Cardiology in the Community What can a GP do? John S K Wong MRCGP FRCP Ashlea Medical Practice, Leatherhead

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1 Cardiology in the Community What can a GP do? John S K Wong MRCGP FRCP Ashlea Medical Practice, Leatherhead

2 AIMS 1. From full-time GP to portfolio GP a personal experience 2. Accreditation as a GPwSI in cardiology PG Diploma in Cardiology British Society of Echocardiography (BSE) accreditation in adult echo Community Cardiology Clinics what can a GPwSI do? 6. Proposed CCG commissioned community cardiology service 2016

3 Portfolio GP 1. What does this mean? 2. From clinical assistant in Hospital Setting ( ) to GPwSI setting up community cardiology services at Leatherhead Community Hospital: 2004 (Direct Access Echo), 2007 (EDICS), 2013 (Ashlea Medical Practice) and 2016 (GPHP Ltd) 3. Current job plan : 4 GP sessions per week (10mins consultations) and up to 4 Community Cardiology Clinics per week (20-40 mins appointments)

4 GPwSI Accreditation 1. Scope of GPwSI accreditation will depend on previous experience and training as well as formal qualifications. 2. Roles can be focussed: example GPwSI in Heart Failure, AF or Echo 3. My current focus is on echocardiography, heart failure and AF but I also see patients with palpitations, chest pains, the dizzy patient and syncope. Basically general cardiology. 4. Accreditation was via PCT appointed panel. Then via interim Deanery Appraisal Process during transition to CCG. 5. Still awaiting formal guidance on accreditation of new GPwSI from NHSE/ RCGP

5 PGDip Cardiology 1 year distance learning course [various institutions] Relevant and not too challenging I would regard this as a basic requirement before undertaking relevant clinical training to develop the necessary skills If motivated and have time MSc cardiology courses helpful, though not essential

6 BSE Accreditation in Echocardiography Essential if doing echos in the community or hospital setting Can have BSE accreditation in Community Echocardiography or Adult Echocardiography [hospital setting all cardiac physiologist must have this to do echo. Likely to be a requirement for consultants cardiologists who does echos. 2 year training programme Written exams: MCQs and video clips Practical exams: log of 250 echos done personally, video log and also assessment of echo skills on a normal echo subject by examiners 5 yearly re-accreditation

7 Community Cardiology Clinics: What can a GPwSI do? A personal experience 1. Direct access echocardiography service offers advice re: significant echo findings needing action by referring GP 2. One stop echo-cardiology clinics: sees 99% of new patient referrals, clinical assessment, performs echo on patients, confirms diagnosis [HF, AF/other arrhythmia, valve disease, other pathology], initiate treatment, arrange further investigations as appropriate to guide management plan, arrange tertiary referrals. A one stop community cardiology service. 3. Supported by 3 consultant cardiologist with specialist interests in: interventional cardiology, heart failure/imaging and Electrophysiology/arrhythmia. Arrange patients FU with Consultants. 4. Reviews results of further investigations, action as appropriate, liaise with relevant consultants if necessary.

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10 Team Without Walls Direct Access Echo (GPSI) YES Abnormal Echo? Leatherhead Cardiology Service NO GP GPSI Intervention? NO Consultant YES St Georges Hospital / ESHUT/St Peter s

11 Direct Access Echocardiography Total Referrals (1267) Referrals returned to GP DNA? LV Dysfunction Murmurs/others

12 Direct Access Echocardiography Reports 80% 70% 60% 50% 40% 30% 20% 10% 0% 22% 58% Normal/Minor abnormalities Confirmed Confirmed Normal/Minor abnormalities? LV Dysfunction (423) Murmurs (387)

13 Community Cardiology Service: Referrals Abnormal ECG 4% Hypertension 3% Others 5% Referrals Syncope/dizzy 6% Chest Pains 13% Murmur 14% Palpitations 18% AF/Flutter 17% LV Function? 20% Palpitations LV Function? AF/Flutter Murmur Syncope/dizzy Chest Pains Hypertension Abnormal ECG Others

14 Reasons for Referrals: Community Cardiology Service 30% 25% 20% 15% 10% 5% 20% 11% 13% 27% 18% 17% 8% 14% 6% 4% 4% 3% 2% 9% 26% Community Acute Trust 0%

15 Community versus Acute Trust Diagnostics 80% 70% 60% 69% 74% 50% 40% 30% 32% 21% 38% Acute Trust 20% 11% 10% 0% Echo ETT ECG + Holter

16 Outcomes of Referrals Intervention, 10% DNA, 5% Follow-up, 42% Discharged, 43% Discharged Follow-up DNA Intervention

17 Interventional Cardiology: Valve Surgery, 9% Total = 65 (10%) CABG /other, 9% DCV, 9% EPS/RFA PPM/CRT Valve Surgery PPM/CRT, 25% Other, 26% PCI, 18% TAVI, 5% CABG /other DCV PCI TAVI EPS/RFA, 22% ASD closure ASD closure, 3%

18 Community Cardiology Service: Referrals 2014 Abnormal ECG 3% Hypertension 4% Chest Pains 3% Syncope/dizzy 7% Others 6% Murmur/Valve 21% Referrals (Total 523) Palpitations 23%? LV Function 21% Palpitations? LV Function AF/Flutter Murmur/Valve Syncope/dizzy Chest Pains Hypertension Abnormal ECG Others AF/Flutter 12%

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21 Summary Differences in use of diagnostic tests reflects differences in referral pattern to community cardiology clinics and acute trusts RTT within 18 weeks in > 90% of referrals achieved in community clinics Community cardiology services are valued by patients with high overall patient satisfaction Community clinics should provide equally high standards of care as Acute Trusts

22 Community Cardiology Proposal 2016 Managed by GP Federation in Epsom GP Health Partners Ltd Total practice population: 200,000 EMIS Web based community clinics - aims to be paperlite/ paperless. Local GPs will be able to access computer records of patients referred into the service and vice versa. Offers practice based ECG and 24 hr AECG service Care nearer home: 2 hubs Epsom & Leatherhead. Proposal include In-house Echo at both sites Collaboration with local acute trust with the aim of reducing costs of outpatient cardiology activity Supported and will be funded by Surrey Downs CCG as part of CCG s STP

23 Thank you for your attention Any Questions?