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

2. 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

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

4. ‘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’

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. Late Diagnosis

12. 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

13. 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

14. 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)

15. 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

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

17. 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.

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. A long and winding road! 1 26