Initial thoughts on Girft

[Joseph]

#11052

The GIRFT report is a very important document and has the potential to significantly improve cardiology care if appropraitely funded. Many if not most of its recommendations seem highly approriate, however, I have a number of concerns about the report particularly from a rhythm perspective.

General Concerns re GIRFT

1) Both the authors were originally interventional cardiologists from large tertiary/quaternary centres although one is now an imaging specialist. There appears to be little input from secondary care or heart failure or electrophysiology. Both authors are both ex-BCS presidents and I note that many of the conclusions of the report recapitulate a BCS report from 2016 written by one of the authors.
2) In contrast to other guidelines and reports there has been little open consultation period.
3) Many of the recommendations are not underpinned by any evidence yet will impose major changes in how cardiology is practiced. In particular they may destabilise smaller centres creating larger number of visiting consultants primarily based at larger centres. In turn this is likely to lead to worse care for patients admitted through the front door of smaller hospitals
4) Many of the reports conclusions are likely to have unexpected consequences: for example increasing out of hours provision for pacing is likely to increase the number of pacing cardiologists leading to either fewer devices per consultant with the consequent worsening of outcomes or more inappropriate implantation of devices to maintain numbers. This is of particular concern with regard to CRT implants where many consultants only just meet the minimum requirements.

Specific Concerns
1)Recommendation 3: “All NHS cardiologists should by default participate in appropriate general and/or subspecialty on-call rotas.”
Why? This is unnecessary. It will discriminate against care providers who are overwhelmingly female. On call is fundamentally inefficient and there is no need for duplication which is a waste of resources.
There needs to be a clear distinction between on call and out of hours working – They are not the same. The latter is planned, paid for and predictable. The former is poorly remunerated and disproportionately causes problems for care providers who have to arrange cover for long periods of time when they are on call but not needed.
Out of hours, we need emergency cardiologists who can place a temporary wire, drain an effusion and do a primary PCI – we already have a group of cardiologists on call who are excellent at this. For many non interventional cardiologists providing regular routine timetabled out of hours sessions (e.g. post take acute cardiology rounds, pacing or imaging lists or additional clinics) provides much better patient care than simply duplicating on call responsibilities.
This recommendation is likely to make cardiology even more unattractive for doctors with caring responsibilities. Already we have the worst gender balance of any medical speciality and it is completely unnecessary.

2)Recommendation 5:7/7 availability of permanent pacing
On the face of it this is very sensible but it is not clearly defined. Do we mean urgent pacemakers only or does it mean a full pacing service?
Most would have no objection to this, although it is not evidence based. It will mean a larger number of pacing doctors which means that the number of CRT implants per operator will be massively reduced.
There is clear evidence that outcomes are related to volumes. Is it better to have a smaller number of operators implanting large number of devices and only providing emergency pacing at weekend or large number of doctors implanting small numbers 7 days a week. It is likely that the latter will result in worse outcomes overall or may even lead to increasing numbers of inappropriate pacemakers as operators try to keep their numbers up.
In contrast trying to run a full pacing service at weekends is incredibly resource intensive and is only likely to benefit a small number of patients (again we have no evidence of overall benefit) whilst at the same time reducing the availability of staff during the week. This is also likely to lead to far larger numbers of highly skilled staff moving to other careers or leaving the profession.
Pacing is becoming increasingly complicated and is likely to become even more so over the next few years– we need to consider if it is better overall for most patients to wait and have the right pacemaker (micra, CRT, ICD, LBBB area pacemaker, VVI or DDD) implanted by a highly skilled specialist in pacing or for them simply to have the simplest device put in by a much less experienced operator 24 hours earlier even if this does mean a tiny proportion of patients (calculated at less than 3 a year in my very large trust) end up with a temporary wire.

3)Guideline 6 : clinics should be by default conducted virtually unless not feasible for the patient or if face to face is required to progress clinical decision making

Again there is no evidence to support this recommendation and increasingly the government and public are expressing their concern and lack of support for virtual clinics.
For many EP clinics virtual appointments are entirely appropriate and often the best option.g. device follow up, but I am not sure this really the gold standard for physician appointments. It means patients cannot easily has 12 lead ECGS and cannot be examined.

