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2 Specialties Cardiovascular medicineall healthcare trusts under proper governance, and incardiovascular networks. Both patients and carersdemand that healthcare professionals consider theirgender, age, ethnic background and religious choices,and should seek advice for unfamiliar problems.Assessment of the impact of diversity on care pathwaysis exemplified by patient involvement in the BCS JointWorking Group recommendations for women’s hearthealth. Patient support groups are recommendedbecause they offer sensible companionship, advice,activities and support.Promoting self-care through educationIt is essential to give appropriate information (such asthat provided by the BHF) to patients early in the acutecare pathway, and patients should have ready access tofurther advice (see below). Self-care is encouraged,particularly for patients moving up from anappropriate local cardiac rehabilitation programme,when the time is right for further training in order forthem to become expert patients, capable of fullyunderstanding and managing their situation, andaccepting challenges so that their life is as tolerable andfulfilled as possible. They can also guide others. Patientscan be further empowered by BHF’s Hearty voices, theConsumer Council’s Stronger voices, and the trainingprogrammes provided by CCP UK and new NHSstructures. Participation in multidisciplinary teams(MDTs) with staff (see section 4) may also improve thepatient experience. Their involvement in supportgroups will help other patients, as will working oncommittees and groups for service users including thenew commissioning structures (see section 10).The role of the carerThe vital link between the patient and the carer isrespected by cardiac network patient and carerpartnerships, and by support groups of the CCP UK.The carers should understand their role as the thirdcorner in the dynamic triangle with the patient and theclinician, and they should be aware of the risks of thepatient’s heart disease and any interventions. Theactivities of the CHF charities since the Bristol Enquiryare good examples of parent and carer empowerment interms of influencing service reviews.Communication with patientsInformation and communication are high priorities.Access to information should be provided at all thedefined stages of an integrated care pathway (eg recentNHS Improvement recommendations for post-PPCIinformation and cardiac rehabilitation). Informationshould be provided in an easy to understand format andshould include websites and contact details for localclinical advisers and patient experts. Newsletters fromdisease-specific support groups are also helpful (such asthe Sudden Arrhythmic Death Syndrome support groupand the Cardiomyopathy Association). Full patientdocumentation (eg copies of letters and test results) isuseful for the patient’s personal health record, as well ashospital and primary care records. In paediatriccardiology, letters are routinely copied to patients andcarers. The CCP UK emphasises that consultants shouldstrive to help every patient reach a level ofunderstanding comparable to that of an expert patient.4 Interspecialty and interdisciplinary liaisonMultidisciplinary team workingMultidisciplinary working is well established incardiology practice, with acute involvement of cardiacnurses, cardiac physiologists and radiographers.Surgeons, anaesthetists, intensivists and cardiacsubspecialties such as interventionalists, pharmacistsand play specialists for children may also be needed.The full cardiac rehabilitation team also benefits fromprofessional expertise in exercise, as well as educationalinput from dietitians, smoking cessation counsellors,clinical psychologists and stress managers. Stronggroups affiliated to the BCS set standards inmultidisciplinary working in many areas, such asechocardiography, nuclear cardiology, intervention,rehabilitation and heart failure, and they have informedBCS’s peer-review process. Clinical governancedemands multidisciplinary working, and many trustshave set up teams to develop quality in practice. TheNSF for coronary heart disease enforced localmultidisciplinary implementation teams, whichreflected the whole integrated care pathway, and cardiacnetworks which involved Service Improvement staff.Working with other specialtiesCardiologists in larger district general hospitals(DGHs) concentrate on patients with cardiovasculardisease within the acute medical ‘take’ and often workin acute medical units to assess patients’ risks. They maycontribute outreach teams to emergency departments. Acontinuing, close and effective working relationship withfront-door teams is essential. Patients admitted as emergencieswith important cardiac diseases should rightlyexpect to be seen by a cardiologist within 24 hours, 4 and24/7 services are rapidly evolving for the cardiac intake.C○ Royal College of Physicians 2013 51
