PRESENTATION BY:PRESENTATION BY:

Evaluation findings presentation

Lauren Roberts, OPM Principal Consultant

Bethan Peach, OPM Senior Consultant

Evaluation of the Breathlessness Pilots

March 2016

CONTENTS

1. Overview of the evaluation

brief

2. Evaluation methodology

3. Key findings 4. Next steps

5. Q & A

• Did the pilot achieve its aims and objectives?

• Can the model be spread?

• Is there a convincing commissioning case?

• Which stakeholders have been involved?

• Are the new models sustainable?

• How important was clinical leadership to success?

• What are the staff and patient / carer experiences?

• What are the lessons learnt?

• What unintended outcomes are there?

• What improvements are needed?

OVERVIEW OF THE EVALUATION BRIEF

Formative and summative learning

Case study learning

Programme-wide learning

Build on the local evaluations

Utilise secondary data wherever

possible

Share emerging insights

EVALUATION METHODOLOGY AND TIMEFRAME

30 Nov

31 Mar

• Project inception meeting

• Initial contact made with all site leads and key stakeholders

• Document review

• Scoping interviews – national and pilot site level

• Interim reporting

• Fieldwork with leads, clinicians, support staff and patients

• Secondary data analysis

• Case study development – drafting and validation

• Analysis and reporting

• Dissemination of the findings

12 Feb

FIELDWORK, DOCUMENTS AND DATA REVIEWED

- Prevalence data- Medicines

management savings

- IPSOS Mori survey data

- Patient experience survey data

- Pilot site applications and Nov 2015 presentations

Report and summaries of background, activities and outcomes of the pilot

- Patient feedback

- Background documents

- Secondary data

Ashton, Leigh and Wigan Wessex Leicester, Leics

and RutlandProgramme

level

Interviews:- Dame

Helena Shovelton

- Dr. Mike Morgan

- Dr. Erika Denton

Steering group meeting (Feb)

- 1-1 interviews with the Lead Respiratory Nurse, a GP and a Consultant- 2x patient interviews- Focus group: Health First team

Semi-structured interviews with 8 stakeholders, including nurses, programme leads and GPs.

Site visits, inc. focus group (5 people)

Semi-structured interviews with 9 stakeholders, including lead specialist consultants, other clinic staff, the programme lead and a commissioner.

SOME CAVEATS TO CONSIDER

Tight evaluation timescales;

programme already underway

Secondary data

analysed / written up

Final report still be drafted

Case studies being

finalised / signed off

Interviews and visits,

but no observations

Small sample sizes

in some cases

Address contextual factors and challenges relating to diagnosing, treating and managing breathlessness

Patients present with symptoms, not ‘diagnoses’, but there is a lack of symptom-based services and interventions

Delays in diagnosis in both primary and secondary care:•E.G. LLR: 18 week wait for clinic appointments and a further 18 week wait for some therapies. •Primary care referral to either respiratory or cardiology can often be incorrect – yo-yoing

Breathlessness is often multi-factorial but co-morbidity is frequently undetected in disease-specific services

Lack of knowledge across primary and secondary care of existing services; inconsistency in available services.

BACKGROUND TO THE PILOTS

• Develop breathlessness pathway

• Diagnosis and results on same day

• Reduced waiting times

• Active searching for patients in primary care

• One stop shop with different specialists

• MDT meetings• Fewer referrals onward

• Public health / lifestyle • Improved uptake and

compliance• Needs effectively addressed• Capacity building for

practice nurses & GPs

• Reduced travelling and appointments

• Understanding & chance to ask questions

• Primary care follow up

Process improvements

Integration of primary and

secondary care

Clinical outcomes

Patient experience

AIMS AND OBJECTIVES OF THE PILOTS

Breathlessness service

Respiratory and Cardiology

Consultants

GPs, Practice Nurses

Leads and coordinators

Phsyios, Physiologists,

Echo Technician

Respiratory Nurses

STAKEHOLDERS INVOLVED

Commis-sionersPatients

STAFF EXPERIENCE

• Enthusiastic, passionate about breathlessness• Focus on solutions, not ‘yo-yoing’

Motivation

PATIENT EXPERIENCE

LLR

• UHL survey of 10 patients attending the clinic:

• All rated it as excellent

• All were treated with dignity and respect

• All said their reason for referral was dealt with satisfactorily

• All would recommend the service to F&F

WESSEX

• AHSN survey:

• 100% satisfied with their experience

• 70% had good compliance with treatment

• 96% felt confidence in managing breathlessness symptoms after the clinic

AL

W

• Health First survey (136 patients):

• 94% felt the clinician was competent

• 94% rated the overall experience as excellent or very good

• 90% felt involved in planning their care

• 91% felt their concerns were addressed

• 92% felt treated with dignity and respect

PATIENT FEEDBACK

“When I asked questions I was given a direct answer I could understand fully, which was very reassuring.”

“There will be a check-up once every six months, which I like. I like to feel they’re keeping an eye on me without having to ask.”

They specialise in one thing and know what they’re doing. When I have tests done they understand it better

than the doctor.”

PATIENT EXPERIENCE – CLINICIAN PERCEPTIONS

More confidence in their diagnosis and treatment - can see the team working together.

Better able to understand and accept their diagnosis - receive consistent messages from different professionals on the same day.

Misinterpretation of info is picked up on the same day.

Patients receive a more specific symptom-focused approach.

No long waiting lists, not passed between specialists.

Receive a more holistic picture of their symptoms, causes, and options for treatment and management

Both clinical and lifestyle factors are covered

Improved symptoms following treatment - QoL

Fewer visits to hospital:

• improved patient experience

• cost savings

• patients with breathlessness are often elderly, frail or have mobility issues.

