Early diagnosis, optimal treatment and more holistic care for people living with heart failure in Southwark and Lambeth
Who: Guy’s and St Thomas’ and King’s College Hospital NHS Foundation Trusts, with King’s Health Partners.
Start date: January 2016
End date: December 2018
Amount awarded: £1,556,200
Supported through: Health Innovation Fund
Heart failure is one of the leading causes of death in our hospitals and local communities. Unlike many other long-term conditions, heart failure is highly treatable. However, local diagnosis of heart failure is poor. Across Lambeth and Southwark, around 3,000 people living with heart failure are known to services, but the real number is estimated at 9,000. We also know that up to half of heart failure patients in our communities are not receiving appropriate treatment. This is partly because services are fragmented and expertise is poorly shared.
By redesigning the pathway for people with heart failure, this project is looking to save up to 80 lives a year and 3,000 bed days, as well as improve the quality of life of people living with heart failure and, where necessary, associated conditions
The pathway is integrating hospital care across Guy’s and St Thomas’ hospitals, King’s College Hospital and care in the community. It is also strengthening links with GPs and other relevant services to develop a joint approach to care.
For the first time dedicated multi-disciplinary teams with named heart failure specialists have been established for each of the five Local Care Networks – the new geographical areas in which Lambeth and Southwark are divided under a new structure for health provision. As well as a named consultant cardiologist and specialist heart failure nurse for each Local Care Network, the service includes pharmacists, a physiologist, a psychologist and psychiatrist.
The new service is giving local GPs day-to-day advice on the management of their patients and running education sessions and ‘virtual clinics’ to ensure that all patients diagnosed with heart failure are treated with the appropriate medication. The service is also producing a comprehensive set of resources to support GPs and other primary care colleagues in diagnosing and treating heart failure.
“Having direct access to specialist heart failure advice has already proven to be immensely beneficial for patients. It has allowed me to discuss the correct tests and treatment for them to ensure they are receiving the best possible care which should reduce their chance of being admitted to hospital.”
Mark Chamley, a GP in Lambeth
Educating and empowering patients to understand their condition and self-manage effectively is a key aim of the programme. Following feedback from people living with heart failure at workshops and interviews, the programme is improving educational resources for patients as well as their families and carers. This includes a suite of educational films and the design of a new heart failure patient ID card and symptom checker.
Around two thirds of heart failure patients are living with other long-term health conditions. The teams are already working closely with Elderly Care and the Integrated Respiratory team and by the end of the two-year pilot, the specialist heart failure service expects to be delivering a seamless pathway that works alongside the other long-term care pathways in Lambeth and Southwark.
“We often have patients with diabetes and lung disease and it's well known that we have to manage several co-morbidities at the same time. The heart failure service is very proactive in making sure that the patient is taken care of as a whole. They're not just their heart - they’re everything and this is their life.”
Carys Barton, lead heart failure nurse at Guy’s and St Thomas’ NHS Foundation Trust
A third of people living with heart failure also experience significant anxiety and depression. The heart failure teams are working closely with the 3 Dimensions of Long Term Conditions (3DLC) project to be able to provide routine depression screening and improve access to psychological support for patients.
This will be the first example of a heart failure pathway in the UK which employs clearly identified and named specialists for each of the five Local Care Networks. The project hopes to save up to 80 lives every year and:
- reduce variations in care, ensuring that every patient with heart failure is overseen by the specialist team
- improve early diagnosis of heart failure and reduce co-morbidities linked with poorly managed heart failure
- save 3,000 hospital bed days per year and reduce costs to the NHS by approximately £500k a year
- reduce avoidable hospital admissions and re-admissions of patients with heart failure
- improve outcomes for patients who are transferred from hospital to the community
- improve quality of life for patients with heart failure through effective medicines management, education and close monitoring within the community
The project has already achieved:
- meeting the target of 50% of GP practices receiving training or virtual clinics by June 2017
- launching a patient ID card and symptom checker (produced in collaboration with Brunel University) and a series of educational films
If successful, the new pathway may be used as a model for other areas around the UK.