GOVERNING BODY REPORT DATE OF MEETING: 20th September 2012 TITLE OF REPORT: KEY MESSAGES: NHS West Cheshire Clinical Commissioning Group has identified heart disease as one of its six strategic clinical priority areas. Nationally, the cost of coronary heart disease is 9 billion per year through health care costs, informal care and production losses associated with mortality and morbidity. Nationally in 2008, 88,000 deaths were caused by coronary heart disease. In West Cheshire, death rates from heart disease and stroke in the under 75s are falling. They are lower than the national average but similar to our Office of National Statistics Cluster group. However, it is deaths from heart disease and stroke and, in particular, coronary heart disease that are driving the widening health inequalities between our most deprived two quintiles and the rest of the population. N-terminal pro b-type natriuretic peptide (NTproBNP) testing was commissioned for use in primary care from the 1 st April 2012. Specialist Assessment two week echocardiogram referrals launched on the 11 th July 2012. Work is progressing on the implementation of the remaining service developments described in the 2012-13 Commissioning Plan and on outline plans for 2013-14. REPORT PREPARED BY: Dr Lesley Appleton, Clinical Lead for Heart Disease Paul Lynch, Planning & Performance Manager Vicky Oxford, Locality Support Manager
NHS WEST CHESHIRE CLINICAL COMMISSIONING GROUP GOVERNING BODY HEART DISEASE UPDATE INTRODUCTION 1. NHS West Cheshire Clinical Commissioning Group has identified heart disease as one of the six clinical priorities that it intends to focus on over the next five years in order to improve health outcomes for its population. 2. This paper sets out the national and local position regarding the impact and costs associated with heart disease. It also details the service developments which have been agreed, their status in terms of implementation and the next steps. NATIONAL POSITION 3. Heart and circulatory disease is the UK s most common cause of death 1. 4. In 2008, over 191,000 people died from heart and circulatory disease in the UK, of which 88,000 deaths were caused by coronary heart disease (this is one in five male deaths and one in eight female deaths). 5. In the UK in 2008 coronary heart disease caused more than 28,000 premature deaths. 6. There are approximately 124,000 heart attacks in the UK each year. 7. The most recent data available shows that in 2006, coronary heart disease in the UK cost the health care system in the region of 3.2 billion per year, of which 73% was in hospital care costs. 8. Coronary heart disease also incurs non-health care costs in the form of production losses associated with mortality and morbidity. In 2006, these were estimated to be in the region of 3.9 billion. 9. In 2006, the cost of informal care for people with coronary heart disease in the UK was around 1.8 billion. LOCAL POSITION 10. Through the Joint Strategic Needs Assessment, heart disease has been identified as a key health issue for our population. 1 1 All national statistics are drawn from: British Heart Foundation Health Promotion Research Group. (2010). Coronary Heart Disease Statistics. Oxford: Department of Public Health University of Oxford. 1
11. Analysis indicates that: In Cheshire West and Chester there are around 3,000 deaths a year, of which 75% are caused by either circulatory diseases, cancer or respiratory conditions; Death rates from heart disease and stroke in the under 75s are falling. They are lower than the national average but similar to our Office of National Statistics Cluster group. However, it is deaths from heart disease and stroke and in particular coronary heart disease that are driving the widening health inequalities between our most deprived two quintiles and the rest of the population; Coronary heart disease contributes 22% to the male health inequality gap and 11% of the female health inequality gap; Although death rates have been improving in the most deprived areas the rate of improvement has not been as fast as in the rest of the population particularly amongst men; There is an ageing population in West Cheshire which means that people will live long enough to develop conditions associated with ageing including coronary heart disease; In West Cheshire, 32.6% (64,100) of adults have raised blood pressure (either being treated for hypertension or have a one-off recording of >140/90); Currently there are 33,750 patients on our GP practice hypertension registers, which equates to 16% of our adult population. There is therefore possibly a further 17% in our population with raised blood pressure; Raised blood pressure is a significant risk factor for coronary heart disease and stroke; In West Cheshire, around 9,650 patients have been diagnosed with coronary heart disease and there are approximately 2,100 patients on the heart failure registers of our GP practices. COST TO THE LOCAL HEALTH ECONOMY 12. In the financial year 2010-11, 9.3million was spent by the Primary Care Trust on coronary heart disease in West Cheshire. ENGAGEMENT 13. Local clinical engagement highlighted a number of key issues which build on requirements set out in the National Institute for Health and Clinical Excellence (NICE) Guidelines and Quality Standards. Issues raised by clinicians included: Lack of availability of N-terminal pro b-type natriuretic peptide (NTproBNP) testing in primary care; Lack of two week referral pathway and specialist assessment for echocardiograms; 2
