REVIEW OF HEART FAILURE INDICATORS IN CHESHIRE AND MERSEYSIDE

Transcription

1 REVIEW OF HEART FAILURE INDICATORS IN CHESHIRE AND MERSEYSIDE DEVELOPING BASELINES TO MEASURE IMPROVEMENTS OCTOBER 2012 SAM JAMES RUTH GRAINGER ANNE PORTER

2 TABLE OF CONTENTS Executive Summary Introduction Prevalence in Cheshire & Merseyside Primary Care Baselines Expected Versues Actual Prevelance Quality and Outcomes Framework (QOF) Heart Failure Indicators Primary Care Questionnaire Results Secondary Care Baselines Admissions Emergency Readmissions & Length of Stay Mortality Following an Admission for Heart Failure Advancing Quality (AQ) Secondary Care Questionnaire Results Conclusions and Next Steps Appendix A QOF Payment Stages Expected versus Actual Prevelance C&M Mortality by Age Group and Sex Mortality by Age Group, Sex and Cluster Mortality by Year and Trust Overall Mortality trend in Cheshire and Merseyside QOF Confirmed Diagnosis QOF - Treatment with ACEi or ARB for LVD QOF Treatment with ACEi or ARB and Beta-Blockers Appendix B Nice Quality Standard Questionnaire Results Primary Care Secondary care Page 2 of 25

3 EXECUTIVE SUMMARY Data from Indicators related to the delivery of heart failure services within Cheshire and Merseyside were analysed and have been presented in this report. The aim of which is to provide a baseline and benchmark for services to measure improvements against. Indicators ranged from QOF relating to primary care management of heart failure patients, to hospital admissions and mortality. A separate questionnaire based on NICE quality standards was also administered to gain a better understanding of heart failure services in Cheshire and Merseyside. Next steps are outlined later in the document but in short it is recommended that the analysis in this report is run periodically as a tool for measuring improvements. Main Findings Prevalence Admissions Prevalence of heart failure is higher in Cheshire and Merseyside than both the North West and England but has seen a slight reduction between 2007 and 2011 Prevalence is slightly higher in Merseyside (0.9%) than in Cheshire (0.8%) Based on models produced by the Public Health Observatory (PHO) actual prevalence is a lot lower than that expected There has been an increase in non-elective hospital admissions in Cheshire and Merseyside over the past 5 years. Going from 104/100,000 in 2007/08 to 124.5/100,000 in 2010/11 The analysis has shown (after age/sex adjustment) that there is an increase in admissions in the Cheshire area, but Merseyside has seen a decrease In 2011/2012, non-elective heart failure admissions in Cheshire and Merseyside cost the NHS 5,209,385 For the same time period excess bed days for non-elective heart failure admissions cost 1,912,113 Length of Stay and Emergency Re-Admissions Mortality The total cost of readmissions following an admission for heart failure in 2011/12 was 1,536,636 The total cost of readmissions with heart failure following an admission for heart failure in 2011/12 was 406,493 The analysis from some Trusts has shown a relationship between length of stay and readmission, e.g. increase length of stay and lower readmission rates. However after some simple correlation analysis it doesn t seem to be statistically significant but may still warrant further investigation Mortality is highest in those aged 85 years and over for both male and females The only age group where mortality is higher in men than women is in the years age group In hospital mortality has been rising over the past 5 years in Cheshire and Merseyside, going from 233 deaths in 2007/08 to 258 in 2011/12 After adjustment for age and sex the mortality rate is higher in Cheshire than in Merseyside Advancing Quality Both Cheshire and Merseyside have seen an increase in heart failure admissions having Left ventricular systolic function (LVSF) assessment Both Cheshire and Merseyside have seen an increase in heart failure admissions having Angiotensin Converting Enzyme Inhibitor (ACEI) or Angiotensin Receptor Blockers (ARB) for Left ventricular systolic dysfunction (LVSD). Whilst there has been an increase in heart failure admissions receiving discharge instructions; it varies from 6 to 83% within Trusts. Page 3 of 25

