Transforming Elective Care Services: Cardiology

This specialist Guidelines summary provides an overview of ideas on what local health and care systems can do to transform cardiology elective care services at pace, why this is necessary, and how the impact of this transformation can be measured.

This summary is intended for use by commissioners, providers, and those leading the local transformation of cardiology elective care services. Refer to the full guidance document for further information on the national context and challenges facing elective care services in England, the national cardiology challenge, an overview of ideas described in the guidance, and taking transformation forward. 

The Elective Care Development Collaborative

• NHS England’s Elective Care Transformation Programme supports local health and care systems to work together to:
  • better manage rising demand for elective care services
  • improve patient experience and access to care
  • provide more integrated, person-centred care
• As part of this programme, the Elective Care Development Collaborative has been established to support rapid change led by frontline teams. In Wave 3 of the Elective Care Development Collaborative, local health and care systems in Dudley, Doncaster, Somerset, and West Suffolk formed teams to develop, test and spread innovation in delivering elective care services in just 100 days (the 100 Day Challenge)
• The teams used an intervention framework to structure their ideas around three strategic themes:
  • rethinking referrals
  • shared decision-making
  • transforming outpatients.

Essential Actions for Successful Transformation

Establish a Whole System Team

• Consider who needs to be involved to give you the widest possible range of perspectives and engage the right stakeholders from across the system as early as possible. It is essential to include patients and the public in your work. 

Secure Support from Executive Level Leaders

• Ensure frontline staff have permission to innovate, help unblock problems, and feed learning and insight back into the system. Involving senior clinicians as early as possible is crucial to reaching agreement and implementing changes effectively across organisational boundaries
• The 100 Day Challenge methodology facilitates cross-system working. Working across multiple organisations in this way is essential to establishing effective integrated care systems.

People to Involve From the Start

• People with lived experience of using the service
• Patient organisations and representatives (including the voluntary sector)
• GPs and primary care staff
• Cardiologists
• Clinical nurse specialists
• Service managers
• Pharmacists
• Commissioners
• Business information analysts
• Administrative team support.

Ensure the Success of Your Transformation Activity can be Demonstrated

• SMART (specific, measurable, attainable, realistic, time related) goals and clear metrics that are linked to the intended benefits of your interventions need to be defined right at the start of your transformation work
• Key questions include:
  • what are you aiming to change?
  • how will you know you have achieved success?
• You may wish to use a structured approach such as logic modelling; consider how you are going to include both qualitative and quantitative data in your evaluation
• Some suggested indicators that are relevant to most interventions in this handbook are described in Table 1.

Table 1: Suggested Indicators to Demonstrate Success 

Rethinking Referrals

Standardised Referral Pathways and Structured Templates

What is the Idea?

• Standardised cardiology referral pathways that are informed by best practice ensure that patients see the right person, in the right place, first time
• Structured templates that are available on primary care IT systems and include explicit referral criteria and guidance can support the use of standard referral pathways. They prompt appropriate onward referrals and ensure that referrers understand both where to direct patients and what information needs to accompany them. They should integrate with the NHS e-Referral Service (e-RS) wherever possible.  

Why Implement the Idea?

• If cardiology referral pathways are unclear, patients may have to undergo several unnecessary appointments before seeing the most appropriate specialist. This can contribute to increased demand for services and long waiting times for routine appointments. Standard referral pathways can reduce unwarranted variation in decision making and the way referrals are made to cardiology services
• If insufficient referral information is provided at the point of referral, this may prevent effective triage and mean that patients experience unnecessary delay. Structured referral templates that include referral criteria and guidance can reduce the number of inappropriate referrals and improve the quality of referral information that accompanies the patient because primary care clinicians have easy access to the information they need when making or receiving referrals. This means they have increased understanding of which cases to refer and the correct information to include in these referrals
• This helps to ensure that patients who need to be assessed and treated by specialists receive appropriate care as quickly as possible, which may improve patient outcomes
• Secondary care clinicians receive the necessary clinical and administrative referral details straight away, meaning a decrease in the clinical time necessary to triage each referral, along with associated costs. This may lead to an increased conversion to treatment rate for referrals.

