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  • 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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
  • 32. o They have moderate to severe symptoms of heart failure that are affecting their daily life, measuring class 3 or class 4 in the New York Heart Association classification system. o Their heart is beating regularly but an electrocardiogram (ECG) shows that the electrical system of the heart is not working properly. o The left ventricle of their heart is pumping out less than 35% of its normal amount of blood (called the left ventricular ejection fraction). o They are taking the drug treatment that is most effective for them.NICE said that a different type of pacing device, containing a defibrillator, may beconsidered for people with heart failure if: o Their heart failure is suitable for treatment with a pacing device – in other words, all the circumstances in the list above apply. o And it is also suitable for treatment with a device called an implantable cardioverter defibrillatorThe new NICE Guidance extends CRT significantly. NICE has advised theDepartment of Health that, because the recommendations in this guidance require anincrease in the number of cardiologists and clinical staff who are trained in CRT, andin the number of implantation centres, it will take 18 months (November 2008) for theNHS to be in a position to fully implement it.The TA120 template has been used to estimate the future need for CRT within theNetwork (see appended document for more detail). Future need is based on new andreplacement CRT-P and CRT-D./home/pptfactory/temp/20101206092607/download1909.doc 32
  • 33. In 2006/07 There were 36 CRT-P procedures undertaken (34 new, 2 replacements)and 29 CRT-D procedures undertaken (21 new, 8 replacements) at STHFT. TheNICE cost calculator estimates that by 2015 this Network will need to increase to 90CRT-P procedures (45 new, 45 replacements) and 238 CRT-D procedures (119 new,119 replacements). CRT-D and CRT-P actual and predicted activity requirement 250 200 number of implants 150 100 50 0 Actual Actual Actual Actual 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2015/16 2016/17 2003/04 2004/05 2005/06 2006/07 projected Total CRT-D 11 22 29 19 24 52 86 119 119 170 205 238 238 238 238 Total CRT-P 5 9 20 36 29 39 41 46 46 46 84 86 92 92 92The Network activity and cost of CRT in 2006/07 was: 2006/07 Elective Emergency Renewal Total Cost £ 164,504 £ 123,378 £ 143,941 £ 431,823 Activity 8 6 7 21The costing template assumes that NICE technology appraisal 95 on ICDs has beenfully implemented. It also assumes a saving due to avoidance of hospitalization.NICE cost calculator estimates that the cost in 2008/09 will be £371,839 rising to£1,064,904 in 2014/15. It is important to note that the costing assumes that NICEguidance 95 - on Implantable Cardioverter defibrillators has been fully implemented.Currently consultants at STHFT are implanting CRT devices according to the newNICE guidance in all appropriate patients referred to them. They note a significantdifference in referral rates for implantation between the health communities. Ensuringthat all health communities across the network are using the same threshold forreferrals for CRT will help promote equity of provision across the Network.It is unlikely that addressing these inequalities alone will raise levels of activity tothose estimated in the NICE Guidance it is believed by clinicians that not all of theactivity estimated by the cost calculator is likely to materialise.It has been agreed by NORCOM to commission CRT in line with NICE GuidanceTA120 from November 2008.The estimated activity and costing figures set out in thispaper are to be used to populate the 2008/09 LDP. It has been noted that these arethe maximum likely activity figures, activity may fall significantly short of this. A more/home/pptfactory/temp/20101206092607/download1909.doc 33
  • 34. realistic estimate will be made by the end of 2007 and actual activity and cost will bemonitored throughout 2008/09.5.4.6 Key Actions• Heart Failure clinical guidelines will be used as the basis upon which a Network strategy for development of secondary and tertiary heart failure services will be produced. The commissioning implications will need to be discussed and recommendations made to the PCTs.• Preferred Place of Care Plan to be implemented across the Network in 2007/08 followed by an audit to ensure effective implementation in 2008/09. Ensure that Patient and public information in appropriate formats and languages• Implementation of NICE Technology Appraisal on Cardiac Resynchronisation Therapy by November 2008.• Developing standards for referral for CRT and a programme of education for clinicians that ensures appropriate and timely referrals for CRT throughout the Network.• Monitoring actual CRT activity and cost throughout 2008/9 to inform future commissioning of CRT. Include: o Education plan required to ensure appropriate identification and referral of patients o This needs to be followed up with an audit to ensure consistent network wide improvement in patient care/home/pptfactory/temp/20101206092607/download1909.doc 34
  • 35. 5.5 Arrhythmia & Sudden Cardiac Death5.5.1 IntroductionThe NSF Chapter 8 - Arrhythmia and Sudden Cardiac Death was published in 2005.It presents three quality requirements:Quality requirement one: Patient SupportPeople with arrhythmias receive timely and high quality support and informationbased on assessment of their needs.Quality requirement two: Diagnosis and TreatmentPeople presenting with arrhythmias, in both emergency and elective settings, receivetimely assessment by an appropriate clinician to ensure accurate diagnosis andeffective treatment and rehabilitation. Quality requirement three: Sudden Cardiac DeathWhen sudden cardiac death occurs, NHS services have systems in place to identifyfamily members at risk and provide personally tailored, sensitive and expert support,diagnosis, treatment, information and advice to close relatives.Locally and nationally it is recognised that: • There is a wide variation in provision for arrhythmia patients in different areas. • A wide range of device implantation rates even within a relatively small geographical area, such as North Trent (see data made available from the National Pacemaker Database). • There is a widespread perception of wide geographic variation in the quality and standard of other aspects of arrhythmia care, such as the management of atrial fibrillation.5.5.2 Arrhythmia ServicesServices for Arrhythmia in North Trent are not developing and improving at the ratethey are developing in other areas of the North of England. For instance theestimated number of patients in North Trent is about 26,000 with Atrial Fibrillation.However there are no Atrial Fibrillation clinics within the Network as yet.The Network recommends that health communities make the development ofArrhythmia Services an area of priority. As a guide the Network recommends thefollowing are undertaken by health communities to facilitate improvement inArrhythmia Service Delivery:• Early and appropriate assessment of all patients with symptoms suggestive of atrial fibrillation• Establishment of atrial fibrillation services in each health community in order to optimise patient treatment, ensure adherence to NICE guidelines and refer patients for specialist secondary/tertiary care as appropriate.• Establishment of fast track services for investigating patients with syncope in each health community.• Appropriate investigation of patients with symptoms of palpitation and treatment (if required) provided by a specialist./home/pptfactory/temp/20101206092607/download1909.doc 35
  • 36. In 2008/09 the Network will support Health Communities in reviewing themselvesagainst the Network recommendations and develop local action plans. To assist, theNetwork has produced generic pathways for use by Health Communities.5.5.3 Inherited Cardiac Conditions (ICC)The Network has a longstanding and well developed Inherited Cardiac Conditionservice for a wide range of genetically inherited cardiac and vascular conditions. Itdeals with patients and their families who have a family history of Sudden CardiacDeath (SADS families). It plays an important role in counselling and supportingpatients and their families (a genetic counselling service) and in tracing familymembers to ensure that those who need screening to make an accurate diagnosisare offered it.In March 2007 the DOH produced guidance on the development of Inherited CardiacCondition Centres (ICCC). The already established ICCC in Sheffield meets almostall of the criteria set out in this guidance and is seen as a leading national centre.It is suggested that there are a number of families across the Network with a historyof Sudden Cardiac Death that have not been referred to an ICC service. The Networkneeds to gain an understanding of the scale of this issue and understand thecommissioning implications of these.As a guide the Network recommends the following are undertaken by healthcommunities to facilitate improvement in care in cases of ICC:• All appropriate cases of suspected adult sudden cardiac death syndrome are referred to the inherited cardiac disease clinics.• All appropriate patient with other inherited cardiac disease are referred to inherited cardiac disease clinics.Again in 2008/09 the Network will support Health Communities in reviewingthemselves against the Network recommendations and develop local action plansand to assist, the Network has produced generic pathways for use by HealthCommunities5.5.4 Pacemaker ImplantationThe Western European average new implantation rate for 2003 to 2007 was 703 permillion population Heart Rhythm UK is now using this as its target. In 2005 thenational average is 437.5 per million population and the network average was wellbelow this at 336.There was also a wide variation in implant rates from 281 per million population inRotherham to 463 per million population in Sheffield South West.In order to address the lower than average implantation rate and the variation acrossNorth Trent, the Network needs to ensure appropriate identification and referral ofappropriate patients to pacing. This will be addressed by a programme of educationof referring clinical staff in 2008.5.5.5 Implantable Cardioverter DefibrillatorNICE technical appraisal 95 – Arrhythmia implantable cardioverter defibrillators(ICDs) was issued in January 2006. It extends the use of ICDs to a wider group ofpatients./home/pptfactory/temp/20101206092607/download1909.doc 36
  • 37. NICE estimate that the cost of fully implementing the appraisal depends on theincreased % of eligible patients. This is very difficult to estimate because there isuncertainty about how many would have been eligible in the original guidance. Theincrease from 50 per million to 100 per million is the maximum that this is likely to be.In 2005 the national average was 48.1 new implants per million population. In2005/06 the network implantable rate was 63 per million population.In order to move towards the rate of implantation of 100 per million population theNetwork needs to ensure that the use of ICD accords to the criteria set out in theNICE technical appraisal 95. This will be addressed by a programme of education ofreferring clinical staff in 2008.5.5.6 Key Actions• Support health communities in reviewing themselves against the Network recommendations for arrhythmia services and the development and implementation of local action plans.• Establish how many families with a family history of Sudden Cardiac Death are not accessing Inherited Cardiac Conditions Services and understand the commissioning implications of addressing this.• Support health communities in reviewing themselves against the Network recommendations for Inherited Cardiac Conditions Services and development of local action.• Develop and deliver a programme of education for clinical staff who refer patients for pacemaker implantation and ICD implantation (and Cardiac Resynchronisation Therapy –see section on heart failure) that ensure appropriate and timely referral of patients. This will include: o Education programme plan that ensures appropriate identification and referral of patients. This needs to be followed up with an audit to ensure consistent network wide improvement in patient care/home/pptfactory/temp/20101206092607/download1909.doc 37
  • 38. 5.6 Aortic Aneurysms Surgery5.6.1 OverviewThe aorta can be affected by aneurysms (dilation and weakening of the vessel wall)at any point along its length. Abdominal aortic aneurysms (aneurysms confined to theabdominal cavity) will not be considered here. Aortic aneurysms affect 500/100,000people and are caused by atherosclerosis and connective tissue disorders includingMarfan’s syndrome. Dissection (rupture) of these aneurysms is directly related to thesize of the aneurysm and is invariably fatal.The risk of dissection with no treatment is 10% per year and without treatmentpatients with aortic aneurysms have a five-year survival between 13-39%. Withappropriate treatment and patient selection five-year survival is significantly higher at60% and for those patients with Marfan’s syndrome life expectancy can be increasedby 30 years.Between 8-10 patients a year in the Network could meet the criteria for treatment.STHFT regional thoracic aortic surgery service recommend the following mangementfor these conditions:1. Ascending aorta. These aneurysms are well managed by current surgicalapproaches. Mortality for first time, elective aortic root replacement, in the best hands(and at STH) is less than 5%.2. Aortic Arch and descending Aorta. Hybrid approach combining open surgerytogether with the placement of an endovascular stent. The hybrid approach involvessurgically bypassing the arteries that arise from the affected section of the aorta andinserting an endovascular stent to exclude the aneurysm. The clinical advantages ofthis approach are that the procedure can be accomplished in one sitting and that theprocedural mortality is lower than the traditional approach (by as much as 50%).3. Thoracoabdominal Aneurysms. This is a hybrid approach involving excluding theaneurysm with a stent graft and then grafting to the visceral vessels. The clinicaladvantages of this approach include significant reductions in paraplegia and othercomplications of traditional approaches including the fact that the surgeon does nothave to open both the thoracic and abdominal cavities and mortality is reduced by atleast 50%.There are no randomised trials comparing the traditional surgical approach withconservative treatment. The current indication for treatment is when the patient andclinician decide that the risk of intervention is less than the risk of death from anuntreated aneurysm. This risk is measured by the size of the aneurysm.5.6.2 Key ActionsThe Network has agreed that the future approach to managing these conditionsshould be that recommended above. The Network will agree long-termcommissioning arrangements for these procedures when sufficient have beenundertaken to assess their cost./home/pptfactory/temp/20101206092607/download1909.doc 38
  • 39. 5.7 Diagnostic Imaging and Diagnostic Testing5.7.1 IntroductionDevelopments and improvement in cardiac services and the development of imagingand diagnostic technologies are leading to an increased need for diagnostic testingand imaging in areas such as: Electrocardiogram ECG Echocardiogram Cardiac Magnetic Resonance Imaging Positron Emission Tomography Myocardial Perfusion Scintigraphy Computerised TomographyThere are major workforce issues across the Network in the diagnostic field; inparticular there are insufficient trained staff.5.7.2 Cardiac Magnetic Resonance Imaging and Positron Emission TomographyIn order to select patients for some of the therapeutic interventions, clinicians rely onaccurate diagnostic tools particularly in the field of imaging. Two imaging techniqueshave emerged in the last two decades: Positron emission tomography and magneticresonance imaging.Contrary to the recently published NICE guidelines for the management of heartfailure; there is evidence for revascularisation in heart failure. Firstly, the CASSsurgical registry proves that patients with three vessel coronary artery disease andimpaired left ventricular contraction are one of two groups in whom surgicalrevascularisation strategy has prognostic (mortality) benefit, beyond the morbidityimpact (pain-relief). Secondly, there are many studies that showed viablemyocardium as a marker for potential benefit from revascularisation in patients withsevere left ventricular impairment. In the era of modern pharmacological intervention,HEART-UK study is currently underway as a randomised trial to assess the impact ofrevascularisation on ischaemic cardiomyopathy.In the management of these patients it is important to have accurate and reliableevidence of clinically significant viable myocardium prior to embarking on high-riskrevascularisation strategy. To attain that, advanced imaging techniques such aspositron emission tomography and cardiac magnetic resonance imaging arevaluable.• Magnetic Resonance Imaging (MRI)MRI provides high resolution images of the anatomy and the contractile as well asthe relaxation functions of the myocardium. It provides excellent information on thecardiac haemodynamics in valvular diseases as well as in the presence of abnormalflow patterns and in shunt detection and calculation. The technique is capable ofproviding detailed information on complex congenital heart diseases, and in thosewith complex thoracic aortic disease. There is increased interest in the use of MRI inthe detection of ischaemia and in the detection of myocardial scarring and myocardialviability./home/pptfactory/temp/20101206092607/download1909.doc 39
