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Cardiac workforce requirements in the UK
David Hackett
Chairman, BCS Cardiac Workforce Committee
June 2005
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Published by:
British Cardiac Society 9 Fitzroy Square London W1T 5HW Tel: +44 (0) 20 7383 3887 Email:
[email protected] Website: www.bcs.com
A company limited by guarantee registered in England number 3005604 Registered charity number 1093321
Page 3 of 45 Contents: Page 1
Headline recommendations
5
1.1
Summary: consultant cardiologists required in the UK
5
1.2
Summary: non-consultant cardiology workforce required
6
2
Introduction
7
3
Background to our methods
7
4
Cardiac services for populations: networks versus institutions
9
5
Independent provision of cardiac services
10
6
Women in cardiology
10
7
Academic and research requirements: academic workload contributions to NHS
10
8
Assumptions: consultant workforce in cardiology
10
9
Assumptions: non-consultant workforce in cardiology
11
10
Clinicians in training
11
11
Workforce needs
11
12
Conclusions
12
Appendix 1: Methodology
13
1
Availability of clinical staff
13
2
Consultant contracts: comparisons with and differences between UK countries
14
3
Assumptions
14
4
Notes on methodology: detailed workforce requirements
15
Appendix 2: detailed workforce requirements
16
Cardiac workforce requirements: National service framework for CHD
16
1
Secondary prevention of CHD
16
1.1
Specialist clinics for hypertension and lipids
16
2
Investigating and treating angina
16
3
Acute chest pain and thrombolysis service: non consultant staffing
17
4.1
Diagnostic cardiac catheterisation and angiography: current requirements
17
4.2
Diagnostic cardiac catheterisation and angiography: future requirements
18
5
Revascularisation: percutaneous cardiac intervention (PCI)
19
6
Miscellaneous cardiac invasive interventional procedures
21
7
Diagnosis and management of heart failure
21
8
Cardiac rehabilitation (phases I-III)
22
9
Cardiac pacing and electrophysiology devices
23
9.1
Implantable loop recorders
25
10
Pacemaker technical follow-up
25
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10.1
Implantable cardiac defibrillator (ICD) follow-up
26
10.2
Biventricular pacemaker follow-up
27
10..3
Patients with ICD implants: post-implant and follow-up support requirements:
28
11
Invasive arrhythmia electrophysiological (EP) studies and ablation
28
Other cardiac workforce requirements 12
Rare cardiac conditions Workforce requirements: general cardiology
29 29 29
13
General outpatient cardiology
29
14
General inpatient cardiology
31
14.1
Future inpatient care
32
14.2
Nurses required for inpatient cardiology care
33
14.3
Workforce rotas for inpatients requiring cardiac care
33
15
Paediatric cardiology
34
16
Adults with congenital heart disease
34
17
Academic cardiologists
35
Non-invasive cardiac imaging
36
18
Echocardiography
36
19
Nuclear cardiology
37
Notes for sections 18 and 19: Adjustment of workforce requirements for dynamic imaging in coronary disease
37
20
Cardiovascular imaging
38
21
Other non-invasive cardiac investigations
38
21.1
Electrocardiograms
38
21.2
Other exercise testing
38
21.3
Ambulatory monitoring
38
21.4
Autonomic investigations
38
22
Assessment of doctors in training in cardiology
39
23
Management requirements in cardiology
39
Summary: subspecialty consultants required
39
Summary: consultant cardiologists required
40
Summary: non-consultant cardiology workforce required
41
Glossary
42
References
45
Page 5 of 45 Headline recommendations: cardiac workforce requirementsa Total consultant cardiologists Total non-consultant cardiology workforce
52.7 – 84.2 per million population 168 – 211 per million population +?b
Summary: consultant cardiologists required in the UKa
1.1.
Total programmed activities (PAs) per million population (pmp) per year
PAs per week pmpc
1166 – 2434 1462 – 2703 1807 – 2667 682 – 931 1808 – 2469
28 – 59 36 – 66 44 – 65 17 – 23 44 – 60
Full time equivalent (FTE) consultants pmp (working 7.5 PAs per week) 3.8 – 7.9 4.8 – 8.8 5.9 – 8.7 2.2 – 3.0 5.9 – 8.0
555 – 1515
14 – 37
1.8 – 4.9
369 – 773
9 – 19
1.2 – 2.5
1120 – 1224 733 – 804
27 – 30 18 – 20
3.6 – 4.0 2.4 – 2.6
-442 4448 – 7669
-11 109 – 187
-1.4 14.5 – 24.9
Imaging: nuclear (6000 stress pmp) Other imaging Trainee assessment Clinical management
1141 – 1557 684 – 934 34 624
28 – 38 17 – 23 1 15
3.7 – 5.1 2.2 – 3.0 0.1 2.0
Total for consultants
16190 – 25896
395 - 632
52.7 – 84.2
Cardiology subspecialties General inpatient and outpatient requirements included pro rata With number of procedures or cases; pmp = per million population
Diagnostic catheters (4412–6750 pmp) Intervention (2200-3000 pmp) Heart failure Rehabilitation (5089 cases pmp) Devices (900 new permanent pacemakers + 700 new implantable cardiac devices + 107 car resonant pmp)
Electrophysiological study (EPS) + ablation (350–700 pmp) Miscellaneous (specialised 2º previous and rare miscellaneous conditions)
Paediatric cardiologists Adults with congenital heart disease Less academic Imaging: Echocardiography (4280047700 pmp)
These estimated requirements imply that the average individual consultant cardiologist will be undertaking 1.5-2 programmed activities (Pas) of inpatient cardiac care, 1-2 PAs of general outpatient cardiac care, and 3-5 PAs of specialised outpatient or laboratory cardiac care, each week; without any PAs for on-call responsibilities or emergency or unpredictable out-of-hours work allocated within the 7.5 PAs of direct clinical care.
a
Ranges provided are the minimum and ideal future requirements No data or estimations are available c Assumes consultants available 41 weeks per year b
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Summary: non-consultant cardiology workforce requiredd
1.2.
Non-consultant cardiology workforce Non-consultant cardiologists, General practitioners with a specialist interest in cardiology (GPwSIs), nurses, cardiac physiologists (CPs), radiographers
Secondary prevention of CHD Rapid access chest pain clinics (RACPC) Acute chest pain and thrombolysis Post myocardial infarction (MI) follow-up Diagnosing heart failure Monitoring heart failure Total specialist cardiac clinicians (mainly nurses?)
Sessions pmp per yeare
(working 9 clinical sessions per week)
2372 3495
6.0 17.6
? 92 662 4590 11211 + ?
28 – 47 0.2 1.7 11.6 65.1 – 84.1
Inpatient nursing care (coronary care units (CCU) + wards) Cardiac catheterisation and angiography Angiography pre-assessment Percutaneous coronary intervention (PCI) PCI pre-assessment Post PCI follow-up Other intervention Devices - implantation Devices – follow-up Other electrophysiological intervention Total invasive cardiac clinicians (physiologists, nurses, radiographers)
FTE clinicians per million population required
344 – 571
3531 – 5401
8.9 – 13.6
338 – 518 4224 – 5760
0.9 – 1.3 11 – 15
169 - 230 337 – 460 177 – 265 1357 (x2) 4800 (x2) 420 – 840 15353 – 19631
0.4 – 0.6 0.9 – 1.2 0.5 – 0.7 6.9 24 2.1 – 4.2 50.4 – 61.0
Echocardiography: CP/sonographers Other non-invasive cardiac investigations Total non-invasive cardiac clinical physiologists
10969 – 15880 ?
28 – 40 ?
10969 – 15880 + ?
27 – 39 + ?
Total cardiac rehabilitation clinical staff
7803
20
Total (excluding CCU + wards) (Non-consultant cardiology workforce)
45336 – 54525
168 – 211 plus ?
d
Ranges provided are the minimum and ideal future requirements Assumes non-medical staff available 44 weeks per year @ 3.75 hours per session; and that non-consultant medical staff undertake 9 sessions of direct clinical work each week.
e
Page 7 of 45 2.
Introduction The British Cardiac Society established the Cardiac Workforce Committee in 2004. This Committee superseded the previous BCS Cardiac Workforce Working Group that produced recommendations in 2003 and 2004 for cardiac workforce requirements in the UK. Patients are increasingly and rightly demanding specialist cardiological care. Patients with acute cardiac conditions have better care and outcomes when managed by cardiologists. Cardiologists should be available to advise and manage patients with acute cardiology conditions. Hospitals receiving acute cardiology patients should have a cardiologist on-call rota. Fundamentally, the workforce requirements must enable the appropriate, effective, efficient and prompt delivery of specialised care. It should allow patients and their carers to have adequate time with professional clinicians to discuss their condition and treatments.
3.
Background to our methods In this document we have estimated the cardiac workforce requirements based on general cardiology needs as well as for each cardiac subspecialty. We also estimate the non-medical cardiac workforce requirements. We do this from the “bottom up” for the UK, based on population or cardiac network needs. We have considered evidence invited and received from each Affiliated Group of the British Cardiac Society.f We have also considered published statistical data from the British Heart Foundation, data of NHS outpatient and inpatient activity from the statistical section of the Department of Health (England) website, and data from other sources. It is difficult to forecast the recommended workforce requirements of the future when there are so many rapid cardiac advances currently being introduced. More cardiac advances are expected and are likely to be introduced into clinical practice within the time frame of our estimated workforce requirements. We expect clinical advances that are as yet clinically unknown to be introduced into cardiac practice within the time frame addressed in this document. However, the workforce consequences of these developments cannot be quantified within our estimated workforce requirements. We have considered the following ranges of workforce requirements: • •
Firstly, the current workforce required for the provision of cardiac services. Secondly, future cardiac workforce requirements, with a range provided from the minimum to the ideal.
We have provided our recommendations for the workforce required to provide cardiac services in the future as a range, from the minimum to ideal. It would be unwise to rely on the bare minimum numbers recommended for workforce requirements. For example, if the need for percutaneous cardiac intervention (PCI) is actually more than 2,200 procedures per million population and is nearer 3,000 per million population, then we could be ‘caught short’ by the number of interventionists. We recognise that neither the minimum nor ideal workforce in cardiology can be instantly achieved. However, our assessments indicate the future numbers of the cardiac workforce required. We should be planning and training for this now. Whilst many advances and changes in cardiac care can be predicted to some extent, their impact on the required workforce and skill mix are more difficult to foresee with f
The Affiliated Groups of the British Cardiac Society are: British Association for Cardiac Rehabilitation (BACR), British Association for Nursing in Cardiac Care (BANCC), British Atherosclerosis Society (BAS), British Cardiovascular Intervention Society (BCIS), British Congenital Cardiac Association (BCCA), British Junior Cardiologists’ Society (BJCA), British Nuclear Cardiology Society (BNCS), Heart Rhythm UK (HRUK), British Society of Echocardiography (BSE), British Society for Heart Failure (BSH), British Society for Cardiovascular Research (BSCR), Heartcare Partnership (UK) (HCP (UK)), Primary Care Cardiovascular Group (PCCG), Society for Cardiological Science and Technology (SCST).
Page 8 of 45 accuracy. We acknowledge that clinical work is being, and will be, undertaken differently from the past. For example, we have assumed that non-consultant cardiologists will see most of the patients attending Rapid Access Chest Pain Clinics, routine follow-up clinics after myocardial infarction, routine follow-up clinics after percutaneous coronary intervention, Rapid Access Heart Failure Clinics, and heart failure follow-up clinics. Patients will frequently be seen by non-medically qualified staff, such as cardiac specialist nurses. We expect more ‘one-stop’ clinics, for example for people with heart murmurs attending clinics in echocardiography laboratories. We do not, and cannot, precisely specify the skill mix and workforce disciplines required for each cardiac subspecialty area. We are not aware of any systematic information (from the NHS Modernisation Agency, for example) about possible new ways of working which has allowed the redeployment of clinicians. For example, clinical work that has previously and conventionally been undertaken by consultant cardiologists or junior cardiologists, that is now undertaken by other clinicians such as nurses or clinical physiologists. So we cannot accurately and systematically calculate by how much the future cardiac medical workforce requirements might be reduced through new ways of working. There are many other issues that we expect will affect cardiac workforce requirements in the future. These include modernisation and new ways of working. In future, we expect more flexible working hours, an optional extended retirement age, changing job plans at different stages of careers and reduced working hours as a consequence of the European Working Time Directive. We also expect multi-skilling, changing roles such as nurse practitioners, increasing patients’ expectations, more specific clinical governance and revalidation issues requiring more people to do the same work as undertaken in the past, a reduction in service contribution by academics and trainees, and less service delivery by trainers because of more specific training requirements. We expect more part-time clinicians working in cardiology in the future, especially amongst women. It is notable that 83% (20 out of 24) of female specialist registrars in cardiology are considering part-time work on completion of their training (see section 6 below)1. If substantially more consultant cardiologists choose to work part-time in the future, there will be implications for substantial increases in the numbers of trainees required. We expect the net result of all these changes will be the need for more clinicians. We will need a more specialised medical and non-medical workforce compared to the present ways and means of delivering cardiac services. Extra staff to provide new ways of working should result in improvement in the consistency and quality of care that patients receive. These new ways of working may reduce the demands on cardiologists and their time. However, in some cases, supervision of the new ways of working may increase the demands on cardiologists, who will be responsible for running these services. Non-medical staff will not be able to become competent in and undertake all of the current duties of medical staff. Furthermore, all of the above new ways of working will not diminish the estimated requirements for cardiologists undertaking the assessment and clinical care of patients. This applies especially emergency and acute cases, and performing invasive procedures, as outlined in this document. If these changes in medical working practices are to be successfully delivered, there remains widespread concern within the cardiac community in regard to the availability of the additional non-medical professional clinical staff who will be required.
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4.