4 % Prevalence heart failure 1. INTRODUCTION The prevalence of heart failure is expected to rise as a result of an ageing population, improved survival of people with ischaemic heart disease and more effective treatments for heart failure (NICE clinical guidelines 108, 2010). Furthermore the numbers of hospital admissions due to heart failure are projected to rise by 5 in the next 25 years (Owan et al, 2006). It is important therefore to have an understanding of current levels of activity and prevalence related to heart failure so that an accurate assessment on current position can be made and planning for the future can be developed. This report helps make that assessment by providing analysis on indicators related to heart failure. The report has been prepared on behalf of the Cheshire & Mersey Cardiac and Stroke Network to present baseline data to allow benchmarking of services. It covers the patient journey across the pathway from diagnosis and treatment in primary care to admissions to hospital and post acute care and case management. In order to achieve this, data from national datasets has been analysed (such as QOF), as well as local hospital systems and two short questionnaires based on NICE quality standards for heart failure have also been developed and administered. The analysis is split into two main sections (primary care and secondary care) and data has been presented with regional and national (where available) data to help with benchmarking. Finally the report has been produced collaboratively between the Contract & Information Shared Service Unit (CISSU), Cheshire and Merseyside Clinical Networks and NHS North West. 2. PREVALENCE IN CHESHIRE & MERSEYSIDE The British Heart Foundation estimates that heart failure affects 1% to 2% of the population in the UK (Sutherland 2010). However the latest QOF data (2011) has but the level of prevalence for England at 0.7%. The actual prevalence in Cheshire and Merseyside is just over this despite it decreasing over the past five years going from 0.91% in 2007 to 0.85% in Furthermore the expected prevalence that has been modelled (section 3.1) suggests that there are more people in the community with heart failure than have been identified through the GP registers. 2. Prevalence of Heart Failure % 1. N=18,377 N=17,957 N=17,457 N=17,240 N=17, % Cheshire & Merseyside North West England Source: Quality Outcomes Framework (QOF) Page 4 of 25

5 Percentage difference between observed and expected numbers of heart faiure patients on GP registers PRIMARY CARE BASELINES Better management of heart failure patients can improve quality of life and reduce hospital admissions (in turn reducing costs), therefore it is important to understand the current prevalence and QOF results locally. To help better evaluate where additional focus needs to be given and where best practice can be gleaned. 3.1 EXPECTED VERSUES ACTUAL PREVELANCE As can be seen from the chart below all PCTs within Cheshire and Merseyside have a higher expected prevalence than that being currently captured on GP registers. Actual prevalence varies from 0.7 in Warrington to 1.11% in Sefton. However the expected prevalence is much higher ranging from 1.16% in Liverpool to 2.06% in Western Cheshire. Whilst it is recognised that Central and Eastern Cheshire PCT are outside of the scope of the cardiac network they have been included in this analysis for completeness 2.5% Heart Failure Prevalence: QOF Actual and Expected 2010/2011 Actual % Expected % % % 0. Warrington Liverpool Wirral Central & Eastern Cheshire Western Cheshire Halton & St Helens Knowsley Sefton The funnel plot below shows the percentage difference between actual and expected prevalence by PCT. For example in Knowsley there are 71% more patients expected to have heart failure than those currently on GP registers. 4 Observed Numbers of Heart Failure Patients on GP Registers Compared with Expected ,000 1,500 2,000 2,500 3,000 3,500 4, Warrington Knowsley Western Cheshire Wirral Halton & St Helens Sefton Central & Eastern Liverpool -10 Numbers on GP Register Lower 95% CI Upper 95% CI Lower 99% CI Upper 99% CI No Difference PCT Source: QOF, ONS and the expected prevalence is calculated using Doncaster Public Health Intelligence Unit s methodology where age specific prevalence from a national study is applied to a specific population Page 5 of 25

