A case study on improving patient outcomes through successfully implementing a national innovative programme in the North East and North Cumbria in response to local health needs.
Themes: Health Inequalities, Partnership Working
Case study summary
The Accelerated Access Collaborative (AAC)/Academic Health Science Network (AHSN) Lipids & Familial Hypercholesterolemia (FH) National Programme aims to improve the management of cholesterol, increase the detection of people with FH and optimise the use of all medicines for patients on the cholesterol management pathway. Delivery of this programme in North East & North Cumbria (NENC) has been via an approach that focusses upon patient risk stratification to identify those at highest risk of CVD in primary care. This case study will focus on the implementation of a standardised approach to searching electronic patient records in primary care to identify relevant cohorts of patients, and more specifically the development of a standardised operating procedure and education/training toolkit to facilitate implementation.
What was the problem or opportunity?
In 2019, NHSE commissioned the AHSN Network to deliver a 3-year programme of work using a Population Health Management (PHM) approach to improve cardiovascular health. In parallel, the Accelerated Access Collaborative (AAC) were targeting lipid management with their Rapid Uptake Products and Pathway Transformation Funded programme. In 2020 the AHSN and AAC programmes came together into the AAC/AHSN Lipids & Familial Hypercholesterolemia (FH) National Programme. This alignment aims to improve patient care and outcomes across the lipid management clinical pathway.
Together with the Clinical Network team; the Northern Lipid Forum; and the regional FH team based at the Northern Genomic Medicine Service a standardised approach to searching electronic patient records in primary care was developed to identify patients at high-risk of FH or who would benefit from lipid optimisation in primary care. The search tool aims to operationalise the NICE endorsed AAC Lipid Management Guideline.
How did this support innovation adoption and spread?
The GP IT system patient searches were developed locally in consultation with clinical staff who would eventually be involved in implementing them. They were initially piloted in 4 GP practices (population 45,123) and subsequently iteratively refined to increase specificity. In the pilot phase, the AHSN NENC supported a small team of Clinical Pharmacists (CPs) working locally, to deploy the searches and to act as a point of contact and dedicated support for GP practices, in order to help them navigate subsequent clinical activity in the care pathway; to raise awareness of lipid management; and to deliver training and education sessions with GP practices across the ICS.
All CPs involved in the roll out of the programme were invited to attend specialist training in FH that covered a range of topics relevant to the lipid management clinical pathway. Following completion of this training, CPs worked closely with GP practices to invite suitable patients (identified via the searches) to dedicated outreach FH clinics.
Once this approach had been piloted and refined across a number of PCNs, a rigorous process mapping exercise was conducted, bringing a range of stakeholders together (including CPs working locally; FH nurses working in the region, GPs, consultants and non-clinical AHSN colleagues) to develop a standard operating procedure (SOP). The group adopted an iterative approach to SOP development (meeting as a working group) to ensure the views, experience and expertise of those who would be operationalising the tool were taken into consideration. This SOP is now being used across the ICS to underpin adoption and spread and could be used as a blueprint for other clinical areas.
How were patients and the public involved?
Representatives of the British Heart Foundation and HEART UK are members of the AHSN NENC Lipid Management Steering Group, and their views and perspective were drawn upon throughout the course of the programme.
What were the results?
In the short to medium term, outcomes relate to increased identification of those with high cholesterol, and improvement in the adoption of evidence based treatments, which in the long-term should translate to reductions in cardiovascular mortality and morbidity; and improvement in healthy life expectancy.
Implementation of the search tools and the associated optimisation of the lipid management pathway should also see an increase in operational efficiency and best use of PCN, secondary care and patient time.
A dedicated work stream focused upon health inequalities has also been developed, where NENC AHSN are working directly with the 10% most deprived primary care practices in the region (the Deep End practices). This work aims to ensure those in most need are not disadvantaged and will be facilitated by the development of specific evidence-based approaches to engaging people in these communities. This work is funded by the Beneficial Changes Network and delivered in partnership with our NIHR Applied Research Collaborative (ARC).
What were the learning points?
The delivery of this programme has shown how effectively teams and organisations can work together to facilitate implementation of a nationally commissioned programme of innovative work at the local level, ensuring that approaches are developed in consultation with all relevant stakeholders. The AHSN NENC have worked in close partnership with their local Cardiovascular Clinical Network, pharmacy colleagues in their Local Pharmaceutical Committee’s, CCG teams and colleagues in primary care to understand the challenges they face and to ensure everyone within the system is brought into the same vision and is committed to the same outcome.
Learning points included the following:
- Ensuring GP practices had access to specialist advice, triaging and signposting, from CPs with specialist FH training working locally, was key to implementation of the searches. It allowed PCNs to grow their confidence in using the searches and ensure they were making the best use of secondary care specialist services;
- Ensuring that the views and perspectives of those who would eventually be ‘doing the work’ were built in via the iterative consultative process, when both refining the searches and developing the SOP, was key to smooth implementation and engagement with the tool;
- Having significant and active support from key stakeholders such as the Cardiovascular Clinical Network team including at a Senior Leadership level was also key to the success of this work;
- A CP involved in implementation was able to trial the use of an innovative text message service to obtain patient consent for low risk changes to statin management. Suitable patients were identified via a modified version of the search tool. This worked well and planning is underway to potentially scale this approach in other PCNs in the region, which could become a blueprint for other text appropriate prescription notifications, especially for patients who find it challenging to travel for medical appointments;
- Colleagues involved in the roll-out of the searches, found that capacity in primary care (especially compounded by the COVID-19 pandemic and rollout of the vaccination programme) was a barrier to implementation;
- The time taken to bring about consensus between the various stakeholders involved was also considerably longer than expected, which led to reflection on the importance of being realistic in expectations around time frames at the outset; and
- The implementation team also recognised immediately that for the programme to be successful it was critical that they worked collaboratively, to avoid duplication, and to ensure that all involved were using resources to push in the same direction.
Next steps and sustainability
The NENC AHSN are currently offering to support all PCNs in NENC with education, training, and the associated roll out of the SOP across the entire ICS area. They also continue to support a number of CPs who can directly influence the implementation of the programme using the materials that have been developed during the pilot phases. In the long term it is envisaged that ongoing education and training, together with work to raise awareness amongst both patients and professionals, will ensure that this programme is fully embedded within primary care and has an associated benefit upon cardiovascular disease mortality and morbidity in NENC. The materials underpinning the implementation of this work are available for other areas to adapt to their local needs to support adoption and spread.
Find out more
- Some of the initial planning work has now been published in the journal atherosclerosis. All materials are available through the AHSN NENC web site, including the SOP that underpins adoption and spread across the whole region
- AHSN NENC Cardiovascular Disease Prevention Programme