Delivering the QIPP programme: making existing services improve patient outcomes Produced by Glyn Davies MP, Chair All-Party Parliamentary Group on AF in association with the Atrial Fibrillation Association (AFA). Introduction The Quality, Innovation, Productivity and Prevention (QIPP) programme is the largest transformational programme ever attempted within the NHS which involves all NHS staff, patients and the voluntary sector. The objectives of QIPP are to improve the quality of care in the NHS, increase productivity and make 20 billion of efficiency savings by 2014-15, which would then be re-invested back into front line services. In order to help the NHS meet the aims of the QIPP programme it is important to highlight what best practice in Atrial Fibrillation (AF) prevention and treatment entails and how it can then be implemented. In order to identify this, the All-Party Parliamentary Group on Atrial Fibrillation held a meeting to discuss best practice in AF and highlight where it is currently being applied across the NHS. Attendees at the meeting focused on four areas where adopting best practice could help save the NHS money and improve patient care. 1. Integrated care 2. GP and patient education programmes 3. Greater use of Patient decision aids (PDAs) 4. Raising standards through QOF or LES Further examples of best practice and statements on quality care can be found in Healthcare Pioneers: Showcasing innovative practice in Atrial Fibrillation on the AFA s website at www.atrialfibrillation.org.uk. Healthcare Pioneers was successfully launched at a previous APGAF meeting. What is the QIPP Programme? To make efficiency savings and drive productivity, the QIPP programme aims to deliver fundamental cultural change in the NHS, challenging the view that improving quality automatically means higher costs. Similarly it aims to improve health as well as sickness services, with more emphasis on prevention, earlier intervention and standardised care based on proven methods, whilst integrating services around patient needs. The programme is also designed to make the NHS more productive by delivering a whole-scale transformation of healthcare systems to raise standards, decommission relatively ineffective interventions, shift care into more cost-effective settings and drive quality and cost improvements across providers to reduce variability. 1
AF within QIPP There is currently one AF QIPP case study which is part of the Long-Term Conditions work stream and focuses on the detection and optimal therapy in primary care by encouraging opportunistic screening by pulse palpitation of patients over 65. This has been used in 18 regions to improve the detection and prevention of AF. Published in November 2009, the QIPP case study aims to improve the identification, diagnosis, risk stratification and optimal management of patients with AF to reduce the risk of stroke. The roll-out of this programme was supported by the Stroke Improvement Programme and the cardiac and stroke networks which enabled Primary Care Trusts (PCTs), Practice Based Commissioners (PBCs) and General Practitioners (GPs) to apply evidence based learning. Similarly it enabled them to access tools, resources and education programmes developed for primary care through the first phase of pilot projects to improve the identification, diagnosis and optimal therapy for AF patients to reduce the risk of stroke. What was the impact of the AF QIPP Case Study? The pilot projects were delivered within a 6-18 month period and 18 priority projects were managed within Heart and Stroke networks. A further nine sites were introduced in October 2009. The pilots were assessed on whether they improved safety, effectiveness, patient experience and productivity. It was found that the pilot improved detection of AF through opportunistic and systematic pulse palpitation and that quality outcomes for patients with AF were improved through optimal therapy to reduce the risk of stroke. Similarly, improved productivity through the reduction in referrals and bed days was achieved whilst improving patient survival rates. This was delivered in Bedfordshire and Hertfordshire where opportunistic screening of over 65s was introduced. Similarly the West Yorkshire Cardiovascular Network helped pilot the GRASP- AF tool to highlight patients with a CHADS 2 score greater than one who are in need of anticoagulation. These pilots were deemed a success with consistent cash-releasing saving, productivity gain or gain in the quality of services achieved. A similar scheme in Durham, where patients received an opportunistic pulse check prompted by a flag to the GP clinical system, led to 1,569 patients receiving a pulse check; with 207 being identified as having an irregular pulse and no known AF. From this 99 patients received an ECG and 36 patients were diagnosed with previously unknown AF. A scheme in York where known AF cases were reviewed using the GRASP-AF tool, led to 3,613 patients being diagnosed with AF and 53% of them had a CHADS 2 score of two. This then lead to 41 new warfarin prescriptions. 2
What additional measures should be included to help reach QIPP targets? 1. Joined up care AF is the most common heart arrhythmia, diagnosed in approximately one million people in England alone. It is further estimated that another 50-100 per cent are undiagnosed. Attendees noted that whilst schemes to know your pulse were essential in order to diagnose people with AF, this is no guarantee that they will then go on to receive effective treatment. Attendees suggested that in order to treat AF and prevent stroke it would be necessary to join up all aspects of the patient pathway to ensure that when diagnosed with AF a patient does not fall off the radar. Even if you do identify an irregular pulse, that doesn t mean the patient will receive treatment Attendees highlighted the pilot taking place in NHS Corby as an example of how to ensure that all elements of the patient pathway are working together to improve outcomes. When establishing the barriers to effective AF care, the organisers highlighted reluctance from patients to take warfarin and the lack of AF commissioning focus and local guidelines. In order to rectify this, the pilot set up five different workstreams that looked at all aspects of the AF patient pathway. To ensure that these workstreams co-ordinated their activities, they included a broad range of stakeholders within the planning and delivery process. This included representatives from the primary care, secondary care, voluntary sector, local councillors, the pharmaceutical industry and medical device companies. These organisations then worked together to develop a programme of AF support which included: training on how to diagnose and manage AF, how to use GRASP-AF and a review of all patients on the AF register to assess the support that they were receiving. Full data on the effectiveness of the NHS Corby pilot will be available within the next few months. 2. GP education programmes Attendees highlighted that one of the biggest barriers to effective patient treatment was a lack of knowledge on the part of patients and clinicians on how best to cope with the condition. Two problems were identified: firstly reluctance on the part of GPs to prescribe anything apart from Aspirin and nervousness from patients about moving on to anticoagulants. GPs were considered to be reluctant to prescribe warfarin as if a patient suffered a bleed it was considered to be their fault, whereas a stroke when a patient was receiving aspirin was deemed a natural consequence of having AF. Patient concern about the affects of taking anticoagulants was the central reason why GPs were unwilling to prescribe the treatment. Attendees highlighted that patients were concerned about the suitability of warfarin both in terms of safety and the inconvenience that it would cause their day-to-day lives. The failure to effectively treat AF and the subsequent stroke risk was highlighted by attendees as a significant cost burden to 3
