NHSCANCER                                   NHS ImprovementDIAGNOSTICS              Continuing to ImproveHEART            ...
Continuing to Improve Cardiac Services   |   3Contents                                Foreword                            ...
4 | Continuing to Improve Cardiac ServicesForeword                              In the 10 years since the launch of the Na...
Continuing to Improve Cardiac Services   |   5Introduction                              This document details the areas th...
6 | Continuing to Improve Cardiac Services                           Reducing avoidable delays in non                     ...
Continuing to Improve Cardiac Services   |   7NHS Health CheckAims of the projectTo support the successfulimplementation a...
8 | Continuing to Improve Cardiac Services NHS Improvement has also supported           Current estimates indicate that ov...
Continuing to Improve Cardiac Services   |   9Stroke prevention in primary care:managing atrial fibrillationAims of the pr...
10 | Continuing to Improve Cardiac ServicesIn parallel, at a national level, NHS         Based on numbers needed to treat ...
Continuing to Improve Cardiac Services   |   11National roll-out of primary PCI for ST segmentelevation myocardial infarct...
12 | Continuing to Improve Cardiac Services3. PCI audit                                  Contact detailsThe Care Quality C...
Continuing to Improve Cardiac Services   |   13Arrhythmia - cardiac devices andinherited cardiac conditionsAims of the pro...
14 | Continuing to Improve Cardiac ServicesSustaining cardiac pathways - cardiac surgeryAims of the projectThe attention f...
Continuing to Improve Cardiac Services   |   15Improvement to the patient pathway - summary of recommendations  1. Referra...
16 | Continuing to Improve Cardiac Services  3. Scheduling                                 4. Discharge and post operative...
Continuing to Improve Cardiac Services             |        17Heart failurePiloting, testing and promotinggood quality, sy...
18 | Continuing to Improve Cardiac Services                                                                               ...
Continuing to Improve Cardiac Services   |   19        Case History: Nora P.               There are potential savings of ...
20 | Continuing to Improve Cardiac ServicesCardiac rehabilitationAims of the projectThe overall aim of this project, which...
Continuing to Improve Cardiac Services   |   21Where required one-to-one support at     (Effectiveness), new community and...
22 | Continuing to Improve Cardiac ServicesNHS Improvement SystemWhat is it?                                   Where can I...
ResourcesAll the publications listed below           Delivering the NHS Health Check: A          National Priority Project...
CANCERDIAGNOSTICSHEARTLUNGSTROKE              NHS Improvement              With over ten years practical service improveme...
Continuing to Improve Cardiac Services - National Project Summaries 2009/10
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Continuing to Improve Cardiac Services - National Project Summaries 2009/10
This document details the areas that the Heart Improvement Programme has been working on during 2009/10, briefly describing the various ideas that have been tested by commissioners and providers across England

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  1. 1. NHSCANCER NHS ImprovementDIAGNOSTICS Continuing to ImproveHEART Cardiac Services Heart Improvement Programme National Project Summaries 2009/10LUNGSTROKE
  2. 2. Continuing to Improve Cardiac Services | 3Contents Foreword 4“So far, improvements inthe pathway and transferarrangements have saved Introduction NHS Health Check 5 7the equivalent of some 959 Atrial fibrillation in primary care 9NHS beds each year acrossEngland. We know that National roll-out of primary PCI for STthere is a lot more that can segment elevation myocardial infarction 11be done to take this furthersaving the NHS a great deal Arrhythmia - cardiac devices and inherited cardiac conditions 13of money and patients agreat deal of stress and Sustaining cardiac pathways - ”worry. cardiac surgery 14Professor Roger Boyle CBE, Heart failure 17National Director forHeart Disease and Stroke Cardiac rehabilitation 20Signpost to Improving CardiacInter Hospital Transfers,Heart Improvement Programme, NHS Improvement System 22(2007) Resources 23
  3. 3. 4 | Continuing to Improve Cardiac ServicesForeword In the 10 years since the launch of the National But there is more to be done - there are still Service Framework (NSF) for Coronary Heart unnecessary waits for transfer to surgical and Disease in 2000, we have seen a substantial specialist centres. The recent National Audit of improvement in cardiac services which has led Cardiac Rehabilitation (NACR) figures show the way in the NHS for improved and equitable that uptake remains low and that access to services. Mortality rates have fallen commissioning and provision of adequate quickly and health inequalities have narrowed. cardiac rehabilitation remains a challenge; the Waiting times for diagnosis, heart surgery and provision of integrated heart failure services angioplasty have fallen dramatically and the across the whole patient pathway is also inProfessor Roger Boyle, CBE care of patients with acute coronary syndromes need of focused attention.National Director for Heart has changed dramatically. We are operatingDisease and Stroke, on more people with higher levels of risk and As we move forward, we face an even biggerDepartment of Health co-morbidity, whilst delivering better outcomes. challenge to continue to provide high quality We have also witnessed opportunities for care while at the same time delivering it much health care professionals to widen their skills more efficiently. This will be the biggest and expand their roles and scope of practice. challenge that has faced us in the history of the NHS. The progress and improvements made over the last 10 years to achieve the NSF have been I hope you will join me in celebrating all that made possible by a collaborative effort by all we have achieved together at the NHS organisations and staff across the NHS. The Improvement – Heart Conference which marks CHD Collaborative started in 2000 with just 11 the 10th anniversary of the National Service local sites, moving quickly to 30 collaboratives Framework. The following pages outline for and was followed by the development of the wider NHS the range of national areas of clinical networks. Today, cardiac networks work delivered by NHS Improvement – Heart, continue to be uniquely placed to assist with that have helped increase productivity and the delivery of the quality agenda by linking efficiency in services and have improved the clinicians, managers and commissioners experience for cardiac patients and staff. together in every aspect of the patients’ journey through primary, secondary and tertiary care. They continue to be well positioned to Professor Roger Boyle CBE reflect local relationships between clinicians National Director for Heart Disease across organisational boundaries to further and Stroke, Department of Health develop safe and effective pathways of care for patients by providing an opportunity for clinicians and managers to work together on the redesign and commissioning agenda. The work of NHS Improvement and its predecessor organisations has been a constant source of support to these improvements and pivotal in the development of systems that deliver high quality care.