6 Central & Eastern Cheshire Halton & St Helens Knowsley Liverpool Sefton Warrington Western Cheshire Wirral Central & Eastern Halton & St Helens Knowsley Liverpool Sefton Warrington Western Cheshire Wirral Centrao & Eastern Halton & St Helens Knowsley Liverpool Sefton Warrington Western Cheshire Wirral 3.2 QUALITY AND OUTCOMES FRAMEWORK (QOF) HEART FAILURE INDICATORS Reviewing QOF data can help give an indication on the management of heart failure patients within the primary care setting. For all three indicators the payment stages vary giving different minimum and maximum levels (for breakdowns see Appendix A). For all three heart failure related QOF indicators, all PCTS are achieving the minimum payment stage and some PCTs are exceeding the upper threshold as well. In 2011 the proportion of people treated with ACEI or ARB for LVD ranged between 88%-9 across PCTs. Whilst this is a good achievement, up to 12% of a PCT population eligible for treatment with ACEI or ARB did not receive it QOF - patients with a diagnosis of heart failure (diagnosed after 1 April 2006) which has been confirmed by an echocardiogram or by specialist assessment QOF - patients with a current diagnosis of heart failure due to left ventricular dysfunction (LVD) who are currently treated with an ACE inhibitor or angiotensin receptor blocker, who can tolerate therapy and for 10 whom there is no contraindication QOF - patients with a current diagnosis of heart failure due to LVD who are currently treated with an ACE inhibitor or angiotensin receptor blocker, who are additionally treated with a beta-blocker licensed for heart failure, or 10 recorded as intolerant to PCT Source: QOF Page 6 of 25

7 3.3 PRIMARY CARE QUESTIONNAIRE RESULTS As well as the analysis of data from routine collections a short questionnaire was devised based on the NICE quality standards and sent to primary care colleagues. A summary of the results are below, for a more detailed view including comments received please see Appendix B. Is there provision for B-Type natriuretic peptide (BNP) measurement for people, suspected of heart failure with previous MI? Is there access to a specialist in heart failure and or a palliative care service, for people with moderate to severe chronic heart failure, and their carer(s)? No 29% Yes 10 Yes 71% Are people with stable chronic heart failure and no precluding condition or device, offered a supervised group exercise-based cardiac rehabilitation programme that includes education and psychological support? Are people with chronic heart failure offered personalised information, education, support and opportunities for discussion throughout their care, to help them understand their condition and to be involved in its management, if they wish? Partially 25% Yes 37% Yes 10 No 38% Does your service offer people with stable chronic heart failure, a clinical assessment at least every 6 months, including a review of medication and measurement of renal function? Yes 43% No 57% Source: In house questionnaire Page 7 of 25

8 Rate per 100,000 population 4. SECONDARY CARE BASELINES The data presented in this section focuses on hospital based activity. Here we present information on admissions, readmission, hospital mortality, length of stay and data from the Advancing Quality (AQ) programme. It is estimated that the total annual cost of heart failure to the NHS is around 2% of the total NHS budget: approximately 7 of this total is due to the costs of hospitalisation (Petersen et al. 2002, Stewart et al.2002). It is important therefore to have an understanding of current activity 4.1 ADMISSIONS The focus of this analysis has been on non-elective admissions. In the main, these will be emergency admissions but there may well be urgent transfers included. During 2010/2011 non-elective admissions cost the NHS in Cheshire and Merseyside 5,209,385 and the excess bed days over the same period cost the NHS 1,912,113 (based on national costing report 2010). Excess Bed Days Costs, 1,912,113 Non-Elective Heart Failure Admisisons Costs, 5,209,385 Source: CISSU and the national costing report 2010 Non-elective admissions due to heart failure have been on the increase in Cheshire and Merseyside going from 104 per 100,000 in 2007/2008 to per 100,000 in 2010/2011. The national rate has also increased over this time period but it has been less aggressive than that seen in Cheshire and Merseyside Non Elective Admissions for Heart Failure Cheshire & Merseyside England / / / /2011 Source: CISSU Page 8 of 25

