National Service Frameworks

1. National Service Frameworks • What are National Service Frameworks? • Part of modernisation of NHS • Provide standards & service models • Spread good practice across the country • Ensure everybody has access to good standards of care • Evidence-based • E.g. CHD, Elderly, Mental Health

2. National Service Framework for Coronary Heart Disease • 10 year programme published by the government in 2000 • Sets out 12 national standards for prevention and treatment of CHD • Recommends service delivery models • Gives milestones to mark progress • Lays down audit requirements

3. The 12 standards • 1 & 2: Reducing heart disease in the population, reducing smoking • 3 & 4: Preventing CHD in high-risk groups • 5,6 & 7: Heart attacks and other acute coronary symptoms • 8: Stable angina • 9 & 10: Revascularisation • 11: Heart failure • 12: Cardiac rehabilitation

4. NSF requirements for primary care • Standards 1 & 2: Reducing heart disease in the population, reducing smoking • Standards 3 & 4: Preventing CHD in high risk patients • Standard 11: Management of heart failure

5. What is required to make it happen? A systematic approach to preventive cardiac care Clinical protocols for dealing with established heart disease Led at NSMC by Susan Neal, Nurse Practitioner and Stephen Newell, GP

6. Objectives • Accurate disease registers of existing CHD and heart failure • Accurate registers of those at high risk • Registers actively used • Clinical team meeting regularly • Appropriate management of high risk and existing CHD patients with aspirin, statins, beta blockers & lifestyle advice.

7. Systems for two groups • Those with existing CHD • Those with a new or future diagnosis

8. Disease Registers • To organise disease management effectively and efficiently • To measure clinical outcomes and performance of a target group • Provide epidemiological data of prevalence/incidence to inform needs assessment

9. Identification of patients • Agree what constitutes CHD • Heart failure, non-rheumatic AF, angina as a clinical syndrome, MI • Positive EST/thallium scan • Arterial disease • Coronary artery surgery/revascularisation

10. Identifying data • Know how this data is recorded in your current system, e.g. manually, computer, Read code sets • Agree future recording system • Agree how new diagnoses will feed into system

11. Strategies for finding patients • Search for those with diagnosis e.g. IHD • Search other known high risk groups e.g. diabetics • Drug searches – nitrates, low dose aspirin, warfarin, nicorandil, digoxin, statins • Opportunistic case finding – clinician recall, other PHCT members, phamacist, reception, prescriptions, posters, hospital discharge letters, correspondence • Validate existing registers – should find 3-5% practice population

12. Which model of care? • Special clinics? • Protected time? • Opportunistically, but with structure? • Targeted contact? • What about those with other chronic disease? • Length of appointments, frequency of attendance

13. Call and Recall System • How will this be managed? • Who will manage this system? • Invitation • Non-responders • Housebound

14. Who will be involved? • Nurses • Doctors • Support staff • ? resourcing

15. New/future diagnosis • How will these patients be picked up? • How will they be added to register? • When/how often should they be seen?

16. Evidence based interventions • Protocols/guidelines • Aspirin • Blood pressure management • Lipid management • ACE inhibitors for LV dysfunction • Beta-blockers for those post MI • Warfarin/aspirin for AF • Tight diabetic control • Life style interventions

17. Tools • Dedicated record card/computer template • Invitation letter • Identification system/register • Recall facility • Risk calculators • Evidence-based, practice agreed protocol for clinical management