Outline Business Case for the Development of Docum… · Web viewCommunity Based COPD Services in West Hertfordshire. Dr Corina Ciobanu. M W Jones. 10 October 2007. Revised June

Outline Business Case for the Development ofCommunity Based COPD Services in West Hertfordshire

Dr Corina CiobanuM W Jones

10 October 2007Revised June 2008

This business case is supported by the following PBC GroupsDac Comm PBC

Stach Comm PBCWat Comm PBCHertsmere PBC

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This document is the property of the authors and must not be copied or reproduced in whole or in part without their permission.

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Contents:Executive Summary.......................................................................................................................................... 3

1.1. Strategic Context............................................................................................................................. 31.2. Project Objectives:........................................................................................................................... 31.3. Service Monitoring and Targets.......................................................................................................31.4. Financial Case................................................................................................................................. 41.5. Risks................................................................................................................................................ 41.6. Contracting...................................................................................................................................... 4

Business Case.................................................................................................................................................. 51. Introduction.......................................................................................................................................... 52. Service Outline.................................................................................................................................... 52.1. Principles to underpin service delivery:...........................................................................................52.2. Service Aims:.................................................................................................................................. 52.3. Service Specifications..................................................................................................................... 73. Benefits to the Patients:....................................................................................................................... 73.1. Direct Access to the COPD Community Clinic................................................................................73.2. Patients as Partners in Care............................................................................................................83.3. Services closer to patients’ homes..................................................................................................83.4. Maximising patient’s quality of life...................................................................................................84. Evidence to Support Clinical Effectiveness and Clinical Efficiency......................................................94.1. Evidence to support the clinical effectiveness of the interventions detailed in the service specification.................................................................................................................................................. 94.2. Evidence to support the clinical efficiency of the interventions detailed in the service specifications

105. Evidence of Stakeholders’ and patients’ support...............................................................................116. Management Resources Required:...................................................................................................127. Cost of the Service:........................................................................................................................... 138. Impact on National and Local Priorities.............................................................................................139. Assessment of Risks for the Service:................................................................................................1410. Action Plan for Commissioning the Service / Procurement Process:.............................................17

Appendix 1: Service Specification for the Provision of Care for COPD Patients in West Herts.....................201. Service Description............................................................................................................................ 202. Service Aims...................................................................................................................................... 203. Service to be Provided....................................................................................................................... 204. Referrals to the COPD Community Clinic..........................................................................................215. COPD Community Clinics Specifics..................................................................................................226. Service Standards/ Guidelines...........................................................................................................247. Targets for the Service:...................................................................................................................... 248. Audit and Monitoring.......................................................................................................................... 249. Communication.................................................................................................................................. 2510. Working Practices..........................................................................................................................25

Appendix 2: Financial Model..............................................................................................................................27

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Executive Summary

1.1. Strategic ContextLong Term Conditions has been identified as one of the 3 top priorities for the NHS in the period up to 2008. NHS Improvement Plan set out the government's priority to improve care for people with long term conditions by moving away from reactive care based in acute systems, towards a systematic, patient-centered approach. Care needs to be rooted in primary care settings and underpinned by vastly improved communication and new partnerships across the whole health and social care spectrum. The East of England Strategic Health Authority published in May 2008 it’s clinical vision for our NHS in the next decade – “Towards the best, together “. Long Term Conditions is one of the 8 areas were recommendations have been made for service improvements.In West Herts patients suffering from COPD are currently being monitored and treated by GPs. When their condition deteriorates they are often admitted to hospital for long inpatient stays. There is no robust specialized community service addressing the complex needs of these patients including education and self monitoring, supporting them at times of crisis. This is why COPD exacerbation is the second commonest reason for admission to hospital representing a significant burden to the local health economy.DacCom PBC is proposing a full redesign of COPD Services aiming to provide patients the most intensive care in the least intensive setting. This proposal has been initiated by clinicians in both Primary and Secondary care and sets out a complete shift of services from acute to primary care settings.

1.2. Project Objectives: Setting up COPD Community Clinic to monitor, treat and educate patients

identified as high risk. Community Clinics will be run by Respiratory Consultants / GPWSI and respiratory

nurse specialists. Early detection and treatment of disease exacerbation to prevent hospital

admissions. The service will provide an on-going coordinated support and maintain close

links with other services in order to produce better health outcomes and quality of life and reduce disability.

To provide direct and open access to all patients with unstable COPD. To ensure effective home care for COPD patients in need and ensure patients and

their carers feel supported in self-care.

1.3. Service Monitoring and TargetsThe new service will be closely monitored for clinical safety, quality and governance.The service provider will be expected to demonstrate whether the specific needs of population groups such as disabled people (including those with learning difficulties or mental health needs), the differing needs of men and women and of the diverse age

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groups, different faiths and sexual orientation of individuals and groups accessing the service have been taken into account.The Service Specification attached includes defined targets for the delivery of this service in the community.Regular audits, Significant Events Analysis and Patients Satisfaction Survey will be run as required in the service specifications to monitor service progress and demonstrate clinical effectiveness and efficacy.The provider of the new service must ensure outcomes that deliver measurable and meaningful improvement.

