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North Trent Network of Cardiac Care         Bassetlaw, North Derbyshire and South Yorkshire                Cardiac Strateg...
1 PART A. INTRODUCTION AND BACKGROUND...................................................................................61...
5 PART E – STRATEGY FOR DEVELOPING CLINICAL SERVICES.....................................................215.1 Process for...
5.11.3 Key Actions...........................................................................................................
9.5 Appendix E Equality Impact Assessment ...................................................................................
1 PART A. INTRODUCTION AND BACKGROUND1.1 About the StrategyThe Cardiac Strategy has been written by the North Trent Networ...
In March 2008 a User Group was formed and since then has been working as apartner with the Network Board. The role and fun...
1.5    Equality Impact AssessmentEquality Impact assessments (EIA) are a way of examining the main functions andpolicies o...
PART B. APPROACH TO DELIVERY OF THE STRATEGY2In delivering the strategy set out in this document the Cardiac Network is co...
3 PART C. EPIDEMIOLOGY3.1 IntroductionThis section sets out:    • The population of North Trent (2007) and predicted popul...
DoncasterBarnsley                   230,435                            BarnsleyDoncaster                  292,529Bassetlaw...
Prevalence of risk factors by PCTPrevalence (%) of Risk Factors         Smoking 2000-                      Alcohol1       ...
3.6 Prevalence of Cardiac ConditionsOver 80,000 people in the North Trent Network suffer from Coronary Heart Disease(CHD)....
3.7 Mortality from All Circulatory Disease                                                                            Mort...
3.8 Mortality from Coronary Heart Disease and Myocardial InfarctionMortality across the Network continues to fall. May PCT...
Circulatory disease mortality rates                                           300   Mortality rate per 100,000 population ...
Fem ale under 75 CHD m ortality     70.00     60.00     50.00     40.00                                                   ...
4 PART D. PREVENTING CARDIAC DISEASE     AND REDUCING MORTALITY4.1 IntroductionIn recent years the Network has focused on ...
prevention; allowing appropriate treatment to be provided. Both these standardsshould be reflected in Primary Care Trust (...
4.7 Key ActionsIn 2008 the Network will plan and deliver a North Trent Primary Prevention Projectthat:• Recommends a total...
5 PART E – STRATEGY FOR DEVELOPING CLINICAL  SERVICES5.1 Process for Planning DevelopmentsThis section identifies a number...
Biventricular Pacing                                                #       #        #        #       Implantable Defibri...
5.3     Acute Coronary Syndrome and Stable Angina5.3.1 An Overview of the Development of Services for ST Segment Elevation...
Rotherham PCT                                                                                                             ...
A number of models, including Martin et al were produced following the 2000 targetto make some of the assumptions behind t...
Symptoms of a                                                                  Heart Attack                               ...
5.3.5   Elective and Urgent Revascularisation for the Treatment of Acute        Coronary Syndromes and AnginaElective reva...
5.3.7 Development of the Elective Angioplasty PathwayCurrently all elective angioplasty takes place at STHFT. Patients are...
5.3.10 Key Actions    • Commissioner sign off of the North Trent Angioplasty Service Specification by      April 2008.    ...
failure are receiving a full package of effective investigations and interventionsdemonstrated by clinical audit.In July 2...
for considerable unmet palliative needs of patients and informal carers in heartfailure. The main areas of need include sy...
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  1. 1. North Trent Network of Cardiac Care Bassetlaw, North Derbyshire and South Yorkshire Cardiac Strategy April 2009/home/pptfactory/temp/20101206092607/download1909.doc 1
  2. 2. 1 PART A. INTRODUCTION AND BACKGROUND...................................................................................61.1 About the Strategy.............................................................................................................................61.2 Context................................................................................................................................................61.3 Involvement ........................................................................................................................................61.4 Consultation........................................................................................................................................71.5 Equality Impact Assessment.............................................................................................................81.6 Health Inequality Impact Assessment..............................................................................................8PART B. APPROACH TO DELIVERY OF THE STRATEGY....................................................................93 PART C. EPIDEMIOLOGY ...................................................................................................................103.1 Introduction.......................................................................................................................................103.2 Background.......................................................................................................................................103.3 Geography.........................................................................................................................................103.4 Population.........................................................................................................................................103.5 Risk factors ......................................................................................................................................113.6 Prevalence of Cardiac Conditions .................................................................................................133.7 Mortality from All Circulatory Disease...........................................................................................143.8 Mortality from Coronary Heart Disease and Myocardial Infarction.............................................153.9 Geographical and Deprivation Differences....................................................................................153.10 Gender Differences........................................................................................................................163.11 Age Differences..............................................................................................................................173.12 Ethnic Differences..........................................................................................................................173.13 Conclusions....................................................................................................................................174 PART D. PREVENTING CARDIAC DISEASE AND REDUCING MORTALITY....................................184.1 Introduction.......................................................................................................................................184.2 Using Practice Registers to Identify ‘At Risk’ Patients.................................................................184.3 Cardiovascular Disease High Risk Framework.............................................................................194.4 Lifestyle Interventions.....................................................................................................................194.5 Statin Prescribing.............................................................................................................................194.6 Wider Determinants of Health.........................................................................................................194.7 Key Actions.......................................................................................................................................20/home/pptfactory/temp/20101206092607/download1909.doc 2