  4. 4. Continuing to Improve Cardiac Services | 5Introduction This document details the areas that the Moving on to next year, the new priorities Heart Improvement Programme has been have already been agreed. Inevitably, given working on during 2009/10, briefly the financial context in which we are now describing the various ideas that have been working, there is a focus on productivity, but tested by commissioners and providers across that does not mean that quality of care is England. The priority areas were agreed at relegated to second place and we look the start with the policy team with input forward to expressions of interest from from the cardiac networks. The networks anyone who is committed to developing new were then asked to put forward proposals ways of working and improving services forMark Dancy for work in these areas and selected projects patients.Consultant Cardiologist andNational Clinical Chair, were facilitated both by the networks and byNHS Improvement - Heart the national team. We chose projects that Priority projects for 2010/11 had clear objectives and scope, were achievable in a manageable timeframe Cardiac rehabilitation (usually less than two years), and would The work will aim to increase the provision produce new ways of working that could be and uptake of cardiac rehabilitation (CR) by adopted by others. working with the Department of Health to develop a commissioning pack designed to This summary document is not intended to help PCTs and providers improve the describe the individual projects in detail, but specification, commissioning and potential further information is easily available from procurement of CR services. The the contacts given in the text. I would commissioning pack will form the main tool encourage anyone interested in carrying out in a programme of improvement work and similar work to get in touch with the teams its roll out and implementation will be who have been involved in these priority supported by NHS Improvement. projects as they have invested considerable resource learning what works and what Heart failure doesn’t and that can save a lot of time and As highlighted in ‘NHS 2010 - 2015: From anguish. good to great’ (2009,) the main aim of this work will be to improve clinical outcomes As you will see from the descriptions of the and patient experience by decreasing the projects, there have been some very number of emergency admissions, successful initiatives which have measurably readmissions and in-patient bed days improved the quality of care for patients and through optimising care for patients with carers, and I congratulate the teams on their heart failure. The scope will include early hard work and perseverance. If others can accurate diagnosis, optimising management, take these ideas and develop them in their integrated care, the role of the care own localities, the potential health gain is coordinator and end of life care. considerable.
  5. 5. 6 | Continuing to Improve Cardiac Services Reducing avoidable delays in non elective inpatient management Cardiac devices This initiative builds on lessons learned in This initiative will continue to engage with elective inpatient management for surgery network and provider device clinical leads to and revascularisation and in previous review local service provision and address interhospital transfer studies. The work aims equity of access in cardiac networks. This will to improve clinical outcomes and patient be underpinned by supporting the device experience by decreasing in-patient bed survey team to drive up data quality and days through optimising care for patients submission timeliness whilst expanding the with acute coronary syndromes (ACS), functionality of existing data sources for arrhythmias and those requiring cardiac clinical users for clinical audit and surgery. commissioning purposes. Atrial fibrillation NHS Health Check This work will build on existing priority Work to support the implementation of this project work on atrial fibrillation (AF) with a major initiative will move from NHS view to accelerating progress, sharing Improvement to NHS Diabetes and Kidney lessons learned and extending and Care from May 2010. NHS Health Check embedding the use of tools, methodologies remains a key policy initiative for the and resources for AF developed and tested prevention of cardiovascular disease and during the pilot and prototype phases. The work in cardiac and stroke networks on this focus will be on raising awareness of AF, important area will continue. training and education of clinicians in detection and treatment, exploring all Some of the projects from this year are still opportunities for screening for AF and running, but networks will be looking out for ensuring anticoagulation and treatment are people who think they may be able to optimised in both primary and secondary contribute their ideas in the various project care. A substantial reduction in the number areas for 2010/11 and if you think you might of resulting strokes is anticipated and the want to join us I would encourage you to work will contribute considerably to the speak to your network as soon as possible quality and productivity challenge. even if only to discuss your proposal informally. Primary angioplasty (reperfusion) This work will involve a continuation of the primary percutaneous coronary Mark Dancy intervention (PPCI) project workstream with National Clinical Chair implementation across England and the NHS Improvement - Heart development of a sustainable service across the whole patient journey. This will include a focus on the adoption of robust cardiac rehabilitation pathways and an emphasis on the improvement of the data quality for local and national audit.
  6. 6. Continuing to Improve Cardiac Services | 7NHS Health CheckAims of the projectTo support the successfulimplementation and delivery of theNHS Health Check programme - asystematic and integrated programmeof vascular risk assessment andmanagement which will offerpreventative checks to all eligiblepeople aged 40-74 to assess their riskof vascular disease (heart disease,stroke, diabetes and kidney disease)followed by appropriate managementand interventions. The proposals for theNHS Health Check programme(formerly vascular checks) were set outin ‘Putting Prevention First’, publishedon 1 April 2008 and aim to ensuregreater focus on the prevention ofvascular disease and a reduction inhealth inequalities. Implementation ofthis major national programme beganin April 2009 and all Primary Care Approach taken the Department of Health, and toTrusts are expected to achieve full roll The NHS Health Check Learning signpost to other useful informationout by 2012/13. Network includes NHS commissioners sources. and providers, independent andProject overview voluntary sector organisations, The NHS Health Check LearningTo coincide with the publication of individuals and a wide range of other Network website acts as a centralPutting Prevention First, NHS stakeholders who are interested or repository for the network and hasImprovement, in collaboration with the involved in the implementation