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2 Specialties Cardiovascular medicine7 Opportunities for integrated careCardiac networks are a reflection of the major progressthat has been made in integrating cardiac care over thelast decade. 1 Once care pathways are clearly defined,further opportunities for integrated care may berecognised and made cost-effective under the QIPPprogramme: one-stop clinics for more firstconsultations, initial investigations and counselling;joint GUCH/adult and paediatric/cardiology localclinics with a significant educational focus; in-reachcommunity heart failure teams to help support heartfailure patients admitted to hospital; or progressivepatient involvement in MDT meetings about care.There is a need for vigilance around the new strategicclinical networks (SCNs) to ensure no dilution ofimpact as the model is extended to other specialties.8 Workforce requirements for the specialtyCurrent workforce numbersThe NHS electronic staff records identified 855consultant cardiologists (whole-time equivalent (WTE):825) in May 2010. There were 580 trainees according toa recent BCS survey, with 980 consultants in England,and 1,200 across UK. Around 12% of consultants and21% of trainees are women, and their recruitment isencouraged to the specialty. There are currently only90 paediatric cardiologists.Number of consultants needed to provide aspecialist service for a population of 250,000The BCS has estimated 10 that the UK requires acontinuing increase in numbers of consultantcardiologists (including at least three paediatricconsultants) per million of the population to providecomprehensive cardiac services. For a population of250,000, no less than a 1:6 on-call ratio should be aimedfor, with more subspecialist consultant cardiologistsrequired for secondary, tertiary and community cardiaccare. Because of PPCI, more interventionalists are nowrequired. Similarly, the new chest pain guidelines willresult in the need for more imagers. The currentpriorities of cardiac rehabilitation and heart failureshould also be recognised in programmed activities(PAs) allocation in job plans for consultants.National workforce requirementsOnly 25% of consultant cardiologists now undertakeacute medicine. The estimated number of consultantcardiologists required does not include those withTable 3 Typical weekly job plan for a consultantcardiologistActivityDirect clinical careProgrammedactivities(PAs)Inpatients (CCU, ward rounds, referrals) 1.5–2.0Outpatients (plus additional outreach forpaediatric cardiologists)Laboratory work (or other specialised clinicalwork)Meetings of the MDT (PCI, cardiac surgery,imaging, arrhythmia)2.0 (+ 2.0)2.0–3.00.5Clinical administration 1.0On call 0.5Total 7.5–9.5Supporting clinical careClinical management, audit, clinicalgovernance, service improvement anddevelopment, teaching, CPD, research,advisory appointments committees, work forexternal organisations for the greater goodof the NHS2.5CCU = cardiac care unit; CPD = continuing professional development;MDT = multidisciplinary team; PCI = percutaneous coronaryintervention.responsibilities for acute medicine or academicmedicine, nor does it take account of the more recentpriorities as described above.9 Consultant work programme/specimenjob planTable 3 outlines the typical work programme ofconsultants undertaking cardiovascular medicine.10 Key points for commissioners1 The principle of working together, enshrinedin the RCP/BCS response to the NHS White PaperEquity and excellence: liberating the NHS, 11has been upheld by all health professionalopinions. The implementation of the Health andSocial Care Bill 2012 demands vigilance undergovernance.2 An essential building block includes liaison at localvascular/chronic disease management board levelC○ Royal College of Physicians 2013 57
Consultant physicians working with patientsbetween the local cardiology service and primarycare clinical commissioning groups. The new CVDOutcomes Strategy 2013 will emphasise anintegrated model of all cardiovascular care withprevention and rehabilitation.3 There should be agreed care pathways for cardiacconditions across the local health economy and thelarger cardiovascular, paediatric and GUCHnetworks. For instance, future commissioningrequirements are likely to mandate screening by apaediatrician with an interest in cardiology prior toreferral to a cardiologist in congenital heart disease.4 Commissioners (NCB and CCGs) should committo reviewing, through the specialty’s clinicalreference group and local senates/networks,achievements in national cardiac audits, both thosewithin NICOR, and those without (eg NACR),together with local mortality trends, in settingpriorities.5 Cardiovascular networks are recognised tohave provided a key (and improving) relationshipwith commissioning. A very successful exampleis the network-based roll-out of PPCI andsubsequent cardiac rehabilitation pathwayreview. 1,126 Service level agreements should define expectedoutcomes to meet national cardiac auditoutcomes and standards (see point 4 above andBox 1).7 Priority investment in development, delivery andintegration of heart failure, cardiac rehabilitation,palliative care and arrhythmia services should bebalanced with a reduction and decommissioning ofothers, without destabilising any aspect of care,whether acute or long term, or causingdisadvantage to patients.8 There should be a sustainable mechanism for inputof the specialty standards of the RCP and BCS,including those of affiliated groups, with patientsthrough CCP UK, via the Joint SpecialtyCommittee/Specialty clinical reference group in thecommissioning process.9 It is hoped that the NHS Commissioning Board inEngland and planning mechanisms for devolvednations will utilise cardiology’s innovativeapproaches to development and acknowledgerelevant informative reports 5,6,7,13 in specialisedand local commissioning.10 A new Strategic Commissioning Development Unit(SCDU) Department of Health model ofcommissioning guide, pioneered for Cardiacrehabilitation (October 2010, see Box 1),provides a model for future commissioning ofservices. 13References1 NHS Improvement-Heart. Growth of primary PCI forthe treatment of heart attack patients in England2008–2011: theroleofNHSImprovementandthecardiacnetworks. www.improvement.nhs.uk/heart2 NHS Specialised Services. Review of children’s congenitalcardiac services in England, July 2012. Judicial review,February 2013.www.specialisedservices.nhs.uk/safeandsustainable3 Department of Health. National service framework forcoronary heart disease. London: DH, 2000.4 Fifth report on the provision of services for patients withheart disease. Heart 2002;88(Suppl III):iii1–59.www.heart.bmj.com [Accessed 25 April 2013]5 Cardio & Vascular Coalition. Destination 2020. A plan forcardiac and vascular health. The voluntary sector vision forchange. London: British Heart Foundation, 2009.www.cardiovascularcoalition.org.uk6 Oxford Healthcare Associates. Access to cardiac care in theUK. A report on invasive procedures in cardiac conditions.Recent trends, variations in access and future need.BritishCardiovascular Society and British Heart Foundation,2009.7 Ray S for British Cardiovascular Society. Commissioningof cardiac services – a resource pack from the BCS.London:BCS, 2011.8 Department of Health. National service framework forcoronary heart disease – chapter eight: arrhythmias andsudden cardiac death. London: DH, 2005.9 Royal College of Physicians. Consultant physiciansworking with patients: the duties, responsibilities andpractice of physicians in medicine, 4th edn. London: RCP,2008.10 Hackett, D. Cardiac workforce requirements in the UK.London: British Cardiovascular Society, 2005.www.bcs.com11 Department of Health. Equity and excellence: liberatingthe NHS. London: Stationery Office, 2010.12 Shahid M, Varghese A, Moqsith A et al.Surveyofcardiacrehabilitation across the English cardiac networks2007–2009. Br J Cardiol 2011;18:33. www.bjcardio.co.uk13 NHS Improvement-Heart rehabilitation team. Quality,innovation and value in cardiac rehabilitation:commissioning for improvement. www.improvement.nhs.uk/ePublications/cardiacrehab/files/html5/index.html58 C○ Royal College of Physicians 2013
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AbbreviationsA&EAACsAMUsARCPCCGsCCS
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