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
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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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
National Meeting of strategic clinical network cardiac leads
12.00 – 12.45 LUNCH AND NETWORKING
12.45 Welcome Huon Gray12.50 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 BREAK14.30 SCN agendas
How to integrate local and national priorities?
ALL
15.15 CRGs specialist commissioning
Dr Jim McLenachan
16.00 Sharing of policiesHow 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 Consultant Cardiologist, University Hospital of Southampton
AGENDA for today
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
SCN Cardiac Leads: Using data and information to improve outcomes and quality of care for people with cardiovascular disease2nd July 2014
National Cardiovascular Intelligence Network (NCVIN), Public Health EnglandNational Institute for Cardiovascular Outcomes Research (NICOR), UCL
Lorraine Oldridge, Associate Director (NCVIN)Dr Julie Sanders, Chief Operating Officer, NICOR (UCL)Dr Mark deBelder, NCVIN Clinical Lead (NCVIN)Andrew Hughes, Head of Health Intelligence (NCVIN)Sally Crick, Programme Manager (NCVIN)
Objectives of the session
To provide insight to what data/information is currently availableTo brief you on 2014/15 prioritiesTo consult with you on your data/information requirements
Universities and science minister unveils £73m big data fundingDavid 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.
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
Analysis
Where does the CCG compare poorly against its cluster group?
Analysis by pathway stage (page 1 of 2)
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 indicatorOpportunity - 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
Analysis
Analysis by pathway stage (page 2 of 2)
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 indicatorOpportunity - 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 admissionsHeart failure: average cost per female emergency admission (13.3 % higher) £65K CVD: average male elective LOS (41.8 % higher) 334 bed daysCVD: average female elective LOS (134.9 % higher) 643 bed daysStroke: average male emergency LOS (240.3 % higher) 632 bed daysAngiography procedures: female average cost (78.2 % higher) £71K Angiography procedures: male LOS (119.1 % higher) 1,331 bed daysAngiography procedures: female LOS (87.4 % higher) 512 bed daysAngioplasty procedures: female average cost (12.9 % higher) £19K CABG procedures: male (DSR) (74.6 % higher) 34 proceduresCABG procedures: male (LOS) (104 % higher) 929 bed daysCABG procedures: female (LOS) (111.3 % higher) 259 bed daysNew 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
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 elevationLower 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.
* (p) = PCT based indicator For data sources used, see slide 23
Opportunity
CHD: average female elective LOSCHD: average male elective LOS
CHD female elective admissions (DSR)CHD male elective admissions (DSR)
CHD: average cost per female elective admissionCHD: average cost per male elective admission
CHD: average female emergency LOSCHD: average male emergency LOS
CHD female emergerncy admissions (DSR)CHD male emergerncy admissions (DSR)
CHD: average cost per female emergerncy admissionCHD: average cost per male emergerncy admission
CVD: average female elective LOSCVD: average male elective LOS
CVD female elective admissions (DSR)CVD male elective admissions (DSR)
CVD: average cost per female elective admissionCVD: average cost per male elective admission
CVD: average female emergency LOSCVD: average male emergency LOS
CVD female emergerncy admissions (DSR)CVD male emergerncy admissions (DSR)
CVD: average cost per female emergerncy admissionCVD: average cost per male emergerncy admission £207K
£158K 222 admissions200 admissions3,930 bed days1,752 bed days----334 bed days643 bed days£160K £157K 53 admissions35 admissions184 bed days209 bed days£52K £3K --
Chapters on risk factors; diabetes, heart, stroke and renal
Prevalence Overview
Care processes and treatment indicators and variation at practice level
Treatment in secondary care
Mortality trends
Outcome Versus Expenditure Tool: CardiovascularJuly 2014
www.ncvin.org.uk
Your Views
What information have you had and was it useful?What would be important for you to know? Trends; long term outcomes; mortality; benchmarkingWhat level of reporting would be helpful to you?What kind of visual displays of information should we be using?How would you prefer to access this information? PDFs, online, Apps
ResearchInformation and adviceWork force development– heart
failure/palliative care specialists/PDCs Service innovation & re-design• Caring Together • IV diuretics• Integrated Care• Work on ICD and deactivation
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
Commissioning for Value Insight Packs
Quality = Excellence in Patient safety, clinical
effectiveness and patient experience
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
The BHF Integrated Care Pilots
NHS Lanarkshire
NHS Tayside
NHS Fife
East Cheshire NHS Trust
Oxleas NHS Trust
NHS Bristol
North Somerset
CCG
BetsiCadwaladr
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
Pilots have demonstrated increased diagnosis and
management from acute to community settings
Before After
Secondary care
Primary and community care
AdmissionFollow-up
Diagnosis
Secondary care
Primary and community care
Admission
Follow-upDiagnosis
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
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.
IV Diuretics:Key findings
• 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
• 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
• 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
Is it clinically effective? Is it safe?
Does it improve the patient and
carer experience?
Is it cost effective?
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.
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
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
Jim McLenachan,Co-Chair, Complex Invasive Cardiology CRG
National Meeting of SCN Cardiac Leads, London, 2nd July, 2014
Topics
•What is Specialist Commissioning?•What is the role of the CRG?•How do we deal with innovation?•The future – a personal view
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.
Who commissions?
2012-2013 2013-2014
PCTs Clinical Commissioning Groups
SCGs x 10 National Specialised Commissioning Service
Who commissions?
2012-2013 2013-2014
PCTs Clinical Commissioning Groups
SCGs x 10 National Specialised Commissioning Service
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
Clinical Reference Groups (CRGs)
•n = 76
•Cover all areas of specialised medicine – medical, surgical, paediatric, psychiatric etc. etc.
Clinical Reference Groups (CRGs)
•Chairmen•12 Senate area representatives (14)•4 Specialist Society representatives•4 Patient and Public engagement representatives
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
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.
Cardiology CRG “products” 2012•5 service specifications (complex devices, EP, ICC,
“….only evidence-based treatments will be commissioned…”
“……innovation is key in the NHS…..”
“….commissioners do not fund research……”
“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
“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
The Future
Predictions are difficult, especially about the future….
Niels Bohr
Specialised Commissioning
CRGsService
Specifications CPAGArea Teams
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)