Special feature: Testing times

It can be a worry, waiting for an echocardiogram (echo).

The test – an ultrasound scan of the heart – is used to diagnose a range of heart conditions, showing the structure of the heart, its chambers, valves and how blood is flowing through them.

“The implication of having to wait for one is that you sometimes can’t make a definite diagnosis without the scan, so you’re going with your best guess meantime,” says Amanda Manson, a cardiology specialist nurse for NHS Orkney.

“You’re treating them according to their symptoms when you don’t actually know what’s wrong. It can be tough for the patient, not having a definite diagnosis.

“If the GP suspects heart failure, they’ll put the patient on basic heart failure drugs and then after the echo, if heart failure is confirmed, they might introduce others. 

“But it might turn out not to be heart failure at all.”

She adds that sometimes an echo is required to investigate minor changes on a patient’s electrocardiogram (ECG) [a read-out of the heart’s electrical activity]. “Minor changes might be deemed ‘low risk’, and these patients may have a longer wait… and the more they wait, the more worried they can become without a definite answer.  

“If the scan could be done more quickly patients could have that reassurance that there’s actually nothing wrong, or a diagnosis can be reached and a treatment plan started.”

An ECG provides key diagnostic information for conditions like heart failure and heart valve disease as well as assessing the impact from a heart attack, but delays to echos can cause problems in other contexts too. “You might be delaying someone’s surgery because they need an echo to assess their anaesthetic risk. Without it, you can’t progress their care,” adds Manson. “With chemotherapy treatment for cancer, if you are taking drugs that are cardiotoxic you have to have regular echos over months and you can’t start treatment until you have the first one.”

Yet although the scans are crucial pieces of the diagnostic and treatment puzzle, many patients can’t get one on demand. Due to a lack of trained cardiac physiologists to carry them out, waiting lists for echos are going up and up.

BHF Scotland has revealed that almost 24,000 people were waiting for this test in June 2024, compared to under 10,000 in 2019. Of these, 6,231 people had been waiting more than a year.
Fewer than a third of people are seen within the six-week target.

The figures were compiled from responses to Freedom of Information requests by Scotland’s 14 territorial health boards. 

The test is not one of the Scottish Government’s eight key diagnostic tests on which Public Health Scotland regularly reports waiting list numbers. 

There is a stark difference between waits for those tests – such as endoscopies and computed tomography (CT) scans – and waits for echos, with 67 per cent more people waiting a year for an echo than for the eight tests combined. 

You sometimes can’t make a definite diagnosis without the scan, so you’re going with your best guess meantime. You’re treating them according to their symptoms when you don’t actually know what’s wrong

“Echocardiograms are a key diagnostic test for heart disease, which remains Scotland’s single biggest killer. The importance of this test can be seen in the sheer number of people waiting,” says Jonathan Roden, policy and public affairs manager for British Heart Foundation (BHF) Scotland. “But some people are getting sub-optimal treatment or delays in starting treatment due to delays in getting the scans.”

The waiting time for an echo in NHS Grampian is currently 32 weeks, though specialist staff continually review the triage process to ensure that those who need the scans more urgently get them quickly, while also continuing to deal with routine cases.

Shenbagam Govindan, the echo clinical lead cardiac physiologist at Aberdeen Royal Infirmary, describes the process of managing the waiting list as “challenging and stressful”. She observes that there has been an increase in the demand for echos, especially since Covid, but there is not enough capacity to meet the demand. She is hoping that three new specialist physiologists who are currently in training with the health board will take up posts in three years’ time, but there are no guarantees. And it doesn’t help with the immediate demand anyway. Staff are undertaking overtime to try and help tackle the waiting list.

NHS Orkney does not have a significant waiting list for echos but the lack of a permanent cardiac physiologist in Kirkwall who can perform the tests, and reliance instead on locums and other professionals, makes NHS Orkney vulnerable to sudden disruptions.

The board has a regular cardiologist who comes for two weeks per month and often has to perform the scans alongside his many other duties. Having a consultant cardiologist taking the time out of his busy schedule to perform an echo that a physiologist could do is cardiologist time wasted, says Manson. “It means they are not able to see as many patients as clinic time is being taken up doing this basic scan,” she explains. 

