north of scotland cardiac services …so what are the challenges?

North of ScotlandPlanning Group


North of Scotland Cardiac Services

…so what are the challenges?

Mr Hussein El-Shafei

Regional Clinical Lead

30th October 2012



Why Are We Meeting Today?

?



•Ageing PopulationAgeing Population

•Higher Patient ExpectationsHigher Patient Expectations

•Super SpecialisationSuper Specialisation

•New Therapeutic ModalitiesNew Therapeutic Modalities

•Expensive TechnologyExpensive Technology

Healthcare Challenges



Global RecessionGlobal Recession



Population 1,282,758 (25% Scottish population), 66% Scottish Land Mass...

To grow 2.5% to 1,335,500 (2015), 4.9% to 1366,500(2020) 8persons/sq Km-2400p/Sq Km



Remote Areas



• Success story: Death rate from CHD more than halved since 1995, less benefit for those in the most deprived 15% Postcodes.

• Still 12,000 people/Year have heart attacks.• Still 140,000 people who have had heart attacks• 260,000 people with angina• 60,000 people with heart failure• More premature death in Men (50%), and in

women (90%) than SW England• Socio-economic, and Financial Cost

CHD in SCOTLAND



• BETTER HEART DISEASE AND STROKE CARE ACTION PLAN ; CHD Improvement Management Programm “NHS QIS”; and Healthcare Quality Strategy, (2009)

• Broadened the spectrum CHD, to other forms including Heart Failure, Valve disease, Inherited heart disease,etc.

• Waiting Time 18 Weeks (R To T) by December2011

Improvement of Services



NOT ONLY CHD

• Heart Failure: 60,000-100,000 Patients in Scotland, screening, impact of Nurse –led Service

• EP Therapies

• Rehabilitation

• Adult Congenital Heart disease

• Inherited Conditions, Sudden Death

• Cardiac surgery



Improving the service needed for people with established heart disease; access to New developments, technologies and treatments

• More emphasis on Primary prevention of heart disease• To tackle unacceptable health inequalities “Equitable

Access”• Dealing with “Rurality Nature” • Sustainability of services • Financial constraints• Dynamic (Response to change) provision of planning and

monitoring of services, capacity, workforce and quality

CHALLENGES for NOS Cardiac Services



• Building on (Already achieved):• -SLAs, Planning ,Delivery, Education, Networking..

- Interventional services in NHS Tayside, PPCI 24/7 in Ninewells

- Interventional services NHS Highlands, working towards PPCI 24/7.

- New Cath Lab ..PPCI 24/7 in NHSG

- EPS in NOS, ICDs in NHST and NHSH repatriation of CRT to NHSG from Gla and Edinb.

- CT angio , Raigmore

- Investment in workforce.. New consultants cardiologist posts in NHSG (1EPS)=10, NHSH=4,NHST=9.5

-Well North....

NOS Cardiac Services... Achieved



Regional Delivery Plan , Cardiac Services(2011-15)What would a North of Scotland model for delivering cardiac

services look like?

IT ehealth support

Medical recordsInformation management

RRT

ARITertiary Centre

ComplexCardiology,P

PCI, EPCardiac Surgery

Teaching

Community HospitalsRGHsGPwsi

Specialist nursesHeart failure

#Cardiac RehabETT, Echo

NinewellsDundee DGHCardiology

PPCI,EPTeaching

Community+Practice

Nursing teamsMonitor

Heart ManualHF CR

Intermediate careACP

RaigmoreInverness

DGHCardiology

PPCI,EPTeaching



Glasgow Herald 23rd September 2012

• Professor Oldroyd said heart-attack patients in Aberdeen are being treated in line with the latest European recommendations, while in the west of Scotland and Edinburgh they are not. Angioplasties – when a stent is placed in a blocked artery – are seen as one of the best treatments for heart-attack patients.



Glasgow Herald 27th September 2012

• Heart specialists at odds over Scots coronary care

Published on 27 September 2012

Helen Puttick

“DISPUTES between cardiologists are delaying access to new medicines and treatments for heart patients”, a key Government adviser has claimed

• Speaking exclusively to The Herald, Dr Barry Vallance said it was not controlling costs that stopped patients getting access to new treatments, in a robust defence of the health service's record in coronary care.



Ageing Population In Scotland

• Younger people decreasing, older people increasing

• Population continues to age; 50% increase in over 60s by 2033

• Age-related public expenditure predicted to increase from 20.1% of GDP(2007) to 26.6% (2057)

• Urban/rural distribution not even Over 60s 16% up to 21% in rural areas



Predicted Population Structure -UK



Thrombolysis Tissue Plasminogen activator



“Drip and Ship”

• It is generally regarded that patients with AMI will benefit more from PPCI than thrombolysis is delay to opening artery is <120 mins in total.

