SCN cardiac leads national meeting July 2014

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NHSIQ hosted a meeting of Strategic Clinical Network Cardiac Leads on Wednesday 2nd July in London. Discussions covered making best use of data with NCVIN and NICOR, also the development of a cardiac data dashboard. The group looked at how to integrate local and national SCN priorities. The British Heart Foundation came to talk about the work of national and regional teams including the exciting new resource including ‘innovation in practice’ which supports of evidencing and implementation of good practice case studies.

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SCN cardiac leads national meeting July 2014

  1. 1. National Meeting of strategic clinical network cardiac leads Welcome! We will start at 12.45 Please help yourselves to lunch and refreshments Professor Huon Gray, National Clinical Director for Cardiac Care NHSE Elaine Kemp, Programme Delivery Manager, Living Longer Lives, NHSIQ
  2. 2. National Meeting of strategic clinical network cardiac leads 12.00 – 12.45 LUNCH AND NETWORKING 12.45 Welcome Huon Gray 12.50 Information and data availability Presentation from National Cardiovascular Intelligence Network (NCVIN): making best use of existing data sources Discussion Lorraine Oldridge, NCVIN and Dr Julie Sanders, NICOR ALL 13.50 Examples of Integrated Care Christopher Annus and Elaine tanner, BHF 14.15 TEA / COFFEE BREAK 14.30 SCN agendas How to integrate local and national priorities? ALL 15.15 CRGs specialist commissioning Dr Jim McLenachan 16.00 Sharing of policies How do we share best practice, best standard of care identification, progress and monitoring plans? ALL 16.15 Communication going forward ALL 16.30 CLOSE Chair: Professor Huon Gray, National Clinical Director for Cardiac Care, NHS England and Co AGENDA for today
  3. 3. My Agenda • FH • ICC • SCD – CPR & AEDs • PHE (HC, BP, SOB) • AF detection & Rx • Mental Health CVD (Lester+) • Data (NCVIN, NICOR, Dashboard) • Spec Comms (CRG, CtE, QIPP) • Cong Cardiac Review • NICE liaison & QS • HF best practice tariff • Integrated care & Rehab • Enquiries (PQs, DH & others) • Medical Patient Safety EG • 24x7 and 7/7 working • BHF, BCS, HEART-UK, Resus Council etc. • Support for SCNs
  4. 4. SCN Cardiac Leads: Using data and information to improve outcomes and quality of care for people with cardiovascular disease 2nd July2014 NationalCardiovascularIntelligence Network(NCVIN),PublicHealthEngland NationalInstituteforCardiovascularOutcomesResearch(NICOR),UCL LorraineOldridge,AssociateDirector(NCVIN) DrJulieSanders,ChiefOperatingOfficer,NICOR(UCL) DrMarkdeBelder,NCVINClinicalLead(NCVIN) AndrewHughes,HeadofHealthIntelligence(NCVIN) SallyCrick,ProgrammeManager(NCVIN)
  5. 5. Objectives of the session To provide insight to what data/information is currently available To brief you on 2014/15 priorities To consult with you on your data/information requirements
  6. 6. Universities and science minister unveils £73m big data funding David Cameron: Big data pledge; pledge that every patient is a research patient University College London (Farr Institute @ London), University of Manchester (Farr Institute @ HeRC N8), Swansea University (Farr Institute @ CIPHER), and the University of Dundee (Farr Institute @ Scotland). • With a £17.5m-research award from a 10-funder consortium, plus additional £20m-capital funds from the Medical Research Council. • Aims to deliver high-quality, cutting-edge research linking electronic health data with other forms of research and routinely collected data, as well as build capacity in health informatics research.
