabus for healthcare professionals can be developed, which includes VTE as a national, mandatory requirement. Undergraduate education on VTE must be supported via professional revalidation and new staff induction. This is essential if we are to deliver a long-term legacy of high quality VTE prevention in the NHS and avoid thousands of preventable deaths each year from the condition.

Submission

1. Lifeblood: The Thrombosis Charity (Lifeblood) is delighted to submit evidence for the Health Select Committee’s inquiry into education, training and workforce planning.

2. This submission is made further to a meeting held with Rt Hon Stephen Dorrell MP on 5 July 2011 in his capacity as Chair of the Health Committee, about the urgent need to improve NHS health professionals’ undergraduate and postgraduate education, particularly around awareness of venous thromboembolism (VTE).

3. VTE—blood clots—includes both deep vein thrombosis (DVT) and pulmonary embolism (PE). Blood clots form in the veins deep in the leg, usually in the calf or thigh, although occasionally DVT can occur in other veins of the body. The majority of deaths from VTE are caused by part of the clot breaking off, travelling around the body and eventually blocking the pulmonary arteries (arteries in the lungs). This is known as a pulmonary embolism (PE).

Background (i): Health Select Committee 2005 inquiry into VTE prevention in hospitalised patients

4. On 8 March 2005, the Health Select Committee published an inquiry into VTE, “The Prevention on Venous Thromboembolism in Hospitalised Patients” (Second Report from the Health Committee Session 2004–05: HC99.)

5. The Report recognised that “each year, over 25,000 people in England die from VTE contracted in hospital. This is more than the combined total of deaths from breast cancers, AIDS and traffic accidents”.1

6. The Report went on to recognise the financial cost of VTE to the NHS, noting that “even more alarming than the scale of the problem is the fact that VTE in hospitalised patients is largely preventable through the use of thromboprophylaxis during the hospital stay of the patient and, in some cases, continuing after discharge.”2

7. The Health Select Committee published 12 recommendations aimed at improving VTE prevention in the NHS. These were all accepted by the Government in its response.3

8. Of particular significance is recommendation 6, focussed on the need to support improved professional awareness of VTE:

“We recommend that VTE and its prevention, including the implementation of, and adherence to, guidelines relating to thromboprophylaxis, counselling and risk assessment, be given more prominence in undergraduate medical education, continuing professional development (CPD), and other relevant aspects of medical and paramedical training. We further recommend that the Royal Colleges bring forward proposals to this end to raise awareness of the problems of VTE. In addition, NHS Trusts should ensure that all physicians and surgeons receive training about the subject.”4

9. While Lifeblood is delighted that VTE prevention has been named a national clinical priority for the NHS since 2010—with key principles of best practice set out in the NICE Quality Standard on VTE prevention and supported by national policy levers including the NHS Outcomes Framework and the Commissioning for Quality and Innovation Payment Framework—we remain concerned at evidence that suggests that education around VTE prevention continues to be unaddressed on a national level and across the healthcare disciplines. The result is that VTE prevention is not always front of mind for healthcare professionals, meaning that potentially life-saving, simple and cost-effective preventative procedures are not always implemented.

Background (ii): The missed diagnosis of community acquired VTE

10. DVT can be clinically very difficult to diagnose but early recognition and appropriate treatment can improve clinical outcomes. It is estimated that 18,000 deaths occur annually from undiagnosed VTE.

11. As a charity, Lifeblood is inundated with correspondence from distressed relatives and individuals where VTE had been missed on a visit to the General Practitioner (GP) or during a hospital visit.

12. The symptoms and signs of DVT and PE can be subtle. For example, in 80% of cases, there is no swelling or redness in DVT, just pain. These facts are not common knowledge among medical professionals and so many patients are sent away after seeing health professionals because they don’t fit the textbook case. As a consequence, some may some die, some may present acutely in secondary care later with a worse DVT or a PE. For the NHS, this treatment can prove costly—in both time and money. For the patient, an undiagnosed DVT can have tragic consequences.

Evidence of a Lack of Progress on VTE Education

13. The All-Party Parliamentary Thrombosis Group (APPTG) undertook a Freedom of Information (FoI) request in December 2010, asking the Medical Schools Council how VTE education is currently delivered by medical schools in the UK. The response, made available in early 2011, indicates that six years on from the Health Select Committee’s recommendation, there continues to be wide variation in VTE education across England. There is a clear lack of consistency in the amount of time allocated to VTE as well as in the format in which VTE prevention, diagnosis and management is taught and reinforced to undergraduate medical students.

14. The response to the APPTG’s FoI is supported by an independent academic study of the state of UK undergraduate haematology medical education, published in The Bulletin of The Royal College of Pathologists in April 2011. The study was based on a survey of medical schools in the UK to support a UK generic core curriculum for undergraduates being developed by the British Society for Haematology. While there is no specific data on teaching of VTE, the findings underlined that haematology undergraduate programmes vary widely across the UK. The study noted that a core curriculum will not only raise the profile of haematology, but it will provide a “solid grounding in the subject for all future clinicians”.5

15. Lifeblood wrote to the Nursing & Midwifery Council in early 2011 asking them to outline how VTE is addressed in nursing and midwifery education. The response indicated that there is no national standard education on the issue, indeed for midwifery, “despite extensive consultation on the new standards VTE was not mentioned as something that ought to be included”.

