Continuing to Improve Cardiac Services - National Project Summaries 2009/10

NHSNHS Improvement

HEART

LUNG

CANCER

DIAGNOSTICS

STROKE

Continuing to ImproveCardiac ServicesHeart Improvement ProgrammeNational Project Summaries 2009/10

Continuing to Improve Cardiac Services | 3

ContentsForeword 4

Introduction 5

NHS Health Check 7

Atrial fibrillation in primary care 9

National roll-out of primary PCI for STsegment elevation myocardial infarction 11

Arrhythmia - cardiac devicesand inherited cardiac conditions 13

Sustaining cardiac pathways -cardiac surgery 14

Heart failure 17

Cardiac rehabilitation 20

NHS Improvement System 22

Resources 23

So far, improvements in

the pathway and transfer

arrangements have saved

the equivalent of some 959

NHS beds each year across

England. We know that

there is a lot more that can

be done to take this further

saving the NHS a great deal

of money and patients a

great deal of stress and

worry.

Professor Roger Boyle CBE,National Director forHeart Disease and Stroke

Signpost to Improving CardiacInter Hospital Transfers,Heart Improvement Programme,(2007)

”

“

4 | Continuing to Improve Cardiac Services

Foreword

In the 10 years since the launch of the NationalService Framework (NSF) for Coronary HeartDisease in 2000, we have seen a substantialimprovement in cardiac services which has ledthe way in the NHS for improved and equitableaccess to services. Mortality rates have fallenquickly and health inequalities have narrowed.Waiting times for diagnosis, heart surgery andangioplasty have fallen dramatically and thecare of patients with acute coronary syndromeshas changed dramatically. We are operatingon more people with higher levels of risk andco-morbidity, whilst delivering better outcomes.We have also witnessed opportunities forhealth care professionals to widen their skillsand expand their roles and scope of practice.

The progress and improvements made over thelast 10 years to achieve the NSF have beenmade possible by a collaborative effort by allorganisations and staff across the NHS. TheCHD Collaborative started in 2000 with just 11local sites, moving quickly to 30 collaborativesand was followed by the development ofclinical networks. Today, cardiac networkscontinue to be uniquely placed to assist withthe delivery of the quality agenda by linkingclinicians, managers and commissionerstogether in every aspect of the patients’journey through primary, secondary and tertiarycare. They continue to be well positioned toreflect local relationships between cliniciansacross organisational boundaries to furtherdevelop safe and effective pathways of care forpatients by providing an opportunity forclinicians and managers to work together onthe redesign and commissioning agenda.

The work of NHS Improvement and itspredecessor organisations has been a constantsource of support to these improvements andpivotal in the development of systems thatdeliver high quality care.

But there is more to be done - there are stillunnecessary waits for transfer to surgical andspecialist centres. The recent National Audit ofCardiac Rehabilitation (NACR) figures showthat uptake remains low and thatcommissioning and provision of adequatecardiac rehabilitation remains a challenge; theprovision of integrated heart failure servicesacross the whole patient pathway is also inneed of focused attention.

As we move forward, we face an even biggerchallenge to continue to provide high qualitycare while at the same time delivering it muchmore efficiently. This will be the biggestchallenge that has faced us in the history ofthe NHS.

I hope you will join me in celebrating all thatwe have achieved together at the NHSImprovement – Heart Conference which marksthe 10th anniversary of the National ServiceFramework. The following pages outline forthe wider NHS the range of national areas ofwork delivered by NHS Improvement – Heart,that have helped increase productivity andefficiency in services and have improved theexperience for cardiac patients and staff.

Professor Roger Boyle CBENational Director for Heart Diseaseand Stroke, Department of Health

Professor Roger Boyle, CBENational Director for HeartDisease and Stroke,Department of Health

Introduction


This document details the areas that theHeart Improvement Programme has beenworking on during 2009/10, brieflydescribing the various ideas that have beentested by commissioners and providers acrossEngland. The priority areas were agreed atthe start with the policy team with inputfrom the cardiac networks. The networkswere then asked to put forward proposalsfor work in these areas and selected projectswere facilitated both by the networks and bythe national team. We chose projects thathad clear objectives and scope, wereachievable in a manageable timeframe(usually less than two years), and wouldproduce new ways of working that could beadopted by others.

This summary document is not intended todescribe the individual projects in detail, butfurther information is easily available fromthe contacts given in the text. I wouldencourage anyone interested in carrying outsimilar work to get in touch with the teamswho have been involved in these priorityprojects as they have invested considerableresource learning what works and whatdoesn’t and that can save a lot of time andanguish.

As you will see from the descriptions of theprojects, there have been some verysuccessful initiatives which have measurablyimproved the quality of care for patients andcarers, and I congratulate the teams on theirhard work and perseverance. If others cantake these ideas and develop them in theirown localities, the potential health gain isconsiderable.

Moving on to next year, the new prioritieshave already been agreed. Inevitably, giventhe financial context in which we are nowworking, there is a focus on productivity, butthat does not mean that quality of care isrelegated to second place and we lookforward to expressions of interest fromanyone who is committed to developing newways of working and improving services forpatients.

Priority projects for 2010/11

Cardiac rehabilitationThe work will aim to increase the provisionand uptake of cardiac rehabilitation (CR) byworking with the Department of Health todevelop a commissioning pack designed tohelp PCTs and providers improve thespecification, commissioning and potentialprocurement of CR services. Thecommissioning pack will form the main toolin a programme of improvement work andits roll out and implementation will besupported by NHS Improvement.

Heart failureAs highlighted in ‘NHS 2010 - 2015: Fromgood to great’ (2009,) the main aim of thiswork will be to improve clinical outcomesand patient experience by decreasing thenumber of emergency admissions,readmissions and in-patient bed daysthrough optimising care for patients withheart failure. The scope will include earlyaccurate diagnosis, optimising management,integrated care, the role of the carecoordinator and end of life care.

