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A whole of system approach to cardiac services

Ischaemic Heart Disease (IHD), also known as coronary heart disease, is the second leading cause of death in New Zealand. According to the 2014-15 Health Survey, 4.6% of the NZ population over 15 had been diagnosed with IHD. That’s approximately 169,000 of your fellow Kiwis.

While deaths from IHD have declined over the past 30 years, our ageing population, new medication, modern interventions and technology advances mean that the number of people surviving heart attacks and living with heart disease is increasing. This in turn increases the demand on health services.

Research also shows health outcomes and timeliness of interventions from cardiac disease are significantly affected by ethnicity, level of deprivation and where a person lives.

In this context, TAS was asked to facilitate the Central Region Cardiac System of Care Strategic Plan to achieve a long term vision for equitable access to cardiac services across the region. The Central Region Cardiac Network was heavily involved in development of the plan. The Network includes managerial, clinical and Māori health representation from across the Central Region DHBs - Nelson Marlborough, Capital & Coast, Hutt Valley, Wairarapa, Whanganui, MidCentral and Hawke’s Bay – as well as members of the Heart Foundation and the National Cardiac Network.

Currently access to services for patients is variable and inconsistent across the region. For example, if a patient has a heart disease in Palmerston North or Hawke’s Bay the local hospitals can do angiography, an x-ray of the heart to see where the blockage exists but they can’t do an angioplasty that enables them to unblock the artery. Therefore, the patient is flown to Wellington Hospital to have the procedure to unblock the artery. This means patients endure two operations.

Palmerston North is making progress towards developing a business case for an interventional service.

Dr Nick Fisher, head and founder of the cardiology department for Nelson Marlborough DHB, holds the role of Clinical Director on the Central Region Network. “We realised that for equity to be achievable we all had to ‘play by the same rules’. Therefore we developed the NZ recommendations for referral and access to secondary care which all DHBs have signed up to.”

“Based on this nationally accepted document it was readily apparent that there were major inequities” he says. “Timely access to care mortality rates.”

“Access to echocardiography and time critical treatment for ischaemic heart disease are the two fundamental pillars of cardiac investigation and treatment. These have been long standing challenges in the Central Region, and we have decided that these are the main focus moving forward,” Dr Fisher continues. The Central Region is also focusing on improving access to primary care for Māori.

The Cardiac Network was tasked with formulating a deep understanding of existing services and models of care and recommending options to build a sustainable approach with more equitable access and better outcomes for the future.

Taking a whole of system viewpoint meant looking across home, primary, secondary and tertiary settings, working collaboratively with key groups across the system and using health informatics to inform the approach.

Informatics depicting population data by ethnicity, deprivation and locality were analysed. Other analysis included the prevalence and incidence of six heart disease categories in the Central Region population to determine unmet need. The data analysis showed that there is inconsistent access to primary care, cardiovascular risk assessments and triple therapy. For Māori there are significant inequalities as they are less likely to access primary care for treatment and are more likely to die from ischaemic heart disease.

The consumer perspective was also taken into account to ensure patients were kept at the heart of service design.

Greg Edmunds held the role of consumer representative on the Central Region Cardiac Network. “My role was to ensure that, where indicated, the experience of the consumer remained the focal point of any discussion." Greg’s overarching hope is that regardless of where you live or your ethnicity, you have equity of access to appropriate care.

The Network identified that it was important to have a thorough engagement process. During the three consultation workshops that were carried out recommendations were formed to address the short and long term challenges for cardiac services in the region.

Debbie Chin, CE of Capital & Coast District Health Board and Lead CE for the Central Region Cardiac Network, says “one of the successes of the Network is the excellent collaboration amongst clinicians across the region. They also had a shared commitment to improve equity and co-ordinate quality of care. This sets an example for other networks to follow.”

The options to improve outcomes in the cardiac health system of care require a focus on:

  • Improving access to primary care for Māori
  • Supporting the agreed clinical pathways and the NZ recommendations for referral and access to secondary care
  • Supporting the focus on prevention,treatment and management of atrialfibrillation and heart failure including access to echocardiography and urgent angioplasty/percutaneous coronary intervention (PCI) across the Central Region
  • Recalibrating sub-regional networks to improve access to specialist cardiac health workforce including echocardiography and specialists.

Now the project moves into an implementation phase over the next five years as it rolls out the recommendations across the region.