1.4. Financial CaseWe have prepared a cash flow plan based on the assumption that the new COPD service will be commissioned in Dacorum and Watford & Three Rivers only.The base case cash flow plan provides the following data:

Maximum investment required (approximate): £319k

Investment recovered by: 2Q Year 2

Cumulative net savings at end Year 3: £687k

Annual net savings thereafter: £448k

1.5. RisksClinical Risk: The potential clinical risks have been discussed with the 4 PBC Groups and are detailed in chapter 9.A large body of evidence has been provided to demonstrate that, provided adequate clinical leadership is in place, the service will be safe and effective.Financial Risk:To test the robustness of the financial model we conducted a detailed sensitivity analysis. The financial model is robust to variation in all of the key assumptions. Even a combination of significant inaccuracies in the financial model failed to prevent a break-even in a little more than 3 years, with a healthy annual saving thereafter.Whilst the service redesign is intended primarily to deliver improved patient care, we are confident that the financial model is sound and that in the medium term significant savings will be achieved.

1.6. ContractingIn the context of procurement, the essential elements of this proposal are:a) A transfer of service provision from secondary to primary care.b) Single Community Clinics in Dacorum, Watford and St Albans.

To achieve economies of scale, it is essential this service is not fragmented.

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Business Case

1. IntroductionChronic Obstructive Pulmonary Disease (COPD) is a slowly progressive disorder characterised by airways obstruction, which does not change markedly over several months.COPD affects an estimated 3 million people in the UK resulting in approximately 30,000 deaths annually and with direct cost to the NHS of almost 500 million pounds each year. Unsurprisingly, patients with the severest disease cost the most, at £1,307.10 a year. The personal cost to people with COPD is incalculable, with increasing immobility and loss of working opportunities as their disease progresses. COPD is the second commonest cause of medical admissions in the UK.In West Herts there are in around 6,300 patients with COPD out of which 900 (15 %) are clinically unstable with poor quality of life requiring frequent hospital admissions for episodes of disease exacerbation.This business case proposes a service change based on evidence-based effective interventions available that can significantly improve the quality of life for patients with COPD, reduce disease exacerbations and subsequent hospital admission.

2. Service Outline

2.1. Principles to underpin service delivery: Early detection and early treatment of unstable COPD patients to prevent

hospital admission with focus on timely interventions. Optimize pharmacological and non-pharmacological management of

unstable COPD patients. Those providing care and support work together to ensure an integrated,

accessible and flexible service is delivered to the patients. Patients are partners in care – they receive care via a personalised care

plan that is tailored to their individual needs. Maximise quality of life and aim to enhance people’s ability to live

independent lives. Outcomes that deliver measurable and meaningful improvement.

These principles address the case for change as detailed in the East of England clinical vision document “Towards the best, together”.

2.2. Service Aims: Organise and coordinate COPD Services under the umbrella of the COPD

Community Clinic. Actively planned and managed integrated care which is delivered in a

community setting by the most qualified and experienced clinicians:

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Respiratory Consultants and GPWSI leading multidisciplinary teams of clinician.

To utilize resources for detecting and treating the unstable COPD patients (15% of all COPD patients).

To provide an effective alternative to acute hospital admissions for selected patients with acute exacerbations of COPD.

To provide effective home care for COPD patients after discharge from the hospital.

Provide a central and open point of access to all unstable COPD patients. Accept referrals from primary care, hospital teams, intermediate care, social

services, emergency care practitioners, etc. To liaise and be able to make referrals to hospital teams, intermediate care,

social services, palliative care services, metal health services, etc. To offer teaching and support to other colleagues who care for patients with

COPD. Assessment and provision of pulmonary rehabilitation programmes for “all

who need it”. Home Oxygen assessments and reassessments to facilitate the provision of

LTOT and AOT; monitor all patients on home oxygen therapy. To empower patients to manage their condition effectively through the

provision of teaching and support. To ensure the services are focused on the needs of the individual and their

carers. To ensure all relevant staff have received training on delivering a self care

approach.

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Figure 1: Patient’s Journey

2.3. Service SpecificationsPlease see Appendix 1 for full Service Specifications.

3. Benefits to the Patients: Direct Access to Specialist Services Patients as “Partners in Care” Specialist Services Closer to Patient’s Homes Maximising Quality of Life for Patients with COPD

3.1. Direct Access to the COPD Community ClinicPatients known to suffer with COPD will be able to, and should be advised to self refer to the COPD Community Clinic early – soon after a deterioration in their condition is noted. Patients will thus benefit from immediate specialist assessment and advice on their condition. The Staff at the COPD Clinic will

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arrange home visit for house bound COPD patients as requested. Home oxygen assessments will be carried out both at home and at the COPD Clinic.

3.2. Patients as Partners in Care A key component of developing suitable chronic disease management programmes is to develop patients’ skills and knowledge in managing their own condition. It is anticipated the service provided by the COPD Community Clinic will support the “ethos” of developing “expert patients”. The following components will be considered as part of this service model: Self Management Plans / patient diaries. Patient at risk of having exacerbations should be given guidance on self-

management ensuring they respond quickly to symptoms of exacerbation. Developing of accessible and comprehensive patient information to support

pro-active self-management. Discuss and agree with the patient’s groups a set of patient outcome and

patient experience indicators.

