1. NHS Yorkshire & the Humber Monthly QIPP Resource Pack April 2011 1

2. 2 Introduction This is the thirteenth QIPP resource pack. The pack has two components: BETTER FOR LESS EXAMPLES: We have worked with you to develop practical examples of schemes which have been developed locally and have potential to deliver better quality at lower cost. This month the ‘better for less’ example focuses on heart failure. LONG TERM CONDITIONS ‘HOT TOPIC’: Each month we will produce one ‘hot topic’ briefing which provides more detailed analysis on a subject relevant to QIPP. This month the hot topic is long term conditions. The analyses presented here are designed to offer insight and raise questions about variation in performance. They need to be interpreted in the local context. Note that we have decided to discontinue the QIPP metrics component of these packs. This is because we have now developed a more detailed set of metrics which is used to underpin our Single Accountability and Assurance Process. If you require further information on this please contact Andrew Tookey (andrew.tookey@yorksandhumber.nhs.uk) The final resource pack in the current format will be published week commencing May 9 th. The hot topic will be on capital and estates. After this time we will be moving to analysis at cluster level. If you have any questions or comments on the pack, please contact Ian Holmes. (Ian.holmes@yorksandhumber.nhs.uk)

3. 1) Healthy Ambitions: Better for Less 3

4. 4 Better for Less Early pathology input and the use of laboratory tests in clinical pathways are essential to aid timely and cost effective management of conditions such as hear failure. Tests for Brain Natriuretic Peptide (BNP) can help identify patients who are at the greatest risk of heart failure and act a cost effective pre- screening ensuring only those patients deemed at higher risk are referred on for specialist assessment with echocardiography Why Heart Failure? Heart failure occurs when the heart is unable to pump blood at a sufficient rate for metabolic requirements. The most common causes are coronary artery disease and hypertension. 30-40% of patients diagnosed with heart failure die in one year, thereafter mortality is less than 10% per year. Around 6,400 people each year in the region are diagnosed with heart failure. The prevalence is expected to rise as a result of an ageing population and improved survival rates of people with ischaemic heart disease. The investigation most commonly used to confirm diagnosis is echocardiogram and access to the diagnostic test and consultant outpatient is a limited and costly resource. Better for Less – BNP testing for heart failure

5. 5 Better for Less The difficulty in diagnosing heart failure in primary care is that symptoms are often non-specific and thus patients can be left undiagnosed and untreated in the early stages of the disease. Evidence suggests that patients with raised BNPs and NT Pro-BNP concentration have dramatically decreased survival rates compared with patients with normal BNPs. There is a clear relationship increasing BNP and heart failure severity. How could we provide better for less? A simple pathology test to determine the levels of BNP hormones in the blood can be used as a precursor to referral on to specialist assessment. (including echocardiogram). If BNP result is negative, and in the absence of other clinical signs or symptoms, it is possible to exclude heart failure as a causative factor and rule out echocardiogram. Benefits The establishment of BNP testing could lead to significant financial benefits and allow earlier detection to reduce the severity of heart failure. The benefits include: Improved use of outpatient services and reduction in inappropriate referrals Improved decision making resulting in better use of resources Reduced waiting times and cost of echocardiogram Earlier detection leading to improved outcomes for patients.

6. 6 Better for Less Better for Less – BNP testing for heart failure Case Study: Wakefield District NHS Wakefield District has had a BNP service since 2005. During the financial year 2009-10, a total of 680 patients had their BNP tested. According to NICE guidelines patients with a normal level of BNP do not require onward referral for specialist assessment or echocardiography. Based on this criteria 415 patients (61%) would not have required an echocardiogram in Wakefield District. For further information visit: www.healthyambitions.co.uk

7. 2) Hot topic: Long term conditions II 7

8. Long term conditions II- Contents Overview Asthma in adults Neurological conditions Annexes Contents 8

9. Long term conditions II- Contents Overview Asthma in adults Neurological conditions Annexes Contents 9 Overview

10. This information pack is the thirteenth in a series ‘hot topics’ that will be produced by the SHA to support organisations in developing their understanding of some of the challenges and opportunities presented by the QIPP agenda. While recognising that it may raise more questions than answers, we hope it will stimulate thought and debate within organisations and health communities. Clearly the data presented need to be interpreted in the local context. We would be delighted to receive comments on the contents together with any ideas for further long term conditions analysis. Overview 10 Long term conditions II - Overview

