Coronary Revascularisation:

the DoH View

Dr Roger Boyle

National Director for Heart Disease

NSF StandardsStandard nine

“People with angina that is increasing in frequency or severity should be referred to a cardiologist urgently or, for those at greatest risk, as an emergency”

Standard ten

“ NHS Trusts should put in place hospital-wide systems of care so that patients with suspected or confirmed coronary heart disease receive timely and appropriate investigation and treatment to relieve their symptoms and reduce their risk of subsequent events”

National Service Framework

• Accepted– effectiveness of revascularisation– low rates in UK– inequity of access– history of under-investment

NSF and NHS Plan Targets

• Initial NSF target (March 2000) 3000 additional revascularisations by April 2002

• Second NHS Plan target (July 2000)6000 additional procedures by April 2003

• “Further targets will be set”!

NSF waiting time goals

• Referral by GP to specialist

assessment/consultant appointment:

two weeks maximum

• Prompt investigation and revascularisation

within three months of the decision to treat

Priorities and Planning Framework 2003-6

Improve access to services across the patient pathway and increase patient choice:– by achieving the two week wait standard for

Rapid Access Chest Pain Clinics; – by setting local targets to make progress to the

NSF goal of a 3 month maximum wait for angiography;

– by delivering maximum waits of 3 months for revascularisation by March 2005 or sooner.

Strategies for delivery• RACPC’s

– Target 150, 186 achieved– 71% seen within 2 weeks, Target 100%

• Catheter lab investment programme• National capacity reviews

– based on SMR adjusted targets

• Immediate revenue injection• Workforce development programme

Revenue invested in revascularisation

Year Non-recurrent

£m

Recurrent£m

Total£m

2000/2001 31 0 312001/2002 15 50 652002/2003 0 110.8 160.8

Capital schemes

• Over £300m for expansion– Expansion at James Cook, Bristol and Papworth

complete– Entirely new centre at Wolverhampton– Expansion at Blackpool, Liverpool, Manchester

(South and Central), Southampton, Sheffield, Leeds and Plymouth

• £80m for new catheter labs– plans for 86 new or replacement labs in train

Extending Patient Choice

• Total eligible since 1st July 2002– 4621

• Clinically eligible– 3298

• Exercised choice– 3183

• Opting for treatment elsewhere– 1531 have now been treated elsewhere

CABG waiting times in England

0

500

1000

1500

2000

2500

3000

Jun-9

8A

ug-98

Oct

-98

Dec

-98

Feb-

99A

pr-9

9Ju

n-99

Aug-

99O

ct-9

9D

ec-9

9Fe

b-00

Apr

-00

Jun-0

0A

ug-00

Oct

-00

Dec

-00

Feb-

01A

pr-0

1Ju

n-01

Aug-

01O

ct-0

1D

ec-0

1Fe

b-02

Apr

-02

Jun-0

2A

ug-02

Oct

-02

Num

ber

of p

atie

nts

wai

ting

12 month +9-11 month

CABG waiters in England (over 6 months)

0

500

1000

1500

2000

2500

April May June July Aug Sept Oct Nov

LeicesterWalsgraveBirminghamPapworthNottinghamN StaffsBristolSotonPlymouthOxfordBrightonSouth TeesS McrSheffieldFreemanLeedsHullCentral McrLiverpoolBlackpoolUCLHSt Mary'sSt George'sRoyal FreeRBHKingsHammersmithGuys' & St Thomas'BLT

Trends in waits for CABG

0

500

1000

1500

2000

2500

3000

April

May

June Ju

lyAug

Sept

OctNov Dec Ja

nFeb

Mar Apr Ju

n Jul

2002/3

Num

ber

of 6

mon

th w

aite

rs

Actual

Projected

Revascularisation waits(more than 6 months)

0

500

1000

1500

2000

2500

3000

April May June July Aug Sept Oct Nov

2002/3

Pat

ient

s w

aiti

ng m

ore

than

6

mon

ths

PCICABG

Revascularisation waits(all waiters)

0

2000

4000

6000

8000

10000

12000

April May June July Aug Sept Oct Nov

2002/3

Tot

al n

umbe

rs w

aiti

ng

PCICABG

NSF and NHS Plan Targets

• Initial NSF target (March 2000)3000 additional revascularisations by April 2002

achieved by April 2001

• Second NHS Plan target6000 additional procedures by April 2003

achieved by April 2002

NSF waiting time goals(for 2008)

• Referral by GP to specialist assessment/consultant appointment: two weeks maximum - achieved for 71%

• Prompt investigation and revascularisation

within three months of the decision to treat

- angio waits to be monitored from April

- 3 month wait for revascularisation in sight

Remaining challenges for PCI

• Equity of access

• Ratio of PCI to CABG

• Revising the activity target

• Primary PCI

• Eluting stents

• Staffing requirements to handle growth

CAGB rate versus SMR for CHD by StHA in 2000/1

100

200

300

400

500

600

700

800

900

80 90 100 110 120 130SMR

Ra

te p

er m

illi

on

(Aggregated up from DHA data)

Correlation coefficient 0.6, p=0.0004

Y=3.732x+73.312

PCI rate versus SMR for CHD by DHA in 2000/1

0

200

400

600

800

1000

1200

50 70 90 110 130 150

SMR

Rat

e pe

r m

illi

on

p=NS

Data from HES (FCEs in England only)

15,00017,00019,00021,00023,00025,00027,00029,00031,000

PCICABG

Ratio 1.3 : 1

Data from HES (FCEs in England only)

15,000

17,000

19,000

21,000

23,000

25,000

27,000

29,000

31,000

1998/1999 1999/2000 2000/2001 2001/2002

PCICABG

Ratio 1.3 : 1Efficiency gains

17%

19%

Primary PCI - how, where and when?

• Better than pre-hospital thrombolysis?

• Volume affects outcome

• Ambulance triage?

• Rescue and thrombolysis-ineligible cases only or all?

• Is it really cost-effective?

• How does it rank with other priorities?

Expansion of PCI - one scenario

• Current activity (England)– 30,000

• Additional activity to achieve 1000 pmp– 20,000

• Incidence of STEMI (MINAP)– 24,000

• Total activity needed (?)– 74,000 or an increase of 147%