  • 40. South Yorkshire Cardiothoracic Centre in Sheffield provides tertiary cardiological andcardiac surgical care for the population of the region. Currently it undertakesapproximately 50 scans per year. Demand for the scan outstrips capacity. It isestimated that a capacity of approximately 300 per year is required rising to 500 peryear by 2012.Access to cardiac MRI for the appropriate imaging of patients with grown-upcongenital heart (GUCH) diseases, cardiomyopathies (including ischaemic), aorticdiseases and valvular heart diseases would enhance the diagnostic ability in terms ofquality, accuracy and quantity; thus allowing best therapeutic choices to be madeincluding invasive and non-invasive interventions.A strategy is needed to increase the provision of cardiac MRI from 50 per year in2007 to 500 per year in 2012 needs to be considered.• Positron Emission Tomography (PET)PET is a nuclear technique using short acting radiopharmaceutical agents producedby cyclotrons. PET allows the assessment of myocardial perfusion, metabolism andneuro-myocardial receptors. This technique is superior to other nuclear techniquesdue to its attenuation correction, and the ability to study more accurately the variousmetabolic pathways (fatty acids, glucose, oxygen, etc), as well as the neuro-myocardial receptors. Of the patients with severe ischaemic heart failure, 55% arelikely to have viable myocardium that could potentially benefit from revascularisation.Their detection could be done by several techniques, the gold standard of which ismetabolic-perfusion imaging by PET.NICE has recommended PET imaging be available to every Cancer centre. Thenetwork feels that access to PET scanning is required in cases where no otherimaging modality will provide the information required. It is estimated that this will bein less than 10 cases per year.5.7.3 Myocardial Perfusion ScintigraphyMyocardial Perfusion Scintigraphy (MPS) is a well-established, non-invasive imagingtechnique. MPS is effective in the diagnosis and management of ischaemic heartdisease and heart failure. It is more accurate than the exercise ECG in detectingmyocardial ischaemia, and it is the single most powerful technique for predictingfuture coronary events. Thus it is more than a diagnostic tool, by allowing prognosisto be reliably determined.MPS allows reliable risk stratification and guides the selection of patients for furtherinterventions. This allows more appropriate utilisation of resources and greater cost-effectiveness. MPS is particularly important in investigating certain subgroups,including women, the elderly and those with diabetes.Like other parts in the United Kingdom, we are under-utilising this technique, incomparison with the numbers of coronary angiographic and revascularisationprocedures. The long waiting times may be one of several causes of under-utilisationnationally and locally. Nationally, it is hoped that the current rate of 1200 MPS/millionpopulation/year will increase to 4000 MPS/million population/year.For the test to have impact on the management of patients and to achieve the 18week wait target, waiting times need to be less than 6 weeks Improved access to MPS, by installing more cameras in the Medical Physics Departments, and allocating cameras purely for cardiac work./home/pptfactory/temp/20101206092607/download1909.doc 40
  • 41.  Increasing the paramedical workforce in the nuclear cardiology/medical physics department. This will facilitate professional (non-medical) led MPS, when Adenosine is being used for stress imaging. Cardiologists to lead the reporting process so that the physician with the best cardiological knowledge offers the interpretation of the images obtained. Incorporation of the nuclear cardiology module in the training of specialist registrars in Radiology and Cardiology. Routine use of ECG gating to reduce the frequency of false positive results. Development of either a Positron Emission Tomographic facility centrally to look into the issue of myocardial viability in patients with ischaemic cardiomyopathy; or the provision of tracers other than tetrofosmin, to provide reliable viability assessment e.g. FDG SPECT, or Thallium re-injection protocols with SPECT.Referring to the NICE Technology Appraisal on Angina and Myocardial Infarction –Myocardial Perfusion Scintigraphy , the Network will need to consider the impact ofthese recommendations on service delivery and resources. As such a cost benefitanalysis will need to be carried out and the output of this to be fed into the Networkplanning cycle 2008/09 if agreed.5.7.4 Computerised Tomography (CT)CT scanning is increasing in its sophistication. Early work suggests that this imagingmodality could replace some Angiography.5.7.5 Diagnostic Services Provision in Primary CareA view across the Network of which cardiac diagnostic tests could be undertaken inprimary care would be beneficial. Health community teams could then develop aview of the pattern of cardiac diagnostic provision in each Health Community.5.7.6 Key Actions• The Network to undertake an analysis of the workforce implications of the increasing need for imaging and diagnostic intervention by 2009.• The Network will consider the feasibility of increasing the provision of Cardiac MRI from 50 per year in 2007 to 500 per year in 2012.• Referring to the– Myocardial Perfusion Scintigraphy, the Network will consider the impact of the NICE Technology Appraisal on Angina and Myocardial Infarction on service delivery and resources by undertaking a cost benefit analysis and feeding the output of this to be into the Network planning cycle 2009/10.• Review which cardiac diagnostic tests could effectively be undertaken in primary care to assist health communities in planning cardiac diagnostic provision in their patch by 2010./home/pptfactory/temp/20101206092607/download1909.doc 41
  • 42. 5.8 Adult Congenital Cardiology Service5.8.1 BackgroundThere has been a significant increase in the numbers of adults with complexcongenital heart defects palliated by previous surgery. This is due to improvements incongenital cardiac surgery; 80% of patients born with a congenital cardiac defect cannow expect to survive to adulthood, whereas 40 years ago 80% of these patientsdied before reaching adulthood.To date there is currently no formal structure within the region for the care of adultswith congenital heart disease. There is currently a supra-regional specialist centre atthe Leeds Teaching Hospitals NHS Trust, which offers the full range of services forcomplex patients from around the region. The service at Sheffield TeachingHospitals NHS Trust runs on a combined outreach service from the unit in Leeds.Other patients (usually the more straightforward) are seen by cardiologists in DGHsin general adult cardiology clinics.There are believed to be a significant number of patients that have been lost to followup within the region.Emergency admissions are taken to their geographically nearest hospital if admittedby ambulance even if under the care of the specialist centre. These patients aresometimes transferred into the local specialist centre or supra-regional specialistcentre, the same day or during that admission, depending upon need.5.8.2 National Guidance‘A Commissioning Guide for Services for Young People and Grown Ups withCongenital Heart Disease (GUCH)’ was published by the Department of Health inMay 2006. In response to this the Yorkshire and the Humber Adult Congenital HeartDisease Network developed a Yorkshire and Humber ACHD Strategy.5.8.3 Yorkshire and Humber StrategyThis strategy advocates the development of a Yorkshire and Humber wide three tierhub and spoke service model, offering timely access to expert care in the specialistcentre when necessary, while maintaining access to appropriate local services for themajority of patients. It also proposed the development of a Network to:• Provide the highest possible quality care to adult patients with congenital heart defects across the whole region. Care should be delivered in an environment, which is appropriate to the complexity of their condition, but still be as close to their home as possible.• Create a more cohesive high quality service where expertise is concentrated in a small number of specialist centres but at the same time awareness of congenital heart disease in other parts of the NHS, including primary care, is raised• Ensure equity of access to care across the region• Provide a forum for training for medical staff and allied health care professionals• Enhance strategic planning for future needs• Provide a forum for patients to influence planning of their services/home/pptfactory/temp/20101206092607/download1909.doc 42
  • 43. 5.8.4 Key ActionsThe Network will work with the Yorkshire and Humber Adult Congenital HeartDisease Network where appropriate to ensure the implementation of the Yorkshireand Humber ACHD Strategy./home/pptfactory/temp/20101206092607/download1909.doc 43
  • 44. 5.9 Rehabilitation and Ongoing Support5.9.1 RehabilitationDespite its proven ability to reduce all cause mortality by 20% and widespreadendorsement in numerous clinical guidelines, cardiac rehabilitation (CR) remainspatchily provided & under-funded.In consulting with users of cardiac services access and provision of cardiacrehabilitation and ongoing support was identified as one of the key issues thatneeded to be addressed. Where services were received patients were generallysatisfied with care but users did feel that there was a lack of consistency in terms ofaccess to service provision across the Network.Locally there continues to be under provision within the Network April 2005 to March 2006 % patient with MI % patient with % patient with receiving CABG receiving Coronary rehabilitation rehabilitation Angioplasty receiving rehabilitation South Yorkshire SHA 62 28 40 Trent SHA 40 50 23(From the BHF – National Audit of Cardiac Rehabilitation 2007)Average costs for hospital based rehabilitation have been estimated as £350-£490per patient (in 2001) and for a home based self-management programme, range from£99-250 according to delivery method. Cardiac Rehabilitation is highly cost effective:• The estimated cost of £6,900 per QALY.• A home based cognitive behavioural self-management rehabilitation programme for heart attack patients reduced readmissions by 30%• Scottish research has shown it saves costs within 6 months of hospital discharge.• Locally patients who had attended rehabilitation programmes rated them as a good service and an important part of their care (source Network Strategy Listening Event).The Network has produced baseline guidelines for the delivery of rehabilitationservices. It will undertake a review of cardiac rehabilitation activity across theNetwork and provide recommendations to commissioners for improving the deliveryof rehabilitation services.The Network could also participate in the National Audit for Cardiac Rehabilitation.This could improve understanding of the need for investment & opportunities toimprove services & improve patient outcomes. The network will to consider thebenefits of being involved in the national audit5.9.2 Post rehabilitation support and patient support groupsThe CHD NSF stated the need for social support and education of patients with heartfailure and their carers not only about their condition and self-management but alsoabout practical nutritional and dietary advice, physical activity, providing links withSocial Services and a social support structure. This is seen to be particularlyimportant for patients with Heart Failure.Locally, patients that have been discharged from NHS care felt that they wouldbenefit considerably from continuing support to help them live with their ongoing/home/pptfactory/temp/20101206092607/download1909.doc 44
  • 45. cardiac conditions. They state the need for support and education both whilstundergoing treatment and following discharge from hospital for all cardiac conditions.Development of support groups would meet some of these needs for patients andtheir carers. The social networking aspect of such a group would offer great supportto carers in particular. A planned programme of events and speakers would givepatients and carers increased awareness of the management of the condition andhelp to educate, as well as giving access to activities to promote physical andemotional well-being. Whilst the Network has supported the development ofcommunity based patient support groups the mechanism to support the developmentand continuation of support groups needs to be reviewed and formalised.5.9.3 Key Actions1. Review of cardiac rehabilitation activity across the network and provide recommendations by end 2008.2. Assess the benefits of participating in the National Audit for Cardiac Rehabilitation and if appropriate ensure participation and use of data to inform service development by end 2008.3. Review and formalise Network input into the development and continuation of patient support groups by end 2008./home/pptfactory/temp/20101206092607/download1909.doc 45
  • 46. 5.10 Meeting the 18 Week Wait TargetThe role of the Network in meeting the 18 week wait target is to work with itsconstituent organisations to assist in its delivery. To ensure that by December 2008no one waits more than 18 weeks from GP referral to hospital treatment.5.11 Current Position against TargetReferral to treatment (RTT) times for patients whose 18 week clock stopped during the month with an inpatient/day caseadmission.It is important to view this performance data in conjunction with the data completeness assessment score for eachorganisation. Total (known Total (known clock start)Commissioner Treatment Function Total (all) clock start) within 18 weeks % within 18 weeksBARNSLEY PCT Cardiothoracic Surgery 36 36 22 61.11%BARNSLEY PCT Cardiology 12 11 11 100.00%DONCASTER PCT Cardiothoracic Surgery 14 14 9 64.29%DONCASTER PCT Cardiology 20 20 17 85.00%DERBYSHIRE COUNTY PCT Cardiothoracic Surgery 41 41 27 65.85%DERBYSHIRE COUNTY PCT Cardiology 98 98 86 87.76%BASSETLAW PCT Cardiothoracic Surgery 9 9 7 77.78%BASSETLAW PCT Cardiology 16 16 13 81.25%ROTHERHAM PCT Cardiothoracic Surgery 13 13 7 53.85%ROTHERHAM PCT Cardiology 33 33 27 81.82%SHEFFIELD PCT Cardiothoracic Surgery 39 39 24 61.54%SHEFFIELD PCT Cardiology 85 84 59 70.24%Referral to treatment (RTT) times for patients whose 18 week clock stopped during the month for reasons other than aninpatient/ day case admission.It is important to view this performance data in conjunction with the data completeness assessment score for eachorganisation. Total (known Total (known clock start)Commissioner Treatment Function Total (all) clock start) within 18 weeks % within 18 weeksBARNSLEY PCT Cardiothoracic Surgery 16 16 11 68.75%BARNSLEY PCT Cardiology 29 29 22 75.86%DONCASTER PCT Cardiothoracic Surgery 33 33 22 66.67%DONCASTER PCT Cardiology 13 13 9 69.23%DERBYSHIRE COUNTY PCT Cardiothoracic Surgery 36 36 23 63.89%DERBYSHIRE COUNTY PCT Cardiology 281 281 239 85.05%BASSETLAW PCT Cardiothoracic Surgery 7 7 7 100.00%BASSETLAW PCT Cardiology 10 10 6 60.00%ROTHERHAM PCT Cardiothoracic Surgery 16 16 9 56.25%ROTHERHAM PCT Cardiology 56 56 43 76.79%SHEFFIELD PCT Cardiothoracic Surgery 61 61 40 65.57%SHEFFIELD PCT Cardiology 430 430 320 74.42%Referral to treatment (RTT) times for patients whose 18 week clock is still running. % within 18 Total within weeks (columnCommissioner Treatment Function Total 18 weeks BH/column BG)BARNSLEY PCT Cardiothoracic Surgery 69 46 66.67%BARNSLEY PCT Cardiology 128 87 67.97%DONCASTER PCT Cardiothoracic Surgery 104 76 73.08%DONCASTER PCT Cardiology 82 64 78.05%DERBYSHIRE COUNTY PCT Cardiothoracic Surgery 148 114 77.03%DERBYSHIRE COUNTY PCT Cardiology 796 579 72.74%BASSETLAW PCT Cardiothoracic Surgery 31 28 90.32%BASSETLAW PCT Cardiology 52 39 75.00%ROTHERHAM PCT Cardiothoracic Surgery 81 60 74.07%ROTHERHAM PCT Cardiology 332 278 83.73%SHEFFIELD PCT Cardiothoracic Surgery 148 91 61.49%SHEFFIELD PCT Cardiology 1504 1083 72.01%/home/pptfactory/temp/20101206092607/download1909.doc 46
