RESPIRATORY CLINICAL REFERENCE GROUP (RCRG) PROGRESS REPORT

Transcription

1 RESPIRATORY CLINICAL REFERENCE GROUP (RCRG) PROGRESS REPORT 1. Executive Summary The Purpose of this report is to provide the Wandsworth Clinical Commission Group Board with an update on the progress on developing and delivering service improvements aimed at the identification, clinically accredited diagnoses and treatment of Chronic Obstructive Pulmonary Disease (COPD) and Asthma for the population of Wandsworth. The focus is on the outcomes achieved over the previous year and the future plans for delivering service improvements. 2. Background Respiratory diseases are a major cause of morbidity and mortality and place a huge demand on NHS resources. In England, Chronic Obstructive Pulmonary Disease (COPD) is the second most common cause of emergency admissions and one of the mostly costly inpatient conditions to be treated. Chronic Obstructive Pulmonary Disease (COPD) is a lung disease characterised by chronic obstruction of the airflow that interferes with normal breathing and is not fully reversible. COPD exacerbations are the second most common cause of emergency admission to hospital and the fifth commonest cause of re-admission according to the Department of Health. National surveys suggest the number of patients recorded as having COPD is low compared to the number diagnosed. The QOF COPD register for 2012/2013 shows a population prevalence of 0.90% (3219), this is lower than both the London Average of 1.08% and the National average of 1.80%. The expected prevalence in Wandsworth is approximately 2.53%; therefore in Wandsworth we were missing about 4,000 patients. Moreover, in Wandsworth emergency COPD admission rates (470 - CVD Profile 2012) are significantly higher than the England average (Wandsworth COPD Profile 2012) and premature and overall COPD death rates are significantly higher than the national average. 3. Wandsworth Respiratory Clinical Reference Group The group consists of representatives from St Georges including a Nurse Consultant, Community Specialist Nurses, GPs, Public Health and CCG Medicine Management representation. The group note that there is currently no active patient representation or member who sits on the group however regular contact is maintained with the local Breathe Easy patient support groups. The work of the CRG is underpinned by delivering agreed targets that link to the NHS Outcome Framework, these include: Domain 1: Preventing People from dying prematurely. 1.2 Under 75 mortality from Respiratory Disease Domain 2: Enhancing quality of life for people with Long Term Conditions 2.1 Proportion of people feeling supported to manage their condition Domain 3: Helping people to recover from episodes of ill health or following injury 1

2 3a Emergency admissions for acute conditions that should not usually require hospital admission 3b Emergency readmissions within 30 days of discharge from hospital The work of the Respiratory CRG has built upon the success of the previous year to fully implement the COPD pathway and further improve upon COPD care delivered in Wandsworth. In 2013/14 the group focussed on delivering the following outcomes: Implementation of the COPD pathway Development of a consultant - led Integrated respiratory clinic Supporting the commissioned Community Respiratory Specialist Nursing Team Increased opportunities for COPD and Asthma management in primary care training Implementation of a COPD Missing millions project Updated Asthma medicine guidelines 4. Performance/Progress over the last 12 months 4.1 Implementation of the COPD pathway This workstream supports newly diagnosed and current patients to receive their care in the appropriate setting, thus supporting a reduction in the number of non-elective admissions by providing appropriate clinics in the community. In the Respiratory CRG focussed on developing the a specification for an integrated consultant- led clinic which will offer patients at risk of exacerbation rapid access to Consultant care closer to home. Stakeholders from SGH, Kingston Hospital and Wandsworth community teams have been involved in this work; which was also supported in 2013/14 with a St Georges CQUIN. This work will continue into 2014/15 and an additional CQUIN for this period is currently in negotiation to support the implementation of these community clinics. Non Elective Admission data for the first two quarters of 2013/14 indicate that there has been a reduction in admissions of approximately 7% against the same period in 2012/ Community Respiratory Nursing Team The Community Respiratory Specialist Nursing team is pivotal to the delivery of the pathway through delivering COPD management, training and support in primary care, specialist clinics and a rapid access service; all of which aim to reduce the need for patients to access acute care for specialist treatment. In 2013/14 additional non-recurrent funding was secured to increase capacity within the team to meet demand for rapid response and hospital at home services. Unfortunately due to the timing of the release of the funding and that it was non-recurrent meant that the Community Nursing Team were not able to capitalise on this opportunity; with capacity only increasing towards the later part of the year. 2014/15 will see the Team integrated into the Community Adult Health Service redesign and we have secured an additional 2 WTE nurses as part of the redesign which will continue to support the development of the COPD pathway. 4.3 Missing millions The gap between recorded and estimated prevalence for COPD indicates that approximately 4000 people in Wandsworth remain undiagnosed. This year the RCRG continued to work towards reducing the estimated number of undiagnosed COPD patients by implementing 2

