Meeting: IPG Date: 9 th December 2009 Item: 52/09 (i) NORTH OF SCOTLAND PLANNING GROUP Review of the Regional Development Plan For Electrophysiology Services September 2009
This is a discussion paper to review the progress of the NoSPG Regional Electrophysiology (EP) Development Plan, which gained final approval from NoSPG Partner Boards at the North of Scotland Planning Group (NoSPG) Chief Executives meeting in February 2008. Aim The Regional development plan for Electrophysiology services for North of Scotland patients, has been operational now for 18 months. The early appointment of an additional full time NoS EP Consultant (July 2009) provides an opportunity to benchmark progress, provide feedback for monitoring purposes and facilitate discussion as to what is required to meet the objectives outlined within the EP plan. It will also provide an opportunity to identify and plan for the way forward over the next 3 5 years. Background In June 2007, the North of Scotland Planning Group (NoSPG), agreed in principle to develop the existing regional Electrophysiology (EP) Service for the benefit of NoSPG residents in response to a ministerial commitment to expand capacity. A 3 year plan was developed in consultation with key stakeholders, including the NoS Electrophysiology Short Life Working Group, which is a sub group of the NoS Cardiac Sub Group. Electrophysiology (EP) and Arrhythmia Interventions An arrhythmia is an abnormality of the electrical rhythm of the heart, either caused by an inherited problem or by an acquired condition that disturbs the electrical impulses which regulate the heart. The heart may beat too slowly, too quickly or in an irregular way. The symptoms a person may experience include palpitations, loss of consciousness, dizziness and breathlessness. In extreme cases certain types of arrhythmia can cause sudden cardiac death. Summary of the original Regional EP Development Plan proposals The proposal agreed by NoSPG in June 2007 and signed off by partner boards in February 2008 contained four elements: 1. Expand regional EP service capacity to a level which is comparable with the United Kingdom (UK) activity levels, whilst delivering a safe, efficient and quality service, which meets the needs of patients and satisfies waiting time guarantees. 2. NHS Highland and NHS Tayside, to develop local Implantable Cardioverter Defibrillator (ICD) services, thus releasing capacity in the NoS regional service to work towards point 1, above. This development would reduce future patient flow for ICD s, to the regional EP services based in Glasgow and Edinburgh. 3. Repatriation of Cardiac Resynchronization Therapy (CRT) and Radio Frequency Ablation (RFA) activity to the NoS EP service, from the West of Scotland EP service, based in Glasgow. 2
4. Repatriation of CRT and RFA activity to the NoS EP service, from the South East regional service, based in Edinburgh. In addition to the above, the NoS Cardiac Sub Group requested that the plan incorporated the proposal for surgical ablation for atrial fibrillation patients, who undergo cardiac surgery. This is the surgical aspect of EP. EP is the most rapidly expanding Cardiology sub specialty, which has major connotations for services across Scotland, as it is a complex service to provide, both in terms of resources and cost per procedure. EP can be divided into generalized EP, which in effect is pacemakers and cardioversions and specialized EP, which is the focus of regional service delivery. Specialised EP procedures relate to three specific procedures, these are, Cardiac Resynchronisation Therapy (CRT), Implantable Cardioverter Defibrillators (ICD) and Radio Frequency Ablation (RFA). (EP Development plan). Proposed NoS Electrophysiology Service Model The proposed regional EP model is illustrated in Appendix 2 of the plan. Key changes in the service model were that: ICD services would be delivered in Grampian, Highland and Tayside. RFA and CRT will continue to be delivered as a regional service, based in Grampian. Phased increases in capacity over the 3 years will allow activity to be comparable with UK levels. It was proposed that ICD services were developed as follows: 1 Highland and Tayside to set up and deliver local ICD services as of 1 st April 2008. 2 Highland envisaged that their ICD activity would be absorbed within current resources and infrastructure. A review is required to assess any financial pressures due to growth in consumable costs over the next 3 years, since the introduction of the service. 3 Tayside envisaged that their ICD service activity and consumable costs would be absorbed within current resources and infrastructure in 2008/09. Tayside have identified the additional costs for 2009/10 and 2010/11 in order to deliver this service and manage the projected growth in activity. 4 The 3 year growth projections made for each service, took into account the increase in demand due to local service provision. 5 Grampian to continue to provide ICD services to Grampian, Orkney and Shetland residents. 6 It was estimated that 6 sessions per year would be released in Grampian, through the repatriation of ICD activity by Highland and Tayside. The 6 sessions to assist the current NoS EP service to maintain the current 16 week access target and to move towards the March 2009, 15 week access target. 3
