NATIONAL AUDIT OF CARDIAC RHYTHM MANAGEMENT DEVICES

NATIONAL AUDIT OF CARDIAC RHYTHM MANAGEMENT DEVICES

Acknowledgments is a partnership of clinicians, IT experts, statisticians, academics and managers which manages six cardiovascular clinical audits and three clinical registers. NICOR analyses and disseminates information about clinical practice in order to drive up the quality of care and outcomes for patients. The British Cardiovascular Society promotes education, training and research in cardiovascular health and upholds clinical and professional standards. The British Heart Rhythm Society (formerly Heart Rhythm UK) is an affiliated group of the British Cardiovascular Society and the Arrhythmia Alliance, and is dedicated to improving all aspects of cardiac arrhythmia care and electrical device based therapies. It provides an essential link between professionals working within pacing, devices and electrophysiology in the UK. The Healthcare Quality Improvement Partnership (HQIP) is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing and National Voices. Its aim is to promote quality improvement, and in particular to increase the impact of clinical audit in England and Wales. HQIP hosts the contract to manage and develop the National Clinical Audit and Patient Outcomes Programme (NCAPOP). The programme comprises 40 clinical audits that cover care provided to people with a wide range of medical, surgical and mental health conditions. Founded in 1826, UCL (University College London) was the first English university established after Oxford and Cambridge, the first to admit students regardless of race, class, religion or gender, and the first to provide systematic teaching of law, architecture and medicine. It is among the world s top universities, as reflected by performance in a range of international rankings and tables. IHMT is a consulting firm in France that specializes in medical market intelligence and strategic assessment. They provide the geographic mapping services for this report. Authors Report produced by David Cunningham, Senior NICOR Strategist Richard Charles, Lead Clinician CRM Audit Reports Morag Cunningham, CRM Database Coordinator, NICOR Adél de Lange, Analyst 2

The National Cardiac Rhythm Management Audit of Devices is managed by the National Institute for Cardiovascular Outcomes Research (NICOR), which is part of the National Centre for Cardiovascular Prevention and Outcomes, based at University College London. Specialist clinical knowledge and leadership is provided by the British Cardiovascular Society and British Heart Rhythm Society. The strategic direction and development of the audit is determined by the audit project Board. This includes major stakeholders in the audit, including cardiologists, the professional societies, physiologists, commissioners and patient group representatives. We would especially like to thank the contribution of all NHS Trusts and the individual physiologists, clinicians and audit teams who collect data and participate in the audit. Without this input the audit could not continue to produce credible analysis, or to effectively monitor and assess the standard of care in England and Wales. This report is available online at www.devicesurvey.com or www.ucl.ac.uk/nicor/audits/cardiacrhythmmanagement/publicreports First publication date January 31, 2014. The contents of this report may not be published or used commercially without permission. 3

National Audit of Cardiac Rhythm Management Devices CRM Audit Reports up to 2011 have analysed data related to Primary Care Trusts (PCTs) and Cardiac Networks. From 2012, as set out in the Health and Social Care Act 2012, data are analysed on the basis of Clinical Commissioning Groups (CCGs) and Local Area Teams (LATs). CCGs are groups of General Practitioner (GP) Practices that are responsible for commissioning most health and care services for patients within their local communities. As at the end of March 2013 there were 211 CCGs. They replace PCTs and are overseen by NHS England, including its regional offices and LATs. There are 25 LATs which are the 'local offices' of the NHS Commissioning Board. All LATS have the same core functions relating to CCG development and assurance, quality and safety and system oversight, amongst other tasks. Ten of the LATs lead on specialised commissioning across England. The current National CRM Device report analyses data in relation to CCGs and LATs. Since these are not geographically equivalent to the previous administrative structure, their demographics will also differ. It is therefore not valid to make direct comparisons with the PCT and Cardiac Network data from previous reports. To obviate this problem, and thus restore the comparability which is essential for assessing serial performance, the data for 2010 and 2011 have been re-analysed according to the new boundaries for the purposes of the 2012 Report. January to December 2012 This 8th annual report of the National CRM Audit describes cardiac device implantation performance in each Local Area Team in England and Wales for 2012. The report places local performance within a national and international context. It compares UK rates with other European countries. The report provides information on implantation rates within the UK and between Local Area Teams of England and Wales. For each Local Area Team of England and Wales this report will: Identify the CCGs (Local Health Boards in Wales) within the Teams and the principal hospitals implanting cardiac devices within them; summarise the age and sex structure of the CCGs allowing calculation of the relative need for device treatment locally; correct the actual device implant rate within the CCG for its relative need, allowing a valid direct comparison of implant rates between CCGs and LATs for the three years 2010 2012, illustrated for each CCG by performance tables and colour coded maps; show local performance for 2010 2012 compared to both current national average and national target implant rates; summarise the survey conclusions for each Local Area Team. The report is aimed at clinicians, healthcare managers, clinical governance leads, commissioners and all those interested in improving the provision and quality of device and arrhythmia services in the UK. 4

Contents Acknowledgments... 2 Foreword from National Clinical Director... 6 Foreword from President of British Heart Rhythm Society... 7 The future of the UK Cardiac Rhythm Management Audits... 8 Introduction...10 Overview of Device Implants in the UK...12 National Implant Rate Maps...14 Implant Rates in the Local Area Teams in 2012...15 European and International Implant Rates...22 New Pacemaker Implants 2012... 22 New ICD Implants 2012... 24 CRT Total Implant Rate 2012... 26 All High Energy Devices 2012... 28 Ratio of CRTD to CRTP Implants in Europe... 30 Quality Indicator...31 Physiological Pacing... 31 Physiological Pacing and Age... 33 Complex Device Implants...34 Left Ventricular Ejection Fraction... 35 NYHA Functional Class... 36 QRS Duration... 37 Aetiology... 38 Presenting Symptom... 39 Indication for Implantation of High Energy Devices... 40 Ratio of CRTD:CRTP implants by Local Area Team All implants 2012... 41 Ratio of ICD:CRTD implants by Local Area Team All Implants 2012... 42 Local Area Teams Implant Reports England...43 Arden, Herefordshire and Worcestershire Local Area Team...44 Bath, Gloucestershire, Swindon and Wiltshire Local Area Team...49 Birmingham and The Black Country Local Area Team...53 Bristol, North Somerset, Somerset and South Gloucestershire Local Area Team...58 Cheshire, Warrington and Wirral Local Area Team...62 Cumbria, Northumberland, Tyne and Wear Local Area Team...67 Derbyshire and Nottinghamshire Local Area Team...72 Devon, Cornwall and Isles of Scilly Local Area Team...77 Durham, Darlington and Tees Local Area Team...81 East Anglia Local Area Team...86 Essex Local Area Team...91 Greater Manchester Local Area Team...97 Hertfordshire and The South Midlands Local Area Team... 102 Kent and Medway Local Area Team... 107 Lancashire Local Area Team... 112 Leicestershire and Lincolnshire Local Area Team... 117 London Local Area Team... 122 Merseyside Local Area Team... 129 North Yorkshire and Humber Local Area Team... 133 Shropshire and Staffordshire Local Area Team... 138 South Yorkshire and Bassetlaw Local Area Team... 143 Surrey and Sussex Local Area Team... 147 Thames Valley Local Area Team... 152 Wessex Local Area Team... 157 West Yorkshire Local Area Team... 162 Cardiac Network Implant Reports Wales... 167 Wales... 168 North Wales Cardiac Network... 170 South Wales Cardiac Network... 175 Appendix 1 - Methodology... 181 Device Registration... 184 5

Foreword from National Clinical Director I am pleased to welcome publication of this, the 8th UK Cardiac Rhythm Management (CRM) Device Audit Report, covering the use of cardiac pacemakers, implantable defibrillators (ICDs) and cardiac resynchronisation therapy (CRT) in the calendar year 2012. I am delighted to see the continued progress of this project. The core audit group has worked closely with the Council of the British Heart Rhythm Society (BHRS), to incorporate key clinical descriptors, which allow correlation of guideline compliance with clinical outcomes. This is now a full clinical audit, led by the relevant national specialist society, and comparable to those published by other specialist groups affiliated to the British Cardiovascular Society. An additional report on cardiac arrhythmia ablation is expected in Spring 2014. A national clinical audit requires dedicated input from a wide range of skilled professionals. Dr. David Cunningham and his staff and colleagues at NICOR have provided funding stability, together with expertise in data collation and analysis. But complete and accurate data requires the continued efforts of clinical physiologists, nurses and clinicians at the device centres. Their time is often unfunded, yet freely given, and all concerned deserve our recognition and thanks. The results for 2012 offer real encouragement. Implant rates for both pacemakers and CRT have risen substantially; for ICDs the implant rate is probably stable, the apparent fall being partly artefactual, as explained in the report. However, as in previous years, optimism must be tempered by the fact that UK device implant rates remain significantly below those of comparable European countries, and it appears that inequity of device provision continues. For England, the Health and Social Care Act (2012) resulted in national specialised commissioning of devices being the responsibility of NHS England. This more centralised process offers an opportunity to reduce both inequity of access and unmet need, and future audits will allow us to monitor progress towards these important objectives. This national CRM device audit continues to provide an essential tool for understanding current practice, and how we should best plan for future improvement. As before, I warmly commend it to all who commission and deliver cardiac device therapy for our patients. Professor Huon Gray National Clinical Director for Cardiac Care NHS England 6

Foreword from President of British Heart Rhythm Society It is a great pleasure to contribute a foreword to the 2012 National Cardiac Rhythm Management (CRM) Device report. Since its inception, and throughout its 10 year evolution, the UK CRM audit project has naturally enjoyed the explicit support of our national society through its own evolution from the British Pacing and Electrophysiology Group (BPEG), through Heart Rhythm UK to its current, and hopefully settled, name. However, the past two years have seen increasingly active collaboration of the Society with the core audit group, and I pay tribute to the sterling efforts of Francis Murgatroyd and Nick Linker in driving the major developments in the CRM device and ablation database content described in their contribution to this 2012 Report. In 2010 my predecessor, Edward Rowland, alluded to the precarious state of funding for the CRM audits. I am pleased to say that with the welcome transfer of the audits to the care of NICOR, their funding is secure until April 2016, covering an important period of database development and clinical outcomes content for the audits. For their support in this we thank Huon Gray, National Director for Heart Disease, and both John Deanfield and Julie Sanders, the Director and Chief Operating Officer respectively, of NICOR. As ever, thanks must go to David Cunningham and his staff at NICOR who have worked tirelessly to collect, collate and analyse the raw data, and the clinical physiologists, clinicians and managers who provide our device services for their indispensible efforts which underpin the whole CRM audits. A central task of the CRM device audit has always been, and will remain, a description of the total implant volume and equity of access to the three main implantable cardiac device types pacemakers (PM) for bradycardia, the implantable cardioverter defibrillator (ICD), and cardiac resynchronisation therapy (CRT) devices for advanced heart failure. My colleagues sections and the body of the Report itself will record that in 2012 we saw a resumption of the annual increase in new PM implant rates after an unwelcome plateau, a striking increase in CRT implants, but an apparent reduction in ICD rates. The implications of the headline figures are discussed in the Report, but we must remain aware that the NHS continues to perform poorly in the provision of device services compared to our neighbouring health economies in Western Europe, and inequity of provision remains as striking as ever. This audit uniquely describes what we have done, but must increasingly be deployed as a weapon to drive future improvement. Readers of previous reports will notice the absence this year of a section on arrhythmia ablation. I am pleased to say that the reason for this is entirely positive. The quantity, quality and scope of data describing ablation practice in the UK have improved to a degree that warrant a separate report, and its publication is scheduled for Spring 2014. For this reason, the current report has reverted to the title "Cardiac Rhythm Device Management". Finally, the CRM Device National Audit Report provides a central core of clinical audit that I am certain will remain of value to all those involved in commissioning, planning and delivering device therapy for cardiac arrhythmias and heart failure. I am also confident that it will stimulate contributions that can lead to further improvements in the quality and equity of care for all our patients in the UK. Dr. Stephen Furniss President, British Heart Rhythm Society. 7

The future of the UK Cardiac Rhythm Management Audits Congratulations and thanks are again due to David Cunningham, Morag Cunningham, Dick Charles and Adél de Lange, for another highly detailed report on cardiac device activity in the UK. This is the eighth year of these reports, which have provided vital information on the provision of pacemakers, defibrillators, and cardiac synchronisation therapy across the country. From the start, they have highlighted the UK's poor performance compared with national targets and our EU neighbours, and great regional differences in provision of these vital treatments. The bar is rising, however, among the other national cardiac audits, as are the expectations of government and the public. The "BPEG database" was the first in the world, but its structure is ageing and suffers from two problems. Firstly, it struggles to reflect the complexity of modern device practice. Secondly, outcome data has received insufficient priority, and this is no longer acceptable. Outcome data (both complications and benefits) are critical in driving high standards, and in demonstrating that our costly "one-off" treatments offer genuine value for money. The ablation database, though younger, suffers from some of the same issues. The national audits undertaken by BHRS and NICOR need to provide more details of the interventions undertaken by device and electrophysiology specialists, and the outcomes of these interventions. If we do not do this, then others will try, possibly using less accurate, careful, and fair methods. How can we address these issues? We have undertaken a one-year review process, involving a wide panel of specialist physicians and allied professionals, with representation from government agencies (e.g. NICE, MHRA, NHS Improvement), NICOR, and patients. This resulted in two completely revised datasets, and a consultation period over the summer of 2013 drew invaluable feedback from around 50 centres. The datasets were locked in September and are available on the BHRS website. This gives centres and IT providers almost six months to prepare - the new datasets will be mandatory from 1 April 2014. The device dataset has been redesigned from top to bottom, and now permits detail of all cardiac implantable electronic device procedures (at least all that we could think of), including those done by surgeons, leadless pacemakers, implantable monitors, and lead extraction. The ablation dataset has been widened to include invasive EP studies, as well as new mapping and ablation technologies. A section has been added asking a little more detail for patients undergoing AF ablation procedures. Overall, the number of questions is not significantly increased; they are different, however, and will require care in completion. For both datasets, we are asking for the GMC number of operators as well as the consultant responsible. This is in line with the other specialist databases and it is essential that this is accurately and completely recorded to avoid errors or duplication. We have tried to select clinically relevant outcomes. The new dataset should be able to monitor adherence to implant guidelines, and record important complications of device implants. Importantly, centres will be required to track these for the first year of follow-up, even if patients' care is transferred elsewhere. For catheter ablation we will be looking at acute success, and complications occurring up to three months post procedure. For AF ablation in particular we will be rolling out a programme of recording Patient Reported Outcome Measures (quality of life questionnaires) before and one year post procedure. Hitherto, only a minority of the datasets have been used or published. As a result, complete data submission has been patchy, and some important parts of the data unreliable. This is 8

particularly the case for complication reporting, which has been very patchy. Many centres (including some of the largest) have reported no complications over years. This is simply not credible, and we are exploring ways of "policing" complication reporting, including the use of re-interventions and HES data. In the future, a track record of complete reporting of complications will be an essential part of the forthcoming centre accreditation process. The next (2013) annual device and ablation reports will therefore be the last to be derived from the current dataset. Thereafter, reports will be by financial year, in line with most other national audits. We anticipate starting to report activity by centre and consultant in 2015, and outcomes for FY 2014-15 the following year. We realise that these changes will be somewhat burdensome, disruptive, and sometimes painful. Despite our best efforts, we may not have got everything right first time, but hope that any problems are minor and soluble. However, feedback at the recent Heart Rhythm Congress was very positive, and the relevance and importance of our changes was understood. A final point: we believe that compliance with the national datasets is an inherent role of cardiac IT systems. For now, we will continue to provide a free web-based entry system (currently using Lotus Notes, though NICOR is exploring more modern alternatives). Further changes to the national datasets are likely to be tweaks, and we will give several months notice so that centres and IT providers have time to prepare. In return, we believe that commercial software providers should ensure that updates to the datasets are included automatically as part of their annual service contract, and should not require hard pressed Trusts to come up with extra cash every time there is a change. Francis Murgatroyd Audit lead, British Heart Rhythm Society Chair, BHRS Registry and Audit Steering Committee Nick Linker Secretary and President Elect, British Heart Rhythm Society 9