  • 47. 5.11.1 Agreed PathwaysThe following pathways were agreed by the Main Network Group in February 2007.The activity required to achieve this pathway has been modelled and included in theLDP 2007/08 and 2008/09. Cardiology 2007/08 Secondary Care Tertiary Care Referral Outpatients Diagnostic Referral to received Tests Tertiary Inpatient Maximum 10 weeks Maximum 12 weeks TOTAL 22 Cardiology 2008/09 Secondary Care Tertiary Care Referral Outpatients Diagnostic Referral to received Tests Tertiary Inpatient Maximum 9 weeks Maximum 9 weeks TOTAL 18 Cardiac Surgery 2007/08 Secondary Care Tertiary Care Referral Outpatients Diagnostic Referral to received Tests Tertiary Outpatients Inpatients Maximum 10 weeks Maximum 12 weeks TOTAL 22 Cardiac Surgery 2008/09 Secondary Care Tertiary Care Referral Outpatients Diagnostic Referral to received Tests Tertiary Outpatients Inpatients Maximum 9 weeks Maximum 9 weeks TOTAL 185.11.2 ChallengesIn July 2006 the Network undertook a baseline assessment of the referral totreatment time for Cardiology patients. Whilst the data is quite crude and based ononly 98 patients it provides an indication of the scale of improvement required toachieve the 18 week wait target.Result of Referral to Treatemnt (RTT) Tracking July 2006 Referral received to referral to Referral received to Tertiary Centre Intervention Total RTT Mean - in Range - in Mean - in Range - in Mean - in weeks days weeks days weeks2007/08 target 10 12 222008/09 target 9 9 18Network 15.75 0-301 14.6 6-273 29.91BHFT 14.8 4-234 13.01 6-223 27.19CNDRHFT 10.2 0-179 16.95 64-167 27.23DBHFT 11.3 0-174 12.92 6-215 23.32RHFT 20.7 47-301 14.09 8-182 34.19STHFT 17.79 0-264 17.02 16-273 34.81/home/pptfactory/temp/20101206092607/download1909.doc 47
  • 48. The collection of accurate data that reflects the current position against the targetand provision of timely reports to assist service improvement has been seen as aNetwork priority to the achievement of the 18 week wait. The Network is undertakinga Data Collection project in order to address this.Whilst it is possible for the commissioners to fund the activity required to deliver the18 week wait target there remains a challenge to the network of finding the capacityin 2007/08 and 2008/09 to deliver the extra activity to achieve the targets.5.11.3 Key ActionsIn order to assist in the achievement of the 18 week wait by December 2008 theNetwork will:• Provide an overview across the Network of the 18 week wait plans in Cardiology and Cardiac Surgery• Provide support to Network organisations when required• Ensure commissioning plans, capacity, finance, workforce and redesign are integrated.• Develop a robust 18 week wait data collection and reporting system that crosses the inter organisational boundaries• Monitor performance against milestones and targets/home/pptfactory/temp/20101206092607/download1909.doc 48
  • 49. 6PART F – DELIVERING SUPPORTIVE AND CARINGSERVICESThe Network is committed; not only to ensuring that patients receive the best qualitycare, but in ensuing that this is delivered in a supportive and caring environment. Inexperiencing cardiac services, patients and the public felt that the following wereimportant areas to be addressed:6.1 Improving communicationThe public and patients were keen to ensure that patients and their familiesunderstood what was happing to them and that this information was provided to themquickly and clearly.The Network is committed to ensuring that services are provided that providepatients and their families with appropriate good and timely information about theircare.6.2 Supporting family and friendsThe public and patient were keen to ensure that for patients were receiving care at ahospital a long way from home (in particular emergency care), that there would beadequate facilities for family and friends. For instance for the family of patients thisshould include Provision of good information about travel to and parking at hospital sites Information about how the hospital can be contacted Somewhere for family members to purchase a snack and a drink (must be 24/7) Somewhere for close family members to rest/ wait (must be 24/7)The Network is committed to ensuring that appropriate information and adequatefacilities are provided to support families of patients who are receiving emergencycare.6.3 Ensuring seamless care throughout the patient pathwayThe public and patients were keen to ensure that information about patients and theircare was transferred swiftly to the next heath care professional and/ or organisationalong the patient pathway. They were also keen to ensure that following dischargefrom hospital patients were linked in well to primary care services for review andongoing support.The Network is committed to ensuring seamless care throughout the patientpathway./home/pptfactory/temp/20101206092607/download1909.doc 49
  • 50. PART G – DEVELOPING THE NETWORK77.1 IntroductionThe North Trent Network of Cardiac Care is a collaborative partnership between NHSHospital Foundation Trusts, Primary Care Trusts and Ambulance Trusts. As aNetwork they jointly review, plan, commission and develop cardiac services for theBarnsley, Bassetlaw, Doncaster, North Derbyshire, Rotherham and Sheffield healthcommunities. It was formed to meet the priorities of NSF for CHD.The Network is accountable to the North Derbyshire, South Yorkshire and BassetlawCommissioning Consortium (NORCOM). The constituent organisations are:Hospital Trusts Primary Care TrustBarnsley Hospital NHS Foundation Trust Barnsley PCTDoncaster & Bassetlaw Hospitals NHS Foundation Trust Doncaster PCTRotherham Hospital NHS Foundation Trust Rotherham PCTSheffield Children’s Hospital NHS Foundation Trust Sheffield PCTSheffield Teaching Hospitals NHS Foundation Trust Bassetlaw PCTChesterfield Royal NHS Foundation Trust Derbyshire County PCTAmbulance Trusts Strategic Health AuthoritiesYorkshire Ambulance Service Yorkshire & the Humber Strategic HealthEast Midlands Ambulance Service Authority East Midlands Strategic Health Authority7.2 Network DevelopmentThe North Trent Network of Cardiac Care is a collaborative partnership between NHSHospital Foundation Trusts, Primary Care Trusts and Ambulance Trusts. As aNetwork they jointly review, plan, commission and develop cardiac services for theBarnsley, Bassetlaw, Doncaster, North Derbyshire, Rotherham and Sheffield healthcommunities. It was formed to meet the priorities of NSF for CHD.The Network is accountable to the Yorkshire and the Humber SCG andCollaborative.7.3 Network DevelopmentThe Network has existed since its establishment in 2002. In Autumn 2007 theNetwork reviewed its structure and function. The following presents a new networkmodel that began to be implemented from 1st January 2008. This local review hasties into the Yorkshire and the Humber SCG Clinical Network Stocktake, which isreviewing the need for clinical networks and where the need is proven (as is the casefor cardiac networks) whether the networks meets its key functions (i.e. the keyfunctions of a formal managed network).7.4 The Network ModelThe Network has been defined, by NORCOM, as a ‘Formal Managed Network’. Thismeans that it is:• Required by Department of Health for: o Strategy Development and Planning o Allocating Resource o Development of Clinical Pathways/home/pptfactory/temp/20101206092607/download1909.doc 50
  • 51. o Focus for Department of Health communications• Formal requirement for whole system co-operation• The organisation and management structure of the Network is specified by Department of Health• The Network is the vehicle through which services are developed• All parties involved participate in clinical information capture and audit to inform national bodies• The management structure for ensuring the delivery of services within individual organisations is specified by Department of Health• The Network has formal links to research bodies• The Network will operate a formal commissioning substructureThe Network will ensure that it plays a key role in ensuring PCTs ‘Commission aPatient Led NHS’ and as such the business of the Network needs to be underpinnedby the commissioning process particularly in those services that span the more thanone PCT/provider. This will involve:• Strategic service development, including service planning, specification, target setting and quality monitoring• Care pathway management to ensure high quality service provision to patients particularly when a patient’s journey spans more than one health sector• Provider development• Monitoring of health care outcomesPractically this means that the collective Network of commissioners supported by theNetwork team will have responsibility for:• Assessing overall needs and deciding network-wide cardiac priorities• Designing services and detailed pathway development• Managing demand through clinical guidelines• The performance management and quality assurance of services, across the patient pathway, to the network population• Engaging users and acting on views• Being confident that providers have systems in place for developing cross organisational strategy and implementation plans for workforce, information systems, redesign skills and researchTo achieve this, clinical engagement and involvement from providers is critical.Through the Health Community CHD Groups, the local commissioners will continueto have responsibility for:• Assessing local needs and local cardiac priorities including contributing to the setting of network-wide priorities• Designing local services• Ensuring network clinical guidelines are in place to manage demand• Performance managing local providers through contracts and service level agreements• Engaging users and acting on views locally7.5 Decision Making and RecommendationsNetwork business will be underpinned by the commissioning process, the role of theNetwork Board will be to make considered and appropriate recommendations toNORCOM about the commissioning of Cardiac Services. In order for the NetworkBoard to fulfil its role, a clear decision making process must be in place./home/pptfactory/temp/20101206092607/download1909.doc 51
  • 52. Recommendations made by the Network must be prioritised and must ensure equity of service provision to all patients across North Trent. Recommendations should be based on:• Existing gaps in service as identified through reviews and audits of services and patient experience• Existing deficiencies as demonstrated by waiting times, sustainability and service redesign• Ensuring equity of access to clinical services and quality services based on clinical outcome data and clinical guideline development• Access to new technology/treatments etc• Local developments are shared and rolled out NORCOM NETWORK BOARD  Chair of the Network  Network Director  Network Lead Clinician  Network Public Health Lead  PCT Chief Executives or their designated deputies (x6)  Chief Executive or designated deputy of each acute trust and ambulance trust  User group representative Invited to attend:  Primary Care Clinical Leads (if not the PCT Chief Executives designated deputy)  Health Community CHD Leads (if not the PCT Chief Executives designated deputy)  SCG – Director of Collaboration and Networks Lead USER GROUP CLINICAL ADVISORY GROUP COMMISSIONING GROUP HEALTH COMMUNITY Membership: Membership: Membership: CHD LEADS  Network Director  Network Lead Clinician  Network Director (chair) Membership:  Patient & Carer  Network Public Health Lead  PCT Executive Directors or designated  Network Public Health Lead representatives  Network Director PCT commissioning lead for cardiac  Network Director  Voluntary Sector  1 Cardiac Surgeon services  Health Community CHD Lead Organisation  Cardiologist from each clinical centre (including STH) from each PCT Representatives  Primary Care Cardiac Clinical Leads (one from each PCT) Invited to attend:  Representative from YAS (to link with EMAS as appropriate)  Health Community CHD Leads  Nurse representative  Cardiac Physiologist  Network Clinical Improvement Co-ordinator Task and Finish Group(s) Task and Finish Group(s)Stakeholders in the decision making process: Public and Patients Primary Care Trusts Provider Trusts and Practice Based Commissioning ConsortiaNetwork Board N N NUser Group UClinical Advisory Group C CCommissioning Group CHealth Community CHD LLeads Group7.6 Network BoardThe role of the Board is to ensure collective responsibility and co-operation by all theorganisations within the Cardiac Network in developing adult cardiac services in linewith national and local requirements./home/pptfactory/temp/20101206092607/download1909.doc 52
  • 53. The Board is recognised by the Chief Executives of provider Trusts and PCTs as thegroup which makes decisions and recommendations to NORCOM about thecommissioning of Cardiac Services. The Board:• Coordinates the development of consistent network policy for the commissioning of cardiac services.• Coordinates the development of consistent network policy and the achievement of common standards for the provision of cardiac services.• Develops agreements which feed into the local delivery plan.• Agrees cardiac service delivery proposals.• Agrees the clinical and corporate governance framework for cardiac services across the network, ensuring clear lines of accountability are explicit and clearly understood.The Board is the Network focus for business on issues relating to:- - development of a cardiac services strategy - views to interested parties outside the NHS on such services - collaboration with other cardiac networks Membership will be:• Chair of the Network• Network Director• Network Lead Clinician• Network Public Health Lead• PCT Chief Executives or their designated deputies (x6)• Chief Executive or designated deputy of each acute trust and ambulance trusts• User Group representativeInvited to attend• Primary Care Clinical Leads (if not the PCT Chief Executives designated deputy)• Health Community CHD Leads(if not the PCT Chief Executives designated deputy)• SCG -Director of Collaboration and Networks Lead7.7 Commissioning GroupThis group will provide a North Trent focus for strategy implementation and thecommissioning of cardiac services.The Group is responsible for the coordination and consistency of investment incardiac services across the Network and is responsible for advising the NetworkBoard on commissioning business and investment decisions.This group will act as one of the key network links to local practice basedcommissioning consortia to ensure their engagement in Network business.Membership• Network Director (chair)• PCT Executive Directors or designated PCT commissioning lead for cardiac servicesInvited to attend/home/pptfactory/temp/20101206092607/download1909.doc 53
  • 54. • Health Community CHD Leads7.8 Clinical Advisory GroupThis group will advise the Network on clinical issues relating to the commissioning ofCardiac Services for the Network population by providing the Network Board with:• Advice on the on the delivery of new developments in clinical practice; and on national guideline and recommendations. Specifically advise the Network Board on the impact these will have on patient care and on service delivery. and propose clinical models for future service delivery.• Develop and propose standards for cardiac service provision of both new and existing services across the Network• Develop and propose network wide protocols for service delivery• Through clinical audit provide the Network Board with an assessment of the quality of provision of clinical practice across the Network, propose plans to improve the quality of practice and monitor the impact of changes in practiceMembership:• Network Clinical Lead• Network Public Health lead• Network Director• 1 Cardiac surgeon• Cardiologist from each clinical centre (including STH)• Primary Care Cardiac Clinical Leads (one from each PCT)• Representative from YAS (to link with EMAS as appropriate)• Nurse representative• Cardiac Physiologist• Network Clinical Improvement Co-ordinator7.9 User GroupTo participate in and become partners in:• The development of consistent network policy for the commissioning of cardiac services.• The development of consistent network policy and the achievement of common standards for the provision of cardiac services.• Prioritisation of developments for local delivery plan.• Agreeing cardiac service delivery proposals.• Agreeing the clinical and corporate governance framework for cardiac services across the network, ensuring clear lines of accountability are explicit and clearly understood.Membership:• Network Director• Network PPI Lead• Patient and Carer representatives• Voluntary Sector Organisation Representatives/home/pptfactory/temp/20101206092607/download1909.doc 54
