Case for Change & Model of Care...4/6/18 Redraft – 11/7/18 0.4 Rachel Noble & Alex Vincent of Case...

Case for Change & Model of Care

Respiratory services V0.14

Title Case for Change & Model of Care for Greater Manchester Respiratory Services

Theme Lead Diane Whittingham

Project Lead Darren Banks, Provider Transformation Lead (Director of Strategy, Manchester University NHS Foundation Trust)

Author Dr Jennifer Hoyle, Clinical Lead (Consultant Respiratory Physician, Pennine Acute NHS Foundation Trust)

Alex Vincent

Version 0.14

Target Audience Theme 3 Clinical Reference Group HR & Workforce Reference Group Theme 3 Board

Date Created 24/01/2018

Date of Issue

Document Status Draft

Description This document presents the clinical case for change and outline model of care for respiratory services within Greater Manchester.

File name & path

Document History:

Date Version Author Notes

24/01/18 0.1 Ruth Clark First draft

03/03/18 0.2 Ruth Clark Additional work on first draft

21/03/18 0.3 Ruth Clark Amendments and additions

4/6/18 – 11/7/18 0.4 Rachel Noble & Alex Vincent Redraft of Case for Change

13/7/18 0.5 Rachel Noble Population of Case for Change in combined document

13/7/18 - 16/7/18 0.6 Alex Vincent Development of combined document with Clinical Lead

17/7/18 - 18/7/18 0.7 Alex Vincent Changes made after discussion with Clinical Lead

20/7/18 0.8 Alex Vincent Draft prepared for circulation CRG

4/9/18 – 7/9/18 0.9 Alex Vincent Development based on feedback

17/9/18 0.10 Alex Vincent Final amendments for circulation to DOF

02/10/18 0.11 Alex Vincent Amendments following DOF

09/10/18 0.12 Rachel Noble Amendments following ECAP

11/10/18 0.13 Jenny Hoyle Clinical review and amendments following ECAP

12/10/18 0.14 Rachel Noble Review and final ECAP amendments

Approved by:

Greater Manchester Health and Social Care Partnership

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Distribution

Ver. Group Date Purpose

0.8 Clinical Reference Group 20/7/18 For meeting 25/7/18

0.10 Design Overview Forum 17/9/18 For meeting 20/9/18

0.11 Provider Transformation Lead,

Clinical Lead and Theme 3 Board 02/10/18 FERG, WRG & ECAP

0.14 Theme 3 Exec 12/10/18 For meeting 17/10/18

T A B L E O F CO N T E N T S

Table of Contents 4

1. Executive Summary 7

1.1. Case for change 7

1.2. Outline Model of Care 8

2. Context 10

2.1. Scope and purpose 10

2.2. Background – work completed to date in GM 11

2.3. Recent developments 12

3. Key drivers for change 16

3.1. Demographic Changes 16

3.2. Health Outcomes 17

3.3. Activity and Spend on Delivery 20

3.4. Referral to Treatment Times (RTT) 28


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3.5. Patient Safety & Experience 29

3.6. Current outcomes in GM 30

3.7. Current Respiratory sites & provision within GM 31

3.8. Headlines: Fixed points 33

3.9. SWOT Analysis 34

4. Design Approach 36

4.1. Engagement and Co-design Process 36

4.2. Patient Principles and Feedback 36

5. Challenges 38

5.1. Key Risks 38

5.2. Seven Day Working 41

6. Recommendations 43

6.1. Theme 3 – Acute & Specialised Care 43

6.2. Summary of Financial and Operational Efficiency Benefits 44

7. Preferred Model of Care 45

7.1. Model of Care 45

7.2. Governance & Clinical Leadership 47

7.3. Service Description and Care Pathway 47

7.4. COPD Model of Care 48

7.5. GM Framework for Influenza 56

7.6. Pneumonia 57

7.7. Standard Respiratory Offer 60

7.8. Service Access Requirements 62

7.9. Follow up and aftercare 63


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7.10. Audit, Research and Education 64

