Summary

Westcliffe Medical Practice modernised its long-established community-based anticoagulation service in preparation for a forecast increase in numbers of patients that would require treatment. The practice took full advantage of the local primary to secondary shift schemes at that time and was at the forefront of quality improvements with local commissioners in becoming an accredited provider of community based anticoagulation services. The service has gone far beyond its original specification of monitoring stable patients, as passed from the hospital service, and now initiates patients and offers a range of options from warfarin, NOACs, self-monitoring, as well as domiciliary care. It also operates opportunistic screening to identify patients with AF, while to those already known to have AF it seeks to educate them about anticoagulants.

Challenge

The number of patients needing anticoagulation intervention has been increasing rapidly, and hospitals have been struggling to cope with demand, resulting in a poor experience. Westcliffe has already become an accredited provider of community-based anticoagulation services – as part of a general shift into the community setting under the wing of general practice, providing a safe and more holistic, personalised approach to care - but needed to modernise its offering.

Objectives

The main objectives were to empower patients and improve their experience; improve clinical outcomes; provide value for money; bring services closer to the patient in the community; ensure safe, continuous care and gain a substantial market share as a provider of community-based anticoagulation services in the local health economy.

Solution

The service has moved far beyond its original specification of monitoring stable patients passed from the hospital service, and now initiates patients and offers a range of options from warfarin, NOACs, self-monitoring and domiciliary care, as well as opportunistic screening to find patients with AF. Led by two doctors and a senior manager, the team comprises practice nurses, pharmacists, three specialist Advanced Nurse Practitioners trained in anticoagulation and four GPs providing support and managing patients via agreed protocols. The team meets regularly to agree objectives.

Results

Results, including the proactive management of patients in screening for AF, indicate the service has saved approximately 11 patients per annum from having a stroke. The impact of this model nationally could save substantial NHS resources as well as improve population mortality rates and other public health statistics. Outcomes have improved: 85% of referrals are treated for AF - 74% of this group are currently treated with warfarin and 10% with NOACs. For those on warfarin, time in therapeutic range is above 80%, well above NICE recommendations. The commissioner recently reviewed all local tariffs and set recent AQP to Westcliffe rates which meant a drop for all providers. Westcliffe performance data routinely shows high achievement against clinical outcomes and standards achieved at what was the lowest tariff. Patient survey shows 100 % satisfaction, (20% good, 80% excellent).  Patients offer testimonials and routinely comment and compliment the team, with no complaints. Westcliffe is the largest community-based provider locally.

Learnings

The service is easily transferable as the same infrastructure can be replicated through the recruitment and training of appropriate staff, purchase of dosing software and booking systems. Ensuring robust clinical governance processes is key to ensure the safety of the service, with common audits, peer review, case review and tools in place to help guide staff in the day-to-day provision of the service. Some areas may be stifled if their CCGs are not willing to offer procurement options but developing good relationships with key experts and being part of wider networks is also crucial as clinical knowledge in the service needs to be robust, not only to be up to date but to identify and help spread new ways of working.

Evaluation

The team measured the success of the service through the use of clinical data via INR Star software. As part of provision of the service the team provide to the commissioner agreed performance data in line with the national patient safety standards that is then fed back in open benchmarking within the district. In addition the team has undertaken patient surveys including the NHS Friends and Family Test (FFT) and measured its own success via regular meetings that include case studies and reviews of complaints and critical incidents as well as markers at individual staff level - such as how many times the dosing software is overridden.