Clinician of the Month – Dr Ameet Bakhai

We caught up with Ameet to find out more about the Heart Health Improvement Challenge he is pioneering and launching with DigitalHealth.London and HealthXL.

Ameet has been a front line Consultant Cardiologist at Royal Free London NHS Foundation Trust since 2004, with a focus on heart failure, complex hypertension, atrial fibrillation, acute coronary syndromes and cardiovascular risk factor reduction. He is also the Trust R&D Deputy Director. He is one of the few cardiologists to be accredited as a Fellow of the European Society of Cardiology, an accredited member of the European Heart Failure Association, an accredited member of the European Society of Hypertension and an appointed Fellow of the Royal College of Physicians.

More recently, Ameet assumed position as the Heart Function Improvement Service CCG Lead for Barnet.

Health impact/challenges affecting the delivery of care

Heart failure is a chronic, life threatening condition, which will involve 1 in 5 people over 40 years old. In-patient mortality nationally is around 10% and 50% at 5 years after diagnosis. Heart failure accounts for 3% of admissions with average length of stay of 11 days and 40% readmission rates within 12 months attributing to 3-5% of NHS budget, the majority of which is due to hospital admissions.

Locally in Barnet £9 million was spent in treating and managing Heart Failure patients in 2015. There are currently 1409 patients being cared for across 62 GP practices. There are more patients aged 81 years and older presenting on admission with Heart Failure, with a 16% rate of pre-discharge mortality.

The care of these patients can be improved in multiple domains from experience to outcomes, from prevention of first admission to improving the quality of a final admission. We aim to improve the health of both patients and the effectiveness of the staff delivering care to the patients with weakened heart function via viable and useful technologies to improve quality of life and reduce unplanned NHS resource use.

Access to positive, insightful ways to self manage is difficult as many of the older patients do not enjoy, or can’t make the effort to travel easily. Motivating them to stay fit at home and take up cardiac rehabilitation in this setting has been a major challenge and we are working with innovative digital teams like Tickerfit to address exactly that.

Introducing innovation

Our innovation has been to propose a Digital Health London Improving Heart Function challenge to bring together companies that can focus on innovating in this clinical area to partner with us on the clinical front within the Barnet Heart Function Improvement Service. This will allow us to plan ahead how to partner with technology companies to meet the gaps in care for challenged heart function patients and our staff looking after them.

We are looking across the entire pathway for Heart Failure: prediction, screening, diagnosis, assessment, treatment, management and self -care. We would like to integrate with technology companies to undertake some or all of the points along the management pathway of patients with insufficient cardiac output or ‘heart failure’:

• Remote monitoring support technologies (ECGs, heart rate, blood pressure, weight, pulse oximetry, pulmonary artery pressures, activity trackers)
• Admission and readmission prevention technologies (destabilisation tracking technologies, arrhythmia detection, alert buttons or virtual cardiac rehab)
• Medicines optimisation technologies (apps / devices / reminders / adherence trackers / on-line social support)
• Screening technologies (ECG, echo or point of care test)
• Therapeutic technologies (cardiac output device optimisation, exercise coach, breathing coach, positive psychology and social support)
• Patient record transfer

Patient benefit

Through this programme we aim to:

• Reduce variations in care, ensuring that patient who presents with heart failure are reviewed by / under care of the specialist team
• Improve early detection of heart failure exacerbations
• Reduce annual mortality by 20%, within 3 years saving between 40 and55 lives a year
• Save 500 hospital bed days per year via reduced emergency admissions and readmissions, within 2 years and reduce costs to the NHS by approximately ~£200k a year in bed days
• Empower patients with heart failure to self manage through the community team with appropriate technology enablement confirmed via needs assessments before and after digital and technology innovations change.

Whilst our digitally enabled solution for patients with impaired heart function are still to be deployed, we expect the following benefits for patients, their partners and the care staff, compared to prior to the technologies being available:

• Patients empowered to know early about fluid retention or increased breathlessness to alert care-givers for attention
• Reduced emergency hospital admissions
• Reduced time outside hospital care
• Patients encouraged to see the benefits of medications and lifestyle advice through technologies and hence improve concordance
• Increased satisfaction with their care-givers via interaction of results from digital technologies
• Increased motivation to attend cardiac rehabilitation
• Increased activity levels and quality of life
• Increased appreciation of disease
• Reduced dependence on relatives and partners for disease management support
• Higher optimisation of drug treatments

Driving adoption

I have always been fascinated by the use of technologies in medicine and have always advocated their use during my daily clinical duties. I have spent a huge amount of time to deeply understand and research the available technologies and critically challenge many of these innovative tools to improve, before introducing them into the vision for staff to review to allow adoption. My unique blend of clinical, research, curiosity, with a dose of tenacity has helped greatly in this pursuit.

By providing in depth information about available technologies within my credentials of trust and safe innovation, and by setting an example in clinical practice I have created an atmosphere where staff own the problem and adopt the solutions.

Additionally, I have nurtured an environment where all staff can clearly envisage future solutions and innovation strengths and do not have fear, apathy or fatigue towards change but have respect for partners creating future solutions.

Our partners involved include Barnet CCG, Royal Free London, University College London Partners & Imperial College Health Partners AHSNs and DigitalHealth.London and via these we have access to more than 10 other CCGs such as Brent and Harrow CCG, Camden CCG, Enfield CCG.

Scaling

Partnership and strong working relationships with leadership team as well as the finance teams are essentials to successfully achieve a new innovation. These relationships together with an effective delivery team of health care professionals allow us to plan and envisage all the challenges ahead. By sharing the vision early with innovative platforms like HealthXL and University College London Partners, Imperial College Health Partners AHSNs and DigitalHealth.London, we’re able to bring the right partners together to co-create.

Co-creation is always more successful than silo working if driven by focused lead. So at present, we have agreed to structure a pathway for digital innovation across the primary and secondary care sector for Barnet CCG and Royal Free London. We have offers to extend our work to Brent and Harrow CCGs already and also via Digital Health London to other acute care sector providers.

So whilst we have not deployed solutions, we have prepared the path for the solutions to scale already, through preparing our partnerships early and sharing our vision widely.

By proving the clinical and cost effectiveness of viable solutions at grass roots level, this will allow others to adopt a true solution model to be scaled nationally by local champions.

There is good collaboration between clinicians usually and commissioners to enable this when the benefits are clear. However we are aware that different CCGs have varying priorities and Community services may not be available identically between CCGs. Some CCGs do not have a dedicated Community heart function team and this makes matters difficult when frail patients have to travel to hospitals for device deactivations as part of end of life care instead of services coming to them at home. Such variations can be reduced if we can prove a pathway is robustly cost effective in a CCG, hence working with Barnet, one of the largest CCGs in England.

The benefits of working in collaboration with DigitalHealth.London on this programme are that when patients benefit from a pathway change in one location or CCG, it is viable to spread this benefit to patients in neighbouring CCGs often helped through the Academic Health Science Networks across the whole of London.

As a national research clinical investigator I have led on many national and even international research studies, so I am aware of using publications, conference presentations, NICE technology appraisals, and AHSN press releases to drive national awareness of viable solutions, once we’ve generated the evidence.

Impact on the healthcare system

So far we have met partners to articulate our needs, and exchange solutions and intelligence to put together a menu of potential digital solutions to deploy for 2017 into a purpose built care pathway. We are designing a needs assessment for patients with heart failure to see what digital solutions may suit them. It’s too early in our journey to be able to share any outcomes, however we are preparing the ground to innovate in a formal and structured way and we are collecting the current standards of care and outcomes against which to measure the impact of future solutions.