Agenda Item: 8.1 CLINICAL COMMISSIONING GROUP CCG GOVERNANCE BOARD EXECUTIVE SUMMARY SHEET DATE: 15 th August 2017 TITLE OF PAPER: RightCare Respiratory - Progress Update EXECUTIVE Fran Beck RESPONSIBLE: Contact Details: Ext: Email: fran.beck1@nhs.net AUTHOR (if different Tim Cullinan from above) Contact Details: Ext: Email: tim.cullinan@nhs.net CCG OBJECTIVE: To improve commissioning of effective, safe and sustainable services which deliver the best possible outcomes based upon the best available evidence. For Information For decision For performance monitoring EXECUTIVE SUMMARY Following a review of the NHS England RightCare Programme data packs, and data from Public Health England (PHE) the CCG agreed to set up a Respiratory project which aims to: - Reduce non-elective admissions Telford & Wrekin CCG spends less than RightCare CCG peers on respiratory related non-elective admissions; however there are opportunities to make savings in some areas within respiratory (e.g. pneumonia) and by moving to the average of the top 5 performing CCGs in our peer group. - Improve the respiratory service model The current service meets the majority of agreed best practice standards including community based consultant multi-disciplinary team (MDT) meetings & clinics and community respiratory nursing hospital in-reach. However, to meet all best practice standards the service should also include psychological support & post exacerbation pulmonary rehabilitation To date the project has made progress on a number of important initiatives. These include; - Establishing an effective local clinical working group which meets monthly and includes; CCG GP Respiratory Lead, Secondary Care Respiratory Consultant, Community Respiratory Nursing Lead, Head of Medicines Management and Improving Access to Psychological Therapies (IAPT) Lead - Securing additional CCG monies ( 35k) from the 2016/17 CCG Quality Premium (QP) to fund an education and self-management programme provided by the British Lung Foundation (BLF) for COPD patients at the greatest risk of respiratory related admission. The BLF provided the same programme within Hardwick CCG and reduced non-elective admissions Page 1
by 30% - Clinical pathways developed for COPD, Bronchiectasis, and weaning patients off Inhaled Corticosteroids (ICS); improving patient care and reducing risk of admission - Agreement for three dedicated IAPT workers to become part of an integrated community Respiratory team; training provided by IAPT lead to community respiratory nursing team - Care Homes data analysis undertaken with a training plan developed to include a full day of respiratory training for care homes held July The next stage of this work will focus on: - Roll out of the redesigned pathways for COPD, Bronchiectasis, and weaning patients off Inhaled Corticosteroids (ICS). The roll out process will include an education session on the pathways provided by the Respiratory Consultant at the GP Protected Learning Time (PLT) event in October. - Fully integrating the IAPT into the respiratory team with the aim of c.250 additional respiratory patients seen per year - Engagement and cost benefit analysis developed for domiciliary pulmonary rehabilitation - Engagement and cost benefit analysis developed a centralised spirometery service - Opportunities associated with the Care Home Pharmacist and Care Home Pharmacy Technician explored and implemented - Continued support and monitoring of the BLF education and selfmanagement support programme This paper updates the Board on progress of the Respiratory project, and seeks the Board s support for the planned activities in the next phase of work. FINANCIAL IMPLICATIONS: EQUALITY & INCLUSION: PATIENT & PUBLIC ENGAGEMENT: As a result of the BLF education & self-management programme and introducing dedicated psychological support net savings in the region of 155,000 are anticipated over a 2-year period 2017/18-18/19. These savings are attributable to reduced respiratory related non-elective admissions in those most likely to be admitted. Further savings are anticipated via the care homes, pathways, pulmonary rehabilitation and spirometery work streams, the impact of which is being developed. Equality Impact Assessment completed as part of Gateway 2 process (Approved at CCG Programme Management Committee April-17) Patient & public engagement will be an important part of the work to redesign or develop any services; this includes the spirometery, pulmonary rehabilitation and the development of increased psychological support. This will be supported by the CCG patient and public engagement lead. Page 2
