Symptom led diagnostic services for breathlessness

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Symptom-led diagnostic services for breathlessness: real life examples - Hilary Walker, Head of Programmes, Living Longer Lives, NHS Improving Quality and Wendy Fairhurst, Nurse Partner, Marus Bridge Practice

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  • My task is to give a very brief introduction to some background research that NHS IQ commissioned on early diagnosis.

    The scoping exercise will underpin the development and evaluation of new models of care to support early diagnosis.

    The research report is being prepared as I talk but I have been tasked with presenting a few of the highlights before handing over to our next speaker (Wendy Fairhurst) who will talk us through a real life example of a service model identified by the research.
  • Background to the Living Longer Lives programme in NHS IQ

    Much of the work to date on raising public awareness of symptoms and early diagnosis of disease has focused on supporting PHE and DH campaigns, e.g. BCOC.

    However, in 2014/15 NHS IQ plans to pilot new models of care which improve access to services and facilitate earlier diagnosis and treatment for people who experience breathlessness as a symptom.

    More often than not, existing referral pathways, services and payment systems in the NHS are largely organised around clinical specialities and do not readily accommodate patient referrals within and between specialities, or facilitate clinical collaboration or organisational integration.

    Our plans for improvement reflect an increasing focus on seeing patients as a whole and not just treating individual clinical conditions = better for patients and carers and better for the NHS.
  • I’ve already hinted at some of then reasons behind our planned work in this area, but what are the other reasons? And why the focus on breathlessness?
    (refer to bullet points)

    NB. Audience will have already heard about the PHE public awareness campaign in Oldham and Rochdale- our work should help pave the way for the commissioning and provision of services to support people who present to their GP with breathlessness.
  • Our first step was to commission some desk research to understand what evidence, good practice, service models and evaluations (UK and beyond) exist which might influence how we move forward with any pilot work, and ensure we don’t reinvent the wheel.

    The scope included examples…

    Of early diagnosis of (relevant) disease generally;
    With a focus on early diagnosis of disease from a symptom-based perspective;
    With a specific focus on the symptom breathlessness…..

    The report is still being finalised but the following slides provide a very brief overview of some of the findings.



  • Our first research question was about early diagnosis generally:

    There is a huge amount of literature on early diagnosis of ANY disease, so we chose to narrow the search to look at early diagnosis in COPD, asthma, lung cancer, heart failure, and atrial fibrillation.
  • Our second research question focused on examples of symptom-based services and pathways.

    Implementation of the Rapid Access Chest Pain Clinic model in particular offers lots of potentially relevant learning points.
  • Our last research question focused specifically on breathlessness as a symptom.

    The research highlighted the work already undertaken by IMPRESS – we’ve already heard about the algorithms from Sian but there’s much more that we can learn from going forward.

    Only a few examples of breathlessness clinics were identified in the literature and several of these were still in development. There was limited published data on patient outcomes or cost-effectiveness.

    What is clear from the literature is that one size does not fit all.

    We’ve managed to obtain further details of some of the existing services- unfortunately colleagues from Bolton could not join us today but further details are available on the sharing table.

    However, I’m delighted that one of the examples cited is here to tell us more [introduce Wendy Fairhurst, Nurse Partner Marus Bridge Practice and Clinical Director of Health First Ashton Leigh and Wigan Community Interest Company]


  • Symptom led diagnostic services for breathlessness

    1. 1. Symptom-led Diagnostic Services for Breathlessness- Real Life Example(s) Hilary Walker Head of Programmes- Living Longer Lives NHS Improving Quality Improving health outcomes across England by providing improvement and change expertise
    2. 2. Living Longer Lives • Three broad workstreams aimed at reducing premature mortality from heart disease and stroke, cancer, liver and respiratory disease – Cardiovascular Disease Outcomes Strategy and NHS Health Check – Engaging clinicians and primary care in the five ‘big killers’ – Raising public awareness of symptoms and early diagnosis of disease • Developing and evaluating new models of care which improve access to services and facilitate earlier diagnosis and treatment for people who experience breathlessness
    3. 3. Why? And Why Breathlessness? • Early detection and diagnosis of disease can improve the scope for successful treatment and reduce unnecessary pain and suffering • We are not very good at it (compared with our European counterparts) • Next to pain, breathlessness is the most common symptom for which patients seek help and relief from their doctor • Potential to address multi-morbidity and the complex interaction between physical and mental health • Necessary adjunct to the PHE public awareness campaign for breathlessness as a symptom
    4. 4. How? • Commission scoping research to: – Understand and apply ‘best practice’ from the UK and internationally for early diagnosis generally and with a focus on breathlessness as a symptom; – Learn from past and present models of care (both successful and unsuccessful); – Horizon scan/ consider how emerging trends and developments in this area might potentially affect future work • Methods: Secondary desk research • Output: Written report based on three Research questions • Following slides provide a snapshot
    5. 5. What’s already out there on early diagnosis generally? • Focus on models of care for heart disease and stroke, cancer and respiratory disease • Research highlighted examples of: – Targeted case-finding in primary care, e.g. spirometry with smokers – Screening and pre-screening in those at risk, e.g. open access spirometry for COPD and CT for cancer – Nurse-led community diagnostic clinics, e.g. for respiratory assessment – Use of new diagnostic technologies, e.g. ‘mini’ spirometer for pre-screening, – Use of biomarkers in diagnosis of asthma
    6. 6. What’s out there for diagnosis of disease from a symptom-based perspective? • Focus on models of care for chest pain, AF, blackouts, palpitations, heart murmur and breathlessness • Research highlighted examples of: – RACPC model implementation – Rapid access clinics for arrhythmia/ AF, e.g. Charing Cross Hospital, palpitations and blackout – Diagnostic pathway for heart murmur, e.g. Papworth Direct One Stop Service • Models of care worthy of further exploration: lumps and bumps, unexplained weight loss, unexplained bleeding, & fatigue
    7. 7. What’s out there for diagnosing disease with a focus on breathlessness as a symptom? • Research concluded: – IMPRESS have already undertaken a huge amount of work in this area, including collating examples of good practice, providing support for commissioners and providers – The IMPRESS algorithm is currently the only available evidence- based pathway for breathlessness – One size does not fit all: services need to evolve to reflect local need, resources and priorities – There are some examples of diagnostic breathlessness clinics in the literature but limited outcome/ cost-effectiveness data: • Outpatient breathlessness clinic run jointly by cardiology and respiratory consultants, e.g. University Hospital North Staffs • One stop breathlessness clinics, e.g. Chelsea and Westminster, Royal Brompton & Harefield • Rapid Access Breathlessness Clinic, NHS Bolton • GP referral to a one stop shop diagnostic service, Ashton, Leigh and Wigan…….
    8. 8. @NHSIQ enquiries@nhsiq.nhs.uk www.england.nhs.uk/nhsiq Improving health outcomes across England by providing improvement and change expertise.

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