Issues with waiting times for diagnostic echocardiograms, for example, patients waiting longer for an echocardiogram than the six week target; Lack of formal cardiac rehabilitation programme for heart failure patients. 14. Patient and public engagement has taken place with groups including the Local Involvement Network, a local carer s support group, the Chester Youth Parliament and the Older Peoples Network around the health priorities for the local population and heart disease was identified as an area of concern. 15. Further engagement is planned on the heart disease agenda in November 2012 where the Clinical Lead for Heart Disease will be meeting the Chester Heart Support Group to talk about the Clinical Commissioning Group s current plans and future intentions. STRATEGIC AIMS AND OUTCOMES 16. The local clinical engagement feedback has been included in West Cheshire Clinical Commissioning Group s strategic plan for 2012-17 which sets out what we want to achieve during that period: Review the Heart Failure diagnostics in line with national guidance; Review access and increase uptake to cardiac rehabilitation; Increase the uptake of Smoking Cessation Programmes. Patients who are diagnosed with coronary heart disease who stop smoking can significantly improve their health outcomes; Improve prescribing. We will ensure the increased prescription of non-branded statins where appropriate, ensuring that those patients, who would benefit from taking a statin, do so. IMPLEMENTATION AND PROGRESS 17. The following section illustrates our progress against the aims set out in the 2012-13 Commissioning Plan Heart Failure Pathway 18. Following the clinical feedback and research into service gaps the Commissioning Delivery Committee approved a business case to develop the heart failure pathway in West Cheshire in line with NICE Guidance and Quality Standards. The service developments agreed were: The implementation of the NICE Heart Failure Guidance which consists of the commissioning of NTproBNP testing and its use for monitoring appropriate patients, the commissioning of echocardiogram specialist assessment and a redesign of cardiac rehabilitation to incorporate a programme for patients with heart failure; The pathway will be implemented using a phased approach. 3
19. A project group has been established and the following progress has been made: Hypertension N-terminal pro b-type natriuretic peptide testing was commissioned for use in primary care from the 1 st April 2012; Two week specialist assessment for echocardiogram was launched on the 11 th July 2012; A service specification has been developed for an expanded cardiac rehabilitation service to incorporate a programme for patients with heart failure. This is currently being negotiated with the provider and it is anticipated that the heart failure programme element will commence in January 2013. 20. In response to local need and the revised NICE Guidelines on Hypertension, an application for funding from the Innovation Fund was developed and this was discussed at the Ellesmere Port and Neston GP Network and a recommendation for approval was made to the Commissioning Delivery Committee. The Commissioning Delivery Committee approved the bid and the following development was agreed: A 24 hour blood pressure monitor and five years servicing for the monitor will be purchased for each of the 37 member practices using funding from the Innovation Fund. 21. The following progress has been made: The 24 hour blood pressure monitors have been ordered and distributed to member practices in September; A training session on how to utilise the units will be arranged for each locality. Cardiology One Stop Shop 22. The following progress has been made against our intention to investigate the feasibility of a cardiology one stop shop: An Initial Viability Assessment for a cardiology one stop shop was produced and approval was given by the Project Delivery Group to develop an outline business case; An outline business case has been developed with a proposed model of care; The model of care would include consultant input; echocardiogram; 24 hour blood pressure monitoring; 7 day event recording; cardio memo event recording; nurse led clinics; and out-patient clinics; The proposed model of care was presented to the three GP Locality Networks in September for further clinical comment; 4
An outline business case will be submitted and discussed by the Commissioning Delivery Committee in October where a decision on the next steps will be made. Health Check Local Enhanced Service 23. A Health Check Local Enhanced Service has been developed by Public Health. The scheme will target high risk populations and seek to address some of the health inequalities and lifestyle related conditions that impact on the prevalence and incidence of heart disease and stroke in accordance with the NHS Constitution. To date, 33 practices of the 37 member practices have committed to deliver health checks to the targeted cohorts of patients. The 33 practices started the Health Check Local Enhanced Service in June and the target is to deliver health checks to 20% of the target population each year, over a five year rolling programme. 