CORONARY HEART DISEASE (CHD)

MANAGED CLINICAL NETWORK (MCN) PROJECT BOARD

Minutes of meeting held at 5.30pm on Thursday 3 February 2005 in the Conference Room, Summerfield House

Present: / Dr Malcolm Metcalfe, Chairman, Lead Clinician CHD MCN and Consultant Cardiologist
Dr James Black, Lead GP, CHD & Stroke MCNs
Mr Milne Weir, Network Manager for CHD and Stroke
Mr Alastair Ramsay, Member of Public
Mr Andrew Dickson, Member of Public
Mr El-Shafei, Consultant Cardiothoracic Surgeon
Ms Heather Kelman, Aberdeen CHP
Mrs Jackie Bremner, Service Planning Lead for Aberdeen CHP
Ms Judith Hendry, Dietetics
Ms Linda Juroszek obo Mr George Downie
Mr Richard Carey, Chief Operating Officer
Dr Robert Liddell, Turriff Health Centre
Mrs Roberta Eunson, Service Manager
Mr Roddy Wood, Public Representative and CHD Steering Group
Mr Tony Collins, Member of Public

Mrs Christine Gray, Secretary

In attendance (by video link) – Dr Jamie Hogg, Lead GP Moray CHP and Mr Andrew Fowlie, General Manager, Moray CHP
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1. / Welcome and Apologies
Welcome – Christine Gray, Secretary, CHD and Stroke MCNs
Apologies – Dr Gordon Peterkin, Mr George Downie, Mrs Gillian Lewis,
Dr Eric Baijal, Dr S Walton
2. / Notes of Coronary Heart Disease MCN Project Board Meeting held on 2 December 2004
Amend page 3 top paragraph, first sentence to read, “The Heart Failure Nurses will be working with GP Practices to ensure optimum treatment of post discharge heart failure treatment”. / CG
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3. / Matters arising.
No outstanding issues
4. / NHS Grampian CHD Strategy Allocation – update
In summary the following projects had been approved to date through the CHD Strategy allocation:
(a)  Integration of Post MI and Post Cardiac Surgery Phase 3 Cardiac
Rehabilitation Programmes
(b)  Non-recurring investment into Cardiac Surgery and a Mobile Cardiac Catheter Laboratory sessions
(c)  Approval of Community Based Cardiology Outpatient Project -
Development of 4 Community Cardiology Centres in Grampian –
1 in Aberdeen, 2 in Aberdeenshire and 1 in Moray. This excludes
those centres already established in Turiff and Inverurie
-  £80k of capital investment to expand community cardiology outpatient facilities at Dr Gray’s Hospital in Elgin
-  Lease of Echocardiography Machine and Exercise Tolerance Test Machine to be used in the David Anderson Building in Aberdeen. Purchase of Resuscitation Equipment and minor refurbishment work in the David Anderson Building to make it into a community cardiology centre.
-  Appointment of a new Consultant Cardiologist, Dr Andrew Hannah,
to support the Community Cardiology Project.
-  Appointment of 2 Cardiac Technicians to support the Community Cardiology Project
-  Capital Purchase of 2 Vivid 3 Echocardiography Machines For use in 2 Aberdeenshire Community Cardiology Centres
-  £31,222 of recurring funding for GP Sessions. It assumes 40 GP sessions per annum for each of the 4 Community Cardiology Centres. Payment rates are still being finalised but a salaried GP would receive around £254 per session (2004/05 rates).
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(4)
cont / -  A further £15k will be required from NHS Grampian waiting time monies to make the funding package for GP sessions achievable across all 4 centres.
-  Total recurring funding of £5,328.66 is available per annum for nursing and administrative time in each of the Community Cardiology Centres. Increased funding has been set aside for the David Anderson building which will run on a more frequent basis and will include 2 new chest pain clinics per week.
(d)  Recurring funding for Cardiology Database Staff as advised by ISD and
the SEHD
Big Lottery Funded Projects
The following projects are funded by the Big Lottery Fund until 31st March 2006.
(e) Community Based Phase 3 Cardiac Rehabilitation Classes
(f) Heart Failure Nurse Project
There is sufficient scope within the CHD Strategy allocation to pick the costs of these projects up on a recurring basis from 1st April 2006. This will be subject to further discussion within the Project Board. The projects will be fully audited over the duration of the lottery funding and members of the project board will closely examine the results.
5. / CHD MCN Project Board Sub Groups update