Mark DancyConsultant Cardiologist andNational Clinical Chair,NHS Improvement - Heart


Reducing avoidable delays in nonelective inpatient managementThis initiative builds on lessons learned inelective inpatient management for surgeryand revascularisation and in previousinterhospital transfer studies. The work aimsto improve clinical outcomes and patientexperience by decreasing in-patient beddays through optimising care for patientswith acute coronary syndromes (ACS),arrhythmias and those requiring cardiacsurgery.

Atrial fibrillationThis work will build on existing priorityproject work on atrial fibrillation (AF) with aview to accelerating progress, sharinglessons learned and extending andembedding the use of tools, methodologiesand resources for AF developed and testedduring the pilot and prototype phases. Thefocus will be on raising awareness of AF,training and education of clinicians indetection and treatment, exploring allopportunities for screening for AF andensuring anticoagulation and treatment areoptimised in both primary and secondarycare. A substantial reduction in the numberof resulting strokes is anticipated and thework will contribute considerably to thequality and productivity challenge.

Primary angioplasty (reperfusion)This work will involve a continuation ofthe primary percutaneous coronaryintervention (PPCI) project workstream withimplementation across England and thedevelopment of a sustainable service acrossthe whole patient journey. This will include afocus on the adoption of robust cardiacrehabilitation pathways and an emphasis onthe improvement of the data quality for localand national audit.

Cardiac devicesThis initiative will continue to engage withnetwork and provider device clinical leads toreview local service provision and addressequity of access in cardiac networks. This willbe underpinned by supporting the devicesurvey team to drive up data quality andsubmission timeliness whilst expanding thefunctionality of existing data sources forclinical users for clinical audit andcommissioning purposes.

NHS Health CheckWork to support the implementation of thismajor initiative will move from NHSImprovement to NHS Diabetes and KidneyCare from May 2010. NHS Health Checkremains a key policy initiative for theprevention of cardiovascular disease andwork in cardiac and stroke networks on thisimportant area will continue.

Some of the projects from this year are stillrunning, but networks will be looking out forpeople who think they may be able tocontribute their ideas in the various projectareas for 2010/11 and if you think you mightwant to join us I would encourage you tospeak to your network as soon as possibleeven if only to discuss your proposalinformally.

Mark DancyNational Clinical ChairNHS Improvement - Heart


Aims of the projectTo support the successfulimplementation and delivery of theNHS Health Check programme - asystematic and integrated programmeof vascular risk assessment andmanagement which will offerpreventative checks to all eligiblepeople aged 40-74 to assess their riskof vascular disease (heart disease,stroke, diabetes and kidney disease)followed by appropriate managementand interventions. The proposals for theNHS Health Check programme(formerly vascular checks) were set outin ‘Putting Prevention First’, publishedon 1 April 2008 and aim to ensuregreater focus on the prevention ofvascular disease and a reduction inhealth inequalities. Implementation ofthis major national programme beganin April 2009 and all Primary CareTrusts are expected to achieve full rollout by 2012/13.

Project overviewTo coincide with the publication ofPutting Prevention First, NHSImprovement, in collaboration with theDepartment of Health, established anational Learning Network in order tolearn from, build upon and share thelearning and experience of bothexisting and emerging vascular riskassessment and managementprogrammes across the country. TheLearning Network has focused ontackling the many challenges toimplementation and delivery of theprogramme, including commissioningand procurement, workforce capacity,training and education, informatics,checks in community settings,leadership and clinical engagementand so on.

the Department of Health, and tosignpost to other useful informationsources.

The NHS Health Check LearningNetwork website acts as a centralrepository for the network and hasbeen developed to help commissionersand providers locate relevant resourcesand information to support localimplementation. It includes details ofnational workshops as well as keyguidance documents and latest newsrelating to the NHS Health Checkprogramme, a useful links section, anexpanding number of case studies, anda resource library containing‘documents for sharing’- to savecommissioners and providers fromreinventing the wheel.

Approach takenThe NHS Health Check LearningNetwork includes NHS commissionersand providers, independent andvoluntary sector organisations,individuals and a wide range of otherstakeholders who are interested orinvolved in the implementation of theNHS Health Check, including thecardiac and stroke networks.

The Learning Network is underpinnedby a series of interactive workshopswith a strong focus on sharing andlearning and featuring presentations,discussions and interactive group workaround the emerging issues andthemes.

The Learning Network is also supportedby the publication of a regular eBulletinwhich aims to keep subscribers up todate with news and information fromacross the Learning Network and from

NHS Health Check


NHS Improvement has also supported19 carefully selected ‘test bed’ sites toinvestigate different aspects andmodels of delivery to help inform policyand assist with the development offurther guidance. Funded by theDepartment of Health, learning fromthe test bed programme is currentlybeing shared across the LearningNetwork, largely via the production of aseries of practical implementationguides, the first of which was publishedin November 2009.

Results and achievementsTo date, NHS Improvement, alongsidethe Department of Health, hasfacilitated seven national learningevents attended by well over 1,000delegates. These national workshopshave generated a great deal of interestfrom a wide range of stakeholdersacross the country and have been verywell received and evaluated byattendees:

Today's workshops have beenfantastic. It's really valuable tohear what's happening fromthe centre and in other areas.”

Eight eBulletins have been published toa growing distribution list of almost900 people, and the website continuesto achieve a high ‘hit rate’.

The first implementation guide on Pointof Care Testing proved extremelypopular and has received very positivefeedback.

Contact details

Julie [email protected]

Mel VarvelNational Improvement [email protected]

Current estimates indicate that over85% of PCTs in England will havecommenced roll out of NHS HealthCheck in 2009/10 and it is likely thatthe establishment of the nationalLearning Network has made asignificant contribution to this inaddition to tangible (figures to beconfirmed) progress towards thedelivery of 1,000,000 checks by April2010 (as cited inWorking Together –Public Services On Your Side publishedin March 2009).