Cardiac services for populations: networks versus institutions The cardiac workforce requirements have been estimated for network populations, based on the needs of each million of the population. Of course, the population is not necessarily simply divided into ‘one million’ pockets for the purposes of workforce calculations. In this way, cardiac networks can estimate their workforce and subspecialty requirements, rather than base their needs on individual institutions, or on the competency need for single institutions or individual clinicians. For example, in some areas, large secondary care hospitals may provide all secondary and some tertiary care cardiac services. On the other hand, in other regions, small secondary care hospitals may provide little specialist secondary or tertiary care cardiology. These services might be provided by tertiary care hospitals for the local cardiac network. Cardiac workforce requirements for secondary care cardiac services can be calculated based on a referral population basis. Cardiac workforce requirements for tertiary care cardiac services should be calculated in the same way. It can be more difficult to estimate, however, as the size of the tertiary referral population may be less certain. Furthermore, most tertiary care cardiac units also provide secondary care cardiac services for their local, smaller population. Our workforce recommendations are based on an average population need. They should be adjusted for the local burden of cardiac disease, and for geographical factors such as sparse population density. Where the local incidence or prevalence of cardiac illness is high, for example in Scotland and in Northern Ireland, then the cardiac workforce requirements should be adjusted accordingly. However, where the local incidence or prevalence of cardiac illness is lower than average, for example in prosperous parts of England, it is highly debatable whether the cardiac workforce requirements should be adjusted down accordingly. Demographic trends will, in fact, result in the need for an increased cardiac workforce in the future. The reduction in mortality of coronary heart disease leads to an increase (not a decrease) in the prevalence of cardiac morbidity and the numbers of patients with cardiac problems. An increased ageing of the population and the improved management of patients with cardiovascular diseases results in a higher prevalence of cardiac disease. The prevalence of disease will grow faster than the rate of population growth. The British Cardiac Society has published a report on regional differences in the provision of cardiac services in the UK.2 This report points out that there are large discrepancies and disparities in the commissioning, investment, workforce, facilities, waiting times, capacity and volume of procedures, and availability of new technologies, in different parts of the UK. These differences are unfair and unacceptable. The National Service Framework (NSF) for Coronary Heart Disease (CHD) in England published in 20003 has resulted in a marked investment in cardiac services and improvement in cardiac health of the population. Further investment and improvements will be expected with the publication Chapter 8 of the NSF for CHD: Arrhythmias and Sudden Cardiac Death.4 These initiatives are expected to result in further increases in demands on cardiac services, and from patients and people. In turn, these increased demands will result in the need for greater workforce numbers and a more specialised cardiac workforce. These factors will result in an increase in the prevalence of patients with chronic coronary heart disease, heart failure, and arrhythmias, particularly atrial fibrillation, etc. People are visiting, and are expected to increasingly visit, their physicians more frequently. Therefore, we see no reason to consider a reduction in our recommendations of the need for the cardiac workforce in the future with a reduction
Page 10 of 45 in age-specific cardiac mortality as observed in the UK, or with improved cardiac services. 5.
Independent provision of cardiac services The cardiac workforce requirements recommended in this document are for the provision of all cardiac services for populations or cardiac networks. Where there is substantial independent provision, for example from the private sector, then the National Health Service workforce requirements could be reduced accordingly. No systematic data is available on the volume of provision of cardiac services to each cardiac network by the independent sector, however. There is no public data that could be used to adjust the NHS cardiac workforce requirements relative to the independent provision of cardiac services for the local cardiac network. We do not expect the required cardiac workforce numbers to be affected in any major or important way by the independent provision of cardiac services.
6.
Women in cardiology: The British Cardiac Society has recently published a report from a working group on Women in UK Cardiology. This report points out that in 2002 and 2003, women represented 60.5% of entrants to medical school, but only 16.8% of specialist registrar trainees in cardiology, and only 7.5% of consultant cardiologists. Recommendations in this report include the encouragement of recruitment of women, the facilitation of flexible training, the establishment of more part-time consultant posts, and the opening up of cardiac subspecialties to more women, with mentoring support available at all levels. The implications for the cardiac workforce requirements will be the need to increase the number of trainees and training posts by more than the number of expected full-time equivalent consultant cardiology posts required.
7.
Academic and research requirements: academic workload contributions to NHS The RCP Consultant Census survey of academic physicians in September 2002 indicated that each academic cardiologist worked an average of 9.2 notional half-days (NHDs) for the NHS in excess of their contract. There needs to be a formal recognition that academic cardiologists cannot continue to shoulder this level of individual clinical workload in the future. The increased numbers of under-graduate medical students, and post-graduate students and trainees, will result in a need for an increase in the number of academic cardiologists with relatively less NHS commitments (see section 16 in the appendix). The British Cardiac Society strongly supports cardiovascular research, whether undertaken by those with primary academic appointments or by staff with full-time NHS appointments. The NHS has formally specified the importance of research (and development). Substantial teaching or research cannot be shoehorned into one of the average of 2.5 programmed activities of supporting professional activity as part of a job plan. The time required for and devoted to teaching and research must be recognised in individual job plans; and sessions or programmed activities of direct clinical care replaced by research activities will require more staff to deliver clinical care.
8.
Assumptions: consultant workforce in cardiology Our estimates of cardiac workforce requirements for consultant cardiologists are based on the new consultant contract (2003) in England.5 Our assumptions are that: • •
A programmed activity (PA) for consultant medical staff is 4.0 hours. Each full-time equivalent consultant undertakes 7.5 programmed activities (PAs) of direct clinical care each week. However, each individual consultant and job plan may differ in the number of programmed activities of direct
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•
clinical care undertaken. Individual job planning and contracts will determine the individual number of consultants required. Where consultant availability and working times vary compared with the consultant contract (2003) in England, the estimates for the consultant cardiology workforce required will need to be adjusted accordingly, for example in other UK countries.
The recommendations for proposed sub-specialty workforce requirements should not be seen as being too rigid. Many consultant cardiologists could have interests in general and secondary care cardiology as well as in a subspecialty. Other consultant cardiologists might have interests and skills that span more than one subspecialty. Our recommendations will, however, allow cardiac networks to estimate their needs for subspecialty workforce requirements. The estimated cardiac workforce needs are provided here on the basis of overall numbers of programmed activities or sessions required. This will allow a cardiac network to plan the overall workforce needs for its communities, taking the specific individual interests of the consultant cardiologists into account. We have not included the needs of acute (general) medicine for those consultants with combined appointments in cardiology and acute (general) medicine in these estimates of cardiac workforce requirements. 9.
Assumptions: non-consultant workforce in cardiology Our assumptions are that: • • •
10.
A clinical session for non-medical clinical staff is 3.75 hours (based on the terms and conditions of Agenda for Change).6 Each full-time equivalent clinician undertakes an average of 9 sessional activities of direct clinical care each week. However, each individual clinician may differ in the number of sessions of direct clinical care undertaken. Where clinical staff availability and working times vary compared with the terms and conditions of Agenda for Change, the estimates for the nonconsultant cardiac workforce required will need to be adjusted accordingly.
Clinicians in training We strongly believe that the contribution of clinical trainees to delivering routine service workload should not be considered or included in substantive workforce planning. With more formal training programs and competency-based assessments, more of the trainer’s time will be required to train the trainees in the future. In fact, the needs of trainers in training the trainees is likely to require additional (training) time over and above the estimated requirements for delivering the service workload by trained, substantive clinicians. Training places for doctors should probably be numerically targeted for the needs of subspecialty training. In addition to the needs for general and secondary care cardiology, it will be necessary to consider national or regional quotas of numbers of doctors in training in intervention, devices and arrhythmias, heart failure, cardiac imaging, paediatric cardiology, and in adults with congenital heart disease (ACHD), etc.
11.
Workforce needs The number of specialist clinicians required for the cardiac workforce are specified as full time equivalents (FTE). With the new 2003 consultant contract (in England), some consultant cardiologists may work more than 7.5 programmed activities (PAs) of direct clinical care. This will result in an overall reduction in the total consultant numbers required for the cardiac workforce. On the other hand, we expect more part-time clinicians in the future, especially more part-time consultant cardiologists, particularly
Page 12 of 45 amongst women. This will result in an overall increase in the total numbers required for the cardiac workforce. However, the FTE workforce requirements would remain the same. These trends will obviously have quite different implications for the numbers of trainees required. There were 710 (equivalent to 663 FTE - Department of Health data 2004)7 or 630 (Royal College of Physicians of London data 2003)8 consultant cardiologists in England, representing 12.4 – 14.5 per million population. If all current cardiology specialist registrar trainees with a national training number in England were appointed to consultant cardiology posts, we understand that by 2010, there would be approximately 900 consultant cardiologists in England, or 18 per million population. We fear that this level of provision will be very inadequate for the consultant cardiac workforce requirements of the UK. 12.
Conclusions Cardiac workforce requirements in the UKg
Total consultant cardiologists Total non-consultant cardiology workforce
g
Ranges provided are the minimum and ideal future requirements
52.7 – 84.2 per million population 168 – 211 per million population +?
Page 13 of 45 Appendix 1: Methodology 1.
Availability of clinical staff: NHS staff
Medical staff England (new consultant contract 2003)
Annual leave Public holidays Internal clinical governance leave Study leave External professional leave Sickness absence leave rate
30 – 32 days 8 days ? 10 days (30 days for SpRs) ? 1.4%h (England)
Estimated subtotal leave Total annual leave (5-day working week) Total working year Average working year Working hours per week (excluding breaks) Working hours per session
48 – 60 days 10 – 12 weeks
Non-medical clinical staff (Agenda for Change)6 27 – 33 days 8 days ? ? ? 4.7% (England: see below) 36 – 52 days 7 – 10 weeks
40 – 42 weeks 41 weeks 40 hours
42 – 45 weeks 44 weeks 37.5 hours
4.0 hours per Programmed Activity (PA) 7.5 PAs (75% of total)
3.75 hours per session 9 sessions? (assumption 90% of total?) ~75%
Work time spent in direct clinical care
Annual work time of a FTE clinician spent in direct clinical care
~60%
We do not know how much time is spent, on average, by clinical staff on activities that require internal or external professional leave in the UK. Many NHS Trusts have clinical governance half-days every month which all clinical staff attend. This will reduce clinical availability of individuals by perhaps 8 sessions or programmed activities of direct clinical care over a year. It is uncertain how much time is spent, on average, by cardiologists on external professional activities. The Department of Health has specifically supported activities involving the need for external professional leave for the greater good to the NHS. After allowing for leave, and time spent outside direct clinical care, it can be seen that each full-time equivalent consultant cardiologist is available for work involving direct clinical care for about 60% of their annual time. Therefore for consultant cardiologists to provide a full-time, 40 hours per week, 52 weeks per year, service that covers their leave, and covers their work activities that are not direct clinical care, requires 1.7 full time equivalent consultants. It is not known whether sickness absence rates for consultant medical staff in the NHS are different in the various countries in the UK. Similarly after allowing for leave, and time spent outside direct clinical care, it can be seen that each full-time equivalent non-medical clinical staff is available for work involving direct clinical care for about 75% of their annual time. Therefore for non-medical clinical staff to provide a full-time, 37.5 hours per week, 52 weeks per year, service that covers their leave, and covers their work activities that are not direct clinical care, requires 1.3 full time equivalent nonmedical clinical staff. Reported sickness absence leave rates for all staff working in the NHS in different countries of the UK: • h i
England
4.7%i
http://www.nhspartners.org.uk/subscribers/Inter_org_summary.pdf http://www.dh.gov.uk/assetRoot/04/08/71/28/04087128.xls
Page 14 of 45 • • •
Wales Scotland Northern Ireland
6.0%j 4.9%k 4.9%l
The reported sickness absence rates for all staff working in the NHS in Scotland and in Northern Ireland are similar to those in England, but are greater in Wales. Therefore, the requirements for the non-consultant cardiac workforce in Wales should be increased by about 1.3% more than the estimates provided in this document for England. 2. Consultant contracts: comparisons with and differences between UK countries: Country Annual leave Public holidays Study leave Total leave# Usual working hours Sessional or PA hours Direct clinical care #
Englandm 30 – 32 days 8 days 10 days 48 – 50 days 40h per week 4h per PA 7.5 PAs/week
Walesn 30 days 8 days 10 days 48 days 37.5h per week 3.75h average 7 sessions/week
Scotlando 30 days 10 days 10 days 50 days 40h per week 4h per PA 7.5 PAs/week
N Irelandp 30 – 34 days 10 days 10 days 50 – 54 days 40h per week 4h per PA 7.5 PAs/week
includes internal clinical governance leave, external professional leave and sickness absence leave
Leave entitlements are broadly similar between the various countries in the UK (although slightly greater in Northern Ireland for consultants with more than 7 years of completed service). But the terms and conditions of service for consultants in Wales results, on average, in 12.5% fewer hours (26.25 hours compared with 30 hours in England) of direct clinical care each week. Therefore, the requirements for the consultant cardiac workforce in Wales should be increased by about 12.5% more than the estimates provided in this document. 3. Assumptions: Cardiac activities which are generally consultant-based: • Diagnostic cardiac catheterisation and angiography • Percutaneous Coronary Intervention (PCI), carotid intervention, ASD/PFO closure • Device implantation and replacement • Invasive cardiac electrophysiology studies and ablations • Trans-oesophageal and stress echocardiography • Reporting cardiac resynchronisation, magnetic resonance and nuclear studies • Management of rare conditions: cardio-myopathies, pulmonary hypertension, Marfans syndrome, muscular dystrophies, etc • Paediatric cardiology, adults with congenital heart disease (ACHD) • Formal clinical management (eg clinical director, service director, lead clinician) Cardiac activities which are generally not consultant based, but with consultant supervision: • Device follow-up • Trans-thoracic echocardiography • Reporting non-invasive cardiology investigations, echocardiography
j k l m
n
o p
http://www.agw.wales.gov.uk/publications/2004/agw2004_1es.pdf http://www.isdscotland.org/isd/files/040525_web.pdf http://www.dhsspsni.gov.uk/hss/governance/documents/HPSS_RMGen_Induction.pdf http://www.dh.gov.uk/assetRoot/04/07/04/06/04070406.pdf http://www.dh.gov.uk/assetRoot/04/06/99/50/04069950.pdf http://www.wales.nhs.uk/sites3/documents/433/Nat_Consultant_Contract.pdf http://www.wales.nhs.uk/sites3/docmetadata.cfm?orgid=433&id=23209&pid=3907 http://www.show.scot.nhs.uk/sehd/paymodernisation/ConsultantContract.htm http://www.dhsspsni.gov.uk/publications/2004/Consultant_TCS_%20FinalVersion.pdf; http://www.dhsspsni.gov.uk/publications/2004/NewConsultantContract.pdf
Page 15 of 45 Cardiac activities which are generally not consultant based, but with consultant lead and direction: • • • • • • • • •
Secondary prevention Rapid access chest pain clinics Acute chest pain and thrombolysis Pre-assessment for angiography and percutaneous coronary intervention Post myocardial infarction follow-up Post percutaneous coronary intervention follow-up Rapid access heart failure clinics Monitoring and follow-up of heart failure Cardiac rehabilitation
4. Notes on methodology: detailed workforce requirements Note1: The tables are numbered for each section. For each table: A refers to consultant cardiologist requirements B refers to non-consultant requirements for clinicians, both medical and non-medical. Note 2: There are several areas where data are not available for cardiac workload and thus not available for cardiac workforce estimations. Where no data or estimations are available, a “?” has been entered rather than leave it blank. We would prefer to acknowledge our uncertainty rather than ignore the requirements. Thus, where estimated workforce requirements have been listed as “?” or as “data +?”. It implies that the actual numbers are not easily estimated, and will be greater than those listed in this document. Note 3: PMP or pmp = per million population. DCC = Direct clinical care PA = Programmed Activity
Page 16 of 45 Appendix 2: detailed workforce requirements Cardiac workforce requirements: National Service Framework for CHD 1.