8. Financial Considerations 65

8.1. Financial principles for Theme 3  65

8.2. Logic modelling for financial impact of new model of care  66

9.1. Enablers 69

9.2. Critical Success Factors 70

10. Appendices 72

10.1. Appendix A - Supporting Data 72

10.2. Appendix B - Table 6: Population of CCGs at mid-point 2016 78

10.3. Appendix C - Right Care, Commissioning for Value; Pathway on a page 79

10.4. Appendix D – Clinical COPD Audit Participants 82

10.5. Appendix E – Attendance Sheet at COPD Workshop 83

10.6. Appendix F - Patient Questionnaire 84

10.7. Appendix G - Clinical Co-dependencies 93

10.8. Appendix H - Service Standards 96

10.9. Appendix I – Free Vaccination for Influenza 99

10.10. Appendix J - Abbreviations Table 100


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1.EX E C U T I V E S U M M A R Y

This document is designed to inform the decision-making process on the transformation of Greater

Manchester (GM) Respiratory Services, focussing on Theme 3, Standardising Acute and Specialist

Care. Respiratory medicine covers the diagnosis and treatment of a wide variety of diseases of the

airway and lungs, their linings and blood vessels and the muscles and nerves required for breathing.

A list of respiratory medicine services is described in Appendix A.

1.1. Case for change

Greater Manchester has some of the highest rates of respiratory disease in the country, and

mortality rates for preventable respiratory disease are high. The conurbation has a high prevalence

of lung cancer, Chronic Obstructive Pulmonary Disease (COPD), asthma and unacceptable variation in

length of stay across a number of respiratory disease areas. Demand for respiratory services is high

and in 2016/17, there were over 50,000 hospital spells for respiratory disease and over 70,000

Finished Consultant Episodes (FCEs). When weighted by age and gender, premature mortality from

respiratory disease is significantly higher than the national rate in seven of the twelve Greater

Manchester CCGs, and similar for the remaining five.

From a public health perspective, Greater Manchester has higher-than average smoking rates, and

insufficient smoking cessation services to meet demand (though a strategy is being put in place to

address this1). 18.4% of the adult population smokes compared to a national average of 15.5%2, and

this contributes to above-average prevalence of smoking-related disease. Greater Manchester’s

industrial history has also contributed to an increased incidence of industrial lung disease.

1 http://www.gmhsc.org.uk/wp-content/uploads/2018/04/Tobacco-Free-Greater-Manchester-Strategy.pdf 2 http://www.gmhsc.org.uk/wp-content/uploads/2018/04/Tobacco-Free-Greater-Manchester-Strategy.pdf


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There are significant opportunities across GM to improve patient experience and potentially, to

reduce secondary care costs through reducing variation, a reduction in length of stay (LOS) and

avoiding admission through the provision of responsive, accessible, high-quality community, primary

and intermediate care. The model includes the appropriate use of evidence-based risk-stratification

tools to be standardised across GM in order to avoid admission in the acute footprint where possible.

1.2. Outline Model of Care

Focussing on three aspects of respiratory care, the outline model of care makes recommendations

for further development:

i. Chronic Obstructive Pulmonary Disease (COPD); creation of a single model of care delivered to

an agreed set of standards across all GM

ii. Influenza; development of a single policy framework and commissioning for influenza, across

all themes in GM

iii. Pneumonia; development of a deeper understanding of the pneumonia challenge, through

detailed diagnosis review, prior to developing a single model of care for GM

Creating a single COPD pathway, accessible to all, which incorporates both in-reach and outreach

support by specialist respiratory nurses alongside early specialist clinical review, will improve not

only the quality of care received by patients, but also their length of stay in hospital and the support

they receive on discharge. Virtual Multidisciplinary Team (MDT) clinics, training of community staff

and inclusion of pulmonary rehabilitation, smoking cessation, education, vaccination and

psychosocial support will enable those diagnosed with COPD to remain healthier longer. For hospital

admissions, standardising the respiratory pathway, making it shorter and more responsive, with a

focus on Non-Invasive Ventilation (NIV) national standards and domiciliary services (including home-

NIV) will have similar benefits.