  • 55. 7.10 Heath Community CHD LeadsThe role of this group is: • To promote a co-ordinated approach between and within health communities towards identifying and tackling inequalities in the disease, and within patient pathways • To influence the plans and work programme of the network to take account of health inequalities and the needs of individual health communities • To promote a forum for the dissemination and promotion of best practice and effective initiatives across health communities and where problems of common interest can be discussed • This group will act as one of the key network links to local practice based commissioning consortia to ensure their engagement in Network business.Membership: • Network Public Health Lead • Network Director • Health Community CHD Lead from each PCT7.11 Development of the Network TeamTo support the new Network structure the Network team will be developed:• Development of a new Network Director role to replace the Chair of the Cardiac Commissioning Subgroup and Network Coordinator• Increased in the Public Health resource available to the Network• Development of the Network Lead Clinician role• Review of the role of the Service Improvement Team in Network business7.12 Key Network RelationshipsBeyond the Network the team has a number of key working relationships (seediagram)/home/pptfactory/temp/20101206092607/download1909.doc 55
  • 56. Key Working Relationships ACHD Network East Midlands Strategic Health Yorkshire & The Authority Humber Strategic Health Authority North Trent Network of Cardiac Care North East West Yorkshire Yorkshire and North Cardiac Network Lincolnshire Cardiac Network Department of Health Heart Improvement Team7.13 North Trent Stroke Strategy ProjectIn December 2007 the Department of Health issued the National Stroke Strategy. Todelivery the National Stroke Strategy the Cardiac Network Team will support thedevelopment and implementation of a North Trent Stroke Strategy Project. Thisproject will ensure collaborative working of the clinicians and managers from StrokeServices across North Trent on elements of the Stroke Strategy that requirecollaborative planning, commissioning and delivery.7.14 Ensuring Patient Centered ServicesA core aim of the Network is to ensure that Adult Cardiac Care Services are patientcentred. This means that when NHS Hospital Trusts, Ambulance Service Trusts andPrimary Care Trusts jointly review, plan, commission and develop services, itinvolves public and patients in that process.Section eleven of the Health and Social Care Act (Jan 2003) set out requirements forpatients and the public to be involved and consulted in service planning andoperation, and in the development of proposals for changes. There is a duty to:• Involve patients and public in assessing healthcare needs and prioritising expenditure• Involve patients and the public in decision making.• Commissioners will have a duty to respond to patients in relation to what they have said concerning services and prioritiesPatient and public representation occurs on some local groups and there is clearevidence of involvement informing plans. However there is limited evidence of localinvolvement informing Network plans, of patient and public consultation prior to the/home/pptfactory/temp/20101206092607/download1909.doc 56
  • 57. development of Network services, or that the development of Network services aredriven by the patients and the public.Network projects facilitated by the Network’s Service Development Team now havemechanisms for listening to and responding to the views of patients and public. Thisneeds to be broadened to include mechanisms for listening to patient views withregards to the commissioning of services.The Service Development Team has been collecting evidence of how listening to theviews of patients and public has then prompted the initiation of a new serviceimprovement project. This activity is logged on a central database held by theNetwork.As part of the process of developing this strategy focus groups have been held tolisten to patient and carer views about the service and these have been incorporatedinto the strategy.The Network proposes the setting up of a User Group that will work in partnershipwith the Network Board. The role and function of the User Group will be to add apatient and public voice to the decision making/commissioning process of the NorthTrent Network of Cardiac Care. The User Group will be supported until fullpartnership is realised and there is NTNCC patient and public representation that hasequal influence in setting the agenda on the network board.To participate in and become partners in:• The development of consistent network policy for the commissioning of cardiac services.• The development of consistent network policy and the achievement of common standards for the provision of cardiac services.• Prioritisation of developments for local delivery plan.• Agreeing cardiac service delivery proposals.• Agreeing the clinical and corporate governance framework for cardiac services across the network, ensuring clear lines of accountability are explicit and clearly understood.7.15 Approach to Audit and Clinical GovernanceThe benefits of audit, clinical governance and continuing professional developmentare embraced by cardiology and cardiac surgery services throughout the Network.The development of a Network audit programme adds to that work and assists indeveloping and improving patient pathways that take place across the organisation‘boundaries’ and improving the quality of services to all parts of the North Trentpopulation.This strategy will form the basis of the North Trent Network of Cardiac Care AuditProgramme and will ensure that service developments take place to provide care thatis equitable and of high quality. Where appropriate audit points are highlightedalongside the strategy, these audit points will be summarised in an audit strategy andaudit support will be provided for this programme.All interventions should be audited for their equity - the degree to which individualswith similar capacity to benefit receive comparable treatments. This is an importantnational commitment and some reductions in overall efficiency may have to beaccepted in order to deliver equity./home/pptfactory/temp/20101206092607/download1909.doc 57
  • 58. Statutory organisations have responsibility for clinical governance within theirorganisation. However, Network audit and improvement monitoring may highlightclinical governance issues. These will be referred back to host organisations throughthe existing mechanisms.7.16 Approach to ResearchResearchers in the Network have made important contributions to the understandingand treatment of heart disease. Research into the basic and clinical aspects ofcardiovascular disease takes place throughout the Network but is inevitably mostconcentrated within the Teaching Hospital and University environment of theNorthern General (NGH) and Royal Hallamshire (RHH) Hospitals of the SheffieldTeaching Hospitals NHS Trust (STHT).The largest research grouping is the Cardiovascular Research Group (CVRG), jointlyheaded by Professor David Crossman (Professor of Clinical Cardiology) andProfessor Paul Hellewell (Professor of Vascular Biology). This is based within theClinical Sciences Centre on the NGH site. The research of the CVRG is funded bygrants from the British Heart Foundation, Wellcome Trust, Medical Research Counciland other research funding councils and charitable institutions. The CVRG currentlycomprises more than 40 individuals, of which several are funded by the STHT andmany by the University of Sheffield, with research interests that include the geneticsof cardiovascular disease, inflammatory mechanisms in vascular disease,interventional cardiology, platelet biology and gene therapy. On the RHH site, DrChanners group has a major interest in the role of androgens in cardiovasculardisease. There is also a growing emphasis on clinical research into chronic heartfailure under the direction of Dr Abdallah Al-Mohammad and Dr Laurence OToole. It is very important that this contribution continues since it is needed for progressiveand effective development and delivery of health care The Network will be, whereappropriate, a vehicle for the discussion, development and delivery of researchprojects where a Network-wide approach is favoured. The Network will also considerthe results and conclusions of key research projects and assess its implication on thefuture delivery of cardiac services for the Network.7.17 Key Actions• Implementation of the new Network Model by March 2008. This will include the development of a user group of public and patient representatives who will participate in Network business• Participation in the Y&H Network Review in 2008 and implementation of the Network Improvement Plan• Initiation of a North Trent Stroke Project by March 2008• Development of the North Trent Stroke Strategy Project Plan by May 2008/home/pptfactory/temp/20101206092607/download1909.doc 58
  • 59. 5 GLOSSARYACEI - Angiotensin Converting Enzyme Inhibitor: An anti-hypertensive and heart failure drugACS - Acute Coronary SyndromeACHD - Adult Congenital Heart DiseaseA&E - Accident and EmergencyAMI - Acute Myocardial InfarctionBCIS -British Cardiovascular Intervebtional SocietyBHFT - Barnsley Hospital NHS Foundation TrustBH - Bassetlaw HospitalBMJ -British Medical JournalBNP - B Type Natriuretic PeptideCABG - Coronary Artery bypass GraftCASS - Coronary Artery Surgery StudyCAYAH - Collaborative Agency Yorkshire And HumberCCAD - Central Cardiac Audit DatabaseCCU - Coronary Care UnitCHD - Coronary Heart Disease (syn. Coronary Artery Disease)CHF - Congestive Heart FailureCMR - Cardiovascular Magnetic resonanceCRHFT - Chesterfield Royal Hospitals NHS Foundation TrustCPD - Continuing Professional DevelopmentCR - Cardiac RehabilitationCRT - Cardiac Resynchronisation TherapyCRT-D -Cardiac Resynchronisation Therapy - DefibrillatorCRT-P -Cardiac Resynchronisation Therapy - PacingCT - Computerised TomographyCTN - Call To NeedleCVD - Cardiovascular DiseaseCVRG - Cardiovascular Research GroupDBHFT - Doncaster and Bassetlaw Hospitals NHS Foundation TrustDGH - District General HospitalDOH - Department of HealthDRI - Doncaster Royal InfirmaryECG - ElectrocardiogramEIA - Equality Impact AssessmentEMAS - East Midlands Ambulance Services TrustEP - ElectrophysiologyETT - Exercise Treadmill TestFCE - Finished Consultant EpisodeFDG - Flourodeoxyglucose: A tracer used in PET scanningGDP - General Dental PractionerGP - General PractionerGUCH - Adult (Grown Up) Congenital Heart DiseaseHA - Health AuthorityHAZ - Health Action ZoneHIIA -Health Inequalities Impact AssessmentHIP - Heart Improvement ProgrammeICC - Inherited Cardiac ConditionICCC - Inherited Cardiac Condition CentreICD - Implantable Cardioverter DefibrillatorICU - Intensive Care UnitIT - Information Technology/home/pptfactory/temp/20101206092607/download1909.doc 59
  • 60. LIT - Local Implementation TeamsLDP - Local Delivery PlanLREC - Local Research Ethics CommitteeLTHT - Leeds Teaching Hospital foundation TrustLV - Left VentricleLVEF - Left Ventricular Ejection Fraction: a measure of heart PerformanceLVSD - Left Ventricular Systolic DysfunctionMDT - Multi-Disciplinary TeamMI - Myocardial InfarctionMPS - Myocardial Perfusion Scintigraphy: A non-invasive imaging techniqueMRI - Magnetic Resonance ImagingMUGA - Multiple Gated Acquisition – A radionuclide imaging techniqueNGH - Northern General HospitalNHS - National Health ServiceNICE - National Institute of Clinical ExcellenceNORCOM - North Derbyshire, South Yorkshire and Bassetlaw Commissioning ConsortiumNSF for CHD - National Service Framework for Coronary Heart DiseaseNSTEMI - Non ST segment elevation myocardial infarctionNTNCC - North Trent Network of Cardiac CareNTproBNP - N Terminal pro Brain Natriuretic PeptideNYHA - New York Heart Association (functional classification)ONS - Office for National StatisticsPCG - Primary Care GroupPCI - Percutaneous coronary InterventionPCT - Primary Care TrustPET - Positron Emission Tomography: A specialised imaging techniquePMP - Per Million PopulationPPC - Preferred Place of CarePPCI - Primary Percutaneous Coronary InterventionPPI - Patient & Public InvolvementPSA - Public Service AgreementPTCA - Percutaneous Transluminal Coronary AngioplastyQALY - Quality Adjusted Life Year(s)QRS - Not a real acronym but the letters assigned to the most prominent waveform of the electrocardiographic signalRFT - Rotherham NHS Foundation TrustRACPC - Rapid Access Chest Pain ClinicRHH - Royal Hallamshire HospitalROSC - Return of Spontaneous CirculationRTT - Referral to TreatmentSADS - Sudden Arrhythmic Death SyndromeSCD - Sudden Cardiac DeathSCG - Specialised Commissioning GroupSPECT - Single Photon Emission Computed Tomography: A specialised imaging techniqueSpR - Specialist RegistrarSTHFT - Sheffield Teaching Hospitals NHS Foundation TrustSTEMI - ST segment elevated myocardial infarctionTA - Technology AppraisalTIA - Transient Ischaemic AttackUA - Unstable Angina/home/pptfactory/temp/20101206092607/download1909.doc 60
  • 61. VT - Ventricular TachycardiaWTE - Whole Time EquivalentYAS - Yorkshire Ambulance ServiceY&H - Yorkshire & the Humber/home/pptfactory/temp/20101206092607/download1909.doc 61
  • 62. 8 REFERENCESPART A INTRODUCTION AND BACKGROUNDDoH Expenditure planshttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/AnnualReports/Browsable/DH_4931497British Heart Foundation Statistics website. CHD stats 2004 additionhttp://www.heartstats.org/uploads/documents%5C2004pdf.pdfDoH Policy and Guidance National service Framework for CHDhttp://www.dh.gov.uk/en/Policyandguidance/Healthandsocialcaretopics/Coronaryheartdisease/index.htmCompendium of Clinical and Health Indicators NCHOD 2006http://www.nchod.nhs.uk/North Trent Cardiac Network Service Review 2005 ReportNHS Health Development Agency briefing paper. Relative contributions of changes in riskfactors and treatment to the reduction in Coronary Heart Disease mortality.www.hda.nhs.ukDoH Policy and Guidancehttp://www.dh.gov.uk/en/Policyandguidance/Organisationpolicy/Commissioning/CommissioningapatientledNHS/index.htmNHS Heart Improvement Programme http://www.heart.nhs.uk/scripts/default.asp?site_id=23&id=5363Arrhythmia – Implantable Cardioverter Defibrillators – NICE guidance TA095 January 2006http://guidance.nice.org.uk/TA95Healthcare Commission: Thrombolysis – 60 minute call to needle timehttp://ratings2005.healthcarecommission.org.ukDoH Publications and Statistics – Patient choice at the heart of reformhttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/AnnualReports/Browsable/DH_5297198HM Treasury – Public Service Performance reportinghttp://www.hmtreasury.gov.uk/documents/public_spending_reportingTable .7 Numbers of deaths and age-standardised death rates from CHD for men and womenunder 6 by local authority, 2002/2004. CHD Statistics 2006.http://www.heartstats.org/temp/2006spwholespdocumenths2hs.pdfRegistered PCT populations from CHD prevalence modelwww.apho.org.uk/apho/models.aspxDr Foster Case notes 2005. BMJ 331; 1362Incidence (first presentation) per 100,000 population (25-74 years) per annum of CHD in menand women in the community calculated from Bromley CHD register.Atrial fibrillation costing template NICEhttp://www.nice.org.uk/page.aspx?o=cg36costingtemplateNkomo VT et al Burden of valvular heart diseases: a population-based study. Lancet. 2006Sep 16;368 (9540):1005-11Adult Congenital Heart Disease DH 2006./home/pptfactory/temp/20101206092607/download1909.doc 62