How to Achieve Success

Develop the Pathways and Templates

• Engage the right stakeholders from all relevant disciplines as early as possible. Consider who will be making and receiving referrals. Ensure commitment
• Ensure you have considered the perspective of everyone who will be making and receiving referrals. Patient insight is essential to pathway redesign
• Review existing local cardiology pathways and referral forms. Map the patient journey and seek input from stakeholders to understand what is working well and what needs to change
• Review example pathways and templates from elsewhere. Understand what could work well in your service and develop a version relevant to your local context
• Develop a smart template on the primary care patient record system that includes explicit referral criteria for specific clinics. This should prompt the referrer to access relevant guidance when making a referral, thereby optimising opportunities for shared learning. However, try to keep the referral template and questions as simple and relevant as possible
• Ensure that referral forms can integrate with local Advice and Guidance systems and patient management systems. Seek IT expertise from the start to ensure that forms can be uploaded and adjustments to improve usability (such as automatic pop-ups and pre-population of patient details) can be made
• Consider the structure of the referral form and how to include minimum requirements for referrals. If it leads the referrer through a series of questions and indicators, it will enable them to ensure that all actions required have been completed. This may include essential information on diagnostics and tests that have already been completed. This helps to reduce duplication, provide useful information and expedite the patient’s journey
• Agree key outcome measures and establish a baseline to measure progress against. Seek input from key stakeholders on the metrics necessary to demonstrate impact of your intervention.

Implement the Pathways and Templates

• Develop, test and refine on a small scale to demonstrate early impact. This makes attempting to scale across multiple clinical commissioning group (CCG) or sustainability and transformation partnership areas much easier
• Ensure that the success of the form is measured. In the early stages of implementation, feedback is key to future refinement. Link the information captured through the key metrics.

Provide Useful Information for Patients

Consider the needs of patients using your service and provide appropriate information to help them make shared decisions about their treatment. It may be useful to refer to NHS England’s guidance on shared decision-making.

Metrics to Consider for Measuring Success

• Awareness and uptake (for example, percentage of referrers using the referral form, percentage of referrals made using the referral form)
• Effectiveness (for example, time spent completing the referral by the referrer, feedback on ease of use)
• Quality of referrals made (for example, time spent reviewing each referral once received, feedback from receiving practitioners on the quality of referrals and accompanying information, number of referrals returned to referrer, conversion rate for GP referrals to first outpatient attendances and from first outpatient attendance to treatment).

Shared Learning Opportunities

What is the Idea?

• Shared learning opportunities in cardiology give practitioners and commissioners from across primary and secondary care the chance to improve their knowledge and understanding of current practice and outcomes for their patients
• There are a number of opportunities for shared learning. These include: formal training or peer mentoring; system wide shared learning sessions or events; optimising feedback from Advice and Guidance services or triage of referrals by specialists; multidisciplinary team case review meetings and system wide audits
• Tools like GRASP-AF can be used to identify patients with atrial fibrillation for joint review by GPs and pharmacists. Co-ordinated audits across primary and secondary care can enable services across the system to learn where there is capacity for diagnostic tests such as blood pressure monitoring and electrocardiogram (ECG).

Why Implement the Idea?

• Providing opportunities to share knowledge and learning enables individuals to ask questions and check their understanding. This helps to build capability and expertise across the local system. Topics may include common cardiac conditions such as atrial fibrillation, or assistive technology such as telecardiology. Sessions and information packs can be delivered by GPs with an extended role or specialists from secondary care
• If learning and knowledge about the appropriate treatment of cardiological conditions is shared, patients should benefit from improved assessment and support to manage their condition in primary care, along with more integrated care and comprehensive and effective treatment plans
• Primary care clinicians can gain a better understanding of which cases to refer to secondary care and the correct information to include in these referrals. Their knowledge, confidence, and expertise about cardiology will improve, meaning that referrals are only made into secondary care when necessary
• As the quality of referrals improves, receiving clinicians will have the information necessary to accept referrals first time and will therefore be able to spend more time seeing patients. The number of inappropriate referrals should reduce, along with associated costs
• Shared learning improves communication and builds trust between practitioners, helping to improve patient management across care settings.

