Welcome!
Innovation in Changing Respiratory Practice
Respiratory Strategic Clinical Network
Tuesday 24 November 2015
#eoerscn
Agenda
09:30 – 10:15
Programme
Speaker
‘Take a Breath and Prepare for Winter’
Amanda Cousins
Working smarter together to turn winter
chaos back into winter pressure
AD of Service Improvement and Transformational Change
Co-Commissioning:
10:15 – 11:00
11:00 – 11:20
Is joint working between Secondary &
Community Care a theory or reality?
NELCSU
Catherine Tooley (James Paget Hospital)
Carl Dodd (Great Yarmouth CCG)
Refreshments
Respiratory Pathway Re-design:
Amanda Flower
The Challenges of Change – a local perspective
AD Planned Care and Long Term Conditions
Luton CCG
11:20 – 12:20
Examples from:
Dr Jonathan Douse
Consultant Respiratory Physician Ipswich Hospital
12:20 – 12:45

Luton CCG

Ipswich & East Suffolk CCG
Respiratory SCN Update & Future
Lianne Jongepier
EoE RSCN Team
12:45 – 13:30
Buffet Lunch
Amanda Cousins
AD of Service Improvement and
Transformational Change
NELCSU
Take a breath and
prepare for Winter !
Amanda Cousins NEL Healthcare Consulting
The challenge we all face
• 1/3rd Fewer beds
• 37 % increase in people turning up in emergency
care
• 2/3rds of urgent care patients are > 65 years
• We need to change to survive
5
How do we plan the provision of urgent or unplanned
care ?
• Regional System Resilience Groups (share good practice and work
on regional issues)
• Local System Resilience Groups (drive the local system
development)
• Capacity planning Groups (operational weekly)
• Operational System management
- Underpinning escalation plans for
trusts and for systems
- Commissioner and provider on call
6
The dimensions which impact on demand – non one
easy fix
Age profile of the
local population
The viral load or disease
profile
Environment
Demographics
7
What is everyone up to ?
• People are all working to a common set of goals
but we have different starting points, challenges
and opportunities.
• Everyone is talking about the need for radical
change and integration
• The most effective and impressive changes have
been achieved by
- Getting back to basics and keeping things simple
- Involving the shop floor in planning improvements
- Overcoming tribalism and barriers to change
8
Work together on the total pathway
Primary
Prevention
NICE Guidance
Early Diagnosis
Effective and
Timely Treatment
Patients
empowered to
manage their own
condition
Crisis management
and recovery plans
9
Influencing Factors: National Standards, Strategies and Guidance
National
1. “Transforming Urgent and Emergency care in England –
guidance for commissioners”
2. Ongoing provision of 111 services across the country;
dissemination of best practice from areas where this appears to
be working well and learning from those areas where services
are still struggling
3. Ongoing push with regard to use of smart technologies to
support patient self management for long term conditions,
heart failure and COPD
4. Ongoing push to provide services to support self management
of chronic or recurring problems e.g. direct access
physiotherapy for back pain patients; personal health budgets
5. Promotion of integrated health and social care provision for frail
older people with complex needs including crisis planning and
rapid access intensive support
6. Primary care development
7. Mental Health Services waiting times and increased access to
services (political aspirations currently)
8. Workforce planning – guidance is around on many aspects,
push for wider use of prescribers in the system ( nurses,
pharmacists and physiotherapists)
‘‘Sir Bruce Keogh’s review
of urgent and emergency
care services in England is
the latest driver for
change nationally’’
‘‘Improving access to
urgent and emergency
care services seven days
a week is a key
national priority’’
‘’Urgent and
emergency care
networks should play
a role in coordinating
resources across the
system’’
Some good local pilots where new initiatives are being tried so we
need to learn from others.
10
So what are others up to ? Visualising the future
together
11
Looking at the influencing Factors: Primary Care
National Position
Increase in responsibility
• Development of new relationships with neighbouring practices to deliver high quality care (networked models
of care)
• Promotion of equal relationships with every patient (models of shared decision making)
• Drive towards 7-day services (8am-8pm, 7days)
Population changes
• Expected growth in the number of people aged 85 and older and those living with one or more long term
conditions likely to rise from 1.9 million in 2008 to 2.9 million in 2018.
Workforce
• Gradual increases in the number of GPs working part time hours.
• GP workforce that has only increased at half the rate of other specialities in the medical field.
• Over reliance on locum GPs
Finance
• A decrease in real time spending on GP services
• NHS England sole commissioners of Primary Care services
IMPORTANT NOTE: The GP taskforce report identified major gaps in workforce information needed to underpin effective
workforce planning. They reconfirm the recommendation of the Centre for Workforce Intelligence (CfWI) that the GP workload
survey must be urgently re-commissioned, along with a more effective vacancy survey.