Next stepsThe national Learning Network is setto continue to support ongoingimplementation and delivery thoughthe facilitative role played by NHSImprovement will transfer to NHSDiabetes and Kidney Care in Spring2010.

Supporting informationTo find out more about the NHS HealthCheck Learning Network, and todownload any of the supportingguidance and resources, visit thewebsite at: www.improvement.nhs.uk/nhshealthcheck

Further information on the nationalpolicy can be found on theDepartment of Health’s website at:www.dh.gov.uk/nhshealthcheck

Public-facing information is available onthe NHS Choices website at:www.nhs.uk/Planners/NHSHealthCheck/Pages/NHSHealthCheck.aspx

“


Stroke prevention in primary care:managing atrial fibrillation

Aims of the projectTo improve quality outcomes forpatients with atrial fibrillation (AF) andreduction in health and social care costsby reducing their risk of stroke throughservice improvement to improvedetection, diagnosis and optimaltherapy and management in primarycare.

Chapter Eight of the National ServiceFramework for Coronary Heart Disease;Arrhythmias and Sudden CardiacDeath, published in March 2005, setout the quality requirements for theprevention and treatment of patientswith cardiac arrhythmias. In December2008, the publication of the NationalStroke Strategy affirmed theimportance of this work for strokeprevention within Quality Marker 2‘Managing Risk’.

Atrial fibrillation is the most commonsustained dysrhythmia, affecting atleast 600,000 (1.2%) people in Englandalone. It is also a major predisposingfactor to stroke, with 16,000 strokesannually in patients with AF of whichapproximately 12,500 are thought tobe directly attributable to AF.

The annual risk of stroke is five to sixtimes greater in AF patients than inpeople with normal heart rhythm and istherefore a major risk factor for stroke.Uniquely, it also in an eminentlypreventable cause of stroke with asimple highly effective treatment.

This treatment is also highly costeffective. The treatment of AF withwarfarin reduces risk of stroke by50-70%:• The estimated total cost ofmaintaining one patient on warfarinfor one year, including monitoring, is£383

• The cost per stroke due to AF isestimated to be £11,900 in the firstyear after stroke occurrence.

Project overviewThe first phase of priority projects wereestablished in October 2007 andcompleted April 2009. Eighteenindividual projects were establishedacross 15 cardiac and stroke networksA variety of approaches wereundertaken responding to the needs ofthe local health communities.

Key areas for piloting newapproaches centred on:• Detection of AF through opportunisticscreening at flu clinics

• Local enhanced service (LES) schemesfor detection, screening and reviewof AF

• New models for anti-coagulationservices in primary and communitysettings

• Development of tools to support thereview of patients with AF, riskstratify for stroke and consideroptimal therapy

• Guidelines for primary to secondarycare referral.

All projects found the need to includeeducation for professionals andpatients around:• Pulse palpation• Barriers to anti-coagulation inprimary care

• ECG training and interpretation• Patient awareness.

Approach takenThese projects led by NHS ImprovementHeart and Stroke Programmes, soughtto work with primary care trusts (PCTs),general practices, practice basedconsortia (PBC) acute trusts andvoluntary organisations to address thedetection of atrial fibrillation, whetherpatients were appropriately treatedwith anti-coagulants and to considerthe best pathways for managing atrialfibrillation in primary care.

Regular peer support meetings wereheld to encourage the sharing ofresources, learning and collaborativeworking to drive forward improvementsin care and maximise benefits.


In parallel, at a national level, NHSImprovement has sought to achieve aconsensus approach across England tothe management of AF patients withinprimary care with key stakeholdersresulting in the publication of acommissioning guide in May 2009 andcontinues to make formalrepresentation to influenceamendments to the current AFindicators within the Quality andOutcomes Framework.

Results and achievementsThe learning and outcomes from thefirst phase of projects has beenidentified as one of the six keyrecommended interventions under theNational Quality and Productivityagenda within NHS Evidence.www.library.nhs.uk/qualityandproducitvity

In particular we have seen:• The early piloting of opportunisticscreening through pulse palpation atflu clinics by Bedfordshire andHertfordshire Heart and StrokeNetwork replicated in other areas,eg: Colchester Practice BasedCommissioning Group.

• Opportunistic pulse check promptedby flag to GP clinical systems inDurham

• GRASP-AF tool developed and pilotedby West Yorkshire CardiovascularNetwork in collaboration with theirBritish Heart Foundation (BHF)arrhythmia nurses and PRIMIS+for use on GP clinical systems toidentify for review AF patients withhigh risk of stroke, not on warfarin,now available for use across Englandfor all GP clinical systems viawww.improvement.nhs.uk/graspaf

• Decision support tool ‘The Auricle’www.theauricle.co.uk

Based on numbers needed to treatranging from 25 to 37 (Kerr), the costsof each stroke prevented with warfarinare in the range £9,500 to £14,000.

Each year appropriate anti-coagulationcould prevent 4,500 strokes in patientswith AF at an additional cost of £63.5million.

Next stepsThe second phase of nine projects waslaunched in October 2009 to spreadand embed sustainable improvementapplying a developed suite of tools andresources, supported by evidence-basedlearning, and develop alternativemodels.

2010/11 accelerated spread ofimproved detection and optimaltreatment of AF patients to reduce riskof stroke.

Supporting informationFull details of the outcomesdocumented and published can befound at: www.improvement.nhs.uk

Atrial fibrillation in primary care:making an impact on stroke prevention(October 2009).

Commissioning for stroke prevention inprimary care: The role of atrialfibrillation (June 2009).

Heart Improvement: Atrial fibrillation inprimary care (May 2008).

National PublicationsNational Stroke Strategy – QualityMarker 2: Managing Risk (2007).