The huge variation currently seen in the treatment of those with influenza will be reduced by a single

GM-wide policy framework incorporating:

Health promotion

Vaccination criteria


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Diagnosis criteria and process

Treatment standards

Prescribing information

Pneumonia requires further examination. Initial investigation suggests that although, the diagnostic

process is well understood, not everyone diagnosed with pneumonia has undergone this process,

with diagnosis made based on history and current symptoms. By understanding this assumption

more fully, a coherent, comprehensive model can be developed for this cohort.

With a flexible specialist workforce which will support the patient and MDT across themes, the

document describes a model of care that wraps around the patient and their families.

Delivery of this model requires a development in how the clinical and nursing teams work, along with

the widening of their skill set. An increased number of specialist respiratory nurses will be required,

along with a possible increase in access to radiology services. Services based on single sites will need

to increase their outreach, allowing patients to be treated at home, creating improved outcomes and

better mental health and wellbeing, along with a reduction in time spent in hospital.

Financial sustainability is created through the reduction of inpatient care and admissions, by using

the appropriate person to deliver care, based on a multi-skilled respiratory specialist nursing team

and earlier clinical intervention when people present at the Emergency Department (ED).


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2.CO N T E X T

This case for change builds on the recommendations made in the scoping assessment and is for

Acute and Specialist Respiratory services in GM only.

2.1. Scope and purpose

Respiratory and Cardiology services were made a priority area for transformation under Theme 3,

noting that the frail elderly must be an underpinning theme. The Project Initiation Document (PID)

for Respiratory and Cardiology Services was completed and signed off in October 2016 by the Theme

3 Delivery Board.

The PID recommended that:

A whole-system scoping exercise would be required to fully understand current issues and

variations across the whole cardiology and respiratory pathway

The programme would focus on the standardisation of acute respiratory and cardiology

services through the development of a single GM single operating model and GM wide

clinical and patient standards as well as ensuring flow and fit across the entire system

There should be an improved interface between primary and secondary care

Likely areas of pathway development for respiratory medicine, would include severe

respiratory failure, chronic respiratory conditions, and respiratory infection

Following on from the recommendations made in the PID, a scoping assessment was produced in

order to better understand the current issues and variations across the entire Respiratory and

Cardiology pathway. The scoping assessment was signed off by the Clinical Reference Group (CRG) in

September 2017 with the following recommendations agreed:


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Respiratory and Cardiology should be split into two separate work streams, each with its own

case for change and model of care

The Respiratory and Cardiology work streams, although separate, would still need to link in

closely with Themes 1 and 2 to ensure a fully integrated, seamless service providing a high-

quality service for all. Respiratory-related projects in Themes 1 and 2 are key to supporting

this case for change and therefore key stakeholders from all three themes must work

together in an integrated way

2.2. Background – work completed to date in GM

Whist there has been a significant amount of work relating to respiratory care across GM, this has

taken place in individual localities and has added to the variation we see across CCGs. Focus has been

on Theme 2 primary and community support, along with admission avoidance for people with

respiratory disease. Virtual clinics, outreach respiratory nurse specialists, and even advanced nurse

practitioners working alongside the ambulance service to identify possible opportunities to avoid

escalation to hospital and deliver increased provision of domiciliary care have all been incorporated

into locality plans.

The focus of this project however is Theme 3, acute and specialist care, and whilst some of the

models described above will support the management of acute exacerbations in the community,

patients will still escalate to secondary care. By engaging with the localities and using the best of

these developments to describe a Theme 2 and 3 interface - and wherever possible incorporating

these aspects into the new model - a pathway for the most acute patients can be created that utilises

existing best practice, whilst creating a future proof model.

It is worth noting that the extra clinical resource from Theme 3, planned into Theme 2’s model,

would create additional workload pressures in the short to medium term, although it is expected that

- with additional knowledge and skills within the community - a proportionately reduced number of

patients would need to escalate or attend the acute services. It is recognised that it traditionally


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takes up to five years for the knowledge and skill transfer to take place and for the impact of change

to be felt, during which time there would be a continued additional pressure on secondary care

provision.

