Breakout 1.3 Improving COPD Care in the West Midlands - Colin Gelder Clinical Lead Respiratory Midlands Region, NHS Midlands & EastMidlands East 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 COPD Care in the
West Mildands
Colin Gelder
Clinical Lead Respiratory
Midlands Region, NHS Midlands & East
1

2. 2

3. 3

4. Purpose of Data
Purpose of Data
4

5. West Midlands Non-Elective
COPD Admissions
3.5
2009/10
Admissions per 100,000 population
3.0 >2 fold variation
2.5
2.0
1.5
1.0
0.5
0.0
West Midlands COPD Non-Elective
Admissions
COPD admissions per 1000 population COPD admissions per 1000 registered pts Rank within SHA National rank
PCT 2007/08 2008/09 2009/10 2007/08 2008/09 2009/10 2007/08 2008/09 2009/10 2007/08 2008/09 2009/10
National 2.1 2.3 2.2 146 155 140 - - - - - -
SHA 2.0 2.2 2.2 147 154 143 - - - - - -
Herefordshire PCT 1.5 1.5 1.4 117 109 98 1 1 1 23 16 22
Heart Of Birmingham Teaching PCT 1.6 1.6 1.5 229 237 215 4 2 2 31 23 27
Warwickshire PCT 1.6 1.6 1.6 133 126 119 5 3 3 35 30 36
Shropshire County PCT 1.7 1.8 1.7 110 118 108 6 5 4 45 44 42
Telford and Wrekin PCT 2.0 2.3 1.8 127 134 101 9 9 5 74 79 49
Worcestershire PCT 1.5 1.9 1.8 122 147 130 3 6 6 30 54 52
South Staffordshire PCT 1.5 1.7 1.8 109 121 127 2 4 7 24 36 55
North Staffordshire PCT 2.1 2.1 2.0 128 122 108 10 8 8 82 73 70
Solihull Care Trust 2.0 2.4 2.1 139 164 136 8 12 9 73 89 77
Dudley PCT 2.1 2.4 2.2 160 169 149 11 11 10 83 87 86
Wolverhampton City PCT 2.1 2.3 2.2 156 162 149 12 10 11 84 84 88
South Birmingham PCT 2.3 2.6 2.4 151 167 150 13 13 12 94 100 96
Coventry Teaching PCT 1.9 2.1 2.4 135 142 156 7 7 13 71 72 98
Sandwell PCT 2.8 3.0 2.7 170 176 157 14 14 14 119 117 115
Walsall Teaching PCT 3.0 3.0 2.7 194 181 153 17 16 15 129 119 116
Birmingham East and North PCT 2.9 3.1 3.0 212 226 210 15 17 16 122 123 124
Stoke On Trent PCT 3.0 3.0 3.3 163 162 166 16 15 17 125 118 133
5

6. Coventry PCT COPD Admissions
West Midlands non-elective COPD
hospitalisation costs
COPD tariff per 1000 population COPD tariff per 1000 registered pts Rank within SHA National rank
PCT 2007/08 2008/09 2009/10 2007/08 2008/09 2009/10 2007/08 2008/09 2009/10 2007/08 2008/09 2009/10
National 4.2 4.6 5.1 297 314 329 - - - - - -
SHA 4.1 4.6 5.1 297 315 336 - - - - - -
Heart Of Birmingham Teaching PCT 3.4 3.3 3.5 495 500 491 6 2 1 43 23 25
Herefordshire PCT 3.1 3.1 3.5 241 227 238 3 1 2 27 15 26
Shropshire County PCT 3.3 3.4 3.8 212 220 239 5 3 3 36 27 31
Warwickshire PCT 3.3 3.6 4.1 272 271 297 4 6 4 35 39 41
Worcestershire PCT 2.8 3.5 4.2 219 268 301 1 5 5 13 38 45
Telford and Wrekin PCT 3.9 4.6 4.2 244 271 238 7 9 6 61 76 46
North Staffordshire PCT 4.4 4.0 4.4 263 231 239 11 7 7 87 58 55
South Staffordshire PCT 2.9 3.5 4.6 212 245 320 2 4 8 18 32 66
Solihull Care Trust 4.1 5.1 4.8 286 349 311 10 12 9 77 100 72
Dudley PCT 4.0 4.3 5.0 298 303 334 8 8 10 68 67 73
Wolverhampton City PCT 4.6 4.8 5.2 334 331 348 12 11 11 93 84 83
Coventry Teaching PCT 4.0 4.6 5.7 279 308 366 9 10 12 73 79 100
South Birmingham PCT 4.9 5.7 5.8 328 367 369 13 13 13 104 109 106
Sandwell PCT 5.5 5.7 6.2 332 332 358 15 14 14 116 111 110
Walsall Teaching PCT 6.5 6.8 6.8 426 407 381 17 16 15 133 131 119
Birmingham East and North PCT 6.2 6.9 7.0 452 501 493 16 17 16 129 132 124
Stoke On Trent PCT 5.5 6.0 7.2 304 320 362 14 15 17 115 116 127
6