Secondary prevention of CHD
UK statistics from British Heart Foundation (UK population 58.789m) Myocardial infarction UK Angina UK All CHD UK
Incidence UK
Prevalence UK
275000 = 4678 pmp 335000 = 5698 pmp
1.2 million = 20412 pmp 2.0 million = 34020 pmp 2.65 million = 45076 pmp
Coronary heart disease statistics; 2003 edition: http://www.heartstats.org/uploads/documents%5C2003stats.pdf
1B. Secondary prevention of CHD (non-consultant based) New cases: Incidence of MI @4678 pmp @15 miniutes each New MIs for 2º prevention: 50% discharged alive and survive >30d New cases: incidence of angina @5698 pmp @ 15 minutes each New angina for 2º prevention: 80% Follow-up cases: prevalence of CHD @45076 pmp @ 10 minutes each Follow-up Coronary Heart Disease for 2º prevention: 80% Secondary prevention time Allow 15% extra capacity to allow for peaks and troughs Total secondary prevention time Sessions @3.75h each If each clinician available 44 weeks per year If each clinician works 9 sessions per week 1.1.
Requirement pmp (1170 hours) 585 hours (1425 hours) 1140 hours (7513 hours) 6010 hours 7735 hours 1160 hours 8895 hours 2372 sessions 54 sessions per week 6.0 FTE clinicians pmp
Specialist clinics for hypertension and lipids
There is a requirement for specialist regional hypertension clinics, run by consultants, for people with “resistant or difficult” hypertension. There are perhaps 30-40 such clinics in the UK. There is a requirement for specialist regional hyperlipidaemia clinics, run by consultants, for people with “resistant or difficult” hyperlipidaemia. There are perhaps 30-40 such clinics in the UK. We have assumed 2 PAs per week for each of these clinics. 1A. Specialist prevention clinics (Consultant based) 30-40 hypertension clinics with 2 PAs per week 30-40 hyperlipidaemia clinics with 2 PAs per week Total specialist prevention clinics Per million population If each consultant available 41 weeks per year If each consultant works 7.5 PAs per week in direct clinical care 2.
Requirement pmp 3120 – 4160 PAs UK 3120 – 4160 PAs UK 6240 – 8320 PAs 106 – 142 PAs pmp 2.6 – 3.5 PAs per week pmp 0.3 – 0.5 consultants pmp
Investigating and treating stable angina
2B. Rapid access chest pain clinics Incidence of angina @335,000 UK Referrals for chest pain = 2x incidence Clinic time required @1h each referral (including Exercise
Requirement pmp 5698 pmp 11396 pmp 11396 hours
Page 17 of 45 ECG testing) Allow 15% extra capacity to allow for peaks and troughs and for inefficiency* Sessions @3.75h each If each clinician available 44 weeks per year FTE staff required (Two of nurse, physiologist, GPwSI, or nonconsultant cardiologist) each clinician working 9 sessions per week
13105 hours 3495 sessions pmp 79 sessions per week pmp 17.6 FTE
* It is not possible to do a partial number of cases in each session (eg 3.5 cases in 3.5 hours); only whole numbers of cases can be seen and investigated.
3.
Acute chest pain and thrombolysis service: non-consultant staffing
We expect in the future that some ambulance and paramedical services will diagnose ST-segment elevation myocardial infarction, and may administer thrombolytic treatment before hospital admission. We expect that chest pain specialist nurses will initially assess and diagnose patients to confirm or exclude chest pain with cardiac causes, and initiate treatment. To provide a 24h/7d/52w service with prospective cover would require a bare minimum of 6 FTE cardiac specialist nurses in each acute admitting hospital; we understand that Southampton General Hospital, for example, requires 10 FTE specialist nurses for these responsibilities. 3B. Chest pain specialist nurses Acute hospital units UK: 274 x 6 -10 specialist nurses each 3B. Post MI follow-up Myocardial infarction @ 275000 UK MI: 50% discharged alive and survive >30d Post MI clinic time @ 0.5h each Allow 15% extra capacity to allow for peaks and troughs and for inefficiency Sessions @ 3.75h each If each clinician available 44 weeks per year FTE staff required each clinician working 9 sessions per week
PMP 28 – 47 FTE staff
4678 2339 1170 1346 hours 92 sessions pmp 2.1 sessions per week pmp 0.2 FTE
4. Diagnostic cardiac catheterisation and angiography 4.1.
Current requirements
The requirements for diagnostic cardiac catheterisation and angiography laboratories was estimated in 2002 based on the predicted numbers of revascularisation procedures suggested in the National Service Framework published in 2000.9 It is now clear that the required population numbers recommended for diagnostic cardiac angiography and percutaneous coronary intervention are much too conservative. The ratio of diagnostic cardiac catheterisation to all cardiac interventions (both PCI and cardiac surgery), used to estimate the population requirement for diagnostic cardiac angiography, was estimated in 2002 at 2.2 to 1. This is also now too conservative a ratio. The numbers of percutaneous coronary intervention (PCI) procedures are increasing exponentially: the mean rate of growth in total PCI numbers in the UK has been 15% per year since 1991. Planning for a current volume of 1500 PCI procedures pmp is now appropriate. Best estimates for current planning for future PCI requirements in the UK should be within a range of 2200-3000 procedures pmp (for detailed data see PCI section 5 below). And a ratio of 2.5:1 for diagnostic cardiac catheterisation procedures to all interventions (PCI and cardiac surgery) is more appropriate for future planning. It is assumed that perhaps one-third of PCI cases will be a direct follow-on from diagnostic angiography. Previously estimates were that the average time required for diagnostic cardiac catheterisation and angiography was a weighted average of 37.5 minutes (from patient entry to until exit from the cardiac catheterisation laboratory). St Mary’s Hospital, London, reviewed accurate records for the overall duration of diagnostic cardiac catherisation and angiography procedures in the cardiac
Page 18 of 45 catheterisation laboratory databases. The average duration in 2002-03 was 36.8 minutes (34.5 minutes for elective cases, 39.2 minutes for acute cases). We use an average duration of 37.5 minutes for each diagnostic cardiac angiography case for calculating future workforce requirements. 4A. Diagnostic cardiac catheterisation and angios: consultants required now Cardiac interventions: total PCI Cardiac interventions: Angiography before PCI (⅔) Cardiac interventions: cardiac surgery Total cardiac interventions Diagnostic cardiac catheterisation and angiography = 2.5x interventions @ 37.5 minutes Allow for 20% inefficiency* and for peaks and troughs Programmed Activites @ 4h each If each consultant available 41 weeks per year If each consultant works 7.5 PAs/week in direct clinical care 4B. Diagnostic cardiac catheterisation and angios: physiological staff required now Non-medical staff: nurses (2), physiologists (1), radiographers (1) Sessions @3.75h each If each clinician available 44 weeks per year If each clinician works 9 sessions per week
Procedure need pmp 2200-3000 1465-2000 700 2165-2700 5412 – 6750 pmp
Procedure time pmp
3383 – 4219 hours pmp 4060 – 5063 hours pmp 1015 – 1266 PAs pmp 24.8 – 30.9 PAs per week pmp 3.3 – 4.1 FTE consultants pmp
16204 – 20252 hours 4321 – 5401 sessions pmp 98 – 123 sessions per week pmp 10.9 – 13.7 FTE pmp
* It is not possible to do a partial number of cases in each programmed activity (eg 6.4 cases in 4 hours); only whole numbers of cases can have procedures performed.
4.2.
Future requirements
Future trends: • Current developments in multi- (ie 64 or 128) slice, simultaneous, fast acquisition, cardiac computed tomography (CT) imaging with sufficient resolution might replace diagnostic (epicardial) coronary angiography within the next few years. As a result, there may be fewer isolated diagnostic coronary angiography cases required in the medium and longterm future. Until this technology becomes available, it is very difficult to quantify how many current patients undergoing diagnostic coronary angiography might have similar useful diagnostic information provided by future cardiac CT imaging. • It is expected that in future there will be proportionately more diagnostic coronary angiography cases proceeding directly to percutaneous intervention (PCI) at the same time; and therefore fewer sole diagnostic coronary angiography cases. It is very difficult to quantify with confidence or precision how many fewer sole diagnostic coronary angiograms might be required in the medium and longer-term future. The following estimates must be treated with considerable caution. On the assumption that either: • two thirds rather than one-third of PCI is combined angiography and directly proceeding to intervention at the same time = 733 – 1000 pmp fewer sole diagnostic angiography cases; or alternatively, • if most patients with acute myocardial infarction or acute coronary syndromes have urgent in-hospital angiography and consideration of directly proceeding to PCI: with a total of 4678 pmp myocardial infarctions, say 50% (= 2339 pmp) initially survive and are admitted to hospital, and say 75% of these might actually have urgent angiography and consideration of PCI, perhaps twice as many as currently undertaken acute diagnostic followed on by intervention cases as at present (= one-half of 1750 = 875 fewer pmp) fewer diagnostic angiography cases; a very similar estimation to that above.
Page 19 of 45 •
Because of the considerable uncertainty of the future need for sole diagnostic coronary angiographic laboratories, we have assumed that the future requirement might range from the possible future reduction indicated above to the current predicted need.
4A. Diagnostic cardiac catheterisation and angios: consultants required in future Diagnostic cardiac catheterisation and angiography = 2.5 x interventions @ 37.5 minutes Allow for 20% inefficiency* and for peaks and troughs
Procedure need pmp 4412 – 6750 pmp
Programmed activities @ 4hours each If each consultant available 41 weeks per year If each consultant works 7.5 PAs/week in direct clinical care 4B. Diagnostic cardiac catheterisation and angios: physiological staff required in future Non-medical staff: nurses (2), physiologists (1), radiographers (1) Sessions @3.75h each
2758 – 4219 hours pmp 3310 – 5063 hours pmp 828 – 1266 PAs pmp 20.2 – 30.9 PAs per week pmp 2.7 – 4.1 FTE consultants pmp
13240 – 20252 hours 3531 – 5401 sessions pmp 80 – 123 sessions per week pmp 8.8 – 13.7 FTE pmp
If each clinician available 44 weeks per year If each clinician works 9 sessions per week 4B. Pre-angiography assessment Clinic time required @15 mins each
Procedure time pmp
4412 –6750 pmp
Allow for 15% inefficiency* and for peaks and troughs Sessions @3.75h each If each clinician available 44 weeks per year If each clinician works 9 sessions per week
1103 – 1688 hours pmp 1268 – 1941 hours pmp 338 – 518 sessions pmp 7.7 – 11.8 sessions per week pmp 0.9 – 1.3 FTE pmp
* It is not possible to see or do a partial number of cases in each programmed activity (eg 6.4 cases in 4 hours); only whole numbers of cases can have procedures performed.
5.
Revascularisation: Percutaneous Cardiac Intervention (PCI)
In 2003, there were 53,261 PCI procedures performed in the UK, a rate of 894 per million population (pmp). The mean rate of growth in total PCI numbers has been 15% per year since 1991. The estimated ratio of PCI to isolated CABG surgery in the UK is now 2.1:1, and is increasing. The proposed NSF rates for myocardial revascularisation of at least 750 PCI and 750 CABG procedures pmp are no longer enough for PCI, nor an appropriate ratio. Planning for a current volume of 1500 PCI procedures pmp is now appropriate. This would be an increase to 88,200 procedures (= 1500 PCI pmp) in the UK. In 2001, France and Switzerland undertook 1500 PCI pmp, and Germany 2300 PCI pmp; it is expected that these numbers will increase in the next few years, perhaps substantially with the introduction of drugeluting stents. Best estimates for current planning for future PCI requirements in the UK should be within a range of 2200-3000 procedures pmp.10 Accurate records for the overall duration of percutaneous cardiac intervention procedures have been reviewed in the cardiac catheterisation laboratory databases at St Mary’s Hospital in London. The average time (from patient entry to until exit from the cardiac catheterisation laboratory) in 2002 and 2003 was 85.9 minutes (80.3 minutes for elective cases, and 89.7 minutes for acute cases, including diagnostic angiography immediately beforehand). In the future, it is expected that
Page 20 of 45 there will be a relatively greater proportion of acute cases, and more complex cases, for intervention. An average duration of 90 mins for each case in the future for planning PCI needs is used here for calculating workforce requirements. 5A. Percutaneous coronary intervention: consultants now Percutaneous coronary intervention @ 90 minutes Allow for 20% inefficiency* and for peaks and troughs Programmed Activites @ 4hours each If each consultant available 41 weeks per year If each consultant works 7.5 PAs/week in direct clinical care
Procedure need pmp 1500 pmp
5B. PCI: other clinical staff now Non-medical staff: nurses (2), physiologists (1), radiographers (1) Sessions @ 3.75h each If each clinician available 44 weeks per year If each clinician works 9 sessions per week
Procedure time pmp 2250 hours pmp 2700 hours pmp 675 PAs pmp 16.5 PAs per week pmp 2.2 FTE consultants pmp
10800 hours 2880 sessions pmp 65 sessions per week pmp 7.3 FTE clinicians
* It is not possible to do a partial number of cases in each programmed activity (eg 2.7 cases in 4 hours); only whole numbers of cases can have procedures performed.