How to Achieve Success

Plan for Learning Opportunities Across Your Local System

• Establish where there are gaps in learning. Ask primary care practitioners which areas of cardiology they would like to explore and where there are areas for development. Ask secondary care clinicians where they think learning should be directed. The wider the range of people involved in planning the learning opportunities, the wider the range of perspectives
• Identify where there are skills and expertise that can be utilised. Think about who will be producing, giving and receiving the education and information materials. Engage clinicians from across primary and secondary care from the beginning and ensure the mutual benefits of shared learning are explained and understood so that people are willing to give of their time and knowledge
• Keep key stakeholders involved. Organisational support and local ownership are vital for engagement. Send full updates by email and take the opportunity to present at any clinician meetings or events. Through engaging with people from across the system, you may be able to start having different conversations, share learning and improve the care being delivered
• Involve people with lived experience and gain their insights. This can be a powerful way to influence change
• Review existing resources to establish what is most and least helpful. It is easy to get stuck and held back by overthinking your offer. You may find that there is information available but people aren’t aware of how to access it, in which case you may wish to focus on consolidating and promoting this material. Alternatively, you may find that the available resources are not fit for purpose in your local context, so adapting these or designing your own may be a better option.

Decide upon the Approach You Will Take

• Training and peer mentoring in primary care. Specialists can deliver structured training and become peer mentors for clinicians who do not have the same level of specialist knowledge. Mentors can come from a range of disciplines including cardiology consultants, cardiology specialist nurses and pharmacists
• Shared learning events and forums. These can count towards continuing professional development (CPD). They usually have a specific focus and bring together individuals with similar interests and learning needs
• Virtual multidisciplinary team review meetings. These allow a team of professionals from across primary and secondary care to gain holistic oversight of complex patients. They allow for learning and expertise to be shared and are an opportunity to ensure that care pathways and treatment plans are integrated and aligned across the multidisciplinary team.

Plan Ahead for Implementation

• Get the right focus and engage expert presenters. Identifying a specific focus (such as a theme or patient cohort) for an event or virtual review meeting can be a useful first step towards engaging the right people and recruiting any GP champions. This needs to be communicated to practitioners in good time to enable cases to be prepared for discussion and to ensure that all relevant clinicians can attend
• Develop and share resources. These may include specific information (for example,  algorithms, information packs, resources for patients). Agree a process to share these resources, for example, via face-to-face meetings or a shared learning event. Such resources can be invaluable when planning subsequent meetings and events
• Identify suitable venues and dates. Ensure events are accessible and attractive to the intended attendees. Consider holding CPD/shared learning events during scheduled CPD time and ensure an appropriate venue is available. Remember to promote resources developed to practitioners at CPD education event. Keep costs low or free for attendees wherever possible. It may be useful to identify administrative support to help co-ordinate venues and invites for speakers and participants
• Share learning as widely as possible. If speakers are happy to be filmed and participants are willing to share feedback, their experiences and perspectives can be shared more widely online
• Promote shared learning opportunities to the intended audience. Approach your local communications team either in the CCG or local trusts to help you produce information resources and market any events and materials. Work with local clinical networks to attract attendees and ensure the right people are involved. Get dates into diaries as far in advance as possible and schedule and price events in a way that meets people’s needs
• Seek feedback and review your learning offer regularly. Consider the best way to evaluate each shared learning opportunity and ensure that they meet your key aims. Further iterations and opportunities should be developed based on the feedback received and impact achieved
• Optimise informal opportunities for shared learning. For example, referral mechanisms may be a useful tool for improving communication and sharing learning between referrers and specialists across primary and secondary care. When consultants respond with feedback on the referral, referrers can share this learning with colleagues for future reference. Work across the system to enable shared learning to happen organically alongside developing formal learning opportunities.

