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1000 Lives Plus and primary medical careProposal for National Programme Board 03.03.2011

Situation

Successful 2 year 1000 Lives Campaign moving into 1000 Lives Plus. Mostly secondary care; penetration into primary care small and sustainability

uncertain. 1000 Lives Plus needs to work in whole systems and communities. Increased involvement of Public Health Wales is sought and Primary Care Quality

Information Service is keen to support.

Background

Work in Heart Failure and Warfarin monitoring within the 1000 Lives Campaign has delivered safer and more evidence based care in a few areas but projects are not necessarily being sustained and outcomes not consistently monitored. In the absence of an established measure of harm in primary care, a primary care trigger tool has been developed in Wales and used in some practices. Pilot work is needed to test its acceptability and learn more about its potential benefits.

Recent years have seen significant quality and service development initiatives in primary care e.g. the primary and community strategy, the National Primary Care Programme, Annual Primary care reports for LHBs, The Clinical Governance Practice Self Assessment Tool (CGPSAT) and medical revalidation. There is increasing acceptance by General Medical Practices that they need to improve and demonstrate systems to ensure quality and safety. Work by professional organisations such as the Royal College of General Practitioners and the British Medical Association is leading to cultural changes which will facilitate this improvement

Analysis

There are several areas in primary care which could be advanced or variability reduced by adoption and implementation of the 1000 lives+ improvement methodology. Some of these areas have already begun to be addressed in some areas of Wales but there is lack of consistency in content and approach

Included within the 1000 Lives Campaign: Heart failure Warfarin monitoring

Included in 1000 Lives Plus: Primary care global trigger tool Heart failure

Included in other programmes and initiatives: Atrial Fibrillation Prescribing safely Polypharmacy in the elderly

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Delayed diagnosis of cancer Antibiotic stewardship Assessment and management of vascular risk.

For all these areas there is likely to be a reasonable evidence base to identify practicable changes to improve patient experience and outcomes. As with all programmes there would be a need to review that evidence base for the latest research, look what is happening elsewhere and identify priorities for patients, primary care practitioners and LHBs. At the same time we have to select low cost interventions and those which can be readily measured using existing systems. Some of these areas are existing national or local priorities and there may be existing projects or local programmes.

Several programmes within 1000 Lives Plus will also benefit from the developing work in primary care because they include or intend to include work in primary and community care. They are:

Dementia Depression Falls Transient ischaemic attack Stroke rehabilitation Enhanced recovery after surgery

There will be a need to ensure that these programmes benefit from the learning within the primary care focussed programmes.

Opportunities

PCQIS (Primary Care Quality Information Service) has some existing toolkits for improvement and monitoring.

There are good relationships between primary care teams in PHW, the Postgraduate Deanery, Royal College of GPs (RCGPW) in Wales and General Practitioner Committee Wales (GPCW).

LHBs are required to produce a quality based annual report on primary care. There are existing CPD networks. Some LHBs support Protected Learning Time sessions for GPs and their staff. The existence of combined primary, community and secondary care provider

organisations (the LHBs). The formation of localities and appointment of clinical leads in each locality. Audit plus extraction software in vast majority of practices.

Threats

Practices perceive themselves as overwhelmed with routine work, enhanced services, monitoring and a pressure to take on work traditionally provided by secondary care.

LHBs still tend to be more focussed on the high cost area of secondary provision.

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Financial pressures leading to a reduction in staff numbers and loss of staff familiar with primary care processes and governance systems in LHBs and a possible loss of constructive relationships with practices.

Tendency for different groups/organisations to be working on similar projects without coordination or collaboration.

Conclusion

There is a need for the 1000 Lives Plus programme to include and engage with primary care with a relatively easy national improvement programme that is likely to show results in 1 – 2 years. Sustained improvement relies on the Will to do better which is prevalent in primary care, Ideas which are presented here and which have been supported by other groups across Wales. Now we need to plan effective Execution to implement those ideas.

Process

Priority areas agreed by National Programme Board. Primary Care Quality Forum considers feasibility and likely impact.

