Cardiac Catheterisation Facilities

Development of

Cardiac Catheterisation Facilities

in the North of Scotland

Business Case

May2006

Contents

Developing Cardiac Catheterisation Facilities in the North of Scotland

1.Executive Summary

This business case seeks approval from NHS Grampian, NHS Highland, NHS Orkney, NHS Shetland and NHS Tayside (NHS Tayside is asked to support this business case in the context of the Electrophysiology service only) to expand cardiac catheterisation capacity in the North of Scotland by 2010/11 through

The business case is set within the strategic context of matching diagnostic and interventional cardiac catheter laboratory capacity in the North of Scotland with projected demand to 2010/11. It is consistent with the recommendations made in the “Capacity Review for Coronary Heart Disease Services – Angiography and Cardiac Revascularisation” published in June 2004, and the Coronary Heart Disease and Stroke Strategy for Scotland published in October 2002. The key recommendations of the capacity review report are outlined below:

The North of Scotland Cardiac Services Sub Group organised two planning workshops (the first in November 2004 and the second in August 2005) to look at the development of cardiac catheterisation facilities in the North of Scotland. It set out develop a regional strategyfor expanding cardiac catheter laboratory capacity in order to meet nationally agreed waiting time guarantees set out in ‘Fair to All, Personal to Each’.The 2nd planning workshop in August 2005 was underpinned by detailed activity analysis and demographic profiling which resulted in a preferred option being identified. A report on the workshops was submitted to the North of Scotland Planning Group on 30th September 2005. A copy of the report is set out in Appendix one. The North of Scotland Planning Group noted the contents of the report and agreed that a business case should be produced by the end of March 2006. This approach to regional planning was highly commended by the National Advisory Group on Coronary Heart Disease (CHD) in December 2005.

“Regional Planning groups will establish the volume of service provision needed across the region for each specific condition based on advice from the National Advisory Group for Coronary Heart Disease. Once that has been agreed, the cost of each NHS Board’s activity will be calculated, and the Board will then enter into a binding agreement on its contribution to the total cost of that regional service. It is helpful that HDL(2002)10 acknowledges the need for clear links between the regional planning groups and managed clinical networks”.

(CHD/and Stroke Strategy for Scotland published in October 2002)

There are significant clinical gains that would result from the approval of this business case for NHS Boards and CHD Managed Clinical Networks in the North of Scotland. In summary it provides the following clinical gains.

a)The ability to maximise clinical skills and expertise across the North of Scotland

b) To provide safe and effective services to achieving high standards and

improving quality for patients

b)The ability to deliver national waiting time guarantees set out in ‘Fair to All,

Personal to Each’.

d)To cope with a predicted increase in demand for diagnostic and interventional

cardiacprocedures driven by several factors, such as demographics, changes

in clinical practice, the introduction of troponin testing and reduction in waiting

time guarantees

The business case is guided by recommendations made by a Joint Working Group on Coronary Angioplasty of the British Cardiac Society (BCS) and British Cardiovascular Intervention Society (BCIS) The Joint working group set out indicators relevant to the delivery of a quality interventional cardiology service, the means by which these indicators might be assessed, and the training required for those who will become interventional cardiologists in the future.

A long list of options was prepared and reviewed during the process and five short list options were considered as follows:

Extending the working day to 3 sessions was considered but discounted at this stage due to a number of factors – see section 7.1.

The option appraisal considered the optimum development of cardiac catheter laboratory facilities in the North of Scotland over the next 5 years. The preferred option was identified asoption Dproviding the clinical gains outlined above.

Capital andrevenue costs by NHS Board are outlined in pages 41 to 44. This business case seeks approval tothe capital and revenue costs outlined on these pages.

