1. A view from the Clinical Lead Malcolm Metcalfe

2. NoS Cardiology Although much good work has been achieved there remain major challenges ahead. In order to continue to improve access to high quality cv services it remains essential that many services be planned and operated on a Regional basis. This is a difficult and sometimes uncomfortable process for individuals from differing HBs. Often this lead to a “mismatch” between aspiration and reality.

3. Major issues (not exhaustive) Optimal reperfusion PCI in Highland Role out of EP services for NoS Cardiothoracic surgery provision Transcatheter aortic valve implantation Multi-slice CT scanning Transport issues Workforce planning

4. Optimal Reperfusion Watch this space…

5. PCI in Highland Business case for PCI in Highland region agreed. Equipment now available Formal BCIS inspection visit was on 12/2/10. Generally very favourable assessment Generally very favourable assessment No issue re modest numbers No issue re modest numbers Issues re emergency transfer and on-call cover for procedures to be resolved Issues re emergency transfer and on-call cover for procedures to be resolved Should start elective work April 2010 Should start emergency/PPCI office hours work August 2010 Major success for NoS partners!

6. Role out of EP services Following on from agreed plan Feb 2008 Full-time EP Consultant started in July. Full-time EP Consultant started in July. Tayside and Highland undertaking ICD implantation (1’ prevention numbers still small) Tayside and Highland undertaking ICD implantation (1’ prevention numbers still small) RFA numbers increasing as predicted RFA numbers increasing as predicted CRT implantations increasing and likely to increase quire markedly due to new evidence of benefit. CRT implantations increasing and likely to increase quire markedly due to new evidence of benefit. Pacemaker lead extractions have become an unexpected issue. Pacemaker lead extractions have become an unexpected issue.

7. Cardiothoracic surgery provision NoS service Despite concerns numbers have remained static for last few years at >600. Despite concerns numbers have remained static for last few years at >600. Actual demand may be nearer 750 assuming that Highland and Tayside continue to refer numbers to ERI. Actual demand may be nearer 750 assuming that Highland and Tayside continue to refer numbers to ERI. Issue of “bulge” due to abolishing “gaps” and achieving 18 week target – but this may no longer be an issue given unexpectedly low referrals this year. Issue of “bulge” due to abolishing “gaps” and achieving 18 week target – but this may no longer be an issue given unexpectedly low referrals this year. Cost of service now greater than “charging cost” – will need adjustment. Cost of service now greater than “charging cost” – will need adjustment. Problems with junior staff provision most pressing issue. Problems with junior staff provision most pressing issue.

8. Transcatheter aortic valve implantation (TAVI) No longer experimental technique Excellent results (short-medium term) Excellent results (short-medium term) Extends envelope to patients who would otherwise die Extends envelope to patients who would otherwise die Relatively simple Relatively simple Expensive (c£25 000). Expensive (c£25 000). Calculated demand 16 pmp Calculated demand 16 pmp Long way behind England Long way behind England No Scottish centre No Scottish centre High-level meeting with SEHD last year. External assessment underway External assessment underway Agreement to develop “universal” referral criteria and for each Region to work up Business case. Agreement to develop “universal” referral criteria and for each Region to work up Business case. Many patients have already been referred from NoS region (eg 9 from Grampian) so genie out of bottle.

9. Multi-slice CT imaging Has potential to replace coronary angiography in certain circumstances (?20%) Results from studies to date not easy to interpret. Pilot in Highland with useful preliminary results Cost vs coronary angiography may not be as favourable as predicted. Older machines impart high radiation burden. Ideal is to use modern 256/320 slice machines which impart 1mSv radiation, can image in single heart beat but cost c£100 000 more than workhorse 28-128 slice imagers.

10. Transport issues Increased liaison and discussion with ambulance services PPCI PPCI Transfers from other centres (eg currently longer by air than road from Raigmore to ARI!) Transfers from other centres (eg currently longer by air than road from Raigmore to ARI!) Changes by virtue of “drip and ship” policies (eg Elgin, Wick, Islands), potential emergency transfer of PCI patients to ARI etc Changes by virtue of “drip and ship” policies (eg Elgin, Wick, Islands), potential emergency transfer of PCI patients to ARI etc

11. Workforce Planning Very important issue but difficult to both influence and predict change CEOs have apparently predicted no growth in Consultant numbers for next few years (before financial crisis!) CEOs have apparently predicted no growth in Consultant numbers for next few years (before financial crisis!) Recruiting technicians remains a major issue – NES have offered some support. Closing date 25 th June. Recruiting technicians remains a major issue – NES have offered some support. Closing date 25 th June. Eventually one would like some degree of standardisation across the North. Eventually one would like some degree of standardisation across the North.

12. Summary A lot is happening! Lack of reliable information makes life very difficult (aspiration vs reality) for planning. Service managers frequently do not seem to be aware of NoS working. NoS working is difficult as inevitable compromise is required. NoS working however is essential in order to provide the best care for our patients.

13. Non-NoS working…