9 When viewing the data by cluster it can be seen that the increase in admissions has been in the Cheshire area with Merseyside showing a slight decline. Source: CISSU 4.2 EMERGENCY READMISSIONS & LENGTH OF STAY Emergency readmissions following an admission for heart failure cost the NHS in Cheshire and Merseyside 1,536,636 during 2011/12. When looking at those readmissions for heart failure the total cost is calculated at 406,493. The table below shows how much all emergency readmissions cost following an admission for heart failure in 2011/2012 as well as how much emergency readmissions cost for Heart Failure specifically (i.e. when both the admission and readmission are for heart failure). The data is unadjusted for case mix therefore direct comparisons between PCTs cannot be made. Patients from Macclesfield and Leighton have been included in this analysis. PCT Central and Eastern Cheshire Total Heart Failure Admissions Total Emergency Readmissions within 30 days Emergency Readmissions for Heart Failure Cost of readmissions Cost of readmissions for HF , , Halton and St Helens , , Knowsley , , Liverpool , , Sefton , , Warrington , , Western Cheshire , , Wirral , , Total ,536, , Source: CISSU Page 9 of 25

10 Aintree Countess Leighton Macclesfie ld RLBUHT Southport Warringto n Whiston Wirral Readmission rate This table shows the age/sex adjusted rate. Wirral PCT looks like an outlier with 135/100,000 heart failure admissions, when compared with other PCTs in Cheshire and Merseyside. Both Halton and St Helens and Wirral have the highest rates of emergency readmissions at 30 and 31 per 100,000 respectively. 2011/2012 age and sex adjusted rates per 100,000 PCT Central and Eastern Cheshire Adjusted Total Heart Failure Admissions Adjusted Total Emergency Readmissions within 30 days Adjusted Emergency Readmissions for Heart Failure Adjusted Cost of readmissions per 100,000 population Adjusted Cost of readmissions for HF per 100,000 population , , Halton and St Helens , , Knowsley , , Liverpool , , Sefton , , Warrington , , Western Cheshire , , Wirral , , Cheshire & Merseyside , , Source: CISSU Overall in both Cheshire and Merseyside the emergency re-admission rate has remained largely unchanged over the past three years. However there does seem to have been some variation at Trust level. Aintree has seen a year on year reduction going from 3 in 2009/10 down to 24% in 2011/12, whilst other Trusts such as Leighton, Macclesfield, Royal Liverpool and Warrington have seen a year on year increase in emergency readmissions following an admission for heart failure. This is unadjusted data so comparisons between Trusts should not be made on this data alone, however individual Trusts may wish to consider their trend in emergency readmissions within their own organisaitons. Emergency readmissions following a non 35% elective admission for heart failure 3 Cheshire Mersey 25% 15% 1 5% 35% 3 25% 15% 1 5% Non-Elective Heart Failure Admissions who Readmit as an Emergency Within 30 Days 2009/ / / / / /2012 Source: CISSU Page 10 of 25

11 Age and sex adjusted Mortality Rate per 100,000 Population 2007/ / / / /2012 Age and Sex Adjusted Mortality Rate per 100,000 Population 2007/ / / / /2012 Aintree Countess Leighton Macclesfield RLBUHT Southport Warrington Whiston Wirral Median Length of Stay (Days) Length of stay was analysed alongside the emergency readmissions to see if there was any correlation. Whilst there was no statistically significant correlation Trusts that have shown a decrease in emergency re-admissions have seen an increase in length of stay (Aintree for example). This may warrant further analysis looking at the relationship between length of stay and re-admission rate for patients admitted with heart failure. Length of Stay for a Non Elective Heart Failure Admission / / / / Source: CISSU 4.3 MORTALITY FOLLOWING AN ADMISSION FOR HEART FAILURE In hospital mortality in patients admitted with heart failure has been rising in Cheshire and Merseyside. In 2010/11 there were 285 deaths and whilst this went down to 258 in 2011/12 it is still higher than 2007/08 where mortality was at 233. This increase has been reflected in both the Cheshire and Merseyside areas and after age/sex adjustment the mortality rate is higher in the Cheshire area. In Hospital Mortality Rate for Non Elective Heart Failure Admissions - Cheshire In Hospital Mortality Rate for Non Elective Heart Failure Admissions - Merseyside Source: CISSU Page 11 of 25