2.Introduction

2.1 Background

This business case seeks approval from NHS Grampian, NHS Highland, NHS Orkney, NHS Shetland and NHS Tayside (NHS Tayside is asked to support this business case in the context of the Electrophysiology service only) to expand cardiac catheterisation capacity in the North of Scotland by 2010 through

The last few years has seen a large growth in diagnostic and interventional cardiac procedures driven by several factors, such as demographics, changes in clinical practice, the introduction of troponin testing and reduction in waiting time guarantees. As a consequence existing cardiac catheter laboratory facilities in the North of Scotland are reaching the end of their useful lives and were recognised to be increasingly unreliable and unable to cope with increasing demand. The business case is set within the strategic context of matching diagnostic and interventional cardiac catheter laboratory capacity in the North of Scotland with projected demand to 2015. It follows on from detailed activity analysis and demographic profilingundertaken by the North of Scotland Cardiac Services Sub Group.The business casemakes reference to therecommendations made in the “Capacity Review for Coronary Heart Disease Services – Angiography and Cardiac Revascularisation” published in June 2004, and the Coronary Heart Disease and Stroke Strategy for Scotland published in October 2002.

2.2 Evolution of the Project

The North of Scotland Cardiac Services Sub Group organised two planning workshops (the first in November 2004 and the second in August 2005) to look at the development of cardiac catheterisation facilities in the North of Scotland. It set out developa regional strategyfor expandingcardiac catheter laboratory capacity in order to meet nationally agreed waiting time guarantees set out in ‘Fair to All, Personal to Each’ – see overleaf

‘By the end of 2007, the target is for all patients to have received both angiography and revascularisation (PCI and CABG) intervention within 16weeks’

The current waiting time is 8 weeks for angiography and 18 weeks for PCI and CABG.

The workshops were well attended by clinical and non-clinical staff from NHS Boards in the North of Scotland (with the exclusion of the Western Isles who send referrals to Glasgow and Edinburgh). The 2nd planning workshop in August 2005 was underpinned by detailed activity analysis, projections and demographic profiling which resulted in a preferred option being identified.A report on the workshops was submitted to the North of Scotland Planning Group on 30th September 2005. A copy of the report is set out in Appendix One. The North of Scotland Planning Group noted the contents of the report and agreed that a business case should be produced by the end of March 2006.

This approach to regional planning was highly commended by the National Advisory Group onCoronary Heart Disease (CHD) in December 2005.

2.3 Strategic Objectives

The strategic objectives of the project are:

• To provide services locally to support local communities

• To provide safe and effective services so achieving high standards and improving quality

• To provide sustainable services

• To provide quick access to treatment

• To reflect effective planning and use of resources

2.4 Clinical Needs

NHS Scotland published the Capacity Review for Coronary Heart Disease Services – Angiography and Cardiac Revascularisation in June 2004. Outlined below is a summary of the recommendations made in the final report

The clinical benefits of Percutaneous Coronary Intervention (PCI)as an established and effective therapy for a defined group of patients with coronary artery disease are set out inAppendix Two.

2.5 Proposed Outcomes

• To improve local access to services

• To improve the timeliness of treatment for patients

• To cope with a predicted increase in demand for diagnostic and interventional cardiac procedures resulting from new waiting times, improvements in technology, better detection of Acute Coronary Syndrome and an increase in the ageing population.
• To increase progressively the number of revascularisation procedures being undertaken per million population in line with the CHD and Stroke Strategy for Scotland

2.6 Health Profile in the North of Scotland

2.7 Regional Planning in the North of Scotland

The North of Scotland Cardiac Services Sub Group is committed to developing a regional strategy for cardiac services. This is consistent with recommendations set out in the CHD and Stroke Strategy Report and NHS HDL(2003)39 Tertiary / Specialist Services – Capital Developments – see statements below

“Regional Planning groups will establish the volume of service provision needed across the region for each specific condition based on advice from the National Advisory Group for Coronary Heart Disease. Once that has been agreed, the cost of each NHS Board’s activity will be calculated, and the Board will then enter into a binding agreement on its contribution to the total cost of that regional service. It is helpful that HDL(2002)10 acknowledges the need for clear links between the regional planning groups and managed clinical networks”.

(CHD/and Stroke Strategy for Scotland published in October 2002)

“When a new development is planned, and investment is required, all NHS Board areas which use, or will use, these services, are expected to contribute both revenue and capital funds, on an agreed shared basis. NHS Board areas who host these types of services have not been allocated capital or revenue, to specifically support such developments. Conversely, it is essential Boards providing these services embark upon collective discussions with all interested parties to ensure agreement, throughout the planning process, is achieved regarding the financial expectations of the proposed development”.

