Are there ways of improving care and achieving QIPP?

1. Are there ways of improving care and achieving QIPP? Colin Gelder & Sandy Walmsley Respiratory Leads West Midlands SHA

2. NHS

4. PCT Revenue Limits £bn

5. PCT Revenue Limits £bn

6. PCT Revenue Limits £bn

7. PCT Revenue Limits £bn 0.55 1.0-1.3 1.6-2.0

10. Summary of Patient Priorities • Better Information • Respect • Support for Self Management • Pulmonary Rehabilitation • Improved Access • End of Life Care

11. Summary of Secondary Care Recommendations • Integrated Commissioning • Integrated Care • Better Diagnosis/Registers • Increased Access to Pulmonary Rehabilitation • Oxygen Services • Self Management • End of Life Care

12. ……..so what do we have to do? Is it

14. Plan is to…………………..

15. Are there better ways to deliver care?

16. Quality and productivity: IMPRESS's More for Less • Keep up to date with NHS Policy: summary of Operating Framework and Outcomes Framework • www.impressresp.com

17. May 2011

19. COPD Care

20. 1. Active Support For Self Management

21. COPD & Self Management • Advice on how to stay healthy • Advice on how to recognise onset of exacerbation • Advice as to when to seek further support • Telehealth

22. Self-Management of Exacerbations Encourage people at risk of having an exacerbation to respond quickly to the symptoms of an exacerbation by: • adjusting bronchodilator therapy to control symptoms • starting oral corticosteroid therapy (unless contraindicated) • starting antibiotic therapy if their sputum is purulent

23. 2. Primary Prevention

25. COPD & Primary prevention • Public Health approach • Starts early in life • Promote “lung health” rather than lung disease

26. Long-term effectiveness & cost-effectiveness of smoking cessation interventions in patients with COPD Tiotropium £7,112/QUALY Eur J Health Econ. 2007; 8(2): 123135 Pulmonary Rehabilitation £2,000-8,000/QALY Hoogendoorn M, Feenstra TL, Hoogenveen RT, Rutten-van Mo¨lken MPMH Thorax 2010: 65:711-718

27. 3. Secondary Prevention

28. Secondary Prevention • Smoking cessation • Opportunistic case finding • Self management • Pulmonary rehabilitation

29. 4. Effective Medicines Management

30. COPD and Medicines Management • Oxygen • Appropriate prescribing in line with NICE/ COPD Strategy • Appropriate for individual patients: Inhaler technique • Integration with other therapies e.g. Pulmonary rehabilitation

32. Current Overview • Home Oxygen Service provides O2 therapy to ~85,000 people in England • In some areas there is no quality assured assessment • 60% have COPD • NHS cost £110 million • 25% of little or no clinical benefit • 300 NPSA alerts/SUIs, 44 deaths • Current contracts expire in Jan 2011 (exc. South West) • Services need to be fully integrated into the whole patient pathway

33. Potential Savings • In PCT with formal review of oxygen registers coupled with introduction of oxygen assessment services up to £400,000 /year has been saved • Potentially £10-20 million savings in England per year

34. Optimising pharmacological maintenance treatment for COPD in primary care Rupert Jones, Anders Ostrem Primary Care Respiratory Journal 2011; 20(1): 33-45

35. IMPRESS GUIDE TO INFORMATION ABOUT USE OF MEDICINES IN THE NHS A SECTION OF THE IMPRESS GUIDE TO INFORMATION This document is not about best practice prescribing or information about medicines for patients, but about the information available to help clinicians, commissioners and managers to know what is being prescribed by whom, for whom, at what cost, and at what benefit and how this compares to other geographic and disease areas. It draws together the information available across the primary, community and secondary care system. It focuses on respiratory care, but many of the lessons are of wider relevance to the management of long term conditions.

36. Right Care Respiratory Prescribing NICE 2010 • ‘Ensure all patients with COPD are on the appropriate therapy for the severity of, and symptoms from, their disease.’

37. Right Care Respiratory Prescribing NICE 2010 • ‘‘Offer nicotine replacement therapy, varenicline or bupropion (unless contraindicated) combined with a support programme to optimise quit rates… to all people with COPD who still smoke at every opportunity.’

38. Total cost of Respiratory Medication by BNF Chapters 2008 and 2009 for England £ millions ~£1 billion on respiratory medication not including antibiotics… Source: NHS Information Centre

39. Volume of Respiratory Medication by BNF Chapters 2008 and 2009 for England Number of prescriptions (millions) but a relatively low volume of respiratory prescriptions ... Source: NHS Information Centre

40. Item cost of Respiratory Medication by BNF Chapters 2008 and 2009 in EnglandAverage net ingredient cost per prescription item £ Respiratory items are the most expensive category of item prescribed ..... …… inhalers Source: NHS Information Centre

41. NHS budget & respiratory meds Of the top 5 costliest drugs to the NHS currently 3 are inhalers • Seretide (all) is the highest cost drug • Seretide 250 Evohaler is the most expensive individual item (second is atorvastatin): Switch to accuhaler • Symbicort 200 is 5th most expensive item Source: NHS Information Centre

43. 5. Managing Ambulatory Care Sensitive Conditions

44. Ambulatory care in COPD • Quality assured diagnosis • Accurate registers • Empower patients to understand condition • Self management plans with written instructions • Quality assured Pulmonary Rehabilitation • Integrated care across whole health and socail care economy

45. Pulmonary Rehabilitation Pulmonary rehabilitation available to all • Post discharge • MRC3 or above/symptomatic

46. COPD and Urgent Care • Assessing to admit NOT admitting to assess! • Integration between Acute & Community Care can reduce admissions • Self management plans & rescue medications • EoL planning with Advance Care Plans

47. 6. Care co-ordination through integrated health & social care teams

48. Integrated health care in COPD Teams should be fully integrated across health & social care, enabling • Right care, right place, right time, right person • Communication across integrated team VITAL • Leading to reduced inappropriate admissions BUT……we need to make sure that we are doing the right things, right!

49. 7. Managing elective activity-referral quality

50. COPD and Elective Referral • Networks to improve standards and reduce secondary care referrals, integrated working • Genuine integrated care pathways across health economy • Intermediate/community clinics either Nurse or Consultant led will lead to reduced referrals to secondary care