Shared learning database

Enhancing Quality
Published date:
February 2011

Using local experience of implementing B-type natriuretic peptide (BNP) testing in East Sussex, this provides a summary of helpful tips, planning guidance, quality standards, how much to commission and how to monitor compliance. It is supported by a simple care pathway and education package that can be used with GPs.

* This example was originally submitted to demonstrate implementation of NICE guideline CG108. It has been reviewed and the practice described remains in alignment with the updated NICE guidance (NG106). The updated NICE guideline should be referred to if replicating this initiative.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

  • To spread learning of best practice across the South East Coast on the implementation of BNP testing for primary care to improve quality of care for patients with suspected heart failure.
  • To improve the quality of care for patients with suspected heart failure.
  • To increase the use of BNP by General Practice in South East Coast.
  • To encourage commissioners to learn from an exemplar site and make their jobs easier by providing a simple toolkit for them to follow.
  • To educate GPs in the use of BNP To promulgate the new pathway for suspected heart failure.
  • To reduce wastage and costs.

Reasons for implementing your project

The use of BNP across South East Coast was variable based on the initial assessment. Even where it was available, it had not been commissioned to a standard that allowed the benefits to be enjoyed, for example waiting time for results were 2 weeks by which time the GP had referred for echo and outpatient appointment leading to inefficiencies of unecessary echocardiograms and cardiology costs. GPs held mixed views of the benefit of use of BNP. The cut off levels cited in NICE guidance use evidence from untreated patients, in this population, it would be reasonable that patients will already be under some treatment for related conditions and therefore local cut off levels were agreed with cardiologists and pathologists.

How did you implement the project

In the exemplar site, commissioners and budget holders had to be convinced that this was a contribution to QIPP as the contract for the BNP had to be signed up front. Agreeing 'cut off' levels was challenging as the evidence used related to untreated patients which would be unlikely in this population. It was finally agreed to use lower cut off levels to avoid 'missing' patients. The Enhancing Quality Programme is funded across the region and supported the roll out of learning gained in the exemplar site. Communicating with GPs and embedding the change into everyday practice is a continual process requiring constant feedback when the pathway has not been followed.

Key findings

The results to date in the exemplar site are demonstrating that about 50% of echos and referrals can be avoided by using BNP properly amounting to about £15,000 per month in just one population around an acute hospital. The anticipated volumes are proving to be accurate but as GPs accept the new pathway that may increase.

Key learning points

Communicate regularly and through every means possible to GPs. Use simple messages and a clinical champion to get the message across.

Convince the finance team using the business case that it will deliver financial efficiencies if GPs adopt the pathway.

Start the discussion with cardiologists and pathologists early about the cut off levels to be adopted. Talk to our clinical lead on

Contact details

Kay Mackay
Director Enhancing Quality
Enhancing Quality

Is the example industry-sponsored in any way?