7. IMPROVING THE EXPERIENCE OF CARE
7.1Better Health, Better Care makes clear NHSScotland's determination to provide patient-centred care which is respectful, compassionate and responsive to individual patient preferences, needs and values. It sets out plans for a new programme of work, Better Together, which listens to the experiences of patients in Scotland and uses this understanding to drive changes in the way in which services are designed and delivered. The initial focus of this programme is on inpatient care, GP services and long term conditions and will therefore provide a series of opportunities to improve the experiences of cardiovascular patients.
7.2 Patient Focus and Public Involvement initiatives have made good progress in involving patients, carers and local communities in the design and delivery of cardiovascular services. "Hearty Voices" Scotland training provided by Chest, Heart and Stroke Scotland and the British Heart Foundation Scotland has supported this involvement by providing the skills and increasing the confidence of cardiac patients and their carers to enable them to work effectively with health professionals to influence change.
Self Management
7.3 Self management is a person-centred approach to care, in which the individual is empowered and has ownership over the management of their life and condition. The role of health and social care professionals, services and treatments is to support patients and their carers to continue "normal life", while managing their condition.
7.4 The forthcoming publication of the self management strategy developed by the Long Term Conditions Alliance Scotland provides an opportunity for NHS Boards, social care and the third sector to work together in a new partnership to support patients, their families and their carers in managing their cardiovascular conditions. In particular, it will focus on supporting innovative self management projects across Scotland, identifying and realising the benefits of new technology in delivering care closer to home and improving the information that is available at all stages of the patient's journey.
7.5 Research by the British Heart Foundation highlighted a number of weaknesses in communication within the medical profession. This reported that patients perceived care to be overly compartmentalised and that a lack of effective communication between GPs and hospital consultants left them feeling abandoned after discharge from hospital. Managed Clinical Networks are well placed to address such concerns and will need to prioritise actions in this area.
7.6 The cardiac and stroke Managed Clinical Networks can be made even more effective as agencies for local implementation of the Strategy through the participation of "lay" representatives who have received proper training both in their condition and in the workings of the NHS. The Scottish Government has provided funding to allow for the extension of the "Hearty Voices" programme, to help those who have had a stroke who wish to participate in the work of their local stroke MCN.
Waiting Times
7.7 Patients want investigation and treatment to be undertaken as rapidly as possible. Since December 2004, the Scottish Government's waiting time standards for CHD have meant that patients have waited no longer than eight weeks between a review by a heart specialist and access to diagnostic angiography and, if required, no more than 18 weeks between angiography and cardiac revascularisation. A new target was introduced from December 2007, with a maximum waiting time of 16 weeks to treatment following referral by a GP. This target is sub-divided into time specific stages with a maximum waiting time of one or two weeks (depending on the hospital) for assessment at a rapid access chest pain clinic, a maximum wait of four or five weeks for angiography/follow-on revascularisation and a maximum wait of 10 weeks for revascularisation or valve surgery.
7.8Better Health, Better Care included the commitment that from 2011 there will be a maximum waiting time of 18 weeks from referral to treatment for all conditions, including CHD and stroke. To begin the move towards achieving this new target, the maximum routine waiting time for cardiac outpatient clinics has been set at 18 weeks from December 2007, reducing to 15 weeks or less at March 2009.
7.9 At present, there are no specific waiting time targets relating to stroke services, but standards produced by NHSQIS define the maximum delays patients should experience in line with best clinical practice. Data from the Scottish Stroke Care Audit shows that, averaged over Scotland, the proportion of patients receiving care in line with NHSQIS standards has increased significantly between 2005 and 2007 and meets the standard with respect to early access to brain imaging. However, there remains scope for continued improvement.
Clinical Guidelines
7.10NHS Quality Improvement Scotland is currently establishing a structured programme of work that pulls together a range of initiatives that support the implementation of clinical guidelines for CHD and stroke across Scotland. This includes:
- work by a cardiovascular programme board to raise awareness of and implement the five clinical guidelines published by SIGN in 2007 on the prevention and management of coronary heart disease and cardiovascular disease;
- the development of a SIGN guideline on Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention;
- a patient version of the new guideline in collaboration with Chest, Heart and Stroke Scotland; and
- a selective update of SIGN 64: Management of patients with stroke: rehabilitation, prevention and management of complications, and discharge planning which will begin in September 2008.