3 the COPD Missing Millions project in Primary Care, which supports the identification and assessment of patients with or at risk of developing COPD. We have made a number of changes to the risk profile and included a NICE validated risk tools in order to capture at risk patients not previously targeted. Results from the Missing Millions Programme include (EMIS data extraction 18/03/14) are: Indicator Result Patients who had a COPD admin code and now a COPD diagnosis added 79 Patients on repeat COPD medications and who now have a COPD diagnosis 4 Patients who had a code for Spirometry referral or indication but who had not 30 had a diagnosis until missing millions Patients who had a code for Spirometry referral or indicated but had not had a 249 referral made until missing millions Number of lung function questionnaires undertaken to determine patients 247 suitability for Spirometry testing The final 2013/14 data is not yet available as the programme is running until the end March 2014; however initial indications look like the numbers on the COPD registers have increased by approximately 250 although this will need to be confirmed when the QoF data is released. 4.4 Pulmonary Rehabilitation (PR) Service The Pulmonary Rehabilitation service is provided by Community Services Wandsworth. A Pulmonary Rehabilitation Programme aims to improve quality of life and increase independence by improving patients exercise function, increase exercise tolerance, reducing shortness of breath and enable patients to better manage their disease. On average the service receives over 350 referrals over a 12 month period, although the current capacity of the service is about 140 per annum based on the number of classes available and the length of each class cycle. This means that the service has been operating at approximately 50% of the current demand; and as such waiting times increased for the service. The issues with commissioning the PR projects year-on-year have previously been identified, however in 2013/14 additional funding was approved to increase capacity, although as the funding was non recurrent and the team were unable to effectively recruit to provide a sustainable increase in activity. Despite this we have worked with the team to look at how best to utalise the funding and locum cover has been provided during Feb and March. The additional funding has also supported the implementation of a community based support programme which aims to improving referral rates to the service, updating GPs on the referral pathway, support GP education session and improve communication and awareness on the service that is currently be provided. Outcomes of the current PR project To identify the lost PR referrals in Wandsworth To identify COPD patients that would benefit from out-patient respiratory physiotherapy and PR 3

4 Provide an updated referral pathway for GPs and other refers Host educational events/patient focussed groups on PR at key locations in Wandsworth Host drop in sessions at the key GP refers Produce laminated posters to be displayed in GP centres and community centres Produce a PR educational booklet for COPD patients The service also supports a number of joint educational events with the Community Respiratory Nurses aimed at selected practices for both GP s and Practice Nurses. Appendix 1 highlights some of the success stories from this service. 4.5 Clinical Guidelines The group have updated and re-launched our Asthma and COPD medicine management guidelines and have held a series of awareness and training events for primary care clinicians to ensure dissemination and that we remain compliant with NICE guidance. 4.6 Training & Education 4 education and training sessions have been run (2 on COPD and 2 on Asthma) for GPs, Practice Nurses and Pharmacists. Attendance at the training has been mixed with 25 Wandsworth staff have been trained on COPD and 48 on Asthma. Spirometry education for practice nurses and health care assistants has been commissioned to ensure that staff are adequately trained in effectively performing the Spirometry tests. A Respiratory Diploma course has also been commissioned. 4.7 Pilot Smoking cessation Programme Our West Wandsworth Locality Lead GP set up a pilot study in his practice which looked at trying to tailor smoking cessation sessions to people with COPD who still smoked. The quit rate at 3 months was 40% - this was 20% of those who originally agreed to take part in the pilot. This compares favourably with standard smoking cessation quit rates for people with COPD. 4.8 Telehealth In 2013/14 the RCRG has worked with the Telehealth team to support the Telehealth remote access DES in designing searches to identify suitable COPD patients within Primary Care who would benefit from a possible Telehealth intervention. As part of the DES approximately 800 patients in Wandsworth have been identified as potentially suitable for Telehealth monitoring. This project will continue into 2014/15 with the introduction of the Locally Enhanced Service contract which should see more COPD patients benefitting from access to this technology. 4.9 Self Management Leaflets It was identified that patients should be supported to manage their condition; as such 2500 British Lung Foundation Leaflets were purchased for use with the Pulmonary Rehabilitation Teams, Primary Care Professionals and Respiratory Specialist Nurses Patient Engagement 4