of the been developed to help commissionersDepartment of Health, established a NHS Health Check, including the and providers locate relevant resourcesnational Learning Network in order to cardiac and stroke networks. and information to support locallearn from, build upon and share the implementation. It includes details oflearning and experience of both The Learning Network is underpinned national workshops as well as keyexisting and emerging vascular risk by a series of interactive workshops guidance documents and latest newsassessment and management with a strong focus on sharing and relating to the NHS Health Checkprogrammes across the country. The learning and featuring presentations, programme, a useful links section, anLearning Network has focused on discussions and interactive group work expanding number of case studies, andtackling the many challenges to around the emerging issues and a resource library containingimplementation and delivery of the themes. ‘documents for sharing’- to saveprogramme, including commissioning commissioners and providers fromand procurement, workforce capacity, The Learning Network is also supported reinventing the wheel.training and education, informatics, by the publication of a regular eBulletinchecks in community settings, which aims to keep subscribers up toleadership and clinical engagement date with news and information fromand so on. across the Learning Network and from
  7. 7. 8 | Continuing to Improve Cardiac Services NHS Improvement has also supported Current estimates indicate that over Contact details 19 carefully selected ‘test bed’ sites to 85% of PCTs in England will have investigate different aspects and commenced roll out of NHS Health Julie Harries models of delivery to help inform policy Check in 2009/10 and it is likely that Director and assist with the development of the establishment of the national julie.harries@improvement.nhs.uk further guidance. Funded by the Learning Network has made a Department of Health, learning from significant contribution to this in Mel Varvel the test bed programme is currently addition to tangible (figures to be National Improvement Lead being shared across the Learning confirmed) progress towards the mel.varvel@improvement.nhs.uk Network, largely via the production of a delivery of 1,000,000 checks by April series of practical implementation 2010 (as cited in Working Together – guides, the first of which was published Public Services On Your Side published in November 2009. in March 2009). Results and achievements Next steps To date, NHS Improvement, alongside The national Learning Network is set the Department of Health, has to continue to support ongoing facilitated seven national learning implementation and delivery though events attended by well over 1,000 the facilitative role played by NHS delegates. These national workshops Improvement will transfer to NHS have generated a great deal of interest Diabetes and Kidney Care in Spring from a wide range of stakeholders 2010. across the country and have been very well received and evaluated by Supporting information attendees: To find out more about the NHS Health Check Learning Network, and to“ Todays workshops have been download any of the supporting guidance and resources, visit the fantastic. Its really valuable to website at: www.improvement.nhs.uk/ hear whats happening from nhshealthcheck the centre and in other areas.” Further information on the national Eight eBulletins have been published to policy can be found on the a growing distribution list of almost Department of Health’s website at: 900 people, and the website continues www.dh.gov.uk/nhshealthcheck to achieve a high ‘hit rate’. Public-facing information is available on The first implementation guide on Point the NHS Choices website at: of Care Testing proved extremely www.nhs.uk/Planners/NHSHealthCheck popular and has received very positive /Pages/NHSHealthCheck.aspx feedback.
  8. 8. Continuing to Improve Cardiac Services | 9Stroke prevention in primary care:managing atrial fibrillationAims of the project Key areas for piloting newTo improve quality outcomes for approaches centred on:patients with atrial fibrillation (AF) and • Detection of AF through opportunisticreduction in health and social care costs screening at flu clinicsby reducing their risk of stroke through • Local enhanced service (LES) schemesservice improvement to improve for detection, screening and reviewdetection, diagnosis and optimal of AFtherapy and management in primary • New models for anti-coagulationcare. services in primary and community settingsChapter Eight of the National Service • Development of tools to support theFramework for Coronary Heart Disease; review of patients with AF, riskArrhythmias and Sudden Cardiac stratify for stroke and considerDeath, published in March 2005, set optimal therapyout the quality requirements for the • Guidelines for primary to secondaryprevention and treatment of patients care referral.with cardiac arrhythmias. In December2008, the publication of the National All projects found the need to includeStroke Strategy affirmed the education for professionals andimportance of this work for stroke patients around:prevention within Quality Marker 2 This treatment is also highly cost • Pulse palpation‘Managing Risk’. effective. The treatment of AF with • Barriers to anti-coagulation in warfarin reduces risk of stroke by primary careAtrial fibrillation is the most common 50-70%: • ECG training and interpretationsustained dysrhythmia, affecting at • The estimated total cost of • Patient awareness.least 600,000 (1.2%) people in England maintaining one patient on warfarinalone. It is also a major predisposing for one year, including monitoring, is Approach takenfactor to stroke, with 16,000 strokes £383 These projects led by NHS Improvementannually in patients with AF of which • The cost per stroke due to AF is Heart and Stroke Programmes, soughtapproximately 12,500 are thought to estimated to be £11,900 in the first to work with primary care trusts (PCTs),be directly attributable to AF. year after stroke occurrence. general practices, practice based consortia (PBC) acute trusts andThe annual risk of stroke is five to six Project overview voluntary organisations to address thetimes greater in AF patients than in The first phase of priority projects were detection of atrial fibrillation, whetherpeople with normal heart rhythm and is established in October 2007 and patients were appropriately treatedtherefore a major risk factor for stroke. completed April 2009. Eighteen with anti-coagulants and to considerUniquely, it also in an eminently individual projects were established the best pathways for managing atrialpreventable cause of stroke with a across 15 cardiac and stroke networks fibrillation in primary care.simple highly effective treatment. A variety of approaches were undertaken responding to the needs of Regular peer support meetings were the local health communities. held to encourage the sharing of resources, learning and collaborative working to drive forward improvements in care and maximise benefits.