2.3. Recent developments and disease burden

There have been a significant number of developments in respiratory care in recent years, with a

particular focus on community and primary care services, supported self-management and the

introduction of evidence-based, best-practice pathways. In summary:

The British Thoracic Society has published the Quality Standards for Pulmonary Rehabilitation3

NHS RightCare has published a COPD pathway which is based on best-practice and NICE

guidance

The successful lung cancer screening project run in partnership between Wythenshawe

Hospital and Macmillan has been commissioned by MHCC to provide an additional screening

round for the North Manchester population

MRI and Wythenshawe Hospitals partnered on a Royal College of Physicians Future Hospitals

programme to improve community COPD care

Development of Greater Manchester Medicines Management Group (GMMMG) guidance on

COPD pharmacological treatments

Development of GMMG guidance on tobacco control and the introduction of the CURE

programme at MFT

Working with the housing sector to promote health in the local population

A working group with urgent care (111, NWAS, Go2Doc) to pilot an admission avoidance

scheme using care records that can be shared across the urgent care system

Local planning group with British Lung Foundation to increase awareness of respiratory disease

in the local population and promote peer support

Patient experience group (led by patients)

3https://www.brit-thoracic.org.uk/document-library/clinical-information/pulmonary-rehabilitation/bts-guideline-for-pulmonary-rehabilitation/

https://www.brit-thoracic.org.uk/document-library/clinical-information/pulmonary-rehabilitation/bts-guideline-for-pulmonary-rehabilitation/

https://www.brit-thoracic.org.uk/document-library/clinical-information/pulmonary-rehabilitation/bts-guideline-for-pulmonary-rehabilitation/


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The delivery of influenza and pneumonia vaccinations to high risk patients in secondary care

Nationally, lung disease and other respiratory conditions constitute large part of UK hospital

admissions. Lung disease, for example, is responsible for over 700,000 hospital admissions and more

than 6.1 million hospital bed days in the UK each year4. Lung cancer, COPD and pneumonia are

within the top six most common causes of death in the UK.

In recent years, it has also been recognised that, whilst there has been some noticeable

improvements in COPD-related care, unacceptable national variation still exists in regards to the

treatment of this condition. One important aspect to highlight in regards to this variation is the

differing proportions of admitted COPD patients who have access to specialist respiratory services

such specialist treatment, interaction with specialist staff and administration of NIV5.

Linking hospital-based care with community based care (i.e. clear evidence of follow-up care being

provided between different services) has also been recognised as an area of importance in regards to

various respiratory conditions. Services such as pulmonary rehabilitation programmes for example

have been associated with improved outcomes in regards to both reduced hospital admission rates

and reduced rates of mortality6 for patients with conditions such as COPD.

Idiopathic pulmonary fibrosis (IPF) is a type of lung disease that causes progressive scarring and

inflammation of the lungs. Despite it being a relatively uncommon disease when compared to

conditions such as COPD, it has a noticeable impact on those that it afflicts in regards to mortality.

Statistics on IPF suggest that the median survival rate from IPF is 3 years from diagnosis and only 20%

of IPF patients are reported to survive to 5 years post diagnosis7. Recent advancements in the

treatment of IPF in the UK include4:

4 The Battle For Breath Report, 2016, British Lung Foundation 5 COPD Who Cares Organisational Audit, November 2014, Royal College of Physicians, British Thoracic Society 6 Pulmonary Rehabilitation: Beyond Better Breathing, 2017, Royal College of Physicians, British Thoracic Society 7 The British Thoracic Society Interstitial Lung Disease Registry Programme Annual Report, 2015/16, British Thoracic Society


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Clear NICE guidelines for the diagnosis and management of adults with IPF

Quality standards of care for IPF patients published by NICE

New IPF treatments have become available, including the drugs pirfenidone and nintedanib

In a similar fashion to other respiratory conditions, developments relating to IPF have emphasised

the importance of both specialist clinician input and cross boundary care between hospital and

community services.

