Commissioning the right COPD care for Londoners

7 November 2011

Royal College of Physicians

Case for change in London respiratory services

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 2010-13Clinically-led multi-disciplinary team (0.5 -1 day/week)

Community and hospital health professionalsPatient/carer voice and Programme Manager

Right Care

Doing the right things …… and doing things right

Value Framework

Health Outcomes

Patient definedbundle of care

CostValue=

Health Outcomes Cost of delivering

Outcomes

Porter ME; Lee TH NEJM 2010;363:2477-2481; 2481-2483

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

• Admission rate varies 1.9-4.9 per 1000 practice population

• Q1 2009/10 2nd 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

COPD ‘Value’ PyramidWhat we know so far…. Cost/QALY

Londoners dying from smoking

‘1 in 5 deaths due to smoking’

Why Commissioners need to invest in Pulmonary Rehabilitation in London

….May 2011

Now?

Review of packsQ & A

Earlier Diagnosis and Stopping Smoking

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

Stop smoking in inpatients CQUIN Enablers

National VTE CQIN

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)

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.

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

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

• 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

• 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

Responsible respiratory prescribing

Responsible respiratory prescribing

1. Review and share data and select the questions you find most relevant

2. Prepare poster with actions that you commit to (with names)

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?

Reducing exacerbations and admissions

Reducing exacerbations and admissions

1. Review and share data and select the questions you find most relevant

2. Prepare poster with actions that you commit to (with names)

• 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

• 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

• 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

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

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

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