Metrics to Consider for Measuring Success:

• GP feedback on the value of shared learning events and information resources (including increase in knowledge and confidence)
• Reach of shared learning opportunities and events (number of primary care staff attending).

Shared Decision Making and Self-management Support

Self-management Education and Information

What Is the Idea?

• Self-management education supports patients to understand and manage their own condition effectively. It is one of the core components of person-centred care and enables patients and health professionals to take ‘shared responsibility for health’. Self-management education can be provided in various ways, for example, face-to-face sessions (either one to one or through local group workshops) or as an online resource such as NHS.uk. It enables patients to understand the variety of options available to them and facilitates informed, shared decision making. Self-management education is particularly important for cardiac rehabilitation
• Digital tools for self-management can improve communication, enable monitoring of health status and facilitate direct access to patient-held health records and self-management resources.

Why Implement the Idea?

• Self-management education can increase patient activation. Highly activated patients report increased confidence and higher levels of satisfaction. They are more likely to adopt healthy behaviours, attend appointments and use medication effectively. They have better clinical outcomes and lower rates of hospitalisation, as they know when to escalate their concerns and seek appropriate help
• Commissioning self-management support increases the amount and quality of information available. This can give practitioners and patients increased knowledge and confidence so they have more effective shared decision-making conversations. This can reduce the workload for health professionals and delay the need for surgical intervention.

How to Achieve Success: Implementing Self-management Education and Information

Establish Your Local Offer

• Make use of available resources. Review the existing self-management education and support offer locally and nationally, such as the patient information leaflets produced by the British Heart Foundation. Refer to NHS England’s guidance on shared decision-making. Tailor or adapt resources where necessary to ensure that messages fit your local context and develop resources where you identify any gaps
• Provide a range of options for people to access self-management education and support. This may include structured education sessions, support groups, emails, text messages, coaching sessions or digital health tools such as self-monitoring devices or applications
• Decide on the format for any structured education sessions. Reviews suggest that outcomes are better when health professionals are involved and peer support is available. Self-management education and patient information is most effective in combination with other forms of support
• Create patient information resources in a range of formats, involving clinicians and people with lived experience in the development process. Disparate resources can be pulled into one information pack
• Ensure your offer is easily accessible. A large amount of information is often available but it is not always easy to access. Consider the health literacy of your cohort
• Ensure that chosen self-management education and information resources are of high quality and are relevant to the needs of local patients. The best resources for self-management education have often been trialled and evidenced. The Quality Institute for Self-Management Education and Training (QISMET) may be useful to check for certified resources. The Evidence Standards Framework for Digital Health Technologies can be used to ensure that new technologies are clinically effective and offer economic value
• It is crucial to involve people with lived experience and members of the public in the development of self-management education and information resources to understand what people want.

Implement, Promote, and Evaluate Your Education Offer

• Integrate education programmes, information resources and patient decision aids into local referral pathways. These should include content around the need to review self-management if symptoms change and emphasise that people with learning disabilities or who are not fluent in English might need additional support to self-manage. Self-management education can be offered as part of a person-centred care and support plan
• Publicise resources through social media and with cardiology clinical specialists. Creating patient decision aids and videos that can be shared online and through social media provides a way for clinicians to easily access content in their practices. It also enables patients to share content with family and friends after their consultation
• Evaluate the success of any sessions or resources. Ensure a survey has been created and circulated to everyone who sees the new material to gauge their reaction to the material, and whether and how it influenced their decision making.

Top Tip

• Consider extra communications support to help tweeting and re-tweeting messages, website info, booklet, posters and information cards.

