1. National ambition- Local action

2. NHS England was not responsible for the 2012 Health and Social Care Bill !

3. Health structures in England 2013

5. Support for CCGs CSUs SCN CCG Clinical Senates AHSN

6. Strategic Clinical Networks Focus on priority areas to improve outcomes and bring together users, providers and commissioners. Cancer Cardiovascular (inc Cardiac, Stroke, Diabetes ) Maternity and children Mental health, dementia and neurological conditions

7. SCNNHS IQ AHSNs PHE Intelligence centre

8. SCNNHS IQ AHSNs PHE Intelligence centre

9. AHSN SCN

10. Getting commissioners interested in Respiratory Disease Internal NHS England Priorities External drivers Local priorities

11. Read the business plan!

12. Total budget 2014/15 £98.4 billion CCGs£65.8 billion Primary care £12.3 billion Specialised services £13.5 billion + offender health, dental, pharmacy etc

13. “Targets an impediment to care” “Need more community hospitals” “European working time directive makes things difficult” “Financial rewards for adopting a healthy lifestyle” “Co-commissioning of primary care” Hospital generalists The NHS in 2014

14. Developing commissioning models Direct commissioning Highly specialised Co-commissioning with CCGs Collaborative CCG commissioning Local CCG commissioning

15. Reality check! Respiratory disease is not a priority (no SCN) Improvement work is now generic Review of SCNs unlikely Some support from SCNs & AHSNs Specialised commissioning is in difficulty Primarily have to work through CCGs

16. NHSE respiratory ambitions Drive more prevention and earlier diagnosis of respiratory disease Support better management of respiratory disease in primary care Provide tools and resources to support commissioners in driving quality improvement Ensure robust and transparent outcomes information. Empower patients with information to support choices about their own health and care

17. Pneumonia BTS care bundle45,000 COPD19,455 Prevention Earlier and accurate diagnosis Systematic acute and long term care Non-invasive ventilation Home oxygen therapy Correct use of acute oxygen therapy Pulmonary rehabilitation Opportunities to reduce respiratory PYLL

20. Long term conditions “House of Care” LTCs are those conditions that cannot, at present, be cured, but can be controlled by medication or lifestyle modifications.

21. Multiple LTCs South Somerset Symphony project

22. 80,000 deaths pa Late diagnosis Lack of priority 2011 Outcomes Strategy not implemented Low awareness Investment in better care is cost effective Inadequate pulmonary rehabilitation 21 Recommendations

23. Failure to seek help Failure to recognise worsening symptoms Poor disease education Adverse social and psychological factors Inadequate treatment with corticosteroids Overreliance on bronchodilators Lack of personal asthma plan Inaccurate death certification

24. NHS England’s response to NRAD Specialised commissioning for severe and difficult asthma National asthma audit Children and young persons work programme NRAD Implementation task group Electronic surveillance of asthma care (GRASP Asthma?) Acute care bundles and CQUINs Safety alerts around single LABA use National review template New guidelines and quality standards

25. National Breathlessness symposium 1 st July 2014 Diagnostic pathways & Generic approaches to treatment

27. Influencing CCGs and Primary Care Advice Senates, SCNs, AHSNs NHSIQ projects CCGOIS Local stakeholder networks HWBs Incentives and Levers CQUINs Quality Premiums QOF Enhanced services Contract sanctions Better Care Fund Marginal rates Readmission penalties Challenge and support Value Patient power

30. Identifying variation

31. Tools for clinical improvement in COPD

32. Delayed or inaccurate diagnosis 85% patients with COPD have had missed diagnostic opportunities up to 20 years prior to diagnosis Approximately 30% of COPD patients admitted to hospital have new diagnosis Almost 50% of patients in NRAD who died from asthma did not have the condition

33. Now and the future Now Delayed diagnosis Casual acceptance of symptoms Fragmented commissioning Inadequate rehabilitation capacity Focus on admission avoidance Future Early case finding Electronic detection Risk reduction Intelligent commissioning Value based care Shared decision making Supported self management Rehabilitation capacity Access to expert care

35. The wall! Primary care Acute Trusts Family Medicine Expert Care

38. Glenfield pulmonary rehabilitation programme 1993-2011

39. Improving rehabilitation capacity Community programmes Telehealth (remote) solutions Home based:- Personal Telephone coaching Paper manual Internet Tablet

40. Quality?

41. What makes PR effective?

42. Where can respiratory SCNs make a difference? Working with CCGs to develop local strategy Early diagnosis New commissioning models (system wide) Acute CQUINs (COPD, Asthma, Pneumonia, Smoking cessation) Generic diagnostic/therapeutic approach to breathlessness Improving rehabilitation capacity IPF, OSA etc Quality assurance

43. Reasons to be cheerful! CQUINs for pneumonia etc National Asthma audit (after NRAD) NCROP National TB Strategy Expanding specialised commissioning Breathlessness campaign Diagnostic spirometry regulation Clinical service accreditation Respiratory Alliance (Futures) ( Portal, IMPRESS, INHALE ) Local Health Community Strategic Plans