Empowering GPs to work collectively to improve patient care - Dr Richard Healicon and Mel Varvel Free GRASP tools for GPs for atrial fibrillation, heart failure and COPD Presentation from the Health and Care Innovation Expo 2014

1. Empowering GPs to Work Collectively to
Improve Patient Care
Mel Varvel
Dr Richard Healicon
NHS Improving Quality

2. Introduction
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NHS Improving Quality
An ambitious call to action
System levers and drivers
Roles and responsibilities
Carrots and sticks
The GRASP Approach

3. NHS Improving Quality
• Set up from 1 April 2013 and hosted by NHS England
• Improving health outcomes across England by providing improvement and
change expertise
• An evidence-based organisation that is aligned to the current needs and
challenges of the NHS
• Builds on the wealth of knowledge, expertise and experience that has gone
before
• The ‘go to’ organisation leading improvement in England
• Working with partners in design and delivery across the service

5. Five Transformational Change Programmes
• Living longer lives
• Promoting and enabling integrated care and support
• 7 day services
• Patient safety
• Valuing patient experience

6. Living Longer Lives
• Supporting implementation of the CVD Outcomes
Strategy (and NHS Health Check)
• Raising public awareness of symptoms and supporting
early diagnosis of disease
• Engaging with clinicians and primary care in the nation’s
biggest killers

7. An Ambitious Call to Action

8. System Levers and Drivers
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GMS Contract
Enhanced service contracts (DES)
Extended service contracts (LES)
Quality and Outcomes Framework
From April 2014
– Named, accountable GP for >75s
– Greater role in reducing avoidable emergency admissions
• CCG Outcomes Indicator Set (CCG OIS)

10. Roles and Responsibilities
Flow of funding and contracting in general practice under current system
Commissioning
bodies
NHS England
Clinical
Commissioning
Groups
Core Contracts
Funding
streams and
contracts
Quality and
Outcomes
Framework
(QOF)
GP practices are
rewarded
according to
their
performance
against a number
of indicators
Communitybased services
(formerly Local
Enhanced
Services)
Public Health
Includes things
like screening
and
immunisation
from April 2014
Voluntary/ additional contracts
GPs supply
services to the
NHS via three
contracting
routes.
• GMS
(nationally
agreed)
• PMS (locally
agreed)
• APMS (locally
agreed)
Local
Authorities
Enhanced
Services
Payments
currently linked
to extended
hours of service
provision, minor
surgery and
other enhanced
clinical services
GP Provider organisations (almost all payments go to the GP provider organisation and not individual GPs)

11. Carrots and Sticks

12. From Compliance to Commitment

13. The GRASP Approach
• Simple audit tool to improve the management of a number of LTCs
• Collective goal setting
– no minimum performance standard
• Bottom up approach
– No hierarchical control
• Voluntary participation
– Not delivered through formal control mechs
• Delivery through shared commitment
– Not performance managed
• A vehicle for engagement and improvement
– GPs firmly in the driving seat

14. The GRASP Suite of Audit Tools
Dr Richard Healicon
Programme Delivery Lead, Living Longer Lives
Mel Varvel
Improvement Manager, Living Longer Lives

15. Outline
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Introduction- GRASP Suite
Focus on GRASP-AF
Guidance on management of stroke risk in AF
Tools to help: GRASP-AF and CHART Online
Other toolkits
Summary
How to access the GRASP Suite

16. GRASP toolkits
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Free primary care audit tools
AF, COPD and HF
Aligned to NICE/ ESC guidance
Each has a case finder
Compatible with all GP systems in England
Stand alone (patient identifiable)
CHART Online (anonymised data)

17. GRASP-AF
• Guidance on Risk Assessment and Stroke Prevention in AF

18. Stroke is a frequent complication of AF
• Stroke is the leading complication of AF
• Patients with AF have a five-fold higher stroke risk than those without AF
• Without preventive treatment, each year approximately 1 in 20 patients (5%)
with AF will have a stroke
• It is estimated that 15% of all strokes are caused by AF and that 12,500
strokes per year in England are directly attributable to AF

