How to win friends and influence people Delivering Quality Care Closer to Home using a whole systems approach June Roberts Salford PCT and Salford Royal Hospital Foundation Trust With thanks to Dr N Diar Bakerly and Anna Thompson

What are the key issues in Respiratory care delivery today? Current State Desired State Driving ForcesResisting Forces Lewin, 1951 Force Field Analysis

Crunch creativity  Close to the box thinking, keeping one eye firmly on time, cost and quality  Little and clever ideas and solutions – quick results with big impact  Sweating existing assets to their maximum potential  Right and left brain thinking together – feelings and logic/big picture and detail in harmony Impact Innovation 2008

Salford  SMR respiratory 1.72  Prevalence of respiratory disease  Smoking prevalence  Admissions  Length of stay  All above national average Population 227,034.

Salford PBC Winter plan 2006/7  Accurate diagnosis  Stratify COPD register  Treat according to guidelines  Monitor admissions and referrals  Establishment of joint working group  Education programme  Stakeholder consultation events

 Appointment of Integrated respiratory physician (40/60)  Appointment of Respiratory Nurse Consultant (60/40)  Health needs analysis and benchmarking  Process mapping and Gap analysis  Development of COPD strategy  IT system and industry support vital

Co-production Integrated COPD Service

Baseline Health Needs Analysis  Establish actual and predicted prevalence of COPD across Salford and within PBC clusters  Establish baseline levels of severity of COPD across Salford and within clusters according to FEV 1 % predicted (NICE 04), hospital admissions and LOS  Map severity of COPD to IMD at PBC cluster level  Establish baseline levels of maintenance treatment for COPD across Salford and PBC clusters Roberts J and Diar Bakerly N Thorax 2007 (abstract)

Benchmarking and evaluation at 12 months  To compare baseline data with that available at 12 months (Q4) for Prevalence Severity by FEV 1 % predicted (NICE 2004) Smoking status MRC score Current medications To establish General Practice adherence to guideline recommendations on COPD follow up and management Roberts J and Diar Bakerly N Thorax 2008 (abstract)

Methods Retrospective analysis of: 1- COPD General Practice register (POINTS) 2- Quality Outcome Framework (QOF) data 2008 and compared to baseline 3- HRG and ICD10 coding hospital admissions and length of Stay

Practices suitable for data collection n= 52 Practices with (Baseline) data available for analysis (Jul 07)) n= 31 (3532 patients) (70% of the COPD population) Practices with 12 month data available For analysis (Jul 08) n= 25 (3291 patients) (56% of the COPD population) Practices with 15 month data available For analysis (Oct 08) n= 22 (3036 patients) (52% of the COPD population) Total COPD population at baseline 5039 Total COPD population at 12 months 5850 Project flow

Stage 1a Primary Care Primary prevention Health promotion and education Stage 1b General Practice Accurate diagnosis Spirometry screening of high risk patients in community and general practice Accurate performance and interpretation of spirometry COPD register Stratification of disease severity: mild, moderate, severe Referral pathways to specialist support for diagnostic difficulty Stage 2 General Practice Treatment and management of stable disease Salford COPD treatment pathway/ NICE guidelines to optimise treatment Vaccination POINTS templates to guide management Specialist medication reviews by community pharmacist Self management education and written individualised action plans Anticipatory care Knowledge and support for carers Stage 3 Enhanced General Practice and community specialist services Complex / severe disease Case management by appropriate case manager (generalist ACM or Respiratory Nurse Specialist) Telehealth/ virtual ward Community specialist service and clinics with MDT support (including physiotherapy, psychology, oxygen) Non Invasive Ventilation Planned hospital admission for those who need it Stage 4 Specialist and generalist community, hospital and OOH services Unscheduled care Admission avoidance through intermediate care Hospital admission Supported discharge to reduce LOS via CAST/ RNS or intermediate care Pathways post admission follow up Stage 5 Specialist and generalist community and hospital End of life care Gold Standards Framework Prognostic indicators for primary and secondary care Specialist support Referral pathways Treatment and management Pulmonary Rehabilitation Admission avoidance Smoking cessation, health promotion and self care Co-ordinated social care Supportive and palliative care Education and clinical support Information and Clinical Audit Salford COPD Integrated Care Pathway