The survey collected data from voluntary submissions up to 2010.
12
Setting priorities for action: Hospital Non elective admissions
Diagnostic variations
Analysis of admissions by primary diagnostic groups show that, where marked increase in admissions occur an increase in age is
also apparent. This is consistent with the previous slides. [N.B. age is in the data but is not visible in the charts]
Ave. age on admission
increased by 4 years. Variation
respect to 11/12 +16%
Admissions by diagnostic category
Age a factor for morbidity?
Ave. age on admission increased by
3.5 years. Variation +19%. Note:
change in coding moved activity to
infections.
10,000
9,000
8,000
7,000
6,000
5,000
4,000
3,000
2013/14
2,000
2012/13
1,000
2011/12
-
Ave. age on admission
increased by 4 years. Variation
respect to 11/12 +140%
Ave. age on admission
increased by 4 years. Variation
respect to 11/12 +32%
13
Looking at the detail: deep dives : Non elective admissions
Respiratory: an increasing problem
The table shows the increase in non elective admissions to one acute trust associated with respiratory problems during 13/14 if
compared with 11/12 (2 years). A crude calculation to convert admissions to bed days/just bed has been done to show the
magnitude of the problem. The age profile of patients presenting with respiratory problems has increased significantly for
respiratory infections and pneumonia.
14
Looking at the detailed pathway - Review of a pneumonia
pathway. Dr Paul Jarvis - Consultant in Emergency Medicine.
What can you do to help your systems ?
• We need you to have lots of coffee and
conversations with GP’s, A&E and MFE
colleagues…..
How can we better manage the older person with pneumonia ?
How do we standardise the treatment of respiratory patients turning up
in A&E including timing and who should be triaging these patients ?
How can we reduce variation in the management of respiratory LTCs
across practices ?
16
Other developments to join up to the pathways we
design
•
•
•
•
•
•
•
•
Patient registers
Risk stratification
MDT care delivery
Rapid response teams in the community
Advanced crisis planning
Personal health budgets
Social and voluntary sector support
Single points of access for specialist advice
(specialist nurses)
17
Pitfalls to avoid
• Pilotitis “The NHS has more pilots than the RAF”
be prepared to take a few calculated risks if
something does not work then stop and think again.
• Talk to your local urgent care leads and you are
most welcome to join we need you on board !
• Do not ignore the patient views - test the patient
experience.
18
George – use case studies to learn from
•
George has advanced respiratory disease and is living alone at home with continuous
oxygen. George used to be in the forces and he likes to be in control so he has a care plan
which he has helped devise, he has the ability to self medicate if he feels unwell and he
manages his own oxygen and his own personal budget from social services enables him to
arrange his own home support. He likes his hobbies and uses skype to keep in touch with
family abroad. What does George value….
- He has a much loved respiratory specialist nurse who had trained him to manage his
condition and she with her team can always be accessed on the phone during working
hours she visits to review regularly. Out of hours he has a local arrangement with the
OOHs district nurses who he also trusts as they are briefed on his crisis plans.
- George has a hospital outpatient appointment which he is cancelling as he feels OK and
when he does not he cannot travel anyway. He does not like crowds ! Hospitals are
viewed as a hazard to his wellbeing !
- George wants outpatient clinics which he can skype into for advice ?
- George wants do more of his own testing ?
19
To know more
If you would like to discuss any element
of this presentation, please contact
Amanda Cousins
Tel: 01603 257025
Email: Amanda.cousins@nelcsu.nhs.uk
www.nelcsu.nhs.uk
You can find all of our work on:
www.respiratoryfutures.org.uk
Don’t forget to complete your
evaluation form (in your pack)
Are you on
?
Then please tweet about today!
#eoerscn
All presentations will be available
on…
www.respiratoryfutures.org.uk
(click on ‘regions’ then ‘EoE’
Wifi code:
Integrated care
Catherine Tooley & Carl Dodd
Respiratory Integrated Team (RIT)
The Vision
• To deliver improved services for adult patients,
ensuring an integrated approach to both acute and
chronic respiratory disease management for
patents registered with the Great Yarmouth and
Waveney General Practices.