The plan proposed that the regional CRT service be developed as follows: 1 The plan estimates that there would be projected growth in CRT activity by 20% in 2008/09 and then 10% annually for the following 2 years. 2 NoS service activity was 21 CRT sessions in 2006/07. It was projected that CRT sessions would increase by an additional 22 sessions in 2008/09 and then a further 4 sessions annually for 2009/10 and 2010/11. 3 The projections included the repatriation of activity being directed to the NoS, with the exception of Tayside, where 68% of total activity would be directed to the NoS. 4 The plan outlined the pressure on the existing service; in that it was felt it could not cope with any further growth or manages any repatriation of activity, until additional EP capacity was in place. The plan proposed that the regional RFA service would be developed as follows: 1 The plan estimated projected growth in RFA activity/capacity by 20% in 2008/09 and then 10% annually for the following 2 years. 2 NoS service activity was 59 RFA sessions in 2006/07. The plan projected that RFA sessions would increase by an additional 44 sessions in 2008/09, a further 9 sessions in 2009/10 and then a further 16 sessions in 2010/11. 3 These projections included the repatriation of activity, based on all NoS RFA activity being directed to the NoS with the exception of Tayside, where 60% of total activity would be directed to the NoS service. 4 The projections also took into consideration the anticipated growth in complex ablation cases over the next three years, as already experienced by other UK and Scottish centres. 5 The plan emphasized that the existing service would not cope with any further growth or manage any repatriation of activity, until additional EP capacity was in place. For planning purposes the Regional EP development plan assumed the following NoS population spread: Health Total Health Board Planning Comments Boards Population Assumptions Made For EP Plan Grampian 525,000 525,000 Highland 319,153 229,329 (26,300) Excludes Argyll & Bute as pt flow is directed to West of Scotland Western Isles who also direct referrals to WoS Orkney 22,000 22,000 Shetland 20,000 20,000 Tayside 389,000 254,000 Excludes Perthshire as they tend to be directed to Lothian Totals 1,275,153 1,050,329 Breakdown of NoS Population for NoS EP Services Based on Health Board Population Data used in the EP plan 4
It was noted within the EP Development plan that both NHS Tayside and NHS Highland have agreements with other planning groups for a specific portion of cardiac patient flow, managed within other regional services. Costs, within the EP plan, (Option 2) were agreed to be shared with fixed costs split between the boards as detailed below. (The percentage split agreed, was based on the previous year s activity). Each health board is then charged, on an annual basis, for the variable costs of actual activity performed. Variable costs would include the cost of consumables and devices only. Benchmarked activity against the original projected fixed cost split reflects variation from baseline activity and this may require to be revisited to identify why this might be. Fixed Cost split as per EP Development plan NHSG NHSH NHSO NHSS NHST 54% 21% 2% 2 21% Source: Cardiac MMI supplied by NHSG Despite differences in expected activity levels for the different procedures, costs remain within budgeted projections for activity completed at the tertiary centre. To identify the true cost of the Regional EP service, a review of actual and projected costs, within NHS Highland and NHS Tayside, should be carried out to measure the impact of the introduction of ICD implantations locally. Present situation Recent developments which provide support for enhancing regional EP service delivery: 1 In line with recommendations within the NoS EP Development plan, a full time NoS EP consultant was appointed in July 2009, (Option 2), to support the roll out of the EP service across the north. This appointment was made earlier than planned and so costs are incurred in 2008/09 as opposed to 2010/2011; however it provides increased capacity, towards expanding the service, meeting waiting times guarantees, RTT etc. 2 Both NHS Tayside (April 2008) and NHS Highland (February 2008) now provide a local ICD service at Ninewells, in Dundee and Raigmore, in Inverness. ARI continue to provide an ICD service to NHS Grampian, NHS Shetland and NHS Orkney patients. This fulfils point 2 of the original EP Development plan. 3 NHS Grampian continues to provide RFA and CRT services, at the tertiary centre for all NoS patients and ICD s for patients from NHS Orkney, NHS Shetland and NHS Grampian. 5
