Are there ways of improving care and achieving QIPP? Colin Gelder & Sandy Walmsley Respiratory Leads West Midlands SHA

NHS

PCT Revenue Limits £bn

Summary of Patient Priorities Better Information Respect Support for Self Management Pulmonary Rehabilitation Improved Access End of Life Care

Summary of Secondary Care Recommendations Integrated Commissioning Integrated Care Better Diagnosis/Registers Increased Access to Pulmonary Rehabilitation Oxygen Services Self Management End of Life Care

……..so what do we have to do? Is it

Plan is to…………………..

Are there better ways to deliver care?

Quality and productivity: IMPRESS's More for LessMore for Less Keep up to date with NHS Policy: summary of Operating Framework and Outcomes Framework Operating Framework and Outcomes Framework

May 2011

Prevention & Identification Finding the ‘missing millions’ High quality care and support End of life care COPD Care

1. Active Support For Self Management

COPD & Self Management Advice on how to stay healthy Advice on how to recognise onset of exacerbation Advice as to when to seek further support Telehealth

Self-Management of Exacerbations Encourage people at risk of having an exacerbation to respond quickly to the symptoms of an exacerbation by: adjusting bronchodilator therapy to control symptoms starting oral corticosteroid therapy (unless contraindicated) starting antibiotic therapy if their sputum is purulent

2. Primary Prevention

COPD & Primary prevention Public Health approach Starts early in life Promote “lung health” rather than lung disease

Long-term effectiveness & cost-effectiveness of smoking cessation interventions in patients with COPD 1 year abstinence % QALY £ Usual care1.4 Minimal counselling2.614,735 Intensive counselling67,149 Intensive counselling + pharmacotherapy 12.32,092 Tiotropium £7,112/QUALY Eur J Health Econ. 2007; 8(2): Hoogendoorn M, Feenstra TL, Hoogenveen RT, Rutten-van Mo¨lken MPMH Thorax 2010: 65: Pulmonary Rehabilitation £2,000-8,000/QALY

3. Secondary Prevention

Secondary Prevention Smoking cessation Opportunistic case finding Self management Pulmonary rehabilitation

4. Effective Medicines Management

COPD and Medicines Management Oxygen Appropriate prescribing in line with NICE/ COPD Strategy Appropriate for individual patients: Inhaler technique Integration with other therapies e.g. Pulmonary rehabilitation

Current Overview Home Oxygen Service provides O2 therapy to ~85,000 people in England In some areas there is no quality assured assessment 60% have COPD NHS cost £110 million 25% of little or no clinical benefit 300 NPSA alerts/SUIs, 44 deaths Current contracts expire in Jan 2011 (exc. South West) Services need to be fully integrated into the whole patient pathway

Potential Savings In PCT with formal review of oxygen registers coupled with introduction of oxygen assessment services up to £400,000 /year has been saved Potentially £10-20 million savings in England per year

Optimising pharmacological maintenance treatment for COPD in primary care Rupert Jones, Anders Ostrem Primary Care Respiratory Journal 2011; 20(1):

IMPRESS GUIDE TO INFORMATION ABOUT USE OF MEDICINES IN THE NHS A SECTION OF THE IMPRESS GUIDE TO INFORMATION This document is not about best practice prescribing or information about medicines for patients, but about the information available to help clinicians, commissioners and managers to know what is being prescribed by whom, for whom, at what cost, and at what benefit and how this compares to other geographic and disease areas. It draws together the information available across the primary, community and secondary care system. It focuses on respiratory care, but many of the lessons are of wider relevance to the management of long term conditions.

London Respiratory Team Right Care Respiratory Prescribing NICE 2010 ‘ Ensure all patients with COPD are on the appropriate therapy for the severity of, and symptoms from, their disease.’

London Respiratory Team Right Care Respiratory Prescribing NICE 2010 ‘‘ Offer nicotine replacement therapy, varenicline or bupropion (unless contraindicated) combined with a support programme to optimise quit rates… to all people with COPD who still smoke at every opportunity.’

Total cost of Respiratory Medication by BNF Chapters 2008 and 2009 for England £ millions Source: NHS Information Centre ~£1 billion on respiratory medication not including antibiotics…

Volume of Respiratory Medication by BNF Chapters 2008 and 2009 for England Number of prescriptions (millions) Source: NHS Information Centre but a relatively low volume of respiratory prescriptions...

