Cardiac Magnetic Resonance Imaging

Joint Committee Meeting 16 November 2015 Title of the Committee Paper Cardiac Magnetic Resonance Imaging Executive Lead: Acting Director of Planning Author: Specialist Planner Contact Details for further information: Luke Archard, Specialist Planner Email: luke.archard@wales.nhs.uk Telephone: 01443 443443 ext.8141 Purpose of the Committee Paper The purpose of this report is to: Update Joint Committee on the progress in each Health Board implementing the commissioning intentions for Cardiac MRI (CMRI) agreed by the Joint Committee in March 2015; Advise Joint Committee of the risks to quality of patient care and to cardiology training in Wales of the current low levels of provision of CMRI and of delay to implementing to the agreed timescales; Outline the work in progress on the commissioning framework for CMRI, in particular, the development of a commissioning policy and service specification. Executive Board Resolution (insert ) to: APPROVE ENDORSE SUPPORT NOTE Recommendation Members are asked to: NOTE the commissioning intentions and phased plan agreed by the Joint Committee; NOTE the benefits of CMRI to patients and the risks of further delay in increasing provision, particularly to cardiology training in Wales; NOTE the current position in each Health Board in relation to implementing the commissioning intentions and increasing access to CMRI for its residents; NOTE that Management Group members have Cardiac MRI Page 1 of 15 Joint Committee Meeting

agreed to report progress to their Health Boards and to report back to the All Wales Cardiac MRI Commissioning Group on the risk management strategy and escalation process within their Health Boards; NOTE the work in progress on the commissioning policy and service specification. Governance Link to WHSSC Strategic Objective(s) Link to Integrated Commissioning Plan Supporting evidence This service is not within WHSSCs commissioning remit. It is commissioned directly by Health Boards for their local populations. This service is part of Health Board IMTPs. It is not included within the WHSSC integrated commissioning plan. Evidence sources: Commissioning Intentions for Cardiac MRI (Joint Committee, March 2015). Meetings of the Cardiac MRI Commissioning Group. Health Board correspondence to WHSSC confirming their commissioning intentions for CMRI. Engagement Who has been involved in this work? This work has been developed by Health Boards, with support from WHSSC, through the Cardiac MRI Commissioning Group comprising clinical, commissioner and service manager representatives from across Wales. Management Group has supported the submission of this report to Joint Committee. This paper has been considered and supported by: Finance Х Clinical Evidence Evaluation Group Х Programme Team Executive Board Managemen t Group Joint Committe e Х Other Commissioner Health Board affected Abertawe Bro Morgannwg Aneurin Bevan Betsi Cadwaladr Cardiff and Vale Cwm Taf Hwyel Dda Powys Provider Health Board affected Cardiac MRI Page 2 of 15 Joint Committee Meeting

Abertawe Bro Morgannwg Aneurin Bevan Betsi Cadwaladr Cardiff and Vale Cwm Taf Hwyel Dda X Powys X Summarise the Impact of the Committee Paper Equality and diversity Legal implications Population Health Quality, Safety & Patient Experience Resources Risks and Assurance No equality and diversity issues have been identified. No legal implications of this report have been identified. CMRI will improve population health through improving diagnostic information to inform the clinical management of patients. CMRI is safe and has a substantial evidence base demonstrating how it can improve patient management and the targeting of treatment. Patient experience can be improved through the avoidance of multiple tests due to the ability of CMRI to provide assessment of both structure and function. The resource implications of CMRI are addressed through Health Board IMTPs. This report outlines the key risks for Health Boards, including the future of cardiology training in Wales if the commissioning intentions for CMRI are not implemented. Standards for Health Services Workforce 7. Safe and Clinically Effective Care 8. Care Planning and Provision The workforce implications of implementing the commissioning intentions for CMRI are addressed through Health Board implementation plans. Cardiac MRI Page 3 of 15 Joint Committee Meeting