12 Aintree Chester Leighton Macclesfield RLBUHT Southport Warrington Whiston Wirral Aintree Chester Leighton Macclesfield RLBUHT Southport Warrington Whiston Wirral Aintree Chester Leighton Macclesfield RLBUHT Southport Warrington Whiston Wirral Aintree Chester Leighton Macclesfield RLBUHT Southport Warrington Whiston Wirral 4.5 ADVANCING QUALITY (AQ) Advancing Quality working with colleagues in the North West has developed a number of clinical process measures specifically for heart failure patients to ensure that patients receive the best possible care. The programme reported results based on 3 years: October 2008 September 2009 (Yr 1) October 2009 March 2010 (Yr 2) April 2010 March 2011 (Yr 3) The results have shown increase over time in all four quality indicators apart from AQ4 across all Trusts. AQ 1 - Heart Failure admissions having Left ventricular systolic function (LVSF) assessment AQ2 - Heart Failure admissions receiving ACEI or ARB for Left ventricular systolic dysfunction (LVSD) Year 1 Year 2 Year Year 1 Year 2 Year 3 Source: Advancing Quality (AQ) The percentage of patients having LVSF assessment (AQ1) ranged from 91% in year 3 in Macclesfield to 10 in Royal Liverpool. Percentage of patients receiving ACEI or ARB for LVSD (AQ2) in year 3 was also very high across all Trusts ranging from 91% in Leighton to 10 in Whiston, Royal Liverpool and Southport. AQ3 - Heart Failure admissions receiving Discharge instructions AQ4 - Heart Failure admissions receiving adult smoking cessation advice/counselling Year 1 Year 2 Year Year 1 Year 2 Year Source: Advancing Quality (AQ) Page 12 of 25

13 Whilst there has been improvements in AQ3 and AQ4 the charts above show that some further work may be required in order to improve patient care. Improving advice on smoking cessation and giving discharge instructions may also have an impact on reducing emergency readmissions and better hand over back to primary care. 4.6 SECONDARY CARE QUESTIONNAIRE RESULTS As with primary care, a questionnaire was sent to Trusts based on the NICE quality standards and the responses have been summarized below. Again for a more detailed breakdown including comments received please see Appendix B. Do people who are admitted with heart failure and are discharged only when stable, receive a clinical assessment from a member of the multidisciplinary heart failure team within 2 weeks of discharge? Is there access to a specialist in heart failure and palliative care service for people with moderate to severe chronic heart failure and their carer(s)? Yes 25% Depends 63% No 12% Yes 10 Source: In house questionnaire Is there provision for people with chronic heart failure to be cared for by the multidisciplinary heart failure team, led by professionals, with appropriate competencies from primary care and secondary care, and are given a single point of contact for the Do people admitted to hospital, because of heart failure, have a personalised management plan, which is shared with them, their carer(s) and their GP? Yes 10 No 25% Not sure 13% Yes 62% Source: In house questionnaire Page 13 of 25