11. Long term conditions II – Overview Foreword Last June we published a long term conditions QIPP resource pack covering chronic obstructive pulmonary disease, diabetes and coronary heart disease. The overarching message was that proactive and effective management in primary and community settings can significant improve the lives of patients with these conditions, as well as reducing cost. Treatment and care of people with LTCs accounts for approximately 69% of the primary and acute care budget in England. There are a wide range of LTCs that significantly impact the health and wellbeing of the population of Yorkshire & the Humber. This pack focuses on asthma and a group of neurological conditions. The key messages for these areas is on a similar theme to other long term conditions - evidence suggests that there is the potential for improved service quality, outcomes for patients and opportunities for efficiency savings. Understanding the underlying drivers of this variation, and putting in place processes to address it will be key to the delivery of QIPP. Ivan Ellul Director of Performance NHS Yorkshire and the Humber 11

12. Long term conditions II – Overview Overview of long term conditions Long term conditions (LTCs) are those which cannot currently be cured but can be controlled with the use of medication and/or other therapies. People in Yorkshire & the Humber can currently expect to live between 15 years (men) and 17 years (women) in poor health or disability towards the end of their lives as a result of LTCs. It is estimated that the number of people with at least one LTC will rise in YH to nearly 1.5m people by 2020. 12 This resource pack focuses on asthma in adults and neurological conditions: Asthma affects over 200,000 adults in Yorkshire and the Humber. There is evidence that pro-active management of the condition can improve health outcomes and reduce the need for secondary care treatment. Around 8 million people in England have a neurological condition. There are a large number of conditions and the precise cause of many is unknown. Accurate diagnosis and appropriate care pathways can significantly improve quality and efficiency of services.

13. Long term conditions II – Overview 13 Possible savings in Yorkshire & the Humber The treatment and care of people with LTC accounts for approximately 69% of the primary and acute care budget in England. People with LTC are far higher users of health and social care services than average, accounting for approximately 55% of general practice consultations, 68% of A&E attendances and 77% of inpatient bed days. An estimated £570m was spent in YH in 2008/09 on unplanned admissions directly related to LTC alone. The overall costs of LTC management will be far greater when prescribing and primary care costs are also accounted fore. Better management of LCTs can help to prevent a large proportion of health care contacts, these efficiency gains are supported by benefits to patients and their families. Systematic, coordinated, proactive and preventative care and management of long term conditions across the health and social care system together with reducing associated avoidable emergency admissions presents the largest of all quality and efficiency opportunities. The challenge now is to make the necessary efficiency savings in a way in which this medium-term radical agenda is accelerated and not set back 1. 1 Nuffield Trust (2010). Making Progress on efficiency in the NHS in England: Options for System Reform.

14. Long term conditions II- Contents Overview Asthma in adults Neurological conditions Annexes Contents 14 Asthma in adults

15. Long term conditions II – Asthma in adults Asthma in adults 15 Asthma is a chronic inflammatory disease of the airways characterized by variable and recurring symptoms, reversible airflow obstruction, and Bronchospasm. Asthma can start at any age but most commonly starts in childhood. At least 1 in 10 children have asthma however almost half grow out of it by the time they are adults. There are estimated to be over 200,000 adults suffering with asthma across the region. The prevalence of asthma has increased significantly since the 1970s and it is estimated that up to half a million people in the region have the condition. NHS Comparators, The NHS IC The key risks for asthma include genetic and environmental factors, and these tend to be less well understood than other long term conditions. The aim of asthma care is to control symptoms and enable people to lead a normal life. Emergency admissions indicates a loss of control of the condition, and many of these could be avoided through early identification and effective and proactive management the condition.

16. Long term conditions II – Asthma in adults Asthma – Years of life lost The concept of measuring years of life lost is to estimate the length of time a person would have lived had they not died prematurely. (This measure covers all people under age 75.) In Yorkshire & the Humber on average there are around 2.5 years of life lost as a result of asthma mortality. This is around 25% higher than the national average. There is also significant variation across the region - Bradford and Airedale has just over 1 year of life lost, and Kirklees has over 3.5. 16 Years of life lost due to mortality from asthma, 2006-2008 The NHS IC, Compendium of health and clinical indicators