Introduction The British Heart Rhythm Society (formerly Heart Rhythm UK) is pleased to present the eighth consecutive annual UK National Cardiac Rhythm Management Device Audit for the calendar year 2012. As Steven Furniss, BHRS President, recounts in his Foreword, the Device Audit Group which has been responsible for all the CRM audit reports to date - with the explicit support of the national society - is now collaborating more closely at a practical level with BHRS Council. This is a development which the core audit group has long sought and welcomes without reservation. The content of this and subsequent reports should thus rightly be seen as the product and responsibility of BHRS. The CRM Device audit has always rooted its methodology in the demographics of geographical areas defined by the prevailing structure of the NHS. This has provided the unique ability to make valid comparison between the performance, both in total volume and equity of access to implantable cardiac devices, of those entities until recently Primary Care Trusts and Cardiac Networks. The structural changes to the NHS inherent in the Health and Social Care Act 2012 have now given us Clinical Commissioning Groups (CCGs) and Local Area Teams (LATs), the geographical boundaries of which vary from the former structure. It is therefore evident that the precise demographics of the new structures may also vary from the old, which would invalidate direct and detailed local comparisons with the reports of previous years. To obviate this problem, and thus restore the comparability which is essential for assessing serial performance, the data for 2010 and 2011 have been re-analysed according to the new boundaries for the purposes of the 2012 Report. However, it is worth emphasising that the core methodology of the CRM Device Audit remains unchanged. The power of its output benefits incrementally because of the ever increasing completeness and accuracy of the raw data supplied to it through the tireless efforts of hard pressed clinical physiologists, clinical staff, David Cunningham and his staff at NICOR, and the refinement of device classification systems the latter relevant to the apparent change in ICD implant rates in 2012. There have been no changes to agreed UK target implant rates for any of the three main device classes for several years [700 new implants/million (M) population for PM, 100 new implants/m for ICD and 130 total (new + replacement)/m for CRT], although there are cogent reasons for these to be revisited, as I advocated in the Introduction to the 2011 Report. So, what are the headline results for 2012? In England, the PM new implant rate is 559/M, restoring progress from the plateau of 524/M in 2011. There has been an apparent fall in new ICD implant rates in all constituent countries of the UK, but this is in part due to a prior system mis-classification which gave an artificially high rate in 2011. The new ICD implant rate for England in 2012 is 66/M. Conversely, all UK countries have seen a striking rise in total CRT implant rates; the rate for England is 136/M with thirteen LATs exceeding the national target of 130/M. The implications of these changes are discussed within the body of the Report. Whilst news on national implant rates is generally positive, it would be remiss of me to omit my usual and heartfelt caveat the NHS provides poorly for UK patients who meet the professionally accepted criteria for cardiac device implantation. UK new implant rates remain substantially lower than those in comparable Western European countries (and much lower than those in the USA) for no identifiable reason of disease prevalence. Postcode variability in access to therapy remains a fact of life. By contrast, there is much evidence that 10

inadequacies in education, patient screening, referral pathways, and both human and capital resources for device medicine are significant culprits. An inextricable part of the audit process should be to use the results as an engine for change. Great progress has been made in improving UK device therapy over the lifetime of these reports, but much remains to be done. There is no cause for complacency. I once again commend this Report to all healthcare colleagues who continue to strive every day for excellence in arrhythmia therapy for UK patients. Dr Richard Charles Lead Clinician, CRM Audit Reports. 11

Overview of Device Implants in the UK General note: up to 2010, population estimates were year-on-year projections (from ONS) of the population, extrapolating from the 2001 census. In general these projections tend to under-estimate the true population. The 2011 rates use the accurate population from the 2011 census, so a slight increase in actual implant rate might be masked by replacing a population under-estimate with a true estimate. 'This and subsequent reports are based on the 2011 census (Note: the rates in these graphs are NOT adjusted for age and sex). New Pacemakers Comments Pacemaker implant rate in England has increased (559 per million population). Significant increase in new pacemaker rate in Wales and a slight increase in N Ireland. Data submissions from Scotland have improved but are still incomplete. per million population 600 500 400 300 200 100 0 England Wales Scotland N Ireland 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 year New ICDs Comments ICD rate fell significantly in N Ireland but still remains above the rest of the UK. England and Wales rates have decreased from 2011. Slight decrease in Scottish rate actually reflects better data submission, but is still not 100% complete. per million population 140 120 100 80 60 40 20 0 England Wales Scotland N Ireland 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 year 12

Total CRTs Comments The total CRT rate (all implants CRT-P and CRT-D) for England has increased significantly, achieving the highest rate since these devices were introduced, as well as exceeding the national target of 130 for the first time. There was a large increase in the CRT rate in Wales. The N Ireland implant rate has returned to 2008 levels after falling away in last few years. The Scotland implant rate has increased but remains very low and well below the rest of the UK. per million population 160 140 120 100 80 60 40 20 0 England Wales Scotland N Ireland 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 year 13

National Implant Rate Maps It is immediately apparent that the 2012 pacing implant map is very similar to 2011. In contrast, a decrease in ICD rate is shown by the fewer dark red colours on the centre map. An increase in national CRT rate masks areas where the implant rate remains very low. 14

Implant Rates in the Local Area Teams in 2012 Pacemakers corrected for age and sex of LAT population Average: 559 Highest: 638 North Yorkshire and Humber Lowest: 379 Arden, Herefordshire and Worcestershire Whilst there has been a welcome increase in the national new pacemaker implant rate, this appears to have been achieved largely by increases in localities which have historically had the lowest implant rates, continuing the trend noted in the 2011 Report of regression towards the national mean rate, rather than the target rate. Comparable to 2011, no LAT approaches the target new PM implant rate of 700/M population. 15

The grey line represents the national average rate. The blue line is the national target rate. Pacemaker New Implant rate 2012 adjusted for age and sex North Yorkshire and Humber Leicestershire and Lincolnshire Hertfordshire and The South Midlands Surrey and Sussex East Anglia Lancashire London Greater Manchester Devon, Cornwall and Isles Of Scilly Wessex Durham, Darlington and Tees Cheshire, Warrington and Wirral South Yorkshire and Bassetlaw Bath, Gloucestershire, Swindon and Wiltshire West Yorkshire Birmingham and The Black Country Merseyside South Wales Cumbria, Northumberland, Tyne and Wear Thames Valley Bristol, North Somerset, Somerset and South Gloucestershire Essex Shropshire And Staffordshire Kent and Medway North Wales Derbyshire and Nottinghamshire Arden, Herefordshire and Worcestershire 0 100 200 300 400 500 600 700 800 NB: North Wales and South Wales have a higher than average need for pacing so the adjusted rates shown here are lower than the unadjusted national rate for Wales shown on Page 12. 16

ICD corrected for age and sex of LAT population Average: 66 Highest: 92 Hertfordshire and The South Midlands Lowest: 41 Lancashire The national ICD implant rate in 2011 was artificially increased by the misclassification of certain devices which should have been recorded as CRT-D devices. This has now been identified and corrected but as the next graph shows, new ICD implant rates for Local Area Teams are all below the national target rate of 100. As in previous analyses, the Lancashire area remains at a very low level. Hertfordshire & South Midlands is the only area to get close to the target rate. 17

The grey line represents the national average rate. The blue line is the national target rate ICD New Implant rate 2012 adjusted for age and sex Hertfordshire and The South Midlands Durham, Darlington and Tees Derbyshire and Nottinghamshire Birmingham and The Black Country North Wales London Cumbria, Northumberland, Tyne and Wear Thames Valley Essex Bath, Gloucestershire, Swindon and Wiltshire North Yorkshire and Humber Leicestershire and Lincolnshire Surrey and Sussex Bristol, North Somerset, Somerset and South Gloucestershire Kent and Medway Greater Manchester Merseyside Shropshire And Staffordshire Devon, Cornwall and Isles Of Scilly West Yorkshire South Yorkshire and Bassetlaw South Wales Cheshire, Warrington and Wirral Wessex East Anglia Arden, Herefordshire and Worcestershire Lancashire 0 20 40 60 80 100 120 18

All CRT devices corrected for age and sex of LAT population Average: 136 Highest: 210 Merseyside Lowest: 80 Derbyshire and Nottinghamshire The striking increase in the national total CRT implant rate in 2012 appears to have been achieved by increases across the board - in localities historically registering both the lowest and highest rates. It is notable that the national mean implant rate (136/M) is now higher than the national target rate (130/M) for the first time. Fourteen of the 27 LATs (include 2 Wales LHBs) have achieved or exceeded the national target rate in 2012. 19

The grey line represents the national average rate. The blue line is the national target rate. All CRT Total Implant rate 2012 adjusted for age and sex Merseyside Lancashire Birmingham and The Black Country Cheshire, Warrington and Wirral Wessex Surrey and Sussex North Wales Greater Manchester London Kent and Medway West Yorkshire Bath, Gloucestershire, Swindon and Wiltshire Devon, Cornwall and Isles Of Scilly Hertfordshire and The South Midlands East Anglia Thames Valley North Yorkshire and Humber Shropshire And Staffordshire Essex Arden, Herefordshire and Worcestershire Cumbria, Northumberland, Tyne and Wear Leicestershire and Lincolnshire South Yorkshire and Bassetlaw South Wales Durham, Darlington and Tees Bristol, North Somerset, Somerset and South Gloucestershire Derbyshire and Nottinghamshire 0 50 100 150 200 250 20

All High Energy devices (ICD + CRT-D, new and replacement) Average: 155 Highest: 195 Merseyside Lowest: 112 Arden, Herefordshire and Worcestershire All Defib Devices (ICD + CRT-D) New Implant rate 2012 adjusted for age and sex Merseyside London Birmingham and The Black Country Hertfordshire and The South Midlands North Wales Surrey and Sussex Devon, Cornwall and Isles Of Scilly Durham, Darlington and Tees Kent and Medway Thames Valley Greater Manchester Cumbria, Northumberland, Tyne and Wear Essex Bath, Gloucestershire, Swindon and Wiltshire Wessex Cheshire, Warrington and Wirral Derbyshire and Nottinghamshire Lancashire North Yorkshire and Humber Shropshire And Staffordshire South Yorkshire and Bassetlaw Bristol, North Somerset, Somerset and South Gloucestershire Leicestershire and Lincolnshire West Yorkshire South Wales East Anglia Arden, Herefordshire and Worcestershire 0 50 100 150 200 250 21

European and International Implant Rates New Pacemaker Implants 2012 22

New Pacemaker Implants 2012 per million population Germany Iceland France Italy Austria Sweden Finland Estonia Malta Czech Republic Lithuania Denmark Belgium Switzerland Spain Poland Norway Slovakia United Kingdom Greece Slovenia Croatia Portugal Latvia Hungary Netherlands Ireland Serbia Israel Bulgaria Montenegro Belarus Luxembourg Russia Cyprus Macedonia Bosnia Tunisia Armenia Romania Ukraine Georgia Morocco Egypt Azerbaijan Sources: Eucomed 2012 0 200 400 600 800 1000 1200 23

New ICD Implants 2012 24

New ICD Implants 2012 per million population Germany Czech Republic Austria Poland Denmark Italy Belgium Norway Netherlands Ireland Slovakia Switzerland Finland France Israel Sweden Luxembourg Iceland Portugal United Kingdom Greece Hungary Slovenia Spain Cyprus Estonia Malta Montenegro Serbia Lithuania Latvia Croatia Belarus Bosnia Macedonia Bulgaria Armenia Tunisia Romania Georgia Russia Azerbaijan Ukraine Morocco Egypt 0 50 100 150 200 250 300 25

CRT Total Implant Rate 2012 (CRTP+CRTD, New and Replacement) 26

Total CRT Implants 2012 per million population Italy Germany Denmark Czech Republic Netherlands France United Kingdom Austria Israel Norway Sweden Hungary Switzerland Poland Finland Slovakia Estonia Belgium Ireland Malta Spain Iceland Portugal Slovenia Serbia Luxembourg Greece Lithuania Latvia Montenegro Cyprus Bulgaria Croatia Romania Macedonia Tunisia Russia Bosnia Belarus Georgia Armenia Azerbaijan Egypt Ukraine Morocco 0 50 100 150 200 250 27

All High Energy Devices 2012 ICD+CRTD, New and Replacement 28

Total ICD & CRT-D Implants 2012 per million population Germany Czech Republic Italy Denmark Austria Netherlands Norway Israel Belgium Poland France Switzerland United Kingdom Sweden Ireland Finland Iceland Hungary Slovakia Portugal Luxembourg Spain Malta Greece Slovenia Estonia Serbia Cyprus Montenegro Lithuania Latvia Croatia Bulgaria Macedonia Bosnia Belarus Romania Tunisia Armenia Russia Georgia Azerbaijan Ukraine Egypt Morocco 0 100 200 300 400 500 600 29

Ratio of CRTD to CRTP Implants in Europe Ratio of CRT D to CRT P Implants 2012 0% 20% 40% 60% 80% 100% Greece Germany Israel Poland Italy Ireland Czech Republic Netherlands Slovakia Spain Austria Portugal Denmark France Belgium Switzerland Finland Norway Russia United Kingdom Sweden Hungary Romania Serbia CRTD CRTP 30

Quality Indicator Physiological Pacing Physiological pacing may be defined as cardiac pacing in which the pacemaker senses or stimulates cardiac activity such that it emulates as closely as possible the normally conducted sinus rhythm. This of course means that the physiological contribution of the atria should not be ignored, where possible, and in consequence the atria should be paced if necessary, or otherwise sensed. Another definition is artificial pacing that maintains the heart's normal contraction sequence, with resulting haemodynamic benefits, emphasising that it is physiologically better for the patient to have the atria and ventricles beating in synchrony rather than at different rates. In practice we define physiological pacing as atrial-based pacing, i.e. any pacing mode which senses or paces the right atrium. These modes will include: atrial pacing (whether rate responsive or not modes AAI and AAIR) dual chamber pacing (whether rate responsive or not modes DDD and DDDR) non-p synchronous pacing with dual chamber sensing (modes DDI and DDIR) managed ventricular pacing modes (MVP, AAI>DDD, AAIR>DDDR, AAIsafeR) Atrial based pacing does NOT include: Ventricular inhibited pacing (VVI mode) Ventricular inhibited pacing with rate response (VVIR mode) 29% 71% Atrial based Ventricular based So physiological pacing is used in the majority of patients. 31

In 2012, the thirteen most common pacing modes 1 were employed as follows: Atrial based modes 2012 2011 DDDR 26701 67.49% 66.90% DDD 830 2.10% 2.40% AAIR 132 0.33% 0.01% AAI>DDD 42 0.11% 0.01% AAIR>DDDR 40 0.10% 0.00% AAI 33 0.08% 0.00% DDI 10 0.03% 0.02% AAIsafeR 2 0.01% 0.00% DDIR 1 0.00% 0.01% Ventricular based modes 2012 2011 VVIR 11057 27.95% 29.80% VVI 285 0.72% 0.50% VDD 67 0.17% 0.26% VDDR 12 0.03% 0.03% Two-thirds of devices implanted now have dual chamber rate responsive capability, although 30% of devices are still ventricular based 1 Some centres register the pacing mode when the patient leaves the cath lab. The final programmed mode at discharge is reflected better by the maximum capable mode (MCM) of the pacemaker generator, and it is that maximum capable mode which is used in all of these analyses. 32

Physiological Pacing and Age The graph below shows atrial-based pacing (in blue) and ventricular-based pacing (grey) as % of total new implants in England and Wales in 2012. Atrial based Ventricular based 100% 90% 80% % of New Implants 70% 60% 50% 40% 30% 20% 10% 0% Unknown 0 4 5 9 10 14 15 19 20 24 25 29 30 34 35 39 40 44 45 49 Age 50 54 55 59 60 64 65 69 70 74 75 79 80 84 85 89 90 94 95 110 In children ventricular pacemakers are often implanted due to practicalities such as generator size and concerns about growth; however after the age of 5 we see most patients receive atrial-based devices even up to the age of 80, but after the age of 40 the proportion of atrial-based devices begins to fall, dropping to 31% in patients 95 years and older. Is this appropriate? In theory, no. Older patients should receive physiological devices even if relatively inactive, as these devices may help prevent the onset of atrial fibrillation or heart failure. Obviously factors such as co-morbidity become increasingly important as patients become older - especially a marked increase in the prevalence of atrial fibrillation, in which atrial based pacing is contraindicated. However, in the absence of AF, unless a patient is terminally ill with another condition, such as cancer, it could be argued that a physiological device would still be beneficial. It is likely that international comparisons will help in assessing whether the UK is using physiological pacing appropriately; these have yet to be carried out in detail. However, there is published guidance from NICE which states that: "Dual-chamber pacemakers are recommended to treat symptomatic bradycardia in people with sick sinus syndrome, atrioventricular block, or both." It is therefore appropriate to use this as a performance indicator. 33