24. GP practices that are not currently committed to deliver the service will have the opportunity to commit if they wish to do so within the next six months. Stroke Care Pathway 25. We are moving forward with our plans to improve the delivery of care to maximise patient independence and reduce the burden on health and social care services. The proposed next steps, some of which will be subject to funding availability include: Maximising the identification and effective management of patients with Atrial Fibrillation (AF) to enhance Stroke prevention; Supporting proposals to develop an integrated and combined Acute and Rehabilitation Stroke Unit to include integrated therapy services to enable improved patient management and a reduced average length of stay; The unbundling of the mandatory Payment by Results (PbR) tariff for Stroke to separate payment for various phases of care (e.g. A&E, hyper-acute, acute/acute rehabilitation) and support for a proposal to conduct a pilot to deliver a costed pathway for stroke patients; Investigating improving access to psychological support for stroke and Transient Ischaemic Attack (TIA) patients and their carers; Investigating the commissioning of a six month post stroke review service Developing the capacity of community based services to support and manage patients with Percutaneous Endoscopic Gastrostomy (PEG) feeding tubes and Nasogastric feeds appropriately within their usual place of residence; A community based Early Supported Discharge / Supported Discharge service has already been commissioned. 5
MEASURABLE BENEFITS 26. The following benefits have been identified: Commissioning of NTproBNP testing will lead to a reduction of up to 40% in the number of echocardiograms for a diagnosis of heart failure. This, in turn, will alleviate some of the pressure on waiting times for diagnostic tests. This will be monitored through the contracting dataset with our main provider; Patients identified as being at high risk of heart failure can be referred to the specialist assessment within two weeks facilitating earlier identification and management of heart failure and help reduce hospital admissions (23% reduced risk per patent of being admitted to hospital within the first six months). This will contribute to the NHS Outcomes Framework (2011), Domain 1: Preventing people from dying prematurely Reducing premature mortality from the major causes of death; Implementation of these services will improve patient experience through a redesigned pathway, provide care closer to home where appropriate and facilitate a reduction in waiting times for diagnostic echocardiograms. Patient reported outcomes will also improve through quicker exclusion of heart failure diagnosis providing reassurance to patients. Patient experience and patient reported outcomes will be monitored through key performance indicators, a contractual requirement for all service providers; A potential reduction in cardiology out-patient follow up appointments through the development of a cardiology one stop shop; Increased GP confidence in excluding heart failure; The provision of 24 hour ambulatory blood pressure monitors in primary care will alleviate the need to send patients to secondary care for a 24 hour ambulatory blood pressure test, and promote care closer to home. FINANCIAL IMPACT 27. Initial estimates from the NICE costing model for the heart failure pathway indicate potential savings of 98,946 per annum. This is based on the commissioning of NTproBNP testing and its use in monitoring appropriate patients, specialist assessment and the expansion of cardiac rehabilitation to include a heart failure programme. The estimated savings are predicated on a reduction in the number of echocardiograms for a diagnosis of heart failure and a reduction in hospital admissions for heart failure. 28. The NICE guidelines for hypertension recommend 24 hour ambulatory blood pressure monitoring for patients presenting with suspected hypertension, which will result in an increased number of patients requiring the diagnostic test currently available in secondary care and increased costs for the test, along with a potential increase in waiting 6
times. Initial modelling based on hypertension incidence indicated that costs could increase by approximately 85,000 per annum. The provision of 24 hour ambulatory blood pressure monitors in primary care will alleviate this increase in costs and help mitigate the impact on diagnostic waiting times. 29. The financial modelling completed for the cardiology one stop shop is predicated on a reduction in out-patient follow-up appointments as patients will receive the diagnostic test, consultant opinion and results in the same appointment rather than re-attending for test results. Initial modelling estimates that savings in the region of 59,000 per annum may be achieved. 