14 5. CONCLUSIONS AND NEXT STEPS This report has been produced to provide baseline data that can be used for benchmarking purposes, so that improvements in the care of patients with heart failure can be measured. The report has shown that there are a lot of nationally and regionally established indicators that can be used to provide an insight into the care of patients within Cheshire and Merseyside. The data has also shown that there are some big variations at a local level between organisaitons and this may warrant further investigation. For example the potential for under diagnosis, given the difference between expected and actual prevalence is an area where additional focus could be given. Most of the analysis in this report can be reproduced periodically to monitor improvements in this and other areas. Dividing the report into two main sections of primary and secondary care has helped highlight both the unique roles both parts play but also the level of interdependency that needs to be cultivated e.g. the improvement in discharge notes/plans back to primary care and the ongoing systematic review of patients to help reduce emergency admissions. The inclusion of questionnaires linked to the NICE quality standards helped give an insight into service provision for patients with heart failure. It should be noted however, that this information was not available by routine collection and had to be collated using a bespoke questionnaire. If this analysis was to be re-run then another questionnaire would have to be sent. Prevention has been outside of the scope of this report, however in order to gain a better understanding into future demand for heart failure services, indicators relating to smoking cessation, obesity and healthy lifestyle should all be considered. Whilst the national CVD strategy is being developed and will help give guidance when produced, this report has highlighted areas where more focus could be given. As such based on the findings of the report it is recommended that the next steps to service monitoring and improvement for heart failure should include actions listed below: Use the findings of this report to provide focus when engaging with stakeholders Use the most recent data for some/all of the indicators presented in this report as a baseline for future improvements to be measured against Use of the indicators to develop a heart failure framework for Cheshire and Merseyside to measure improvements Focus on supporting improvements in AQ measures 3 and 4 to bring all Trusts up to similar levels Use of PHO models to investigate and reduce the gap between expected and actual prevalence in primary care Disseminate this report to commissioners and providers so best practice can be shared Develop an indicator to look at in-appropriate referrals Further analysis looking into length of stay and re-admission rate Page 14 of 25

15 6. APPENDIX A Additional analysis using the heart failure data and further information 6.1 QOF PAYMENT STAGES Table showing QOF indicators related to heart failure, points and payment stage. Source: Quality and Outcomes Framework for 2012/13, Guidance for PCOs and practices Page 15 of 25

16 Mortality Rate 6.2 EXPECTED VERSUS ACTUAL PREVELANCE C&M Expected and Actual Prevalence of Heart Failure in Cheshire and Merseyside 2010/ Cheshire Prevalence Cheshire Expected Prevalence Merseyside Prevalence Merseyside Expected Prevalence Both Cheshire and Merseyside prevalence is lower than expected suggesting that not all patients with heart failure are registered as having heart failure within primary care. The gap between actual and expected is larger in the Merseyside cluster. The expected values are calculated using national HF prevalence rates, applied to local populations. See MORTALITY BY AGE GROUP AND SEX Cheshire and Merseyside In-Hospital Mortality for Heart Failure % 1 5% and over Age Group % Male % Female In hospital mortality from heart failure is highest in the 85Yrs and over age group. Male mortality is higher in the age group. Page 16 of 25

17 % of non-elective admissionsresulting in death Raw Unadjusted Mortality Rate 6.4 MORTALITY BY AGE GROUP, SEX AND CLUSTER Cheshire and Merseyside In-Hospital Mortality for Heart Failure % 16% 14% 12% 1 8% 6% 4% 2% and over Age Group % Male (Cheshire Heart Failure) % Female (Cheshire Heart Failure) % Male (Mersey Heart Failure) % Female (Mersey Heart Failure) This data is unadjusted so comparisons between Cheshire and Merseyside are hard to make. However it is worth mentioning that in Cheshire, mortality seems greater in males up to 84Yrs than in females. 6.5 MORTALITY BY YEAR AND TRUST 25% 15% 1 5% In-Hospital Mortality for Non-Elective Heart Failure Admission Hospital 2008/ / / /2012 Page 17 of 25

18 Number of Deaths 6.6 OVERALL MORTALITY TREND IN CHESHIRE AND MERSEYSIDE In Hospital Mortality for Non-Elective Heart Failure Admissions in Cheshire and Merseyside / / / / / QOF CONFIRMED DIAGNOSIS QOF - patients with a diagnosis of heart failure (diagnosed after 1 April 2006) which has been confirmed by an echocardiogram or by specialist assessment Cheshire Mersey Northwest UK Page 18 of 25

19 6.9 QOF - TREATMENT WITH ACEI OR ARB FOR LVD 10 QOF - patients with a current diagnosis of heart failure due to left ventricular dysfunction (LVD) who are currently treated with an ACE inhibitor or angiotensin receptor blocker, who can tolerate therapy and for whom there is no contraindication Cheshire Mersey Northwest UK QOF TREATMENT WITH ACEI OR ARB AND BETA-BLOCKERS 10 QOF - patients with a current diagnosis of heart failure due to LVD who are currently treated with an ACE inhibitor or angiotensin receptor blocker, who are additionally treated with a beta-blocker licensed for heart failure, or recorded as intolerant to Cheshire Mersey Northwest UK Page 19 of 25

