1. Commissioning the right COPD care for Londoners 7 November 2011 Royal College of Physicians

2. Case for change in London respiratory services

3. Our aim is to improve the experience of Londoners with COPD and reduce the impact of the disease NHS London Respiratory Team Funded by DH 2010-13 Clinically-led multi-disciplinary team (0.5 -1 day/week) Community and hospital health professionals Patient/carer voice and Programme Manager

4. Right Care Doing the right things … … and doing things right

5. Value Framework Health Outcomes Patient defined bundle of care CostValue = Health Outcomes Cost of delivering Outcomes Porter ME; Lee TH NEJM 2010;363:2477-2481; 2481-2483

6. What COPD 'costs' in London Spend £646m (or £17.m per pathfinder) on respiratory budget Including over £100m pa on COPD Plus £16m on lung cancer Respiratory programme budget expenditure up by average of 21% 2008/09-2009/10 Varies between 1/3 – 2/3 on secondary care Inpatient cost per person per year ~ £5,000

7. Admission rate varies 1.9-4.9 per 1000 practice population Q1 2009/10 2 nd highest cause of emergency admission Total bed days over 91,000 pa Average length of stay varies 4.9-8.6 days What COPD 'costs' in London

8. COPD ‘Value’ Pyramid What we know so far…. Cost/QALY Triple Therapy £35,000- £187,000/QALY LABA £8,000/QALY Tiotropium £7,000/QALY Pulmonary Rehabilitation £2,000-8,000/QALY Stop Smoking Support with pharmacotherapy £2,000/QALY Flu vaccination £?1,000/QALY in “at risk” population

9. Londoners dying from smoking ‘1 in 5 deaths due to smoking ’

10. Why Commissioners need to invest in Pulmonary Rehabilitation in London …. May 2011 Now?

12. Review of packs Q & A

13. Earlier Diagnosis and Stopping Smoking

16. Southwark PCT: Spend by practice ( £ per patient per year) on NRT + Varenicline

17. Stop smoking in inpatients CQUIN Enablers National VTE CQIN

18. Stop smoking in inpatients CQUIN proposal Numerator: all adult emergency and elective admissions from all specialities coded as F17.2 (narrative = dependent smoker, cessation advice given) Denominator: all adult emergency and elective admissions coded as F17.1 (if the narrative accepted by coders is patient asked and confirmed that they smoke)

19. Stop smoking in inpatients CQUIN proposal Target levels Expect numerator to reflect the adult smoking prevalence in the local community (rates will be PCT-based not catchment based). Suggest minimum 20% CQUIN target: recording of 50% of those. That is, 10% of the adult hospital population. We would expect 90% of those 10% to receive advice to trigger CQUIN payment.

20. Earlier Diagnosis and Stopping Smoking 1.Review and share data and select the questions you find most relevant 2.Prepare poster with 3 actions that you commit to

21. Earlier Diagnosis and Stopping Smoking What is the smoking prevalence of your COPD and asthma population? The trends? If you don't know, how might you get the data? If you do know, how can you get the rate lower? Where are the smokers? Consider routine and manual workers, different ethnic groups, people with mental health problems

22. Do you accept the stop smoking as the treatment for COPD message? What does that mean for how stop smoking services are organised, delivered and monitored? –In the community –In hospitals What incentives are you prepared to consider eg LES, CQUINs Earlier Diagnosis and Stopping Smoking

23. What is the trend in diagnostic rates for COPD? What is the spread of disability, in terms of MRC scores? How is the quality of spirometry assured? What comparative data do you have to share with practices? Earlier Diagnosis and Stopping Smoking

24. Responsible respiratory prescribing

25. 1.Review and share data and select the questions you find most relevant 2.Prepare poster with actions that you commit to (with names)

26. Responsible respiratory prescribing Do you accept the LRT’s seven messages? If not, why not? What do you need to do differently? What do others need to do differently? How can you take it forward locally? What opportunities are there to tie in with medicines use reviews? How do you assure the competence of the professionals teaching inhaler technique?

27. Reducing exacerbations and admissions

28. 1.Review and share data and select the questions you find most relevant 2.Prepare poster with actions that you commit to (with names)

29. What do you know about your admissions and readmissions for COPD? Number, trend over last three years; quality of coding? What do you know about length of stay? What proportion of your admissions for a COPD exacerbation were undiagnosed prior to admission? What patterns do you observe in admissions (people, times of year, times of week)? Reducing exacerbations and admissions

30. How do your services match the demand? What is your reaction to the COPD discharge bundle – have you/could you implement it? How do you incentivise right care - eg continuity of care with a GP (Purdy)? Will you commit to describing right care to two (or more) colleagues? Reducing exacerbations and admissions

31. What capacity do you have to offer all people admitted with MRC2 or above access to a PR programme? If you need to expand it, how will you do that? Are there other places that have similar problems to you that you can learn with/from? Reducing exacerbations and admissions

33. Proposed COPD discharge bundle CQUIN Numerator: Number of patients admitted for more than 48 hours coded: J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection OR J44.1 Chronic obstructive pulmonary disease with acute exacerbation, unspecified in first or second position and are discharged with a completed care bundle

34. Proposed COPD discharge bundle CQUIN Denominator: Number of patients admitted for more than 48 hours with ICD10 code J44.0 or J44.1 in first and second positions Payment threshold: 75% in year one and 95% in year two 2012/13

36. ‘ A call for action’ for Stop Smoking interventions in respiratory disease …