  9. 9. 10 | Continuing to Improve Cardiac ServicesIn parallel, at a national level, NHS Based on numbers needed to treat National PublicationsImprovement has sought to achieve a ranging from 25 to 37 (Kerr), the costs National Stroke Strategy – Qualityconsensus approach across England to of each stroke prevented with warfarin Marker 2: Managing Risk (2007).the management of AF patients within are in the range £9,500 to £14,000.primary care with key stakeholders National Service Framework forresulting in the publication of a Each year appropriate anti-coagulation Coronary Heart Disease (CHD) –commissioning guide in May 2009 and could prevent 4,500 strokes in patients Chapter 8: Arrhythmias and Suddencontinues to make formal with AF at an additional cost of £63.5 Cardiac Death (2006).representation to influence million.amendments to the current AF Management of atrial fibrillation,indicators within the Quality and Next steps National Institute for Health andOutcomes Framework. The second phase of nine projects was Clinical Excellence (NICE) Clinical launched in October 2009 to spread Guideline (2006).Results and achievements and embed sustainable improvementThe learning and outcomes from the applying a developed suite of tools and 2010 National Audit Office ‘Progress infirst phase of projects has been resources, supported by evidence-based improving stroke care report’.identified as one of the six key learning, and develop alternativerecommended interventions under the models. Contact detailsNational Quality and Productivityagenda within NHS Evidence. 2010/11 accelerated spread of Sue Hallwww.library.nhs.uk/qualityandproducitvity improved detection and optimal National Improvement Lead treatment of AF patients to reduce risk sue.hall@improvement.nhs.ukIn particular we have seen: of stroke.• The early piloting of opportunistic Dr Campbell Cowan screening through pulse palpation at Supporting information Consultant Cardiologist and National flu clinics by Bedfordshire and Full details of the outcomes Clinical Lead, NHS Improvement - Heart Hertfordshire Heart and Stroke documented and published can be campbell.cowan@leedsth.nhs.uk Network replicated in other areas, found at: www.improvement.nhs.uk eg: Colchester Practice Based Dr Matt Fay Commissioning Group. Atrial fibrillation in primary care: GP and National Clinical Lead• Opportunistic pulse check prompted making an impact on stroke prevention matthew.fay@bradford.nhs.uk by flag to GP clinical systems in (October 2009). Durham• GRASP-AF tool developed and piloted Commissioning for stroke prevention in by West Yorkshire Cardiovascular primary care: The role of atrial Network in collaboration with their fibrillation (June 2009). British Heart Foundation (BHF) arrhythmia nurses and PRIMIS+ Heart Improvement: Atrial fibrillation in for use on GP clinical systems to primary care (May 2008). identify for review AF patients with high risk of stroke, not on warfarin, now available for use across England for all GP clinical systems via www.improvement.nhs.uk/graspaf• Decision support tool ‘The Auricle’ www.theauricle.co.uk
  10. 10. Continuing to Improve Cardiac Services | 11National roll-out of primary PCI for ST segmentelevation myocardial infarctionAims of the project 4. Liaising with MyocardialThe National Infarct Angioplasty Project Infarction National Audit Project(NIAP) was published in October 2008. (MINAP) to monitor nationalThis demonstrated that a strategy of progress of the roll-outprimary PCI (angioplasty) for patients programme.presenting with ST segment elevation 5. Sharing national learning via themyocardial infarction was feasible in a reperfusion web pages and theUK setting. Following the publication, primary PCI newsletter.the Government stated that primaryPCI would be rolled out to cover 95% Results and achievementsof the population within three years. Progress has been rapid. In the yearNHS Improvement was invited to to 1 April 2009, 10,048 ST elevationfacilitate this roll-out process. MI patients were treated with thrombolysis and 7,919 were treatedApproach taken with primary PCI. Between 1 April 2009The principal aim of the project was to and 1 December 2009, there was aensure that primary PCI became the ‘crossing over’ with PPCI becoming thedefault treatment for the vast majority dominant reperfusion strategy. Duringof patients in England presenting with this eight month period, 4,835 patientsST segment elevation myocardial received thrombolysis compared withinfarction. This necessitated a 24/7 PPCI 6,643 treated with primary PCI. Thusservice. This in turn meant that not all 58% of those patients receivingacute hospitals, and not even all PCI reperfusion treatment received PPCIcentres, would be able to provide this during the first eight months of the Next stepsservice. For this reason, a cardiac current MINAP year compared with 1.Interim reportnetwork approach was taken to find a 44% in the previous year. Currently, all April 2010 represents the half-waylocal solution for each network. In cardiac networks in England have a point in the three year PPCI roll-out. Asome areas, a solution for a Strategic strategy to deliver PPCI to their survey of the cardiac networks isHealth Authority (SHA) which included population by October 2011. Between planned together with comparison ofseveral cardiac networks was sought. April and November 2009, the their actual PPCI rates from the MINAPThe role of NHS Improvement in the commencement of PPCI roll-out database. These will then beroll-out of PPCI was that of facilitation. programmes was captured by the incorporated into an interim reportThis included: MINAP data collection which showed which should highlight if there are any that 8 cardiac networks were providing areas of concern nationally.1. Providing bespoke advice to PPCI to 30-70% of their ST elevation cardiac networks and SHAs on MI patients by the end of November 2.Patient information their PPCI roll-out plans. 2009 having been providing PPCI to Patients who have a primary PCI have2. Providing generic guidance on less than 30% of their population eight shorter hospital stays and with these PPCI roll-out (eg publication of a months previously. short stays come the challenge of Guide to Implementing Primary giving patients and carers the Angioplasty (April 2009). information they require prior to3. Liaising with DH through the discharge. Guidelines for staff that care Cardiac Emergencies Board on for these patients are in development. issues around PPCI roll-out.
  11. 11. 12 | Continuing to Improve Cardiac Services3. PCI audit Contact detailsThe Care Quality Commission haveset a standard of 150 minutes Carol Marleydoor-to-balloon time for PPCI. This is a National Improvement Lead‘whole service’ standard since the time NHS Improvementinterval may include data collection carol.marley@improvement.nhs.ukfrom the ambulance service, from anon-PPCI hospital and from the PPCI Dr Jim McLenachancentre. Data collection for around this Consultant Cardiologist and Nationalstandard is, therefore, more challenging Clinical Lead, NHS Improvement - Heartthan for a simple door-to-balloon time jim.mclenachan@leedsth.nhs.ukwithin one institution. Nevertheless, it isimportant that we collect whole service Sheelagh Machindata. It is equally important that the Director - NHS Improvementresults of PPCI are set in the context of sheelagh.machin@improvement.nhs.ukoutcomes of the total ST elevation MIpopulation to ensure that shocked andelderly patients, usually those withmost to gain from PPCI, are benefitingfrom appropriate access to primary PCI.Supporting informationDepartment of Health (2008) Treatmentof Heart Attack National Guidance –Final Report of the NationalAngioplasty Project (NIAP).NHS Improvement (2009) A Guide toImplementing Primary Angioplasty.Primary PCI as the preferred reperfusiontherapy in STEMI: it is a matter of timeC J Terkelsen et al, Heart 2009;95:362-369.www.improvement.nhs.uk/heart/reperfusion
