Patients’ lives are being put at risk because of “severe delays” in cardiac care, leading doctors have told i.
Amid widespread pressure on the NHS, staff shortages, and a backlog of heart patients, waiting times for urgent scans such as an electrocardiogram (ECG), – a simple test of the heart’s rhythms and electrical activity – are now as much as two months, with a fifth of people waiting over three months for echocardiograms (ultrasound examinations) and appointments to see cardiologists taking up to nine months.
An analysis by i has revealed that 25 hospitals across England currently have an average waiting time of more than 20 weeks for a first outpatient appointment in cardiology. And the proportion of patients waiting more than six weeks for an echocardiogram has increased more then 10-fold since the pandemic. The overall number of people waiting for this test has nearly doubled.
The two-week target for rapid access chest pain clinics, set by the National Institute for Care and Health Excellence (NICE) guidelines, isn’t being met in many cases, according to a leading cardiologist. And in desperation, patients are having to resort to private healthcare for basic tests.
The delays have today prompted two of Britain’s biggest cardiac institutions and two royal colleges to speak out in an attempt to raise the alarm about the danger this poses to patients and the crisis now engulfing the cardiology profession. The British Heart Foundation warns, “severe delays to vital tests, procedures and operations can lead to avoidable, unplanned hospital admissions, avoidable heart failure, or tragically can cost lives” and called on the government “to address the shortages in specialist cardiac staff”.
In a rare public statement, the British Society of Echocardiology (BSE) told i there are “more patients waiting longer for their echocardiogram and an already strained workforce pushed to the brink”. Its president said cardiology staff “are often asked to do more and quicker, but this raises unacceptable risks for… patient safety”.
And a leading consultant cardiologist, Dr Rohin Francis, told i that although emergency cases are still being treated promptly, the delays elsewhere in cardiology threaten public health.
“I’ve never known it to be like this before,” he said. “There’s no two ways about it: this is putting patients at risk.”
Some, he added, don’t live long enough to attend their appointment.
“I don’t see the ones that never make it to clinic because they’re no longer around – and without a doubt that is happening. We know patients are dying waiting for angioplasty and we know patients are dying waiting for bypass [surgery].”
Dr. Francis’ concerns were echoed by the President of the Royal College of Physicians. “As a cardiologist, I know that any delay to the diagnosis and treatment of heart patients can, in some cases, have tragic consequences,” Dr Sarah Clarke told i. “The NHS workforce is in a perilous position and the Royal College of Physicians and many others have long been saying that investment in our staff is essential if we’ve any hope not just of getting the NHS back on an even keel, but also of ensuring that it can meet the needs of patients in the future.”
Even the first stage of specialist heart care is affected: tests following a referral by a GP. At London’s Homerton Hospital, administrative staff have told patients there is a six-week wait for appointments, with one patient who’d been given a referral marked “urgent” having to wait nearly two months for an ECG.
‘Astonishing and frightening‘
The Homerton patient’s referral letter, seen by i, reveals that despite being an urgent case and being referred by his GP in early January, he was given an appointment for the ECG in early March.
Years earlier, he had been diagnosed with mitral-valve regurgitation (where one of the heart’s valves leaks) and has suspected supraventricular tachycardia (SVT), where the heart beats more quickly sometimes for hours. Having laid dormant for years, he suffered several hours of palpitations, prompting a visit to his GP and the urgent referral.
Concerned that he wouldn’t have the ECG test until March, he contacted i, rang the hospital back, and a second administrator also told him patients are waiting six weeks, not only for ECGs but also across diagnostic heart tests.
The patient, who spoke on the condition of anonymity, said: “It’s not the hospital’s fault, they just seem to be overwhelmed. I’m extremely anxious about my own situation because I have this heart condition and high blood pressure. When my GP said that he’d given me an urgent referral I assumed I’d get an appointment quickly. To then be told it was March was astonishing and frightening.”
Despite seeing the evidence of his nearly two-month wait for an ECG and what administrators had told this patient, when i approached Homerton Hospital for comment, a spokesperson denied there was a problem with ECGs before conceding that there are delays with other heart tests.
“Homerton does not have a backlog for ECGs and our service has capacity next week for routine walk-ins from GPs referrals and through outpatients. There is also daily capacity for urgent patients requiring ECGs,” said the spokesperson.
“It is true there have been backlogs in some day case diagnostic testing due to the build up of cases during the pandemic. We are working with other local providers and the independent sector to clear that backlog.”
But this has not helped the patient who spoke to i. “I didn’t feel it was safe to wait, so I’ve had to go private for the ECG,” he said. “It shouldn’t come to this. It’s my heart. And my case was marked urgent. How is this a functioning system?”
