COMMUNITY BASED AMBULATORY ECG SERVICE AND PALPITATIONS PATHWAY

COMMUNITY BASED AMBULATORY ECG SERVICE AND PALPITATIONS PATHWAY SECTION 1 SUMMARY BUSINESS CASE BACKGROUND: This document summarises the proposed community based, direct access Ambulatory ECG service and treatment pathway for Palpitations. This proposal has previously been considered by the Flexible Healthcare Steering Group and the presented papers are attached in Section 2. The Flexible Healthcare Steering Group supports the introduction of this service. Ambulatory ECG is a highly effective method of ruling out serious heart disease in patients who complain of palpitations. Currently to access this test, GPs need to refer patients for an outpatient appointment. The new service will make Ambulatory ECG available within each GP Federation via a host GP Practice or Community Hospital. The tests will be reported by the cardiology teams at Taunton and Yeovil. The pilot established highly effective procedures which will be replicated in the new service. The results of the pilot were very successful with only 24% of patients having to be referred on for an outpatient attendance. The full results are summarised in the papers attached in Section 2. SERVICE DESCRIPTION: The service will provide 24, 48 and 72 hour Ambulatory ECG testing. It is expected that the majority or requested tests will be 24 hour tests. The machine fitting element of the service will be provided by a Host practice(s) within the following GP Federations: West Somerset Bridgwater Bay Health North Sedgemoor West Mendip South Somerset Chard, Crewkerne, Ilminster Taunton area Machines will be allocated to Federations on the basis of population size and geography. It is expected that one machine will be provided for approximately every 1

30,000 head of population. The GP Federations will be supplied with the number of machines appropriate for their population size and can determine locations for those machines, although we would expect those practices who participated in the pilot would be offered first refusal. The reading of the tests will be undertaken by Yeovil District Hospital and Taunton and Somerset NHS Foundation Trusts. XXX will be responsible for the maintenance of the ECG machines. REFERRAL PROCESS: Each Practice refers patients to the nominated host practice within their Federation. The host practice contacts the patient and arranges for an appointment within 8 working days The patient attends the practice and the machine is fitted. The patient returns the machine at the end of the test period. The host practice post the card to the relevant Cardiology department The test is reported on and the results are sent directly to the referring GP Full details are included in the example service agreement included in the supporting material supplied with this business case. OBJECTIVES: To provide care closer to home To reduce unnecessary secondary care Cardiology outpatient activity SUCCESS CRITERIA: A reduction in first outpatient attendances for patients with primary diagnosis of palpitations Number of people referred on following an Ambulatory ECG test RISKS: Incorrect activity forecasts Inappropriate use of tests by GPs GPs not following the pathway correctly IMPLEMENTATION PLAN: Business case approval June 2012 Agree contractual arrangements July 2012 Identify community based host sites July 2012 Purchase new equipment and consumables July 2012 Complete staff training, where needed August 2012 Pathway published on Pathway Navigator App September 2012 Service Launch September 2012 First Evaluation Report September 2013 2

FINANCIAL IMPACT: The pilot identified that this pathway could deliver significant savings which would be achieved through a reduction in outpatient activity within secondary care. The full cost comparison is detailed in the attached papers in Section 2 and summarised below. Forecast activity is 2100 patients per annum undergoing an Ambulatory ECG test. Current service Currently all 2100 patients would be referred to Secondary care @ 210 per First Outpatient Attendance (PbR Tariff 2012/13) Proposed service Practice costs for fitting @ 16 per patient Costs of reading the tape @ 55 per patient Costs of First Outpatient Attendance for 24% of patients referred following the test (based on pilot results) Total cost 441,000 33,600 115,500 105,840 254,940 Potential annual saving 186,060 Table 1: Comparison of costs savings based on 2100 patients per annum between current service and proposed new community based Ambulatory ECG service This scheme has previously been identified in the 2012/13 QIPP plan. Investment required: 2012/13 2013/14 2014/15 Revenue Costs Set up costs for community host sites x @ 300 per site* 2100 N/A N/A Practice Fitting costs @ 16 per patient 16,800** 33,600 33,600 (includes consumables) Total Revenue costs 18,900 33,600 33,600 Capital Costs Additional memory cards x 20 (excl VAT) 725.12 N/A N/A Annual ECG Machine maintenance costs for 18 machines *** 3078 3078 3078 Capital replacement costs (5 year cycle) **** 6156 6156 6156 Total Capital costs 9959.12 9234 9234 Table 2: Summary of investment required Notes: *Training costs will not be required where the host practice participated in the pilot 3

