Around 27,000 people live with heart failure in Greater Manchester, costing the health and care system almost £800m each year. If heart failure related problems were detected and treated earlier, improved patient outcomes and reduce treatment costs could be achieved.

Currently, the management of Heart Failure (HF) is reactive and the lack of a standardised heart failure care plan is contributing towards poor experiences and outcomes for patients. It has also been leading to variation in care delivery and impacting on the flow of care information between patients and clinical practitioners in both primary and secondary care.

As part of the NHSX Innovation Collaborative, which is accelerating the deployment of remote monitoring technologies across England in response to COVID-19, Greater Manchester is developing a digital care plan for people with heart failure to provide enhanced continuity of care across settings and support people to be treated safely at home. Ensuring people who are most vulnerable to COVID-19 can stay at home is a key part of the response plan.

What is being proposed?

Working closely with our partners; the GMEC Cardiac Strategic Clinical Network (SCN), the Manchester Heart Centre at the Manchester Royal Infirmary and the patient advocacy charity the Pumping Marvellous Foundation, our system-wide approach to service improvement and transformation has enabled providers, commissioners, patients and the voluntary sector to work together to improve our care planning process for heart failure.

This partnership project will transform care planning in HF from a variable, ad-hoc paper-based process to a standardised digital heart failure care plan that can be utilised across care settings via the GM Care Record. It will be enhanced by an interoperable patient facing app and will support HF patients to be managed more effectively within the community, while also empowering patients to take greater control and be more informed about their condition.

How will this be achieved?

In response to COVID-19, the deployment of the GM Care Record has been accelerated with over 99% of GM citizens now included on the Record. Resolving information governance issues enables patient data in the Record to be shared at the point of care across the city-region, across historic geographic and organisational boundaries. The GM Care Record will be used to develop and share digital care plans to improve self-care and management for patient with long-term conditions, and specifically for this project, heart failure.

Through the Local Health and Care Record (LHCR), Greater Manchester has also procured a patient facing portal that can be repurposed for different use cases. In this instance, the patient facing portal will be used for patient access to their care plan and support self-care.