1. PURPOSE OF REPORT The purpose of this report is to: Update Management Group on the progress in each Health Board implementing the commissioning intentions for Cardiac MRI (CMRI) agreed by the Joint Committee in March 2015; Advise Management Group of the risks to quality of patient care and to cardiology training in Wales of the current low levels of provision of CMRI and of delay to implementing to the agreed timescales; Outline the work in progress on the commissioning framework for cardiac MRI, in particular, the development of a commissioning policy and service specification. 2. INTRODUCTION In March 2015, the Joint Committee agreed the commissioning intentions for cardiac MRI and agreed that Health Boards would reflect the 5 year phased commissioning plan within their IMTPs. WHSSC was asked to continue to support the coordination of Health Board plans to implement the phased plan. Cardiac MRI remains a direct Health Board commissioning responsibility; WHSSC s only role in relation to this service is to facilitate implementation by the Health Boards through coordination of plans and the development of a common commissioning framework (including access criteria, commissioning policy and service specification). The purpose of this paper is to provide an update to Management Group on progress across Health Boards in putting in place plans to increase access and provision. This paper will: Outline the benefits to patients of CMRI; Advise of the risks to cardiology training from delay to implementation; Outline the current position for each Health Board; Note the action being taken to develop a commissioning policy and service specification. 3. CLINICAL BENEFITS OF CARDIAC MRI AND RISKS OF DELAY TO IMPLEMENTATION Clinical and service benefits Cardiac MRI has benefits and advantages for both patients and health services. Key to these benefits are: flexibility, allowing the assessment of both anatomy and function, avoiding the need for multiple tests; non-invasive, avoiding use of ionising radiation; Cardiac MRI Page 4 of 15 Joint Committee Meeting

the acquisition of improved diagnostic and prognostic information where other investigative techniques have provided limited information; and enabling diagnoses and prognoses to be refined, with potential to lead to improved targeting of treatment and better patient outcomes. The current low level of provision means that patients in Wales are often not being offered the clinically optimal diagnostic strategy, are often required to undergo multiple tests when a single MRI scan would provide the diagnostic information needed, and may not receive the optimal treatment approach. For patients that require regular imaging to monitor their condition (particularly patients with congenital heart disease), CMRI improves safety and outcomes by avoiding exposure to ionising radiation. These patients are a priority group for CMRI. Heart Disease Implementation Plan National strategy for heart disease includes the need for timely access to appropriate diagnostics for cardiac patients, including to MRI. Access to CMRI is part of the Cardiac National Service Framework which is now incorporated within the more recent Heart Disease Delivery Plan. The Heart Disease Delivery Plan states that patients should have:..prompt and equitable access to appropriate interventions, including new diagnostic procedures, technologies, treatment and techniques, in line with the latest evidence and guidance. CMRI is also prudent healthcare: it improves the efficiency of resource use by avoiding multiple tests; it improves management decisions and the targeting of treatment; it improves patient outcomes. Risks to Cardiology Training Dr Claire Williams, Consultant Cardiologist, Cwm Taf UHB, and Chair of the Specialty Training Committee for Cardiology, has written to WHSSC, Welsh Government and Health Board Chief Executives, to highlight the risks to cardiology training in Wales arising from the current lack of a CMRI service. Dr Williams letter notes the following: CMRI has been a training requirement since 2007; Trainees in Wales have to go to England to complete this aspect of their training (both core and advanced); Imminent changes to the core training requirements will increase the CRMI element; Risk that Wales will find it increasingly difficult to compete for trainees with training programmes in England that are able to offer the full curriculum; Cardiac MRI Page 5 of 15 Joint Committee Meeting