17. Long term conditions II – Asthma in adults Prevalence 17 According GP Quality and Outcomes Framework data 6% of the population suffer from asthma in Yorkshire and the Humber, over 330,000 people. However QOF data is considered to underestimate the true prevalence of asthma. Relative to epidemiological results, up to almost 40% of those with asthma are not recognised on QOF registers. QOF results for our region are closer to expected levels than nationally. In Yorkshire and the Humber the ration of actual to expected rates of asthma vary from 0.62 in Leeds to 0.73 in Doncaster. Asthma prevalence, QOF 2008/09 Ratio of actual to expected prevalence, 2008/09 Quality & Outcomes Framework, The NHS IC NHS Comparators, The NHS IC Y&H England

18. Long term conditions II – Asthma in adults Asthma – spend and prevalence Annually, almost £95m is spent on asthma in Yorkshire & the Humber, an average of £1.8m per 100,000 population. There is a weak positive relationship between asthma spend and recorded prevalence across Yorkshire and the Humber. PCTs with higher level of spending may want to consider how this expenditure is split across the pathway and what actions could be taken to improve quality and efficiency. 18 Asthma spend per 100,000 population and prevalence, 2008/09

19. Long term conditions II – Asthma in adults Asthma – management in primary care Effective long-term management of asthma requires appropriate monitoring of the condition. Long term management should minimise chronic symptoms, prevent exacerbations and enable patients to maintain near normal activity levels and reduce secondary health care contacts. Asthma patients who have records of the measures of the severity of the disease are more likely to have an accurate diagnosis of their condition and be treated appropriately given the level of their symptoms. 19 Proportion of asthma patients receiving reviews in the last 15 months, QOF 2009/10 Quality & Outcomes Framework, The NHS IC Asthma prevalence with measures of variability and reversibility, 2008/09

20. Long term conditions II – Asthma in adults Asthma – QOF exception reporting QOF exceptions are patients who are excluded from calculation of QOF performance because of failure to attend appointments or where medicine cannot be prescribed due to a contra-indication or side effect. High levels of exception reporting can mean that practices are receiving QOF payments but patients conditions are not being effectively managed. Up to 83% of patients on registers across PCTs in the region have had a review of their condition in the most recently reported 15 month period. Of the 50% of PCTs with the highest proportion of patients receiving reviews, 3 have QOF exception rates for this indicator of more than 5%. 20 Proportion of asthma patients receiving reviews in the last 15 months and rate of QOF exceptions for indicator, QOF 2009/10 Quality & Outcomes Framework, The NHS IC QOF exceptions for asthma, QOF 2009/10

21. Long term conditions II – Asthma in adults Asthma – hospital admissions The standardised admissions ratio compares the number of asthma related admissions for the PCT to the national average. Over half of PCTs in the region have fewer admissions than expected. Bradford & Airedale has one of the highest admissions ratios in the region but the shortest median length of stay; in contrast North East Lincs has the lowest admissions ratio but high length of stay. 21 Standardised admissions ratio Median length of stay and bed days Asthma UK, Y&H asthma dashboard

22. Long term conditions II – Asthma in adults Asthma – re-admissions Readmissions data indicates the extent to which a patient’s health need is met and managed prior to hospital discharge. The median length of stay for asthma complaints in NHS Bradford & Airedale was the lowest in the region, however the readmissions ratio is the highest; NHS North Lincolnshire has the lowest readmissions ratio in the region but the longest length of stay. There also appears to be a weak positive relationship between the admissions and readmissions ratios within PCTs. Commissioners should consider these data together to understand the outcomes for patients after their first hospital admission, and whether more pro-active action in primary and community settings could be taken to avoid re-admissions. 22 Standardised readmissions ratio Asthma UK, Y&H asthma dashboard Comparison of standardised admissions and readmissions ratios

23. Long term conditions II – Asthma in adults Asthma – emergency bed days The rate of emergency bed days for asthma across Yorkshire & the Humber is greater than the national average, and there is more than two- fold variation across PCTs. North East Lincolnshire has the lowest emergency bed days rate in the region and the lowest rate compared to expected, they also have the highest median length of stay. PCTs should consider the relationship between non-urgent and emergency care to establish the secondary care management of asthma for patients in their region. 23 Emergency bed days for asthma per 1,000 population (standardised rate) NHS Comparators, The NHS IC Y&H England

24. Long term conditions II – Asthma in adults Asthma – Ambulance trust performance The Care Quality Commission use two asthma related indicators in assessing ambulance trust performance. These are the proportion of patients with suspected asthma who have peak flow recorded before treatment, and the proportion of patients with suspected asthma with spot oxygen saturation recorded before treatment. Yorkshire Ambulance Service performs close to the national average on these measures, achieving 50% on peak flow measurement and 85% on the oxygen saturation measurement. 24 Proportion of patients with suspected asthma with peak expiratory flow recorded before treatment Proportion of patients with suspected asthma with spot oxygen saturation (SP02) recorded before treatment