LEGAL IMPACT: CONFLICTS OF INTEREST: RISKS/ OPPORTUNITIES: RECOMMENDATIONS: No legal implications anticipated. None identified Risks: Limited Improvement Opportunities in the Service Model: The current model is already considered close to best practice therefore the options for large scale service redesign and improvement are reduced. Opportunity: Strong Local Clinical Leadership: Currently there is a significant level of clinical buy-in and there have been a number of rapidly developed and rolled out initiates and pathways over the past six months. CCG Governance Board is asked to note the work of this Project and support the planned work for the next phase. Page 3
Introduction CLINICAL COMMISSIONING GOVERNANCE BOARD REPORT Respiratory Project Telford & Wrekin CCG commissioned respiratory services already meet many best practice standards; however there may be opportunity for improvement in the following areas: 1. Reducing non-elective admissions Telford & Wrekin CCG spends less than RightCare CCG peers on respiratory related non-elective admissions as a whole; however there are opportunities to make improvements in non-elective admissions (and therefore savings) in the following areas: a. Frequent Attenders Respiratory related spend data suggests that a relatively small cohort of patients drive a significant amount of acute spend. The 100 patients with highest acute respiratory spend over the previous two years cost the CCG 1.4m (577 Admissions and 535 A&E Attends). In this cohort the average spend per patient per year was 7,109 (2.9 Admissions / 2.7 A&E Attends). b. Improving performance in the areas of greatest spend Analysis of RightCare and updated hospital spend data has found that of the total respiratory spend (as defined by RightCare) the largest proportion (38% / 2.2m) is coded as relating to influenza and pneumonia, the majority of which being pneumonia related (34% / 1.9m). Engagement with local clinical and medicines management leads has suggested that there may be opportunities for reduced spend related to pneumonia. c. Care Homes - In 2015/16 respiratory spend relating to Telford & Wrekin CCG patients in care homes was 563,910 (193 admissions at 2,922 per admission). As well as the high overall spend there was notable variation in spend per bed across the care homes in the CCG. d. Paediatric Asthma - The CCG is performing significantly worse than peers on non-elective spend and admission rate for asthma in children aged 0-19. There is a separate project relating to paediatric asthma. 2. The service model The current service meets the majority of agreed best practice standards including community based consultant MDT and clinics and community respiratory nurse hospital in-reach. However, to meet all best practice standards the service would need to include; a. Psychological Support Evidence suggests that mental health problems are around three times more prevalent among people with chronic obstructive pulmonary disease than in the general population (NICE 2009). Anxiety disorders are particularly common; for example panic disorder is up to 10 times more prevalent than in the general population (Livermore et al 2010). b. Post Exacerbation Pulmonary Rehabilitation Robust evidence has found that postadmission pulmonary rehabilitation reduces mortality in COPD. A Cochrane Review (2011) of Pulmonary Rehabilitation following exacerbations of COPD found it reduced mortality and admissions; with one life being saved for every 6 treated, and one admission being avoided for every 4 treated. Page 4
Further information about Respiratory in Telford and Wrekin and the CCGs performance relative to its peers can be found in APPENDIX A. Project Aims 1. Reducing non-elective admissions a. Frequent Attenders: Self-Management and Coaching Workshops (British Lung Foundation) People with COPD identified as having increased risk of admission by GP practices, Respiratory Nurses or who have been admitted at least twice within the last year will be targeted. They will be invited to complete an education & self-management programme consisting of telephone coaching from a respiratory clinician trained in motivational interviewing and attendance at two ½ day self-management workshops. The same course was delivered in NHS Hardwick CCG and resulted in a 30% reduction in non-elective admissions. 