Clinical governance lead Dr Paul Twomey describes how his PCG set up a successful programe to facilitate implementation of the NSF for CHD in North East Lincolnshire

The North East Lincolnshire PCG Coronary Heart Disease (CHD) Clinical Development Programme 1999/2000 was set up to help practices implement the long-awaited National Service Framework (NSF) for CHD.1 Key aims of the project are shown in Table 1.

Table 1: Key objectives of the CHD Clinical Development Programme

To promote good practice
To enable each practice to develop disease registers
To facilitate information systems to undertake a base assessment prior to setting up an appropriate Clinical Development Programme
To be sensitive to the current position of each principal/practice and support clinical development in each case, acknowledging the variation in infrastructure and computerisation
To support both individual practices in implementing the NSF for CHD and appropriate facilitation by the primary care group (PCG).
To promote the philosophy of practice clinical development plans, which would then constitute key elements of the primary health care team (PHCT) and PCG clinical development plans

The Programme was drawn up by the Clinical Governance/Development Committee and adopted by the PCG Board in May 1999. Administrative support for the initiative was provided by QED (Quality, Clinical Effectiveness and Development group).

Financial resources were allocated for each part of the CHD Development Programme and were payable on completion.

All practices in NE Lincs were invited to 'sign up' to the Programme, which comprised:

  • Stage 1: CHD register
  • Stage 2: CHD baseline data collection
  • Stage 3: CHD action plan.

Letters were circulated to all GPs. This was followed by two 'question and answer' type meetings in which the proposal was discussed and concerns were clarified.

It was proposed that a member of each practice be nominated the lead/ contact person for the Programme. The lead varied from practice to practice, but the majority were either practice nurses or administrators.

Acknowledging the need for a designated lead, the philosophy behind the initiative was that a team response incorporating all clinical and administrative staff would provide the most effective response and make the process more likely to be sustainable. The team approach would enable individual practices to respond to future NSFs by the development of appropriate systems.

The CHD Development Programme was initiated on 1 July 1999, and it was anticipated that each practice would complete the programme by 31 December 1999. In the light of the delay of the publication of the NSF for CHD, the deadline was extended to the end of January 2000.

The pace at which practices undertook each stage was discretionary. However, it was suggested that 2 months be allocated for each stage. It was thought that the action plan would not be completed by the end of 2 months and that the majority of practices would require this period to draw up a preparatory plan which would then be implemented over the coming year.

The first stage required practices to set up a CHD register and complete a monitoring form giving details of how the register had been developed and how it would be updated.

Those practices that already had a register in place were required to give details of their existing system and also check the validity of their current register.

In accordance with the Caldicott guidance,2 the PCG had no requirement for a register that provided details such as patient name, address etc.

For the purposes of this project, the objective was to enable the individual practice to develop and/or upgrade its own CHD register. The only requirement of the PCG was evidence of the system utilised to develop the register and maintain its sustainability.

The absolute number of patients on individual registers was requested, to help to guide the initial commissioning and development of the local service. Practices were informed that further details of their practice-based register may be required later to support the appropriate development of the commissioning of the local clinical service.

The recommended working definition of patients with CHD for the purposes of compiling and maintaining a practice CHD register was as follows:

Patients for whom a clinical diagnosis of coronary heart disease has been made in primary or secondary care, and who are currently receiving regular or 'as required' (prn) treatment for this condition, e.g. nitrates.

This definition is not necessarily exhaustive, but it was felt to be an appropriate starting point for developing or interrogating CHD registers.

A more robust diagnosis of CHD and allocation to a disease register can be made if all patients are shown to have an appropriately positive exercise test, angiogram or documented myocardial infarction (MI). However, at the time of developing this register, a significant number of patients had not undergone these investigations or this information was not necessarily readily accessible.

It was suggested that a possible starting point would be to look at repeat prescribing records for patients on nitrates (sublingual, oral or topical), aspirin, beta-blockers, or lipid-reducing drugs. Practices with computerised records may have been able to identifyppatients with a record of relevant disease headings (e.g. angina, history of MI, coronary artery bypass graft, angioplasty) or outpatient procedures (e.g. exercise test, thallium scan).

