Aspiring to Clinical Excellence
IN GENERAL PRACTICE
PRACTICE TEAM BRIEFING – September 2014
You may have heard your GPs or Practice Manager talking about the ACE Excellence Programme. Three Sutton
Practices, namely Manor Practice, Vesey Practice and Sutton Park Surgery, recently joined together to bid to
become one of the Pilot collaborative for the Ace Excellence programme. Unfortunately we were unsuccessful
in the first round, but resubmitted our case and were accepted to take part in the second round as Early
Adopters of the programme.
This document is designed to give you a general overview of what the ACE programme is about. If you require
additional information or wish to seek clarification on any points contained in this briefing, please email your
queries to Ellen.pearce@nhs.net. Alternatively you can speak to your practice ACE Lead:
Manor Practice – Dr Howland
Vesey Practice – Dr Garbutt
Sutton Park Surgery – Dr Mantella
If you wish to view the complete ACE: Excellence Early Implementers Service Framework, please let Ellen know
and she will email a copy to you.
The aim of the ACE scheme is to look at how we can improve the management of long term medical conditions
in General Practice with the ultimate aim of reducing emergency admissions. For this to take place, our practices
have joined together to enable us to share our experiences and best practice and to provide the full range of
services for patients.
The overall rational for introducing the ACE Excellence scheme is to create a fully integrated health and social
care system that ensures every patient in Birmingham receives proactive, joined up care, supporting them to live
as independently as possible in the most appropriate setting and achieving the best outcomes.
In order to achieve this we will have to ensure that every stage of the patient journey is improved and works
effectively. The ACE Excellence programme has three key priorities:
1. Improving further the quality of general practice across the city, making a comprehensive and
universal offer to our patients, ensuring that all patients in five years are receiving the same high
quality of care that the best now receive;
2. Transforming quality and access to mental health services; and
3. Transforming the way in which our urgent care system currently operates, by improving processes
at the front and back doors of our hospitals, and building capacity in primary care (by which we mean
general practice, community health services, mental health services outside of hospital, and social
care).
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ACE Components – in brief
Holistic Care and Diagnosis of patients with Long Term Conditions.
Aims
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Holistic patient centred care management of multiple LTCs which frequently co-exist.
Improved outcomes in terms of reduced morbidity and long term complications, increased life
expectancy through better control of optimal evidenced based targeted treatment and interventions
Reduction in emergency admissions for diabetes, heart failure and COPD
Reduction in first OPD for diabetes, heart failure, COPD and asthma.
To deliver the Integration of specialist skills into an integrated primary care team approach to disease
management.
Diabetes and Pre-Diabetes
Diabetes
Delivery to over 90% of patients all eight diabetes care processes. The evidence is that this reduces future
significant complications. Currently under 50% of diabetic patients in Birmingham receive all eight. These eight
care are:
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five risk factors (weight (BMI), blood pressure, smoking, glucose levels (HbA1c), and serum cholesterol)
Three tests for early complications (laboratory urine micro albumin: creatinine ratio, serum creatinine
and foot nerve and circulation examination).
Pre-Diabetes
Identification of a cohort of at risk patients, delivery of lifestyle advice and referral to appropriate lifestyle
services such as exercise. The more additional risk factors an individual has the more likely they are to develop
diabetes. The progression to diabetes for people with IGT is 6-10% per year and for individuals with both IFG and
IGT, the cumulative incidence of diabetes may be as high as 60% in 6 years Diabetes UK –pre diabetes
Recent data from the US Diabetes Prevention Program (DPP) suggests that an HbA1c ≥ 6.0% approximately
doubles the rate of progression to Type 2 diabetes in people with other risks such as obesity. The
recommendations focus on two major activities:
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Identifying people at risk of developing type 2 diabetes using a staged (or stepped) approach. This
involves a validated risk-assessment score and a blood test – either the fasting blood glucose or the
HbA1c test to confirm high risk.