= Improved compliance overall

Enabled patients to receive an accurate diagnosis and appropriate treatment plan more quickly than would otherwise have happened.

There has been an increase in patients on the asthma and COPD register in practices where the pilot has taken place, due to misdiagnosed patients being identified and correctly diagnosed. Appropriate treatment was then put in place.

CODP prevalence has increased by up to 44% in practices taking part in the pilot.

30% increase in people classing themselves as ‘ex-smokers’ 5-months after.

There are reported medicines management savings of £40,000 over a 6-month period across the borough, as a result of more appropriate prescribing.

There has been increased diagnosis of heart failure. One practice increased the number of patients diagnosed as experiencing heart failure from 119 to 222 over a 10-month period after joining the pilot (an 86% increase).

Other conditions that have been diagnosed in the clinics include valve disease, aortic fibrillation, bronchiectasis, pulmonary fibrosis; emphysema, lung cancer, and patients eligible for lung transplants.

SNAP SHOT OF IMPACTS - ALW

UNINTENDED OUTCOMES AND LEARNING

“I was surprised that all the

patients turned up. At the clinics at the hospital

we usually get a lot of patients

who don’t come. I don’t know if

it’s because we’re not in the practice and it’s

too far to come. I don’t know but that would be

something interesting to

look into.” Specialist clinical

team

All but 2 of the patients who confirmed did attendSmall changes in comms can make a big difference –

‘HDM’

Importance of 1-1 relationship with practicesPatients will accept lifestyle advice – holistic is key

Medicines management savings

Importance of patient perception of their condition and experience of diagnosis pathway = compliance

Holistic approach can tackle other LTCs, wider benefits

CRITICAL SUCCESS FACTORS

Wider context and environment

Partners and relationships

Core team and focus

• Passionate, motivated staff• Clinical leaders• In-kind resources• Make it as easy as possible for patients• Quantitative outcomes & KPIs

OTHER ENABLERS

•Supportive approach to engaging GPs in developing the primary care pathway•Use evidence: nearly 20% of patients seen in the client could have been diagnosed in primary care; 35% had no investigations prior to secondary care referral

LLR

•Strong local partnership network•Fortnightly meetings - reflection•AHSN committed to tackling respiratory conditions as a priority

Wessex

•Local staff involved; understand demographics and local population•Open and honest dialogue – with patients and each other

ALW

ALW•GP engagement – lead-in time•BNP testing machine•Echo tech locum reliance•Hard to keep on top of GP turnover - comms•Covered half the borough – but no audit of ‘control group’•‘Fits and starts’ in numbers at clinics•Commissioner buy-in / re-tendering

LLR•Availability of resources, inc. staff, space, equipment•Identifying patients for the clinics (going through referrals)•QI project = behaviour change is vital, but takes time to embed•Innovative approaches often slow to implement locally = challenges in getting the work up and running.

Wessex•Initial CCG and GP buy-in was low. Only 1 out of 40 CCGs was interested; limited practice interest •100s identified by GRASP – need for prioritisation of people with overlapping COPD, asthma and cardiac symptoms •GRASP tool dependent on codes assigned by GPs, which vary•Patients who couldn’t attend: holidays, post-surgery, prior commitments.

CHALLENGES

SUGGESTED IMPROVEMENTS

Funding – clear blockages in systemImprove links with lifestyle and behaviour change support. Incorporate into clinic

Systematise the coding of conditions – to support GRASP useWiden out to focus not just on the top priority ‘high risk’ patientsFace-to-face engagement rather than the paper based EOI initially

Roll-out across Borough – postcode lotteryEvidencing longer term outcomes

SUSTAINABILITY, COMMISSIONING CASE AND SPREAD

Early results indicate longer term potential for efficiency savings: Shorter pathway to accurate diagnosisReduced need for secondary care apptsReduced misdiagnosisMedicines management savingsStaff retention Improved self-management: avoiding

exacerbations and other LTCs Improved patient QoL and MHBut: small dataset - be cautious about extrapolating the benefitsStrong profile, local networks and in-kind contributions – above the £15kHard to incentivise GPs sufficiently

LLR: For the next phase of the pathway, where primary care implementation will take place, the main challenges expected are the geographical spread of the population, varying GP knowledge, interest and resources. Also, potential to use the Uni Sports Centre?

Wessex: Clinics cost £142 per patient to run (exc in-kind), compared with £241 tariff for cardiac and resp outpatient referral appts. • ASHN and partners are currently

launching MISSION ABC, making a case for expanding this model to offer a ‘one-stop shop’ in asthma, breathlessness and COPD.

• Widespread interest from CCGs in adopting the model.

• The specialist team became more confident and familiar with the clinic process = better gauging of appt timings.

ALW: British Oxygen Respiratory Service, separate to diagnostic

service

CONCLUSIONS

Process improvements, impacts on clinical outcomes and experience

The models improve the pathway for patients with breathlessness

Built capacity and understanding amongst primary care teams to diagnose and treat breathlessness symptoms more effectively

Improved patient experience, understanding and self-management

Patients’ symptoms explored holistically; potential wider impact on other LTCs.

Improved relationships and integrated working

Staff satisfaction – potential re retention and morale = impact on patient care

But – reliance on committed staff, requires a core team

Logistical challenges

Challenge of engaging commissioners

May take years to evidence full impacts

Relatively small-scale pilots: sufficient evidence for commissioners?

NEXT STEPS WITH THE EVALUATION

Case study final validation

Word report and stand-alone summary

Dissemination activity

Contact usLauren Roberts:

lroberts@opm.co.ukBethan Peach:

bpeach@opm.co.ukCaitlin McMillan:

cmcmillan@opm.co.uk

Thank you

www.opm.co.uk 020 7239 7800