A view from the Clinical A view from the Clinical LeadLead

Malcolm MetcalfeMalcolm Metcalfe

NoS CardiologyNoS Cardiology

Although much good work has been achieved Although much good work has been achieved there remain major challenges ahead.there remain major challenges ahead.

In order to continue to improve access to high In order to continue to improve access to high quality cv services it remains essential that many quality cv services it remains essential that many services be planned and operated on a Regional services be planned and operated on a Regional basis.basis.

This is a difficult and sometimes uncomfortable This is a difficult and sometimes uncomfortable process for individuals from differing HBs. Often process for individuals from differing HBs. Often this lead to a “mismatch” between aspiration and this lead to a “mismatch” between aspiration and reality.reality.

Major issues (not exhaustive)Major issues (not exhaustive)

Optimal reperfusionOptimal reperfusionPCI in HighlandPCI in HighlandRole out of EP services for NoSRole out of EP services for NoSCardiothoracic surgery provisionCardiothoracic surgery provisionTranscatheter aortic valve implantationTranscatheter aortic valve implantationMulti-slice CT scanning Multi-slice CT scanning Transport issuesTransport issuesWorkforce planningWorkforce planning

Optimal ReperfusionOptimal Reperfusion

Watch this space…Watch this space…

PCI in HighlandPCI in Highland

Business case for PCI in Highland region agreed.Business case for PCI in Highland region agreed.Equipment now availableEquipment now availableFormal BCIS inspection visit was on 12/2/10. Formal BCIS inspection visit was on 12/2/10.

Generally very favourable assessmentGenerally very favourable assessment No issue re modest numbersNo issue re modest numbers Issues re emergency transfer and on-call cover for procedures Issues re emergency transfer and on-call cover for procedures

to be resolvedto be resolved

Should start elective work April 2010Should start elective work April 2010Should start emergency/PPCI office hours work August Should start emergency/PPCI office hours work August 20102010Major success for NoS partners!Major success for NoS partners!

Role out of EP servicesRole out of EP services

Following on from agreed plan Feb 2008Following on from agreed plan Feb 2008 Full-time EP Consultant started in July. Full-time EP Consultant started in July. Tayside and Highland undertaking ICD implantation Tayside and Highland undertaking ICD implantation

(1’ prevention numbers still small)(1’ prevention numbers still small) RFA numbers increasing as predictedRFA numbers increasing as predicted CRT implantations increasing and likely to increase CRT implantations increasing and likely to increase

quire markedly due to new evidence of benefit.quire markedly due to new evidence of benefit. Pacemaker lead extractions have become an Pacemaker lead extractions have become an

unexpected issue.unexpected issue.

Cardiothoracic surgery provisionCardiothoracic surgery provision

NoS serviceNoS service Despite concerns numbers have remained static for Despite concerns numbers have remained static for

last few years at >600.last few years at >600. Actual demand may be nearer 750 assuming that Actual demand may be nearer 750 assuming that

Highland and Tayside continue to refer numbers to Highland and Tayside continue to refer numbers to ERI.ERI.

Issue of “bulge” due to abolishing “gaps” and Issue of “bulge” due to abolishing “gaps” and achieving 18 week target – but this may no longer be achieving 18 week target – but this may no longer be an issue given unexpectedly low referrals this year.an issue given unexpectedly low referrals this year.

Cost of service now greater than “charging cost” – will Cost of service now greater than “charging cost” – will need adjustment.need adjustment.

Problems with junior staff provision most pressing Problems with junior staff provision most pressing issue.issue.

Transcatheter aortic valve Transcatheter aortic valve implantation (TAVI)implantation (TAVI)

No longer experimental techniqueNo longer experimental technique Excellent results (short-medium term)Excellent results (short-medium term) Extends envelope to patients who would otherwise dieExtends envelope to patients who would otherwise die Relatively simpleRelatively simple Expensive (c£25 000).Expensive (c£25 000). Calculated demand 16 pmpCalculated demand 16 pmp Long way behind EnglandLong way behind England No Scottish centreNo Scottish centre

High-level meeting with SEHD last year.High-level meeting with SEHD last year. External assessment underwayExternal assessment underway Agreement to develop “universal” referral criteria and for each Agreement to develop “universal” referral criteria and for each

Region to work up Business case.Region to work up Business case.

Many patients have already been referred from NoS Many patients have already been referred from NoS region (eg 9 from Grampian) so genie out of bottle.region (eg 9 from Grampian) so genie out of bottle.

Multi-slice CT imagingMulti-slice CT imaging

Has potential to replace coronary angiography in certain Has potential to replace coronary angiography in certain circumstances (?20%)circumstances (?20%)Results from studies to date not easy to interpret.Results from studies to date not easy to interpret.Pilot in Highland with useful preliminary resultsPilot in Highland with useful preliminary resultsCost vs coronary angiography may not be as favourable Cost vs coronary angiography may not be as favourable as predicted.as predicted.Older machines impart high radiation burden.Older machines impart high radiation burden.Ideal is to use modern 256/320 slice machines which Ideal is to use modern 256/320 slice machines which impart 1mSv radiation, can image in single heart beat impart 1mSv radiation, can image in single heart beat but cost c£100 000 more than workhorse 28-128 slice but cost c£100 000 more than workhorse 28-128 slice imagers.imagers.

Transport issuesTransport issues

Increased liaison and discussion with Increased liaison and discussion with ambulance servicesambulance services PPCIPPCI Transfers from other centres (eg currently Transfers from other centres (eg currently

longer by air than road from Raigmore to longer by air than road from Raigmore to ARI!)ARI!)

Changes by virtue of “drip and ship” policies Changes by virtue of “drip and ship” policies (eg Elgin, Wick, Islands), potential emergency (eg Elgin, Wick, Islands), potential emergency transfer of PCI patients to ARI etctransfer of PCI patients to ARI etc

Workforce PlanningWorkforce Planning

Very important issue but difficult to both Very important issue but difficult to both influence and predict changeinfluence and predict change CEOs have apparently predicted no growth in CEOs have apparently predicted no growth in

Consultant numbers for next few years Consultant numbers for next few years (before financial crisis!)(before financial crisis!)

Recruiting technicians remains a major issue Recruiting technicians remains a major issue – NES have offered some support. Closing – NES have offered some support. Closing date 25date 25thth June. June.

Eventually one would like some degree of Eventually one would like some degree of standardisation across the North.standardisation across the North.

SummarySummary

A lot is happening!A lot is happening!Lack of reliable information makes life very Lack of reliable information makes life very difficult (aspiration vs reality) for planning.difficult (aspiration vs reality) for planning.Service managers frequently do not seem Service managers frequently do not seem to be aware of NoS working.to be aware of NoS working.NoS working is difficult as inevitable NoS working is difficult as inevitable compromise is required.compromise is required.NoS working however is essential in order NoS working however is essential in order to provide the best care for our patients.to provide the best care for our patients.

Non-NoS working…Non-NoS working…