Download Agenda Item - Suffolk County Council

Agenda
Item 6
Health Scrutiny Committee
20 July 2009
Emergency Heart Attack Services in Suffolk
Summary
This paper provides information on Emergency Heart Attack Services in Suffolk. It
considers changes proposed by the East of England Specialised Commissioning Group,
their decision making process and concerns raised on behalf of Suffolk people.
Background information is included about a review commissioned jointly by the East of
England Specialised Commissioning Group and NHS Suffolk when the concerns of Suffolk
residents became known and were given voice through the local media.
There will be an opportunity for the Committee to find out the outcomes of the review from
Professor Boyle who led the review.
The paper also includes, for information of the members of the Committee and for the
public generally, information about heart attacks, an understanding of which is helpful in
terms of looking at the issues raised in relation to proposed changes.
Objective of the Scrutiny
The objective of this scrutiny is to provide the Committee with an opportunity to:
a) Gain an understanding of when heart attacks occur and how patients are
treated, and some of the medical terms used.
b)
Consider the reasons for changes in relation to primary percutaneous coronary
intervention (PPCI) and what factors were taken into account in coming to this
decision.
c)
Scrutinise the impact of proposed changes to the treatment of heart attack
patients in Suffolk.
The Committee may, having considered the paper and information provided at the
meeting:
a) Identify further improvements that could be made to communication
arrangements from NHS in relation to proposed and actual service changes.
b)
Raise further issues of concern that it would like the Specialised Commissioning
Group to consider.
c)
Decide that the proposed arrangements are not in the interests of the people of
Suffolk and give reasons why.
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Contact Details
Name
Telephone
E-mail
Scrutiny Officer
Sue Morgan
01473 264512
[email protected]
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Local Councillor
All Councillors
Introduction
1. The Health Scrutiny Committee has a wide ranging remit. It may review any matter
relating to the planning, provision and operation of health services in the county. It may
report to Cabinet and local NHS bodies or other organisations on matters it has
reviewed or scrutinised.
2. The Health Scrutiny Committee has 8 County Councillors and one co-opted
representative from each if the seven district and borough councils in Suffolk. District
and borough councillors co-opted onto the Health Scrutiny Committee may vote on all
matters relating to health service issues. They may not vote on issues relating to the
County Council’s Constitution.
3. To help in carrying out its role the Health Scrutiny Committee may create joint
committees with other councils affected by a health service issue.
Main terms referred to in this paper
4. This section includes some definitions that offer an explanation of some of the terms
used in this scrutiny. Health scrutiny committee members are local government elected
representatives, and an explanation of the terms will assist them and members of the
public in understanding the issues involved. A full glossary is provided at the end of this
paper.
5. The following definitions are from the document ‘Consultations by Specialised Services
Commissioners’ published by the Centre for Public Scrutiny as a practical guide for
health scrutiny committees.
Specialised Commissioning Groups (SCGs) are formal joint committees of PCTs,
and are responsible for the collaborative commissioning of specialised services,
including medium/low security mental health services and screening services. They
are coterminous with the boundaries of the 10 Strategic Health Authorities (SHAs).
Specialised services are services provided in a small number of specialist centres
to catchment populations of more than a million people.They range from bone
marrow and kidney transplants to the provision of secure forensic mental health
services. What constitutes a specialised service may change over time, influenced
by developments in treatments and clinical skills. So as well as new specialised
services being introduced into the NHS, some other services will become more
commonplace and cease to be specialised. Specialised services are subject to
collaborative commissioning arrangements rather than being commissioned by
individual PCTs.
Specialised services providers are those providers with the recognised capacity,
skills and resources to provide specific, high quality specialised services. Providers
of specialised services have to address a number of challenges, including training
specialist staff, supporting high quality research programmes and making the best
use of scarce resources such as staff expertise, expensive equipment or the use of
donated organs. These challenges influence the cost, mode of delivery and
availability of specialised services.
6. PPCI (Primary Percutaneous Coronary Intervention), often referred to as primary
angioplasty, is a treatment for heart attack patients which unblocks an artery carrying
blood to the heart. A small balloon is inserted on the end of a long thin tube, via an
artery in the groin or arm, and guided to the point of blockage. Then the balloon is
inflated to allow a rigid "stent" (tube) to be put in place which squashes the blockage
and opens up the artery allowing blood to flow freely. The procedure needs to be
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carried out by highly trained cardiologists in a catheterisation laboratory (cath lab) in a
hospital.
