Agenda Item No. 13 Reference No. IESCCG 15-62 From: Richard Watson, Chief Redesign Officer RESPIRATORY TRANSFORMATION FUTURE MODEL OF CARE 1. Purpose 1.1 This report provides members with an overview of the CCG s transformation plans for respiratory services for the next five years. In summary the CCG plans are to commission an integrated service that will provide: a complete multidisciplinary respiratory service for our population a sustainable service for the future population needs within our cost envelope specialised expertise closer to home structured around a community respiratory multidisciplinary team a service which promotes self-care and is focused on outcomes defined by patients themselves support to primary care and the rest of the health care system 1.2 Members are specifically requested to note: 2. Background the CCG s new proposed model of care the patient engagement undertaken the strategic context for planned care and the CTG process the transformation approach and next steps for delivery of the integrated model of care 2.1 Respiratory disease is a major cause of distressing symptoms to patients, such as breathlessness, chest pain and cough. The wide variety of disease includes: Chronic obstructive pulmonary disease (COPD), including emphysema and chronic bronchitis, with irreversible lung damage, often due to smoking; Asthma, reduction of airflow with the lungs due to inflammation; Infections, such as pneumonia; Cancers; Rarer diseases, such as lung fibrosis and blood clots. Occupational diseases such as asbestosis 2.2 The effects of respiratory illness vary dramatically between patients some make a full recovery from an episode, whereas others have long-term health problems or even require palliative care. As such a very wide team of people can potentially become involved, including GPs, practice nurses, community health services, social workers and hospital staff alongside the patients and carers. Page 1 of 5
2.3 Patients with COPD are frequent users of both GP and hospital services and COPD is one of the main causes of emergency admissions to Secondary Care, particularly over the winter months. Surveys of patients who survive acute admissions have also revealed that being admitted with an acute exacerbation is one of the most damaging features to their quality of life. 3. Current Services 3.1 Care for respiratory patients is provided in Primary Care by GPs and Practice Nurses and in Secondary Care by Ipswich Hospital (IHT). There is further care in the community by the COPD team run by the consortium of Ipswich Hospital, West Suffolk Hospital Trust and Norfolk Community Health and Care. Other non-specialist support to respiratory long-term conditions is probably provided by other consortium staff but this is not well defined. 3.2 If primary care need help and advice the only way to get it is via a referral to the hospital, and there is no alternative to admission for most respiratory patients that need same day assessment by secondary care. 3.3 Unfortunately, the fragmented nature of current services means that when patients become unwell they are generally seen by a doctor, nurse or paramedic who has never seen them before. The clinician doesn t know what normal is for the patient and how they normally cope at home. When faced with a patient with abnormal physiology there is a tendency to admit the patient. 3.4 There is also a group of patients who feel safe only in the environment of the hospital and they are repeatedly admitted to hospital. 3.5 The community service is available only to patients with COPD and excludes patients with other diagnosis with a similar level of need. Patients are only under the care of the COPD team for a few days at a time before being discharged back to primary care. 3.6 There are a number of issues that prevent patients having access to best possible care: Waiting times to be seen in chest clinic are long (average of 12 weeks for routine appointments in the last four months). Patients whose problems could be nipped in the bud if dealt with early can deteriorate and unnecessary admissions can occur. There have been long waiting times for pulmonary rehabilitation. There is a perception that there is a variation in the quality of care provided in primary care for respiratory disease. This may be due to the different skills and interests of practitioners. Consequently there is a reluctance to discharge some patients from outpatient clinics on the basis that the patient or clinician suspects they will not get sufficient support in the community or primary care. 3.7 Ipswich and East Suffolk Clinical Commissioning Group made it a priority to work with patients and partners to improve services. A key element of this was integration. A leading evidence review body known as the Cochrane Collaboration recently issued a report that showed that integrated care can, over and above the individual components of traditional services, lead to improved quality of life, reduced admissions and reduced a patient s length of stay in an acute setting. Page 2 of 5
4 The Rationale for Change 4.1 A number of publications have also informed the case for change for local Respiratory services: The NHS Outcomes Framework 2014/15, which aims to act as a catalyst for driving up quality by encouraging a change in culture and behaviour towards improving patient outcomes from care and experience of care The Health & Social Care Act 2012 which requires patients to be involved in decisions relating to their care and promotes far more services being delivered safely and effectively in the community or closer to home Corrigan & Hicks. What organisation is necessary for commissioners to develop outcomes based contracts? The COBIC case study. Right Care Casebook series, Department of Health. October 2012 Corrigan & Laitner. The Accountable Lead Provider. Developing a powerful disruptive innovator to create integrated and accountable programmes of care. RightCare Casebook series, Department of Health. July 2012 East of England Strategic Health Authority. Towards the Best, Together strategy (March 2009) which pledges that more treatment will be available in the community, freeing up acute capacity for more complex patients Kruis AL, Smidt N, Assendelft WJ, Gussekloo J, Boland MR, Rutten-van MM, et al. Integrated disease management interventions for patients with chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2013 Oct 10;10:CD009437. 