COPD SERVICE RE-DESIGN

Dr Mukesh Singh

GP Principal & GPwSI Respiratory Medicine, Horse Fair Practice, Rugeley

Clinical Lead LTC & Governing Body member Cannock Chase CCG

COPD

DRIVERS FOR RE-DESIGN

835000,

Severe

Disease*

3 Million

SUBCLINICAL COPD

Clinical COPD - Tip of the Iceberg

DOH DATA 2011

• The 2009 General Lifestyle Survey suggests that people with LTCs account for:

• 50% of all GP appointments

• 64% of outpatient appointments

• 70% of all inpatient bed days

• In total around 70% of the total health care spend in England (£7 out of every £10) is attributed to caring for people with LTCs

• This means that 30% of the population accounts for 70% of the NHS spend.

Looking back to look forward:

Uncoordinated, outdated and over

stretched

•Increase in demand for services

•An unsustainable system

•Paternal culture of management

•Lack of incentives to drive

integration

•Demographic pressures

Transforming services for COPD

COPD What we did

•Clinically led service redesign

•Worked with multiple healthcare professionals and organisations to develop care pathways

•Joint business case for change

•Commissioning and delivery of a proactive and integrated community service

•Whole-system approach to managing patients with COPD

COPD What we’ve achieved as a health economy

• The redesign of the COPD pathway and integration of patient management has resulted in a 37.2% reduction in COPD emergency admissions activity over two years

• Delivery of agreed pathways

• Patients managed in their homes

The success of the reduction is attributed to the multi-disciplinary approach taken to redesign the pathway and the subsequent patient management

CCG 2012 /

2013

2013 /

2014

2014 /

2015

% difference from

12/13 to 13/14

% difference from

13/14 to 14/15

% difference from

12/13 to 14/15

STAFFORD &

SURROUNDS

296 228 186 -23.0% -15.4% -37.2%

COPD Primary Care

• POINTS programme rolled out in primary care which up-skilled GP practices in the use of spirometry to diagnose COPD;

• Self-management plans for COPD patients, rolled out as part of the innovations group, designed with the community respiratory team;

• Nurse Clinical Collaborative focusing on COPD. This was attended by Practice nurses, Community Respiratory Team and Respiratory nurses from Mid Staffs FT. The programme covered respiratory assessment, consultation skills, inhalers, medication reviews, self-management, exacerbations and case studies; and

• Practices also identified patients suitable for “Flo” Simple telehealth and practices have been given pulse oximeters and thermometers with the aim to empower patients to take more responsibility for their health and wellbeing and seek to improve healthcare use across the different health sectors.

COPD Community Care

• Continued delivery of proactive care, including MDTs with GP practices and pulmonary rehab;

• Step up of COPD patients went via the community instead of secondary care;

• Consultant-led outpatient appointments for COPD patients as part of an MDT with the community respiratory nurse specialists;

• Hot clinics for patients needing a rapid review by a Consultant; and

• Follow-up appointment from an emergency admission to be had in the community.

COPD Secondary Care

• CQUIN implemented to ensure all patients admitted with COPD were assessed and seen by a consultant in a timely manner (admission bundle);

• CQUIN implemented to ensure all patients discharged following a COPD emergency admission have been referred to the appropriate follow-on services including follow-up in the community, smoking cessation, pulmonary rehab, community oxygen services (discharge bundle); and

• Decommissioned COPD outpatients in a secondary care setting and re-commissioned in the community via the community respiratory team with Consultant oversight and access.

In a single UK primary care

cohort

Friday @ 18:00hrs… COPD patient + Feeling breathless + Confused + No integrated care plan

GP Pharmacy 999 Admission A&E

No record of

care plan,

unable to give

antibiotics

Closed Ambulance

visits patient,

takes to A&E

A&E assess,

not happy

with patient

SATs and

decide to

admit

Antibiotics,

more

confused,

long LOS as

SATs don’t

improve

Passing the buck costs big bucks!

COPD

Thank You