  3. 3. 5 PART E – STRATEGY FOR DEVELOPING CLINICAL SERVICES.....................................................215.1 Process for Planning Developments..............................................................................................215.2 Summary of Service Provision........................................................................................................215.3 Acute Coronary Syndrome and Stable Angina..............................................................................23 5.3.1 An Overview of the Development of Services for ST Segment Elevation Myocardial Infarction (STEMI) ...............................................................................................................................................23 5.3.2 An overview of the future need for Revascularisation.................................................................24 5.3.3 Development of a Network Wide Primary Angioplasty for ST Segment Elevation Myocardial Infarction (STEMI) ...............................................................................................................................25 5.3.4 Thrombolysis for the Treatment of ST Segment Elevation Myocardial Infarction (STEMI) ........26 5.3.5 Elective and Urgent Revascularisation for the Treatment of Acute Coronary Syndromes and Angina..................................................................................................................................................27 5.3.6 Development of Elective Angioplasty Services...........................................................................27 5.3.7 Development of the Elective Angioplasty Pathway.....................................................................28 5.3.8 Development of the Non Elective Angioplasty Pathway.............................................................28 5.3.9 Development of the Coronary Artery Bypass Graft Provision (CABG) Pathway.........................28 5.3.10 Key Actions...............................................................................................................................295.4 Heart Failure .....................................................................................................................................29 5.4.1 Background.................................................................................................................................29 5.4.2 Healthcare Commission Review.................................................................................................30 5.4.3 Heart Failure in Secondary and Tertiary Care ...........................................................................30 5.4.4 Palliative Care Services .............................................................................................................30 5.4.5 Cardiac Resynchronisation Therapy (CRT)................................................................................31 5.4.6 Key Actions.................................................................................................................................345.5 Arrhythmia & Sudden Cardiac Death ............................................................................................35 5.5.1 Introduction.................................................................................................................................35 5.5.2 Arrhythmia Services....................................................................................................................35 5.5.3 Inherited Cardiac Conditions (ICC).............................................................................................36 5.5.4 Pacemaker Implantation.............................................................................................................36 5.5.5 Implantable Cardioverter Defibrillator..........................................................................................36 5.5.6 Key Actions.................................................................................................................................375.6 Aortic Aneurysms Surgery..............................................................................................................38 5.6.1 Overview.....................................................................................................................................38 5.6.2 Key Actions.................................................................................................................................385.7 Diagnostic Imaging and Diagnostic Testing .................................................................................39 5.7.1 Introduction.................................................................................................................................39 5.7.2 Cardiac Magnetic Resonance Imaging and Positron Emission Tomography.............................39 5.7.3 Myocardial Perfusion Scintigraphy..............................................................................................40 5.7.4 Computerised Tomography (CT)................................................................................................41 5.7.5 Diagnostic Services Provision in Primary Care...........................................................................41 5.7.6 Key Actions.................................................................................................................................415.8 Adult Congenital Cardiology Service.............................................................................................42 5.8.1 Background.................................................................................................................................42 5.8.2 National Guidance.......................................................................................................................42 5.8.3 Yorkshire and Humber Strategy..................................................................................................42 5.8.4 Key Actions.................................................................................................................................435.9 Rehabilitation and Ongoing Support..............................................................................................44 5.9.1 Rehabilitation..............................................................................................................................44 5.9.2 Post rehabilitation support and patient support groups...............................................................44 5.9.3 Key Actions.................................................................................................................................455.10 Meeting the 18 Week Wait Target..................................................................................................465.11 Current Position against Target....................................................................................................46 5.11.1 Agreed Pathways......................................................................................................................47 5.11.2 Challenges................................................................................................................................47/home/pptfactory/temp/20101206092607/download1909.doc 3
  4. 4. 5.11.3 Key Actions...............................................................................................................................486 ..............................................................................................................................................................496.1 Improving communication...............................................................................................................496.2 Supporting family and friends.........................................................................................................496.3 Ensuring seamless care throughout the patient pathway............................................................49PART G – DEVELOPING THE NETWORK ...........................................................................................507.1 Introduction.......................................................................................................................................507.2 Network Development......................................................................................................................507.3 Network Development......................................................................................................................507.4 The Network Model...........................................................................................................................507.5 Decision Making and Recommendations.......................................................................................517.6 Network Board..................................................................................................................................527.7 Commissioning Group.....................................................................................................................537.8 Clinical Advisory Group...................................................................................................................547.9 User Group........................................................................................................................................547.10 Heath Community CHD Leads.......................................................................................................557.11 Development of the Network Team...............................................................................................557.12 Key Network Relationships...........................................................................................................557.13 North Trent Stroke Strategy Project.............................................................................................567.14 Ensuring Patient Centered Services.............................................................................................567.15 Approach to Audit and Clinical Governance ..............................................................................577.16 Approach to Research ..................................................................................................................587.17 Key Actions ....................................................................................................................................585 GLOSSARY...........................................................................................................................................598 REFERENCES......................................................................................................................................629 APPENDICES.......................................................................................................................................649.1 Appendix A National Strategy.........................................................................................................649.2 Appendix B Review of Previous Strategy .....................................................................................679.3 Appendix C Summary of Strategy Consultation Feedback..........................................................719.4 Appendix D Health Inequalities Impact Assessment....................................................................82/home/pptfactory/temp/20101206092607/download1909.doc 4