In order to provide a 24hour/7day interventional service, including primary percutaneous coronary intervention in acute myocardial infarction, interventions would need to be provided in a network facility where there would be a rota of a minimum of at least 6 interventionists, preferably 10 interventionists in each unit, to provider adequate cover for leave: see cardiac workforce document 2003.10 5A. Percutaneous coronary intervention: consultants in future Percutaneous coronary intervention @ 90 minutes Allow for 20% inefficiency* and for peaks and troughs Programmed Activites @ 4hours each If each consultant available 41 weeks per year If each consultant works 7.5 PAs/week in direct clinical care
Procedure need pmp 2200 3000 pmp
990 - 1350 PAs pmp 24 – 33 PAs per week pmp 3.2 – 4.4 FTE consultants pmp
15840 – 21600 hours 4224 – 5760 sessions pmp 96 – 131 sessions per week pmp 11 – 15 FTE clinicians pmp
If each clinician works 9 sessions per week
Allow for 15% inefficiency* and for peaks and troughs Sessions @3.75 hours each If each clinician available 44 weeks per year If each clinician works 9 sessions per week
3300 - 4500 hours pmp 3960 - 5400 hours pmp
5B. PCI: other clinical staff in future Non-medical staff: nurses (2), physiologists (1), radiographers (1) Sessions @ 3.75 hours each If each clinician available 44 weeks per year
5B. PCI pre-assessment Clinic time required @15 minutes each
Procedure time pmp
2200 – 3000 pmp
550 – 750 hours 633 – 863 hours pmp 169 – 230 sessions pmp 3.8 – 5.2 sessions per week pmp 0.4 – 0.6 FTE clinicians pmp
Page 21 of 45 5B. Post PCI follow-up Post PCI clinic time follow-up @0.5 hours each
2200 – 3000 pmp
Allow for 15% inefficiency* and for peaks and troughs Sessions @3.75 hours each If each clinician available 44 weeks per year
1100 – 1500 hours pmp 1265 - 1725 hours pmp 337 – 460 sessions pmp 7.7 – 10.5 sessions per week pmp 0.9 – 1.2 FTE clinicians pmp
If each clinician works 9 sessions per week
* It is not possible to do a partial number of cases in each programmed activity (eg 2.7 cases in 4 hours); only whole numbers of cases can have procedures performed.
6.
Miscellaneous cardiac invasive interventional procedures:
Examples of these include percutaneous closure of PFO/ASD, percutaneous carotid intervention, percutaneous mitral valvuloplasties, and percutaneous septal ablation in hypertrophic cardiomyopathy. We have excluded adults with congenital heart disease procedures. Assume that each interventional cardiac centre requires an average of 1.0 PA each week for all of these miscellaneous interventional procedures; currently there are 56 NHS interventional cardiac centres in the UK; with expansion of PCI, there may be perhaps 66 interventional cardiac centres in the UK with a population of 58.8 million. 6A. Miscellaneous cardiac invasive interventional procedures: consultants UK: 56 – 66 tertiary cardiac centres @ 1 PA per week each If each consultant available 41 weeks per year If each consultant works 7.5 PAs per week in direct clinical care
Procedure need pmp 56 – 66 PAs per week
6B. Miscellaneous cardiac invasive interventional procedures: other clinical staff Non-medical staff: nurses (2), physiologists (1), radiographers (1) Sessions @ 3.75 hours each per week
48 – 56 PAs pmp per year 1.2 - 1.4 PAs per week pmp 0.2 FTE consultants pmp
12.8 – 19.2 hours per week pmp 3.4 – 5.1 sessions per week pmp 177 – 265 sessions per annum pmp 4.0 – 6.0 sessions per week 0.5 – 0.7 FTE clinicians pmp
Sessions per year If each clinician available 44 weeks per year If each clinician works 9 sessions per week
7.
Procedure time pmp
Diagnosis and management of heart failure
The British Society of Heart Failure recommends that patients presenting with suspected heart failure should be seen by a consultant cardiologist specialising in heart failure. Furthermore, a consultant specialising in heart failure should lead in the monitoring and follow-up of patients with heart failure; each patient should be reviewed on average annually by a consultant cardiologist with a special interest in heart failure. UK statistics from British Heart Foundation11 (UK population 58.789m) Heart failure
Incidence UK
Prevalence UK
63500 = 1080 pmp
880000 = 14969 pmp
Page 22 of 45
7B. Rapid access heart failure clinics (diagnostic) Incidence of heart failure @ 63500 UK Referrals with symptoms = 2x incidence Clinic time required @ 1hour each referral (incl echo) Allow 15% extra capacity to allow for peaks and troughs and for inefficiency Sessions @3.75 hour each If each clinician available 44 weeks per year FTE staff required (One of nurse, physiologist, GPwSI, or nonconsultant cardiologist) each clinician working 9 sessions per week
Requirement pmp 1080 pmp 2160 pmp 2160 hours 2484 hours 662 sessions pmp 15 sessions per week pmp 1.7 FTE clinicians pmp
7A. Consultants with special interest in diagnosing heart failure Clinic time required @ 20-30 minutes each patient Allow 15% extra capacity to allow for peaks and troughs and for inefficiency PAs @ 4.0hour each If each consultant available 41 weeks per year If each consultant works 7.5 PAs/week in direct clinical care
Requirement pmp
7B. Monitoring of heart failure Prevalence of heart failure @ 880000 Clinic time required 6 monthly* @ 15 minutes each Echo time required annually @ 30 minutes each Allow 15% extra capacity to allow for peaks and troughs and for inefficiency Sessions @ 3.75 hours each If each clinician available 44 weeks per
Requirement pmp 14969 pmp 7484 hours 7485 hours 17214 hours
FTE staff required (nurse, physiologist, GPwSI, or non-consultant cardiologist) each clinician working 9 sessions per week 7A. Consultants with special interest in monitoring heart failure Clinic time required annually @15 minutes each Allow 15% extra capacity to allow for peaks and troughs and for inefficiency PAs @ 4hours each If each consultant available 41 weeks per year If each consultant works 7.5 PAs/week in direct clinical care
719 - 1080 hours 827 - 1242 hours 207 – 311 PAs pmp 5 – 8 PAs per week pmp 0.7 – 1.1 FTE consultants
4590 sessions pmp 104 sessions per week pmp 11.6 FTE clinicians pmp
Requirement pmp 3742 hours 4303 hours 1076 PAs pmp 26 PAs per week pmp 3.5 FTE consultants
* ”At least 6 monthly”: http://www.nice.org.uk/pdf/CG5NICEguideline.pdf
7A. Total Consultants specialising in heart failure Diagnosing heart failure Monitoring heart failure Total consultants specialising in heart failure 8.
Requirement pmp 0.7 – 1.1 FTE consultants pmp 3.5 FTE consultants pmp 4.2 – 4.6 FTE consultants pmp
Cardiac rehabilitation (phases I-III)
In each cardiac network, cardiac rehabilitation should be provided locally. The British Association for Cardiac Rehabilitation (BACR) website specifies that at least two staff should supervise each exercise session; that the ratio of staff to patients in these classes should be 1 to 30days Percutaneous coronary intervention Cardiac surgery Total coronary heart disease for cardiac rehabilitation
4678 2339 2000 750 5089
8A. Rehabilitation: consultants Consultants with special interest: 2 PAs per week at each acute hospitals @ 274 acute hospitals PMP for UK
Requirement pmp 548 PAs per week UK 9.3 PAs per week pmp 11.8 PAs per week pmp 1.6 FTE consultants pmp
If each consultant available 41 weeks per year If each consultant works 7.5 PAs per week in direct clinical care
8B. Rehabilitation: other clinicians Cardiac rehabilitation @5089 pmp: one 3.75 hour session twice weekly for 6w Allow for 15% inefficiency* and for peaks and troughs If working 9 sessions each week Per week (50 weeks per year) If each clinician available 44 weeks per year FTE clinicians required working 9 sessions per week (≥6 FTE of CR practitioners ideally comprising a multidisciplinary group)
61068 sessions pmp per year 70228 sessions pmp per year 7803 sessions pa fulltime 156 sessions per week 177 sessions per week 20 FTE pmp
* It is not possible to see a partial number of patients in each session; only whole numbers of cases can be seen.
9.
Cardiac pacing and electrophysiology devices
In 2004, there were 19650 new pacemaker implants performed in England, a rate of 386 per million population. New pacemaker implants represent about 75% of the total, with about 25% being replacements. About 65% were dual chamber implants, about 35% single chamber, although there is a continuing trend towards more dual chamber devices. (National Pacemaker Database 2004, David Cunningham, personal communication.) The population requirement for pacemaker implants is very sensitive to age; this need increases exponentially with increasing age. With the average age at first implant steadily increasing in the UK, it is expected that the overall population requirement for pacemaker implants will steadily increase in the future. Furthermore, the population requirements provided here for pacemaker and other device implants and replacements are an average for the UK. Where the age structure of the local population differs from the UK average, with a greater or lower proportion of older people, the local population requirement for pacemaker and device implants and replacements should be adjusted accordingly. 9A. Devices: pacemaker implants now Pacemakers: 80% dual chamber @ 2.0 hours Pacemakers: 20% single chamber @ 1.5 hours
Device need 360 pmp 90 pmp
Implant time pmp 720 hours 135 hours
Page 24 of 45 4% reoperation rate @ 1.5 hours 25% generator changes per year @ 1.0 hours Total pacemaker implant time Allow for 20% inefficiency* and for peaks and troughs Programmed Activites @ 4 hours each If each consultant available 41 weeks per year If each consultant works 7.5 PAs/week in direct clinical care
18 pmp 113 pmp 581 pmp
27 hours 113 hours 995 hours 1194 hours pmp 299 PAs pmp 7.3 PAs per week pmp 1.0 FTE consultants pmp
9A. Devices: pacemaker implants in future Pacemakers: 80% dual chamber @ 2.0 hours Pacemakers: 20% single chamber @ 1.5 hours 4% reoperation rate @ 1.5 hours 30% generator changes per year @ 1.0 hours Total pacemaker implant time Allow for 20% inefficiency* and for peaks and troughs Programmed activites @ 4 hours each If each consultant available 41 weeks per year If each consultant works 7.5 PAs/week in direct clinical care
Device need 720 pmp 180 pmp 36 pmp 270 pmp 1206 pmp
Implant time pmp 1440 hours 270 hours 54 hours 270 hours 2034 hours 2441 hours pmp 610 PAs pmp 14.9 PAs per week pmp 2.0 FTE consultants pmp
* It is not possible to do a partial number of cases in each programmed activity (eg 2.6 pacemakers in 4 hours); only whole numbers of cases can have procedures performed.
9A. Devices: ICD implants now ICDs @ 2.0 hours 4% revisions @ 2 hours 20% generator changes per year @ 1.5 hours Total ICD implant time Allow for 20% inefficiency* and for peaks and troughs Programmed activites @ 4 hours each If each consultant available 41 weeks per year If each consultant works 7.5 PAs/week in direct clinical care
Device need 50 pmp 2 pmp 10 pmp 62 pmp
Implant time pmp 100 hours 4 hours 15 hours 119 hours 143 hours pmp 36 PAs pmp 0.9 PAs per week pmp 0.1 FTE consultant pmp
9A. Devices: ICD implants in future ICDs @ 2.0 hours 4% revisions @ 2.0 hours 25% generator changes per year @ 1.5 hours Total ICD implant time Allow for 20% inefficiency* and for peaks and troughs Programmed activites @ 4 hours each If each consultant available 41 weeks per year If each consultant works 7.5 PAs/week in direct clinical care
Device need 700 pmp 28 pmp 175 pmp 903 pmp
Implant time pmp 1400 hours 56 hours 263 hours 1719 hours 2063 hours pmp 516 PAs pmp 12.6 PAs per week pmp 1.7 FTE consultant pmp
* It is not possible to do a partial number of cases in each programmed activity (eg 2.6 ICDs in 4 hours); only whole numbers of cases can have procedures performed.
9A. Devices: cardiac resynchronisation therapy in future* Heart failure: incidence 10% benefit from CRT: new implant time @ 3.75 hours 10% revisions @3.75h 25% generator changes per year @ 1.5 hours Total CRT implant time Allow for 30% inefficiency** and for peaks and troughs Programmed activites @ 4 hours each If each consultant available 41 weeks per year If each consultant works 7.5 PAs/week in direct clinical care
Device need 1072 pmp 107 pmp 11 pmp 27 pmp 138 pmp
Implant time pmp
401 hours 44 hours 41 hours 486 hours 632 hours pmp 158 PAs pmp 3.9 PAs per week pmp 0.5 FTE consultants pmp
Page 25 of 45 * We have assumed that all those patients who have biventricular pacemakers implanted will also have an ICD implanted, so the future numbers of ICD implants estimated above have been reduced accordingly. **It is not possible to do a partial number of cases in each programmed activity (eg 2.6 ICDs in 4 hours); only whole numbers of cases can have procedures performed.