PHW including PCQIS undertakes evidence search for effective interventions and makes recommendations to 1000 lives executive board which selects programmes

PCQIS provides How to Guides and toolkits (using existing methodology) on what is best practice regarding interventions and management and suggests data sets (including recommended READ codes) to support and evidence change

Health care improvement team uses existing improvement methodology to implement change supported by LHBs, Deanery and relevant professional groups. Clinical change champions need to be identified in LHBs (possibly locality leads).

PCQIS and the Public Health Observatory assist in quality assuring data collection and analysis which is fed back to LHBs and practices to make changes as needed.

Recommendations

1. The 1000 Lives Plus Programme Board supports review and the expansion of the programmes in Heart Failure and Anticoagulation with the addition of work on Atrial Fibrillation, which is closely linked to the first two, to be implemented during 2011.

2. The proposed Primary Care Trigger Tool will be critically evaluated as to effectiveness and if appropriate spread to other GP IT systems to develop a reliable safety measurement instrument for primary care across Wales.

3. Existing 1000 Lives Plus programmes on Stroke, Depression, Dementia and Falls be reviewed to increase the involvement of and expansion into primary care.

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4. Scoping work is undertaken on the feasibility of national projects looking at antibiotic stewardship and safer prescribing including consideration of the reliability of evidence, the likely impact on patients and the service and the feasibility of collecting useful data at minimal cost to permit change to be made and improvements proven (with a view to 2012 implementation).

5. 1000 Lives Plus leads on the implementation of the plan arising from the current Vascular risk review being undertaken by PHW.

6. A register kept by 1000 Lives Plus of all national clinical improvement programmes in Wales to ensure shared learning, consistency of language, coordination and avoidance of duplication. This will link to the National Audit Steering Group through the Medical Director, WAG.

7. Commission the Primary Care Quality Information Service and PHW Observatory to review the evidence, look at the options for data collection and work with the Healthcare Improvement Team to design new Primary Care Improvement Programmes.

8. PCQIS will network with LHBs, the Primary Care Programme board and other organisations to agree the priority areas and acceptability of improvement proposals.

1000 Lives Plus improvement Programme Proposals - Rationales

1. Heart Failure

What are we trying to accomplish? Extend the life expectancy of people with Left Ventricular Dysfunction by optimising treatment; reduce the number of unscheduled admissions, improve quality of life for people with heart failure

How will we know a change in an improvement a reduction in unscheduled admissions, appropriate prescribing, patient assessment of symptoms and activity

What changes can we make Implementation of best practice including drug treatment, monitoring and patient education

2. Warfarin monitoring

What are we trying to accomplish? Reduce episodes of bleeding secondary to warfarin, reduce number of avoidable CVAs (through under treatment)

How will we know a change is an improvement. Reduction in INRs> 8.0 (and/or 5) increase in number of INRs within therapeutic range, reduction in admissions with bleeding, reduction in incidence of CVAs (TIAs)

What changes can we make? Adoption of safer monitoring and improved risk assessment when commencing patients on anticoagulant treatment

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3. Atrial Fibrillation

What are we trying to accomplish? Reduction in TIAs, ?Reduction in acute pulmonary oedema

How will we know a change is an improvement? Reduction in acute admissions for uncontrolled AF, reduction in TIAs, management of AF according to best practice

What changes can we make? Consistent implementation of NICE/ Cardiac Network Guidelines

4. Management of Cardiovascular Risk

What are we trying to accomplish? Reduction in Myocardial Infarction, CVA, premature death

How will we know a change is an improvement? Greater proportion of the population will have had a record of a CVS risk assessment. Individuals show improvement in risk factors, reduction in incidence of MI and CVA , (below an agreed age limit), reduction in CVS mortality (below an agreed age limit)

What changes can we make? Implementation of Halcox CVSRisk report recommendations

5. NSAID (Non steroidal anti inflammatory drugs) Prescribing

What are we trying to accomplish? Reduction in episodes of bleeding, incidence of renal damage secondary to use of NSAIDs

