26th January

SESSION XIV – DEBATE

DGH vs Tertiary intervention –

Is there really a conflict?

Department of Health Perspective

Roger Boyle

No conflict of interest to declare

DGH cardiologist Tertiary centre cardiologist

Cardiac surgeons

Cardiology in the district hospital.Report of a working group of the British Cardiac SocietyBr Heart J. 1987; 537-546

“The district cardiologist may wish to maintain skills by participating in catheter sessions….”

A report of a working group of the British CardiacSociety: cardiology in the district hospital.Br Heart J. 1994; 72: 303-308

“It is becoming commonplace for district hospitals to develop their owncatheterisation facilities…………..”

BCS Council Meeting circa 1994

Statement by the Council of the British CardiacSociety. Strategic planning for cardiac servicesand the internal market: role of catheterisationlaboratories in district general hospitals.Br Heart J. 1994; 71: 110-112

DGH cardiologists should be offered specific sessions in tertiary labs

Some DGHs that are geographically disadvantaged might developtheir own labs

Over time, DGH labs would become the norm!!!!!!!!!

BCS Working Group:The changing interface between district hospitalcardiology and the major cardiac centresHeart 1997; 78: 519-523

Main conclusions

• The establishment of new cardiac catheterisation laboratories in DGHs remote from a major centre should be encouraged provided the workload is adequate to ensure efficient use of the facility

• Cardiologists working in districts close to a major centre should be encouraged to catheterise their patients at the centre

UK Centres - 2005

52 52 53 54 54 5358 61 63 66 64 64

738377

87

6568

83

0

20

40

60

80

10019

91

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

No.Centres

PCI Angio only

2005 data: Ludman

England - Revascularisation - Numbers - CABG & PCI 1999/2000-2004/05 (Source: DH Returns)

0

10000

20000

30000

40000

50000

60000

70000

80000

1999-2000 2000-2001 2001-2002 2002-2003 2003-2004 2004-2005estimate

CABG

PCI

Total

Revascularisation trends

Rate per million in England

0

200

400

600

800

1000

1200

1400

1600

1989

/90

1990

/91

1991

/92

1992

/93

1993

/94

1994

/95

1995

/96

1996

/97

1997

/98

1998

/99

1999

/00

2000

/01

2001

/02

2002

/03

2003

/04

2004

/05

2005

/06

CABG

PCI

Total

Angiography waiters from April 2005

0

5,000

10,000

15,000

20,000

25,000

April

May

June Ju

ly

Augus

t

Septe

mbe

r

Octob

er

Novem

ber

Decem

ber

Janu

ary

Febru

ary

Mar

chApr

ilM

ayJu

ne July

Augus

t

Septe

mbe

r

Octob

er

Novem

ber

9+

08-Sep

07-Aug

06-Jul

05-Jun

04-May

03-Apr

02-Mar

01-Feb

0-1

PCI waiters by length of wait April 2002 onwards

0

1,000

2,000

3,000

4,000

5,000

6,000

Apr Jul

OctJa

nApr Ju

lOct

Jan

Apr Jul

OctJa

nApr Ju

lOct

Jan

Apr Jul

Oct

9 to 12

6 to 9

3 to 5

0 to 3

2002/3 2003/4 2004/5 2005/6 2006/7

Southampton – November 2006

SEPHO Revascularisation Model - Version 5 - Rates pmp

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

Rate pmp 2003/4

Rate pmp 2015 Model

1900 pmp

2200 pmp

2500 pmp

83

87

PCI centres

Angiography onlyCentres

2005

‘A discussion of the drugs administered in a case of coronary thrombosis is not relevant here – but for pain relief morphine is often given by an attending doctor or on arrival at hospital….the patient should not be questioned unduly or in any way alarmed.’

1970

Heart Attack: Progress Since the NSF

• Percentage of patients treated within 30 minutes of arrival at hospital rose from 38% to 83%

• Paramedics trained to assess, diagnose and provide thrombolysis

• Percentage of patients treated within 60 minutes of a call for help rose from 30% to 65%

• Pilot schemes set up to test feasibility of primary angioplasty in the NHS

Reperfusion treatment 2003-6

0

10

20

30

40

50

60

70

80

90

100

2003 2004 2005 2006

In hospital lysis

Prehospital lysis

PPCI

12.6%

14.4%

%

[plus patients in NIAP not yet transferred~ 2.5%]

Access to PPCI

• 37/68 English & Welsh hospitals with interventional facilities on site perform primary angioplasty

• 14/37 provide an internal service only– Only 4 provide 24/7, the rest lab hours or ‘occasional’

• 23/37 offered a service to other hospitals– Reporting that they provided this to 78 hospitals

– NB only 42 non interventional hospitals said they received a routine PPCI service, suggesting that service to other hospitals might be irregular / occasional

James Cook - Friarage

Leeds- SJUH- Bradford

East London- R London- Whipps X- King George- Oldchurch- Homerton- Newham

Leeds- SJUH- Bradford

SE London-Lewisham-Bromley-Sidcup-Mayday

Manchester (2)-North Mcr-Salford-Stockport-Tameside-Trafford

NW London (3)-Hammersmith-W Middlesex-Ealing-Charing X-St Mary’s-Northwick-Hillingdon-Harefield-Brompton-Hemel

Exeter

Trust Catchment Areas

Secondary - Acute MI Tertiary - CABG

No. of Trusts 153 28

Ave Pop Served 321,000 1.7 million

Largest 787,000 3.2 million

Smallest 104,000 816,000

Acute MI Catchments Tertiary CABG Catchments

Conclusion

• District hospital angiography has improved access to care and the capacity is needed

• Still a great deal of unmet need particularly in the North• We are a long way from providing a comprehensive

PPCI service at the present• Many places are ‘dabbling’• We need a comprehensive strategy within each network

with formal involvement of the ambulance service• No reason to exclude DGHs from providing this but the

rota requirements are onerous