1. A Primary Care Trust Perspective NHS North Lancashire

2. Dr Jim Gardner Medical Director & PEC Chair NHS North Lancashire Jim.gardner@northlancs.nhs.uk

3. PCT Perspective Corporate Objectives Commission health care Improve health outcomes Reduce health inequalities Achieve financial balance ‘Patient Safety First’ Whole-systems thinking Not experts in VTE

6. VTE Improvement Cycle

7. Sources of data Primary Care –PRIMIS –QoF Secondary Care –Regional Data Warehouse (SUS) –CHKS –Hospitals’ own – pathology/haematology

8. Primary Care Prevalence from PRIMIS searches Total number of patients diagnosed with either DVT or PE as a % of a total GP population of 298,371 (5 practices data was not included due to discrepancies in the data collection)

9. Primary Care Patients on Warfarin from PRIMIS search Total number of patients prescribed Warfarin (in last 3/12) from the total GP population of 298,371 (5 practices data was not included due to discrepancies in the data collection)

10. Annual Hospital Incidence from SUS data. Data from Cumbria & Lancashire Commissioning Intelligence Support (CaLCIS) North Lancashire Residents (population 340,000).

11. Benchmarked Analysis of Venous Thromboembolism 2006-2008 data

12. Venous Thromboembolism – primary or secondary position

13. Venous Thromboembolism – Length of Stay by type 2008 only NHS North Lancashire - Population 340,000.

14. Venous Thromboembolism – mortality rates 2008 only NHS North Lancashire – Population 340,000

15. VTE Improvement Cycle

16. Commissioning for Quality What is quality? –Safety, efficacy, personalisation, outcome ‘Advancing Quality’ – carrots v sticks Risk Assessment for all hospital admissions embedded in contracts Financial support to providers PCT Project Manger for VTE to monitor and support –Audits / Root Cause Analyses/ Trajectories

17. Refining DVT diagnosis in primary care >140,000 referrals for ?DVT/year in UK 80 – 90% do NOT have DVT Need to refine tests in primary care Clinical Decision Process including near- patient-testing ‘Safely Ruling out Deep Venous Thrombosis in Primary Care’. Buller et al. Ann intern Med. 2009; 150:229-235 One PBC consortium implementing.

19. VTE Mind Map from PCT Perspective

20. Project Plan Understand the data and the issues Raise awareness Set standards in contracts Support improvement initiatives Measure outcomes Link VTE to other initiatives Manage the project through a Lead Share learning

21. Questions In our PCT area, our two acute hospital trusts have different heparin regimes at discharge. This causes confusion for our community staff. In the interests of safety, should we (as a PCT) seek to standardise heparin protocols across our health economy? Should we, as an exemplar community, look to standardise heparin protocols across England?