This month, Guidelines in Practice carries two articles designed to assist clinical audit. One is a report on compiling a coronary heart disease (CHD) register and the other is an audit plan for chronic heart failure. Both have been produced in response to the National Service Framework (NSF) for CHD1 published in March 2000.
The treatment of ischaemic heart disease and heart failure has taken a quantum leap in effectiveness and complexity over the past decade. In primary care we need to know who our heart disease patients are and whether they are benefiting from therapeutic advances.
This is likely to involve all of us in a frenzy of auditing over the next few years, especially as similar recommendations for good practice will be coming out as we see NSF guidelines for more conditions.
In the middle of all this administration we are reminded not to lose sight of less measurable patient needs by a recent paper in the BMJ.2
In this descriptive study, the authors interviewed elderly patients with heart failure. They showed that technically good medical practice was not always associated with good patient understanding. In fact, patients could often be left frightened and confused.
Ischaemic heart disease and heart failure occur most often in older patients. These people have neither acquired the familiarity with popular medical issues that younger generations possess nor have they the same confidence to challenge doctors if they do not understand. They may also have other impediments such as deafness or memory problems.
As doctors we deal with complex concepts all the time, and it is sometimes difficult to steer the line between being patronisingly simple and confusingly technical.
Personally I feel that patients find it easier to ask me to expand an explanation if it is too obvious than to admit that it was too complicated for them to understand in the first place.
Time taken to ensure that your patient is well informed is never wasted but it does not feature on an audit report. It is important that funding and planning of NSF guidelines take account of the labour intensiveness of bringing about high standards in primary care populations.
Our practice is already running a CHD clinic giving 20-minute appointments to patients on our register. In almost every case we are able to improve management, but this generates more tests and follow-ups, so that the price in terms of professional time is high. So far there is little sign of extra staff funding.
It is also frustrating that while we try to comply with NSF standards we have seen no sign of movement in secondary care. Our patients still wait far too long for investigation and treatment. In some areas, this impacts directly on our own ability to comply with the NSF requirements we cannot get an echocardiogram to help the diagnosis of heart failure in under 6 months, for example.
I am keen to support audit initiatives such as those proposed, but we must argue for good funding to allow us to spend sufficient time with the patient and must press for secondary care improvements to keep pace with primary care improvements.
- Department of Health. National Service Framework for Coronary Heart Disease. London: DoH, March 2000.
- Rogers AE, Addington-Hall JM, Abery AJ et al. Knowledge and communication difficulties for patients with chronic heart failure: qualitative study. Br Med J 2000; 321: 605-7.
- See also 'PCG initiative supports the development of practice CHD registers' and 'New package will simplify audit of heart failure management' .