This Cardiology Blog will keep track of all the activity undertaken by the Cardiology Specialty Group, noting and reporting insights along the way, and will be a shared point of contact for anyone who wished to keep up to date on the groups progress or contribute to the ongoing work. If you have any enquires about the project or any of the blog posts, please go to the Scottish Access Collaborative contact page and email us direct.
On Wednesday 21st March the Cardiology Specialty Group came together in Stirling for their initial Scottish Access Collaborative meeting involving the Digital Health and Care Institute (DHI) design team. The aim for the cardiology group at this first meeting with the DHI team was for them to collectively map out the current state of the existing cardiology pathways, and highlight some of the key areas for change that could deliver real impact for the services. To begin the meeting NHS Scotland director of Performance and Delivery, Alan Hunter, spent some time introducing the concept of the Scottish Access Collaborative, its aims and the six core principles that will guide service changes across all the specialty groups working with the collaborative. The principles set out the key characteristics of future patients pathways and include: patients shouldn’t travel unnecessarily; referrals should be vetted by senior staff or processed via agreed pathways; referral pathways should be clear and published; joint understanding of capacity and demand between hospital and referral system; local systems should understand pathways to diagnostics; and improved published metrics.
With these principles in mind the cardiology specialty group with support from the DHI design team began to discuss and map the current typical steps involved in cardiology related pathways. In such a complex system as a health care pathway, with many technical, cultural, and human variables, mapping a ‘typical’ route is a very demanding task. We as a group spent a lot of time describing the very start of a pathway from a patient perspective and how they come to be ‘on’ a pathway and the different entry points that has. From connecting with a GP, self-referral, via ambulance service, or though NHS direct a patient will first touch the NHS service at this point. It was not surprising that this small but complex part of the system soon led onto discussion of the many ways that a patient transitions from primary to secondary care, and the variable ways in which individuals manage this transition across different health boards. The group discussed challenges in accurate referral, confidence in decision making, efficient vetting and local variations. These seemed like priority areas for the group although they did not close in any one opportunity at this stage. After a time spent thinking about how patients get onto a pathway, and the transition from primary to secondary care from a clinical and patient perspective, the group moved on to focus on and map the end of a pathway and how patients exit or ‘loop’ back into the system. Issues raised by the group included how results from diagnostics are shared with patients at this stage, and there was some discussion about how digital intervention could support better access to data for patients and the potential impact on the service from such a change in the system among other areas for change.
Cardiology Workshop Two
On Thursday the 3rd of May, the Cardiology Specialty Group and the Digital Health and Care Institute design team once again came together at the Stirling Court Hotel conference centre for their second Scottish Access Collaborative workshop. The overall aim for the Cardiology group, as with all the individual specialty groups involved in The Collaborative, is to improve waiting times for NHS patients and improve services for a more sustainable NHS future. The DHI design team are working with the Cardiology group to help them to map out their current patient pathways, to find key challenge areas to focus efforts for improvement, and to prioritise challenges to take forwards. Following workshop one, the group reconvened to scrutinize some of their existing patient pathways, and focus in on key challenge areas to take forward to the third and final workshop.
Focus on Symptoms
In the first cardiology workshop the group mapped out the high level systemic picture for cardiology in the NHS, looking at routes from primary into secondary care, patient management, rehabilitation, and the impact of vetting (see the Cardiology Workshop One blog for a detailed summary). For this workshop the group took a much more detailed look at individual aspects of cardiology pathways and asked where significant and valuable improvements could be made. To do this the group used symptoms as the unit of analysis, and tracked common presentations seen by clinicians as they move through pathways, developing some common symptom profiles and identifying key challenge areas for each.
At the beginning of the workshop we spent some time discussing the common symptoms the group had identified as areas of interest, coming up with four main symptoms to focus on, and answering the question: why focus on this?
Firstly, Chest Pain, chosen by the group as the symptom that has a high variation in how it enters onto a cardiology pathway and also a symptom that presents in a significantly high volume, so a god opportunity for impact.
Secondly, Shortness of Breath, chosen because it presents in high volumes and is a symptom that is investigation heavy, meaning it takes a lot of resource and so a good candidate for impact through improvement.
Thirdly, Palpitations and Arterial Fibrillation, these two symptoms were joined together and chosen for the time taken for diagnosis, the anxiety it causes patients, and the opportunity for primary care to be more involved before the transition to secondary care.
Fourthly, Syncope, chosen because while it is a relatively small number of presentations into secondary care it has a high volume for primary care, a lot of time needs to be spent on collecting patient history and making a diagnosis, and the implications of getting a diagnosis wrong for the patients can have a significantly detrimental impact on the patient’s life.
Key Challenge Areas
Using the four Symptom Profiles the group mapped detailed pathways for each, noting elements of Consultation, Diagnostic Testing, Diagnosis, Treatment and Follow Ups in the system. Once mapped the group were able to identify and share examples of best practice, see and understand variations in service, and to highlight key challenge areas in the system to focus improvements. The challenge areas were collected into 5 main themes:
Cardiac Rehabilitation: what are the most appropriate approaches to manage follow up monitoring for cardiac patients? Can this be improved?