9A. Device therapy now: summary Pacemakers ICDs Total devices If each consultant available 41 weeks per year If each consultant works 7.5 PAs/week in direct clinical care 9A. Device therapy in future: summary Pacemakers ICDs CRT Total devices If each consultant available 41 weeks per year If each consultant works 7.5 PAs/week in direct clinical care
9B. Device implantation: technical requirements now Devices Sessions required @ 3.75 hours per session If staff available 44 weeks per year FTE technical staff required (two clinicians performing implants) working 9 sessions/week
9B. Device implantation: technical requirements in future Devices Sessions required @ 3.75h per session If staff available 44 weeks per year FTE technical staff required (two clinicians performing implants) working 9 sessions/week 9.1.
New device need 450 pmp 50 pmp 500 pmp
New device need 900 pmp 700 pmp 107 pmp 1707 pmp
Implant need pmp 299 PAs 36 PAs 335 PAs 8.2 PAs per week pmp 1.1 FTE consultants pmp
Implant need pmp 610 PAs 516 PAs 158 PAs 1284 PAs 31.3 PAs per week pmp 4.2 FTE consultants pmp
Device need
Implant need pmp
643 pmp
1340 hours per year 357 sessions per year 8 sessions per week 1.8 FTE staff
Device need
Implant need pmp
2247 pmp
5088 hours per year 1357 sessions per year 31 sessions per week 6.9 FTE staff
Implantable loop recorders
We have assumed that the professional clinical time needed for implanting and explanting these devices can be accommodated within the general invasive cardiac electrophysiology arrhythmia and ablation workforce requirements (See section 12 below). 10.
Pacemaker technical follow-up
We are very grateful for the following information from the National Pacemaker Database supplied by Dr David Cunningham. The average age at the time of first pacemaker implantation is about 75 years old. It is not surprising that mortality increases in this age group after pacemaker implants; mortality in the first full year after first implant is approximately 9%, and increases thereafter. Approximately 50% of patients are alive at 5 – 6 years after first pacemaker implant, and 26% alive at 10 years, in England. Therefore, although there are about 20,000 new pacemaker implants performed each year in England, this activity translates into a net increase of about 6000 new follow-up pacemaker
Page 26 of 45 patients each year. In 2004, it is estimated that there were about 11,000 patients with pacemaker implants alive being followed-up in England, a prevalence of about 2260 patients per million population. The average age at the time of first defibrillator implantation is about 62 years old. It is not surprising that mortality increases in this age group after defibrillator implants, but also with a younger age group that this mortality is less than that after pacemaker implants. The number of defibrillator implants is increasing rapidly in the UK, an exponential increase of about 30% per year, with 1794 new implants in the UK in 2002, a rate of 30 per million population. In 2004, it is estimated that there were about 11,000 patients with defibrillator implants alive being followed-up in England, a prevalence of about 225 patients per million population. The National Pacemaker Database indicates that after a pacemaker implant, patients are generally followed-up at about one week, at about three months, at about 6 months, and thereafter on average about every 200 days for up to six years. Subsequently, as would be expected with battery depletion and run-down, patients are followed-up every six months for 2 or 3 years, and thereafter about every 4 months on average. In the National Pacemaker Database, there was an average of 20 pacemaker follow-up checks over 9 years, a mean of 2.2 follow-up checks per year (including the 3 visits in the first year after implantation). No detailed records are available for defibrillator implant follow-ups. But it would be expected that ICDs should be reviewed with a follow-up check every 3 months throughout the life of the device. No specific data or detail is available from the National Pacemaker Database about biventricular pacemaker follow-up. There should be a consultant cardiologist with expertise in pacing and devices available in the outpatient device follow-up clinic for advice for technical or patient clinical enquiries (see section 11). 10B. Pacemaker follow-up now Patients alive with pacemakers: (2004) On average 2.2 follow-up visits per year @ 0.5 hours Allow 15% extra capacity to allow for peaks and troughs and for inefficiency Sessions required @ 3.75 hours per session If staff available 44 weeks per year FTE physiological staff required (two clinicians working 9 sessions per week)
Device need pmp Prevalence 2260 pmp 4972 visits pmp
Follow-up time pmp
5718 visits pmp
2859 hours
10B. Pacemaker follow-up in future Pacemakers: expected patients 5266 pmp On average 2.2 follow-up visits per year @ 0.5 hours Allow 15% extra capacity to allow for peaks and troughs and for inefficiency Sessions required @ 3.75 hours per session If staff available 44 weeks per year FTE technical staff required (two clinicians working 9 sessions per week)
Device need pmp Prevalence 5266 pmp 11585 visits pmp
Follow-up time pmp
13323 visits pmp
6662 hours
10.1.
2486 hours
762 sessions /year 17.3 sessions /week pmp 3.8 FTE pmp
5793 hours
1777 sessions/year 40.4 sessions/week pmp 9.0 FTE pmp
Implantable cardiac defibrillator (ICD) follow-up
Follow up requires an average of 30 minute appointments. Follow-up is required every 3 months. It is also necessary one month after implantation or system change and monthly when the system is near its end-of-battery-life, over perhaps a six-month period. Thus, say an annual average of 5 follow-up visits over the life of one ICD system. The average life of an implant of system is approximately 5 years.
Page 27 of 45 10B. ICD follow-up now @ 50 pmp Patients alive with ICDs: (2004) On average 5 follow-up visits per year @ 0.5 hours Allow 15% extra capacity to allow for peaks and troughs and for inefficiency Sessions required @ 3.75 hours per session If staff available 44 weeks per year FTE physiological staff required (two clinicians working 9 sessions per week)
Device need pmp Prevalence 225 pmp 1125 visits pmp
Follow-up time pmp
1294 visits pmp
647 hours
10B. ICD follow-up in future @700 pmp Patients alive with ICDs: On average 5 follow-up visits per year @ 0.5 hours Allow 15% extra capacity to allow for peaks and troughs and for inefficiency Sessions required @ 3.75 hours per session If staff available 44 weeks per year
Device need pmp Prevalence 3140 pmp 15700 visits pmp
Follow-up time pmp
18055 visits pmp
9028 hours
173 sessions/year 3.9 sessions/week pmp 0.9 FTE pmp
7850 hours
2407 sessions/year 54.7 sessions/week pmp 12.2 FTE pmp
FTE physiological staff required (two clinicians working 9 sessions per week) 10.2.
563 hours
Biventricular pacemaker follow-up
We have assumed that there is a similar mortality in patients with biventricular pacemakers as in those with ICDs, then the prevalence of biventricular devices might be expected to be about 803 pmp in future. We assume all biventricular pacemakers will also be ICDs. Biventricular pacemakers require follow-up every 3 months, with an average duration of 30 minutes required. In addition, after implantation or system change, follow up will be required at one month; furthermore, when the system is near its end-of-battery-life, follow up will be required perhaps monthly. Thus, say an extra 6 follow up visits over the life of one biventricular pacemaker system, an annual average of 5 follow-up visits; with the average life of the system being approximately 5 years. 10B. Biventricular pacemaker follow-up in future @ 107 new systems pmp Patients alive with biventricular pacemakers: On average 5 follow-up visits per year @ 0.5 hours Allow 15% extra capacity to allow for peaks and troughs and for inefficiency Sessions required @ 3.75 hours per session If staff available 44 weeks per year
Device need pmp
Follow-up time pmp
Prevalence 803 pmp 4015 visits pmp
2008 hours
4617 visits pmp
2309 hours 616 sessions/year 14.0 sessions/week pmp 3.1 FTE pmp
FTE physiological staff required (two clinicians working 9 sessions per week) 10B. Devices: summary of technical follow-up requirements now Pacemakers ICDs Total devices If staff available 44 weeks per year If 2 staff perform follow up working 9 sessions/week
New device need 450 pmp 50 pmp 500 pmp
10B. Devices: summary of technical follow-up requirements in future Pacemakers ICDs
New device need 900 pmp 700 pmp
Follow-up need pmp 762 sessions 173 sessions 935 sessions 21 sessions/week pmp 4.7 FTE pmp Follow-up need pmp 1777 sessions 2407 sessions
Page 28 of 45 Biventricular pacemakers Total devices If staff available 44 weeks per year If 2 staff perform follow-up working 9 sessions/week 10.3.
107 pmp 1707 pmp
616 sessions 4800 sessions 109 sessions / week pmp 24.2 FTE pmp
Patients with ICD implants: post-implant and follow-up support requirements:
Many patients who have had an ICD implanted (or a combined biventricular pacemaker with ICD) require rehabilitation, mainly with psychological support. This support is not yet generally provided in the UK. There needs to be an agreed level of service provision and specific subspecialty input and staffing needs (clinical cardiac physiologists, cardiac rehabilitation staff) in order to plan the workforce requirements for each cardiac network in the UK. 11.
Invasive arrhythmia electrophysiological (EP) studies and ablation
In 2002, Spain undertook 124 and Portugal 142 cardiac electrophysiological or ablation procedures per million population. It is projected that the USA will undertake 1320 cardiac electrophysiological or ablation procedures per million population in the future. These numbers are rapidly increasing In the United Kingdom from a low baseline. It is expected that there will be a considerable increase in the future in cardiac electrophysiology ablation treatments, specifically for atrial fibrillation, complex ablation procedures, ablation in adults with congenital heart disease (ACHD), more ablations of ventricular tachycardia, etc. Perhaps the future need would be for double those numbers of cardiac ablations used in present planning estimates (not the numbers of actual cardiac electro-physiology ablations currently performed). These could be very conservative estimates of future need if ablation techniques for atrial fibrillation become widespread, and their use considerably increases. Chapter eight of the National Service Framework for Coronary Heart Disease published in 2005 indicated the need for specialist assessment and treatment of patients with arrhythmias or suspected arrhythmias.4 It is likely that rapid access arrhythmia clinics will evolve and be developed. It is currently uncertain what the population requirement for this might be. Also, it is likely that a more diverse range of heart rhythm specialists will evolve, as well as the need for NSF arrhythmia care coordinators. 11A. EP (non-device) cardiologists required Diagnostic and therapeutic invasive cardiac electrophysiology studies: 350 – 700 pmp @ 3.75 hour each Allow for 20% inefficiency* and for peaks and troughs Programmed activities @ 4 hours each Consultants available 41 weeks per year Consultant staff working 7.5 PAs of direct clinical care per week 11B. EP (non-device) technical staff required Diagnostic and therapeutic invasive cardiac electrophysiology studies: Sessions required @ 3.75 hours per session If staff available 44 weeks per year FTE physiological staff required (two clinicians working 9 sessions per week)
Requirement pmp 1313 – 2625 hours pmp pa 1576 – 3150 hours pmp pa 394 – 788 PAs pmp 9.6 – 19.2 PAs per week pmp 1.3 – 2.6 FTE pmp
1576 – 3150 hours pmp pa 420 – 840 sessions / year 9.5 – 19.1 sessions / wk pmp 2.1 – 4.2 FTE pmp
* It is not possible to do a partial number of cases in each programmed activity (eg 2.6 studies in 3.5 hours); only whole numbers of cases can have procedures performed.
Page 29 of 45 Other cardiac workforce requirements (outside the National Service Framework for Coronary Heart Disease) 12.
Rare cardiac conditions:
For example, primary cardiomyopathies (HCM, DCM, etc), infiltrative and secondary cardiomyopathies, Marfans syndrome, muscular dystrophies, primary pulmonary hypertension, etc Population diagnostic and follow-up requirements for these conditions is unknown. If it is assumed that a range of either three PAs in each tertiary centre (~55 centres) or one PA in each acute hospital (~274 hospitals) might be required. Approximately 400 people aged less than 40 years old die from sudden unexpected cardiac death each year in the United Kingdom. Chapter eight of the NSF for CHD indicates the need for screening and management of relatives of patients who have died from sudden cardiac death. Screening will involve perhaps 6-10 relatives each, or 2400 each year, equivalent to 40 people per million population per year. This would require about one PA per month pmp, or about 0.25 PAs per week pmp. This screening will probably need to be undertaken jointly between adult and paediatric cardiology units across local cardiac networks. 12A. Rare acquired conditions Range: 3 PAs in 55 centres or 1 PA in 274 hospitals PMP for UK Screening relatives of sudden cardiac death Total requirement If each consultant available 41 weeks per year If each consultant works 7.5 PAs per week in direct clinical care
Requirement pmp 165 – 274 PAs per week UK 2.8 – 4.7 PAs per week pmp 0.25 PAs per week pmp 3.0 – 5.0 PAs per week pmp 3.8 – 6.3 PAs per week pmp 0.5 – 0.8 consultants pmp
Workforce requirements: General cardiology 13.