**Part year effect for 2012/13 as service starts September 2012 ***Maintenance cost based on 10% of machine price ( 1718 excl VAT). ****Replacement costs based on 20% of machine price ( 1718 excl VAT). N.B. Costs for the reading of tapes at Taunton and Yeovil are included in the existing contracts. A contract variation would need to be agreed based on actual activity at year end. MONITORING: Monthly activity reports will be provided for audit purposes and for the purpose of monitoring activity levels. Monitoring will be completed by the Flexible Healthcare team. A full review of the service will be undertaken by the Flexible Healthcare Cardiology clinical team 12 months after the commencement of the service. PATHWAY The pathway for palpitations is shown overleaf RECOMMENDATION: That COG approve this pathway and the required funding to commence the service in September 2012. 4

Patient complains of palpitations Take history/ examination Check pulse; BP; FBC; U&E;TFT Undertake12 lead ECG PATHWAY FOR THE MANAGEMENT OF PALPITATIONS Locations ECG services for 12 lead ECG Abnormal? NO Undertake 24/48/72 hr ECG YES YES Abnormal? NO Re-assess/ Reassure. Offer advice on lifestyle, caffeine and alcohol AF VT or 3 block ECTOPICS OTHER ABNORMALITY Anticoagulation AF referral pathway Refer to A&E? Beta blockade Consider referral to Cardiologist 5

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SECTION 2 PREVIOUS PAPERS OUTLINING THE SCHEME FLEXIBLE HEALTHCARE CARDIOLOGY CLINICAL TEAM COMMUNITY BASED AMBULATORY ECG PILOT EXECUTIVE UPDATE 1 INTRODUCTION 1.1 At the Flexible Healthcare Steering Group held in October 2011, a number of questions were raised following presentation of the review of the Ambulatory ECG pilot that was undertaken between September 2010 and July 2011. Following discussions with the Flexible Healthcare Cardiology clinical team, this paper sets out further information responding to the questions that were raised. 1.2 For completeness, a copy of the pilot review document is attached at Appendix 1. 2 ADDITIONAL INFORMATION 2.1 The Flexible Healthcare clinical team confirms that currently patients within the Taunton and Yeovil catchments requiring investigation using an Ambulatory ECG are referred as a Cardiology outpatient to access this test. This differs to the position in Central and East Mendip where GPs already have direct access to Ambulatory ECG at Shepton Mallet and Frome community hospitals, reporting on which is provided by the Royal United Hospital, Bath. 2.2 To understand the potential demand for such a service within the Yeovil and Taunton catchment areas, an annual demand projection has been calculated based on the rate of referral observed in the existing service in East and Central Mendip. This service has been established for a number of years and is embedded in local clinical practice. 8