This causes many problems for example we have seen a significant number of old fashioned subacute bacterial endocarditis recently, with very delayed presentations because they had never been seen in a face to face clinic or examined. It also leads to a massive increase in the use of diagnostic resources such as ECHO and tapes – If we go down this line we are moving to a position where all cardiology patients will end up coming in to hospital for an ECHO and at least an ECG if not a tape prior to their appointment rather than simply coming in once for a single face to face appointment.

There are also serious concerns about confidentiality and influence of other family members. For example many of my younger patients do not want to talk about contraception or drugs in front of their parents. In a face to face consultation it is easy for me or my nurse to take the patient off and have confidential discussions.
Similarly many of my patients have controlling relatives or partners and it can be very difficult to distinguish exactly what the patient wants. In a virtual appointment this is impossible to assess and we do not even know who is in the room with the patient.

4)Recommendation 14 “Cardioversion should, by default, be nurse physiologist or ACP led and undertaken outside the Cath lab.”

Again the basis of this recommendation is unclear and unnecessary. Nurses ACP or physiologists do of course provide excellent cardioversion services and in many centres this is an excellent model. However, this does not mean that there is a benefit over and above cardioversions being provided by doctors where that is the most locally appropriate solution. The real problem with cardioversion is why there is such a large disparity between the cardioversion rates at different centres. This is particular important for a procedure like cardioversion where there is actually very little evidence for its benefit outside a comprehensive atrial fibrillation service. We need local solutions for local problems.
Is there any evidence that centres where doctors are not involved in the cardioversion service have shorter waiting times, fewer inappropriate cardioversions or better outcomes? If cardioversion becomes totally divorced from the clinicians there is a risk it will come to be seen as just another test like an echo, or a tape rather than part of a comprehensive AF pathway.

In addition I have concerns that taking cardioversions completely out of the medical realm will make it increasingly difficult for medical trainees to get experience in this a core skill for all medical registrars. The document makes a number of other suggestions to improve care without making direct recommendations. For example using sedation in preference to GA for AF ablation. In that case it advises hospitals consider whether they can reduce the amount of GA used. It would have been much more appropriate for GIRFT to advise hospitals to review their entire cardioversion pathway and consider how the use of nurses, physiologists and ACPs could streamline the pathway rather than simply mandating that doctors should not do them.

5)In secondary care, patients identified with AF during an admission should be reviewed by a specialist nurse-led team under the supervision of a cardiologist and appropriate treatment commenced without delay. Page 38

This is an unrealistic goal likely to swamp services and mean that patients with AF who need intervention are much less likely to get good care.
It might have been far more sensible to have stated “identified with NEW AF during an admission”. Although even then, many of these patients are best managed by other specialists, for example health care of older people specialists.
There are huge numbers of patients particularly on the elderly care ward who have stable atrial fibrillation which is perfectly managed by specialists (Specialists in care of the elderly) or who have already been seen by the cardiology team and have a plan in place.
Do we really need to use resources to see these patients?
Similarly many patients come into hospital electively for operations with stable well controlled atrial fibrillation and a clear plan in place –do these really need to be seen by the AF team during their admission. What are we going to do about cold elective surgery sites that often have no cardiology provision? Do they need to have onsite cardiology review?

[James Glancy]

#11067

Fully agree with all the above. Horse has bolted I am afraid as already seems to have been taken on as NHS policy and is not a consultation document.
The Network model needs to be piloted to see if it works, it is an evidence free zone.
The reality of a portable workforce may well be stuck in traffic queues, impossible parking, working with unfamiliar teams and equipment, making cardiology recruitment deeply unattractive.
Odd report with lots of detail about minutiae such as mandating who delivers a cardioversion service, but nothing about primary care, working with front door teams, or the crisis in cardiac surgery.
Would have been better to concentrate on one or two things that would make a real difference – sorting out cardiac physiology workforce as an absolute priority would be my number one, rather that many action points most of which will never be achieved.

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