1. Find out more online: www.worcestershire.nhs.uk Improving the quality of respiratory care Dr Felix Blaine

2. Find out more online: www.worcestershire.nhs.uk West Midlands Quality review service Long term conditions ● Personalised Care ● Primary Care development ● Primary care Guidelines ● Early identification and case finding ● Risk stratification ● How do the CCG’s know they are commissioning quality services

3. Information & Education for patients Assessment & Diagnosis 1. Diagnosis Management of stable COPD 3. Inhaled and oral therapies 4. Annual Comprehensive Assessment 5. Smoking Cessation Support 6. Pulmonary Rehabilitation Oxygen Therapy 8. Initial assessment for LTOT 9. Review of long- term oxygen therapy Exacerbation of COPD 7. Management of exacerbations 10. Care in hospital11. NIV in hospital 12. Review within 2 weeks of discharge Palliative care 13. Palliative care 2. Management planning

5. Find out more online: www.worcestershire.nhs.uk 2012/13 COPD LES ● Formalised annual reviews ● Develop use of written action plan ● Ensure a reduction in variation in quality ● Spirometry audit ● Review on discharge ● Flexible approach to education ● Prevalence – link to FEV6s

6. Find out more online: www.worcestershire.nhs.uk The role of the WRST ● Develop the role of practice nurses within the CCG ● Support staff within primary care ● Reduce variation within primary care

7. Find out more online: www.worcestershire.nhs.uk The role of the WRST ● Mentor nurses through courses and secure funding for them ● Skills need analysis with further in house training as needed ● Admission rates with discussion re frequent flyers ● Draw attention to ICS spend and discuss medication guidance for both COPD and asthma ● Help with coding ● Action plan training with guidance on stepping up and down ● Spirometry support inc. CQC requirements, training and interpretation training and further support for difficult readings ● Email and telephone support on any aspect of respiratory care ● Provided info re oxygen and rehab inc. referral pathways ● Update data base of nurses in Worcester who have and use the asthma and COPD diploma ● Signpost resourses, i.e. asthma UK, BLF and PCRS etc ● Sit in with nurses running clinics to give feedback and assist with skills and knowledge gaps. Build confidence. ● Discuss both LES's and their requirements with Practiced Managers and GP's

8. Find out more online: www.worcestershire.nhs.uk Course title How many attended? Spirometry training Oct & Nov 2012 43 Asthma LES and Self-management Plan January 2013 23 CBT quit smoking, exercise & encouraging better health for GP’s January 2013 12 Diploma In COPD 6 Diploma in Asthma 10 Diploma in Spirometry 14 + 3 Degree students Support for education

9. Find out more online: www.worcestershire.nhs.uk Education for Health Online modules ● Performing Spirometry ● Interpreting Spirometry ● Asthma action plan

10. Find out more online: www.worcestershire.nhs.uk End of Life Care

12. Potential Savings £0.00£57,281.20£117,674.14£182,278.52£250,722.68£323,009.53

14. Find out more online: www.worcestershire.nhs.uk Emergency admissions for Chronic asthma in our Strategic Health Authority in 2011/12. The blue bar is Worcestershire.

15. Find out more online: www.worcestershire.nhs.uk GOLD Guidelines on co-morbidities ● Ischemic Heart Disease ● Atrial Fibrillation ● Heart Failure ● Osteoporosis ● Anxiety and depression ● Lung cancer ● Diabetes

16. Find out more online: www.worcestershire.nhs.uk Asthma ● Guy’s and St Thomas’s: reducing A&E readmissions ● Mid Yorkshire hospital: Asthma discharge bundle ● Durham dales CCG: local pharmacists and MUR’s

17. Find out more online: www.worcestershire.nhs.uk COPD ● Southampton: finding the ‘missing millions’ Focus on patients with multiple admissions ● Imperial College Health Care trust: COPD Discharge bundle

18. Find out more online: www.worcestershire.nhs.uk Clinical commissioning: Improving the quality of care ● Case Finding ● New Diagnosis ● Annual Review ● Review after admission ● Commissioning services

20. Find out more online: www.worcestershire.nhs.uk Case Finding ● Opportunities where case finding can be undertaken: ●Smoking cessation clinics ●NHS health checks ●Lung age ●Asthma review ●IT screening ( eg smokers over 35) ●Smokers who are having inhalers ( asthma possible list) ●Winter chest infections GP can do FEV6 reading ●Poster in surgery

21. Find out more online: www.worcestershire.nhs.uk COPD case finding tool PracticeList SizeRegisterPrevDif NatDif PCTDif GrpPPPValueAdd 0% PossiblesPoss PrevPoss Extra Abbottswood Medical Centre 101651561.53%-0.07%-0.01%0.00%£221.34£6,640.331.53%£0.00101.63%£425.66 Spring Gardens150142451.63%0.03%0.09%0.10%£347.62£10,428.721.63%£0.00201.77%£851.32 Stourport Health centre 83761692.02%0.42%0.48%0.37%£239.79£7,193.692.02%£0.00302.38%£1,276.99 Each additional patient is worth £42.56

22. Find out more online: www.worcestershire.nhs.uk The ‘New patient’ ● CONSISTENCY Each patient has the same care. How would you organise the surgery to ensure each patient gets the same? ● ● Spirometry results - are they accurate? How do you ensure that? ● Accurate interpretation- trained to interpret? ● History and examination ● Other tests- x ray and bloods? ● Receiving diagnosis- who does this? ● Initial education ● Smoking cessation. All done with same team? ● Treatment according to condition ● Written information- ‘what to expect at review’

23. Find out more online: www.worcestershire.nhs.uk The Annual Review ● Letter to patient asking to attend review. What does the letter say? Does it explain why they need to come /bring inhalers /’what to do if you are ill’ information / what to expect at review. ● Inhaler technique ? step down treatment. Pharmacy review. In check device ● Exacerbation review- teaching self medication at home ● Education review ● Importance of exercise ● Management plan ● Personal care plans ( more than exacerbation care) ● Rehab- For all? ● Reduce cancellations by ensuring they attend for review regardless of exacerbations ( high DNA rate) ● Anxiety and depression ● Annual bloods- cardiovascular risk ● Home visits. Should care for ALL ● Severity score. Who alters this?

24. Find out more online: www.worcestershire.nhs.uk Review after admission ● Review after admission or A@E attendance ● ● Who follows up? When? ● How long is appt? ● The ‘story’ from the patient re reason for admission ● Check care plan. ● Inhaler technique- check again? Are the taking meds? ● Early warning signs? ● Managing cause of admission if not respiratory related ie anxiety ● Are all of the above CONSISTENTLY achieved? ● ● What happens after the third admission? ● ● ?? Consultant Management Plans

25. Find out more online: www.worcestershire.nhs.uk Commissioning respiratory services ● What are our priorities?

26. Find out more online: www.worcestershire.nhs.uk Summary