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The NHS Five Year Plan-Simon Gillespie and Karen Smith presentation
- 1. Applying the principles of the Five Year Forward View The British Heart Foundation Innovation Pilots Simon Gillespie
- 2. Ensure that everyone in the UK with CVD has access to high- quality, integrated health and social care services
- 3. The Forward View into Action: Co-creating new models of care • Address local need • Co-design to accelerate change • Demonstrate proof of concept • Prototype that can be replicated elsewhere
- 4. Service Innovation Timeline 1980s 1990s 2000 2004 2006 2009 2012 2013 2014 2015 Heart Helpline Pioneered the model of nurse-led services 2 models of BHF service design on QIPP website Heart Failure & IVD Resources CPD Accredited Heart Support Groups House of Care Innovation through multi-skilling clinical staff Integrated Care BHF Alliance FH Nurses
- 5. 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 • £1 million • 9 sites • Independently evaluated Consistent with 5YFV: • Multispecialty community providers • Integrated primary and acute care systems • Models of enhanced health in care homes
- 6. BHF rationale for funding pilot projects Pump Prime & Test Hypothesis Redesign care and support pathways Evaluate & build evidence basePublish and Disseminate Spread & Adoption of Best Practice Learning & new hypotheses
- 8. BHF Pilot with East Cheshire NHS Trust The Challenge: • 15.5% increase in emergency admissions for CHD between 2009 – 2011 • East Cheshire fastest growing elderly population in North West • Chest pain, AF and HF identified as generating greatest no of admissions • LOS longer than the national average • Commissions wanted to upskill primary care to deal with demand and reduce duplication of care
- 9. BHF Pilot with East Cheshire NHS Trust The Solution: • Developed generic cardiology specialist nurse team – expanded remit • In-reach programme: identifying patients in A&E and Medical Assessment Unit • New pathways and community clinics for chest pain, AF and Heart Failure and delivering IVD in peoples’ homes • Joint assessments and care plans for LTCs with diabetes, respiratory, pain management and palliative care teams • Training and support with social care and care homes
- 10. Outcomes and Impacts 1 Reduction in LOS (days) 0 2 4 6 8 10 12 14 16 Angina MI AF HF 2011-2012 2012-2013
- 11. Outcomes and Impacts 2 In-patient bed days saved: 2391 Saving £1,195,000 Cost benefit ratio 1:8.8 (for every £1 invested, the NHS saves £8.80)
- 12. Example Multispecialty Community Provider for an Integrated Community Cardiac Team Care Co-ordinator - working with Patient Cardiac Nurse Respiratory Nurse Home Intravenous Therapy Team Social Care Team and Carer Support Community Mental Health Team Palliative Care Team
- 13. New patient pathways have moved activity – increased diagnosis and follow- up care - from acute to primary and community care Before After Secondary Care Primary and community Care Admission Diagnosis Follow-up Admission Follow-up Diagnosis
- 14. The British Heart Foundation Innovation Pilots NHS Tayside Karen Smith Nurse Consultant Cardiology NHS Tayside School of Nursing and Midwifery University of Dundee
- 15. BHF Pilot with NHS Tayside The Challenge: • Review of National CHD standards (Quality Improvement Scotland 2010) highlighted some major shortfalls in arrhythmia management within NHS Tayside • Three main work streams • Atrial fibrillation • Implantable Devices (ICDs and CRT) • Inherited cardiac conditions • Opportunity to work in partnership with the teams in primary care to develop and evaluate new models of integrated care improving the patients referral, diagnostic and care pathways and consequently patient experience • Upskill health care teams
- 16. Achievements for AF • 10 Rapid Access AF clinics per month rolled out across all 3 community health partnerships • Referrals via Referral Management System and Consultant referral – aim to see within 2 weeks • Integration of patients with LT arrhythmia management • Improved patient pathways for DC cardioversion • Anticoagulation, less cancellations, timely intervention, early review (4 weeks & 6 months versus 4-6 months from cardiologists)
- 17. Improvements in Cardioversion Improved waiting times for procedure In contrast through the arrhythmia service Anticoagulation “instead of having to wait for the cardiologist,…we got pretty quickly the letter about the flutter clinic’ their previous experience highlighted that ‘It just took forever. I can’t remember when you actually got your first cardioversion. I can’t remember. It took months” “So you’ve got a very defined timeline, rather than…… sitting in limbo waiting on things to happen … And I think the service, that way it’s worked out, for us has certainly been better, knowing full well that that’s the time you’re going to get it done” “I knew that obviously this is not the best thing to be on. But I was unaware of how intrusive it is as regards the INR readings, going to the clinic, getting a booking at the clinic even, because it’s like a week in advance when it’s really full. So I think that was the next sort of hassle, was getting INR level to the right level, so I could then go for cardioversion”
- 18. Quality of life - AFEQT – Overall score good quality of life, limited disability associated with their AF. Improvements symptoms scores and daily activities @ 6 months Knowledge – overall scores 60-70% but still identified areas for improvement in understanding of AF – eg 44% did not know why it was important to take medications – ? impact on compliance Self management - Patient Activation Measure (PAM)- Underlying knowledge skills and confidence integral to managing one’s own health and healthcare. PAM categorises respondents into one of four activation levels: Level 1 – Disengaged & overwhelmed Level 2 – Becoming aware but still struggling Level 3 – Taking action Level 4 – Maintaining Behaviours and pushing further AF Outcomes
- 19. Patient feedback – Atrial Fibrillation “I think I would have felt different if I’d just been left with the consultant cardiologist completely I think…. the old service as regards you felt you were being processed……… But with the change, it probably makes you aware that somebody maybe does care and is looking after your interests. And that’s quite a big change from route number one of being processed to then being an individual that you’ve got this key contact that’s looking after you”