  12. 12. Continuing to Improve Cardiac Services | 13Arrhythmia - cardiac devices andinherited cardiac conditionsAims of the project The national clinical leads worked to number of implants of each type ofCardiac devices - Facilitate the support key stakeholders in forming a device within the UK, broken down byimprovement of implantation rate and professional clinical organisation the both network and PCT. Their work hasequity of access by working with key Association of Inherited Cardiac demonstrated a dramatic inequitystakeholders. Conditions. The Association of between different PCTs and networks in Inherited Cardiac Conditions (AICC) device implant rates for all three typesInherited cardiac conditions (ICC) - brings together professionals from both of device. Although the database onSupport the review of ICC service genetics and cardiology who work which the survey is based containsprovision and framework for future together supporting patients and substantial clinical information aboutcommissioning and professionally led families affected by and living with an the clinical recipients of these devices,performance management. inherited cardiac condition. most of the emphasis hitherto has been on device numbers rather than clinicalProject overview Results and achievements characteristics of recipients.Cardiac devices - To support The cardiac devices national surveyimprovement and facilitate local submissions have been reduced Whilst the intention for the comingperformance review, two key elements allowing the 2009 data to be released year is not for NHS improvement towere addressed. The first was working earlier than usual and a reduction of a focus on cardiac devices as a nationalwith key stakeholders to help improve further six months is expected in 2010 workstream, it is hoped that developingthe currently available device for the 2009 data. In addition, the and utilising this valuable informationimplantation data, collated and network specific reports have been will act as a clinical audit tool, whichpublished by the devices survey team, released earlier and funded for every might be used to help define andwhich had evolved from an network. The expectation is that the compare patient populations for theimplantation registry. The data was focus on earlier review of performance benefit of clinicians, networks,readily available as a national data set will support and encourage networks commissioners and ultimately patients.and could be commissioned as a and providers to address any localcardiac network specific review but due access and equity issues. Supporting informationto delays in registering implants was For further information visit thepublished a year in arrears. The second For inherited cardiac conditions, NHS websites at:element recognised that improving Improvement hosted a very well www.improvement.nhs.uk/service equity and provision could not attended launch event for the Heart to heart/arrhythmiasbe achieved with one national solution Heart, a review of ICC services www.devicesurvey.combut required local clinical leadership produced by the PhG foundation. www.phgfoundation.organd review to implement change Further work between the PhG teamtailored to each provider or network’s and DH has resulted in the Specialist Contact detailscircumstances. Commissioning Groups (SCG) agreeing to consider inherited cardiac conditions Elaine KempInherited cardiac conditions - The services as a priority in their designation NHS Improvement Leadnational role was to facilitate and timetable for 2010/11. This work will be elaine.kemp@improvement.nhs.ukadvise service providers about the lead by the Yorkshire and Humber SCG.mechanism for review and Dr Campbell Cowanimprovement. Supporting the launch The Association for Inherited Cardiac Consultant Cardiologist and Nationaland dissemination of the Foundation Conditions has now completed the Clinical Lead, NHS Improvement - Heartfor Genomics and Population Health elections for council membership. campbell.cowan@leedsth.nhs.uk(PhG foundation) DH commissionedreport released in June 2008. Next steps Sheelagh Machin Cardiac devices - For some years the Director - NHS Improvement Network Device Survey Group have sheelagh.machin@improvement.nhs.uk provided detailed information on the
  13. 13. 14 | Continuing to Improve Cardiac ServicesSustaining cardiac pathways - cardiac surgeryAims of the projectThe attention focused on cardiacdiagnostics and 18 week pathwaysas part of the portfolio of workcoordinated by NHS Improvement -Heart during 2007/08 highlighted aneed to shift attention to cardiacsurgery to develop sustainablesolutions. Eight NHS Trusts supportedby their local cardiac networks wereinvolved as demonstration sites during2008/09 testing out new approaches tocare and improvement to frontlinepatient services. The focus of workundertaken by these sites considered tobe constraints within the managementof smooth patient flows included thefollowing:• Optimising surgical work up through models of pre assessment• Referral management • Queen Elizabeth Hospital, University Results and achievements• Theatre scheduling Hospitals Birmingham NHS Lessons drawn from the demonstration• Post operative length of stay and Foundation Trust and Good Hope sites suggest that quality improvement discharge management. Hospital, Heart of England NHS to elective and non elective cardiac Foundation Trust, Birmingham surgery services requires smarterProject overview Sandwell and Solihull Cardiac and working, the enhancement of staffThe eight NHS Trusts supported by their Stroke Network roles and a shared overview of thelocal cardiac networks that participated • Royal Brompton and Harefield NHS patient journey and patient experienceas lead demonstration sites in the Foundation Trust, North West London across referring providers and thecardiac surgery project were: Cardiac and Stroke Networks tertiary centre. • St George’s Healthcare NHS Trust,• Basildon and Thurrock University South London Cardiac and Stroke Hospitals NHS Foundation Trust, Networks Essex Cardiothoracic Centre, Essex • University Hospitals Birmingham NHS Cardiac and Stroke Network Foundation Trust: Queen Elizabeth• Blackpool, Fylde and Wyre Hospitals Hospital, Heart of England NHS NHS Foundation Trust, Royal Victoria Foundation Trust, Good Hope Hospital, Cardiac and Stroke Hospital Networks in Lancashire and Cumbria • University Hospitals Leicester:• Papworth Hospital NHS Foundation Glenfield Hospital, East Midlands Trust, Anglia Cardiac and Stroke Cardiac and Stroke Network. Network
  14. 14. Continuing to Improve Cardiac Services | 15Improvement to the patient pathway - summary of recommendations 1. Referral management services There is often an information gap between referring provider units and the tertiary centre: • Manage variation in the referral process from provider units and in-house reducing multiple referral points through development of agreed referral criteria to relieve pressure on waiting times for surgery. • Develop central systems for optimising referral efficiency by streamlining administrative process and referral management linking clinical teams across secondary and tertiary care to triage referrals and advise on appropriate tests/investigations. • Introduce pooled referrals across consultants as this significantly impacts on waiting times. • Use appropriate clinical staff to confirm referrals are complete and discuss work up criteria with referrer. • Introduce a single point of contact at the tertiary centre for referrers and patients. The role of the trained clinical coordinator is pivotal in tracking individual patients and in ensuring the consultant team is kept informed of significant events. 2. Pre-admission provision • Manage variation in pre-assessment services. • Adopt investigation guidelines which state agreed timeframes from test to planned date of surgery and only carry out investigations which are relevant, indicated and likely to alter management. • Introduce ‘one-stops’ for outpatients to avoid wasted clinics for medical staff and patients. • Maximize opportunities for multidisciplinary team assessment and emphasise use of technology an example would be use of video link between hospitals. • Maximize pre-assessment opportunities as they help manage patient health and reduce risk. • Maximize pre admission diagnostics particularly in referring district general hospitals by establishing agreed pre operative protocols. • Maximize patient work up prior to admission and agree the schedule for each clinical scenario for example surgery for coronaries, mitral valve, aortic valve and combination. This has a beneficial effect on waiting times. • Train and support key clinical and managerial staff to deliver some of the work undertaken by junior doctors and reconfigure services to develop opportunities for other health care professionals to widen their skills and scope of relationship with patients. An example is the patient ‘navigator’ role which benefits patients and families by providing information and support following attendance at outpatient and pre assessment clinic. • Maximize the scope of extended practice for nursing roles working in pre operative assessment clinics functioning as part of the consultant led team to streamline cardiac surgery patient care. • Maximize inclusion of different staff groupings for example anaesthetists involved in pre assessment to ensure that all patients presenting for surgery will be adequately assessed as this can reduce cancellation rates, improve operating theatre efficiency and increase patient satisfaction. • Continue to provide information and support.