2.3.1. Virtual Clinics – COPD A consultant-led virtual clinic (VC) model was established in GM in 2016/17 to support GPs in the

management of patients with COPD. Patients were identified through targeted searches and their

primary care record reviewed in a joint primary/secondary care education session. These sessions

aim to educate and up-skill primary care staff, promote non-pharmacological interventions such as

pulmonary rehabilitation and smoking cessation, and promote safe prescribing practices as per the

GMMMG guidelines. In the early stages of the programme, 522 patients were identified and

discussed as a result of the VCs and of those reviewed, 50-75% had treatment stepped down, leading

to a cost-saving of £306 patient/year. Table one summarises the feedback data:

Table 01: Feedback from 5 out of 14 GP practiced after virtual clinics


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3.KE Y D R I V E R S F O R C H A N G E

3.1. Demographic Changes

GM has an ageing population; the 75+ age group is expected to increase by approximately 37%

between 2016 and 2030, and the 60-74 age group has a projected increase of 21% between 2016

and 2030.

The risk and impact of respiratory disease increases with age, with many patients having multiple co-

morbidities, therefore it is expected that there will be a significant increase in activity for respiratory

services if we do nothing.  Wigan Borough CCG has the highest predicted increase in >75 population

at 19.57% with Tameside and Glossop, Bolton and Bury CCG’s being next highest at 13.95%, 13.62%

and 13.60% respectively. 

The highest rates for growth in GM across all age ranges are expected to be in South Manchester

(4.86%), North Manchester (4.44%) and Trafford (3.63%) in the next five years1

 

Whilst there is a significant amount of work to improve the health of the population and reduce the

incidence of respiratory disorders, the number of patients presenting continues to grow and, as the

risk and complexity of certain respiratory related diseases increases as they get older, it can be

assumed that there will be an increase in respiratory related activity in GM in years to come.

Figure 01: Estimated demographic changes 2016 – 2021


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Age group

% increase 2016-

25 % increase 2016-30

0-14 4.70 2.85

15-29 -3.04 0.59

30-44 8.40 6.87

45-59 -3.19 -4.30

60-74 11.33 21.13

75+ 26.34 36.83

Source: Office for National Statistics, mid-2016 population projections by local authority.

3.2. Health Outcomes

Greater Manchester (GM) has some of the most deprived areas and the poorest respiratory health in

the UK, and amongst the highest prevalence rates for lung diseases. 18.8% of adults in GM are

smokers, and Manchester, Salford and Rochdale local authorities had amongst the highest rate of


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premature deaths from lung disease in England between 2013-2015 with Manchester the worst

performing area in the country with a rate of 68.3 premature deaths per 100,000 population.

Figure 02: Bottom 12 ranking local authorities for Lung Disease

Additionally a key driver for change in relation to public health is the prevalence of respiratory

related diseases within the population (figure 03):

11 out of 12 GM CCGs have a reported prevalence of COPD that is above the national average

of 1.85%

Only 2 out of the 12 CCGs have a prevalence that is above that of their comparator CCGs.

There is a variation of 1.35% in reported COPD prevalence between GM CCGs

9 out of 12 GM CCGs have a prevalence of Asthma that is above the national average of 5.91%.

Half of these s also have a prevalence that is above that of their comparator CCGs

There is a variation of 1.52% in Asthma prevalence between GM CCGs


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Figure 03: Respiratory Disease Prevalence in GM CCGs 2015/16

Source: NHS Right Care (2017). ‘Where to look’ packs. [Online] Available at: https://www.england.nhs.uk/rightcare/products/ccg-data-packs/. Last accessed: 26th February 2018

Figure 04: Premature mortality in GM from Respiratory Disease

https://www.england.nhs.uk/rightcare/products/ccg-data-packs/




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Source: NHS Right Care (2017). ‘Where to look’ packs. [Online] Available at: https://www.england.nhs.uk/rightcare/products/ccg-data-packs/. Last accessed: 26th February 2018 Rate of premature mortality has been directly age and sex standardised to England population

Only two of the GM CCGs have a mortality rate for under 75 year olds of less than the national

average. These CCGs are also not where the lowest prevalence occurs, once again demonstrating the

variation in service delivery and its impact on outcomes.

