More than half the primary care trusts (PCTs) in England do not provide serum natriuretic peptide (serum NP) testing as recommended by the NICE diagnostic pathway for heart failure (2010). This test helps GPs to rule out heart failure without the need for referral or further expensive diagnostic tests such as echocardiogram. NHS Improvement has been using computer generated scenarios and cost modelling for PCTs and GP consortia to assess the impact of different pathways for introducing the test, and to help them to choose the most clinical and cost effective solution.
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 facilitate the introduction of serum NP testing, as outlined in the NICE guidance, in the 54% of primary care trusts where it was not available, as quickly as possible, and in the most cost and clinically effective way.
To ensure that serum NP testing is made available for all primary care clinicians referring patients for assessment of possible heart failure symptoms. This test allows primary care clinicians to rule out heart failure in cases where the patients breathlessness is due to another cause and thereby to facilitate those patients entering the correct pathway without delay, and, where serum NP levels are raised, also enables the clinician to objectively measure the clinical imperative and speed of assessment required. The NICE guidelines suggest that patients with a previous history of myocardial infarction or a high level of serum NP, should be seen and have a specialist assessment within 2 weeks, whereas those without a previous history of myocardial infarction and with a raised, but not high, level of serum NP need to be seen and assessed within 6 weeks.
Without access to serum NP, the primary care clinician does not have objective support for the decision on whether, or how quickly, his symptomatic patients without a history of myocardial infarction need to be seen.
Reasons for implementing your project
Early, accurate diagnosis of heart failure in the community allows for earlier treatment, symptom relief, and offers patients a more convenient solution closer to home, but diagnosis is not simple and heart failure referrals to outpatients currently cost the NHS £51million per year.
A simple blood test (serum natriuretic peptide or serum NP), costing £15-25, can rule out heart failure and reduce the need for further investigations by 30-40%.
The NICE Chronic Heart Failure Guideline update in August 2010 recommends use of serum NP testing in the diagnostic pathway to decide both the need for referral and how quickly the specialist assessment needs to take place.
A survey of cardiac networks by NHS Improvement in Aug 2009 showed that only 46% of primary care trusts (PCTs) provided this test in primary care.
Computer simulations of the different scenarios and pathways (using Scenario Generator from Simul8) before and after the introduction of the blood test shows potential cost savings of 25-40%, and if used as an average potential saving per PCT yet to implement the test, the total national savings would be £13.7 million.
NHS Improvement offered to perform computer pathway simulation for any PCTs or GP consortia looking to introduce serum NP testing, in order to facilitate their business case and speed up commissioning of this test in the diagnostic pathway for heart failure.
How did you implement the project
Having implemented serum NP in a number of projects involving services varying in size from small local services, up to including whole region implementation, referral rates before and after implementation were measured and cost savings calculated. In order to save time and money doing more unnecessary pilots, all further work was done using the computer simulation software (Scenario Generator developed for use in the NHS by Simul8 and the Institute for Innovation and Improvement). In each case, using the process simulation software, the current pathway, with proportion of patients following each branch, was mapped and then the pathway costs calculated. The proposed new pathway to include serum NP testing was then mapped and costed as before. A number of best and worst case scenarios were also developed in order to explore all the potential ways the test could be implemented. The resulting cost modelling was then presented to commissioners and clinicians in each PCT and discussed so that they could choose the pathway that best suited their requirements.
Each PCT modelled has been followed up, so that it could be recorded when they commissioned and implemented serum NP testing, and the resultant fall in referral and echocardiography was measured and savings checked against the predicted savings from the process simulation.
Once the results were showing that the simulation predictions looked accurate, NHS Improvement offered to use the process modelling for any PCT or Consortia who wanted this assistance. NICE inserted a slide into the implementation guide referring people to the NHS Improvement website if they required assistance and 34 PCTs responded. Modelling has been completed in 20 to date, some modelled by individual consortia and some by the whole PCT as requested. It is hoped that more will come forward and request assistance when they see the results from other areas, so that serum NP testing benefits can be spread across the country.
In East Riding of Yorkshire, modelling was completed in 2009, and serum NP usage commenced soon after. Modelling predicted cost savings between £66, 000 and £110,000 per year. Analysis of the first 7 months data after implementation showed that the PCT was on course to save £81,000.
Modelling across all 6 PCTs of Lancashire and Cumbria in 2010, predicted savings of between £100,000 and £167,000 per PCT per year, depending on whether or not they had open access echo and what proportion of patients were referred to out patients. As a result of the modelling, three PCTs implemented serum NP testing during April-June 2010, the last three implemented during Sept-Dec 2010. Data from these PCTs will be analysed as available.
A further 27 PCTs have asked for modelling and this has been completed in 13 giving total predicted savings of £2.67m per year.
It is hoped that further PCTs and/or consortia will come forward when the opportunity is further advertised.
Key learning points
Process simulation software is a useful tool in assessing alternative pathways when redesigning a service and can inform commissioning by showing the impact of those different pathways and changes to them without the need for costly and time consuming pilot projects.
It allows commissioners and clinicians to choose the most effective pathway from both a clinical and financial viewpoint and can be modified to fit almost every situation.
National Improvement Lead
Is the example industry-sponsored in any way?