Simple linear relationship between IMD and COPD prevalence at practice level N = 54 (R=0.4 (p=0.003)) Roberts J and Diar Bakerly N (2008) Thorax abstract

Data is power The case for need Demand/capacity Strategic context Option development Financial/non financial Recommend option Implications/value risk Project plan and initiation Evaluation

Cluster 7 Cluster 5 Cluster 8 Cluster 4 Cluster 6 Cluster 1 Cluster 3 Cluster 2 LIFT Centres Community COPD clinic ESDT follow up clinic Home oxygen team EPP Pulmonary Rehabilitation Cluster 1

SART Guidance on End of Life care in COPD Primary indicators to help you decide severity/ prognosis  Severe COPD (FEV1 <30% predicted)  History of ≥3 acute exacerbations in the last 12 months  History of ≥3 admissions with acute exacerbation in last 12 months  Progressive shortening of intervals between admissions  Limited improvement following admission Supporting indicators to help you decide severity/ prognosis  On maximal therapy – no other intervention is likely to alter the progression of the condition  Dependence on oxygen therapy (LTOT, SBOT, ambulatory)  Severe unremitting dyspnoea  Co-morbidities e.g. heart failure  Housebound – unable to carry out normal activities of daily living/self care Assessment of need  Consider - medical, physical, functional, psychological, social and spiritual needs Last Days of Life First Days after Death 1 year Advancing disease Bereavement 6 months 1235 The North West End of Life Care Model 4 Death Increasing decline

QOF vs predicted prevalence* * According to model described by Nacul et al (2007), Population Health Metrics 2007, 5

Social marketing

Education  Training needs analysis  Spirometry audit  Respiratory passport training  Dedicated Community matron/ ACM mentorship and training  Weekly (virtual) MDT  Support materials eg spirometry protocol, directory of services, action plans  Join training with palliative care and mental health services  Targeted practice education programme – mentorship and case note reviews

Results

Prevalence

Gender distribution

Smoking rates N= 3417 N= 2995

COPD severity Classified by FEV1% predicted (NICE 2004) N= 2157 N= 1781

Percentage recorded MRC score

Mild airflow obstruction

Moderate airflow obstruction

Severe airflow obstruction

Annual reviews (12 months data vs. QOF 2008)

Increased level of symptom recording

Importance of READ code  J44 Chronic Obstructive Pulmonary disease  J41 Simple and mucopurulent chronic bronchitis  J42 unspecified chronic bronchitis  J43 emphysema  J45/46 asthma  J 47 bronchiectasis

Importance of checking data source  Dr Foster HRG – 2006/7 724 – 2007/8 658 – 2008/9 605  Dr Foster ICD10 – 2006/7 944 – 2007/8 875 – 2008/9 851  TIS HRG – 2006/7 720 – 2007/8 654 – 2008/9 598  TIS ICD10 – 2006/7 942 – 2007/8 862 – 2008/9 837

Admissions ICD10

Mean length of stay Median LOS 2008 Salford 4 days

Integrated COPD services in Salford 2 years on  Year on year increase in prevalence with a shift to milder disease  Appropriate, cost effective prescribing  Improved access to specialist services closer to home  Reduced unscheduled hospital admissions  Reduced length of stay  High levels of patient satisfaction  Strategic commissioning group (Managed Clinical Network?)

So what have we learnt?

How to win friends and influence people – lessons learnt  Build relationships  Make people like you  Win people over to your way of thinking  Be a leader “Believe that you will succeed – and you will” Dale Carnegie 1936

Thank you