Transforming outcomes for people with lung disease in England

Transforming outcomes for people with lung disease in England

Professor Sue Hill

Chief Scientific Officer and

Joint National Clinical Director for

Respiratory Disease

Why Ministers have been interested in Respiratory Disease?

Variation in quality of care provided

Inequalities in outcomes across country

Burden on the health service and future challenge of LTCs

Cost to the taxpayer Poor performance compared

to other countries Ability to set out expectations

- NHS, PH and SC - and to influence system levers Success in other clinical

conditions eg cancer, coronary heart disease

UK Respiratory Strategies

Wales – Chronic Conditions Scotland - Respiratory

N.Ireland - COPD England – COPD/Asthma

Equity and excellence: Liberating the NHS

White paper: published on 12th July 2010, sets out proposals for the NHS

Free from targets Local accountability Continued focus on QIPP

Vision: Put patients at the heart of everything that we do Achieve quality outcomes that are among the best

in the world Empower our clinicians to deliver results based on

the needs of patients

‘Nothing about us without us’

• Reinforcing personal and community resilience, reciprocity and responsibility, to promote greater independence and choice

• Carers are the first line of prevention. • ‘Payment by Results’ tariff amended from April 2012 so that NHS pays for re ablement and other post-discharge services for 30 days after a patient leaves hospital.

• Health and social care professionals take a joint, evidence-based approach to identifying the needs of local populations and agreeing shared solutions

• Commitment to protecting the population from serious health threats; helping people live longer, healthier and more fulfilling lives, and improving the health of the poorest, fastest.

• A new integrated public health service, Public Health England, will that achieves excellent outcomes and results, unleashing innovation and liberating professional leadership.

•Outcomes to be focused around- Enhanced healthy life expectancy and preventable mortality

- Health improvement - Health inequalities - Prevention of ill-health - Protection and resilience

COPD strategy and the new system

DH Transparency Outcomes Framework

SofS

National Commissioning Board

GP Commissioning Consortia

Public Health Service

Directors of Public Health LAs

Health & Well Being Boards LAs

NHS Outcomes Framework

No.10 HMT

Annual Mandate

Social Care

Public Health Outcomes Framework

Commissioning Outcomes Framework

Social Care Outcomes Framework

Directors of ASSs

NHS OUTCOMES FRAMEWORKDomain 1

Preventing people from

dying prematurely

Domain 2Enhancing the quality of life for

people with LTCs

Domain 3Recovery

from episodes of ill health /

injury

Domain 4Ensuring a

positive patient

experience

Domain 5Safe

environment free from avoidable

harm

NICE Quality Standards (Building a library of approx 150 over 5 years)

Commissioning Outcomes Framework

Commissioning Guidance

Provider payment mechanisms

Commissioning / ContractingNHS Commissioning Board - Specialist services and primary care

GP Consortia – all other services

1

2

3 4

7

Duty of quality

Duty of quality

Dut

y of

qua

lity

tariff standard contract CQUIN QOF

5

6

Duty of quality

NHS OUTCOMES FRAMEWORKDomain 1

Preventing people from

dying prematurely

Domain 2Enhancing the quality of life for

people with LTCs

Domain 3Recovery

from episodes of ill health /

injury

Domain 4Ensuring a

positive patient

experience

Domain 5Safe

environment free from avoidable

harm

NICE Quality Standards (Building a library of approx 150 over 5 years)

Commissioning Outcomes Framework

Commissioning Guidance

Provider payment mechanisms

Commissioning / ContractingNHS Commissioning Board - Specialist services and primary care

GP Consortia – all other services

1

2

3 4

7

Duty of quality

Duty of quality

Dut

y of

qua

lity

tariff standard contract CQUIN QOF

5

6

Duty of quality

Quality improvement will be hardwired into the new system starting with the outcome goals in the NHS Outcomes Framework and informed by NICE Quality Standards

Proactive Strategy for changing the burden of disease across whole pathway

Recognises that different components of system have to come together

-Public health -Social care-Health service

Underpinned by strong clinical leadership at all levels of system-National -Regional-Local through networks

Challenges !

