Dr Stewart Findlay discusses his teamÍs strategy to implement the NSF for coronary heart disease across Durham Dales Primary Care Trust
Coronary heart disease is one of the biggest killers in this country, accounting for more than 135 000 deaths per year in the UK in 1998.1 The Durham Dales area has one of the highest rates of CHD in the country. Every year approximately 47% more people die prematurely in the Durham Dales from heart disease than the national average.2
The Durham Dales PCT serves a population of approximately 87 000 registered with 12 general practices, and covers one of the largest rural areas in the country. Our objectives were to demonstrate an improvement in secondary prevention and to show, using computerised audits, that we are achieving all the milestones for primary care set by the National Service Framework for CHD. Our aim was to achieve these objectives with minimal disruption to practices.
Implementing the NSF for CHD within the Durham Dales PCT has been a multidisciplinary team effort.
Durham Dales was the first PCT in the area to introduce specialist CHD nurses to coordinate, facilitate and run a CHD clinic in each of the 12 practices.
In addition to funding these specialist nurses, the PCT also supports practice nurses who are already involved in running CHD clinics.
The PCT has developed a standardised CHD computer template for use in all 12 practices, and the specialist nurses and practice nurses use locally agreed guidelines to provide a structured follow up for patients with CHD.
The specialist CHD and practice nurses run the quarterly practice meetings for the primary health care team.
The PCT has also recently employed a heart failure specialist nurse. She also works closely with our local trust physician who has an interest in heart failure and assists in running his hospital based clinic. We believe this service is unique.
We have carried out a baseline audit of patients with heart failure in primary care and intend to monitor the benefits and outcomes of our heart failure nurseÍs intervention in primary care.
We have addressed phase II cardiac rehabilitation. A health visitor from each GP practice has attended the Heart Manual facilitator course, and the Heart Manual is now offered to all patients following myocardial infarction.
We have improved the options for all patients following MI, and have addressed some of the causes for nonattendance at an outpatient group rehabilitation programme. All patients, whether they live in the urban or rural areas of the PCT, are now offered:
- The Heart Manual home-based programme;
- An outpatient cardiac rehabilitation group programme coordinated by the cardiac rehabilitation team at the local trust; or
- The Heart Manual home-based programme followed by the outpatient group programme.
The PCT has taken responsibility for monitoring service outcomes. We have developed standard audits, and data are obtained quarterly, meeting one of the April 2003 milestones set by the NSF.
Data collection for all 12 practices began in October 2000, initially using EMIS and now Miquest (see Figures 1 and 2, below).
|Figure 1: Total of CHD patients across the Dales practices|
|Figure 2: Patients attending CHD clinic/DNA or housebound|
Data collected include patientsÍ smoking status, blood pressure and cholesterol levels (Figure 3, 4 and 5, below), and use of aspirin and beta-blockers post-MI (Figures 6 and 7, below) and statins.
|Figure 3: Smoking status of CHD patients|
|Figure 4: CHD patients in whom blood pressure measured in the past year|
|Figure 5: CHD patients with cholesterol recorded in past year|
|Figure 6: Post-MI patients taking aspirin, or aspirin contraindicated|
|Figure 7:Patients post-MI seen in past year on beta-blocker or ACE inhibitor|
Our data show that in the year ending December 2001:
- 2718 CHD patients (80%) had their cholesterol measured, compared with 1716 (64%) at baseline;
- 2174 CHD patients (64%) are now receiving lipid-lowering medication, compared with 1175 (43%) at baseline;
- 71% of patients who have had their cholesterol measured have a level of <5.0mmol/l, compared with 51% at baseline;
- 29% of patients who have had their cholesterol measured have a cholesterol level of >=5.0mmol/l compared with 48% at baseline;
- 2611 (77%) of CHD patients are now prescribed aspirin, compared with 1915 (71%) at baseline.
In November 2001, patients attending the CHD clinic were asked to complete a questionnaire giving their views of the service. The patients remained anonymous, and 312 (61%) responded.
The results of the questionnaire demonstrate overall satisfaction with the service provided. However, it also showed that some patients did not know how to make contact with the CHD nurse; some had not received adequate information on exercise; and information on healthy eating was not necessarily changing dietary habits.
The service is now being developed to take account of these views:
- Cards giving the CHD nurseÍs name and contact details are given to patients at their initial clinic visit;
- We are reviewing the exercise information we give to patients, and developing a community based exercise programme for patients with angina, based at a local leisure centre.
- We have reviewed and changed the education leaflets on diet.
The Durham Dales PCT has supported the GP practices in addressing the standards and milestones set by the NSF for CHD by facilitating CHD and heart failure nurse led clinics and by providing home-based cardiac rehabilitation for patients unable to attend hospital based programmes.
The success of this service is due to the collaborative working of all members of the primary health care team. At the quarterly practice meetings the team decides on the areas that require improvement; these are then addressed by all, resulting ¿ as the data have demonstrated - in an improvement in the management of secondary prevention of CHD. It is now essential that we sustain this improvement. We are committed to the ongoing monitoring and development of our CHD strategy and intend to achieve all the milestones set by the NSF ahead of time.
- British Heart Foundation. Coronary Heart Disease Statistics. London: BHF, 2000.
- Health Improvement and Modernisation Plan for County Durham and Darlington 2002-2005.