The document outlines the improvements made in cardiac services over the past decade, highlighting successful initiatives that have enhanced patient care and reduced health inequalities in the NHS. It discusses ongoing and future priorities, including projects focused on cardiac rehabilitation, atrial fibrillation management, and reducing delays in care delivery. The document emphasizes the need for continued collaboration among healthcare providers to sustain high-quality care amidst financial challenges.

1. NHS
CANCER
NHS Improvement
DIAGNOSTICS
Continuing to Improve
HEART
Cardiac Services
Heart Improvement Programme
National Project Summaries 2009/10
LUNG
STROKE

3. Continuing to Improve Cardiac Services | 3
Contents
Foreword 4
“
So far, improvements in
the pathway and transfer
arrangements have saved
Introduction
NHS Health Check
5
7
the equivalent of some 959 Atrial fibrillation in primary care 9
NHS beds each year across
England. We know that National roll-out of primary PCI for ST
there is a lot more that can segment elevation myocardial infarction 11
be done to take this further
saving the NHS a great deal Arrhythmia - cardiac devices
and inherited cardiac conditions 13
of money and patients a
great deal of stress and
Sustaining cardiac pathways -
”
worry.
cardiac surgery 14
Professor Roger Boyle CBE, Heart failure 17
National Director for
Heart Disease and Stroke
Cardiac rehabilitation 20
Signpost to Improving Cardiac
Inter Hospital Transfers,
Heart Improvement Programme, NHS Improvement System 22
(2007)
Resources 23

4. 4 | Continuing to Improve Cardiac Services
Foreword
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 in
Professor Roger Boyle, CBE care of patients with acute coronary syndromes need of focused attention.
National Director for Heart has changed dramatically. We are operating
Disease and Stroke,
on more people with higher levels of risk and As we move forward, we face an even bigger
Department 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.

5. Continuing to Improve Cardiac Services | 5
Introduction
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 for
Mark Dancy for work in these areas and selected projects patients.
Consultant Cardiologist and
National Clinical Chair, were facilitated both by the networks and by
NHS 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.

6. 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.

7. Continuing to Improve Cardiac Services | 7
NHS Health Check
Aims of the project
To support the successful
implementation and delivery of the
NHS Health Check programme - a
systematic and integrated programme
of vascular risk assessment and
management which will offer
preventative checks to all eligible
people aged 40-74 to assess their risk
of vascular disease (heart disease,
stroke, diabetes and kidney disease)
followed by appropriate management
and interventions. The proposals for the
NHS Health Check programme
(formerly vascular checks) were set out
in ‘Putting Prevention First’, published
on 1 April 2008 and aim to ensure
greater focus on the prevention of
vascular disease and a reduction in
health inequalities. Implementation of
this major national programme began
in April 2009 and all Primary Care Approach taken the Department of Health, and to
Trusts are expected to achieve full roll The NHS Health Check Learning signpost to other useful information
out by 2012/13. Network includes NHS commissioners sources.
and providers, independent and
Project overview voluntary sector organisations, The NHS Health Check Learning
To coincide with the publication of individuals and a wide range of other Network website acts as a central
Putting Prevention First, NHS stakeholders who are interested or repository for the network and has
Improvement, in collaboration with the involved in the implementation of the been developed to help commissioners
Department of Health, established a NHS Health Check, including the and providers locate relevant resources
national Learning Network in order to cardiac and stroke networks. and information to support local
learn from, build upon and share the implementation. It includes details of
learning and experience of both The Learning Network is underpinned national workshops as well as key
existing and emerging vascular risk by a series of interactive workshops guidance documents and latest news
assessment and management with a strong focus on sharing and relating to the NHS Health Check
programmes across the country. The learning and featuring presentations, programme, a useful links section, an
Learning Network has focused on discussions and interactive group work expanding number of case studies, and
tackling the many challenges to around the emerging issues and a resource library containing
implementation and delivery of the themes. ‘documents for sharing’- to save
programme, including commissioning commissioners and providers from
and procurement, workforce capacity, The Learning Network is also supported reinventing the wheel.
training and education, informatics, by the publication of a regular eBulletin
checks in community settings, which aims to keep subscribers up to
leadership and clinical engagement date with news and information from
and so on. across the Learning Network and from

8. 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
“ Today's workshops have been download any of the supporting
guidance and resources, visit the
fantastic. It's really valuable to
website at: www.improvement.nhs.uk/
hear what's 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.