2.3 The table below sets out the annual demand projection based on the observed referral activity in East and Central Mendip Ambulatory ECG service. The projected activity for the Yeovil and Taunton catchments is 2100 tests per annum. Mendip population 72107 Average number of tests per month in Mendip 27 Average annual number tests in Mendip (equates to 1 test per 223 people) Population of Taunton and Yeovil catchments (Taunton, Bridgwater, Chard/Crewkerne, West Mendip, North Sedgemoor, South Somerset and West Somerset GP Federations) Annual projected number of tests per annum, based on observed referral rate in Mendip (i.e.1 test per 223 people) 324 468,205 2100 Table 1: Project Annual Demand for the Taunton and Yeovil catchments (based on the observed activity in Mendip Ambulatory ECG service April 2011 January 2012) 2.4 Based on the projected annual demand set out above, the table below illustrates the costs comparison between the current and proposed services. Analysis of the audit showed that 24% of patients who underwent a test were subsequently referred onto secondary care. Please note these costs are those used for the pilot service and are subject to negotiation. Current service Currently all 2100 patients would be referred to Secondary care @ 210 per First Outpatient Attendance (PbR Tariff 2012/13) Proposed service Practice costs for fitting @ 16 per patient Costs of reading the tape @ 55 per patient Costs of First Outpatient Attendance for 24% of patients referred following the test (based on pilot results) Total cost 441,000 33,600 115,500 105,840 254,940 Potential annual saving 186,060 Table 2: Annual Cost Comparison between current and proposed services for the Taunton and Yeovil catchments (based on the results of the pilot Ambulatory ECG service September 2010 July 2011) 9

2.5 The Flexible Healthcare Cardiology clinical team has also reviewed the clinical criteria for the Ambulatory ECG service. It is felt that the clinical referral criteria are appropriate, however it has been agreed that additional checks will be implemented to guard against inappropriate use of the service. It is proposed to complete regular sample audits of referrals and to monitor referrals closely to identify any patterns of over/inappropriate use by Practices or individual GPs, which will then be investigated. This could be included in the Service Agreement with each Federation having agreed levels of demand which trigger audits and checks. 2.6 In addition to the existing service provided in the East and Central Mendip areas of Somerset there are a number of other similar schemes to that proposed here, such as that implemented in North Norfolk, a summary of which is included in Appendix 2. This pilot demonstrated similar results with 21 patients who underwent a test being referred on out of a total of 103 patients (20%). 3 NEXT STEPS 3.1 The development of direct access Cardiology diagnostics has been identified within the 2012/13 QIPP programme. 3.2 Subject to approval by the Flexible Healthcare Steering Group, PEC and the Clinical Commissioning Group (CCG), the next step will be to present a business case and implementation plan to the QIPP Delivery Group and CCG to access the funding and agree contract changes. 3.3 The Cardiology teams at Taunton and Yeovil have expressed their wish to participate in the scheme by providing the reporting element of the service. As with the pilot service, nominations for the host GP Practices would be sought from the GP Federations. 3.4 This process is subject to any commissioned service meeting local and national procurement and competition rules. 4 SUMMARY 4.1 The Flexible Healthcare Cardiology clinical team sees the provision of such as a service as a positive step towards: 10

Supporting diagnosis earlier in pathway and enabling specialist interpretation to be made leading to informed clinical decision making in primary care Providing care closer to home for our patients. It provides a local service for the projected 76% of patients not requiring a specialist opinion, saving two journeys to their local DGH per patient. The service will also increase access to housebound patients and those with mobility problems, with a knock-on effect of reducing demand on hospital transport services. Improving working relationships between primary and secondary care by allowing GPs, where clinically appropriate, to manage a patient s treatment but having the support of their local specialist Cardiology team, when necessary Ensures that only those patients that need to be referred to a Specialist are able to access them in a timely manner Provide equity with the service currently available to Central and East Mendip patients 5 RECOMMENDATION 5.1 The Flexible Healthcare Steering Group are asked to review the additional information provided in this paper and RECOMMEND the implementation of a community based Ambulatory ECG service for the catchment areas of Taunton and Yeovil, as described in this paper. 11