  7. 7. Established: 2011 Commissioned: HQIP Director: Prof John Deanfield Mission: ‘to provide information to improve heart disease patients' quality of care and outcomes’ National Institute for Cardiovascular Outcomes Research
  8. 8. 8 PROFESSION NHS ADMINISTRATION NHS ENGLAND RESEARCH GRANT BODIES PUBLIC UNIVERSITY DH PUBLIC HEALTH ENGLAND CV INTELLIGENCE • Revalidation • Performance • Centre performance • Dr Foster • CEO/COO • Commissioning through Evaluation • NHS Choices • Governance • Implementation of policy • Research • Research/outcome information • Information regarding choice • Understanding of disease and pathways • Use of data transparency SOCIAL CARE • UCL • FARR Institute Health Checks Social care
  9. 9. Audit Yr Est. Clinical lead Prof Society No records New records/yr Congenital 2000 Rodney Franklin SCTS/BCCA 125,000 11,000 Cardiac Rhythm management Late 1970s Francis Murgatroyd BHRS 900,000 65,000 Heart Failure 2007 Theresa McDonagh BSH 200,000 44,000 PCI 2002 Peter Ludman BCIS 694,598 95,000 MINAP 1998 Clive Weston BCS 1m 80,000 Adult cardiac surgery 1977 Ben Bridgewater SCTS 505,361 34,000 TAVI 2007 Huon Grey BCIS/SCTS 5,000 1,000 New technology audits 2014 NICOR data
  10. 10. 11 CRM HF CARDIAC SURGERY PCI MINAP CONGENITAL NICOR PATIENT OUTCOME REGISTRY COLLABORATIONS UK Renal Registry National Diabetes Audit CPRD HES MRIS Data controller: HQIP Data controller: NICOR Data controller: In discussion
  11. 11. 12 http://www.ucl.ac.uk/nicor/access/application Data access requests
  12. 12. 13 119Applications
  13. 13. Applications from SCN 14 Audit Applications from SCNs Congenital None Cardiac Rhythm management None Heart Failure None PCI None MINAP 9 Adult cardiac surgery None TAVI None
  14. 14. National Cardiovascular Intelligence Network (NCVIN) strategic priorities
  15. 15. Commissioning for value focus pack Clinical commissioning group: Focus area: Cardiovascular disease (CVD) pathway NHS SOUTHAMPTON CCG Version 2 June 2014
  16. 16. Summaryonapage Summary: overarching messages 6 Overarching messages Public health focus on prevention Significant benefit to patients if improvement to primary care management indicators were made High costs for: CHD emergency admissions, heart failure emergency admissions, angiography procedures, angioplasty procedures High numbers of admissions for: stroke emergency admissions, CABG procedures High lengths of stay for: CVD elective admissions, stroke emergency admissions, angiography procedures, CABG procedures
  17. 17. Analysis Where does the CCG compare poorly against its cluster group? Analysisbypathwaystage(page1of2) 11 Table1 *below the average of the best 5 CCGs in the cluster group Number of Indicators where CCG has room for improvement* Indicators in the worst quintile versus benchmark group - difference between the CCG and the benchmark, (p) – PCT based indicator Opportunity - if the CCG were to equal the benchmark No indicators in the worst quintile No indicators in the worst quintile Hypertension ratio (-5.5 % lower) 3,185 people % AF patients stroke risk assessed using CHADS2 (-2.2 % lower) 75 people 3/5 prevention indicators 3/3 observed to expected prevalence ratios 17/20 primary care indicators
  18. 18. Analysis Analysisbypathwaystage(page2of2) 12 Table2 Where does the CCG compare poorly against its cluster group? *below the average of the best 5 CCGs in the cluster group Number of Indicators where CCG has room for improvement* Indicators in the worst quintile versus benchmark group - difference between the CCG and the benchmark, (p) – PCT based indicator Opportunity - if the CCG were to equal the benchmark CHD: average cost per female emergency admission (34.1 % higher) £157K Stroke male emergency admissions (DSR) (34.1 % higher) 47 admissions Heart failure: average cost per female emergency admission (13.3 % higher) £65K CVD: average male elective LOS (41.8 % higher) 334 bed days CVD: average female elective LOS (134.9 % higher) 643 bed days Stroke: average male emergency LOS (240.3 % higher) 632 bed days Angiography procedures: female average cost (78.2 % higher) £71K Angiography procedures: male LOS (119.1 % higher) 1,331 bed days Angiography procedures: female LOS (87.4 % higher) 512 bed days Angioplasty procedures: female average cost (12.9 % higher) £19K CABG procedures: male (DSR) (74.6 % higher) 34 procedures CABG procedures: male (LOS) (104 % higher) 929 bed days CABG procedures: female (LOS) (111.3 % higher) 259 bed days New implantable cardioverter-defibrillator procedures (p) (86 % higher) 159 procedures 1/1 social care indicators No indicators in the worst quintile No indicators in the worst quintile 51/62 secondary care indicators
  19. 19. Analysis Bring it all together: what works, what could work, who should we speak to 15 NICE Guidance, Quality Standards etc Prevention of cardiovascular disease Hypertension Atrial fibrillation Stroke Chronic heart failure Lipid modification Myocardial infarction with ST segment elevation Lower limb peripheral arterial disease Smoking prevention and cessation Obesity Physical activity Contact the NICE field team for support and advice on implementing NICE guidanceThe quality and productivity collection provides quality assured examples of improvements across NHS and social care and include cardiovascular and stroke. Look at NICE shared learning examples from organisations that have put guidance into practice. Examples include peripheral arterial disease, hypertension and obesity NICE is recruiting additional members to join its Commissioning reference panel and to support the NICE commissioning programme.