Complex Device Implants Introduction The 2010 national audit presented for the first time a detailed analysis of implant indications for complex devices ICD and CRT in the United Kingdom. With the presentation of the 2012 report, we now have data for 3 consecutive years. This enables trends to be assessed. Given the lag-time in the survey, it also allows us for the first time to assess the possible impact of previous reports on clinical practice. The general trends observed in 2010 and 2011 are once again evident As might be anticipated, there is a greater representation of patients with impaired LV function amongst patients receiving resynchronisation devices with an accompanying higher proportion of patients with symptomatic heart failure. Interestingly, amongst patients receiving a defibrillator, whether ICD or CRTD, there has been an increase in the proportion reported to have good left ventricular function. It will be interesting to see if this trend persists in future years. Once again there is a greater representation of QRS widening amongst patients receiving CRT devices. There is a greater representation of ischaemic pathologies amongst patients receiving high voltage devices, whether ICD or CRTD, in comparison with patients receiving CRT-P devices. Pleasingly, the improvement in data completeness noted in 2011 has been maintained and indeed further improved upon. To me the most striking and most pleasing feature of the 2012 data is the continuing reduction in variation in practice nationally in relation to CRTP / CRTD and ICD / CRTD selection. One of the most striking features of the 2010 report was the marked variation in CRTP:CRTD and ICD:CRTD ratios by LAT. This variation fell in 2011 and has fallen once again in 2012. One of the requirements for any audit programme is the need to re-audit and assess effects on practice. It is clearly not possible to prove that previous audits have led to greater uniformity in practice, but as this variation was highlighted both in the national report and at subsequent meetings both of individual LATs and nationally, it is tempting to suggest that the original 2010 audit may indeed have been a factor. Campbell Cowan Consultant Cardiologist, Leeds General Infirmary 34

Left Ventricular Ejection Fraction What we expect: ICD patients will have better ventricular function than CRT patients, who will predominantly be in heart failure and therefore have poorer ventricular function. What we found: As predicted and as seen last year ICD patients have better ventricular function than CRT-P patients who in turn have slightly better function on average than CRT-D patients. Interestingly, the proportions of patients reported as having good left ventricular function has risen in both the ICD and CRT-D groups (ICD: from 18% in 2011 to39% in2012; CRT-D: 1% in 2011 to 12% in 2012). Data quality has improved again in 2012. 35

NYHA Functional Class What we expect: CRT patients are likely to have poorer NYHA status than ICD patients. NYHA class III patient are more likely to get CRT therapy than ICD therapy. However CRT therapy is not indicated for NYHA class IV patients, according to NICE guidance. What we found: Data quality is similar to 2011. In parallel with the data on left ventricular function, a higher proportion of patients of the defibrillator groups were reported as NYHA class I in 2012 (ICD: from 37% in 2011 to 47% in 2012). 36

QRS Duration What we expect: QRS prolongation is very frequent in CRT patients, according to NICE guidance. A lower proportion of ICD patients are likely to have QRS prolongation. What we found: QRS prolongation is again very frequent in CRT patients. Proportions are very similar to last year s analysis. Data quality has not improved compared to 2011. 37

Aetiology What we expect: Ischaemic heart disease patients are more likely to have CRTD therapy than CRTP therapy (reflecting NICE guidance). What we found: Ischaemic heart disease patients are more likely to receive a high energy device than a CRT-P. Data quality did not improved compared to 2011, mainly due to exclusion of 'unspecified' as a valid option. NB: In the 2012 analysis "Unknown" and "Unspecified" have been disallowed as valid codes, so the % of missing data has increased. 38

Presenting Symptom Glossary Syncope loss of consciousness Cardiac Arrest absence of an effective heart beat usually requires an electric shock to avoid sudden death Presyncope dizzy spells without losing consciousness Tachycardia a fast heart rate, often accompanied by palpitations, that causes symptoms Bradycardia a slow heart rate that causes symptoms Prophylactic symptom-free but risk factors indicate an implant should be performed What we expect: ICD patients will largely be implanted for Syncope/Arrest or Prophylactic indication. CRT patients will have a high proportion of Heart Failure indications, particularly CRTP patients. What we found: Symptomatology is in line with what we would expect for each class of device, with some anomalies. There is an increase in heart failure indications for CRTD and a decrease in prophylactic implants. Heart failure remains the dominant indication for CRTP implants. 39

Indication for Implantation of High Energy Devices Primary v Secondary Prevention What we expect: There has been an increasing trend towards implants for primary prevention, particularly for CRTD devices. What we found: ICD devices implanted for primary prevention appeared to reduce from 2010 due to classification errors in previous analyses. The majority of CRTD devices are implanted for primary prevention. 40

Ratio of CRTD:CRTP implants by Local Area Team All implants 2012 grey line represents national average 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% South Yorkshire And Bassetlaw Durham, Darlington And Tees Derbyshire And Nottinghamshire Devon, Cornwall And Isles Of Scilly London Thames Valley Kent And Medway Hertfordshire And The South Midlands Surrey And Sussex Bath, Gloucestershire, Swindon And Wiltshire S Wales Shropshire And Staffordshire Cumbria, Northumberland, Tyne And Wear Birmingham And The Black Country Merseyside Essex Arden, Herefordshire And Worcestershire N Wales North Yorkshire And Humber Greater Manchester Wessex Cheshire, Warrington And Wirral Lancashire Bristol, North Somerset, Somerset And South G Leicestershire And Lincolnshire % CRTD % CRTP East Anglia West Yorkshire In some areas 3 in 5 devices were CRTP, whereas in others the ratio is the other way round with almost 3 CRTD devices for every 1 CRTP. The range of ratios is however less extreme than in 2010 and 2011. 41

Ratio of ICD:CRTD implants by Local Area Team All Implants 2012 grey line represents national average 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% South Yorkshire And Bassetlaw Durham, Darlington And Tees Derbyshire And Nottinghamshire Devon, Cornwall And Isles Of Scilly London Thames Valley Kent And Medway Hertfordshire And The South Midlands Surrey And Sussex Bath, Gloucestershire, Swindon And Wiltshire S Wales Shropshire And Staffordshire Cumbria, Northumberland, Tyne And Wear Birmingham And The Black Country Merseyside Essex Arden, Herefordshire And Worcestershire N Wales North Yorkshire And Humber Greater Manchester Wessex Cheshire, Warrington And Wirral Lancashire Bristol, North Somerset, Somerset And South G Leicestershire And Lincolnshire East Anglia % ICD % CRTD West Yorkshire The ratio of ICD:CRTD varies less than it did in 2010 and 2011. 42

Local Area Teams Implant Reports England In 2012 England had 211 CCGs and 25 Local Area Teams. The cardiac LATs cover a population ranging from 0.61 to 0.86 million, and comprise on average 8 CCGs. The total population of England (from the 2011 census) was 53.11 million. The population of Wales was 3.06 million. 43

Arden, Herefordshire and Worcestershire Local Area Team Location: Population: Age and relative need: West Midlands 1.6 million Because the population is older than average there is a 10% greater need for pacemakers and 8% greater for ICDs than the national average. Clinical Commissioning Groups: 7 Main pacemaker implant hospitals: County Hospital Hereford George Eliot Hospital Queen Elizabeth Hospital Edgbaston University Hospital Coventry Warwick Hospital Worcestershire Royal Hospital Main ICD implant hospitals: Queen Elizabeth Hospital Edgbaston University Hospital Coventry Main CRT implant hospitals: Queen Elizabeth Hospital Edgbaston University Hospital Coventry Warwick Hospital 44

per million population per million population 600 550 500 450 400 350 300 250 200 90 80 70 60 50 40 30 20 10 0 Pacemaker New Implant Rate adjusted for age and sex of network population National Arden, Herefordshire and Worcestershire 2010 2011 2012 year ICD New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National Arden, Herefordshire and Worcestershire Pacemakers (national target: 700 new implants per million population) PM implant rate has slightly decreased in 2012, remains well below the national average. ICD (national target: 100 new implants per million population) ICD implant rate has decreased in 2012 and is well below the national average. per million population 160 140 120 100 80 60 40 20 0 CRT Total Implant Rate adjusted for age and sex of network population National Arden, Herefordshire and Worcestershire 2010 2011 2012 year CRT (national target: 130 total implants per million population) CRT implant rate has improved in 2012 but remains below the national average. 45

CCG New Implant Rates Above national target Similar to national target Below national target Below national target and below national average Pacemaker CCG Name 2010 2011 2012 2010 2011 2012 ICD Q53 Arden, Herefordshire and Worcestershire England 528 524 559 72 76 66 388 392 379 44 55 44 05A Coventry and Rugby 356 367 375 64 67 59 05F Herefordshire 489 419 349 27 72 27 05H Warwickshire North 297 360 396 65 50 75 05J Redditch and Bromsgrove 310 314 414 16 42 42 05R South Warwickshire 429 521 413 38 42 31 05T South Worcestershire 386 399 346 42 57 45 06D Wyre Forest 464 240 385 51 51 8 Total CRT CCG Name 2010 2011 2012 Q53 Arden, Herefordshire and Worcestershire England 114 113 136 83 88 107 05A Coventry and Rugby 109 98 137 05F Herefordshire 111 60 96 05H Warwickshire North 52 83 67 05J Redditch and Bromsgrove 85 101 101 05R South Warwickshire 74 91 137 05T South Worcestershire 63 92 105 06D Wyre Forest 75 84 42 Note: Pacemaker, ICD, CRT New Implant rates and CRT Total rates are adjusted for age and sex of local population. 46

Summary The LAT s population is older than average; overall the LAT requires 10% more pacemakers than the national average, and 8% more ICDs. The pacemaker implant rate continues to track well below the national average. The pacemaker implantation rate is the lowest in England and Wales, tracking significantly below the national average. All pacemaker and ICD new implant rates are below the national targets, in all CCGs. 47

New implant rates 48

Bath, Gloucestershire, Swindon and Wiltshire Local Area Team Location: Population: Age and relative need: South West 1.5 million Older than average; overall the LAT requires 9% more pacemakers than the national average, and 6% more ICDs. Clinical Commissioning Groups: 4 Main pacemaker implant hospitals: Royal United Hospital Bath Bristol Royal Infirmary Cheltenham General Hospital The Great Western Hospital Salisbury District Hospital Main ICD implant hospitals: Bristol Royal Infirmary Cheltenham General Hospital The Great Western Hospital Wessex Cardiothoracic Centre Gloucestershire Royal Hospital Main CRT implant hospitals: Royal Bournemouth Hospital Bristol Royal Infirmary Cheltenham General Hospital The Great Western Hospital John Radcliffe Hospital Gloucestershire Royal Hospital 49

per million population per million population per million population 650 600 550 500 450 400 350 300 250 200 90 80 70 60 50 40 30 20 10 0 160 140 120 100 80 60 40 20 0 Pacemaker New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National Bath, Gloucestershire, Swindon and Wiltshire ICD New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National Bath, Gloucestershire, Swindon and Wiltshire CRT Total Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National Bath, Gloucestershire, Swindon and Wiltshire Pacemakers (national target: 700 new implants per million population) PM implant rate has decreased in 2012 and fell just below the national average. ICD (national target: 100 new implants per million population) Implant rate has decreased noticeably in 2012; it remains above the national average. CRT (national target: 130 total implants per million population) CRT implant rate has improved significantly in 2012 and is just below the national average. 50

CCG New Implant Rates Above national target Similar to national target Below national target Below national target and below national average Pacemaker CCG Name 2010 2011 2012 2010 2011 2012 ICD Q64 England 528 524 559 72 76 66 Bath, Gloucestershire, Swindon and Wiltshire 560 594 541 65 81 70 11E Bath and North East Somerset 520 629 658 49 60 93 11M Gloucestershire 457 536 533 72 103 80 12D Swindon 872 711 544 131 91 66 99N Wiltshire 601 616 507 41 65 51 Total CRT CCG Name 2010 2011 2012 Q64 England 114 113 136 Bath, Gloucestershire, Swindon and Wiltshire 115 97 132 11E Bath and North East Somerset 26 83 80 11M Gloucestershire 123 86 130 12D Swindon 259 196 213 99N Wiltshire 89 83 123 Note: Pacemaker, ICD, CRT New Implant rates and CRT Total rates are adjusted for age and sex of local population. Summary The LAT s population is older than average; overall the LAT requires 9% more pacemakers than the national average, and 6% more ICDs. Implant rates for all three device classes are very close to the national average, but for ICD the rate is above the national average. There is marked variability between the CCGs in the LAT. Notably, in Swindon the CRT rate is above the national target. 51

New implant rates 52

Birmingham and The Black Country Local Area Team Location: Population: Age and relative need: Midlands 2.4 million Relatively young require 7% less pacemakers and 7% less ICDs than the national average. Clinical Commissioning Groups: 7 Main pacemaker implant hospitals: Birmingham City Hospital Good Hope Hospital Wolverhampton Heart and Lung Centre Queen Elizabeth Hospital Edgbaston Russells Hall Hospital Sandwell General Hospital Solihull Hospital Manor Hospital Main ICD implant hospitals: Good Hope Hospital Wolverhampton Heart and Lung Centre Queen Elizabeth Hospital Edgbaston Russells Hall Hospital Sandwell General Hospital Manor Hospital Main CRT implant hospitals: Good Hope Hospital Wolverhampton Heart and Lung Centre Queen Elizabeth Hospital Edgbaston Russells Hall Hospital Sandwell General Hospital Manor Hospital 53

per million population per million population 600 550 500 450 400 350 300 250 200 90 80 70 60 50 40 30 20 10 0 Pacemaker New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National Birmingham and The Black Country ICD New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National Birmingham and The Black Country Pacemakers (national target: 700 new implants per million population) PM implant rate has slightly decreased in 2012 and is just below the national average. ICD (national target: 100 new implants per million population) ICD rate remained static and the LAT implant rate is still above the national rate. per million population 200 180 160 140 120 100 80 60 40 20 0 CRT Total Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National Birmingham and The Black Country CRT (national target: 130 total implants per million population) CRT implant rate has improved in 2012 and is well above the national average and target. 54

CCG New Implant Rates Above national target Similar to national target Below national target Below national target and below national average Pacemaker ICD CCG Name 2010 2011 2012 2010 2011 2012 England 528 524 559 72 76 66 Q54 Birmingham and The Black Country 528 548 533 62 80 79 04X Birmingham South and Central 331 472 522 56 94 44 05C Dudley 621 524 479 59 97 117 05L Sandwell and West Birmingham 579 583 593 104 84 56 05P Solihull 494 563 516 35 40 44 05Y Walsall 633 787 534 66 81 107 06A Wolverhampton 445 459 473 66 70 132 13P Birmingham CrossCity 497 486 561 46 85 60 Total CRT CCG Name 2010 2011 2012 England 114 113 136 Q54 Birmingham and The Black Country 157 132 185 04X Birmingham South and Central 245 355 216 05C Dudley 83 72 183 05L Sandwell and West Birmingham 123 112 151 05P Solihull 122 76 168 05Y Walsall 171 120 213 06A Wolverhampton 144 92 152 13P Birmingham CrossCity 209 164 207 Note: Pacemaker, ICD, CRT New Implant rates and CRT Total rates are adjusted for age and sex of local population. 55

Summary The LAT s population is relatively young so requires 7% less pacemakers and 7% less ICDs than the national average. The pacemaker implant rate fell in 2012, the LAT is just below the national average. The ICD new implant rate is static. The rate continues to track above the national average and below national target. There is a significant increase in the total CRT implant rate; it remains well above the national target. All the CCGs in this LAT have exceeded the national target. 56

