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Review finds more heart failure services are in place, but reveals concerns regarding variations in patient access to diagnostic tests, drugs and specialist care

One of the most comprehensive reviews into the services provided to patients with heart failure has been published by the Healthcare Commission today.

It found some ‘very positive’ progress since the last report in 2003/04. This included a continuing reduction in the time patients have to wait to be diagnosed accurately, plus significant increases in the numbers of patients being prescribed drugs to control their symptoms and slow the progression of the condition.

However, the Commission has expressed concern that a significant number of patients with heart failure may not be being identified.

The report’s data shows that the number of people reported as having confirmed heart failure is around 140,000* less than expected. This could be due to problems with recording patient data on GPs’ systems – a lack of clear auditing was one of the enduring issues for the entire review. On the other hand, it could mean that some patients are not getting access to diagnosis and, in turn, treatment.

Heart failure affects 900,000 people in the UK. It arises most commonly following a heart attack or high blood pressure, and is caused by a reduction in the heart’s ability to pump blood around the body. The condition can be extremely debilitating and comes with a high risk of sudden death – up to 40% of patients die within the first year of diagnosis.

Diagnosis of heart failure is difficult: many of the symptoms – tiredness, shortness of breath and swelling of the ankles and feet – can be confused with other similar health problems (such as chronic bronchitis).

Patients therefore need quick and effective access to the tests, drugs and specialists which will help to improve their condition and slow the progression of the condition. In some areas of the country, they have this. In others, they do not.
Anna Walker, Chief Executive of the Healthcare Commission, said:

“Heart failure is a very serious condition. It is therefore very positive to see the improvements made since the last review in 2003/04. Waiting times for diagnostic tests have improved and patients now have better access to effective treatments. Most communities also now have access to specialist services, with almost two thirds of those we reviewed scoring ‘good’ or ‘excellent’.

“But our report suggests that not all those that need treatment are getting it. Primary care trusts and GPs need to monitor the number of patients they deal with in comparison to national statistics. Symptoms and treatments need to be recorded and followed up by GPs. The care provided also needs to be audited so lessons can be learnt and improvements made. We therefore welcome the pilot that is being led by the British Society for Heart Failure.

“Heart failure currently costs the NHS £625 million a year. It is the cause of 5% of our hospital emergency admissions, and re-admissions are among the highest for any chronic condition. But if we can improve all elements of the service, this will be better for patients and improve the use of resources.”

The report, ‘Pushing the Boundaries’, is based on a review which took place in 2005/06. It assessed the heart failure services provided by 303 healthcare communities – each consisting of a primary care trust and its main hospital providers. This helped move the focus away from individual organisations and on to the patients and the care they were receiving.

Nationally, the picture was quite positive: two thirds of the communities scored ‘excellent’ (28) or ‘good’ (160) for their overall services to heart failure patients. A further 89 were assessed to be ‘fair’.

Worryingly, 26 were assessed as ‘weak’. These have since been tasked with producing a plan detailing how they propose to improve. The Healthcare Commission has already commenced work with these communities, some of which have already provided evidence that they have made progress against the areas of concern.

However, the review suggests some areas for improvement in almost every community. Indeed, the level of services varied significantly, leaving some patients without a confirmed diagnosis, while others were left without access to medication or long-term support.

The fact that so many patients could be undiagnosed was a major concern. The Healthcare Commission has therefore called upon all primary care trusts to review the number of heart failure patients they deal with locally for comparison against national predictions. Currently, many are not collecting such data. Just 20% of trusts were able to provide enough information to meet national clinical audit criteria set in 2003.

Indeed, one of the enduring issues for the entire review was the lack of routinely available data, specifically relating to patients with heart failure. Without this information, trusts cannot ensure that all patients with the symptoms of heart failure are being identified, properly investigated and treated appropriately.

Early identification, treatment and care can reduce the number of heart failure patients admitted to hospital in an emergency or re-admitted following diagnosis. To date, this has created a considerable burden on resources, with heart failure services costing the NHS £625 million a year.

The British Society for Heart Failure is developing a national heart failure audit. A pilot, managed by the Health and Social Care Information Centre, has already begun in some hospitals. The scheme will be rolled out nationally, providing better information on the quality of heart failure services offered to patients.