  20. 20. Annexes Annex 1: spine charts 16 Prevention Worse outcome High prevalence Better outcome Low prevalence Prevalence England worst England best Worst quintile in cluster KEY : * (p) = PCT based indicator For data sources used, see slide Opportunit y Obesity (p) Binge drinking (p) % of patients registered with a GP with a LTC who smoke 4 week quitters as a proportion of estimated smokers (p) Smoking (p) 3,071 people 229 people 1,912 patients - - CVD prevention register Atrial fibrilliation Heart failure due to LVD register Heart Failure Hypertension observed to expected prevalence ratio Hypertension Stroke observed to expected prevalence ratio Stroke CHD observed to expected prevalence ratio CHD 58 people 1,259 people 182 people 152 people 585 people 3,185 people 95 people 232 people 178 people 744 people
  21. 21. Annexes Annex 1: spine charts 17 Primary care Worse outcome Better outcome England worst England best Worst quintile in cluster KEY : * (p) = PCT based indicator For data sources used, see slide Opportunit y AF & CHADS2 score > 1, % treated anti-coagulation drug therapy AF & CHADS2 score of 1, % treated anti-coagulation drug therapy % AF patients stroke risk assessed using CHADS2 % of patients with hypertension BP is 150/90 or less % of patients with hypertension record of BP % of new stroke/TIA patients referred further investigation % of stroke patients with a record an anti-platelet agent taken % of patients with stroke/TIA had influenza immunisation % of patients with stroke/TIA cholesterol is 5mmol/l or less % of patients with stroke/TIA record of cholesterol % of patients with stroke/TIA last BP is 150/90 or less % of patients with HF due to LVD, treated with ACE + beta-blocker % of patients with HF due to LVD, treated with ACE inhibitor % of patients with HF confirmed by an echocardiogram % of MI patients treated with an ACE inhibitor % of patients with CHD who have had influenza immunsation % CHD patients treated with a beta blocker % CHD patients record of aspirin % patients with CHD whose cholesterol is 5mmol/l or less % patients with CHD whose last BP reading is 150/90 or less 53 people 14 people 2 people 291 people - - 0 people 12 people 30 people 44 people 90 people 81 people - 10 people 31 people 412 people 778 people 75 people 8 people 86 people
  22. 22. Annexes Annex 1: spine charts 18 Secondary care Worse outcome Better outcome England worst England best Worst quintile in cluster KEY : * (p) = PCT based indicator For data sources used, see slide Opportunit y CHD: average female elective LOS CHD: average male elective LOS CHD female elective admissions (DSR) CHD male elective admissions (DSR) CHD: average cost per female elective admission CHD: average cost per male elective admission CHD: average female emergency LOS CHD: average male emergency LOS CHD female emergerncy admissions (DSR) CHD male emergerncy admissions (DSR) CHD: average cost per female emergerncy admission CHD: average cost per male emergerncy admission CVD: average female elective LOS CVD: average male elective LOS CVD female elective admissions (DSR) CVD male elective admissions (DSR) CVD: average cost per female elective admission CVD: average cost per male elective admission CVD: average female emergency LOS CVD: average male emergency LOS CVD female emergerncy admissions (DSR) CVD male emergerncy admissions (DSR) CVD: average cost per female emergerncy admission CVD: average cost per male emergerncy admission £207K £158K 222 admissions 200 admissions 3,930 bed days 1,752 bed days - - - - 334 bed days 643 bed days £160K £157K 53 admissions 35 admissions 184 bed days 209 bed days £52K £3K - - 54 bed days 14 bed days
  23. 23. Cardiovascular Key Facts
  24. 24. Behavioural risk factors Non Behaviour risk factors Fact sheet 1 Smoking Fact sheet 6 Age, sex, ethnicity, deprivation Fact sheet 2 Obesity Fact sheet 3 Physical activity Fact sheet 4 Nutrition Fact sheet 5 Alcohol consumption Bodily risk factors CVD diseases Fact sheet 7 Hypertension Fact sheet 11 Cardiovascular disease Fact sheet 8 Diabetes Fact sheet 12 CHD and heart failure Fact sheet 9 Kidney disease Fact sheet 13 Atrial fibrillation Fact sheet 10 Familial hypercholesterolaemia Fact sheet 14 Stroke and TIA Fact sheet 15 Vascular dementia Fact sheet 16 Peripheral arterial disease Cardiovascular Key Facts