  • 63. http://www.dh.gov.uk/assetRoot/04/13/46/96/04134696.pdfChart 1. Mortality from all circulatory diseases (ICD9 390-459 adjusted, ICD10 I00-I99):1993-2005 Directly age-standardised rates (DSR) per 100,000 European Standard populationLess than 75 years December 2006 ( nww.nchod.nhs.uk last accessed 16/02/06)Compendium of Clinical and Health Indicators, NCHOD 2006.Ramsay SE, Morris RW, Papacosta O, Lennon LT, et al. Secondary prevention of coronaryheart disease in older British men: extent of inequalities before and after implementation ofthe National Service Framework. Journal of Public Health (2005):27(4); 338http://www.lho.org.uk/Download/Public/8831/1/Ethnic_Disparities_Report_4.pdfPART B STRATEGY FOR DEVELOPING CLINICAL SERVICESNSF Chapter 5 – Revascularisationwww.dh.gov.uk/prod_consum_dh/idcplg?IdcService=GET_FILE&dID=24794&Rendition=WebHealthcare Commission: Thrombolysis – 60 minute call to needle timehttp://ratings2005.healthcarecommission.org.ukNHS Modernisation Agency – Service Improvement Guideshttp://www.wise.nhs.uk/cmsWISE/Clinical+Themes/CHD/documents/improvementguides/improvement+guides.htmBlack, S. Wolfe, J. Clark, M. Hamady, M. Cheshire, N. Jenkins, M. Complexthoracoabdominal aortic aneurysms: endovascular exclusion with visceral revascularisation.Journal of Vascular Surgery 2006; 43(6): 1081-9./home/pptfactory/temp/20101206092607/download1909.doc 63
  • 64. 9 APPENDICES9.1 Appendix A National StrategyThis section summarises key national strategy and guidance that impacts on thefuture development and delivery of Cardiac Services in North Trent.National Service Framework for Coronary Heart DiseaseWhilst the National Service Framework for CHD was published in 2000 with anadditional chapter on Arrhythmia and Sudden Cardiac Death published in 2005 thisdocument still presents a number challenge to the Network.Mending Hearts and BrainsPublished in December 2006 this document sets out the strategic direction for thedelivery of emergency services for people with a suspected ST segment elevationMyocardial Infarction (STEMI) or Stroke. The strategy proposes the delivery of theseemergency services in regional cardiology centres and the inclusion of PrimaryPercutaneous Coronary Intervention as a treatment for Myocardial Infarction.The impact of this document needs to be considered carefully and strategydeveloped locally that reflects the need of the local population.National Institute for Clinical Excellence GuidanceThe National Institute for Clinical Excellence (NICE) technical appraisals produceclinical guidelines, technology appraisals and guidance on interventional procedures.There are many of these that impact on the delivery of Cardiac Services:Guidance Title Status Issued Expected Review DateClinical GuidelineAtrial fibrillation Complete June 2006 N/A June 2010Chronic heart failure Complete July 2003 N/A February 2008Hypertension Complete June 2006 N/A June 2010Lipid modification Complete May 2008 N/A TBCMI: secondary prevention Complete May 2007 N/A TBCProphylaxis against infective Complete March N/A TBCendocarditis 2008Acute chest pain In N/A December development 2009Interventional ProcedureBalloon angioplasty with or without Complete July 2004 N/A N/Astenting for coarctation or recoarctationof aorta in adults and childrenBalloon dilation with or without stenting Complete July 2004 N/A N/Afor pulmonary artery or non-valvar rightventricular outflow tract obstruction inchildrenBalloon valvuloplasty for aortic valve Complete July 2004 N/A N/Astenosis in adults and childrenCryoablation for atrial fibrillation in Complete May 2005 N/A N/Aassociation with other cardiac surgeryEndoaortic ballon occlusion for cardiac Complete May 2008 N/A N/AsurgeryEndoscopic saphenous vein harvest for Complete December N/A N/A/home/pptfactory/temp/20101206092607/download1909.doc 64
  • 65. coronary artery bypass graft 2007Endovascular atrial septostomy Complete August N/A N/A 2004Endovascular closure of atrial septal Complete October N/A N/Adefect 2004Endovascular closure of patent ductus Complete October N/A N/Aarteriosus 2004Endovascular closure of Complete May 2006 N/A N/Aperimembranous ventricular septaldefectEndovascular stent graft placement in Complete June 2005 N/A N/Athoracic aortic aneurysms anddissectionsHigh intensity focussed ultrasound Complete July 2006 N/A N/Aablation for atrial fibrillation as anassociated procedure with other cardiacsurgeryHybrid procedure for interim Complete December N/A N/Amanagement of hypoplastic left heart 2007syndrome in neonatesIntraoperative fluorescence angiography Complete October N/A N/Ain coronary artery bypass grafting 2004Laser sheath removal of pacing leads Complete June 2004 N/A N/AMicrowave ablation for atrial fibrillation in Complete May 2005 N/A N/Aassociation with other cardiac surgeryNon-surgical reduction of myocardial Complete February N/A N/Aseptum 2004Off pump coronary artery bypass Complete January N/A N/A(OPCAB) 2004Partial left ventriculectomy (the Batista Complete February N/A N/Aprocedure) 2004Percutaneous closure of the patent Complete January N/A N/Aforamen ovale for the prevention of 2005cerebral embolic strokePercutaneous fetal balloon valvuloplasty Complete May 2006 N/A N/Afor aortic stenosisPercutaneous fetal balloon valvuloplasty Complete May 2006 N/A N/Afor pulmonary atresia with intactventricular septumPercutaneous occlusion of left atrial Complete June 2006 N/A N/AappendagePercutaneous pulmonary valve Complete November N/A N/Aimplantation for right ventricular outflow 2007tract dysfunctionPercutaneous radiofrequency catheter Complete April 2006 N/A N/Aablation for atrial fibrillationRadiofrequency ablation for atrial Complete May 2005 N/A N/Afibrillation in association with othercardiac surgeryRadiofrequency valvotomy for Complete October N/A N/Apulmonary atresia 2004Short term circulatory support with left Complete June 2006 N/A N/Aventricular assist devices as a bridge tocardiac surgery or recoveryThorascopically assisted mitral valve Complete December N/A N/Asurgery 2007Totally endoscopic robotically assisted Complete June 2005 N/A N/Acoronary artery bypasss graftingTranscatheter aortic valve implantation Complete June 2008 N/A N/Afor aortic stenosis/home/pptfactory/temp/20101206092607/download1909.doc 65
  • 66. Laser transmyocardial revascularisation In N/A Consultation N/Afor refractory angina pectoris development Summer 2008Percutaneous laser revascularisation for In N/A Consultation N/Arefractory angina pectoris development Summer 2007PSA targetsPublic Service Agreements (PSAs) set out the key improvements that the public canexpect from Government expenditure. They are three year agreements, negotiatedbetween each of the main Departments and HM Treasury during the spending reviewprocess. Each PSA sets out a Department’s high level aim, priority objectives andkey outcome based performance targets. Those that impact specifically on cardiacserives are:Objective I: Substantially reduce mortality rates by 2010: • from heart disease and stroke and related diseases by at least 40% in people under 75, with at least a 40% reduction in the inequalities gap between the fifth of areas with the worst health and deprivation indicators and the population as a wholeTackle the underlying determinants of ill health and health inequalities by: • reducing adult smoking rates to 21% or less by 2010, with a reduction in prevalence among routine and manual groups to 26% or less; • halting the year-on-year rise in obesity among children under 11 by 2010 in the context of a broader strategy to tackle obesity in the population as a whole. Joint with the Department for Education and Skills and the Department for Culture, Media and Sport.Objective II: Improve health outcomes for people with long-term conditions • to improve health outcomes for people with long-term conditions by offering a personalised care plan for vulnerable people most at risk; and to reduce emergency bed days by 5% by 2008, through improved care in primary care and community settings for people with long-term conditions.Objective III: Improve access to services • to ensure that by 2008 no one waits more than 18 weeks from GP referral to hospital treatmentObjective IV: Improve the patient and user experience • secure sustained national improvements in NHS patient experience by 2008, as measured by independently validated surveys, ensuring that individuals are fully involved in decisions about their healthcare, including choice of provider./home/pptfactory/temp/20101206092607/download1909.doc 66
  • 67. 9.2 Appendix B Review of Previous StrategyIn 2003 the Network produced the North Trent Network of Cardiac Care – CardiacStrategy 2003 – 2006. This outlined the strategy for the development of hospitalservices and ambulance services for adults with heart disease. This built on progressalready made and set the strategy for the Expansion of Revascularisation and PacingCapacity, Improving the Call to Thrombolysis Time and Delivering Patient Choice.The following section summarises some of the progress made.Expansion of the Network’s Revascularisation CapacityIn order to achieve the National Service Framework for Coronary Heart Disease andthe Planning and Priority Framework targets the Network developed plans to expandits revascularisation capacity. The need to expand the Network’s revascularisationcapacity was identified by detailed modeling work carried out by the North TrentNetwork of Cardiac Care Commissioning Sub Group.The plan involved four key stages:Development of Angiography Services at District General Hospitals (DGHs)Expansion of Theatre Capacity at Sheffield Teaching HospitalsTransfer of Pacing Services to DGHsExpansion of Catheter Laboratory Capacity at Sheffield Teaching HospitalsDuring 2003/04 stage one and two had been completed. This has included thedevelopment of new Catheter Labs in Barnsley Hospital Foundation Trust,Rotherham Hospital Foundation Trust and the expansion of Catheter Labs inDoncaster allowing the transfer of Angiography services. The opening of a fifththeatre at Sheffield Teaching Hospitals allowed the expansion of cardiac surgerycapacity. In 2004/05 stage three saw the Transfer of Pacing from Sheffield TeachingHospitals to the local District General Hospitals. This year the 4th and 5th CatheterLabs at Sheffield Teaching Hospitals were commissioned successfully concluding therevascularisation capacity expansion plan.RevascularisationTarget: Achieve a maximum of 3 month wait for revascularisation by March 2005.Throughout 2005/06 Sheffield Teaching Hospital Foundation Trust has successfullycontinued to achieve the three month waiting time target for revascularisation. Inaddition to this, work began on achieving the waiting time target of 18 weeks fromreferral to treatment.Target: Achieve a revascularisation rate of 1500 per million population (pmp) by2008.In 2007/08 the number of revascularisation was 2144 (1200 pmp) seeing a drop inthe numbers of revascularisations from 2004/05 of over 200 FCEs. There was also ashortfall of 348 per year; the number required to meet the 1500pmp target for theNetwork PCT 2004/05 2005/06 2006/07 2007/08 PCI Activity Barnsley 162 259 202 183 Doncaster 204 300 260 275 Derbyshire 162 285 215 130 Bassetlaw 68 53 79 91 Rotherham 178 341 203 149/home/pptfactory/temp/20101206092607/download1909.doc 67
  • 68. Sheffield 325 420 608 480 Network 1099 1658 1567 1308 CABG Activity Barnsley 161 144 76 107 Doncaster 194 164 100 135 Derbyshire 161 158 112 128 Bassetlaw 55 54 42 43 Rotherham 188 189 129 130 Sheffield 324 236 205 175 Network 1083 945 664 708 TOTAL Activity Barnsley 323 403 278 290 Doncaster 398 464 360 410 Derbyshire 323 443 327 258 Bassetlaw 123 107 121 134 Rotherham 366 530 332 279 Sheffield 649 656 813 655 Network 2182 2603 2231 2016 rate pmp 1212 1446 1239 1222In addition to PCIs at Sheffield an additional 100 PCIs took place in 2006/7 (80Nottingham and 20 in Leeds), 338 valve procedures were performed and this couldinclude CABG at the same time as a valve procedure, there were also a smallnumber of private revascularisations. The current total network activity istherefore estimated to be in the region of 1,330 pmp.There is currently a clear downward trend in the overall angioplasty rates and a slightupward trend in CABGs within the Network and nationally. It is likely that thedownward trend in PCIs will continue with the impact of the smoking ban; a moveaway from elective angioplasty towards coronary artery bypass surgery; and moreaggressive medical management of angina.Implantable Cardioverter Defibrillators (ICDs)Target: NICE guidance TA095 issued in January 2006 suggests an increase inimplantation rate from 50pmp to a maximum of 100pmp./home/pptfactory/temp/20101206092607/download1909.doc 68
  • 69. Network ICD Activity vs Activity Required to Meet Targets 600 558 500 400 No. of Implants 300 200 180 170 100 90 0 Current Activity 2005/6 Activity Required to meet 50 pmp Activity Required to meet 100 pmp Activity Required to meet 300pmp Activity / Target ICDs by Health Community 2003 - 2006 number of implants 2003/04 number of implants 2004/05 number of implants 2005/06 180 160 140 120 No. of Implants 100 80 60 40 20 0 Barnsley Doncaster N Derbyshire Bassetlaw Rotherham Sheffield Network Health CommunityThis year there continued to be an increase in the ICD rate across the Network in allhealth communities. In 2005/06 the rate reached almost 100 per million populationwith the trend for the use of ICD continuing to increase. Work is underway tounderstand the reason for the inequality of implantation rates across the Network.Call to Needle TimeTarget: Increase by a 10% (percentage points) each year the proportion of peoplesuffering from a heart attack who receive thrombolysis within 60 minutes of calling forprofessional help./home/pptfactory/temp/20101206092607/download1909.doc 69
  • 70. North Trent - Call to Needle Time Target - Percentage of patient seen within 60 minutes 90% 84.3% 81.6% 82.4% 82.0% 79.0% 80% 78% 77% 76.0% 75% 74% 74.7% 72.1% 72.0% 71.1% 71.0% 71% 71.0% 69.7% 70.0% 68.8% 68.6% 70% 68% 68.4% 62.0% 59% 60% 57% 58.0% 58.0% 55.9% 51.0% 50.0% 50% 48% 44% 39.0% 40% 38% 37.0% 38.0% 35% 34.0% 33.0% 32.0% 30% 28.0% 24.0% 20% 20% 10% 0% O 2 O 3 O 4 O 5 O 6 Ju 3 Ju 4 Ju 5 Ju 7 Fe 03 Fe 05 Fe 06 O 7 Fe 07 Ap 3 Ap 4 Ap 5 Ap 6 Ju 6 Ap 7 08 Au 02 Au 03 Au 04 Au 05 Au 06 Au 07 D 2 D 03 D 04 D 06 D 7 Fe 2 Fe 4 D 5 r-0 r-0 0 0 0 0 0 0 r-0 0 0 r-0 0 r-0 0 -0 -0 -0 -0 0 -0 g- - g- g- - g- - g- - g- b- b- b- b- b- b- n- n- n- n- n- n- - - - ec ec ec ec ec ec ct ct ct ct ct ct Ju South Yorkshire Derbyshire County (north) Linear (South Yorkshire) Linear (Derbyshire County (north))There continues to be an upward trend in the percentage of patients seen receivingthrombolysis within 60 minutes of their call for an ambulance. Whilst the trend is anupward one there are significant variations from month to month. Work is underwayto investigate these variations./home/pptfactory/temp/20101206092607/download1909.doc 70
  • 71. 9.3 Appendix C Summary of Strategy Consultation Feedback• IntroductionConsultation on the North Trent Network of Cardiac Care Strategy began on 22September 2008 and ran for a period of 3 months. The consultation on the documentwas guided by a series of questions that are outlined later. Responses were receivedfrom all health communities and spanned the health sector and public area. Thefeedback found in this document has been included in this version of the strategy.• SummaryThe themes generated as part of the consultation process were on the whole fairlyconsistent and can be broken down into the following groupings: - Best Clinical Care v Distance to Travel - Communication - Access to and provision of Rehabilitation - Linkages to General Practice Teams - PreventionMost patients and their families wanted to have the best clinical care and although itwould be preferable not to have to travel too far, would do so if required. Both duringtheir stay and certainly post discharge, patients and families want to know that robustrehabilitation programmes were available. There was a large amount of feedbackthat showed that programmes were not always available and that access to supportcould be “patchy”. Access to this support was considered to be imperative to theongoing health and wellbeing of the patient.The feedback themes are described in more detail in section 4 and 5 of thisdocument.• Sources of FeedbackThe table below shows where the feedback was received from. Formal Organisation or Groups Individual Responses NHS Staff Total Number Foundation Patient Patient/PublicLocality of Responses PCT Trust NON NHS Group Responses Clinician Other AnonymousSheffield 18 1 2 13 2Rotherham 1 1Barnsley 3 2 1Doncaster 8 2 1 2 2 1Bassetlaw 10 1 2 7Derbyshire County 7 1 1 5EMAS 1 1YAS 1 1Totals 49 7 1 1 27 4 0 2• Overarching ThemesThere were a number of themes which stand out across all of the sections. Thesehave been broken down into general themes below. o Best Clinical Care v Distance/home/pptfactory/temp/20101206092607/download1909.doc 71
