Are there ways of improving care and achieving QIPP?

Colin Gelder & Sandy WalmsleyRespiratory Leads

West Midlands SHA

NHSNHS

PCT Revenue Limits £bn

PCT Revenue Limits £bn

PCT Revenue Limits £bn

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 Less

• Keep up to date with NHS Policy: summary of Operating Framework and Outcomes Framework

• www.impressresp.com

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 care 1.4

Minimal counselling 2.6 14,735

Intensive counselling 6 7,149

Intensive counselling + pharmacotherapy

12.3 2,092

Tiotropium £7,112/QUALYEur J Health Econ. 2007; 8(2): 123135

Hoogendoorn M, Feenstra TL, Hoogenveen RT, Rutten-van Mo¨lken MPMHThorax 2010: 65:711-718

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 careRupert Jones, Anders OstremPrimary Care Respiratory Journal 2011; 20(1): 33-45

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 admissionsBUT……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 trajectoryOrgan system failure: end of life trajectory

Func

tion

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 No clinical service is designed to routinely meet the needs of this pattern of decline 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 approachCEILING OF CARE / RESUSCITATION PREFERENCES

documentationPlease indicate which of the following “CEILING OF CARE” goals / Please indicate which of the following “CEILING OF CARE” goals / interventions are appropriate. Circle interventions are appropriate. Circle eacheach response. More than response. More than one YES response may apply.one YES response may apply. - SYMPTOM RELIEF: LOW FLOW OXYGEN / BRONCHODILATORS SYMPTOM RELIEF: LOW FLOW OXYGEN / BRONCHODILATORS

/ OPIATES / BENZODIAZEPINES / HALOPERIDOL / OPIATES / BENZODIAZEPINES / HALOPERIDOL Select as appropriate for the patient’s needs Select as appropriate for the patient’s needs ALWAYSALWAYS- PREDNISONE / AMINOPHYLLINEPREDNISONE / AMINOPHYLLINE YES / NOYES / NO- ANTIBIOTICS ANTIBIOTICS YES / NOYES / NO- - NON-INVASIVE VENTILATION (BIPAP) NON-INVASIVE VENTILATION (BIPAP) YES / NOYES / NO- - ICU ADMISSION AND POSSIBLE VENTILATIONICU ADMISSION AND POSSIBLE VENTILATION YES / NOYES / NO- - CPR FOR CARDIO-RESPIRATORY ARREST CPR FOR CARDIO-RESPIRATORY ARREST YES /NOYES /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

DISEASEPROCESS

ADVANCE CAREPLANNINGWHAT DYING MIGHT

BE LIKEINCLUDING

SPIRITUAL ISSUES

(Scullion, 2010)

SYMPTOM CONTROL

COPING MECHANISMS

PRACTICAL ADVICE

CONTINUITY IN CARE

We need companions too!

Third SectorBLF, Asthma UK

Pharma AllianceMSD, 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