The report identified areas for improvement in the majority of communities for one or more of the four criteria. The key findings included:

(1) Diagnosis:
• Waiting times for the most effective diagnostic tests (echocardiography) have dropped significantly in the past two years, and continue to do so. As of March 31, 2006, over 70 per cent of patients had a test within 13 weeks.
• * However, concerns remain that not all patients are being identified; the recorded prevalence falling short of that predicted. In fact, using data from the 204 trusts that provided it (out of 303), there were 140,000 less people reported as being diagnosed with confirmed heart failure than expected.

(2) Treatment:
• Following confirmed diagnosis, many more patients now have access to effective medication. Last year, 85% of patients were receiving initial treatments, compared to fewer than 50% in 2003/04.
• However, at a local level, access to such medication varied significantly and not all patients were getting access to additional drugs proven effective for the treatment of heart failure.
• Heart failure is a debilitating condition, so access to a full range of treatments is essential.

(3) Support & Care:
• The report found that over 80% of communities have begun to establish some form of specialist heart failure service. However, the funding for some of these was not secure, while others with planned developments appeared to be struggling due to lack of funding.
• Over 86% of trusts had a specialist consultant in place but, from a survey, only 22% of patients admitted to hospital with heart failure were referred to them (or a cardiologist) during their stay.
• More attention needs to be given to meeting the needs of patients beyond the immediate control of symptoms; this ensures that their mental wellbeing and quality of life is improved.

(4) Outcomes:
• Few service providers were evaluating their services from a patient perspective through patient satisfaction or quality of life surveys.
• Effective care has been shown to reduce the level of readmissions and mortality for patients with heart failure. The report shows wide variation in these two outcomes which could potentially be reduced by a more rigorous application of national guidelines.

The report concludes with a series of recommendations for the organisations within a healthcare community. Primary care trusts and commissioners will need to:

• ensure that local data on prevalence of heart failure is routinely compared to national trends; gaps and discrepancies must be investigated
• ensure that all patients with suspected heart failure have access to key diagnostic tests
• work together with other healthcare organisation in the community to ensure that all patients have access to specialist advice and services

In turn, service providers in primary and secondary care have been tasked with:

• ensuring that all patients with confirmed heart failure have access to appropriate medication
• developing clinical audit programmes to evaluate the effectiveness of services and benefits for patients
• comparing performance with other communities and identifying areas for improvement


Notes to editors
* As part of the review the Commission asked PCTs to supply data on the number of patients aged 45 and over with confirmed heart failure. Only two thirds of PCTs (204) were able to supply this data. In the majority of those that did, the recorded prevalence was well below the expected level of 2.3%. In fact, the total number of patients recorded with heart failure in those 204 trusts was around 140,000 less than expected.
There are two possible explanations for this:

(a) patients may not be getting access to appropriate diagnostic tests and/or subsequent treatment (eg they may have been diagnosed incorrectly)

(b) there could be problems with recording patient data on GPs' systems (eg people are being diagnosed and treated but not recorded as such)

The data we have does not enable us to distinguish which of these issues is more likely to be the case.

The report and relevant data, together with a briefing note is available at:
http://www.healthcarecommission.org.uk/heartfailuremediainformation.cfm  

Patient advice on heart failure is available on the
British Heart Foundation website: www.bhf.org.uk  

Information on the Healthcare Commission
The Healthcare Commission is the health watchdog in England. It keeps check on health services to ensure that they are meeting standards in a range of areas. The Commission also promotes improvements in the quality of healthcare and public health in England through independent, authoritative, patient-centred assessments of those who provide services.

Responsibility for inspection and investigation of NHS bodies and the independent sector in Wales rests with Healthcare Inspectorate Wales (HIW). The Healthcare Commission has certain statutory functions in Wales which include producing an annual report on the state of healthcare in England and Wales, national improvement reviews in England and Wales, and working with HIW to ensure that relevant cross-border issues are managed effectively.

The Healthcare Commission does not cover Scotland as it has its own body, NHS Quality Improvement Scotland. The Regulation and Quality Improvement Authority (RQIA) undertakes regular reviews of the quality of services in Northern Ireland.

For further information contact the press office on 0207 4489439, or on 07779 990845 after hours.