welcome! innovation in changing respiratory practice respiratory strategic clinical network tuesday...

Welcome!

Innovation in Changing Respiratory Practice

Respiratory Strategic Clinical NetworkTuesday 24 November 2015

#eoerscn

Agenda

Programme Speaker

09:30 – 10:15

‘Take a Breath and Prepare for Winter’

Working smarter together to turn winter chaos back into winter pressure

Amanda Cousins

AD of Service Improvement and Transformational Change

NELCSU

10:15 – 11:00

Co-Commissioning:

Is joint working between Secondary & Community Care a theory or reality?

Catherine Tooley (James Paget Hospital)

Carl Dodd (Great Yarmouth CCG)

11:00 – 11:20 Refreshments

11:20 – 12:20

Respiratory Pathway Re-design:

The Challenges of Change – a local perspective

Examples from:

Luton CCG

Ipswich & East Suffolk CCG

Amanda FlowerAD Planned Care and Long Term ConditionsLuton CCG

Dr Jonathan Douse

Consultant Respiratory Physician Ipswich Hospital

12:20 – 12:45 Respiratory SCN Update & FutureLianne Jongepier

EoE RSCN Team

12:45 – 13:30 Buffet Lunch

Amanda Cousins

AD of Service Improvement and Transformational Change

NELCSU

Take a breath and prepare for Winter !

Amanda Cousins NEL Healthcare Consulting

5

The challenge we all face

• 1/3rd Fewer beds• 37 % increase in people turning up in emergency

care• 2/3rds of urgent care patients are > 65 years• We need to change to survive

6

How do we plan the provision of urgent or unplanned care ?

• Regional System Resilience Groups (share good practice and work on regional issues)

• Local System Resilience Groups (drive the local system development)

• Capacity planning Groups (operational weekly)• Operational System management

- Underpinning escalation plans for trusts and for systems- Commissioner and provider on call

7

The dimensions which impact on demand – non one easy fix

Age profile of the local population Environment

The viral load or disease profile

Demographics

8

What is everyone up to ?

• People are all working to a common set of goals but we have different starting points, challenges and opportunities.

• Everyone is talking about the need for radical change and integration

• The most effective and impressive changes have been achieved by - Getting back to basics and keeping things simple- Involving the shop floor in planning improvements - Overcoming tribalism and barriers to change

9

Work together on the total pathway

Primary Prevention

Early Diagnosis

Effective and Timely Treatment

Crisis management and recovery plans

Patients empowered to

manage their own condition

NICE Guidance

10

Influencing Factors: National Standards, Strategies and Guidance

1. “Transforming Urgent and Emergency care in England – guidance for commissioners”

2. Ongoing provision of 111 services across the country; dissemination of best practice from areas where this appears to be working well and learning from those areas where services are still struggling

3. Ongoing push with regard to use of smart technologies to support patient self management for long term conditions, heart failure and COPD

4. Ongoing push to provide services to support self management of chronic or recurring problems e.g. direct access physiotherapy for back pain patients; personal health budgets

5. Promotion of integrated health and social care provision for frail older people with complex needs including crisis planning and rapid access intensive support

6. Primary care development 7. Mental Health Services waiting times and increased access to

services (political aspirations currently)8. Workforce planning – guidance is around on many aspects,

push for wider use of prescribers in the system ( nurses, pharmacists and physiotherapists)

Some good local pilots where new initiatives are being tried so we need to learn from others.

National

‘‘Improving access to urgent and

emergency care services seven days a

week is a key national priority’’

‘‘Sir Bruce Keogh’s review of urgent and

emergency care services in England is the latest

driver for change nationally’’

‘’Urgent and emergency care networks should

play a role in coordinating

resources across the system’’

11

So what are others up to ? Visualising the future together

12

Looking at the influencing Factors: Primary Care

Increase in responsibility • Development of new relationships with neighbouring practices to deliver high quality care (networked models

of care)• Promotion of equal relationships with every patient (models of shared decision making)• Drive towards 7-day services (8am-8pm, 7days)

Population changes• Expected growth in the number of people aged 85 and older and those living with one or more long term

conditions likely to rise from 1.9 million in 2008 to 2.9 million in 2018.

