Bellevue Medical Centre, Birmingham
The government is currently encouraging the uptake of anticoagulation monitoring in primary care as part of its policy of increasing patient choice and shifting care from hospitals to the community.
Providing oral anticoagulation therapy (OAT) in primary care can benefit both patients and clinical staff, and be financially rewarding for the practice.
It is estimated that almost one million people are currently taking warfarin, the most common OAT.(1) The number of patients requiring anticoagulation monitoring is expected to increase by a factor of five over the next decade, due to the ageing population and the increased clinical use of warfarin, primarily for atrial fibrillation and coronary heart disease.(2)
This increase in demand is already putting pressure on busy hospital outpatient clinics, which has led to patients being offered oral anticoagulation management in primary care through near-patient testing (NPT), which is also intended to offer them more choice, flexibility and a more convenient service.
Healthcare professionals and the DH argue that NPT enables GPs and the wider primary care team to enhance their skill base and encourages patients to become more enfranchised in their treatment and overall health.
Training the primary care team
Some GPs have been reluctant to take on the responsibility of OAT, as warfarin is perceived to be a dangerous drug. But David Fitzmaurice, a GP and professor of primary care at the University of Birmingham, who has published extensively on anticoagulation management, says it is recommended that computerised decision support software is used in primary care alongside point-of-care testing systems. The technology enables clinicians to use the patients' international normalised ratio (INR) result to calculate accurately the next dose of warfarin.
Despite differing opinions over the years, Professor Fitzmaurice says several studies have shown that anticoagulation clinics can be safely and effectively run by GPs and other members of the primary care team.
"My own feeling is that virtually anybody – a GP, practice nurse, laboratory scientist or pharmacist – can manage these patients, as long as they have been trained appropriately," he says.
The advent of the new General Medical Services (GMS) contract and practice-based commissioning (PbC) have, for the first time, provided financial incentives for practices to provide an anticoagulation monitoring service.
The remuneration for providing anticoagulation monitoring as an enhanced service care has been uprated twice since the new GMS contract was introduced in 2004. Practices are now entitled to receive up to £127.86 per INR-managed patient.
Professor Fitzmaurice says this is only an indicative figure negotiated by the British Medical Association (BMA) and is unlikely to cover the true cost of the service. He advises practices to work out the financial implications of providing the service, to draw up a business case and then negotiate with their primary care trust (PCT).
"There are some enlightened PCTs out there – including my own – who, when you go to them with a business case and tell them how much the service will cost, will be prepared to look at it," he says.
Cost is an issue with providing this service in primary care, he adds. "It is almost always going to be more costly to provide services in primary care, simply because of the scale of the operation. If the hospital clinic has to get through 300–400 patients in a morning, compared with only 50 in primary care, it is always going to be cheaper to provide the service in hospital. But patients in primary care will get 10–20-minute appointments and more holistic and better-quality care."
In Professor Fitzmaurice's practice, the Bellevue Medical Centre in Edgbaston, Birmingham, anticoagulation monitoring is provided as a PMS (personal medical services) Plus service, as it was set up before the new GMS contract was introduced.
The service has been running for more than a decade and was awarded beacon status for innovation and excellence under the old NHS Beacon scheme.
Clinics are held twice a week, and are run by three skilled practice nurses supported by a GP, Dr Mark Hirsch, who is also trained to manage oral anti-coagulation. They cater for 40 patients, who are seen on average 10 times a year, and the practice expects this number to continue to grow.
Practice manager Anne Bishop says: "The clinic suits the nurses as they like to develop areas of specialist interest. Patients prefer it because it is easier for them to come to their local practice than to visit the hospital clinic, where they are just number-crunched. The nurses get to know the patients and can spend more time with them. If the patient has a problem between appointments they can ring up. Since the nurses know the patients, they can offer them more holistic care."
The service is profitable for the practice, but Mrs Bishop says they could not afford to run it as an enhanced service under the GMS contract. "We have been under pressure from the PCT to change but have clung on until now. Our motivation for running the clinic is financial, but we also feel the clinical service we offer exceeds the specification for the national enhanced service for warfarin management. The £127.86 offered per patient would not cover it."
Professor Fitzmaurice says currently only around 10% of practices offer anticoagulation monitoring, but he expects PbC will drive that percentage up to 40% over the next five years. If 50% of practices started to deliver services in primary care, substantial funds could be released from secondary care.
Increasing demand for places on an oral anticoagulation management training course that Professor Fitzmaurice established a few years ago at Birmingham University is, he says, indicative of primary care practitioners' growing interest in offering OAT.
Professor Fitzmaurice is in no doubt that, as the role of primary care changes, there are compelling arguments for practices to consider setting up anticoagulation monitoring services. He says: "It fits well with the DH's direction of travel – of more patient self-empowerment, and providing patients with more choice."
Professor Fitzmaurice was speaking at a seminar on anticoagulation service redesign, sponsored by Roche Diagnostics
Information on anticoagulation therapy