National Service Framework forCoronary Heart Disease (CHD) –Chapter 8: Arrhythmias and SuddenCardiac Death (2006).

Management of atrial fibrillation,National Institute for Health andClinical Excellence (NICE) ClinicalGuideline (2006).

2010 National Audit Office ‘Progress inimproving stroke care report’.

Contact details

Sue HallNational Improvement [email protected]

Dr Campbell CowanConsultant Cardiologist and NationalClinical Lead, NHS Improvement - [email protected]

Dr Matt FayGP and National Clinical [email protected]


National roll-out of primary PCI for ST segmentelevation myocardial infarction

Aims of the projectThe National Infarct Angioplasty Project(NIAP) was published in October 2008.This demonstrated that a strategy ofprimary PCI (angioplasty) for patientspresenting with ST segment elevationmyocardial infarction was feasible in aUK setting. Following the publication,the Government stated that primaryPCI would be rolled out to cover 95%of the population within three years.NHS Improvement was invited tofacilitate this roll-out process.

Approach takenThe principal aim of the project was toensure that primary PCI became thedefault treatment for the vast majorityof patients in England presenting withST segment elevation myocardialinfarction. This necessitated a 24/7 PPCIservice. This in turn meant that not allacute hospitals, and not even all PCIcentres, would be able to provide thisservice. For this reason, a cardiacnetwork approach was taken to find alocal solution for each network. Insome areas, a solution for a StrategicHealth Authority (SHA) which includedseveral cardiac networks was sought.The role of NHS Improvement in theroll-out of PPCI was that of facilitation.This included:

1. Providing bespoke advice tocardiac networks and SHAs ontheir PPCI roll-out plans.

2. Providing generic guidance onPPCI roll-out (eg publication of aGuide to Implementing PrimaryAngioplasty (April 2009).

3. Liaising with DH through theCardiac Emergencies Board onissues around PPCI roll-out.

4. Liaising with MyocardialInfarction National Audit Project(MINAP) to monitor nationalprogress of the roll-outprogramme.

5. Sharing national learning via thereperfusion web pages and theprimary PCI newsletter.

Results and achievementsProgress has been rapid. In the yearto 1 April 2009, 10,048 ST elevationMI patients were treated withthrombolysis and 7,919 were treatedwith primary PCI. Between 1 April 2009and 1 December 2009, there was a‘crossing over’ with PPCI becoming thedominant reperfusion strategy. Duringthis eight month period, 4,835 patientsreceived thrombolysis compared with6,643 treated with primary PCI. Thus58% of those patients receivingreperfusion treatment received PPCIduring the first eight months of thecurrent MINAP year compared with44% in the previous year. Currently, allcardiac networks in England have astrategy to deliver PPCI to theirpopulation by October 2011. BetweenApril and November 2009, thecommencement of PPCI roll-outprogrammes was captured by theMINAP data collection which showedthat 8 cardiac networks were providingPPCI to 30-70% of their ST elevationMI patients by the end of November2009 having been providing PPCI toless than 30% of their population eightmonths previously.

Next steps1.Interim reportApril 2010 represents the half-waypoint in the three year PPCI roll-out. Asurvey of the cardiac networks isplanned together with comparison oftheir actual PPCI rates from the MINAPdatabase. These will then beincorporated into an interim reportwhich should highlight if there are anyareas of concern nationally.

2.Patient informationPatients who have a primary PCI haveshorter hospital stays and with theseshort stays come the challenge ofgiving patients and carers theinformation they require prior todischarge. Guidelines for staff that carefor these patients are in development.


3. PCI auditThe Care Quality Commission haveset a standard of 150 minutesdoor-to-balloon time for PPCI. This is a‘whole service’ standard since the timeinterval may include data collectionfrom the ambulance service, from anon-PPCI hospital and from the PPCIcentre. Data collection for around thisstandard is, therefore, more challengingthan for a simple door-to-balloon timewithin one institution. Nevertheless, it isimportant that we collect whole servicedata. It is equally important that theresults of PPCI are set in the context ofoutcomes of the total ST elevation MIpopulation to ensure that shocked andelderly patients, usually those withmost to gain from PPCI, are benefitingfrom appropriate access to primary PCI.

Supporting informationDepartment of Health (2008) Treatmentof Heart Attack National Guidance –Final Report of the NationalAngioplasty Project (NIAP).

NHS Improvement (2009) A Guide toImplementing Primary Angioplasty.

Primary PCI as the preferred reperfusiontherapy in STEMI: it is a matter of timeC J Terkelsen et al, Heart 2009;95:362-369.

www.improvement.nhs.uk/heart/reperfusion

Contact details

Carol MarleyNational Improvement LeadNHS [email protected]

Dr Jim McLenachanConsultant Cardiologist and NationalClinical Lead, NHS Improvement - [email protected]

Sheelagh MachinDirector - NHS [email protected]


Aims of the projectCardiac devices - Facilitate theimprovement of implantation rate andequity of access by working with keystakeholders.

Inherited cardiac conditions (ICC) -Support the review of ICC serviceprovision and framework for futurecommissioning and professionally ledperformance management.

Project overviewCardiac devices - To supportimprovement and facilitate localperformance review, two key elementswere addressed. The first was workingwith key stakeholders to help improvethe currently available deviceimplantation data, collated andpublished by the devices survey team,which had evolved from animplantation registry. The data wasreadily available as a national data setand could be commissioned as acardiac network specific review but dueto delays in registering implants waspublished a year in arrears. The secondelement recognised that improvingservice equity and provision could notbe achieved with one national solutionbut required local clinical leadershipand review to implement changetailored to each provider or network’scircumstances.

Inherited cardiac conditions - Thenational role was to facilitate andadvise service providers about themechanism for review andimprovement. Supporting the launchand dissemination of the Foundationfor Genomics and Population Health(PhG foundation) DH commissionedreport released in June 2008.