  25. 25. Cardiovascular Profiles July/earlyAugust 2014
  26. 26. Available for all CCGs and SCNs in England. Hard copy downloadable PDF Available July/early August 14 Chapters on risk factors; diabetes, heart, stroke and renal
  27. 27. Prevalence Overview
  28. 28. Care processes and treatment indicators and variation at practice level
  29. 29. Treatment in secondary care
  30. 30. Mortality trends
  31. 31. Outcome Versus Expenditure Tool: Cardiovascular July 2014
  32. 32. www.ncvin.org.uk
  33. 33. Your Views What information have you had and was it useful? What would be important for you to know? Trends; long term outcomes; mortality; benchmarking What level of reporting would be helpful toyou? What kind of visual displays of information should we be using? How would you prefer to access this information? PDFs, online,Apps
  34. 34. Delivering Transformational Change Clinical Innovation Research Information and advice Work force development– heart failure/palliative care specialists/PDCs Service innovation & re-design • Caring Together • IV diuretics • Integrated Care • Work on ICD and deactivation
  35. 35. CVD Outcomes Strategy • Manage CVD as a single family of diseases: patients often receive care from multiple teams in a disjointed and uncoordinated way • A more coordinated approach is needed to assessment, treatment and care to improve patient experience and safety • Improving care planning, support self-management and end of life care
  36. 36. Commissioning for Value Insight Packs
  37. 37. Quality = Excellence in Patient safety, clinical effectiveness and patient experience
  38. 38. Models of Best Practice The BHF has been investing in service redesign projects across the UK since 1996. Many have been externally validated and the BHF has published valuable evidence relating to a number of areas. Cardiac Rehabilitation Heart Failure NursesArrhythmia Care Co-ordinators Practice development co- ordinators Community IV Diuretics HMP Cardiac Nurse Integrated Care
  39. 39. The BHF Integrated Care Pilots NHS Lanarkshire NHS Tayside NHS Fife East Cheshire NHS Trust Oxleas NHS Trust NHS Bristol North Somerset CCG Betsi Cadwaladr UHB ABM University Health Board • Improve service quality by improving referral pathways and care coordination • Improve patient quality of life • Up-skill HCPs in improved identification of care needs for patients • Implement preventative measures including improved identification and diagnosis of CVD
  40. 40. Pilots have demonstrated increased diagnosis and management from acute to community settings Before After Secondarycare Primaryandcommunitycare Admission Follow-up Diagnosis Secondarycare Primaryandcommunitycare Admission Follow-up Diagnosis
  41. 41. Integrated Care Pilots Unplanned admissions and estimated savings Project site Estimated reduction in number of unplanned admissions Estimated savings in £ East Cheshire 48 £911,000, based on reduction of length of stay (£500 per bed day), and reduction in admission avoidance (£1000 per admission). AMBU 49 £186,660 (if at £180 per bed day) - £311,100 (if at £300 per bed day), based on admission prevention and reduction in 30 day readmission rates. Betsi Cadwaladr 20 - TOTAL 117 £1,097,660-£1,222,100
  42. 42. Independent Evaluation of BHF HF specialist nurses • By linking with cardiologists, enabled patients to be referred to specialist nurses within days of diagnosis, often being seen at home within days. • Health economies with specialist HF nurses saw a 35% reduction in hospital readmissions • Average net savings per patient were around £2000 compared with those without access to a specialist HF nurse • Supported self-management with the majority reporting that on average heart failure was having less impact on patients’ daily life one year after contact with a specialist HF nurse, than at baseline.