  15. 15. 16 | Continuing to Improve Cardiac Services 3. Scheduling 4. Discharge and post operative care management • Move toward day of surgery • Manage variation in post operative clinical management practice. admission as the standard of • Manage variation in discharge patterns reducing length of stay. care for elective surgery as • Start discharge planning at pre assessment to identify requirement for this can improve the patient support and home aids to reduce requirement for delayed discharge. experience considerably. • Involve a range of health care professionals for example occupational • Maximize theatre efficiency therapists in discharge planning at pre assessment particularly where patients and in particular the elderly may have complex needs. by reducing waste in the • Discharge assessment should form part of the central patient record system for example right staff available throughout the patient journey to all staff groups. in place at the right times • Move toward nurse led discharge. with the right equipment. • Optimise theatre capacity by reducing slot cancellations (clinical/non clinical) and by Next steps employed in meeting the challenge of scheduling procedures that The portfolio of work for 2010/11 will 18 weeks in elective surgery which assist with patient flow include a focus on non elective care inevitably required the focus to extend incorporating cardiology and cardiac to systems and processes that support through intensive treatment surgery. For an informal discussion the whole surgical process, elective or unit/high dependency unit please contact either: otherwise. (ITU/HDU). • Where ever possible pool lists Garry White Resources developed by the to reduce waiting times. garry.white@improvement.nhs.uk demonstration sites are available • Procedure complexity scores through the web links and NHS developed to assist with Wendy Gray Improvement system at scheduling developed as part wendy.gray@improvement.nhs.uk www.improvement.nhs.uk of the multidisciplinary team. /heart/sustainability Rhuari Pike rhuari.pike@improvement.nhs.uk Contact details Networks and organisations will be Wendy Gray invited to submit an expression of National Improvement Lead interest and further details will be Wendy.gray@improvement.nhs.uk announced during April. Tel: 07884 003659 Supporting information Steve Livesey A Guide to Commissioning Cardiac Consultant Cardiac Surgeon and Surgical Services (February 2010) aims National Clinical Lead, NHS to share the lessons drawn from Improvement - Heart demonstration sites participating in the steve.livesey@suht.swest.nhs.uk Cardiac Surgery National Priority Project of 2008/09 with the wider NHS. Gordon Murray This document identifies a range of Consultant Cardiologist and initiatives that have been successfully National Clinical Lead, NHS Improvement - Heart gordon.murray@heartofengland.nhs.uk
  16. 16. Continuing to Improve Cardiac Services | 17Heart failurePiloting, testing and promotinggood quality, systematic, heart Central Manchester: Number of admissions per million population forfailure services across all areas of heart failure per four quarter period (lines vs %LES introduced (bars))deliveryKey messages from the 2008/09National Priority Heart Failure Projects Admissions per million populationhelped inform the five areas needed toprovide a good heart failure service that % LES Introducedare listed in NHS 2010-2015: fromgood to great, preventative, people-centred, productive. (DH Dec 2009).The five areas can be summarised as:1. Early, accurate diagnosis in primary and secondary care: Brain natriuretic peptide (BNP) testing, echo, rapid access heart failure clinics.2. Optimising management: Up- Period titration of medication, cardiac LES Training Pre LES LES Non LES rehabilitation, patient education and self-management, and consideration for devices.3. Integrated care: between primary and secondary care to provide a • Local enhanced service for • Reducing length of inpatient stay seamless service, but also to include patients with left ventricular - Essex: Reducing the average length social care where needed. dysfunction in primary care - of stay for primary diagnosis heart4. Care coordinators: to help navigate Central Manchester: Reducing failure admissions by more than two patients with multiple co-morbidities admissions (30% reduction) and days (reduction in annual bed days of through complex care plans. readmissions (50% reduction) 1,250) by improving and integrating5. End of life care: good symptom through optimising medication and the primary and secondary care control and support services should regular review of heart failure pathways and introducing NT-proBNP be provided where and when patients in GP surgeries. to identify patients and prioritise needed by patients, in all settings - • An integrated model of heart echo. community, hospice, and hospital. failure care - East Riding of Yorkshire: Using simulation softwareThe 2008/09 projects that helped to model potential savings frominform that document: introducing BNP testing to primary care and testing the model, whilstWhole pathway projects also setting up a fully integrated• Heart failure self management - service for identified heart failure Bassetlaw: Use of a group education patients across primary and programme to empower patients to secondary care (still in progress). self manage their condition and pilot the use of social return on investment to gauge its’ impact.