  • 72. On the whole having the Heart Attack Centre was very positively received, knowingthat the best treatment could be available to all was very positive. The main concernsthat were raised were around the distance to travel for both the patient and also thedifficulty for family and visitors to have to travel and also to find parking at theNorthern General Hospital. This was balanced by the view however that family andfriends want to know that their relative was receiving the best care that they couldhave. Bassetlaw and Derbyshire residents and NHS organisation members did raiseconcern about the journey time, in particular when the weather is not good. All partieswere keen to see the development of more specialised services at their local hospitalwhilst in all cases they did not want to see a lowering of skill mix in other units. o CommunicationGood communication was also highlighted as being one of the most important thingsfor family. People wanted to know quickly and clearly, preferably from the doctorswhat was happening to their family member. This was thought to be of even greaterimportance if the patient was being transferred outside of their local healthcommunity. o Access to RehabilitationIn terms of Rehabilitation, those that had been involved had high praise for theservices received. The ability to have access to and build relationships with otherpeople who had been in a similar situation was of great importance. There was adesire for greater support for these programmes and linkages to them upondischarge from hospital. Many thought that having access to support, goodinformation and a friendly voice at the end of a phone was a ‘life saver’. The biggestconcern was the lack of consistent access to rehabilitation programmes, the linkagesto the programmes and the availability. It seemed that this varied across the networkarea. It was queried how patients would be linked back to the programmes in theirlocal areas if they were treated in Sheffield at the Heart Attack Centre. Some level ofassurance was requested around the processes linked to this. o Linkages back to General PracticeFeedback regarding support from General Practice seemed to be quite mixed with alack of consistency across areas. Some patients and NHS Organisation reported thatpatients were being linked well back into their general practice however other areasraised concern that follow up was rather hit and miss and that the primary preventionbeing undertaken was not consistent. This was a particular concern for those patientsat risk. Within the other comment section, it was requested from a number of partiesthat this be looked at. Some patients felt that the annual follow-ups became a little“lost”. o PreventionPrevention attracted quite a wide range of comments. Many people, predominantlypatients were of the opinion that shock tactics were a realistic way to try to educatepeople. They emphasized that medical terminology in advertising should be kept to aminimum and that the truth needed to be told. It was also thought that a large amountof the education should be targeted at schools. Further to this it was increasededucation and support on healthy lifestyle choices, teaching people how to cook andassistance with quitting smoking and taking up the right amount of exercise.Affordability was raised a great deal in this section.All parties were keen to have more focus on primary prevention and were supportiveof the plans laid out in the strategy./home/pptfactory/temp/20101206092607/download1909.doc 72
  • 73. o NHS Organisation Specific FeedbackThere was some specific feedback that came from NHS organisations. The mainthemes in were the potential loss of income for acute trusts if eligible patients were tobe transferred to the Northern General for primary treatment, the possible risk to theachievement of targets for the ambulance service in particular, and the decision tohave the Heart Attack Centre based at the Northern General.Feedback by SectionEmergency Care for Heart AttackSummaryIn favour of Heart Attack Unsure AgainstCentre based at the NorthernGeneral Hospital in Sheffield19 (53%) 17 (47%) 0Overall the feedback from patients in this section indicates that patients want to have the besttreatment available to them and if this means travelling a little further then that would beacceptable, however the people who responded did want assurance that this would not delaytreatment. There was a lot of awareness that time is one of the most significant factors forheart attack patients. The greatest concern against this decision is the travel distance, trafficand parking.Detailed BreakdownThe main view of the having a Heart Attack centre with access to Primary PCI for thewhole of the network based at the Northern General Hospital was very positive.Having a specialist centre was thought to be a good use of resource and skill.There were however a number of points that were highlighted and echoed throughoutthe feedback that was given including:• Concern that ambulances would be passing other hospitals to get the NGH, how would this be justified (Patient/Public)• Could it still provide a personal service or would it be so specialised/large that it would become in personal (Patient/Public)• Does having a specialised centre mean that the local hospitals are incapable of providing emergency treatment of this sort. (Patient/Public)• Concern around the journey time from the person’s home to the NGH, particularly for patients living in North Derbyshire and Bassetlaw (Patients/Public)• Will there be enough volume to cope with the numbers of patients if all patients are to go to the same centre? Will this have an effect on beds and availability of beds? (Patient/Public)• Can there be some assurance to patients that this decision has been based on best treatment rather than financial reasoning (Patient/Public)• This only covers some heart attack patients, what about those whose symptoms are not as obvious (e.g. tiredness/breathlessness) (Patient/Public)• Many patients wanted to praise the care received from their local hospitals (Patients/Public)• Is it always better to rush a patient into a procedure rather than giving them the time to prepare for a procedure? (Patient/Public)• Will clot busters still be an option for patients if it is appropriate to administer? (Patient/Public)• Do not want to destabilise local service provision and de-skill local clinicians. Ambulance service staff will need to be monitored (Patient Group)/home/pptfactory/temp/20101206092607/download1909.doc 73
  • 74. • Will those who experience non ST elevation MI be disadvantaged by having to wait longer for treatment? Need explicit assurance that certain patients are not being disadvantaged alongside clinical developments (1, Patient Group. 2, PCT)• Provision of Phase 1 rehab needs to be given at the NGH and the transfer of rehab needs to be coordinated back to the local hospital, also this may mean that if patients are well enough to go straight home from the NGH this can happen in the Rehab is arranged (PCT)• If there is any question on the quality/reading of the ECG the ambulance service should default to taking that patient to the local hospital rather than to the NGH (PCT)• There will be ambulance costs for patients being taken out of the area e.g. to NGH for elsewhere, in addition there may be ambulance transfers needed for transport back to the DGH once a procedure has been undertaken. This needs to be considered (PCT)• Feedback from some of the DGH’s highlighted that they could incur a loss of income due to the move of emergency treatment to the NGH (Foundation Trust)• The ambulance service have highlighted that the additional journey time may affect their achievement of targets (Ambulance Service)• Has it been considered to have the centre elsewhere or the provision of PPCI being provided in additional centres? (Clinician)• How will it be monitored as to whether patients are receiving treatment within appropriate time (Council Panel)• Could the services be decentralised to reduce transfer times? What about the RHH, there is no mention of services there what so ever? (Anonymous)With regards to patients and their families the feedback echoed that ease of beingable to visit was very important however they also wished that their relative had thebest treatment available to them. Parking and visiting times were also a factor as wellas clear communication regarding their relative’s condition should be given a soon aspossible. It has been highlighted that the communication has not been good to nextof kin. Could it be possible to consider making accommodation for next of kinavailable? It also needs to be considered how the repatriation to the local DGH ishandled and communicated. Infection rates at other hospitals were raised as a query.Highly Specialised Care for Heart ProblemsSummaryIn favour of providing more Unsure Againsthighly specialised care atlocal hospitals24(67%) 12 (33%) 0The feedback for this section is that patients would like to be treated in their localhospital if that was appropriate and available. The feedback also indicates that theremay have been a lack of understanding in some cases between what was beingproposed in Q1 and Q2, where some patients thought that the questions werecontradictory; this however is a speculative comment. Overall there was a great/home/pptfactory/temp/20101206092607/download1909.doc 74
  • 75. amount of support for the local hospital. People did question however whether thiscould "dilute" the skills i.e having more people undertaking the specialisedprocedures across the area rather than concentrating the specialist in one area.Detailed BreakdownThe feedback showed that people are very keen to have specialised care available tothem via their local hospital.It was considered to be very important to both patients and family to have careprovided as close as possible to home where clinically appropriate but they equallywanted to know that their family are receiving the best care possible and if this is at adistance then people will travel for that care. They raised the question of ensuringthat the standard of clinical care should be the same at all hospitals.There were a number of additional points raised, including:• Does the development of specialised services at the local hospital not contradict the development of the Heart Attack centre at the NGH? Would this be a very costly exercise? (Patient/Public)• Ensuring that the clinicians are available to communicate to family, this is very important for worried/frightened family members. (Patient/Public)• Ensuring that follow up visits are available post discharge (Patient/Public)• Having accommodation available for family to use and access to quality food, potentially out of hours (Patient/Public)• Re-assurance about long term implications and communication to families as to how they can help. (Patient/Public)• Communication to patient should be given by the specialist clinician/doctor (Patient/Public)• Should only embark on establishing more specialised centred if there is the resource to support this whilst ensuring that existing centres of excellence are not de-skilled (Patient/Public)• It was highlighted again that the RHH in Sheffield does not appear to be mentioned in the strategy. (Patient/Public)• Complexity of service provision, hasn’t it just been said that specialist care would be given at the NGH? (Patient/Public)• Many people are now more concerned with the standard of the hospital’s care rather than its location. (Patient/Public)• Once treatment has been received the patient should be transferred to a designated “heart” ward rather than a general ward as they are quite disruptive and busy. (Patient/Public)• Patients should be able to have a say in where they have their treatment. Patient Choice. (Patient/Public)• It has been found to be important to patients to also have contact/visits from other people who have had the same conditions as they have (Patient Group)• Stressing the importance of rehab, exercise and lifestyle changes need to be emphasised before and upon discharge with linkages to rehab programmes outside of hospital (Patient Group)• Would this destabilise the local service at Sheffield, would they lose the specialism. (Patient Group)• Will there be enough beds to support the service expansion? (Patient Group)• It would be important that the local cardiology units be open 24/7 if they were to be providing a specialised service particularly relevant for the ambulance service to ensure they know when and where they can transport. (Ambulance Service)/home/pptfactory/temp/20101206092607/download1909.doc 75
  • 76. • The units will need to have a enough activity to ensure competency is maintained (Ambulance Service)• Good repatriation to GP care is important to the patient and their family (PCT)• Decision making criteria for the development of service models and subsequent procurement decisions should be explicit within the strategy (PCT)• People want a quality service without inequality, Sheffield currently have a better service simply due to easier access (Clinician)Rehabilitation and Support ServicesThe feedback showed that rehabilitation and re-assurance, information about how tolive with the condition is extremely important. It was highlighted a number of timesthat there is not enough resource in Rehab and follow-up. Patient confidence wasmentioned on numerous occasions, that confidence needs to be built again afterbeing admitted to hospital.Particular points highlighted included:• Home visits should be implemented as the visit to the Practice Nurse falls short both physically and psychologically, this would provide an opportunity to re- assure the patients worries about progress and the final results (Patient/Public)• Regular follow up, annual check ups at the hospital (Patient/Public)• Getting a normal family life back again, independence (Patient/Public)• Financial support and advice (Patient/Public)• Encouraging patients to take responsibility to improve health status (Patient/Public)• Investment into Phase 3 and 4 Rehab programmes to ensure access is available to everyone. Once completed, patients should have a long term management plan to follow (Patient/public)• There is currently a lack of low level psychological/counselling support (Patient/Public)• Information should be available to the patient however this needs to be given at the right time as patients are unable to take it in too close to the event. (Patient/Public)• Financial support to keep groups going and to help make it affordable to the members, surely it is cheaper to run a rehab group than for a patient to be re- admitted to hospital? (Patient/Public)• More ready access to General Practice (Patient/Public)• Information about support groups, consistent approach (Patient/Public and PCT)• Encouragement to talk with other people with the same condition (Patient/Public and PCT)• Having advice available at the end of a phone line or drop in sessions (Patient/Public, Patient Group)• Knowing what exercise and activities are able to be undertaken (Patient Group)• Patients want choice, rehabilitation needs to be tailored to suit the differing needs of the patients (Patient Group)• Psychological support/advice for both patient and family (Patient Group, PCT, Patient/Public, Foundation Trust)• Ensuring that rehab programmes are available at times that are convenient to those attending, i.e. evening sessions for those who return to work. Sessions/groups should be available close to the patients home (PCT)• Look at alternative ways to equip people as they return to daily life, DVD information, internet based programmes, buddy system (PCT)/home/pptfactory/temp/20101206092607/download1909.doc 76
