Overview of the respiratory medicine landscape

23/11/201823/11/2018

23/11/2018

2016/17 NHS England funding £105.8 billion

NHS pressures Costs rising above income Fiscal environment Health inflation Fiscal environment Trust deficits Brexit Expectations Seven day services New treatments Safety & Quality Demand Demography Social service cuts In common with most health economies there are huge pressures on our health services at present. These include…..

5 year forward view (October 2014) Realistic financial analysis Above inflation investment and 4% CIP Focus on prevention and multi-morbidity New models of care Mixed models of delivery Local prioritisation

23/11/201823/11/2018

23/11/2018

Where does respiratory fit in NHSE agenda? Local priorities New models of care and STP plans Commissioning for value Population level commissioning Prevention agenda (smoking, obesity, physical activity) Urgent and emergency care Mental Health Seven day services

Where does respiratory fit in NHSE agenda? Local priorities * New models of care and STP plans * Commissioning for value * Population level commissioning * Prevention agenda (smoking, obesity, physical activity) Urgent and emergency care Mental Health Seven day services

Why is COPD important to local commissioners? A common long term disabling condition Frequent cause of hospital admissions Most cases remain undiagnosed in primary care Many not diagnosed until admitted to hospital Large variations in care account for avoidable mortality Rehabilitation and self-management work Integrated, anticipatory care is cost effective

“Integrated care can be defined as the best possible care for the patient, delivered by the most suitable health professional, at the optimal time, in the most suitable setting.”

Integrated care delivery The Tower of Babel. Pieter Breugel the elder. 1593

Integrated care? No single definition Multi component & multi disciplinary care Co-ordinated care delivery structures Vertical integration (primary/secondary care) Health/Social Care Triple integration Health/Social Care/ Local Government

Integrated care for COPD Modular care Provider co-ordination Commissioning integration Components Care model Clinical pathway Co-morbidities Vertical integration Population level

The components of care for COPD (NICE 2010) End of life Care Oxygen therapy Exacerbation management Rehabilitation Supported Self Management Smoking cessation Accurate diagnosis Patient Co-morbid conditions Cardiac Metabolic Nutritional Osteoporosis Anxiety/depression Bronchiectasis Lung cancer Asthma (ACOS) Drug therapy

Key points on multi-morbidity In general, the presence of comorbidities should not alter COPD treatment and comorbidities should be treated as if the patient did not have COPD. Assess frailty and develop a tailored approach

Are specialists a barrier to progress? Provider co-ordination (Care models and vertical integration) Hospital specialists General practitioners Are specialists a barrier to progress? It is worth asking the question as to whether the way that we currently work as specialists is impeding or assisting the process. At present and for most of us there has been a historical barrier between reactive hospital based specialists and the general practitioners who refer patients. This is not the model that exists in other arguably more effective countries where patients have better access to specialist advice and specialists have a greater presence in the community.

The patient wants a specialist The system needs generalists Delivery system design Who wants what? The patient wants a specialist The system needs generalists

Whole community responsibility? So in the future I see that every respiratory specialist should have some role out of hospital and feel some responsibility for the community in which they live and work. A specialists work should not be confined by the artificial boundaries of institutions.

Enhancing the skills of GPs and other health care professionals Outreach clinics jointly staffed by hospital consultants and other health care professionals Consultant-run email and telephone helplines Consultant participation in multidisciplinary team (MDT) meetings Consultant-run education sessions Consultants supporting staff to work in extended roles Redesigning the workforce Integrated consultant roles that span hospital and community settings New roles for nurses and other allied health professionals GPs with Special Interests Redesigning the work I would argue however that we need to go further than the traditional models of community working. Some of this was outlined in the Kings Fund report on out of hospital working that incidentally did use the integrated respiratory team from the Whittington as an example. In particular they emphasise joint working and knowledge transfer between primary and secondary care and the development of new roles in both. However, the thing that I don’t thing that we are doing well at the moment is involving commissioners in the development of new ways of working and redesigning care pathways. They recommend relationships between providers and commissioners should follow the Atul Gawande approach and be more like a pit crew than a cowboy (I think I know what that means) 23/11/2018

Settings of care for COPD Primary care Community services Hospital Case finding Diagnostic spirometry Uncomplicated COPD Influenza immunisation Risk reduction Smoking cessation More complicated COPD Pulmonary rehabilitation Home oxygen assessments Frequent exacerbations Advanced COPD LVRS Respiratory failure Diagnostic uncertainty

Population level commissioning “Year of Care” Stratification for: Risk Need Service provision Capitated budgets

STP footprint map 44 footprints Av 4.8 CCGs Av population 1.2m

Supporting STPs and CCGs 23/11/201823/11/2018

Identifying variation

Influencing commissioners

? Tools for clinical improvement in COPD Clinical guidelines Quality standards Implementation tools Care bundles Clinical audit Service accreditation Commissioning incentives Better outcomes ?

National COPD audit programme

Audit and quality improvement incentives Need to take account of New Models of Care At present incentives are limited to individual providers rather than care pathways CQUINs reward whole groups rather than the individual BPT (capitated payment) can improve individual care along a whole pathway Need to have on-going and timely audit in place to inform the QI process

Possible BPT for COPD Patients with COPD exacerbation admitted to hospital should be: Referred to and seen by a member of the Respiratory Team within 24 hours of admission. Seen by a Respiratory Consultant before discharge. Provided with the COPD discharge bundle on transition from hospital. Patients with COPD exacerbation and acidotic hypercapnea on admission who are suitable for NIV should: Receive NIV within 3 hours of admission in a dedicated setting.

National “airway” audit National asthma audit prioritised by NHSE Development work ongoing by HQIP Includes adults and children Primary care in England currently excluded Asthma and COPD will run together Understand the crossover Avoid damage to COPD programme Continuous data collection Linked to quality improvement 23/11/2018

23/11/201823/11/2018

23/11/201823/11/2018