SOUTH EAST WALES CLINICAL COLLABORATIVE GROUP Minutes of the meeting held on Central South Consortium Conference Centre, Ty Dysgu, Cefn Coed, Nantgarw, Cardiff Attendee: Designation Representing Dr Gethin Ellis (Chair) GE Lead Cardiologist South East Wales / South Wales Cardiac Network Consultant Cardiologist Luke Archard LA Specialist Planner Welsh Health Specialised Services Team Dr Jackie Austin JA Consultant Nurse / Lead Cardiovascular Nurse Aneurin Bevan Health Board South Wales Cardiac Network Dr Robert Bleasdale RB Consultant Cardiologist Cwm Taf Health Board (Royal Glamorgan Hospital) Dr Lalit Bhalla LB Consultant Cardiologist Cwm Taf Health Board (Prince Charles Hospital) Dr Philip Campbell PC Consultant Cardiologist Aneurin Bevan Health Board Laurence Clay LC CHC Member Aneurin Bevan CHC Christopher Coslett CC Directorate Manager, Cardiothoracic and Critical Care Cardiff & Vale University Health Board Dr Armon Daniels AD Lead GP South East Wales / South Wales Cardiac Network GP, Rumney Medical Practice, Cardiff Julie Keegan JK Interim General Manager - Commissioning Cwm Taf Health Board Richard Lee RL Lead Nurse for Cardiothoracics Cardiff & Vale University Health Board Robin Petterson RP Clinical Support Officer WAST NHS Trust Paul Smith PS Interim Area Development Manager British Heart Foundation Geraldine Swarfield GS Lead Nurse for Cardiology Cwm Taf Health Board Dr Justin Taylor JT Consultant Cardiologist Cwm Taf Health Board Dr Philip Webb PW Head of Epidemiology and Evidence Welsh Health Specialised Services Assessment Team Sue Wilshere SW Network Manager South Wales Cardiac Network Apologies: Alison Allen Cardiac Nurse Specialist Cwm Taf Health Board Dr Nigel Brown Consultant Cardiologist Aneurin Bevan Health Board Trish Buck Senior Cardiac Rehabilitation Nurse / Practice Development Coordinator for Wales Cwm Taf Health Board British Heart Foundation Dr Margaret Egan Consultant Cardiologist Cwm Taf Health Board Richard Lee Head of Clinical Services WAST NHS Trust Chris Moore Clinical Support Lead WAST NHS Trust Joanne Oliver Interim Regional Development Manager for British Heart Foundation Wales and West Ceri Phillips Senior Nurse for Cardiothoracics Cardiff & Vale University Health Board Celia Satherley Cardiology Directorate Manager Aneurin Bevan Health Board Dr Kevin Thomas Locality Clinical Manager Cwm Taf Health Board In attendance Claire Lewis Network Administrator (Minutes) South Wales Cardiac Network Item: 1. Introductions and Apologies GE welcomed the group to the meeting and apologies were noted. 2. Notes of the meeting held on 19 July 2013 These were agreed as a true and accurate record with the following amendment: Page 5 ICD/CRT Health Board Update Final sentence LA acknowledged that WHSSC had an underspend last year as the Page 1 of 8
increase in box changes was lower than planned and the funding did not need to be drawn on. The funding will be drawn on this year. 3. Action Points and Matters Arising Action 10 Delivery Framework Tier 1 Priority GE reported that a WCS meeting with the Health Minster raised the issue of cardiovascular disease becoming a Tier 1 priority in the NHS Delivery Framework. A follow up letter would be sent. 4. WHSSC Cardiac Services Review Update ACHD Service Implementation Progress LA reported that outstanding issues relating to the ACHD service had been agreed and a revised proposal circulated. A letter was being sent today from WHSSC confirming what will be delivered. The total resource requirement was greater than that originally presented to the Joint Committee. There was enough resource for the first phase, but another business case was required for the second phase. The ACHD Service would not be subject to the prioritisation process. GE was keen that posts were advertised for the new staff. The next step was to develop a service specification with representatives from WHSSC, Cardiff & Vale UHB and the Network. It was queried whether an LHB Cardiologist with an interest in ACHD could be the specified DGH cardiologist with the funding going direct to the HBs or whether Cardiff & Vale would be supplying these sessions. LA confirmed it should be a local cardiologist with an interest in ACHD who would support the outreach clinics. He confirmed that the funding would be provided by the Network or within existing services. SW stated that this was not clear from the paper and no discussions on this had taken place. In addition the Network had no funding to support clinical services. The key issue now was to agree a detailed service specification with clinical input and to get the service running as soon as possible. GE advised managers to scrutinise this report so they realise where the money was being spent. SW asked that this issue be raised at the meeting to draft the service specification. JK queried where the Business case for this had gone as she did not recall seeing it. LA confirmed that it had been agreed in the WHSSC plan last year and following discussions implementation had been changed to a phased implementation, but the resource for that implementation had not been matched. This had been considered within WHSSC as a development already agreed and had not taken it to the Management Group. JK confirmed that the plan should be scrutinised by the Management Group. GE was keen that the service was implemented as soon as possible and asked LA/JK to discuss