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AF Association
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Is there a case for more specialism in Hospitals?

This is a personal opinion and might be controversial, but I am wondering out loud, if there is an argument for not allowing some of the smaller hospitals and units in the UK to perform ablations and even in some cases treatment for specialisms such as AF.

Reading here, I see time and again, people having some challenges after either having ablations, or being referred to units for treatment without (it would seem) the experience of some of the larger units. Of course those challenges can occur within any treatment unit, but they do seem to be more prevalent in the smaller units, and certainly we hear often that some of the smaller cardiology units Poo..Hoo EPs in general and their specialism.

I am not here going to mention anywhere by name, but there are maybe (guessing) 10 to 20 places in the UK where there are "say" more than 3 or 4 EPs and where they carry out more than "say" 15 - 20 ablations a week.

Now of course there can be an excellent EP working at a smaller units or even working alone within a larger cardiac unit, but surely ablation is a procedure where you want experience experience experience in the person performing it.

Plus the equipment for a Cath Lab must be hugely expensive, and you would want the best possible equipment which surely cannot be in all of the units.

And similarly those smaller units are much less likely to have specialist arrythmia nurses, and/or specialist pharmacists and other ancillary services.

Local to me there is a large specialist unit, one of the largest in the country for arrythmias in general, AF and all heart conditions, and yet literally 6 miles away is another hospital with it's own unit and own EP perfoming ablations.

I agree that everyone should have a choice about where they are treated, but is it really in the best interests of the patient or even the NHS for those services to be available at every hospital and not just specialist units?

Your opinion?

Be well

Ian

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Living in rural Cumbria, one expects to travel. Our local hospital, Westmorland General, has a 'Primary Care' something or other that may treat you if you have a bee sting and can do X rays and an ECG, but A & E is 23 miles away - and we're only slightly off the beaten track.

We have no local EP. I have had ablations at Wythenshawe and Blackpool (90 and 55 miles from home) and have not felt that travelling there was a big problem, so I'd support the idea of a few centres of excellence.

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I would and do travel, by choice, to a centre of excellence. It makes perfect sense to me that a number of highly specialised centres interspersed across the country would be a sensible way forward.

Give me the inconvenience of travel any day in preference to less skilled local services. Sadly not all centres can afford the best facilities nor attract the best medics, sad but a fact in the overstretched NHS.

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I think it's an excellent point, Ian. The UK can support maybe 10 CoE which have almost a production line for ablations. I think an EP needs to doing around 5 ablations a week to be on top of their game. That was the concern I had with Prof Morgan of Southampton when I considered him - he was doing only 80-100 p.a.

I think their are other specialisations that could also benefit by operating that way.

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Everything you say makes sense to me, particularly as AF ablation must be one of the most complex procedures to perform and experience, backup and equipment are primary issues.

Choice of venue is something which we don't have in Northern Ireland - it's the Royal Victoria Hospital, Belfast - or else go privately elsewhere. We don't have 'Choose and Book'. This means that the Royal benefits from being our centre of excellence in staffing and equipment, but by English standards, is probably classified as small(er).

I think it takes a brave and wide-ranging appraisal of overall medical care within Trusts properly to plan and implement available health care facilities - not just in ablation procedures. But, the initial impetus needs to come from central government/assemblies in setting up these centres of excellence. Naturally, the smaller centres may resist losing their staff, patients, prestige and the local people will probably strenuously object to travelling and the downgrading of their hospital. (Politically, a very hot potato, I suspect)

This topic was often raised and debated furiously in further/higher education here in NI - smaller colleges were accused of 'mission creep' and millions were probably wasted on replication of resources. None of which was life threatening but there was massive resistance (mea culpa) to the reorganisation of 17 colleges into 5 centres.

Interesting post, Ian and I look forward to other people's ideas.