25. Long term conditions II – Asthma in adults Emergency admissions – underlying drivers of variation 25 There is considerable variation in the standardised emergency admission ratios (SAR) for asthma across GP practices in Yorkshire and the Humber. We have carried out practice level regression analysis to understand the key drivers of this variation. In descending order, the following factors explain 31.0% of the variation in the emergency admission rates for asthma across the region: * Deprivation as measured by the Indices of Multiple Deprivation 2007 * The rating of doctor in asking patients about their symptoms * The percentage of patients with a LTC who report that they definitely or to some extent received enough support to manage their LTC according to the GP Patient Survey * Prevalence of smoking among patients with a LTC * Number of GPs per 1000 patients registered at the practice

26. Long term conditions II – Asthma in adults Emergency admissions – underlying drivers of variation 26 While the circumstances will inevitably vary locally, commissioners and GPs with high rates of emergency admissions will want to consider which of these factors might apply to their patients, and what mitigating actions could be taken to tackle emergency admissions.

27. Long term conditions II – Asthma in adults Asthma – options for action 27 There are a range of actions that could be taken locally to improve the way care is managed, these include the following: Increasing the use of personalised asthma self management plans, and the number of staff trained to support people in self management. Improving staff training, including increasing familiarisation with the British Guideline on the Management of Asthma. Reviewing the percentage of patients who are on inhaled corticosteroids when leaving hospital following an acute admission. Reviewing patients within seven days following discharge relating to an acute admission for asthma.

28. Long term conditions II- Contents Overview Asthma in adults Neurological conditions Annexes Contents 28 Neurological conditions

29. Long term conditions II – Neurological conditions Overview – long term neurological conditions Around 8 million people in England have a neurological condition. There are a large number of conditions and the precise cause of many is unknown. It is estimated that 350,00 people in the UK need help with the activities of daily living because of a neurological condition and 850,000 people care for someone with a neurological condition. There are a wide range of neurological conditions (over 60)which can be both progressive and non progressive. Whilst there are some synergies between these conditions, most tend to have specific needs and specialist requirements across health and social care. 29 Spend on chronic neurological conditions per 1,000 population, 2007/08 and 2008/09 Programme budgeting toolkit, Department of Health This section of the pack focuses on: Epilepsy, Multiple Sclerosis(MS), Motor Neurone Disease (MND)

30. Long term conditions II – Neurological conditions Overview – All conditions: service provision Long term neurological conditions consume a significant proportion of NHS resources, in 200/09 PCTs in Yorkshire & the Humber spent almost £363m on neurological conditions, representing 4% of total programme budget expenditure. Neurological conditions are the third most common reason for seeing a GP and account for 20% of acute hospital admissions. There were over 136,000 elective and almost 168,000 emergency admissions for LTNCs in Yorkshire & the Humber in 2009/10. Commissioners with high emergency admissions, should consider the specialist community neuro-rehab teams are available, and whether this service could be used to improve control of the condition. 30 Elective and emergency admissions for long term neurological conditions, standardised rate per 1,000 population, 2009/10 The NHS IC, NHS Comparators

31. Long term conditions II – Neurological conditions Overview – All conditions: service provision The mean length of stay in hospital for an individual with a long term neurological condition is 10.9 days in Yorkshire & the Humber, comparable to the national average and more than twice as long as those admitted with any other condition (4.4 days). In Doncaster, patients with an LTNC stay on average almost 3 times longer than other patients, Barnsley has the lowest ratio with LTNC patients staying twice as long as others. 31 Number of times longer a patient with an LTNC will stay in hospital than those with all other admissions, 2009/10 The NHS IC, NHS Comparators

32. Long term conditions II – Neurological conditions Epilepsy - overview Epilepsy is common: around 1 in 100 people have the condition. Epilepsy is defined as the recurring tendency to have seizures. Many more people will have single or provoked seizures but will not be diagnosed with epilepsy. Only 52% of people with epilepsy live seizure-free, it is estimated that 70% of people could be seizure free with the right treatment. Misdiagnosis rates in the UK, where a diagnosis of epilepsy is incorrectly made, are between 20 and 31%. As a result, there are estimated to be over 100,000 people with a diagnosis and receiving anti epileptic drugs who do not have the condition (Joint Epilepsy Council) 32 Epilepsy prevalence by age group Source: The Joint Epilepsy Council Reported vs expected prevalence of epilepsy (over age 18), 2008/09 The NHS IC, NHS Comparators