  5. 5. 9.5 Appendix E Equality Impact Assessment .....................................................................................879.6 Appendix F Heath Care Commission – Heart Failure Review Scores........................................909.7 Appendix G Summary of Heart Failure Guidelines......................................................................919.8 Appendix H Arrhythmia and SCD Service Provision in 2006......................................................93/home/pptfactory/temp/20101206092607/download1909.doc 5
  6. 6. 1 PART A. INTRODUCTION AND BACKGROUND1.1 About the StrategyThe Cardiac Strategy has been written by the North Trent Network of Cardiac Careand is intended to compliment PCT strategies for improving Cardiac Services. It setsout the key developments required over the next three years to ensure the delivery ofadult cardiac services that meet the health needs of the population of North Trent. Italso sets the direction of travel for future commissioning of cardiac services.The aim of this strategy is to develop services that are• Patient centred• Provide care that is safe and appropriate• Ensure equity of access• Ensure consistent standards• Responsive to changes in practiceIt does not include the development of Children’s Cardiac Services but does includea summary of the Adult Congenital Heart Disease Network’s Strategy.1.2 ContextAdult cardiac services provided within North Trent Network of Cardiac Care are setagainst the following background:• High disease prevalence within the Network• Major variations in access to services and health inequalities/outcomes across the Network• The NSF for CHD continuing to provide challenges to improving service delivery and a number of NICE publications that require implementation• Considerable capital investment in district general hospital and specialist centre facilities• In some areas the Network is still falling short of treatment targets• A need to develop preventative services whilst moving towards treatment targets• A challenge in providing excellent efficient systems of care in a health economy in which all of its acute hospital providers are Foundation Trusts. The challenge being to work collaboratively as a network whilst recognising the nature of the business environment that we are now in.The strategy is based on the need to achieve many national targets. These are listedat appendix A. The strategy builds on the work already undertaken by the Networkover the past few years. A review of the implementation of the Cardiac Strategy2003-2006 is at appendix B.1.3 InvolvementPatient services must deliver what patients need, and so must provide a patientcentred service. The duty to involve and consult patients was set out in Section 11 ofthe Health and Social Care Act. This places a duty on NHS trusts, Primary CareTrusts and Strategic Health Authorities to make arrangements to involve and consultpatients and the public in service planning and operation, and in the development ofproposals for changes./home/pptfactory/temp/20101206092607/download1909.doc 6
  7. 7. In March 2008 a User Group was formed and since then has been working as apartner with the Network Board. The role and function of the User Group is to addpatient and carer view to the decision making/commissioning process of the NorthTrent Network of Cardiac Care. Members of this group have access to wider patientsupport groups and seek their views and opinions on service strategies and plans.1.4 ConsultationAs part of the development of this strategy, users of cardiac services were involved ina listening event to give their views on cardiac services and how they should bedeveloped. Also the views of the Network User Group have been used to shape thedevelopment of the strategy.The North Trent Network of Cardiac Care have produced this 2008 version of thestrategy document for consultation with all Network stakeholders. The consultationsupplements the consultation that took place from July to September 2007, theoutcome of which has been used to produce this revised versionThe consultation took place in accordance with guidance on public consultationprocesses has been published by the Cabinet Office. This guidance sets out sixconsultation criteria:• Consult widely throughout the process, allowing a minimum of 12 weeks for written consultation at least once during the development of the policy.• Be clear about what your proposals are, who may be affected, what questions are being asked and the timescale for responses.• Ensure that your consultation is clear, concise and widely accessible.• Give feedback regarding the responses received and how the consultation process influenced the policy.• Monitor the effectiveness at consultation, including through the use of a designated Consultation Coordinator.• Ensure your consultation follows better regulation best practice, including carrying out a Regulatory Impact Assessment if appropriate.The consultation period took place for twelve weeks starting from Monday22nd September 2008. During this time Network Stakeholder PCTs consulted on theCardiac Strategy. This consultation included:• Trust Boards• Professional Executive Committees• Overview and Scrutiny Committees• CHD/CVD Boards (or equivalent)• Local User Groups• Cardiac Groups• General Public• Local Provider OrganisationsThe feedback received from the consultation has been included in and used to shapethe strategy. Details of the consultation and the feedback can be found at appendixC./home/pptfactory/temp/20101206092607/download1909.doc 7
  8. 8. 1.5 Equality Impact AssessmentEquality Impact assessments (EIA) are a way of examining the main functions andpolicies of an organisation to see whether they have the potential to affect peopledifferently. Their purpose is to identify and address real or potential inequalitiesresulting from policy and practice development. EIA cover all the strands of diversityand ensure that all receive equitable attention.A EIA has been undertaken on this strategy and has been consulted upon within theNetwork. The detailed is found at appendix E The output of the assessment has beenwoven into the strategy and is cross referenced with the EIA1.6 Health Inequality Impact AssessmentHealth Inequalities Impact Assessment (HIIA) is a process used determine how achange in policy, or the development of strategy, plans, programmes or a project,may have an effect on the health of a population. HIIA assesses how particulardecisions may affect these determinants and, thereby, the likely impact on the healthand wellbeing of different groups (defined by demography and/or geography) in apopulation.A HIIA has been undertaken on this strategy and has been consulted upon within theNetwork. The detailed is found at appendix D. The output of the assessment hasbeen woven into the strategy and is cross referenced with the HIIA./home/pptfactory/temp/20101206092607/download1909.doc 8
  9. 9. PART B. APPROACH TO DELIVERY OF THE STRATEGY2In delivering the strategy set out in this document the Cardiac Network is committedto:• Patient and the public views being central to the planning and delivery of Cardiac Services across the Network.• Focusing on developing services that meet the health needs of the population.• Focusing on the prevention of cardiac disease as well as delivery of cardiac services• Providing the best clinical care as local to the patient as possible but in specialist centres where necessary.• Ensuring that patients, carers and their families feel supported and cared for throughout the patient pathway• The development of Cardiac Services that will be underpinned by the principles of World Class Commissioning./home/pptfactory/temp/20101206092607/download1909.doc 9