Heart Failure Group: Chair - Dr Karen Simpson

Roberta Eunson gave a report on the Group’s progress. See attached Appendix 1. Whilst there was a great deal of positive feedback from the group, a geographical problem had been identified with the 2 Nurses working in the Shire. They have a huge geographical area to cover and a lot of their time was spent in driving long distances to patient’s homes. It was felt that this was not a good use of time. The Heart Failure Nurse for the City and Moray did not have this problem, but it was noted that although matters were fine at present there was no guarantee that their current system of working would be satisfactory in the future.
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(5) cont
(5) cont
(5) cont
(5) cont / Dr Jamie Hogg confirmed that the system was working well in Moray and there were no problems. The heart failure nurses were expected to progress to training up Practice Nurses.
The Chairman asked the Heart Failure Group to consider the points raised. The current situation for Aberdeenshire was clearly unsatisfactory and a solution to effectively use the skills of the (limited) CHF Nurses required. He suggested that this could be along the lines of cascade training. Dr James Black made some good suggestions on how to take this matter forward and he was to work along with the Heart Failure Subgroup to re-think this matter and report back to the next CHD Project Board. It was acknowledged that this could act as a model for Aberdeen and Moray in the future as required.
Heart Failure Awareness Study Day – 3 February 2005. Tony Collins circulated a programme of the day’s events. He reported that the object was to promote awareness of the heart failure nursing service. The day had obviously been a great success and congratulations to Karen Secombes and colleagues were made.

Cardiac Rehabilitation : Chair – Mr Robert Paton

Alastair Ramsay gave a progress report – see attached Appendix 2. In summary the Rehab group is making great progress. New Phase 4 clinics (eg Torry) are coming on stream, plans for instructor training well advanced and the post Cardiac Surgery Rehab service now recruiting with an aim to start in the near future.

