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Providing integrated heart failure care

Heart failure patients are being offered a new lease of life through a collaborative service provided by a local hospital, PCT and GP surgeries. Dr Richard Price explains

Heart failure patients are being offered a new lease of life through a collaborative service provided by a local hospital, PCT and GP surgeries. Dr Richard Price explains

A community heart failure service was launched in Redbridge PCT in east London two months ago, to help diagnose and treat people outside the hospital environment.

The idea was originally proposed by Redbridge's three practice-based commissioning clusters.

The clusters had played a key role in successfully promoting the widespread introduction of low-cost statins during 2007, as previously featured in this magazine (see ‘A prescription for change in statin prescribing' at In return, the PCT agreed that some of the £1m savings made from the medicines management budget would be used to help set up the heart failure service.

A hidden problem

At present, there are approximately 1,400 patients registered with heart failure in Redbridge although the real figure could be as high as 2,600, given the national trend for underdiagnosis of heart failure.

Around 600 of these individuals will have either been recently discharged from hospital or be at a high risk of admission. National statistics show 50% of patients die within two years of being diagnosed with heart failure.

However, the prognosis improves if patients receive out-of-hospital care for even a short period of time after being discharged. Deployment of specialist nurses and dedicated primary care clinics have produced an improvement in the quality of patients' lives as well as a 30% fall in readmissions elsewhere in the UK.

We wanted our service to monitor patients who had suffered heart failure and been discharged from hospital, as well as to identify those who had a potential heart condition.

Its goals would be to:

• improve access to heart failure services

• improve level and quality of treatment

• ensure better diagnosis of heart conditions

• improve patients' quality of life

• reduce hospital admissions and readmissions

• create a seamless service between primary and secondary care

• provide a dedicated training programme for local practitioners

• help meet the 18-week target for referring patients to receive treatment.

Improved care more important than savings

The business case for the service was modelled on national best practice and advice from the North East London Cardiac Network. It was developed by a steering group of local clinicians, managers and key stakeholders.

The business case identified the benefits of improving the care pathway – patients would not need to go to hospital to have medication changes, and would improve their ability to self-manage and gain knowledge of their own condition.

Cost savings of up to £350,000 per year were also identified, from potential reductions in non-elective admissions, but our emphasis was on improving care for patients, not cutting costs.

The plans also set out the costs of the service – between £250,000-£300,000 per year to cover staff costs, administrative support, accreditation costs and a continuing professional development programme for GP practices.

The service's five person team comprises:

• two GPSIs working on a sessional basis (and more are likely to be taken on once they are accredited)

• one heart failure nurse seconded from Whipps Cross Hospital

• three other nurses currently being recruited to work in Redbridge PCT.

The team operates from three large health centres in the community, is accredited by a consultant cardiologist at Whipps Cross and meets periodically to review cases.

The service operates on three levels, depending on the condition of the patient.

• Level 1 – patient self-care supported by GP practice team.

BNP testing may be available as a laboratory-based blood test to all practices at a later date, to allow GPs to rule out heart failure as a diagnosis. The test is not often used in primary care at the moment – however, its use is being reviewed by the North East London Cardiac Network, which will advise on how the test should be used.

• Level 2 – practices trained and supported to provide an enhanced level of care to patients discharged from hospital.

Practices will be supported by specialist nurses, who help identify additional people in need of enhanced support (see pathway, above right). Additional funding will allow a higher standard of examination and treatment, including fluid status and weight, chest X-rays and blood tests.

• Level 3 – specialist nurses work with practices to identify individuals most at risk of admission or readmission due to heart failure, through use of the Patients at Risk of Readmission Tool.

Specialist treatment and advice will be provided in sessions run by GPSIs and specialist nurses, whose skills will include reading echocardiograms and drawing up an appropriate treatment and management plan and monitoring individual patients.

Patients with complex conditions are fast-tracked to hospital.

The service has launched with GPSI clinics, initially concentrating on diagnosing new patients with suspected heart failure who are referred by GP practices. The next stage of implementation will be to discharge patients from secondary care into the service.

A stakeholder event was held involving current heart failure patients and they raised no major concerns about not being treated by their own GP, as long as they were treated by a professional who knew about their condition and was competent to look after them.

The patient's own GP will be updated on the care plan and the ultimate aim is to discharge patients back to their GP with a management plan.

It is early days for the service, but it has potential not only to prevent hospital admissions and improve self-management, but also to identify patients with milder forms of heart failure who may not realise they have the condition, so interventions can be made at an earlier stage and clinical outcomes can be improved.

Primary care is playing an increasingly important role in areas previously the sole domain of hospitals. We know that patients prefer community-based services, and initiatives like the community heart failure service are a step in the right direction.

Cardiology GPSI Dr Harjit Singh (centre) and team members involved in setting up the community heart failure service 60 second summary GPSI view of the new service

Dr Harjit Singh is a GPSI based at Granville Medical Centre in Redbridge and one of the driving forces behind the introduction of the community heart failure service.

He says: ‘I have seen at first hand the debilitating effects of people recovering from heart failure in my surgery and this service will help improve their quality of life.

‘It's a good example of everyone working in partnership to raise the standard of healthcare and will dovetail with the work of hospitals and their treatment of heart failure patients.

‘Nowadays, GPs are increasingly called upon to have an area of special expertise above and beyond their normal day-to-day skills and mine is cardiology.
I think the team can make a real difference and look forward to the benefits it will bring.'

The long-term aim is to identify patients who may not realise they have mild heart failure

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