7. Heart attack – the following definition is taken from ‘Treatment of Heart Attack National
Guidance Final Report of the National Infarct Angioplasty Project (NIAP) published by
the Department of Health.
A heart attack is said to have occurred when the myocardium (heart muscle) is
damaged as a result of impaired blood supply. This is known as a myocardial
infarction. The amount of damage is greatest when the blood supply to part of the
heart is cut off altogether as a result of a thrombus (blood clot formation) within one
of the coronary arteries ( blood vessels) supplying that area of the heart. Under these
circumstances, the electrocardiogram (ECG) recorded after the onset of occlusion
will usually show an abnormality termed ‘ST elevation’. Patients suffering from this
condition are said to have sustained ‘ST elevation myocardial infarction’, abbreviated
to STEMI.
Scrutiny Focus
8. The scope of this scrutiny has been developed to provide the Committee with
information to come to a view on the following key questions:
a)
Who is most at risk of heart attack?
b)
What can be done to reduce the liklihood of heart attack?
c)
What support, advice and guidance is available to the general public
d)
Why are changes to the current service needed?
e)
What factors were considered in making decisions about these services?
f)
What monitoring arrangements will there be to assess the impact of the new
arrangements for heart attack victims in Suffolk?
g)
What information is there about the implications of these changes for people in
Suffolk?
h)
What action has been taken to address local people’s concerns about the
changes?
i)
How are the findings of the action taken going to be communicated?
j)
What is the impact on the commissioning of coronary care facilities at Ipswich
Hospital?
Background on regional health scrutiny relating to Primary Angioplasty
9. Suffolk Health Scrutiny Committee is represented at an East of England Regional
Health Overview and Scrutiny Chairs’ Forum (the Chairs’ Forum). This role has been
filled by Councillor David Yorke-Edwards.
10. The Chairs’ Forum is not a scrutiny body but may make recommendations that a joint
scrutiny committee is established and may propose terms of reference for that scrutiny
committee. When it does make a recommendation, each of the respective Health and
Overview and Scrutiny Committees are asked to agree to joint arrangements and
nominate members.
11. To prevent delays in establishing joint scrutiny arrangements the Suffolk Health
Scrutiny Committee nominated a member and a substitute member to take part in any
regional scrutiny (Councillor Vincent, who is a co-opted member from Forest Heath
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District Council and Councillor Michelle Bevan Margetts, a co-opted member from
Ipswich Borough Council respectively).
12. The Chairs’ Forum is administered by one of the authorities in the Eastern region for a
period of one year, rotating with the Chairmanship. Currently Essex fulfils this role,
with a handover to another authority (not Suffolk) due in September 2009.
13. A Regional Health Scrutiny Committee was established to scrutinise the East of
England Strategic Health Authority (SHA) strategy, “Towards the best, together – a
Clinical Vision for our NHS, now and for the next decade”. Unfortunately, due to
unforeseen circumstances, Suffolk Health Scrutiny Committee was not represented on
the joint Committee.
14. The report of the Joint Health Overview and Scrutiny Committee was made available
as a public document. The following points are relevant in that the strategic document
referred to a range of ‘Acute Services’:
The Joint Committee was concerned that it did not have before it information relating
to the timescales and locations of the specialised centres and was not therefore able
to make any judgements about the accessibility by patients to these services. The
Committee welcomes the reconfiguration of triage and patient pathways to provide a
patient focus and perspective. The Committee also welcomes the provision of 24/7
acute urgent services.
15. The Joint Health Overview and Scrutiny Committee recommended (among other
things)
“that at an early date the Strategic Health Authority publishes and consults on its
proposals for the function and location of specialist centres.”
16. At the 17 March 2009 Chairs’ Forum a member of the Specialised Commissioning
Group (SCG) sought the views of Chairmen about potential consultation on Primary
Angioplasty Services with a closing date of end of June 2009. It was promoted as a
new service and in line with the principles set out in the strategic document ‘Towards
the Best Together’.
17. The Chairs’ Forum considered that the timescales would prevent consideration of this
matter by a regional Joint Health Scrutiny Committee because councils do not hold
meetings during the six weeks period preceding the election date. Further, as the
elections were held on 4 June most councils would not be in a position to appoint
chairmen and committee members until the last week of June.