The national clinical leads worked tosupport key stakeholders in forming aprofessional clinical organisation theAssociation of Inherited CardiacConditions. The Association ofInherited Cardiac Conditions (AICC)brings together professionals from bothgenetics and cardiology who worktogether supporting patients andfamilies affected by and living with aninherited cardiac condition.

Results and achievementsThe cardiac devices national surveysubmissions have been reducedallowing the 2009 data to be releasedearlier than usual and a reduction of afurther six months is expected in 2010for the 2009 data. In addition, thenetwork specific reports have beenreleased earlier and funded for everynetwork. The expectation is that thefocus on earlier review of performancewill support and encourage networksand providers to address any localaccess and equity issues.

For inherited cardiac conditions, NHSImprovement hosted a very wellattended launch event for the Heart toHeart, a review of ICC servicesproduced by the PhG foundation.Further work between the PhG teamand DH has resulted in the SpecialistCommissioning Groups (SCG) agreeingto consider inherited cardiac conditionsservices as a priority in their designationtimetable for 2010/11. This work will belead by the Yorkshire and Humber SCG.

The Association for Inherited CardiacConditions has now completed theelections for council membership.

Next stepsCardiac devices - For some years theNetwork Device Survey Group haveprovided detailed information on the

number of implants of each type ofdevice within the UK, broken down byboth network and PCT. Their work hasdemonstrated a dramatic inequitybetween different PCTs and networks indevice implant rates for all three typesof device. Although the database onwhich the survey is based containssubstantial clinical information aboutthe clinical recipients of these devices,most of the emphasis hitherto has beenon device numbers rather than clinicalcharacteristics of recipients.

Whilst the intention for the comingyear is not for NHS improvement tofocus on cardiac devices as a nationalworkstream, it is hoped that developingand utilising this valuable informationwill act as a clinical audit tool, whichmight be used to help define andcompare patient populations for thebenefit of clinicians, networks,commissioners and ultimately patients.

Supporting informationFor further information visit thewebsites at:www.improvement.nhs.uk/heart/arrhythmiaswww.devicesurvey.comwww.phgfoundation.org

Contact details

Elaine KempNHS Improvement [email protected]

Dr Campbell CowanConsultant Cardiologist and NationalClinical Lead, NHS Improvement - [email protected]


Arrhythmia - cardiac devices andinherited cardiac conditions


• Queen Elizabeth Hospital, UniversityHospitals Birmingham NHSFoundation Trust and Good HopeHospital, Heart of England NHSFoundation Trust, BirminghamSandwell and Solihull Cardiac andStroke Network

• Royal Brompton and Harefield NHSFoundation Trust, North West LondonCardiac and Stroke Networks

• St George’s Healthcare NHS Trust,South London Cardiac and StrokeNetworks

• University Hospitals Birmingham NHSFoundation Trust: Queen ElizabethHospital, Heart of England NHSFoundation Trust, Good HopeHospital

• University Hospitals Leicester:Glenfield Hospital, East MidlandsCardiac and Stroke Network.

Aims of the projectThe attention focused on cardiacdiagnostics and 18 week pathwaysas part of the portfolio of workcoordinated by NHS Improvement -Heart during 2007/08 highlighted aneed to shift attention to cardiacsurgery to develop sustainablesolutions. Eight NHS Trusts supportedby their local cardiac networks wereinvolved as demonstration sites during2008/09 testing out new approaches tocare and improvement to frontlinepatient services. The focus of workundertaken by these sites considered tobe constraints within the managementof smooth patient flows included thefollowing:

• Optimising surgical work upthrough models of preassessment

• Referral management• Theatre scheduling• Post operative length of stay anddischarge management.

Project overviewThe eight NHS Trusts supported by theirlocal cardiac networks that participatedas lead demonstration sites in thecardiac surgery project were:

• Basildon and Thurrock UniversityHospitals NHS Foundation Trust,Essex Cardiothoracic Centre, EssexCardiac and Stroke Network

• Blackpool, Fylde and Wyre HospitalsNHS Foundation Trust, Royal VictoriaHospital, Cardiac and StrokeNetworks in Lancashire and Cumbria

• Papworth Hospital NHS FoundationTrust, Anglia Cardiac and StrokeNetwork

Sustaining cardiac pathways - cardiac surgery

Results and achievementsLessons drawn from the demonstrationsites suggest that quality improvementto elective and non elective cardiacsurgery services requires smarterworking, the enhancement of staffroles and a shared overview of thepatient journey and patient experienceacross referring providers and thetertiary centre.


1. Referral management servicesThere 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 pointsthrough 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 referralmanagement linking clinical teams across secondary and tertiary care to triage referrals and advise onappropriate 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 trainedclinical coordinator is pivotal in tracking individual patients and in ensuring the consultant team is keptinformed 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 outinvestigations 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 beuse 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 preoperative protocols.

• Maximize patient work up prior to admission and agree the schedule for each clinical scenario for example surgeryfor 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 andreconfigure services to develop opportunities for other health care professionals to widen their skills andscope of relationship with patients. An example is the patient ‘navigator’ role which benefits patients and families byproviding 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 aspart 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 allpatients presenting for surgery will be adequately assessed as this can reduce cancellation rates, improveoperating theatre efficiency and increase patient satisfaction.

• Continue to provide information and support.

Improvement to the patient pathway - summary of recommendations


4. Discharge and post operative care management• Manage variation in post operative clinical management practice.• Manage variation in discharge patterns reducing length of stay.• Start discharge planning at pre assessment to identify requirement forsupport and home aids to reduce requirement for delayed discharge.

• Involve a range of health care professionals for example occupationaltherapists in discharge planning at pre assessment particularly wherepatients and in particular the elderly may have complex needs.

