Transforming outcomes for people with lung disease in England

Dr Robert Winter

Medical Director, NHS East of England and

Joint National Clinical Director for

Respiratory Disease

The approach

Staying healthy

Mental health

Children’s health

Planned care

Long term conditions

Acute care

Acute care

Acute care

Acute care

Acute care

Acute care

End of lifecare

Maternity and newborn

COPD – the need for improvement

5th biggest cause of death and rate exceeds many other EU countries

2nd most common cause of emergency admission

One of the most costly, in terms of acute care (£930m)

Total cost to UK £3900m

170,000 prescriptions for oxygen

Inhaler therapy in top 3 drug costs

• Mortality• Specialist care• NIV• EDS/LOS• Quality standards – self scores• End of Life Care• Primary Care

NCROP 2008, evidence of massive unexplained variation

COPD mortality varies between PCTs providing healthcare to similar populations

Indirectly standardised mortality rates from bronchitis, emphysema and other COPD (ICD10 J40-J44) 2006-2008

Compared PCTs in same deprivation decile before aggregating nationally

Clinical leaders and leadership within local communities

Paul Corris

Sharon Haggerty

John White

Mike Ward

Jane Scullion

Dermot O’Ryan

John Williams

June Roberts

Stephen Gaduzo

Colin Gelder

Sandy Walmsley

Steve Holmes

James Calvert

David Halpin Maxine Hardinge

Jo Congleton

Jo Wookey

Julia Bott

Tony Davison

Leanne JongpierLouise Restrick

and team

• Design and create a local structure

• Interact with the improvement projects

• Develop links with interrelating work streams e.g. QIPPS, LTCs etc

• Engage with local community to develop Communities of Practice

Maria Read

6

2008/2009 APHO ONS Cluster Average – Each diamond represents a disease category and shows spend and outcomes compared to the cluster average

Knowsley has higher spend and worse outcome for Respiratory problems when compared to similar PCTs

Mortality from

bronchitis under 75s

7

Knowsley has an above average expenditure on respiratory problems when compared to PCTs within its SHA

Respiratory Programme Expenditure £million per 100,000 weighted population

Years of life lost due to mortality from bronchitis, emphysema and other COPD Directly age-standardised rate per 10,000 population, less than 75 years, all persons 2005-2007

Knowsley has the highest rate of years of life lost due to mortality from COPD of all similar PCTs

9

Hospitalisation: Respiratory system problems. All non-elective admissions, indirectly age-standardised rate per 100,000 population, all ages FY 2007/2008

Knowsley has the highest number of non-elective admissions when compared to similar PCTs

10

IVET: PCT inpatient expenditure for selected disease/intervention compared to a user defined benchmark.

Knowsley would reduce spend to the national average through a reduction in inpatient activity of 1,284

‘Doing the same thing over and over again and expecting different results’

Albert Einstein

COPD – EXACTLY THE SAME THING YEARAFTER YEAR

Insanity….

Patients in the frequent admission group (3 time in past 12 months) have an almost 60 per cent chance of admission during the following winter, compared to just a 10 per cent chance for those with one previous admission.

85 per cent of COPD admissions during the winter peaks have had no recorded admission in the previous 12 months. These account for about 90 per cent of the rise in admissions during winter.

This means that to reduce hospital admissions all COPD patients must be reached, not just those at high risk.

COPD…..

Transforming care in COPD

Admission avoidance Prompt access to assessment and treatment 7/7 Access to specialist respiratory care in community Prompt admission when required Specialist respiratory care in hospital Safe oxygen therapy Early measurement of blood gas status Prompt access to NIV Optimal management of co-morbid conditions Early supported discharge and hospital at home

National Improvement Projects ; objective

evidence of quality matched to productivity and value

•Accurate Diagnosis

•Transforming Acute Care

•Oxygen

•Chronic Care/Self-Management

•End of Life

•Pulmonary Rehabilitation

Soon to be announced:

• Asthma

4

7

24

6

3

4

3

4

11

Admission avoidance

Rice KL et al. Am J Respir Crit Care Med 2010; 182(7):890-6. Epub 2010 Jan 14.

743 patients with severe COPD

Intervention group patients received a single education session, an action plan for self-treatment of exacerbations, and monthly follow-up calls from a case manager.

Integrated COPD care Outcomes in South East Essex

Financial year 07/08 08/09 09/10

Number COPD admissions

909 841 740

Number COPD bed days

6,969 5,925 5,327

Cost per 9/10 PbR (saving)

£2,141,259 £2,067,171

(£74,088)

£1,781.052

(£360,207)

Saving from oxygen service

£250,000

Total saving £610,207

Summary of key reductions in terms of reduction in emergency COPD admission, bed days and cost

How can we get there ? Working in partnership with others

Transforming care - what is required of clinicians

From where we are…

Variation in admission avoidance

Variation in bed use

Variation in outcome

Generalist care

5/7 service

No integration

good local and regional hospital some excellent speciality services good clinical performance strong financial performance talented and committed staff respected clinical school leaders in biomedical research

We need a spotlight on … patient experience healthcare-acquired infection communication effectiveness

To where we want to be …

The expert patient

Personalised care - self management plan

Admission avoidance

Daily senior ward round

High quality care by respiratory team

• Reduce unwarranted variationunderuse, overuse, under co-ordination

• Improve outcomes for patients provide best value health care reduce waste, drive up quality

• Benchmarking to provide comparison across local healthcare services

• Health investment analysis with programme budgeting tools

• Striving for innovation and excellence