When he phoned Vista health, a private provider for scans and tests, “they told me that they’ve been inundated with NHS patients who can’t get appointments quickly enough. Although I’m able to pay for the tests I need, many won’t be able to, so what happens to them?”
It’s not just electrocardiograms but echocardiograms – which the BSE describe as “a complex, detailed ultrasound examination of the heart” – where delays are being felt. Before the pandemic, in February 2020, only four per cent of patients in England were waiting more than six weeks for an echocardiogram and nobody waited more than 13 weeks.
The latest official figures from November show 41 per cent of patients are waiting more than 6 weeks for this test and a further 21 per cent are waiting more than 13 weeks. The backlog is clear: about 88,000 people were waiting for this scan before Covid. Now it’s over 153,000 – nearly double. Last year, the waiting times were longer still.
The Royal College of Emergency Medicine told i: “Patients who experience delays to diagnostics, treatment or surgery are of course more vulnerable to experiencing complications, with many ending up in the Emergency Department as a result. The entire system is interconnected – backlogs in elective care have a knock-on effect on emergency care.
“The risk of complications posed to cardiology patients is particularly high, due to the nature of their condition. While the chances of something going wrong might still be quite low, the impact any problem could have is far higher for these patients, including death.
“All parts of the healthcare system are struggling, and all parts are understaffed, meaning that waiting times for care are up across the board. This poses particular problems for overstretched EDs, who are seeing patients they might not if other parts of the system weren’t also so overwhelmed. But Emergency Departments cannot get patients into hospital quick enough because we have too few beds. We also need to be able to discharge people with suspected angina who aren’t bad enough to come into hospital into a functioning elective system.”
When approached by i, an NHS spokesperson said: “Waiting lists for echo scans have fallen by 11 per cent since peaking in May last year thanks to the NHS investing in over 90 community diagnostics centres across the country and supporting local areas to boost diagnostic activity by 120 per cent of pre-pandemic levels by March this year.
“The NHS is committed to growing the cardiac workforce and in 2022 launched a fast-track programme providing over 140 training places for new cardiac physiologists to help people get the care they need as quickly as possible.”
But according to key cardiac organisations, serious problems remain, with waiting times and staff shortages.
“The British Society of Echocardiology is very aware of the delays some patients are experiencing in getting access to many diagnostic tests including an echocardiogram. We are working with our members, NHS England, Health Education England (HEE) and other bodies to identify solutions in the safest and most sustainable way,” the a spokesperson for the society told i.
The problem of insufficient clinicians in the field stretches back several years.
The spokesperson for the society added: “Pre-pandemic, the BSE identified that demand for echocardiograms was increasing at a time when the workforce was shrinking. We have worked with HEE and particularly with the National School for Healthcare Science to bring more people in to the profession, but it takes a considerable amount of time to train people to perform high quality, safe scans.”
Covid only exacerbated the shortfall in cardiology staff, the society said. “Many of our members were diverted throughout the pandemic, dealing with very sick patients and routine clinics were paused in most areas. The ramifications have been two-fold; more patients waiting longer for their echocardiogram and an already strained workforce pushed to the brink.”
The effects on echocardiographers has been profound, according to the BSE.
“In our recent workforce survey, our members reported just how physically and mentally drained they are with the burden of work and staff shortages. They are often asked to do more and quicker, but this raises unacceptable risks for them both around patient safety, for example, an important diagnosis might get missed, and their own physical health, with repeated strenuous scans impacting significantly on their musculoskeletal health. It is only as a result of the echocardiographers’ expertise and relentless determination to maintain quality standards that mistakes are avoided.”
The strain on cardiology staff has meant they’re now leaving the NHS.
BSE president Dr Claire Colebourn added, “More pressure on our members simply forces more of them out of the NHS and creates even further backlogs. We are in discussions to ensure that proposed solutions are well informed and meet the needs of both patients and our members. It is possible to achieve both, but it requires investment and genuine insight into the risks for all involved.”
Dr Colebourn’s sentiments were echoed by Dr Sonya Babu-Narayan, associate medical director at the British Heart Foundation, and a consultant cardiologist.
Dr Babu-Narayan said: “It’s demoralising to see heart care waiting lists rise month-on-month and such high numbers of people waiting longer than they should. People who need heart care can’t wait – severe delays to vital tests, procedures and operations can lead to avoidable unplanned hospital admissions, avoidable heart failure or tragically can cost lives.”
“Healthcare staff are doing all they can, but there aren’t enough of them to make a dent in the ever-growing backlog of care. We urgently need Government to address the shortages in specialist cardiac staff.”
Dr Rohin Francis, who documents life in his specialism on social media and has half a million subscribers to his YouTube channel, told i that “patients are waiting in limbo” to see cardiologists.