3.3. Services closer to patients’ homesNICE guidance recommends that for most patients with stable severe disease regular hospital review is not necessary, but there should be locally agreed access to specialist assessment when necessary. The COPD Community Clinic would support the management of COPD patients in Primary Care as part of an integrated service with secondary care.The service will actively look to identify and monitor COPD patients at high risk of exacerbation and support them in the community with the aim of avoiding emergency hospital admissions. Few clinical trials have found a significant decrease in hospital admissions and length of hospital stays for acute exacerbations of COPD in patients treated with LTOT. This service will be partly dedicated to home health care services assisting patients in the proper use of these measures.

3.4. Maximising patient’s quality of life Careful monitoring of patients at high risk of exacerbation will reduce both

hospital admissions as well as the risks of developing long-term complications. Patients will have quick access to specialist advice especially as the condition progresses

The healthcare provided will be focused on Quality of Life incorporating increasing independence and End of life issues. The aim should be for patients to maintain functional ability after each required intervention.

All patients reviewed will be receiving optimum medication according to NICE guidelines and adjusted to their personal needs and lifestyle.

Improve the palliative care of patients with end stage COPD using a multi-disciplinary approach with the Palliative Care Teams.

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Patients will have access to Social Services at the appropriate time and provided in the appropriate setting by using the COPD Community Clinic links with the Adult Care Services.

4. Evidence to Support Clinical Effectiveness and Clinical Efficiency

4.1. Evidence to support the clinical effectiveness of the interventions detailed in the service specification

4.1.1. Early intervention can prevent disease exacerbation/ targeting high risk patients and reviewing their disease management van Schayck CP, Loozen JMC, Wagena E – Detecting patients at high risk of

developing chronic obstructive pulmonary disease in general practice: a cross- sectional case-finding study. BMJ. 2002; 324:1370-4

Lokke A, Lange P, Scharling H , Fabricus P, Vestbo J. – Developing COPD: a 25 year follow up study of the general population. Thorax 2006; 61;935-9

Clearing the air: A national study of chronic obstructive pulmonary disease. Healthcare Commission 2006.

George J, King DCM, Thomas R, Stewart K.- Factors associated with medication nonadherence in patients with COPD. Chest. 2005;128: 3198 – 204.

4.1.2. Pulmonary rehabilitation programmes results in major improvements in exercise levels and quality of life Best et al – Longitudinal trends in exercise capacity and health status after

pulmonary rehabilitation in patients with COPD. Respiratory Medicine 2003; 97: 173- 80

Ries at al.- Effects of pulmonary rehabilitation on physiological and psychological outcomes in patients with chronic obstructive disease. Annals of Internet Medicine 1995; 122: 823-32

Griffiths TLB. Results at 1 year of outpatient multidisciplinary rehabilitation: a randomised controlled trial. Lancet 2000 APR 8:355(9211):1280

4.1.3 Self- management action plans reduce disease exacerbation and hospital admissions Monninkhof et al. Self-management education for patients with chronic

obstructive pulmonary disease (Cochrane review). The Cochrane Library. Oxford:update Software 2003.

Bourbeau et al. Reduction in hospital utilization in patients with chronic obstructive pulmonary disease – A disease-specific self management intervention. Archives if Internal Medicine 2003:163:163:585-91.

Gallefoss et al. How does patient education and self-management among asthmatics and patients with chronic obstructive pulmonary disease affect medication? American Journal of Respiratory and Critical Care Medicine 1999:160:2000-5.

Hernandez etal. Home hospitalisation of exacerbated chronic obstructive pulmonary disease patients. ERJ. 2003;21:58-67.

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Cotton et al. Early discharge for patients with exacerbations of chronic obstructive pulmonary disease: randomised controlled trial. Thorax 2000;55:902-6

4.1.4. Hospital at home, case management and assisted discharges reduces frequency of hospital admissions and improves quality of life Neff DF, Madigan E, Narsavage G.Home Health c Nurse. 2003 Aug;21(8):543-

50 APN-directed transitional home care model: achieving positive outcomes for patients with COPD

Ram FS, Wedzicha JA, Wright J, Greenstone M. Cochrane Database Syst Rev. 2003(4):CD003573. Hospital at home for acute exacerbations of chronic obstructive pulmonary disease.

Skwarska et al. Randomised controlled trial of supported discharge in patients with exacerbations of chronic obstructive pulmonary disease. Thorax 2000;55:907-12.

Davies et al. “Hospital at home” versus hospital care in patients with exacerbations of chronic obstructive pulmonary disease: prospective randomised controlled trial. BMJ 2000;321:1265-8.

Ojoo et al. Patients’ and carers’ preferences in two models of care for acute exacerbations of COPD: results of a randomised controlled trial. Thorax 2002;57:167-9.

Hernandez et al. Home hospitalisation of exacerbated chronic obstructive pulmonary disease patients. ERJ. 2003;21:58-67.

Cotton et al. Early discharge for patients with exacerbations of chronic obstructive pulmonary disease: randomised controlled trial. Thorax 2000;55:902-6.

