Domain 1 – case studies

  1. Nottingham City: Prostate specific Antigen service
  2. Erewash: Atrial Fibrillation Detection Programme
  3. Thurrock: Introduction of Telehealth
  4. South London: Screening Programmes/development
  5. Leicestershire & Lincolnshire: Adoption of jointly Created Decision Architecture
  6. Leicestershire & Lincolnshire: Collaborative Commissioning with CCG’s
  7. Hertfordshire & South Midlands: MMR Catch up campaign
  8. Norwich: Healthy Norwich
  9. Birmingham South & Central: BSC Community Gynaecology & Direct Access Ultrasound
  10. Coventry: Improving COPD Care
  11. NHS England: Specialised Services

Nottingham City: Prostate specific Antigen service

Nottingham has a higher than average ‘new to follow-up’ ratio in urology. Secondary care clinicians spend significant time on follow-up appointments at the expense of seeing new patients.

A new clinical pathway directs patients with stable prostate cancer to a more convenient setting outside hospital. The PSA Local Enhanced Service went live in April 2012.

The new PSA pathway optimises resources and reduces prescribing spend in primary care and meets NICE guideline 58. It delivers more effective follow-up appointment management, resulting in reduced spend in secondary care, and contributes to the CCG meeting QIPP targets.

Patients with stable prostate cancer now receive the same level of follow-up care closer to home.  The ‘new to follow-up’ ratio is reducing, releasing consultant and specialist nurses to focus on new appointments and delivering holistic care assessments in patients with advanced disease. Patients managed in a community setting who develop complications can now be seen rapidly in the urology clinic if necessary.

The service delivered at practice level is monitored to ensure that all patients receive consistently high quality care.

This new service will deliver projected full year cost savings of £71k, (£44k in reduced follow-ups, and £27k for drug costs).


Erewash: Atrial Fibrillation Detection Programme

NHS Erewash CCG Board identified the reduction of health inequalities with a specific focus on cardiovascular prevention as one of its key strategic priorities. In addition, the Erewash Local Strategic Partnership prioritised cardiovascular disease prevention. 33% of the deaths that contribute to the life expectancy gap between Erewash’s most deprived area and the England average are due to cardiovascular disease.

About ‘Atrial Fibrillation – detection and optimal therapy in primary care’.

It has been highlighted as a potential high impact change by NHS Evidence.  Atrial fibrillation (AF) is a major cause of stroke and also increases the risk and severity of stroke. Recognition and optimal treatment of AF is of particular importance as strokes due to AF are preventable.

Between June 2012 and January 2013, the outcomes of the AF Detection Programme in Erewash were:

  • 6,556 people aged 65 and over have been screened for AF
  • 37.0% of population aged 65 and over have been screened for AF – one practice has achieved an uptake of screening of 71.2%
  • An additional 116 patients have been identified as having AF
  • The percentage of patients diagnosed with AF has increased by an average of 7.7% across the GP practices
  • The practice that has screened 71.2% of population aged 65 and over for AF has identified an additional 20 people with AF increasing the population with AF in the practice by 19%
  • Modelling of the impact of the AF Detection Programme to date, eight strokes will have been prevented of which two or three would have been fatal
  • The saving in avoiding a stroke is £18,000 in NHS costs. A reduction of eight strokes per annum in Erewash would save £144,000. The scheme will result in cost savings to the NHS and social care in both the short and long-term.
  • In addition, the lead GP, Dr Neerunjun Jootun, who conducted the initial pilot of the WatchBP Home A machine, found that using the machine had detected a number of patients with AF who had the diagnosis later confirmed through ECG, but on whom taking a pulse check, fibrillation could not be detected. This demonstrated additional diagnostic accuracy beyond use of pulse checks.

AF Detection Programme: Quality, Innovation, Prevention & Productivity (QIPP) in Action

The AF detection programme helped to deliver an innovative and effective stroke prevention programme which supports delivery on a strategic priority and delivers real benefits in quality of life for patients. This programme truly helped to deliver the CCG’s mission statement of Better Care, Better Health, Better Value.

