SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST
Meeting Trust Board Date 4 December 2008
Subject Business Case for Interventional Enclosure P
Nature of item For information
Decision required Business Case presented for approval
General Report Author Mel Duffy, Deputy Director of Development
Information With contributions from:
Yasser Haider, Consultant Cardiologist
Najmi Qureshi, Consultant Cardiologist
Karen Wentworth, Radiology Manager
Lead Director Jayne Blacklay, Director of Development
Received or Meeting Management Board
approved by Date 14 November 2008
Use of Estate
Freedom of Confidential (Y/N) No
Information (if yes, give reasons)
Final/draft format Final
Intended for release Yes
to the public
GENERAL HOSPITALS NHS TRUST
Cardiology – PCI
South Warwickshire General Hospitals NHS Trust
Outline Business Case
Reference number: Directorate:
Outline of Proposal:
To develop an elective and appropriate non-elective PCI service at the Trust from 1st April 2009.
This would be for approximately 150 cases in the first year, increasing to 300 in the second year
with a further projected rise to 410 cases from April 2011.
Initially 2 of the Warwick Cardiologists would need to gain re-accreditation and this would be
carried out at one of the following facilities:
The remaining cardiologists would then be trained to meet the anticipated increase in demand over
the next 1-2 years.
This proposal also supports the achievement of the Cardiovascular Network’s key priorities to
deliver care closer to home and ensure equitable access to cardiovascular care.
Huge progress has been made in the UK in terms of the delivery of Cardiac services in line with
the National Service Framework (NSF) for Coronary Heart Disease which was launched in 2000
seeking to improve the prevention, diagnosis and treatment of coronary heart disease. This has
led to the expansion of Cardiac services at Warwick from a single handed cardiologist to the
current four consultants, one-stop diagnostic clinics for patients with chest pain and an onsite
Cardiac Catherisation laboratory suite and day unit.
It is now proposed that the Trust develop community cardiology services and on-site interventional
cardiology to support improved access to percutaneous coronary intervention (PCI) and the
national drive for locally delivered services for the population of South Warwickshire. PCI
encompasses a variety of procedures used to treat patients with occluded coronary arteries that
can cause heart attacks. Typically, a balloon-tipped catheter is inserted into the problem artery of
the heart and dilated to restore blood flow through the artery. Within the Cardiac Network of
Coventry and Warwickshire, the provision of PCI services has been exclusively undertaken within
the tertiary cardiac centre at UHCW with the support of on-site cardiac surgery. The purpose of
this business case is to secure support for the establishment of a locally provided PCI service
based at Warwick Hospital, representing a significant development in cardiac service provision
within the Network in line with government vision and anticipated growth in demand.
Evidence Base to Support Delivery of PCI at Warwick Hospital
1. Quality Service Standards
The British Cardiac Interventional Society (BCIS) has published clear guidelines for the
development of new PCI services recommending the need to maintain volume for both the centre
and the individual to deliver better clinical outcome for patients with stable and unstable coronary
syndromes. Non-surgical services with appropriate operator and institutional volumes have been
clearly demonstrated to be able to provide a high standard of PCI. The current BCIS
recommendation is that new PCI services should deliver a minimum of 200 cases and have robust
plans to increase activity to a minimum of 400 cases per annum within a defined timescale.
Independent operator minimum activity requirements are 75 PCIs per year rising to 125 per year
for recognised trainers.
2. Access, Demand and Capacity
Current PCI activity volumes in South Warwickshire support the minimum requirement of 200
cases but do not enable the Trust to meet the 400 requirement with existing access rates in
Coventry and Warwickshire.
Professor Roger Boyle, the national director for Coronary Heart Disease, supported by the British
Cardiac Society (BCS) had recommended a 1,125 pmp for PCI with a proportionate reduction in
coronary bypass procedures. This recommendation was then further revised and accepted by the
BCIS following the publication of a BCS Workforce Group to 1400 pmp. However, at the recent
Angioplasty Consensus Meeting, hosted by the national Heart Improvement Programme, Dr
Stephen Green of the DH Vascular Programme presented revascularisation projections ranging
from a minimum 1900 to 2500 pmp by 2015 based on the Cardiac Stocktake methodology and
current uptake in western Europe.
Access to PCI in Warwickshire is currently limited to 1053 pmp and realization of these projections
would result in PCI demand exceeding supply with an activity plan of between 380 and 560 per
annum for the population of South Warwickshire, currently 270,000. This would effect a minimum
activity increase of 40% for South Warwickshire based on the 272 PCIs delivered in 2007/08.
