Cardiovascular disease is the main cause of death in the UK and with our ageing population, stroke incidence is likely to increase.
Stroke is a major pressure on the NHS and society. Its cost is substantial (in the order of £12,000 per patient in the first year alone). Morbidity is significant and life changing.
There are several modifiable risk factors, such as smoking, hypercholesterolaemia, hypertension, diabetes and AF, which, if addressed, may significantly reduce the burden.
Responsibility and aims
All GPs are commissioners and anybody can take an interest in stroke, not just those on the CCG executive board. Your CCG may be yet to consider a scheme to improve stroke outcomes, or may appreciate input to schemes it is already considering.
Once you decide you would like to develop a stroke programme, the next step is to consider what you want to achieve (your CCG may give you a steer). This will formulate the aims to present to your CCG.
It is important to focus on outcomes as well as process; mistakes are often made when the process is focused on, rather than the outcomes to be achieved.
There are several ways to do this. Bringing the right people together (nurses, doctors, patients, NHS managers and so on) will provide diverse 'soft intelligence'. Involving these people from the start will enhance their commitment to the project.
Data on prevalence of AF, anticoagulation in AF, hypertension control, 'door to needle' times for thrombolysis, length of stay on a stroke unit and complication rate are a few of many possible areas on which to focus.
All stroke units are mandated to provide audit data on their performance and scrutinising these data may reveal further areas to explore. While much stroke care is an acute provider function and influence on improvement may be through clinical meetings and even contractual arrangements and levers, primary care has a huge part to play in prevention.
This is where commissioners can have an impact through new enhanced service type schemes.
An important exercise is to map current patient pathways. I view this as an 'opportunity map'. They often show wasted steps and and highlight potential areas of improvement.
There are several opportunities to improve stroke outcomes using a 'quality scheme' approach.
For example, if the desired outcome is to reduce AF-related strokes, your business case will include a background detailing potential improvement in quality of life (QoL), given that AF-related strokes are more severe and patients are less likely to live independently than those with non AF-related stroke.
It should also include financial implications, your intervention, and details on monitoring and sustainability. In this case, the intervention could be opportunistic or targeted screening for AF.
Payments cannot be made for ensuring anticoagulation because this is already incentivised in the QOF. A method for collecting data and ensuring the work is being done is important. It is sensible to let your LMC know about the scheme.
Finances and sustainability
Your scheme has to improve outcomes and quality of care, and be within the CCG's financial scope, so it is important to be clear on the spend saved in-year, the costs and likely net savings. Costs include how much to pay a GP practice or other provider to carry out whatever intervention you specify.
Many schemes operate initially as a pilot. Success usually means quality increases and costs decrease, so the new pathway pays for itself, with money to spare and reinvest in care.
A comment about sustainability would usually be needed in your business case. Someone will need to continue to champion the project and monitor the work, and this will need to be factored into costings.
Many projects are initiated, but there is a need to measure what they deliver and assess how they would be terminated if they fail. Here, setting the target and monitoring costs, AF prevalence, anticoagulation rate and stroke incidence are among the key considerations.
The new NHS has forced us to look at clinical quality. Good, innovative ideas that are well thought out, properly managed, have robust governance and are outcome-focused can deliver an excellent result for all.
'Selling' the scheme
Once you have presented your case and gained approval from your CCG executive board, the next step is to 'sell' the project to GPs.
The timing of when you do this is relevant; for example, just before QOF year-end is best avoided.
We know the workload in primary care has increased and our net income is falling. Basing the project on quality, improving the lives of patients, reducing stroke risk and reducing the risk to the health economy are all selling points, and there will be many others.
- Dr Thakkar is a GP in Wooburn Green, Buckinghamshire, and clinical commissioning director for planned care, Chiltern CCG