Alongside delays for tests and scans, he said, “the key problem is waiting times for appointments themselves. Clinic spaces. And I think that’s across the board in cardiology, everywhere in the country. If, for example, we want to bring in someone who has an urgent referral from a GP, there’s just no space, and we don’t have sufficient staff”.
“The wait to see a cardiologist now can be six or nine months,” said Dr Francis. “In most regions, people are waiting several months to get a cardiac MRI, and that can have major implications for their treatment. For something like a bypass operation, waiting times in many areas are about a year.”
Many hospitals provide a “rapid access chest pain clinic”, which is designed to provide swift assessments of patients presenting to their GP with chest pains. The NICE guidelines from 2010 recommend such clinics see such patients with two-weeks. “But people that I talk to – colleagues in different regions – feel that this is not being met. Some of the waiting times are extremely long now.”
How much is the pandemic to blame?
The scale of heart problems in the UK is huge, with more than 7 million people suffering from some form of cardiac or circulation condition, and more than a 100,000 a year dying from it.
When the pandemic hit, doctors, nurses and a range of clinical and administrative staff were diverted away from other specialisms onto the biggest health crisis in living memory. This affected all areas of medicine, but there was a particular squeeze on cardiology – a field devoted to the most fundamental organ in the human body.
In August 2021, the British Heart Foundation released a report into the effect of all this. “The Covid-19 pandemic has had a profound impact on all aspects of cardiovascular care – from prevention and diagnosis to treatment and support services,” the report said.
“In England, 5800 more people than expected died of heart and circulatory diseases in the first year of the pandemic.”
This translated to roughly 100 more people per week. The reasons were clear, the charity said: patients weren’t seeking help as much, there was a reduction in cardiology services, and care was shifting online.
“With services now facing significant backlogs of care and increasing numbers of people waiting longer for routine procedures and treatment, these trends are likely to continue unless there is significant investment in the infrastructure and workforce needed to keep pace with the needs of patients.”
Eighteen months on from this report, the backlogs are still there, and every doctor and organisation that spoke to i said that the fundamental, underlying problem was a lack of staff.
This arises from under-investment, they said, but also from a range of other factors: clinicians leaving the public sector, or leaving the country to return to their country of origin, problems now recruiting from the EU since Brexit, and the length of time it takes to train doctors and nurses in cardiology.
As the British Society of Echocardiography points out, even administering echocardiograms – just one type of investigation – is “carried out by a highly specialised workforce, educated to postgraduate level”.
The evidence suggests that Covid exacerbated everything, but the problems were already brewing – and may take many years to fully rectify.
With the heart being such a vital organ, he said: “Any delay, at any stage in the process, is a genuine risk. I’m in no doubt that people’s health and potentially their lives are being adversely affected by these delays.”
Acute emergencies are being treated promptly, said Dr Francis, but the problems lie mostly with outpatients. “A functioning service should be able to see these people within a few weeks,” he said. “Everybody’s falling into either ‘super emergency’, in which case they’ll be dealt with quickly – which is good – but everything else is now being massively delayed.”
Although the pandemic has placed extra pressure on the system, “the number one thing is lack of capacity and lack of staff,” he said. “And the underlying cause is a lack of investment.”
Dr Francis believes Brexit is part of the problem.
“Particularly in cardiology, we’re seeing huge shortages in some of our physiologists, many of whom came from the EU, and a lot of them have left and we’re not able to attract a lot of cardiac physiologists to the UK now. That’s a major area of shortage.”
The past six months have been particularly bad, he said, with delays affecting patient outcomes and prognosis, but also their overall wellbeing. “It’s the emotional and psychological stress of waiting so long. I sometimes have to start consultations by apologising to patients that they’ve been waiting so long,” he said.
But staff are suffering too. “It’s quite depressing. Morale is lower. People are routinely having to do the jobs of multiple members of staff. It’s standard to expect a shift with insufficient staff. We all went into this profession to try to help people and it feels like we’re not delivering the service that we would want for ourselves or for our loved ones.”
In desperation, people are turning to private medicine, according to Dr Francis. “I’ve had many patients that have paid for some initial tests privately before they’ve seen me. It is just the start of a two-tier health service that those who can afford to access treatment and investigations will do so. And those that can’t will be further disenfranchised.”
A Department of Health and Social Care spokesperson said they are in the process of training and recruiting more staff and that “no one should be waiting longer than necessary for treatment, which is why we are prioritising services with up to £14.1bn in the next two years to address the most pressing issues facing the NHS and social care.
“The pandemic had a significant impact on services, but we are focused on delivering the biggest catch-up programme in NHS history – including reducing waits of 18 months for routine treatment by more than half in a year, and virtually eliminating waits of more than two years.”