Risk of losing trainees with an interest in CMRI after they qualify (the aim of the training programme is to keep cardiologists in Wales after they qualify). This risk has been recorded on the WHSSC cardiac programme risk register as a risk for Health Boards and NHS Wales, with action to bring this risk to the attention of Health Boards in reflection of WHSSC s current role in relation to this service. Health Boards will need to consider how this risk is reflected within their own risk management processes and CMRI development plans. WHSSC has responded to Dr Williams to outline the actions being taken in relation to the risks to training highlighted in her letter. As one of these actions, the Acting Managing Director of Tertiary and Specialised Services Commissioning wrote to the Deputy CMO and Health Board Chief Executives to outline the current position and progress across Health Boards towards implementing the CMRI commissioning intentions. 4. COMMISSIONING INTENTIONS: PHASED IMPLEMENTATION PLAN The commissioning intentions state that: The aim for Wales should be to commission a level of access to cardiac MRI consistent with current best evidence and guidance, to maximise the benefits to patients and the health care system. Accordingly, the aspiration should be to commission to the BSCMR/BSCI recommended access rates of 2275 per million population. The commissioning intentions set out the following phased plan to achieve the recommended levels of access: Year 5 Table 1: Commissioning plan to increase access up to clinically recommended access rates per million population over 5 years from 2015/16 to 2019/20 (number of scans by Health Board). All Target PMP Wales Scans ABM UHB AB UHB BC UHB CV UHB CT UHB HDU HB PtH B Baseline position 2014-15 (262) 800 109 62 329 162 3 48 63 Year 1 2015-16 475 1464 247 275 329 227 140 182 63 Year 2 2016-17 700 2158 364 405 484 335 207 269 93 Year 3 2017-18 1000 3082 521 579 692 479 295 384 133 Year 4 2018-19 1500 4624 781 869 1038 718 443 576 199 2019-20 2275 7000 1185 1317 1574 108 9 671 873 302 The commissioning intentions also include reference to the quality standards that should apply to CMRI in Wales. Commissioned providers should deliver to the clinical governance and quality standards set out by the BSCMR/BSCI Cardiac MRI Page 6 of 15 Joint Committee Meeting

(2010). In particular, commissioned providers should meet standards for minimum volumes and reporting arrangements: Providers must achieve minimum annual numbers of at least 300 scans (and more than 500 per annum for training centres); Reporting: o Responsibility for CMR reports always lies with a consultant; o Reporting in isolation should be avoided; o CMR reports should conform to appropriate national standards. 5. CURRENT POSITION ACROSS WALES WHSSC has facilitated the All Wales Cardiac MRI Commissioning Group to bring together lead clinicians, commissioners and service managers, to coordinate Health Board plans for implementing the commissioning intentions. Health Boards have been working to clarify their strategies for how this service will be provided for their populations in the short term (years 1 to 2) and the medium to longer term (years 3 to 5). For planning purposes, the CMRI Commissioning Group has categorised scans into 3 main types of activity: Congenital Heart Disease - CMRI for adults with congenital heart disease requires specialist expertise and is provided for the whole of South Wales by CVUHB; adults with congenital heart disease in North Wales are referred to Manchester for CMRI. These patients form a small proportion of overall CMRI activity. In-Patient activity - These are urgent scans for patients during an admission to hospital. Scans for in-patients will be delivered as part of CMRI activity for patients admitted to tertiary centres for specialised interventions. In future, as CMRI is provided more locally, these scans will also be provided for patients admitted under secondary care cardiology services. Out-patient activity (non congenital) - These scans form the vast majority of CMRI activity. Overview of All Wales Position Table 2 shows a RAG rating reflecting WHSSC s assessment of what has been achieved to date developing and implementing plans to deliver the levels of CMRI activity set out in the commissioning intentions for 2015/16 and 2016/17 (years 1 and 2). The table refers to provision of out-patient (non congenital) scans which form the majority of CMRI activity. Year 1 (2015/16) is divided into quarters to show the stages of development reached through the course of the first year of the plan. Cardiac MRI Page 7 of 15 Joint Committee Meeting

Table 2: Summary of current position across Wales implementing years 1 and 2 of the commissioning intentions. Comments Rating Year 1 (2015/16) Year 2 (2016/17) BCUHB Intentions confirmed. Q1 Q2 Q3 Q4 Plan in place to increase activity from Jan 2016 at YG. Operational risks identified and mitigating actions currently being implemented. Rated green from Q4 onwards on basis plans are currently on track. ABMUHB Intentions confirmed. Yr 1 plan developed and implemented from Sept 2015 at year 1 rate of activity for South West population (part year effect for 7/12). Plans in development to deliver year 2 activity. HDUHB Intentions to commission from ABMUHB confirmed. Implementation timescales and RAG rating as per ABMUHB ABUHB Intentions confirmed. Plan to commission from mix of external providers in years 1 and 2. Dependent on provider capacity to deliver. Rated green from Q3 onwards on basis selected providers are able to deliver. CTUHB Intentions confirmed. Intention to provide CMRI as part of diagnostic hub development. In interim (year 1), CTUHB will commission from CVUHB (reflected as green rating for quarters 3 and 4 2015/16). Year 2: dependent on diagnostic hub business case and implementation process; potential provision within CTUHB commencing in 2016; intention to commission from CVUHB in interim (rated amber). Arrangements with CVUHB in process of being agreed via LTA meetings, including contracting and networked delivery. CVUHB Plan developed for yr 1 to commence from November 2015 (part-yr effect). Operational plan in place to deliver yr 2. However, rated amber due to Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Cardiac MRI Page 8 of 15 Joint Committee Meeting