1. NORTH OF SCOTLAND EP SERVICE DEVELOPMENT Over the past 4 years the EP regional service has achieved remarkable growth both in terms of increased activity and also the widening of access for north of Scotland patients. The chart below highlights the growth trend over the past 4 years, for specialised EP procedures for North of Scotland patients, performed at ARI. Details of progress towards meeting UK recommended rates per million populations (pmp) are highlighted later in the report. The following table reflects percentage increases, (2008/09 compared to 2007/08), by procedure for CRT, ICD, RFA and overall. Patient Activity trends over past 4 years Procedure % increase 2008/09 2007/08 2006/07 2005/06 CRT 80% 45 25 14 0 ICD 95% 53 + 27+ 29 56 53 63 RFA 13% 111 98 87 81 Total 48% 265 179 154 144 Source Cardiac MMI NHSG The graph below shows activity trends by procedure and in total over the past 4 years. NoS Activity trend over last 4 years 300 250 200 150 100 50 CRT ICD RFA Total 0 2005/06 2006/07 2007/08 2008/09 The Regional EP service has grown steadily over the last 4 years and shows a 48% increase in the financial year 2008/09 compared to 2007/08. 6
Growth by individual Health board area, over the last 4 years, is highlighted below NHS Highland EP service growth over last 4 years 35 30 25 20 15 10 5 0 2005/06 2006/07 2007/08 2008/09 CRT ICD ICD/Local RFA NHS Tayside EP service growth over last 4 years 30 25 20 15 10 CRT ICD ICD local RFA 5 0 2005/06 2006/07 2007/08 2008/09 NHS Grampian EP service growth over last 4 years 70 60 50 40 30 20 10 0 2005/06 2006/07 2007/08 2008/09 CRT ICD ICD local RFA 7
NHS Orkney EP service growth over last 4 years 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 2005/06 2006/07 2007/08 2008/09 CRT ICD RFA NHS Shetland EP service growth over the last 4 years 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 2005/06 2006/07 2007/08 2008/09 CRT ICD RFA 8
2. NEW SERVICE MODEL ICD S DELIVERED AT ARI, NINEWELLS & RAIGMORE Growth in service provision v that which was expected, as outlined in the Regional EP Development plan Comparison of actual v projected activity as per the EP Development plan (2008/09) 300 250 200 150 100 50 0 CRT ICD RFA Total Projected Actual The EP development plan acknowledged the difficulties in projecting accurate service growth in an area which is one of the most rapidly expanding aspects of cardiac care. Due, in part, to the introduction of local ICD provision, the service has grown by 15% more than what was expected. CRT activity is exactly as projected, whereas ICD implants have expanded much more rapidly than predicted, within the new service model. RFA, highlighted as predicting the highest growth, is below that which was projected. This may be due to resource constraints in terms of available operator time at the tertiary centre. Sessional split per Health Board area as a percentage of total activity undertaken at ARI, for 2008/09 EP s e s s io n a l s p lit b y No S He a lt h b o a r d 2 0 0 8 /0 9 2 1 % 2 % 3 % 1 4 % 6 0 % NHS G NHS H NHS O NHS S NHS T 9
Although the roll out of the expanded service is fairly recent (18 months), data suggests that the projected percentage split of fixed costs, differs from what was expected and this would benefit from discussion to identify why this might be. 3 & 4 REPATRIATION Repatriation of activity, for NoS patients, completed at other tertiary centres One of the aims of the EP Development plan was the repatriation of activity performed for NoS patients at other tertiary centres in West of Scotland (WoS) and South East and Tayside (SEAT). In 2008/09, 90 EP procedures were performed at Edinburgh Royal Infirmary (SEAT) and 33 procedures performed at Golden Jubilee Hospital (WoS), for north of Scotland patients. This represents 46% of NoS total EP activity. The chart below highlights activity performed at other tertiary centres, out with ARI, by Health Board split. EP Activity for NoS patients performed at other tertiary centres 2008/09, by Health board split 100 90 80 70 60 50 40 30 20 10 0 NHST NHSH NHSG WI NHSS NHSO Total GJH RIE As outlined above, the EP Development plan detailed an aim to repatriate activity from Glasgow and Edinburgh, once additional capacity was in place to cope with the envisaged increased demand. It is acknowledged within the EP Development plan that NHS Tayside would continue to refer to other tertiary centres, however 68% of their total activity, would be referred to Aberdeen. From the information provided by the other tertiary centres, the table below details referring patterns for EP activity carried out at the 3 regional centres for north of Scotland patients, in 2008/09. It should be noted that Argyll and Bute, Perthshire and Western Isles patient flows to WoS and SEAT are not differentiated in the table below. 10
