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The NHS Five Year Plan-Simon Gillespie and Karen Smith presentation
1. Applying the principles of the Five Year
Forward View
The British Heart Foundation Innovation Pilots
Simon Gillespie
2. Ensure that
everyone in the
UK with CVD has
access to high-
quality, integrated
health and social
care services
3. The Forward View into Action:
Co-creating new models of care
• Address local need
• Co-design to accelerate change
• Demonstrate proof of concept
• Prototype that can be replicated
elsewhere
4. Service Innovation Timeline
1980s 1990s 2000 2004 2006 2009 2012 2013 2014 2015
Heart Helpline
Pioneered the
model of
nurse-led
services
2 models of BHF
service design on
QIPP website
Heart Failure
& IVD
Resources CPD
Accredited
Heart Support
Groups
House of Care
Innovation
through
multi-skilling
clinical
staff
Integrated
Care
BHF Alliance
FH Nurses
5. 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
• £1 million
• 9 sites
• Independently evaluated
Consistent with 5YFV:
• Multispecialty community
providers
• Integrated primary and
acute care systems
• Models of enhanced
health in care homes
6. BHF rationale for funding pilot
projects
Pump Prime
& Test
Hypothesis
Redesign
care and
support
pathways
Evaluate &
build
evidence
basePublish and
Disseminate
Spread &
Adoption of
Best
Practice
Learning &
new
hypotheses
8. BHF Pilot with East Cheshire NHS Trust
The Challenge:
• 15.5% increase in emergency admissions for CHD between 2009 –
2011
• East Cheshire fastest growing elderly population in North West
• Chest pain, AF and HF identified as generating greatest no of
admissions
• LOS longer than the national average
• Commissions wanted to upskill primary care to deal with demand
and reduce duplication of care
9. BHF Pilot with East Cheshire NHS Trust
The Solution:
• Developed generic cardiology specialist nurse team – expanded remit
• In-reach programme: identifying patients in A&E and Medical
Assessment Unit
• New pathways and community clinics for chest pain, AF and Heart
Failure and delivering IVD in peoples’ homes
• Joint assessments and care plans for LTCs with diabetes, respiratory,
pain management and palliative care teams
• Training and support with social care and care homes
10. Outcomes and Impacts 1
Reduction in LOS (days)
0
2
4
6
8
10
12
14
16
Angina MI AF HF
2011-2012
2012-2013
11. Outcomes and Impacts 2
In-patient bed days saved:
2391
Saving £1,195,000
Cost benefit ratio 1:8.8
(for every £1 invested, the
NHS saves £8.80)
12. Example Multispecialty Community Provider for
an Integrated Community Cardiac Team
Care Co-ordinator
- working with
Patient
Cardiac Nurse
Respiratory
Nurse
Home
Intravenous
Therapy Team
Social Care
Team and
Carer Support
Community
Mental Health
Team
Palliative Care
Team
13. New patient pathways have moved
activity – increased diagnosis and follow-
up care - from acute to primary and
community care
Before After
Secondary Care
Primary and community Care
Admission Diagnosis
Follow-up
Admission
Follow-up
Diagnosis
14. The British Heart Foundation Innovation Pilots
NHS Tayside
Karen Smith Nurse Consultant Cardiology
NHS Tayside
School of Nursing and Midwifery University of Dundee
15. BHF Pilot with NHS Tayside
The Challenge:
• Review of National CHD standards (Quality Improvement Scotland
2010) highlighted some major shortfalls in arrhythmia management
within NHS Tayside
• Three main work streams
• Atrial fibrillation
• Implantable Devices (ICDs and CRT)
• Inherited cardiac conditions
• Opportunity to work in partnership with the teams in primary care to
develop and evaluate new models of integrated care improving the
patients referral, diagnostic and care pathways and consequently
patient experience
• Upskill health care teams
16. Achievements for AF
• 10 Rapid Access AF clinics per month rolled out across all 3 community
health partnerships
• Referrals via Referral Management System and Consultant referral – aim to
see within 2 weeks
• Integration of patients with LT arrhythmia management
• Improved patient pathways for DC cardioversion
• Anticoagulation, less cancellations, timely intervention, early review
(4 weeks & 6 months versus 4-6 months from cardiologists)
17. Improvements in Cardioversion
Improved waiting times for procedure
In contrast through the arrhythmia service
Anticoagulation
“instead of having to wait for the cardiologist,…we got pretty quickly the letter about the flutter
clinic’ their previous experience highlighted that ‘It just took forever. I can’t remember when you
actually got your first cardioversion. I can’t remember. It took months”
“So you’ve got a very defined timeline, rather than…… sitting in limbo waiting on things to happen …
And I think the service, that way it’s worked out, for us has certainly been better, knowing full well
that that’s the time you’re going to get it done”
“I knew that obviously this is not the best thing to be on. But I was unaware of how intrusive it is as
regards the INR readings, going to the clinic, getting a booking at the clinic even, because it’s like a
week in advance when it’s really full. So I think that was the next sort of hassle, was getting INR
level to the right level, so I could then go for cardioversion”
18. Quality of life - AFEQT –
Overall score good quality of life, limited disability associated with their AF. Improvements
symptoms scores and daily activities @ 6 months
Knowledge –
overall scores 60-70% but still identified areas for improvement in understanding of AF –
eg 44% did not know why it was important to take medications – ? impact on compliance
Self management - Patient Activation Measure (PAM)- Underlying
knowledge skills and confidence integral to managing one’s own health and healthcare.