GY&W population circa 230,000
The Drivers
• National drivers
• CCG
- Access to care,
- Equity of provision
- Integration of services
- Improved self management
QIPP
•
•
•
•
Acute LOS, reduced admissions and attendances
Reduced prescribing costs
Increased referrals for pulmonary rehabilitation
HOSAR, smoking cessation
Background
•
•
•
•
•
•
CQUIN
Network development – membership
Senior nurse – backfill to lead project
Specialist nursing support for practices
COPD Bundle within Primary care
Respiratory physician presents case to GP clinical
leads
• Retained GP - Clinical service reviews
- shadowing community team
- Respiratory ward
- Outlying wards
Integrated Respiratory Care
What have we had to do?
Design of an Early Supported
Discharge (ESD) Service
Work with ECCH in redesigning the current
Community RNS service.
Combined recruitment.
Work with the CCG in redefining what is required
to reduce Attendances and
admissions
Breathe Easy /Focus Group
Involvement
Develop PDGs for
the community
Work with the walk in centres/ambulance
services/palliative care to ascertain the
needs of people with lung disease
Data collection and
analysis
Develop connections with
the OOH team/community
matrons and district nurses
Audit of JPUH Practice
Patient journey
Asthma care
Designated respiratory
consultant and senior
RNS working in primary
care
Re-design the role of the
RNS within the JPUH
Patient pathway in
JPUH
Working with CCG on Joint drug formulary to
reflect safe,cost effective prescribing
Teaching programme to for the hospital
and the community to upskill other
HCP in Respiratory care
The challenges beginning
• Two Trusts acute &
community (social enterprise)
bidding for one service
• Uncertainty, endless meetings
• 2 trusts actually TRUSTING
each other
• Change in key stakeholder
personnel
• Clarity of what the service will
look like by all parties
Communication
Current Challenges
•
Business case approved but as yet awaiting final agreement
•
Behind predicted timeline
•
Awaiting honorary contracts
•
Change in staff working patterns, JD’s, hours of service …all need to be
discussed and agreed. Involves HR, different management approach
•
Being paid from one employer yet managed by another…. How does this feel
to the employee
•
Data collection and analysis
•
IT ongoing, lack of systems communicating with primary, secondary care and
community setting
•
Service specification & CQRA
Helping our patients achieve their Dreams
Any Questions?
You can find all of our work on:
www.respiratoryfutures.org.uk
Don’t forget to complete your
evaluation form (in your pack)
Are you on
?
Then please tweet about today!
#eoerscn
All presentations will be available
on…
www.respiratoryfutures.org.uk
(click on ‘regions’ then ‘EoE’
Wifi code:
Respiratory Pathways Project
Amanda Flower, AD Planned Care, Luton CCG
‘Creating Confidence, Pride, and a Positive Image for Luton’
Facts about Luton
• £230m budget for Health
Services (deficit)
• Population 220,000
registered with 30 GP
Practices
Variation:
Recorded prevalence on practice disease registers:
COPD Regional 1.8%
Luton 1.2%, range 0.3% - 2.2%
Asthma Regional 6.1%
Luton 5.4%, range 3.3% - 8.4%
Non elective admissions:
COPD - range from 1.35 admissions per 1,000 weighted list size to 6.60 admissions
per 1,000 weighted list size
Asthma – range from 0.58 per 1,000 weighted list size to 5.89 admissions per
1,000 weighted list size
Why?
JSNA Recommendations
Providers:
30 GP Practices
Cambridgeshire Community Services NHS Trust
Luton & Dunstable Hospital NHS Foundation Trust
Live Well Luton
East London NHS Foundation Trust
The System Challenge:
1. Significant variation
2. Duplication
3. Joint working
Primary Care:
•
•
•
•
•
•
•
Multi Disciplinary Practice Visits
Practice dashboard
Share good practice
Raise awareness of guidelines
Local respiratory resource folder
‘Enhanced’ primary care disease template
Use of OPC Audit Tool to target patients in need of review
and intervention to optimise their care
• Practice questionnaire – training – how care is
organised/delivered
• Training (needs identified through questionnaire)
• Community respiratory nurses aligned to practices
MDT Practice Visits
2 plus 8 (probably all eventually)
GP Clinical Lead, Chair
Practice Team
Respiratory Nurses – Acute and Community
Consultant in Respiratory Medicine
Medicines Management and Optimisation
Clinical Specialist Physio
2 Hours
Guidelines and Pathways
Dashboard
3 case discussions
Optimum Patient Care:
Tailored practice reports compare outcome measures with that of the general
service. The reports allow the practice to target patients in need of review
and intervention to optimise care and help the practice to achieve QOF
targets.
