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
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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
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7
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6
3
4
3
4
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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