Late diagnosis and impactSize of smoking legacyGeneric LTC approach, chronic disease

management and specialist interventionAmenable morbidity and outcome

measures Lack of research evidence across

pathway

Late Diagnosis

Hit early and hit hard!Early intervention with to stop progression and exacerbations

Symptoms and decrease of lung function

COPD in control COPD in control

Mild exacerbation

Early detection and intervention

Usual time point for intervention

Severe exacerbation

Time

Morbidity in the undiagnosed Recent Canadian study showed 21% of those with undiagnosed

COPD had severe or very severe disease (Gold 3 and 4) Quality of life and physical/social function significantly reduced in all

stages of disease from mild to severe Exacerbations common even in moderate disease 10% of emergency COPD admissions are undiagnosed - recent London

study 34% admissions in undiagnosed patients, 20% in respiratory failure Co-morbidities common at all stages of COPD and are often

diagnosed late - primary care evidence suggests that 30% COPD patients have undiagnosed heart failure

Patients with COPD are at a much higher risk of premature mortality from heart disease and strokeHowever, substantial variation in performance and interpretation of spirometry with survey evidence showing 27% patients on COPD registers do not have COPD

Smoking legacy

If everyone gave up smoking today, it would be decades before we saw any difference in the rates of COPDMannino D. (Chest 2005)

Proactive Case FindingLocal enhanced services to promote early case finding in primary care

NHS Doncaster, NHS Islington, NHS Sandwell

Use of practice registers to identify patients more likely to have COPD Durham and Darlington, NHS Salford

Determining optimal approach to identifying COPD individuals study University of York in conjunction with primary care in Hull and York

Audit tools, clinical support and training for primary care Partnership with pharma –– eg GSK, AZ, Medimark programme

Awareness raising and community targeting South Tyneside PCT with British Lung Foundation (‘Love Your Lungs’)

Lung age testing linked to stop smoking services Hartlepool and Stockton

The care pyramid – the right service for right patient, generalist versus specialist

Long Term Conditions Workstream Delivering national support & improvement programme Support local areas to implement a generic LTC model based on 4

key principles:

1. Commissioners understanding the needs of their population and managing those at risk to prevent disease progression

2. Empowering patients to maximise self-management including ensuring patients have a care plan and appropriate information and knowledge about how to manage their condition.

3. Providing joined up and personal services particularly in community and primary care and working closely and effectively with social care.

4. Strong professional and clinical leadership and workforce development.

Severe COPD Pyramid

Emergency,exacerbation visits

Co morbid conditions

Bed days, hospitalisations

Disability: days off work, pensions

Costs

COPD deaths

Reduce COPD burden

•Reduce mortality from current 26,000 pa

•Reduce hospital admissions

•Reduce readmissions from rate of 33%

•Reduce direct costs from £1billion pa

•Reduce indirect costs and lost productivity

Acute non invasive nasal ventilation – substantial reduction in mortality, 1 to 8 survival benefit

Long term domiciliary NIV- survival improvements Supplemental long term oxygen therapy – survival

improvements Regular moderate or high level physical activity – 30 to

50% reduction in risk of both hospital admission and respira tory mortality Pharmacotherapy - new preparations showing reductions in

mortality from respiratory and cardiovascular causes at 4 years Prompt medical therapy at start of exacerbation –

reductions in hospitalisations

Challenge is appropriate outcome measures

Evidenced Interventions impacting on mortality

Research is needed:

Multidisciplinary careIntegrated careClinical pathwayTransmural care

Self-managementTele-monitoringTele-consultingRehabilitation

‘Teams without walls’ Royal College of Physicians 2009

‘Greater standardisation ’Sustainable health systems KPMG 2009

Improved survivalEarly and accurate diagnosisImproved QOL and social functioningSlower disease progressionReduced exacerbation rateReduced admission/readmission ratesHigh quality end of life care

Outcomes Matter to Patients

A Quality COPD Service Proactive and opportunistic case finding to minimise the impact of late

diagnosis on individuals and the healthcare system

Quality assured, accurate diagnosis and assessment of severity and ongoing monitoring and review of the condition through a proactive chronic disease management model.

People with COPD are screened, assessed and managed with pharmacological and non-pharmacological interventions in line with NICE/quality guidelines

People with COPD are educated and supported in the management of their condition so that they can become active partners in care.

Effective prevention and management of exacerbations and of hospital admissions

Effective palliative, end of life care and bereavement support for people with COPD

Smoking cessation Smoking cessation Smoking cessation

Awareness raising •Lung health•Lung symptoms•Lung age testing

Case finding – Early diagnosis

Social Care/Re-ablement

Accurate diagnosisQuality Spirometry

Physical activity

Proactive chronic disease management/QoL measures

Pulmonary Rehab

Evidence based treatment/medicines management

LTOT/NIV

EOL

Improving Outcomes in COPD

Prompt therapy in exacerbations/review

Home Oxygen ServiceRe-procurement Timetable

Currently 3 Suppliers 11 regions inc Wales (approx 90k patients)

Bidders/Suppliers appointed on Framework to be announced 3rd December with mini-competitions starting January 2011

Engagement of and leadership by clinicians is essential

A call to action and focus on clinical leadership for delivery

Outcomes will improve when clinicians are engaged, and creativity, research participation and professionalism are allowed to flourish

A long and winding road!

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