New implant rates 57

Bristol, North Somerset, Somerset and South Gloucestershire Local Area Team Location: Population: Age and relative need: South West 1.4 million This LAT serves a population which is older; there is a 10% higher need for pacemakers and a 5% need for ICDs compared to the national average. Clinical Commissioning Groups: 4 Main pacemaker implant hospitals: Royal United Hospital Bath Bristol Royal Infirmary Frenchay Hospital Musgrove Park Hospital Weston General Hospital Yeovil District Hospital Main ICD implant hospitals: Bristol Royal Infirmary Musgrove Park Hospital Main CRT implant hospitals: Bristol Royal Infirmary Musgrove Park Hospital 58

per million population per million population per million population 600 550 500 450 400 350 300 250 200 90 80 70 60 50 40 30 20 10 0 160 140 120 100 80 60 40 20 0 Pacemaker New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National Bris tol, No rth So merset, So merset and South Gloucestershire ICD New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National Bris tol, No rth So merset, So merset and South Gloucestershire CRT Total Implant Rate adjusted for age and sex of network population National Bris tol, No rth So merset, So merset and South Gloucestershire 2010 2011 2012 year Pacemakers (national target: 700 new implants per million population) PM implant rate has decreased in 2012 and fell well below the national average. ICD (national target: 100 new implants per million population) An improvement in 2012, the LAT implant rate matches the national rate. CRT (national target: 130 total implants per million population) CRT implant rate has improved in 2010 but remains well below the national average. 59

CCG New Implant Rates Above national target Similar to national target Below national target Below national target and below national average Pacemaker CCG Name 2010 2011 2012 2010 2011 2012 ICD Q65 England 528 524 559 72 76 66 Bristol, North Somerset, Somerset and South Gloucestershire 465 533 484 78 53 66 11H Bristol 438 557 452 97 72 100 11T North Somerset 461 440 505 72 38 72 11X Somerset 588 618 539 88 46 54 12A South Gloucestershire 190 375 364 55 70 44 Total CRT CCG Name 2010 2011 2012 Q65 England 114 113 136 Bristol, North Somerset, Somerset and South Gloucestershire 61 64 87 11H Bristol 98 86 135 11T North Somerset 72 99 94 11X Somerset 48 60 84 12A South Gloucestershire 44 19 26 Note: Pacemaker, ICD, CRT New Implant rates and CRT Total rates are adjusted for age and sex of local population. Summary The LAT s population is older than average; overall the LAT requires 10% more pacemakers than the national average, and 5% more ICDs. For ICD rate matches the national average. The pacemaker and CRT rate are well below the national average. All implant rates are below the national targets, in all CCGs, except for Bristol s ICD and CRT rate. 60

New implant rates 61

Cheshire, Warrington and Wirral Local Area Team Location: Population: Age and relative need: North West 1.2 million Older than average require 11% more pacemakers and 10% more ICDs than the national average. Clinical Commissioning Groups: 6 Main pacemaker implant hospitals: Liverpool Heart and Chest Hospital Countess of Chester Hospital University Hospital North Staffs Warrington Hospital Arrowe Park Hospital Wythenshawe Hospital Main ICD implant hospitals: Liverpool Heart and Chest Hospital University Hospital North Staffs Wythenshawe Hospital Main CRT implant hospitals: Liverpool Heart and Chest Hospital Manchester Royal Infirmary University Hospital North Staffs Wythenshawe Hospital 62

per million population per million population 600 550 500 450 400 350 300 250 200 90 80 70 60 50 40 30 20 10 0 Pacemaker New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National Cheshire, Warrington and Wirral ICD New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National Cheshire, Warrington and Wirral Pacemakers (national target: 700 new implants per million population) PM implant rate has very slightly decreased in 2012 and is just below the national average. ICD (national target: 100 new implants per million population) ICD implant rate has decreased in 2012 and is now below the national average. per million population 180 160 140 120 100 80 60 40 20 0 CRT Total Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National Cheshire, Warrington and Wirral CRT (national target: 130 total implants per million population) CRT implant rate has improved in 2012 and exceeds the national target. 63

CCG New Implant Rates Above national target Similar to national target Below national target Below national target and below national average Pacemaker ICD CCG Name 2010 2011 2012 2010 2011 2012 England 528 524 559 72 76 66 Q44 Cheshire, Warrington and Wirral 540 556 548 59 78 51 01C Eastern Cheshire 580 620 481 44 57 52 01R South Cheshire 387 353 503 63 58 47 02D Vale Royal 303 370 348 28 46 55 02E Warrington 418 358 366 44 83 24 02F West Cheshire 678 744 706 86 117 63 12F Wirral 619 636 650 68 86 57 Total CRT CCG Name 2010 2011 2012 England 114 113 136 Q44 Cheshire, Warrington and Wirral 119 124 166 01C Eastern Cheshire 146 108 128 01R South Cheshire 47 79 116 02D Vale Royal 85 57 122 02E Warrington 72 97 167 02F West Cheshire 125 174 192 12F Wirral 169 153 210 Note: Pacemaker, ICD, CRT New Implant rates and CRT Total rates are adjusted for age and sex of local population. 64

Summary The LAT s population is older than average; overall the LAT requires 11% more pacemakers than the national average, and 10% more ICDs. The new PM implant rate remains close to the average but below the target. The ICD rate fell sharply by 33% in 2012, and is now clearly below the national average. Warrington CCG fell by more than 40% compared to 2011. Three CCGs; Warrington, West Cheshire and Wirral exceeded the CRT national target. 65

New implant rates 66

Cumbria, Northumberland, Tyne and Wear Local Area Team Location: Population: Age and relative need: North West 1.9 million The population is older than average and there is a consequent 9% increased need for pacemakers and 9% for ICDs, compared with the national average. Clinical Commissioning Groups: 8 Main pacemaker implant hospitals: Wansbeck General Hospital Cumberland Infirmary Freeman Hospital Queen Elizabeth Gateshead South Tyneside District Hospital Westmoreland General Hospital Sunderland District Hospital Main ICD implant hospitals: Wansbeck General Hospital Freeman Hospital Main CRT implant hospitals: Wansbeck General Hospital Freeman Hospital Lancashire Cardiac Centre Blackpool 67

per million population per million population per million population 650 600 550 500 450 400 350 300 250 200 80 75 70 65 60 55 50 160 140 120 100 80 60 40 20 0 Pacemaker New Implant Rate adjusted for age and sex of network population National Cumbria, Northumberland, Tyne and Wear 2010 2011 2012 year ICD New Implant Rate adjusted for age and sex of network population National Cumbria, Northumberland, Tyne and Wear 2010 2011 2012 year CRT Total Implant Rate adjusted for age and sex of network population National Cumbria, Northumberland, Tyne and Wear 2010 2011 2012 year Pacemakers (national target: 700 new implants per million population) PM implant rate has decreased in 2012 and is below the national average. ICD (national target: 100 new implants per million population) A significant improvement in 2012, the LAT implant rate is well above the national rate. CRT (national target: 130 total implants per million population) CRT implant rate has improved in 2012 but remains below the national average. 68

CCG New Implant Rates Above national target Similar to national target Below national target Below national target and below national average Pacemaker CCG Name 2010 2011 2012 2010 2011 2012 ICD Q49 England 528 524 559 72 76 66 Cumbria, Northumberland, Tyne and Wear 595 597 498 74 64 74 00F Gateshead 492 604 481 127 75 136 00G Newcastle North and East 678 632 690 94 102 77 00H Newcastle West 649 600 597 92 54 85 00L Northumberland 496 592 442 64 61 96 00N South Tyneside 784 848 509 101 50 38 00P Sunderland 573 625 468 45 87 83 01H Cumbria 601 500 493 59 53 46 99C North Tyneside 662 631 497 85 57 57 Total CRT CCG Name 2010 2011 2012 Q49 England 114 113 136 Cumbria, Northumberland, Tyne and Wear 88 94 106 00F Gateshead 88 83 117 00G Newcastle North and East 125 161 127 00H Newcastle West 108 163 150 00L Northumberland 65 52 71 00N South Tyneside 122 86 69 00P Sunderland 90 115 108 01H Cumbria 82 93 115 99C North Tyneside 79 70 118 Note: Pacemaker, ICD, CRT New Implant rates and CRT Total rates are adjusted for age and sex of local population. 69

Summary The LAT s population is older than average and there is a consequent 9% increased need for pacemakers and 9% for ICDs, compared with the national average. PM implant rate has decreased and is now below the national average. ICD and CRT rates both increased in 2012, substantially so for the ICD rate. The ICD rate exceeds the national average, but remains below the national target. There is substantial variability in rates between CCGs in the LAT, especially for ICD. 70

New implant rates 71

Derbyshire and Nottinghamshire Local Area Team Location: Population: Midlands 2.0 million Age and relative need: Slightly older than average has a 3% excess need for pacemakers and 3% for ICDs. Clinical Commissioning Groups: 10 Main pacemaker implant hospitals: Chesterfield Royal Nottingham City Hospital Royal Derby Hospital Kings Mill Hospital Main ICD implant hospitals: Nottingham City Hospital Glenfield Hospital Kings Mill Hospital Northern General Hospital Main CRT implant hospitals: Nottingham City Hospital Glenfield Hospital Kings Mill Hospital Northern General Hospital 72

per million population per million population per million population 600 550 500 450 400 350 300 250 200 90 80 70 60 50 40 30 20 10 0 160 140 120 100 80 60 40 20 0 Pacemaker New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National Derbyshire and Nottinghamshire ICD New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National Derbyshire and Nottinghamshire CRT Total Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National Derbyshire and Nottinghamshire Pacemakers (national target: 700 new implants per million population) PM implant rate has slightly decreased in 2012 and remains well below the national average. ICD (national target: 100 new implants per million population) An improvement in 2012 takes the LAT implant rate to well above the national rate. CRT (national target: 130 total implants per million population) CRT implant rate has improved in 2012 but remains well below the national average. 73

CCG New Implant Rates Above national target Similar to national target Below national target Below national target and below national average Pacemaker ICD CCG Name 2010 2011 2012 2010 2011 2012 England 528 524 559 72 76 66 Q55 Derbyshire and Nottinghamshire 409 458 433 63 71 83 03X Erewash 344 364 372 51 51 51 03Y Hardwick 562 459 452 41 82 74 04E Mansfield & Ashfield 654 642 497 74 134 99 04H Newark & Sherwood 332 484 558 46 53 137 04J North Derbyshire 431 516 480 38 28 57 04K Nottingham City 357 391 449 96 92 130 04L Nottingham North & East 449 551 517 32 83 90 04M Nottingham West 274 480 499 141 125 66 04N Rushcliffe 386 441 377 66 82 82 04R Southern Derbyshire 347 365 321 58 46 67 Total CRT CCG Name 2010 2011 2012 England 114 113 136 Q55 Derbyshire and Nottinghamshire 32 47 80 03X Erewash 31 41 83 03Y Hardwick 33 66 57 04E Mansfield & Ashfield 45 66 116 04H Newark & Sherwood 15 60 98 04J North Derbyshire 55 74 69 04K Nottingham City 35 49 117 04L Nottingham North & East 32 32 64 04M Nottingham West 16 16 124 04N Rushcliffe 24 32 122 04R Southern Derbyshire 19 31 41 Note: Pacemaker, ICD, CRT New Implant rates and CRT Total rates are adjusted for age and sex of local population. 74

Summary The LAT s population is slightly older than average; overall the LAT requires 3% more pacemakers than the national average, and 3% more ICDs. The PM implant rate has slightly decreased in 2012 and remains well below the national average. The ICD rate increased and exceeds the national average. This is the third highest ICD implant rate achieved by a LAT in 2012, with two CCGs, Newark & Sherwood and Nottingham City exceeding the national target. The Total CRT implant rate continues to track well below the national average. This is the lowest CRT implant rate in England and Wales, tracking significantly below the national average. 75

New implant rates 76

Devon, Cornwall and Isles of Scilly Local Area Team Location: Population: Age and relative need: South West 1.7 million The average age in the LAT is older than the national average, so 30% more pacemakers and 19% ICD are needed. Clinical Commissioning Groups: 3 Main pacemaker implant hospitals: Derriford Hospital Royal Cornwall Hospital Royal Devon & Exeter Hospital Torbay Hospital Main ICD implant hospitals: Derriford Hospital Royal Cornwall Hospital Royal Devon & Exeter Hospital Main CRT implant hospitals: Derriford Hospital Royal Cornwall Hospital Royal Devon & Exeter Hospital Torbay Hospital 77

per million population per million population per million population 700 650 600 550 500 450 400 350 300 250 200 90 80 70 60 50 40 30 20 10 0 160 140 120 100 80 60 40 20 0 Pacemaker New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National Devon, Cornwall and Isles Of Scilly ICD New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National Devon, Cornwall and Isles Of Scilly CRT Total Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National Devon, Cornwall and Isles Of Scilly Pacemakers (national target: 700 new implants per million population) PM implant rate has decreased in 2012 and tracks the national average. ICD (national target: 100 new implants per million population) ICD implant rate has decreased in 2012 and tracks below the national rate. CRT (national target: 130 total implants per million population) CRT implant rate has improved in 2012 but remains just below the national average. 78

CCG New Implant Rates Above national target Similar to national target Below national target Below national target and below national average Pacemaker ICD CCG Name 2010 2011 2012 2010 2011 2012 England 528 524 559 72 76 66 Q66 Devon, Cornwall and Isles Of Scilly 572 651 571 51 68 60 11N Kernow 593 629 518 66 65 74 99P North, East, West Devon 594 711 679 56 78 59 99Q South Devon and Torbay 473 527 370 35 82 38 Total CRT CCG Name 2010 2011 2012 England 114 113 136 Q66 Devon, Cornwall and Isles Of Scilly 96 112 130 11N Kernow 123 133 169 99P North, East, West Devon 100 119 124 99Q South Devon and Torbay 50 71 74 Note: Pacemaker, ICD, CRT New Implant rates and CRT Total rates are adjusted for age and sex of local population. Summary The LAT s population is older than average and there is a consequent 30% increased need for pacemakers and 19% for ICDs, compared with the national average. The PM and ICD rates both decreased in 2012. The CRT rate has increased significantly. All three rates track very close to the national average. There is substantial variability in rates between CCGs in the LAT. The CRT rate for Kernow CCG has exceeded the national target. 79

New implant rates 80

Durham, Darlington and Tees Local Area Team Location: Population: Age and relative need: North 1.2 million Slightly older than average require 3% more pacemakers and 6% more ICDs than the national average. Clinical Commissioning Groups: 5 Main pacemaker implant hospitals: Darlington Memorial Hospital University Hospital of North Durham Freeman Hospital James Cook University Hospital University Hospital of Hartlepool Main ICD implant hospitals: Freeman Hospital James Cook University Hospital Main CRT implant hospitals: Freeman Hospital James Cook University Hospital 81

per million population per million population per million population 650 600 550 500 450 400 350 300 250 200 90 80 70 60 50 40 30 20 10 0 160 140 120 100 80 60 40 20 0 Pacemaker New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National Durham, Darlington and Tees ICD New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National Durham, Darlington and Tees CRT Total Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National Durham, Darlington and Tees Pacemakers (national target: 700 new implants per million population) A decrease in the PM implant rate places the LAT just below the national average. ICD (national target: 100 new implants per million population) A big improvement in 2012 places the LAT implant rate above the national rate. CRT (national target: 130 total implants per million population) CRT implant rate has improved in 2012 but remains well below the national average. 82

CCG New Implant Rates Above national target Similar to national target Below national target Below national target and below national average Pacemaker ICD CCG Name 2010 2011 2012 2010 2011 2012 England 528 524 559 72 76 66 Q45 Durham, Darlington and Tees 583 610 554 60 71 84 00C Darlington 522 582 604 72 27 54 00D Durham Dales, Easington and Sedgefield 619 545 540 72 69 69 00J North Durham 509 421 414 47 70 39 00K Hartlepool and Stockton-on-Tees 613 706 568 52 70 108 00M South Tees 604 760 659 56 81 127 Total CRT CCG Name 2010 2011 2012 England 114 113 136 Q45 Durham, Darlington and Tees 69 65 91 00C Darlington 27 98 136 00D Durham Dales, Easington and Sedgefield 92 59 89 00J North Durham 71 67 91 00K Hartlepool and Stockton-on-Tees 50 46 43 00M South Tees 70 66 123 Note: Pacemaker, ICD, CRT New Implant rates and CRT Total rates are adjusted for age and sex of local population. 83

New implant rates 84

Summary The LAT s population is slightly older than average; overall the LAT requires 3% more pacemakers than the national average, and 6% more ICDs. The PM implant rate has decreased in 2012 and now matches the national average. ICD and CRT rates both increased in 2012, substantially so for the ICD rate. The ICD rate exceeds the national average, but remains below the national target. There is substantial variability in rates between CCGs in the LAT. The ICD rate for South Tees CCG has exceeded the national target. 85