the NHS as AF related strokes are more severe than non AF strokes and therefore placed a greater cost burden on the NHS. In order to improve patient access to treatment it is important to train GPs on the need to prescribe appropriate treatments and not to rely on aspirin for treatment, which has been proven to be vastly inferior to warfarin in preventing AF-related strokes. An example of where this has been successfully implemented is in NHS Lincolnshire where they are currently in the process of sending 18 GPs on an AF diploma course. If a patient has a stroke that s seen as natural, if a patient bleeds then that s seen as the GP s fault Similarly, NHS Haringey is in the process of recruiting an AF advisor whose role is to monitor the AF pathway and ensure that it is operating effectively. This will improve the advice that Doctors are able to offer patients and provide them with the information to help patients to make a considered and informed choice as to what would prove best for them. 3. Better information for patients and the further development of an AF Patient Decision Aid AF patients were present at the meeting and they explained how one of the big problems surrounding AF is that when one is diagnosed, there is either insufficient information about what management options are or that one is unable to properly comprehend them. Consequently, this is likely to lead to patients making the wrong choice about what treatment they need to follow or even whether they would continue to receive treatment. Attendees heard how in NHS Sheffield clinicians were working to develop a patient decision aid (PDA) to guide patients through the decisions involved and the benefits of the treatments that they might receive. Patient decision aids are designed to help patients make difficult decisions about their treatments and medical tests. They are used when there is no clinical evidence to suggest that one treatment is better than another and patients need help in deciding which option will be best for them. Attendees explained how in some practices patients were asked a series of questions by their GP about their treatment options and how it might affect them. When they had completed these questions they were shown a picture of a heart which displayed their risk of stroke if they chose to continue with that treatment option. It is crucial that patients are part of the decision making process and not just told what to do Similarly, attendees also highlighted the importance of routinely using existing AF stroke risk calculators, which by calculating their CHA 2 DS2VASc score, enabled patients to accurately determine their stroke risk according to the treatment that they pursue. Whilst these tools are currently easily accessible it is not being provided to patients when they are diagnosed with AF and they are therefore unable to make a reasoned choice regarding their treatment options. 4
Attendees agreed that through the development of PDAs and the greater use of existing stroke risk calculators, such as the one created by the AFA, patients would be better informed and would be able to make better decisions throughout their patient journey. This would lead to better engagement with clinicians, which would increase the likelihood of GPs prescribing alternatives to aspirin. 4. Raising standards through existing incentive schemes At the meeting attendees highlighted the issue of whether using existing NHS incentive systems such as the Locally Enhanced Services (LES) system, would improve standards of patient care. The LES system covers optional commissioning of services based on local needs and PCTs determine what funding to provide based on the needs of the local area. NHS North West London was cited as an effective example of using incentive schemes to improve care as the LES system was used to encourage practices to undertake quarterly GRASP-AF assessments to monitor and evaluate their stroke risk. Under this system attendees heard how practices are only paid when they have utilised GRASP-AF in this way and have put in place measures to continuously monitor stroke risk. A further example of this is North East Essex where 37 out of 43 practices signed up to the LES incentive scheme. As a result, 34,201 patients were screened at flu clinics, 3,154 were diagnosed with an irregular pulse, 189 with AF, 342 with other arrthymias and 77 patients were CHADS 2 stratified as being at risk of stroke and anticoagulated. This was achieved at a screening cost of 2 per patient and an outlay of 68,402. It is estimated that this led to five strokes being prevented within the next year. Concluding comments At this meeting attendees highlighted clear instances of how AF best practice which could be rolled out across the NHS. There was widespread support for measures to better join up the planning of AF care, GP education programmes, better information for patients and the development of further patient decision aids as well as using existing incentive systems to encourage PCTs and later CCGs to implement AF best practice. Attendees agreed that a piecemeal approach to adopting best practice would be insufficient and for the NHS to meet the objectives of the QIPP programme, these instances of AF best practice would need to be rolled out across the patient pathway across the country. For more information on this meeting, please contact Glyn Davies MP on 0207 219 3806 or email glyn.davies.mp@parliament.uk. About the APGAF On 8 June 2011 the All-Party Parliamentary Group on Atrial Fibrillation held its inaugural meeting in Parliament. It was agreed at the meeting that the aim of the group is to: Raise awareness of the issues affecting patients diagnosed with Atrial Fibrillation (AF), and work to ensure the diagnosis, care, treatment, management, and research of AF is a priority for the NHS. For more information, please see the Parliamentary Register at: http://www.publications.parliament.uk/pa/cm/cmallparty/register/register.pdf. 5
About the Atrial Fibrillation Association The AFA is a UK registered charity which focuses on raising awareness of AF by providing information and support materials for patients and medical professionals involved in detecting, diagnosing and managing AF. 6