Cardiac workforce requirements in the UK - David Hackett Chairman, BCS Cardiac Workforce Committee

 
Cardiac workforce requirements in the UK - David Hackett Chairman, BCS Cardiac Workforce Committee
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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
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                London
                W1T 5HW

                Tel: +44 (0) 20 7383 3887
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A company limited by guarantee registered in England number 3005604
Registered charity number 1093321
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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
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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     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
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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
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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.
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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).
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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
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     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:

          •   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
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            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
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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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