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5. SERVICES FOR CHD
5.1 People with heart disease and their families understandably want their healthcare needs to be met as locally as possible. Better Health, Better Care emphasises that resources should be directed to supporting local front-line services wherever possible and that such services should be linked by new technology to specialist centres providing additional support and information where this is required.
Optimal Reperfusion for ST Elevation Acute Coronary Syndrome ( ACS)
5.2 Optimal reperfusion therapy depends upon collaborative working between cardiologists, emergency departments and the Scottish Ambulance Service. SIGN Guideline 93 recommends that, where possible, patients with ST elevation ACS should be treated immediately with primary percutaneous coronary intervention ( PCI). Where patients are unlikely to receive angioplasty within 90 minutes of diagnosis, they should receive immediate thrombolytic therapy (where appropriate) and then be taken directly to a specialist intervention centre for urgent coronary angiography or emergency rescue angioplasty.
5.3 A study of a hybrid programme of pre-hospital thrombolysis and primary PCI in NHS Lothian has demonstrated very positive results, with a median ECG to primary PCI balloon time of 48 minutes and apparent reductions in deaths and length of hospital stays. The key to this success was the use of pre-hospital decision-making for patients presenting with chest pain via the Scottish Ambulance Service.
Heart Failure Services
5.4 Improved survival rates from acute myocardial infarction and the demographics of an ageing population mean that heart failure is becoming an increasingly prevalent condition, often associated with co-morbidities.
5.5 Ideally a local physician with a special interest in heart failure should be identified in each secondary care setting to lead a heart failure team that manages patients directly, provides specialist advice to other clinical colleagues and acts as the link to regional and national heart failure services. This team should include a lead consultant, cardiology nursing staff, heart failure nurses (working between acute and community settings) and a pharmacist.
5.6 Managed Discharge (from hospital to primary care) is crucial in the management of patients with heart failure and should aim to provide:
- community support, through, for example, community heart failure nurses;
- outpatient multidisciplinary follow up, including pharmacy input;
- regular review of drug treatment to optimise pharmacological interventions;
- patient information, including self-management programmes, in language which can be readily understood; and
- arrangements for appropriate end of life care.
5.7 Recent research by the British Heart Foundation highlighted the value that patients place upon the care received from specialist nurses in heart failure. Having one person with whom they could build up a relationship of trust and understanding noticeably improved their recovery rate and increased their own confidence in being able to cope with their heart condition. The fact that heart failure nurse specialists are often supplementary prescribers, working with medical and pharmacy colleagues to locally agreed medical therapy guidelines, contributes to the observed reductions in hospital admissions in these nurse led services.
5.8 All such services need to link to the exercise programme component of the local cardiac rehabilitation service, and in remote and rural locations the potential for a "generic" cardiovascular nurse to undertake both heart failure and cardiac rehabilitation roles should be considered.
5.9 The palliative care needs of those with advanced heart failure have long been recognised as an area requiring attention. Publication in March 2008 of the report Living and dying with advanced heart failure: a palliative care approach by the Scottish Partnership for Palliative Care and the British Heart Foundation Scotland sets out a range of recommendations for addressing this issue. The creation by the British Heart Foundation and Marie Curie Cancer Care of a centre of excellence in Glasgow, and their investment in research and development for advanced heart failure patients, represents a major contribution.
Cardiac Rehabilitation
5.10 Comprehensive cardiac rehabilitation consists of exercise training together with education and psychological support. It helps patients to return to normal living and encourages them to make lifestyle changes to prevent further cardiac events. It also provides a vehicle for the delivery of enhanced secondary prevention, by treating medical risk factors and delivering optimal medical therapy.
5.11 Until recently, only patients who had had a myocardial infarction or cardiac intervention (angioplasty or bypass graft) had access to cardiac rehabilitation services. It is now clear that patients who undergo other "step changes" in their condition, such as unstable angina, new onset angina or heart failure, will also benefit from cardiac rehabilitation.
5.12 The Scottish Campaign for Cardiac Rehabilitation, led by the British Heart Foundation Scotland and Chest Heart and Stroke Scotland, has highlighted the opportunity to increase participation rates in cardiac rehabilitation from 60% to 80%. This, the campaign suggests, could be achieved by tailoring services to suit individual patient needs and implementing innovative solutions such as evening provision or home-based programmes to draw in under-represented groups such as those from minority ethnic communities, and those in remote and rural and/or deprived communities.
Cardiac Sub-Specialties
5.13 A number of cardiac sub-specialty components need to be delivered through robust regional arrangements to ensure equity of access. These include coronary interventions, device therapy, electrophysiology services, heart failure services and services for inherited cardiac conditions.