Person Centred Care: how do we ensure pathways encourage patient engagement, decision making and self-management?
Vetting: how can vetting be improved in current pathways? Can telephone vetting help to reduce the number of unnecessary referrals and save time?
Easy Access Technology: with technology developments in diagnostic testing equipment and monitoring can it be made easier for patients to access? Can some tests be brought back to primary care?
Within the 5 Key Challenge themes are a number of individual challenges and areas for improvement. The next steps for the Cardiology Specialty Group will be to map the Challenge landscape and prioritise the areas they want to focus on before moving forward to think about potential solutions to the challenges. In the third workshop scheduled for later in May, the group will make some key decisions about the future direction for the Cardiology Access Collaborative, and develop some prioritised solutions as a basis for future work.
Cardiology Workshop Three
On Tuesday the 22nd of May, the Scottish Access Collaborative Cardiology group met for the third time to continue their work on current cardiology pathway improvements, in collaboration with the Digital Health and Care Institute design team. In the previous two workshops the group had worked together to develop some priority symptom profiles for cardiology, based on the groups knowledge and experiences, mapped some common pathways for each symptom profile, and then identified some key areas of focus for each of the pathways. It was these areas of focus that the group centred on in this third cardiology workshop, working towards some clear issues with each area, and sketching out possible solutions including any current gaps in knowledge and some initial indicators of success.
Prioritising Areas of Focus
The workshop began with a re-introduction to the aims of the Access Collaborative and a summary of the group progress so far. In between workshop two and three the DHI design team had spent some time analysing the data from workshops one and two to summarise the mapping and discussions that had taken place into a set of challenge areas. These were quickly presented back to the group to remind us all what had been agreed previously in terms of moving the project forward. The group then split into two sub groups, and each group was presented with two symptom profiles to work with and challenged to refine the issues for each, define some solutions to tackle issues and to prioritise their propositions into four target areas to take forwards. Facilitated by the DHI design team, the groups determined their priority ideas for their symptoms, laying out the issue, the solution, the motivation, and some success criteria for each. At the end of a busy session the groups came back together to share and discuss their proposals, before allocating individual champions to drive the ideas.
The Areas of Focus
By mapping and analysing current pathways, the cardiology group were able to zoom in on some key areas that could deliver significant pathway improvements for both patients and staff.
Firstly, a focus on how patients might be cared for closer to home was flagged as a key issue. This was defined by a potential change to the current ECG pathway, taking it out of secondary care and into primary. This challenge was seen as modernising protocols that were set a long time ago and need to be reviewed and updated. Technologies have advanced in recent years, and thus could impact on new protocols for ECG testing. This issue serves a high volume of patients, 5000 per year in Glasgow alone, and so change to the existing system was motivated by a potential to have a big impact on a high number of people. It would free up some capacity in secondary care and improve patient experience. Successful changes would result in only appropriate visits to secondary care, the only people there are those who need to be.
Generally keeping patients from unnecessary visits was a second highlight priority. A key question with this highlight was what happens to patient when there is a non-diagnosis, when it is not a serious heart issues. Currently patients can end up on an extended pathway when transitioning from an emergency department with a non-diagnosis to a discharge. The normal pathway would lead a patient from ED back to the GP or to cardiology. The idea was that a virtual clinic that sits between ED and another appointment could keep some patients from multiple follow up visits and shorten pathway length. Also, by issuing better information and support for patients once serious heart problems have been ruled out, patients and their carers may be more able to self-manage and improve their experience. There is a high volume of patients who would fall into this category and so the potential for impact is also high, it could free up resources and bring down waiting times, and reduce travel for patients. Successful changes in this area would reduce the number of visits and ensure meaningful communication with patients.
Thirdly the group wanted to look at options for getting patients on the correct pathway from the start. This manifested in a look toward a national standard for CTCA test. Currently the test is not widely available but is a significantly more suitable test than the current pathway that would use a treadmill test as a first response. The CTCA offers a more robust diagnosis and could significantly impact on both patient and staff experiences. The group decided to focus on this because it could significantly reduce need for extensive testing, it would get people on the right path sooner, bring down waiting time and free up capacity. Ultimately shortening the length of a patient pathway and delivering better quality of care. In this scenario, the capacity of CTCA would go up and patient pathway length would go down. To be successful there would be some agreement between radiologist and cardiologist in terms of who determines the findings so the system would efficiently.
Finally, the group focussed in on the current system for notification when test results are ready. Currently there is no built-in notification system that informs whoever orders tests that the test results are ready. This can have a significant impact on waiting times from referral to treatment as well on patient experience. The group talked about the potential for ‘push’ notification systems to resolve the issue around waiting for test results.
As the day came to a close and the solutions to identified issues had been prioritised, some of the group nominated themselves as champions to take the ideas forward. The next steps will be for the DHI design team to report on the groups work over the three workshops, creating the high-level visualisations for the new pathway ideas as part of the report. The group champions will then work with relevant stakeholders to develop the ideas into more detailed proposals for cardiology pathway improvements.