4.1.5. Palliative Care addressing the needs of patients with end stage COPD Gore et al,Thorax. 2000 Dec;55(12):1000-6. How well do we care for patients

with end stage chronic obstructive pulmonary disease (COPD)? A comparison of palliative care and quality of life in COPD and lung cancer.

4.1.6. Correct administration of oxygen therapy reduces exacerbations and hospitalisation Gore et al,Thorax. 2000 Dec;55(12):1000-6. How well do we care for patients

with end stage chronic obstructive pulmonary disease (COPD)? A comparison of palliative care and quality of life in COPD and lung cancer.

4.2. Evidence to support the clinical efficiency of the interventions detailed in the service specifications

4.2.1. Pulmonary rehabilitation programmes – reducing cost in the long term management of COPD• Bourbeau J et al Arch Intern Med. 2003 Mar 10;163(5):585-91. Reduction of

hospital utilization in patients with chronic obstructive pulmonary disease: a disease-specific self-management intervention.

• Griffiths et al. Cost effectiveness of an outpatient multidisciplinary pulmonary rehabilitation programme. Thorax 2001: 56:779-84.

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4.2.2. New strategies for the management and prevention of the economic burden of COPD• Pauwels RA, Buist AS, Calverley PM, Jenkins CR, Hurd SS. Global strategy for

the diagnosis, management, and prevention of chronic obstructive pulmonary disease . NHLBI/ WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) workshop summary. Am J Respir Crit Care Med 2001;163:1256-76.

• World Health Organization. The GOLD global strategy for the management and prevention of COPD. 2001. www.gold-copd.com,2001.

• Buist AS, Vollmer WM, Sullivan SD, et al. The Burden of Obstructive Lung Disease initiative (BOLD): rationale and design. COPD. COPD: J Chronic Obstructive Pulm Dis 2005; 2:277-83.

• Sullivan SD, Ramsey SD, Lee TA. The economic burden of COPD. Chest 2000;117:5S-9S.

• Wouters EF. Economic analysis of the Confronting COPD survey: an overview of results. Respir Med 2003;97(Suppl. C):S3-S14.

• Tynan A, lane S, Ir Med J. 2005 Feb;98(2):41-2, 44-5. COPD: illness severity, resource utilisation and cost.

• Miravitlles M, Murio C Guerrero T Chest. 2003 Mar;123(3):784-91. Costs of chronic bronchitis and COPD: a 1-year follow-up study.

• Britton M.The burden of COPDIN THE uk.:Results from the Confronting COPD survey. Respir Med 2003; 97 Suppl C:S71-9.

5. Evidence of Stakeholders’ and patients’ supportThe Clinical Concept behind this service has been initially developed by the GP and the Respiratory Consultants from West Herts involved in the “Investing in Your Health” Service Redesigned Project - IMC/LTC Workstream ( Dr David Evans, Dr Julius Cairns and Dr Corina Ciobanu) at the beginning of 2006. The Clinical Pathway Project / Service Redesign has been presented to the Clinical Reference Group in June 2006 by the authors. The project has been approved as clinically sound and referred to financial department for costing, etc.Once the financial analysis has been done the project has been included in the Financial Recovery Plan for the Dacorum Watford and 3 Rivers PCT as a clinically safe project for reducing expenditure within the proposed timescale.The implementation has however been abandoned during the PCT reconfiguration.DacCom PBC views Service Redesign for patients with Long Term Conditions as a priority and has therefore agreed to develop a business case based on clinically sound and evidence proved ideas which would be extremely beneficial to the patients and cost effective in the long term.The integrated services run under the umbrella of the COPD Clinic has been presented by authors at numerous clinical and non clinical meetings between May 2006 to July 2007. Please note patient’s participation at meetings: representation from the “Breathe Easy” Groups from Watford and Dacorum. GPs, Respiratory Consultants, Respiratory Nurses, Primary Care Managers and PCT Managers have been introduced to the principles behind the new proposed service at different events as follows:

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1. West Herts COPD Stakeholder event – Watford 25.05.2006 – presentation to all stakeholders (including patients) by Dr D Evans, Dr C Ciobanu and Dr J Cairns.

2. COPD Clinical Pathway Project emailed to all GPs in West Herts – Invitation to feed back on the proposed model of care attached – May 2006

3. COPD Service Redesign Project presented by Dr D Evan, Dr J Cairns and Dr C Ciobanu to the Clinical Reference Group – West Herts PCTs June 2006

4. COPD Clinical Pathway project presented by Dr J Cairns and Dr C Ciobanu at Dacorum “Hot Topics” Event held at Felden Lodge July 2006

5. COPD Service Redesign discussed at a joint meeting with the provider of Respiratory Nurse Services in West Herts- Watford, Dr C Ciobanu November 2006

6. COPD Management – presentation of the Clinical Concept behind the service redesign – Dr D Evans and Dr C Ciobanu – St Albans March 2007

7. COPD ideas for service redesign – presented as part of the “Acute Services Review” Consultation Document under the heading “Development of Services for patients with Long Term Conditions” June 2007

8. COPD Management in Primary Care – The Case for a Business Case – presented by Dr C Ciobanu at Wat Com PBC Annual General Meeting

9. COPD Service Redesign Project – Update on the Business Case – presented by Dr C Ciobanu to Wat Com PBC Board – January 2008

10. COPD Service Redesign The Business Case – presented by Dr C Ciobanu and Mark Jones to Stah Com PBC Board February 2008

11. COPD Clinical Pathway for West Herts – presented to the West Herts Clinical Conclave by Dr C Ciobanu, Dr D Evans and Dr S Laitner – March 2008

Minutes of the meetings listed above are available on request.