The table below details PCI activity by HRG E15 taking place between April 2007 and March 2008
for the former South Warwickshire PCT population (272 PCIS total).
Rank P rov ider V olum e S hare Tarif f S hare
1 University Hospitals Coventry and Warwickshire NHS Trust 224 82% £989k 85%
2 University Hospital Birmingham NHS Foundation Trust 17 6% £74k 6%
3 Oxford Radcliffe Hospitals NHS Trust 11 4% £36k 3%
4 Heart Of England NHS Foundation Trust 6 2% £18k 2%
5 University Hospitals Of Leicester NHS Trust 5 2% £9k 1%
6 South Warwickshire General Hospitals NHS Trust 2 1% £10k 1%
7 The Royal Wolverhampton Hospitals NHS Trust 2 1% £10k 1%
There would also be a requirement for UHCW to increase capacity to support an additional 27%
increase on current activity if delivering the 2500 pmp revascularisation access for the rest of
Coventry and Warwickshire by 2015. This would result in an annual activity plan of 1180 PCIs for
UHCW (NB excluding South Warwickshire Primary PCIs).
Activity to date PCIs
Total PCI /
Organisation code UHB UHCW UHNST RWHT SWBHT HoE UHL Oxford pop k Access Access
pmp pmp *
el 128 128
Coventry PCT 5MD em 2 245 1 248
Total 2 373 0 1 0 0 0 0 376 304.2 1236 1650 2.98
el 7 175 14 4 14 214
Warwickshire PCT 5PM em 14 317 3 1 11 2 348
Total 21 492 0 3 1 25 6 14 562 533.9 1053 1557 2.09
Coventry and el 7 303 0 0 0 14 4 14 342
Warwickshire em 16 562 0 4 1 11 2 0 596
Total Total 23 865 0 4 1 25 6 14 938 838.1 1119 1511 2.86
UHCW recently received full Network support to implement a Network wide Primary PCI service
for patients suffering from an acute ST segment elevation myocardial infarction to undergo
emergency angiography and PCI as required on a 24/7 basis. This service receives an average of
2 South Warwickshire patients per week and it is not anticipated that the Warwick PCI service will
result in any reduction in PPCI demand.
The Trust is fully supportive of the development of new techniques and ‘cutting edge’ technology
at UHCW, our local tertiary centre, with a view to supporting the repatriation of patients to more
locally delivered specialist services.
Between 1st December 2008 and 31st December 2009, it is proposed that the Cardiologists will
seek re-accreditation at an appropriate facility operating on the required minimum of 75 cases
each per annum. The development of Warwick’s PCI service will take a two-phased approach
which will commence with elective/planned cases in phase 1 before moving to phase 2 with a full
elective and emergency service in normal working hours. During the first few months of operation,
the trained consultants will only carry out elective PCI procedures at Warwick. This will ensure that
the new service is not placed under any undue pressure to carry out more complex emergency
procedures. However, it is anticipated that once the service is established, it will move quickly to
carry out angiography and intervention on patients admitted as emergencies in order to realise the
additional benefits from the local service in releasing bed capacity for patients awaiting an urgent
transfer to the tertiary centre at UHCW. This will also generate significant savings to Warwickshire
There are currently 4 Cardiac Catheter sessions per week for angiography and initially we plan to
increase this to 8 to enable 2 additional sessions per week for PCI and a further 2 to enable
additional emergency angiographies.
The BCIS guidance recommends;
The development of new PCI sites should be planned and coordinated and not occur on an
ad hoc basis.
All PCI sites should adhere to agreed technical, professional and practical standards.
New sites should undergo a peer review visit through BCIS.
Case volume should be met for operators and centre staff.
In order to apply for accreditation, the Trust will be required to submit its intention with a minimum
of 8 weeks’ notice. Before the accreditation visit, the Trust will have to develop robust operational
policies including agreement for provision of an emergency transfer service at a tertiary centre.
Appendices 1 and 2 detail the current and proposed pathway.
This business case meets the following key objectives for the Trust and is included within the
Trust’s integrated business plan.
Meeting Trust objectives:
1 Continue to implement systems that support Zero Tolerance of Hospital Acquired Infections
2 Further reduce waiting times for patients
3 Maintain Financial stability and implement improved systems
4 Improve the Trust’s response to a major emergency
5 Achieve Foundation Trust Status
6 Improve staff involvement in all aspects of the organisation
7 Develop and implement new technology to improve efficiency and patient care
8 Improve local access to specialist care
9 Improve the patient and public experience within the Trust
10 Improve the supporting administrative systems
Meeting National targets:
cancer targets cancelled operations
choose and book delayed transfers of care
inpatients waiting times outpatient waiting times
A & E waiting times waiting times for rapid access chest pain clinic
The benefits of providing a local service are numerous:
• The procedure will be available locally and will reduce the requirement for patients to
• The availability of a service at Warwick will support the Network and commissioners to
meet demand for access in line with recommended best practice and DoH projections.