9. Continuing to Improve Cardiac Services | 9
Stroke prevention in primary care:
managing atrial fibrillation
Aims of the project Key areas for piloting new
To improve quality outcomes for approaches centred on:
patients with atrial fibrillation (AF) and • Detection of AF through opportunistic
reduction in health and social care costs screening at flu clinics
by reducing their risk of stroke through • Local enhanced service (LES) schemes
service improvement to improve for detection, screening and review
detection, diagnosis and optimal of AF
therapy and management in primary • New models for anti-coagulation
care. services in primary and community
settings
Chapter Eight of the National Service • Development of tools to support the
Framework for Coronary Heart Disease; review of patients with AF, risk
Arrhythmias and Sudden Cardiac stratify for stroke and consider
Death, published in March 2005, set optimal therapy
out the quality requirements for the • Guidelines for primary to secondary
prevention and treatment of patients care referral.
with cardiac arrhythmias. In December
2008, the publication of the National All projects found the need to include
Stroke Strategy affirmed the education for professionals and
importance 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 care
Atrial fibrillation is the most common 50-70%: • ECG training and interpretation
sustained dysrhythmia, affecting at • The estimated total cost of • Patient awareness.
least 600,000 (1.2%) people in England maintaining one patient on warfarin
alone. It is also a major predisposing for one year, including monitoring, is Approach taken
factor to stroke, with 16,000 strokes £383 These projects led by NHS Improvement
annually in patients with AF of which • The cost per stroke due to AF is Heart and Stroke Programmes, sought
approximately 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 and
The annual risk of stroke is five to six Project overview voluntary organisations to address the
times greater in AF patients than in The first phase of priority projects were detection of atrial fibrillation, whether
people with normal heart rhythm and is established in October 2007 and patients were appropriately treated
therefore a major risk factor for stroke. completed April 2009. Eighteen with anti-coagulants and to consider
Uniquely, it also in an eminently individual projects were established the best pathways for managing atrial
preventable 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.

10. 10 | Continuing to Improve Cardiac Services
In parallel, at a national level, NHS Based on numbers needed to treat National Publications
Improvement has sought to achieve a ranging from 25 to 37 (Kerr), the costs National Stroke Strategy – Quality
consensus 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 for
resulting 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 Sudden
continues 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 and
Outcomes 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 improvement
The learning and outcomes from the applying a developed suite of tools and 2010 National Audit Office ‘Progress in
first phase of projects has been resources, supported by evidence-based improving stroke care report’.
identified as one of the six key learning, and develop alternative
recommended interventions under the models. Contact details
National Quality and Productivity
agenda within NHS Evidence. 2010/11 accelerated spread of Sue Hall
www.library.nhs.uk/qualityandproducitvity improved detection and optimal National Improvement Lead
treatment of AF patients to reduce risk sue.hall@improvement.nhs.uk
In 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

