1. The Virtual Clinic: Alternative ways of accessing a specialist opinion Dr. Khalid Khan Consultant Cardiologist Betsi Cadwaladr University Health Board (East)

2. Betsi Cadwaladr University Health Board

3. North Wales - Local Story Large geographical area – 3 hospital sites 700,000 population Different financial pressures / incentives Closer integration primary / secondary care Emphasis on community care

4. The Triple Challenge Reducing Treatment Times Reduced Resources Increasing Demand

5. Demand > Capacity 30% growth in referrals to Cardiology in 2yrs

6. Reducing Treatment Times 26 week pathway Referral

7. Reduced Resources Underfunded & savings expected Understaffed & block recruitment

8. Changing Our Perspective Traditionally Patient sees GP Any Problem One Solution (refer to OPD)

9. Classical Patient Pathway Inappropriate/unnecessary referrals & admissions Only 2 options: OPD or Admit as emergency Often non-specialist intermediaries/services ENTRY Slow progress: multiple appointments & serial tests Multiple (junior) doctors: ‘treading water’ Poor communication with patient & GPs DURING ‘Consultant knows best’: annual MOT Interminable FU: no plan, no exit strategy Lack resolution of original diagnosis/management AFTER

10. Different People Different Needs

11. Spectrum of Needs Patient Complexity SimpleComplex Referrers Requirements Reassurance Advice Review Urgent review or admission Usual OP appointment Advice Tests + advice

12. What Should a Consultant Do? A Consultant should consult more See less of everything slowly More of some things quickly

13. Embracing Advancements Moving beyond letters & fax Email & web Mobile technology Technology & Communication GP manage much more Nurse-led clinics Consultants should consult more Roles & Responsibilities New modes investigation Sub-specialty clinics Novel drugs & procedures Medical Developments

14. A Tailored Cardiology Service Built around the needs of the Patient GP Integrated & flexible With other cardiology clinics Across primary / secondary care Deliver more for less Time, money & people Quicker, quality care Adaptable to other services

15. The Virtual Clinic Pathway TelephoneEmailLetterFax 50 GP Practices 275,000 patients Patient Problem, Query, or Concern Single Point Entry & Signposting Specialist Cardiology Clinics One-Stop Cardiology Clinic Possible Testing Virtual Diagnosis, decision or plan by Cardiology Consultant Communicated by telephone, email and/or letter

16. Referral Treatment Nurse-Led Triage Referrals Cardiology services complex Need for clear signposting & tracking Single point entry for all referrals Speed passage & exit of patients through ‘maze’

17. 1-STOP Cardiology Clinic New Patients Cardiorespiratory Department Echo ETT Tilt Test Bloods 24hr BP Holter LungNovacor

18. Initial Results from Pilot Study > 200 new patients dealt with ‘virtually’Equates to 25% of all new patients seen by Consultant One new clinic per Consultant per week Patient Outcomes 95% discharged back to GP (not seen in clinic) 70% underwent one or more tests GPs love it!

19. Virtual Clinic: Email Component BCU.CardiologyVirtualClinic@wales.nhs.uk Secure – Patient Name – NHS Number +/- Hospital number – Question/Query – Attachments ECGs etc Comprehensive response usually within a couple of hours (but officially 5 days) PAS altered to count this activity including RTT

20. CURRENT OVERVIEW GROUPCHRONICACUTEEMERGENCY IHD SINGLE POINT NURSE TRAIGE ONE-STOP CLINIC RACPC (nurse) VIRTUAL CLINIC Low risk CP Paramedic Cardiologist Of Week Cath labACU & CCU (new) MPI & Stress echo / CTChest pain nurses Heart Failure Heart AssessmentRapid FU Saving 1000 lives HF teamHF TeamIP HF service Palliative HF Device therapy Rhythm Disorders AF Primary care2 BHF Arrhythmia Nurses SCD & ICC serviceNurse led cardioversion Arrhythmia/AF clinicPacing care pathway Syncope/TLOC clinicSyncope guidelines Valve Valve Clinic?Too late

21. Health Foundation - SHINE Award Proposal November 2009 (Karen Keating) Interviews & award £75,000 December 2009 Facilitate 1 year project from April 2010 Implement & study in detail impact, benefits and applicability elsewhere (cardiology vs. other specialities, England vs. Wales) Broad representation on project board Measurement domains quality & efficiency

22. England vs. Wales Health Board Purchases & Provides Services Primary Care (QOF) Hospitals (No PBR)

23. Key Challenges Consultant time & job planning Robust tracking of patient outcomes Recognition of virtual activity Quality care & patient ‘safety’ & satisfaction Security & recording of electronic activity Demonstration savings in time, money & resources (dark green vs. light green)

24. Measures of Success Safety Satisfaction Speed Savings

25. The End – Questions…