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At the heart of general practice since 1960

How our echocardiogram service turned round patient care

GP Dr Mohamed Roshan explains how his one-stop heart failure service ensures patients receive a speedy diagnosis and prompt management

GP Dr Mohamed Roshan explains how his one-stop heart failure service ensures patients receive a speedy diagnosis and prompt management

A large proportion of Leicester City's population is of Indo-Asian origin – a group known to have a high rate of CHD and heart failure. Recurrent hospital admissions and inherent difficulties in diagnosis mean a significant NHS spend on cardiology outpatient referrals for both access to echocardiography and consultant opinion on management.

41231092For most patients, cardiac failure can be managed well in the community and patient research showed me this was an area of high priority for the local population.

This prompted me to set up a community heart failure project in my surgery and we now have a one-stop service offering an echocardiogram, diagnosis and management plan all in one visit.

Having access to a local centre is particularly helpful for patients who suffer from cardiac failure as they tend to be elderly and have co-morbidities. Not only is it more convenient, but local centres are usually smaller and less intimidating than a specialist cardiac centre.

About 300 patients have been seen over the last two years – each one receiving one or two appointments at 70% of the hospital tariff and avoiding another two or three appointments entirely.

The time taken to make a diagnosis and start patients on the correct treatment has been cut from what could be several months to two weeks.

Idea development

Previously, anyone with shortness of breath and suspected heart failure had to be referred for an outpatient appointment with a consultant, return to the hospital for an echocardiogram, attend again for the results and the management plan and then return for review. This meant an average of four visits to the hospital.

At the time I was thinking of setting up the one-stop service, PBC was not well established in Leicester City – the consortium I am now in was only just being set up – so the project was set up as a single practice-based service (still under PBC) covering the whole of the City of Leicester PCT.

Referrals now come from consortium GPs as we are in the same locality. I proposed a service to the PCT whereby everything was done locally and at one visit the patient would:

• have a detailed history and examination carried out by myself as well as an ECG
• have an echocardiogram
• receive a diagnosis
• be started on the correct management plan and have any other relevant investigations started.

I had the idea for the plan around September 2006, and had PCT approval by February 2007. The service started in July of that year and was key to getting the scheme off the ground.

There were no problems getting the business plan approved as I had pre-empted a lot of the questions I thought I might be asked.

Business plan

I spoke to the PCT early on to find out whether the project was something they would want to support. If it hadn't fitted into their operating plan and strategy I would have been wasting my time putting a business plan together.

I spent about six months working on the business case and made sure it covered the areas important to the PCT: patient need, what the benefit was going to be, cost-effectiveness, how governance would take place, how people would be referred if they needed hospital care and also the intervention itself – making sure the patients were treated and referring GPs were getting the report back very quickly. The business plan ticked many boxes.

To demonstrate an identifiable need for such a service in the area, I spoke to patient groups and researched public health data which showed that CHD, including heart failure, was the foremost medical problem for the locality. I now had statistics to back me up.

I also had examples of data from other similar schemes which had been set up around the country. The service was approved by the PCT under the any willing provider model.

Staffing

One of the main challenges has been getting a formal connection with the local cardio-thoracic unit. We do get an excellent service from them for patients who need onward referral. I would, however, like to get engagement from the centre so that the service could be even more firmed up and some formal supervision could be put in place.

The community cardiac failure specialist nurses were supportive and they now work with the project following up some of the patients in the community.

Start-up costs were minimal as premises and staff were already in place. I did not have to buy the equipment, very little extra space had to be found for it and the staff needed for the project were already employed by the practice and just had a small increase in hours.

The project has gone remarkably smoothly. The PCT managers were very helpful on this occasion, and I think this is because it was a plan waiting to happen.

The PCT was looking for a safe, accessible, cost-effective and good-quality project and that is what I proposed. Having an accessible radiology service and better collaboration with the hospital is still on my wish-list for future developments.

Sourcing the diagnostics

We have commissioned a private national company called Echotech to provide the echocardiograms. I read in a magazine article how they had won a contract to provide echocardiograms for West Midlands PCT. We chose them mainly because they have very robust clinical governance policies in place, with independent cardiologists assessing the echocardiograms periodically to ensure reporting standards are high.

