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BCCA clinical governance guidelines for congenital heart disease
outpatient consultation duration
April 2007
Background
The Bristol Inquiry Report emphasised that National standards of clinical care should
be patient centred. The Paediatric and Congenital Cardiac Services Review
(PCCSR)1, published by the Department of Health in response to the Bristol Inquiry
was endorsed almost in its entirety by Ministers. The PCCSR set numerous specific
standards of care for patients with congenital heart disease, including endorsement of
the British Cardiac Society (BCS) workforce committee’s recommendation at that
time for a minimum of 2 consultant paediatric cardiologists per million population to
provide an adequate level of care.2 In 2005 the BCS revised this recommendation to 3
per million, based upon the increased demand for specialist consultation and the EU
working time directive.3 These recommendations have not been implemented;
there are currently 76 NHS consultant paediatric cardiologists in the UK (population
approximately 62million) - a huge shortfall from the recommendations of the PCCSR
and the BCS.
The British Cardiac Society’s recommendations for adult congenital cardiologists in
2005, based upon workload data,3 was 1.3 to 1.5 full time consultants per million
population, increasing to double this figure by 2014. These recommendations have
also been ignored; there are currently 14 UK full time consultants (with some part
time support from paediatric cardiologists).
This shortage of manpower is most strongly reflected in the quality of provision of
outpatient care. Neither the PCCSR nor the Department of Health Commissioning
Guide for Adult Congenital Cardiac Services4 made specific recommendations on
standards for duration of outpatient consultations. The BCCA feel that this is a
fundamentally important aspect of quality of care.
Current outpatient practice
Outpatient consultations for children and adults with congenital heart disease are
highly variable, ranging from straightforward and very focussed (for instance an
innocent murmur or mild valvar stenosis) to extremely complex multidisciplinary
episodes (for instance an adolescent or young adult with complex heart disease and
extensive past history who requires advice on lifestyle, prognosis, treatment,
pregnancy and contraception as well as the heart disease itself).
Whilst duration of outpatient consultation does not necessarily equate to quality,
adequate time is clearly a prerequisite for safety. It is apparent that allocation of time
for a consultation varies widely across the UK. The majority of new and follow up
consultations involve the consultant reading relevant correspondence, taking a history
from the patient or parents, getting the patient undressed, carrying out a clinical
examination, in children carrying out an echocardiogram there and then, getting the
patient dressed, sometimes also interpreting an ECG and/or chest Xray, counselling
the patient and/or family, dictating a letter and often writing an echocardiogram report
with diagnostic coding. It is apparent that in some centres the time allocated at present
for all this to be done is 7.5 minutes. The BCCA view this as potentially unsafe.
Cardiologists have traditionally found it difficult to refuse to see patients (particularly
children) because of lack of time. Whilst such an attitude is commendable, it has led
to very large clinics with very short consultation times, has proved counterproductive
in terms of improving patient care and has removed incentive for funding of badly
needed new consultant posts.
The British Cardiac Society’s 5th Report on Cardiovascular Services recommended in
2005 that an average consultation for a child or an adult with congenital heart disease
required between 20 and 30 minutes.2 Hard data on time requirement for a “safe”
consultation is not available, so the following recommendations are based upon a
consensus view from the Council of the BCCA, the Children’s Heart Federation
(CHF) and the Grown up Congenital Heart Patients Association (GUCH).
Overall duration of outpatient clinics (and therefore the overall number of patients
seen) will inevitably vary and will depend upon many factors including availability of
local resources, funding, and consultant travelling time for outreach clinics; what is
most important to optimise quality is the time allocated to each consultation.
In addition to the recommendations set out below, all patients and/or their parents
should have access to a specialist cardiac liaison nurse as recommended by the
PCCSR.
Recommendations for children
Accepting that some straightforward cases will prove less demanding on time and
some complex cases will be more demanding, we recommend that an average of 20
minutes should be allocated to each new patient and an average of 15 minutes for
each follow up consultation. Adolescents in transition from paediatric to adult
congenital services for follow up require will require multidisciplinary input and
should be allocated a minimum of 20 minutes.
Recommendations for adults
Most new patients referred to adult congenital cardiology have many years’ records
from paediatric cardiology which can be very time consuming to digest, even when
the referral has been accompanied by a summary of past history. It is particularly time
consuming to ensure that a young adult has an appropriate understanding of what is
wrong and what treatment has been carried out during childhood as a prerequisite to
making treatment plans and patient counselling. Generally, counselling and
investigations such as echocardiography take more time than a similar consultation
for a child.
We recommend that an average of 40 minutes should be allocated for each new
patient and 20 minutes for each follow up consultation, excluding time for
echocardiography.
Trainees in outpatients
Trainees are usually present in specialist clinics held within a tertiary cardiac centre.
It is the view of the BCCA, the CHF and the GUCH association that trainees attend
clinics to be supervised and trained, not to provide a “subconsultant” consultation.
This will be of particular importance with the introduction of shorter training
programmes in August 2007. We recommend that trainees should be regarded as
supernumerary in outpatients, that clinic sizes should not be increased by allocation of
patients to trainees, and that consultations in a trainee’s presence should be recognised
as being more rather than less demanding on time.
New training programmes introduced under Modernising Medical Careers (MMC)
and the Postgraduate Medical Education and Training Board (PMETB) dictate that
trainees’ competence should be assessed in a wide variety of skill areas, including
outpatient consultations. These assessments (mini clinical evaluation exercises, or
MiniCex) require direct observation of trainee performance by a consultant, with
feedback to the trainee on various aspects of their performance as well as written
documentation of the assessment. Competence assessment is clearly beneficial to
trainees and patients and should be appropriately provided for in outpatient clinic
planning. When a consultation includes a MiniCex we recommend that 15 minutes
should be added to the consultation times suggested above.
References
1. Paediatric and Congenital Cardiac Services Review. November 2002.
www.dh.gov.uk/Consultations
2. Fifth report on the provision of services for patients with heart disease. Heart
2002;88(Suppl III):1–59.
3. Cardiac workforce requirements in the UK. British Cardiac Society, June
2005. www.bcs.com/documents/guidelines
4. Adult Congenital Heart Disease. A commissioning guide for services for
young people and grown ups with congenital heart disease (GUCH).
www.dh.gov.uk/en/Policyandguidance
bcca@bcs.com
April 2007