N Black1, S Langham, C Coshall, J Parker. 1. Department of Public Health and Policy, London School of Hygiene and Tropical Medicine.
Abstract
OBJECTIVE: To describe changes in the availability, utilisation, and waiting times for coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA) between 1987/88 and 1994/95 and to review commissioning of these services. DESIGN: A series of cross sectional surveys and interviews with purchasers and providers. SETTING: Four health regions in the United Kingdom. PATIENTS: All residents aged 25 years or more who underwent coronary revascularisation. RESULTS: There has been little change in the availability of consultants in cardiology in specialist centres, while the number of non-consultant cardiologists has risen significantly. The availability of consultant surgeons more than doubled in some regions, while non-consultant surgical staff increased by 40-90%. The NHS rate of use of both CABG and PTCA has increased steadily since 1987/88. In 1994/95, only two districts had CABG rates of less than 300 per million population. The additional contribution of privately funded cases varied between 14-23% for CABG and 7-30% for PTCA. Regional rates varied 1.3-fold for CABG and threefold for PTCA in 1994/95, while district rates of CABG varied 3.6-fold and PTCA 18-fold. Revascularisation rates were higher in districts with least need in 1991/92 and this persisted over the following three years. The overall waiting time for CABG (214 days) was largely unchanged from 1992/93 (234 days). The overall waiting time for PTCA (138 days) was 25% shorter than in 1992/93 (185 days). Prioritisation of patients waiting over a year had not yet adversely affected the waiting time of more urgent patients. Commissioning has faced a complex web of interconnected problems which, in general, caused more problems for purchasers than providers initially but which appear to be of increasing concern to providers. CONCLUSIONS: The 1991 NHS reforms had had no observable impact on the availability and use of coronary revascularisation by 1995. Continued monitoring is necessary to detect any delayed effect.
OBJECTIVE: To describe changes in the availability, utilisation, and waiting times for coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA) between 1987/88 and 1994/95 and to review commissioning of these services. DESIGN: A series of cross sectional surveys and interviews with purchasers and providers. SETTING: Four health regions in the United Kingdom. PATIENTS: All residents aged 25 years or more who underwent coronary revascularisation. RESULTS: There has been little change in the availability of consultants in cardiology in specialist centres, while the number of non-consultant cardiologists has risen significantly. The availability of consultant surgeons more than doubled in some regions, while non-consultant surgical staff increased by 40-90%. The NHS rate of use of both CABG and PTCA has increased steadily since 1987/88. In 1994/95, only two districts had CABG rates of less than 300 per million population. The additional contribution of privately funded cases varied between 14-23% for CABG and 7-30% for PTCA. Regional rates varied 1.3-fold for CABG and threefold for PTCA in 1994/95, while district rates of CABG varied 3.6-fold and PTCA 18-fold. Revascularisation rates were higher in districts with least need in 1991/92 and this persisted over the following three years. The overall waiting time for CABG (214 days) was largely unchanged from 1992/93 (234 days). The overall waiting time for PTCA (138 days) was 25% shorter than in 1992/93 (185 days). Prioritisation of patients waiting over a year had not yet adversely affected the waiting time of more urgent patients. Commissioning has faced a complex web of interconnected problems which, in general, caused more problems for purchasers than providers initially but which appear to be of increasing concern to providers. CONCLUSIONS: The 1991 NHS reforms had had no observable impact on the availability and use of coronary revascularisation by 1995. Continued monitoring is necessary to detect any delayed effect.