• Discharge assessment should form part of the central patient recordavailable throughout the patient journey to all staff groups.

• Move toward nurse led discharge.

Next stepsThe portfolio of work for 2010/11 willinclude a focus on non elective careincorporating cardiology and cardiacsurgery. For an informal discussionplease contact either:

Garry [email protected]

Wendy [email protected]

Rhuari [email protected]

Networks and organisations will beinvited to submit an expression ofinterest and further details will beannounced during April.

Supporting informationA Guide to Commissioning CardiacSurgical Services (February 2010) aimsto share the lessons drawn fromdemonstration sites participating in theCardiac Surgery National Priority Projectof 2008/09 with the wider NHS.This document identifies a range ofinitiatives that have been successfully

employed in meeting the challenge of18 weeks in elective surgery whichinevitably required the focus to extendto systems and processes that supportthe whole surgical process, elective orotherwise.

Resources developed by thedemonstration sites are availablethrough the web links and NHSImprovement system atwww.improvement.nhs.uk/heart/sustainability

Contact details

Wendy GrayNational Improvement [email protected]: 07884 003659

Steve LiveseyConsultant Cardiac Surgeon andNational Clinical Lead, NHSImprovement - [email protected]

Gordon MurrayConsultant Cardiologist andNational Clinical Lead, NHSImprovement - [email protected]

3. Scheduling• Move toward day of surgeryadmission as the standard ofcare for elective surgery asthis can improve the patientexperience considerably.

• Maximize theatre efficiencyby reducing waste in thesystem for example right staffin place at the right timeswith the right equipment.

• Optimise theatre capacity byreducing slot cancellations(clinical/non clinical) and byscheduling procedures thatassist with patient flowthrough intensive treatmentunit/high dependency unit(ITU/HDU).

• Where ever possible pool liststo reduce waiting times.

• Procedure complexity scoresdeveloped to assist withscheduling developed as partof the multidisciplinary team.

Heart failure

Piloting, testing and promotinggood quality, systematic, heartfailure services across all areas ofdeliveryKey messages from the 2008/09National Priority Heart Failure Projectshelped inform the five areas needed toprovide a good heart failure service thatare listed in NHS 2010-2015: fromgood to great, preventative, people-centred, productive. (DH Dec 2009).

The five areas can be summarised as:1. Early, accurate diagnosis inprimary and secondary care: Brainnatriuretic peptide (BNP) testing,echo, rapid access heart failureclinics.

2. Optimising management: Up-titration of medication, cardiacrehabilitation, patient education andself-management, and considerationfor devices.

3. Integrated care: between primaryand secondary care to provide aseamless service, but also to includesocial care where needed.

4. Care coordinators: to help navigatepatients with multiple co-morbiditiesthrough complex care plans.

5. End of life care: good symptomcontrol and support services shouldbe provided where and whenneeded by patients, in all settings -community, hospice, and hospital.

The 2008/09 projects that helpedinform that document:

Whole pathway projects• Heart failure self management -Bassetlaw: Use of a group educationprogramme to empower patients toself manage their condition and pilotthe use of social return on investmentto gauge its’ impact.

• Local enhanced service forpatients with left ventriculardysfunction in primary care -Central Manchester: Reducingadmissions (30% reduction) andreadmissions (50% reduction)through optimising medication andregular review of heart failurepatients in GP surgeries.

• An integrated model of heartfailure care - East Riding ofYorkshire: Using simulation softwareto model potential savings fromintroducing BNP testing to primarycare and testing the model, whilstalso setting up a fully integratedservice for identified heart failurepatients across primary andsecondary care (still in progress).

• Reducing length of inpatient stay- Essex: Reducing the average lengthof stay for primary diagnosis heartfailure admissions by more than twodays (reduction in annual bed days of1,250) by improving and integratingthe primary and secondary carepathways and introducing NT-proBNPto identify patients and prioritiseecho.

Admissionspermillionpopulation

%LES

Intro

duced

Period

Central Manchester: Number of admissions per million population forheart failure per four quarter period (lines vs %LES introduced (bars))

LES Training Pre LES LES Non LES



• Developing community heartfailure services - Southwark:Establishing a community heartfailure service for the people ofSouthwark and ensure that theservice suits the black and ethnicminority (BME) and femalepopulation by providing clinics closerto home (still in progress).

• Improvement of heart failurediagnosis and management inNorth Staffordshire and Stoke:Improving diagnosis andmanagement of patients with leftventricular systolic dysfunction acrossNorth Staffordshire and Shropshire, inboth primary and secondary care, byincreasing heart failure specialistnurses, streamlining access todiagnostics (echo and BNP) andincreasing specialist involvement(moving to phase 2 in April 2010).

• Improving the Acute Heart FailurePathway - West Hertfordshire:Using BNP testing on admission tohospital to speed up accuratediagnosis, get the patient onto theright care pathway and reducereadmissions and length of stay(readmissions reduced by 30%).

End of life projects• Promoting access to end of lifecare provision within a culturallydiverse community - Brent:Developing a multi-disciplinarycommunity service, improving qualityand accessibility, and preventingunwanted admissions and A&Eattendances (still in progress).

• Developing symptom controlguidelines for heart failure, up toand including the end of life -North Lincolnshire and Goole:Improving knowledge and confidencein symptom control, for all providersand whatever the setting.

• Enhancing end of life care forheart failure patients -Northampton: Developingguidelines, protocols and referralpathways to deliver a model for endof life care in all settings.

• Improvements in palliative care -referral and pathwaydevelopment - West Surrey:Providing a 24 hour communityservice involving all service providersworking together (still in progress).

• Supportive and palliative care forheart failure - Sussex: Improvingsymptom control out of the acutesetting, by joint working withpalliative and community services.

Why is end of life care in heartfailure so important?Because the cost, both human andfinancial, is so great when it goeswrong. The case study (on page 17) isof a real heart failure patient and chartsthe 12 admissions and 21 further A&Eattendances in her last year of life.