General outpatient cardiology
NHS outpatient data returns for cardiology outpatient attendances (code 320) in England in 200203 indicate that 20 acute hospital trusts provided no data, and a further 3 had implausibly low numbers.q There were 21 Primary Care Trusts (PCTs) that also provided data on cardiology outpatient attendances, presumably for patients who consulted cardiologists in PCT facilities. The overall numbers of cardiology outpatients reported as being seen by PCTs were small. There was a national median ratio of 1.8 subsequent attendances for every first attendance (inter-quartile range 1.3-2.7). The national median rate of non-attendance (DNAs) for first cardiology attendances was 5.9% and subsequent non-attendances 9.2% (overall median DNA rate 8.7%). For Strategic Health Authority (SHA) data in 2002-03, there was a median of 8489 (interquartile range 6045-9842) new patient attendances (including DNAs) per million unadjusted population; when adjusted for the population of those hospital trusts without cardiology returns, the first attendances were 9148 pmp (6149-11435). There was a median of 15103 (inter-quartile range 12448-22188) subsequent outpatient attendances (including DNAs) per million unadjusted population; when adjusted for the population of those trusts without cardiology returns, the subsequent attendances were 18795 pmp (12941-23323). Total outpatient attendances in 200203 were a median of 24273 (18756-30963) unadjusted pmp, and 29270 (19996-34827) adjusted pmp. For hospital trusts with substantive data returns in 2002-03, there was a median of 8438 (inter-quartile range 6051-10501) new patient attendances (including DNAs) per million of their estimated referral population; and for subsequent attendances, a median of 12288 pmp (interquartile range 8380-22683). Total outpatient attendances were a median of 21340 pmp (interquartile range 15530-34244). q
http://www.performance.doh.gov.uk/hospitalactivity/data_requests/outpatient_attendances.htm
Page 30 of 45
It would seem prudent to plan for average current national cardiologist numbers for outpatients based on the national 75th percentile of current outpatient activity; this data is very similar across StHAs and hospital trusts with data returns. 13A. Cardiologists required for outpatients now pmp StHAs (75th centile) Trusts (75th centile) If 20-30 minutes for first and 15 minutes for subsequent If 4 hour per outpatient PA If each cardiologist available 41 weeks/year If each cardiologist works 7.5 PAs of direct clinical care per week
First attendances pmp (incl DNAs) 11435 10501 3630 – 5500 hours
Subsequent attendances pmp (incl DNAs) 23323 22683 5750 hours
Total attendances pmp (incl DNAs) 34827 34244 9380 – 11250 hours
908 – 1375 PAs
1438 PAs
2346 – 2813 PAs
22 – 34 PAs/week
35 PAs/week
57 – 69 PAs/week
2.9 – 4.5 cardiologists pmp
4.7 cardiologists pmp
7.6 – 9.2 cardiologists pmp
It seems likely that the number of patients referred to cardiologists in the UK will increase in the future. Currently in the UK demand for outpatient appointments far exceeds supply, so the present volume of outpatient work is not a good indication of need. Furthermore, increasing age and complexity of drug and device therapy probably means more outpatient need in future, although some of this may be offset by work undertaken by General practitioners with a special interest (GPwSIs) in cardiology. However, we cannot presently reliably estimate how many GPwSIs may be undertaking specialist cardiac outpatient work in the future, nor their geographical distribution. NHS outpatient data from 1997 to 2002 indicate that there was a 1.6% increase per year in outpatient attendances for all specialties, and a 5.0% per year increase in cardiology attendances. If these current trends continue, it is estimated that there will be a cumulative increase of ~15% in all outpatient attendances, and a cumulative increase of ~100% in cardiology outpatient attendances, by 2010. We understand since the publication of the NSF for CHD in March 2000 that cardiology new-patient referrals by general practitioners to cardiologists have increased by approximately 50%. Therefore, estimated overall outpatient requirements for cardiology should be increased by 100% to 150% (doubled to trebled) for 2010. Not all these patients would necessarily be seen, or would need to be seen, by consultant cardiologists; but these data do provide an estimate of the number of specialists, physicians as well as non-medical clinicians, which should be required. 13A. Cardiologists required for outpatients in 2010 pmp StHAs (median and 75th centile) 2002-03 Trusts (median and 75th centile) 2002-03 100%-150% increase by 2010 If 20-30 minutes for first and 15 minutes for subsequent If 4 hour per outpatient PA
First attendances pmp (incl DNAs)
Subsequent attendances pmp (incl DNAs)
Total attendances pmp (incl DNAs)
9148 – 11435
15103 – 23323
24273 – 34827
8438 – 10501
12288 – 22683
21340 – 34244
16876 – 34305
24576 – 69969
42680 – 104274
5569 – 17153 hours
6144 – 17492 hours
11713 – 34645 hours
1392 – 4288 PAs
1536 – 4373 PAs
2928 – 8661 PAs
Page 31 of 45 If each cardiologist available 41 weeks/year If each cardiologist works 7.5 PAs of direct clinical care per week
34 – 105 PAs/week
37 – 107 PAs/week
71 – 212 PAs/week
4.5 – 14.0 cardiologists pmp
4.9 – 14.0 cardiologists pmp
9.5 – 28.3 cardiologists pmp
These estimates should be reduced for patient attendances at non-consultant clinics, eg: rapid access chest pain clinic (RACPC), routine post myocardial infarction follow-up and routine post percutaneous coronary intervention follow-up. As all patients attending rapid access heart failure clinics are seen by a consultant specialising in heart failure, it would be appropriate to reduce the general outpatient new-patient requirement by this amount of work. As all patients attending heart failure follow-up clinics will be seen by a consultant specialising in heart failure on average one a year, it would also be appropriate to reduce the general outpatient follow-up requirement by this amount of work. There will also be more general practitioners with a special interest in cardiology (GPwSIs) undertaking specialist cardiac outpatient clinics. If we assume that ⅓ - ⅔ of patients can be seen in these non-consultant clinics without subsequent routine consultant review, and that ⅓ - ⅔ will need subsequent consultant new-patient or follow-up appointments: Reduction in general cardiology outpatient activity 2010 pmp RACPC: ⅓ -⅔ of 11396 Post MI: ⅓ -⅔ of 2339 Post PCI: ⅓ -⅔ of 2200 – 3000 Heart failure: new-patients Heart failure follow-up pts Total reduction
First attendances pmp (including did not attend DNAs) Less 3798 – 7598
Subsequent attendances pmp (including DNAs)
Total attendances pmp (including DNAs)
Less 779 – 1560 Less 733 – 2000
Less 3798 – 7598 Less 779 – 1560 Less 733 – 2000
Less 14969 Less 16481 – 18529
Less 2160 Less 14969 Less 22439 – 28287
Less 2160 Less 5958 – 9758
Adjusted data (Allowing for non-consultant cardiologist run RACPC, post-MI follow-up clinics, etc) First attendances Subsequent Total attendances 13A. Cardiologists required pmp attendances pmp pmp for outpatients in 2010 pmp (incl DNAs) (incl DNAs) (incl DNAs) Required by 2010 16876 – 34305 24576 – 69969 42680 – 104274 Reduce by (see above): Less 5958 – 9758 Less 16481 – 18529 Less 22439 – 28287 Adjusted requirement 10918 – 24547 8095 – 51440 20241 – 75987 If 20-30 minutes for first 3639 – 12274 hours 2024 – 12860 hours 5663 – 25134 hours and 15 minutes for subsequent If 4 hours per outpatient PA 910 – 3069 PAs 506 – 3215 PAs 1416 – 6284 PAs per year If each cardiologist available 22 – 75 PAs/week 12 – 78 PAs/week 35 – 153 PAs/week 41 weeks/year If each cardiologist works 7.5 2.9 – 10.0 1.6 – 10.4 4.7 – 20.4 PAs per week of direct clinical cardiologists pmp cardiologists pmp cardiologists pmp care 14.
General inpatient cardiology
Consultant cardiologists should lead the clinical management of all patients with suspected or confirmed acute primary cardiac conditions, including all of those with acute coronary syndromes. Staffing levels should allow 24h/7d/52w consultant cardiologist led cardiology service for acute coronary syndromes and other primary cardiac conditions. There should be appropriate cardiological input into the care of all acute patients with significant heart disease.
Page 32 of 45 England 2001-02 I00-I09 rheumatic heart disease
Admissions 4,300
I10-I15 hypertensive diseases I20-I25 ischaemic heart diseases
15,024 295,411
I30-I52 other forms of heart disease I70-I79 diseases of arteries, arterioles and capillaries I95-I99 other and unspecified disorders of the circulatory sys Total
195,794
England 2001-02 I26-I28 pulmonary heart disease and diseases of pulmonary circul I60-I69 cerebrovascular diseases I80-I89 diseases of veins and lymphatic system nec Total
Admissions 17,183 98,251 133,338 248,772
61,332 8,687 580,548
NHS data returns for cardiology admissions (Codes I00-I99) in 2001-02 for England indicate that there were 231367 admissions under the care of cardiologists with a mean length of stay of 5.5 days. r There were 829320 admissions of people with a primary cardiac diagnosis, generally not under the care of cardiologists, and who had a mean length of stay of 8.8 days. If admissions with pulmonary heart disease (I26-I28), cerebro-vascular diseases (I60-I69), and venous disorders (I80-I89) are excluded, there were 580548 admissions (11814 pmp) with a primary cardiac diagnosis, which had a mean length of stay of 7.4 days. Of these, 352787 were emergency admissions with a primary cardiac diagnosis (7179 pmp, 61% of total). 14A. Cardiologists required for inpatients now Emergency admissions @7179 pmp: 15-20 minutes each Non-emergency admissions @4635 pmp: 15-20 minutes each Inpatient daily reviews @11814 pmp for 6.4d: 10 minutes each Allow extra 25% of 11814 pmp for other inpt consultations (20 minutes each), and for peaks and troughs of demand Total cardiologists time for inpatients Programmed Activites @4h each If each consultant available 41 weeks per year If each consultant spends 2 PAs/week (8h) on inpatient care 14.1.
Requirement pmp 1795 – 2391 hours 1159 – 1543 hours 12602 hours 984 hours 16540 – 17520 hours 4135 – 4380 hours 101 – 107 PAs per week 51 – 54 consultants pmp
Future inpatient care
Comparison with the USA indicates that there are more cardiology admissions there, but with shorter length of stays, so that there are relatively fewer bed-days used.13 PMP: (Over 65 years old) Cardiology admissions Cardiology bed-days
NHS 20330 185860
Kaiser-Permanente CA 22600 87920
Medicare USA 37190 209580
Cardiology admission rates are higher in the USA (by 11-45%). However, the length of stay is shorter (42-62% of that in the NHS). Therefore, the number of bed-days varies from 53% fewer to 13% more. We would expect that in the NHS in future there will be more cardiology admissions (increased morbidity). There will be shorter lengths of stay (more efficiency). If we assume that in the future there will be 11-45% more admissions, with 42-62% shorter length of stay: 14A. Cardiologists required for inpatient care in future Emergency admissions @7969-10410 pmp:15-20 minutes each Non-emergency admissions @ 5145-6721 pmp:15-20 minutes each
r
Requirement pmp 1993 – 3467 hours 1286 – 2238 hours
http://www.hesonline.nhs.uk/Ease/servlet/DynamicPageBuild?siteID=1802&categoryID=202&catName=Primary%20diagnosis:%20summary
Page 33 of 45 Inpatient daily reviews @13114 - 17131 pmp for 2.9 – 4.6d: 10 minutes each Allow 25% of 13114 - 17131pmp for other inpt consultations (20 minutes each), and for peaks and troughs of demand Total cardiologists time for inpatients Programmed Activites @ 4 hours each If each consultant available 41 weeks per year If each consultant works 7.5 PAs/week of direct clinical care
6338 - 13134 hours 1092 – 1426 hours 10709 – 20265 hours 2677 – 5066 PAs 65 – 124 PAs per week 8.7 – 16.5 consultants pmp
For future inpatient cardiology care, it is evident that a similar average FTE number of consultants will be required as at present, but that the range of possibilities is much wider depending on the nature of inpatient care. If there are more consultants with the resources available to provide the most efficient 24 hours/7 days/52 weeks care for all inpatients (not just emergencies), we would expect that the number of consultants required for inpatient work would be at the lower end of the forecast range. If inpatient cardiology care were provided on a less-efficient 9-5 basis for 5 working days a week, then we would expect that the number of consultants required for inpatient work would be at the higher end of the forecast range. 14.2.
Nurses required for inpatient cardiology
Based on best practice and critical care recommendations, the Fifth Report on the Provision of Services for Patients with Coronary Heart Disease advised that nurse staffing levels should be one nurse to two patients on coronary care units and 1 nurse to 5 patients on cardiac wards.14 15 14B. Nurse staffing for inpatient cardiology CCU beds Nurse staffing 0.5 nurses per bed at any time For 24h/7d/365d care = x 3.5 nurses Add 7 staff per 6 beds for supervisory nurse in charge Total CCU nurses required
Requirement pmp 51 beds pmp 26 CCU nurses pmp at any time 179 CCU nurses pmp 60 supervisory CCU nurses 238 CCU nurses pmp
Cardiology inpatient beds now Nurse staffing 0.2 nurses per bed at any time For 24h/7d/365d care = x1.4 nurses Add 7 staff per 20 beds for supervisory nurse in charge Total cardiac ward nurses required now Total inpatient cardiac nurses including CCU
179 beds pmp 36 cardiac ward nurses pmp at any time 251 cardiac ward nurses pmp 63 supervisory cardiac ward nurses 313 cardiac ward nurses pmp 551 nurses pmp
Cardiology inpatient beds in future Nurse staffing 0.2 nurses per bed at any time For 24h/7d/365d care = x 1.4 nurses Add 7 staff per 20 beds for supervisory nurse in charge Total cardiac ward nurses required in future Total inpatient cardiac nurses including CCU
61 – 190 beds pmp 12 – 38 cardiac ward nurses at any time 85 – 266 cardiac ward nurses pmp 21 – 67 supervisory ward nurses 106 – 333 cardiac ward nurses pmp 344 – 571 nurses pmp
14.3.
Workforce rotas for inpatients requiring cardiac care
There is considerable evidence that inpatients admitted with primary cardiac problems have better medical management when cared for by cardiologists and have better outcomes. Emergency and on-call rotas need to reflect this, with cardiology specialty-based acute medical ‘takes’ and with cardiologist on-call rotas. The first stage should be the move from general medical on-call to general cardiology specialty on-call rotas. The second stage should be to move in time to cardiology subspecialty based oncall rotas, for prompt specialized management of patients who require emergency coronary intervention, arrhythmia or device management, or specialty non-invasive imaging procedures, for example. A network approach covering large populations is likely to be required to provide cardiology specialty and subspecialty based on-call rotas.
Page 34 of 45 15.