East Anglia Local Area Team Location: Population: Age and relative need: East Coast 2.4 million Older than average; overall the LAT requires 17% more pacemakers than the national average, and 11% more ICDs. Clinical Commissioning Groups: 8 Main pacemaker implant hospitals: Addenbrooke's Hospital The Ipswich Hospital Norfolk and Norwich University Hospital Papworth Hospital Peterborough City Hospital Main ICD implant hospitals: Addenbrooke's Hospital Norfolk and Norwich University Hospital Papworth Hospital Main CRT implant hospitals: Addenbrooke's Hospital Norfolk and Norwich University Hospital Papworth Hospital 86

per million population per million population per million population 650 600 550 500 450 400 350 300 250 200 90 80 70 60 50 40 30 20 10 0 160 140 120 100 80 60 40 20 0 Pacemaker New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National ICD New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National CRT Total Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National East Anglia East Anglia East Anglia Pacemakers (national target: 700 new implants per million population) PM implant rate has slightly increased in 2012 and is just above the national average. ICD (national target: 100 new implants per million population) A significant decrease in the 2012 ICD implant rate places the LAT well below the national rate. CRT (national target: 130 total implants per million population) CRT implant rate has improved in 2012 but remains below the national average. 87

CCG New Implant Rates Above national target Similar to national target Below national target Below national target and below national average Pacemaker ICD CCG Name 2010 2011 2012 2010 2011 2012 England 528 524 559 72 76 66 Q56 East Anglia 520 572 587 48 59 45 06H Cambridgeshire and Peterborough 474 597 666 56 73 50 06L Ipswich and East Suffolk 533 616 682 52 56 50 06M Great Yarmouth & Waveney 481 531 443 46 73 77 06V North Norfolk 556 535 504 52 61 39 06W Norwich 508 530 532 26 53 68 06Y South Norfolk 582 543 499 32 76 14 07J West Norfolk 536 555 524 60 42 14 07K West Suffolk 566 584 617 66 41 33 Total CRT CCG Name 2010 2011 2012 England 114 113 136 Q56 East Anglia 99 113 123 06H Cambridgeshire and Peterborough 131 123 145 06L Ipswich and East Suffolk 73 99 92 06M Great Yarmouth & Waveney 95 92 164 06V North Norfolk 90 125 101 06W Norwich 89 114 93 06Y South Norfolk 105 119 97 07J West Norfolk 59 84 113 07K West Suffolk 112 144 151 Note: Pacemaker, ICD, CRT New Implant rates and CRT Total rates are adjusted for age and sex of local population. 88

Summary The LAT s population is older than average; overall the LAT requires 17% more pacemakers than the national average, and 11% more ICDs. The PM and CRT rates both increased in 2012. Both rates track very close to the national average. A significant decrease in the ICD rate places the LAT well below the national average. Six of the eight CCGs in the LAT had a decrease in rate, most notable in the South Norfolk CCG. Three CCGs; Cambridgeshire & Peterborough, Great Yarmouth & Waveney and West Suffolk exceeded the CRT national target. 89

New implant rates 90

Essex Local Area Team Location: Population: Age and relative need: South East 1.7 million Older than average; overall the LAT requires 9% more pacemakers than the national average, and 6% more ICDs. Clinical Commissioning Groups: 7 Main pacemaker implant hospitals: Essex Cardiothoracic Centre Broomfield Hospital Colchester General Hospital Princess Alexandra Hospital Southend Hospital Main ICD implant hospitals: Barts and the London Essex Cardiothoracic Centre Colchester General Hospital University College Hospital Main CRT implant hospitals: Barts and the London Essex Cardiothoracic Centre Papworth Hospital 91

92

per million population per million population per million population 600 550 500 450 400 350 300 250 200 90 80 70 60 50 40 30 20 10 0 160 140 120 100 80 60 40 20 0 Pacemaker New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National ICD New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National CRT Total Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National Essex Essex Essex Pacemakers (national target: 700 new implants per million population) PM implant rate has decreased in 2012 and is below the national average. ICD (national target: 100 new implants per million population) ICD rate remained static and the LAT implant rate is just above the national rate. CRT (national target: 130 total implants per million population) CRT implant rate has improved in 2012 but remains below the national average. 93

CCG New Implant Rates Above national target Similar to national target Below national target Below national target and below national average Pacemaker ICD CCG Name 2010 2011 2012 2010 2011 2012 England 528 524 559 72 76 66 Q57 Essex 566 522 479 54 73 70 06Q Mid Essex 576 470 373 70 60 62 06T North East Essex 697 613 441 50 70 67 07G Thurrock 463 380 430 73 80 73 07H West Essex 514 492 492 44 95 75 99E Basildon and Brentwood 332 439 409 40 96 92 99F Castle Point, Rayleigh and Rochford 677 617 640 54 59 73 99G Southend 618 590 704 68 74 51 Total CRT CCG Name 2010 2011 2012 England 114 113 136 Q57 Essex 74 86 109 06Q Mid Essex 53 63 56 06T North East Essex 57 125 156 07G Thurrock 110 87 94 07H West Essex 110 140 150 99E Basildon and Brentwood 70 82 87 99F Castle Point, Rayleigh and Rochford 75 28 100 99G Southend 87 43 112 Note: Pacemaker, ICD, CRT New Implant rates and CRT Total rates are adjusted for age and sex of local population. 94

New implant rates 95

Summary The LAT s population is older than average; overall the LAT requires 9% more pacemakers than the national average, and 6% more ICDs. A significant decrease in the PM rate places the LAT well below the national average. The ICD implant rate remained static and is just above the English average. There is an increase in the total CRT implant rate; but it remains well below the national average. Two CCGs; North East Essex and West Essex exceeded the CRT national target. 96

Greater Manchester Local Area Team Location: Population: Age and relative need: North West 2.7 million A predominant urban population means the average age is low and in turn, the need for cardiac pacemakers in this LAT is 13% lower than average. The need for ICDs is also lower (7%) than average. Clinical Commissioning Groups: 12 Main pacemaker implant hospitals: Royal Albert Edward Infirmary Rochdale Infirmary Royal Bolton Hospital Manchester Royal Infirmary Royal Oldham Hospital Salford Royal Hospital Tameside General Hospital Wythenshawe Hospital Stepping Hill Hospital Main ICD implant hospitals: Rochdale Infirmary Royal Bolton Hospital Manchester Royal Infirmary Wythenshawe Hospital Main CRT implant hospitals: Rochdale Infirmary Royal Bolton Hospital Manchester Royal Infirmary Wythenshawe Hospital 97

per million population per million population per million population 650 600 550 500 450 400 350 300 250 200 90 80 70 60 50 40 30 20 10 0 200 180 160 140 120 100 80 60 40 20 0 Pacemaker New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National ICD New Implant Rate adjusted for age and sex of network population Greater Manchester 2010 2011 2012 year National CRT Total Implant Rate adjusted for age and sex of network population Greater Manchester 2010 2011 2012 year National Greater Manchester Pacemakers (national target: 700 new implants per million population) PM implant rate has decreased very slightly in 2012 and remains just above the national average. ICD (national target: 100 new implants per million population) A decrease in 2012 in the LAT implant rate. The rate remains just below the national rate. CRT (national target: 130 total implants per million population) CRT implant rate has decreased in 2012 but remains above the national target. 98

CCG New Implant Rates Above national target Similar to national target Below national target Below national target and below national average Pacemaker ICD CCG Name 2010 2011 2012 2010 2011 2012 England 528 524 559 72 76 66 Q46 Greater Manchester 580 592 575 63 68 61 00T Bolton 314 364 417 74 63 48 00V Bury 546 487 533 38 43 38 00W Central Manchester 748 757 678 73 83 74 00Y Oldham 563 463 368 48 96 63 01D Heywood, Middleton & Rochdale 547 637 541 45 81 35 01G Salford 652 724 689 61 80 76 01M North Manchester 559 638 601 76 93 59 01N South Manchester 593 626 622 99 50 50 01W Stockport 562 628 626 53 43 82 01Y Tameside and Glossop 729 661 702 40 52 68 02A Trafford 693 646 696 63 58 94 02H Wigan Borough 580 609 510 64 58 45 Total CRT CCG Name 2010 2011 2012 England 114 113 136 Q46 Greater Manchester 176 161 154 00T Bolton 177 143 165 00V Bury 106 145 117 00W Central Manchester 190 324 353 00Y Oldham 242 212 95 01D Heywood, Middleton & Rochdale 246 184 199 01G Salford 162 138 143 01M North Manchester 186 225 154 01N South Manchester 293 151 190 01W Stockport 157 112 173 01Y Tameside and Glossop 118 181 141 02A Trafford 204 142 149 02H Wigan Borough 107 116 107 Note: Pacemaker, ICD, CRT New Implant rates and CRT Total rates are adjusted for age and sex of local population. 99

Summary The LAT s population is relatively young so requires 13% less pacemakers and 7% less ICDs than the national average. The PM and ICD rates both decreased in 2012, with both rates tracking close to the national average. Although the CRT rate has decreased, it remains above the national target. Eight of the twelve CCGs in the LAT had exceeded the national target, most notable in the Central Manchester CCG, achieving an implant rate of 353. 100

New implant rates 101

Hertfordshire and The South Midlands Local Area Team Location: Population: Age and relative need: South 2.6 million Relatively young require 8% less pacemakers and 5% less ICDs than the national average. Clinical Commissioning Groups: 7 Main pacemaker implant hospitals: Bedford Hospital Harefield Hospital Kettering General Hospital Lister Hospital Northampton General Hospital Watford General Hospital Main ICD implant hospitals: Harefield Hospital Kettering General Hospital Royal Brompton Hospital Northampton General Hospital Papworth Hospital John Radcliffe Hospital Watford General Hospital Main CRT implant hospitals: Harefield Hospital Kettering General Hospital Royal Brompton Hospital Northampton General Hospital Papworth Hospital John Radcliffe Hospital 102

per million population per million population per million population 800 700 600 500 400 300 200 120 100 80 60 40 20 0 160 140 120 100 80 60 40 20 0 Pacemaker New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National Hertfordshire and The South Midlands ICD New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National Hertfordshire and The South Midlands CRT Total Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National Hertfordshire and The South Midlands Pacemakers (national target: 700 new implants per million population) PM implant rate has decreased in 2012 and remains above the national average. ICD (national target: 100 new implants per million population) A decrease in 2012 but the LAT implant rate is still well above the national rate and below the national target. CRT (national target: 130 total implants per million population) CRT implant rate has decreased in 2012 and is now just below the national average. 103

CCG New Implant Rates Above national target Similar to national target Below national target Below national target and below national average Pacemaker CCG Name 2010 2011 2012 2010 2011 2012 Q58 England 528 524 559 72 76 66 Hertfordshire and The South Midlands 657 689 621 102 106 92 03V Corby 496 494 737 107 125 107 04F Milton Keynes 722 759 490 195 186 105 04G Nene 655 734 718 83 98 103 06F Bedfordshire 493 625 590 55 72 46 06K East and North Hertfordshire 539 472 535 90 96 77 06N Herts Valleys 923 920 715 118 109 120 06P Luton 513 572 397 91 67 98 ICD Total CRT CCG Name 2010 2011 2012 Q58 England 114 113 136 Hertfordshire and The South Midlands 139 136 129 03V Corby 154 135 133 04F Milton Keynes 273 246 297 04G Nene 144 176 141 06F Bedfordshire 111 106 99 06K East and North Hertfordshire 122 109 109 06N Herts Valleys 131 100 115 06P Luton 98 137 65 Note: Pacemaker, ICD, CRT New Implant rates and CRT Total rates are adjusted for age and sex of local population. 104

Summary The LAT s population is relatively young so requires 8% less pacemakers and 5% less ICDs than the national average. There is a decrease in the PM implant rate; but it remains above the national average. Although the ICD rate has decreased, it remains above the national average and below the national target. This is the highest ICD implant rate achieved by a LAT in 2012, with four CCGs exceeding the national target. Herts Valleys CCG far exceeds the national target achieving a 120 implant rate. The CRT rate has decreased; and is below the national average. There is substantial variability in rates between CCGs in the LAT. The ICD rate for Herts Valleys CCG and the CRT rate for Milton Keynes CCG have exceeded the national target. 105

New implant rates 106

Kent and Medway Local Area Team Location: Population: Age and relative need: South East Coast 1.7 million Population is slightly older than the national average, and consequently has a 5% higher need for pacemakers and 4% for ICDs. Clinical Commissioning Groups: 8 Main pacemaker implant hospitals: Darent Valley Hospital Kent & Sussex Hospital Maidstone Hospital Medway Hospital Queen Elizabeth Queen Mother St Thomas Hospital William Harvey Hospital Main ICD implant hospitals: King's College Hospital Maidstone Hospital Medway Hospital Queen Elizabeth Queen Mother St Thomas Hospital University College Hospital William Harvey Hospital Main CRT implant hospitals: Maidstone Hospital Medway Hospital Queen Elizabeth Queen Mother St Thomas Hospital William Harvey Hospital 107

per million population per million population per million population 650 600 550 500 450 400 350 300 250 200 100 90 80 70 60 50 40 30 20 10 0 180 160 140 120 100 80 60 40 20 0 Pacemaker New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National ICD New Implant Rate adjusted for age and sex of network population Kent and Medway 2010 2011 2012 year National CRT Total Implant Rate adjusted for age and sex of network population Kent and Medway 2010 2011 2012 year National Kent and Medway Pacemakers (national target: 700 new implants per million population) PM implant rate has significantly decreased in 2012 and is well below the national average. ICD (national target: 100 new implants per million population) ICD implant rate has decreased significantly in 2012. The rate matches the national average. CRT (national target: 130 total implants per million population) The CRT implant rate has decreased in 2012. The rate matches the national average. 108

CCG New Implant Rates Above national target Similar to national target Below national target Below national target and below national average Pacemaker ICD CCG Name 2010 2011 2012 2010 2011 2012 England 528 524 559 72 76 66 Q67 Kent and Medway 608 614 449 92 84 65 09C Ashford 646 835 546 75 66 91 09E Canterbury and Coastal 652 701 479 61 90 75 09J Dartford, Gravesham and Swanley 637 664 516 102 78 78 09W Medway 467 639 467 102 53 45 10A South Kent Coast 582 603 522 90 120 34 10D Swale 403 472 523 92 92 64 10E Thanet 432 516 305 118 125 92 99J West Kent 750 552 368 97 78 63 Total CRT CCG Name 2010 2011 2012 England 114 113 136 Q67 Kent and Medway 121 156 139 09C Ashford 108 199 176 09E Canterbury and Coastal 111 111 106 09J Dartford, Gravesham and Swanley 127 135 128 09W Medway 123 158 108 10A South Kent Coast 111 103 134 10D Swale 77 144 133 10E Thanet 168 96 100 99J West Kent 128 230 184 Note: Pacemaker, ICD, CRT New Implant rates and CRT Total rates are adjusted for age and sex of local population. 109

Summary The LAT s population is older than average; overall the LAT requires 5% more pacemakers than the national average, and 4% more ICDs. The PM implant rate has significantly decreased in 2012 and is well below the national average. Seven of the eight CCGs in the LAT had decreased in rate compared to 2011. Only Swale CCG increased in rate. The ICD and CRT rates both decreased in 2012, with both rates tracking close to the national average. There is variability in rates between CCGs in the LAT. The Ashford CCG and West Kent CCG CRT rates have exceeded the national target. 110

New implant rates 111

Lancashire Local Area Team Location: Population: Age and relative need: North West 1.5 million The population is older than average and there is a consequent 6% increased need for pacemakers and 6% for ICDs, compared with the national average. Clinical Commissioning Groups: 8 Main pacemaker implant hospitals: Liverpool Heart and Chest Hospital Blackburn Royal Infirmary Royal Preston Hospital Lancashire Cardiac Centre Blackpool Westmoreland General Hospital Main ICD implant hospitals: Liverpool Heart and Chest Hospital Manchester Royal Infirmary Lancashire Cardiac Centre Blackpool Wythenshawe Hospital Main CRT implant hospitals: Liverpool Heart and Chest Hospital Manchester Royal Infirmary Lancashire Cardiac Centre Blackpool 112

per million population per million population per million population 650 600 550 500 450 400 350 300 250 200 90 80 70 60 50 40 30 20 10 0 250 200 150 100 50 0 Pacemaker New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National ICD New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National CRT Total Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National Lancashire Lancashire Lancashire Pacemakers (national target: 700 new implants per million population) A slight improvement in the PM implant rate takes the LAT to just above the national average. ICD (national target: 100 new implants per million population) A decrease in 2012, the LAT implant rate remains well below the national rate. CRT (national target: 130 total implants per million population) CRT implant rate has increased in 2012 and is well above the national rate and national target. 113