Future respiratory related care will, therefore, need to have clear links between acute, primary and

community services. Integration of patient pathways across respiratory care can help ensure earlier

diagnosis of conditions such as COPD, promote self-management, help reduce admissions to

secondary care and ensure that appropriate referrals are being made across all respiratory services in

GM.

3.3. Activity and Spend on Delivery

There were just over 52000 respiratory spells in GM in 2016/17 with over 50% of those attributable

to two main disease groupings 1) chronic lower respiratory diseases which includes: asthma; COPD;

emphysema; and simple and mucopurulent bronchitis, and 2) influenza and pneumonia

Median LOS for both disease groupings are:





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4.8 days for chronic lower respiratory diseases;

9.7 days for influenza and pneumonia.

Of the hospitals that treat the highest volume of cases (classed as those which saw over 1000 cases

in 2016/17), the ranges are as follows:

Chronic lower respiratory: shortest – 3.7 (Salford) and longest is 5.9 (MRI)

Influenza and pneumonia: shortest – 6.4 (Fairfield) and longest is 12.6 (MRI)

National data from the COPD Audit Programme suggests an average length of stay for COPD patients

of 4 days, indicating that work is needed in GM to target a reduction in LOS from the existing 4.8days.

Data for average LOS for pneumonia is less readily available but one study suggests a median LOS of

9 days compared to the GM 9.7days.

RightCare identifies Respiratory services as an area of opportunity for eight CCGs (Bolton; Heywood,

Middleton and Rochdale; Manchester; Oldham; Salford; Stockport; Tameside and Glossop; Trafford).

Data on potential lives saved as a result of a reduction in mortality from COPD, emphysema and

bronchitis in the under 75s is not available for all CCGs, but estimates are provided for five. This data

indicates that 125 lives could be saved if these CCGs performed at the level of the five best

performing CCGs in the country. Given the high volume of respiratory cases in GM, it is reasonable to

assume that the potential for lives saved exceeds this estimate

Data for the potential reduction in bed days is provided for seven CCGs and it is estimated that

performing to the same standard as the five best performing CCGs would save around 50,275 bed

days per annum


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Estimated potential savings for non-elective care are provided for seven CCG areas and are

significant: performing at the same standard as the five best-performing CCGs in the country could

equate to savings of £12.1m.

Estimated potential saving on elective respiratory care are provided for seven CCG areas and amount

to £3.2m.

3.3.1. Elective Care Figure 05: Activity by hospital site for elective patients 2016/17

The majority of elective respiratory care takes place at Wythenshawe. Housing the North West Lung

Centre it would be anticipated that elective activity would be highest on this site.

The greatest activity occurs in “Other diseases of the upper respiratory tract”, including tonsil

infections, allergic rhinitis, sinusitis and other larynx and pharynx disorders, followed by “chronic

lower respiratory disease” which includes COPD.

Although Wythenshawe cater to the vast majority of elective admissions, the numbers still remain

small.


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In addition to the above information, the following figures derived from NHS RightCare also provide

an insight into the variation across GM CCGs in terms of elective spending8.

Figure 06: Total elective spend per 1000 population (weighted for age & sex) 15/16

The spend data leaves us able to draw a number of conclusions:

There is variation in elective spend between the 12 GM CCGs when compared with the

national average

9 of the CCGs have an elective spend that is above the national average. Most notable is South

Manchester, which spent £2620 above the national average in 2015/16

3 of the CCGs have an elective spend that is below the national average. Most notable is Bury,

which spent £773 below the national average in 2015/16

8 NHS Right Care (2017) ‘where to look’ CCG Data packs. [Online] Available at: https://www.england.nhs.uk/rightcare/products/ccg-data-

packs/where-to-look-packs/ Last accessed 12th February 2018

https://www.england.nhs.uk/rightcare/products/ccg-data-packs/where-to-look-packs/

https://www.england.nhs.uk/rightcare/products/ccg-data-packs/where-to-look-packs/


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There is also a clear variation in elective spend between the CCGs themselves. There was a

difference in spend of £3,393 between the lowest and highest spending CCGs, Bury and

South Manchester, respectively

3.3.2. Non-Elective Care Figure 07: Activity by hospital site for non-elective patients 2016/17

With a much higher activity in non-elective care, it is clear that those sites with an ED have the

majority of their activity in “Influenza and Pneumonia” and “chronic lower respiratory disease”

condition groups. Activity is also more evenly spread across the sites.