Paediatric cardiology
There is currently a shortfall of 52 paediatric consultant cardiologists compared with the number recommended in the Report of the Paediatric and Congenital Cardiac Services Review Group.16 Changes in the number of paediatric cardiac centres recommended in the Report will not affect the overall numbers of paediatricians required. At least 5 consultant posts remain unfilled because of lack of applicants. If posts are unattractive, specialists will disappear and emigrate: this is what has happened in recent years after the Bristol Royal Infirmary Inquiry. At least 2 recently trained UK paediatric cardiologists have chosen to work abroad rather than in the UK. There is some scope for cross-disciplinary care in paediatric cardiology such as protocol based follow-up care by a nurse led clinic for example. There is very limited scope for redeploying work to other specialists such as general paediatricians or GPwSIs, etc. Accurate data available from Southampton paediatric cardiology have been provided by Dr Barry Keaton. We have used these for the following estimates of need for paediatric cardiology: 15A. Consultants in paediatric cardiology
Appointments Southampton / year Appointments Elsewhere / year If each appointment 20-30min Travel time for external clinics Total echos (incl 51 fetal clinics) @ 8204 patients @15 minutes per echo Cardiac catheterisation time Inpatient, handover, on-call and call-outs, correspondence, admin work Total hours 20% extra capacity for outpatients, echos, and catheters* Total hours required per year PAs per year If each consultant available 41 weeks per year FTE Consultants working 7.5 direct clinical care PAs each week
Southampton Paediatric Cardiology (2002-03 data, referral pop 3.2 million) 5000 1664 2221 – 3332 hours 573 hours 2204 hours
PMP
1282 hours 6790 hours
401 hours 2122 hours
13070 – 14181 hours 1256 – 1478 hours
4085 – 4433 hours 393 – 462 hours
14326 – 15659 hours 3582 – 3915 PAs 87 – 95 PAs per week
4478 – 4895 hours 1120 – 1224 PAs 27 - 30 PAs per week
11.6 – 12.7 consultants
3.6 – 4.0 consultants pmp
2083 694 – 1042 hours 179 hours 689 hours
*To allow for reduction in long waiting times in outpatient clinics, echocardiography, and cardiac catheterisations; and to allow for increased referral numbers; and to allow for the peaks and troughs of demand.
These calculations make no provision for paediatric cardiovascular magnetic resonance, nuclear medicine, pacing and electro-physiology, which are done in Southampton by radiology, nuclear medicine and adult cardiology respectively, although may be done by paediatric cardiology in other centres. There is very limited fetal provision. In Southampton paediatric cardiologists only see abnormal scans; all the initial examinations are done by fetal medicine. This will not be applicable to those centres where the paediatric (fetal) cardiologists undertake screening of the atrisk population. These estimates make no provision for student and postgraduate teaching other than during normal daily activities; teaching hospitals may need more consultants. These estimates make no provision for professional duties, such as those undertaken for college or specialty societies. 16.
Adults with Congenital Heart Disease (ACHD)
In future there will be more people with ACHD than children with congenital heart disease; for example currently it is estimated that the there are 1500 people with ACHD, but by 2020 it is
Page 35 of 45 estimated that there will be several thousands; outpatient consultations are expected to double by 2007 as more survivors of childhood treatment reach 16 years old. It is likely that, by 2008, a minimum of one cardiologist with appropriate specialist training in adult congenital heart disease will be needed per million population in tertiary centres. Staffing requirements beyond then are difficult to predict in such a rapidly expanding specialty, and it will be necessary to reassess the situation on a regular basis. With the rapid increase in adult survivors of childhood surgery and the need for shared care between secondary and tertiary centres, it is likely that at least one cardiologist with some expertise in congenital heart disease will be required in every cardiac department. If the logical development of the network model for delivery of paediatric cardiology care is introduced for adult congenital heart disease, there will be a very substantial need for every secondary care general hospital and teaching hospital to provide a basic level of local care for these patients and to develop the expertise to deliver care at an appropriate level, working closely with the tertiary centres. If all secondary care general hospitals and teaching hospitals were to have a cardiologist with a subsidiary interest in congenital heart disease (there are very few at present), the demand for such consultants could exceed 120 over the next 10 years. Data provided by Dr John Gibbs from Leeds General Infirmary have been used for the following estimates of need for ACHD: 16A. Consultant ACHD requirements
Now
Outpatients: 343 pmp pa @ 20 - 30min each
114 – 172 hours
Outreach clinics: double by 2007 and 50% more by 2014 Echo: 200 pmp pa, 5% TOE studies: Catheterisation: 30 pmp pa @ 2.5 hours; 20% complex and require 2 consultants Inpatients, on-call, case conferences, correspondence, etc = 14h per consultant / week Teaching, audit, clin governance, CPD = 6h per consultant / week Total requirements (hours per year) PAs per year PAs per week (available 41 weeks per year) FTE Consultants pmp (working 7.5 direct clinical care PAs per week)
110 – 146 hours 90 hours 335 hours pa 144 hours pa 793 – 887 198 – 222 4.8 – 5.4 0.6 – 0.7
In future (from 2007) 114 – 172 hours
135 hours
In future (from 2014) 114 – 172 hours 228 – 344 hours 330 – 438 hours 180 hours
728 hours pa
1456 hours pa
312 hours pa
624 hours pa
1623 – 1811 406 – 453 10 - 11 1.3 – 1.5
2932 – 3214 733 – 804 18 – 20 2.4 – 2.7
114 – 172 hours extra 220 – 292 hours
The risk of late sudden death for patients surviving surgery for common congenital heart defects is 25 to 100 times greater than an age-matched control population. This increased risk primarily occurs in patients with cyanotic or left heart obstructive lesions. Increasing numbers of these patients will require more specialized ACHD assessments and monitoring, increasing the workload of ACHD specialists. 17.
Academic cardiologists
There are a total of 104 consultant cardiologists with an academic component in England, Wales and Northern Ireland. The Royal College of Physicians calculates that there would need to be an 87% increase in the number of FTE consultant cardiologists with an academic component to provide the current clinical service by them within their NHS contract. Under the new (nonacademic) consultant contract, it is estimated that this would imply the need for 183 consultant cardiologists with an academic component, or 3.4 per million population for England and Wales. We have assumed that there will be an increase in the number of consultant cardiologists with an academic component to 183 FTE posts. It is assumed that, on average, consultant cardiologists
Page 36 of 45 with an academic component will spend one-half (5 programmed activities) of their professional time on academic matters and one-half (5 programmed activities) on clinical duties. 17A. Academic consultant cardiologists Academic consultant cardiologists: 183 ½ of time on clinical duties for the NHS Pro-rata 7.5 PAs per week on direct clinical care
PMP 3.4 pmp 1.7 pmp clinical work 1.3 pmp clinical work
We can calculate that the NHS requirements for consultant cardiologists can be reduced by 1.3 FTE posts pmp due to the contribution from consultant cardiologists with an academic component. This equates to approximately 442 PAs pmp per year (1.7 FTE pmp multiplied by 5 PAs multiplied by 52 weeks = 442 PAs pmp per year). However, this clinical contribution will still need to be recognised and paid for by the NHS. And this requirement will not result in a reduction in the numbers of trainees: places for both clinical and academic trainees will be required. Non-invasive cardiac imaging 18.
Echocardiography
Need for echocardiography
No of studies per million population per year
Transthoracic: Heart failure Transthoracic: Valve disease Transthoracic: Coronary disease Transthoracic: Arrhythmia Transthoracic: Hypertension Transthoracic: Noncardiac Total transthoracic Stress echocardiography Transoesophageal echo
7800 – 10200 3300 – 5800 4200 3500 20000 4000 42800 – 47700 6000 2000
An average transthoracic study takes 30-40 minutes (one TTE equivalent). The following TTE equivalents apply: inpatient transthoracic 1.5, transthoracic with training 1.5, transoesophageal 2, stress 3, ward-based 2 or 3 (depending on hospital geography), intra-operative 6. In the UK, clinical physiologists currently perform 90% of transthoracic studies. A clinical physiologist can perform about 12 TTE equivalents each day or 1500 equivalents per year. This allows time for CME, annual leave, quality control, and administration. 18B. Need for sonographers Transthoracic studies: 90% 33% teaching with duration 1.5 TTE 33% outpatients, no teaching, duration 1.0 TTE 33% inpatients with duration 1.5 TTE Total equivalents for transthoracic echos Stress echos @6000 with duration 3.0 TTE Transoesophageal echos @2000 with duration 2.0 TTE Total echo studies in TTE equivalents
TTE equivalent per million population 38520 - 42930 19258 - 21463 12837 - 14307 19258 - 21463 51353 - 57233 18000 4000 73353 - 79233
Each TTE equivalent takes 30-40 mins Allow for 20% inefficiency* and for peaks and troughs Sessions @3.75h Allow for reduction of 768 – 1023 sessions (see below) to avoid duplication with dynamic stress nuclear perfusion If staff available 44 weeks per year If staff perform studies working 9 sessions per week
36677 – 52822 hours / year 44012 – 63386 hours / year 11737 – 16903 sessions / year 10969 – 15880 sessions / year 249 – 361 sessions / wk 28 – 40 FTE sonographers pmp
* It is not possible to do a partial number of cases in each session (eg 6.4 cases in 3.75 hours); only whole numbers of cases can have procedures performed.
Page 37 of 45
18A. Need for consultants specialising in echo Complex transthoracic echo: 10% @45min Transoesophageal echo: 1300 pmp @1.0 – 1.33h each Intra-operative TOE: 750 pmp @3.0 – 4.0h each Stress echos: 6000 pmp @1.0 – 1.33 hours each Triage studies, teach, and clinical liaison: 4h per 10002000 TTE studies Total time required Allow for 20% inefficiency* and for peaks and troughs PAs @4.0h each Allow for reduction of 720 – 960 PAs (see below) to avoid duplication with dynamic stress nuclear perfusion studies If each consultant available 41 weeks per year FTE Consultants working 7.5 direct clinical care PAs each week
Need per million population 3210 – 3578 hours / year 1300 – 1729 hours / year 2250 – 3000 hours / y 6000 – 8000 hours / year 171 – 191 hours / year 12931 – 16498 hours / year 15517 – 19798 hours / year 3879 – 4949 PAs / year 3159 – 3989 PAs / year 77.0 – 97.3 PAs per week 10.3 – 13.0 FTE consultants pmp
* It is not possible to do a partial number of cases in each programmed activity (eg 6.4 cases in 4.0 hours); only whole numbers of cases can have procedures performed.
19.
Nuclear cardiology
19A. Nuclear cardiac consultants required Undiagnosed referrals after RACPC assessment = 33% of 11396 MI survivors requiring dynamic imaging = 50% of 2339 Other patients requiring dynamic imaging (post angio, post CABG, pre-operative risk assessment, etc) Myocardial perfusion scintigraphy (stress + rest) Time required @45 minutes each Allow for 20% inefficiency* and for peaks and troughs Programmed activites @4h each Allow for reduction of 540 PAs (see below) to avoid duplication with dynamic stress ECHO If each consultant available 41 weeks per year If each consultant works 7.5 PAs/week of direct clinical care
Requirement pmp 3761 pmp 1170 pmp 1000 pmp 6000 studies 4500 hours 5400 hours 1350 PAs 810 PAs 20 PAs per week 2.7 FTE pmp
* It is not possible to do a partial number of cases in each programmed activity (eg 5.3 cases in 4.0 hours); only whole numbers of cases can have procedures performed. http://www.nice.org.uk/Docref.asp?d=95051
Notes for sections 18 and 19: Adjustment of workforce requirements for dynamic imaging in coronary disease Dynamic stress myocardial perfusion scintigraphy and stress echocardiography provide comparable information with broadly similar sensitivities and specificities in patients with known or suspected coronary disease. The provision of dynamic stress imaging studies will therefore depend on local expertise and which facility may be locally available. This document does not favour or specify one technique over the other. For overall workforce planning estimations without full duplication of both myocardial perfusion scintigraphy and stress echocardiography, there will be some redundancy in the figures for dynamic stress imaging studies. It is suggested that a reduction in provision of 40% for each investigation would be appropriate for an overall estimation of workforce requirements in the UK; but local variation in provision of facilities and expertise would obviously result in a different local balance to this. Duplication of dynamic stress imaging: reduction in staff requirements Stress echos: total 6000 pmp @1.0 – 1.33 hours each Reduction: less 40% = less 2400 studies pmp Allow for 20% inefficiency and for peaks and troughs Reduction in Programmed Activities @4.0h each
Requirement pmp 6000 – 8000 hours / year Less 2400 – 3199 hours / year Less 2880 - 3839 Less 720 – 960 PAs / year
Page 38 of 45 Less sonographer sessions @3.75h
Less 768 – 1023 sessions / year
Myocardial perfusion scintigraphy: total 6000 studies Reduction: less 40% = less 2400 studies pmp Allow for 20% inefficiency and for peaks and troughs Reduction in Programmed Activities @4.0h each
4500 hours Less 1800 hours Less 2160 hours Less 540 PAs
20.
Cardiovascular imaging
Cardiac magnetic resonance imaging is increasingly used and required in congenital heart disease; specific cardiac magnetic resonance imaging expertise should be available in approximately 12 centres for paediatric and ACHD cardiology. It is assumed that an average of one FTE consultant specialising in cross sectional imaging would be required in each tertiary centre (~55 centres): 20A. Cardiovascular imaging: magnetic resonance (MR), computed tomography (CT), electron beam computed tomography (EBCT), positron emission tomography (PET) etc One consultant per 55 centres PAs @10 PAs per week PAs per year pmp If each consultant available 41 weeks per year FTE consultants (working 7.5 PAs of direct clinical care per week)
Requirement pmp
55 consultants UK 550 PAs per week UK 486 PAs per year pmp UK 11.9 PAs per week pmp 1.6 consultants pmp
Current developments in multi- (ie 64 or 128) slice, simultaneous, fast acquisition, cardiac CT imaging with sufficient resolution might replace invasive diagnostic (epicardial) coronary angiography within the next few years. It is very difficult to quantify how much diagnostic coronary angiography might be replaced by future cardiac CT imaging. The British Cardiac Society has recently set up a Working Group on Non Invasive Imaging and Assessment of Coronary Disease. This will assess the role of non-invasive cross-sectional imaging in the future. 21.