33. Long term conditions II – Neurological conditions Epilepsy - overview Epilepsy has implications for the potential for people to live a full life – people with epilepsy are less likely to be employed or be able to drive. 1 in 5 people with epilepsy will also have learning disabilities. Across Yorkshire and the Humber there is significant variation in the years of life lost associated with epilepsy. North and North East Lincolnshire, Doncaster and Rotherham have the highest estimated rates of years of life lost. 33 The NHS IC, NHS Comparators Years of life lost due to mortality from epilepsy: directly standardised rate per 10,000 population under 75 years, 2006-2008 A key challenge facing epilepsy services nationally is the high rate of misdiagnosis. Estimates suggest that misdiagnosis in is the region of 20-31% in England. The Joint Epilepsy Council estimate the costs of misdiagnosis to be in the region of £145m nationally.

34. Long term conditions II – Neurological conditions Epilepsy – prescribing costs 34 Organisations across Yorkshire and the Humber spends close to £40m per annum on epileptic drugs. The increase over the last financial year was around 10%. There is significant variation in the rates and costs of prescribing varies significantly across organisations in the region. Note: Gabapentin and pregabilin which together account for around 30% of prescribing frequency are also used for neuropathic pain as well as epilepsy.

35. Long term conditions II – Neurological conditions Epilepsy – medicines review 35 Reviewing epilepsy patients medication can be important to ensure that the effective and appropriate treatment is being provided. Across Yorkshire and the Humber there appears to be a weak but positive association between the proportion of people receiving a review of their medication and the proportion on a practice list that have suffered a seizure in the last 12 months. Commissioners and GPs with epilepsy patients with high rates of seizure should consider whether medicines reviews should be carried out more routinely to improve seizure control. Source: The NHS IC, Quality & Outcomes Framework, 2009/10 Percentage of patients on drug treatment who have been seizure free in the last 12 months Proportion receiving medication review in last 15 months Proportion seizure free in last 12 months

36. Long term conditions II – Neurological conditions Epilepsy – emergency admissions The rate of emergency admissions related to epilepsy per 1,000 population is slightly higher in Yorkshire & the Humber (0.8) than the national average (0.7). There appears to be a relationship between epilepsy prevalence rates and emergency admissions across PCTs. Doncaster seems to be an outlier with relatively high prevalence but a lower than average emergency admissions rate. The regional mean length of stay following emergency admission for epilepsy is close to the national average. There is a 60% variation in the average length of stay across the region. 36 Comparison of epilepsy prevalence (%) and Emergency admissions for epilepsy per 1000 population 2009/10 Mean length of stay (emergency admissions) 2009/10 Y&H England

37. Long term conditions II – Neurological conditions Epilepsy – potential actions There is significant variation in the rates of seizures and emergency admissions for epilepsy. Some of this is due to underlying prevalence – epilepsy is more prevalent in lower income groups, older age groups, vascular disease and older age groups, however unwarranted variation can be caused by appropriateness of clinical management and differences in the control of the condition. Possible options for action include: Review patients’ prescriptions once a year Identifying approaches to improving patient concordance with prescriptions Establish local epilepsy services to enable not only the identification of people who have epilepsy but also the differentiation of people who have serious brain disorder. 37

38. Long term conditions II – Neurological conditions Multiple sclerosis - overview Around 100,000 people in the UK have multiple sclerosis (MS); it is the most common disabling neurological condition affecting young adults. The condition is most commonly diagnosed in people aged 20 – 40 and women are almost twice as likely to develop it as men (Multiple Sclerosis Society). 38 Source: Health Technology Assessment 2002, vol.6, No 10, Richards et al Proportion of all MS cases by age and sex There is little data determining the baseline prevalence of MS in England. A study in Leeds in 1996 reported prevalence of 75 cases per 100,000 population. However, relative to other areas this is unusually low. Based on the General Practice Research Database national prevalence was estimated to be 102 cases per 100,000 population in 1991. the proportion of missed cases is estimated to be between 10% and 20% (Source: Health Technology Assessment 2002, vol.6, No 10, Richards et al). Incidence of MS is estimated to be 3.5 per 100,000. http://www.hta.ac.uk/fullmono/mon610.pdf