NHST NHSH NHSG WI NHSS NHSO Total GJH 16 10 1 6 0 0 33 RIE 70 14 6 0 0 0 90 ARI 39 28 128 0 4 6 205 As stated within the Regional EP plan NHS Highland and NHS Tayside have referral arrangements with other regional planning groups. Now that there is additional capacity in place to support development of the service for North of Scotland patients, further discussion is required with the Cardiac sub group, regional planners and individual boards to clarify desired levels of repatriation and how this might be achieved. REVIEW OF INDIVIDUAL SPECIALISED EP PROCEDURES V UK RECOMMENDED RATES PMP Cardiac Resynchronisation Therapy (CRT) CRT devices are used to help treat heart failure and can be either a CRT P (pacemaker only) or CRT D (defibrillator/including ICD). They work by making the heart chambers pump at the same time (synchronously) and improve the overall function of the heart so that people feel less breathless and have more energy. NoS CRT activity has almost doubled in 2008/09 with an 80%.increase over the previous year. This is a higher growth rate than projected within the plan; however activity levels are much as projected, and suggest that activity for 2007/08 was well below what it should be for NoS residents. (The regional EP plan projected growth rates of 20% in 2008/09 and 10% annually in the 2 years following). Recent data Access to Cardiac care in the UK June 2009, highlights average growth of 35% a year, since 2000, for new CRT implants, with rates per million population increasing from 3 pmp in 2000 to 51 pmp in 2007. The European average is 60 pmp. (For CRT the UK ranked 8 th of 15 countries with Finland being lowest at 30 pmp and Italy highest at 120 pmp).. Current CRT activity performed at ARI, by Health board split and as a % of total for 2007/08 2008/09 NHSG NHSH NHSO NHSS NHST OTHER Total 2008/09 25 (55%) 6 (13%) 0 0 13 (29%) 1 (2%) 45 2007/08 14 (56%) 1 (4%) 0 0 7 (28%) 3 (12%) 25 11
CRT demand per Health Board using UK and European rates pmp. NHSG NHSH NHSO NHSS NHST NHSWI Total Population 525,000 319,153 20,000 22,000 389,000 26,300 51 pmp 26 16 1 1 20 1 65 60 pmp 31 19 1 2 23 2 128 Note: The chart above shows projected activity by Health board, including Western Isles, using total population figures. CRT activity for NoS patients was 45 for the year 2008/09. Activity has risen sharply above 2007/08 levels and is now only 17% below UK recommended rates pmp. However current referral patterns show no referrals from NHS Orkney and NHS Shetland, and lower than expected referral rates from NHS Highland and NHS Tayside, according to the population data. NHS Western Isles activity is included for illustration purposes. Peripheral clinics are provided to the Western Isles, by NHS Highland, for pacemaker monitoring. Western Isles patient flow for ICD s etc. is directed to West of Scotland. NHS Highland provides a monitoring service for patients who have had their procedure in Glasgow. Target activity for CRT for north of Scotland patients, using the population projections within the EP Development plan and based on 51 pmp, projects increased demand to 54 procedures for 2009/10. This would achieve parity with other UK centres. To achieve parity with European counterparts, activity levels would need to increase to 63 in 2009/10. Future planning options to consider: CRT to be delivered locally extending the area of access for north of Scotland patients could all of Tayside and potentially North Fife be included for referral to Ninewells within NHS Highland, is there potential for some Argyll and Bute and Western Isles patients be referred to Raigmore This would be a sea change in traditional referring practice and would require detailed discussion, careful planning, negotiation and agreement with the other regional planning groups and individual boards, to ensure that capacity and financial support including, infrastructure, staffing and resources are available, within each centre to meet agreed current and future levels of demand. If total population data is taken into account for each health board area, then this projects demand for 66 implants based on 51 pmp or 78 to meet the European equivalent of 60 pmp, for 2009/10. This represents an increase of 46% over current activity and assumes all patient referrals remain within North of Scotland 12