The practice report covers:
• Diagnosis – potentially undiagnosed patients
• Patient demographics
• Disease control and severity
• Risk stratification and exacerbations
• Adherence and concordance with therapy
• Patient reviews and self-management plans
• Management and therapy recommendations based on guidelines
• Focus areas for improvement
Optimum Patient Care:
The individual level patient reports will support clinicians to identify high risk
patients and other patients who would benefit from review and intervention
to optimise care.
The reports include:
• Identification of high risk patients
• Patients associated with recommendations in practice reports
• Disease symptoms and control
• Co-morbidities and smoking status
• Therapy status and overview
Optimum Patient Care
Any Questions?
Amanda Flower
Assistant Director of Planned Care
Amanda.flower@lutonccg.nhs.uk
Thank-you for listening.
You can find all of our work on:
www.respiratoryfutures.org.uk
Don’t forget to complete your
evaluation form (in your pack)
Are you on
?
Then please tweet about today!
#eoerscn
All presentations will be available
on…
www.respiratoryfutures.org.uk
(click on ‘regions’ then ‘EoE’
Wifi code:
Developing the Respiratory Pathway
Jonathan Douse Ipswich Hospital
The Current System
IHT
(Physio, LFU, Chest Clinic, ED)
District Nurses
ESD
COPD
Service
O2
Community
Matrons
Suffolk Family
Health
PR
Live Well Suffolk
Social Care
Palliative Care
Liaison
Psychiatry
Dietetics
Suffolk
Wellbeing
Service
Patient Groups
42 Primary Care Practices
Why change?
• Multiple providers of services
- Lack of joined up working (inefficient)
- Perverse incentives
- Disjointed experience for patients
• More outpatient demand than capacity
- Not all necessary
• Escalation beds in use
- Patients recurrently admitted
- Length of stay longer than necessary
The future
• Integrated Respiratory Service
- Improve quality of care for patients
- Reduce unnecessary admissions
- Reduce unnecessary outpatient attendances
- Responsible prescribing
- Save money for greater healthcare economy
- Improved patient experience
Getting there
• Joint prescribing guidelines
• CQUIN 2014-15
- Liaison psychiatry
- End of life care
- Respiratory network
• Clinical Leaders Training
• Review of other “integrated” services
• National policy
The Pilot Jan –June 2015
IHT
(Physio, LFU, Chest Clinic, ED, Psychiatric Liaison)
(A)
New Nurse
Specialist
District Nurses
ESD
COPD
Service
O2
PR
Community
Matrons
New
Weekly
MDT
Consultant
Social Care
Liaison
Psychiatry
Suffolk
Wellbeing
Service
•
•
Suffolk Family
Health
•
Live Well Suffolk
•
Palliative Care
(B)
New Nurse
Specialist
15 Pilot Primary Care Practices
Dietetics
Patient Groups
•
•
Specialist nurse working
with 15 pilot practices
(joint clinics, prescribing
support, complex case
review)
Specialist nurse working
in IHT, case finding and
discharge support
Consultant facilitating
weekly MDT and input to
primary care
New psychological
support via Suffolk
Wellbeing Service via OP
clinic and Pulmonary
rehab
COPD service involved in
weekly MDT
Supporting winter scheme
use of GRASP
Outcome of the Pilot
• Project cost £91,000
• There were reduced pharmacy costs The whole
year effect was worth £124,000
• Hospital Length of stay (February-June) was
reduced for patients with asthma and COPD by
0.91 days compared to the same period in 2014
and 0.38 days compared to the period JulyNovember.
Outcome of the Pilot
• Readmission rate was reduced by 3%
• 51 new outpatient appointments were avoided
saving £9,592.
• There was an increase admissions for COPD and
asthma from both pilot and no-pilot practices
Feedback from Pilot
• Patient feedback was excellent
• Primary care staff who greatly valued the training
they had received
Getting further
• Clinical transformation Group
• Service specification for integrated respiratory
service
- Released Nov 2015
• Setting up the model of future care
- Funding and KPI
- Getting started Summer 2016
What have I learnt?
• Investigate the agendas of all parties
- Takes time
- Align incentives
• Get a sponsor on the CCG
- Via clinical network
• Make most of existing services
• Get the patients involved
• Sell the vision
Any questions?
You can find all of our work on:
www.respiratoryfutures.org.uk
Don’t forget to complete your
evaluation form (in your pack)
Are you on
?
Then please tweet about today!
#eoerscn
All presentations will be available
on…
www.respiratoryfutures.org.uk
(click on ‘regions’ then ‘EoE’)
Wifi code:
Lianne Jongepier
East of England Respiratory SCN
Manager
Strategic Clinical Networks
NHS England
Thank you.
Hope to see you again 
Respiratory Strategic Clinical Network
Tuesday 24 November 2015
#eoerscn