Comments requirement for approval through IMTP process. Capacity sufficient to provide for South East Wales population if required. Provider of MRI for ACHD for all South Wales and in-patient scans for patients admitted to UHW for specialised care. Rating Year 1 (2015/16) Year 2 (2016/17) PTHB Yet to formally confirm intentions. However, patient pathways are currently predominantly to English Trusts. Dependent on provision at English providers. Rated amber to reflect that cardiology for Powys is provided from English Trusts where cardiac MRI may be provided (e.g. Birmingham). Baseline access is higher than average for Wales. Unclear currently how yr 2 onwards would be achieved. Q1 Q2 Q3 Q4 Key RAG Ratings Green Operational plans are in place to deliver the increased rates of activity for the Health Board for years 1 and 2 as set out in the commissioning intentions. Amber Intentions are confirmed and plans are currently developed, or are in development, to deliver the increased rates of activity for the Health Board for years 1 and 2 as set out in the commissioning intentions. Red Intentions have not been confirmed and there are no plans yet agreed that will deliver the increased rates of activity for the Health Board for years 1 and 2 as set out in the commissioning intentions. The table shows the following: Most Health Boards have confirmed their intentions for the commissioning and provision of CMRI for years 1 to 2 of the plan. The provision of additional activity in ABMUHB commenced in September 2015. This will provide increased access to CMRI for ABUHB and HDUHB residents. Provision of additional activity is scheduled to commence from November 2015 in CVUHB. This will include increased provision of CMRI for ACHD (for all South Wales) in addition to other non congenital out-patient activity for patients in South East Wales. BCUHB has an operational plan in place to increase the activity delivered in Ysbyty Gwynedd, Bangor, from January 2016. CTUHB is in the process of developing the business case for the diagnostic hub which will include provision of CMRI for its population. In the interim, the Health Board will commission from CVUHB. Cardiac MRI Page 9 of 15 Joint Committee Meeting

ABUHB will commission from a mix of providers to secure CMRI for its population. Progress in each Health Board The current status of plans for each Health Board is outlined in more detail in the section below. More information about specific Health Board plans is available on request. Betsi Cadwaladr University Health Board BCUHB has developed operational plans for years 1 to 2 of the commissioning plan based around enhancing provision at the existing service at Ysbyty Gwynedd, Bangor. The North Wales Cardiac Network is currently developing the imaging strategy for BCUHB, including Cardiac MRI. This strategy will determine the longer run shape of the service. Table 3 outlines the location of provision for the 3 broad categories of referral outlined above. Table 4 outlines the current status of operational plans for the short term to deliver the volumes set out in years 1 and 2 of the commissioning plan in table 1 above. Table 3: Location of provision for residents of BCUHB Yr 1 Yr2 Yr3 Yr4 Yr5 2015/16 2016/17 2017/18 2018/19 2019/20 ACHD Manchester Manchester Manchester Manchester Manchester In-Patient YG / LHCH / Manchester YG / LHCH / Manchester Location of provision in medium term will be determined by BCUHB imaging strategy Out-patient (non ACHD) YG YG Location of provision in medium term will be determined by BCUHB imaging strategy Table 4: Operational plans for short term (years 1 to 2) for BCUHB Yr 1 Yr2 2015/16 2016/17 Operational plan developed Yes Yes When will new activity commence Operational constraints currently being addressed Planned to commence from Jan 2016 Procurement of software required; Recruitment of staff; Organisation of sessions and job plans. Planned to commence from Jan 2016 Recruitment of staff; Organisation of sessions and job plans. Cardiac MRI Page 10 of 15 Joint Committee Meeting

