Huge progress has been made within the UK in terms of the delivery of revascularisation therapies in line with the National Service Framework (NSF) for Coronary Heart Disease. Much of this has been due to increased percutaneous coronary intervention (PCI) rather than coronary artery bypass grafting (CABG): the drivers for this change were patient centred and appropriate. Historically there was poor access to revascularisation, and long waiting lists both for elective and non-elective PCI. This much needed increased capacity was strongly supported by BCIS and would not have been possible without the major, and highly successful, expansion of non-surgical angioplasty centres which has happened in the UK over the last five years.
The BCIS guidelines for the development of a new PCI service are clear and among other recommendations argue for the need to maintain volume for both the centre and the individual. BCIS remain convinced that the data supporting the relationship between clinical outcome for patients and operator/institutional volume are robust for both stable and unstable coronary syndromes. Non-surgical centres with appropriate operator and institutional volumes have been clearly demonstrated to be able to provide a high standard of PCI.
With the expansion of services the landscape has changed. Many tertiary centres now have virtually no waiting list for elective or non-elective cases, allowing excellent and rapid access to revascularisation. There has also been a big expansion in the number of diagnostic only cath labs. We have a growing concern that development of new PCI centres is now ‘financially’ driven rather than by a desire to improve patient access to treatment, The National Tariff and ‘Payment By Results’ (PBR) has resulted in perverse incentives, stimulating some PCTs and Trusts to push for the development of multiple low volume PCI centres within a given Network, sometimes against the wishes of the local cardiologists in the same institution.
In addition to concerns about low volume centres, we believe there is a strong argument for the maintenance of some specialist high volume centres (usually supported by surgical units). This is necessary for some complex angioplasty cases, for the development of new techniques and devices which may involve urgent surgical procedures in their development phase, and for some areas of research. In addition the European working time directive and training requirements will necessitate the requirement for high volume units. The emergence of intervention for structural heart disease (e.g. PFO and ASD closure and percutaneous intervention for valvular heart disease) as a multidisciplinary speciality also argues for the maintenance of centres which can accommodate all specialities including general cardiology, interventional cardiology, specialised imaging and cardiothoracic surgery. This multidisciplinary team cannot be assembled in smaller units. If the UK gives up support for such units then it is likely we will fall behind in the development of this new speciality. Maintaining these high volume units within a given Network will require strategic planning rather than simply allowing market forces to drive the development of new PCI centres.
The guidelines for new angioplasty centres are very clear and can be found on this website. The recommendations are that centres should perform a minimum of 200 cases and have robust plans to increase activity to a minimum of 400 cases per annum. In addition the recommended minimum numbers per operator are 75 per year for an independent operator and 125 per year for a teacher.
We believe there are a growing number of centres that will try and challenge these recommendations for financial reasons, to the potential detriment of high quality patient care. We are of the opinion that the establishment of multiple low volume centres and operators within the UK would not be in the best interests of patients. BCIS believe that the current guidelines for new PCI centres safeguard patients, maintain standards and satisfy clinical governance considerations. Comments are welcome; please contact Martyn Thomas directly at mttwins@aol.com.

BCIS Council