Pennine Acute Hospitals Trust
A new NHS clinical service model for Peripheral Arterial Disease (PAD). The service was commissioned and set up in primary care settings and staffed by experienced specialist clinicians. It has resulted in planned, optimum detection and management of peripheral arterial disease along with a reduction in unnecessary referrals to secondary care vascular surgical teams.
The service specification and pathway relates to the majority of the recommendations in the NICE guidance and to the majority of people diagnosed with PAD who require non-surgical management.
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
The aim was to redesign NHS services locally to improve early detection, diagnosis, education and clinical management of people in our catchment population who may have peripheral arterial disease. In North Manchester we have relatively poor cardiovascular outcomes around heart attacks and strokes, as well as fairly high lower limb amputation rates. This service redesign was seen as part of the long term strategy to improve outcomes around these key themes.
-Provide a community based clinical assessment, diagnosis and management service in a choice of locations near to patients homes.
-Offer appointments for all people with suspected non-urgent peripheral arterial disease within 4 weeks of referral from their GP or other community clinicians.
-Inform people diagnosed with peripheral arterial disease education on causes, severity, cardiovascular and limb outcomes, treatment choices including support for lifestyle changes (smoking / exercise / diet), dealing with long term conditions (Expert Patient Programme), medicines management (lipid modification, hypertension, antiplatelets, pain management, diabetes) and surgical options (angioplasty / bypass).
-Negotiate and agree initial treatment plans for all people diagnosed with peripheral arterial disease and refer them to appropriate teams for ongoing management (GP Practice, NHS exercise program (PARS)
, Quit Smoking Team, Weight Management Service, Vascular Surgical Team, Diabetes Team).
-Review all people diagnosed with PAD at 3-12 months, to review the disease progress / stability, impact on quality of life and consider further education, treatment or referral for surgical opinion.
-Provide the GP / referrer and patient a written diagnostic report and agreed treatment plan within 5 days of seeing the patient. Provide all patients with a written patient information leaflet and individual care plan, based on agreements reached in the consultation.
Reasons for implementing your project
Before the service commenced, there was no focus or clinical strategy for early detection and management of peripheral arterial disease. There were no locally agreed clinical indicators for referral of either suspected peripheral arterial disease or critical limb ischaemia. There was no long term condition register of people with PAD. There were no specialist vascular clinicians based in the community to help GPs manage their patients with suspected peripheral arterial disease. Diagnosis and management of people with suspected PAD was often opportunistic, when significant symptoms or key indicators of severe arterial disease triggered referral for a clinical diagnosis. Therefore people with suspected PAD were usually being referred relatively late in the disease progression to secondary care Vascular Surgical Teams to confirm diagnosis and initiate treatment plans. It is accepted in the existing clinical literature that the majority of people diagnosed with peripheral arterial disease do not go on to have a vascular surgical intervention. All people diagnosed do however require health education, information and support around making changes with healthy interventions and cardiovascular medicines. A similar, redesigned NHS service in a neighbouring trust helped save money and reduce unnecessary secondary care vascular referrals by approx 75%, whilst promoting early diagnosis and proactive non surgical management.
It was proposed that we would build a long term conditions register of people with PAD, cut unnecessary secondary care referrals for the majority who are not suitable for surgical intervention, save money on reduced secondary care referrals and increase time spent with each patient on education, negotiation and treatment planning.
How did you implement the project
A business plan was submitted to local commissioners to invest in the service model with the emphasis on reducing unnecessary secondary care referrals in the short term and improving detection and long term management of people with PAD. Employed advanced Band 7 clinicians (2.0 wte) with experience of working in Vascular Clinics (Specialist Podiatrist and Nurse Specialist) and a Band 3 administrator (0.4 wte). Staff level calculated on population estimates for PAD, taken from UK epidemiology studies (Edinburgh Artery Study, Fowkes et al). Key clinicians and commissioners consulted with local hospital Vascular Team and GPs on the service model, clinical pathway and assessment methods, referral triggers for severe/deteriorating PAD. Service awareness campaign designed with patient groups, local cardiovascular teams and clinicians working in community settings. The service is run from existing NHS premises, utilising spare capacity. The service is relatively mobile, clinicians carry their patient records, information leaflets and vascular assessment equipment (automated BP monitor, handheld Doppler, sphyg cuffs). 5 locations are used, offering patients good choice, local to home, maximising accessibility and attendance. All GP referrals are accompanied by summarised medical history, medicines and recent blood results, providing the assessing clinician with high quality patient clinical information. Diagnostic reports are provided to the patient, GP and referring clinician, within 5 days of the patient being seen. All patients diagnosed with PAD are reviewed by the Service up to 2 times following the diagnostic appointment. This charts disease progress, stability or deterioration and to allow the patient time to consider the diagnosis and any sustainable healthy lifestyle changes they can achieve. Ultimately all patients diagnosed with PAD will be referred either back to their GP for long term follow up / monitoring or to a Vascular Surgeon for a surgical opinion.
Our patient satisfaction survey showed very high satisfaction with all aspects of the service, including location choices, time to appointment, clinical assessment & treatment, written and verbal information.
We now have a patient database register for all people diagnosed with peripheral arterial disease, who are registered with North Manchester GPs.
Of all people referred with suspected peripheral arterial disease it was found that over 50% did not have clinical evidence of peripheral arterial disease and did not require a Secondary Care Vascular opinion. We fed back differential diagnoses to GPs and initiated or advised referrals to other teams eg Leg Ulcer Team, Diabetes Team, where appropriate. Common differential diagnosis were musculoskeletal or neuropathic pain, venous disease, arthritic pain and common leg cramp.
Of the people we diagnosed with peripheral arterial disease, approx 80% were then referred for GP led management (lifestyle interventions and medicines) and 20% for vascular surgical opinion. We review all people with diagnosed PAD within 3-12 months, to further consider disease stability and ongoing choices of treatment.
Overall, awareness, detection and early management of PAD has been improved under the umbrella of a locally commissioned clinical service model redesign. Implementing this clinical model results in increased time spent with patients at diagnosis, educating and negotiating treatment plans and an overall 40% cost saving when compared to referring all people with suspected PAD to secondary care Vascular Surgical Teams for diagnosis and treatment.
Key learning points
-Engaging with hospital Vascular Teams, prior to any service redesign is essential. Involving them in the clinical governance, clinical service and pathway design and ideally in staff recruitment, would enhance cooperation and ensure an integrated clinical framework is set up with no NHS organisational divide.
-Recruiting appropriately experienced clinicians with knowledge, skills and experience at working with people who have lower limb vascular disease and cardiovascular disease is essential. Clinical diagnosis, health education / promotion and treatment planning are essential elements of service delivery.
-Utilising existing local clinicians, with relevant lower limb knowledge, skills and experience of vascular assessment and diagnosis (Specialist Podiatrists / Tissue Viability or Leg Ulcer Nurse Specialists, Vascular Nurse Specialists etc) is also an option for organisations.
Please note the 'Pathway attachment' reflects the NICE guideline recommendations detailing what should be assessed and documented when diagnosing lower limb peripheral arterial disease. However, the NICE guideline does not provide instruction about classification of patients based on assessment results, as this pathway does.
Martin Fox and Lisa Smith
Vascular Specialist Podiatrist and Vascular Nurse Specialist
Pennine Acute Hospitals Trust
firstname.lastname@example.org and Lisa.email@example.com
Is the example industry-sponsored in any way?