18. It was agreed that the SHA/SCG should be asked if was possible to defer the end of
the consultation process (to end in July if possible) so that Joint Overview and Scrutiny
Committees including members from the newly reconstituted Councils could be set up
for both Pancreatic Cancer and for Primary Angioplasty. This was subsequently
agreed for Pancreatic Cancer services and a Joint Health Scrutiny Committee was
established and held on 30 June. Further information is included in the Committee’s
Information Bulletin for this meeting.
19. On 8 April 2009, the East of England Specialised Commissioning Group wrote to the
Secretary of the Chair’s Forum regarding Primary angioplasty services, enclosing a
briefing note (Copy attached as Evidence Set 1 Appendix E) suggesting that:
“there is not a requirement to consult further on this, as the proposals are in line with
the model set out in the Strategic Health Authority’s strategic document ‘Towards the
Best Together’ which has already been commented on by a regional Joint Overview
and Scrutiny Committee.
20. The secretary of the Chairs Forum asked for a response from the Chairmen of each
authority. Suffolk Health Scrutiny Committee’s Chairman considered the suggestion
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and the Scrutiny Officer responded to the Secretary of the Chair’s Forum by phone to
say that in Suffolk we take the view that it is not within the remit of the Health Scrutiny
Committee to tell an NHS body that it does not need to consult and that it is a decision
for that body.
21. On 27 April the Secretary of the Chair’s Forum wrote to all members of the Eastern
Region Health Scrutiny Chairs Forum about Primary Angioplasty Services and said:
‘the majority of responses I have had from Chairs is that you support the stance
suggested by Simon Wood (representing the Strategic Health Authority) i.e. that
there is not a requirement to consult further on this as the proposals are in line with
the model set out in the Strategic Health Authority’s strategic document ‘Towards the
Best Together’ which has already been commented on by a regional Joint Overview
and Scrutiny Committee.
22. The Suffolk view was that this letter from the Secretary of the Chairs’ Forum related
only to the establishment of a Joint Health Overview and Scrutiny Committee.
Accordingly arrangements were put in hand for local scrutiny of the proposals by the
Suffolk Health Scrutiny Committee.
23. Although there had been an extraordinary meeting of the Health Scrutiny Committee
scheduled for 21 April, because the letter from the Secretary of the Chairs’ Forum was
not sent until 27 April for the reasons set out above it was not possible to scrutinise the
matter until July.
24. The next scheduled Health Scrutiny Committee Meeting after 27 April was 20 July
2009 (election period intervening). After receiving the letter from the Secretary of the
Chair’s Forum, the Strategic Health Authority, the Specialised Commissioning Group
and NHS Suffolk were contacted on behalf of the Suffolk Health Scrutiny Committee
about scrutiny of ‘emergency heart services’ to provide an opportunity for scrutiny at
local level. Each of these organisations were invited to provide information and to send
a nominated representative to attend the Scrutiny Committee on 20 July 2009.
Review of impact of the proposals in Suffolk
25. In May 2009, NHS Suffolk published information about a review associated with the
implementation of the strategic decision in relation to PPCI (primary percutaneous
coronary intervention). Professor Boyle, National Director for Heart Disease and
Stroke and a team were being asked to look at two issues:

First, assurance that the arrangements for the introduction of the new service for
the east Suffolk population are robust and take due account of the issues
presented by our rural and coastal areas.

Second, to give advice on the overall provision of PPCI (Primary Percutaneous
Coronary Intervention) in the area and coronary angioplasty services at Ipswich
Hospital.
26. While Professor Boyle and his team are undertaking the review the implementation of
PPCI in east Suffolk will be postponed. Patients in east Suffolk who suffer a STEMI
heart attack will continue to receive pre-hospital thrombolysis, the current treatment.
27. The implementation of PPCI in the rest of the east of England will not be affected.
Papworth, the Norfolk and Norwich and Harefield Hospitals will continue to deliver the
service which will also be extended into Essex, from Basildon Hospital, on 1
September.
28. Any action that could have been taken by the Health Scrutiny Committee at this time
would at the best have duplicated the work being undertaken by Professor Boyle and
his team.
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29. Members of the Health Scrutiny Committee were informed, before the election date of
4 June, of the addition of this new item ‘Emergency Heart Services’ on the Committee’s
Forward Work Programme.
30. NHS Suffolk has assisted the consideration of this item by co-ordinating information for
the Committee. The information has come from different sources as referred to below.