PAM categorises respondents into one of four activation levels:
Level 1 – Disengaged & overwhelmed
Level 2 – Becoming aware but still struggling
Level 3 – Taking action
Level 4 – Maintaining Behaviours and pushing further
AF Outcomes
19. Patient feedback – Atrial Fibrillation
“I think I would have felt different if I’d just been left with the consultant
cardiologist completely I think…. the old service as regards you felt you were
being processed……… But with the change, it probably makes you aware that
somebody maybe does care and is looking after your interests. And that’s quite
a big change from route number one of being processed to then being an
individual that you’ve got this key contact that’s looking after you”
20. Aim:
• To address the gaps in psychological support and provision through
nursing intervention offering pre and post implantation support
• Baseline data - ICD concerns high levels invited to attend review
• ICD concerns – guides clinical consultation , assessment improved over
time less number and severity
• Mood - reduced anxiety and depression over time up to 6 months ,
slight inc again by month 10 ? Shocks delivered
ICD patients
21. ICD- Patient experience: adverse
effects
“I mean I think the darkest moments ..goes back to probably the first two years … I
could understand how people commit suicide to be honest. I felt there was no point,
I didn't feel there was any future at all, I couldn’t think of a future. And of course,
people around about you don't really understand this. I am not blaming them, I
think it had a quite serious effect”
“I think I more or less withdrew into not living at all. I was sitting outside in my
chair with a computer doing routine work on a project which I am doing, I was
terrified to go out…..I was feeling so uptight and, that it was changing the rhythm
of my heart”
22. • Regained confidence and Independence
• Travelling
• Returned to golf
• Learnt a new language
• Improved relationships within the family
Transformed lifestyle from isolation,
high anxiety and multiple admissions
23. Prevention of admission
“Well the case where I had the VT in the morning, and I phoned and I left a message
on ‘the nurse’s’ phone and she got back to me and then it wasn't very long, she got
back to me within a couple of hours later. And I could say to her look it has settled
down and she knew. I knew that somebody knew…. Otherwise I would have had to
have said to myself oh dear, do I phone in, do I go up to A&E the ambulance people on
a couple of occasions have been distinctly iffy about taking me”
25. Inherited Cardiac Conditions
• Monthly
multidisciplinary
ICC clinic
• MDT meetings
• Although
smallest clinical
group have
significant
support needs
26. Integration within services
“Having a heart condition can be a scary time. For me personally, I don't think I
would have gotten through the whole thing without fantastic support from the BHF
arrhythmia nurses. But it's not just them. There's a whole team of people involved
in it….. Everyone you provide support for will have their own story to tell, their own
fears…, But without you all providing the support and care that you do so well
everyone's journey would be a very lonely one”
A general intro slide to introduce BHF
A strategic priority is to ensure that all those with CVD receive the highest quality integrated health and social care
In addition to funding biomedical research, BHF also funds new models of care to test new care pathways and service innovation in the NHS across the UK, co-produced with local NHS organisations
Approach and methodology of the BHF is consistent with those articulated in the 5YFV
These are pump-primed for 2 – 3 years to test proof of concept and independently evaluated to assess safety, clinical and cost efficiency and patient experience with the intention that, if effective, these are sustained and can be replicated across the NHS. Several of these are on the QIPP website as case studies
BHF have been pioneering new models of care since the mid 90’s and continue to do so, and in many ways have been delivering models of care consistent with those set out in the Five Year Forward View for several years now.
In 2012, we funded 9 integrated care pilots across the UK
We also 10 sites to assess the feasibility of providing intravenous care for Heart failure patients in the community or their own homes (previously only provided in a hospital setting)
These projects demonstrated effective approaches to vertical integration working across primary, community and acute care and providing care across traditional clinical specialities and with social care providers – consistent with what a Multispecialty Community Provider or Integrated Primary and Acute Care System - as described in the 5YFV - may look like
The rationale for funding new pilots is to test new approaches to care delivery, evaluate and support the spread and adoption of these when independently shown to be effective.
The approach clearly demonstrated reductions in length of stay for the cardiac conditions they were addressing.
Demonstrating significant reductions in in-patient bed days and subsequent substantial cost savings.
This slide demonstrates what a Multispecialty Community Provider model for an Integrated Community Cardiac Team may look like.
Consistent with the 5YFV to move activity from the acute to the community/primary care
Approaches support patient self-management
The recent presentation by a patient at the BHF conference highlighted the benefits of the integration of the 3 elements of the service. This patient accessed the service via referral to the cardiologists for assessment at the inherited cardiac conditions clinic following the sudden unexpected deaths of three of his family members, his father, brother and sister. . After initial assessment and genetic investigation he was then referred for implantation of an ICD, at which point he had further access to the support of the specialist arrhythmia nurses before and after this procedure. Following his device implantation having made a good recovery, he unfortunately went on to develop atrial fibrillation and required admission and DC cardioversion which was again facilitated through the arrhythmia service as he described
Evaluation showed with home based IVD was safe, clinically and cost effective and patients welcomed being treated at home.
Home based care also allowed more opportunities for patient and carer education, supporting self-management
Opportunity to assess broader social care needs and meet more holistic care needs
*mention community teams and specialists working together to demonstrate MCP type working model