  10. 10. 3 PART C. EPIDEMIOLOGY3.1 IntroductionThis section sets out: • The population of North Trent (2007) and predicted population trends • Prevalence of risk factors for cardiovascular disease in North Trent • Prevalence of cardiac disorders in North Trent • Mortality from cardiovascular disease, coronary heart disease and acute Myocardial infarction • Inequalities in cardiac outcomes and access to treatment.3.2 BackgroundCardiovascular disease (CVD), that is diseases of the heart and vascular system arestill the main cause of death in the UK. More than one in three people (37%) die fromCVD. The main forms of CVD are coronary heart disease (CHD) and stroke. CHD byitself is the most common cause of death in the UK. Around one in five men and onein six women will die from the disease. At age 50 a woman has a 40% chance ofdying form coronary heart disease this is higher than the chance of her dying formbreast cancer.Mortality (death) rates from cardiovascular disease have been falling in the UK sincethe early 1970s, although mortality rates from coronary heart disease are still high byinternational comparison. For people under 75 years, mortality rates have fallen by38% in the last ten years. Yet, in the UK, cardiovascular disease still causes 32% ofpremature deaths (death before the age of 75) in men and 24% of premature deathsin women. Nationally there are still marked inequalities in cardiovascular diseasemortality and morbidity, with the highest mortality rates in the North, urban areas,deprived areas and areas with a high South Asian population. Coronary heartdisease is still a major cause of excess winter mortality.The headline indicator for cardiovascular disease is PSA1 (Public ServiceAgreement) to Substantially reduce mortality rates by 2010:from heart disease andstroke and related diseases by at least 40% in people under 75, with a 40% reductionin the inequalities gap between the fifth of areas with the worst health and deprivationindicators and the population as a whole.3.3 GeographyThe North Trent Cardiac Network covers six Primary Care Trusts (PCTs), Barnsley,Bassetlaw, Doncaster, Rotherham, Sheffield and part of Derbyshire County PCT.Three of these PCTs (Derbyshire County, Doncaster and Sheffield) were reorganisedin 2006. These changes to PCT boundaries make attributing data to organisations orlocalities difficult so the data below particularly for the northern part of DerbyshireCounty PCT need to interpreted cautiously.3.4 PopulationIn 2007 almost 1.8 million people were registered with a GP within the North TrentCardiac Network. The following table provides a population breakdown by PrimaryCare Trust.11 Source: attribution data set of GP registered populations 2007/home/pptfactory/temp/20101206092607/download1909.doc 10
  11. 11. DoncasterBarnsley 230,435 BarnsleyDoncaster 292,529Bassetlaw 106,387Rotherham 243,741 Sheffield RotherhamSheffield 529,776 BassetlawAttributed from 370,400Derbyshire County North DerbyshireTotal 1,773,268 The Office of National Statistics (ONS) predicts that the population in Yorkshire and Humber will grow by 14% over the next 20 years but that over the next 5 years only 2-3% population growth (55,000 people) is expected.However, the population groups with the highest levels of coronary heart disease,those over 65 will increase significantly over the next 20 years. The number of peopleaged over 65 is expected to increase by 53% by 2031. By 2031 this could lead to: • 44% increase in number of cases of coronary heart disease • 54% increase in number of cases of heart failure • 46% increase in number of cases of atrial fibrillation By 2015 the Network could see an 11% increase in coronary heart disease, ranging from 5.4% in Sheffield to 14% across Doncaster and Bassetlaw.3.5 Risk factorsSome risks factors for heart disease are not modifiable including age, gender,ethnicity and genetic make up. There are other risk factors that are modifiable andthese include lack of physical exercise, poor diet high blood pressure, cigarettesmoking, obesity, diabetes and excessive alcohol consumption. The Health Surveyfor England has been used to indicate the prevalence of these risk factors locally.North Trent as a whole and South Yorkshire in particular has high rates of smokingand obesity and low rates of physical activity and healthy eating. An increasingnumber of non-traditional risk factors are being recognised including psycho-socialrisk factors and levels of particulate air pollution./home/pptfactory/temp/20101206092607/download1909.doc 11
  12. 12. Prevalence of risk factors by PCTPrevalence (%) of Risk Factors Smoking 2000- Alcohol1 Obesity1 Fruit & Vegetable Physical Hypertensionby PCT (pre october 2006) 021 consumption5 Activity6 Index (BMI) > sensible daily 2 7 Body Mass 3 3 estimates3 estimates3 3 prevalence prevalence nominally synthetic synthetic synthetic synthetic synthetic estimates estimates estimates % above inactive 4 active active limits 30 Persons Persons Persons Adults Children Persons PersonsENGLAND 26.5 25.8 37.2 18.2 21.4 22.1 23.7 37.5South Yorkshire SHA 28.6 37.2 19.6Trent SHA 27.1 35.1 25.1Barnsley 34 32.8 20.7 25.4 12.9 20.0 43 35 22 24.5Doncaster Central 32 31.2 20.0 23.8 14.5 24.1 47 32 21Doncaster East 28 27.9 19.4 23.7 16.4 25.8 47 32 21 24.4Doncaster West 34 32.7 20.8 26.6 11.8 20.0 47 32 21Rotherham 32 29.2 20.3 24.9 15.5 24.2 45 30 25 24.3North Sheffield 38 33.8 19.0 25.7 12.7 22.4 41 35 24Sheffield South West 24 21.1 22.8 18.6 27.7 45.6 41 35 24 23.3Sheffield West 29 25.0 27.6 20.4 22.6 38.0 41 35 24South East Sheffield 35 31.9 19.5 25.0 14.7 24.1 41 35 24Bassetlaw 29 28.0 16.0 27.5 19.6 30.9 25.4Chesterfield 32 27.9 16.7 24.4 20.6 29.4High Peak and Dales 25 20.8 16.2 23.8 23.8 35.5 25.7North Eastern Derbyshire 30 26.6 16.2 25.7 19.2 31.31 England and SHA person (aged over 16) percentages from Health Survey for England 2000-2, age-standardised by year (3-year2 PCT person (aged over 16) percentages from Smoking Epidemic in England HDA 2004 (http://www.hda-online.org.uk/Documents/smoking_epidemic.pdf)3 synthetic estimates "given the characteristics of the local popualtion we would expect a prevalence of approximately x%", Health and SocialCare Inforamtion Centre (HSCIS). Model generated from Health Survey for England and 2001 Census.4 4+ units for men and 3+ for women Significantly better than National Estimates5 percentage eating 5 or more portions of fruit and vegetables per day Overlapping National Estimates6 data from MORI poll. Data for S Yorkshire health communities Significantly worse than National Estimates7 Estimates of the expected prevalence of hypertension and coronary heart disease www.apho.org.uk/apho/models.aspx Over 190,000 people in the Network have a Cardiovascular Disease (CVD) risk greater than 1.5% per year. Health Community Persons with CVD risk greater than 1.5% pa Barnsley 24,611 Doncaster 32,087 Rotherham 26,010 Sheffield 54,297 Bassetlaw 11,932 Northern Derbyshire 43,818 Network 192,750 /home/pptfactory/temp/20101206092607/download1909.doc 12
  13. 13. 3.6 Prevalence of Cardiac ConditionsOver 80,000 people in the North Trent Network suffer from Coronary Heart Disease(CHD). The prevalence of CHD varies from 4.4 % in Sheffield to 5.1% in Barnsley.Estimated prevalence of CHD and heart Failure for new PCTs (based on 2006 data). Expected Expected Prevalence of Estimated incidence (1st incidence atrial Registered Prevalence of number ofPCT presentation) (1st fibrillation population CHD people with CHD per presentation) CHD annum heart failureBarnsley 238,796 5.1% 12,197 468 260 2,928 522 3,803Doncaster 305,616 4.9% 15,104 925 1,405Bassetlaw 108,530 5.0% 5,386Rotherham 253,837 4.8% 12,133 496 275 3,078Sheffield 549,020 4.4% 23,950 990 607 6,676Attributed toNorthernpart of 370,400 4.9% 18,029 759 443 5,286DerbyshireCountyNorth TrentNetwork 1,826,199 4.75% 86,799 3629 2101 23,176Total • In addition to CHD, heart failure and arrhythmias including atrial fibrillation, valvular heart disease and congenital heart disease contribute to the burden of disease. • The prevalence of valvular heart disease in the population is estimated at 0.7% for 18-44 year olds and up to 13% for those over 75. • In 2000 there were over 3,300 adults with congenital heart disease in South Yorkshire alone. This will increase by 2010 to over 4,000./home/pptfactory/temp/20101206092607/download1909.doc 13
  14. 14. 3.7 Mortality from All Circulatory Disease Mortality rates from cardiovascular disease in North Trent continue to fall. However, rates in most localities are above the England average. Men still have twice the rates of cardiovascular disease than women. If progress continues at the current rate all South Yorkshire communities will hit their targets for cardiovascular disease mortality. Chart 1. Under 75 years Mortality from All CirculatoryDirectly Age-Standardised (DSR) rates per 100,000 European std population 180 160 140 120 100 1997-1999 2000-2002 80 2003-2005 60 40 20 0 ENGLAND Barnsley Doncaster Rotherham Sheffield Chesterfield High Peak North East Bassetlaw Derbyshire Circulatory Disease Mortality Rates, 1993-2010 South Yorkshire and England & Wales 220 Rate per 100,000 resident population 200 180 160 140 120 100 80 60 40 20 0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year E&W Rate S Yorkshire Rate Baseline (1995-97) OHN Target Forecast 95% Forecast Interval E&W Forecast /home/pptfactory/temp/20101206092607/download1909.doc 14
  15. 15. 3.8 Mortality from Coronary Heart Disease and Myocardial InfarctionMortality across the Network continues to fall. May PCTs now have mortality belowthe Yorkshire and Humber average. However there is still variation across theNetwork and some rates are still above the average for England. under 75 m ortaltiy from CHD (all people) 100.00 90.00 80.00 70.00 PERSONS 2002 60.00 PERSONS 2003 50.00 PERSONS 2004 PERSONS 2005 40.00 PERSONS 2006 30.00 20.00 10.00 0.00 ENGLAND AND YORKSHIRE Basset law PCT Rot herham Barnsley PCT Shef f ield PCT Doncast er PCT Der byshir e WALES AND THE PCT Count y PCT HUMBERIn all areas mortality from acute myocardial infarction has fallen in line with the fall inoverall coronary heart disease mortality. However, there is greater variability in therates across North Trent for mortality from acute MI than all coronary heart disease. Under 75 Mortality from acute MI 120.00 100.00 80.00 1997-99 60.00 2000- 02 2003- 5 40.00 20.00 0.00 ENGLAND Bar nsley Doncast er Rot herham Shef f ield Chest erf ield High Peak Nor t h East Basset law Der byshire3.9 Geographical and Deprivation DifferencesAlthough the mortality rates for health communities are falling, whole districts mayimprove the average mortality rate but still see the inequality gap between the mostand least deprived parts of their population widen. Across South Yorkshire, Barnsleyand Sheffield have made significant progress in closing their inequalities gap, there isno significant gap in Doncaster, but the gap in Rotherham remained./home/pptfactory/temp/20101206092607/download1909.doc 15