Clinical Standards
7.11 A standards development programme for cardiovascular disease is being established, using the evidence in the SIGN guidelines as a framework, in collaboration with a wide range of stakeholders including MCNs and patient representatives.
7.12NHSQIS first developed stroke standards in 2004, covering the care of the patient in the acute setting. Peer review visits to all NHS Board areas in Scotland were conducted between September 2004 and May 2005 in order to assess performance against the standards. The standards are likely to be revisited and revised in light of the action to update SIGN guidelines detailed above.
National Audits
7.13 National audits will be undertaken during 2008-2009 in relation to heart failure, acute coronary syndromes and cardiac rehabilitation. The National Advisory Committee for CHD's Data and IT Sub-Group has established a working group to update and agree a set of standardised definitions around cardiac rehabilitation and to define an appropriate cardiac rehabilitation participation rate for Scotland.
7.14 The Scottish Stroke Care Audit monitors the quality of care provided by NHS Boards by collating data collected by the MCNs which are used centrally to monitor progress against the current standards for stroke. A steering committee has been set up to conduct a nationwide, prospective, population-based register of intracranial vascular malformations: the Scottish Audit of Intracranial Vascular Malformations. The results will help with treatment decisions for this group of patients.
7.15 To meet the gap in trained staff several NHS Boards have, in collaboration with CHSS, developed stroke in-service training programmes. These are now widespread and highly valued and are being supplemented through the development of web based training which individual staff can access at a time which is convenient to both themselves and the service. They include on-line training in swallowing assessment (available through the e-library) and an on-line training resource focusing on the Stroke Core Competencies developed by NHS Education Scotland ( NES) described below.
7.16NHS Education for Scotland published a set of core competencies for professionals working with people with stroke in April 2005. An e-learning training resource based on the competencies has been developed subsequently by a range of stakeholders including CHSS, the University of Edinburgh, NES and a national steering group which includes expert stroke clinicians. A supporting website www.Strokecorecompetencies.org which was launched in May 2008, provides a multidisciplinary resource which focuses on a wide range of core knowledge and skills required by all staff delivering stroke care. It is now being developed further with more advanced training resources aimed specifically at staff working in acute stroke unit care.
7.17 Exercise After Stroke: Physical Activity and Health is a unique training course designed for specialist exercise instructors which has been developed and validated by Queen Margaret University. The modular course is based around the most up-to-date and highest quality evidence available, and involves 200 hours of study comprising lectures, tutorials, practical sessions and self-directed learning. Representatives of the leisure industry in the participating NHS Board areas are working in partnership with health colleagues to establish patient pathways into exercise and fitness training to maximise recovery for people who have had a stroke.
Practice Development
7.18 The Practice Development Unit ( PDU) of NHSQIS will undertake a scoping exercise to identify how it can contribute to the improvement of practice and services offered by AHPs to patients who have aphasia following stroke. The Unit will also hold a stroke master class to disseminate information from a number of stroke related projects undertaken by PDU over the last year, including dysphagia, aphasia and ankle foot orthosis.
Research
7.19 The Scottish Stroke Research Network ( SSRN) is funded by the Chief Scientist Office and was set up to complement developments in the rest of the UK. It works through a devolved four regional structure and has 21 active research sites, with plans to develop a further three to four sites. Recruitment to trials has risen in 2007-2008 by 50% over the previous two years. Scotland is currently the second highest recruiting region in the UK (with over 500 participants per year) despite having a relatively more demanding portfolio of studies. The Network will continue to consolidate and build upon this progress and begin focusing on supporting activities such as development of the study portfolio, staff training, and service development.
ISSUES TO CONSIDER
What further actions should we take to improve the patient experience of care for both CHD and stroke?