transforming outcomes for people with lung disease in england professor sue hill chief scientific...
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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
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2
3 4
7
Duty of quality
Du
ty o
f qua
lityD
uty
of
qua
lity
tariffstandard 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
Du
ty o
f qua
lityD
uty
of
qua
lity
tariffstandard 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 stroke
However, 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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