- 20. Aim: • To address the gaps in psychological support and provision through nursing intervention offering pre and post implantation support • Baseline data - ICD concerns high levels invited to attend review • ICD concerns – guides clinical consultation , assessment improved over time less number and severity • Mood - reduced anxiety and depression over time up to 6 months , slight inc again by month 10 ? Shocks delivered ICD patients
- 21. ICD- Patient experience: adverse effects “I mean I think the darkest moments ..goes back to probably the first two years … I could understand how people commit suicide to be honest. I felt there was no point, I didn't feel there was any future at all, I couldn’t think of a future. And of course, people around about you don't really understand this. I am not blaming them, I think it had a quite serious effect” “I think I more or less withdrew into not living at all. I was sitting outside in my chair with a computer doing routine work on a project which I am doing, I was terrified to go out…..I was feeling so uptight and, that it was changing the rhythm of my heart”
- 22. • Regained confidence and Independence • Travelling • Returned to golf • Learnt a new language • Improved relationships within the family Transformed lifestyle from isolation, high anxiety and multiple admissions
- 23. Prevention of admission “Well the case where I had the VT in the morning, and I phoned and I left a message on ‘the nurse’s’ phone and she got back to me and then it wasn't very long, she got back to me within a couple of hours later. And I could say to her look it has settled down and she knew. I knew that somebody knew…. Otherwise I would have had to have said to myself oh dear, do I phone in, do I go up to A&E the ambulance people on a couple of occasions have been distinctly iffy about taking me”
- 24. 0 10 20 30 40 50 60 70 80 mean score level 1 level 2 level 3 level 4 Patient activation Measure ICD AF Self Management in AF and ICD patients
- 25. Inherited Cardiac Conditions • Monthly multidisciplinary ICC clinic • MDT meetings • Although smallest clinical group have significant support needs
- 26. Integration within services “Having a heart condition can be a scary time. For me personally, I don't think I would have gotten through the whole thing without fantastic support from the BHF arrhythmia nurses. But it's not just them. There's a whole team of people involved in it….. Everyone you provide support for will have their own story to tell, their own fears…, But without you all providing the support and care that you do so well everyone's journey would be a very lonely one”
- 27. Integrated Specialist Nursing Service Patient Cardiac rehabilitation Nurse Arrhythmia Nurse Heart failure Nurse Chest pain Nurses • Integrated into mainstream services • Opportunity to review & integrate existing nursing roles within specialist nursing team • Streamline our patients pathway
- 28. Independent Evaluation demonstrated: They are clinically effective They are safe They are cost effective They improve the patient and carer experience
Editor's Notes
- A general intro slide to introduce BHF A strategic priority is to ensure that all those with CVD receive the highest quality integrated health and social care
- In addition to funding biomedical research, BHF also funds new models of care to test new care pathways and service innovation in the NHS across the UK, co-produced with local NHS organisations Approach and methodology of the BHF is consistent with those articulated in the 5YFV These are pump-primed for 2 – 3 years to test proof of concept and independently evaluated to assess safety, clinical and cost efficiency and patient experience with the intention that, if effective, these are sustained and can be replicated across the NHS. Several of these are on the QIPP website as case studies
- BHF have been pioneering new models of care since the mid 90’s and continue to do so, and in many ways have been delivering models of care consistent with those set out in the Five Year Forward View for several years now.
- In 2012, we funded 9 integrated care pilots across the UK We also 10 sites to assess the feasibility of providing intravenous care for Heart failure patients in the community or their own homes (previously only provided in a hospital setting) These projects demonstrated effective approaches to vertical integration working across primary, community and acute care and providing care across traditional clinical specialities and with social care providers – consistent with what a Multispecialty Community Provider or Integrated Primary and Acute Care System - as described in the 5YFV - may look like
- The rationale for funding new pilots is to test new approaches to care delivery, evaluate and support the spread and adoption of these when independently shown to be effective.
- The approach clearly demonstrated reductions in length of stay for the cardiac conditions they were addressing.
- Demonstrating significant reductions in in-patient bed days and subsequent substantial cost savings.
- This slide demonstrates what a Multispecialty Community Provider model for an Integrated Community Cardiac Team may look like.
- Consistent with the 5YFV to move activity from the acute to the community/primary care Approaches support patient self-management
- PRI – Wednesday afternoons weekly (3 new, 2 return) NW – Thursday afternoons week 1, 3, and 5 (3 new, 2 return) Arb – Tuesday mornings week 2 & 4 (3 new, 3 return) SXH – Monday afternoons monthly, week 3 (3 new, 2 returns)
- The recent presentation by a patient at the BHF conference highlighted the benefits of the integration of the 3 elements of the service. This patient accessed the service via referral to the cardiologists for assessment at the inherited cardiac conditions clinic following the sudden unexpected deaths of three of his family members, his father, brother and sister. . After initial assessment and genetic investigation he was then referred for implantation of an ICD, at which point he had further access to the support of the specialist arrhythmia nurses before and after this procedure. Following his device implantation having made a good recovery, he unfortunately went on to develop atrial fibrillation and required admission and DC cardioversion which was again facilitated through the arrhythmia service as he described
- Evaluation showed with home based IVD was safe, clinically and cost effective and patients welcomed being treated at home. Home based care also allowed more opportunities for patient and carer education, supporting self-management Opportunity to assess broader social care needs and meet more holistic care needs *mention community teams and specialists working together to demonstrate MCP type working model