7. West Midlands non-elective COPD
hospitalisation length of stay
COPD Length of stay Rank within SHA National rank
PCT 2007/08 2008/09 2009/10 2007/08 2008/09 2009/10 2007/08 2008/09 2009/10
N a ti o n a l 8 .3 8 .0 7 .7 - - - - - -
SHA 8.4 8.2 7.9 - - - - - -
Solihull Care Trust 8.2 8.5 6.7 7 11 1 62 98 23
North Staffordshire PCT 8.7 7.2 6.8 10 4 2 101 34 27
Heart Of Birmingham Teaching PCT 8.7 7.8 7.2 11 9 3 102 62 46
Stoke On Trent PCT 7.4 7.1 7.3 5 3 4 30 29 51
Herefordshire PCT 8.4 7.7 7.4 8 7 5 73 58 55
Birmingham East and North PCT 9.5 9.1 7.6 14 13 6 130 130 65
Telford and Wrekin PCT 6.9 7.5 7.7 1 6 7 17 49 74
Dudley PCT 7.3 6.9 7.8 4 2 8 28 26 77
Sandwell PCT 7.2 6.6 7.9 3 1 9 23 21 91
Walsall Teaching PCT 8.6 9.7 8.1 9 17 10 87 142 97
Wolverhampton City PCT 9.3 8.3 8.1 13 10 11 123 93 100
Shropshire County PCT 9.7 9.4 8.2 17 16 12 139 138 102
South Staffordshire PCT 7.5 7.3 8.2 6 5 13 37 38 104
Worcestershire PCT 7.1 7.7 8.2 2 7 14 22 58 105
Coventry Teaching PCT 9.6 9.1 8.3 16 12 15 136 129 109
Warwickshire PCT 9.1 9.2 8.9 12 14 16 117 134 132
South Birmingham PCT 9.6 9.4 9.4 15 15 17 133 136 144
West Midlands non-elective COPD
hospitalisation 28-day readmission rate
COPD readmissions per spell Rank within SHA National rank
PCT 2007/08 2008/09 2009/10 2007/08 2008/09 2009/10 2007/08 2008/09 2009/10
N a ti o n a l 0 .2 0 0 .2 1 0 .2 2 - - - - - -
SHA 0.19 0.21 0.22 - - - - - -
Herefordshire PCT 0.18 0.16 0.14 5 1 1 38 4 2
Solihull Care Trust 0.20 0.26 0.18 14 17 2 92 145 17
South Staffordshire PCT 0.18 0.18 0.19 6 5 3 39 18 21
North Staffordshire PCT 0.21 0.19 0.19 17 7 4 107 34 22
Heart Of Birmingham Teaching PCT 0.20 0.21 0.19 10 9 5 80 72 27
Telford and Wrekin PCT 0.20 0.22 0.20 9 11 6 76 80 42
Worcestershire PCT 0.15 0.22 0.20 3 12 7 17 87 47
Wolverhampton City PCT 0.14 0.18 0.21 1 6 8 5 27 54
Walsall Teaching PCT 0.20 0.22 0.21 11 14 9 81 100 55
Dudley PCT 0.15 0.16 0.22 4 2 10 18 7 66
Stoke On Trent PCT 0.20 0.21 0.22 12 10 11 84 78 83
Warwickshire PCT 0.19 0.20 0.23 8 8 12 73 54 86
Shropshire County PCT 0.15 0.16 0.23 2 3 13 12 8 88
Coventry Teaching PCT 0.20 0.17 0.24 13 4 14 91 14 104
Sandwell PCT 0.19 0.22 0.24 7 13 15 62 93 106
Birmingham East and North PCT 0.21 0.23 0.25 16 15 16 106 111 110
South Birmingham PCT 0.21 0.23 0.25 15 16 17 97 112 118
7

8. 0.0
2.0
4.0
6.0
8.0
10.0
12.0
PCT average 14.0
West Midlands SHA report
M86613
M86011
M86630
M86022
M86001
M86026
M86037
M86638
M86020
M86634
M86041
M86019
M86005
M86627
M86013
M86028
M86010
M86008
M86033
M86610
M86012
M86032
M86034
M86016
M86015
M86027
M84012
M86044
M86604
M86014
M86030
M86002
M86039
M86021
M86038
M86605
M86629
M86035
Level Data
M86007
M86624
Figure 8.1: COPD non-elective hospitalisations per 1000 population by GP practice
M86009
M86040
M86619
M86023
M86018
M86043
M86006
M86622
M86045
M86607
M86612
M86046
M86017
M86004
M86029
M86633
Making the Case for Change
M86048
Y00140
M86003
M86603
M86617
Coventry: COPD Admissions Practice
M86621
Page | 19
8