Metrics to Consider for Measuring Success

• PROMs, PREMs, and FFT scores
• Patient feedback on the value of the education events and the impact on their confidence to make healthy lifestyle choices
• Patient feedback on their level of knowledge of how to manage their condition.

Transforming Outpatients Appointments

Streamlining Diagnostics

What is the Idea?

• Streamlining diagnostics and outpatients enables ‘one stop’ assessment and preparation by ensuring that patients have the correct diagnostic tests as soon as possible, so that decisions can be made about their treatment at the earliest opportunity
• Patients should receive information in advance, so they are prepared to make informed decisions about their treatment. Results should be reported to primary care in a timely fashion so that patients whose treatment and care can be managed in primary care do not have to make unnecessary trips to hospital.

Why Implement the Idea?

• Patients often attend appointments several times before the point of the ‘decision to treat’. If diagnostic processes are streamlined, patients are able to access appropriate assessment and diagnostics more quickly and easily
• Practitioners have the information necessary to assess, diagnose and (where appropriate) prepare patients for surgery sooner. This avoids unnecessary delays, which can mean diagnostic tests need to be repeated. Use of skills within the workforce can be optimised. The overall number of outpatient attendances and follow-up appointments should reduce and there should be a reduction in the waiting list for urgent and routine outpatient appointments
• Streamlining and standardising diagnostic protocols ensures that patients in most need of urgent assessment and treatment receive this more quickly. Patients have fewer trips to appointments and spend less time waiting, leading to improved patient satisfaction and experience
• If symptoms are found to not require further specialist assessment (for example for people experiencing benign palpitations), patients receive reassurance sooner, which is important to reduce anxiety, improve patient experience and influence future healthcare seeking behaviour.

How to Achieve Success: Implementing Self-management Education and Information

Review Your Current Local Cardiology and Diagnostics Pathways

• Map the existing pathways. Focus on touch-points across the local health system, potential ‘bottlenecks’ or delays and smoothness of transition (including did not attend rates). This provides a useful baseline to measure success against and highlights parts of the pathway with a potential for improvement
• Establish a clearly defined and person-centred goal. For example, you may wish to improve access to echocardiography in primary care to aid the investigation of breathlessness and the early detection of heart failure and valve disease.

Identify Necessary Improvements and Embed in Existing Pathways and Processes

• Develop your proposal with key stakeholders. Identify which diagnostic tests will be necessary and available as part of the pathway. Ensure that clinical discussion of diagnostic findings and of risks and benefits of treatment is included, along with pre-assessment for procedures (where appropriate). Seek feedback from patients and healthcare practitioners throughout this process
• Identify the key metrics to demonstrate impact of the improvements to your pathway and processes. Involve stakeholders throughout this discussion to ensure that the most useful elements are being measured
• Involve NHS Digital for support with access to the diagnostic reporting system (if a review of the ECG is necessary for the management of the condition in the community)
• Identify where and when the diagnostics should take place. This will be dependent on your local context and availability of equipment and clinicians
• Identify the necessary clinicians, technicians and administrative staff. Explain the opportunity and potential benefits. Work through job planning implications to secure involvement
• Consider the information needs of patients using your service. Remember to refer to NHS England’s guidance on shared decision-making.

Implement and Evaluate the New Pathways and Processes

• Consider a trial period so that the changes can be evaluated, particularly if clinical time and resources are stretched. This may help to alleviate concerns regarding changes and ensure that the pathways and processes work in practice. This allows the initial benefits to be observed, which helps make the case for scale
• Agree an implementation plan. This should include the collection of baseline data and initiation of recruitment processes
• Evaluate the streamlined pathways. Following the start of the pilot, live feedback should be encouraged to support changes for next part of the evaluation period. This could be provided verbally or via email between clinicians, patients and management team.

Metrics to Consider for Measuring Success

• Capacity to manage patients, for example, number of clinics held
• Number of patients seen in clinics, including outpatient attendances and follow-up appointments
• Number of referrals that result in no further treatment (conversion rate from referral to treatment)
• Operating costs.