How will we know a change is an improvement? Reduced admissions, deaths from haemorrhage in patients taking NSAIDS. Reduction in incidence of Kidney Disease in patients taking NSAIDs. Reduction in long term prescribing of NSAIDs

What changes can we make? Prescribing NSAIDs in line with recent recommendations. Choosing the safer NSAIDs

6. Benzodiazepine Prescribing

What are we trying to accomplish? Reduced dependency on benzodiazepines, reduction in accidents as a result of benzodiazepine useage

How will we know a change is an improvement? Reduction in Benzodiazepine prescribing, ? reduction in accidents in patients taking benzodiazepines

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What changes can we make? Implementation of best practice – reduced short and long term prescriptions, patient awareness

7. Psychotropics in dementia

What are we trying to accomplish? Improved quality of life for patients with dementia, reduction in sedation

How will we know that a change is an improvement? Reduction of psychotropic prescribing in dementia, ? reduction in falls in dementia patients, ?QOL measures

What changes will we make? Education of carers and prescribers, ?improve provision of primary care mental health practitioners for the elderly

8. Lithium

What are we trying to accomplish? Avoidance of Lithium toxicity (renal damage et al, death)

How will we know that a change is an improvement? Reduction in admissions assoc with lithium toxicity, Frequency of Lithium monitoring, Lithium levels

What changes will we make? Implementation of NPSA recommendations

9. Diuretics and electrolyte imbalance

What are we trying to accomplish? Reduction in incidences related to hyponatraemia,(low sodium) hypokalaemia (low potassium) or hyperkalaemia (high potassium)

How will we know that a change is an improvement? Fewer admissions with the above, improved monitoring in general practice

What changes will we make? Raising awareness of need to monitor Urea and electrolytes when prescribing/ taking diuretics, adoption of protocols

10. Polypharmacy in the elderly

What are we trying to accomplish? Morbidity arising from taking multiple medication including side effects and interactions

How will we know that a change is an improvement? Reduced specified morbidity, falls, dizziness, confusion, altered biochemistry, Reduction in average number of different drugs taken per person

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What changes will we make? Improve the thoroughness and effectiveness of regular medication reviews

.

11. Falls

What are we trying to accomplish? Reduction in hip (and wrist) fractures in the elderly

How will we know that a change is an improvement? Reduction in number of falls in patients over ?70, Reduction in number of hip or wrist fractures,

What changes will we make? Adoption and implementation of care pathways, (Risk assessment, Fall prevention, management of osteoporosis,)

12. Delayed diagnosis of cancer

What are we trying to accomplish? Improved survival, earlier treatment

How will we know that a change is an improvement? Reduced delay between onset of symptoms and referral, referral to treatment times, ? survival times post diagnosis

What changes will we make? Educational packages of symptom recognition for clinical staff and patients. Improve access to diagnostics for GPs.

13. Antibiotic stewardship

What are we trying to accomplish? Reduction in harm from antibiotics, reduced levels of resistance in bacteria to antibiotics. More cost effective prescribing

How will we know that a change is an improvement? Reduction in antibiotic associated morbidity (eg C diff, MRSA in community, reduction in second or third line antibiotics in the community, reduction in antibiotic prescriptions for conditions not usually needing antibiotics

What changes will we make? Guidance and monitoring of antibiotic prescribing in primary care. Use of formularies. Use of patient information leaflets

14. Primary Care Global Trigger Tool

What are we trying to accomplish? Reduction in iatrogenic harm in primary care. Reduction in unscheduled care

How will we know that a change is an improvement. Reduction in recorded specified adverse events , reduction in unscheduled consultations and admissions

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What changes will we make? Improve the functionality of the existing GTT and facilitate its adoption across Wales. Encourage practices to use the data provided by the tool to review their processes and systems of care.

Paul Myres, Clinical Lead Primary Care Quality Information Service

Alan Willson, 1000 Lives Plus Director

18.02.11