APPENDIX A FLEXIBLE HEALTHCARE CARDIOLOGY CLINICAL TEAM COMMUNITY BASED AMBULATORY ECG PILOT EVALUATION SUMMARY 1 INTRODUCTION 1.1 Following the recommendations of the Flexible Healthcare Cardiology clinical team, NHS Somerset commissioned a pilot open access Ambulatory ECG service in four localities; South Somerset, West Somerset, Bridgwater and the Chard/Crewkerne locality. An existing service is provided to Central and East Mendip GP Practices by the Royal United Hospital Bath NHS Trust. Funds were secured to carry out a maximum of 500 tests. 1.2 The pilot commenced in September 2010 and ended on 31 July 2011. In total 345 tests were completed. 1.3 This service change supports the Somerset QIPP Optimising Elective Care programme. 1.4 The project received broad support from both primary and secondary clinicians. 1.5 This report summarises the outcome of the community based pilot and recommends the introduction of a fully commissioned service in the Taunton and Yeovil catchment areas to ensure equity of access for all GP Practices in Somerset. 2 PURPOSE OF THE PILOT 2.1 The objectives of the open access Ambulatory ECG pilot were to identify: whether there was demand for such a service and whether general practitioners would refer to it the impact upon secondary care referral activity 12

whether the service was cost effective whether it was positively received by general practitioners 2.2 This report and the supporting documents summarise the outcome of the community based pilot. 3 PILOT SERVICE ARRANGEMENTS 3.1 GP practices (plus one Community Hospital) hosted the machine fitting service within their localities. Each practice was paid a fee of 16 for each patient who was referred for a test. In addition each site received a one-off 300 payment for training and implementation. 3.2 The Ambulatory ECG machines were fitted by staff at the following locations: Bridgwater - East Quay Medical Centre, Bridgwater Chard/Crewkerne - Springmead Surgery, Chard West Somerset - Minehead Community Hospital West Somerset - Exmoor Medical Centre, Dulverton South Somerset - Oaklands Surgery, Yeovil South Somerset - Milborne Port Surgery 3.3 General practitioners could refer for a 24, 48 or 72 hour test. 3.4 The reading and interpretation of the tests was completed by the Cardiology department at Yeovil District Hospital NHS Foundation Trust (YDH). 3.5 Funding was secured for 260 tests for those patients outside the YDH catchment area (West Somerset, Bridgwater and Chard) at 55 per test, 110 for a 48 hour and 165 for a 72 hour tape. Those tests completed on patients within the YDH catchment area (South Somerset and Crewkerne) were completed as part of the existing contract value for YDH. The pilot was expected to last six to nine months. 3.6 The criteria for eligible patients were: non-critical symptoms suggestive of paroxysmal arrhythmia over the age of 16 compliant to wear a monitor for the required time-frame able to travel to the providing practice 13

3.7 Patients referred to the service were contacted by the host practice within 48 working hours and offered an appointment for a machine fitting within eight working days. Once removed the card was sent to YDH within one working day for interpretation. YDH then reported the test results direct to the referring general practitioner. 3.8 A copy of the Practice Service Level Agreement is included at Appendix 1 and includes the Service Specification. 4 SUMMARY OF FINDINGS Evidence of demand 4.1 The pilot was funded to provide a maximum of 260 tests for the non YDH localities and 240 for the YDH catchment (South Somerset and Crewkerne); a maximum total of 500 tests. The pilot ceased on 31 July 2011 after 345 tests had been completed. The reason for the pilot service closing early was the faster rate of referral within the non YDH localities which exhausted the funding and the decision was made to close the pilot. 4.2 Table 1 shows the total numbers of tests completed by locality over the pilot period. The table also shows how many months the pilot ran in each locality. It should be noted that Oaklands Surgery (South Somerset Yeovil) joined the pilot at a later stage than the other localities and as a result did not complete its expected proportion of the total number of tests based on population size. Locality Population % total pilot Population Total Number of Tests Number of months Bridgwater 68994 26 97 11 West Somerset 30120 12 51 11 Chard/Crewkerne 45726 18 65 11 South Somerset (MP) 26368 10 53 11 South Somerset (OK) 85875 33 51 8 Dulverton 3914 1 28 8 Total 260997 100 345 Table 1: Number of tests completed by Locality 4.3 The business case originally submitted by WyvernHealth predicted 1920 tests per annum for the population of Somerset (530,000). This equates to 14