Essex: Length of stay (LoS) by monthly discharges - Primary diagnosisof heart failure

Next stepsThere is potential in all these five areasto improve the quality of heart failureservices and also to improveproductivity and our work for 2010-11and beyond is to both test and spreadthe ways that these can be done.

Contact details

Candy JeffriesNational Improvement LeadTel: 0116 222 [email protected]

Dr James BeattieConsultant Cardiologist and NationalClinical Lead, NHS Improvement - [email protected]

Mike ConnollyMacmillan Nurse Consultant inSupportive and Palliative Care andNational Clinical Lead, NHSImprovement - [email protected]

David WalkerConsultant Cardiologist and NationalClinical Lead, NHS Improvement - [email protected]


www. improvement.nhs.uk/heart/heartfailure

AD

MIS

SIO

N HH

H

H

HH

HH H

H H

H

SEPT07

OCT07

NOV07

DEC07

JAN08

FEB08

MAR08

APR08

MAY08

JUN08

JUL08

AUG08

4DAYS

12DAYS

9DAYS 4

DAYS9

DAYS 5DAYS

9DAYS

7DAYS

1DAY 4

DAYS

3DAYS

17DAYS

DIED

TOTAL of admissions = 84 bed days

Case History: Nora P.

There are potential savings of£20,000+ if these admissions andA&E attendances were avoided



Cardiac rehabilitation

Aims of the projectThe overall aim of this project, whichbegan in September 2008, continues tobe improved access, equity of provisionand better uptake to quality cardiacrehabilitation (CR) services for heartattack, angioplasty and coronary arterybypass grafts (CABG) patients. TheNICE recommendations on cardiacrehabilitation (NICE clinical guidelinesCG48 on myocardial infarction (MI):secondary prevention) and the NICEcommissioning guide on cardiacrehabilitation were used as a resourceto support improved commissioning.The projects have worked closely withproviders, commissioners, patients andcarers in planning services; shapingworkforce and multi-disciplinary teamapproaches.

Project overviewNHS Improvement cardiac rehabilitationprojects have included 16 sites across12 networks. The project sites are:

1. Derbyshire County PCT2. South West and East London

Cardiac and Stroke Networks3. North Lincolnshire and Goole

NHS Trust4. Dorset Cardiac and Stroke Network5. NHS North of Tyne, North of

England Cardiovascular Network6. Shropshire and Staffordshire Heart

and Stroke Network7. Surrey Heart and Stroke Network8. Black Country Cardiovascular

Network9. North West London Cardiac and

Stroke Network – PPCI project10.Peninsula Heart and Stroke

Network.

Two further projects joined the nationalprogramme at the end of 200911.MyAction Westminster12.North Yorkshire and York PCT.

The emphasis varies within in eachproject however most of the projectsinvolved redesign of services with aview to commissioning integratedservices across an area, or advisingcommissioners of their next steps inservice commissioning. All of theprojects worked on inequities,increasing uptake and timely access toservices, involvement of patients andcarers in informing redesign andimproved information.

Approach takenWorking with cardiac networks,individual PCTs and Trusts, projectteams were supported by a series of

two monthly meetings, to devisesolutions and share their learning. Ledby the national improvement lead andnational clinical lead for cardiacrehabilitation at NHS Improvement andsupported by the national clinicaladvisor these meetings proved a verysuccessful method of providing peersupport. Learning about wider nationalissues such as work around tariffnegotiations, combined with otherprojects proved invaluable toprogressing individual projects.

Project teams shared learning via theNHS Improvement System and on awebsite giving both the project teamsand the wider NHS access to materialfrom the project team days, widerinformation relevant to cardiacrehabilitation, news about tariff andlinks to other areas of interest.

Where required one-to-one support atthe improvement site was undertakenby the national programme lead andnational clinical lead. This wasespecially useful in specificationdevelopment and procurement events.

The team has also supported tariffdevelopment in rehabilitation whichhas helped projects with commissioningand business case initiatives.

Results and achievementsThe main outputs of the projectshave been:

• Redesign of service pathways• Production of detailed servicespecifications and business cases

• One project undertaking fullprocurement

• New and innovative service modelse.g. heart failure rehabilitation incommunity

• Increase in numbers undertakingrehabilitation

• Improved equity of access• Reduced waiting times for CR• Clinical pathway development toensure uptake of rehabilitation forPPCI patients

• Economies of scale by integrationwith national heart failure, cardiacsurgery and PPCI programmes.

Many of the outcomes from theprojects meet the quality, innovationand productivity (QIPP) agenda. Theseinclude:

QUALITY - (Safety) Centralised referraland patient tracking, standardisedprotocols and procedures, riskstratification forms, governancestandards, skills competencyassessment, service specifications

(Effectiveness), new community andhome based programme for ischaemicheart disease (IHD), outcome measures,clear management plans, effective useof staff and programmes. (Experience)Increased patient choice, care providedcloser to home, improved patientinformationINNOVATION - Rehab-led follow up,drug therapy reviews, local task groupacting to coordinate all qualityinitiativesPRODUCTIVITY - Increased number ofpatients accessing rehab, reduced handoffs, using and scheduling staff moreeffectively, rehab led follow up –reduces need for outpatient departmentattendance, production of businesscase for CR.

A major strength of NHS Improvementhas been the ability to share expertiseand experiences across the differentworkstreams which has clearly led togreater productivity and qualityoutcomes benefiting other aspects ofNHS service delivery. This has placedCR in the driving seat for steeringnational initiatives such as tariffimplementation and commissioning.

Now is not a time for standing stillrather it is time to invest in NHSImprovement and engage withthe quality and productivityagenda. I believe CR is one of thebest quality and productivity casesaround and that the CR priorityprojects has the appropriate focusand skills to deliver serviceredesign, innovative commissioningand improved quality”.