it outside of the meeting. Action 1: LA/SW Action 2: LA/JK Cardiac Imaging MRI Proposal Update GE reported that discussions had taken place with WHSSC and the National Imaging Programme Board regarding Cardiac MRI and Cardiac CT services. Cardiac MRI and complex CT need to be set up as regional services commissioned by WHSSC. ABHB were currently sending patients to Spire Hospital, Cardiff but Cwm Taf had not yet outsourced patients. GE confirmed that a clinical proposal for increased cardiac MRI capacity had been requested at the last Network Board and the paper was in preparation by Network cardiologists. It was anticipated that approximately 5,000 scans per year should be undertaken, compared with the current 500. Investment was required in both equipment and staff to undertake the scans. PW said that an evidence review of what MRI is needed for by indication would be required. Surgical Waiting List mortality LA reported that a review undertaken by WHSSC recommended that additional capacity was required to bring cardiac surgical waiting times down. The proposal was to bring the surgical component waiting times down to 10 weeks with 6 weeks from listing. Referral pathways had been agreed and the outsourcing of patients to Birmingham would start in December to meet the waiting times by the end of March. Cardiac Surgery Review Implementation Group LA reported that the Cardiac Surgery Review Implementation Group had been set up to look at issues relating to service efficiency, clinical access, equity and clinical Page 2 of 8
guidelines for referring clinicians which, would be circulated. The In-Hospital transfer pathway drew on work undertaken in London which had proven efficiency gains. LA apologised that the updated action plan had not been circulated and agreed to circulate it. SW queried whether the goal was to meet the target of 36 weeks by the end of March or simply to clear the backlog of patients. LA confirmed it was to meet the 36 week target. PW reported that the Medical Directorate in WHSSC had scrutinised the pathways for all patients who might be transferred as well as less risky patients. Discussions had taken place with clinicians regarding the surgical outcomes at those centres and what happens to the patient on their return. The recommendation of 10 weeks needed formal approval by WG and NHS Wales which would involve more discussions. Dan Phillips was leading on this work on behalf of WHSSC which it was hoped would lead to increased capacity. CC confirmed that Cardiff were funded for 1100 operations pa, but did not have the capacity to deliver 1100 operations pa. Prioritisation Process PW reported that in 2012/13 WHSSC had been told by the Joint Committee to justify its 0.6 billion spend on the basis of clinical and cost effectiveness and to provide assurances on value for money. As there was little empirical data to support this the Medical Director of WHSSC was instructed to develop a systematic approach based on evidence evaluation and assessment as a system of evidence appraisal. In 2012/13 WHSSC had undertaken 85 evidence appraisals and prioritisation recommendations based on an evidence framework consistent with the framework adopted by NHS England. Following on from last years process, the Medical Directorate of WHSSC audited its evidence processes and highlighted that a more upfront clinical engagement process was required, with more input from public and patients. Clinical Access Policies and Service Specifications (including quality outcomes measures and patient experience of the service) would be required to translate the recommendations made by the Prioritisation Panel into key clinical and contractual products. This year, the topics for appraisal and services to be reviewed will be selected by Clinical Evidence Reference Groups (paper tabled at meeting). Clinical involvement was now embedded as part of this process through the establishment of the CT CERG GE felt that the CERGs were trying to replicate NICE and ESR guidance in Wales and was concerned that the Reference Group was a rationing Group. PW clarified the role of the CERGs was to engage with the evidence and then write the clinical access policies, services specifications and define the quality and outcomes frameworks that would be used to measure patient outcomes and quality. PW indicated that he would take any concerns back to the Clinical Chair of the CERG and any clinical comments would be referred to the clinical authors of the respective documents. Aneurin Bevan HB was in the process of auditing the revascularisation stable coronary artery disease policy, and PW suggested that the outcomes of the audit should be presented at the next Clinical Collaborative Meeting. The anecdotal clinical feedback on the revascularisation policy was there were potential variances in patient selected for revascularisation (i.e. PCI or CABG) between Provider units in SE Wales, South Wales and North Wales. GE was concerned that WHSSC were introducing an unnecessary step. PW said this was a systematic evidence based approach and unless the evidence was written down and measured by a proscribed outcomes and quality dashboard, it would be measured. GE was interested to see the outcome of the audit, and if people were using the evidence base to select appropriate patients. JK said this was not about rationing but looking at the evidence base. A whole system approach was required which was more clinically focussed. All HBs are looking at what WHSSC are doing with a view to a similar approach locally. Commissioning could no longer be undertaken on a purely historical numbers basis. RB said that coronary intervention in stable angina is underperformed in Wales and the evidence is robust. It was a mistake for WHSSC to have selected this first. The point of the CRGs was an opportunity to bring in new evidence for new interventions. One issue coming out of the Audit Day was that outcome measures are not well Action 3: LA Page 3 of 8