4.2 As a result of the CCG s desire to improve services a Respiratory Clinical Network was established in April 2014 by the CCG and as a vehicle to oversee the development and implementation of integrated pathways for respiratory patients across primary, community and secondary care services addressing patient needs and influencing outcomes: 4.3 The Clinical Network had excellent clinical, operational and patient support. It organised a pilot of an integrated respiratory service which operated between January 2015 and June 2015, with participation from 14 Ipswich and East Suffolk CCG GP Practices. The July 2015 Governing Body received a report on the pilot from the lead GP Dr Holloway and also heard the experiences of Mr Peter Woods, who was an invaluable patient representative on the steering group. 5. Proposed Model of Care 5.1 In 2015, the Ipswich and East Suffolk CCG introduced Clinical Transformation Groups (CTGs) as part of a new way of engaging partners within the local health economy to participate in the development of new models of care. Planned Care service transformation is working to the following set of commissioning principles: We will commission, where possible, at a whole specialty level We will commission as a whole pathway of care from prevention through to acute care We will commission, where possible and appropriate, as an outcome based approach and not a process approach We will utilise the most effective contract mechanism to achieve the outcomes we have set including exploring prime and alliance contracting and longer contract lengths e.g. 5 years We will align finances across a whole pathway of care moving away from a PbR model to a programme budget of other alternative approach and offer incentives as part of this against outcomes achieved 5.2 The role of these Clinical Transformation Groups (CTGs) is to map current provision and develop a set of issues/improvements required which can translate into a new clinical model, or a series of supporting clinical pathways (where appropriate/needed), a set of Page 3 of 5
Diagnostics, prescribing & clinician education & up-skilling outcomes measures contained within an outline service specification or business case for procurement. 5.3 The Clinical Transformation Group for Respiratory Services undertook an extensive and evidence-based approach to developing the service model, including: Reviewing the Planned Care overarching model Reviewing respiratory data for last three years, data from the respiratory pilot. Reviewing evidence of best practice from British Thoracic Society, Cochrane Collaboration. Breakout sessions focussing on self-care, community care, acute care and cross cutting themes. Agreeing a structure for the service model through which services could be provided as close to the patient as possible, including: Tier 0: Primary Prevention Tier 1: Primary Care Tier 2: Specialist Community Based Services Tier 3: Acute Care Tier 4: Tertiary Care and End of Life Services Reviewing what team structures would be most appropriate for providing those functions within each tier. Developing a draft service specification and draft KPIs for the service. 5.4 The proposed service model is shown below; there is a specific focus on community-based respiratory services including a multidisciplinary team. Respiratory Service Model End of Life & Tertiary Care Level 4 District Nurses Secondary & Emergency Care Level 3 Community Matrons Community Physio Intermediate service LiveWell Suffolk Palliative Care Dietetic MDT (Referral single Point of Access & Triage) Level2 Patient Groups Social Services Mental Health Community Pharmacies Carers Ambulance Clinical Nurse Specialist (Key worker) Referral & Advice Primary Care Respiratory Care Team (O², COPD, Admission Avoidance, Pulmonary Rehab) Diagnosis, case finding, access and support to specialist services across all levels, patient reviews, prescribing, management of respiratory conditions, including development /execution of management plans, input to MDT meetings, training and education Primary prevention & self care Level 1 Level 0 Page 4 of 5
6 Public Engagement Plans 6.1 The Respiratory Clinical Transformation Group and the preceding Respiratory Clinical Network benefited greatly from patient representation at each of their meetings. 6.2 The Project Team have however noted the recommendation from the July 2015 Governing Body and sourced a further patient representative from the Ipswich Hospital User Group. 6.3 In addition, the CCG will be holding the first bespoke workshop on 20 th November specifically for patients so that we can discuss: The content of the service specification Specific measures they would like to see included in the contract such that the service accurately captures patient experience How they would like the CCG to measure whether the service is helping them to achieve their goals 7 Next Steps 7.1 The CCG s Planned Care Work Stream and Clinical Executive have reviewed the service model and the specification that has arisen through the Clinical Transformation Group process. Based on commissioning best practice it has determined that a lead prime contractor providing respiratory services would stand the best chance of: Delivering a single integrated programme of care that will deliver better outcomes Adopting an outcomes based commissioning approach to these services as described Encouraging providers to respond with innovative solutions for how Ipswich and East Suffolk s CCG respiratory services can be transformed to a sustainable and effective system. 7.2 The key next steps are to: Continue the public engagement on the new model and the service specification, as described above. Negotiate with the lead respiratory consultants and their managerial colleagues in the area whether they are willing and capable of providing an end-to-end respiratory model of care. Complete financial and contractual due diligence so that the service can be commissioned. 8 Recommendations 8.1 The Governing Body is specifically requested to note: the CCG s new proposed model of care the patient engagement undertaken the strategic context for planned care and the CTG process the transformation approach and next steps for delivery of the integrated model of care Authors: Dr Mark Lim Trudy Woor Page 5 of 5