Patients with severe heart disease in London are being treated without leaving their living rooms under a pioneering NHS scheme that is on track to save millions of pounds and hundreds of lives, according to preliminary data.
Key to the new approach by Barts Health NHS Trust is moving participants far more rapidly on to high doses of life-saving drugs, then monitoring them remotely so adjustments can be made without a hospital visit.
The NHS is one of the most hospital-centric health systems in Europe. But a 10-year plan for the publicly funded health service, published by ministers in July last year, charted a course to bring services closer to patients’ homes.
It has set a target that, over the coming decade, the share of expenditure on hospital care will fall, with proportionally greater investment in out-of-hospital care, part of a bigger shift in how the 78-year-old NHS operates.
More than 1mn Britons were living with heart failure, a debilitating diagnosis that, left untreated, has a similar prognosis to lung cancer, said Christopher Primus, consultant cardiologist at Barts. Cases are set to nearly double by 2040.
While a range of drugs had transformed survival prospects over the past decade, services funded on the assumption that most patients would have a short life expectancy were now “overwhelmed”, Primus said. Some people were waiting more than a year to secure the right combination of medication to stabilise their condition, he added.
The Structured Titration and Rapid Treatment for Heart Failure (STaRT-HF) service, established by Primus and fellow cardiologist Debashish Das, aims to have patients on the most important drugs in two weeks and the full range in no more than six weeks.
This is achieved by using pharmacists to review blood pressure and heart rate readings submitted daily to a secure online platform by patients. Das said: “It allows us to manage a large cohort of people in a shorter period of time” and to quickly spot if a patient’s care needed to be escalated to a doctor.
Since the programme launched two years ago, a total of 445 patients have taken part and it now has permanent funding.
None has died or required a hospital admission — figures that impressed health service colleagues in south-west London so much that they were now working on similar provision themselves, Primus noted.
One satisfied customer of the Barts service is Michael Perkins, an administrator for a wholesale pharmaceutical company.
A diagnosis of heart failure last year was “a bit of an ‘Oh my God’ moment” for the 51-year-old, since he had believed himself to be essentially fit, he said. His first thought was for his teenage son: “I want to see him grow up, get married.”
Perkins was rapidly stabilised on a drug regimen — the speed of treatment “helped me mentally”, he said — and although he has seen a cardiologist at Barts every few months, it was a relief “not just for me but for my nearest and dearest” to have avoided an inpatient stay.
During its first year the programme also saved £2mn through a reduction in inpatient admissions. If extended to include the entire area covered by the local integrated care board, which plans services and allocates resources, estimates suggested that sum would increase to £5mn, Primus said.
“We are delivering [the service] entirely in their living room and the furthest that they have to go is for an occasional blood test at their local hospital” and to a nearby pharmacy to collect a new prescription, he said.
At 26 weeks after referral for treatment, fewer than half of people on the conventional hospital-centred pathway were receiving all the right drugs at the right doses. By contrast, more than 90 per cent of those on the rapid titration service were stabilised on the correct regimen after just 60 days, Primus said.
“They can go back to work. They can travel . . . And then we see that their hearts recover to the point where, at their first follow-up, they can be discharged in 50 per cent of cases,” he added.
Beccy Baird, senior fellow in health policy at the King’s Fund, who is leading a study of out-of-hospital care for the think-tank, said her research had identified the difficulty of expanding new initiatives beyond the pilot stage in the health service.
Barriers to wider dissemination included cultural issues, such as a reluctance to challenge professional hierarchies, alongside practical ones, including the need for extra staff training when care was being provided in a different location.
“We tend to privilege hospital care over everything else in the NHS,” she said, noting that a failure of patient records to “talk” to one another posed another hindrance to closer working between hospitals and community services.
The final hurdle was that benefits and savings often accrued in different parts of the health system than the one committing the resources.
“The investment might be in pharmacy, and the time and the cost might be in pharmacy, but the benefits are seen in the hospital, and there’s no way of really sharing that,” she said.
However, such financial complexities aside, Perkins embodies the power of the approach as NHS leaders, with an eye to the ageing population, increasingly focus on how to deliver care in more patient-friendly and cost-effective ways.
He has made such good progress that his next heart-related NHS appointment was not scheduled until February 2028, Perkins said, adding: “I did about 14,000 steps yesterday.”