published for the Welsh population although they are readily available in the BCIS database. PW was keen to bring the audits back for scrutiny after the HBs have undertaken them. LC was concerned as how to get this message out to the public as the patient voice was crucial. PW agreed with LC and WHSSC would be engaging with the CHCs as they wanted to include patients as a fundamental part of the process. LC said that most HBs have patient panels which were better than CHCs as they have patients with the specific conditions. RB said that WG need to be honest with the public that patients cannot be treated quickly. This should be a decision for the politicians, not the clinicians or patients. Another grey area was the selection of patients coming up for box changes. Selecting the right patients and the right process was crucial. PW agreed to forward copies of the CERG paper, the Stakeholder paper, a copy of the slides and the Access Policies to the Network to circulate. They would also be published on the WHSSC website which was currently undergoing some development. It was suggested that a link could also be put on the WCS website to WHSSC. PW suggested that once the Clinical Evidence Reference Groups were established that the Chair of the CT CERG should be invited to talk to the Clinical Collaborative Groups. Action 4: PW/Network Action 5: SW/CL 5. Audit National Audit of Cardiac Services in Wales 2013 06/11/2013 GE reported that the National Audit Day (jointly hosted by the Network, WHSSC and the WCS) had been very successful. PC asked if it was possible for someone from ABHB to present and this was welcomed but clinicians would need to volunteer and/or assume leadership roles within national cardiac organisations. PW said that in order to have safe services for patients with good clinical outcomes more outcome data must be presented. GE agreed with this, but it was acknowledged that time limitations were an important factor in deciding the presentations made on the day. PW indicated that each Clinical Access Policy would have a mandated quality and outcomes dashboard that should constitute the basis for any cardiac audit day. This would ensure that the focus of the audit day would be clinical outcomes not just activity. SE Wales MINAP Workshop 06/12/2013 GE reported that a SE Wales MINAP Workshop was taking place on 6 December. The MINAP Report for 2013 had been published and the numbers inputted for Wales were poor (particularly for nstemi). This was largely due to system failure and insufficient audit capacity in the HBs. The purpose of the workshop was to look at how numbers can be improved in SE Wales. The clinicians reported that if audit data was to be monitored there would have to be more resource. PW said that outcome measures as part of clinical audit will be a contractual requirement in the new evidence policies. In England PCTs had made it an outcome measure for the service. CCAD and BCIS are all completed by clinicians as it is requirement of their contracts, but MINAP was not a requirement. JA reported that the National Heart Failure Audit Report for 2012-2013 had been published which had shown an improvement in numbers reported in Wales. 6. Welsh Government Heart Disease Delivery Plan All Wales Heart Disease Implementation Group Minutes 09/10/2013 SW reported that the Heart Disease Delivery Plan Implementation Group had been set up by the Assembly and was chaired by Andrew Goodall with the purpose of delivering the Heart Disease Delivery Plan by 2016. The Implementation Group were taking a wide all Wales overview and there had been a presentation on all the themes at the meeting in October. HBs were required to submit Local Delivery Plans based on health needs assessments by the end of December. The next Implementation Group meeting on 29 January would scrutinise all the Local Delivery Plans. Strategic Delivery Plan draft SW reported that the Network had been charged with co-ordinating the Strategic Delivery Plan for the HDDP IG. The first draft of the Strategic Delivery Plan was Page 4 of 8