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Interesting debate Ian. Down yere in Devon the main cardiology department is in Exeter. some 45 miles or 1 1/2 hours away (Devon Roads) and until about four years ago the nearest EP centre was either Bristol (2 hour) or Plymouth ditto . Of course we have a hearty consultant or two in North Devon District Hospital but that is not sacrosanct with local politics the way they are. When I had my ablations I had to travel to London and these days a trip by train costs about £150 on a good day and a 10 am appointment means a five AM start and late dinner in the evening. Since ablation means you can not travel alone thjs creates many logistical problems.

Exeter now has an E P department who's main consultant was trained by Prof Schilling and who I have met several times at conference etc. but I still prefer to maintain contact with my original EP in London for as long as he is working and CCG allow it.

MY feeling is that these things are usually governed by local finance and politics and that trying to artificially reduce the numbers of EPs will only stagnate training and lengthen waiting lists.

.

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My local county hospital which is 'in special measure' started to perform ablations for the first time in February this year. I am not sure I would want to have one there and if I had one at all would prefer to go to a hospital which had more experience of the procedure even if it meant travelling...

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I agree and would prefer to travel than settle for a lack of experience locally. I think GP education should go hand in glove with specialist referral centres. It may even be useful to have a specialist arrhythmia nurse in one or two hub surgeries in an area. My GP has no specialist nurse and no access to one and defers every question I have to the cardiologist... I have been on rivaroxaban almost a year and have had no blood tests from GP. When I asked about meds monitoring he rather abruptly told me, he would do so when requested by the hospital. Sorry I'm ranting!

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There is a consultation regarding CHD, and which hospitals should be doing cardiac surgery going on at the moment. Not sure if this includes things like ablations or is limited to full heart surgery. However included in these plans is the suggestion that Royal Brompton and Harefield trust no longer do heart surgery. As this is the country's leading heart and lung hospital, there is a campaign to stop this. NHS England have only come up with one reason the Brompton does not meet their standards, and that is that the Brompton is not attached to a full general hospital. the Brompton is about 300 metres from Chelsea and Westminster hospital, and has a full working arrangement between all areas, so that if a patient at Brompton has another problem, Drs from C and W can be at the Brompton within about 10 minutes. All I would say is centres of excellence are a good idea, but what patients ideas of this is, may well differ from what NHS wants. Closing the Brompton, which is what would probably happen in the long run, would mean many years of expertise, research and a world famous reputation would disappear. Also expertise in respiratory disease would also disappear. BTW, the actual consultation where people can give their views has closed, and we are awaiting their decision.

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Dear Ian

I totally agree with you and I agree that your post is very controversial. But I also agree with you that we have read so many tales on our forum which describe such differing approaches and differing results to treating AF and in particular ablation. Sadly it is not the successes that post very often but more often than not those who have had difficulty.

The best EPs using the best equipment has to be the way forward, but with NHS budget restraints and the increasing diagnosises of AF there is no chance of having a centre of excellence within 1 hour of all of the sufferers in the UK.

The trouble with this approach is that many have to therefore embark on very long journeys to have their procedures. This in itself can be traumatic but having said that to not be treated by the best with the best equipment available also cannot be right.

Ablation is a serious undertaking and if the result leaves a patient worse off or they have no improvement it can be very distressing.

I am very fortunate in one respect as I live very near one of the centres of excellence but for me it has been a rocky road and I am in the minority of patients for whom so far, ablation has not been successful. Because of my location I can confidently say that I am one of the medical statistics rather than the lack of success in my case being due to lack of skill or the state of the art equipment.

I also really appreciate that some might say to me that it is all right for me to vote for centres of excellence as I live near one. My support for your suggestion is however, based on the suggestion that we should only be treated for our condition by the best with the best.

Pete

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It has often struck me that people talk of a 6 hour procedure under GA for an ablation for AF. My RF ablation took half that and my report mentions ablating the pulmonary veins, box section, top line and ablating for flutter and I had two CVs as well. So clearly the mapping equipment was state of the art and my EP was very skilled and speedy!

Obviously there is a difficult balance to be struck between meeting demand and maintaining/raising quality.