If one of the locums can’t come as planned, as happened recently due to illness, it causes a backlog. “That’s an example of the impact of relying on so few people,” says Manson.

There is a nationwide shortage of cardiac physiologists. The most recent census of the specialism in 2019 found that vacancies in half of Scotland’s cardiac physiology units stood at 15 per cent. At that time, a similar proportion of cardiac physios were within five years of retiring. 

The same survey found that the number of medical consultants – the main workforce group responsible for ordering echos  – was growing at a faster rate than the number of cardiac physiologists. Professionals describe how new cardiologists are appointed to health boards, who then order more scans, without more cardiac physiologists being recruited to balance the increased demand.

Put it all together and it’s a recipe for longer waiting lists. “Without investment and a change in approach to training the workforce, we will see that demand continue to increase and the number of people waiting increase as well,” says Roden.

The Scottish Government’s Heart Disease Action Plan (HDAP) in 2021 committed to developing a sustainable training and education pathway for cardiac physiology in Scotland. Four years on, there’s been little progress towards achieving that goal, with no increase in training places between 2020-21 and 2022-23.

One issue is the pathway to becoming a cardiac physiologist in Scotland. The route to qualifying requires people to combine a degree-level qualification with training in an NHS role. “It’s largely run through health boards which have an agreement to train cardiac physiologists on the job. That training system puts a lot of pressure on the current workforce’s time,” explains Roden.
Alternative models exist elsewhere in the UK, such as dedicated undergraduate degrees in England and Wales, that offer a direct training pathway.

“This is an issue that has been known about for a long time. As far as we are aware, no lasting way of producing a sustainable workforce has been proposed or implemented by the Scottish Government,” says Roden.

Manson adds that as well as addressing the need to train more people, it is important to ensure cardiac physiologists are assigned to appropriate pay bands. “The job has to be attractive pay-wise,” she says. “It’s a lot of responsibility.”

Govindan also sees merit in the idea of national guidelines for GPs and others who make referrals for echos, with further national guidelines on triaging patients on the waiting lists. In the past, nearly all requests for echos came from cardiologists but some now come from non-medical staff. “That might resolve some confusion and also variation between health boards,” she suggests.

BHF Scotland sees addressing the lengthening waiting list for echocardiograms as a high priority for the new, updated HDAP. 

This month, the charity has launched a new campaign, Scotland’s Hearts Need More, calling for more focus, investment and support for the 730,000 people in Scotland living with heart and circulatory diseases. The campaign is calling for a commitment to renew the current HDAP, which runs out next year, as well as calling for heart disease to be made a priority by parties ahead of the 2026 Scottish Parliament election. 

Alongside a renewed focus on prevention and developing a more person-centred service at community level, BHF Scotland and the medical professionals they work with are anxious to see the diagnostic workforce increased.

“Investing in our NHS workforce is key to tackling the delays in getting echos,” says Roden.
BHF Scotland was closely involved with developing the original HDAP, producing a draft plan alongside clinicians which was largely taken forward. However, the plan has only received £2.2m in funding over its five years. The Cross-Party Group on Heart and Circulatory Diseases inquiry into the HDAP’s implementation found that this was a significant barrier to success.

Public health minister Jenni Minto says the Scottish Government is “determined to drive down waiting times”, adding: “We know that services are facing sustained pressure, and this is not unique to Scotland, with similar challenges being felt right across the UK. But some people have had to wait longer than they should for appointments and referrals – that is not acceptable.

“If approved by parliament, the Scottish Government’s budget for the coming year will invest a record £21.7bn in Scotland’s health and social care services which will help to cut waiting times and increase capacity.”

Roden fears that waiting lists for echos could get longer still. He says: “This problem has not been adequately addressed in spite of past warnings. We can’t miss another opportunity to end these worrying delays and give patients in Scotland the timely diagnosis and treatment they deserve.”

This article is published in association with the British Heart Foundation Scotland.

www.bhf.org.uk