“In the realm of ideas everything depends on enthusiasm... in the real world all rests on perseverance.” Johann Wolfgang von Goethe, Author
With so many GP federations lacking any form of engagement from either the local CCG and/or the local Hospital/Foundation Trust, I thought lifting the gloom with a good news story would help lighten the load and demonstrate the art of the possible.
Step forward Berkshire Primary Care Ltd, a GP Federation of 15Member Practices, which also make up the membership of NHS Bracknell and Ascot CCG, covering a population of around 180,000.
The federation has a contract in place with the CCG for Extended Access, in to which we also negotiated five new, technology based innovative services, two of which are:
• Continuous ECG, using the ePatch from Health Innovation and Technology
• 24 hour ABPM, using the BRPo from HealthSTATS
Both services are properly resourced, and cover all running costs and overheads. The CCG was content to negotiate the opportunity to pilot the new services within the Extended Access project with a firm commitment to commission those which were successful and met the performance indicators agreed in the contract.
The service provides a solution to typical complaints of palpitations/fainting spells, etc, where patients who have had a clinical 12-lead ECG, but where nothing of note or significance has been identified then need a referal for contuous ECG.
A complete patient pathway
In essence, once a clinician has established that a presenting patient has palpitations, they can then:
1. Assign ECG Patch Holter device to the patient (2-4 minutes)
2. Fit the Patch Holter Recorder device on patient (3-5 minutes)
3. Patient returns device to practice after agreed monitoring period where a member of the administrative or HCA team upload data
4. Data is sent to be interpreted and reported on by a team of Cardiac specialists
5. The final report is then made available to the referring Health Care professional within 72hrs
The Patch Holter Recorder can record for up to 3 days (soon to be 5), meaning the availability of continuous recording of ECG for longer periods where this is required.
Traditional continuous ECG measurement provides a significant number of readings over a specific time, usually 24 hours, and this has a diagnostic yield of 2% to 4%. However as this service uses a device that records for up to 72 hours, and has a diagnostic yield of around 30%, this leads to much better patient outcomes.
Example Patient Journey
1. Monday: patient attends complaining of palpitations or is perhaps identified opportunisitically via an arrhythmia screening process, sees a healthcare professional, who applies the Patch Holter Recorder
2. Tuesday: patient returns the device
3. Wednesday: device uploaded for reporting and then ready to go for another patient on the same day
4. Friday/Monday: GP receives the continuous ECG report
This means that at step 4 the GP sees the report and can confirm the diagnosis. The patient can then be anticoagulated that day via Level 4 Enhanced Service if Warfarin is chosen, or alternatively can be started on a DOAC. Whichever type of anticoagulation is chosen, this means that one stroke has been prevented within a WEEK. Furthermore, capacity and cost-effectiveness have been improved upon as there are very few steps in each pathway.
The technology used is the Patch Holter Recorder from Health Innovation and Technology and this services fits perfectly with the NICE challenge to doctors to prevent 8,000 strokes a year:
When delivered in conjunction with 24-Hour ABPM (using BPRO, which checks the patient’s pulse while monitoring ABPM) the two projects combined could have a significant impact on improving quality, reducing variation and avoiding referrals.
24 hour ABPM
Current NICE guidance recommends that a diagnosis of hypertension should be made using 24-hour ambulatory blood pressure monitoring (ABPM). This should be offered to all patients if the clinic blood pressure is 140/90 mmHg or higher. These recommendations are based on substantial new evidence, including a paper published in the Lancet, which suggests that ABPM is a more accurate and cost effective way of diagnosing hypertension than both clinic and home monitoring.
The 24-hour ABPM process involves wearing a type of mobile blood pressure monitor that records numerous blood pressure measurements throughout the day and night. The move towards the use of ABPM will help to avoid the ‘white coat effect’, where patients experience a temporary increase in blood pressure while having their blood pressure measured by a healthcare professional. It’s thought that up to a quarter of patients experience white coat effect, potentially indicating that a patient has high blood pressure when it would be within a healthy range during normal day-to-day activities.
The BPro is a Tonometric device, meaning the inaccuracy issues with older wrist devices do not figure with this device. It derives the Brachial BP from radial pulse wave measurements, not the blood pressure in the wrist. Aside from a much more patient-friendly piece of equipment, this device accurately reflects the Central Aortic Pressure, which is now recognised to be a much more accurate predictor of CVD. The only potential issue is that most of the guidelines are well behind this technology.
Through these projects the opportunity exists for General Practice to bring care into the community, directly supporting the shift from in hospital care to out of hospital care. Whether working through a Federation, or larger practices/super practices, you can now deliver a new, high quality and completely consistent service, with one standard approach to the service across all providers, who will be working to agreed thresholds and protocols/pathways – completely elimintating unwarranted and unexplained variation.
There are a number of significant benefits across these services including:
• Reduction in referrals into secondary care and the potential subsequent associated anxiety which may be experienced by patients
• Providing GPs with relevant and accurate information regarding ECG and ABPM values in days instead of weeks
• Avoiding unnecessary/inappropriate diagnosis of patients with AF or hypertension, which also avoids unnecessary prescribing of medication
• Improve the identification of patients at increased cardiovascular risk due to AF or hypertension
• Reduction in the number of patients having a stroke as a result of having undiagnosed AF
• Initiation of treatment for AF or hypertension before the onset of target organ damage
• Provision of shorter waiting times for patients
• Improvement in patient compliance whilst being tested as they can bathe/shower without removing the equipment
We have the business cases, and a number of projects already negotiated and live, either commissioned directly with the CCG or on subcontract from secondary care. We will be delighted to share the system and process behind these with any interested federations, CCGs and hospitals.
If you are thinking about forming a super practice or federating, and would like more information on how BW Medical Accountants can support you, or to arrange to speak to one of our experts please contact firstname.lastname@example.org or call 0191 653 1022.
Additionally, if you should have questions for us please email Rachael Mackay email@example.com and we will do our best to answer these within the blog.