Cardiac workforce requirements in the UK - David Hackett Chairman, BCS Cardiac Workforce Committee
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Page 1 of 45 Cardiac workforce requirements in the UK David Hackett Chairman, BCS Cardiac Workforce Committee June 2005
Page 2 of 45 Published by: British Cardiac Society 9 Fitzroy Square London W1T 5HW Tel: +44 (0) 20 7383 3887 Email: firstname.lastname@example.org 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 10 contributions to NHS 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 14 countries 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 17 staffing 4.1 Diagnostic cardiac catheterisation and angiography: current 17 requirements 4.2 Diagnostic cardiac catheterisation and angiography: future 18 requirements 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
Page 4 of 45 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 28 requirements: 11 Invasive arrhythmia electrophysiological (EP) studies and 28 ablation Other cardiac workforce requirements 29 12 Rare cardiac conditions 29 Workforce requirements: general cardiology 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 37 for dynamic imaging in coronary disease 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 52.7 – 84.2 per million population Total non-consultant cardiology workforce 168 – 211 per million population +?b 1.1. Summary: consultant cardiologists required in the UKa Cardiology subspecialties Total programmed PAs per Full time General inpatient and outpatient activities (PAs) per week pmpc equivalent (FTE) requirements included pro rata million population consultants pmp With number of procedures or cases; (pmp) per year (working 7.5 PAs pmp = per million population per week) Diagnostic catheters (4412–6750 pmp) 1166 – 2434 28 – 59 3.8 – 7.9 Intervention (2200-3000 pmp) 1462 – 2703 36 – 66 4.8 – 8.8 Heart failure 1807 – 2667 44 – 65 5.9 – 8.7 Rehabilitation (5089 cases pmp) 682 – 931 17 – 23 2.2 – 3.0 Devices (900 new permanent 1808 – 2469 44 – 60 5.9 – 8.0 pacemakers + 700 new implantable cardiac devices + 107 car resonant pmp) Electrophysiological study (EPS) + 555 – 1515 14 – 37 1.8 – 4.9 ablation (350–700 pmp) Miscellaneous (specialised 2º previous 369 – 773 9 – 19 1.2 – 2.5 and rare miscellaneous conditions) Paediatric cardiologists 1120 – 1224 27 – 30 3.6 – 4.0 Adults with congenital heart 733 – 804 18 – 20 2.4 – 2.6 disease Less academic -442 -11 -1.4 Imaging: Echocardiography (42800- 4448 – 7669 109 – 187 14.5 – 24.9 47700 pmp) Imaging: nuclear (6000 stress pmp) 1141 – 1557 28 – 38 3.7 – 5.1 Other imaging 684 – 934 17 – 23 2.2 – 3.0 Trainee assessment 34 1 0.1 Clinical management 624 15 2.0 Total for consultants 16190 – 25896 395 - 632 52.7 – 84.2 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 b No data or estimations are available c Assumes consultants available 41 weeks per year
Page 6 of 45 1.2. Summary: non-consultant cardiology workforce requiredd Non-consultant cardiology workforce Sessions pmp per FTE clinicians per Non-consultant cardiologists, General yeare million population practitioners with a specialist interest in cardiology (GPwSIs), nurses, cardiac physiologists (CPs), required (working 9 clinical radiographers sessions per week) Secondary prevention of CHD 2372 6.0 Rapid access chest pain clinics 3495 17.6 (RACPC) Acute chest pain and thrombolysis ? 28 – 47 Post myocardial infarction (MI) follow-up 92 0.2 Diagnosing heart failure 662 1.7 Monitoring heart failure 4590 11.6 Total specialist cardiac clinicians 11211 + ? 65.1 – 84.1 (mainly nurses?) Inpatient nursing care (coronary care 344 – 571 units (CCU) + wards) Cardiac catheterisation and 3531 – 5401 8.9 – 13.6 angiography Angiography pre-assessment 338 – 518 0.9 – 1.3 Percutaneous coronary intervention 4224 – 5760 11 – 15 (PCI) PCI pre-assessment 169 - 230 0.4 – 0.6 Post PCI follow-up 337 – 460 0.9 – 1.2 Other intervention 177 – 265 0.5 – 0.7 Devices - implantation 1357 (x2) 6.9 Devices – follow-up 4800 (x2) 24 Other electrophysiological intervention 420 – 840 2.1 – 4.2 Total invasive cardiac clinicians 15353 – 19631 50.4 – 61.0 (physiologists, nurses, radiographers) Echocardiography: CP/sonographers 10969 – 15880 28 – 40 Other non-invasive cardiac ? ? investigations Total non-invasive cardiac clinical 10969 – 15880 + ? 27 – 39 + ? physiologists Total cardiac rehabilitation clinical 7803 20 staff Total (excluding CCU + wards) 45336 – 54525 168 – 211 plus ? (Non-consultant cardiology workforce) d Ranges provided are the minimum and ideal future requirements e 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.