CCG New Implant Rates Above national target Similar to national target Below national target Below national target and below national average Pacemaker ICD CCG Name 2010 2011 2012 2010 2011 2012 England 528 524 559 72 76 66 Q47 Lancashire 554 553 583 40 50 41 00Q Blackburn with Darwen 452 537 832 23 16 23 00R Blackpool 611 646 478 76 89 89 00X Chorley and South Ribble 650 692 675 34 46 57 01A East Lancashire 512 491 605 34 47 47 01E Greater Preston 654 546 719 31 31 25 01K Lancashire North 494 392 429 70 53 29 02G West Lancashire 463 469 368 24 48 32 02M Fylde & Wyre 575 663 551 33 66 19 Total CRT CCG Name 2010 2011 2012 England 114 113 136 Q47 Lancashire 113 174 192 00Q Blackburn with Darwen 100 109 132 00R Blackpool 130 321 338 00X Chorley and South Ribble 79 109 107 01A East Lancashire 83 126 145 01E Greater Preston 124 124 141 01K Lancashire North 118 163 235 02G West Lancashire 129 113 136 02M Fylde & Wyre 151 298 302 Note: Pacemaker, ICD, CRT New Implant rates and CRT Total rates are adjusted for age and sex of local population. 114

Summary The LAT s population is older than average; overall the LAT requires 6% more pacemakers than the national average, and 6% more ICDs. The PM rate has increased; and is just above the national average. The ICD implant rate continues to track well below the national average. This is the lowest ICD implant rate in England and Wales, tracking significantly below the national average. The Total CRT implant rate has improved in 2012 and is well above the national target. This is the second highest CRT implant rate achieved by a LAT in 2012, with seven CCGs exceeding the national target. 115

New implant rates 116

Leicestershire and Lincolnshire Local Area Team Location: Population: Age and relative need: Midlands 1.7 million Relatively young require 8% less pacemakers and 7% less ICDs than the national average. Clinical Commissioning Groups: 7 Main pacemaker implant hospitals: Diana Princess of Wales Hospital Glenfield Hospital Pilgrim Hospital Lincoln County Hospital Peterborough City Hospital Main ICD implant hospitals: Nottingham City Hospital Glenfield Hospital Main CRT implant hospitals: Castle Hill Hospital Glenfield Hospital Papworth Hospital 117

per million population per million population per million population 650 600 550 500 450 400 350 300 250 200 90 80 70 60 50 40 30 20 10 0 160 140 120 100 80 60 40 20 0 Pacemaker New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National Leicestershire and Lincolnshire ICD New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National Leicestershire and Lincolnshire CRT Total Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National Leicestershire and Lincolnshire Pacemakers (national target: 700 new implants per million population) PM implant rate has increased and is above the national average and below the national target. ICD (national target: 100 new implants per million population) ICD implant rate has slightly decreased and matches the national average. CRT (national target: 130 total implants per million population) CRT implant rate has improved in 2012 but remains well below the national average. 118

CCG New Implant Rates Above national target Similar to national target Below national target Below national target and below national average Pacemaker ICD CCG Name 2010 2011 2012 2010 2011 2012 England 528 524 559 72 76 66 Q59 Leicestershire and Lincolnshire 517 556 623 58 70 67 03T Lincolnshire East 479 423 640 30 86 83 03W East Leicestershire and Rutland 533 641 658 68 82 62 04C Leicester City 642 648 641 70 66 78 04D Lincolnshire West 529 490 439 25 37 74 04Q South West Lincolnshire 582 487 534 86 100 72 04V West Leicestershire 494 581 691 81 66 61 99D South Lincolnshire 360 581 676 42 60 36 Total CRT CCG Name 2010 2011 2012 England 114 113 136 Q59 Leicestershire and Lincolnshire 70 85 102 03T Lincolnshire East 50 78 88 03W East Leicestershire and Rutland 80 96 117 04C Leicester City 105 134 105 04D Lincolnshire West 20 32 37 04Q South West Lincolnshire 28 42 106 04V West Leicestershire 85 90 132 99D South Lincolnshire 103 97 111 Note: Pacemaker, ICD, CRT New Implant rates and CRT Total rates are adjusted for age and sex of local population. 119

Summary The LAT s population is relatively young so requires 8% less pacemakers and 7% less ICDs than the national average. The PM rate has significantly increased; and exceeds the national average. Five of the seven CCGs in the LAT have increased in rate compared to 2011. The ICD new implant rate has very slightly decreased. The rate is just above the national average. Although the CRT implant rate has improved significantly in 2012 it remains well below the national average. Six of the seven CCGs in the LAT have increased in rate compared to 2011. 120

New implant rates 121

London Local Area Team 122

123

Location: Population: Age and relative need: London 8.2 million Because the population is young there is a relatively low need for pacing. Overall need is 70.1% for pacemakers and 77.8% for ICDs compared to the national average. Clinical Commissioning Groups: 32 Main pacemaker implant hospitals: Barts and the London Barnet General Hospital St George's Hospital Northwick Park Hospital University College Hospital Main ICD implant hospitals: Barts and the London St George's Hospital King's College Hospital Royal Brompton Hospital St Thomas Hospital University College Hospital Main CRT implant hospitals: Barts and the London St George's Hospital King's College Hospital Royal Brompton Hospital St Thomas Hospital University College Hospital Summary The LAT s population is young so requires 30% less pacemakers and 22% less ICDs than the national average. PM and ICD rates both fell in 2012, substantially so for ICD. Both rates track very close to the national average. The Total CRT implant rate is static. The rate continues to track above the national average and below national target. There is substantial variability in rates between CCGs in the LAT. 124

per million population per million population per million population 700 650 600 550 500 450 400 350 300 250 200 120 100 80 60 40 20 0 180 160 140 120 100 80 60 40 20 0 Pacemaker New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National ICD New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National CRT Total Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National London London London Pacemakers (national target: 700 new implants per million population) PM implant rate has slightly decreased in 2012 and remains just above the national average. ICD (national target: 100 new implants per million population) ICD implant rate has significantly decreased in 2012 and remains above the national average. CRT (national target: 130 total implants per million population) CRT rate remained static and the LAT implant rate is still above the national rate. 125

CCG New Implant Rates Above national target Similar to national target Below national target Below national target and below national average Pacemaker ICD CCG Name 2010 2011 2012 2010 2011 2012 England 528 524 559 72 76 66 Q71 London 623 630 579 97 104 76 07L Barking & Dagenham 526 699 658 122 114 69 07M Barnet 705 703 809 123 134 110 07N Bexley 721 610 534 116 63 76 07P Brent 768 655 619 67 96 63 07Q Bromley 435 491 455 75 39 81 07R Camden 603 661 634 53 125 89 07T City and Hackney 468 551 477 87 81 44 07V Croydon 586 523 556 63 56 93 07W Ealing 575 749 608 80 83 99 07X Enfield 634 506 560 106 74 82 07Y Hounslow 574 590 418 61 61 71 08A Greenwich 782 700 555 90 59 53 08C Hammersmith and Fulham 554 759 433 95 111 63 08D Haringey 409 560 446 62 62 51 08E Harrow 918 748 754 106 107 51 08F Havering 590 642 472 131 94 103 08G Hillingdon 727 815 786 77 81 94 08H Islington 576 680 514 77 70 133 08J Kingston 689 679 920 59 119 30 08K Lambeth 490 475 568 96 66 61 08L Lewisham 702 495 462 71 36 61 08M Newham 531 423 409 170 137 104 08N Redbridge 567 677 602 80 147 67 08P Richmond 663 680 497 66 120 72 08Q Southwark 550 360 503 85 74 69 08R Merton 609 655 592 75 163 88 08T Sutton 617 673 562 29 109 86 08V Tower Hamlets 724 616 649 154 133 56 08W Waltham Forest 570 567 681 90 101 69 08X Wandsworth 656 671 541 63 106 72 08Y West London (K&C & QPP) 607 771 510 89 117 45 09A Central London (Westminster) 710 857 587 82 157 52 126

Total CRT CCG Name 2010 2011 2012 England 110 113 136 Q71 London 148 155 152 07L Barking & Dagenham 113 130 124 07M Barnet 102 160 147 07N Bexley 170 209 153 07P Brent 137 156 186 07Q Bromley 119 88 142 07R Camden 166 79 179 07T City and Hackney 87 79 145 07V Croydon 120 67 82 07W Ealing 247 247 131 07X Enfield 103 161 167 07Y Hounslow 155 184 181 08A Greenwich 203 215 143 08C Hammersmith and Fulham 142 199 112 08D Haringey 102 34 132 08E Harrow 231 184 120 08F Havering 89 143 161 08G Hillingdon 147 94 81 08H Islington 176 143 107 08J Kingston 212 235 127 08K Lambeth 216 153 242 08L Lewisham 147 112 88 08M Newham 106 176 136 08N Redbridge 94 146 138 08P Richmond 127 178 173 08Q Southwark 179 193 343 08R Merton 163 176 170 08T Sutton 147 94 149 08V Tower Hamlets 109 172 133 08W Waltham Forest 97 139 186 08X Wandsworth 237 191 194 08Y West London (K&C & QPP) 191 249 150 09A Central London (Westminster) 106 212 228 Note: Pacemaker, ICD, CRT New Implant rates and CRT Total rates are adjusted for age and sex of local population. 127

New implant rates 128

Merseyside Local Area Team Location: Population: Age and relative need: North West 1.2 million The population is slightly younger than average and there is a consequent 1% decreased need for pacemakers and 1% increased need for ICDs, compared with the national average. Clinical Commissioning Groups: 6 Main pacemaker implant hospitals: Liverpool Heart and Chest Hospital University Hospital Aintree Royal Liverpool University Hospital Whiston Hospital Main ICD implant hospitals: Liverpool Heart and Chest Hospital Main CRT implant hospitals: Liverpool Heart and Chest Hospital 129

per million population per million population per million population 700 650 600 550 500 450 400 350 300 250 200 120 100 80 60 40 20 0 250 200 150 100 50 0 Pacemaker New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National ICD New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National CRT Total Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National Merseyside Merseyside Merseyside Pacemakers (national target: 700 new implants per million population) PM implant rate has significantly decreased in 2012 and is below the national average. ICD (national target: 100 new implants per million population) A significant decrease in the ICD implant rate places the LAT below the national rate. CRT (national target: 130 total implants per million population) CRT implant rate has significantly improved in 2012 and is well above the national average and target. 130

CCG New Implant Rates Above national target Similar to national target Below national target Below national target and below national average Pacemaker ICD CCG Name 2010 2011 2012 2010 2011 2012 England 528 524 559 72 76 66 Q48 Merseyside 580 634 532 75 101 61 01F Halton 406 468 451 105 73 105 01J Knowsley 589 778 510 118 111 70 01T South Sefton 692 637 628 52 93 23 01V Southport and Formby 373 486 380 42 84 21 01X St Helens 513 527 448 52 89 42 99A Liverpool 695 740 622 77 113 82 Total CRT CCG Name 2010 2011 2012 England 114 113 136 Q48 Merseyside 186 145 210 01F Halton 112 147 178 01J Knowsley 216 174 218 01T South Sefton 118 73 172 01V Southport and Formby 173 105 117 01X St Helens 159 143 179 99A Liverpool 229 171 282 Note: Pacemaker, ICD, CRT New Implant rates and CRT Total rates are adjusted for age and sex of local population. Summary The LAT s population is slightly younger so requires 1% less pacemakers and 1% less ICDs than the national average. The PM and ICD rates both fell in 2012, with both rates falling just below the national average. The Total CRT implant rate has significantly improved in 2012 and is well above the national average and target. This is the highest CRT implant rate achieved by a LAT in 2012, with five CCGs far exceeding the national target. 131

New implant rates 132

North Yorkshire and Humber Local Area Team Location: Population: Age and relative need: North East 1.7 million This LAT serves a population which is older; there is a 13% higher need for pacemakers and a 10% higher need for ICDs compared to the national average. Clinical Commissioning Groups: 8 Main pacemaker implant hospitals: Castle Hill Hospital Diana Princess of Wales Hospital Harrogate District Hospital Scarborough General Hospital James Cook University Hospital Scunthorpe General Hospital York District Hospital Main ICD implant hospitals: Castle Hill Hospital Yorkshire Heart Centre James Cook University Hospital Main CRT implant hospitals: Castle Hill Hospital Yorkshire Heart Centre James Cook University Hospital 133

per million population per million population per million population 700 650 600 550 500 450 400 350 300 250 200 90 80 70 60 50 40 30 20 10 0 160 140 120 100 80 60 40 20 0 Pacemaker New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National North Yorkshire and Humber ICD New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National North Yorkshire and Humber CRT Total Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National North Yorkshire and Humber Pacemakers (national target: 700 new implants per million population) PM implant rate has slightly decreased in 2012 and remains above the national average. ICD (national target: 100 new implants per million population) A decrease in the ICD implant rate tracks the national rate in 2012. CRT (national target: 130 total implants per million population) CRT implant rate has decreased in 2012 and is below the national average. 134

CCG New Implant Rates Above national target Similar to national target Below national target Below national target and below national average Pacemaker ICD CCG Name 2010 2011 2012 2010 2011 2012 England 528 524 559 72 76 66 Q50 North Yorkshire and Humber 666 645 638 51 78 68 02Y East Riding of Yorkshire 610 651 562 36 83 49 03D Hambleton, Richmondshire and Whitby 453 610 629 83 77 61 03E Harrogate and Rural District 774 596 653 34 57 57 03F Hull 729 731 696 51 77 94 03H North East Lincolnshire 1273 760 968 53 41 107 03K North Lincolnshire 653 673 607 82 66 44 03M Scarborough and Ryedale 447 567 441 44 66 81 03Q Vale of York 553 597 621 49 118 71 Total CRT CCG Name 2010 2011 2012 England 114 113 136 Q50 North Yorkshire and Humber 107 129 121 02Y East Riding of Yorkshire 97 122 111 03D Hambleton, Richmondshire and Whitby 32 64 76 03E Harrogate and Rural District 196 120 167 03F Hull 186 244 147 03H North East Lincolnshire 58 127 123 03K North Lincolnshire 109 77 82 03M Scarborough and Ryedale 54 116 49 03Q Vale of York 105 132 162 Note: Pacemaker, ICD, CRT New Implant rates and CRT Total rates are adjusted for age and sex of local population. 135

Summary The LAT s population is older than average; overall the LAT requires 13% more pacemakers than the national average, and 10% more ICDs. Although the PM rate has slightly decreased, it remains above the national average and below the national target. This is the highest PM implant rate achieved by a LAT in 2012. North East Lincolnshire CCG far exceeds the national target achieving a 968 implant rate. The ICD new implant rate decreased in 2012. The rate continues to track the national average and remains below national target. The Total CRT implant rate has decreased and is now below the national average. Three CCGs; Harrogate and Rural District, Hull and Vale of York exceeded the CRT national target. 136

New implant rates 137

Shropshire and Staffordshire Local Area Team Location: Population: Age and relative need: West Midlands 1.6 million Population is slightly older than the national average, and consequently has a 6% higher need for pacemakers and 9% for ICDs. Clinical Commissioning Groups: 8 Main pacemaker implant hospitals: Queens Hospital Burton Good Hope Hospital Wolverhampton Heart and Lung Centre Stafford Hospital University Hospital North Staffs Princess Royal Hospital Main ICD implant hospitals: Good Hope Hospital Glenfield Hospital Wolverhampton Heart and Lung Centre Queen Elizabeth Hospital Edgbaston University Hospital North Staffs Princess Royal Hospital Main CRT implant hospitals: Glenfield Hospital Wolverhampton Heart and Lung Centre Queen Elizabeth Hospital Edgbaston University Hospital North Staffs Princess Royal Hospital 138

per million population per million population per million population 600 550 500 450 400 350 300 250 200 90 80 70 60 50 40 30 20 10 0 160 140 120 100 80 60 40 20 0 Pacemaker New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National Shropshire And Staffordshire ICD New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National Shropshire And Staffordshire CRT Total Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National Shropshire And Staffordshire Pacemakers (national target: 700 new implants per million population) PM implant rate has slightly increased in 2012 and remains well below the national average. ICD (national target: 100 new implants per million population) A decrease in 2012, the LAT implant rate remains below the national rate. CRT (national target: 130 total implants per million population) CRT implant rate has improved in 2012 but remains below the national average. 139