9. Savings if Non-Elective COPD Admissions
Reduced to National Average
£1,000,000
£800,000
£600,000
£400,000
£200,000
£-
Savings if Non-Elective COPD Admissions Reduced
by 20% (QIPP Target)
£700,000
£600,000
£500,000
£400,000
£300,000
£200,000
£100,000
£-
9

10. PCT Cost Saving Potentials for COPD
COPD COPD COPD admissions Cost per Admissions reduced Savings if average Savings if Savings if
PCT Population
Register admissions per 1000 population spell (£) if average admissions (£) admissions -10% (£) admissions -20% (£)
National 54,003,337 829,767 116,130 2.2 2,350 0 0 27,286,400 54,572,800
SHA 5,707,214 86,020 12,299 2.2 2,350 26 61,292 2,890,700 5,781,400
Herefordshire PCT 180,142 2,649 259 1.4 2,436 0 0 63,100 126,200
Heart Of Birmingham Teaching PCT 313,934 2,218 476 1.5 2,288 0 0 108,900 217,800
Warwickshire PCT 546,003 7,527 899 1.6 2,488 0 0 223,700 447,400
Shropshire County PCT 295,342 4,688 504 1.7 2,222 0 0 112,000 224,000
Telford and Wrekin PCT 169,429 2,996 304 1.8 2,342 0 0 71,200 142,400
Worcestershire PCT 572,989 7,993 1,038 1.8 2,318 0 0 240,600 481,200
South Staffordshire PCT 605,435 8,726 1,112 1.8 2,511 0 0 279,200 558,400
North Staffordshire PCT 208,582 3,846 414 2.0 2,222 0 0 92,000 184,000
Solihull Care Trust 220,953 3,400 463 2.1 2,281 0 0 105,600 211,200
Dudley PCT 312,366 4,631 692 2.2 2,238 20 45,398 154,900 309,800
Wolverhampton City PCT 256,543 3,848 575 2.2 2,329 23 54,315 133,900 267,800
South Birmingham PCT 386,532 6,122 918 2.4 2,461 87 213,578 225,900 451,800
Coventry Teaching PCT 349,333 5,420 846 2.4 2,346 95 222,401 198,500 397,000
Sandwell PCT 322,378 5,612 883 2.7 2,277 190 432,151 201,100 402,200
Walsall Teaching PCT 266,448 4,773 731 2.7 2,488 158 393,223 181,900 363,800
Birmingham East and North PCT 424,787 6,059 1,270 3.0 2,350 357 837,982 298,500 597,000
Stoke On Trent PCT 276,018 5,512 915 3.3 2,183 321 701,557 199,700 399,400
Making the Case for Change in
Coventry
Metrics Patient
Feedback
Pathway
Analysis
10

11. Patient & Carer Feedback
Access to a central specialist service
with good parking
Better information about what COPD is
& what treatment to expect
Better information on managing COPD,
especially exacerbations (who to call and when)
Patient & Carer Feedback
Carers wanted more information about COPD &
how to help the patient
More information about services that are
available to support them and how to access
them
Ongoing support after completing pulmonary
rehabilitation programme
Consistent care
11

12. Pathway Analysis
 High admissions & rising year on year
 Many admitted patients not on respiratory
ward nor S/B specialist
 Only 46% followed up post discharge
 QOF prevalence below expected levels
 Significant variation in Primary Care
spirometry QA
 Less than 20% patients on HOS had
specialist assessment
 No clear pathway to suport EOLC for COPD
12

13. 13

14. Risk
Stratification Self
Management
Integrated Care
Pulmonary
Rescue packs
Rehabilitation
Quality
Spirometry
Case Finding
14

15. Staff Training
Medicines
Management
Post Discharge
Review
Telehealth
End of Life
Oxygen
15

16. Risk
Stratification Self
Management
Pulmonary Rescue packs
Rehabilitation
Staff Training
Medicines of Life
End
Management
Quality
Case Finding Spirometry
Post Discharge
Review
Telehealth
Integrated Care Oxygen
Whole System Approach
16

17. Long Term Conditions
Long Term Conditions
Level 3
High Complexity
Case Management
Level 2
High Risk
Disease & Care Management
Level 1
70-80% LTC Population
Self Care/ Support Management
17