Background

NHS Erewash CCG Board identified the reduction of health inequalities with a specific focus on cardiovascular prevention as one of the key strategic priorities for Erewash CCG. In addition, the Erewash Local Strategic Partnership prioritised cardiovascular disease prevention. 33% of the deaths that contribute to the life expectancy gap between Erewash’s most deprived area and the England average are due to cardiovascular disease.

The four CCG GP clinical leads identified the detection of Atrial Fibrillation (AF) as a priority area for work to support stroke prevention. By identifying people with atrial fibrillation and ensuring that they received appropriate preventive treatment this would reduce stroke occurrences.

As at March 2012, there were 1,469 people on general practice registers in Erewash with a diagnosis of AF which is a prevalence of 1.52%.  Four of the 13 practices have a population with AF higher than expected ratio with the reminder having AF population below expected levels.

‘Atrial Fibrillation – detection and optimal therapy in primary care’ has been highlighted as a potential high impact change by NHS Evidence.  Atrial fibrillation (AF) is a major cause of stroke and also increases the risk and severity of stroke. Recognition and optimal treatment of AF is of particular importance as strokes due to AF are preventable.

The detection programme

Whilst the CCG was developing its plans for atrial fibrillation detection, from our research we found an innovative Blood Pressure machine which also detected atrial fibrillation. The Microlife WatchBP Home Machine has been used in other CCGs (e.g. Hull) to support AF detection programmes.

A cost impact assessment published in May 2012 by Newcastle Upon Tyne Hospitals and York Health Economics Consortium concluded that the WatchBP Home A when used in a primary care clinical setting is likely:

  • To be cost saving to the NHS and personal social services over both the short and long term in patients at relatively high risk of AF and therefore stroke
  • To lead to the clinical benefit of reducing strokes in this patient group.

In January 2012, Dr Neerunjun Jootun, GP clinical lead for the AF project agreed to trial one of the BP machines in his practice using the BP machine to take blood pressures during routine consultations.  A paper was taken to the CCG Board in January 2012 which proposed a focus on AF detection. The CCG Board were keen to support work in primary care on atrial fibrillation detection and gave the go ahead for the clinical leads and commissioning managers to develop a full proposal to come back to the Board.

Since the AF Detection Programme commenced in Erewash in June 2012, NICE published the Technology Appraisal on the WatchBP Home A machine in January 2013 which stated that:

“The case for adopting WatchBP Home A in the NHS, for opportunistically detecting asymptomatic atrial fibrillation during the measurement of blood pressure by primary care professionals, is supported by the evidence. The available evidence suggests that the device reliably detects atrial fibrillation and may increase the rate of detection when used in primary care.”

What was done and how it was done

It was agreed by clinical leads that using flu clinics as well as opportunistic screening during routine consultations were the best ways to target the at risk population aged 65 and over.  The clinical leads reviewed the evidence on the use of the BP machine to detect AF and supported their use by general practices in Erewash to support the AF detection programme and preferred this to use of pulse palpation method. The AF detection programme was also developed as a QIPP scheme which would impact on reducing admissions for stroke as well as impact on other costs .e.g. rehabilitation and social care costs.

An updated paper setting out the proposed AF Detection Programme was approved by the Remuneration Committee in March 2012 and this decision was subsequently ratified by the Governing Body.   A proposal to use the 2% transformation fund to purchase the BP machines for provision to general practice was approved by the Primary Care Trust.

The AF Detection Programme was launched at the Quest event on 13th June. This presented the case for the AF Detection Programme, launched the programme and trained the practice staff on use of the new BP machines.