20 7. APPENDIX B NICE QUALITY STANDARD QUESTIONNAIRE RESULTS 7.1 PRIMARY CARE Question 1: Is there provision for B-Type natriuretic peptide (BNP) measurement for people, suspected of heart failure with previous MI? Liverpool Community Health NHS Trust Wirral Community NHS Trust Knowsley Community CVD Service Litherland Town Hall Health Centre Cheshire and Wirral Partnership NHS Foundation Trust Bridgewater Community Health Care NHS Trust Warrington Community Cardiac Services Response NO NO Comments Use it for non-ischaemic pts As a community service, we don t use it, but it is available to GP s as part of a diagnostic pathway with the acute trusts We offer a one stop diagnostic service. At this clinic, the pts will have a consultation, ECG, Echo and a diagnosis is made, so BNP not necessary or appropriate in this case Question 2: Are people with chronic heart failure offered personalised information, education, support and opportunities for discussion throughout their care, to help them understand their condition and to be involved in its management, if they wish? Liverpool Community Health NHS Trust Wirral Community NHS Trust Knowsley Community CVD Service Litherland Town Hall Health Centre Cheshire and Wirral Partnership NHS Foundation Trust Bridgewater Community Health Care NHS Trust Warrington Community Cardiac Services Response Page 20 of 25

21 Question 3: Does your service offer people with stable chronic heart failure, a clinical assessment at least every 6 months, including a review of medication and measurement of renal function? Liverpool Community Health NHS Trust Wirral Community NHS Trust Knowsley Community CVD Service Litherland Town Hall Health Centre Cheshire and Wirral Partnership NHS Foundation Trust Bridgewater Community Health Care NHS Trust Warrington Community Cardiac Services Response NO NO NO NO Comments Funding for Stable HF pts, as per NICE, was allocated to practice nurses to undertake routine reviews only. Stable pts are referred back to the GP for a 6 monthly review. Unstable pts remain within the HF Team, where they are clinically assessed according to need and condition We aim to titrate the pts to optimum medical therapy and educate re selfcare and disease management then refer back to GP to be reviewed 6 monthly as per NICE guidance Stable HF pts are referred back to the GP with a management plan, recommending a 6 monthly review. The HF services do not have the capacity to monitor stable pts and the GPs have agreed to undertake this practice Question 4: Is there access to a specialist in heart failure and or a palliative care service, for people with moderate to severe chronic heart failure, and their career(s)? Liverpool Community Health NHS Trust Wirral Community NHS Trust Knowsley Community CVD Service Litherland Town Hall Health Centre Cheshire and Wirral Partnership NHS Foundation Trust Bridgewater Community Health Care NHS Trust Warrington Community Cardiac Services Response Page 21 of 25

22 Question 5: Are people with stable chronic heart failure and no precluding condition or device, offered a supervised group exercise-based cardiac rehabilitation programme that includes education and psychological support? Liverpool Community Health NHS Trust Wirral Community NHS Trust Knowsley Community CVD Service Litherland Town Hall Health Centre Cheshire and Wirral Partnership NHS Foundation Trust Bridgewater Community Health Care NHS Trust Warrington Community Cardiac Services Response PARTLY PARTLY NO NO Comments There are no specific rehab classes in South Sefton, however they will receive rehab if they have had a recent ischaemic event with a diagnosis of HF. Southport and Ormskirk have HF rehab which both hospital and community teams can access. HF cardiac rehab is not funded at Warrington site. Pts are referred to Halton Ellesmere Port and Chester available on a limited basis due to resources currently being reviewed by commissioners Liverpool only issue is about accessing phase 4 Page 22 of 25

