1. Overview of the respiratory medicine landscape

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4. 2016/17 NHS England funding £105.8 billion

5. NHS pressures Costs rising above income Fiscal environment
Health inflation
Fiscal environment
Trust deficits
Brexit
Expectations
Seven day services
New treatments
Safety & Quality
Demand
Demography
Social service cuts
In common with most health economies there are huge pressures on our health services at present. These include…..

6. 5 year forward view (October 2014)
Realistic financial analysis
Above inflation investment and 4% CIP
Focus on prevention and multi-morbidity
New models of care
Mixed models of delivery
Local prioritisation

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9. Where does respiratory fit in NHSE agenda?
Local priorities
New models of care and STP plans
Commissioning for value
Population level commissioning
Prevention agenda (smoking, obesity, physical activity)
Urgent and emergency care
Mental Health
Seven day services

10. Where does respiratory fit in NHSE agenda?
Local priorities *
New models of care and STP plans *
Commissioning for value *
Population level commissioning *
Prevention agenda (smoking, obesity, physical activity)
Urgent and emergency care
Mental Health
Seven day services

11. Why is COPD important to local commissioners?
A common long term disabling condition
Frequent cause of hospital admissions
Most cases remain undiagnosed in primary care
Many not diagnosed until admitted to hospital
Large variations in care account for avoidable mortality
Rehabilitation and self-management work
Integrated, anticipatory care is cost effective

13. “Integrated care can be defined as the best possible care for the patient, delivered by the most suitable health professional, at the optimal time, in the most suitable setting.”

14. Integrated care delivery
The Tower of Babel. Pieter Breugel the elder. 1593

15. Integrated care? No single definition
Multi component & multi disciplinary care
Co-ordinated care delivery structures
Vertical integration (primary/secondary care)
Health/Social Care
Triple integration Health/Social Care/ Local Government

16. Integrated care for COPD
Modular care
Provider co-ordination
Commissioning integration
Components
Care model
Clinical pathway
Co-morbidities
Vertical integration
Population level

17. The components of care for COPD (NICE 2010)
End of life
Care
Oxygen
therapy
Exacerbation
management
Rehabilitation
Supported
Self
Management
Smoking
cessation
Accurate
diagnosis
Patient
Co-morbid conditions
Cardiac
Metabolic
Nutritional
Osteoporosis
Anxiety/depression
Bronchiectasis
Lung cancer
Asthma (ACOS)
Drug therapy

18. Key points on multi-morbidity
In general, the presence of comorbidities should not alter COPD treatment and comorbidities should be treated as if the patient did not have COPD.
Assess frailty and develop a tailored approach

19. Are specialists a barrier to progress?
Provider co-ordination
(Care models and vertical integration)
Hospital specialists
General practitioners
Are specialists a barrier to progress?
It is worth asking the question as to whether the way that we currently work as specialists is impeding or assisting the process. At present and for most of us there has been a historical barrier between reactive hospital based specialists and the general practitioners who refer patients. This is not the model that exists in other arguably more effective countries where patients have better access to specialist advice and specialists have a greater presence in the community.

20. The patient wants a specialist The system needs generalists
Delivery system design
Who wants what?
The patient wants a specialist
The system needs generalists

21. Whole community responsibility?
So in the future I see that every respiratory specialist should have some role out of hospital and feel some responsibility for the community in which they live and work. A specialists work should not be confined by the artificial boundaries of institutions.

22. Enhancing the skills of GPs and other health care professionals
Outreach clinics jointly staffed by hospital consultants and other health
care professionals
Consultant-run and telephone helplines
Consultant participation in multidisciplinary team (MDT) meetings
Consultant-run education sessions
Consultants supporting staff to work in extended roles
Redesigning the workforce
Integrated consultant roles that span hospital and community settings
New roles for nurses and other allied health professionals
GPs with Special Interests
Redesigning the work
I would argue however that we need to go further than the traditional models of community working. Some of this was outlined in the Kings Fund report on out of hospital working that incidentally did use the integrated respiratory team from the Whittington as an example.
In particular they emphasise joint working and knowledge transfer between primary and secondary care and the development of new roles in both.
However, the thing that I don’t thing that we are doing well at the moment is involving commissioners in the development of new ways of working and redesigning care pathways. They recommend relationships between providers and commissioners should follow the Atul Gawande approach and be more like a pit crew than a cowboy (I think I know what that means)
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23. Settings of care for COPD
Primary care
Community services
Hospital
Case finding
Diagnostic spirometry
Uncomplicated COPD
Influenza immunisation
Risk reduction
Smoking cessation
More complicated COPD
Pulmonary rehabilitation
Home oxygen assessments
Frequent exacerbations
Advanced COPD
LVRS
Respiratory failure
Diagnostic uncertainty

24. Population level commissioning
“Year of Care”
Stratification for:
Risk
Need
Service provision
Capitated budgets

25. STP footprint map
44 footprints
Av 4.8 CCGs
Av population 1.2m

26. Supporting STPs and CCGs
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27. Identifying variation

29. Influencing commissioners

30. ? Tools for clinical improvement in COPD Clinical guidelines
Quality standards
Implementation tools
Care bundles
Clinical audit
Service accreditation
Commissioning incentives
Better outcomes ?

31. National COPD audit programme

32. Audit and quality improvement incentives
Need to take account of New Models of Care
At present incentives are limited to individual providers rather than care pathways
CQUINs reward whole groups rather than the individual
BPT (capitated payment) can improve individual care along a whole pathway
Need to have on-going and timely audit in place to inform the QI process

33. Possible BPT for COPD
Patients with COPD exacerbation admitted to hospital should be:
Referred to and seen by a member of the Respiratory Team within hours of admission.
Seen by a Respiratory Consultant before discharge.
Provided with the COPD discharge bundle on transition from hospital.
Patients with COPD exacerbation and acidotic hypercapnea on admission who are suitable for NIV should:
Receive NIV within 3 hours of admission in a dedicated setting.

34. National “airway” audit
National asthma audit prioritised by NHSE
Development work ongoing by HQIP
Includes adults and children
Primary care in England currently excluded
Asthma and COPD will run together
Understand the crossover
Avoid damage to COPD programme
Continuous data collection
Linked to quality improvement
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