Transforming outcomes for people with lung disease in England Dr Robert Winter Medical Director, NHS East of England and Joint National Clinical Director for Respiratory Disease The approach

Staying healthy Mental health Children’s health Planned care Long term conditions Acute care Acute care Acute care Acute care Acute care Acute care End of life care Maternity and newborn COPD – the need for improvement 5th biggest cause of death and rate exceeds many other EU countries 2nd most common cause of emergency admission One of the most costly, in terms of acute care (£930m) Total cost to UK £3900m 170,000 prescriptions for oxygen Inhaler therapy in top 3 drug costs

Mortality Specialist care NIV EDS/LOS Quality standards – self scores End of Life Care Primary Care NCROP 2008, evidence of massive unexplained variation

COPD mortality varies between PCTs providing healthcare to similar populations Indirectly standardised mortality rates from bronchitis, emphysema and other COPD (ICD10 J40-J44) Compared PCTs in same deprivation decile before aggregating nationally

Clinical leaders and leadership within local communities Paul Corris Sharon Haggerty John White Mike Ward Jane Scullion Dermot O’Ryan John Williams June Roberts Stephen Gaduzo Colin Gelder Sandy Walmsley Steve Holmes James Calvert David Halpin Maxine Hardinge Jo Congleton Jo Wookey Julia Bott Tony Davison Leanne Jongpier Louise Restrick and team Design and create a local structure Interact with the improvement projects Develop links with interrelating work streams e.g. QIPPS, LTCs etc Engage with local community to develop Communities of Practice Maria Read

6 2008/2009 APHO ONS Cluster Average – Each diamond represents a disease category and shows spend and outcomes compared to the cluster average Knowsley has higher spend and worse outcome for Respiratory problems when compared to similar PCTs Mortality from bronchitis under 75s

7 Knowsley has an above average expenditure on respiratory problems when compared to PCTs within its SHA Respiratory Programme Expenditure £million per 100,000 weighted population

Years of life lost due to mortality from bronchitis, emphysema and other COPD Directly age-standardised rate per 10,000 population, less than 75 years, all persons Knowsley has the highest rate of years of life lost due to mortality from COPD of all similar PCTs

9 Hospitalisation: Respiratory system problems. All non-elective admissions, indirectly age-standardised rate per 100,000 population, all ages FY 2007/2008 Knowsley has the highest number of non-elective admissions when compared to similar PCTs

10 IVET: PCT inpatient expenditure for selected disease/intervention compared to a user defined benchmark. Knowsley would reduce spend to the national average through a reduction in inpatient activity of 1,284

‘Doing the same thing over and over again and expecting different results’ Albert Einstein COPD – EXACTLY THE SAME THING YEAR AFTER YEAR Insanity….

 Patients in the frequent admission group (3 time in past 12 months) have an almost 60 per cent chance of admission during the following winter, compared to just a 10 per cent chance for those with one previous admission.  85 per cent of COPD admissions during the winter peaks have had no recorded admission in the previous 12 months. These account for about 90 per cent of the rise in admissions during winter.  This means that to reduce hospital admissions all COPD patients must be reached, not just those at high risk. COPD…..

Transforming care in COPD  Admission avoidance  Prompt access to assessment and treatment 7/7  Access to specialist respiratory care in community  Prompt admission when required  Specialist respiratory care in hospital  Safe oxygen therapy  Early measurement of blood gas status  Prompt access to NIV  Optimal management of co-morbid conditions  Early supported discharge and hospital at home

National Improvement Projects ; objective evidence of quality matched to productivity and value Accurate Diagnosis Transforming Acute Care Oxygen Chronic Care/Self-Management End of Life Pulmonary Rehabilitation Soon to be announced: Asthma

Admission avoidance Rice KL et al. Am J Respir Crit Care Med 2010; 182(7): Epub 2010 Jan patients with severe COPD Intervention group patients received a single education session, an action plan for self- treatment of exacerbations, and monthly follow-up calls from a case manager.

Integrated COPD care Outcomes in South East Essex Financial year07/0808/0909/10 Number COPD admissions Number COPD bed days 6,9695,9255,327 Cost per 9/10 PbR (saving) £2,141,259£2,067,171 (£74,088) £1, (£360,207) Saving from oxygen service £250,000 Total saving£610,207 Summary of key reductions in terms of reduction in emergency COPD admission, bed days and cost

How can we get there ? Working in partnership with others

Transforming care - what is required of clinicians From where we are… Variation in admission avoidance Variation in bed use Variation in outcome Generalist care 5/7 service No integration good local and regional hospital some excellent speciality services good clinical performance strong financial performance talented and committed staff respected clinical school leaders in biomedical research We need a spotlight on … patient experience healthcare-acquired infection communication effectiveness To where we want to be … The expert patient Personalised care - self management plan Admission avoidance Daily senior ward round High quality care by respiratory team Reduce unwarranted variation underuse, overuse, under co-ordination Improve outcomes for patients provide best value health care reduce waste, drive up quality Benchmarking to provide comparison across local healthcare services Health investment analysis with programme budgeting tools Striving for innovation and excellence