Results

Between June 2012 and January 2013, the outcomes of the AF Detection Programme were:

  • 6,556 people aged 65 and over have been screened for AF
  • 37.0% of population aged 65 and over have been screened for AF – one practice has achieved an uptake of screening of 71.2%
  • An additional 116 patients have been identified as having AF
  • The percentage of patients diagnosed with AF has increased by an average of 7.7% across the GP practices
  • The practice that has screened 71.2% of population aged 65 and over for AF has identified an additional 20 people with AF increasing the population with AF in the practice by 19%
  • Modelling of the impact of the AF Detection Programme to date, 8 strokes will have been prevented of which 2 or 3 would have been fatal
  • The saving in avoiding a stroke is £18,000 in NHS costs. A reduction of 8 strokes per annum in Erewash would save £144,000. The scheme will result in cost savings to the NHS and social care in both the short and long-term.

In addition, the lead GP Dr Neerunjun Jootun who conducted the initial pilot of the WatchBP Home A machine found that the use of the machine had detected a number of patients with AF (who had the diagnosis later confirmed through ECG but on whom taking a pulse check, fibrillation could not be detected. This demonstrated additional diagnostic accuracy beyond use of pulse checks.

Conclusions

The AF detection programme helped to deliver an innovative and effective stroke prevention programme which supports delivery on a strategic priority and delivers real benefits in quality of life for patients. This programme truly helped to deliver the CCG’s mission statement of Better Care, Better Health, Better Value.

Dr Neerunjun Jootun, Clinical Lead for the AF Detection programme commented:

“AF is the most common heart rhythm disorder and significantly increases an individual’s risk of stroke if they are not receiving appropriate anticoagulation.

“Given the significant implications AF has, both on the health of individuals and in terms of subsequent cost to the NHS, we decided as a CCG to trial the WatchBP device as a means of detection.

“The results of the programme clearly show how effective this device is in detecting AF.

“On more than one occasion the device detected AF but when a manual pulse was taken the AF could not be detected, which demonstrates the device has diagnostic accuracy beyond manual pulse checks.

“By trialling the device we increased the numbers of patients on AF registers across the GP surgeries by an average of nearly 8%.

“Those patients identified are now on appropriate anticoagulant medication to manage the significantly increased risk of stroke associated with AF.”

Contact for Further Information:

Helen Rose, NHS Erewash CCG, helen.rose@erewashccg.nhs.uk, 0115 9316100


Thurrock: Introduction of Telehealth

 


South London: Screening Programmes/development

Direct commissioning of screening programmes across London offers a unique opportunity for the development of a London screening centre offering equity of access to high quality prevention and to early diagnosis and treatment for all Londoners. The new system will centralise administrative aspects of screening bringing cost efficiencies, enable increased choice of referral for people who screen positive and raise quality by routine circulation of comparative outcomes across providers and to the general population.

Direct commissioning of immunisation programmes across London provides a unique opportunity to streamline the many information systems in use across the city and creating confusion in the determination of uptake rates.  A single strategy will also enable focus on improving uptake in groups not registered with a GP and for people in vulnerable groups such as recently arrived migrants, travelling communities and people living in short term accommodation such as hostels or bed and breakfast.

Planned improvements to the Child Health Record Systems now being commissioned by a single organisation provides a unique opportunity to combine for parents and their children a single record covering a number of key aspects of care especially the immunisation record and their ante natal screening history.  Ensuring that this is available to all providers and to GPs will ensure all opportunities can be taken to offer updates for outstanding immunisations or to advise on other health issues.


Leicestershire & Lincolnshire: Adoption of jointly Created Decision Architecture

Why?

As a consequence of new service specifications, and earlier diagnosis initiatives, the demand for radiotherapy will increase.

