Respiratory disease programme for Darlington : a catalyst for change. Dr Basil Penney Sr. Claire Adams Darlington CCG Respiratory Leads

 Landscape of health care is changing rapidly  The burden of chronic disease  The pursuit of value in healthcare provision  New ways of working with other partners in commissioning services that meet the needs of the local population.  Financial constraints  Primary care will need to change Respiratory disease programme for Darlington : a catalyst for change.

 Embed the concept of making every contact count in all practices and develop practice pathways for smoking cessation  Encourage a culture of reviewing activity, sharing best practice and professional development across practices  Commission a smoking cessation service for Darlington  Guidance/support for practices to help identify ‘missing millions’ for COPD-through implementation of IT targeted searches and development of a diagnostic pathway in primary care  Develop a breathlessness pathway in primary care  Develop a “quality assured “ spirometry pathway in each practice  Development of “an expert in inhaler technique” in every practice  Help to set up processes in practice for ensuring review of patients following Asthma or COPD exacerbations  Effective template working  Tips on reviewing those with a diagnosis of COPD/asthma against the background of multiple co-morbidity  Promotion of value based interventions eg pulmonary rehabilitation, influenza vaccination.  Identification and implementation of value –based medication changes where it is safe to do so.  Implementation of actions for primary care set out in National Review of Asthma Deaths  Effective stepwise Asthma management (identifying possible ‘stepping down’ based on high dose ICS)  Offer to provide general respiratory update to clinicians (GP and nurses)  Development of agreed commissioning intentions for Darlington Objectives are derived from assessment of the NEQOS report on COPD and NRAD report on asthma deaths

 For a long time practices have been working in silos on disease specific targets generated by QOF. In Darlington Respiratory Team (DART) we have been able to come together to develop pathways of care, which have been successful.   We have also tackled variation, which is often a sensitive issue and underpins a lot of variables including how we work in practice and the different populations we serve. While people are very busy in their practices dealing with their own patients, it is often difficult for them to see and question what they are doing in their own practice let alone see their role in a wider community of practices and the CCG.   Our experience with variation in spirometry use within and between practices has demonstrated the need to work with practices individually, with a view to developing collective visions on pathways, efficiencies and sharing best practice.  The development of a culture that questions the heart of what we do will serve to facilitate change and encourage greater involvement in commissioning.   COPD is an exemplar for LTC’s and challenges our approach to prevention, diagnosis and management in the acute and chronic setting. Patients with COPD are responsible for significant healthcare expenditure by virtue of the high numbers of COPD patients being admitted to hospital. 50% of COPD patients have 3 or more co-morbidities.  Asthma on the other hand is the commonest LTC in children.   This programme would have a number of streams interlinked with the agenda for co-morbidities, self-management and prevention (smoking cessation).  The outline of objectives are derived from our assessment of the NEQOS report on COPD (Appendix B) and NRAD report on asthma deaths (Appendix C)

Barnett K et al;Lancet 2012; 380: 37–43

 LTC agenda-demand v resources  Co-morbidities  Holistic v disease specific 14-18% of people with COPD only have COPD and when actively assessed for co-morbidities it may be as low as 3%  Breathlessness is mentioned as a reason for encounter in primary care in about 1% of the recorded consultations in general practice  Primary care agenda Why breathlessness?

Practice Name Whinfield 34 Orchard court 0 Moorlands 13 Neasham Road 38 Carmel 36 Blacketts 0 Cliffton Court 0 Denmark Street 45 Rockliffe Court 6 Felix House 9 Parkgate Surgery Diagnostic spirometry / year-data from 8 practices DIAGNOSTIC SPIROMETRY APRIL- JULY 2014

Breathlessness Questionnaire-49 /79 response

 Under use of CXR  Lack of recognition of role anxiety/depression  Understanding of Guidelines  Role of HCA  Spirometry taking up to 6 weeks(variation)  Underuse of microspirometry 3 case studies of breathlessness

CONCLUSIONS: Pre-bronchodilator microspirometry seems to be able to reliably preselect patients for further assessment of airflow obstruction by means of regular diagnostic spirometry. However, use of microspirometry alone would result in overestimation of airflow obstruction and should not replace regular spirometry when diagnosing COPD in primary care. npj Primary Care Respiratory Medicine (2014) 24, 14033; doi: /npjpcrm ;

 Increase awareness of breathlessness  Code for breathlessness  Measure diagnostic activity- spirometry ; ECHO; BNP  New Diagnoses COPD and HF with breathlessness code  Adult Breathlessness Assessment Algorithm  Breathlessness Pathway?  Quality Assured Spirometry  GP to GP referral?  Community Clinics? Further Action

Unforseen Risk!