NHS HDL(2003)39 Tertiary / Specialist Services – Capital Developments

3.Service Description

Existing cardiac catheter laboratory facilities in the North of Scotland are reaching the end of their useful lives and are recognised to be increasingly unreliable and unable to cope with increasing demand.

3.1 Aberdeen Royal Infirmary

3.1.1 Service Overview

Aberdeen Royal Infirmary has one dedicated cardiac catheter laboratory which is now 10 years old and requires regular maintenance. Due to its age there is increasing down time and this places significant pressure on patient care. In order to achieve and maintain nationally agreed guarantee waiting times, a mobile cardiac catheter laboratory was added in November 2004. It operates 3 days a week, 48 weeks per annum, with additional days purchased when required. This is a short term solution and is financially unviable in the medium to long term.

The existing cardiac catheter laboratory at Aberdeen Royal Infirmary undertakes a range of activities including

• Left and right heart catheterisation;
• Insertion of pacemakers;
• Diagnostic angiogram;
• Left and right heart catheterisation;
• Investigation and treatment of adult congenital heart disease;
• Electrophysiological studies – investigation and treatment;
• ICD and Cardiac resynchronisation device activity
• Heart failure investigation and myocardial biopsy;
• Percutaneous Coronary Intervention (PCI).

Appendix Three (pg 64) sets out definitions of cardiac catheterisation procedures outlined above.

3.1.2 Referral Patterns

The cardiac catheter laboratory at Aberdeen Royal Infirmary takes referrals from Grampian, Highland, Shetland, and Orkney. A small number of referrals are received for electrophysiology from Tayside. The receiving population is therefore 790,594.

3.1.3Number of Cardiac Catheter Laboratory Sessions per week

The existing cardiac catheter laboratory at Aberdeen Royal Infirmary operates 10 planned sessions per week, 48 weeks per annum. The 10 planned sessions per week are routinely exceeded due to workload (at least once a week) An on-call team is available 24 hours a day, 7 days a week. The Consultant Cardiologists operate a 1:6 on-call rota and do not have any commitments to the general medicine within Aberdeen Royal Infirmary.

The modular cardiac catheter laboratory operates 6 sessions per week (3 days), 48 weeks per annum, with additional days purchased when required.

3.1.4 Workforce Profile

There are 5 Consultant Cardiologists, 1 Senior Lecturer and 5 Specialist Registrars based at Aberdeen Royal Infirmary. There is 1 Consultant Cardiologist based at Dr Gray’s Hospital in Elgin, who has a full day in the cardiac catheter laboratory at Aberdeen Royal Infirmary. There are no vacant posts.

3.1.5 Activity

The total activity of the cardiac catheter laboratory at Aberdeen Royal Infirmary for the three year period 2003/04 to 2005/06 (first 6 mths) is outlined below in table one:

Table One Cardiac Catheter Laboratory Activity at ARI 2003/04 to

2005/06 (first 6 mths)

Table Two highlights the significant growth in PCI activity by NHS Board area over the last three years within the cardiac catheter laboratory at Aberdeen Royal Infirmary.

Table Two PCI Activity at ARI by NHS Board area 2003/04 to

2005/06 (first 6 mths)

94% of the 602 PCI procedures undertaken during 2004/05 had stents implanted.An average of 1.6 stents is used during each PCI procedure. The increasing use of drug eluting stents for a defined group of patients (predicted 30% of all PCI procedures as per NoSDrug Eluting Stent paper – see Appendix four) will increase the overall cost of a PCI procedure.

3.2 RaigmoreHospital

3.2.1 Service Overview

RaigmoreHospital has one catheter laboratory which is now 9.5 years old. The cardiology service shares the catheter laboratory with the radiology service. Like Aberdeen Royal Infirmary, due to its age, there is increasing down time in the catheter laboratory at RaigmoreHospitaland this places significant pressure on patient care. There is no planned out of hour’s service for cardiac proceduresin the catheter laboratory.

The catheter laboratory at RaigmoreHospital undertakes a range of cardiac activities including

• Insertion of pacemakers;
• Diagnostic angiogram;
• Left and right heart catheterisation;

3.2.2 Referral Patterns

The catheter laboratory at RaigmoreHospitaltakes the majority of its referrals from NHS Highland.