The minimum data set required for each patient on the CHD register was:

  • Patient's name
  • Date of birth
  • Hospital number (where available)
  • Address
  • Documented MI (where applicable).

Stage 2 involved the collection of data on all patients included on the CHD register developed (or reviewed) in stage 1. It was emphasised that this was intended to provide a baseline only, and no standards had been set (i.e. no target percentages). The criteria selected for data collection are shown in Table 2.

Table 2: Criteria for data collection*

% of patients reviewed in the past year by the practice
% of patients who have had their blood pressure (BP) measured over the past year within the practice
% of patients who have been shown to be normotensive (i.e. BP consistently <=140/90 mmH)2 during the past year
% of patients who have had a cholesterol measurement in the past 3 years
% of patients who have a cholesterol <5.0mmol/l2
% of patients on aspirin, and % of patients where there is a contraindication (to be noted) or where the therapy has been shown to be poorly tolerated
% of patients where smoking status is recorded, and the current distribution of smokers within this population.
% of patients with a recorded body mass index (BMI)
% of patients whose BMI is >=30
% of patients who are on a beta-blocker
% of patients with documented myocardial infarction on a beta-blocker
* Based on the Emerging Findings report for the NSF for CHD3

No age limit was set for inclusion of patients on the CHD register; however, the data required for the baseline data collection were divided up in order to assist practices in highlighting possible differences in management across three different age groups: <60 years; 60–75 years; and >75 years.

To qualify for payment for this step, practices had to complete the baseline data collection monitoring form satisfactorily and return it to the QED office. To ensure consistency in the data returned, notes were provided on definitions, time periods etc.

The action plan was designed to enable practices to focus on the results of their baseline data collection, identify areas for improvement and the mechanisms planned to achieve change.

It was intended at the outset that each practice would compare its baseline data with the objectives outlined within the NSF for CHD. However, owing to the delay in publication, a number of practices utilised anticipated objectives.

Practices were asked to identify at least three areas for improvement from the eight broad areas of CHD management covered by the data collection criteria, namely:

  1. Annual review of patients with CHD
  2. Blood pressure management
  3. Cholesterol management
  4. Aspirin status/management
  5. Smoking status/management
  6. BMI status/management
  7. Specific secondary prevention management of patients with documented MI
  8. Beta-blocker therapy.

Each practice was informed that it would be expected that the development plan would develop following practice meeting(s) that incorporated a wide spectrum of clinical and non-clinical practice staff, within which the baseline data would be considered.

Within the action plan for each of the three objectives, it was anticipated that an appropriate practice lead would be identified. It was expected that the action plan would be supported by an appropriate framework, with achievable milestones, and supported by appropriate audit.

Level of participation

Table 3 shows an encouraging response to the initiative, with the participation figures for each stage of the Development Programme.

Table 3: Results of each stage of the CHD Development Programme

Stage of CHD Development Programme
No. practices participating (%)*
Population coverage
1. CHD register
29/35 (83%)
150 521 (89%)
2. Baseline data collection
28/35 (80%)
147 432 (87%)
3. Action plan
27/35 (77%)
146 497 (86%)
* These figures are based on the numbers of NE Lincolnshire practices at the time of preparing this report. Total population of NE Lincolnshire = 170 000.

CHD register

Of the 29 practices that participated in stage one, 15 already had a CHD register in place. The remaining 14 practices set up a register as part of the CHD Development Programme.

The general information supplied to QED regarding the format of the registers revealed that approximately 22 practices held the register as part of the practice computer system. The majority of these were updated on an ongoing basis. Two practices stored their register in manual form, and the remaining five practices did not indicate the format of their registers.

The percentage of the practice population identified with CHD across the PCG varied considerably between practices: from 1.2% to more than 8% in one case (see Figure 1, below). There is significant variation in size and demographics of the practices within NE Lincs PCG, supporting the need for further validation of the registers. For the majority of practices the incidence of CHD is around 3–5%, which is comparable to the health authority's predicted incidence.