completed with some overlaps between All Wales and HB level. SW would circulate an updated version once input had been received. Action 6: SW 7. Health Board updates and Local Delivery Plans Cardiff & Vale UHB LDP CC reported that work was in progress on the LDP in Cardiff led by Dr Peter O Callaghan with a submission deadline of the following week. Public Health Wales had done their needs assessment and Andrew Nelson was undertaking modelling work to look at 26 week and 18 week targets as PO C wanted to reflect the service and waiting times in England. It would be integrated into the 3 year plan. Locum Cardiac Surgeons RL reported that two new Locum Cardiac Surgeons had been appointed - Miklosh Bitay and Govind Chetty. RL agreed to e-mail information to CL. Action 7: RL RTT CC reported that C&V were struggling to meet 36 weeks target by the end of March. Extra clinics for cardiac surgery were taking place during December. SW reported that as part of the HDDP Outcome and Assurance Measures RTT was being looked at by WG. Access 2009 had originally included component waits and factored in patients going from DGHs to the Tertiary Centre. PW said that each HB was responsible for its component waits. Andrew Nelson had previously worked with the DSU looking at what was required for referral into tertiary centre. There was a need to look at how patients could be treated within 18 weeks and how we measure against other countries. Aneurin Bevan HB Local Delivery Plan PC reported that their LDP was would be going to the ABHB Board next week. RTT PC reported they were still struggling to meet the RTT target. There was a significant increase in referrals to cardiology. They were using the Blackberry advice line, virtual clinics and holding peer review meetings which was an MDT meeting every other week for one hour at which all the clinicians bring their referrals. VC Equipment Informal MDT meetings were taking place. There were ongoing discussions with Cardiff & Vale regarding agreeing funds for regular MDTs. Acute Heart Failure Nurse Project JA reported that an acute Heart Failure Nurse had been appointed at the Royal Gwent Hospital to look at reducing heart failure readmissions within 30 days. Cardiologist Appointment PC confirmed that Dr Shantu Bundhoo had been appointed as the third cardiology interventionalist at ABHB. Cwm Taf HB Local Delivery Plan RB reported that Cwm Taf HB were struggling without support to complete the process. JK reported that work was ongoing on Theme 1 Inverse Care Law project. JK was keen to see the plans fully integrated with the 3 year plan and other elements of cardiac services in Cwm Taf. She was concerned that they had not linked in very well with WHSSC and the specialist end of services. She felt this should be common in all the plans and should be the same for all HBs. RTT JK confirmed that the RTT was not being delivered and she recognised that the HB was failing. The component waiting times appeared to have been lost in Cwm Taf. Page 5 of 8
The referral from GP to cardiologist was a problem area. Complex devices plan JK reported that there was an agreement in principle regarding the complex devices plan. This would need formal approval by the Executive Board and a meeting had been arranged with Ruth Alcolado. Arrhythmia Service RB reported the crisis was over and the staff would be returning to work in April. He withdrew this item from the agenda. WAST NHS Trust Local Delivery Plan Unfortunately RL was unable to attend the meeting so no update on the WAST LDP was available. WAST Cardiac Arrest Survival Plan Robin Petterson reported to the Group that he and Carl Powell had been appointed as Clinical Support Officers funded by the BHF. He had been tasked with writing the WAST Cardiac Arrest Survival Plan. Both he and Carl Powell had visited Edinburgh where there were similar problems and they had changed the way they responded to cardiac arrests. WAST had learned lessons from the Edinburgh approach which produced far better outcomes for patients. WAST would be undertaking a pilot scheme in 2014 with C&V. They were working with C&V to tighten up data collection as well as working with clinical team leaders on improving basic CPR on patients. They were also looking at using a chest compression device. Automatic External Defibrillators RP reported that WAST were working with the BHF on mapping the location of AEDs. The problem arose because organisations apply for AEDs which are signed off by BHF and sent out, but WAST are not told where they are located. RB was developing a register of locations for all AEDs in South Wales. 7. Primary Care FH Service Update AD reported that South Wales were languishing behind North Wales who had been proactive in using the biochemistry labs to identify patients with high cholesterol who needed screening and were expecting a high yield. GE was concerned that some HB labs were reluctant in sharing information on patients identified as having a very high cholesterol. In South Wales the labs and the LMCs had been a barrier. An educational module for primary care consisting of a DVD and distance learning package was being developed in conjunction with NWIS and this would be rolled out. University of South Wales primary care ECG Training 4/4/14 AD reported that Network were working with the University of South Wales in Pontypridd in co-ordinating bespoke refresher training for primary care clinicians in interpreting ECGs. A training day was planned for 4 April 2014. Cardiovascular Risk assessment programme AD reported this was being taken forward as part of the HDDP Healthy Hearts workstream, led by Dr Karen Gully and Dr Hugo van Woerden. The work undertaken by Professor Julian Halcox was also being used. Progress would be reported via the HDDP Implementation Group at its meeting in January. 8. Secondary Care PPCI Update SE Wales GE reported that all HBs will have been visited by Dr Tim Kinnaird at UHW relating to the introduction of PPCI for patients self presenting to A&E outside of UHW. The management of STEMI had improved, but there were still a few loose ends to tie up. This service reorganisation was a major step forward without any additional funding. Communications Page 6 of 8
