1. National Service Frameworks Dr Stephen Newell February 2002

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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.

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

9. 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

10. 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

11. 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

12. 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

13. 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

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

15. Who will be involved? Nurses Doctors Support staff ? resourcing

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

17. 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

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