Baseline data collection and action plan

All elements of the baseline data collection were collated by QED. Examples of the baseline data are shown in Figures 1–4 (below).

Figure 1: Percentage of practice population identified with CHD
bar chart
Figure 2: Criterion 2 – patients reviewed in the past year by practice
bar chart
Figure 3: Criterion 3 – patients with BP recorded within the past year
bar chart
Figure 4: Patients shown to be normotensive* during the year
bar chart
* Blood pressure consistently <=140/90mmHg4

Given the variation in incidence of CHD within practice-based registers and the acknowledged requirement for further validation within the coming year, there is a plan to support practices reviewing the baseline data collection and instigate systems to allow this to become a sustainable process.

It was not expected or anticipated that all practices would complete the action plan element within the 6-month period of the initiative. Implementation of action plans was also hindered by the delay in publication of the NSF for CHD. The majority of practices have their action plans ongoing during this financial year and the PCT plans to support practices to achieve and complete their plan through the instigation of a local quality develoment programme (NE Lincs PCG became a PCT in April 2000).

Further work needs to focus on validating information, to ensure that the registers are based on an agreed definition of CHD, and to develop a standard method of identifying patients across the PCT. Practices that did not participate in the scheme may require assistance in setting up a register.

However, we feel that the work undertaken within the programme has provided a good foundation for the appropriate and effective implementation of the NSF for CHD and represents a very significant undertaking.

The next step was the Action Plan for NSF for CHD (incorporating the Health Improvement Programme – HImP).4

Commitment of the PCT as a local health organisation within the NSF

The PCT's responsibility is to develop a positive environment and provide the framework for the introduction of the NSF for CHD. However, its implementation within each practice is the responsibility of the individual GPs and their practice staff.

Proposed action plan (until 31 March 2001)

  • Active involvement in authority-wide implementation group for NSF.
  • Ongoing project team, incorporating local primary and secondary care leads, looking to consolidate a shared approach to implementation of the NSF with the development of a shared local care pathway.
  • A key element is a proposed open meeting for local health professionals in the autumn to consider the NSF and the development of a local care pathway.
  • We are shortly to implement a local quality development programme,5 which we anticipate will achieve the following objectives:
    • all practices and clinical teams actively involved in the development of the NSF via the instigation of protected clinical development sessions
    • universal practice-based CHD registers supported by an appropriate PHCT framework*
    • a strategy to support the appropriate coverage of date-ordering of notes across all local practices.
  • Validation of practice CHD registers is expected to be supported by the developing PHCT framework. However, initial validation will be provided by a review of commissioning data recently collated for patients who have undergone coronary angiography, angioplasty or bypass surgery during the past 5 years. This information will shortly be circulated to all practices.

    In addition, our local acute trust has now agreed to provide monthly updates, on an individual practice basis, of its own CHD register. This comprises patients who had either an appropriate positive exercise test or angiogram or proven MI.

* NE Lincs PCT covers a population of 170 000, principally within the towns of Grimsby, Cleethorpes and Immingham. Within the PCT there are 35 practices which are aggregated into eight PHCTs incorporating approximately 20 000 patients.

The success of the project to date reflects the wide involvement and commitment of local primary care health professionals. However, it is appropriate to acknowledge the support of QED and, in particular, Liz Lenaghan, who facilitated the project.

  1. Department of Health. National Service Framework for Coronary Heart Disease. London:DoH, March 2000.
  2. Caldicott Guardians. HSC 1999/012.
  3. Department of Health. National Service Framework for Coronary Heart Disease – Emerging Findings Report.November, 1998.
  4. Action Plan for National Service Framework for Coronary Heart Disease (incorporating the HImP) – NE Lincs PCT, July 2000.
  5. Local Quality Development Programme, August 2000. Consultation document: proposed to be initiated within NE Lincs PCT from October 2000.

Guidelines in Practice, October 2000, Volume 3
© 2000 MGP Ltd
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