Planning Group (NoSPG) which would mean changing existing patient flow patterns. [The projected increased demand for CRT as reported by the Access to Cardiac Care in the UK report (June 2009) is included for comparison, under the future planning section. It is recognised that Scotland requires a growth rate of 7% above UK rates pmp to meet demand] Within the EP Development plan it was suggested that 'CRT and RFA would continue to be delivered as a regional service, at Aberdeen, for the foreseeable future and certainly could not be expanded without increased capacity within the EP service'. The recent appointment of additional EP consultant capacity enables this aspect of the NoS EP service to be reviewed, earlier than planned, however there are also associated financial and resource implications in terms of support staff, catheter laboratory and theatre availability to be considered. [The National Advisory Committee (NAC) CHD report (2004) recommended that resources should be made available to enable current and proposed ICD centres to offer CRT in addition to conventional ICD implantation. Operator recommended rates are 20 30 per year]. Following recent meetings between NHS Highland, NHS Tayside and the tertiary centre within NHS Grampian, it was felt that devolving CRT to local provision is inevitable and will happen as referral numbers increase to acceptable levels. Discussions have begun in order to ascertain how this can be facilitated in an effective way, within an appropriate and acceptable timescale. The EP development plan suggests that the north would benefit from an ICD network and this might be an opportune time to put this in place. If it is desirable and approved by NoSPG, to devolve CRT to other centres (Tayside and Highland) the infrastructure and capacity will require to be available to take this forward. Both boards have expressed a wish to do this, however a clear plan is required as to how this can be achieved, while maintaining tertiary centre service provision, for north of Scotland patients, in the interim. A visiting consultant from NHS Tayside joined colleagues at the tertiary centre, for shared clinics, during the past year and NHS Tayside may be in a position to offer CRT, supported by the newly appointed North of Scotland Consultant, in the near future. NHS Highland requires to develop consultant expertise in this specialised area and would benefit from joining colleagues at the tertiary centre to take this forward. Both centres will need to plan for timely support staff training locally to coincide with the introduction of this aspect of a local service if this becomes a proposal and gains approval from NoSPG. One of the suggestions put forward during recent discussions was the provision of a joint EP clinic based at Dr 13
Grays hospital in Elgin for the benefit of NHS Highland and Moray patients. The table below shows patient flows for Moray patients in 2008/09, by postcode. IV 30 IV 31 IV 32 IV 36 CRT 0 0 0 0 ICD 5 0 0 2 RFA 5 1 2 4 IV 30 = Elgin, IV 31 = Lossiemouth, IV 32 = Fochabers, IV 36 = Forres As stated previously, consideration could be given to reviewing population catchment areas and current referral arrangements for NoS patients. Is the transport infrastructure in place to assist? Implantable cardioverter defibrillator (ICD) A self contained device implanted under the skin or muscle of the upper chest wall and connected to electric leads passing through the veins to be fixed to the heart muscle of the atrium and/or ventricles. This device monitors the electrical rhythm of the heart, and if it detects certain severe abnormalities, can deliver an electrical shock directly to the heart to resynchronise the heart rhythm back to normal, and so restart the heart. ICD activity split by Health board and as a % of total 2007/08 2008/09 NHSG NHSH NHSO NHSS NHST OTHER Total 2008/09 43 (77%) 4 (7%) 4 (7%) 0 2 (4%) 0 56 (TC) Inc local 29 0 27 109 (NoS) 2007/08 24 14 2 1 12 3 56 Overall ICD activity has increased by 94% in 2008/09 following the expanded capacity provided at Ninewells and Raigmore. For NHSG patients this is an increase of 79%, on the previous year, for NHSH this increase is 135%, for NHST 158%. NHS Orkney and NHS Shetland remain fairly constant, however the lack of any referrals from NHS Shetland would benefit from investigation. ICD growth rate within the plan was factored at 10% annually. Tertiary activity is down by 5% only which may suggest that the overall increase in activity may be in response to unmet need, in addition to repatriation. It is recognised that when a new service is introduced to an area, demand increases sharply, initially. Projected ICD activity for NHS Highland was 17 in 2008/09, following repatriation, gradually increasing to 22 by 2010/2011. Actual activity for 2008/09 was 29 implants which is 70% above what was projected. 14