39. Long term conditions II – Neurological conditions Multiple Sclerosis – elective admissions There are fewer elective admissions for MS in Yorkshire & the Humber per 1,000 population than the England average. However, there is 6-fold variation across the region, with 0.2 admissions per 1,000 in Kirklees compared to 1.2 in East Riding. The tariff price for elective MS admissions is £1,293. There is also wide variation in the mean length of stay across PCTs in the region; the average is 2.5 days less than the England average. The long stay trim point is 10 days, the mean length of stay in Sheffield is greater yielding additional bed day payments for the average patient. 39 Elective admissions, MS and demyelinating diseases 2009/10 Mean length of stay for inpatients, MS and demyelinating diseases 2009/10 Y&H England

40. Long term conditions II – Neurological conditions Multiple Sclerosis – emergency admissions Across PCTs in Yorkshire & the Humber there are 0.1 emergency admissions per 1,000 population. There is however wide variation in the rate of emergency admissions compared to the expected level based on national activity. In East Riding there were almost twice as many emergency admissions as expected, there were nearly 40% fewer in Doncaster. The tariff price for non-elective Multiple Sclerosis is £3,039. There is almost 5 fold variation in the non-elective mean length of stay for MS across PCTs. 40 Ratio of actual to expected count of elective admissions, 2009/10 Mean length of stay emergency admissions, MS and demyelinating diseases 2009/10

41. Long term conditions II – Neurological conditions Motor Neurone Disease - overview MND is a rapidly progressive, fatal disease, the cause is unknown and there is no known cure. The highest incidence is amongst people aged 50 – 70; most people diagnosed are over 40. In contrast to MND, men are more commonly affected by MND than women, the ratio of men: women affected is 3:2. Based on estimates of national incidence and prevalence rates derived in 2003; there are estimated to be over 3,600 people living with MND in Yorkshire & the Humber in 2010 (prevalence rate of 7 per 100,000). The number of cases per PCT varies from 10 to 60 dependent on the size of the population. There are estimated to be over 100 new diagnoses of MND in the region each year, the incidence rate has been estimated at 2 per 100,000. 41

42. Long term conditions II – Neurological conditions Motor Neurone Disease – elective admissions In 2009/10 there were just over 2.3 admissions per 100,000 population in Yorkshire & the Humber, compared to 2.8 nationally. Given the low volume of patients and nature of the condition there is wide variation in mean length of stay across PCTs in the region. 42 Mean length of stay elective admissions, MND & spinal muscular atrophy 2009/10

43. Long term conditions II – Neurological conditions Motor Neurone Disease – emergency admissions Nationally there were less than 1,000 emergency admissions relating to MND in 2009/10. There were a total of 15,301 bed days for MND in England however there were 16.5% more bed days in Yorkshire & the Humber than expected based on national data. Compared to other neurological diseases, MND is the third highest cause of death, accounting for 1 in almost 500 deaths in 1996. 43 Mean length of stay emergency admissions, MND & spinal muscular atrophy 2009/10

44. Long term conditions II – Neurological conditions MND – providing effective services In 1995 the MND association established the Care Centre Programme, there are 17 centres, including 1 in Leeds. Best practice care for MND patients requires a co-ordinated multi-disciplinary and holistic approach to care management. MND is not a common condition, General Practitioners may only see 1 or 2 cases in their entire career. However, people with MND have high health care service requirements, Care Centre teams provide specialist support for local more generalist services. (NHS Evidence). NICE GUIDELINES Respiratory muscled weakness resulting in respiratory impairment is a major feature of MND and is a strong predictor of quality of life and survival. Non-invasive ventilation can improve symptoms and signs related to respiratory impairment and hence survival. The latest NICE guideline contains recommendations for the use of non-invasive ventilation for MND patients (http://www.nice.org.uk/nicemedia/live/13057/49885/49885.pdf). 44

45. Long term conditions II- Contents Overview Asthma in adults Neurological conditions Annexes Contents 45 Annexes

46. Long term conditions II – Annexes Contacts Colin McIlwain – Associate Director, Care Partnerships, NHS Y&H Colin.McIlwain@yorksandhumber.nhs.uk Ian Holmes – Associate Director, Economics and System Management, NHS Y&H Ian.Holmes@yorksandhumber.nhs.uk Jake Abbas – Deputy Director, YHPHO Jake.abbas@york.ac.uk 46