1. COPD in West Essex Dr.Angus Henderson Prof.Mike Roberts
GP Clinical Vice Chair, West Essex CCG
Prof.Mike Roberts
Programme Director Education and Capability &
Clinical Academic Lead for Population Health, UCLPartners
Professor of Medical Education for Clinical Practice, QMUL
Associate Director Clinical Effectiveness Unit, RCP

2. Stalls in the Foyer

3. 2016 NHS England - Right Care

4. What does good look like?
Pulmonary rehabilitation
Smoking cessation
Flu Vaccination

5. Getting the diagnosis right….
It isn’t
A&E discharge
CXR report
Poorly performed spirometry
Asthma etc
But it is
Post-bronchodilator spirometry showing obstruction

6. 9 High Impact Interventions in COPD
1. Diagnosis
2. Co-morbidity
3. Influenza & PPV
4. CAT, exacbns and MRC
5. Smoking cessation
6. Pulmonary rehabilitation
7. Optimise meds
8. Self-management
9. Care navigation

7. GOLD risk stratificationGP B 
EPUT C D 
Secondary care

8. How we changed
Practice visits
GP time to learn
GP membership meetings
LES – 1) diagnosis and 2) 9 HIIs
Local guidelines
Hospital A&E pathway
Hospital MDTs

9. How we develop from here?
In-reach from secondary and community care to practices (MDTs)
Quality assured spirometry
ICP to work together with General Practice to ensure all of our COPD patients have received the 9 HIIs

10. HAS IT WORKED….?

13. pulmonary rehabilitation referrals
Year
Number
2016/17
295
2017/18
428
2018/19
465

14. Impact on hospital admissions

15. Obstructive airways disease 2016 emergency admissions
Year
Spend
2016
£1,220,000
2018
£950,000

16. Respiratory Medicine: The National Picture
Professor Mike Roberts

17. The Long Term Plan: Respiratory
Earlier Diagnosis
Better uptake of pulmonary rehabilitation
Better use of medications
Better management of community acquired pneumonia
Joining pulmonary and cardiac exercise programmes

18. National and Regional Initiatives
QOF
Clinical Networks
Eastern & London
BPT
Academic Health Science Networks
UCLPartners & Eastern
CQUIN
RightCare
NHSE and I
Accreditation
Getting it Right First Time programme NHSI

19. An integrated system which supports the primary care networks
The Delivery Model
Patient activation
Social Services
Secondary Care
Specialist Services
Community Care
Services