6. Management Resources Required:To set up the service:We envisage a project lasting six-months. A longer or shorter timescale could be accommodated at the same cost, as the total resources required are likely to be insensitive to timescale within reasonable limits. The following resources will be required:a) An expert clinician to lead the project. We have allowed 6 hours per week for 6

months @ £100 per hour. b) A project manager. This could be a contractor working 18 hours per week for six

months. We have assumed a rate of £40 per hour based on experience of this field.

c) Administrative support. We have allowed 0.5 FTE for six months at a cost of £24k FTE per annum.

To run the service:

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Clinical leadership will be delivered by a GPwSI / Consultant spending 10 hours per week in each clinic on this activity. The clinical lead will be supported by 2 FTE Administrative staff per clinic.

7. Cost of the Service:We have prepared a cash flow plan based on the assumption that the new COPD service will be commissioned in Dacorum and Watford & Three Rivers only. See Appendix 2.Set up costs and running costs for the service have been estimated on the basis of a detailed requirements analysis.The savings forecast is based on data generated by Dacorum and Watford & Three Rivers PCT for the 2006 Financial Recovery Plan. The elements of savings are:a) 50% reduction in cost of non-elective admissionsb) 20% reduction in outpatient activityc) 75% reduction in A&E attendancesThe clinical effectiveness of the service depends on factors such as patient education and awareness. We have assumed the new service does not reach full clinical effectiveness until 1 year post-launch. In the first year we have assumed effectiveness of 10, 50 70 and 90% for first, second, third and fourth quarters respectively.Inflation has been discounted in this financial model as we assume cost inflation can be contained at similar levels to any changes in tariff for the diverted secondary care activity. The cash flow plan for this base case provides the following data:





8. Impact on National and Local PrioritiesThe main themes for service redesign presented in the business case are congruent with the NHS current agendas as follows:

1. Clinically lead, evidence based and patient centred services – “Towards the best, together” – East of England clinical vision for our NHS, now and for the next decade. Dr C Ciobanu is a member of the Long Term Conditions Clinical Pathway Group and provided advice on the published version of the document.

2. Patients focused new services – “The NHS Improvement Plan :Supporting people with long term conditions to live healthy lives” . and “Keeping it Personal: Clinical Case for Change” Feb 2007

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3. Care delivered in the least invasive manner and the least intensive setting – The White Paper: “Our Health, our care, our say” DoH January 2006 .

4. Addressing needs for vulnerable patients with complex needs – “Our NHS, Our Future” - NHS Next Stage Review - Interim Report by Professor Lord Darzi October 2007 and also .”Improving Lives; Saving Lives” 2008 – a series of pledges for the next 3 years to 2011.

5. Reduction in hospital admissions and referrals – Public Service Agreements and “Independence, wellbeing and choice” DoH 2005

6. Shift from Secondary to Primary Care for LTC - Working NHS Plan –“Liberating the Talents”/”LTC Strategy”/”Choosing Health” 2005

7. Improve access times – “The NHS in England: The Operating Framework for 2007/2008”

8. Supporting the modernisation and reconfiguration of services by clinical dialogue with Acute Providers – “Commissioning Framework for Health and Wellbeing” – DoH March 2007

9. Patient involvement in planning and delivering care – “Creating a Patient- Lead NHS” DoH March 2005

The project supports delivery of PCT targets and priorities:1. Reducing emergency admissions and readmission2. Reduction in GP referrals to secondary care3. Modernise and redesign services which best meet the needs of local

people and provide best value for money4. Providing care in community setting to improve access for local people5. Part of the DacCom PBC Business Case approved by the PCT

9. Assessment of Risks for the Service:Clinical Risk:

The commissioning PBC Groups should be aware of the following potential clinical risks the users of the service will be taking:

a. Failure by the GP Surgeries users of this service to timely identify COPD patients in need of referral to the COPD Community Clinics

b. Failure to refer according to referral criteriac. Failure to support and monitor the implementation of Management Care Plans for

individual patients as agreed with the staff at the COPD Community Clinicsd. Failure to prescribe and review medication as per agreed pathway for the use of

drugs in COPDe. Failure to change the current practising habits of referring suspected COPD

patients to the WHH OPD or other acute providersf. Breakdowns in communication between the GPs and the COPD Community clinics

i.e. failure to update the clinics on major clinical changes in their patient’s condition

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The risks listed above have been discussed with the commissioning 3 PBC Executive Boards when support for this business case has been sought.

The PBC Commissioning Boards will be taking the responsibilities of informing, supporting and monitoring the activity of the GP Surgeries using the new service and take necessary steps to minimise clinical and financial risks. The PBC Groups might choose to elect a responsible individual who will be monitoring the activity of the local surgeries using data collected and compiled by the provider of the COPD Service. Ideally reports should be presented to the PBC Boards twice a year or more often required.

