VOL: 97, ISSUE: 36, PAGE NO: 39
STEVE HAM, BSc, RN, is coronary heart disease facilitator for primary care, Swindon Primary Care GroupCardiovascular disease, coronary heart disease (CHD) and stroke kill 150,000 people a year in England (Health Development Agency, 2000). The incidence of angina, stroke and hypertension is on the increase and represents a serious burden of disease.
Cardiovascular disease, coronary heart disease (CHD) and stroke kill 150,000 people a year in England (Health Development Agency, 2000). The incidence of angina, stroke and hypertension is on the increase and represents a serious burden of disease.
The National Service Framework for Coronary Heart Disease (2000) sets out a comprehensive 10-year programme for improving the care of people with CHD and those at significant risk of developing it. It sets evidence-based standards, goals and milestones that primary health care teams, primary care groups and trusts must meet.
The National Service Framework for Coronary Heart Disease presents both challenges and opportunities for those working in primary care, offering PHCTs a central role in the development and delivery of care to patients who are at risk.
Many PCGs and PCTs have employed nurses to implement standards three and four (see box). This has given nurses the chance to develop and project-manage the primary care sections of the national service framework.
I have been a coronary heart disease facilitator for the past six months, having worked in a coronary care setting for the previous five years. Swindon PCG covers a population of about 200,000 and has 30 general practices. My role covers five areas of development and support which are:
- Audit: the National Service Framework for Coronary Heart Disease highlights a structured approach to identifying and managing CHD patients. By April 2003, audit data must be no more than 12 months old. This requires a culture that embraces audit, making it meaningful and relevant to everyday practice. Nurses have led the way on auditing practice;
- Education: this provides the tools and opportunities for practice nurses to develop their skills in CHD. Clinical decision-making skills are well-developed among experienced practice nurses, but the finer elements of CHD - the management of acute myocardial infarction and heart failure, the interpretation of electrocardiograms and drug therapy - needed to be developed;
- Clinical support: this has centred on helping practice nurses develop systematic reviews of patients, for example by running CHD clinics, supporting existing structures in general practice and acting as a clinical resource;
- Facilitation: is about empowering the whole team and supporting everyone's learning needs;
- Monitoring performance: the national service framework gives clear performance indicators. This is reflected in local clinical governance plans and health improvement programmes. The facilitator post supports primary care to meet local milestones and is a practical example of clinical governance in action.
Primary care is a dynamic and complex environment, and as a secondary care nurse much of my early work centred on developing relationships. Despite complaints about a lack of resources and time, most practices have welcomed my role.
The CHD framework sets out a guide for improvement, but nurses have long been in the forefront of pioneering services with support from GP colleagues. Many improvements highlighted in the national service framework have already been established in general practice. What has been missing is the systematic recording of data, and part of my role has been to encourage teams to use information systems to support clinical activity.
This might mean, for example, developing templates to aid decision-making and employing GP clinical information systems to provide data that supports clinical activity. The emphasis has been on developing virtual CHD registers, improving the input of data and encouraging meaningful audit to highlight areas where we are doing well and those for further improvement.
The national service framework provides an evidenced-based tool for developing and improving services, so the role of the CHD facilitator will inevitably develop in line with the changing needs of the health care system and the community. As future frameworks are developed, nurse facilitator roles will evolve and will be central to ensuring the successful implementation of standards and goals.