30. These estimated savings would contribute towards the Clinical Commissioning Group s Quality, Innovation, Productivity and Prevention (QIPP) programme. QUALITY IMPROVEMENTS Commissioning for Quality and Innovation 31. The 2012/13 Commissioning for Quality and Innovation (CQUIN) scheme agreed with Cheshire and Wirral Partnership NHS Foundation Trust contains a goal to develop advanced care planning and an end of life care pathway for patients with heart failure. Quarterly milestones have been set for this goal and performance against these is reported through the regular quality and risk meetings as part of the contract monitoring process. Quarter one milestones were reported in August and all requirements were met. Quarter two progress will be reported in October. Quality Incentive Scheme 32. In 2012-13, member practices have signed up to our Quality Incentive Scheme which supports the continuous quality improvement of its member GP Practices. As part of the Quality Incentive Scheme, member GP practices undertake three quality indicators aimed at improving the health and wellbeing of the clinical commissioning group s population. Three of the seven indicators in the 2012-13 Scheme focus on heart disease and stroke: Improving cholesterol control in patients with coronary heart disease (CHD) 19 GP practices are undertaking this indicator; Review of heart failure care against NICE Clinical Guideline 108, to include beta blocker prescribing 17 GP practices are undertaking this indicator; Improving the identification of atrial fibrillation through opportunistic pulse checking in patients aged 65 years and over (for GP practices whose actual prevalence rate is below their predicted prevalence rate) 15 GP practices are undertaking this indicator. 7
COLLABORATIVE WORKING WITH LOCAL AUTHORITY PARTNERS 33. As part of the work on stroke, a community based Early Supported Discharge / Supported Discharge service has been commissioned which integrates health and social care to provide a seamless pathway. 34. We are also working as an active partner in the Altogether Better Cheshire Programme in collaboration with partner organisations including the Cheshire West and Chester Council. A full business case is currently in development with the aim of creating integrated health and social care teams wrapped around GP practice populations. These teams will focus on managing people, predominantly older adults and those with long term conditions such as heart failure, in the community, avoiding hospital admissions where appropriate and supporting patients who have been discharged from secondary care in the community. A workshop focused on the development of integrated teams is being held in each of the three GP Locality Networks in September. The programme is also in the process of recruiting resources to lead the planning and implementation process. 35. Community teams such as the Heart Failure Specialist Nurse Service also work in conjunction with colleagues in the local authority facilitating the support of patients in the community using assisted technology such as Telecare and Telehealth. 36. A key focus from September 2012 will be the development of the commissioning intentions for Heart Disease and Stroke for 2013-14. RECOMMENDATIONS 37. The Governing Body is asked to note the scope of current work around heart disease and stroke services. 38. The Governing Body is also asked to support the details contained in the implementation plan and note the timescales involved. Dr Lesley Appleton, Clinical Lead for Heart Disease Paul Lynch, Planning & Performance Manager Vicky Oxford, Locality Support Manager September 2012 8
Does this report / its recommendations have implications and impact with regard to the following: A. Clinical Commissioning Group Aims and Objectives 1. Quality (including patient safety, clinical effectiveness and patient experience) please outline impact The developments outlined in the report will significantly improve the quality of patient care and patient experience. 2. Commissioning Of Hospital And Community Services please outline impact The developments outlined in the report will impact on hospital and community services i.e. the commissioning of NTproBNP testing from secondary care pathology services, diagnostics in secondary care, delivery of specialist assessment in secondary care and the development of a cardiac rehabilitation programme for heart failure patients by community services. The Community Heart Failure Specialist Nurse Service will also be integrated within the heart failure pathway. The development of a cardiology one stop shop will have an impact on activity within secondary care. Yes Yes 3. Commissioning and Performance Management of GP Prescribing please outline impact Yes Earlier identification of heart failure and hypertension is likely to impact on prescribing as patients with these conditions will need to be clinically managed. However, it is anticipated that these costs will be off-set with savings generated by a reduction in hospital admissions. 4. Delivering Financial Balance please outline impact Yes The heart failure pathway is expected to deliver annual savings and the proposed cardiology one stop shop is anticipated to deliver savings through a reduction in out-patient activity. 5. Development Of The Clinical Commissioning Group as a Commissioning Organisation please outline impact No B. Governance please outline impact No 1. Does this report: provide the Governing Body with assurance against any of the risks identified in the assurance framework (identify risk number) have any legal implications promote effective governance practice 2. Additional resource implications (either financial or staffing resources) No 3. Health Inequalities No 4. Human Rights, Equality and Diversity Requirements No 9
5. Clinical Engagement Yes Has this report been developed with clinical input and do local clinicians support the report s recommendations? If yes, please outline the clinical engagement Heart Disease has been identified as a priority by practices and clinical Leads. 6. Patient and Public Engagement Yes Patients and Public Engagement around the Clinical Commissioning Group s Strategy identified heart disease and priority area. 10