No of tests a rate of 3.6 tests per 000 population. It is difficult to calculate an accurate rate from the pilot data due to the slow build up of referrals over the early months of the pilot (see Graph 1) the pilot period spanning less than one year the referral rate in some localities had not reached a plateau at the end of the pilot period and still appeared to be growing Exmoor Medical Centre in Dulverton only served its own population and it rate was significantly higher than the other localities Oaklands (serving the largest locality population) did not come on-stream until a few months after the first practices and so the referrals in that locality had not met the expected levels when the pilot ended 45 40 35 30 25 20 15 10 5 0 Graph 1: Total Referrals by month 4.4 The activity breakdown shown in Table 1 was prorated up to provide an estimate of 12 months activity (approximately 410 tests). Based on this, the pilot demonstrated a rate of around 1.5 tests per 000 population. However, due to the reasons listed at 4.3 this is probably an underestimate. This would need to be considered when building a business case for any permanent service. A rate of around 2.0 2.5 tests per 000 population would be more realistic. 4.5 Table 2 shows the number of 24, 48 and 72 hour tests that were requested. Although 48 hour and 72 hour tests were available, the majority of test requests were for 24 hour tests. This may be due to 15

misunderstanding or a lack of clarity in the communication to GP Practices. 24-hr 48-hr 72-hr Number requested 335 6 4 Table 2: Number of Ambulatory ECG test types requested 4.6 Analysis of the referral data demonstrates that across all the localities 125 individual general practitioners used the service. Across the localities 35 out 42 practices used the service at least once. General Practitioner Feedback 4.7 As part of the pilot evaluation a survey was sent to 78 general practitioners. 40 responses were received. A copy of the questionnaire is included in Appendix 2. 4.8 The results of the survey were generally positive. A summary of the results from the survey is included in Appendix 3. 4.9 The cardiology clinical team has also received positive support for such a service from general practitioner representatives on the group and representatives of the GP Federations. Patient Feedback 4.10 The following comments were received from the GP practices who hosted the machine fitting service:- All the patients we have seen have praised the service. Delivering the machine back to us has had the most praise as normally patients would have had to make a 23 mile round trip normally to do this with Musgrove. I think we have seen more elderly patients by offering this service as they have been able to return the machine more easily, either themselves or family members. There was no negative remarks, all positive, liked the ease of car parking unlike the hospital parking which was found to be awkward at times. Impact upon secondary care referrals 16

4.11 In order to measure the impact of the pilot Ambulatory ECG service upon secondary care referrals to cardiology, Secondary Uses Service (SUS) data was used to track patients, to identify those that subsequently went on to have a cardiology first outpatient attendance in the period of time following their Ambulatory ECG test. Due to the time lag between hospital outpatient activity taking place and SUS data being received by NHS Somerset, only those patients who underwent an Ambulatory ECG test between September 2010 and May 2011 were analysed. This subset consisted of 256 patients. 4.12 Table 3 summarises the outcome of the analysis of this subset of patients. Of the 256 patients who had used the pilot Ambulatory ECG service only 61 (24%) were referred to secondary care for a cardiology outpatient attendance. Centre referred to ECG Tests Cardiology OP Appointment % Dulverton 19 4 21% East Quay Bridgwater 72 13 18% Milborne Port 40 13 33% Minehead Hospital 41 9 22% Oaklands 36 9 25% Springmead Chard 48 13 27% Grand Total 256 61 24% Table 3: ECG Pilot Patients subsequently attending a Cardiology Appointment At Any Trust. ECG Tests carried out between September 2010 and May 2011 4.13 The number of patients referred for a cardiology outpatient appointment after having had an Ambulatory ECG test is very low. However, when interpreting this analysis, consideration needs to be given to the potentially lower referral threshold for a local diagnostic service compared to a consultant led cardiology clinic i.e. would general practitioners refer to this service because it is available locally so inflating its use. Cost effectiveness 4.14 The treatment costs for this subset of 256 patients were calculated based on the actual activity undertaken. The calculation is shown below. Assumption: All tests incur an interpretation tariff of 55. 17