11. Continuing to Improve Cardiac Services | 11
National roll-out of primary PCI for ST segment
elevation myocardial infarction
Aims of the project 4. Liaising with Myocardial
The National Infarct Angioplasty Project Infarction National Audit Project
(NIAP) was published in October 2008. (MINAP) to monitor national
This demonstrated that a strategy of progress of the roll-out
primary PCI (angioplasty) for patients programme.
presenting with ST segment elevation 5. Sharing national learning via the
myocardial infarction was feasible in a reperfusion web pages and the
UK setting. Following the publication, primary PCI newsletter.
the Government stated that primary
PCI would be rolled out to cover 95% Results and achievements
of the population within three years. Progress has been rapid. In the year
NHS Improvement was invited to to 1 April 2009, 10,048 ST elevation
facilitate this roll-out process. MI patients were treated with
thrombolysis and 7,919 were treated
Approach taken with primary PCI. Between 1 April 2009
The principal aim of the project was to and 1 December 2009, there was a
ensure that primary PCI became the ‘crossing over’ with PPCI becoming the
default treatment for the vast majority dominant reperfusion strategy. During
of patients in England presenting with this eight month period, 4,835 patients
ST segment elevation myocardial received thrombolysis compared with
infarction. This necessitated a 24/7 PPCI 6,643 treated with primary PCI. Thus
service. This in turn meant that not all 58% of those patients receiving
acute hospitals, and not even all PCI reperfusion treatment received PPCI
centres, would be able to provide this during the first eight months of the Next steps
service. For this reason, a cardiac current MINAP year compared with 1.Interim report
network approach was taken to find a 44% in the previous year. Currently, all April 2010 represents the half-way
local solution for each network. In cardiac networks in England have a point in the three year PPCI roll-out. A
some areas, a solution for a Strategic strategy to deliver PPCI to their survey of the cardiac networks is
Health Authority (SHA) which included population by October 2011. Between planned together with comparison of
several cardiac networks was sought. April and November 2009, the their actual PPCI rates from the MINAP
The role of NHS Improvement in the commencement of PPCI roll-out database. These will then be
roll-out of PPCI was that of facilitation. programmes was captured by the incorporated into an interim report
This 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 have
2. 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 to
3. 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.

12. 12 | Continuing to Improve Cardiac Services
3. PCI audit Contact details
The Care Quality Commission have
set a standard of 150 minutes Carol Marley
door-to-balloon time for PPCI. This is a National Improvement Lead
‘whole service’ standard since the time NHS Improvement
interval may include data collection carol.marley@improvement.nhs.uk
from the ambulance service, from a
non-PPCI hospital and from the PPCI Dr Jim McLenachan
centre. Data collection for around this Consultant Cardiologist and National
standard is, therefore, more challenging Clinical Lead, NHS Improvement - Heart
than for a simple door-to-balloon time jim.mclenachan@leedsth.nhs.uk
within one institution. Nevertheless, it is
important that we collect whole service Sheelagh Machin
data. It is equally important that the Director - NHS Improvement
results of PPCI are set in the context of sheelagh.machin@improvement.nhs.uk
outcomes of the total ST elevation MI
population to ensure that shocked and
elderly patients, usually those with
most to gain from PPCI, are benefiting
from appropriate access to primary PCI.
Supporting information
Department of Health (2008) Treatment
of Heart Attack National Guidance –
Final Report of the National
Angioplasty Project (NIAP).
NHS Improvement (2009) A Guide to
Implementing Primary Angioplasty.
Primary PCI as the preferred reperfusion
therapy in STEMI: it is a matter of time
C J Terkelsen et al, Heart 2009;95:362-
369.
www.improvement.nhs.uk/
heart/reperfusion