Projected ICD activity for NHS Tayside is not clearly defined within the EP plan however to meet UK recommended activity levels (2007/08), the plan recommended a total of 39 implants, based on a population of 389,000 (all of NHS Tayside). Actual activity for 2008/09 was 27 implants which is 31% lower than suggested to meet UK standards. Of total regional ICD activity, 50% is now completed at the tertiary centre and 50% between Raigmore and Ninewells. The small number of cases referred to NHSG from NHSH and NHST are assumed to be complex/to meet waiting time guarantees? Assuming a rate of 100 pmp North of Scotland activity, using the populations within the EP development plan, exceeds the UK average by 3.8% and for 2009/10 should be 105 or 108 if Western Isles refer to Raigmore. If total populations for NoS boards are included, to maintain parity with UK rates pmp, recommended activity would be 126 or 129 including Western Isles. For 2009/10 This would be an increase of 17% over activity levels for 2008/09 using the present planning area. NHSG NHSH NHSO NHSS NHST NHSWI Total Population 525,000 319,153 20,000 22,000 389,000 26,300 1,301,453 100 pmp 52 31 2 2 39 3 129 122 pmp 64 39 2 3 47 3 158 Note: The chart above shows projected activity by Health board using total population data. The ICD implantation rate for the population of Shetland is below that which might be expected and is slightly below what might be expected for Grampian and Tayside taking into account referrals made elsewhere. The reasons for this would benefit from closer investigation. NICE guidance in January 2006, estimated that, when implemented, the ICD rate would need to increase to 100 pmp and this has been achieved overall, for north of Scotland patients. ` [The UK ranked 14 th out of 16 comparable European countries, for ICD implantations] Radio Frequency Ablation (RFA) Intentional destruction of a small amount of electrical cardiac tissue to permanently isolate, interrupt or destroy a tachycardia focus or circuit. The intention is to stop or break the electrical cause of a rhythm disturbance. Overall RFA activity increased by 13% on the previous year; however this is 21% lower than projected in the EP development plan. 15
RFA activity by Health Board and as a % of total 2007/08 2008/09 NHSG NHSH NHSO NHSS NHST OTHER Total 2008/09 60 (54%) 18 (16%) 2 (2%) 4 (4%) 24 (21%) 3 (3%) 111 2007/08 62 (63%) 13 (13%) 2 0 19 (19%) 2 (2%) 98 The UK Ablation rate = 122 pmp. For the population data used in the Regional EP development plan, the rate for NoSPG population should be 128. 111 procedures were completed in 2008/09 and this is 14% below the UK recommended rate pmp. It is clear that RFA activity is increasing although at a slower than anticipated rate why might this be? [The UK ranked 16 th out of 16 countries for ablation. Scotland is one of the areas which have been identified as having a projected need for EPS/Ablation of 5% above the UK rate pmp]. Source: Access to Cardiac Care in the UK Oxford Healthcare Associates, June 2009. A Cardiologist view Atrial fibrillation (AF) will be the commonest indicator, in the future with prevalence of 10% of the population in the over 80 s age group. This would estimate 1 in 100 patients will come forward for ablation and in 5 years time we might see 250 ablations per year. CRT will to expand as indications are going to become more liberal. CRT P will go up slowly. ICD s may remain much as they are at present. Complex ablations are increasing and PVI will be the procedure that drives EP activity within the next few years. Areas with low uptake of the service should be investigated to identify any underlying cause. It is appreciated that consideration should be given to introducing CRT locally, to both NHS Tayside and NHS Highland. Dr Paul Broadhurst. CAPACITY & DEMAND 2009/10 and beyond Activity levels for first quarter of 2009/10 Activity performed at the tertiary centre for first 4 months of 2009/10 by Health Board split 20 15 10 5 0 ICD CRT P CRT D RFA SVT RFA AF RFA complex NHSG NHSH NHSO NHSS NHST Tot al 16
