Unnecessary hospital admissions are bad for the patient and expensive for commissioners. Inpatient care makes up the majority of the costs of heart failure treatment, and there are evidence-based interventions that reduce hospital admissions, and prolong life, that are not being implemented in practice.
In 2007, admissions from central Manchester practices were running at about four per 1,000 population per year, and around one patient in four was being readmitted again soon after discharge. This was much higher than other areas, and was attributed to Manchester having high levels of ‘deprivation'. There is a large tertiary cardiology centre in the middle of our patch – but no community heart failure service.
I wanted to challenge the notion that we should accept poor performance just because we work in a deprived area.
What we did
The first step was to persuade people in the PCT and the tertiary cardiologists that it might be possible to make a difference to the patients. I devised a local enhanced service (LES) specification (see below) based on NICE guidelines for heart failure management, which included patient education. The business case was made on projected outpatient savings, and I was able to win the argument to run it as a pilot.
I then had to devise an education programme and accreditation process for practices. One GP and one practice nurse from each practice needed to be accredited. I persuaded the local cardiology department to get involved, and they presented a one-day educational session.
The GP and practice nurse then attended at least three outpatient clinics, with a doctor and specialist nurse respectively. Each practice also had to undertake an audit of its care and a significant-event analysis of one of its a hospital admissions. These were presented at an accreditation meeting, alongside a description of how the practice intended to deliver the LES.
Five practices were successful on the first occasion, and a further five were accredited two years later. Since the LES began, we have been meeting about three times a year to discuss developments in heart failure, progress of the LES within practices and any problems we have encountered.
The heart failure LES is very much about implementing evidence-based interventions. Doctors are educated in those interventions and are responsible for up-titration of medication, regular review and for referral back to a specialist if necessary.
The task for the practice nurses is equally important, as they educate the patient and manage their concerns. Patients are taught to monitor themselves – in particular, they note their symptoms and weigh themselves regularly.
They are encouraged to contact the surgery, often through the practice nurse, if their symptoms deteriorate. They are also asked to make contact if they put on more than one kilogram in a day or two in a week, or if symptoms get worse. In that way the practice can intervene before the patient gets so ill they need admission.
With increased confidence, practices can manage people at the end of life and don't feel they need to rush patients into hospital when they deteriorate. Advanced care planning – set up back in 2007 in the Manchester area – can be more easily discussed and patients enabled to stay at home if they wish.
Along the way, several lessons have been learned. These things take a long time to set up, so there needs to be a willing champion to carry the programme through difficulties and hard times.
The main problem was getting the LES to be accepted by the PCT and, in particular, its finance committee. These days it should be easier with the CCGs, but a sound business case will still need to be made.
It was vital to get the confidence of the secondary and tertiary care consultants. This was done by persuading them of the potential benefits and involving them in the accreditation and education programme.
Finally, I had to persuade a handful of practices that it was worth the effort and expense. To help things along they were given an education grant to cover attendance at the outpatient clinics.
For the LES practices, admissions fell to about 2.4 patients per 1,000 per year and readmissions to 0.6 per 1,000 per year within a year, and continued to fall to 1.6 and 0.2 admissions and readmissions respectively. They have stabilised at about this level since.
The cost of heart failure admissions added to the cost of running the LES is about £1,500 per 1,000 population covered by the LES practices per year. The cost for the population not covered by the LES is about £2,500 per 1,000 per year.
Stable heart failure patients, currently being followed up as outpatients, have now been discharged back to their practices for routine follow-up. There is an understanding that they can be referred back if necessary.
Although not quantifiable, another outcome has been to develop relationships between GPs and specialists, and practice nurses and specialist nurses.
The GP ensures gradual up-titration of medication and support for the practice nurse. The practice nurse's role is vital to patient education, as well as being a contact in the practice for the patient for advice (and monitoring if necessary).
One of the big advantages of this model is that there is a ‘vertical' relationship developed between the GP and practice nurse and the hospital team.
Stable heart failure patients being followed up in outpatients have often been discharged to LES practices – and this saving has not been included in the costings of the LES, but is considered an extra financial benefit.
The main benefit has been to keep people – often towards the end of their lives – well enough to stay out of hospital. This outcome is priceless.
There have been other spin-offs. The hospital acute trust has become more confident that primary care can deliver change and provide high-quality management for our patients. This has allowed us to develop other areas of patient care.
We now have a clinical integrated care board that examines planned and urgent care and has started to develop integrated community teams. We have been able to dramatically reduce urgent and planned care activity too.
For the immediate future, we are rolling
out the LES to another five or so practices.
I have also been able to persuade the CCG that we can use the same model to improve on diabetes care in central Manchester, where again we are said to be trailing others due to having a deprived population.
In Manchester, we perform less well than we could in diabetes care. There is a high admission rate and QOF indicators fall lower than the national average. When we audited referrals to secondary care, about one in three could have been managed by an up-skilled practice.
Thanks to the success of the heart failure model, the CCG has been able to invest in an education programme and LES for diabetes. The outcomes have so far been better QOF performance, fewer outpatient referrals and few urgent admissions for hypo- or hyperglycaemia.
In addition, we would like to use this LES to get practices that haven't been trained for the diabetes LES to refer to LES practices if the problem is glycaemic or one of blood pressure control.
Finally, by identifying and optimally managing cardiovascular disease, we aim to reduce the gap in life expectancy between our ‘deprived' population and the rest of the country by one out of the three years it stands at currently.
Dr Ivan Benett is a GPSI in cardiology and clinical director for Central Manchester CCG
The LVSD LES
The LES specifically targeted specialised services for patients with left ventricular systolic dysfunction (LVSD) in primary care, and its stated aims were to improve the quality of care, wellbeing and satisfaction of patients with LVSD, and to reduce hospital admissions in the same group.
Clinicians were instructed to register patients who had LVSD, to perform an ECG to confirm diagnosis and to get patients onto a maximum tolerable dose of ACE inhibitors or ARBs before being seen by a cardiologist to assess the need for angiography or an implantable cardioverter defibrillator.
The patient would then be handed back to the practice for a series of six-monthly reviews concerning lifestyle, medication, weight and electrolyte measurement. The patients would also be taught more about the condition, and surveyed on their satisfaction with the service being given.
The practice gets a one-off payment of £278 for each newly diagnosed patient in the scheme, and an annual payment of £52 a year per patient to cover the two reviews in that period.