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A view from the Clinical Lead

A view from the Clinical Lead. Malcolm Metcalfe. NoS Cardiology. Although much good work has been achieved there remain major challenges ahead.

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A view from the Clinical Lead

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  1. A view from the Clinical Lead Malcolm Metcalfe

  2. NoS Cardiology • Although much good work has been achieved there remain major challenges ahead. • In order to continue to improve access to high quality cv services it remains essential that many services be planned and operated on a Regional basis. • This is a difficult and sometimes uncomfortable process for individuals from differing HBs. Often this lead to a “mismatch” between aspiration and reality.

  3. Major issues (not exhaustive) • Optimal reperfusion • PCI in Highland • Role out of EP services for NoS • Cardiothoracic surgery provision • Transcatheter aortic valve implantation • Multi-slice CT scanning • Transport issues • Workforce planning

  4. Optimal Reperfusion • Watch this space…

  5. PCI in Highland • Business case for PCI in Highland region agreed. • Equipment now available • Formal BCIS inspection visit was on 12/2/10. • Generally very favourable assessment • No issue re modest numbers • Issues re emergency transfer and on-call cover for procedures to be resolved • Should start elective work April 2010 • Should start emergency/PPCI office hours work August 2010 • Major success for NoS partners!

  6. Role out of EP services • Following on from agreed plan Feb 2008 • Full-time EP Consultant started in July. • Tayside and Highland undertaking ICD implantation (1’ prevention numbers still small) • RFA numbers increasing as predicted • CRT implantations increasing and likely to increase quire markedly due to new evidence of benefit. • Pacemaker lead extractions have become an unexpected issue.

  7. Cardiothoracic surgery provision • NoS service • Despite concerns numbers have remained static for last few years at >600. • Actual demand may be nearer 750 assuming that Highland and Tayside continue to refer numbers to ERI. • Issue of “bulge” due to abolishing “gaps” and achieving 18 week target – but this may no longer be an issue given unexpectedly low referrals this year. • Cost of service now greater than “charging cost” – will need adjustment. • Problems with junior staff provision most pressing issue.

  8. Transcatheter aortic valve implantation (TAVI) • No longer experimental technique • Excellent results (short-medium term) • Extends envelope to patients who would otherwise die • Relatively simple • Expensive (c£25 000). • Calculated demand 16 pmp • Long way behind England • No Scottish centre • High-level meeting with SEHD last year. • External assessment underway • Agreement to develop “universal” referral criteria and for each Region to work up Business case. • Many patients have already been referred from NoS region (eg 9 from Grampian) so genie out of bottle.

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

  10. Transport issues • Increased liaison and discussion with ambulance services • PPCI • Transfers from other centres (eg currently longer by air than road from Raigmore to ARI!) • Changes by virtue of “drip and ship” policies (eg Elgin, Wick, Islands), potential emergency transfer of PCI patients to ARI etc

  11. Workforce Planning • Very important issue but difficult to both influence and predict change • CEOs have apparently predicted no growth in Consultant numbers for next few years (before financial crisis!) • Recruiting technicians remains a major issue – NES have offered some support. Closing date 25th June. • Eventually one would like some degree of standardisation across the North.

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

  13. Non-NoS working…

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