  43. 43. IV Diuretics: Key findings • 100% of patients and 93% of carers preferred home-based treatment to hospital admission •100% of patients and 96% of patients would choose it again in future •869 bed days saved over pilot duration •£199,458 net savings over the pilot duration •Average cost of £491.13 per intervention •20 cases of cannula problems, but only 5 needed to stop treatment •13 cases of renal dysfunction, but 9 managed whilst continuing treatment •10 cases of a phlebitis score of 1 (on one or more occasions), but never higher and all resolved •4 cases of HAI, all unrelated to IV diuretics •63% of interventions clinically successful (target reduction in oedema, weight and/or resolved symptoms) •16% partially successful (didn't meet target but achieved enough improvement to avoid admission) •21% required admission •Average length of treatment = 7 days Is it clinically effective? Is it safe? Does it improve the patient and carer experience? Is it cost effective?
  44. 44. IV Diuretics Evaluation • Many HF patients will require hospital admission for intravenous diuretic (IV)therapy as their condition progresses - average length of stay of 13 days accounts for 2% of all NHS bed days. • BHF has piloted 9 health economies to train and deliver this therapy in the community including peoples’ homes. • Independent evaluation: - has shown that this is safe and clinically effective - resulting in 512 bed days saved in the first 18 months - net average cost saving of £3000 per successful intervention. • Patients and carers expressed a high degree of satisfaction with all opting to choose to receive their IV diuretic therapy at home again when required. • Accepted as a QIPP Proven Quality and Productivity Case Study.
  45. 45. Integrated Care Pilots: Early interim findings • Improved early identification and diagnosis • More robust processes for assessment and review of patients – anticipatory care planning • Streamlined care pathways – greater productivity within existing resources • Reduced unplanned admissions • Improved optimal medical management • Improved patient reported confidence in self- management • Enhanced mental health outcomes • Better understanding of CVD across the system – specialist and generalist staff
  46. 46. Robust and independent programme evaluations Gain recognition & validation of these projects through formally recognised channels e.g. QIPP Quality and Productivity:Proven Case Studies contributing to the evidence base Development of portfolio of products to support implementation of best practice/ service redesign for service leads and commissioners Communication Strategy to raise profile of BHF’s HC&I programme and support the accelerated adoption of best practice into mainstream service delivery Commissioning Support Programme Project Sustainability and Mainstreaming
  47. 47. Business Case Toolkit
  48. 48. Communication & Dissemination
  49. 49. Promoting innovation and best practice to: • CCGs • Health and Wellbeing Boards • Strategic Clinical Networks • Clinical Senates etc… Commissioning Support
  50. 50. Regional Service Development Team
  51. 51. CRGs and Specialist Commissioning Jim McLenachan, Co-Chair, Complex Invasive Cardiology CRG National Meeting of SCN Cardiac Leads, London, 2nd July, 2014
  52. 52. Topics • What is Specialist Commissioning? • What is the role of the CRG? • How do we deal with innovation? • The future – a personal view
  53. 53. What is Specialised Commissioning? • Any procedure / treatment for which there are no more 50 providers in England. • A procedure / treatment where a provider (hospital) would provide the service to a population of 1 million people.
  54. 54. Who commissions? 2012-2013 2013-2014 PCTs Clinical Commissioning Groups SCGs x 10 National Specialised Commissioning Service
  55. 55. Who commissions? 2012-2013 2013-2014 PCTs Clinical Commissioning Groups SCGs x 10 National Specialised Commissioning Service
  56. 56. National Commissioning Board (established 1st April, 2013) • £ 20 –25 billion budget • £ 12 billion for specialised commissioning • Cardiovascular medicine specialised commissioning spend approximately £ 1.2 billion • Innovation Fund of £ 100 million
  57. 57. Clinical Reference Groups (CRGs) • n = 76 • Cover all areas of specialised medicine – medical, surgical, paediatric, psychiatric etc. etc.