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Interesting question for a Sunday morning Ian. On a very different scale, our CCG was (and probably still is) exploring the benefits of setting up centres of excellence to deal with the majority of mainstream heart conditions, a form of "one stop shopping". Having been referred by your GP, you would then be set on a treatment programme by a unit that was equipped to do all the necessary tests and possibly cardioversions etc but probably not equipped to undertake ablations and mainstream heart surgery. I was involved in some of the discussions which were very interesting and a good insight into the workings of the NHS. One of the important benefits was the fact that they would be staffed by experts in their field of expertise and it was felt that standards would evolve upwards due to good ideas and good practise.

My only experience of ablation is St. George's a year ago and I was impressed with the standard of care I received. That said, I think the Hospital is in special measures at the moment, but not sure why. The principal of "Centres of Excellence" has to make sense, especially where procedures are generally completed within 24 hours. However, I also think the other serious problem is the terrible lack of initial support many patients receive once diagnosed. Again, I was lucky, my GP had a sound knowledge of AF and the surgery had an anticoagulant clinic which was first class even though the surgery was, and still is, unable to carry out an ECG. But sadly, the surgery has sufferred from financial constraints which, to some extent, supports the point which started my post.

Rural and remote areas will always be challenging, one of the prices one must pay if that's the environment people choose to live in, but more heavily populated areas have their challenges too, who'd be Jeremy Hunt!!!

Maybe it would help if they sorted out their procurement procedures first, then have a crack at reducing internal pilfering as that would generate eyewatering savings which would enable all sorts of good and useful things to be done to improve the lot of the poor patient and the medical profession. Here endeth the final lesson....well it is Sunday!!!

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When I lived in Cambridge I was initially referred to Addenbrookes but then requested that I see an EP and moved my care to Papworth. I was due to have an ablation but whilst waiting relocat d to Northern Ireland. My GP here advised me to stay with Papworth and have my ablation there. I didn't want to be a plane ride or ferry ride from home, and was all "what if something went wrong" 2 and a half years down the line a big part of me wishes I had kept my care at Papworth. RVH is really good but healthcare over here is in chaos. Our assembly has collapsed and the politicians seem to be doing very little to move forward. Our hospitals and schools are in crisis with no budget set. However, a regional centre of excellence here would be a fantastic idea. My consultant is based at RVH but I have had my investigations and cardioversion at City hospital , a mile away, but will have my ablation back at rvh. Sorry if this has been too political but that is the state of play over here x

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I so agree with everything you write, Jollies and the politics cannot be ignored, wherever we live. At the end of the day, health care provision has to be driven by the politicians, may the gods help us.

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Thank you. It was you who gave me the details of Dr Lau, for which I am grateful. I am also lucky to have a GP who listened to me and instead of referring down the regular route, listened and followed my request to be referred straight to an EP at a different hospital.

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One other thing to add is the issue of GPs blocking referrals. It is clear from reading many posts on our forum that this is a big issue for many and in particular when a patient does not live near to a centre of excellence.

Pete

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I completely agree that only centres of ablation excellence should offer the procedure. If I was able to I would willingly travell to one of these but would have to pay privately as I live in Wales and wouldnt be referred although if there was no facility in South Wales I probably would be able to go to the nearest centre which would probably be Bristol. At present, a significant number of ablation patients are treated at low turnover hospitals. X

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Yes indeed Pete. I am lucky in that I have a very good relationship with my EP in London and deal direct either with him or his secretary. My GP quietly ignores my riding roughshod over the CCG system and has been known to use the same methods. Fortunately so far this has not involved any major treatment since my third ablation nine years ago but once referred in 2005 ALL treatment has been managed directly from RBHT including any intruction to local hospitals. EG Cardioversion or Echo etc.

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Hi Ian - in this area - Devon - there is only one hospital in the area with 2 EPs performing ablations but I think in the SE you will have much bigger concentration of both population, specialists and facilities.

In principle I entirely agree with your premise but think they should also be distributed at regional level so people do not have to travel too far.

I think there is also an argument for an integrated system - but we are a long, long way away from that ideal! Hospitals & specialists chase the money so they will accumulate in some areas for all sorts of reasons such as that will be where the training is.