Professor Patrick DohertyNational Clinical Lead NHS Improvement

Next stepsNHS Improvement is jointly leading thedevelopment of a CR CommissioningPack for PCTs with the StrategicDevelopment Unit at the Departmentof Health. NHS Improvement will takeresponsibility and lead a national roll-out of the Commissioning Pack fromJune 2010 which will aim, within thecontext of quality and productivity, toincrease the numbers of patientsreceiving a quality cardiac rehabilitationservice.

Supporting informationCardiac Rehabilitation National Priorityproject: Lessons and learning one yearon…. (October 2009).

Contact details

Linda BinderNational Improvement [email protected]

Professor Patrick DohertyNational Clinical [email protected]

Dr Jane Flint,National Clinical [email protected]

Julie [email protected]

www.improvement.nhs.uk/heart/cardiacrehabilitation


“


NHS Improvement System

What is it?The NHS Improvement System is acomprehensive, online tool to supportsharing of quality service improvementresources in NHS services. Giving youdirect access to useful information andstories from around the country, it willassist you in your own serviceimprovement work.

Why use it?The NHS Improvement System activelyhelps organisations to effectivelyachieve their objectives in line withWorld Class Commissioning. It enablesusers to be more strategic and alignlong-term goals that can help to deliverhigh quality, patient focussed healthoutcomes.

Which specialties are included?The system can be used to supportsustainable service improvementin any specialty.

What does it contain?• Service improvement toolsand resources

• Practical guidance• Case studies• Useful contacts• Signposting and links.

Where can I see ademonstration of the system?Demonstrations of some of the keymodules are available on theimprovement system home page at:www.improvement.nhs.uk/improvementsystem

Who can use the system?The system is free of charge and can beused by all staff working for NHSorganisations in England.

How can I register to use thesystem?Access to the system is controlledby user ID and password.

To request an ID [email protected]

A guide to commissioningcardiac surgical servicesEight NHS Trusts supported by theirlocal cardiac networks were involved asdemonstration sites during 2008/09 inthe Cardiac Surgery National PriorityProject. Lessons drawn from these sitesare outlined in the publication 'A Guideto Commissioning Cardiac SurgicalServices' (March 2010).

Cardiac Rehabilitation - NationalPriority Projects: Lessons andlearning one year on...Cardiac rehabilitation (CR) is a nationalpriority project of NHS Improvementfocusing on increasing the access to,equity of provision and uptake of CRservices for heart attack, angioplastyand CABG patients. The projectsummaries include issues to beaddressed, baseline position, actionstaken, key learning, QIPP outcomes andresults to date from the 11 projectsparticipating in this work (October2009).

A Guide to ImplementingPrimary AngioplastySince the publication of new nationalgood practice guidance on treatmentof heart attack, NHS Improvement haslooked at the major issues andobstacles to implementing primarypercutaneous coronary angioplasty(PPCI) services across England and allthe learning has now been pulledtogether in a useful implementationguide (June 2009).

Delivering the NHS Health Check: APractical Guide to Point of CareTestingIdentifies some of the pros and cons tothe use of Point of Care Testing (POCT)as well as practical ‘solutions’ andlearning from the field (November2009).

Heart Failure - A quick guide toquality commissioning across thewhole pathway of careThis practical guide sets out to helpcommissioners develop integrated heartfailure services by highlighting evidencebased practice and measurableoutcomes. It draws on the NICECommissioning Guidelines (Feb 2008),Our NHS Our Future (specifically longterm conditions, urgent care and endof life). (September 2008).

Atrial fibrillation in primary care:making an impact on strokepreventionThis document aims to capture the finalsummary of their individual approach,lessons learned, improvements topractice and quality outcomes, alsosharing tools and resources developedto enable other health communities todrive this agenda forward (October2009).

Commissioning for StrokePrevention in Primary Care: the roleof Atrial FibrillationDeveloped following a nationalconsensus meeting of opinion leadersin the field, this document is to developa concerted strategy towards themanagement of AF in primary care, inparticular anticoagulant managementand its significance in relation toreduction in the risk of stroke (June2009).

National Priority Projects 2007/08Summary DocumentsSummary documents from the HeartImprovement Programme’s 2007/08national priority projects:• Making Best Use of Inpatient Beds• Atrial Fibrillation in Primary Care• 18 Weeks Whole Pathways• 18 Weeks - Focus on CardiacDiagnostics.

Guidance on Risk Assessmentand Stroke Prevention for AtrialFibrillation (GRASP-AF) ToolThis tool should be used as partof a systematic approach to theidentification, diagnosis and optimalmanagement of patients with AFto reduce their risk of stroke.www.improvement.nhs.uk/graspaf

Using Discovery Interviewsto improve carewww.improvement.nhs.uk/discoveryinterviews

Improving Cardiac PatientPathways: The SustainabilityToolkitwww.improvement.nhs.uk/heart/sustainability

The Cardiac Data Dashbordwww.improvement.nhs.uk/heart/dashboard

Resources

All the publications listed beloware available to download at:www.improvement.nhs.uk/publications

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

With over ten years practical service improvement experience in cancer,diagnostics and heart, NHS Improvement aims to achieve sustainableeffective pathways and systems, share improvement resources andlearning, increase impact and ensure value for money to improve theefficiency and quality of NHS services.

Working with clinical networks and NHS organisations across England,NHS Improvement helps to transform, deliver and build sustainableimprovements across the entire pathway of care in cancer, diagnostics,heart, lung and stroke services.

Delivering tomorrow’simprovement agendafor the NHS

HEART

LUNG

CANCER

DIAGNOSTICS

STROKE

©NHSImprovement2010

|AllRightsReserved

|March2010

Health & Medicine

Continuing to Improve Cardiac Services - National Project Summaries 2009/10