Workforce• Gradual increases in the number of GPs working part time hours.• GP workforce that has only increased at half the rate of other specialities in the medical field.• Over reliance on locum GPs

Finance• A decrease in real time spending on GP services• NHS England sole commissioners of Primary Care services

IMPORTANT NOTE: The GP taskforce report identified major gaps in workforce information needed to underpin effective workforce planning. They reconfirm the recommendation of the Centre for Workforce Intelligence (CfWI) that the GP workload survey must be urgently re-commissioned, along with a more effective vacancy survey.The survey collected data from voluntary submissions up to 2010.

National Position

13

Setting priorities for action: Hospital Non elective admissions

Analysis of admissions by primary diagnostic groups show that, where marked increase in admissions occur an increase in age is also apparent. This is consistent with the previous slides. [N.B. age is in the data but is not visible in the charts]

Diagnostic variations

I - Inf

ectio

ns

II - Neo

plasm

s

III - D

isease

of th

e bloo

d

IV - E

ndocrin

e, nu

tritio

nal and

metab

olic d

isease

s

V - M

ental

VI - D

isease

of th

e nervo

us

VII - D

isease

of th

e eye

VIII D

isease

of th

e ear

IX - D

isease

of th

e circ

ulatory

X - Re

spira

tory

XI - D

isease

s of the

dige

stive

XII - D

isease

s of the

skin

XIII -

MSK

XIV - G

enito

urina

ry

XVI -

Perin

atal co

nditio

ns

XVII -

Cong

enita

l malf

ormati

ons

XVIII - S

ymptom

s, sign

s and

abno

rmal lab

orato

ry fin

di...

XIX - I

njury

and p

oison

ing

XXI -

Facto

rs infl

uencing

healt

h stat

us an

d con

tact w

it...

(blan

k) -

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

Admissions by diagnostic categoryAge a factor for morbidity?

2013/142012/132011/12

Ave. age on admission increased by 3.5 years. Variation +19%. Note: change in coding moved activity to infections.

Ave. age on admission increased by 4 years. Variation respect to 11/12 +16%



14

Looking at the detail: deep dives : Non elective admissions

Respiratory: an increasing problem

The table shows the increase in non elective admissions to one acute trust associated with respiratory problems during 13/14 if compared with 11/12 (2 years). A crude calculation to convert admissions to bed days/just bed has been done to show the magnitude of the problem. The age profile of patients presenting with respiratory problems has increased significantly for respiratory infections and pneumonia.

Looking at the detailed pathway - Review of a pneumonia pathway. Dr Paul Jarvis - Consultant in Emergency Medicine.

16

What can you do to help your systems ?

• We need you to have lots of coffee and conversations with GP’s, A&E and MFE colleagues…..

How can we better manage the older person with pneumonia ?

How do we standardise the treatment of respiratory patients turning up in A&E including timing and who should be triaging these patients ?

How can we reduce variation in the management of respiratory LTCs across practices ?

17

Other developments to join up to the pathways we design

• Patient registers • Risk stratification• MDT care delivery• Rapid response teams in the community• Advanced crisis planning• Personal health budgets• Social and voluntary sector support• Single points of access for specialist advice

(specialist nurses)

18

Pitfalls to avoid

• Pilotitis “The NHS has more pilots than the RAF” be prepared to take a few calculated risks if something does not work then stop and think again.

• Talk to your local urgent care leads and you are most welcome to join we need you on board !

• Do not ignore the patient views - test the patient experience.

19

George – use case studies to learn from

• George has advanced respiratory disease and is living alone at home with continuous oxygen. George used to be in the forces and he likes to be in control so he has a care plan which he has helped devise, he has the ability to self medicate if he feels unwell and he manages his own oxygen and his own personal budget from social services enables him to arrange his own home support. He likes his hobbies and uses skype to keep in touch with family abroad. What does George value….

- He has a much loved respiratory specialist nurse who had trained him to manage his

condition and she with her team can always be accessed on the phone during working

hours she visits to review regularly. Out of hours he has a local arrangement with the

OOHs district nurses who he also trusts as they are briefed on his crisis plans.

- George has a hospital outpatient appointment which he is cancelling as he feels OK and

when he does not he cannot travel anyway. He does not like crowds ! Hospitals are

viewed as a hazard to his wellbeing !

- George wants outpatient clinics which he can skype into for advice ?

- George wants do more of his own testing ?