A large body of evidence has been provided elsewhere in this document to demonstrate that, provided adequate clinical leadership is in place, the service will be safe and effective.

Financial Risk:To test the robustness of the financial model we have conducted a sensitivity analysis including the following scenarios:

1. Running Costs increased by 20%Our estimate of running costs is comprehensive and we have valid data for comparison. The elements of cost for a COPD Community Clinic are very similar to those for a General Practice. So the risk of a significant cost over-run is quite low.The impact of a 20% increase in running costs is:





The impact of increased set up costs was not assessed as the effect is trivial.

2. Service Efficiency reduced by 20%Service Efficiency is defined as the effectiveness of the new service in realising the planned savings. This would be reduced if the savings divert less activity than expected from secondary care.We have provided good evidence elsewhere in this document to show that the planned reductions in activity can be achieved. Risk of failure will be mitigated by strong clinical management and by rigorous monitoring of referral and A&E data.In this scenario:

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We then tested the individual elements of Service Efficiency separately.

3. Failure to meet targets for reducing cost of non-elective admissionsThe base case assumes a 50% reduction in costs. In this scenario we assumed a 30% reduction only. This scenario also tests the financial model for sensitivity to inaccuracy in the PCT’s data for cost and current activity levels.





4. Failure to meet targets for reducing outpatient activityThe base case assumes a 20% reduction in activity. In this scenario we assumed a 10% reduction only. This scenario also tests the financial model for sensitivity to inaccuracy in the PCT’s data for cost and current activity levels.





5. Failure to meet targets for reducing A&E attendancesThe base case assumes a 75% reduction in costs. In this scenario we assumed a 50% reduction only. This scenario also tests the financial model for sensitivity to inaccuracy in the PCT’s data for cost and current activity levels.




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6. Nightmare ScenarioWe tested the following scenario:

a) Set up costs over run by 50%b) Operating costs over run by 10%c) Reduction in cost of non-elective admissions limited to 40%d) Reduction in outpatient activity limited to 15%e) Reduction in A&E attendances limited to 66%



Cumulative net savings at end Year 3: -£64k (loss)


7. ConclusionsThe financial model is robust to variation in all of the key assumptions. The most critical target is the reduction in A&E attendances, but this is also one of the easiest to monitor and control. Strong clinical management and effective patient education will ensure patients make a timely self-referral to the new service (allowing effective intervention) rather than attending A&E.Even a combination of significant inaccuracies in the financial model failed to prevent a break-even in a little more than 3 years, with a healthy annual saving thereafter.Whilst the service redesign is intended primarily to deliver improved patient care, we are confident that the financial model is sound and that in the medium term significant savings will be achieved.

10. Action Plan for Commissioning the Service / Procurement Process:In the context of procurement, the essential elements of this proposal are:c) A transfer of service provision from secondary to primary care.d) A Community Clinic in Dacorum, Watford and St Albans. To achieve economies of

scale, it is essential this service is not fragmented.

Procurement of a Community Based COPD service

The PCT and PBC Groups have three options for procuring re-designed services:

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Re- specifying quality standards and re-negotiating existing contracts. ‘Any willing provider’ Tender

Formal competitive tender process to award a contract.

The strengths and weaknesses of these routes in relation to the proposed changes for COPD are assessed in the table below.

Procurement route

Strengths Weaknesses

Re-specifying within existing contracts

Could be done quickly (potential for implementation from October 2008)

Less disruptive to staff Open to further re-

negotiation as service develops

Would not preclude using tender/any willing provider at future stage

Against the fundamental principles of service redesign – i.e. moving care closer to patient’s homes, shifting services from secondary to primary care

No evidence to suggest benefits to the patients or financial savings. Historically such changes have proved to be only “cosmetic”

Commissioning with organisations rather than commissioning a single pathway through a single provider or consortium of providers

More difficult to monitor impact of service change and realise savings

Dependent on the future of the current provider

Would not test the market for different approaches/costs

Any willing provider

Quicker than tender process

Brings in range of providers with potential for innovative approaches

Will create multiple providers which would make it complex to manage long term relationships and follow-up.

Payment on cost per case basis would not be suitable for patients with long term conditions who are normally frequent attainders

Will not be able to commission the whole service but parts of it

Tender Full and robust test of Lengthy process (nearly a

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different approaches and costs

A single contract can be awarded for providing the full pathway

Transparency of costs and impact of service to monitor savings realised

Tests the market for potential providers

Clear responsibilities allocated to a single provider contractually bound to deliver as per the service specifications

year from sign off of case for change)

Considerable uncertainty for service and staff during tender process

Having considered these options the PBC Groups supporting this business case have agreed to choose formal tendering as their preferred procurement route.

None of the other two options will serve the principles underpinning service delivery as presented in the business case. These principles are identical to those on which the East of England document “Toward the best, together” is based and set a clear bottom line for judging this proposal

Formal tender has been discussed with clinicians in secondary care who are fully supportive of it. Further negotiations with the current providers will be necessary as the new service will require:

- decommission 60% of respiratory nurse services ( as 60% of their activity is around COPD) – offer to become part of the COPD Community Clinics

- de commission out patients clinics dealing with COPD patients (approximately 20% of the respiratory OPD activity) as all such services will be provided in the COPD Community Clinics

The PBC Groups supporting the business case will have to split the cost of the service according to service usage.