Quality Assurance : Chair – Dr Stephen Lynch

Milne distributed a draft copy of the CHD Quality Assurance Framework Document. Although this was a generic template, from Lanarkshire, it was intended to use it as a model for the rest of Scotland. As it was unlikely that the document would change radically we could therefore start to use it as a model for our own service.
The 6 quality standards as mentioned in the last minute of 2 December 2004 were to be delegated to each of the CHD Sub Groups. Milne would update at future meetings.
Public Involvement Sub Group: Chair - Milne Weir
‘Learning from the Experiences of Patients and Carer’s.
Milne Weir and Roddy Wood reported that the public involvement workshops were going well. Patients and carer’s involved in phase 3 and phase 4 cardiac rehabilitation classes were being asked to describe their patient journeys, highlighting areas of good practice and areas that could be improved upon by service providers. They reported good verbal feedback from these sessions. Some people at stage 3 had obviously welcomed the opportunity to talk about their experience, fears etc. They had not always had the opportunity to talk in the stage 1 and stage 2 process.
Information from these workshops is currently being collated and will be summarised in a document called ‘Learning from the Experiences of Patients and Carer’s’. This document will be used to help with strategic planning for CHD services in Grampian and will also be used to inform and educate service providers.
The methodologies for capturing information i.e template and public involvement workshops, will be rolled out into CHPs so that further information can be gathered.
Fraserburgh Practical Health Project
The Fraserburgh Practical Health Project was now underway. There are 4 arms to this: – Food and Health, Physical Activity, Environment and Families and Communities.
Milne reported that he had visited Loch Pots Primary School on Monday 31 January and one of the open days. He saw Primary 5-7s. They enjoyed a healthy eating session of pineapple and other fruits. Some of the young people had also been visiting clubs to speak to older people about their project and give out the message.
Cardiology Community Cardiology Outpatient Project
Dr Metcalfe and Dr Black submitted papers outlining both general and specific proposals for community based cardiology centres across Grampian, in keeping with the aims of the MCN. See Appendix 3.
Aberdeenshire
Dr Metcalfe briefly outlined that it was intended to enhance the existing services at Inverurie and Turriff together with developing new services in Fraserburgh/Peterhead and Stonehaven. This would require a combined approach from the Aberdeenshire CHP and the MCN. The MCN could however provide technical resources (eg echo machines, treadmills and Holters), Technicians, Consultant input and funding for some GP specialist sessions. Obviously a lot of work was required to work this up but the document presented was aimed at outlining the first steps. A very useful meeting with Dr Liddell had already taken place and the aim was to have a worked up business case prepared as soon as possible in order to take advantage of possible Waiting List funds. It is not yet decided between Fraserburgh or Peterhead as the regional DTC.
It was proposed to start immediate specialised training of the GPs already involved in the Inverurie and Turriff service to enhance their skills and effectiveness. Thereafter similar training for the other centres will be commenced.
Dr Hannah has been employed to undertake DTC cardiology clinics and would rotate between Turriff, Fraserburgh/Peterhead and Stonehaven. Dr Walton is already undertaking clinics at Inverurie.
Aberdeen:
The Aberdeen DTC will be based in the David Anderson Building. A meeting with the operational staff has taken place and practicalities established. All parties were keen to start. It was proposed to initially introduce 2 additional chest pain clinics and a general cardiology clinic. Clinical Activity would then be progressively increased, for example the Nurse led CHF clinic. It was hoped that clinics would commence from May 2005. Concern was expressed that MCN did not become too dependent on the building as it was proposed that the facilities would be moved in about 2 years. However, the Chairman agreed that this was quite acceptable and that clinical activity could be relocated elsewhere if necessary. The only proviso being that for practical reasons it would probably have to be in one location.
In time it is likely that more involvement of GP specialists will occur.

Moray:

It was noted that Morayshire had different issues
Firstly the local Cardiologist, Dr Deepak Garg, is away in Vancouver at present on extended study leave and will return in July 2005. Meantime Dr Hannah, a Consultant Cardiologist, Dr Hassan Ali, a Staff Grade Cardiologist and a locum Consultant Physician, Dr Cumming, are filling his role. However it was acknowledged that when Dr Garg returns he will be skilled in cardiology but no longer able to undertake General Medicine duties. Furthermore it is no longer acceptable for single-handed Cardiologists to practice in isolation. The proposal was therefore to adapt Dr Grays into a major Diagnostic and Treatment Centre setting up a triage system for inpatients requiring cardiology care. Specialist GP colleagues and his role of undertaking cardiac intervention in Aberdeen enhanced could then support Dr Garg.
Refurbishment of the Cardiac Department in Dr Gray’s Hospital would cost £80,000 and would allow greater efficiency. Currently the treadmill, echo machine etc were all in the same room. This will be hopefully commissioned very shortly using funds provided from the MCN.
The core MCN group is to meet with Andrew Fowlie and Jamie Hogg in the near future regarding these issues.
General:
In addition to the specialised training above, GPs were to be encouraged in taking part in a Cardiology Fellowship education programme. Negotiations with Pfizer were ongoing but it is hoped that a bursary of £12,000 to train 12 GPs will be made available. A similar scheme for Diabetes has been very successful.
Dr Metcalfe was confident that the 26-week cardiology waiting times could be achieved by the measures being taken by the MCN notably the specialist training of GPs to provide intermediate care, the increase in general capacity (5 new clinics/week) and involving GPs with vetting referral letters. / JB / KS
MW
MW / RW
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6. /