Evidence Set 1
31. Evidence Set 1 – Review of Primary Percutaneous Coronary Intervention - a brief
paper written by the Director of Strategic Commissioning at NHS Suffolk. The paper
a)
provides Health Scrutiny Committee members with background information to
the National Director of Heart and Stroke review of plans to implement PPCI in
the East of England and particular in respect of the Suffolk population.
b)
Explains that, at the time the written papers were prepared, Professor Boyle
had not presented his report and recommendations, but indicates he will attend
the Health Scrutiny Committee on 20 July to report the outcomes from his
review to them.
c)
Outlines that NHS Suffolk will lead an open communications campaign to inform
Suffolk people of the plans and future provision of heart attack services.
d)
States that NHS Suffolk and the East of England recognise and apologises for
the lack of engagement and information which has led to the high degree of
public anxiety and concern about the planned changes to heart attack services.
e)
Gives an undertaking that NHS Suffolk will ensure that before any changes are
made, there is clear communication through open sessions across the county.
f)
Refers to the following briefing information for members:Paper
Appendix A
Appendix B
Appendix C
Appendix D
Appendix E
Appendix F
Appendix G
Appendix H
Item
Dr Sarah Clark’s presentation on heart attack centres to
give background information
Specialised Commissioning Group presentation to
Professor Boyle on 18th June 2009 about plans to
implement PPCI and how they had been developed and
addressing key Suffolk issues. Pages 39 to 43 refer to
‘issues around this review for Suffolk’.
Anne Nicholls, Member of Suffolk Link and Chair of the
Independent Lay Advisory Board (ILAG) to the PCT
presentation made to Professor Roger Boyle about
public concerns
The agenda for Professor Boyle’s review team visit
Specialised Commissioning Group briefing note issued
to HSC Chairs through the East of England Chair’s
Forum
Local demographic information
Data about incidence of heart attacks in Suffolk
A summary of the concerns raised by NHS Suffolk about
these plans
Evidence Set 2
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32. Anne Nicholls, Member of Suffolk Link and Chair of the Independent Lay Advisory
Board (ILAG) to the PCT has submitted a paper on ‘Proposed changes to cardiac
services’. It highlights local concerns, particularly from people in east Suffolk, and has
been produced after obtaining views from members of the public, members of the
Interim Suffolk LINks and the Interim Lay Advisory Group (ILAG) and assessing press
coverage to identify issues raised. (It expands on information submitted to Professor
Boyle’s review, referred to in Evidence Set 1 as Appendix C)
Evidence Set 3
33. Information which a member of the public could access for information about heart
attacks, causes and treatments.
Evidence Set 4
34. This is an extracted minute of the Ipswich Borough Council meeting on 24 June
regarding concern about proposed changes to services at Ipswich hospital.
Evidence Set 5
35. This is a copy of a letter from Suffolk Coastal District Council to the Chief Executive of
NHS Suffolk regarding concerns about proposed Heart Attack Services.
Other Information
36. Further background information has not been included with these papers. Schedule A
includes a list of relevant information. Copies of which are available from the Scrutiny
Team Manager.
37. NHS Suffolk’s concerns about the PPCI services are referred to in a letter which was
considered by the NHS Suffolk Board on 27 May 2009.
38. Page 43 of Appendix B, ‘Why weren’t local people asked?’ refers to Health Scrutiny
Committee input. This is addressed in paragraphs 13 to 24 in this paper.
39. Professor Roger Boyle, the National Director of Heart and Stroke Review is expected
to present his report and recommendations to the Health Scrutiny Committee on 20
July and to take questions from the Committee. ‘Mending Hearts and Brains: Clinical
case for change:Report by Professor Roger Boyle, National Director for Heart Disease
and Stroke’ provides background information about the reason for changing the way
heart attack is treated. It is available on the following website:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuid
ance/DH_063282
40. Anne Nicholls, Member of Suffolk Link and Chair of the Independent Lay Advisory
Board (ILAG) to the PCT has been invited to attend the meeting.
41. Tracey Dowling, Director of Strategic Commissioning at NHS Suffolk has been invited
to attend the meeting on behalf of NHS Suffolk.
42. Trevor Myers, of the East of England Specialised Commissioning Group has been
invited to attend the meeting. He has given his apologies, but should be sending a
representative.
43. Members of the public have been in contact with the County Council and expressed an
interest in the Health Scrutiny Committee’s meeting. Some have indicated that would
like to attend the meeting, and may, if given the opportunity, give their comments.