  58. 58. Clinical Reference Groups (CRGs) • Chairmen • 12 Senate area representatives (14) • 4 Specialist Society representatives • 4 Patient and Public engagement representatives
  59. 59. What is the role of the CRG? • No budgetary responsibility (!) • To be the sole source of clinical advice to NHS England • To ensure commissioners are properly informed by developing: a) service specifications for established treatments b) commissioning policies for new treatments
  60. 60. Service Specifications • National context and evidence base • Care pathway • Inclusion and exclusion criteria • Key service outcomes • Interdependencies with other specialties • Extensive “cutting and pasting” from national professional societies’ guidance.
  61. 61. Cardiology CRG “products” 2012 • 5 service specifications (complex devices, EP, ICC, MRI, PPCI). • 5 commissioning policy documents - TAVI - renal denervation - PFO closure - LAAO - MitraClip
  62. 62. The NHS Innovation conflict: “…..Britain is open for business…..” “….only evidence-based treatments will be commissioned…” “……innovation is key in the NHS…..” “….commissioners do not fund research……”
  63. 63. “Commissioning through Evaluation” • For treatments that are somewhere between “research” and “evidence-based” • All have NICE IPG • None have NICE CG / TA • None have cost-effectiveness data • Limited numbers of procedures • Limited numbers of centres • MDT to select those most likely to benefit • Mandatory data collection to bespoke database
  64. 64. “Commissioning through Evaluation” No. of centres No. of procedures per annum Renal denervation 12 400 MitraClip 8 200 LAA Occlusion 12 600 PFO closure 12 720
  65. 65. The Future Predictions are difficult, especially about the future…. Niels Bohr
  66. 66. Specialised Commissioning CRGs Service Specifications CPAG Area Teams
  67. 67. South Yorkshire and Bassetlaw Area Team • Head of Specialised Commissioning (1) • Service Specialists - one for each PoC (4, 2 in post) • One contract lead for each network (3) • External support from PHE (1 WTE) • Pharmacy Lead (1)
  68. 68. South Yorkshire and Bassetlaw Area Team • Population covered 5.7 million • Budget £ 1.2 billion • 170 Service Specifications • 143 Specialised Services
  69. 69. Specialised Commissioning CRGs Service Specifications CPAG Area Teams
  70. 70. NHS England 5 year strategy • To be announced July 2014 • May recommend a smaller number of providers for specialised services. • ? 15 -30 providers nationally for specialised services
  71. 71. NHS England 5 year strategy Options for cardiology • Re-centralise - bring all CRT/ICD/CMR/PPCI into 15-30 centres • Transfer commissioning of the above to CCGs. • Consider commissioning groups/networks/consortia
  72. 72. ICDs and CRT for Arrhythmias and Heart Failure • TA95 (Jan 2006) and TA 120 (May 2007) • TA314 (June 2014)
  73. 73. ICDs and CRT for Arrhythmias and Heart Failure (TA314) • TA95 (Jan 2006) and TA 120 (May 2007) East Midlands discussion on DCM ACC / ECS guidance Service Specifications • TA314 (June 2014)
  74. 74. Summary CRGs and Specialised Commissioning Good Not so good • National service • End to postcode lottery • National quality standards • Specs developed in isolation from financial situation. • “Rolls Royce” service specs • Difficult for CPAG to prioritise. • Difficult to monitor compliance with specifications. • Future plans unclear.
  75. 75. National Meeting of strategic clinical network cardiac leads Contacts of hosts and speakers– NHSE NCD Huon Gray huon@cardiology.co.uk NHSIQ PDM Elaine Kemp elaine.kemp@nhsiq.nhs.uk 07747 763930 BHF Elaine Tanner tannere@bhf.org.uk 01656 648301 Christopher Annus annusc@bhf.org.uk 0207 554 0383 NICOR Julie Sanders j.sanders@ucl.ac.uk NCVIN Lorraine Oldridge Lorraine.Oldridge@phe.gov.uk CRG Jim McLenachan Jim.McLenachan@leedsth.nhs.uk

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