• It will reduce demand for capacity at specialist centres allowing them to concentrate on
more complex cases.
• It will improve bed capacity within the Trust reducing the number of delayed transfers
• It will provide the ability to carry out a one-stop service and therefore reduce the
number of episodes of care, offering the additional benefit of savings to the
commissioner for reinvestment in alternative local services for patients.
Full details are provided in Appendix 3.
Activity and Income:
For this analysis the following assumptions have been made:
• The majority of the activity is elective
• Additional angiography is undertaken due to PCI availability on-site.
• Income lost due to introduction of a one-stop pathway
• Loss of income indicates the level of saving to the PCT.
2009/10 2010/11 2011/12
Spells £ Spells £ Spells £
Elective PCIs 150 566,550 250 944,250 340 1,284,180
Non Elective 0 0 50 250,500 60 300,600
Additional Angiography 53 201,333 53 201,333 53 201,333
Loss of Income -150 -188,250 -300 -464,600 -400 -607,720
Total 150 579,633 300 931,483 400 1,178,393
MFF (12.04%) 69,788 112,151 141,879
Income 649,421 1,043,634 1,320,272
2009/10 2010/11 2011/12
Pay Costs (£) 174,771 159,171 159,171
Non-Pay (£) 305,773 632,368 836,679
Total Costs: 480,544 791,539 995,850
Year 1 (2009/10): £168,877
Year 2 (2010/11): £252,095
Year 3 (2011/12) £324,422
PCT Financial Implications:
• Transfer of expenditure for PCI from other providers to Warwick (up to 272 cases based on
• From 2010/11 the PCT would be required to fund the growth in PCI activity in line with DoH
• Reduction in double spell expenditure due to introduction of one-stop pathway.
2009/10 2010/11 2011/12
Spells £ Spells £ Spells £
Transfer of expenditure
Elective PCIs 150 566,550 150 566,550 150 566,550
Non Elective PCIs 0 0 22 110,220 22 110,220
Angiography 53 201,333 53 201,333 53 201,333
Elective PCIs 0 0 100 377,700 250 717,630
Non Elective PCIs 0 0 28 140,280 38 190,380
Reduction in double spells -150 -188,250 -300 -464,600 -400 -607,720
Total cost to PCT -188,250 53,380 300,290
A significant element of the additional costs which will be incurred will be on consumables used as
and when required in line with activity volumes. There are some upfront set-up costs, most notably
the cost of the sessions for the consultants to achieve re-accreditation and backfill costs to
maintain activity volumes and meet demand.
Further to the review of the level of activity required for centres to be accredited by BCIS it is now
suggested that centres registering an intent to undertake PCI must demonstrate plans to achieve a
minimum of 400 PCIs per annum within a 2 year timescale from implementation to be classed
viable. South Warwickshire activity will only increase to the level required if local PCI rates rise to
the 1900 per million population minimum rate projected by the DoH to match clinical need. Network
and PCT commissioning decisions about PCI projections could mean this proposed development
does not gain sufficient support, resulting in failure to achieve British Cardiac Interventional Society
(BCIS) accreditation and preventing the development from going ahead.
The development of local interventional cardiology has always been integral to the Trust’s strategy
for optimal utilisation of the Cardiac Catheterisation Laboratory at Warwick. Failure to achieve
agreement for this development may result in a Trust decision to disinvest in existing Lab services
due to under utilisation of the facility. This may, in turn, have implications for other cardiology and
acute services at Warwick and throughout the Network.
Approval sought for
The Trust needs to approve the following:
• Support the case to provide Elective and Non Elective PCI to the population of South
Warwickshire from the earliest possible date following consultant re-accreditation.
Business case approval
Approval sought from:
Capital Committee Management Board Trust Board
Management Board (14th November 2008): Approval to proceed with training programme. Number
of cardiologist to be trained is dependant on the growth, approved two initially then to be reviewed.
Referred to Trust Board for final approval.
Business case approved by: ………………………………………………………..
Business case monitoring
1. Risks that need to be added to the risk register:
Is this included in the risk register? yes no
If yes reference number
Category of risk
Score on risk register
Responsible officer for monitoring:
Name: Date: Follow-up
2. Equality Impact Assessment
Has the proposal been assessed for any impact relating to Equality?