GE reported that communications between Tertiary Centres and DGHs had improved. GS reported that not all Cardiac Rehab referrals to Cwm Taf were being faxed. A&E/Inpatient transfer protocol GE asked if the DGHs/A&E Depts knew about the Inpatient Transfer Protocol. PC was not aware of it. JT said there had been some engagement in Prince Charles Hospital. GE agreed to circulate the Protocol and to publish it on the Network website. The key point in the Protocol was how to interact with WAST. Repatriation delays review RL reported that repatriations were still being monitored but were improving. Primary PCI repatriation was not a problem. However, non-cardiac and complex patients were a problem. In September and October the transfer times went down for ACS and complex patients, but there were major problems this week with 15 patients on the ACS list and 4 complex patients. Nine cardiology beds had been closed and would reopen on 24 November to allow seven patients to be brought in on Sunday evening from NHH. It was agreed that this should continue to be a standing agenda item. As the winter period approached cardiology beds had been protected until the hospital got to a Level 4. Cardiac surgery beds are now completely protected. RL would continue to collect, circulate and monitor the data. PC reported that there had been an issue on Wednesday night (20 November) relating to a patient from ABHB who had been directed to the Royal Gwent Hospital RL agreed to check whether this was a bed related issue. RB had a similar problem where both labs had been full so they had been advised to thrombolyse the patient. LB had an ITU issue where a patient had been ventilated but there were no ITU beds available and it had taken 2 hours to find a bed. On this occasion Cardiff agreed to take the patient and sort it out once the patient arrived. GE reported that as the service improved and evolved this sicker group of patients would need to be considered. Mid and West Wales had already undertaken some work on this. All Wales Cardiac Rehabilitation Advisory Group JA reported that the former All Wales Cardiac Working Group and the SWCN Cardiac Rehabilitation Group had now merged to form one all Wales Group. The new Cardiac Rehabilitation Advisory Group would be chaired by Julie Thomas with Elizabeth Hocking from ABMU as Vice Chair. Referral of Heart Failure patients for exercise based rehabilitation JA reported that as GPs now get QOF points for the referral of heart failure patients for exercise based rehabilitation the Cardiac Rehab Centres were seeing an increase in the number of referrals which they couldn t deal with. She had asked the Centres to keep a record of the number of referrals they were receiving. AD indicated that there were likely to be further increases by the end of March. JA felt that HBs should advise GPs on what to do as it was bad practice to create expectation that cannot be met. JA had produced a paper on this which had included the likely numbers and HBs should have been able to anticipate these. AD offered to liaise with his colleagues on the primary groups in each HB. GE proposed that the Network write to the Primary Care Leads in the HBs to ask what they are doing about Heart Failure patients and exercise based rehabilitation. Care Plans JA reported that the CR Group and the BHF had been tasked with looking at a care plan as requested in the Heart Disease Delivery Plan. JA also wanted the All Wales Heart Failure Group to be involved in this work. SW reported that a Care Plan was committed to in the Assembly Programme of Government and now appeared in every Delivery Plan. SW had a meeting arranged with the SW Cancer Network to find out more about the work they had done. CR were looking at it from a view as to what the content should be, as they had already developed patient held records. The key issue for a care plan was the patient having ownership of it and the information being available to clinicians across the pathway when they need it. Action 8: GE/CL Action 9: SW/CL Action 10: RL Action 11: AD/SW 10. South Wales Programme Update Page 7 of 8
GE reported that Andrew Goodall had spoken on the SWP at a recent WCS meeting. GE felt that in some ways it may be easier to separate maternity and paediatric services from A+E but that this was more difficult with for cardiac care. The decision on future services was due to be ratified by HB CEOs in December. This could be challenged by a CHC or LHB and if that happened it would be referred to the Health Minister. The interdependency between specialist services and the proposals in the South Wales programme had yet not been factored in, so the effect on those services was not known. 11. Clinical Networks, Advisory process, WHSSC and future SW reported that the HB CEOs and WG would be considering the future of the clinical networks, together with the national advisory groups and other structures and the question of whether there should be single all Wales Networks. However this was not expected to be decided on soon. 12. Any Other Business GE reported that both he and AD would be standing down from the Network in the near future. Any interested parties were asked to contact GE/AD/SW. 13. Date for next meeting The next meeting will be held on Friday 14 March 2014 Page 8 of 8