16. However, Lifeblood is aware that a clear unmet need exists around nursing and midwifery education, particularly on VTE prevention. I have been supporting the UK Thromboprophylaxis Forum, Royal College of Nursing and National Nursing and Midwifery Network to run two workshops during 2011 on thromboprophylaxis in obstetrics, courses aimed at midwives and obstetricians. These classes were inundated with over 100 attendees each—and we have now agreed to continue running these classes during 2012 to meet the obvious demand and fill a clear unmet need.

17. Needless to say, the press continues to cover stories of failings in VTE prevention, diagnosis and management, often covering avoidable deaths from the condition. Indeed, as this submission is being drafted, Lifeblood is aware of three stories that have been covered in the press in the two weeks since the beginning of December, two relating to preventable hospital acquired VTE, the other relating to a death from VTE missed by a GP and later in hospital.

18. All the above clearly demonstrates that VTE education remains inconsistent across the UK. The issue is yet to be adequately addressed by medical schools and institutions offering medical and nursing education, despite a clear call for improvement from the Health Select Committee over five years ago on education around VTE prevention, and evidenced through the continuing calls that Lifeblood receives around missed DVTs.

Lifeblood’s Recommendations to Improve VTE Prevention Education

19. Lifeblood firmly believes that it is vital that our doctors, pharmacists and nurses of tomorrow be equipped with the knowledge and training to prevent further avoidable deaths from VTE due to hospital admission and missed DVTs.

20. Lifeblood advocates that VTE prevention, diagnosis and management must be adequately taught to all healthcare students, across the disciples, from the outset of their careers.

21. Lifeblood further advocates that basic principles of high quality VTE prevention must also be reinforced during professional development. All too often, avoidable instances of harm are not investigated and followed up adequately, meaning medical professionals fail to learn from these mistakes and are often free to repeat them with impunity. This is certainly the case in VTE, which often presents clinically once a patient has been discharged from hospital. This means those clinicians responsible for a patient’s care whilst in hospital are unaware of their failures in preventing a DVT, or more seriously, a fatal pulmonary embolism, which were contracted as a result of a patient’s hospital admission. Addressing this through a systematic approach to education and accountability will help embed VTE prevention as a minimum standard of safe quality care.

22. This is especially important during times of financial austerity, considering that VTE prevention is one of the top ten NICE recommended cost saving interventions. There are significant medico-legal costs associated with inadequate VTE prevention, diagnosis and management. Data presented at the joint Department of Health and All-Party Parliamentary Thrombosis Group VTE Prevention Leadership Summit in March 2011 estimated that successful VTE claims have cost the NHS Litigation Authority a staggering £112 million in damages and legal costs in approximately 140 claims made over the past five years. This equates to more than £22 million per year.

23. To address these concerns, Lifeblood fully endorses the relevant recommendations made by the All-Party Parliamentary Thrombosis Group (APPTG) in their latest research report on the various stages of education on VTE. The recommendations are copied below and are focussed on preventing VTE in hospital, though they apply equally to the diagnosis and management of VTE in the community and in a hospital setting. Lifeblood urges the Health Select Committee to investigate how these recommendations can be best addressed:

(a)The APPTG recommends that as part of a wider review of undergraduate education, all relevant Royal Colleges and Societies should establish a core syllabus for VTE prevention for undergraduate students across the medical and healthcare disciplines.

(b)The APPTG recommends that all Individual Royal Colleges and Societies should develop a core syllabus on VTE prevention for the revalidation of medical and healthcare professionals.

(c)The APPTG recommends that all NHS Trusts should ensure that local policies on VTE risk assessment and prophylaxis are included within their protocols for staff induction across the disciplines.6

24. Lifeblood firmly believes that a mandatory, nationally consistent and high quality focus on VTE at undergraduate and postgraduate level is essential if we are to deliver a long-term legacy of high quality VTE prevention in the NHS, and avoid thousands of avoidable deaths each year from the condition.

25. Lifeblood would be more than happy to provide more evidence on the matter in writing or verbally for the Committee where required.

December 2011

1 House of Commons Health Committee (2004–05) “The Prevention on Venous Thromboembolism in Hospitalised Patients” (HC 99) p7

2 ibid

3 Government response to the House of Commons Health Committee report on the Prevention on Venous Thromboembolism in Hospitalised Patients—Second Report of Session 2004–05 (July 2005) Cm 6635

4 House of Commons Health Committee (2004–05) “The Prevention on Venous Thromboembolism in Hospitalised Patients” (HC 99) p29

5 Marrin C, Jenkins C, “The State of UK Undergraduate Haematology Medical Education”. RCPath Bulletin 2011:154;p121–123

6 All-Party Parliamentary Thrombosis Group (2011) “Fifth Annual Audit of Acute NHS Trusts” VTE Policies, p11

Prepared 22nd May 2012