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.

Established: 2011

Commissioned: HQIP

Director: Prof John Deanfield

Mission: ‘to provide information to improve heart disease patients' quality of care and outcomes’

National Institute for Cardiovascular Outcomes Research

8

PROFESSION

NHS

ADMINISTRATIONNHS ENGLAND

RESEARCH GRANT BODIES

PUBLIC

UNIVERSITY

DH

PUBLIC HEALTH ENGLAND

CV INTELLIGENCE

• Revalidation• Performance• Centre

performance

• Dr Foster• CEO/COO • Commissioning through

Evaluation• NHS Choices• Governance• Implementation of policy

• Research• Research/outcome

information

• Information regarding choice• Understanding of disease and

pathways• Use of data transparency

SOCIAL CARE

• UCL• FARR Institute

Health ChecksSocial care

Audit Yr Est. Clinical lead Prof Society No records New records/yr

Congenital 2000 Rodney Franklin SCTS/BCCA 125,000 11,000

Cardiac Rhythm management

Late 1970s

Francis Murgatroyd BHRS 900,000 65,000

Heart Failure 2007 Theresa McDonagh BSH 200,000 44,000

PCI 2002 Peter Ludman BCIS 694,598 95,000

MINAP 1998 Clive Weston BCS 1m 80,000

Adult cardiac surgery

1977 Ben Bridgewater SCTS 505,361 34,000

TAVI 2007 Huon Grey BCIS/SCTS 5,000 1,000

New technology audits

2014

NICOR data

http://www.nhs.uk/

11

CRM

HF

CARDIAC SURGERY

PCI

MINAP

CONGENITAL

NICORPATIENT OUTCOME

REGISTRY

COLLABORATIONS

UK Renal Registry

National Diabetes

Audit

CPRD

HES MRIS

Data controller: HQIP

Data controller: NICOR

Data controller: In discussion

12

http://www.ucl.ac.uk/nicor/access/application

Data access requests

13

119 Applications

Applications from SCN

14

Audit Applications from SCNs

Congenital None

Cardiac Rhythm management None

Heart Failure None

PCI None

MINAP 9

Adult cardiac surgery None

TAVI None

National Cardiovascular Intelligence Network (NCVIN) strategic priorities

Commissioning for value focus pack

Clinical commissioning group:

Focus area:Cardiovascular disease (CVD) pathway

NHS SOUTHAMPTON CCG

Version 2June 2014

Sum

mary on a page

Summary: overarching messages

6

Overarching messages

Public health focus on prevention

Significant benefit to patients if improvement to primary care management indicators were made

High costs for: CHD emergency admissions, heart failure emergency admissions, angiography procedures, angioplasty procedures

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)

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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

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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.

Annexes

Annex 1:spine charts

16

PreventionWorse outcome \ High prevalence

Better outcome \ Low prevalence

Prevalence

England worst

England best

Worst quintile in cluster

KEY:

* (p) = PCT based indicator For data sources used, see slide 23

Opportunity

Obesity (p)Binge drinking (p)

% of patients registered with a GP with a LTC who smoke4 week quitters as a proportion of estimated smokers (p)

Smoking (p) 3,071 people229 people1,912 patients--

CVD prevention registerAtrial fibrilliation

Heart failure due to LVD registerHeart Failure

Hypertension observed to expected prevalence ratioHypertension

Stroke observed to expected prevalence ratioStroke

CHD observed to expected prevalence ratioCHD 58 people

1,259 people182 people152 people585 people3,185 people95 people232 people178 people744 people

Annexes

Annex 1:spine charts

17

Primary careWorse outcome Better outcome

England worst

England best

Worst quintile in cluster

KEY:

* (p) = PCT based indicator For data sources used, see slide 23

Opportunity

AF & CHADS2 score > 1, % treated anti-coagulation drug therapyAF & CHADS2 score of 1, % treated anti-coagulation drug therapy

% AF patients stroke risk assessed using CHADS2% of patients with hypertension BP is 150/90 or less

% of patients with hypertension record of BP% of new stroke/TIA patients referred further investigation

% of stroke patients with a record an anti-platelet agent taken% of patients with stroke/TIA had influenza immunisation

% of patients with stroke/TIA cholesterol is 5mmol/l or less% of patients with stroke/TIA record of cholesterol