13. Continuing to Improve Cardiac Services | 13
Arrhythmia - cardiac devices and
inherited cardiac conditions
Aims of the project The national clinical leads worked to number of implants of each type of
Cardiac devices - Facilitate the support key stakeholders in forming a device within the UK, broken down by
improvement of implantation rate and professional clinical organisation the both network and PCT. Their work has
equity of access by working with key Association of Inherited Cardiac demonstrated a dramatic inequity
stakeholders. Conditions. The Association of between different PCTs and networks in
Inherited Cardiac Conditions (AICC) device implant rates for all three types
Inherited cardiac conditions (ICC) - brings together professionals from both of device. Although the database on
Support the review of ICC service genetics and cardiology who work which the survey is based contains
provision and framework for future together supporting patients and substantial clinical information about
commissioning 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 clinical
Project overview Results and achievements characteristics of recipients.
Cardiac devices - To support The cardiac devices national survey
improvement and facilitate local submissions have been reduced Whilst the intention for the coming
performance review, two key elements allowing the 2009 data to be released year is not for NHS improvement to
were addressed. The first was working earlier than usual and a reduction of a focus on cardiac devices as a national
with key stakeholders to help improve further six months is expected in 2010 workstream, it is hoped that developing
the currently available device for the 2009 data. In addition, the and utilising this valuable information
implantation data, collated and network specific reports have been will act as a clinical audit tool, which
published by the devices survey team, released earlier and funded for every might be used to help define and
which had evolved from an network. The expectation is that the compare patient populations for the
implantation 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 local
cardiac network specific review but due access and equity issues. Supporting information
to delays in registering implants was For further information visit the
published 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/arrhythmias
be achieved with one national solution Heart, a review of ICC services www.devicesurvey.com
but required local clinical leadership produced by the PhG foundation. www.phgfoundation.org
and review to implement change Further work between the PhG team
tailored to each provider or network’s and DH has resulted in the Specialist Contact details
circumstances. Commissioning Groups (SCG) agreeing
to consider inherited cardiac conditions Elaine Kemp
Inherited cardiac conditions - The services as a priority in their designation NHS Improvement Lead
national role was to facilitate and timetable for 2010/11. This work will be elaine.kemp@improvement.nhs.uk
advise service providers about the lead by the Yorkshire and Humber SCG.
mechanism for review and Dr Campbell Cowan
improvement. Supporting the launch The Association for Inherited Cardiac Consultant Cardiologist and National
and dissemination of the Foundation Conditions has now completed the Clinical Lead, NHS Improvement - Heart
for Genomics and Population Health elections for council membership. campbell.cowan@leedsth.nhs.uk
(PhG foundation) DH commissioned
report 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

14. 14 | Continuing to Improve Cardiac Services
Sustaining cardiac pathways - cardiac surgery
Aims of the project
The attention focused on cardiac
diagnostics and 18 week pathways
as part of the portfolio of work
coordinated by NHS Improvement -
Heart during 2007/08 highlighted a
need to shift attention to cardiac
surgery to develop sustainable
solutions. Eight NHS Trusts supported
by their local cardiac networks were
involved as demonstration sites during
2008/09 testing out new approaches to
care and improvement to frontline
patient services. The focus of work
undertaken by these sites considered to
be constraints within the management
of smooth patient flows included the
following:
• 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 smarter
Project overview Sandwell and Solihull Cardiac and working, the enhancement of staff
The eight NHS Trusts supported by their Stroke Network roles and a shared overview of the
local cardiac networks that participated • Royal Brompton and Harefield NHS patient journey and patient experience
as lead demonstration sites in the Foundation Trust, North West London across referring providers and the
cardiac 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

15. Continuing to Improve Cardiac Services | 15
Improvement 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.

16. 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

17. Continuing to Improve Cardiac Services | 17
Heart failure
Piloting, testing and promoting
good quality, systematic, heart Central Manchester: Number of admissions per million population for
failure services across all areas of heart failure per four quarter period (lines vs %LES introduced (bars))
delivery
Key messages from the 2008/09
National Priority Heart Failure Projects
Admissions per million population
helped inform the five areas needed to
provide a good heart failure service that
% LES Introduced
are listed in NHS 2010-2015: from
good 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 heart
4. 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 integrating
5. 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 software
The 2008/09 projects that helped to model potential savings from
inform that document: introducing BNP testing to primary
care and testing the model, whilst
Whole 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.

18. 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).