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.
Page 9 of 45 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
Page 11 of 45 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: • 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 non- consultant cardiac workforce required will need to be adjusted accordingly. 10. 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 52.7 – 84.2 per million population Total non-consultant cardiology workforce 168 – 211 per million population +? g Ranges provided are the minimum and ideal future requirements
Page 13 of 45 Appendix 1: Methodology 1. Availability of clinical staff: NHS staff Medical staff England (new Non-medical clinical consultant contract 2003) staff (Agenda for Change)6 Annual leave 30 – 32 days 27 – 33 days Public holidays 8 days 8 days Internal clinical governance leave ? ? Study leave 10 days (30 days for SpRs) ? External professional leave ? ? Sickness absence leave rate 1.4%h (England) 4.7% (England: see below) Estimated subtotal leave 48 – 60 days 36 – 52 days Total annual leave (5-day working 10 – 12 weeks 7 – 10 weeks week) Total working year 40 – 42 weeks 42 – 45 weeks Average working year 41 weeks 44 weeks Working hours per week 40 hours 37.5 hours (excluding breaks) Working hours per session 4.0 hours per Programmed 3.75 hours per Activity (PA) session Work time spent in direct clinical care 7.5 PAs (75% of total) 9 sessions? (assumption 90% of total?) Annual work time of a FTE clinician ~60% ~75% spent in direct clinical care 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 non- medical clinical staff. Reported sickness absence leave rates for all staff working in the NHS in different countries of the UK: • England 4.7%i h http://www.nhspartners.org.uk/subscribers/Inter_org_summary.pdf i http://www.dh.gov.uk/assetRoot/04/08/71/28/04087128.xls
Page 14 of 45 • Wales 6.0%j • Scotland 4.9%k • Northern Ireland 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 Englandm Walesn Scotlando N Irelandp Annual leave 30 – 32 days 30 days 30 days 30 – 34 days Public holidays 8 days 8 days 10 days 10 days Study leave 10 days 10 days 10 days 10 days Total leave# 48 – 50 days 48 days 50 days 50 – 54 days Usual working hours 40h per week 37.5h per week 40h per week 40h per week Sessional or PA hours 4h per PA 3.75h average 4h per PA 4h per PA Direct clinical care 7.5 PAs/week 7 sessions/week 7.5 PAs/week 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 http://www.agw.wales.gov.uk/publications/2004/agw2004_1es.pdf k http://www.isdscotland.org/isd/files/040525_web.pdf l http://www.dhsspsni.gov.uk/hss/governance/documents/HPSS_RMGen_Induction.pdf m http://www.dh.gov.uk/assetRoot/04/07/04/06/04070406.pdf http://www.dh.gov.uk/assetRoot/04/06/99/50/04069950.pdf n 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 o http://www.show.scot.nhs.uk/sehd/paymodernisation/ConsultantContract.htm p 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 Incidence UK Prevalence UK Foundation (UK population 58.789m) Myocardial infarction UK 275000 = 4678 pmp 1.2 million = 20412 pmp Angina UK 335000 = 5698 pmp 2.0 million = 34020 pmp All CHD UK 2.65 million = 45076 pmp Coronary heart disease statistics; 2003 edition: http://www.heartstats.org/uploads/documents%5C2003stats.pdf 1B. Secondary prevention of CHD Requirement pmp (non-consultant based) New cases: Incidence of MI @4678 pmp @15 miniutes each (1170 hours) New MIs for 2º prevention: 50% discharged alive and survive 585 hours >30d New cases: incidence of angina @5698 pmp @ 15 minutes (1425 hours) each New angina for 2º prevention: 80% 1140 hours Follow-up cases: prevalence of CHD @45076 pmp @ 10 (7513 hours) minutes each Follow-up Coronary Heart Disease for 2º prevention: 80% 6010 hours Secondary prevention time 7735 hours Allow 15% extra capacity to allow for peaks and troughs 1160 hours Total secondary prevention time 8895 hours Sessions @3.75h each 2372 sessions If each clinician available 44 weeks per year 54 sessions per week If each clinician works 9 sessions per week 6.0 FTE clinicians pmp 1.1. 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 Requirement pmp (Consultant based) 30-40 hypertension clinics with 2 PAs per week 3120 – 4160 PAs UK 30-40 hyperlipidaemia clinics with 2 PAs per week 3120 – 4160 PAs UK Total specialist prevention clinics 6240 – 8320 PAs Per million population 106 – 142 PAs pmp If each consultant available 41 weeks per year 2.6 – 3.5 PAs per week pmp If each consultant works 7.5 PAs per week in direct clinical 0.3 – 0.5 consultants pmp care 2. Investigating and treating stable angina 2B. Rapid access chest pain clinics Requirement pmp Incidence of angina @335,000 UK 5698 pmp Referrals for chest pain = 2x incidence 11396 pmp Clinic time required @1h each referral (including Exercise 11396 hours