The chart below shows actual versus estimated activity, performed at the tertiary centre, for NoS patients, 2009/10 Actual v estimated activity performed at the tertiary centre to date 2009/10 (4 months) 90 80 70 60 50 40 30 20 10 0 VR ICD DR ICD CRT P CRT D RFA SVT RFA AF RFA Comp Total Actual Estimated Using data from the first 4 months of 2009/10, projected actual versus estimated activity for the whole year 2009/10. EP projected activity performed at the tertiary centre for 2009/10 compared to estimations in EP plan 300 250 200 150 100 Actual Estimated 50 0 VR ICD DR ICD CRT P CRT D RFA SVT RFA AF RFA Comp Total Staffing in post and WTE dedicated to EP (Tertiary centre) Current staffing consists of the following: 2 wte Cardiac Physiologists 2 Band 5 nurses allocated to lists from main pool of staff 1 p/t EP nurse to support the service 2 wte Consultants though 1 does other work also 17
Dedicated sessions per week There are 4 sessions per week for EP activity and approximately 200 sessions provided annually, at present. 181 sessions were used in 2008/09 due to having only 1 consultant and clarity is required as to how this will rise following the appointment of the second EP consultant. Waiting Times and pressures The Unit Operation Manager reports that there have been no breaches of waiting times guarantees with 12 weeks for both In patient and Out patients being maintained. Achieving Referral to treatment (RTT) standards by 2011 will reduce overall waiting times to 18 weeks and 9 weeks for Inpatients. Providing staffing to support additional sessions (nursing, technicians, and admin) for the new Consultant is challenging. There has been a rapid and large increase in the number of cases requiring general anaesthetic and this is an additional pressure. Provision of new equipment to keep up with technological change can be an added pressure and in addition, the increasing number of indications for EP, suggests that a review is required to identify capacity, demand and financial impact of levels of provision within this expanding service. Possible causes of variation and inequity of access According to the findings within the Access to cardiac Care in the UK report, variation in access and different levels of local provision within and across the UK and associated inequity are not new phenomena within the NHS and may simply be a reflection of historical local service development over a number of years, financial, physical capacity and workforce constraints. There are many points along the patient pathway which may result in possible lower access to the most appropriate secondary and tertiary care and treatment: 1 Patients have to recognise they have a problem and decide to see a GP 2 Access levels to primary care services may vary 3 It is likely that there is variation in referral practice from primary to secondary care and to cardiologists, partly dependant on the availability of specialist cardiac care locally 4 The speciality of hospital doctor that sees the patient on admission with a heart attack may affect the type of treatment they receive, e.g. cardiologists are 50% more likely to refer patients having a heart attack, for angiogram, than general physicians 5 The provision of more local specialist services itself affects demand and may increase general awareness, case identification, referral and treatment and therefore access rates. Source Access to Cardiac Care in the UK, Oxford Healthcare Associates, June 2009 18
Future planning considerations EPS/Ablation projected rates pmp and index comparisons with UK rates based on 5%, 10% and 15% growth per year for 2010, 2015, and 2020 as outlined in the Access to Cardiac Care in the UK report by Oxford Healthcare Associates June 2009. EPS/Ablation rates pmp UK index rate pmp Scotland 2010 2015 2020 2010 2015 2020 UK 2020 low 5% 198 258 335 103 104 105 319 med 10% 228 375 613 103 104 105 584 high 15% 261 635 1080 103 104 105 1041 Projected new CRT's per Health Board based on 7.2% annual growth for 2010, 2015, 2020 NHSG NHSH NHSO NHSS NHST W Isles Total 2010 low 33 21 1 1 26 2 84 med 37 24 2 2 30 2 97 2015 low 46 30 2 2 36 3 119 med 67 44 3 3 52 4 173 2020 low 66 42 3 3 49 4 167 med 120 77 5 5 89 6 302 Projected new ICD's per Health Board based on 7.2% annual growth Total NHSG NHSH NHSO NHSS NHST W Isles 2010 96 37 24 2 2 29 2 2015 143 57 36 2 2 43 3 2020 220 88 55 4 4 64 5 Total 182 116 8 8 136 10 Source: Access to Cardiac Care in the UK report June 2009 19