Consultant physicians working with patientsIn tertiary centres, the multidisciplinary forum, whichincludes cardiac surgeons and cardiac interventionalists(for both adults and children), is a vital quality standardfor assessing the appropriate treatments for all patients,including children. The interface between radiologyand cardiology in terms of expertise in imagingand its place within the MDT in the future is an areafor development. The way it evolves will largely dependon local interest and expertise. There is improvingcooperation among the BCS-affiliated groups forimaging modalities. The increasing focus on vascularmedicine is facilitating closer working relationshipsbetween specialists in vascular surgery, nephrologyand diabetes, particularly with respect to preoperativeassessment, and these will also extend from the CVDOutcomes Strategy 2013. The treatment of patientswith infective endocarditis involves cooperationof specialists in microbiology and cardiac surgery withthose in cardiology. There are increasing numbers ofjoint GUCH clinics, which allow specialists to visit localcentres.Working with GPs and GPs with a special interest(GPwSIs)Some GPs are especially interested in cardiovascularmedicine, and GPwSIs have been developed with inputfrom the RCP, the BCS and NHS Improvement foraccreditation. Clinical assistants and hospitalpractitioners should receive this further training toallow them to contribute to services that they typicallyprovide in outpatient or non-invasive investigativecardiology settings. They have a useful role in localmanagement boards and networks for vascular andchronic diseases, and they may become leads, forexample, in developing community cardiac clinics forhypertension and palpitations. The Primary CareCardiovascular Society is an important affiliated groupof the BCS.Other specialty activity beyond local servicesSpecialised commissioning activity often relates to agroup of networks for which standards must be agreedto allow development, and the BCS can contribute thestrength of its affiliated groups and committees.Regional and national reviews of services have beeninfluenced, for example, by the workforce requirementsidentified by the BCS (see section 8). Closercooperation with other organisations is a formalstrategy, as exemplified by the Cardio & VascularCoalition through the production of Destination 2020and Access to cardiac care in the UK. 5,6 Hopefully thiswill be noted in new commissioning structures (seesection 10). A specific resource pack on commissioningof cardiac services has been produced by the BCS. 75 Delivering a high-quality serviceCharacteristics of a high-quality serviceA national cardiac conference was held in March 2010(see Box 1) to celebrate the achievements over 10 yearsfollowing the publication of NSF for coronary heartdisease in England, which enumerated 12 standards ofcare. These were further elaborated on over that 10-yearperiod by Chapter eight: arrhythmias and sudden cardiacdeath, 8 a GUCH guide, and multiple guidelines fromNICE (see Table 2).Success has been seen with rapid-access chest painclinics for angina and the prompt referral of patientswith acute coronary syndrome to cardiologists forangiography, percutaneous coronary intervention orcoronary artery bypass grafting. There has also been amajor reduction in waiting times for investigations andtreatment.However, there is still room for improvement in manyareas, such as cardiac rehabilitation. There is also anincreasing demand for heart failure services andarrhythmia detection, particularly atrial fibrillation foranticoagulation to prevent stroke (a priority of the DH’sQuality, Innovation, Productivity and Prevention(QIPP) programme). Care for congenital heart diseasein both children and adults should be organisedaround regional networks led by congenital cardiaccentres. Access to adequate pacing services andimplantation of complex devices could be improved.Particularly challenging issues involve the developmentand maintenance of high-quality informationtechnology and transfer services, as well as developingcardiology imaging services as recommended inBox 1.Maintaining and improving the qualityof careThe recurrent cycles of national audits for heart disease,which have been increasingly comprehensive, have ledto improvements both in practice (eg with the movefrom hospital thrombolysis to pre-hospitalthrombolysis or PPCI) and of the audit tools thatcomplement the MINAP. The National Institute forClinical Outcomes Research (NICOR) now hostsMINAP, the British Cardiovascular InterventionsSociety (intervention), the SCTS (surgery) and the52 C○ Royal College of Physicians 2013
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