Tower Hamlets: managed practice networks to improve rates of cardiovascular disease
Using managed clinical networks to improve care of people with high blood pressure (hypertension), stroke, chronic heart disease and diabetes.
Tower Hamlets, an inner-London borough with one of the most deprived and ethnically diverse populations in the UK, ranks fourth in England for premature cardiovascular death.
From 2009 NHS Tower Hamlets spent an additional £2 million per year to improve the quality of primary care. This included the implementation of a system of managed clinical networks across all primary care teams in 2009.
The introduction of the managed clinical networks was associated with moving from the bottom national quartile of performance to the top national quartile in 3 years across a range of outcomes. Improvements over 3 years included:
- a 10% increase in high blood pressure prescribing
- an improvement of 6% in reaching the target of less than 150/90mmHg for those on hypertension registers (compared to less than 2% improvement in England overall)
- an 18% greater reduction in chronic heart disease (CHD) mortality (45% in Tower Hamlets versus 25% nationally)
Tower Hamlets was the highest ranked of the 221 CCGs in England in the 2013 to 2014 Quality and Outcome Framework for blood pressure control in people with coronary heart disease and diabetes.
Contact person
Dr John Robson, Queen Mary University of London
Region
London
Location
Tower Hamlets
Partner organisations
Tower Hamlets CCG (formerly PCT) and GP practices, Queen Mary University of London
See description from UCL Partners.
Target population
People with
- hypertension
- stroke
- chronic heart disease
- diabetes
Aim
To evaluate CVD managed practice networks in one entire local health economy using practice networks, compared with neighbouring areas, London and England.
Programme structure
Eight managed practice networks were established in 2009, consisting of 4 to 5 practices located in the same geographical area serving a local population of 30,000 to 50,000.
Each network had a network manager, an administrative assistant, and an educational budget to support practices in their network to deliver the care packages.
The CVD care package consisted of 4 components:
- hypertension
- stroke
- CHD
- NHS Health Check
Each component had network targets agreed by the local GP representatives.
These included:
- blood pressure <140/90mmHg for hypertension, stroke, and CHD
- blood pressure <140/80mmHg for diabetes
Network financial incentives replaced the earlier ‘local enhanced service’ incentives costing £1 million per network. Practices in a particular network were paid if their combined network average exceeded the target, with payment pro rata based on attainment and practice patient numbers.
Three whole-time community specialist CVD nurses supported training for practice nurses and were aligned with the new targets, providing clinical care to some ‘off target’ patients in poorly performing practices.
Clinical guidelines were developed and published to support each element of the CVD care package and were circulated to all practice staff. A lead clinician in each network practice worked with the network manager. More proactive clinicians acted as peer educators supporting staff in other practices within their network.
Practices in all 3 local PCTs used a web-enabled computer system which facilitated IT interventions. Standard data entry templates were developed and these were further enhanced as monthly performance ‘dashboard’ reports for networks and practices, with ‘rag ratings’, charts, and trend lines to visually convey the comparative performance of each network and of individual practices within networks.
Regular review of the dashboards took place at commissioning level, network manager forums, and within networks, targeting additional support to practices that needed it and learning from successful teams.
Standardised searches of electronic records improved recall of ‘off target’ patients so that clinics could contact patients by letter or, if overdue, by telephone in their own language.
Over the 3 years, the network managers collaborated to build up a sophisticated system of locally-tailored solutions, customising IT searches, register cleaning, patient recall tools, on-screen prompt, and support to poorly performing practices.
Activity to date
The networks started in 2009 and are still in operation today.
Outcome measures
Relevant to blood pressure:
- QOF data for blood pressure <150/90mmHg and serum cholesterol <5mmol/l
- blood pressure control <150/90mmHg in people with CHD, stroke and hypertension
- mortality from heart attacks
- mortality from CHD
Outcomes
In 2012 and 2013, QOF data for blood pressure <150/90mmHg and serum cholesterol <5mmol/l ranked Tower Hamlets first out of 225 CCGs in England for both measures in CHD and diabetes, sixth and second respectively for stroke, and top in London on all measures.
Improvement in Tower Hamlets took place at a faster rate than England, London, or comparable areas after implementation of networks.
For blood pressure control <150/90mmHg in all three domains (CHD, stroke, and hypertension), Tower Hamlets improved faster than London or England. Specifically:
-
for hypertension, from 2009 to 2012: blood pressure control in Tower Hamlets improved from 74.9% to 80.8% (5.9%); London 75.0% to 76.7% (1.7%); England 75.5% to 77.4% (1.9%).
-
for stroke: blood pressure control in Tower Hamlets improved from 83.6% to 88.5% (4.9%); London 84.2% to 85.0% (0.8%); England 84.6% to 85.5% (1.1%).
-
for CHD: blood pressure control in Tower Hamlets improved from 87.5% to 91.9% (4.4%); London 87.0% to 87.7% (0.7%); and England 87.1% to 88.1% (1.0%).
-
for diabetes: in 2012 and 2013, blood pressure <140/80mmHg was 76.6% in Tower Hamlets, London 66.5%, and England 67.2%, and comparable targets were not available for 2009.
Tower Hamlets has shown a faster rate of decline in deaths from heart attack in the 3 years since 2008 than neighbouring areas, London, or the national average.
Male mortality from CHD in Tower Hamlets was fourth highest in England in 2008. It reduced substantially more than any other area in the next 3 years: a reduction of 43% compared with an average of 25% for the top 10 PCT in 2008 ranked by mortality.
Lessons learned
Managed geographical practice networks delivered a step-change in key CVD performance indicators in comparison with England, London, and neighbouring areas.
External evaluation
Peer-review publication: Robson J, Hull S, Mathur R, Boomla K. Improving Cardiovascular disease using managed networks in general practice. British Journal of General Practice 2014; 64(622): 268-74
Level 3 (Causation): the positive change amongst the users of the product or service is happening because of the product or service.