19. Stroke is a serious complication of AF
• Stroke in AF is associated with a heavy burden of morbidity and mortality
• AF related stroke is usually more severe than stroke due to other causes
• Compared with other stroke patients, those with AF are more likely to:
– Have cortical deficit (e.g. aphasia), severe limb weakness and diminished
alertness, and be bedridden on admission
– Have longer in-hospital stay with a lower rate of discharge to their own home
• The mortality rate for patients with AF is double that in people with normal
heart rhythm

20. Stroke Risk Stratification

21. Stroke risk in AF: CHADS2

22. Stroke risk in AF: CHA2DS2VASc

23. Stroke risk in AF

24. ESC Guidelines Focussed Update 2012

25. GRASP-AF
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One of three free audit tools developed by NHS IQ and PRIMIS
Case Finder
Identifies patients with a history of atrial fibrillation
Searches for co-morbidities and calculates both a CHADS2 and CHA2DS2-VASc
score
• Searches for current medication- warfarin, aspirin or newer oral anticoagulant
• Searches for recorded reasons for NOT treating with warfarin
• Gives a simple alert for those at high risk and not on warfarin or newer oral
anticoagulant

26. The GRASP-AF toolkit in action

33. CHART Online
• Voluntary upload of data to CHART online
• Web based analysis tool with a variety of comparative viewing options
available
• Secure and restricted access
• For both primary care staff and commissioners

39. Clarification about security
• Only anonymised patient level data is uploaded and that this is transmitted
and stored securely
• Viewing data in CHART Online is restricted to people registered on the
PRIMIS Profile Centre who are validated by either PRIMIS or NHS Improving
Quality
• Users who are validated by PRIMIS or NHS Improving Quality will only be
able to view a Practice's national code if given specific permission by the
Practice

40. CHART Online data- management
September 2013:
183,334 patients with a CHADS2≥2 in those 2,515 practices:
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48.4% patients on oral anticoagulation (OAC) alone
8.4% patients on OAC and aspirin
34.5% patients on aspirin alone
8.7% are not on either
Of those 79,082 patients not on OAC:
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9.8% OAC declined
3.6% contraindicated
86.6% no reason given

42. Chart Online
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Benchmark own practice against others in CCG
Benchmark CCG against others in SCN/ National
Practices control who sees their national identifier
Facility to email all in CCG to seek permission for this

43. CHART Online
• Opportunity for
– GP/ Practice level audit- revalidation
– CCG/ SCN level audit- improve together
– Data sharing with SCNs/ AHSNs

44. Current Issues
• Data sharing
– GPs are data controllers
– How to share more widely- CCGs, SCNs, AHSNs,
NHS IQ

45. GRASP-COPD

46. GRASP-HF

47. Summary
• Almost one third of GP practices in England using GRASP-AF and uploading
data to CHART Online
• GRASP-AF is improving the way stroke risk in AF is managed; changes are
small but potential impact is great
• NHS Improving Quality wants to build on the success of GRASP-AF by
developing a ‘suite’ of similar tools for other conditions.
• GRASP-COPD is now available.
• GRASP-HF is now available.

48. Getting GRASP

49. Getting GRASP

50. Reducing premature mortality: Supporting CCGs
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Webpage resources & PDF version ‘Our
Ambition to Reduce Premature Mortality’
now on NHS England website. Produced with
partner organisations (NHS IQ, PHE,
Commissioning Assembly quality working
group)
Information on prevention, earlier diagnosis,
case finding - including GRASP tools - &
interventions likely to have greatest impact on
reducing premature mortality.
Further development of resources planned for
April/May
See www.england.nhs.uk/premature-
mortality/

51. @NHSIQ
#GRASP_suite
Visit us on Stand C20
enquiries@nhsiq.nhs.uk
www.nhsiq.nhs.uk
Improving health outcomes across England
by providing improvement and change expertise.