Appendix 1: Service Specification for the Provision of Care for COPD Patients in West Herts.

1. Service DescriptionThis service will deliver specialist community COPD therapy and nursing to patients in West Herts. The COPD Team based in the Community Clinics responds to, monitors,

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assesses and evaluates the condition of and delivers appropriate care/therapy to patients diagnosed with COPD.

2. Service Aims Organise and coordinate COPD Services under the umbrella of the COPD

Community Clinic. Actively planned and managed integrated care which is delivered in a community

setting by the most qualified and experienced clinicians: Respiratory Consultants or GPWSI leading multidisciplinary teams of clinicians.

To utilize resources for detecting and treating the unstable COPD patients (15% of all COPD patients).

To provide an effective alternative to acute hospital admissions for selected patients with acute exacerbations of COPD and to reduce unnecessary admissions to hospital.

To provide effective home care for COPD patients after discharge from the hospital. Provide a central and open point of access to all unstable COPD patients. Accept referrals from primary care, hospital teams, intermediate care, social

services, emergency care practitioners, as well as patients self referrals. To liaise and be able to make referrals to hospital teams, intermediate care, social

services, palliative care services, metal health services, etc. To offer teaching and support to other colleagues who care for patients with COPD. Assessment and provision of pulmonary rehabilitation programmes for “all who

need it”. Home Oxygen assessments and reassessments to facilitate the provision of LTOT

and AOT; monitor all patients on home oxygen. To empower patients and their carers to manage their condition effectively through

the provision of teaching and support. To develop patient self-management skills. To provide holistic care to patients within their own place of residence.

3. Service to be Provided Regular (x2 week) Consultant / GPSI lead multidisciplinary meetings to discuss new

patients and agree discharges. Follow up of the early discharge scheme patients. Optimize pharmacological & non-pharmacological management of unstable COPD

patients. Early assessment and treatment of the unstable COPD patients to prevent hospital

admission. Home O2 assessment and reassessment to facilitate the provision of LTOT and

AOT; monitor all patients on home O2 therapy. Assessment and provision of pulmonary rehabilitation programmes to further

reduce dependence on health care resources.

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Review of unstable house bound COPD patients in their homes including: medication review, O2 therapy review and complete mandatory home O2 nurse re-assessment.

Coordinate the care of COPD patients between Primary Care and Secondary Care ensuring constant communication and accurate record keeping- i.e. care plans, etc.

Regular multidisciplinary Case Meetings with Palliative Care. To review all COPD patients after an in patient stay (all COPD patients should be

discharged to the COPD Community Clinic). To follow up all COPD patients discharged to intermediate care beds for further

treatments or rehabilitation. All COPD patients needing specialist review will be seen in the COPD Community

Clinic; There will be no Out Patients appointments for COPD Patients. Liaise with the Public Health Department’s Representatives as appropriate (i.e.

health policies). Maintain good communication with Patient’s Groups and seek patient’s feedback

regularly. Organise educational events for clinicians from both secondary and primary care. Offer support for family and carers.

4. Referrals to the COPD Community Clinic4.1. Self referral – any unstable COPD patient should be educated to self refer to the COPD Community clinic. The COPD Team has to ensure a quick and efficient response.4.2. Clinician’s referrals – referrals will be accepted from both Primary and Secondary Care. Referrals should be made according to a basic set of referral criteria:Referrals Criteria:A. Unstable Patients with Acute Exacerbationa. Main Clinical Features of Exacerbation

1. Worsening Cough - new onset / increased sputum purulence / increase sputum volume

2. Increased Dependency on medicationb. Predictors for poor outcome

1. Track Record of admissions (1 or more admissions over the previous 6 months.

2. Inability to cope at home requiring Social Services immediate assessment.3. Confusion (new onset).4. Significant co-morbidity (CCF, AF, Diabetes, Renal impairment).5. Established Cor Pulmonale - particularly if new onset / worsening

peripheral oedema6. Patient already on long term O2

Patients requiring referral should have any one of the following:

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1. An acute exacerbation clinically and at least 1 predictor for poor outcome.2. An acute exacerbation not responding to treatment by the GP within 24 to

48 hours3. A COPD patient with sub-acute instability as detailed below:

B. COPD Patients with Sub-Acute Instability1. Frequent exacerbation (2-3 episodes / 6m).2. Clinical symptoms disproportionate to lung function tests.3. Rapid Clinical or FEV1 decline.4. Problematic withdrawal of steroids.Other reasons for referral:5. Below age 40y at diagnosis / FH of emphysema6. Need for palliative care assessment7. Assessment for use of nebulised bronchodilators8. Assessment for pulmonary rehabilitation 9. Assessment for home or ambulatory oxygen10. The provider will undertake to see patients in the Community Clinic as followsa. Urgent referrals – within 24 hours b.Routine referrals 7 to 10 working days

5. COPD Community Clinics Specifics5.1. Location

3 Community Clinics covering a population of over 2600 COPD patients per clinic

Community Clinics should be based in: Dacorum, Watford, St Albans & 3 Rivers and where the recipients of this service are located