  16. 16. Circulatory disease mortality rates 300 Mortality rate per 100,000 population 250 200 150 100 50 Whole communities Deprived quintile 0 Barnsley Barnsley Doncaster Doncaster Rotherham Rotherham Sheffield Sheffield 1995-97 2002-04 1995-97 2002-04 1995-97 2002-04 1995-97 2002-043.10 Gender DifferencesMale mortality from CHD is still over twice that of female mortality and the samegeographical pattern remains. Male under 75 CHD m ortality 200.00 180.00 160.00 140.00 120.00 1997-99 100.00 2000- 2002 2003- 2005 80.00 60.00 40.00 20.00 0.00 ENGLAND Barnsley Doncast er Rot her ham Shef f ield Chest er f ield High Peak Nort h East Basset law Derbyshire/home/pptfactory/temp/20101206092607/download1909.doc 16
  17. 17. Fem ale under 75 CHD m ortality 70.00 60.00 50.00 40.00 1997-99 2000- 2002 30.00 2003- 2005 20.00 10.00 0.00 ENGLAND Bar nsley Doncast er Rot her ham Shef f ield Chest er f ield High Peak Nort h East Basset law Derbyshire3.11 Age DifferencesPublished studies conclude that age inequalities exist. Older CHD patients are 60%less likely to receive secondary prevention particularly statins than younger patients.The possibility of age inequalities across North Trent needs to be explored.3.12 Ethnic DifferencesSouth Asian people are 50 per cent more likely to die prematurely from coronaryheart disease than the general population. The prevalence of stroke among AfricanCaribbean and South Asian men is 40 per cent to 70 per cent higher than for thegeneral population.3.13 ConclusionsCardiovascular diseases are still a major cause of mortality and morbidity across theNetwork. However mortality rates are falling and most districts will have mortalityrates below the national average by 2010. In almost all areas inequalities bothbetween and within health communities have narrowed. These gains have arisenquickly and can be explained by the more systematic use of medical technologyincluding the acute treatment of heart attacks, secondary prevention (includingaspirin and statin prescribing) and in some cases revascularisation. Long term gainswill only be realised by addressing both immediate risk factors (e.g. smoking,physical activity) and the wider determinants of health including poverty, deprivation,housing, unemployment, mental health the built environment and work related health.The reduction in mortality together with the leveling off of revascularisation activitysuggests that the current capacity is sufficient to meet the current demand. Forecastincreases in the incidence of cardiovascular diseases as the population ages willneed to be considered carefully in any service change as these individuals may beidentified earlier and therefore adequately treated with lifestyle interventions andmedical therapy and may not need the same rates of revascularisation./home/pptfactory/temp/20101206092607/download1909.doc 17
  18. 18. 4 PART D. PREVENTING CARDIAC DISEASE AND REDUCING MORTALITY4.1 IntroductionIn recent years the Network has focused on improving the delivery of cardiacservices and in particular those services that are provided in secondary and tertiarycare. All network stakeholders, including the patients and the public, agree thatensuring that cardiac disease is prevented is very important. This strategy thereforepresents a shift in focus from development and improvement of service provisionalone to one which has much greater emphasis on preventing cardiac disease.In the past two main policies have set out the national approach to the prevention ofCHD; The National Service Framework for Coronary Heart Disease (2000) sets fourkey standards:• Standard One – The NHS and Partner agencies should develop, implement and monitor policies that reduce the prevalence of coronary risk factors in the population and reduce inequalities in the risk of developing heart disease• Standard Two – The NHS and partner agencies should contribute to a reduction in smoking in the local population.• Standard three –. General Practitioners and primary care teams should identify all people with established cardiovascular disease and offer them comprehensive advice and appropriate treatment to reduce their risks• Standard four - General Practitioners and primary care should identify all people at significant risk of Cardiovascular disease but who have not yet developed symptoms and offer then appropriate advice and treatment to reduce their risks.Our healthier nation (1999) sets the following target for reduction in premature deathsfrom the baseline year of 1996 to 2010:-• Target: to reduce the death rate from coronary heart disease, stroke and related disease in people under 75 years by at least two fifths by 2010.Very recently two further publications update and bring greater focus to theprevention agenda• NICE Lipid management• NICE (other)• Vascular ScreeningThe Network considers primary prevention as a priority area in reducing andmanaging CVD across North Trent. It is important to have a coherent and consistentapproach to tackling identification and treatment of those people who are most at riskof a cardiovascular event for all cardiac pathways. It will delay and reduce the impactof an event and identify those people (with risk factors), who perhaps do not visit theirGP frequently, yet would benefit from preventative interventions.4.2 Using Practice Registers to Identify ‘At Risk’ PatientsThe establishment of registers for people who had symptoms of coronary heartdisease was set out as an early standard for the Coronary Heart Disease NationalService Framework. As was development of registers of those people who are athigh risk. The purpose of these standards was to support implementation of early/home/pptfactory/temp/20101206092607/download1909.doc 18
  19. 19. prevention; allowing appropriate treatment to be provided. Both these standardsshould be reflected in Primary Care Trust (PCT) Local Delivery Plans.The Network advocates that the most effective tool for achieving early detection andtreatment of people with, and at risk of, cardiovascular events is interrogation ofpractice based CVD registers to identify and target those ‘at risk’. In addition, theNetwork recommends a collaborative approach; fully utilising the multiple agencieswith primary prevention roles, in order to achieve a joined up approach.4.3 Cardiovascular Disease High Risk FrameworkThe Network aims to support PCTs to reduce deaths from cardiovascular disease.This will include the development of a high level plan which identifies best practice toaid the achievement of national and local targets, and key milestones for reducingdeaths from cardiovascular disease; and to promote a consistent multidisciplinaryapproach to the personalised management of people with established CHD, andothers at high risk of developing symptomatic CHD and related illness.4.4 Lifestyle InterventionsThe Network endorses an increasing focus on lifestyle determinants of coronaryheart disease and cardiovascular disease. Key lifestyle indicators include: supportinga reduction in smoking prevalence, reduction in salt intake, promotion of physicalactivity, improve diet as contributors to reduced obesity and a reduction in excessivealcohol consumption. Promotion and support of such interventions at a local level(through, for example, primary care based risk registers, accurate recording ofsmoking status and the delivery of brief interventions by the primary care team) arekey to implementing effective interventions.The Network will support such initiatives by developing guidelines for primary caretrusts, practice based commissioning consortia and GP practices on strategiesinitiatives likely to reduce the prevalence of cardiac disease and to reduceinequalities. They will also, where required, be a key resource to facilitating thedelivery of such initiatives.4.5 Statin PrescribingFor England and Wales, the use of statins for primary prevention and treatment forhypertension was estimated to save 19343 life years from deaths averted in the year2000, or around 10% of life years gained from interventions for CVD. Secondaryprevention for patients following MI, CABG or angioplasty was estimated to save62182 life years from deaths averted in 2000, or approximately 32% of life yearsgained from interventions for CVD.Statin therapy is recommended as part of the management strategy for the primaryprevention of cardiovascular disease in adults who have a 20% or greater 10 yearrisk of developing CVD. North Trent Network has been identified as above currentnational percentages of low cost statin prescribing. PCTs need to continue their focuson this issue and to ensure that maximum benefit of statin prescribing is delivered toall those who require it.4.6 Wider Determinants of HealthThere wider determinants of health (poverty, unemployment, housing, education etc)all contribute to heart health. Both structural and psycho-social causes need to beaddressed and the network will need to consider how best to engage with thisagenda./home/pptfactory/temp/20101206092607/download1909.doc 19