Also they were willing to charge on a cost-per-case basis, rather than the block contracts which other companies we looked at were offering, which makes it more cost-efficient.

Another advantage of Echotech is that if we do have to refer to secondary care, they are happy to transfer the whole tape of the echocardiogram rather than just sending a report, meaning the cardiologist we refer to doesn't have to do another echocardiogram.

They charge substantially lower than the tariff rate of approximately £90 for an echocardiogram. As this rate is now more affordable, where I previously carried out a BNP test to see whether to do an echocardiogram, I now no longer do that but instead go straight to the echocardiogram.

Clinic logistics

Potentially 63 practices can access the service. In reality about 12 in the locality – roughly 35,000 patients – use the service actively. Those further away would not get the access advantages.

At the moment I am doing one three-and-a-half hour session a week, in which I see between five and seven patients. I have seen about 300-400 patients over the last two years.I have an administrator who arranges appointments and sends out letters, reports and results. Echotech provides a technician to come in and do regular echocardiograms.

There is no set time for the clinic – Echotech come in to the surgery on a weekly basis but will be flexible at times of varying demand.

Once they attend, I see the patient together with the practice nurse. They are assessed, have an ECG and blood tests which are done by the practice staff and then the echocardiogram is done by Echotech. The patient then comes back to see me for the management plan. The echocardiogram is analysed and reported on by the technician.

If they are found to have cardiac failure (about 50% of patients) they are started on treatment in line with guidelines. The patient is seen again after three weeks to ensure everything is progressing well. If necessary they are monitored at home by the community cardiac failure specialist nurses. If they are found not to have heart failure, they are sent straight back to their own GP.

If the patient's condition is serious or urgent they are referred on to acute care, but most patients simply require medication and only a minority need secondary care involvement.

Outcomes

The referral form (see attached) has a box for GPs to tick if they would otherwise have sent the patient to secondary care so I know how many referrals have been avoided. So far that box has been ticked on 100% of patients – each one an avoided referral. This is good news financially for the PCT and good news for the patient, who has not had to travel to several different appointments further away.

An unexpected development is that GPs are now referring patients to me for echocardiograms not just because they suspect heart failure but also for other reasons to avoid a two-month waiting list at the hospital (I can see them in two weeks).

I charge a lower rate than the cardiac failure tariff for these patients as they do not need to see a doctor – they just come in and see the technician who carries out the echocardiogram and the report is sent to the patient's own GP.

The scheme has already made substantial savings. Charges for appointments are 70% of those at the hospital. The tariff for a first hospital outpatient's appointment is £170 which includes the echo and I charge £119.

A follow-up hospital appointment is £80 whereas I charge £56.

There are further savings in the number of appointments needed. If a patient is referred to hospital they may have to go there four times, whereas 50% of patients just have one appointment with me and the other 50% attend twice.

The potential saving for each patient I see twice is £235. Even taking as an average a very conservative £100 saved per patient, this is £30,000 in savings so far.

But for me the best result is that patients have to make one or two journeys to a local surgery rather than four to the hospital. The 50% who turn out not to have cardiac failure can be reassured very quickly – within two weeks rather than four months of worrying.

Those who do have heart failure can be started immediately on treatment. For any urgent cases, I liaise with secondary care and pass on the results of the echocardiogram.A necdotal feedback from patients has been very complimentary, and GPs are telling me they are very pleased with the service and the quick response they get.

In the future I would like to get some projects off the ground as a consortium rather than as a single practice-based scheme. These include providing investigations for ischaemic heart disease – for instance safe exercise electrocardiography in the community.

I would also like to provide community services for managing atrial fibrillation and arrhythmias. We hope to get at least one of these off the ground within the next year.

Dr Mohamed Roshan is a GP in Leicester

Having access to a local centre is particularly helpful for patients who suffer from cardiac failure as they tend to be elderly Having access to a local centre is particularly helpful for patients who suffer from cardiac failure as they tend to be elderly 60-second summary Cardiac failure referral form

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