Improving Coronary Heart Disease Care in the United Kingdom

As improvement results go, it’s hard to beat these: a fourfold reduction in mortality as a result of your work. More than 800 lives saved over a two-year period.
 
These are the results of a nationwide effort by the United Kingdom’s National Health Service (NHS) to improve care for coronary heart disease (CHD) patients. The project is part of a broader effort called the National Primary Care Collaborative (NPCC), a multi-year project run by the National Primary Care Development Team (NPCT) to improve access, care and coordination of care for the nation’s citizens. It is believed to be the largest health care quality improvement project in the world.
 
A close partner of the Institute for Healthcare Improvement (IHI), the NHS is not new to mammoth improvement projects. In 1999, it launched a two-year effort to improve access to cancer care, and made dramatic improvements. Next, the NHS turned its attention to primary care. By training a large staff of improvement experts who run Collaboratives and support local NHS communities in their improvement efforts, the NHS is spreading improvement methodology nationwide. Four NHS communities are participants in IHI’s Pursuing Perfection initiative and plan to serve as models for a redesigned NHS.
 
The National Primary Care Collaborative seeks to bring rapid improvement again to the entire system, this time in primary care. National in scope, the program must also respect local priorities. Ambitious, challenging, undoubtedly overwhelming at times, the project has nevertheless been remarkably successful at achieving its aims.
 
During 1999 and 2000, the regions involved in the improvement project experienced a dramatic drop in CHD deaths compared to regions not yet involved, by a factor of four. "The improvement . . . translates to just over 800 extra lives saved compared to the rest of England," states the NPCC’s report titled The First Two Years.
 
"Put simply, there are people walking around now who wouldn’t have been if these teams had not done this work," said Dr. John Oldham during a British Broadcasting Corporation (BBC) interview about the project. Oldham is head of the National Primary Care Development Team, which established the NPCC.
 
A Framework for Improvement
"This work" that Oldham refers to involved creating a framework designed to maximize health gains for patients with CHD. The key elements of the framework include:
  • Developing systems for maintaining validated CHD registries
  • Implementing practice protocols
  • Embedding protocols in computer templates
  • Running nurse led clinics
 
Implementing these components across a large system was a significant challenge, so it was done in waves of PCTs. (PCTs are free-standing, regional bodies of the NHS. At present there are more than 300 PCTs, which include dozens of practices in their regions, providing, commissioning and monitoring health care services throughout the country. They are responsible for the management, development and integration of all primary care services, including medical, dental, pharmaceutical, and optical, as well as hospital and community services.)
 
Initially, about 200 General Practitioner (GP) practices worked to implement the improvements; now, the program has expanded to include 2,000 practices, covering 18.2 million people.
 
Four measures are tracked and reported monthly:
  • Percent of CHD patients on aspirin
  • Percent of CHD patients on statins
  • Percent of post-myocardial infarction (MI) patients on beta-blockers
  • Percent of patients with blood pressure less than 140/85
 
"On CHD, we have learned that the monthly audit process is an efficient and relatively easy way of gradually improving care," says Dr. David Rivers, whose Hasting House Surgery in the Stratford Primary Care Trust (PCT) participated in the first wave of improvement. "By regularly feeding back the figures to clinical staff and discussing ways of improving, we have been able to achieve a gradual but highly significant improvement in all measures."
 
Vigilance pays. As of July 2002, the project boasted the following results:
  • More than 85 percent of patients with CHD were on aspirin
  • More than 70 percent of CHD patients were on statins
  • More than 80 percent of patients who had a myocardial infarction in the past 12 months were on beta-blockers
  • More than 60 percent of patients with CHD had blood pressure below 140/85
 
Know Your Patients
Collaborative practices focused initially on ensuring that they knew who their CHD patients were. They created reliable, valid registries of patients with proven CHD and determined that these patients were receiving appropriate medication. From there, practices developed systems to ensure that patients were part of a proactive care program that includes regular medication review, counseling about lifestyle choices (diet, smoking, exercise) and management of blood pressure. Practices used the Model for Improvement to introduce changes in the way that they managed their registries and cared for patients on an ongoing basis.

To facilitate more proactive management of CHD, many practices developed multidisciplinary teams, often comprising the practice manager, a nurse and the GP. The development of teams led to a clearer sense of shared ownership in the care of CHD patients. The teams worked together to implement guidelines and protocols, and to develop and use computer templates for delivery of consistent care and proactive call and recall systems.
 
Because the NPCC was not pushing cookie-cutter solutions for better CHD care on PCTs and practices, there was variation in the approaches taken within the parameters of the framework. But most practices agreed that getting nurses more involved was the right idea. The majority of practices chose to transfer much of the CHD care to nurses.
 
In some cases, this involved freeing up nurse by altering other responsibilities, or expanding other roles such as phlebotomists or health care assistants.
 
In the Easington PCT, for instance, nurses led the work on improving CHD care. The nurse team there developed a PCT-wide strategy for structured care for patients with CHD that called for a partnership approach to providing comprehensive care across all settings. The team also supported the development of nurse-led clinics for CHD patients; developed templates for gathering information and protocols for ensuring consistently managed care; and implemented a system of audits and a strategy to meet training needs.
 
The Nelson Fold Practice in Salford PCT implemented an innovative program of calling patients around their birthdays to invite them to come in for an annual Heart Check. The practice also sends patients Happy Birthday invitations to remind them of the importance of keeping the appointment. Early results show the program is improving compliance.
 
A practice in the Ealing PCT was experiencing significant problems with non-attendance for CHD reviews. So they developed a telephone template that is used by nurses who call "no-shows," and gather information over the phone about the patient’s health, medication compliance and lifestyle.
 
Spinney Surgery in Huntingdonshire PCT targeted male patients are risk for CHD. They held a Men’s Health Evening, providing cholesterol, blood pressure and glucose testing stations, and dispensing advice about diet and exercise.
 
The successes realized by practices such as these throughout the United Kingdom are, in Oldham’s words, "staggering." And hitting those targets represents more than just academic success: it represents the most important health care success of all: saving patients’ lives.
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