  20. 20. 4.7 Key ActionsIn 2008 the Network will plan and deliver a North Trent Primary Prevention Projectthat:• Recommends a total risk approach to CHD risk assessment for the systematic identification of people at high risk of CHD, incorporating the risk assessment of the asymptomatic population.• Defines lifestyle and risk factor interventions with thresholds and targets which reflect the growing scientific evidence base for managing high risk people.• Provides a Network wide baseline position of our primary prevention activities both in existence and plans for the future.• Identify any practical support which the Network can offer to health communities.• Recommend a Network wide minimal set of standards of care• Considers how best to involve the Network with the wider determinants in health where it could add value.• Action to reduce health inequalities: o Ensure that that the plans for best practice identify how best to achieve reducing CHD mortality and preventing the development of CHD in the hard to reach groups o Patient and public information is provided in appropriate formats and languages/home/pptfactory/temp/20101206092607/download1909.doc 20
  21. 21. 5 PART E – STRATEGY FOR DEVELOPING CLINICAL SERVICES5.1 Process for Planning DevelopmentsThis section identifies a number of areas of cardiac services that requiredevelopment. Each of these will have been or be currently subject to rigorousexamination by the Network. This process includes the development of evidencebased service specifications, cost benefit analysis, capacity and demand analysis,development of models for service delivery and development of a business case.Subsequently the Network will take a decision on whether to support thedevelopment, the priority that should be placed on the development and will makerecommendations to this effect to Yorkshire and the Humber SCG and Collaborative(South).When cases have been agreed by Yorkshire and the Humber SCG and Collaborative(South).these will be fed into the Local Delivery Plan (LDP) cycle. The Network willthen be responsible for monitoring performance against activity planned in theNetwork’s LDP.The Network Cardiac Commissioning Group will monitor performance information toestablish performance against planned target and work with providers to ensuretargets are met.5.2 Summary of Service Provision BHFT CRHFT DBHFT RHFT STHFT Secondary and Tertiary ServicesServices provided by the DGHs:• Acute Cardiac Care     • Diagnostic Catherisation     • Pacing o Implantation      o Follow up     • Echocardiography      o Open Access     Rapid Access Chest Pain Clinic     Arrhythmia Clinics     Coronary Care Unit     Trans-oesophageal Echocardiography P    On call rota Specialised Services currently provided by the tertiarycentres• Cardiac Surgery • Interventional Cardiology Techniques • Coronary Angioplasty # # # # • Stent implantation • Percutaneous balloon valvuloplasty • Atrial septal defect closure • Complex ElectrophysiologyAblation /home/pptfactory/temp/20101206092607/download1909.doc 21
  22. 22. Biventricular Pacing # # # # Implantable Defibrillators # # # # • Specialised investigation techniquesCardiac MRI CNuclear or Positron Emission tomography scanning C• Highly Specialised ServicesTransplantation o Assessment  o Surgery  o Follow up Treatment of adults with Congenital Heart Disease Paediatric Services On call rota 24 hours a day/ 365 days a year WorkforceNumber of wte Cardiologists 2 3 5 2 16 (+2) (+1)Number of wte Cardiac Surgeons 8Key: = provided  = not provided P = planned C = currently not provided but consideration needsto be given to future provision # = where services are not being provided but trusts are consideringwhether to develop them/home/pptfactory/temp/20101206092607/download1909.doc 22
  23. 23. 5.3 Acute Coronary Syndrome and Stable Angina5.3.1 An Overview of the Development of Services for ST Segment Elevation Myocardial Infarction (STEMI)An Acute Myocardial Infarction or ST Segment Elevation Myocardial Infarction(STEMI) is the most severe type of heart attack. Approximately 800 patients haveSTEMIs each year in North Trent.Most patients who have a suspected STEMI are seen at their local District GeneralHospital (either to the A&E department or to the Coronary Care Unit). Here, ifappropriate, patients are given a thrombolytic drug. The target is to give this drugwithin one hour of onset of symptoms (the call to needle time target).Thrombolytic drugs can also be given by appropriately trained paramedics (pre-hospital thrombolysis) before being transported to their local hospital. Whilst pre-hospital thrombolysis is available to the Bassetlaw and Derbyshire County, pre-hospital thrombolysis is not yet provided in South Yorkshire.After discharge from hospital following treatment of STEMI with thrombolysis, a largenumber of patients will be followed up with an outpatient attendance, an electiveangiogram and then an angioplasty. It is estimated that approx 25% of STHFT’selective angioplasty workload relates to this group of patients.A Primary Angioplasty (syn. Primary Percutaneous Coronary Intervention or PPCI) isan interventional cardiology procedure that is now considered to be superior tothrombolysis for the treatment of STEMI. There is a strong evidence base thatproviding angioplasty rather than thrombolysis as first line treatment for STEMI willreduce the number of deaths, reduce the risk of stroke in these patients and preventthe need for further treatment downstream.In Mending Hearts and Brains – the Clinical Case for Change (December 2006),Professor Roger Boyle, National Director for Heart Disease and Stroke set out thecase for changes to the emergency management of acute myocardial infarction. Theservice model proposed involves reorganisation of services so that patients sufferingfrom a STEMI are triaged by paramedics and where appropriate are transporteddirectly to regional heart attack centres for a primary angioplasty. This has beenendorsed by the Y&H Strategic Health Authority in their response to the DarziReview, Healthy Ambitions.Following an 18 month pilot in April 2008 a Primary Angioplasty service wascommissioned for all appropriate patients who present with symptoms whilst in theSheffield area. This is a 24 hour a day 365 day a year service. It has now beenrolled out to the Rotherham area too.Within the Network therefore there is currently a range of different types of care forpeople with heart attacks. In summary, service provision for care of people withSTEMI at August 2008 was:/home/pptfactory/temp/20101206092607/download1909.doc 23
  24. 24. Rotherham PCT Sheffield PCT Bassetlaw PCT Barnsley PCT PCTDerbyshire County Doncaster PCT• Prehospital Thrombolysis      • Hospital Thrombolysys      • Primary Angioplasty  It is difficult to forecast exact numbers but, Network wide, it is estimated that up to800 patients per annum could benefit from Primary Angioplasty. This would include:• Better patient outcomes from best modern treatment• Improved revascularisation rates for the Network• Leaner care pathway would speed up patient treatment times• Leaner care pathway would reduce the number of admitted patient spellsIn October 2007 the Y&H SCG (South) acknowledged the need for primaryangioplasty and that there should be one provider, Sheffield Teaching Hospitals. Itwas agreed that a clear care pathway needed to be developed to ensure equity ofaccess.In consulting with the public and patients, a ‘Heart Attack Centre’ at the SheffieldTeaching Hospital was positively received by patients from all areas of the Network.The main concern patients and the public had, was about visiting arrangements forfamily and friends who have to travel a long way (this is dealt with in section F).There is an acknowledgement that for a small number of patients PrimaryAngioplasty may not be suitable and that in this instance pre hospital thrombolysisshould be considered. The Network therefore plans to extend access to the PrimaryAngioplasty as part of a ‘mixed economy’ of primary angioplasty and pre hospitalthrombolysis across the whole of the Network population.5.3.2 An overview of the future need for RevascularisationThe Coronary Heart Disease National Service Framework (NSF) set targets in 2000for coronary revascularisation at 1,500 per million population (pmp). Initially thistarget was distributed evenly between percutaneous coronary intervention (PCI) andcoronary artery bypass grafting (CABG). Subsequent increases to the target havebeen advocated by the British Cardiovascular Interventional Society (BCIS) and thetarget has been proposed to be as high as 2-3,000 pmp. This BCIS target would seethe UK have similar rates to other European countries.The number of revascularisations required should be related to the level of need inthe population. However, the original assumptions behind the 1,500 pmp target werenever made explicit. Although revascularisation rates have increased they haveplateaued in recent years and the current North Trent Cardiac Network rate is in theorder of 1,300 pmp. In the face of increased revascularisation capacity and rapidlydeclining coronary heart disease mortality rates this calls into question whether the1,500 pmp or even 2-3,000 pmp targets are still realistic./home/pptfactory/temp/20101206092607/download1909.doc 24