Context:

  • Provider’s ability to meet the new national service specifications
  • Provider mergers or linkages to strengthen their service
  • Providers considering their strategic options regarding providing cancer services in the future
  • Risks in delay in increasing capacity and future over capacity in region as a result of competing providers all developing capacity

Solution:

The Area Team agreed to set out a framework to support a transparent and robust process to enable the reaching a consensus agreement going forward.  The Area Team and the Strategic Clinical Networks (SCN) will review:

  • Provider Strategic Outline Case
  • Provider plans to develop network model across three sites including the sustainability
  • Evidence for satellite radiotherapy services delivering good outcomes.
  • Consequences to patient pathways , service quality, clinical outcomes, fragmentation of services and impact on other clinical services

Outcome:

Capacity plans for RT will reflect patient need and accessible services will be provided safely and cost effectively.


Leicestershire & Lincolnshire: Collaborative Commissioning with CCG’s

Why?

As a consequence of new service specifications, the demand for bariatric surgery will increase, coupled with increased demand for CCG commissioned weight management programmes.

Context:

  • Contracted services will not meet the new policy and service specification.
  • Opportunity to review provision and service quality with partners in both the CCGs and Public Health Teams in L As in order to ensure patient access and transition between service Tiers to receive right care at the right time in the right place.

Solution:

The AT will implement a collaborative approach reviewing service models and capacity including:

  • AT, CCGs and LA’s to establish demand projections using a consistent approach across Providers
  • Establishing current Provider position, options and work plans for service improvements
  • Understanding impact in primary care (specialist weight management) and conversion rate of patients being referred after receiving primary care intervention
  • Assessment of service and growth potential to identify how to build capacity and quality

Outcomes:

  • Identification of any reconfiguration or tendering of services
  • Improved quality of services, patient access and convergence towards national specification

Hertfordshire & South Midlands: MMR Catch up campaign

The NHS England Area Team for Hertfordshire and South Midlands drew together a steering group to drive forward the MMR catch up campaign; involving local authority public health colleagues, those from Public Health England and the CCGs.

  • Local authority Public health leads worked with safeguarding colleagues to identify all looked after children who were under or unimmunised to facilitate targeting of these vulnerable groups
  • A communications log was compiled to identify and share examples of how areas were engaging with media, schools and other partners locally.
  • CCGs provided their support to the campaign, encouraging any slow-responding practices to sign up to the DES; by 14th June over 93% of practices were engaged with the process.

At the 1st June 2013, MMR vaccine ordering over the preceding 5 months had increased by 37% when compared to the same period in 2012 which highlights the increased number of children and young people that will benefit from this campaign.


Norwich: Healthy Norwich

  • NHS Norwich CCG together with Norwich City Council, NHS Norfolk and Waveney Public Health and Norfolk’s Drug and Alcohol Action Team (DAAT) worked closely together in late 2012 to gain ‘Healthy Cities’ status for Norwich and become a member of the World Health Organisation (WHO), UK Healthy Cities Network.
  • A healthy city is not one which has a particular health status – good or bad. It is one that is conscious of health and is committed to improving it.
  • Through the partnership approach, NHS Norwich CCG is able to share its knowledge, evidence and expertise with partners to identify opportunities for improving health and wellbeing of the people living in Norwich and collaborate – to change health outcomes and change lives.
  • Healthy Norwich formally launched on the 14th February 2014. There are seven core theme/priorities:
  • Physical Activity
  • Diet, Nutrition and Healthy Weight
  • Education, training and employment
  • Sexual Health
  • Health Screening and Prevention
  • Healthy Urban Environment
  • Smoking, Drugs and Alcohol
  • Since the February launch, many projects having commenced under the ‘banner’ of Healthy Norwich including commissioned Weight Management services, the completion of a Norwich alcohol needs assessment and resulting strategy and awareness campaigns available at: http://www.youtube.com/playlist?list=PLshxNXU7A7wxtlLKnJjbA_UlsOD98AqFQ

A full work programme is planned for 13/14; with a key focus on health promotion within local businesses.