44. The Chairman of the Committee has complete discretion over who is allowed to speak
at the meeting and for how long.
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Officer recommendation
45. It is recommended that the Committee:
a)
Consider the written evidence submitted as part of this paper
b)
Hear the report and recommendations of the Review by Professor Boyle
c)
Decide if the concerns of local people have been adequately addressed in the
report and recommendations
d)
Seek feedback from local people at the meeting
e)
Identify any further recommendations to either the Specialised Commissioning
Group, the SHA or NHS Suffolk.
f)
Determine what future scrutiny is required and how this will take place.
Supporting Information
For more information on ‘Towards the best, together’ visit: www.eoe.nhs.uk/vision
Below are links to the NIAP report setting out the evidence for PPCI and 'Mending Hearts
and Brains' the report by Prof Boyle on the future treat of heart and brain treatment in the
UK.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuid
ance/DH_089455
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuid
ance/DH_063282
‘Consultations by Specialised Services Commissioners’ published in July 2007 by the
Centre for Public Scrutiny.
‘Mending Hearts and Brains: Clinical case for change:Report by Professor Roger Boyle,
National Director for Heart Disease and Stroke’, published by Department of Health 2006
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuid
ance/DH_063282
NHS Choices website
http://www.nhs.uk/conditions/heart-attack/Pages/Introduction.aspx
Glossary
Angioplasty - the stretching open of an artery with a balloon catheter
BCIS - British Cardiovascular Intervention Society
BCS – British Cardiovascular Society
Commissioning - is the overall term used to describe the process of planning, funding,
procuring and monitoring healthcare services. It can include all or some of these functions.
CTB - Call to balloon time: the length of time between the patient requesting help and
receiving PPCI for a STEMI
CTN - Call to needle time: the length of time between the patient requesting help and
being given thrombolysis for a STEMI
Coronary arteries: arteries supplying the heart muscle with oxygen
CPG Clinical Pathway Group
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DANAMI DH – Department of Health
Electrocardiogram (ECG): an electrical trace of the heart muscle’s activity
EAAST – East of England Ambulance Service Trust
EoE – East of England
ERPHO – Eastern Region Public Health Observatory
Heart attack - A heart attack is said to have occurred when the myocardium (heart muscle)
is damaged as a result of impaired blood supply. This is known as a myocardial infarction.
The amount of damage is greatest when the blood supply to part of the heart is cut off
altogether as a result of a thrombus (blood clot formation) within one of the coronary
arteries ( blood vessels) supplying that area of the heart. Under these circumstances, the
electrocardiogram (ECG) recorded after the onset of occlusion will usually show an
abnormality termed ‘ST elevation’. Patients suffering from this condition are said to have
sustained ‘ST elevation myocardial infarction’, abbreviated to STEMI.
HAC – Heart Attack Centre
HOSC – Health Overview and Scrutiny Committee/Health Scrutiny Committee
MI - Myocardial infarction - a heart attack with damage to the heart muscle
Myocardium: the heart muscle
NIAP - National Infarct Angioplasty Project – a feasibility study looking at how far primary
angioplasty can be rolled out as the main treatment for heart attack in place of clot-busting
drugs.
NNUH – Norfolk and Norwich University Hospital
OOH – Out of Hours
PCI PHAC – Papworth Heart Attack Centre
PHT pre hospital thrombolysis
PPCI (Primary Percutaneous Coronary Intervention), often referred to as primary
angioplasty, is a treatment for heart attack patients which unblocks an artery carrying
blood to the heart. A small balloon is inserted on the end of a long thin tube, via an artery
in the groin or arm, and guided to the point of blockage. Then the balloon is inflated to
allow a rigid "stent" (tube) to be put in place which squashes the blockage and opens up
the artery allowing blood to flow freely. The procedure needs to be carried out by highly
trained cardiologists in a catheterisation laboratory (cath lab) in a hospital.
SCG – Specialised Commissioning Group SHA: Strategic Health Authority, based near Cambridge for East of England
ST segment: a part of the ECG trace
STEMI: ST segment elevation myocardial infarction (a heart attack in which the ECG
shows ST segment elevation)
Stent - tubular metal mesh designed to hold open a coronary artery once it has been
stretched by angioplasty
Thrombolysis: removal of clot using clot-busting medication given via a drip
Thrombus: a blood clot
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