The document discusses the challenges and solutions for managing breathlessness in Wigan Borough, focusing on integrated healthcare services and improving patient care for individuals with COPD and heart failure. It emphasizes the need for early diagnosis, holistic management of co-morbidities, and personalized care plans to prevent exacerbations, while highlighting positive outcomes from pilot programs. Key principles include effective collaboration among healthcare providers, mentorship for primary care staff, and proactive patient identification and support.

1. 1
Breathlessness Service
Wigan Borough CCG
Wendy Fairhurst
Clinical Director
Health First ALW CIC

2. 2
Health Equity Audits COPD and
Heart Failure
 Deprivation
 Low prevalence
 High Admissions
 Excessive mortality rates

3. 3
Why Breathlessness?
 Start from symptom based approach rather than disease based
approach
 Problems with multiple pathology
 Problems with diagnosis between cardiac and
respiratory causes of breathlessness
 Multiple pathologies managed individually not holistically
 Limited post-exacerbation follow-up in practice teams – many
factors
 No detailed personalised management plans

4. 4
Feedback from Primary Care
 Difficulties in the management of patients with multiple pathology
 Patients referred to multiple hospital consultants and specialist
nurses – inconvenience and confusing for patients – delays in
appropriate treatment
 Difficulties for some patients in accessing services
 Travelling is difficult for this group of breathless patients
 There are a high number of follow-up out-patient appointments.
These are inconvenient for patients result in a high level of DNAs
and are costly

5. 5
The sort of support that practices
need
Diagnosing more difficult cases – this includes especially differentiating
COPD from asthma and heart failure, but also other conditions.
Doing reviews and optimising care on patients with multiple co-morbidities
– especially lung disease, heart disease, other vascular disease, diabetes
and CKD
Doing reviews that go significantly beyond what is required for QoF –
especially post exacerbation reviews that analyse causes of exacerbations
and devise a plan for preventative measures
Identifying high risk patients - Just working with those patients who have
been admitted is not enough – most of the year’s admissions were not
identified from the lists of previous admissions.

6. 6
Principles
 Integrated working
 Early and accurate diagnosis
 Service based in Primary Care
 Active searching for patients in Primary Care who may be at
risk of deterioration
 Reviewing difficult cases in Primary by specialist nurses –
working alongside practice teams
 Giving each patient a self-management plan
 Consultant – led clinics in Primary Care – leading to more
integrated working
 Reviewing patients post-discharge in Primary Care
 Developing clinical resources for use within Primary Care

7. 7
Integrated Working
 Patient journey – not clear and equitable
across the borough.
 Working with other agencies ( Primary Care,
Secondary Care, Tier 2)
 Need to eliminate duplication

8. 8
Early and accurate diagnosis
 Previously 6 attendances to diagnosis
 One stop shop diagnosis of Heart Failure
and/or respiratory disease
 Working with acute trust and community trust
to deliver the service in Primary Care
 Screening

9. 9
Diagnostic Service Pathway

10. 10
Service based in Primary Care
 Support and mentorship. Up- skilling –
working alongside staff in Primary Care
 Training days
 Key role of practice nurses
 Mentorship for Gps and practice nurses
 Training for practice staff

11. 11
Active searching for patients who may be at
risk of deterioration in Primary Care
 Preventing deterioration
 Searches
 Not waiting for referrals

12. 12
Assessment in Primary Care by
Specialist nurse
 Reviewing difficult cases in Primary Care by specialist
nurses – working alongside practice teams (helps with
up-skilling) – leading to more integrated working
 Causes of exacerbations (medication/environmental)
 Optimising medication
 Patient education and empowerment
 Giving each patient a self-management plan
 Work with INT project

13. 13
Developing clinical resources for use within
Primary Care
 Guidelines for the treatment of exacerbations
 Cold weather warnings
 Desk top guidance
 Long term conditions template

14. 14
Consultant – led clinics in Primary Care leading to
more integrated working
 Consultant – works in different practices around
the locality on a twice monthly basis
 Direct communication with GP’s and practice
teams
 Mentorship
 Care Closer to home
 2 week waiting list

15. 15
Reviewing patients post-discharge in Primary
Care
 Preventing re-admissions and further
exacerbations
 Duplication
 Working with Acute Trust

16. 16
Pilot
 £121k verified savings ( unscheduled
admissions, outpatients and medicines
management)18/24 practices.
 £180 – estimated - if all 24 practices had been
involved
 12 month period ( 6 month set up time)
 Based on one HRG code – J44 ( COPD
admissions)
 Initial difficulties in integrating with secondary
care ( COPD unit, discharge information)

17. 17
Diagnosis service results
Referred
to service
New
COPD
COPD
Diagnosis
confirmed
Treatment
optimized
New
Asthma
Asthma
diagnosis
confirmed
treatment
optimized
Heart
Failure
Other DNA Under
investigatio
n
282 88 29 27 13 35 43 12 35

18. 18
Qualitative results
highlights
 Improved data input and data collection in Primary
Care ( e.g. recording of exacerbations)
 Increased prevalence for all 3 diseases ( more
accurate diagnosis, picking people up early, early
treatment)
 Average age of diagnosis reduced
 Increased referrals to smoking cessation and
pulmonary re-habilitation