Hundreds of patients on Teesside suffering from the symptoms of life-limiting heart failure have already benefitted from an innovative approach that has helped to improve their quality of life and increased prescribing of evidence-based medications.
Heart failure effects around one million people in the UK and occurs when the heart is unable to pump blood effectively. There is no cure, but there are several proven treatments that, combined with lifestyle changes, can allow many people with heart failure to live well for longer and remain out of hospital for many.
Derby-based Oberoi Consulting, which specialises in population health tools coupled with clinical support services to the NHS, were commissioned by NHS England to deploy the service in the North East and North Cumbria Integrated Care Board (ICB) area. The innovative model is now starting to be rolled out in other parts of the UK.
Oberoi’s Digital Audit and Quality Improvement Platform for Heart Failure analyses GP patient records to identify those that may be missing from heart failure registers and those that are not optimised on treatment in line with the latest clinical evidence.
In Teesside, the service has supported GP practices to identify patients at practices across Middlesbrough, Stockton-on-Tees, Hartlepool and Redcar & Cleveland.
Using the platform, more than 2,000 patient records were identified and reviewed by Oberoi’s specialist Heart Failure Nurses. This resulted in nearly 300 people being added to heart failure registers and 600 patients correctly categorised with the type of heart failure. Following clinics, an additional 125 patients were optimised on treatments recommended by current guidelines for heart failure.
Kavita Oberoi OBE is the founder and managing director of Oberoi Consulting.
“Our heart failure management service is already delivering tangible results and is now being rolled out to other parts of the UK.”
Oberoi’s lead specialist heart failure nurse, Amanda Crundall, continued:
“By stratifying patients through our population health tool and optimising the treatment plans, we can improve people’s quality of life, keep them out of hospital – which is good for them and the NHS – and ensure they can live better for longer.
With additional clinical and coding training for the GP practices, we are also ensuring that the service improvements are sustainable in the future.”
Professor Ahmet Fuat, Medical Director at Oberoi Consulting, added:
“I have seen first-hand the improvements that have been made to patients’ lives through this proactive service, as the initial pilot was carried out across 11 practices in Darlington where I used to practice as a GP.
By combining sophisticated data analysis with the professional support from the Oberoi nurse practitioner team, we have been able to make a real difference to the treatment and outcomes for patients.”
Dr Ifti Lone MBE, GP partner at Normanby Medical Centre and Clinical Director of Eston Primary Care Network in Redcar & Cleveland said:
“Oberoi’s Digital Audit Platform for heart failure is a great quality improvement process.
It has helped us to improve our heart failure coding, increased prevalence of heart failure patients and the input of the specialist heart failure nurses working to local guidelines helped increase uptake of evidence-based treatment for the patients of my practice and across Eston Primary Care Network.
The feedback I received from practices was that they were, in addition, able to achieve QOF and heart failure targets and related funding.
The Oberoi nurse allocated through our PCN was very efficient – contacting the practices to have access to our data so that she could carry out her work. The responses I received from patients after their recommended treatment had been implemented has improved their conditions. I highly recommend this service to other practices and PCNs.”
Dr Janet Walker, medical director, North East and North Cumbria Integrated Care Board (ICB) said:
“The ICB recognises the importance of improving the prevention, detection and management of long term conditions for our population.
We know that cardiovascular disease causes a quarter of all deaths in the UK and is the largest cause of premature mortality in deprived areas, with the Tees Valley Local Authority areas falling within the top 20% of deprivation areas within England. Prevention, early detection and treatment of CVD can help patients live longer, healthier lives.
We are proud to work with partners across the health system to utilise all opportunities available to increase access to services that support the appropriate detection of health conditions, and upon diagnosis ensure that conditions are managed and optimised effectively.
We were very supportive of the funding provided by NHS England to commission the Oberoi project across targeted practices in the Tees Valley to support improving local outcomes. We hope that the learning gained from this work can be applied to other practices across our localities and we can continue to improve the CVD care provided across our region.”
Patient, Carol Owen from Hartlepool concluded:
“I was contacted by one of the specialist nurses following a review on my records.
The nurse then liaised with my GP and they worked together to arrange for me to have further investigations to manage my condition more effectively. I can’t thank them enough for their intervention.”