To know moreIf you would like to discuss any elementof this presentation, please contact Amanda CousinsTel: 01603 257025Email: [email protected]

All presentations will be available on…

www.respiratoryfutures.org.uk(click on ‘regions’ then ‘EoE’

Don’t forget to complete your evaluation form (in your pack)

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You can find all of our work on:www.respiratoryfutures.org.uk

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Integrated care

Catherine Tooley & Carl Dodd

Respiratory Integrated Team (RIT)

The Vision

• To deliver improved services for adult patients, ensuring an integrated approach to both acute and chronic respiratory disease management for patents registered with the Great Yarmouth and Waveney General Practices.

GY&W population circa 230,000

The Drivers

• National drivers • CCG

- Access to care, - Equity of provision- Integration of services- Improved self managementQIPP

• Acute LOS, reduced admissions and attendances• Reduced prescribing costs• Increased referrals for pulmonary rehabilitation • HOSAR, smoking cessation

Background

• CQUIN• Network development – membership• Senior nurse – backfill to lead project• Specialist nursing support for practices• COPD Bundle within Primary care• Respiratory physician presents case to GP clinical

leads• Retained GP - Clinical service reviews

- shadowing community team- Respiratory ward- Outlying wards

Breathe Easy /Focus GroupInvolvement

Work with the walk in centres/ambulance services/palliative care to ascertain the

needs of people with lung disease

Audit of JPUH Practice Patient journey

Asthma care

Patient pathway in JPUH

Develop connections with the OOH team/community matrons and district nurses

Work with the CCG in re-defining what is required

to reduce Attendances and admissions

Re-design the role of the RNS within the JPUH

Work with ECCH in re-designing the current

Community RNS service. Combined recruitment.

Design of an Early Supported Discharge (ESD) Service

Designated respiratory consultant and senior

RNS working in primary care

Data collection and analysis

Integrated Respiratory CareWhat have we had to do?

Teaching programme to for the hospital and the community to upskill other HCP

in Respiratory care

Working with CCG on Joint drug formulary to reflect safe,cost effective prescribing

Develop PDGs for the community

The challenges beginning

• Two Trusts acute & community (social enterprise) bidding for one service

• Uncertainty, endless meetings• 2 trusts actually TRUSTING

each other• Change in key stakeholder

personnel• Clarity of what the service will

look like by all parties

Communication

Current Challenges

• Business case approved but as yet awaiting final agreement

• Behind predicted timeline

• Awaiting honorary contracts

• Change in staff working patterns, JD’s, hours of service …all need to be discussed and agreed. Involves HR, different management approach

• Being paid from one employer yet managed by another…. How does this feel to the employee

• Data collection and analysis

• IT ongoing, lack of systems communicating with primary, secondary care and community setting

• Service specification & CQRA

Helping our patients achieve their Dreams

Any Questions?




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Respiratory Pathways Project

Amanda Flower, AD Planned Care, Luton CCG

‘Creating Confidence, Pride, and a Positive Image for Luton’

Facts about Luton

• £230m budget for Health Services (deficit)

• Population 220,000 registered with 30 GP Practices

Variation:Recorded prevalence on practice disease registers:COPD Regional 1.8%Luton 1.2%, range 0.3% - 2.2%

Asthma Regional 6.1%Luton 5.4%, range 3.3% - 8.4%

Non elective admissions: COPD - range from 1.35 admissions per 1,000 weighted list size to 6.60 admissions per 1,000 weighted list size

Asthma – range from 0.58 per 1,000 weighted list size to 5.89 admissions per 1,000 weighted list size

JSNA Recommendations

Providers:

30 GP Practices

Cambridgeshire Community Services NHS Trust

Luton & Dunstable Hospital NHS Foundation Trust

Live Well Luton

East London NHS Foundation Trust

The System Challenge:

1. Significant variation

2. Duplication

3. Joint working

Primary Care:

• Multi Disciplinary Practice Visits • Practice dashboard• Share good practice • Raise awareness of guidelines • Local respiratory resource folder • ‘Enhanced’ primary care disease template • Use of OPC Audit Tool to target patients in need of review

and intervention to optimise their care • Practice questionnaire – training – how care is

organised/delivered• Training (needs identified through questionnaire)• Community respiratory nurses aligned to practices

MDT Practice Visits2 plus 8 (probably all eventually)

GP Clinical Lead, ChairPractice TeamRespiratory Nurses – Acute and CommunityConsultant in Respiratory MedicineMedicines Management and OptimisationClinical Specialist Physio

2 Hours

Guidelines and Pathways

Dashboard

3 case discussions

Brief action plan to be followed up by community service

Optimum Patient Care:Tailored practice reports compare outcome measures with that of the general service. The reports allow the practice to target patients in need of review and intervention to optimise care and help the practice to achieve QOF targets.

