Coronary Revascularisation: the DoH View Dr Roger Boyle National Director for Heart Disease

NSF Standards Standard 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 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

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

CABG waiters in England (over 6 months)

Trends in waits for CABG Actual Projected

Revascularisation waits (more than 6 months)

Revascularisation waits (all waiters)

NSF and NHS Plan Targets Initial NSF target (March 2000) 3000 additional revascularisations by April 2002 achieved by April 2001 Second NHS Plan target 6000 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 (Aggregated up from DHA data) Correlation coefficient 0.6, p= Y=3.732x

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

Data from HES (FCEs in England only) Ratio 1.3 : 1

Data from HES (FCEs in England only) Ratio 1.3 : 1 Efficiency 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%