ISIP is helping to pull together existing work on prevention and treatment to tackle Hull's high mortality rates, reports Alison Moore

Coronary heart disease takes a terrible toll on the lives of people in Hull, with a mortality rate far above the national average.

But tackling a combination of deprivation, some unhealthy lifestyle choices and a population with relatively low expectations of their own health and healthcare is no easy task. All too often, rather than discussing prevention or early indications of heart disease with their GP, many with the condition would present at accident and emergency in the acute phase of the disease - or die before accessing any services.

The answer has been provided with the help of the NHS Integrated Service Improvement Programme.

Hull teaching primary care trust became a demonstrator site for the programme, using an integrated approach through primary prevention and reformed services.

PCT commissioning assistant director Phil Davis says: "Historically, initiatives took place in one area without necessarily being linked to others. We had some bits of work on coronary heart disease in the past but we saw the programme as the opportunity to bring it all together and to give us some external support."

ISIP local change consultant Danielle Procter was seconded to the project for a year, providing valuable project management skills and "chivvying us along", says Mr Davis. All the other staff working on the project had other responsibilities, so having one person working on it full time helped the focus.

Thinking radically

ISIP's approach also helped the team keep the final benefits and purpose of the project in mind: to bring about significant improvements in people's health.

Ms Procter says it has not always been easy but the project team, which includes managers and clinicians from across both primary and secondary care, has worked hard to realise its objectives.

North and East Yorkshire and Northern Lincolnshire cardiac network manager Alan Nobbs says his role was to "challenge people around service design and improvement. The primary care teams and service teams involved have been very receptive to thinking radically."

He adds: "All our early indications are that this kind of model can work. We have not lost sight of the fact that this is really about challenging what we do, where we do it and, to some extent, who does it."

The project has had two main thrusts. The first identifies patients at risk and offers them information on self-care and self-management and, where appropriate, treatment.

"We were keen to look at the development of care pathways for coronary heart disease, including the primary prevention side of things as well," says Mr Davis. "We were specifically looking at people in the 40-64 age group who were not on any register for CHD but were potentially at some risk. We have begun to develop a systematic risk assessment process."

The process looks at risk factors such as smoking, high blood pressure and high cholesterol and is currently nurse led, although the PCT plans to introduce it as an enhanced local service which GP practices will be paid for. The nurse-led pilot has seen 1,000 patients in 18 months but across the city there are potentially 80,000 people who could benefit.

Targeted information for patients at risk has been developed through the programme. Helping people to make healthy lifestyle choices is notoriously hard but there are signs that the project is encouraging patients to make changes. An evaluation suggested half of patients had been advised to change their lifestyle and 85 per cent said they had done so.

The other thrust of the project has dealt with patients who need investigations for potential cardiac problems. The PCT has developed a streamlined service for cardiology referrals in one locality.

Patients referred into this stream have an appointment with a one-stop clinic where they can have all the normal tests and get both a diagnosis and a management plan. This is usually a very quick process. Patients will go from first point of contact with their GP to an outpatient's appointment within two weeks, a process that will help the acute trust meet the 18-week target.

Patient co-ordinators who guide patients through this process are crucial and provide a level of personalised care. The service has a zero did-not-attend rate.

"Generally the people who are using this service are finding it invaluable to have a point of contact," says Mr Nobbs. "The patients say it is very user friendly."

In some cases, patients will see a consultant and get a management plan which will then be monitored in primary care.

"We can actually manage a process where people don't get lost in the system and we can line up the appropriate tests at the same time," says Mr Davis. "We have some community-based specialist cardiac nurses who are part of the clinic. They can follow up patients in the community."

Low expectations

As Danielle Procter points out, in theory other providers could be commissioned to provide these services but it has been important for the PCT to work through what the service would look like.

"The work is commissioner led but the PCT has worked very closely with both the acute trust and the community provider to work out what works and test that so we can include it in a commissioning framework," she says.

The challenge for both sides of the project now is to move from pilot to mainstream.

With heart disease having such an effect on the population's health, it has not been hard to get the support of the PCT for funding projects. Screening of at-risk patients, for example, will be done in primary care through a local, enhanced service.

Mr Davis has been able to put forward a case for funding this using financial modelling of the potential benefits of patients not developing heart disease.

But some challenges remain. For example, mainstreaming the one-stop system will affect how the acute trust deals with waiting lists and will involve some staff taking on new roles as patient co-ordinators.

How to involve patients has remained a thorny issue. The project team was keen not to just appoint a token patient to the board and has instead looked at using "discovery" interviews and "big questions" approaches.

The project has also had to cope with a population with low health expectations and devise solutions that pull the patient through the system rather than relying on them to push. Developing a culture of self care and involvement of individuals in their own health is vital.

Closer to home, there have been the standard problems of scheduling meetings that everyone can attend and keeping the momentum going, especially when those vital to the project also have other commitments.

"The thing they have found really hard is having regular meetings, making sure that actions occur in those meetings and between then and keeping things forward focused," says Ms Procter. The guiding project board tried to have meetings every six weeks and also reviewed its membership to ensure that key stakeholders were represented.

But there are some very encouraging signs. "We have had very good clinical engagement throughout this," says Mr Davis. "If you have a clinical champion it makes things much easier."

Not fade away

Ms Procter points out the importance of using clinicians' time to best advantage, rather than the more routine aspects of project management. Cardiologist Farqad Alamgir - from Hull and East Yorkshire Hospitals trust, the acute care provider - and GP Mark Hancocks were crucial to the project but their time had to be used wisely. "We have focused them on the areas of work where we required clinical background and knowledge," says Ms Procter.

For example, they pointed out that cancelled appointments in secondary care often had a knock-on effect in primary care as patients turned to their GP for advice.

Cardiac network manager Mr Nobbs says that Dr Hancocks and Mr Davis have put in a lot of time working with GP practices. And he is adamant that the process of developing the service will continue: "It has brought us together and focused us. It is not something that is going to fade away. There is a commitment to progressing it."

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