5.14 Coronary artery bypass grafting is delivered in three regional centres, which are aligned to interventional cardiology hubs. The establishment of isolated cardiac catheterisation facilities within district general hospitals ( DGHs) is not the preferred model for Scotland and existing DGH cath labs must be involved in a wider interventional network at regional level to ensure optimal use of resources. Invasive cardiac investigations should be performed in these regional centres, with DGH cardiologists participating in the service on a sessional basis.
West of Scotland Heart and Lung Centre
5.15 The new West of Scotland Heart and Lung Centre at the Golden Jubilee National Hospital ( GJNH) became operational in 2007 and made a significant contribution to meeting the waiting time guarantee in cardiac activity by 31 December 2007. The migration of clinical services from Glasgow and Lanarkshire to the GJNH was completed in spring 2008, making the Centre one of the largest in the UK serving the residents of all six West of Scotland NHS Boards. It also houses three of Scotland's national services:
- Scottish Advanced Heart Failure Service, including the heart transplant unit;
- Scottish Pulmonary Vascular Unit; and
- Scottish Adult Congenital Cardiac Service, previously known as the Grown-Up Congenital Heart Unit.
The Centre also links to the Glasgow Heart and Lung Institute, the result of a partnership between the NHS in the West of Scotland and the University of Glasgow, including the British Heart Foundation's Glasgow Cardiovascular Research Centre. The Institute will broaden and strengthen collaboration between clinicians and scientists with the aim of translating research into care as swiftly as possible.
5.16 The Centre offers patients:
- an integrated heart and lung centre with equal access to a wide range of specialist services for all patients in the West of Scotland;
- concentration of expertise, enabling sub-specialisation;
- excellent accommodation and environment in a modern, purpose-built facility;
- access to £4 million of new equipment;
- R & D and academic activity that will lead to innovation and improvements in patient care, building on existing academic links; and
- ongoing service redesign to improve patient care and patient experience.
5.17 Following approval by the West of Scotland Regional Planning Group, an Enhanced Reperfusion service will be implemented across the West of Scotland in 2008. Patients with ST elevation ACS will be brought by the Scottish Ambulance Service directly to either GJNH or Hairmyres Hospital for primary PCI, if they are within the agreed travel time. Patients outwith the agreed travel time will receive thrombolysis (where appropriate) prior to being brought to the intervention centre for follow-up care.
National Centre for the Treatment of Advanced Heart Failure
5.18 The national CHD and Stroke Strategy Update published in 2004 allocated £450,000 to establish a National Centre for the treatment of advanced heart failure.
5.19 The National Centre is a nationally designated service which includes the Scottish Heart Transplant Unit. Falling donor rates and the development of new medical technologies such as cardiac resynchronisation therapy ( CRT) for the management of chronic heart failure mean that the historical patterns of patient referral and care to the Scottish Heart Transplant Unit are changing. Heart transplantation is increasingly seen as one of a range of treatment options.
5.20 The National Centre will improve patient management in this area by:
- updating and educating professional and management colleagues throughout NHSScotland about the new service;
- acting as a tertiary source of advice to clinical colleagues at regional and local level;
- addressing the unmet needs of heart failure patients;
- establishing appropriate "rescue" services for acute severe heart failure;
- promoting the role of non-transplant cardiac surgery in heart failure patients; and
- working synergistically with the nationally designated Scottish Adult Congenital Cardiac Service and Scottish Pulmonary Vascular Unit.
Familial Arrhythmia Network Scotland
5.21 A national Managed Clinical Network, the "Familial Arrhythmia Network Scotland" ( FANS) is being developed to raise awareness of familial arrhythmias, define and agree referral protocols, develop national guidelines for clinical and genetic testing and establish a national register. The register will support long term follow-up, including testing for the late onset of a condition, administration of new therapies and scope for identifying new genes and genetic tests as they become available.
5.22FANS is only a partial solution to problems associated with sudden cardiac death, in that it addresses deaths related to arrhythmias but not those related to abnormalities such as hypertrophic cardiomyopathy. The aim therefore is to develop a parallel Network for cardiomyopathies. The third element of this Network approach is to promote links with the existing Scottish Muscle Network, which covers cardiac problems related to inherited neuro-muscular conditions such as myotonic dystrophy or Duchenne Muscular Dystrophy. In the course of time, these Networks will be merged into a fully multidisciplinary specialist Network covering all inherited cardiac conditions.
Heart Screening for Amateur Athletes
5.23 The Cabinet Secretary for Health and Wellbeing announced recently the Scottish Government's intention to work with the Scottish Football Association to establish a pilot programme that will provide, for the first time, a free heart screening service for amateur athletes in Scotland. The pilot programme will be based at the sports medicine centre at Hampden stadium and will include collaboration with Dundee University. Funding of around £100,000 has been identified from within existing resources to support this research project.
ISSUES TO CONSIDER
What further actions should we take to improve the range and quality of CHD services in Scotland and how should these actions be prioritised?
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