Birmingham South & Central: BSC Community Gynaecology & Direct Access Ultrasound

Context

For Birmingham South & Central CCG in 2011/12, gynaecology represented the 5th highest cost/activity outpatient speciality, with almost 20,000 attendances per annum at a cost of £1.9m. When benchmarked against other areas it was evident that BSC rates of referral were significantly higher than both the Area Team and the national average.

The factors contributing to the higher rate included:

  • A comparatively young patient population
  • Cultural sensitivity surrounding gynaecological issues and the need to support choice in terms of accessing a female clinician.
  • Lack of access to diagnostic investigations

A patient focus group was established, including representatives from local Women’s Groups and patient networks, to redesign the local gynaecology service.

Alongside the patient focus group, a GP working-group of member practices was also established to lead the redesign of these services and establish the future model of gynaecology services.  A procurement process was followed to identify a provider that could meet the requirements of both the patient groups and GP commissioners.

Impact

The service has delivered a range of improvements, including:

  • Consultant-delivered clinics within the community
  • Patients are offered an outpatient appointment within 4 weeks of being referred.
  • GPs have access to ultrasound investigations within two weeks of referral
  • GPs receive a report detailing the outcome of consultations/investigations within 48 hours of the appointment taking place.
  • Patients are offered a ‘one-stop’ service
  • DNAs for outpatient appointments have reduced

Further Detail

Birmingham South Central Integrated Plan 13/14 – 15/16 – Section 9: Priorities and Commissioning Intentions – https://www.bhamsouthcentralccg.nhs.uk/images/BSC_Integrated_Plan_v2.1_KMS_Portal.pdf


Coventry: Improving COPD Care

“We have transformed COPD care in Coventry for patients with the most complex needs. Strong clinical engagement was vital, as was the development of the consultant-led community COPD team which provides high quality care for patients, helping them to self-manage and stay healthy and out of hospital”  Michelle Horn, Practice Nurse, Godiva Locality Board Member

Reason for change

A Pulmonary Disease audit revealed that 74% of COPD patients admitted to hospital made contact with their practice in the month before admissions and 58% had received 3 or more courses of antibiotics in the year prior to admissions indicating there was potential for interventions to reduce the risk of admissions.

How was the change made?

Central to this improvement was the development of the community COPD team which is funded from the reduction in admissions and outpatient appointments. COPD guidelines on preferred prescribing were agreed and given out to GPs and Practice Nurses and education sessions were offered. QOF QP indicators were used to drive implementation including increasing the use of self management plans.

Impact of change

A reduction in admissions (as seen below) due to fewer acute exacerbations has resulted in better quality of life and slower disease progression for patients. A patient satisfaction showed 98% positive feedback about the service.

 

Insert chart


NHS England: Specialised Services

Specialised services are often at the ‘cutting edge’ of healthcare but also present challenges in demonstrating relative clinical and cost effectiveness given patient numbers may be small.

A new innovative – Commissioning through Evaluation (CtE) – approach has been developed to enable promising procedures (meeting sufficient safety requirements), which have not yet demonstrated sufficient evidence to be routinely commissioned, to be undertaken in a small number of treatment centres as part of a formal evaluation process.

Working with stakeholders we will identify key evaluation questions (such as ‘is this procedure more effective than other treatments that are already routinely available?’, ‘what is the total cost of care including any care falling outside of specialised hospitals?’, ‘what do patients and their carers think of their experience of this procedure?’) to inform what is commissioned and funded in the future.

Initial CtE proposals include life extending or life enhancing procedures, include:

  • Selective Internal Radiotherapy (an advanced treatment for liver tumours)
  • Left Atrial Appendage Occlusion (a treatment to reduce the chance of clots forming in patients with Atrial Fibrillation who are unable to use blood thinning drugs).
  • MitraClip (a non-surgical approach to repairing the mitral valve in the heart)
  • Patent Foramen Ovale Closure (closing a hole in the heart wall)
  • Renal Denervation (a treatment to reduce high blood pressure)
  • Selective Dorsal Rhizotomy (reducing spasticity in children with cerebral palsy)