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Delivering improved outcomes for

respiratory diseases

Professor Sir Mike Richards

February 2013

Delivering improved outcomes: Overview

• The ‘new’ NHS.

• Challenges for respiratory diseases.

• How can we make the new system work for respiratory diseases?

The ‘new’ NHS: Context

• Multiple new organisations (but provider organisations largely unchanged).

• New approach to commissioning.

• New Secretary of State, with new priorities.

• Francis report: Emphasis on cultural change, transparency and openness.

The new NHS: Multiple new organisations

DH LAs

NHS CB HWBs

PHE NHS IQ

CCGs SCNs

CSUs AHSNs

New approach to commissioning

• The Mandate: This sets out the Secretary of State’s expectations from the NHS.

• The NHS Outcomes Framework: Arranged around 5 ‘domains’ with 60 indicators.

• Everyone counts: Planning for patients 2013/14 (NHS CB guidance to commissioners).

• Commissioners • NHS CB - Primary care

- Specialist commissioning

• CCGs – The rest (e.g. DGH services)

• Expectation of continuous improvement against indicators, but with no specific ‘targets’.

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The NHS Outcomes Framework

Question: how many people here today are confident that they can name the five domains of the NHS Outcomes Framework?

The NHS Outcomes Framework made simple

If you were seriously unwell, what would you be likely to want?

• To have your life saved

• To have a good quality of life thereafter

• To recover quickly

• To have a good experience of care from the NHS

• To be treated safely

Progress and challenges for respiratory diseases

• We need to recognise and build on the excellent work that has been done in recent years

• We then need to consider how we can make the new system work best to improve outcomes for people with respiratory diseases

Progress on respiratory diseases

• Leadership • National Clinical Directors

• DH policy team

• Key stakeholder organisations

• NHS Improvement – lung programme

• Primary Care Commissioning

• Regional and local networks

• Toolkit and publications

Eg: Home Oxygen Service contracts – leading to improved service

and substantial cost saving to the NHS (£25m pa)

Challenges: Mortality (Domain 1)

• Respiratory diseases are one of the “five big killers” in England

• COPD accounts for 23,000 deaths pa

• If the whole NHS performed to the level of the top quartile, 7,800 lives would be saved each year in COPD alone

• Premature mortality from pneumonia in people under 75 varies by almost tenfold between PCTs (2.6 to 22.3 per 100,000 between 2007 and 2010)

Challenges: Mortality (Domain 1) • Late diagnosis/non-diagnosis

• 2.1m people are living with undiagnosed COPD – an estimated 70% of all COPD

• 10% of acute admissions for COPD are in people without a prior diagnosis

• Wrong diagnosis • Over 25% of people with a label of COPD have been wrongly

diagnosed

So we need to ensure there is a focus on earlier and accurate diagnosis, with commissioning of evidence-based interventions that reduce mortality such as oxygen and pulmonary rehabilitation

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Challenges: Quality of life (Domain 2) • How well do we measure QoL in patients with respiratory diseases (or other

long term conditions)?

• How well do we support patients with COPD (e.g. Pulmonary rehabilitation)

• We do know that the risk of being admitted as an emergency with COPD varies fivefold across England

• We also know that many people with COPD have multiple co-morbididities, requiring integrated care

• A significant proportion of people with COPD have anxiety and/or depression

So we need to ensure there is a focus on more generic approaches to management of people with multi-morbidities using templates and pro-active management

Challenges: Recovery (Domain 3)

• Fewer than half of people admitted with COPD are managed by a respiratory specialist

• One in 12 people admitted with COPD die during their stay

• One in three are readmitted within 3 months

So we need to ensure we look at how we can drive the system using levers such as CQUINS

Challenges: Patient experience (Domain 4)

• Until now we have not routinely measured patient reported experience of care measures (PREMs), but this will be done in the forthcoming COPD audit

So we need to make sure we use COPD audit to measure patient experience

Challenges: Patient safety (Domain 5)

• 30% of people with COPD receive high-flow oxygen in emergency situations without assessment, with risk of respiratory failure

So we need to look at making oxygen toxicity a never event

How can the new system continue to deliver better outcomes? (1)

• Leadership: 5 Domain Directors New National Clinical Director

• NHS Improving Quality: Programme will be arranged around themes (e.g. early diagnosis; integrated care; rehabilitation) – these themes are central to improving outcomes for people with respiratory disease

• Strategic Clinical Networks: Although there are no dedicated SCNs for respiratory disease, we need to look for alliances (e.g. with cancer and CVD)

How can the new system continue to deliver better outcomes? (2)

• Measurement and publication • National Clinical Audits. • Publication of comparative information on quality/outcomes at

LA, CCG, hospital service and general practice levels. • Publication of expected versus reported prevalence ratios • Commissioning

• Using NICE Quality Standards and guidelines

• Incentives • QOF (e.g. Asthma 2012/13 and COPD x 2 2013(14) • CQUINS (e.g. pneumonia care?) • Tariffs (e.g. year of care?) • Quality Premium (emergency admissions)

• Training and competencies • e.g. diagnostics, inhaler technique

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Summary

• Thank you for all that you have done to improve outcomes over the past few years

• The challenges remain huge

• We have many of the building blocks in place – now need to utilise these tools for COPD and asthma and look at other areas such as pneumonia

• We must seize the new opportunities to deliver better outcomes

NHS Blackpool

Knowsley Community COPD Service Isle of Wight NHS Trust & Isle of Wight CCG

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Breathe On UK NHS South (South East Coast)

Knowsley Community COPD Service