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