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Wallasey Heart Centre: leading by example

Anthony Cummins
MB BCh BAO MRCGP ALSCert
Clinical Director
Wallasey Heart Centre
E:wallasey.heartcentre@bkwpct.nhs.uk
W:www.wallaseyheartcentre.nhs.uk

The dawn of the new millennium is a time of immense change in the NHS, with the various National Service Frameworks (NSFs) and the NHS Plan. The greatest change has been the shifting of chronic disease management from secondary to primary care, facilitated by the development of primary care trust (PCT) intermediate services. These involve partnerships between GPs with a special interest (GPwSI) and development managers, individual practices, hospital consultants, local council/social services and voluntary organisations. One such programme has been very successful, serving as a model for others to adapt: Wallasey Heart Centre (WHC).(1,2)

Wallasey Heart Centre

Background
Following the collapse of the shipbuilding industry on Merseyside and the lack of inward investment in industry, unemployment has been high in Wallasey, as has coronary heart disease (CHD) risk factor prevalence. Until recently, the CHD death rate in Wallasey was among the UK's highest. Many residents had very low expectations of care, such that they expected to live limited lives controlled by illness. Ethnic minority residents and services were mutually invisible, in particular the UK-born Irish who, by being both white and English-accented, went unrecognised as a high-risk group.(3) Since 1993 we had developed a GP Exercise Prescription Scheme to reduce CHD risk factors. Women attended these services but men didn't, so we successfully took the service to men via pubs and betting shops!
Before 2000, cardiac rehabilitation services existed only for heart attack and bypass patients. They were situated some distance from our population, and public transport (a two-bus journey each way) was the sole option for many. Nonattendance was significant.
There were two huge service gaps - angina and diabetes. One man's tale was central - when told that there was no service for him, he asked, "You mean I'll have to have a heart attack and then I can go to rehab?" This was the trigger to redesigning the service for both  users and carers.

Objectives

  • To improve outcomes and quality of life.
  • To raise awareness among primary healthcare teams (not just GPs).
  • To increase implementation of CHD treatments.
  • To impact on referrals to secondary care.(*)
  • To reduce the high CHD death rate.(*)

*These last two are complex issues, influenced by disparate factors, many outside our direct control. We could not promise to definitely improve them.

Progress
WHC, a prevention and management service, opened in October 2000, made up of three components: GPs with a special interest (GPwSI); a cardiac rehabilitation service; and a lifestyle and weight management service. The other players involved were:

  • The users and carers.
  • Birkenhead and Wallasey PCT's GPs and practice nurses.
  • Wirral Hospital Trust.
  • Wirral Borough Council's leisure services ­department.
  • HealthLinks (Health Promotion Agency).
  • Irish Community Care Merseyside.
  • Wirral multicultural centre.
  • Wirral HeartBeat - a local charity providing ­volunteers and funding.
  • Wirral fire service gyms (for postrehabilitation exercise).

Since opening, the WHC has shown improvements in the following areas:

  • Increased accessibility.
  • Reduced nonattendance.
  • Wider ethnic reach.
  • Improved user and carer experience.
  • Increased GP prescribing.
  • Reduced referrals to secondary care outpatients.
  • Decreased CHD mortality.

Management
A steering committee was formed including GPs, practice nurses, a cardiologist, specialist nurses and a project manager. Its initial remit was protocol development and secondary care referral criteria. Progress was monitored against objectives intermittently. Staff were kept informed through meetings, emails, and so on. Current and ex-patients' input was invaluable, and led to further developments, such as angina management and diabetes programmes. With the end of central three-year funding, Birkenhead and Wallasey PCT took on its management. Through its CHD modernisation team, continued development was ensured and led to a further centre in Birkenhead.

Range of services
This has increased since we originally started and now comprises:

  • GPwSI assessments.
  • Cardiac rehabilitation.
  • Lifestyle and weight management.
  • Electrocardiogram (ECG) reporting.
  • Ambulatory blood pressure monitoring.
  • Cardio-memo service (a portable, palm-sized ­cardiac event recorder that is given to patients with palpitations to identify the rhythm ­disturbance).
  • Echocardiography.
  • Exercise ECG service.
  • BNP (brain natriuretic peptide) testing to predict/ exclude heart failure.
  • A heart failure programme run by the author and a heart failure specialist nurse.
  • A vascular specialist nurse for peripheral vascular disease sufferers.

