Transforming outcomes for people with lung disease in England Professor Sue Hill Chief Scientific Officer and Joint National Clinical Director for Respiratory Disease

Why Ministers have been interested in Respiratory Disease? Variation in quality of care provided Inequalities in outcomes across country Burden on the health service and future challenge of LTCs Cost to the taxpayer Poor performance compared to other countries Ability to set out expectations - NHS, PH and SC - and to influence system levers Success in other clinical conditions eg cancer, coronary heart disease

UK Respiratory Strategies Wales – Chronic Conditions Scotland - Respiratory N.Ireland - COPD England – COPD/Asthma

‘Nothing about us without us’ Equity and excellence: Liberating the NHS White paper: published on 12th July 2010, sets out proposals for the NHS Free from targets Local accountability Continued focus on QIPP Vision: Put patients at the heart of everything that we do Achieve quality outcomes that are among the best in the world Empower our clinicians to deliver results based on the needs of patients ‘Nothing about us without us’

Reinforcing personal and community resilience, reciprocity and responsibility, to promote greater independence and choice Carers are the first line of prevention. ‘Payment by Results’ tariff amended from April 2012 so that NHS pays for re­ablement and other post-discharge services for 30 days after a patient leaves hospital. Health and social care professionals take a joint, evidence-based approach to identifying the needs of local populations and agreeing shared solutions

Commitment to protecting the population from serious health threats; helping people live longer, healthier and more fulfilling lives, and improving the health of the poorest, fastest. A new integrated public health service, Public Health England, will that achieves excellent outcomes and results, unleashing innovation and liberating professional leadership. Outcomes to be focused around - Enhanced healthy life expectancy and preventable mortality - Health improvement - Health inequalities - Prevention of ill-health - Protection and resilience

COPD strategy and the new system No.10 HMT DH Transparency Outcomes Framework NHS Outcomes Framework SofS Social Care Annual Mandate Public Health Service Social Care Outcomes Framework National Commissioning Board Public Health Outcomes Framework Directors of ASSs Commissioning Outcomes Framework Directors of Public Health LAs GP Commissioning Consortia Health & Well Being Boards LAs

Quality improvement will be hardwired into the new system starting with the outcome goals in the NHS Outcomes Framework and informed by NICE Quality Standards

Proactive Strategy for changing the burden of disease across whole pathway Recognises that different components of system have to come together Public health Social care Health service Underpinned by strong clinical leadership at all levels of system National Regional Local through networks

Challenges ! Late diagnosis and impact Size of smoking legacy Generic LTC approach, chronic disease management and specialist intervention Amenable morbidity and outcome measures Lack of research evidence across pathway

Late Diagnosis

Hit early and hit hard! Early intervention with to stop progression and exacerbations Usual time point for intervention Symptoms and decrease of lung function Early detection and intervention Severe exacerbation Mild exacerbation COPD in control COPD in control Time

Morbidity in the undiagnosed Recent Canadian study showed 21% of those with undiagnosed COPD had severe or very severe disease (Gold 3 and 4) Quality of life and physical/social function significantly reduced in all stages of disease from mild to severe Exacerbations common even in moderate disease 10% of emergency COPD admissions are undiagnosed - recent London study 34% admissions in undiagnosed patients, 20% in respiratory failure Co-morbidities common at all stages of COPD and are often diagnosed late - primary care evidence suggests that 30% COPD patients have undiagnosed heart failure Patients with COPD are at a much higher risk of premature mortality from heart disease and stroke However, substantial variation in performance and interpretation of spirometry with survey evidence showing 27% patients on COPD registers do not have COPD 13

Smoking legacy If everyone gave up smoking today, it would be decades before we saw any difference in the rates of COPD Mannino D. (Chest 2005)

Proactive Case Finding Local enhanced services to promote early case finding in primary care NHS Doncaster, NHS Islington, NHS Sandwell Use of practice registers to identify patients more likely to have COPD Durham and Darlington, NHS Salford Determining optimal approach to identifying COPD individuals study University of York in conjunction with primary care in Hull and York Audit tools, clinical support and training for primary care Partnership with pharma –– eg GSK, AZ, Medimark programme Awareness raising and community targeting South Tyneside PCT with British Lung Foundation (‘Love Your Lungs’) Lung age testing linked to stop smoking services Hartlepool and Stockton

The care pyramid – the right service for right patient, generalist versus specialist

Long Term Conditions Workstream Delivering national support & improvement programme Support local areas to implement a generic LTC model based on 4 key principles: Commissioners understanding the needs of their population and managing those at risk to prevent disease progression Empowering patients to maximise self-management including ensuring patients have a care plan and appropriate information and knowledge about how to manage their condition. Providing joined up and personal services particularly in community and primary care and working closely and effectively with social care. Strong professional and clinical leadership and workforce development.

Severe COPD Pyramid Reduce COPD burden Reduce mortality from current 26,000 pa Reduce hospital admissions Reduce readmissions from rate of 33% Reduce direct costs from £1billion pa Reduce indirect costs and lost productivity Emergency, exacerbation visits Co morbid conditions Bed days, hospitalisations Disability: days off work, pensions Costs COPD deaths

Evidenced Interventions impacting on mortality Acute non invasive nasal ventilation – substantial reduction in mortality, 1 to 8 survival benefit Long term domiciliary NIV- survival improvements Supplemental long term oxygen therapy – survival improvements Regular moderate or high level physical activity – 30 to 50% reduction in risk of both hospital admission and respira tory mortality Pharmacotherapy - new preparations showing reductions in mortality from respiratory and cardiovascular causes at 4 years Prompt medical therapy at start of exacerbation – reductions in hospitalisations Challenge is appropriate outcome measures

Research is needed: Multidisciplinary care Integrated care Clinical pathway Transmural care Self-management Tele-monitoring Tele-consulting Rehabilitation ‘Teams without walls’ Royal College of Physicians 2009 ‘Greater standardisation ’Sustainable health systems KPMG 2009

Outcomes Matter to Patients Improved survival Early and accurate diagnosis Improved QOL and social functioning Slower disease progression Reduced exacerbation rate Reduced admission/readmission rates High quality end of life care

A Quality COPD Service Proactive and opportunistic case finding to minimise the impact of late diagnosis on individuals and the healthcare system Quality assured, accurate diagnosis and assessment of severity and ongoing monitoring and review of the condition through a proactive chronic disease management model. People with COPD are screened, assessed and managed with pharmacological and non-pharmacological interventions in line with NICE/quality guidelines People with COPD are educated and supported in the management of their condition so that they can become active partners in care. Effective prevention and management of exacerbations and of hospital admissions Effective palliative, end of life care and bereavement support for people with COPD

Smoking cessation Smoking cessation Smoking cessation Improving Outcomes in COPD Smoking cessation Smoking cessation Smoking cessation Proactive chronic disease management/QoL measures Awareness raising Lung health Lung symptoms Lung age testing Evidence based treatment/medicines management Accurate diagnosis Quality Spirometry Physical activity Pulmonary Rehab Social Care/Re-ablement Case finding – Early diagnosis Prompt therapy in exacerbations/review LTOT/NIV EOL

Home Oxygen Service Re-procurement Timetable Currently 3 Suppliers 11 regions inc Wales (approx 90k patients) Bidders/Suppliers appointed on Framework to be announced 3rd December with mini-competitions starting January 2011

Engagement of and leadership by clinicians is essential Outcomes will improve when clinicians are engaged, and creativity, research participation and professionalism are allowed to flourish A call to action and focus on clinical leadership for delivery

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