Item cost of Respiratory Medication by BNF Chapters 2008 and 2009 in England Average net ingredient cost per prescription item £ Source: NHS Information Centre Respiratory items are the most expensive category of item prescribed..... …… inhalers

NHS budget & respiratory meds Source: NHS Information Centre Seretide (all) is the highest cost drug Seretide 250 Evohaler is the most expensive individual item (second is atorvastatin): Switch to accuhaler Symbicort 200 is 5th most expensive item Of the top 5 costliest drugs to the NHS currently 3 are inhalers

5. Managing Ambulatory Care Sensitive Conditions

Ambulatory care in COPD Quality assured diagnosis Accurate registers Empower patients to understand condition Self management plans with written instructions Quality assured Pulmonary Rehabilitation Integrated care across whole health and socail care economy

Pulmonary Rehabilitation Pulmonary rehabilitation available to all Post discharge MRC3 or above/symptomatic

COPD and Urgent Care Assessing to admit NOT admitting to assess! Integration between Acute & Community Care can reduce admissions Self management plans & rescue medications EoL planning with Advance Care Plans

6. Care co-ordination through integrated health & social care teams

Integrated health care in COPD Teams should be fully integrated across health & social care, enabling Right care, right place, right time, right person Communication across integrated team VITAL Leading to reduced inappropriate admissions BUT……we need to make sure that we are doing the right things, right!

7. Managing elective activity -referral quality

COPD and Elective Referral Networks to improve standards and reduce secondary care referrals, integrated working Genuine integrated care pathways across health economy Intermediate/community clinics either Nurse or Consultant led will lead to reduced referrals to secondary care

Managing Emergency Activity -Urgent care

8. Improving the management of patients with both mental & physical health needs

Anxiety & Depression Be alert to the presence of depression in individuals with COPD Patients found to be depressed should be treated with conventional pharmacology Antidepressant therapy should be supplemented by explanation of why depression needs to be treated alongside the physical disorder

9. Improving primary care management of end of life care

Organ system failure: end of life trajectory Function Death High Low Frequent admissions, self-care becomes difficult 2-5 years but death often “unexpected” Time No clinical service is designed to routinely meet the needs of this pattern of decline Occasions of discontinuity of care

Terminal care End of life care Palliative care

Advanced Care Planning – why? “ACP is about ensuring that futile treatments are not continued to the exclusion of appropriate end-of-life care”. “ACP is not about abandonment – it is about ensuring that abandonment does not happen. Futile interventions can lead to abandonment”.

Changing the professional approach CEILING OF CARE / RESUSCITATION PREFERENCES documentation Please indicate which of the following “CEILING OF CARE” goals / interventions are appropriate. Circle each response. More than one YES response may apply. SYMPTOM RELIEF: LOW FLOW OXYGEN / BRONCHODILATORS / OPIATES / BENZODIAZEPINES / HALOPERIDOL - SYMPTOM RELIEF: LOW FLOW OXYGEN / BRONCHODILATORS / OPIATES / BENZODIAZEPINES / HALOPERIDOL Select as appropriate for the patient’s needs ALWAYS Select as appropriate for the patient’s needs ALWAYS - PREDNISONE / AMINOPHYLLINE YES / NO - ANTIBIOTICS YES / NO - NON-INVASIVE VENTILATION (BIPAP) YES / NO - ICU ADMISSION AND POSSIBLE VENTILATION YES / NO - CPR FOR CARDIO-RESPIRATORY ARREST YES /NO

The Journey A map – idea of route and destination An informed guide Companions Appropriate travel equipment Supplies Comfort breaks End destination

The Journey Starts with noticing symptoms and being given a diagnosis This is the point of no return...

A story with no beginning A middle that is a way of life An uncertain and unlooked for end

Patients with COPD information needs DIAGNOSIS TREATMENT DISEASE PROCESS ADVANCE CARE PLANNING WHAT DYING MIGHT BE LIKE INCLUDING SPIRITUAL ISSUES (Scullion, 2010) SYMPTOM CONTROL COPING MECHANISMS PRACTICAL ADVICE CONTINUITY IN CARE

We need companions too! Third Sector BLF, Asthma UK Pharma Alliance MSD, Pfizer, Novartis, Glaxo Smithkline, Astra Zeneca, Teva

Why are we here? 2 key reasons for involvement; -We all supply medicines for COPD and Asthma -Strategic steer from the DH to encourage dialogue and joint working between the NHS and industry

Vision and Mission “ To ensure that all individuals with COPD in the West Midlands receive state of the art, patient focused, cost effective care ”

The WIN/WIN By industry and the NHS working together to achieve ‘state of the art’ evidence- based appropriate use of medicines, we will help reduce in-patient care; resulting in health, social and economic benefits

What have we achieved? …We continue to support the journey of strategy through to implementation… Examples of work undertaken with support of the Alliance; Stakeholder mapping Data project COPD needs assessment Access to an independent external facilitator Support for World Spirometry Day Raising awareness of cluster meetings

The Future We can offer;  Expertise  Resources BUT the real value is;  Working together

Hierarchy Network