Hywel Dda University Health Board HDUHB has confirmed that it plans to commission out-patient (non congenital) and in-patient CMRI from ABMUHB over the 5 years of the plan. Scans for congenital heart disease will be undertaken at Cardiff & Vale UHB for all South Wales patients. Table 5: Location of provision for residents of HDUHB Yr 1 Yr2 Yr3 Yr4 Yr5 2015/16 2016/17 2017/18 2018/19 2019/20 ACHD CVUHB CVUHB CVUHB CVUHB CVUHB In-Patient ABMUHB ABMUHB ABMUHB ABMUHB ABMUHB Out-patient (non ACHD) ABMUHB ABMUHB ABMUHB ABMUHB ABMUHB Operational plans: see ABMUHB below. Abertawe Bro Morgannwg University Health Board ABMUHB has confirmed its broad intentions and, further to approval of an internal business case, has increased provision of CMRI since September 2015 for patients from ABMUHB and HDUHB. Table 6: Location of provision for residents of ABMUHB Yr 1 Yr2 Yr3 Yr4 Yr5 2015/16 2016/17 2017/18 2018/19 2019/20 ACHD CVUHB CVUHB CVUHB CVUHB CVUHB In-Patient ABMUHB ABMUHB ABMUHB ABMUHB ABMUHB Out-patient (non ACHD) ABMUHB ABMUHB ABMUHB ABMUHB ABMUHB Table 7: Operational plans for short term (years 1 to 2) for ABMUHB and HDUHB residents Yr 1 Yr2 2015/16 2016/17 Operational plan developed Yes In development When will new activity commence Operational constraints currently being addressed to implement plan Commenced in Sept 2016 To be confirmed Options being explored to increase scanner time at Morriston/NPT available for CMRI. Cardiac MRI Page 11 of 15 Joint Committee Meeting

Cwm Taf University Health Board Cwm Taf UHB has confirmed its intentions: All ACHD and IP/Complex work will be commissioned from C&VUHB; Routine elective work will be provided from Cwm Taf once the diagnostic hub is established; In the interim, routine elective activity will be commissioned from C&VUHB. Table 8: Location of provision for residents of CTUHB Yr 1 Yr2 Yr3 Yr4 Yr5 2015/16 2016/17 2017/18 2018/19 2019/20 ACHD CVUHB CVUHB CVUHB CVUHB CVUHB In-Patient CVUHB CVUHB/ hub) Out-patient (non ACHD) CVUHB (interim) hub) and, if required, CVUHB CVUHB/ hub) hub) CVUHB/ hub) hub) CVUHB/ hub) hub) Table 9: Operational plans for short term (years 1 to 2) for CTUHB Yr 1 Yr2 2015/16 2016/17 Operational plan developed Intends to commission from CVUHB (interim arrangement until diagnostic hub established). Business case and implementation plans for diagnostic hub development, including CMRI. Intends to commission from CVUHB during interim until diagnostic hub in place. When will new activity commence Operational constraints currently being addressed to implement plan CVUHB capacity available from November 2015. See CVUHB plans below. Depends on timescales of diagnostic hub development. See CVUHB plans below. Future implementation plans for diagnostic hub development. See CVUHB plans below. Aneurin Bevan University Health Board ABUHB has written to WHSSC to set out its short term and longer term strategic intentions for CMRI. The Health Board has a three point strategic plan: Cardiac MRI Page 12 of 15 Joint Committee Meeting