I think NHS has been moving toward Centres of Excellence for specialisms for a long time. The danger of that is when you have people like me and things go wrong. I have am acquaintance who is constantly being transported between 2 major hospitals several hundred miles apart because their conditons are so rare they can only be treated in Centres of Excellence.

I think it a double edged sword.

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It's what the DoH are trying to do, but the public fight it tooth & nail every step of the way. I recall listening to an MP bemoaning that they know they can improve mortality rates and productivity by closing small hospitals and concentrating facilities in centres of excellence, but every time they try, a campaign is got up to keep them open.

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Yes but distances are highly relevant., As CDreamer says, down here in Devon these are great. I know CD but we live about fifty miles apart. In London area there must be at least ten EP centres in that area! Are they going to close nine of them? Of course not. One centre of excellence in any specialism in an area of over 8,000 sq miles seems a little miserly especially where transport links are as poor as they are here. During my indisposition early this year I had to endure an hour and half ride in a cold, tired and bumpy ambulance during transfer because the local hospital does not do angiograms. I also had to occupy a bed for eight days as there was no free bed in Exeter for that time. I was not alone and worked out that the cost to the NHS of this fiasco in "hotel costs" alone was about £4000 and adding in the other patients I met with similar stories was in the region £50.000 for one week and from one local hospital and one department there. This doesn't include any treatment or transfer costs. The ambulance spends it entire life trudging backwards and forwards as I often see it and wave to the driver who recognises me now.

With more and more local services such as maternity, stroke, audiology etc being threatened with centralisation it can only get worse.

I don't know but can only guess that Cornwall is even worse! John, --care to comment?

Sorry rant over. I'm sure you are all jealous that we live where we do but there are down sides.

Bob

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Geography and population distribution is always going to be a factor and I am not sure there are ever going to be an economic and effective solution to that.

Mind you it isn't until you visit larger countries and talk to people who have to drive for 3 days to get to their treatment Centres that you appreciate that small can be beautiful.

Seems we mostly agree upon the principles of having CoE son not as controversial after all but of course we would all like to live near one.

And I do think that Wales and N. Ireland need a much improved service.

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The problem in our area is that BECAUSE of closing so many hospital beds in the small cottage hospitals the demand on the main regional hospital causes the problems that Bob describes in his post - i.e. there is a huge amount of bed blocking - which used to be catered for in the local hospitals eg:- stroke unit which used to be based at a local hospital closed, with its', bed allocation, moved to the regional hospital but their was no corresponding reallocation of beds.

There needs to be a good bit of joined up thinking of consequences when planning these changes, which doesn't seem to be happening right now.

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I agree Ian- all the studies show much lower complication rates in places where volume of cases is high- also specialist places attract those capable of research etc

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My local hospital is Peterborough, it is a brand new hospital (about 6 years old) and has wonderful ward facilities (i.e. only four beds to a ward and loads of space). I have come to the conclusion that the cardiac ward is very small scale considering the size of the hospital. This I beleive is because we have Papworth not that far from us and a lot of people are referred there.

There used to be in the first few years a EP clinic one day a week in Peterborough with an EP coming from Papworth, we not longer have this. We also seem to have quite a few papworth Cardio who work in Peterborough one or two days a week, the actual cardiolgist staff permanently at Peterborough is very low.

I have several times asked to be referred to an EP and have just hit a blank wall, you donn't need tp see one just keep up with the mediction. When I first asked my GP to help me to see an EP, she said what is an EP. Anyway will finanly see Dr Andrew Grace at Papworth next week via a private appointment.

So big shiny new hospital but no decent cardiac resources and as I have said above probably because Papworth is close. You would have thought that such a large new hospital would have a decent cath lab.

Cassie

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Travelling for care is a way of life if you're in a rural area, and the nearest 'big' specialist centre to us is Liverpool. I have to say, I think I'd rather be treated there than locally because it has such a good reputation. I think that matters more than mileage.

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I rarely take part in the discussions but follow them with great interest. I am a Carer to my husband who has several chronic health conditions. Not least Hypertrophic Cardiomyopathy, he is in AF 24/7, on his third ICD, much medication and in heart failure.