18. Long Term Conditions
Level 3
High Complexity
Case Management
Primary Care
Level 2
High Risk
Disease & Care Management
Level 1
70-80% LTC Population
Self Care/ Support Management
Long Term Conditions
Role of COPD Team
Level 3
Shared care High Complexity
Case Management
Primary Care
Specialist Level 2
High Risk
Opinion Disease & Care Management
Support & Level 1
Education 70-80% LTC Population
Self Care/ Support Management
18

19. Long Term Conditions
Primary Care
COPD Diabetes
Neurological
Heart Failure conditions
Long Term Conditions
Social Care
Primary Care
COPD Diabetes
Neurological
Heart Failure conditions
19

20. From Vision to Reality
From Vision to Reality
Local engagement/ownership of CCG KoL
Empowering local champions
Relationship building at practice level (GP,
Nurses, practice Managers)
Flexible commissioning with risk sharing
Clear & progressive goal(s) setting
incorporating regular patient feedback
Clear governance across integrated pathways
20

21. Progress
• Community team established
• COPD high on the agenda
• Widespread sign up to the model of care
• 75% of practices use POINTS
• Reduction in admissions
• 90% outpatient activity now in community
• High levels patient satisfaction
• All patients offered post discharge follow up
Quality
Up skilling Primary Care
Adherence to NICE Guidance & Quality
Standards
Alignment with COPD Outcomes Framework
Minimising unnecessary variations
Patient satisfaction
End of Life Care
21

22. Patient Feedback
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%100%
The appointment me was convenient for me.
I had confidence in the nurse/therapist who
visited me.
I was involved in the decisions about my care Strongly Disagree
and treatment.
I understood what the nurse/therapist said to
Disagree
me. Agree
I feel knowledgeable and in control of my
symptoms.
Strongly Agree
I was instructed on the use of my medica ons N/A
in a way I could understand.
No Answer
I was given advice about other services and
support that is available to me.
I was treated with respect and dignity.
Overall I was sa sfied with the standard of
treatment I received.
Overall I was sa sfied with the venue.
Innovation
Working Smarter
Network
Integration
Care closer to home
Empowering patients
Education/ SPACE manual
Using data
Tele health
22

23. Productivity
Admissions avoidance
Moving out patient care to community
Efficient use of resources
Medicines management
Home oxygen
COPD Admissions
1200
1000
800 2006-07
2007-08
600
2008-09
400 2009-10
2010-11
200 2011-12
0
Coventry Teaching Warwickshire PCT
PCT
23

24. COPD Admissions by CCG
500
400
COPD Admissions
300
2010/11
200
2011/12
100
0
Godiva Inspires
Prevention
Primary: Smoking cessation, education
Secondary: Early detection, smoking
cessation, self management, pulmonary
rehabilitation, rescue packs, oxygen alert
cards
24

25. Savings & Investment
£600,000
£400,000
£200,000
£-
£(200,000)
£
£(400,000)
£(600,000)
£(800,000)
£(1,000,000)
£(1,200,000)
2011/12 2102/13 2013/14
Savings (including growth) £(308,597) £(635,565) £(989,747)
Additional Investment £353,000 £353,000 £353,000
Net Costs/savings £44,403 £(282,565) £(636,747)
25

26. Karen Jackson Paul Davies Practice Tracy King
physiologist Practice Manager
nurse Finance COPD
Rhea Fielding Manager UHCW Chris Mullins nurse
Jerry Head UHL Dan
Horne of Munday
Mark Galloway Breathe Easy pulmonary rehabilitation
Tim Berry
Head of medicines
management Coventry
Professor
PCT GP & LTC lead Sally Consultant
palliative care
Godiva CCG Singh IM&T
Fiona Shally Andrew Michelle
Hardy Park
John Thompson
Directorate Manager
Dymphna Medlock
Lead Nurse UHCW
Community CEO UHCW Contract Manager COPD
nurse
COPD Team PCT Jo
Peter Shakespeare
O’Brien
Jeremy Bacon Stephen Mark Jones
Jones Estates Manager
GP & LTC lead CEO
Arden Head of Respiratory
BLF Inspires CCG Cluster Physiology UHCW
PCT
Roy
Sarah Phipps Lee Sharrard Thompson
Head of information Angela Wall
Associate general Finance Community
UHCW Claudia Roginski manager UHCW Manager PCT matron CWPT
Business
rcp.nhslocal.nhs
www.inhale.nhs.uk
26

27. 0
5
10
15
20
25
1
11
21
31
41
51
61
71
81
91
101
111
121
131
141
151
161
171
181
191
201
211
221
231
241
251
261
271
281
291
301
311
321
331
341
351
361
371
381
391
401
411
421
431
441
451
461
471
Hospital Coventry 2010/11
481
491
501
COPD Admissions to University
511
521
531
541
551
561
571
581
591
601
27