  • 77. • The Network should clearly identify its role related to non specialised services for example rehabilitation and diagnostics. This should be focussed on supporting commissioners to develop appropriate, relevant and high quality services that meet the needs of individual health communities. (Council Panel, PCT)• More coordinated approach to putting in place support services to facilitate prompt dischargePreventing Heart ProblemsThe feedback was supportive of the proposals to investing in preventative measures.It was seen to be very important. The feedback did focus on ensuring that the peoplewho were most at risk were targeted and questioned the best and most appropriateways to do this. Affordability of changes in lifestyle and access to exercise healthyeating was raised and also making the education readily available inappropriatesettings. It was suggested that there is also a need for information to be presented inlay terms rather than using a large amount of medical terminology.Starting the education at a young age through schools was thought to be a sensibleidea and some feedback suggested that shock tactics be used (REAL informationabout the consequences of lifestyle decisions). This was quite a significant theme.Other feedback included: • Emphasising the obvious whilst giving practical tips rather than just highlighting the issues for example: How to Exercise; What foods to eat and ideas for recipes; Encouragement not to drive for small journeys etc (Patient/ Public) • Having TV campaign around “what causes a heart attack”. Developing advertising similar to that for drink driving around Christmas time (Patient/Public) • Information should be packaged without frills, information should be published in every public location (Patient/Public) • Peer pressure (Patient/Public) • Education around affordability of healthier foods. (Patient/Public) • Reduction in the opening hours for pubs, clubs and the sale of alcohol and a complete ban on tobacco (Patient/Public) • An opinion that normal screening does not work (Patient/Public) • Excellent, however these plans seem to have been around for a long time however they never seem to be put in place (Patient/Public) • Set up community based groups to help people get information and the right messages (Patient/Public) • The plans are very good in concept; however you cannot force people to change. How is this going to be tackled? (Patient Group) • Knowing your family history can make a difference (Patient Group) • Peer support (Patient Group) • Having access to support services such as dietician (Patient Group) • There needs to be a family/community/group approach rather than an individual approach (Patient Group, Patient/Public) • Subsidise Gym Subscriptions (Patient/Public, Patient Group) • Screening programmes targeted directly at those at risk (Council Panel) • Any information should be developed in line with the National direction. The Network should clarify its role in this process as standard setting and/home/pptfactory/temp/20101206092607/download1909.doc 77
  • 78. disseminating good practice, which allow health communities to commission services that meet the needs of their population (PCT) • Need to take into consideration psycho-social aspects of an individuals life as these may need to be addressed in line with other factors (Anonymous)Other CommentsMuch of the comments in this section related to the positive treatment received bypatients. The importance of cardiac rehab was emphasised, particularly in relation togroup and peer support. The importance of having a strategy that coveredprevention, diagnostics, hospital treatment, rehab and support was raised by anumber of responses.Some of the more individual comments included • DGH’s and the services that they can offer to the local community to be factored into future developments of the service • Waiting times are still long (Patient/Public) • More co-operation between drug companies and medics (Patient/Public) • Phase 4 rehab seems to be poorly supported (Patient/Public) • What will be the acceptance criteria for patients being taken to the new centre (Patient/Public) • Will additional ambulance crews be available should a crew have to take a patient to the NGH where previously it would have been a local transport (Patient/Public) • Perception that GPs are not interested post discharge (Patient/Public) • Need to use innovative ways to get message across (Patient/Public) • Nothing in strategy about primary care, the strategy needs to be more public friendly. The strategy is too long and the summary document is too brief. (Patient/Public) • Heart Failure nurses key to patient care (Patient/Public) • Seems to be a reduction in the amount of rehab available. Used to be quite a broad range of activities and support available, this seems to not be the case now. The hospitals do not appear interested. (Patient/Public) • More work could be done with GP practices to encourage the practice to target prevention of heart conditions. Feeling that GPs don’t understand cardiac issues. Don’t feel that the GP is bothered when approached regarding patients cardiac issues (Council Panel, Patient/Public) • Concern around survival of those from more affluent areas v those from less affluent areas post angioplasty (Patient Group) • The document does not set out key priorities for the next 12-24 months (PCT) • Needs to be stronger links between the network and local CHD commissioning leads. The absence of a SIF from the Network for Derbyshire PCT has left the area without a valuable resource to support service redesign locally (PCT) • Objectives should be clearly defined – the strategy needs to span all parts of the pathway, it is particularly surgically and hospital focussed (PCT) • Aortic Aneurysm – AAA screening programme should be in the action plan (PCT) • Atrial Fibrillation – important cause of TIA stroke – does not get a mention in the key actions. Should be considered as part of primary prevention (PCT)/home/pptfactory/temp/20101206092607/download1909.doc 78
  • 79. • The strategy should be clear regarding its status as a commissioner led strategy and as such World Class Commissioning Principals should be central (PCT) • PPI should be central to any future developments (PCT) • Timeliness of patients being transported to the NGH within the timescales required for primary angioplasty – particular issue for patients in Bassetlaw (rural) where ambulance response times are often slower (PCT) • Strong views were expressed in relation to the potential negative impact on patients and their families of having to travel long distances to specialist centres (Patient Group/PCT) • Seems as though decisions have already been made regarding Primary PCI and Rehab, was this just a paper exercise? Should be moving towards core services being provided in each centre, sub specialist services to be provided where there is an interest and services which require specialist equipment to be provided in the regional centre (Clinician)/home/pptfactory/temp/20101206092607/download1909.doc 79
  • 80. Cardiac Strategy – Your FeedbackIt is important to us what you tell you think about the Cardiac Strategy. In particular we wouldlike to know your views about the following: We would be very grateful if you would take yourtime to provide us with your feedback 1. Emergency care for heart attack • In the future emergency treatment for heart attacks will be provided at the Heart Attack Centre 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 Heart Attack Centre. • There patients will have an emergency angioplasty (a treatment that is now considered to be the best treatment for heart attacks) within hours of having a heart attack. • When patients have recovered enough they will be taken to their local hospital to be cared for until well enough to go home. What do you think about these plans? What would matter to patients and their families in this situation? 2. Highly specialised care for heart problems • Highly specialised care for heart problems usually takes place at the Northern General Hospital at Sheffield. • It may be possible in future to provide some parts of this care at local hospitals in Barnsley, Doncaster, Rotherham, Chesterfield or Workshop. What do you think about these plans? Is the location of the hospital that provides specialist care for heart problems important to patients and their families? What else would matter to patients who need specialist care, and their families?/home/pptfactory/temp/20101206092607/download1909.doc 80
  • 81. 3. Rehabilitation and support services • Getting better and returning back to daily life after a heart attack or an operation on the heart often means that patients needs to have a programme of rehabilitation. • We would like to improve the rehabilitation services that people receive What matters to patients and their families about getting back to daily life after developing a heart problem? What other support might patient need in order to return back to daily life and on an ongoing basis? 4. Preventing heart problems • All Primary Care Trusts in the Network have plans in place to improve people’s general health and prevent heart disease from developing or getting worse. • These include help with stopping smoking, increasing levels of exercise people take, improving diet and providing treatment for high cholesterol levels and high blood pressure. • In the future it will mean that more people will receive a screening appointment so that their risk of developing heart disease and provide them with advice on healthier living. What do you think about these plans? What do you think would help people take up a healthier lifestyle? 5. Other Comments? Are there any other comments you would like to make about the Cardiac Strategy or Cardiac Services that you have used./home/pptfactory/temp/20101206092607/download1909.doc 81
  • 82. 9.4 Appendix D Health Inequalities Impact Assessment Strategy Section Title Key Action Positive Impact Negative Impact Action to Enhance or Mitigate Section Impact 3.7 Reducing CHD Development of a high level (network wide) plan Ensuring that all PCTs across North Trent There are hard to reach groups in the Ensuring that that the plans for best Mortality which identifies best practice in reducing CHD have robust plans in place to reduce mortality population who may not access services practice identify how best to achieve mortality rates. which work with patients to reduce their reducing CHD mortality in the hard to risk of CHD mortality. reach groups Groups that may be most affected BME groups, special needs Patient and public information in GROUP North Trent population specifically appropriate formats and languages vulnerable Groups that may be most affected BME groups, special needs IMPACT high LIKELIHOOD high 3.7 Primary Prevention In 2008 the Network will plan and deliver a North Ensuring that all PCTs have robust plans in There are hard to reach groups on the Ensure that that the plans for best Trent Primary Prevention Project. place that will ensure effective delivery of population who may not access services practice identify how best to achieve primary prevention. which work with patients to prevent risk implement primary in the h factors for CHD. prevention in hard to reach groups GROUP North Trent population specifically vulnerable Groups that may be most Patient and public information in affected BME groups, special needs appropriate formats and languages IMPACT high LIKELIHOOD high/home/pptfactory/temp/20101206092607/download1909.doc 82
  • 83. 4.3 Acute Coronary Development of a strategy and plan for the future The development of plans for the future delivery of this service will need to address all As part of the planning process a Syndrome and delivery of elective angioplasty services in 2008/09. aspects of quality and access for all populations. There are potential issues around access HIIA will be undertaken Stable Angina to quality services for some parts of the population that will need to be addressed. Development of a Primary Angioplasty Service Access by Sheffield population from June Primary Angioplasty can be undertaken Plan to increase public awareness based at Sheffield Teaching Hospitals Foundation 2008 to current best practice in the treatment within a ‘window’ of up to12 hours post especially in vulnerable groups of Trust for the Sheffield PCT population in 2008/09 of STEMI onset of symptoms. Patients who do not symptoms of STEMI and the need to seek help early enough following onset of call for help immediately. Achieving national strategy Mending Heart symptoms may fall outside the ‘window’ for and Brains undertaking a STEMI. Patient and public information in GROUP: Sheffield PCT population appropriate formats and languages specifically vulnerable groups such as elderly BME communities and special needs groups IMPACT medium LIKELIHOOD medium Development of a Sheffield PCT only service. There will be no access to this Development of a clear role out plan service for non Sheffield population of the for Primary Angioplasty to the Network in 2008/09. population of North Trent GROUP: Barnsley, Doncaster, Bassetlaw, Rotherham, North Derbyshire PCT population IMPACT medium LIKELIHOOD high Strategy implies no access to Primary Angioplasty for none Sheffield PCT Clarity needs to be sought on none patients who suffer a STEMI whilst in the Sheffield PCT patients who suffer a Sheffield area and are taken to STHFT for STEMI whilst in the Sheffield area emergency care GROUP: Barnsley, Doncaster, Bassetlaw, Rotherham, North Derbyshire PCT population IMPACT medium LIKELIHOOD low/home/pptfactory/temp/20101206092607/download1909.doc 83
  • 84. 4.4 Heart Failure  Heart Failure clinical guidelines will be used as HIIA will be undertaken on any plans that are developed. the basis upon which a Network strategy for development of secondary and tertiary heart failure services will be produced. The commissioning implications will need to be discussed and recommendations made to the PCTs.  Preferred Place of Care Plan to be Ensure consistent network wide None currently foreseen Patient and public information in implemented across the Network in 2008/09 implementation of the preferred place of care appropriate formats and languages from across the Network PCTs  Implementation of NICE Technology Appraisal Implementation of national guidance on best Referred for CRT dependant on DGH Education plan required to ensure on Cardiac Resynchronisation Therapy practice in the treatment of heart failure clinical awareness/ assessment and appropriate identification and referral (CRT)by November 2008 referral for CRT of patients GROUP North Trent population IMPACT medium This needs to be followed up with an LIKELIHOOD high audit to ensure consistent network wide improvement in patient care/home/pptfactory/temp/20101206092607/download1909.doc 84
  • 85. 4.5 Arrhythmia &  Support health communities in reviewing This will assist in highlighting inequalities None currently foreseen Sudden Cardiac themselves against the Network across North Trent so that action plans can Death recommendations for arrhythmia services and be developed to address any identified the development and implementation of local inequalities action plans.  Establish how many families with a family Directly addresses inequalities in case of None currently foreseen history of Sudden Cardiac Death are not families so that plans can be developed to accessing Inherited Cardiac Conditions address this. Services  Support health communities in reviewing This will assist in highlighting inequalities None currently foreseen themselves against the Network across North Trent so that action plans can recommendations for Inherited Cardiac be developed that addresses inequalities Conditions Services and development of local action.  Develop and deliver a programme of education Implementation of national best practice Referral for pacemakers/ICD dependent Education programme plan required for clinical staff who refer patients for consistently across North Trent on GP/DGH clinician awareness and that ensures appropriate pacemaker implantation and ICD implantation referral for procedure identification and referral of patients (and Cardiac Resynchronisation Therapy – GROUP North Trent population see section on heart failure) that ensure IMPACT medium This needs to be followed up with an appropriate and timely referral of patients. LIKELIHOOD high audit to ensure consistent network wide improvement in patient care 4.6 Aortic Aneurysms  The Network will agree long-term North Trent wide access to complex hybrid None currently foreseen Surgery commissioning arrangements for these aortic aneurism surgery for appropriate procedures when sufficient have been patients undertaken to assess their cost. 4.7 Diagnostic Imaging  Referring to the – Myocardial Perfusion Ensure consistent network wide None currently foreseen and Diagnostic Scintigraphy, the Network will consider the implementation of access to diagnostics Testing impact of the NICE Technology Appraisal on across the Network PCTs Angina and Myocardial Infarction on service delivery and resources by undertaking a cost benefit analysis and feeding the output of this to be into the Network planning cycle 2009/10./home/pptfactory/temp/20101206092607/download1909.doc 85
  • 86. 4.8 Rehabilitation and  Review of cardiac rehabilitation activity across Ensure consistent network wide None currently foreseen Ongoing Support the network and provide recommendations by implementation of the rehabilitation across end 2008. the Network PCTs  Review and formalise Network input into the HIIA will be undertaken on any plans that are developed. development and continuation of patient support groups by end 2008./home/pptfactory/temp/20101206092607/download1909.doc 86
