1. North of Scotland Planning Group North of Scotland Planning Group North of Scotland Cardiac Services …so what are the challenges? Mr Hussein El-Shafei Regional Clinical Lead 30 th October 2012

2. North of Scotland Planning Group North of Scotland Planning Group Why Are We Meeting Today? ?

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4. North of Scotland Planning Group North of Scotland Planning Group Ageing Population Ageing Population Higher Patient Expectations Higher Patient Expectations Super Specialisation Super Specialisation New Therapeutic Modalities New Therapeutic Modalities Expensive Technology Expensive Technology Healthcare Challenges

5. North of Scotland Planning Group North of Scotland Planning Group Global Recession

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7. North of Scotland Planning Group North of Scotland Planning Group 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

8. North of Scotland Planning Group North of Scotland Planning Group Remote Areas

9. North of Scotland Planning Group North of Scotland Planning Group 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

10. North of Scotland Planning Group North of Scotland Planning Group 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

11. North of Scotland Planning Group North of Scotland Planning Group 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

12. North of Scotland Planning Group North of Scotland Planning Group 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

13. North of Scotland Planning Group North of Scotland Planning Group 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

14. North of Scotland Planning Group North of Scotland Planning Group Regional Delivery Plan, Cardiac Services(2011-15) What would a North of Scotland model for delivering cardiac services look like? IT ehealth support Medical records Information management RRT ARI Tertiary Centre Complex Cardiology,P PCI, EP Cardiac Surgery Teaching Community Hospitals RGHs GPwsi Specialist nurses Heart failure #Cardiac Rehab ETT, Echo Ninewells Dundee DGH Cardiology PPCI,EP Teaching Community+ Practice Nursing teams Monitor Heart Manual HF CR Intermediate care ACP Raigmore Inverness DGH Cardiology PPCI,EP Teaching

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16. North of Scotland Planning Group North of Scotland Planning Group 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.

17. North of Scotland Planning Group North of Scotland Planning Group Glasgow Herald 27 th 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.

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19. North of Scotland Planning Group North of Scotland Planning Group 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

20. North of Scotland Planning Group North of Scotland Planning Group Predicted Population Structure -UK

21. North of Scotland Planning Group North of Scotland Planning Group Thrombolysis Tissue Plasminogen activator

22. North of Scotland Planning Group North of Scotland Planning Group “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.

23. North of Scotland Planning Group North of Scotland Planning Group 30-60 min drive times

24. North of Scotland Planning Group North of Scotland Planning Group 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

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27. North of Scotland Planning Group North of Scotland Planning Group Scotland at Last!

28. North of Scotland Planning Group North of Scotland Planning Group NEXT SHOW: MITRACLIP

29. North of Scotland Planning Group North of Scotland Planning Group Transportation

30. North of Scotland Planning Group North of Scotland Planning Group Transportation Gratitude to SAS for providing the excellent service we have. Communication between clinicians and SAS Education of crews Relatives Transportation Air Ambulance

31. North of Scotland Planning Group North of Scotland Planning Group Far Behind in Technology….

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33. North of Scotland Planning Group North of Scotland Planning Group Six Sigma and Flight Industry 6 Sigma = 3.4 error/Million CABG Mortality = 1.9% = 19,000 error/million

34. North of Scotland Planning Group North of Scotland Planning Group We re Fortunate

35. North of Scotland Planning Group North of Scotland Planning Group Heathcare for ALL

36. North of Scotland Planning Group North of Scotland Planning Group Patient’s CHOICE

37. North of Scotland Planning Group North of Scotland Planning Group WORKFORCE PLANNING -Education -Development -Recruitment -Retention

38. North of Scotland Planning Group North of Scotland Planning Group It is the quality of our work that will please God,It is the quality of our work that will please God, And not the quantity and volume “And not the quantity and volume “ “Mahatma Gandhi“Mahatma Gandhi True…but you did not have 18 weekTrue…but you did not have 18 week Referral to Treatment Target !! Referral to Treatment Target !!

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40. North of Scotland Planning Group North of Scotland Planning Group 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

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42. North of Scotland Planning Group North of Scotland Planning Group Audit Scotland – February 2012 Key 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%

43. North of Scotland Planning Group North of Scotland Planning Group Audit Scotland- February 2012 Key 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

44. North of Scotland Planning Group North of Scotland Planning Group Audit Scotland – February 2012 Key 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

45. North of Scotland Planning Group North of Scotland Planning Group Audit Scotland – February 2012 Key Messages Recommendations -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

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47. North of Scotland Planning Group North of Scotland Planning Group Regional Planning Identify 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

48. North of Scotland Planning Group North of Scotland Planning Group Why Are We Meeting Today? 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

49. North of Scotland Planning Group North of Scotland Planning Group Why Are We Meeting Today? 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.

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51. North of Scotland Planning Group North of Scotland Planning Group 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