Improving outcomes for people with respiratory disease: Keeping up the momentum Professor Sue Hill and Dr Robert Winter Joint National Clinical Directors for Respiratory Disease Part of a set of presentations from NHS Improvement event: Better value, better outcomes held on Thursday 21 February 2013, Guoman Tower Hotel, London How to deliver quality and value in chronic care:sharing the learning from the respiratory programme

1. Improving outcomes for
people with respiratory disease:
Keeping up the momentum
Professor Sue Hill and Dr Robert Winter
Joint National Clinical Directors for Respiratory Disease
Respiratory Programme:
the beginning
What was the catalyst for change?
CMO’s Annual Report 2004:
• The Government should continue to
pursue strong programmes of tobacco
control …which will be reducing the human
and financial cost of COPD.
• Consultant expansion programmes should
be reviewed against the need for
respiratory physicians at a local level,
and adjustments made where necessary
• More primary care staff should be provided
with training in the use of spirometry as
a tool to detect COPD
• A National Service Framework should be
formulated for COPD.
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2. Respiratory Programme:
the beginning
Why was a national respiratory programme established?
– Unwarranted variation in quality of care
– Inequalities in outcomes across country
– Poor performance compared to other countries
– Burden of respiratory disease on the health service
and future challenge of long-term conditions
– High cost to the taxpayer
• Clear objectives and expectations needed to be set out for
NHS, Public Health and Social Care
Respiratory Programme:
the beginning
What were the community calling for?
– Better patient involvement and engagement
– Better partnership working (charities, industry, professional bodies etc)
– Better multi-disciplinary working
– Better data to drive change
– Determining and sharing good practice and improvement
– Better uptake of the interventions that matter
– More respiratory clinician involvement/leadership
– Focus on clinical assessment and home oxygen re-procurement
– A national strategy and inclusion in NHS-wide national plans
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3. Respiratory Programme:
the beginning
…and patients and carers?
Respiratory Programme:
where we were
Strengths Weaknesses
•Willingness to work together • Limited evidence apart for severe
•Influence of patient organisations disease
•Recognition national action needed •Fragmented care pathway
•Clinical guidelines •Late diagnosis/under diagnosis
•National audit data •Inaccurate spirometry
• Ad hoc adherance to clinical
guidelines
Opportunities Threats
•To take a whole pathway approach •Keeping respiratory disease high on
•Drive new models of integrated care the agenda
•Promote R and D and innovation •Limited resources
•Embrace other respiratory conditions •Move to LTC approach
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4. Respiratory Programme:
the challenge
A whole pathway approach:
proactive services,
focussed on
To reactive prompt and quality-
respiratory …to… assured diagnosis
move services, treating across the disease
moderate and spectrum, disease
from… severe disease management and
evidence based
interventions
Respiratory Programme:
the challenge
A whole pathway approach:
Smoking cessation Smoking cessation Smoking cessation
Proactive chronic disease management
and self-management
Evidence based treatment/medicines management
Awareness raising
Accurate diagnosis
•Lung health Quality spirometry
•Lung symptoms
Physical activity Pulmonary rehab
•Lung age testing
Social Care/Re-ablement
Case finding
Early diagnosis
Prompt therapy & follow-up in exacerbations
Structured hospital admission with specialist care
LTOT/NIV
EOL
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5. Respiratory Programme:
setting a national strategy
• Public consultation in February
Spring 2010
• Followed review of evidence
and advice from expert
reference group
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Risk stratification
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6. Respiratory Programme:
setting a national strategy
• Published a national strategy –
the Outcomes Strategy for
COPD and Asthma – with a
suite of associated tools and
resources
• Supported publication of a
NICE Quality Standard for
COPD
• Had respiratory disease
highlighted as a key priority in
the NHS Outcomes Framework
Respiratory Programme:
setting a national strategy
Outcomes Strategy: objectives
To improve the respiratory health and well-being of all
communities
To reduce the number of people who develop COPD by ensuring
good lung health and well-being
To reduce the number of people with COPD who die prematurely
through a proactive approach to early identification, diagnosis and
intervention
To enhance quality of life for people with COPD
To ensure that people with COPD receive safe and effective care
To ensure that people with asthma are free of symptoms
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7. Respiratory Programme:
setting a national strategy
The NHS Companion Document
• Published May 2012
• 20 high level actions to help clinicians,
service managers and commissioners
improve care locally
• Mapped across the 5 domains of the
NHS Outcomes Framework
• Bringing together information from the
Outcomes Strategy for COPD and
Asthma, NICE Guidance and
NICE Quality Standard
How the Outcomes Strategy maps to the NHS
Outcomes Framework domains
1 Diagnose earlier and accurately
Prevent progression
Prolong survival
2 Risk stratify and understand the local population
Support self-management & shared decision-making
Provide and optimise treatment
3 The right care in the right place at the right time
Ensure structured hospital admission
Support post-discharge
4 Empower people through information and education
Assess psychosocial support and social care needs
Assess palliative care needs
5 Deliver high flow and emergency oxygen safely
Prescribe steroids using evidence-based guidance
Robustly risk manage home oxygen environments
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8. So what have we done?