  • 87. 9.5 Appendix E Equality Impact AssessmentDepartment/Team : Yorkshire and the Humber Collaborative SouthLead Officer: Sarah HalsteadContact Details: Hillder House, 49-51 Gawber Road, Barnsley, S75 2PY Telephone : 01226 3738 Email: sarah.halstead@barnsleypct.nhs.ukFunction: Cardiac Network StrategyPolicies used to Sets out the developments required over the next 3 years tocarry out function: ensure delivery of cardiac services that meet the health needs of the population of the North TrentGroups who the Adult population of North Trent who are at risk of developingfunction should cardiac conditions or who have a cardiac conditionbenefit:Are all groups affected equality by this function/policy?Step 1 Who should be served by the function/ Information Gathered policy? Make use of …….. North Trent Population Baseline information on the general population and the groups the function should benefit e.g. Population size 1.8 million  Census data (or more up to date population projections)  Other survey data  Population at risk factors for  Information of social and economic Cardiac diseases factors, such as age, income levels,  Population who has cardiac health etc which are indicators of disease need.  Population who access cardiac servicesStep 2 Do you have monitoring data? If yes (go to 3) If no (go to 4) Examples . . . Yes - but strategy doesnt really profile  Workforce Data the population to the  Audit or Review information detail intimated.  Satisfaction survey results Although individual Service user profile broken down into: PCTs have this detail Sexual Orientation. Gender, Race, the network doesnt religion, Belief & Disability hold it. Action - The PHO may do this as part of the needs assessment work being proposed for the networks in the Y&H region./home/pptfactory/temp/20101206092607/download1909.doc 87
  • 88. Step 3 Who is using the function/policy? Notes  What does your monitoring data on See epidemiology section of strategy your service users tell you?  High rate of smoking and obesity  Are any groups under or over  Low rate of health eating and represented compared to what you exercise would expect to see from the baseline data  80,000 people in North Trent  What does your monitoring data suffering with CHD. Varying outcomes tell you? E.g. are some prevalence across the patch groups more likely to be serviced  Mortality rate for circulatory better by your function, service and disease above England average policies etc compared to what you and varies across the Network would expect to see from the baseline PCTs data on their needs?  Equity gap between deprived  South Asian people are 50% more likely to die prematurely of CHDStep 4 What evidence do you have that Evidence sources your service is accessible equitably to all groups taking into account sexual orientation, gender, age, race, religion, belief and disability  Customer Satisfaction Survey results  Consultation Network wide of all  Local and national research organisations within the Network  Consultation from end of July to end of  Observation September 2008  User GroupStep 5 What action have you taken to Evidence of action implemented to ensure that your users are all date serviced equitably?  Staff trained in how to treat  ‘Listening to you’ event in June services users with specific needs 2008 – where members of the  Service information produced in a public were invited to comment on range of formats to assist all the cardiac strategy groups  Development of a Cardiac network  Service changes made directly to User Group. This group has the reflect changes in the service user role of bringing the patients/carer profile perspective to the developing and  Service users consulted prior to delivery of the strategy planned changes to the service  A further consultation on the being implemented strategy planned. This will include  Staff groups made aware of public consultation and Scrutiny service user groups who may be of strategy being disadvantaged by existing policy, practice and procedure  Staff being consulted to assess how new policies and procedures may impact on themStep 6 Do you know whether your service List reasons why this may or may not/home/pptfactory/temp/20101206092607/download1909.doc 88
  • 89. delivery is being compromised be the case and the evidence you because of any issues relating to: have to support your belief. Sexual Orientation, Gender, Race, Religion, Belief & Disability? A key aim of the Cardiac Network strategy is to reduce inequalities across the whole of the North Trent population specifically ensuring ‘equity of access’ and ‘consistent standards’. This will involve reviewing service delivery and proposals for changes to service delivery to ensure that they provide equitable services to the population of North Trent. It is planned that each developing will have both an ‘Equality Impact Assessment’ and ‘Health Inequality Impact Assessment’ undertaken.Action 1. Develop a population profile appropriately segmented – including aPlan decision about the percentage of the Derbyshire County population is included in the North Trent Network figures 2. Review of data quality in both primary and secondary care 3. Agree a programme of equity audits 4. Consider the possibility of an analysis post for the Network/home/pptfactory/temp/20101206092607/download1909.doc 89
  • 90. 9.6 Appendix F Heath Care Commission – Heart Failure Review ScoresCommunity Overall Criterion 1 score: Criterion 2 score: Criterion 3 score: Criterion 4 score: Review Suspected heart Patients are There are Services are Score failure are being receiving adequate and having a positive effectively evidence-based effective impact on diagnosed treatment multidisciplinary hospital consistent with services and admissions, NICE guidelines care processes mortality and and are being in place, which patient monitored provide patients experience effectively to and carers with ensure optimum adequate treatment and education and quality of life supportBarnsley Community 3 3 2 2 3Bassetlaw Community 3 3 2 4 3Chesterfield Community 2 2 1 2 2Doncaster Central 3 3 2 4 3CommunityDoncaster East 3 3 2 4 3CommunityDoncaster West 3 3 2 4 3CommunityHigh Peak and Dales 2 2 1 2 2CommunityNorth Eastern Derbyshire 2 2 2 2 2CommunityNorth Sheffield Community 1 1 2 4 2Rotherham Community 3 4 1 4 2Sheffield South West 1 1 2 4 2CommunitySheffield West Community 1 1 2 4 2South East Sheffield 1 1 2 4 2CommunityAll scores are on a 1-4 scale:1 performance that does not meet minimum requirements or the reasonable expectations of patients and the public2 performance that meets minimum requirements and the reasonable expectations of patients and the public3 performance that goes beyond minimum requirements and the reasonable expectations of patients and the public4 performance that goes well beyond minimum requirements and the reasonable expectations of patients and the public.A leader in this aspect of performance./home/pptfactory/temp/20101206092607/download1909.doc 90
  • 91. 9.7 Appendix G Summary of Heart Failure GuidelinesHeart failure is best defined as an inability of the heart to deliver blood (and O2) at arate commensurate with the requirements of the metabolizing tissues, despite normalor increased cardiac filling pressures. The condition assumed increasing importancein the latter part of he Twentieth Century due to its increasing prevalence, highmorbidity and mortality. The condition affects1–2% of the general population with the rate rising to 10-20% amongst the elderly(>80 years) and this latter group is growing in Western Europe and North America.Heart failure is associated with a worse quality of life than most other chronic medicalconditions and has a high hospitalisation and re-hospitalisation rate, usually for along period of time. Expenditure on heart failure in the United Kingdom accounts for1-2% of the total NHS 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.InvestigationsThe purpose is to establish the diagnosis of heart failure, define the cardiacaetiology, identify any precipitating factor, guide and monitor the management and toobtain prognostic information.All patients are expected to have routine blood tests, chest X-ray and 12 leadelectrocardiogram. A normal ECG is unlikely to be seen if heart failure is caused byleft ventricular systolic dysfunction. Transthoracic echocardiography is the bestsource of objective evidence of cardiac dysfunction at rest and other non invasivetechniques include radionuclide venticuography (MUGA) and cardiac MRI (CMR).Cardiac catheterisation can provide evidence of coronary disease as one of thecauses of heart failure and some patients will require revascularisation because ofangina or ischaemic cardiomyopathy.Non Pharmacological ManagementGeneral advice must be offered to patients with chronic heart failure. This can befacilitated by the Heart Failure Specialist Nurses.This should include explanation of the causes and symptoms of heart failure andwhat to do if they occur along with advice on lifestyle modification and selfmanagement techniques with regard to weight monitoring, drug regimes andexercise, amongst others.Pharmacological managementPharmacological agents include Diuretics, Angiotensin Converting Enzyme Ihibitors(ACEI), β-Adrenoceptor antagonists, Aldosterone receptor antagonists,Antothrombotic and Antiarrhythmic agents, amongst others.These drug regimens are complex and advice on indication, dosage and titrationschemes etc can be found in the full guidance.The new role for the heart failure specialist nurse:The precedent is in the diabetes specialist nurse who has been allowed for manyyears to adjust the insulin doses once the medical practitioner has decided toinstitute a particular type of insulin. It is proposed that the patient who is referred tothe heart failure specialist nurse with a decision to commence an ACEI inhibitor or a/home/pptfactory/temp/20101206092607/download1909.doc 91
  • 92. β-receptor antagonist; could have their doses up-titrated according to the protocol’srecommendation by the heart failure specialist nurse. This requires the support of themedical referring team and the Consultant Cardiologists with special interest in HeartFailure.Non-pharmacological interventions • RevascularisationPatients with ischaemic heart disease and angina; can be offered revascularisation,percutaneously and surgically at a high risk (because of left ventricular systolicdysfunction).In the absence of angina; there are some cardiologists and cardiac surgeons who areprepared to offer revascularisation to patients demonstrated to have objectiveevidence of myocardial ischaemia and myocardial viability (beyond the existence ofcoronary artery disease). This is based on observational evidence of prognosticbenefit. • Pacing & Implantable cardioverter defibrillatorIn addition to the usual indications of pacing, biventricular pacing should beconsidered when patients with severe heart failure have wide QRS complexes (>120msec), are in sinus rhythm, with evidence of dilated left ventricular cavity andsecondary mitral valve regurgitation. It is now believed, that in order to avoid pacingthe 30% of these patients who do not respond to this therapy, selection by strictechocardiographic criteria of dys-synchrony ought to be demonstrated beforesubjecting the patient to Cardiac Re-synchronisation Therapy (CRT).Patients with heart failure, who have no correctable cause (such as ischaemia), whoare on full pharmacological therapy, and whose left ventricular ejection fractionremains less than 30% could be considered for an implantable cardioverterdefibrillator (ICD). Similarly patients after a cardiac arrest with severe LVSD orpatients 40 days after an MI, with LVEF <30% could be considered for ICD.Heart transplantationThis is an established modality of therapy when the cardiac dysfunction is neitherreversible nor amenable to the orthodox therapeutic options listed above.Heart Failure (HF) Management Outline1. Establish the patient has HF.2. Assess the severity of symptoms.3. Determine the aetiology of HF.4. Identify the precipitating factors.5. Identify concomitant diseases.6. Estimate prognosis.7. Anticipate complications.8. Counsel the patient and the relatives.9. Choose appropriate management and follow up plan./home/pptfactory/temp/20101206092607/download1909.doc 92
  • 93. 9.8 Appendix H Arrhythmia and SCD Service Provision in 2006 The following table outlines services across the network of Arrhythmia and Sudden Cardiac Death Health Position in 2006CommunityBarnsley • Syncope Nurse and a Falls and Blackout Clinic up and running, both under the Care of the Elderly consultant • Assessment of relatives of patients who had Sudden Cardiac Death • Assessment of patients with suspected arrhythmia in General Cardiology ClinicBassetlaw • Arrhythmia patients currently managed in Cardiology services • Bassetlaw has been identified as a development site for the Competency Framework • Tilt table available on site, although no syncope service in place • Muse system in place on CCU (for transporting ECG recordings via mobile phone signal) • Electronic storage system for ECGs in place on CCU • Primary care premises all equipped with defibs and ECG machines • First responder scheme in place for the rural areas • Formal bid submitted for BHF funding to recruit an Arrhythmia Care Coordinator and Support Officer for Doncaster and Bassetlaw Trust - unsuccessfulDoncaster • Arrhythmia clinic slots offered within general cardiology clinic, thus ensuring that people presenting with arrhythmias have timely and accurate specialist assessment • Assessment of relatives of people who have experienced a sudden cardiac death • Development and expansion of local pacing services • Formal bid submitted for BHF funding to recruit an Arrhythmia Care Coordinator and Support Officer for Doncaster and Bassetlaw Trust - unsuccessfulNorth • Arrhythmia patients are currently managed in line with the existing system for allDerbyshire people who present with a cardiological problemRotherham • Arrhythmia patients follow normal referral pattern to OPD, being seen according to their priority. No specific referral pattern for arrhythmia patients • Following appropriate investigations patients either continue follow up with DGH or are referred back to GP • Syncope clinic (Care of the Elderly)Sheffield • Current service provision is voluntary and an informal agreement between consultants • Established Network-wide electrophysiology, ICD and pacing service, based at NGH • (see ‘Network-wide current position’ below) • 1 Genetic Heart Disease Specialist Nurse • Established service of interested specialists, based at NGH • (see ‘Network-wide current position’ below) /home/pptfactory/temp/20101206092607/download1909.doc 93
  • 94. Health Position in 2006Community • Well established Genetic Heart Disease Clinics (2-3 per week) receiving network- wide referrals • (see ‘Network-wide current position’ below) • The Royal Hallamshire Hospital has a Syncope Clinic • Establishment of regular Genetic Heart Disease Multidisciplinary Team – DNA testing channelled through this • Links with Coroners have been developed for sudden cardiac death referrals • Established links with all major related charities • A number of educational events for primary care and hospital staff have already been undertakenNetwork- • Established Network-wide electrophysiology, ICD and pacing service, based atwide NGH. Comprises: - Established tertiary electrophysiology service – 2 consultants with a third planned - Established ICD implantation service - Specialist electrophysiological study and catheter ablation service - Specialist pacing, including biventricular pacing, service • Provision of Network-wide Genetic Heart Disease clinics, based at NGH in Sheffield. Clinics take on index cases and offer family screening to investigate entire families rather than individuals • Service of interested specialists available to patients Network-wide – comprises a Cardiologist, a Genetic Heart Specialist Nurse (soon to be 2), a dedicated Echocardiographer, an Aortic Surgeon, an Electrophysiologist, an Ophthalmologist, 3 Clinical Genetics Consultants /home/pptfactory/temp/20101206092607/download1909.doc 94
  • 95. For further information about this Strategy or the North Trent Network ofCardiac Care contact:Sarah HalsteadNetwork CoordinatorNorth Trent Network of Cardiac CareYorkshire and the Humber SCG and Collaborative (South)Hillder HouseGawber RoadBarnsleySouth YorkshireS75 2PY01226 433738sarah.halstead@barnsleypct.nhs.ukwww.ntncc.nhs.uk/home/pptfactory/temp/20101206092607/download1909.doc 95