19. 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
DAYS
Next steps David Walker
There is potential in all these five areas Consultant Cardiologist and National
to improve the quality of heart failure Clinical Lead, NHS Improvement - Heart
services and also to improve david.walker@esht.nhs.uk
productivity and our work for 2010-11
and beyond is to both test and spread Sheelagh Machin
the ways that these can be done. Director - NHS Improvement
sheelagh.machin@improvement.nhs.uk
Contact details
www. improvement.nhs.uk/
Candy Jeffries heart/heartfailure
National Improvement Lead
Tel: 0116 222 1415
candy.jeffries@improvement.nhs.uk
Dr James Beattie
Consultant Cardiologist and National
Clinical Lead, NHS Improvement - Heart
james.beattie@heartofengland.nhs.uk
Mike Connolly
Macmillan Nurse Consultant in
Supportive and Palliative Care and
National Clinical Lead, NHS
Improvement - Heart
michael.connolly@uhsm.nhs.uk

20. 20 | Continuing to Improve Cardiac Services
Cardiac rehabilitation
Aims of the project
The overall aim of this project, which
began in September 2008, continues to
be improved access, equity of provision
and better uptake to quality cardiac
rehabilitation (CR) services for heart
attack, angioplasty and coronary artery
bypass grafts (CABG) patients. The
NICE recommendations on cardiac
rehabilitation (NICE clinical guidelines
CG48 on myocardial infarction (MI):
secondary prevention) and the NICE
commissioning guide on cardiac
rehabilitation were used as a resource
to support improved commissioning.
The projects have worked closely with
providers, commissioners, patients and
carers in planning services; shaping
workforce and multi-disciplinary team
approaches.
Project overview
NHS Improvement cardiac rehabilitation Two further projects joined the national two monthly meetings, to devise
projects have included 16 sites across programme at the end of 2009 solutions and share their learning. Led
12 networks. The project sites are: 11. MyAction Westminster by the national improvement lead and
12. North Yorkshire and York PCT. national clinical lead for cardiac
1. Derbyshire County PCT rehabilitation at NHS Improvement and
2. 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 very
3. 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 national
4. Dorset Cardiac and Stroke Network services across an area, or advising issues such as work around tariff
5. 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 to
6. Shropshire and Staffordshire Heart projects worked on inequities, progressing individual projects.
and Stroke Network increasing uptake and timely access to
7. Surrey Heart and Stroke Network services, involvement of patients and Project teams shared learning via the
8. Black Country Cardiovascular carers in informing redesign and NHS Improvement System and on a
Network improved information. website giving both the project teams
9. North West London Cardiac and and the wider NHS access to material
Stroke Network – PPCI project Approach taken from the project team days, wider
10. 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.

21. Continuing to Improve Cardiac Services | 21
Where required one-to-one support at (Effectiveness), new community and Next steps
the improvement site was undertaken home based programme for ischaemic NHS Improvement is jointly leading the
by the national programme lead and heart disease (IHD), outcome measures, development of a CR Commissioning
national clinical lead. This was clear management plans, effective use Pack for PCTs with the Strategic
especially useful in specification of staff and programmes. (Experience) Development Unit at the Department
development 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 from
development in rehabilitation which INNOVATION - Rehab-led follow up, June 2010 which will aim, within the
has helped projects with commissioning drug therapy reviews, local task group context of quality and productivity, to
and business case initiatives. acting to coordinate all quality increase the numbers of patients
initiatives receiving a quality cardiac rehabilitation
Results and achievements PRODUCTIVITY - Increased number of service.
The main outputs of the projects patients accessing rehab, reduced hand
have 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
Director
Many of the outcomes from the
the quality and productivity Julie.harries@improvement.nhs.uk
projects meet the quality, innovation agenda. I believe CR is one of the
and 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 focus
QUALITY - (Safety) Centralised referral and skills to deliver service
and patient tracking, standardised
protocols and procedures, risk
redesign, innovative commissioning
stratification forms, governance and improved quality”.
standards, skills competency Professor Patrick Doherty
assessment, service specifications National Clinical Lead NHS Improvement