Revised Population data: Source GROS 2004, updated 2007 Health Board Total Populations Population for revised Comments EP plan Grampian 524,020 Incl 86,740 Moray Highland 302,530 Inc 91,190 Argyll & Bute Orkney 20,000 Shetland 22,000 Tayside 387,908 Inc 137,430 Perth & Kinross Western Isles 26,300 Total 1,282,758 Column 2 requires to be decided Note: The revised EP Development plan will need to take account of a different population mix to ensure best access for patients who are referred both to the tertiary centre and locally. Scotland covers 77,925 square kilometres and the North of Scotland Planning Group area accounts for 66% of this land area, covering 52,178 square kilometres. The table below shows population data, land area and population density by council and health board area. Est. population 30 June 2004 Area Persons per sq km Scotland 5,078,400 77,925 65 NHSG Aberdeen city Aberdeen shire Moray 205,710 231,570 86,740 186 6,313 2,238 1,107 37 39 Highland Argyll & Bute 211,340 91,190 25,659 6,909 8 13 Orkney 19,500 990 20 Shetland 21,940 1,466 15 Tayside Angus Dundee city Perth & Kinross 108,350 142,170 137,430 2,182 60 5,286 50 2,376 26 Western Isles 26,260 3,071 9 Total 1,282,758 (rounded) 20
SUMMARY & KEY POINTS 1. The regional Electrophysiology service has grown considerably (48%) over the last 18 months and the regional EP Development plan is well on track to achieve much of what it set out to do. 2. The new service model encompassing a local ICD service, provided at Ninewells and Raigmore established 18 months ago is working well. Individual Health board referral rates for ICD's are slightly below what might be expected for the populations of Shetland, Grampian and Tayside and this would benefit from closer investigation to identify why this might be. implantations rate for NoS patients now exceeds the UK recommended rate pmp by 3.8%. Overall the ICD 3. CRT s have expanded rapidly within the past year and are now only 17% below recommended UK rate pmp. Where individual health board referral rates are lower than might be expected, this should be investigated, to identify possible underlying causes. 4. RFA growth has been slower than expected (13%) however it is predicted that the rate of complex ablations is set to grow rapidly. RFA rates remain 14% below the UK recommended rate pmp. 5. It is acknowledged that both Tayside and Highland refer to all 3 tertiary centres and this has an impact on service growth within NoS. NHS Grampian continues to provide an EP service for Orkney and Shetland patients. 6. Repatriation, which was a major aim within the EP plan, has not been achieved due to lack of consultant/capacity at the tertiary centre. 7. It is recommended that detailed demand and capacity discussions, with individual boards and other regional planning groups should now take place to identify desired levels of regional service provision for the next 3 5 years. 8. Capacity and resource requires to be clarified if planning towards repatriation of NoS patients, who are referred to SEAT and WoS, at present. 9. It is acknowledged that a level of referral out with NoS may still be required in order to continue to meet demand, RTT etc. 10. With additional consultant capacity in place, it is recommended that plans now be put forward to NoSPG to identify how this post will support continuing EP service provision. CRT to be taken forward as a local service, to Ninewells in the first instance, followed by Raigmore should be fully costed as an option. 11. The formation of a NoS ICD network would provide support and structure for local specialised services and would ensure patient pathways remain robust and equitable. 12. Costs of providing the regional EP service remain within budgeted projections however they do not take account of local centre costs for ICD provision. 13. A review of costs is recommended to reflect potential demand from repatriation along with projected increased demand within a service which is expanding rapidly across the north of 21
Scotland. 14. Future planning assumptions will need to take account of financial constraints, future service pressures and levels of service provision which are realistic in terms of service development in the short to medium term. 15. It is recommended that following demand and capacity discussions with each board, a revised Regional EP plan outlining service objectives for the next 3 5 years, should be submitted to NoSPG for approval. Dr Malcolm Metcalfe Clinical Lead Fiona MacDonald Regional Cardiac Service Improvement Manager September 2009 22
REFERENCES: 1 NoSPG Regional development Plan for Electrophysiology Services. Authors: Dr M Metcalfe & Ms Lorraine Scott February 2008 2 Development of Electrophysiology in the North Discussion paper. Author: Dr A K Ingram August 2006 3 Access to Cardiac Care in the UK, Oxford Healthcare Associates, June 2009. This report presents results of a study commissioned by the British Heart Foundation and the Cardio & Vascular Coalition (CVC). Oxford Healthcare Associates are an independent healthcare services consultancy. Data for Scotland was provided by ISD and GROS, the lead clinicians for EP/Arrhythmia services in the 3 cardiothoracic centres providing specialist services in Scotland, and the Scottish Revascularisation Register. 23