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Acute-led development of an ambulatory care service

This is one of five examples from our report Making the case for quality improvement: lessons for NHS boards and leaders. Each example illustrates how quality improvement approaches are being used by teams and organisations in different parts of the NHS in England to improve care and value for money.

Ambulatory Heart Failure Clinic: University Hospitals of North Midlands NHS Trust 

What was the problem?

Heart failure currently affects around 900,000 people in the UK. It causes or complicates about 5 per cent of all adult emergency admissions and is the commonest cause of admission in people aged over 65 (National Institute for Cardiovascular Outcomes Research 2017; British Heart Foundation 2015; Azad and Lemay 2014). Admissions are expected to rise over the next 20 years as the population ages and survival from heart disease increases. 

As well as being resource-intensive and expensive – the average length of stay for a heart failure patient is 13 days and the typical cost is around £3,800 – a hospital admission is often not what patients want from their care (British Heart Foundation 2015). Many heart failure patients are frail older people who, given the choice, would prefer to remain at home. Being in hospital for an extended period may also have an impact on their mobility, independence and confidence, as well as the support structure that has been built up around them at home.

The University Hospitals of North Midlands NHS Trust aimed to reduce the need for some hospital admissions by making specialist treatment, which had previously only been accessible to inpatients, available on an outpatient basis. The project team estimated that around 30 per cent of heart failure admissions to the trust could be avoided by redesigning the service in this way.

What did they do?

In 2011, a nurse-led, consultant-supported ambulatory heart failure clinic was set up at the City General Hospital in Stoke. The clinic compresses a full day of inpatient care into a single session lasting a few hours, avoiding the need for overnight stays. As well as the usual range of outpatient services, the clinic offers emergency ‘same day’ care and ‘next day’ slots for specialist review. It also offers self-management advice and psychological support for patients who could manage their condition at home with the right support. 

The launch of the clinic means that someone with chronic heart failure living at home can avoid a hospital admission at points when their condition becomes unstable. After a rapid review and diagnosis from a cardiologist, a care management plan covering the patient’s ongoing care and medication needs is produced, with the aim of keeping them at home whenever possible. People with worsening heart failure can also be referred to the clinic directly from the emergency department, rather than being admitted, while inpatients can now be discharged home at an earlier stage via the clinic. 

What impact has it had? 

The clinic is now an established service within the trust. It has negotiated its own tariff with the local clinical commissioning group and is getting referrals from both primary care and acute care. 

An analysis by the project team of the outcomes of all patients referred to the clinic in 2015/16 suggested that, by preventing the need for some heart failure patients to be admitted to hospital, the clinic had freed up the equivalent of 12 inpatient beds. The clinic’s 30-day readmission rate was also comparable to that of heart failure patients discharged by hospitals across England. Moreover, only 2 of the 383 patients referred to the clinic opted for inpatient care over the ambulatory model of care during the year.

This suggests, the project team argues, that providing specialist care in an ambulatory setting is safe, popular with patients and can release some acute capacity for other purposes. However, this impact is contingent, the team believes, on the presence of a comprehensive and integrated local heart failure pathway that allows patients to be referred from both primary care and secondary care in a timely way.

Other work from the project