5 Patient focus groups have been established in West Wandsworth and Battersea with the aim of educating patients around pulmonary rehabilitation, to date currently two sessions are planned with 51 patients invited to attend. In March the Wandsworth Health Improvement Zone 5 day event focussed on smoking and COPD. Both pulmonary rehabilitation team members and respiratory nurses attended this event to highlight their services and engage patients in how they can manage COPD and raise awareness of the condition. 134 members of the public signed up to the Wandsworth CCG patient group database at this event, providing a new cohort to find active patient participation members. Patient feedback has also been sought on the developed of the patient COPD Care Checklist. 5. Future plans The following detail a number of proposals put forward as part of the two year and out of hospital planning process: COPD Care Checklist supporting an increase in patients understanding of their condition and how to manage it, knowledge of the options available to them and awareness of what optimal care should comprise of and how to take steps towards achieving this. This will also support patient self-management, not only in their condition and day to day issues but also in terms of taking active direction of their care and better managing the relationship with their GP. COPD Missing Millions - Still a number of undiagnosed missing COPD patients within the borough therefore a more coordinated approach to finding these patients has been proposed. The group would like to look at alternative models to supporting this piece of work, which would also include a potential GP EMIS tool to identify this cohort (GRASP-COPD). We also propose a more coordinated approach to developing this project in conjunction with the Spirometry LES review as these areas of work are intrinsically linked. Development of the Pulmonary Rehabilitation Service - There is a significant need to develop the Pulmonary Rehabilitation Service to offer more capacity within the service. Proposal have been put forward which look to increase this and also allow for a development of the service to include community clinics, home visits and a dedicated community physio post. These proposals are included in the Out of Hospital Plan which would see an agreement to provide sufficient funding to capacity within the service and look at implementing community clinics and home based pulmonary rehabilitation. COPD Integrated Model - All the work that we are proposing links to the development of the Integrated COPD model. The continuation of the CQUIN with St Georges will allow for the Community Consultant led clinics to be piloted for 6 months in 2014/15. Following an evaluation of the pilot the aim will be to fully procure this service for 2015/16. Smoking Cessation training - the CRG are looking at an integrated approach to up skilling healthcare professionals by working with the Public Health Smoking Team to train smoking cessation advisors in inhaler technique training. This will utalise the advisors within primary care to increase the provision of trained staff across the borough. 5

6 6. Recommendations The Board are asked to note the progress of the Respiratory CRG over the past 12 months and continue to support the work of the group. The Board should note the increased 2 year funding for the Pulmonary Rehabilitation service as part of the Out of Hospital Strategy. In 2014/15 the CRG will be working towards a more proactive approach to finding the missing millions patients by coordinating the development of the Spirometry Primary Care Contract with the COPD Missing Millions project, and the board are asked to support this. 6

7 Appendix 1 Pulmonary Rehabilitation Patient Case Studies "The benefits of circuits training in a friendly professional company have been tremendous. I have been able to enhance my strength, endurance and general fitness. I will be forever grateful for the investment made by the NHS" - John Hill "I can now go up my stairs without stopping a single time! Before I did Pulmonary Rehabilitation I had to stop twice." - Rosa Banks "My mobility, balance and exercise tolerance have all improved. The atmosphere is friendly, relaxed and helpful. There has been the opportunity to ask questions about ones health and self care. The talks have always been informative." - Marian Knox Pulmonary Rehabilitation does you good! You meet people similarly inflicted with lung disease. The gym is run by pleasant and capable staff - Keith Allen, age 86 7