UNAPPROVED CORONARY HEART DISEASE (CHD)

MANAGED CLINICAL NETWORK (MCN)
Minutes of meeting of the CHD Community Cardiology Clinic Sub
Group at 9.00am
Wednesday 18 April 07, NHSG Summerfield House, Meeting Room 2

Present: Chairman: Dr Bob Liddell, Lead Clinician, CHD MCN

Dr Jim Black, Lead GP, CHD MCN

Dr Mike Crilly, Senior Lecturer, Public Health

Dr Deepak Garg, Consultant Cardiologist, NHSG

Dr Andrew Hannah, Consultant Cardiologist, NHSG

Mr Sandy Reid, Network Manager, CHD & Stroke MCN

Dr David Rutledge, General Practitioner and GPwSI

Dr Stephen Walton, Cardiac Unit Clinical Director, NHSG

Mr Roddie, Wood, Public Representative

Mrs Christine Gray, Secretary

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1. / Apologies: Vince Shields
Minutes of Meeting on 14 March 07
Agreed subject to amendment. Add Mike to list of attendees. / CG
2. / Timescales
After some discussion on the suggestion by Sandy that the group should have a maximum of 3 meetings in total, it was agreed that the last meeting of the group in May would be followed by a report for the 7 June CHD MCN Project Board. It was, however, realised that work around re-structuring the Clinics would continue beyond this time.
3. / Position Paper
Deepak circulated a copy of the draft position paper that he had received from Malcolm Metcalfe. It was agreed that Deepak would email Christine a copy of this for distribution to group members in advance of final meeting.
/ DG/CG
4. / Purpose of Community Clinics within Cardiology Network in Grampian
Risk Stratification - A long discussion took place around risk stratification particularly with regard to diagnosis of angina.
A large component of individuals who presented to their GP with chest pain were low risk. However, there was the need to identify those who were potential “high risk” so that they could be “fast tracked” through the system. To note that once a patient was prescribed Aspirin and Statin then that immediately lowered their risk. If a patient was still symptomatic on taking medication and deemed to be still at risk then there needed to be a mechanism to identify this group of patients so they were not lost in the system.

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Whether a patient actually had angina needed to be established first. Exercise testing (treadmill) although a poor diagnostic tool in itself actually did give clinicians some indication as to the likelihood of whether a patient had angina, although it was no way conclusive proof one way or the other and patients needed to be aware of this fact. To note current exercise testing could be enhanced by a Clinical assessment. Guidelines for exercise testing to be drawn up.
Profusion scanning was discussed. Clinical assessment was a pre-requisite. To note that it was not appropriate for all patients to undergo profusion scanning. It was left to the decision of the individual Consultant Cardiologist. These were carried out in some cases where patients for one reason or another were unable to exercise e.g. arthritis. Concern was expressed regarding waiting times/delay factors before this scanning could be carried out and any “at risk” patients should go straight to angiogram/surgical if the delay posed too great a risk.
Direct Access – to note currently all referrals to the community cardiology clinic funded by the MCN from GPs were sent to Aberdeen Royal Infirmary suggesting where the patient might most appropriately be seen but they were screened and triaged first. It was agreed that there would be value in direct access to the Community Cardiology Clinics in the future.
Where to refer? – it was suggested that more severe symptomatic patients could be referred to the Cardiology Department at Aberdeen Royal Infirmary. The less symptomatic patients could be more appropriately seen in the Community Cardiology Clinics. The question arose as to what group of patients had the most to gain by going through the Community Cardiology Clinics but at this stage it was not clear. It was agreed that it was appropriate that GPs would make the initial assessment of where to refer. There was a need for open access for echos across Grampian.
Clinician Roles: Clinical Assessment – to note that good assessment was the key in appropriate onward referral. There was a greater need for GP education on clinical assessment and where to refer. This needed to be addressed, possibly commencing with “Chest Pain” (angina).
GPs with Special Interest (GPwSI) – there was discussion around when the appointed GpwSI was ready to take clinics solo. They should be involved with their Clinical Supervisor (Consultant) in education of GPs on a regular basis.
Protocols – It was suggested to start looking at Chest Pain (angina) in the first instance and see where the role of the GPwSI fitted in. Once a clear protocol was established then this model could be used with regards patients with palpitation and heart failure.
Administrative Support – Sandy stated that the CHD MCN core team were looking at their longstanding funding allocations to see whether they were still appropriate or whether allocated monies could be freed up for better use. Once this exercise was complete and if any monies were identified then they could look to possibly hold additional GP sessions in Community Cardiology Clinics. / AH
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5. / Evaluation
Mike tabled two papers:
General health tick box questionnaire
Seattle Angina Questionnaire
To note that Mike was not clear when evaluating about the use of a comparison group. He was still to explore this matter further and would report in more detail to the final meeting.
6. / Actions Arising – Lead Responsibilities
Risk Stratification – Deepak would draw up a draft protocol bearing in mind discussions in item 4 above and keeping in line with SIGN guidelines and circulate for comments etc. in advance of the final meeting.
Evaluation – Mike would continue with his evaluation plans in the light of decisions made by the group. To note that Mike was working with Health Intelligence and would be exploring a “geographical” information data system.
Discussion Paper – Bob would draw up a paper following the meeting to take future plans forward, which would ultimately be shared with the 7 June CHD MCN Project Board. / DG
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RL
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Date of Final Meeting

Wednesday 16 May 2007 at 9am in Meeting Room 1, NHS Grampian, Summerfield House.

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