BNP Testing

It was noted that Dr Metcalfe was arranging a meeting, via the MCN Secretary, to discuss the introduction of BNP tests. Many patients could have CHF excluded by using this “stick test” which would potentially be considerably cheaper and potentially more accessible than echocardiography. Concerns were expressed at the test’s reliability. (Also one member had heard that the cost of the test was £21 not £14). These issues obviously need to be taken to the expert biochemists for advice.
It was noted that evidence as to its usefulness would be needed before funding could be sought. Following the meeting, the Chairman would look at the formulation of a business case.
It was noted that the NHS had a Diagnostic Group Chaired by Julie Fletcher, which might be a useful contact. / CG
7. / Meetings with CHP Teams/Patient Pathway Workshops
Following the success of the Aberdeen workshop, Milne reported that further patient pathway workshops were going to be arranged in Aberdeenshire and Moray to look at Palpitation and Chest Pain.
8. / Cardiac Catheter Laboratory Proposed Development – update
Milne reported that the North of Scotland health intelligence teams were actively working on this project and that matters were progressing in terms of agreeing a common methodology and undertaking a validation exercise of ISD data against local data. Dates for this workshop will be agreed in April 2005 once this exercise has been completed.
Meetings will be ongoing locally to decide on where the 2nd catheter laboratory should be located on the ARI site. Confusion has now arisen as a new plan for combined new AMAU, MRI and cardiac catheter facility has been produced. Whilst laudable the Chairman was skeptical that this could be achieved within a short time scale and that it would prevent progression of the much needed and enhanced cardiac catheterisation facility. Mr Carey was of the opinion however that this was realistic, much needed and in his view NHSG’s most important priority.
The existing laboratory was 9 years and 10 months old and will cease to be supported by the manufacturers after 10 years. The Chairman pointed out that running it for a maximum of a further year could be contemplated but discussion will need to take place as to its ongoing acceptability for PCI patients. The equipment will undoubtedly become more unreliable and if it were to break down in the middle of a PCI case it could result in a patient death.
It was noted that the introduction of the mobile cardiac catheter laboratory on site at ARI since November last year was successful in meeting the new waiting time targets. It would remain on site until a second more permanent cardiac catheter laboratory was put in place.
Milne mentioned high resolution CT angiography as it has attractions of being non-invasive and being quicker. The manufacturers are going to do an evening presentation and then following day a workshop on this subject.
The Chairman noted that if we were looking to a 3rd laboratory then CT angiography might be the way forward. Otherwise it was not a practical option for Aberdeen as there were still doubts about its true clinical utility and the continued expansion of coronary intervention and electro-physiology requiring more than one cath lab.
9. / AOCB
Ministerial Visit 16 February 2005 – Milne reported that there would be a visit from Mr Andrew Kerr, Minister for Health and Social Care on 16 February to look at the use of the mobile cath laboratory. It was suggested that his visit timetable should be well planned so best use of the visit was made to highlight the positive work being undertaken in Grampian.
Patient Hospital Hotel for Island Patients – a suggestion was made for a hospital hotel with addition capacity for patient relatives to be considered for cardiac patients from Orkney and Shetland. It was noted that whilst this was a good concept it could not be realistically considered at present. Island patients would have to continue using the British Red Cross service. Milne, however, would liase with Mr El Shafei with respect to this.
Risk Factor Guidelines – the CHD MCN has taken the lead in an attempt to create uniform guidelines across the whole service with respect to cardiovascular risk factors. The agreed guideline for the use of “statins” is nearly complete and the proposal is to move onto diabetes, hypertension and general primary prevention policy. Gillian Stewart has already produced an excellent basis for the latter.
10. / Dates of Next Meetings
Thursday 7th April 2005 at 5:30pm in Summerfield House
Thursday 2nd June 2005 at 5:30pm in Summerfield House
Thursday 4th August 2005 at 5:30pm in Summerfield House
Sandwiches would be provided

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