Government and NHS Initiatives
This article describes how use of the Cardionetics C.Net5000 ambulatory ECG monitor in primary care is supported by Government and NHS initiatives.
Practice Based Commissioning: Practical Implementation
According to the Department of Health publication, Practice Based Commissioning: Practical Implementation, practice based commissioning places primary care professionals including GPs, nurses and practice teams, at the heart of decision making to commission services for their local population.
A growing proportion of the patient population will suffer symptoms indicative of cardiac arrhythmia. Referral to a cardiology outpatient department (OPD) usually involves significant inconvenience to patients, and waiting time for a first consultation can be from 26 to 40 weeks for some patients.
A general practice can contribute to meeting national priorities, including delivery of the 18 week target and supporting health improvement, by redesigning services and identifying resources that could be released from the indicative budget. The acquisition of equipment to enable the surgery to undertake ambulatory ECG tests that would otherwise require a referral to a cardiology OPD would allow timely diagnosis and help the practice achieve the 18 week delivery target. It would also improve patient satisfaction by avoiding the need for the patient to travel to a cardiology OPD.
A general practice can establish local priorities for early diagnosis of cardiac arrhythmia and stroke prevention and, with agreement of the PCT, obtain funding through practice based commissioning to allow provision of an ambulatory ECG monitoring service within the practice.
National Service Framework Chapter 8: Arrhythmias and Sudden Cardiac Death
The National Service Framework, Chapter 8: Arrhythmias and Sudden Cardiac Death identifies the incidence of cardiac arrhythmia:
- Arrhythmia affects more than 700,000 people in England and is consistently in the top 10 reasons for hospital admission.
- Atrial fibrillation (AF) is the most common arrhythmia, affecting up to 1% of the population (rising to 4% in the over 65s), and absorbs almost 1% of the entire NHS budget.
- The incidence of stroke is approximately 5% in people with AF so it is a significant cause of mortality in England.
- There are approximately 100,000 sudden cardiac deaths each year, the majority of which are caused by coronary heart disease (CHD).
- Most sudden deaths in people under 30 years of age are caused by inherited cardiomyopathies and arrhythmias.
- 125,000 patients suffer from supraventricular tachycardia and most could be completely cured.
- Blackouts cause 1% of all hospital admissions, with over 10,000 patients in the UK misdiagnosed with epilepsy.
According to Chapter 8, redesigning service provision to use ambulatory cardiac monitoring in general practice "provides new models of care and markers of quality to support further improvement in services for arrhythmias and better prevention of sudden cardiac death."
- Quality requirement 1: Patient Support — People with arrhythmias receive timely and high quality support and information, based on an assessment of their needs.
- Quality requirement 2: Diagnosis and Treatment — People presenting with arrhythmias, in both emergency and elective settings, receive timely assessment by an appropriate clinician to ensure accurate diagnosis and effective treatment and rehabilitation.
NICE Clinical Guideline 36: Atrial Fibrillation
Atrial fibrillation is the most common sustained cardiac arrhythmia. The prevalence roughly doubles with each advancing decade of age, from 0.5% at age 50-59 years to almost 9% at age 80-89 years. It is also commonly associated with congestive heart failure and strokes.
The Clinical Guideline recommends as a priority for implementation that an electrocardiogram (ECG) should be performed in all patients, whether symptomatic or not, in whom AF is suspected because an irregular pulse has been detected.
In patients with suspected paroxysmal AF, undetected by a standard (resting) ECG recording, a 24-hour ambulatory ECG monitor should be used on those patients with episodes less than 24 hours apart.
National Audit Office report, “Joining forces to deliver improved stroke care”
The National Audit Office report, Joining forces to deliver improved stroke care indicates that stroke care costs the NHS about £2.8 billion a year in direct care costs — more than the cost of treating coronary heart disease — and costs the wider economy some £1.8 billion more in lost productivity and disability.
Stroke accounts for 11 per cent of the deaths in England and Wales a year. Between 20 and 30 per cent of people who have a stroke die within a month. Every five minutes someone in England will have a stroke, and around one in four people can expect to have a stroke if they live to 85 years of age.
The report estimates that, each year, more efficient practice could save £20 million, prevent around 550 deaths and ensure that some 1,700 people fully recover from their strokes that would not have otherwise done so.
Preventing just two per cent of strokes in England would save around £37 million in care costs.
General Medical Services Contract and Quality Outcomes Framework
The General Medical Services (GMS) contract identifies enhanced services as a key tool to help PCTs reduce demand on secondary care. An expanded range of local services is able to meet local needs, improve convenience and choice, and ensure value for money.
The Quality Outcomes Framework (QOF) includes atrial fibrillation from 2006-07, as shown in the table below.
Department of Health White Paper, “Our Health, Our Care, Our Say”
The Department of Health White Paper, Our health, our care, our say: A new direction for community services, recommends more services to be provided in a community setting, more services to be provided by practices, and more convenient services for patients. It sets out a vision to provide people with good quality social care and NHS services in the communities where they live:
Health and social care services will provide better prevention services with earlier intervention. GP practices and Primary Care Trusts (PCTs) will work much more closely with local government services to ensure that there is early support for prevention.
Practice Based Commissioning will give GPs more responsibility for local health budgets, while individual budget pilots will test how users can take control of their social care. These will act as a driver for more responsive and innovative models of joined-up support within communities, delivering better health outcomes and well-being, including a focus on prevention. It will be in the interests of primary care practices to develop more local services, which will provide better value for money.
Innovative primary care services are already working to identify at-risk patients on their lists and target interventions and advice to them. The new primary medical services contracts include a powerful set of incentives, through the QOF, for practices to identify patients with long-term conditions or lifestyle risk factors such as smoking, and manage their care effectively.
The 18 Weeks Delivery Target
Delivering an 18 week patient pathway from GP referral to the start of treatment is a key objective for the NHS. The Department of Health report, Transforming Cardiac Diagnostic Services to Deliver 18 weeks: A Good Practice Guide, June 2007, identifies cardiac diagnostics as a significant risk to delivering the 18 Weeks target.
The number of patients referred to hospital cardiology outpatients has doubled since 2000. While there is no nationally available activity data, anecdotally departments report an associated increase in demand an activity for ECGs, ambulatory ECGs and exercise tests.
Significant numbers of people are waiting for exercise tests, ECGs and ambulatory monitoring.
Providing diagnostic testing early in the patient journey, where possible in the primary care setting or through direct access secondary care services or in one-stop clinics.
These new pathways are driving changes in the way in which cardiac diagnostics need to be performed and delivered in order to:
- Exclude those patients who do not have a cardiac problem, resulting in avoiding unnecessary outpatient appointments and A&E attendances.
- Make an early diagnosis for patients with a cardiac problem, to optimise care and clinical outcomes.
- Ensure patients are put onto the correct treatment and management as soon as possible.
- Deliver tests in a location that is convenient for patients and close to home.
Having the right level of cardiac diagnostic services is critical to the early detection and treatment of cardiac disease and can greatly improve outcomes for patients by getting them on the right pathway of care as soon as is clinically possible.
Using new and cutting edge technology and innovation (e.g., developments in medical science) is critically important in delivering cardiac diagnostic services for 21st century healthcare. Commissioners and providers should consider the opportunity that technology brings to the efficient delivery of diagnostic investigations within the healthcare arena, whether this is in primary or secondary care.
Using new technology can transform services and benefits patients by bringing quicker access, helping to reduce patient anxiety by providing earlier diagnosis, which in turn will assist with faster treatment and better outcomes.
With advances in technology, the use of portable machines provides an opportunity to undertake many diagnostic tests in a non hospital environment.