The practice report covers:• Diagnosis – potentially undiagnosed patients• Patient demographics• Disease control and severity• Risk stratification and exacerbations• Adherence and concordance with therapy• Patient reviews and self-management plans• Management and therapy recommendations based on guidelines• Focus areas for improvement

Optimum Patient Care:The individual level patient reports will support clinicians to identify high risk patients and other patients who would benefit from review and intervention to optimise care.

The reports include:• Identification of high risk patients• Patients associated with recommendations in practice reports• Disease symptoms and control• Co-morbidities and smoking status• Therapy status and overview

Optimum Patient Care

Any Questions?

Amanda FlowerAssistant Director of Planned [email protected]

Thank-you for listening.

mailto:[email protected]




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Developing the Respiratory Pathway

Jonathan Douse Ipswich Hospital

O2

ESD

PR

The Current System

IHT (Physio, LFU, Chest Clinic, ED)

42 Primary Care Practices

LiaisonPsychiatry

Suffolk Wellbeing

Service

Social Care

CO

PD

S

ervi

ce

District Nurses

Community Matrons

Suffolk Family Health

Live Well Suffolk

Palliative Care

Dietetics

Patient Groups

Why change?

• Multiple providers of services- Lack of joined up working (inefficient)- Perverse incentives- Disjointed experience for patients

• More outpatient demand than capacity- Not all necessary

• Escalation beds in use- Patients recurrently admitted- Length of stay longer than necessary

The future

• Integrated Respiratory Service- Improve quality of care for patients- Reduce unnecessary admissions- Reduce unnecessary outpatient attendances- Responsible prescribing- Save money for greater healthcare economy- Improved patient experience

Getting there

• Joint prescribing guidelines• CQUIN 2014-15

- Liaison psychiatry- End of life care- Respiratory network

• Clinical Leaders Training• Review of other “integrated” services• National policy

O2

ESD

PR

The Pilot Jan –June 2015

• Specialist nurse working with 15 pilot practices (joint clinics, prescribing support, complex case review)

• Specialist nurse working in IHT, case finding and discharge support

• Consultant facilitating weekly MDT and input to primary care

• New psychological support via Suffolk Wellbeing Service via OP clinic and Pulmonary rehab

• COPD service involved in weekly MDT

• Supporting winter scheme use of GRASP

IHT (Physio, LFU, Chest Clinic, ED, Psychiatric Liaison)

15 Pilot Primary Care Practices

LiaisonPsychiatry

Suffolk Wellbeing

Service

Social Care

CO

PD

S

ervi

ce

District Nurses

Community Matrons

Suffolk Family Health

Live Well Suffolk

Palliative Care

Dietetics

Patient Groups

(A)New Nurse Specialist

(B)New Nurse Specialist

NewWeekly

MDT

Consultant

Outcome of the Pilot

• Project cost £91,000• There were reduced pharmacy costs The whole

year effect was worth £124,000• Hospital Length of stay (February-June) was

reduced for patients with asthma and COPD by 0.91 days compared to the same period in 2014 and 0.38 days compared to the period July-November.

Outcome of the Pilot

• Readmission rate was reduced by 3%• 51 new outpatient appointments were avoided

saving £9,592.• There was an increase admissions for COPD and

asthma from both pilot and no-pilot practices

Feedback from Pilot

• Patient feedback was excellent• Primary care staff who greatly valued the training

they had received

Getting further

• Clinical transformation Group• Service specification for integrated respiratory

service- Released Nov 2015

• Setting up the model of future care- Funding and KPI- Getting started Summer 2016

What have I learnt?

• Investigate the agendas of all parties- Takes time- Align incentives

• Get a sponsor on the CCG- Via clinical network

• Make most of existing services• Get the patients involved• Sell the vision

Any questions?


www.respiratoryfutures.org.uk(click on ‘regions’ then ‘EoE’)


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Lianne Jongepier

East of England Respiratory SCN Manager

Strategic Clinical NetworksNHS England

Thank you.

Hope to see you again

Respiratory Strategic Clinical NetworkTuesday 24 November 2015

#eoerscn