Page 17 of 45 ECG testing) Allow 15% extra capacity to allow for peaks and troughs and 13105 hours for inefficiency* Sessions @3.75h each 3495 sessions pmp If each clinician available 44 weeks per year 79 sessions per week pmp FTE staff required (Two of nurse, physiologist, GPwSI, or non- 17.6 FTE consultant cardiologist) each clinician working 9 sessions per week * 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 PMP Acute hospital units UK: 274 x 6 -10 specialist nurses each 28 – 47 FTE staff 3B. Post MI follow-up Myocardial infarction @ 275000 UK 4678 MI: 50% discharged alive and survive >30d 2339 Post MI clinic time @ 0.5h each 1170 Allow 15% extra capacity to allow for peaks and troughs and for 1346 hours inefficiency Sessions @ 3.75h each 92 sessions pmp If each clinician available 44 weeks per year 2.1 sessions per week pmp FTE staff required each clinician working 9 sessions per week 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 Procedure Procedure time pmp angios: consultants required now need pmp Cardiac interventions: total PCI 2200-3000 Cardiac interventions: Angiography before PCI (⅔) 1465-2000 Cardiac interventions: cardiac surgery 700 Total cardiac interventions 2165-2700 Diagnostic cardiac catheterisation and angiography = 5412 – 3383 – 4219 hours pmp 2.5x interventions @ 37.5 minutes 6750 pmp Allow for 20% inefficiency* and for peaks and troughs 4060 – 5063 hours pmp Programmed Activites @ 4h each 1015 – 1266 PAs pmp If each consultant available 41 weeks per year 24.8 – 30.9 PAs per week pmp If each consultant works 7.5 PAs/week in direct 3.3 – 4.1 FTE consultants clinical care pmp 4B. Diagnostic cardiac catheterisation and angios: physiological staff required now Non-medical staff: nurses (2), physiologists (1), 16204 – 20252 hours radiographers (1) Sessions @3.75h each 4321 – 5401 sessions pmp If each clinician available 44 weeks per year 98 – 123 sessions per week pmp If each clinician works 9 sessions per week 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 long- term 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 Procedure Procedure time pmp angios: consultants required in future need pmp Diagnostic cardiac catheterisation and angiography = 4412 – 2758 – 4219 hours 2.5 x interventions @ 37.5 minutes 6750 pmp pmp Allow for 20% inefficiency* and for peaks and troughs 3310 – 5063 hours pmp Programmed activities @ 4hours each 828 – 1266 PAs pmp If each consultant available 41 weeks per year 20.2 – 30.9 PAs per week pmp If each consultant works 7.5 PAs/week in direct 2.7 – 4.1 FTE clinical care consultants pmp 4B. Diagnostic cardiac catheterisation and angios: physiological staff required in future Non-medical staff: nurses (2), physiologists (1), 13240 – 20252 hours radiographers (1) Sessions @3.75h each 3531 – 5401 sessions pmp If each clinician available 44 weeks per year 80 – 123 sessions per week pmp If each clinician works 9 sessions per week 8.8 – 13.7 FTE pmp 4B. Pre-angiography assessment Clinic time required @15 mins each 4412 –6750 1103 – 1688 hours pmp pmp Allow for 15% inefficiency* and for peaks and troughs 1268 – 1941 hours pmp Sessions @3.75h each 338 – 518 sessions pmp If each clinician available 44 weeks per year 7.7 – 11.8 sessions per week pmp If each clinician works 9 sessions per week 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 drug- eluting 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 Procedure Procedure time pmp now need pmp Percutaneous coronary intervention @ 90 minutes 1500 pmp 2250 hours pmp Allow for 20% inefficiency* and for peaks and troughs 2700 hours pmp Programmed Activites @ 4hours each 675 PAs pmp If each consultant available 41 weeks per year 16.5 PAs per week pmp If each consultant works 7.5 PAs/week in direct clinical 2.2 FTE consultants pmp care 5B. PCI: other clinical staff now Non-medical staff: nurses (2), physiologists (1), 10800 hours radiographers (1) Sessions @ 3.75h each 2880 sessions pmp If each clinician available 44 weeks per year 65 sessions per week pmp If each clinician works 9 sessions per week 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: Procedure Procedure time pmp consultants in future need pmp Percutaneous coronary intervention @ 90 2200 - 3300 - 4500 hours pmp minutes 3000 pmp Allow for 20% inefficiency* and for peaks and 3960 - 5400 hours pmp troughs Programmed Activites @ 4hours each 990 - 1350 PAs pmp If each