Cardiology Nurse is currently expanding the service by undertaking clinical skills and prescribing training. Nurse James Connor who is joining the team as an ANP trainee will also provide support into the service having passed exams in ECG interpretation. Current services are set out below. In general, difficult to manage cardiology patients can be referred in by the GP. Whilst not a one stop clinic or super specialised service it can provide a route by which patients can be better optimised or advice given. Patients will often be passed back to primary care with advice or treatment suggestions. We proactively find patients who have recently had an MI to check their medications and condition are optimised. Patients will be fed into the social prescribing service when needed post MI. ECGs are interpreted by Claire and passed back to practice. For urgent issues post ECG, the PCN Clincial Director if present will offer support, but if not present this will be passed back to the practice much in the way hospital ECGs are.
Funding source
ARRS – care coordinator Cardiology
Enhanced Access
Budget
1 WTE Nurse via Health & Well Being Coach on ARRS
PCN Management Lead
Mr Ross Hawkins
PCN Overall Accountable Person (CD or Deputy CD)
Dr Lunn (Clinical Director)
Team Lead
Claire Watson – Cardiology Nurse
Individuals Team Members Supervision / Education
Claire Watson – Prescribing – Dr Lunn / Dr Urwin
Clinical Queries – Dr Lunn / Urwin or task back to practice
Claire Watson supervision of HCA ECGs
Areas of responsibility
Post MI reviews
Anticoagulation switches
Heart Failure reviews
Complex Cardiology reviews
Lipid management
Pneumonia vaccination
ECG interpretation
Metrics needed
IIF DOAC
Practice QoF HF indicators
FROM DES 2022/23 – we will continue to embed
A PCN must:
a. improve diagnosis of patients with hypertension, in line with NICE guideline NG13664 by ensuring appropriate follow-up activity is undertaken to confirm or exclude a hypertension diagnosis where a blood pressure of ≥140/90mmHg in a GP practice, or ≥135/85 in a community setting, is recorded. This will include proactive review of historic patient records, to identify patients who have had a previous elevated blood pressure reading but have not had an appropriate diagnostic follow up; and
b. undertake activity to improve coverage of blood pressure checks, by:
i. increasing opportunistic blood pressure testing where patients do not have a recently recorded reading;
ii. undertaking blood pressure testing at suitable outreach venues, agreeing the approach with local partners and targeting need as informed by local data on health inequalities and potentially at-risk groups; and
iii. working pro-actively with community pharmacies to improve access to blood pressure checks, in line with the NHS community pharmacy hypertension case finding service.
In addition a PCN must:
a. improve the identification of those at risk of atrial fibrillation, in line with NICE guideline NG196, through opportunistic pulse checks alongside blood pressure checks undertaken in a clinical setting
b. undertake network development and quality improvement activity to support CVD prevention including:
ii. supporting the development of system pathways for people at risk of CVD through liaison with wider system partners
iii. collaboration with commissioners to improve levels of diagnostic capacity for ‘ABC’ testing, including availability of ambulatory blood pressure monitors (ABPMs) and electrocardiogram (ECG) monitors; and
iv. ensuring processes are in place to support the exchange of information with community pharmacies, including a process for accepting and documenting referrals between pharmacies and GP practices for the Community Pharmacy Blood Pressure Check Service
c. identify patients at high risk of Familial Hypercholesterolaemia (as defined in NICE guideline CG71, section 1.1), and make referrals for further assessment where clinically indicated. This should include systematic searches of primary care records to identify those aged 30+ with Chol > 9mmol/L or with Chol > 7.5mmol/L aged less than 30;
d. offer statin treatment to patients with a QRISK2&3 score >= 10%, where clinically appropriate, and in line with NICE guideline CG181; and
e. support the earlier identification of heart failure (HF), through building awareness among PCN staff around the appropriate HF diagnostic pathway, and early identification processes for HF including the timely use of N-terminal pro B-type natriuretic peptide (NTProBNP) testing.
By 30 September 2022, as part of a broader social prescribing service, a PCN and commissioner must jointly work with stakeholders including local authority commissioners, VCSE partners and local clinical leaders, to design, agree and put in place a targeted programme to proactively offer and improve access to social prescribing to an identified cohort with unmet needs. This plan must take into account views of people with lived experience. From 1 October 2022, a PCN must commence delivery of the proactive social prescribing service for the identified cohort. By 31 March 2023, a PCN must review cohort definition and extend the offer of proactive social prescribing based on an assessment of the population needs and PCN capacity.
Who leads on team metrics
Dr Lunn
Staff Place of work / Practice
Claire Watson – Cardiology Nurse Oxford Centre (Employed by Stephenson Park)