Majority of provision in-house at SCCC; CVUHB to provide ACHD MRI service; Long term strategic alliance with NHS Bristol. In the medium to long term, ABUHB will provide its own CMRI service for its population (the exceptions being those scans that need to take place in other centre for reasons of expertise (such as ACHD) and scans for in-patients admitted to other centres for specialist care). The Health Board will develop its own service through a relationship with NHS Bristol (particularly for training and CPD) which has an established CMRI service. From a clinical perspective in ABMUHB, the issue has been raised that commissioning from a range of providers may allow a wider range of types of CMRI test to be commissioned for patients, in particular, stress testing. This issue will need to be addressed in the CMRI commissioning policy. In the short term, the Health Board has signalled its intention to commission from a mix of providers including from the private sector, NHS England and within Wales. While it has not explicitly committed to commissioning CMRI activity from Cardiff & Vale UHB, it is likely capacity would be needed from CVUHB to achieve the access rates in the commissioning intentions. Table 10: Location of provision for residents of ABUHB Yr 1 Yr2 Yr3 Yr4 Yr5 2015/16 2016/17 2017/18 2018/19 2019/20 ACHD CVUHB CVUHB CVUHB CVUHB CVUHB In-Patient Out-patient (non ACHD) Welsh providers Mix of providers Welsh providers Mix of providers Welsh providers Welsh providers / SCCC Welsh providers /SCCC Bristol SCCC / Bristol SCCC / Bristol Table 11: Operational plans for short term (years 1 to 2) for ABUHB Yr 1 Yr2 2015/16 2016/17 Operational plan developed ABUHB has clarified the volumes it will commission from across a mix of providers. ABUHB has clarified the volumes it will commission from across a mix of providers. When will new activity commence Operational constraints currently being addressed to implement plan Dependent on provider capacity Dependent on provider capacity see CVUHB plan below see CVUHB plan below see CVUHB plan below see CVUHB plan below Cardiac MRI Page 13 of 15 Joint Committee Meeting

Cardiff & Vale University Health Board CVUHB has confirmed its intention to commission and provide a CMRI service for its population from within CVUHB. The Health Board has also developed a proposal with options for delivering this activity plus all activity required for South East Wales in the first 2 years of the commissioning intentions. It will provide all CMRI for its population (including for congenital heart disease patients in its role as the regional cardiology centre for ACHD for South Wales). Table 12: Location of provision for residents of CVUHB Yr 1 Yr2 Yr3 Yr4 Yr5 2015/16 2016/17 2017/18 2018/19 2019/20 ACHD CVUHB CVUHB CVUHB CVUHB CVUHB In-Patient CVUHB CVUHB CVUHB CVUHB CVUHB Out-patient (non ACHD) CVUHB CVUHB CVUHB CVUHB CVUHB Table 13: Operational plans for short term (years 1 to 2) for CVUHB (with capacity available for CTUHB and ABUHB populations) Yr 1 Yr2 2015/16 2016/17 Operational plan developed Plan developed by CVUHB with capacity for all South East Wales Plan developed by CVUHB with capacity for all South East Wales When will new activity commence Operational constraints currently being addressed to implement plan From November 2015 Radiographer availability for Sunday working; Radiographer recruitment ; Consultant reporting capacity. Could commence from April 2016 (to be confirmed through IMTP process) Radiographer recruitment; Consultant reporting capacity. Powys Teaching Health Board Powys thb has not to date formally responded to outline its intentions to commission CMRI for its population. However, cardiology pathways for Powys patients currently flow through English providers. WHSSC analysis of contract activity in cross border providers has indicated CMRI activity for Powys taking place in Birmingham. There has been minimal CMRI activity for Powys residents in Cardiff or Swansea, reflecting current pathways. WHSSC is currently liaising with Powys to confirm activity currently taking place and future strategy over cardiology pathways. Cardiac MRI Page 14 of 15 Joint Committee Meeting

6. COMMISSIONING FRAMEWORK A clinical working group has been established to develop the commissioning policy and service specification for CMRI. In view of the growth in activity that is planned to take place over the next 5 years, and the changes in service that will take place as the scale is increased, the documents will be designed to apply to the first couple of years, after which they will be reviewed. A number of clinicians have nominated themselves to join this clinical working group. The intended timescales are as follows: Commissioning policy o development: November and December o sign-off through Management Group in January/February 2016 Service specification o development: November January o sign-off through Management Group in March 2016. 7. RECOMMENDATION Members are asked to: NOTE the commissioning intentions and phased plan agreed by the Joint Committee; NOTE the benefits of CMRI to patients and the risks of further delay in increasing provision, particularly to cardiology training in Wales; NOTE the current position in each Health Board in relation to implementing the commissioning intentions and increasing access to CMRI for its residents; NOTE that Management Group members have agreed to report progress to their Health Boards and to report back to the All Wales Cardiac MRI Commissioning Group on the risk management strategy and escalation process within their Health Boards; NOTE the work in progress on the commissioning policy and service specification. Cardiac MRI Page 15 of 15 Joint Committee Meeting