  25. 25. A number of models, including Martin et al were produced following the 2000 targetto make some of the assumptions behind the target explicit. Revascularisation ratesbetween 555 pmp (current 1998 practice) and 1861 pmp (model of need), with amaximum sensitivity of 2626 pmp (model of need) were predicted. However, anumber of the assumptions of the model have changed and some of the reasons foroverestimating the number have been eliminated.These include • Falling rates of CHD mortality and incidence of chronic stable angina • Aggressive medical management has been instituted • Change in case mix with a greater proportion of mild angina therefore not appropriate for revascularisation • No backlog of patients waiting to be referred to secondary care • No backlog of patients waiting for revascularisationAn update of the Martin model would predict the population need for coronaryrevascularisation to be 1,300 pmp, with the roll out of primary PCI rates totalrevascularisation rates may approach 1,400 pmp, with an upper sensitivity estimateof 1,625 pmp. This update also has limitations as it does not adjust for changingclinical practice, technological improvements, does not dictate how revascularisationshould be distributed between PCI and CABG or how revascularisation servicesshould be organised.5.3.3 Development of a Network Wide Primary Angioplasty for ST Segment Elevation Myocardial Infarction (STEMI)Early in 2008 the Network drew up service specification that laid out thecommissioner specification for the provision of all angioplasty services includingprimary angioplasty services to the population of North Trent.A primary angioplasty working group was established early in 2008. This group leadby an interventional cardiologist with a special interest in Primary Angioplasty andhas representation form all stakeholder organisation and professional groups. Itspurpose is to provide the Network Board with advice and recommendations on thedevelopment of the pathway, clinical governance and the mechanism forimplementation of plans. In addition the Network User is advising the board of theirview on the development of plans.The proposed pathway for the care of patients presenting with a STEMI is as follows• In the future emergency treatment for STEMIs will be provided at the Northern General Hospital in Sheffield.• This means that all suitable patients from across South Yorkshire, Bassetlaw and North Derbyshire will be taken directly by ambulance to the Northern General Hospital, assessed for suitability for angioplasty and where appropriate have the procedure immediately• When patients have recovered sufficiently they will be taken to their local district general hospitals to be cared for until well enough to go home. Patients who live in Sheffield will remain at the Northern General HospitalsOutline pathway for treatment of STEMI./home/pptfactory/temp/20101206092607/download1909.doc 25
  26. 26. Symptoms of a Heart Attack 999 Call Not suitable for angioplasty. Assessment Assessment by the ambulance crew and delivery of pre hospital thrombolysis for Primary Angioplasty if appropriate. Taken to Heart Attack Centre – Sheffield Teaching Hospital Primary Angioplasty Inpatient care at Heart Attack Centre Patient assessed as stable Patient transferred to local District General Hospital for further care as neededThis pathway will be rolled out to the North Trent population according to thefollowing timetable:Rotherham PCT March 2009Barnsley PCT May 2009Doncaster PCT July 2009Bassetlaw PCT September 2009Derbyshire County PCT September 2009Please note that his is a challenging timetable intended to ensure swift delivery.5.3.4 Thrombolysis for the Treatment of ST Segment Elevation Myocardial Infarction (STEMI)Whilst Primary Angioplasty is the preferred treatment for STEMI there will beinstances where thrombolysis is indicated. The Network will therefore retain thecapability of delivering hospital thrombolysis and develop the paramedic skills indelivery of prehospital thrombolysis where appropriate. All patients with the indicationfor thrombolysis (and no contraindications) should receive this treatment by the firstavailable qualified person able to provide care within 60 minutes of the call for help./home/pptfactory/temp/20101206092607/download1909.doc 26
  27. 27. 5.3.5 Elective and Urgent Revascularisation for the Treatment of Acute Coronary Syndromes and AnginaElective revascularisation may be indicated in the treatment of stable Angina. TheNSF for CHD stated ‘people with symptoms of angina or suspected angina shouldreceive appropriate investigations and treatment to relieve their pain and reduce theirrisk of a coronary event’. Patients should expect to receive treatment to relievesymptoms and to reduce cardiovascular risk. Referral for elective angiography forpatients who may require revascularisation should occur in patients who have • evidence of existing ischaemia • angina that persists despite optimal medical therapy and lifestyle adviceHowever a recent evidence published in the BMJ suggest that in some patients withstable coronary heart disease, cardiac surgery may be more cost effective thanangioplasty but the latter is much less invasive and effective at relief of symptoms inappropriately selected patientsA review the decision making pathway is required to ensure that the correct care isprovided for stable coronary heart disease will be undertaken.Urgent revascularisation can be indicated in the treatment of non ST segmentelevation myocardial infarction (NSTEMI) and unstable angina (UA). In the firstinstance patients should be admitted as an emergency/urgent case for bed rest, painrelief, thrombolytics, and anti-ischaemic medication. Following this, patients shouldexpect to receive treatment to relieve symptoms and to reduce cardiovascular riskand assessment of the potential benefit of revascularisation. Arrangement should bein place for all patients to receive systematic rehabilitation and prevention.5.3.6 Development of Elective Angioplasty ServicesAngioplasty services in the Network are provided at Sheffield Teaching HospitalFoundation Trust (STHFT). The annual cost of angioplasty in North Trent isapproximately £6 million per year.The Network is developing a strategy for the future delivery of angioplasty across theNetwork in which it is considering the development of primary angioplasty, nonelective and elective angioplasty. As part of this it is considering if and when it wouldbe appropriate to consider a further angioplasty centre within the Network.Developing the strategy raises the challenge of providing services that are in the bestinterest of the patients but in a health economy where organisations have to considerbusiness opportunities and threats. Whilst the Network is supportive of the concept ofestablishing a DGH angioplasty service in the future, the development of DGHangioplasty services needs to considered in the following context:• The falling number of angioplasties required over recent years.• The impact of withdrawing angioplasty activity on STHFT.The Network will consider cases for the development of angioplasty services inDGHs that meet the North Trent Angioplasty Service Specification following this,agreement will be subject to commissioner consideration of the benefits and risks ofthe service development in wider context of Network service provision./home/pptfactory/temp/20101206092607/download1909.doc 27
  28. 28. 5.3.7 Development of the Elective Angioplasty PathwayCurrently all elective angioplasty takes place at STHFT. Patients are seen inoutpatient and have their angiography at their local DGH (for patients who live inSheffield this is STHFT). Patients who are identified as requiring an angioplasty areput on the waiting list for an angioplasty at STHFT. In some cases where it is notclear if a patient requires surgery or angioplasty a case may be reviewed at a Multidisciplinary Team Meeting (MDT). This involves a joint meeting of clinical staff fromthe DGH and STHFT. MDTs take place every 2-4weeks.The 18-week wait target applies to the elective angioplasty pathway. This poses achallenge to the Network as the pathway spans the boundaries of organisations.Please see section on the 18 week wait.5.3.8 Development of the Non Elective Angioplasty PathwayPatients with suspected Acute Coronary Syndrome ACS are admitted as an inpatientand undergo an urgent angiogram.The Network standards for treating patients with ACS are as follows:• All patients admitted to hospital with suspected ACS will be assessed by a Cardiologists within 24 hours. (Where this is not possible appropriate protocols must be in place).• All patients requiring urgent transfer from their DGH to STHFT for an urgent PCI will be transferred within 48 hours of the request. (Where this is not possible appropriate protocols must be in place).• All requests for transfer will be made by a Cardiologist.Currently a transfer to the tertiary centre is required for an urgent revascularisation tobe carried out. STHFT now guarantee the availability of an urgent angioplasty within48 hours for patients identified as needing an urgent revascularisation in both STHFTand the DGHs. In order to deliver this the ambulance service need to be able totransfer patients to meet the standard. STHFT will continue to provide urgentrevascularisation within 48 hours of being informed of the need.5.3.9 Development of the Coronary Artery Bypass Graft Provision (CABG) PathwayCoronary Artery Bypass Grafts (CABGs) are a revascularisation procedure. Currentlyall elective CABGs take place at STHFT. Provision of CABGs to the North Trentpopulation costs about £5 million pounds a year.Patients are seen in outpatients and have their angiography at their local DGH (forPatients who live in Sheffield this is STHFT). Patients who are identified as requiringa CABG are put on the waiting list for CABG at STHFT. In some cases where it is notclear if a patient requires surgery or angioplasty a case may be reviewed at an MDT.This involves a joint meeting of clinical staff from the DGH and STH that takes placeevery 2-4 weeks.The 18-week wait target applies to the elective surgery pathway. This poses achallenge to the Network as the pathway spans the boundaries of organisations.Please see section on the 18 week wait./home/pptfactory/temp/20101206092607/download1909.doc 28