CCG New Implant Rates Above national target Similar to national target Below national target Below national target and below national average Pacemaker CCG Name 2010 2011 2012 2010 2011 2012 England 528 524 559 72 76 66 Q60 Shropshire And Staffordshire 452 437 451 55 66 60 04Y Cannock Chase 476 577 492 58 29 72 05D East Staffordshire 620 382 515 70 47 70 05G North Staffordshire 378 368 385 54 41 41 05N Shropshire 447 437 436 58 88 52 South East Staffs and Seisdon and 05Q Peninsular 462 435 471 60 69 69 05V Stafford and Surrounds 412 521 514 57 74 57 05W Stoke on Trent 372 354 416 43 51 43 05X Telford & Wrekin 591 517 455 31 88 107 ICD Total CRT CCG Name 2010 2011 2012 England 114 113 136 Q60 Shropshire And Staffordshire 82 100 117 04Y Cannock Chase 53 106 112 05D East Staffordshire 24 103 111 05G North Staffordshire 49 131 148 05N Shropshire 69 80 78 South East Staffs and Seisdon and 05Q Peninsular 177 82 142 05V Stafford and Surrounds 79 62 79 05W Stoke on Trent 72 116 160 05X Telford & Wrekin 95 116 100 Note: Pacemaker, ICD, CRT New Implant rates and CRT Total rates are adjusted for age and sex of local population. 140

Summary The LAT s population is older than average; overall the LAT requires 6% more pacemakers than the national average, and 9% more ICDs. The PM and Total CRT rates both improved in 2012, but both rates remain below the national average. There was a slight decrease in the new ICD implant rate. The rate remains just below the national average. Three CCGs; North Staffordshire, South East Staffs & Seisdon & Peninsular and Stoke on Trent exceeded the CRT national target. 141

New implant rates 142

South Yorkshire and Bassetlaw Local Area Team Location: Population: Age and relative need: East Midlands 1.5 million The population is slightly younger than average and there is a consequent 0.1% decreased need for pacemakers and 2% increased need for ICDs, compared with the national average. Clinical Commissioning Groups: 5 Main pacemaker implant hospitals: Barnsley District General Hospital Doncaster Royal Infirmary Northern General Hospital Rotherham General Hospital Main ICD implant hospitals: Yorkshire Heart Centre Northern General Hospital Main CRT implant hospitals: Northern General Hospital 143

per million population per million population per million population 600 550 500 450 400 350 300 250 200 90 80 70 60 50 40 30 20 10 0 160 140 120 100 80 60 40 20 0 Pacemaker New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National South Yorkshire and Bassetlaw ICD New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National South Yorkshire and Bassetlaw CRT Total Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National South Yorkshire and Bassetlaw Pacemakers (national target: 700 new implants per million population) PM rate has slightly decreased in 2012 and is just below the national average. ICD (national target: 100 new implants per million population) A slight improvement in 2012 but the LAT implant rate remains just below the national rate. CRT (national target: 130 total implants per million population) CRT implant rate has improved in 2012 but remains below the national average. 144

CCG New Implant Rates Above national target Similar to national target Below national target Below national target and below national average Pacemaker ICD CCG Name 2010 2011 2012 2010 2011 2012 England 528 524 559 72 76 66 Q51 South Yorkshire and Bassetlaw 520 550 543 59 51 56 02P Barnsley 621 567 531 65 65 49 02Q Bassetlaw 349 494 447 39 31 24 02X Doncaster 491 495 436 51 45 42 03L Rotherham 418 608 562 33 37 55 03N Sheffield 584 558 625 77 58 75 Total CRT CCG Name 2010 2011 2012 England 114 113 136 Q51 South Yorkshire and Bassetlaw 64 69 101 02P Barnsley 46 58 66 02Q Bassetlaw 47 39 55 02X Doncaster 48 51 32 03L Rotherham 71 78 123 03N Sheffield 81 85 161 Note: Pacemaker, ICD, CRT New Implant rates and CRT Total rates are adjusted for age and sex of local population. Summary The LAT s population is slightly younger so requires 0.1% less pacemakers and 2% less ICDs than the national average. The PM new implant rate has slightly decreased and is just below the English average. ICD and CRT rates both increased in 2012, substantially so for the CRT rate. Both rates remain below the national average. There is moderate variability in corrected implant rates between the CCGs in the LAT. 145

New implant rates 146

Surrey and Sussex Local Area Team Location: Population: Age and relative need: South 2.7 million Older than average; overall the LAT requires 19% more pacemakers than the national average, and 8% more ICDs. Clinical Commissioning Groups: 12 Main pacemaker implant hospitals: Conquest Hospital Eastbourne DGH East Surrey Hospital Royal Sussex County Hospital St Peter's Hospital St Richards Hospital Worthing Hospital Main ICD implant hospitals: Eastbourne DGH St George's Hospital Royal Brompton Hospital Royal Sussex County Hospital St Peter's Hospital St Richards Hospital Worthing Hospital Main CRT implant hospitals: Eastbourne DGH St George's Hospital Royal Sussex County Hospital St Peter's Hospital St Richards Hospital Worthing Hospital 147

per million population per million population per million population 800 700 600 500 400 300 200 100 90 80 70 60 50 40 30 20 10 0 180 160 140 120 100 80 60 40 20 0 Pacemaker New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National ICD New Implant Rate adjusted for age and sex of network population Surrey and Sussex 2010 2011 2012 year National CRT Total Implant Rate adjusted for age and sex of network population Surrey and Sussex 2010 2011 2012 year National Surrey and Sussex Pacemakers (national target: 700 new implants per million population) PM implant rate has decreased in 2012 and remains above the national average. ICD (national target: 100 new implants per million population) A big fall in the ICD implant rate in 2012. The rate matches the national rate. CRT (national target: 130 total implants per million population) CRT implant rate has improved in 2012 and exceeds the national target. 148

CCG New Implant Rates Above national target Similar to national target Below national target Below national target and below national average Pacemaker ICD CCG Name 2010 2011 2012 2010 2011 2012 England 528 524 559 72 76 66 Q68 Surrey and Sussex 647 677 613 59 89 67 09D Brighton & Hove 656 602 484 30 90 60 09F Eastbourne, Hailsham and Seaford 770 753 623 54 89 40 09G Coastal West Sussex 577 731 665 79 143 117 09H Crawley 652 616 687 67 101 101 09L East Surrey 686 628 687 69 52 46 09N Guildford and Waverley 640 368 500 53 58 48 09P Hastings & Rother 880 970 646 100 123 41 09X Horsham and Mid Sussex 527 550 731 73 82 60 09Y North West Surrey 595 639 585 47 104 51 10C Surrey Heath 526 609 513 62 10 31 99H Surrey Downs 649 738 620 66 126 80 99K High Weald Lewes Havens 662 665 500 73 57 47 Total CRT CCG Name 2010 2011 2012 England 114 113 136 Q68 Surrey and Sussex 99 122 156 09D Brighton & Hove 134 205 150 09F Eastbourne, Hailsham and Seaford 98 140 154 09G Coastal West Sussex 71 145 177 09H Crawley 125 114 199 09L East Surrey 102 102 163 09N Guildford and Waverley 172 158 143 09P Hastings & Rother 91 115 121 09X Horsham and Mid Sussex 105 131 159 09Y North West Surrey 67 88 161 10C Surrey Heath 125 73 84 99H Surrey Downs 129 88 153 99K High Weald Lewes Havens 119 129 162 Note: Pacemaker, ICD, CRT New Implant rates and CRT Total rates are adjusted for age and sex of local population. 149

Summary The LAT s population is older than average; overall the LAT requires 19% more pacemakers than the national average, and 8% more ICDs. PM and ICD rates both decreased in 2012, substantially so for the ICD rate. Both rates remain just above the national average. The CRT implant rate has improved significantly in 2012 and exceeded the national target. Ten of the twelve CCGs in the LAT exceeded the national target. 150

New implant rates 151

Thames Valley Local Area Team Location: Population: Age and relative need: South Coast and Central England 2.0 million Relatively young require 7% less pacemakers and 4% less ICDs than the national average. Clinical Commissioning Groups: 10 Main pacemaker implant hospitals: Wycombe General Hospital Royal Berkshire Hospital John Radcliffe Hospital Wexham Park Hospital Main ICD implant hospitals: Royal Berkshire Hospital Harefield Hospital Royal Brompton Hospital John Radcliffe Hospital University College Hospital Wexham Park Hospital Main CRT implant hospitals: Royal Berkshire Hospital Royal Brompton Hospital John Radcliffe Hospital Wexham Park Hospital 152

per million population per million population 600 550 500 450 400 350 300 250 200 80 75 70 65 60 55 50 Pacemaker New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National ICD New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National Thames Valley Thames Valley Pacemakers (national target: 700 new implants per million population) PM implant rate has decreased in 2012 and the LAT is below the national average. ICD (national target: 100 new implants per million population) A significant improvement in 2012 places the LAT rate well above the national average. per million population 160 140 120 100 80 60 40 20 CRT Total Implant Rate adjusted for age and sex of network population National Thames Valley CRT (national target: 130 total implants per million population) CRT rate was static in 2012 and is below the national average. 0 2010 2011 2012 year 153

CCG New Implant Rates Above national target Similar to national target Below national target Below national target and below national average Pacemaker ICD CCG Name 2010 2011 2012 2010 2011 2012 England 528 524 559 72 76 66 Q69 Thames Valley 555 557 488 75 65 71 10G Bracknell and Ascot 627 597 515 51 59 51 10H Chiltern 628 623 522 73 67 112 10M Newbury and District 573 551 386 78 68 19 10N North & West Reading 557 670 385 80 20 60 10Q Oxfordshire 456 457 457 73 51 61 10T Slough 581 627 456 121 121 121 10W South Reading 572 462 567 67 13 67 10Y Aylesbury Vale 408 566 506 41 88 67 11C Windsor, Ascot and Maidenhead 772 697 534 111 89 81 11D Wokingham 707 600 577 58 58 52 Total CRT CCG Name 2010 2011 2012 England 114 113 136 Q69 Thames Valley 98 122 123 10G Bracknell and Ascot 183 211 154 10H Chiltern 132 126 134 10M Newbury and District 122 71 30 10N North & West Reading 31 51 82 10Q Oxfordshire 59 88 109 10T Slough 175 280 265 10W South Reading 46 31 61 10Y Aylesbury Vale 59 119 59 11C Windsor, Ascot and Maidenhead 220 278 261 11D Wokingham 67 67 120 Note: Pacemaker, ICD, CRT New Implant rates and CRT Total rates are adjusted for age and sex of local population. 154

Summary The LAT s population is relatively younger so requires 7% less pacemakers and 4% less ICDs than the national average. PM implant rate has decreased and is now below the national average. The ICD rate has increased and exceeds the national average, with two CCGs, Chiltern and Slough exceeding the national target. The CRT implant rate is static. The rate is just below the national average. There is moderate variability in corrected implant rates between the CCGs in the LAT. 155

New implant rates 156

Wessex Local Area Team Location: Population: Age and relative need: South Coast and Central England 2.7 million This LAT serves a population which is older; there is an 18% higher need for pacemakers and a 9% higher need for ICDs compared to the national average. Clinical Commissioning Groups: 9 Main pacemaker implant hospitals: Royal Bournemouth Hospital Frimley Park Hospital Basingstoke and North Hampshire Hospital Poole General Hospital Queen Alexandra Hospital Wessex Cardiothoracic Centre Dorset County Hospital Main ICD implant hospitals: Royal Bournemouth Hospital Queen Alexandra Hospital Wessex Cardiothoracic Centre Dorset County Hospital Main CRT implant hospitals: Royal Bournemouth Hospital Queen Alexandra Hospital Wessex Cardiothoracic Centre Dorset County Hospital 157

per million population 700 650 600 550 500 450 400 350 300 250 Pacemaker New Implant Rate adjusted for age and sex of network population National Wessex Pacemakers (national target: 700 new implants per million population) A fall in the PM implant rate in 2012. The rate matches the national rate. 200 2010 2011 2012 year per million population per million population 90 80 70 60 50 40 30 20 10 0 180 160 140 120 100 80 60 40 20 0 ICD New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National CRT Total Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National Wessex Wessex ICD (national target: 100 new implants per million population) ICD implant rate has decreased in 2012 and the LAT is well below the national average. CRT (national target: 130 total implants per million population) CRT implant rate has improved in 2012 and exceeds the national target. 158

CCG New Implant Rates Above national target Similar to national target Below national target Below national target and below national average Pacemaker ICD CCG Name 2010 2011 2012 2010 2011 2012 England 528 524 559 72 76 66 Q70 Wessex 645 631 560 79 76 49 10J North Hampshire 667 629 600 62 71 24 10K Fareham and Gosport 791 833 574 47 84 42 10L Isle of Wight 263 282 314 11 63 40 10R Portsmouth 1057 1163 686 103 63 75 10V South Eastern Hampshire 645 717 653 54 75 38 10X Southampton 639 529 283 122 71 51 11A West Hampshire 544 493 437 87 66 42 11J Dorset 691 650 666 114 113 67 99M North East Hampshire and Farnham 587 638 652 66 56 25 Total CRT CCG Name 2010 2011 2012 England 114 113 136 Q70 Wessex 101 109 157 10J North Hampshire 130 110 64 10K Fareham and Gosport 58 80 114 10L Isle of Wight 37 52 38 10R Portsmouth 59 107 187 10V South Eastern Hampshire 102 102 137 10X Southampton 110 94 155 11A West Hampshire 88 103 87 11J Dorset 131 147 272 99M North East Hampshire and Farnham 143 90 84 Note: Pacemaker, ICD, CRT New Implant rates and CRT Total rates are adjusted for age and sex of local population. 159

Summary The LAT s population is older than average; overall the LAT requires 18% more pacemakers than the national average, and 9% more ICDs. The PM implant rate has decreased in 2012 and now matches the national average. The ICD implant rate has significantly decreased in 2012 and is well below the national average. A significant increase in the CRT rate places the LAT well above the national target. Four CCGs in the LAT exceeded the national target. 160

New implant rates 161

West Yorkshire Local Area Team Location: Population: Age and relative need: North East 2.3 million Relatively urban population, slightly younger than the national average. 8% less need for pacemakers and 5% less need for ICDs than average. Clinical Commissioning Groups: 10 Main pacemaker implant hospitals: Airedale General Hospital Bradford Royal Infirmary Dewsbury District Hospital Huddersfield Royal Infirmary Yorkshire Heart Centre Pinderfields General Hospital Calderdale Royal Hospital Main ICD implant hospitals: Bradford Royal Infirmary Dewsbury District Hospital Huddersfield Royal Infirmary Yorkshire Heart Centre Pinderfields General Hospital Main CRT implant hospitals: Airedale General Hospital Bradford Royal Infirmary Dewsbury District Hospital Huddersfield Royal Infirmary Yorkshire Heart Centre Pinderfields General Hospital 162

per million population 600 550 500 450 400 350 300 250 200 Pacemaker New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National West Yorkshire Pacemakers (national target: 700 new implants per million population) PM implant rate has slightly decreased in 2012 and is just below the national average. per million population 90 80 70 60 50 40 30 20 10 0 ICD New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National West Yorkshire ICD (national target: 100 new implants per million population) A big fall in the ICD implant rate in 2012. The rate fell just below the national rate. per million population 160 140 120 100 80 60 40 20 0 CRT Total Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National West Yorkshire CRT (national target: 130 total implants per million population) The CRT implant rate remains just above the national average. 163