22. 22 | Continuing to Improve Cardiac Services
NHS Improvement System
What is it? Where can I see a
The NHS Improvement System is a demonstration of the system?
comprehensive, online tool to support Demonstrations of some of the key
sharing of quality service improvement modules are available on the
resources 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 improvementsystem
assist you in your own service
improvement work. Who can use the system?
The system is free of charge and can be
Why use it? used by all staff working for NHS
The NHS Improvement System actively organisations in England.
helps organisations to effectively
achieve their objectives in line with How can I register to use the
World Class Commissioning. It enables system?
users to be more strategic and align Access to the system is controlled
long-term goals that can help to deliver by user ID and password.
high quality, patient focussed health
outcomes. To request an ID contact
support@improvement.nhs.uk
Which specialties are included?
The system can be used to support
sustainable service improvement
in any specialty.
What does it contain?
• Service improvement tools
and resources
• Practical guidance
• Case studies
• Useful contacts
• Signposting and links.

23. Resources
All the publications listed below Delivering the NHS Health Check: A National Priority Projects 2007/08
are available to download at: Practical Guide to Point of Care Summary Documents
www.improvement.nhs.uk/ Testing Summary documents from the Heart
publications 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 Beds
A guide to commissioning learning from the field (November • Atrial Fibrillation in Primary Care
cardiac surgical services 2009). • 18 Weeks Whole Pathways
Eight NHS Trusts supported by their • 18 Weeks - Focus on Cardiac
local cardiac networks were involved as Heart Failure - A quick guide to Diagnostics.
demonstration sites during 2008/09 in quality commissioning across the
the Cardiac Surgery National Priority whole pathway of care Guidance on Risk Assessment
Project. Lessons drawn from these sites This practical guide sets out to help and Stroke Prevention for Atrial
are outlined in the publication 'A Guide commissioners develop integrated heart Fibrillation (GRASP-AF) Tool
to Commissioning Cardiac Surgical failure services by highlighting evidence This tool should be used as part
Services' (March 2010). based practice and measurable of a systematic approach to the
outcomes. It draws on the NICE identification, diagnosis and optimal
Cardiac Rehabilitation - National Commissioning Guidelines (Feb 2008), management of patients with AF
Priority 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/graspaf
Cardiac rehabilitation (CR) is a national of life). (September 2008).
priority project of NHS Improvement Using Discovery Interviews
focusing on increasing the access to, Atrial fibrillation in primary care: to improve care
equity of provision and uptake of CR making an impact on stroke www.improvement.nhs.uk/
services for heart attack, angioplasty prevention discoveryinterviews
and CABG patients. The project This document aims to capture the final
summaries include issues to be summary of their individual approach, Improving Cardiac Patient
addressed, baseline position, actions lessons learned, improvements to Pathways: The Sustainability
taken, key learning, QIPP outcomes and practice and quality outcomes, also Toolkit
results 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/sustainability
2009). drive this agenda forward (October
2009). The Cardiac Data Dashbord
A Guide to Implementing www.improvement.nhs.uk/
Primary Angioplasty Commissioning for Stroke heart/dashboard
Since the publication of new national Prevention in Primary Care: the role
good practice guidance on treatment of Atrial Fibrillation
of heart attack, NHS Improvement has Developed following a national
looked at the major issues and consensus meeting of opinion leaders
obstacles to implementing primary in the field, this document is to develop
percutaneous coronary angioplasty a concerted strategy towards the
(PPCI) services across England and all management of AF in primary care, in
the learning has now been pulled particular anticoagulant management
together in a useful implementation and its significance in relation to
guide (June 2009). reduction in the risk of stroke (June
2009).

24. CANCER
DIAGNOSTICS
HEART
LUNG
STROKE
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