256 patients x 16 per test for fitting = 4096 plus 256 patients x 55 per test for interpretation = 14080 plus 61 Outpatients Appointments x 215 per attendance = 13115 plus One-off implementation costs = 1500 Total Costs for the 256 patients = 32791 4.15 Assuming that all 256 patients would have been referred to secondary care for an outpatient appointment this would have cost 55040 (256 x 215). On this assumption, there was a saving for this cohort of 256 patients of 22249. 5 OPERATIONAL FEEDBACK 5.1 Key points that were raised in feedback from the host practices that needs to be considered as part of planning any permanent service:- the number of monitors/cards required by each practice to ensure they can meet acceptable wait times for the fitting of machines a crib sheet for referrers and booking staff to make patients aware of what they need to do to prepare for the machine fitting e.g. do not wear body lotion and ensure ankles are accessible to fit the machine the majority of tests requested were 24 hour tapes however 48 and 72 hour tapes were available. Need to specify the options available to referrers and communicate accordingly. The appropriate funding needs to be in place to meet demand for the additional tests as the pilot did not reveal this. 18

6 CONCLUSIONS 6.1 Based on the service review undertaken there is evidence that the pilot service was using widely by GP practices and individual general practitioners. However the option to request a 48 or 72 hour test was not clear to all referring general practitioners. This was reflected in the tests requested and feedback from some general practitioners. 6.2 The results of the general practitioner survey were generally positive. The negative comments were limited to comments from three individuals. The overwhelming view of those general practitioners who had used the service and responded to the survey was that it was a very useful service and should be retained. 6.3 The patient feedback received via the GP practices was positive. It provided a service closer to home and within their communities. It also provided timely intervention where necessary for some patients. Dr Andrea Trill at Dulverton reported that the Ambulatory ECG pilot has literally saved a life when a gentleman with a 12 second pause was picked up as a result of the ECG and sent the next day to Musgrove Park Hospital for a pacemaker. 6.4 As demonstrated in section 4, the analysis shows that of the 256 patients who underwent an Ambulatory ECG test and could be tracked; only 24% were referred on for a cardiology outpatient appointment. Even allowing that general practitioners may have a lower threshold for referring to such a service as opposed to referring for a cardiology appointment this is a potentially significant reduction in cardiology referral activity. 6.5 In terms of cost effectiveness, the analysis outlined in section 4.10 shows that there was an overall saving of 22249 for this cohort of 256 patients. 19

APPENDIX A PRACTICE ACTIVITY REPORTING SCHEDULE The Practice should submit a monthly activity report to Steve Thole, NHS Somerset. The report should provide a summary of all referrals including the following information for each referral. 1. Patient Forename 2. Patient Surname 3. Patient DOB 4. Patient Age 5. Patient Gender 6. Referring Practice Number 7. Referring Practice Name 8. Referring GP Name 9. Referral Date 10. Date of Fitting 11. Date card sent to YDH 12. Were there any incomplete referral forms that had to be returned to the referring GP and resulted in delay of investigations if so which practices? 20

APPENDIX 2 Community Based Ambulatory ECG pilot GP Survey Dear Colleague, In conjunction with the Yeovil District Hospital cardiology team, we have been running a community based Ambulatory ECG pilot service in your locality. As a user of the service, we would welcome your views as part of our evaluation of the pilot. I would appreciate it if you could find the time to answer the short questionnaire attached. Yours sincerely, Dr Mike Gorman GP Question 1 - Quality Were you satisfied with the quality of the service? (please one box) 1 Dissatisfied 2 Neither Satisfied or Dissatisfied 3 Satisfied Please use the space below to add any other comments: 21