Other non-invasive cardiac investigations
We do not have detailed data available on these medical and physiological requirements. Cardiac workforce planning will need to include appropriately qualified staff for the following procedures: 21.1.
Electrocardiograms (ECG)
Resting ECGs, signal averaged ECGs. 21.2.
Other exercise testing
Other indications for exercise ECG testing, eg for routine follow-up after coronary intervention, exertional arrhythmias, chronotropic incompetence, cardio-respiratory assessment (VO2max), risk assessment with T-wave alternans, in hypertrophic cardiomyopathy etc. 21.3.
Ambulatory monitoring
Ambulatory electrocardiogram monitoring (24 hour and 7 day and event monitors), heart rate variability assessment, ambulatory blood pressure monitoring, analysis and reporting of these investigations. 21.4.
Autonomic investigations
Tilt table testing, neurocardiogenic investigations.
Page 39 of 45 22.
Assessment of doctors in training in cardiology
Dr Anthony Mourant, Chairman of BCS Education Committee has provided the following data. Each educational supervisor of an individual specialist registrar (SpR) is likely to spend around 4 sessions per annum on the new methods of assessment. These calculations are for assessment of trainees, and not for training the trainees. The time required should be in addition to, or instead of, that worked in direct clinical care. They take no account of the time we all spend at present, and will spend in future, on SpR training. It has been estimated that an additional 25% of time should be allowed for those procedures (or a reduction in caseload by 25%) when training a trainee. 22A. Assessment of doctors in training Theoretical assessment programme DOPs, miniCEX and 3600 assessments and feedback Overall RITA assessment Total PMP If each consultant available 41 weeks per year Consultants required @10 PAs per week 23.
Requirement for ~500 SpR trainees 1200 consultant PAs per year 625 consultant PAs per year 144 consultant PAs per year 1969 consultant PAs per year 34 consultant PAs per year pmp 0.8 PAs per week 0.1 consultants pmp
Management requirements in cardiology
There should be recognition of the requirements for the clinical management of cardiac services: 23A. Clinical management of cardiac services Tertiary cardiac centres (n=38): clinical director in cardiology: 3 PAs / week Secondary cardiac hospitals (n=236): lead clinician in cardiology: 2 PAs / week Cardiac networks: lead clinician in cardiology (n=39?): 3 PAs / week Total PAs per year If each consultant available 41 weeks per year Consultants required @10 PAs per week
pmp 2 PAs per week pmp 8 PAs per week pmp 2 PAs per week pmp 12 PAs per week pmp 624 PAs per year pmp 15.2 PAs per week 1.6 consultants pmp
Summary: Subspecialty consultants required Subspecialty consultants required by procedure
PAs per year pmp
FTE consultants per million population required (working exclusively in their subspecialty for 7.5 NHS direct clinical care PAs of 4h each per week)
1A. 4A. 5A. 6A. 7A. 7A. 8A. 9A. 11A. 12A. 13A. 14A. 15A. 16A.
Specialist prevention clinics Diagnostic angiography PCI Other invasive interventions Diagnosing heart failure Monitoring heart failure Leading cardiac rehabilitation Device implantation Other EP and arrhythmias Miscellaneous acquired conditions Gen outpatient cardiology Gen inpatient cardiology Paediatric cardiologists ACHD
106 – 142 828 – 1266 990 – 1350 48 – 56 207 – 311 1076 484 1284 394 – 788 156 – 260 1416 – 6284 2677 – 5066 1120 – 1224 733 – 804
0.3 – 0.5 2.7 – 4.1 3.2 – 4.4 0.2 0.7 – 1.1 3.5 1.6 4.2 1.3 – 2.6 0.5 – 0.8 4.7 – 20.4 8.7 – 16.5 3.6 – 4.0 2.4 – 2.7
Page 40 of 45 17A.
18A. 19A. 20A. 22A. 23A.
Academic cardiologists: clinical work (reduction: academic contribution to clinical work reduces overall NHS consultant cardiologist requirements) Imaging: echo Imaging: nuclear Imaging: other incl MR, CT, etc Assessment of trainees Clinical management Total consultant cardiologists
Less 442
Less 1.3
3159 – 3989 810 486 34 624 16190 – 25896 (PAs pmp)
10.3 – 13.0 2.7 1.6 0.1 1.6 52.7 – 84.2 (Consultants pmp)
Increasingly cardiologists will practice in a cardiology subspecialty interest. However, we do not expect cardiologists to practice exclusively doing procedures for all their programmed activities of direct clinical care, or undertaking general cardiology outpatients or general inpatient cardiology for all of their professional working time! In order to allocate the need for general cardiology outpatients and general inpatient cardiology to appropriate subspecialty interests, we have apportioned this need to each subspecialty interest pro rata in the following table. Summary: Consultant cardiologists required Cardiology subspecialties
PAs required pmp per year
General outpatient cardiologys (PAs pmp per year)
General inpatient cardiologys (PAs pmp per year)
Total PAs pmp per year
PAs per week pmpt
FTE Consultants pmp (working 7.5 PAs per week)
Diagnostic cath
828 – 1266 1038 – 1406 1283 – 1387 484 1284 394 - 788 262 - 402
117 – 647
221 – 521
1166 – 2434
28 – 59
3.8 – 7.9
147 – 718
277 – 579
1462 – 2703
36 – 66
4.8 – 8.8
181 – 709
343 – 571
1807 – 2667
44 – 65
5.9 – 8.7
68 – 247 181 – 656 56 – 413 37 – 205
129 – 199 343 – 529 105 – 325 70 – 166
682 – 931 1808 – 2469 555 – 1515 369 – 773
17 – 23 44 – 60 14 – 37 9 – 19
2.2 – 3.0 5.9 – 8.0 1.8 – 4.9 1.2 – 2.5
1120 – 1224
27 – 30
3.6 – 4.0
733 – 804
18 – 20
2.4 – 2.6 -1.4 14.5 – 24.9
Intervention Heart failure Rehabilitation Devices EPS + ablation Miscellaneous (specialised 2º previous and rare miscillaneous conditions)
Paediatric cardiologists ACHD Less academic Imaging: Echo Imaging: nuclear Other imaging Trainee assess Clinical management Total for consultants
1120 – 1224 733 – 804 -442 3159 – 3989 810
446 – 2038
843 – 1643
-442 4448 – 7669
114 – 414
216 – 334
1141 – 1557
-11 109 – 187 28 – 38
486 34 624
69 – 248
130 – 200
684 – 934 34 624
17 – 23 1 15
2.2 – 3.0 0.1 2.0
12097 – 14546
1416 – 6284
2677 – 5066
16190 – 25896
395 - 632
52.7 – 84.2
3.7 – 5.1
The totals here differ very slightly from the previous table because of rounding-up of totals to whole numbers. s t
Allocated pro-rata according to sub-specialist requirements Assumes consultants available 41 weeks per year
Page 41 of 45
Summary: Non-consultant cardiology workforce required
1B. 2B. 3B. 3B. 7B. 7B.
Non-consultant cardiology workforce Non-consultant cardiologists, PwSIs, nurses, cardiac physiologists, radiographers Secondary prevention of CHD RACPC Acute chest pain and thrombolysis Post MI follow-up Diagnosing heart failure Monitoring heart failure Total specialist cardiac clinicians (mainly nurses?)
Sessions pmp per year (@ 3.75 hours per session)
2372 3495 ? 92 662 4590 11211 + ?
FTE clinicians per million population required (working 9 clinical sessions per week) 6.0 17.6 28 – 47 0.2 1.7 11.6 65.1 – 84.1
14B.
Inpatient nursing care (CCU + wards)
4B. 4B. 5B. 5B. 5B. 6B. 9B. 10B. 11B.
Cardiac catheterisation and angio Angiography pre-assessment PCI PCI pre-assessment Post PCI follow-up Other intervention Devices - implantation Devices – follow-up Other EP intervention Total invasive cardiac clinicians (physiologists, nurses, radiographers)
3531 – 5401 338 – 518 4224 – 5760 169 - 230 337 – 460 177 – 265 1357 (x2) 4800 (x2) 420 – 840 15353 – 19631
8.9 – 13.6 0.9 – 1.3 11 – 15 0.4 – 0.6 0.9 – 1.2 0.5 – 0.7 6.9 24 2.1 – 4.2 50.4 – 61.0
18B. 21B.
ECHO: CP/sonographers Other non-invasive cardiac investigations Total non-invasive cardiac clinical physiologists
10969 – 15880 ?
28 – 40 ?
10969 – 15880 + ?
27 – 39 + ?
Total cardiac rehab clinical staff
7803
20
Total (excluding CCU + wards) (Non-consultant cardiology workforce)
45336 – 54525
168 – 211 plus ?
8B.
344 – 571
Page 42 of 45 Glossary: ACHD
Adults with congenital heart disease: care of patients who have been born with heart disease.
Acute chest pain
A range of conditions that reflect reduced or absent blood flow to the heart muscle; includes unstable angina and heart attack.
AMI
Acute myocardial infarction
Cardiac ablation
Using an energy source such as radio frequency or laser energy to destroy a small area of the heart and prevent further arrhythmias.
Clinical cardiac electrophysiology
The mechanisms, functions, and performance of the electrical activities of specific regions of the heart.
CABG
Coronary artery bypass graft: operation carried out by cardiac surgeons in tertiary centres to ”bypass” blocked coronary arteries.
CCU
Coronary care unit: specialist cardiac unit for the care of patients having had myocardial infarction.
CHD
Coronary heart disease: disease that leads to angina and heart attacks caused by narrowing of the coronary blood vessels. Secondary prevention of CHD: preventative treatment of patients with established coronary heart disease to reduce the risk of further heart problems.
CP
Cardiac physiologist
CR
Cardiac rehabilitation: an intervention program designed to help heart patients achieve their optimal physical, medical, psychological, social, emotional, vocational, and economic status after the diagnosis of heart disease or a heart attack.
CRT
Cardiac resynchronisation therapy: using a biventricular pacemaker, a small, battery-operated, electronic device implanted under the skin. It is connected to three chambers of the patient's heart, which reorganises and regulates the heart beat in cases of un-coordinated heart beats.
CT
Computed tomography: A special radiographic technique that uses a computer to assimilate multiple X-ray images into a 2 dimentional cross-sectional image.
DCC
Direct clinical care (a specified type of programmed activity)
DCM
Dilated cardiomyopathy: A group of disorders where the heart muscle is weakened and cannot pump effectively. The net result is dilation of the cardiac chambers or cardiac enlargement. The poor cardiac function results in congestive heart failure.
Diagnostic cardiac catheterisation and angiography
Cardiac catheterisation involves the passage of a catheter (a thin flexible tube) into the heart. Coronary angiography is a procedure in which a contrast material (dye) is injected into one of the arteries of the heart to outline them and that can be seen using X-rays.
DNA
Did not attend
EBCT
Electron beam computed tomography: imaging technique to detect coronary calcification, associated with the presence of atherosclerosis.
Echocardiography
ECG
A procedure that evaluates the structure and function of the heart by using sound waves recorded on an electronic sensor that produce a moving picture of the heart and heart valves. Electrocardiogram:
EPS
Electrophysiological study: assessment of the mechanism underlying
Page 43 of 45 abnormalities of cardiac rhythm measuring electrical impulses within the heart. FTE
Full time equivalent
GPwSI
General practitioners with a specialist interest in cardiology
HCM
Hypertrophic cardiomyopathy: overgrowth of heart muscle which impedes blood flow into and out of the heart.
Heart failure
A condition caused when the heart is unable to pump enough blood to meet the needs of the body.
ICD
Implantable cardiac defibrillator: an inserted electronic device that constantly monitors your heart rate and rhythm. When it detects a very fast, abnormal heart rhythm, it delivers electrical energy as an internal electrical shock to the heart muscle. This causes the heart to beat in a normal rhythm again.
Loop recorder
A small recorder (monitor) attached to electrodes on the chest. It is worn continuously for a period of time. If patients feel symptoms, they can depress an event button and the heart's rhythm is recorded and saved in the recorder.
MI
Myocardial infarction: the coronary artery becomes blocked and part of the heart muscle dies as a result. It is treated by unblocking the artery by a balloon (PCI) or thrombolysis.
MPS
Myocardial perfusion scintigraphy: nuclear scanning procedure to evaluate coronary blood flow.
MR/MRI
Magnetic resonance/magnetic resonance imaging: technique to show the heart’s anatomy using magnetic fields and radio waves.
NSF for CHD
National service framework for coronary heart disease: sets standards by which coronary heart disease should be treated within England in primary, secondary and tertiary care.
Nuclear cardiology
Non-invasive tests to evaluate heart disease using a small amount of radioactive substance. Radionuclide is injected into a vein and its presence is detected by a gamma camera.
PA
Programmed activity
Paediatric cardiology
Diagnosis and treatment of diseases of the heart of infants and children.
PCI
Percutaneous coronary intervention (also called angioplasty): a balloon catheter is used to create a bigger opening in the coronary artery to increase blood flow. Angioplasty is commonly performed with stenting, in which a balloon is used to expand a metal sleeve inside the artery.
PCT
Primary care trust
PET
Positron emission tomography: imaging technique used mainly to measure blood flow and the metabolism in tissues, such as the heart muscle.
PMP
Per million population
PPM
Permanent pacemaker: a small, battery-operated, electronic device implanted under the skin and connected to the patient's heart, which stimulates and regulates the heart beat in cases of severe slowing of heart rate.
RACPC
Rapid access chest pain clinic
RAHFC
Rapid access heart failure clinic
Page 44 of 45 RCP
Royal College of Physicians
Stable angina
Regular or predictable angina symptoms that have been occurring for over 2 months
SHA
Strategic health authority
TOE
Transoesophageal echocardiography
TTE
Transthoracic echocardiography
Thrombolysis
Dissolving a blood clot (thrombus) in a blood vessel usually by administration of medication. Thrombolysis can occur physiologically (that is, without intervention) or subsequent to administration of a thrombolytic drug.
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