The Community Clinics should be closely linked/ nearby Acute/Community Hospitals to facilitate access to diagnostic services (X-rays, CT scans)

5.2. StaffThe following staff is required for each clinic in order to be able to deliver the service as described above: 3 Respiratory Nurse Specialists 1 Health Care Assistant 2 Physiotherapists 2 Admin / Clerical staff 2.5 PA Consultant / GPWSI sessions per week (10hours/week)

5.3 Opening Hours Monday – Friday 08:00 to 20:00 Saturday 08:00 to 14:00

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5.4. Details of Services Provided 1. Direct Interventions

Examination / assessment Nebulizer Services Diagnostic of complications Management plans (short and long term) medical and non medical Phlebotomy Arterial Blood Gases Measurements Spirometry and complete Lung Function Tests Pulse Oxymetry Inhaler Techniques Smoking Cessation PR, BP measurements Nutrition and mobility interventions O2 Assessments Pulmonary Rehabilitation Programmes Breathing Techniques and Relaxation Behavioural Interventions Holistic Palliative Care Patient / Carer education and Empowerment Observation of specific respiratory conditions

2. Indirect Interventions: Ensure confidential patient’s data flow Direct referrals to other services: palliative care, dieticians, intermediate care,

social services, district nurses, secondary care Communicate with and support patient’s families and carers

3. Non-client Interventions: Create and maintain an accurate contemporary COPD Patients Community

Register Education to other Health Care Professionals Audit and Research

5.5. Core Skills/ Competencies of Staff Respiratory nurses with post- registration experience / qualifications; should be

able to provide expert assessment and monitoring with core skills and competencies over and above general nursing care.

Physiotherapist qualified to run Pulmonary Rehab Programmes. Health care assistants qualified to deliver services as described above. Consultants in Respiratory Medicine registered as such with the GMC.

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GPWSI in Thoracic Medicine with accredited qualifications.

6. Service Standards/ GuidelinesThis COPD Service supports and works to the NICE COPD Management Guidelines 2004 and the Global Initiative for Chronic Lung DiseaseThe COPD Service has been developed to meet the relevant Core Standards set out by the National Service Framework for Older People and the Primary Care Service Framework for Management of Long Term Conditions in Primary Care January 2007.The service is based on the agreed West Herts Clinical Pathway.

7. Targets for the Service: 30% reduction in emergency admissions due to COPD exacerbation. 75% reduction in A&E attendances for COPD exacerbation (patients currently

treated and discharged the same day). 10% reduction in COPD patient admissions through implementation of the reviewed

home O2 services. 5% reduction in COPD admissions through the provisions of adequate palliate care. 50% reduction of length of stay (LOS) through the supported early discharge

scheme for 30% of patients. 50% reduction in LOS through the provisions of pulmonary rehabilitation services. 20% reduction in the overall Chest Clinic Outpatient appointments as COPD

patients will not be followed up in the hospital.

The service’s performance will be assessed yearly against these targets

8. Audit and Monitoring For audit purposes and to enable local evaluation of the service, providers will be expected to collate and report the following information: Number of COPD patients seen in the Community Clinic (self referred, referral from

primary care, secondary care, etc) Number of COPD Patients followed up after discharge from the hospital Number of COPD Patients discharged back in the community Number of COPD Patients referred on to other services Number of home visits Number of first or follow up O2 assessments Waiting times for first appointment Review of patient’s feedback; patients views collected through

patients questionnaire

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Review of patients complaints 3 monthly analysis of Significant EventsThe following records must be maintained for reviews Records of x2 weekly multidisciplinary meetings The number of sessions undertaken The number of patients seen within each sessions The diagnosis for each patient seen The outcome for each patient The number of DNAs Records of educational meetings with other health care professionals Records of meetings with patients Annual reviews of complaints Full records of all procedures should be maintained in such a way that aggregated

data and details of individual patients are readily accessibleThe Provider of the COPD Community Service is expected to collect data for the following purposes: To enable an audit process to inform Quality Improvement Process To monitor achievement of standards – NSF, NICE & COPD Collaborative To measure impact on acute hospital admissions and length of stayData analysis will be used to monitor access to services, the quality of care delivered and also used for future service development and accurate planning through the LDP and commissioning process.

9. CommunicationThe provider of the COPD Community Service must ensure that every contact with a COPD patient is communicated back to the patients GP within 2 working days and no longer.Every patient’s discharge from the Community Clinic must be accompanied by a long term management plan containing clear instructions for the patient and patient’s GP.Patient’s confidentiality must be respected at all times when communicating information to other health care professionals.

10. Working PracticesThis COPD Services will observe: PCT’s Health and Safety Regulations Reporting of Injuries, Diseases and Dangerous Occurrences Regulations PCT’s Infection Control Regulations PCT’S Fire Regulations Patient Confidentiality and Data Protection Regulations Codes of Professional Practices as provided by Professional Governing

Organisations

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Appendix 2: Financial Model.

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Documents

Outline Business Case for the Development of Docum… · Web viewCommunity Based COPD Services in West Hertfordshire. Dr Corina Ciobanu. M W Jones. 10 October 2007. Revised June