consultant available 41 weeks per year 24 – 33 PAs per week pmp If each consultant works 7.5 PAs/week in direct 3.2 – 4.4 FTE consultants clinical care pmp 5B. PCI: other clinical staff in future Non-medical staff: nurses (2), physiologists (1), 15840 – 21600 hours radiographers (1) Sessions @ 3.75 hours each 4224 – 5760 sessions pmp If each clinician available 44 weeks per year 96 – 131 sessions per week pmp If each clinician works 9 sessions per week 11 – 15 FTE clinicians pmp 5B. PCI pre-assessment Clinic time required @15 minutes each 2200 – 550 – 750 hours 3000 pmp Allow for 15% inefficiency* and for peaks and 633 – 863 hours pmp troughs Sessions @3.75 hours each 169 – 230 sessions pmp If each clinician available 44 weeks per year 3.8 – 5.2 sessions per week pmp If each clinician works 9 sessions per week 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 – 1100 – 1500 hours pmp 3000 pmp Allow for 15% inefficiency* and for peaks and 1265 - 1725 hours pmp troughs Sessions @3.75 hours each 337 – 460 sessions pmp If each clinician available 44 weeks per year 7.7 – 10.5 sessions per week pmp If each clinician works 9 sessions per week 0.9 – 1.2 FTE clinicians pmp * 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 Procedure need Procedure time pmp interventional procedures: consultants pmp UK: 56 – 66 tertiary cardiac centres @ 1 PA 56 – 66 PAs per 48 – 56 PAs pmp per per week each week year If each consultant available 41 weeks per 1.2 - 1.4 PAs per week year pmp If each consultant works 7.5 PAs per week in 0.2 FTE consultants pmp direct clinical care 6B. Miscellaneous cardiac invasive interventional procedures: other clinical staff Non-medical staff: nurses (2), physiologists 12.8 – 19.2 hours per (1), radiographers (1) week pmp Sessions @ 3.75 hours each per week 3.4 – 5.1 sessions per week pmp Sessions per year 177 – 265 sessions per annum pmp If each clinician available 44 weeks per year 4.0 – 6.0 sessions per week If each clinician works 9 sessions per week 0.5 – 0.7 FTE clinicians pmp 7. 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 Incidence UK Prevalence UK (UK population 58.789m) Heart failure 63500 = 1080 pmp 880000 = 14969 pmp
Page 22 of 45 7B. Rapid access heart failure clinics (diagnostic) Requirement pmp Incidence of heart failure @ 63500 UK 1080 pmp Referrals with symptoms = 2x incidence 2160 pmp Clinic time required @ 1hour each referral (incl echo) 2160 hours Allow 15% extra capacity to allow for peaks and troughs and for 2484 hours inefficiency Sessions @3.75 hour each 662 sessions pmp If each clinician available 44 weeks per year 15 sessions per week pmp FTE staff required (One of nurse, physiologist, GPwSI, or non- 1.7 FTE clinicians pmp consultant cardiologist) each clinician working 9 sessions per week 7A. Consultants with special interest in diagnosing heart Requirement pmp failure Clinic time required @ 20-30 minutes each patient 719 - 1080 hours Allow 15% extra capacity to allow for peaks and troughs and for 827 - 1242 hours inefficiency PAs @ 4.0hour each 207 – 311 PAs pmp If each consultant available 41 weeks per year 5 – 8 PAs per week pmp If each consultant works 7.5 PAs/week in direct clinical care 0.7 – 1.1 FTE consultants 7B. Monitoring of heart failure Requirement pmp Prevalence of heart failure @ 880000 14969 pmp Clinic time required 6 monthly* @ 15 minutes each 7484 hours Echo time required annually @ 30 minutes each 7485 hours Allow 15% extra capacity to allow for peaks and troughs and for 17214 hours inefficiency Sessions @ 3.75 hours each 4590 sessions pmp If each clinician available 44 weeks per 104 sessions per week pmp FTE staff required (nurse, physiologist, GPwSI, or non-consultant 11.6 FTE clinicians pmp cardiologist) each clinician working 9 sessions per week 7A. Consultants with special interest in monitoring heart Requirement pmp failure Clinic time required annually @15 minutes each 3742 hours Allow 15% extra capacity to allow for peaks and troughs and for 4303 hours inefficiency PAs @ 4hours each 1076 PAs pmp If each consultant available 41 weeks per year 26 PAs per week pmp If each consultant works 7.5 PAs/week in direct clinical care 3.5 FTE consultants * ”At least 6 monthly”: http://www.nice.org.uk/pdf/CG5NICEguideline.pdf 7A. Total Consultants specialising in heart failure Requirement pmp Diagnosing heart failure 0.7 – 1.1 FTE consultants pmp Monitoring heart failure 3.5 FTE consultants pmp Total consultants specialising in heart failure 4.2 – 4.6 FTE consultants pmp 8. 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
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