  17. 17. 18 | Continuing to Improve Cardiac Services • Developing symptom control Essex: Length of stay (LoS) by monthly discharges - Primary diagnosis guidelines for heart failure, up to of heart failure and including the end of life - North Lincolnshire and Goole: Improving knowledge and confidence in symptom control, for all providers and whatever the setting. • Enhancing end of life care for heart failure patients - Northampton: Developing guidelines, protocols and referral pathways to deliver a model for end of life care in all settings. • Improvements in palliative care - referral and pathway development - West Surrey: Providing a 24 hour community service involving all service providers working together (still in progress). • Supportive and palliative care for heart failure - Sussex: Improving symptom control out of the acute setting, by joint working with• Developing community heart • Improving the Acute Heart Failure palliative and community services. failure services - Southwark: Pathway - West Hertfordshire: Establishing a community heart Using BNP testing on admission to Why is end of life care in heart failure service for the people of hospital to speed up accurate failure so important? Southwark and ensure that the diagnosis, get the patient onto the Because the cost, both human and service suits the black and ethnic right care pathway and reduce financial, is so great when it goes minority (BME) and female readmissions and length of stay wrong. The case study (on page 17) is population by providing clinics closer (readmissions reduced by 30%). of a real heart failure patient and charts to home (still in progress). the 12 admissions and 21 further A&E• Improvement of heart failure End of life projects attendances in her last year of life. diagnosis and management in • Promoting access to end of life North Staffordshire and Stoke: care provision within a culturally Improving diagnosis and diverse community - Brent: management of patients with left Developing a multi-disciplinary ventricular systolic dysfunction across community service, improving quality North Staffordshire and Shropshire, in and accessibility, and preventing both primary and secondary care, by unwanted admissions and A&E increasing heart failure specialist attendances (still in progress). nurses, streamlining access to diagnostics (echo and BNP) and increasing specialist involvement (moving to phase 2 in April 2010).
  18. 18. Continuing to Improve Cardiac Services | 19 Case History: Nora P. There are potential savings of £20,000+ if these admissions and A&E attendances were avoided SEPT OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG 07 07 07 07 08 08 08 08 08 08 08 08 H 4 DAYS H ADMISSION 12 H H DAYS 9 DAYS 4 H DAYS H 9 DAYS 5 DAYS H 9 H H DAYS 7 H 3 H TOTAL of admissions = 84 bed days 1 DAYS DAY DAYS 4 DAYS DIED H 17 DAYSNext steps David WalkerThere is potential in all these five areas Consultant Cardiologist and Nationalto improve the quality of heart failure Clinical Lead, NHS Improvement - Heartservices and also to improve david.walker@esht.nhs.ukproductivity and our work for 2010-11and beyond is to both test and spread Sheelagh Machinthe ways that these can be done. Director - NHS Improvement sheelagh.machin@improvement.nhs.ukContact details www. improvement.nhs.uk/Candy Jeffries heart/heartfailureNational Improvement LeadTel: 0116 222 1415candy.jeffries@improvement.nhs.ukDr James BeattieConsultant Cardiologist and NationalClinical Lead, NHS Improvement - Heartjames.beattie@heartofengland.nhs.ukMike ConnollyMacmillan Nurse Consultant inSupportive and Palliative Care andNational Clinical Lead, NHSImprovement - Heartmichael.connolly@uhsm.nhs.uk
  19. 19. 20 | Continuing to Improve Cardiac ServicesCardiac rehabilitationAims of the projectThe overall aim of this project, whichbegan in September 2008, continues tobe improved access, equity of provisionand better uptake to quality cardiacrehabilitation (CR) services for heartattack, angioplasty and coronary arterybypass grafts (CABG) patients. TheNICE recommendations on cardiacrehabilitation (NICE clinical guidelinesCG48 on myocardial infarction (MI):secondary prevention) and the NICEcommissioning guide on cardiacrehabilitation were used as a resourceto support improved commissioning.The projects have worked closely withproviders, commissioners, patients andcarers in planning services; shapingworkforce and multi-disciplinary teamapproaches.Project overviewNHS Improvement cardiac rehabilitation Two further projects joined the national two monthly meetings, to deviseprojects have included 16 sites across programme at the end of 2009 solutions and share their learning. Led12 networks. The project sites are: 11. MyAction Westminster by the national improvement lead and 12. North Yorkshire and York PCT. national clinical lead for cardiac1. Derbyshire County PCT rehabilitation at NHS Improvement and2. South West and East London The emphasis varies within in each supported by the national clinical Cardiac and Stroke Networks project however most of the projects advisor these meetings proved a very3. North Lincolnshire and Goole involved redesign of services with a successful method of providing peer NHS Trust view to commissioning integrated support. Learning about wider national4. Dorset Cardiac and Stroke Network services across an area, or advising issues such as work around tariff5. NHS North of Tyne, North of commissioners of their next steps in negotiations, combined with other England Cardiovascular Network service commissioning. All of the projects proved invaluable to6. Shropshire and Staffordshire Heart projects worked on inequities, progressing individual projects. and Stroke Network increasing uptake and timely access to7. Surrey Heart and Stroke Network services, involvement of patients and Project teams shared learning via the8. Black Country Cardiovascular carers in informing redesign and NHS Improvement System and on a Network improved information. website giving both the project teams9. North West London Cardiac and and the wider NHS access to material Stroke Network – PPCI project Approach taken from the project team days, wider10. Peninsula Heart and Stroke Working with cardiac networks, information relevant to cardiac Network. individual PCTs and Trusts, project rehabilitation, news about tariff and teams were supported by a series of links to other areas of interest.