Details of the assessment and any issues or concerns:
Details of any further Impact Assessment required:
Non elective admission
with chest pain
Troponin Negative Troponin Positive
In patient Await transfer to UHCW
exercise test 2-14 days
Await transfer Returned to SWH
Out patient CAG Home
to UHCW Home following day
Returned to SWH
Home 48 hours later
Stay at UHCW or return
to SWH to await CABG
Non elective admission
with chest pain
Troponin Negative Troponin Positive
In patient exercise test In patient CAG
Positive Negative For Medical treatment
Out patient CAG In patient CAG Home Home ?same day
Home within 24hours
For CABG/High Risk PCI
Await transfer to
PCI - Costs to the Trust
Income 2009/10 2010/2011 2011/12
Spells £ £ Spells £ £ Spells £ £
Elective PCI cases 150 3777 566550 250 3777 944250 340 3777 1284180
Number of Non Elective Additional Angiographies 50 3744 187200 50 3744 187200 50 3744 187200
3 4716 14133 3 4716 14133 3 4716 14133
E15 Non-Elective Tariff for PCI 0 5010 0 50 5010 250500 60 5010 300600
Less income from "double spells"
E11 and E12 0 3017 0 50 3017 -150850 60 3017 -181020
E13 and E14 elective double -150 -188250 -250 -313750 -340 -426700
Add MFF at 12.04% 69788 112151 141879
TOTAL ADDITIONAL INCOME TRUST 649421 1043634 1320272
Locum Consultant - Full time for 2 months 78000 15600
Consultant 0.4 46200 0.4 46200 0.4 46200
Band 7 Nurse 0.8 39899 31919 0.8 39899 31919 0.8 39899 31919
Band 6 Nurse 0.6 33139 19883 0.6 33139 19883 0.6 33139 19883
Band 2 Nursing Auxilliary 0.6 16614 9968 0.6 16614 9968 0.6 16614 9968
Band 7 - Radiographer 0.6 39899 23939 0.6 39899 23939 0.6 39899 23939
Band 7 - Medical Measurement 0.6 39899 23939 0.6 39899 23939 0.6 39899 23939
Band 2 Portering 0.2 16614 3323 0.2 16614 3323 0.2 16614 3323
Total Pay 174771 159171 159171
Number Cost per Number Cost per Number Cost per
per Pack/Item per Pack/Item per Pack/Item
Procedure £ Procedure £ Procedure £
Procedure pack (drapes, pots, needles gauze) 1 61 9144 1 61 18288 1 61 24384
Sheath, introducer 1 31 4575 1 31 9150 1 31 12200
Diagnostic wire, catheter 1 24 3600 1 24 7200 1 24 9600
Guide wire, guide catheter 1.5 101 22725 1.5 101 45450 1.5 101 60600
Balloons 1.5 150 33750 1.5 150 67500 1.5 150 90000
Ketch, indeflator, torque 1 39 5850 1 39 11700 1 39 15600
Pressure wire 1 80 12000 1 80 24000 1 80 32000
Stents (bare metal) 50% of patients 0.8 176 19828 0.8 176 42300 0.8 176 56400
Stents (drug eluting) 50% of patients 0.8 588 66094 0.8 588 141000 0.8 588 188000
Angioseal 1 75 11250 1 75 22500 1 75 30000
Reopro (50% of patients) 0.5 500 7500 0.5 500 25000 0.5 500 32000
Contrast 300 mls 1 555 83250 1 555 166500 1 555 222000
Pressure line 1 above 1 above 1 above
Drugs including clopidogrel 1 100 15000 1 100 30000 1 100 40000
Additional Cost of Angios 211 11207 211 21780 211 23895
Total Non Pay 305773 632368 836679
TOTAL PAY AND NON PAY 480544 791539 995850
NET CONTRIBUTION 168877 252095 324422
E11, E12 non-elective double spells
In year 1 it is assumed that no non-elective PCI will take place at W arwick and patients requiring non-elective PCI will transfer to UHCW as at present,
resulting in 2 E11/12 spells at W arwick before and after the transfer for PCI.
In years 2 and 3, it is assumed that some non-elective PCI will take place at Warwick resulting in the loss of income from the 2 E11/12 spells taking place at
W arwick before and after the transfer to UHCW for PCI. However, a single non-elective PCI spell will be recorded at W arwick
E13/E14 elective double counts
It is assumed that all elective PCIs will result from a consultant decision to proceed to intervention immediately after the diagnostic angiogram. This will
result in the loss of income from the elective angiogram spell (E13/E14) and a single elective PCI spell will be recorded at Warwick.