Innovative features
WHC has some innovative features, for example:

  • The service is PCT-wide - promptly responsive to GPs' and users' needs.
  • A tickbox referral form with same-day fax/email to the GP.
  • Diagnoses are Read-coded so that surgeries can quickly update CHD registers.
  • There is more time available with individual users and carers.
  • Letters are copied to users.
  • Users have access to our website's "user forum".
  • Wirral HeartBeat, British Cardiac Patients Association and Wirral Healthy Communities are all involved.
  • It is possible to identify high-risk minorities such as the Irish, south Asians and Afro-Caribbeans. Irish adults have among the highest prevalence and death rates from CHD in the UK. The centre has links with Irish Community Care Merseyside to develop strategies for GPs' identification through Read codes available since the last census (2001).
  • Patient-held records (PHRs) have improved blood pressure control.
  • The GP "phone advice service" resolves clinical issues, prevents referral and facilitates users' GP access.
  • Electronic GP referrals are available via website.
  • Computerised psychological assessments are ­possible.(4)
  • WHC?has a tertiary care partnership with the National Refractory Angina Centre in Liverpool
  • "Bited-size training" means achievable learning goals for staff.    

Awareness raising
Before the launch of WHC there was a two-day training programme for practice nurses. Since then this has been offered to health visitors and district nurses.
For the launch there was a half-day symposium that all GPs and practice nurses attended. GP out-of-hours (GPOoH) services covered surgeries to facilitate this.
There have been a number of measures to continue raising awareness, such as:

  • A visit by the National Clinical Director for Heart Disease, Dr Roger Boyle, to celebrate our achievements.
  • Publicity locally via the PCT and media.
  • Protected learning time updates for GPs and ­practice nurses.
  • Development of a website (www.wallaseyheart
  • centre.nhs.uk ) to keep practices, users and carers abreast of all "news" and "links".
  • GPs can access management guidelines from the website.

Outcomes and measurement
Waiting times are virtually nonexistent: 98% of GPwSI referrals are seen within two weeks. At inception, the secondary care wait was 6-7 months.
Nonattendance is less than 2% (and less than 0.5% for the lifestyle and weight management ­programme).
Of GPwSI referrals (October 2000-September 2003), 91% were managed by a GP using GPwSI-initiated plan. Only 9% were referred to secondary care.
An independent GP prescribing audit (July 2001-June 2004) for cardiovascular drugs showed that Wallasey GPs' prescribing was significantly greater than both Cheshire and Merseyside Strategic Health Authority and the UK average.
Wallasey has shown a steep fall in CHD death rate. By 2002, Wallasey's rate was below the national average. It has fallen further since then ­- the Wallasey SMR (standardised mortality ratio) for CHD for over-75-year-olds is now almost half the UK ­average.
We have developed a heart failure programme with novel features: computerised mental health assessments via GMHAT (Global Mental Health Assessment Tool); economic aspects of living with chronic disease using CAB (Citizens Advice Bureau) staff ensures receipt of appropriate ­benefits, such as disability living allowance, ­attendance allowance and DS1500.
There are regular independent evaluations by the Cheshire Public Health Research Unit (Chester College) and the Centre for Health Services Management (Birmingham University), with very ­positive outcomes.
The achievements of WHC have been recognised nationally, not only by the National Director for Heart Disease, Dr Roger Boyle, but also with acknowledgement via the Health and Social Care Awards (2001), the Primary Care Report's Best Practice Awards (2002) and winning the "Clinical Service Redesign" category at the Health Service Journal Awards (November 2004).

Conclusion
We are in a time of radical change with services moving from secondary to primary care. PCTs need to develop more locally accessible chronic disease care. Users (and carers) benefit from the user-centred approach of GPwSI- and specialist nurse-led teams. They are seen more quickly, they have more time with the staff, they have access to other means of communication (as do their GPs and practice nurses), such as by phone, email and the website, their concerns and fears are acknowledged and assessed, they use PHRs to partake in their own care, and their nonattendance rate is very low.
WHC?has shown that active management of hard-to-reach patients pays off in terms of good outcomes. The involvement of patients in service redesign is essential to outcomes. It offers a different model of care through integrated, cost-effective, user-focused management that can be adapted elsewhere in the UK.
If the patient with a chronic disease were a member of your family, which service would you want for him/her?

References

  1. Cummins A. Development of an intermediate cardiovascular clinic.J Irish Coll Gen Practitioners 2001;March:27-32.
  2. Cummins A, Rimmer F, Farrar A, McIntosh S, McCammon K. Partnerships for patients: Wallasey Heart Centre. Cardiology News 2003;April/May.
  3. Sharma VK, Lepping P, Cummins AG, Copeland J, Mottram P, Parhee R. Global Mental Health Assessment Tool - primary care version: development, validation and reliability. World Psychiatry 2004;3(2):53-7.
  4. Cummins AG. GPwSIs: a source of equitable heart healthcare for the UK Irish? Presented at Irish Health Summit: Challenging the health deficit of the Irish in Britain. Manchester International Conference Centre; July 2004.