90 Telford & Wrekin patients will be supported via 6 workshops delivered over 18 months the first of which started in June. To enable a recurrent benefit two local community respiratory nurses have been recruited and trained by the BLF to deliver the course. b. Improving performance in the areas of greatest spend The Telford & Wrekin CCG local clinical working group which includes; CCG GP Respiratory lead, Secondary Care Respiratory Consultant, Community Respiratory Nursing Lead, Head of Medicines Management and IAPT Lead, have developed a series of pathways to improve patient care these include; COPD, Bronchiectasis, and weaning patients off Inhaled Corticosteroids (ICS). These pathways will improve condition management and reduce the risk of admission in areas where the CCG has the greatest areas of spend e.g. pneumonia. Pathways will be rolled out at the October GP Protected Learning Time (PLT) event. There will also be work to improve spirometery services to ensure improved diagnosis and management of asthma and COPD. c. Care Homes There is a separate CCG piece of work on care homes that considers all conditions; however this project has and will continue to produce data on respiratory admissions from care homes to inform the respiratory care home education days. This project will also consider the role of the new Care Home Pharmacist and Care Home Pharmacy Technician roles in how they can support respiratory patients in care homes particularly in relation to the new COPD and ICS weaning pathways with a view to reducing pneumonia related admission risk. 2. The Service Model a. Psychological Support The CCG was successful in applying for Wave 2 IAPT expansion monies to increase overall access to IAPT over the next 4 years; part of this expansion is to provide an integrated IAPT service for patients with long term conditions. As respiratory is a priority area for the CCG it has been agreed that half of the funding will be used to employ and fund two Psychological Wellbeing Practitioner (PWP) trainees and one Cognitive Behaviour Therapy (CBT) trainees to work as part of the community respiratory team for one year fixed term. This additional respiratory dedicated resource will provide integrated support to those patients with anxiety or any other low-level psychological conditions that may currently be contributing to respiratory exacerbations. Page 5
b. Post Exacerbation Pulmonary Rehabilitation To reflect a best practice service model that considers post exacerbation rehab a business case will be developed. This is likely to focus on domiciliary patients who are both the least likely to be able to access traditional pulmonary rehabilitation classes and have the highest re-admission rates. This work will ensure that by the end of 2020/21; 1. Total Respiratory non-elective spend is no greater than 23,154 (Per 1,000 population) (Baseline: 29,338-14/15) 2. Influenza and pneumonia non-elective spend is no greater than 9,543 (Per 1,000 population) (Baseline: 12,492-14/15) 3. Chronic Lower Respiratory non-elective spend is no greater than 5,151 (Per 1,000 population) (Baseline: 7,112-14/15) 4. Obstructive Airways non-elective spend is no greater than 3,182 (Per 1,000 population) (Baseline: 5,152-14/15) 5. Other Diseases of Pleura non-elective spend is no greater than 713 (Per 1,000 population) (Baseline: 1,452-14/15) The targets above have been developed on a case by case basis using a methodology that considers the CCGs current position relative to RightCare peers. For example where the CCG is the worst in its RightCare group it will initially move to the RightCare peer group average over 2 years (by 2018/19) then to the average of the best 5 peers in the following 2 years (by 2020/21). Where the CCG is currently performing well compared to RightCare peers, targets are based on improving to the best in the RightCare group. All the targets for the project have been discussed and agreed with local clinical leads and also approved as part of the gateway process at Programme Management Committee. Page 6
Progress to date The project has made progress in a number of areas and is on track to deliver to plan. Subject Area Actions Timeline Defining the scope of the RightCare packs and Public Health England (PHE) data reviewed with areas of opportunity identified Nov 16 - Jan 17 project Desk based research on best practice undertaken alongside engagement with local providers and stakeholders Setting up project and identifying Clinical Leads agreed; Jim Hudson (CCG/Primary Care), Nawaid Ahmed (Secondary Care) Stephanie O Neil (Community), Jacqui Seaton (Medicines management) Jan 17 - Apr 17 measures Baseline measures developed based on RightCare, and local data on hospital spend Baseline assessment Stakeholder engagement Achievements so far Project Documentation - Gateway 2 Approved by PMC on 25 April Frequent Attenders - The 100 patients with highest acute respiratory spend over two years cost the CCG 1.4m (577 Admissions & 535 A&E Attends). In this cohort the average spend per patient per year was 7k (2.9 Admissions & 2.7 A&E Attends). The service model The current service meets the majority of agreed best practice standards including community based consultant MDT and clinics. However, to meet all best practice standards the service would