Who are we and why are we needed?

The White paper can be summed up as a message to GPs;

Make care better and cheaper. I don’t care how you do it, just make sure patients are at the heart of the approach you use.”

It is a great idea and a genuinely radical move. Get rid of top down targets, clear out the PCT bureaucrats who have stifled innovation and give the budget to GPs to decide how best to spend it. Massive savings must be made without damaging the service, but without advice from trusted independent experts such as Virtual Angina, GPs will not get the best deal for the taxpayer in their negotiations with the Foundation Trusts. It is generally understood that the PCT commissioners failed to get a good deal from acute Trusts because they lacked expert knowledge and were too timid to tackle the high-spending providers. Foundation Trusts have an even greater incentive to obstruct healthcare improvements that will reduce their income.

With years of practical insider knowledge on both sides of the commissioner/provider divide Virtual Angina is uniquely positioned to provide high value commissioning advice for angina and other long term conditions.

How can Virtual Angina help GP commissioners?


  • How to engage users in service commissioning
  • Motivational techniques to energise patient-centred commissioning teams.
  • Practical approaches to patient experience monitoring and interpretation.
  • Independent evidence based review of cardiac service business cases.
  • Advice on cardiac service contract negotiation

Service development: (This requires GP and community nurse upskilling)

  • We can train and support a GP led team to design and deliver a community-based patient-centred angina clinic as an alternative to orthodox secondary angina care. The training is designed to enable the service design skills to be transferrable to other longterm conditions. Taking training and staff costs into account the new service is likely to break even within six to nine months depending on the patients who enroll in the programme. The biggest yield in terms of improved patient outcomes and cost savings (“better & cheaper”) comes from two subgroups of angina patients:
  1. End of line chronic refractory angina patients who frequently attend accident and emergency. Most 999 calls and unscheduled admissions for angina are avoidable, but strategies aimed at fending off patients with chest pain and trying to keep them out of A&E once they have called for help, raises understandable concerns. The patient-centred approach is based on educating patients and carers according to existing guidelines, so they are able to avoid calling 999 in the first place. Properly educated patients have fewer uncontrollable angina episodes, are less anxious, call 999 less often and require substantially fewer admissions. They appear to have fewer MIs and have a better than expected prognosis.
  2. Low to moderate risk angina patients being considered for palliative revascularisation. Many interventional cardiologists argue that whilst comprehensive patient education is desirable, it is not possible in busy cardiological practice. Others promote the specious pseudo scientific argument that the “evidence” for education is “unconvincing.” It is true that the scientific evidence for education is technically weak, but only in the same way the scientific evidence for breathing is technically weak. It is because no ethics committee would allow a study whose control arm would deliberately withhold breathing or education, because to so would obviously be wrong. In any event the case against education on evidence-based grounds is moot because clinical guidelines, the GMC and EU law all insist that patient education is the foundation of acceptable practice. Given the moral ethical and legal imperatives, it is for those interventionalists who do not properly educate their patients to defend their actions, not the proponents of comprehensive education.  Education is an investment and health education enables patients to actively participate in decisions. Different lines of evidence shows that properly educated patients are able to make rational choices not to undergo risky palliative interventions. For return on investment calculations  Link to ready reckoner.


Genuine patient-centred care involves a fundamental change management and NRAC has won major awards and accolades, including the NHS’s most prestigious awards for modernisation and innovation. NRAC’s commitment to safety was has also been recognised.  Senior figures in the NHS have testified to NRAC’s values. In 2000, the Prime Minister described NRAC as, “representing the very best of the NHS.”The Secretary of State for Health, Alan Milburn stated, “NRAC is leading modernisation in the NHS”and in 2003 Sir Nigel Crisp stated, “NRAC is an essential service that is leading the way in modern patient centred care.” In 2003, the Commission for Health Improvement described NRAC’s innovation in the design and evolution of patient centred services, as: “something from which the rest of the NHS could learn.”

In 2006, Bob Ricketts Senior commissioner at the DoH wrote to Duncan Selbie, Director General of the NHS: “I heard Mike [Chester] present at Harrogate and have also discussed with Ian Rutter and others the underpinning evidence.  This is deeply impressive work which could generate substantial benefits in terms of improved patient care and value for money.”

In a Westminster Hall debate on 15 Oct 2008, the Parliamentary Under-Secretary of State for Health (Ann Keen) stated: “We must all do what we can to ensure that the lessons learned from [NRAC's] collaborative approach are used to develop not just other refractory angina services, but patient-centred chronic disease management generally.”

Virtual Angina Limited

Patient-Centred Service Redesign

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