Providing those at high risk with a quality-assured evidence-based, intensive lifestyle change programme
to prevent or delay the onset of type 2 diabetes
Cardiology
Diagnostics in General practice
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ECG –recording and interpretation
Ambulatory blood pressure monitoring for diagnosis of hypertension- 24 hour or 7 day recording
Heart failure up titration of treatments to effective tolerated doses in all patients Case management,
with possible tele-monitoring, for patients with severe heart failure or admissions
The three practices have purchases Microlife Watch ABPM machines to help support this indicator and training
has been arranged.
Respiratory
Diagnostics and interpretation in General practice
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Spirometry
Management of COPD and Asthma.
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Patients at risk of admission or severe exacerbations provided with self management plans and rescue
packs as appropriate.
Patients should be given easy access to advice from GP practice in the event of an exacerbation.
Optimised treatment
The impact of exacerbations should be minimised by:
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giving self-management advice on responding promptly to the symptoms of an exacerbation
starting appropriate treatment with oral steroids and/or antibiotics
use of non-invasive ventilation when indicated
use of hospital-at-home or assisted-discharge schemes. [2004]
Ensure multidisciplinary working , involvement of ACMs.
Written action plans, given as part of structured education can improve outcomes such as self-efficacy,
knowledge and confidence for people with asthma, particularly for people with moderate to severe asthma
whose condition is managed in secondary care. For people with asthma who have had a recent acute
exacerbation resulting in admission to hospital, written personalised action plans may reduce readmission rates.
Shared care For Long term conditions.
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Shared with Secondary care for patients suitable for ongoing monitoring and prescribing in General
Practice
Covers cytotoxic drug prescribing such as DMARDS for rheumatological, gastroenterological and
respiratory conditions,
Must be underpinned by shared care agreements and protocols
Also covers ongoing monitoring of some stable conditions, within clear criteria for monitoring and re
referral to secondary care
Integration of community teams into General practice and delivery of
holistic care
Aims
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to integrate community teams fully into General Practice setting,
support enhanced services to patients over 75 and those patients receiving case management including
patients near the end of life
identification and support for patients with dementia and their carers
Outcomes
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True integrated nursing and allied health professional teams delivering care to a practice population
both in surgeries and in patients own home as appropriate
Improved continuity of care to patients
Reduction in duplication of services
An ability for practices to define teams on the basis of local population health needs and configure this
around the patient.
Pilot to explore integration of teams, models of delivery and working, job plans, relationship and local
accountability of BCHC.
Pilot also to explore integration of social worker into the team
Integration of specialist community services to support delivery of holistic care
Identification and case management via the integrated team approach with a focus on prevention,
enablement and self-management
Care and residential home support with an outcome of reducing admissions by 30%.
Achieve dementia diagnosis rates to 67% and support carers through ACE foundation
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Involvement of practice teams
For us to succeed and improve the patient experience and the services we offer, we need everyone to
be fully committed to the delivery of the ACE Excellence scheme.
Please come forward with any ideas you may have for service delivery or any problems / issues you
have identified so that we can plan future improvements.
Following our initial meeting in August, the following early actions were identified:
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Mental Health – It was agreed that all practices should engage in the following:
o Review patients attending A & E with mental health issues
o Ensure effective use of Birmingham Healthy Minds and Open Door Youth Counselling
o Use of enhanced template for referrals.
Asthma – practice use of management plans.
Pre-diabetes – It was agreed that this was an area that needed a fair amount of input as the
provision seemed to vary quite significantly between practices. Looking at an email sub-group.
DMARDS – Discussion regarding repeat medication and blood monitoring. The group is looking
at developing a policy / protocol to move DMARD medication from repeat to acute and not
issue unless monitoring has been done.
Dementia & Carers –
o Carers register – actively recording carer information / contact details on clinical
systems.
o Looking at a repository of information for carers of patients with dementia and carers in
general.
o Leaflet / handout of local help groups and information to be developed – this has
already been circulated to practices.
o Information on bereavement services
Further information and updates will be sent to all practice clinical teams as we progress with the ACE
Programme over the coming months. If you wish to contribute or have any communication you wish
to put forward, please let Ellen have the details – Ellen.pearce@nhs.net
September 2014
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