need to include; Psychological support and Post Exacerbation pulmonary rehabilitation Local TWCCG Clinical meetings re-developed including additional clinical input; much improved engagement and attendance Initial discussions held with; British Lung Foundation, SCHT, GP practices, & LA Funded BLF project developed and up and running from June 2017 Two local Respiratory nurses recruited to deliver support the BLF in the delivery of the self-management and coaching workshops. Up skilling the local Respiratory Nursing team to continue to deliver similar content following the completion of the BLF course Care Homes data analysis undertaking and training plan developed to include full day of respiratory training Confirmation of funding and training for three additional IAPT workers who will be integrated into the community respiratory team Training session delivered by IAPT workers to respiratory team as part of integrating teams Bronchiectasis pathway developed and agreed to allow more patients to be supported at home COPD Guidance and pathway updated using GOLD guidance ICS weaning protocol developed and agreed to improve prescribing and reduce pneumonia risk Jan 17 - Feb 17 Feb 17 - On-going Feb 17 - Jul 17 Page 7
Future developments Moving forward the Respiratory project will focus on the following; 1. Pathway Implementation Roll out and practice support with the redesigned pathways for COPD, Bronchiectasis, and weaning patients off Inhaled Corticosteroids (ICS); this will include a session at the GP PLT event. 2. Psychological Support integrated within the Community Respiratory Team Fully integrating the IAPT workers into the respiratory team from September with the aim of around 250 additional respiratory patients receiving psychological support 3. Post Exacerbation Pulmonary Rehabilitation Undertake engagement and a cost benefit analysis for post exacerbation pulmonary rehabilitation in addition to the current pulmonary rehabilitation provision 4. Spirometery Undertake engagement and a cost benefit analysis for redesigned spirometery services 5. Care Homes Exploring opportunities to better support care homes and their patients in relation to medicines management and the implementation of the redesigned pathways for COPD and weaning patients off ICS 6. BLF self-management and coaching programme Continued support and monitoring of the BLF self-management and coaching programme Recommendations CCG Governance Board is asked to: Note the progress which the project has made to date; and Support the planned work for the next phase of the project as outlined in the Future Developments section. Page 8
APPENDIX A: NHS RightCare Programme & CCG Performance NHS RightCare Programme The NHS RightCare Programme is aimed at improving people s health and outcomes. As part of this programme Commissioning for Value - Where to Look data packs have been produced for each CCG. These packs identify areas of clinical and financial variation and areas of opportunity. The packs compare CCG data with 10 demographically similar CCGs. It also compares GP practice data with 15 national GP clusters with similar demographic profiles. CCGs are required to review 40% of the identified opportunities within these packs. The CCG has identified three priority areas for improvement; Circulatory (including diabetes & hypertension), Respiratory and Mental Health. Respiratory opportunities overview Table 1 below shows the comparative data from the RightCare Respiratory Pack (Apr-16) for areas of non-elective spend where the CCG is performing worse than the average of the top 5 performing RightCare Peers. Table 1. Telford and Wrekin CCG performance compared to RightCare Peers and England Average Telford & Wrekin CCG Peer Avg. Best 5 Peer Avg. Best CCG Peer England Avg. Total Opportunity^ for Telford & Wrekin CCG Total Respiratory - Non-Elective Spend* 29,338 30,717 23,815 23,154 25,798 906,000* Influenza and pneumonia Non-Elective Spend 12,492 11,220 9,543 8,418 10,936 469,000 Chronic Lower Respiratory Non-Elective Spend 7,112 6,855 5,151 4,548 5,704 333,000 Obstructive Airways Disease - Non-Elective Spend 5,152 5,325 3,881 3,182 4,290 213,000 Other Diseases of Pleura Non-Elective Spend 1,452 965 713 662 965 124,000 Asthma Non-Elective Spend 1,546 1,158 996 830 1,002 98,000 Acute Upper Respiratory Non-Elective Spend 1,228 1,063 872 681 851 65,000 Chronic Upper Respiratory Non-Elective Spend 368 254 179 140 268 33,000 ^Saving by moving to the average spend of the best 5 performing peers *The updated January 2017 RightCare Where to Look pack (which only provides top level information) shows a reduced total opportunity of 798,000 Page 9
NHS RightCare Telford & Wrekin CCG; Respiratory non-elective spend relative to peers Page 10