26 th January

1. 26th January SESSION XIV – DEBATE DGH vs Tertiary intervention – Is there really a conflict? Department of Health Perspective Roger Boyle

2. No conflict of interest to declare

3. Cardiac surgeons Tertiary centre cardiologist DGH cardiologist

4. Cardiology in the district hospital. Report of a working group of the British Cardiac Society Br Heart J. 1987; 537-546 “The district cardiologist may wish to maintain skills by participating in catheter sessions….” A report of a working group of the British Cardiac Society: cardiology in the district hospital. Br Heart J. 1994; 72: 303-308 “It is becoming commonplace for district hospitals to develop their own catheterisation facilities…………..”

5. BCS Council Meeting circa 1994

6. Statement by the Council of the British Cardiac Society. Strategic planning for cardiac services and the internal market: role of catheterisation laboratories in district general hospitals. Br Heart J. 1994; 71: 110-112 DGH cardiologists should be offered specific sessions in tertiary labs Some DGHs that are geographically disadvantaged might develop their own labs Over time, DGH labs would become the norm!!!!!!!!!

7. BCS Working Group: The changing interface between district hospital cardiology and the major cardiac centres Heart 1997; 78: 519-523

8. Main conclusions • The establishment of new cardiac catheterisation laboratories in DGHs remote from a major centre should be encouraged provided the workload is adequate to ensure efficient use of the facility • Cardiologists working in districts close to a major centre should be encouraged to catheterise their patients at the centre

9. 2005 data: Ludman UK Centres - 2005

11. Revascularisation trends

12. Angiography waiters from April 2005

13. PCI waiters by length of wait April 2002 onwards 2006/7 2002/3 2003/4 2004/5 2005/6

14. Southampton – November 2006

16. 2005 PCI centres 83 Angiography only Centres 87

18. ‘A discussion of the drugs administered in a case of coronary thrombosis is not relevant here – but for pain relief morphine is often given by an attending doctor or on arrival at hospital….the patient should not be questioned unduly or in any way alarmed.’ 1970

19. Percentage of patients treated within 30 minutes of arrival at hospital rose from 38% to 83% Paramedics trained to assess, diagnose and provide thrombolysis Percentage of patients treated within 60 minutes of a call for help rose from 30% to 65% Pilot schemes set up to test feasibility of primary angioplasty in the NHS Heart Attack: Progress Since the NSF

20. Reperfusion treatment 2003-6 14.4% % 12.6% [plus patients in NIAP not yet transferred ~ 2.5%]

21. Access to PPCI • 37/68 English & Welsh hospitals with interventional facilities on site perform primary angioplasty • 14/37 provide an internal service only • Only 4 provide 24/7, the rest lab hours or ‘occasional’ • 23/37 offered a service to other hospitals • Reporting that they provided this to 78 hospitals • NB only 42 non interventional hospitals said they received a routine PPCI service, suggesting that service to other hospitals might be irregular / occasional

22. Manchester (2) • North Mcr • Salford • Stockport • Tameside • Trafford James Cook - Friarage Leeds - SJUH - Bradford Leeds - SJUH - Bradford NW London (3) -Hammersmith -W Middlesex -Ealing -Charing X -St Mary’s -Northwick -Hillingdon -Harefield -Brompton -Hemel East London - R London - Whipps X - King George - Oldchurch - Homerton - Newham • SE London • Lewisham • Bromley • Sidcup • Mayday Exeter

23. Acute MI Catchments Tertiary CABG Catchments

24. Conclusion • District hospital angiography has improved access to care and the capacity is needed • Still a great deal of unmet need particularly in the North • We are a long way from providing a comprehensive PPCI service at the present • Many places are ‘dabbling’ • We need a comprehensive strategy within each network with formal involvement of the ambulance service • No reason to exclude DGHs from providing this but the rota requirements are onerous