% of patients with stroke/TIA last BP is 150/90 or less% of patients with HF due to LVD, treated with ACE + beta-blocker

% of patients with HF due to LVD, treated with ACE inhibitor% of patients with HF confirmed by an echocardiogram

% of MI patients treated with an ACE inhibitor% of patients with CHD who have had influenza immunsation

% CHD patients treated with a beta blocker% CHD patients record of aspirin

% patients with CHD whose cholesterol is 5mmol/l or less% patients with CHD whose last BP reading is 150/90 or less 53 people

14 people2 people291 people--0 people12 people30 people44 people90 people81 people-10 people31 people412 people778 people75 people8 people86 people

Annexes

Annex 1:spine charts

18

Secondary care Worse outcome Better outcome

England worst

England best

Worst quintile in cluster

KEY:

* (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 --

54 bed days14 bed days

Cardiovascular Key Facts

Behavioural risk factors Non Behaviour risk factorsFact sheet 1 Smoking Fact sheet 6 Age, sex,

ethnicity, deprivationFact sheet 2 ObesityFact sheet 3 Physical activityFact sheet 4 NutritionFact sheet 5 Alcohol consumption

Bodily risk factors CVD diseasesFact sheet 7 Hypertension Fact sheet 11 Cardiovascular diseaseFact sheet 8 Diabetes Fact sheet 12 CHD and heart failureFact sheet 9 Kidney disease Fact sheet 13 Atrial fibrillationFact sheet 10 Familial hypercholesterolaemia

Fact sheet 14 Stroke and TIAFact sheet 15 Vascular dementiaFact sheet 16 Peripheral arterial disease

Cardiovascular Key Facts

Cardiovascular Profiles July/early August 2014

Available for all CCGs and SCNs in England.

Hard copy downloadable PDF

Available July/early August 14

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

Delivering Transformational Change Clinical Innovation

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

Commissioning Support Programme

Project Sustainability and Mainstreaming

Business Case Toolkit

Communication & Dissemination

Promoting innovation and best practice to:

• CCGs• Health and Wellbeing

Boards• Strategic Clinical Networks• Clinical Senates etc…

Commissioning Support

Regional Service Development Team

CRGs and Specialist Commissioning

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,

MRI, PPCI).

•5 commissioning policy documents- TAVI- renal denervation- PFO closure- LAAO- MitraClip

The NHS Innovation conflict:

“…..Britain is open for business…..”

“….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)

South Yorkshire and Bassetlaw Area Team

•Population covered 5.7 million•Budget £ 1.2 billion•170 Service Specifications•143 Specialised Services

Specialised Commissioning

CRGsService

Specifications CPAGArea Teams

NHS England 5 year strategy

•To be announced July 2014

•May recommend a smaller number of providers for specialised services.

•? 15 -30 providers nationally for specialised services

NHS England 5 year strategyOptions for cardiology

•Re-centralise- bring all CRT/ICD/CMR/PPCI into 15-30

centres

•Transfer commissioning of the above to CCGs.

•Consider commissioning groups/networks/consortia

ICDs and CRT for Arrhythmias and Heart Failure

•TA95 (Jan 2006) and TA 120 (May 2007)

•TA314 (June 2014)

ICDs and CRT for Arrhythmias and Heart Failure (TA314)

•TA95 (Jan 2006) and TA 120 (May 2007)

East Midlands discussion on DCM

ACC / ECS guidanceService Specifications

•TA314 (June 2014)

SummaryCRGs and Specialised Commissioning

Good Not so good

• National service• End to postcode lottery• National quality standards

• Specs developed in isolation from financial situation.

• “Rolls Royce” service specs• Difficult for CPAG to

prioritise.• Difficult to monitor

compliance with specifications.

• Future plans unclear.

National Meeting of strategic clinical network cardiac leads

Contacts of hosts and speakers–

NHSE NCD Huon Gray huon@cardiology.co.ukNHSIQ PDM Elaine Kemp elaine.kemp@nhsiq.nhs.uk

07747 763930

BHF Elaine Tanner tannere@bhf.org.uk01656 648301

Christopher Annus annusc@bhf.org.uk0207 554 0383

NICOR Julie Sanders j.sanders@ucl.ac.uk

NCVIN Lorraine Oldridge Lorraine.Oldridge@phe.gov.uk

CRG Jim McLenachan Jim.McLenachan@leedsth.nhs.uk