How to win friends and influence people - A whole systems approach to improving care in COPD June Roberts Respiratory Nurse Consultant Margaret O’Dwyer LTC Commissioning Lead Nawar Bakerly Consultant Respiratory Physician

Deprivation and the health gap in Salford NWPHO Health priorities 2006

LAIA, 1996 Standardised mortality ratios By District Health Authority in England and Wales and Health Board in Scotland, Age 65+, Source: Office for National Statistics (ONS) & General Register Office, Scotland < >130 menwomen Salford - SMR respiratory Prevalence of respiratory disease - Smoking prevalence - Number of COPD admissions - LOS for COPD admissions All above national average Impact of COPD

Inability to do anything Isolation Alienation Restriction Low morale and depression Low confidence and self esteem Impact of COPD on patients and carers

Drivers for change NHS plan Accessibility Partnership working Co-production LIFT developments SART Joint targets Joint appointments

Starting Points Gather National and local data Key stakeholder engagement What services have we got? What services do we need?

Health Needs Assessment and Benchmarking Retrospective cross sectional analysis of pooled data from COPD database, QMAS, Dr Foster, NWRHA Establish actual and predicted prevalence of COPD across Salford and within PBC clusters Establish baseline levels of severity of COPD across Salford and within clusters according to FEV 1 % predicted (NICE 04), hospital admissions and LOS Map severity of COPD to IMD at PBC cluster level Use data to inform service redesign Roberts J and Diar Bakerly N, Thorax 2008

Providers of acute care for Salford Patients 2006/7

Acute COPD Admissions (SPCT)

Associations between IMD and COPD at cluster level OutcomeIMD IMD & QOF prevalence N=8 r = 0.76 p = 0.02 % patients with severe COPD (FEV 1 <30%) r = 0.46 p = 0.25 Unscheduled admission rater = 0.26 p = Length of stayr = 0.18 p = 0.20 Pearsons’s correlation coefficient

QOF vs predicted COPD prevalence* * According to model described by Nacul et al (2007), Population Health Metrics 2007, 5:8 doi: /

Patients Home Secondary care Primary care Patients in control and at the centre of their care

Stage 1a Primary Care Primary prevention Health promotion and education Stage 1b General Practice Accurate diagnosis Spirometry screening of high risk patients in community and general practice Accurate performance and interpretation of spirometry COPD register Stratification of disease severity: mild, moderate, severe Referral pathways to specialist support for diagnostic difficulty Stage 2 General Practice Treatment and management of stable disease Salford COPD treatment pathway/ NICE guidelines to optimise treatment Vaccination POINTS templates to guide management Specialist medication reviews by community pharmacist Self management education and written individualised action plans Anticipatory care Knowledge and support for carers Stage 3 Enhanced General Practice and community specialist services Complex / severe disease Case management by appropriate case manager (generalist ACM or Respiratory Nurse Specialist) Telehealth/ virtual ward Community specialist service and clinics with MDT support (including physiotherapy, psychology, oxygen) Non Invasive Ventilation Planned hospital admission for those who need it Stage 4 Specialist and generalist community, hospital and OOH services Unscheduled care Admission avoidance through intermediate care Hospital admission Supported discharge to reduce LOS via CAST/ RNS or intermediate care Pathways post admission follow up Stage 5 Specialist and generalist community and hospital End of life care Gold Standards Framework Prognostic indicators for primary and secondary care Specialist support Referral pathways Treatment and management Pulmonary Rehabilitation Admission avoidance Salford COPD Team – Integrated Care Pathway Smoking cessation, health promotion and self care Co-ordinated social care Supportive and palliative care Education and clinical support Information and Clinical Audit Salford COPD integrated care pathway

Cluster 7 Cluster 5 Cluster 8 Cluster 4 Cluster 6 Cluster 1 Cluster 3 Cluster 2 LIFT Centres Community COPD clinic ESDT follow up clinic Home oxygen team Pulmonary Rehabilitation GP practice sites of community COPD clinics

Results

COPD Prevalence

Smoking rates N= 3417 N= 2995

COPD severity Classified by FEV1% predicted (NICE 2004) N= 2157 N= 1781

Percentage recorded MRC score

Pharmacological management - severe airflow obstruction

Number of Acute Admissions Annually (ICD-10) SPCT 792 admissions

LOS for Acute COPD Admissions - SPCT 6.9 LOS

Cost of COPD Admissions (HRG) SPCT £167,000 saving

Lessons Learned Use local data and make sure it is accurate -involve local clinicians Continually engage with key stakeholders - make good links with PBC groups Develop a strategy and services based on local health needs Make business cases evidence based and financially sound Posts that span primary and secondary care are worth considering You may already have the bones of good service – it may just need vision and leadership to pull it together

Mary’s story