• Therefore for patients outside of this transit time patients should receive PHT and be immediately transferred to a PCI Centre.

• The 30% who show no evidence of reperfusion will be immediately offered PCI rescue.



30-60 min drive times



• ORT (Optimal Reperfusion Therapy)...PPCI- PHT( Pre-Hospital Thrombolysis) , 33% no reperfusion hence “Drip and Ship”. “ Sign Guideline 93.9, QIS”....Transport implication

• TAVI(Trans Aortic Valve Implantation): 16-30/million... Now available in Scotland (Oct.12)

• Expansion in EPS: ICD, CRT, AF Ablation (cath/surgery), VADs

• CT-Angio• Minimally Invasive Cardiac Surgery• Telehealth, ehealth

New Treatments/ Technologies and developments



Scotland at Last!



NEXT SHOW: MITRACLIP



Transportation



Transportation

• Gratitude to SAS for providing the excellent service we have.

• Communication between clinicians and SAS

• Education of crews

• Relatives Transportation

• Air Ambulance



Far Behind in Technology….



Six Sigma and Flight Industry

• 6 Sigma = 3.4 error/Million

• CABG Mortality = 1.9%

= 19,000 error/million



We re Fortunate



Heathcare for ALL



Patient’s CHOICE



WORKFORCE PLANNING-Education

-Development-Recruitment-Retention


North of ScotlandPlanning Group• It is the quality of our work that will It is the quality of our work that will

please God ,please God ,• And not the quantity and volume “And not the quantity and volume “

• ““Mahatma GandhiMahatma Gandhi

• True…but you did not have 18 week True…but you did not have 18 week • Referral to Treatment Target Referral to Treatment Target !! !!



Catches in collecting information for WT

• Replace the 4 target with one target ..underway

• Flexibility within the system?

- MDT Cases..

-Direct admission cases (No Surg OPC)

- Unsuccessful PCI cases



Audit Scotland – February 2012Key Messages

• Reduction in death rate from all heart disease (40% over 11 years), from 216/100,000 to 129/100,000

• Reduction in death from MI (50% over 11 years , from 104.7 to 55.7 deaths per 100,000

• Reduction in New cases of CHD, and reduction of MIs from 7, 326(2000/1) to 4,577 (2009/10)

• Improved 30 day survival after Em admission with MI 83.1% to 89%, and HF 82.4 to 85.5%



Audit Scotland- February 2012Key Messages

• National targets of WT: Lack of systems to capture information for the overall wait, WT are instead reported four 4 groups , RACPC, OPC, Angio, surgery:

• All NHS Boards met quarterly WTT for the quarter ending Sept 2011.

• New 18 Wks Referral to treatment replaces the four cardiac targets from Dec 2012



Audit Scotland – February 2012Key Messages

• Rolling over the Keep Well Programme to the 40-64 year olds in most deprived areas (£35 Million), and to monitor outcome 2012-15

• Scope to have efficiency savings of £ 4.4 million (Less expensive tests,LOS, prescribing, procurement)

• Variations between Boards providing less expensive non-invasive and rates of more invasive testing (Potential saving of 0.5 to 0.8 million0non



Audit Scotland – February 2012Key MessagesRecommendations

-Evidence base to identify priorities of spending for Scotland

-Accurate information on activity, workforce, cost and quality should be available and should be shared nationally

-NHS Boards should work with Regional Planning Groups to examine variation in Cardiology services to ensure services are provided in the most efficient way and identify scope for improving efficiency



Regional PlanningIdentify

commonalities, save duplication while

facilitating planning.. All virtues of

NETWORKING Optimization of TRANSPORT

strategies with (SAS) , Remote and Rural,

across board Improvement of WORKFORCE

PLANNING and utilization,

development and training

Harness of the LINK between local MCNs

role and national strategies and targets

Regional DELIVERY PLANS

WORKING TOGETHER... Better efficiency ..WTs

CO-ORDINATION in the introduction of service developments; new technology




• No tight agenda• Opportunity to explore together the best way

forward to improve level of communication and networking between various areas in the region

• Awareness that you as a decision making individuals and organizations need to do more work to address the challenges that we are facing now and in the future




We may succeed to initiate and agree on achievable and practical actions of collaboration that can improve our services and effect efficiency savings

Invitation to you to participate in shaping the future of an efficient , modernized and sustainable service for the management of cardiac disease in the North of Scotland.



CONCLUSION

• The main challenges that faces healthcare providers are demographic, technological and financial.

• The need for collecting the right amount and level of information is vital for any current or future improvement in healthcare

• The improved and modernized communication and networking between various areas in the healthcare system is essential for raising the quality of care, cost savings and sustainability

north of scotland cardiac services …so what are the challenges?

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