CCG New Implant Rates Above national target Similar to national target Below national target Below national target and below national average Pacemaker ICD CCG Name 2010 2011 2012 2010 2011 2012 England 528 524 559 72 76 66 Q52 West Yorkshire 518 553 539 65 84 58 02N Airedale, Wharfedale and Craven 461 379 475 57 57 46 02R Bradford Districts 597 562 544 62 35 59 02T Calderdale 575 614 554 69 118 69 02V Leeds North 608 738 680 44 136 34 02W Bradford City 621 188 577 43 43 21 03A Greater Huddersfield 466 473 502 68 76 34 03C Leeds West 541 656 463 70 56 100 03G Leeds South and East 547 657 551 47 128 43 03J North Kirklees 349 424 472 76 47 52 03R Wakefield 460 502 573 73 94 70 Total CRT CCG Name 2010 2011 2012 England 114 113 136 Q52 West Yorkshire 147 125 139 02N Airedale, Wharfedale and Craven 120 98 118 02R Bradford Districts 121 82 86 02T Calderdale 81 137 112 02V Leeds North 167 125 163 02W Bradford City 182 104 102 03A Greater Huddersfield 87 109 109 03C Leeds West 213 202 137 03G Leeds South and East 231 138 143 03J North Kirklees 190 184 225 03R Wakefield 117 75 174 Note: Pacemaker, ICD, CRT New Implant rates and CRT Total rates are adjusted for age and sex of local population. 164

Summary The LAT s population is younger so requires 8% less pacemakers and 5% less ICDs than the national average. PM and ICD rates both decreased in 2012, substantially so for the ICD rate. Both rates are below the national average. The Total CRT implant rate has increased and tracks the national average. Five CCGs in the LAT exceeded the national target. 165

New implant rates 166

Cardiac Network Implant Reports Wales Wales has two cardiac networks and seven Local Health Boards. The total population is 3.06 million. The North network comprises 1 new LHB (previously 6 old LHBs) and has a population of 0.69 million. The South network comprises 6 new LHBs (previously 16 old LHBs) and has a population of 2.38 million. 167

Wales Wales Summary There has been an increase in pacemaker implant rate across Wales in 2012. The pacemaker new implant rate remained below the English average. The ICD implant rate had decreased and is now below the English average. The CRT total implant rate rose noticeably in 2012 but remains below the English average and national target. Note: implant rates are shown for new Local Health Boards and also for old LHBs to permit detailed historical comparison. 168

New implant rates 169

North Wales Cardiac Network Location: Population: Age and relative need: North Wales 0.7 million The population is very old compared to the average for England and Wales. There is a consequent 21% extra need for pacemakers and 16% for ICDs compared to the average. Local health boards (old): 6 Local health boards (new): 1 Main pacemaker implant hospitals: Liverpool Heart and Chest Hospital Glan Clwyd District General Hospital Gwynedd Hospital Maelor Hospital Main ICD implant hospitals: Liverpool Heart and Chest Hospital Gwynedd Hospital Main CRT implant hospitals: Liverpool Heart and Chest Hospital Gwynedd Hospital Maelor Hospital 170

per million population per million population 600 550 500 450 400 350 300 250 200 90 80 70 60 50 40 30 20 10 0 Pacemaker New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year ICD New Implant Rate adjusted for age and sex of network population National 2010 2011 2012 year North Wales National North Wales Pacemakers (national target: 700 new implants per million population) PM implant rate has very slightly decreased in 2012 and remains well below the England average. ICD (national target: 100 new implants per million population) An increase in 2012, the implant rate exceeds the England rate. per million population 180 160 140 120 100 80 60 40 20 0 CRT Total Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National North Wales CRT (national target: 130 total implants per million population) CRT implant rate has significantly improved in 2012 and is above the England average. 171

Old LHB Implant Rates Above national target Similar to national target Below national target Below national target and below national average Pacemaker ICD CCG Name 2010 2011 2012 2010 2011 2012 National 528 524 559 72 76 66 North Wales 412 438 437 82 71 78 6A2 Gwynedd 380 346 405 111 50 106 6A7 Conwy 334 383 434 99 81 35 6B1 Isles Of Anglesey 437 298 504 83 93 164 6B4 Wrexham 537 538 447 50 57 73 6B5 Flintshire 437 564 375 98 72 70 6C1 Denbighshire 292 460 507 43 80 34 Total CRT CCG Name 2010 2011 2012 National 114 113 136 North Wales 112 96 156 6A2 Gwynedd 73 102 161 6A7 Conwy 87 81 109 6B1 Isles Of Anglesey 112 44 204 6B4 Wrexham 115 71 190 6B5 Flintshire 156 115 143 6C1 Denbighshire 106 153 158 Note: Pacemaker, ICD, CRT New Implant rates and CRT Total rates are adjusted for age and sex of local population. 172

New LHB Implant Rates Above national target Similar to national target Below national target Below national target and below national average Pacemaker ICD CCG Name 2010 2011 2012 2010 2011 2012 National 528 524 559 72 76 66 North Wales 412 438 437 82 71 78 Betsi Cadwaladr University Health Board 412 438 437 82 71 78 Total CRT CCG Name 2010 2011 2012 National 110 117 136 North Wales 112 96 156 Betsi Cadwaladr University Health Board 112 96 156 Summary The Network serves a very elderly population compared to the average for England and Wales. There is a consequent 21% extra need for pacemakers and 16% for ICDs compared to the average. The PM implant rate has very slightly decreased in 2012 and remains well below the England average. ICD and CRT rates both increased in 2012, substantially so for the CRT rate. Both rates are above the England average. The CRT rate exceeds the national target, with five of the six LHBs (old) in the network exceeding the national target. There is substantial variability in device implant rate performances between the LHBs in the Network. 173

New implant rates 174

South Wales Cardiac Network Location: Population: Age and relative need: South Wales 2.4 million The population is older than the average for England and Wales. Because of this there is an 8% extra need for pacemakers and a 7% extra need for ICDs compared to average. Local health boards (old): 16 Local health boards (new): 6 Main pacemaker implant hospitals: Royal Gwent Hospital Morriston Hospital Nevill Hall Hospital Princess Of Wales Hospital Royal Glamorgan Hospital University Hospital of Wales West Wales General Main ICD implant hospitals: Morriston Hospital University Hospital of Wales Main CRT implant hospitals: Morriston Hospital Royal Glamorgan Hospital University Hospital of Wales 175

per million population per million population 600 550 500 450 400 350 300 250 200 90 80 70 60 50 40 30 20 10 0 Pacemaker New Implant Rate adjusted for age and sex of network population 2010 2011 2012 year ICD New Implant Rate adjusted for age and sex of network population National 2010 2011 2012 year South Wales National South Wales Pacemakers (national target: 700 new implants per million population) PM implant rate has increased in 2012 and remains below the England average. ICD (national target: 100 new implants per million population) A large decrease in the ICD implant rate and it remains below the England average. per million population 160 140 120 100 80 60 40 20 0 CRT Total Implant Rate adjusted for age and sex of network population 2010 2011 2012 year National South Wales CRT (national target: 130 total implants per million population) CRT implant rate has increased slightly in 2012, but remains well below the England average. 176

Old LHB Implant Rates Above national target Similar to national target Below national target Below national target and below national average Pacemaker ICD CCG Name 2010 2011 2012 2010 2011 2012 England 528 524 559 72 76 66 South Wales 382 463 500 69 68 53 6A1 Monmouthshire 503 455 523 47 64 35 6A3 Pembrokeshire 332 484 423 104 86 32 6A4 Ceredigion 268 406 521 32 22 43 6A5 Neath Port Talbot 385 418 396 72 58 64 6A6 Swansea 433 460 423 65 56 19 6A8 Cardiff 491 581 558 102 89 76 6A9 Rhondda, Cynon, Taff 284 362 572 83 66 51 6B2 Caerphilly 475 499 490 89 54 47 6B3 Bridgend 337 442 487 55 54 27 6B6 Vale Of Glamorgan 443 557 598 52 59 72 6B7 Carmarthenshire 331 483 573 46 78 48 6B8 Merthyr Tydfil 285 642 499 137 115 17 6B9 Newport 333 459 471 50 97 104 6C2 Blaenau Gwent 404 278 471 40 0 97 6C3 Torfaen 398 428 609 51 82 51 6C4 Powys 332 316 408 47 70 55 Total CRT CCG Name 2010 2011 2012 England 114 113 136 South Wales 55 84 91 6A1 Monmouthshire 101 131 72 6A3 Pembrokeshire 50 19 84 6A4 Ceredigion 11 54 66 6A5 Neath Port Talbot 47 64 79 6A6 Swansea 28 59 109 6A8 Cardiff 113 118 102 6A9 Rhondda, Cynon, Taff 64 123 85 6B2 Caerphilly 54 110 102 6B3 Bridgend 51 54 41 6B6 Vale Of Glamorgan 47 109 104 177

Total CRT CCG Name 2010 2011 2012 6B7 Carmarthenshire 28 97 149 6B8 Merthyr Tydfil 127 132 68 6B9 Newport 58 48 99 6C2 Blaenau Gwent 14 40 54 6C3 Torfaen 62 41 115 6C4 Powys 61 56 51 Note: Pacemaker, ICD, CRT New Implant rates and CRT Total rates are adjusted for age and sex of local population. New LHB Implant Rates Above national target Similar to national target Below national target Below national target and below national average Pacemaker CCG Name 2010 2011 2012 2010 2011 2012 England 528 524 559 72 76 66 South Wales 382 463 500 69 68 53 7A2 Hywel Dda Health Board 319 468 515 62 69 42 Abertawe Bro Morgannwg University Health 7A3 Board 394 444 433 64 56 33 7A4 Cardiff and Vale University Health Board 478 575 569 89 81 75 7A5 Cwm Taf Health Board 284 418 557 94 76 44 7A6 Aneurin Bevan Health Board 423 444 507 61 64 66 7A7 Powys Teaching Health Board 332 316 408 47 70 55 ICD 178 Total CRT CCG Name 2010 2011 2012 England 114 113 136 South Wales 55 84 91 7A2 Hywel Dda Health Board 32 63 112 Abertawe Bro Morgannwg University Health 7A3 Board 39 59 83 7A4 Cardiff and Vale University Health Board 95 116 103 7A5 Cwm Taf Health Board 77 125 82 7A6 Aneurin Bevan Health Board 59 78 93 7A7 Powys Teaching Health Board 61 56 51

Summary The Network serves a population older than the average for England and Wales. Because of this there is an 8% extra need for pacemakers and a 7% extra need for ICDs compared to average. 2012 saw encouraging growth in PM and CRT rates, whilst the ICD rate decreased significantly. For all three device classes the implant rates are below national average and well below target levels. There is very marked variability in corrected implant rates between the LHBs within the Network. 179

New implant rates 180

Appendix 1 - Methodology Sources used to identify pacemaker implants and the geographic location of the patient: The great majority of the CCG locations of patients were derived from the patient postcode submitted by the hospital that performed the implant. In order to acquire the remainder a number of other data sources were used, including the Royal Mail Postcode Address File (via Capscan Matchcode software) and the Electoral Roll (via www.192.com). The few remaining cases were mapped to the observed pattern of implants for each hospital, where possible, to assign a CCG to the remainder that was consistent with the hospital's previous practice. In the end, the overall national completeness for CCG allocation was 97.4%. "New" and "Total" Pacemaker Implants There are three classes of device considered in this report: Pacemakers (PM) - for treatment of symptomatic bradycardia Implantable defibrillators (ICD) - for treatment of cardiac arrest and patients suffering or at risk from life threatening ventricular tachyarrhythmias. Cardiac resynchronisation devices (CRT) - for treatment of heart failure. Note: CRT devices can use low energy pacing-type pulses only (CRT-P) or can also have the capability to deliver defibrillating shocks (CRT-D). The two types of device are mostly counted together in this report. The first time a patient receives a device, the procedure is classed as a "new implant". If that device is replaced with another of the same class (due usually to battery depletion) then that procedure is classed as a "replacement implant". If however the patient's device type is changed, for instance from a pacemaker to a CRT device, then the CRT implant will be classed as a "new implant". For the purposes of this Report, the word "total" is defined as "new plus replacement" implants. Where data are combined for different modes e.g. single plus dual chamber, CRT-P plus CRT-D, this is made clear in the text, or the word "all" is used. 181

Maps LAT maps are colour coded by CCG for age and sex corrected implant rates of pacemakers, ICDs and CRT devices, in each of 2010, 2011 and 2012. Implanting centres are shown on the maps as yellow or green dots. LAT analysis For each Team the constituent CCGs and the implanting centres within the CCGs were identified. The demographic structure of each CCG by age and sex was determined for comparison with the national average. From the Cardiac Rhythm Device Management Database (CRM) all registered device implants and the postcode of each device recipient was identified. Device and postcode registration deficits and inaccuracies were subject to stringent retrieval and correction procedures by collaboration with the implanting centres. A service standard of 98% registration completeness for devices and postcodes in each Team was obtained before analysis of data in that Team. Where device registration deficits were discovered by implanting centres only after presentation of the first draft Report, any missing data provided were included in the final Team Report. The raw implant rate for a CCG was then adjusted to account for its demographic structure to give a corrected implant rate per million population. A CCG with a population relatively older than the national average will have a higher relative need for a given implant rate whilst a CCG with a younger population will have a lower relative need, since the conditions for which device implants are indicated increase in prevalence with age. Corrected new implant rates for pacemakers and ICDs were then compared to accepted national target national implant rates to indicate the percentage deficit (or excess) in each CCG. For bradycardia pacemakers the national target of 700/million was used (the European average new implant rate for 2004, accepted by British Heart Rhythm Society in 2005 as the revised target rate), superseding the previous target of 450/million new implants per year. For ICDs the most recent NICE recommendation of 100/million was used. For CRT devices the target for total (new plus replacement) devices was agreed during 2008 to be 130/million. This target was agreed with both British Heart Rhythm Society and the British Society for Heart Failure. Each year the Audit Group looks at current European practice and whether these target rates remain valid. It will be clear when European data is presented that Pacemaker and CRT rates remain reasonably fair, but the new ICD target rate needs urgent revision. A target of 140 would more reasonably reflect current practice than 100. For each Team reported, the analysed data were presented in several formats. 182

Full disclosure of numerical data reflecting demographics, raw and corrected implant rates by CCG. Please note that the numerical data is presented in a colour coded table. Where a number is shaded dark blue, the value is statistically significantly below the national average. Where a number is shaded light blue, the value is not statistically significantly below the national average but is significantly below the national target. A value shaded red is above the national target. Where a number is not shaded (i.e. the background remains white), the value is not statistically different from the national target. In the national Summary Report implant rate graphs for pacemakers, ICD and CRT, from 2010 to 2012, are presented for each Team. A conclusion section was provided, representing, in the view of the Audit Group, the salient findings in each Team. 183

Device Registration How to register device implants Methods that you CAN use We supply free online applications for registering CRM implants. These can be accessed either via a Lotus Notes installation or via a web browser. The methods are: 1. Use the CRM application on Lotus Notes for direct data entry. 2. Use the CRM web portal for direct data entry. 3. Upload a suitably formatted (CSV) export file (created by your local database) into CRM via Lotus Notes or the NICOR web portal. 4. Send a suitably formatted (CSV) export file from your local system to the CRM Data Coordinator via the NICOR secure dropbox. 5. Using the EPS97-CRM conversion tool upload an export file from your EPS97 (Microsoft Access based) system into CRM via Lotus Notes or the NICOR web portal. 6. Using the EPS97-CRM conversion tool then send the export file to the CRM Data Coordinator via the NICOR secure dropbox. 7. If none of these 6 methods are suitable for your centre, it may be possible for us to accept data in another format. Please contact the CRM Data Coordinator to discuss. What about data security? NICOR has current permission (section 251 exemption) to receive and securely store patient identifiable data. The data is encrypted in transit and when stored. You can find more on security issues on the NICOR website (www.ucl.ac.uk/nicor). Why does the database need to receive patient identifiers? NICOR uses patient identifiers for three purposes: to track patient mortality data (via the NHS Central Register) and other clinical outcomes. to identify patients treated in more than one hospital (and having different hospital numbers). to identify the implanted device in deceased patients when local documentation is missing. NICOR receives between 200 and 300 such enquiries each year, and it is an important Health and Safety issue, as explanting a high energy device without switching it off could be hazardous to mortuary staff. 184

Do I need to register devices with the National CRM Cardiac Device Database? If your hospital is in England, you are required to register all implanted cardiac devices 2. It is part of the contract that your hospital has with the Department of Health that you must participate in all audits that are part of the National Clinical Audit and Patient Outcomes Programme. The CRM devices clinical audit is part of that programme. How can I contact the National Cardiac Device Database? Your first port of call for assistance is the NICOR Helpdesk (nicor-helpdesk@ucl.ac.uk) You can also call the database office direct on 01505 612829, or email morag.cunningham@ucl.ac.uk. 2 from 2011/12 Standard Terms and Conditions for Acute Hospital Services Gateway Reference 15458 ("Standard Acute Terms"). 185