Respiratory Programme 2009 – 2013:
• Setting the direction informed by bottom up involvement and engagement
(publications consultation, outcomes strategy and guidance docs)
• Clinical leadership and engagement (creation of regional leads, clinical
networks)
• Focusing on change for improvement and gathering the
evidence (NHS improvement, research and evidence base, robust data)
• Creating lasting partnerships (with patient groups, professional groups)
• Making strategic connections (NHS Outcomes Framework etc)
Respiratory Programme:
what we have achieved
Since 2009 we have… • Supported a programme of
work through NHS
Improvement - Lung
• Supported regional clinical
leads and programme
managers in 10 areas of the
country, driving local leadership
and networks
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9. Respiratory Programme:
what we have achieved
Since 2009 we have… • Supported initiatives to drive
better data collection and use,
including:
– The Respiratory Atlas of
Variation, with 18 indicators of
care and outcomes
– INHALE, a central online
resource on data and
variation
Respiratory Programme:
what we have achieved
Since 2009 we have… • Led a successful home oxygen
contract re-procurement, which
was:
– Clinically led
– Patient focussed, with the
involvement of BLF and
patients
• The new contract will lead to:
– Better patient outcomes
– Annual savings for the NHS
of £35million
• Work was double award winning:
Guardian Public Service Awards
and Civil Service Awards
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10. Respiratory Programme:
what we have achieved
On asthma we have… • Published a good practice guide
for services for adults with
asthma
• And…
NICE Quality Standard for
Asthma – published today
QS1 People with newly diagnosed asthma are diagnosed in accordance with
BTS/SIGN guidance.
QS2 Adults with new onset asthma are assessed for occupational causes.
QS3 People with asthma receive a written personalised action plan.
QS4 People with asthma are given specific training and assessment in
inhaler technique before starting any new inhaler treatment.
QS5 People with asthma receive a structured review at least annually.
QS6 People with asthma who present with respiratory symptoms receive an
assessment of their asthma control.
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11. NICE Quality Standard for
Asthma – published today
QS7 People with asthma who present with an exacerbation of their
symptoms receive an objective measurement of severity at the time of
presentation.
QS8 People aged 5 years or older presenting to a healthcare professional
with a severe or life-threatening acute exacerbation of asthma receive
oral or intravenous steroids within 1 hour of presentation.
QS9 People admitted to hospital with an acute exacerbation of asthma have
a structured review by a member of a specialist respiratory team before
discharge.
QS10 People who received treatment in hospital or in an out-of-hours centre
for an acute exacerbation of asthma are followed up by their own GP
practice within 2 working days of treatment.
QS11 People with difficult asthma are offered an assessment by a
multidisciplinary difficult asthma service.
The future: setting out the
challenge
• Up to 30% of people are still misdiagnosed
• In COPD at least 8000 lives a year could be saved, and
asthma around 80% of deaths preventable
• Where somebody lives markedly affects their chances of:
– being admitted or readmitted to hospital as an
emergency
– receiving appropriate treatment
– dying from lung disease
– even being diagnosed in the first place
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12. The future: setting out the
challenge
• People still don’t always perform quality assured
spirometry, or train people in the correct inhaler
technique
• Levers and incentives are still not all well aligned
• There are other respiratory diseases which have not
yet had significant focus
• The management of multi-morbidities remains a
challenge
• Prevention and treatment strategies are not yet properly
aligned with other healthcare interventions, such as
smoking cessation, health checks, etc, to maximise the
patient contact
And more still to do……
Pneumonia
• National CQUIN for pneumonia/review of death certification data
from DH pilot
OSA
• Review of service models and commissioning guidance
Bronchiectasis
• Engagement with specialised commissioning in the development of
commissioning guidance/Improved patient information and support
Asthma
• Good practice guide for children with asthma/exploring provision of
salbutamol inhalers to schools for emergencies/ CQUIN for asthma
Data
• National review of asthma deaths
• National clinical audit for COPD
Education & Training
• A step by step guide to how quality diagnostic spirometry can be
delivered in primary care and elsewhere
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13. Over to you!
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