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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

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.

What was the catalyst for change?

Respiratory Programme:

the beginning

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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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Respiratory Programme:

the beginning

…and patients and carers?

Respiratory Programme:

where we were

Strengths

•Willingness to work together

•Influence of patient organisations

•Recognition national action needed

•Clinical guidelines

•National audit data

Weaknesses

• Limited evidence apart for severe

disease

•Fragmented care pathway

•Late diagnosis/under diagnosis

•Inaccurate spirometry

• Ad hoc adherance to clinical

guidelines

Opportunities

•To take a whole pathway approach

•Drive new models of integrated care

•Promote R and D and innovation

•Embrace other respiratory conditions

Threats

•Keeping respiratory disease high on

the agenda

•Limited resources

•Move to LTC approach

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Respiratory Programme:

the challenge

A whole pathway approach:

reactive respiratory

services, treating moderate and

severe disease

proactive services, focussed on

prompt and quality-assured diagnosis across the disease spectrum, disease management and evidence based

interventions

To

move

from…

…to…

Smoking cessation Smoking cessation Smoking cessation

Awareness raising •Lung health•Lung symptoms•Lung age testing

Case finding

Early diagnosis

Social Care/Re-ablement

Accurate diagnosis

Quality spirometry

Physical activity

Proactive chronic disease management

and self-management

Pulmonary rehab

Evidence based treatment/medicines management

LTOT/NIV

EOL

Prompt therapy & follow-up in exacerbations

Structured hospital admission with specialist care

Respiratory Programme:

the challenge A whole pathway approach:

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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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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

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

Respiratory Programme:

setting a national strategy

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• 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

Respiratory Programme:

setting a national strategy

The NHS Companion Document

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

How the Outcomes Strategy maps to the NHS

Outcomes Framework domains

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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)

So what have we done?

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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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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• Published a good practice guide

for services for adults with

asthma

• And…

Respiratory Programme:

what we have achieved

On asthma we have…

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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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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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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Over to you!