  20. 20. Continuing to Improve Cardiac Services | 21Where required one-to-one support at (Effectiveness), new community and Next stepsthe improvement site was undertaken home based programme for ischaemic NHS Improvement is jointly leading theby the national programme lead and heart disease (IHD), outcome measures, development of a CR Commissioningnational clinical lead. This was clear management plans, effective use Pack for PCTs with the Strategicespecially useful in specification of staff and programmes. (Experience) Development Unit at the Departmentdevelopment and procurement events. Increased patient choice, care provided of Health. NHS Improvement will take closer to home, improved patient responsibility and lead a national roll-The team has also supported tariff information out of the Commissioning Pack fromdevelopment in rehabilitation which INNOVATION - Rehab-led follow up, June 2010 which will aim, within thehas helped projects with commissioning drug therapy reviews, local task group context of quality and productivity, toand business case initiatives. acting to coordinate all quality increase the numbers of patients initiatives receiving a quality cardiac rehabilitationResults and achievements PRODUCTIVITY - Increased number of service.The main outputs of the projects patients accessing rehab, reduced handhave been: offs, using and scheduling staff more Supporting information effectively, rehab led follow up – Cardiac Rehabilitation National Priority• Redesign of service pathways reduces need for outpatient department project: Lessons and learning one year• Production of detailed service attendance, production of business on…. (October 2009). specifications and business cases case for CR.• One project undertaking full Contact details procurement A major strength of NHS Improvement• New and innovative service models has been the ability to share expertise Linda Binder e.g. heart failure rehabilitation in and experiences across the different National Improvement Lead community workstreams which has clearly led to linda.binder@improvement.nhs.uk• Increase in numbers undertaking greater productivity and quality rehabilitation outcomes benefiting other aspects of Professor Patrick Doherty• Improved equity of access NHS service delivery. This has placed National Clinical Lead• Reduced waiting times for CR CR in the driving seat for steering P.Doherty@yorksj.ac.uk• Clinical pathway development to national initiatives such as tariff ensure uptake of rehabilitation for implementation and commissioning. Dr Jane Flint, PPCI patients National Clinical Advisor• Economies of scale by integration “Now is not a time for standing still Jane.Flint@dgoh.nhs.uk with national heart failure, cardiac rather it is time to invest in NHS surgery and PPCI programmes. Improvement and engage with Julie Harries DirectorMany of the outcomes from the the quality and productivity Julie.harries@improvement.nhs.ukprojects meet the quality, innovation agenda. I believe CR is one of theand productivity (QIPP) agenda. These best quality and productivity cases www.improvement.nhs.uk/include: around and that the CR priority heart/cardiacrehabilitation projects has the appropriate focusQUALITY - (Safety) Centralised referral and skills to deliver serviceand patient tracking, standardisedprotocols and procedures, risk redesign, innovative commissioningstratification forms, governance and improved quality”.standards, skills competency Professor Patrick Dohertyassessment, service specifications National Clinical Lead NHS Improvement
  21. 21. 22 | Continuing to Improve Cardiac ServicesNHS Improvement SystemWhat is it? Where can I see aThe NHS Improvement System is a demonstration of the system?comprehensive, online tool to support Demonstrations of some of the keysharing of quality service improvement modules are available on theresources in NHS services. Giving you improvement system home page at:direct access to useful information and www.improvement.nhs.uk/stories from around the country, it will improvementsystemassist you in your own serviceimprovement work. Who can use the system? The system is free of charge and can beWhy use it? used by all staff working for NHSThe NHS Improvement System actively organisations in England.helps organisations to effectivelyachieve their objectives in line with How can I register to use theWorld Class Commissioning. It enables system?users to be more strategic and align Access to the system is controlledlong-term goals that can help to deliver by user ID and password.high quality, patient focussed healthoutcomes. To request an ID contact support@improvement.nhs.ukWhich specialties are included?The system can be used to supportsustainable service improvementin any specialty.What does it contain?• Service improvement tools and resources• Practical guidance• Case studies• Useful contacts• Signposting and links.
  22. 22. ResourcesAll the publications listed below Delivering the NHS Health Check: A National Priority Projects 2007/08are available to download at: Practical Guide to Point of Care Summary Documentswww.improvement.nhs.uk/ Testing Summary documents from the Heartpublications Identifies some of the pros and cons to Improvement Programme’s 2007/08 the use of Point of Care Testing (POCT) national priority projects: as well as practical ‘solutions’ and • Making Best Use of Inpatient BedsA guide to commissioning learning from the field (November • Atrial Fibrillation in Primary Carecardiac surgical services 2009). • 18 Weeks Whole PathwaysEight NHS Trusts supported by their • 18 Weeks - Focus on Cardiaclocal cardiac networks were involved as Heart Failure - A quick guide to Diagnostics.demonstration sites during 2008/09 in quality commissioning across thethe Cardiac Surgery National Priority whole pathway of care Guidance on Risk AssessmentProject. Lessons drawn from these sites This practical guide sets out to help and Stroke Prevention for Atrialare outlined in the publication A Guide commissioners develop integrated heart Fibrillation (GRASP-AF) Toolto Commissioning Cardiac Surgical failure services by highlighting evidence This tool should be used as partServices (March 2010). based practice and measurable of a systematic approach to the outcomes. It draws on the NICE identification, diagnosis and optimalCardiac Rehabilitation - National Commissioning Guidelines (Feb 2008), management of patients with AFPriority Projects: Lessons and Our NHS Our Future (specifically long to reduce their risk of stroke.learning one year on... term conditions, urgent care and end www.improvement.nhs.uk/graspafCardiac rehabilitation (CR) is a national of life). (September 2008).priority project of NHS Improvement Using Discovery Interviewsfocusing on increasing the access to, Atrial fibrillation in primary care: to improve careequity of provision and uptake of CR making an impact on stroke www.improvement.nhs.uk/services for heart attack, angioplasty prevention discoveryinterviewsand CABG patients. The project This document aims to capture the finalsummaries include issues to be summary of their individual approach, Improving Cardiac Patientaddressed, baseline position, actions lessons learned, improvements to Pathways: The Sustainabilitytaken, key learning, QIPP outcomes and practice and quality outcomes, also Toolkitresults to date from the 11 projects sharing tools and resources developed www.improvement.nhs.uk/participating in this work (October to enable other health communities to heart/sustainability2009). drive this agenda forward (October 2009). The Cardiac Data DashbordA Guide to Implementing www.improvement.nhs.uk/Primary Angioplasty Commissioning for Stroke heart/dashboardSince the publication of new national Prevention in Primary Care: the rolegood practice guidance on treatment of Atrial Fibrillationof heart attack, NHS Improvement has Developed following a nationallooked at the major issues and consensus meeting of opinion leadersobstacles to implementing primary in the field, this document is to developpercutaneous coronary angioplasty a concerted strategy towards the(PPCI) services across England and all management of AF in primary care, inthe learning has now been pulled particular anticoagulant managementtogether in a useful implementation and its significance in relation toguide (June 2009). reduction in the risk of stroke (June 2009).
  23. 23. CANCERDIAGNOSTICSHEARTLUNGSTROKE NHS Improvement With over ten years practical service improvement experience in cancer, diagnostics and heart, NHS Improvement aims to achieve sustainable effective pathways and systems, share improvement resources and learning, increase impact and ensure value for money to improve the efficiency and quality of NHS services. Working with clinical networks and NHS organisations across England, NHS Improvement helps to transform, deliver and build sustainable improvements across the entire pathway of care in cancer, diagnostics, heart, lung and stroke services. 3rd Floor | St John’s House | East Street | Leicester | LE1 6NB Telephone: 0116 222 5184 | Fax: 0116 222 5101 www.improvement.nhs.uk ©NHS Improvement 2010 | All Rights Reserved | March 2010 Delivering tomorrow’s improvement agenda for the NHS

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