23 7.2 SECONDARY CARE Question 1: Do people who are admitted with heart failure and are discharged only when stable, receive a clinical assessment from a member of the multidisciplinary heart failure team within 2 weeks of discharge? Royal Liverpool and Broadgreen University Hospital NHS Trust Warrington and Halton Hospitals NHS Foundation Trust Aintree University Hospitals NHS Foundation Trust St Helens and Knowsley NHS Trust Countess of Chester NHS Foundation Trust Liverpool Heart and Chest Hospital NHS Foundation Trust Wirral University Teaching Hospital NHS Foundation Trust Southport and Ormskirk NHS Trust Response DEPENDS DEPENDS NO DEPENDS DEPENDS DEPENDS Comments Most of the time as clinic space allows All pts are discharged to the community service no facility to track these pts If pts do not wish to travel to the tertiary centre for a review at 2weeks (covers a large geographical area) they will be followed up in the local DGH or community If the pt is seen by the HF Team as an inpatient, a referral will be sent for review within 2 weeks. When the pts are not referred to the HF Team, as an inpatient, they will not receive follow up Will generally aim for 2-3 week review by ourselves or the community HF Team. Not always possible or practical, as the clinical condition of the pt can vary wildly All depends what type of HF. The Community Team can only take LVSD, because of capacity would need extra funding to extend the service to diastolics Page 23 of 25

24 Question 2: Is there access to a specialist in heart failure and palliative care service for people with moderate to severe chronic heart failure and their carer(s)? Royal Liverpool and Broadgreen University Hospital NHS Trust Warrington and Halton Hospitals NHS Foundation Trust Aintree University Hospitals NHS Foundation Trust St Helens and Knowsley NHS Trust Countess of Chester NHS Foundation Trust Liverpool Heart and Chest Hospital NHS Foundation Trust Wirral University Teaching Hospital NHS Foundation Trust Southport and Ormskirk NHS Trust Response Comments/Explanations When pt is identified for palliative care, there is a palliative care team we can refer to If the pt is at End Stage, approx. 2 months to live, as an inpatient, they are referred to McMillan Pt is reviewed by a Consultant Cardiologist, HFSN and/or palliative care nurse specialist as an inpatient. This service also runs the HF Clinics Yes, but not for everyone who needs it. Some community teams do have specialist HF palliative care nurses in post We have direct links with the Hospital palliative care team and have day therapy places with all local hospices Palliative Care involvement is not automatic as it is not always necessary Question 3: Is there provision for people with chronic heart failure to be cared for by the multidisciplinary heart failure team, led by professionals, with appropriate competencies from primary care and secondary care, and are given a single point of contact for the team? Royal Liverpool and Broadgreen University Hospital NHS Trust Warrington and Halton Hospitals NHS Foundation Trust Aintree University Hospitals NHS Foundation Trust St Helens and Knowsley NHS Trust Countess of Chester NHS Foundation Trust Liverpool Heart and Chest Hospital NHS Foundation Trust Wirral University Teaching Hospital NHS Foundation Trust Southport and Ormskirk NHS Trust Response Page 24 of 25

25 Question 4: Do people admitted to hospital, because of heart failure, have a personalised management plan, which is shared with them, their carer(s) and their GP? Royal Liverpool and Broadgreen University Hospital NHS Trust Warrington and Halton Hospitals NHS Foundation Trust Aintree University Hospitals NHS Foundation Trust St Helens and Knowsley NHS Trust Countess of Chester NHS Foundation Trust Liverpool Heart and Chest Hospital NHS Foundation Trust Wirral University Teaching Hospital NHS Foundation Trust Southport and Ormskirk NHS Trust Response NOT SURE NO NO Comments No, but all pts have a discussion with a member of the MDT; receive a booklet; Community HF nurses can access Meditec system, where there is a discharge summary and the echo but there is no direct contact with the GP Unclear All the pts have a plan but they are not provided with a physical document listing a specific plan Question 5: Are people with chronic heart failure offered personalised information, education, support and opportunities for discussion throughout their care to help them understand their condition and be involved in its management, if they wish? Comments re limitations/restrictions Seem to be an increasing number of confused/demented pts. Because of time constraints, sometimes difficult to assess/meet up with the carers Clinic space can be a major issue Page 25 of 25