Adding to this, we live in rural West Wales so travel to a specialist heart centre is inevitable. This is a 120 mile -150 mile round trip to Morriston Hospital in Swansea, or 200+ to UHW in Cardiff. My husband needed an alcohol septal ablation several years ago, which was performed at the London Heart Hospital because of the lack of such specialist facilities here in Wales. Even simple monitoring of his ICD through the telephone line is difficult because of the lack mobile cellular coverage here, so has to be done at Swansea.

I am trying somewhat inarticulartly to say, is that the mindset of many patients/ public, expects the NHS to provide everything everywhere which is impossible! Clinical strategies must change - however demographics, deprivation and the domino effect of moving specialist services on smaller general hospitals must also be considered. This in order for us all to receive a safe and equitable service from the NHS and improve outcomes.

Sorry if this post sounds like a moan, my husband and I are so grateful for the care from NHS Wales without which, may not be here to tell the tale! We just know from experience that nothing is easy!

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I think you expressed yourself very articulately with a very considered response from personal experience.

Your husband is lucky to have you.

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Beancounter, I could not believe your post, as I just faxed my insurance company yesterday in reqard to requesting approval to have my ablation for Jan. 05, 2018 at a higher volume top facility. I can have it here within 80 miles at no deductible on my insurance plan, but to go out of approved network will cost me $6,000.00 deductible plus 20% of the balance of the bill. I had a cardiac arrest at the local facility after the second dose of Tikosyn, (which caused it) it was a miracle I survived due to the fact the leads to EKG had previously been disconnected for a MRI and left off once I returned to my room. The sole purpose for being hospitalized was to be monitored while administering this new drug. Also, the first dose converted me to NSR, but my rate was in the 30’s! My normal was 44-52. The torsades de pointe deadly rhythm is predisposed by slow heart rate( bradycardia) I entire life my rate has been considered brady. I flew at my own expense Nov 2 to the #1 heart center here in the US. Cleveland Clinic in Ohio. I am having my first ablation with Dr Patrick Tchou, who has been doing ablations since they began in the 90’s. I figure if it fails or I have complications, it will be at the best facility, best doctor, best team and best equipment. Even if I felt confident with my physician, he has to have a well trained high volume team. I just could not feel confident totally with all the foul ups that occured with me. I had only been reconnected a very few minutes when the cardiac arrest occurred. It was sudden with 2-3 second warning, I could have never called for help as it was like being sedated. I just went limp like being drugged, peaceful. Like oh ok, I am relaxed, but yet I knew because the nurse ran in and ask WHAT ARE YOU DOING? I said, nothing... looked at my chest and thought the leads were not connected properly. Then I said, I am going out. I could hear her yell, get the cart. My point is, you said everything I literally faxed to my insurance company yesterday. Whether they approve or pay I am still choosing the fly to Cleveland as I figure my life does not have a price tag. I will just have a payment plan if that is the case. Right on Beancounter..... I do not want to be the experiment.

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Dear Spoiler

I am not in the US, not am I subject to an insurance based system, and like most Brits I suspect I never want to be. Our system is far from perfect, but in my view still preferably to an insurance based system.

So I really don't understand your concerns here, in the UK which of course is much much smaller than the US, I am simply arguing for centres of excellence. Geographically in the UK this is much less of a problems than in the US. The equipment, and staff training needs for catheter labs is astronomically expensive, and yet a smaller hospital with maybe only a very small cardiology team, can carry out ablations.

My challenge in this post was simply, should they? Given the budgetary constrainsts would the UK not be better not allowing the smaller units to perform catheter ablations, and instead have to go to a centralised and more specialised units. In the UK I doubt this would ever be more than 100 miles, except perhaps for the islands.

So I am certainly not asking you to be an experiment and I wish you well

Be well

Ian

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The hospital locally has only been doing atrial ablations a couple of years and my insurance will pay for it there 100%. I had a bad experience there, so therefore you can appeal to your insurance company for approval at another facility if you choose, but it does not mean they will approve it for payment.

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