  29. 29. 5.3.10 Key Actions • Commissioner sign off of the North Trent Angioplasty Service Specification by April 2008. • Development of a Primary Angioplasty Service based at Sheffield Teaching Hospitals Foundation Trust for the Sheffield PCT population in 2008/09. • Development of a Network Primary Angioplasty Roll-out Plan for delivering Primary Angioplasty (and thrombolysis where primary angioplasty is not appropriate) to the North Trent Population in 2008/09, with a view to rolling out Primary Angioplasty where agreed by 2010. • As part of the planning process undertaken a Equity and Health Inequalities Impact Assessment this will include o Plan to increase public awareness especially in vulnerable groups of symptoms of STEMI and the need to call for help immediately o Patient and public information in appropriate formats and languages o Development of a clear role out plan for Primary Angioplasty to the population of North Trent • A review of the use of angioplasty versus the use of cardiac surgery in the treatment of stable angina is required by end 2009. • Development of a strategy and plan for the future delivery of elective angioplasty services in 2008/09. This will provide a clear steer on the need for additional angioplasty centre(s) within the Network and feed into the LDP 2009/10 where appropriate. If an additional centre is required undertaken a Equity and Health Inequalities Impact Assessment this will include o Plan to increase public awareness especially in vulnerable groups of symptoms of STEMI and the need to call for help immediately. o Patient and public information in appropriate formats and languages o Plan to deliver an alternative high quality service to those patients who are not able to access angioplasty services. • Delivery of the 18 week wait target by December 2008 for elective angioplasty and the elective cardiac surgery pathways.5.4 Heart Failure5.4.1 BackgroundHeart failure is best defined as an inability of the heart to deliver blood (and oxygen)at a rate commensurate with the requirements of the metabolizing tissues, despitenormal or increased cardiac filling pressures. The condition assumed increasingimportance in the latter part of the Twentieth Century due to its increasingprevalence, high morbidity and mortality. The condition affects 1–2% of the generalpopulation with the rate rising to 10-20% amongst the elderly (>80 years) and thislatter group is growing in Western Europe and North America. Heart failure isassociated with a worse quality of life than most other chronic medical conditions andhas a high hospitalisation and re-hospitalisation rate, usually for a long period of time.Expenditure on heart failure in the United Kingdom accounts for 1-2% of the totalNHS budget.The prognosis of heart failure is uniformly poor if the cause is not, or cannot, berectified and it carries a higher mortality rate than many malignancies.The National Service Framework described the desired models of deliveringmultidisciplinary specialist services. It set milestones for achievement of the overallgoals for primary care teams and hospitals to ensure that all patients with heart/home/pptfactory/temp/20101206092607/download1909.doc 29
  30. 30. failure are receiving a full package of effective investigations and interventionsdemonstrated by clinical audit.In July 2003, the National Institute for Health and Clinical Excellence (NICE)published its Guideline on the Management of Chronic Heart Failure in Adults inPrimary and Secondary Care. This set out advice for best practice in the care ofadults with symptoms or a diagnosis of heart failure. The following priorities were setout:• All patients with suspected heart failure should be effectively diagnosed using recommended investigations (including echocardiography), and only those with a confirmed diagnosis should be managed in accordance with the remainder of the guideline• All patients with heart failure due to left ventricular systolic dysfunction should be considered for treatment firstly with an ACE inhibitor, and then with beta-blockers licensed for use in heart failure• All patients with chronic heart failure should be regularly monitored to detect and manage fluctuations in their clinical condition, thereby helping to avoid unnecessary admission to hospital• Patients with heart failure should only be discharged from hospital once their clinical condition has been stabilised and their management plan optimised. This plan must be shared with the primary care team, the patient and their carer• All patients should be supported, with their care management being seen as a shared responsibility between the patient and the healthcare professional5.4.2 Healthcare Commission ReviewIn 2006 the Healthcare Commission undertook a review of heart failure services aspart of a programme of service reviews. Each local community, comprising a PCTand the acute trusts received a detailed local assessment of their services, usingdata relating to 2005/06. They measured performance using a four-point scale of‘excellent’, ‘good’, ‘fair’ and ‘weak’. Of the 303 communities assessed, 9.2% scored‘excellent’ and 52.8% scored ‘good’. However, 29% of communities scored ‘fair’ and8.6% scored ‘weak’. See appendix F for further detail.Locally some health communities scored ‘fair’ or ‘weak’. Whilst the accuracy of thescoring system in reflecting the quality of service provision has been recognised asflawed, in these particular areas PCTs have action plans in place to addressperceived issues.5.4.3 Heart Failure in Secondary and Tertiary CareThe Network will develop a strategy for Heart Failure in secondary and tertiary care.Appendix G provides a summary of a detailed and comprehensive guideline on thediagnosis and management of heart failure written by Dr. A Al-Mohammad ofSheffield Teaching Hospitals NHS Trust.These clinical guidelines will be the basis upon which a strategy for servicedevelopment will be produced. The commissioning implications will need to bediscussed and agreed.5.4.4 Palliative Care ServicesThe aim of palliative care is to improve the quality of life for patients with incurabledisease. It also aims to improve the quality of dying and to ameliorate the potentiallydevastating effects of dying on the family and carers. There is substantial evidence/home/pptfactory/temp/20101206092607/download1909.doc 30
  31. 31. for considerable unmet palliative needs of patients and informal carers in heartfailure. The main areas of need include symptom control, psychological and socialsupport, planning for the future and end of life care.Our Health, Our Care, Our Say, a new direction for community services waspublished by the Department of Health in 2006. This White paper recognises theneed for additional support and services to enable people to die at home if that istheir preferred place of care. The need for further training for all staff to improve thecare of the dying patient is highlighted alongside the importance of using the end oflife tools to facilitate good care (Department of Health 2006).Heart Failure produces greater suffering and is associated with worse prognosis thanmany cancers. Yet patients with heart failure find that very little time is given toexploring their quality of life, their expectations and discussion of their prognosis(Supportive and Palliative Care in Heart Failure, NHS Modernisation Agency 2004).Most healthcare professionals will be involved in the care of patients who are in thepalliative stage of their disease. The National Council of Palliative Care published theresults of a 2006 National survey of Heart Failure nurses involvement in palliativecare. It found that 80% of heart failure nurses identified a need for palliative caretraining in, symptom control, communication skills and breaking bad news.In some non-malignant diseases, patients experience a less predictable illnesstrajectory. They are likely to experience episodes of acute deterioration on abackground of slower decline. It can be more difficult to predict the course of thedisease for these patients. The symptoms they are experiencing and any fears orconcerns should be elicited and priority given to addressing them (Murray, 2005;Lynn, 1997). Advance care planning is essential to understand the patient’s wishesand their understanding of the disease.The North Trent Network of Cardiac Care will hold an advanced care planning (PPC)training event in 2007. The training aims to aid implementation of PPC across theNetwork. The Preferred Place of Care Plan gives patients the opportunity to exploretheir quality of life, prognosis and their expectations.Following the Preferred Priorities of Care training event, a cascade model of trainingwas adopted across the Network.An audit will then be carried out by the Network to ensure implementation of thePreferred Priorities of Care Plan5.4.5 Cardiac Resynchronisation Therapy (CRT)Cardiac Resynchronisation Therapy (CRT) using a pacing device is recommendedas a possible treatment for people with heart failure.In 2003 NICE Clinical Guideline (CG05) said that for Chronic Heart Failure CRTshould be considered in selected patients with left ventricular systolic dysfunction (leftventricular ejection fraction = 35%), drug refractory symptoms, and a QRS duration >120 ms.In May 2007 NICE published Technology Appraisal (TA120) on CRT. Itrecommended CRT as a possible treatment for people with heart failure where all ofthe following circumstances apply./home/pptfactory/temp/20101206092607/download1909.doc 31

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