Question 2 - Timeliness Were you satisfied with the timeliness of the service i.e. did you receive reports in a timely fashion? (please one box) 1 Dissatisfied 2 Neither Satisfied or Dissatisfied 3 Satisfied Please use the space below to add any other comments: Question 3 - Effectiveness Were you satisfied with the effectiveness of the service i.e. did the service allow you to manage patients in primary care? (please ) 1 Dissatisfied 2 Neither Satisfied or Dissatisfied 3 Satisfied Please use the space below to add any other comments: 22

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APPENDIX 3 AMBULATORY ECG PILOT GP SURVEY RESPONSES JUNE 2011 78 Surveys were distributed to named general practitioners who according to records had referred to the service 40 general practitioners responded 1 general practitioner did not complete the survey as they had not referred any patients 1 general practitioner advised that their practice owned a machine and would not be regular users of the service Comments received: "very good" "very happy with the service - needs to continue" "very efficient" "seemed a fast efficient service" "very good service" It is useful and highly efficient service. The patients are being seen quickly and likewise we are receiving the results quickly" "Excellent - did exactly what it said on the tin - allowed patients to avoid travelling to Taunton "Effective - very much so - though there were no surprises I would have felt obliged to refer to a cardiologist for mine and the patients reassurance" "Thorough report" "Very prompt" "Ideal service close to patient. Very lucky to have access to it." "For us in a rural community it is of great benefit for our patients" "Has been quick and very helpful" "has saved a number of cardiologist appointments" "Excellent service - easy to access and well liked by patients as community based" "very useful service has saved time and hospital POD appointments" "this is a good speedy alternative to formal cardiology referral. Great. "very convenient for our patients" "extremely efficient service" "a lot patients were reassured by the ECG and did not need onward referral to cardiology" "useful for some patients to avoid hospital referral" "well received by patients" 24

Summary of responses to Questions Survey Question Satisfied Neither Satisfied or Dissatisfied Dissatisfied No Response Q1. Were you satisfied with the quality of the service? Q2. Were you satisfied with the timeliness of the service (e.g. Did you receive reports in a timely fashion)? Q3. Were you satisfied with the effectiveness of the service (e.g. Did the service allow you to manage patients in primary care)? 36 2 0 1 37 1 1 0 35 3 0 1 * Reasons given where dissatisfied/neither satisfied/nor dissatisfied/no response: ¹ felt 24-hr tape not long enough ² one response indicated that the practice owned their own machine ³ no reasons given 40 35 30 25 20 15 10 5 0 GP Survey Results 1 2 3 Satisfied Neither Satisfied or Dissatisfied* Dissatisfied* No Response* 25

APPENDIX 2 HEART MONITOR SAVES HOSPITAL TRIP A trial project in Norfolk, in which GPs gave portable heart monitors to patients, saved 82 people a trip to the local hospital it has emerged. The ambulatory ECGT pilot was set up by the North Norfolk Health Consortium. For six months, from April, patients suffering from palpitations or dizzy spells were given a heart monitor for 24 hours. GPs could then look at the results and diagnose the problem rather than sending patients to hospital for tests. ECG tests are not routinely available at GP practices, so had the portable heart monitors not been available all of the 103 people taking part in the trial would have been referred to hospital for tests. Pacemaker insertion But because GPs could confirm or rule out heart problems from the heart monitor readings, only 21 patients were referred to hospital for further tests. Dr Anoop Dhesi, a GP and chair of the North Norfolk Health Consortium, said: We are delighted that the 24-hour ECG pilot achieved its goal of reducing unnecessary referrals to hospitals by identifying potential heart problems quickly in a GP setting. In addition these tests also help GPs identify much more quickly a small number of patients who need to be referred urgently to hospital, for example for pacemaker insertion. We are still receiving feedback but once we have this in full we will look at how we may be able to refine the process and widen it out to more GP practices. Extract from BBC News Channel BBC Norfolk http://news.bbc.co.uk/1/hi/england/norfolk/8402078.stm 26