Figure 08: influenza and Pneumonia non-elective admissions


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Source: RightCare Greater Manchester Respiratory Insight, May 2018

The highest levels of non-elective admissions for influenza (flu) and pneumonia occur between

November and March each year, with the older age bands contributing the most to admissions. The

growth in admissions can be seen clearly with the number of admissions increasing by nearly 500

(23%) between January 2015/16 and 2016/17.

Empirically every Trust and CCG manages influenza patients differently, so variation amongst this

group of patients is large, and opportunities for standardisation numerous.

Figure 09: Percentage of people over 65 years vaccinated at 31st March 2017


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Flu, whilst not totally avoidable, can have the incidence significantly reduced by vaccinating the

population. The variation in vaccines given to the age 65+ population, most vulnerable to flu, is

significant across GM, with only two CCGs performing better than the highest 5 similar peers.

Empirically, not all patients diagnosed with pneumonia have undergone a formal process for

diagnosis and have confirmed physiological changes expected to be seen in those with the disease.

Anecdotally this is particularly true for those who have died, with an existing respiratory disease and

expectorations. Although the evidence is limited at this time, an audit to understand the extent of

these reported concerns should be undertaken.

Figure 10: Total non-elective spend per 1000 population (weighted for age & sex) 15/16


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Source: NHS Right Care (2017) ‘where to look’ CCG Data packs.

Again the RightCare data demonstrates:

Only 1 out of the 12 GM CCGs spent below the national average. This CCG was Bury, and spent

£2,889 below the national average

The other 11 CCGs spent varying amounts above the national average, most notably South

Manchester, which spent £19,903 above the national average in 2015/16

There is also a clear variation in non-elective spend between the CCGs themselves. There was a

difference in spend of £22,793 between the lowest and highest spending CCGs, Bury and

South Manchester, respectively

It is interesting to note that GM currently spends £9.6m more on non-elective admissions for

Influenza and Pneumonia than the best 5 CCGs.

Figure 11: Non-elective spend on admissions for Influenza and Pneumonia


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By using the RightCare data with values of spend and bed days per 1000 population (adjusted for age

and sex), these do not take into account the complexity of a particular patient’s diagnosis or

treatment. This could be the reason why South Manchester, which houses the specialist services

located in the NWLC, has such a high rate of spend and bed days compared to the other GM CCGs for

both elective and non-elective care.

3.4. Referral to Treatment Times (RTT)

The average wait for new referrals into GM respiratory service remains under 60 days and has done

so for the last 2 years, however consultant to consultant referrals for the most complex cases and

domiciliary NIV assessment into Wythenshawe have a mean referral time of 396 days and a median


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of 168 days9. This wait has been increasing over the last year, suggesting that the demand for these

services outweighs the capacity.

This assumption is supported by anecdotal evidence and empirical verification, including the delivery

of a separate service for Wigan CCG patients, delivered by WWL, again highlighting variation of

service and standards.

3.5. Patient Safety & Experience

From the data above it is clear to see that the variation in care across GM is significant, inherently

suggesting that not all GM patients are receiving the best possible care.

Best practice tariffs are attached to COPD care and GM patients are only receiving these in 38% of

cases10. It should be noted that not all providers submitted data for this audit.

Figure 12: Achievement of Best Practice Tariffs 2017

Source: RightCare Greater Manchester Respiratory Insight, May 2018

9 Dr Foster outpatient waiting times; accessed on the 17/07/18. 10 Data from the National Asthma and COPD Audit; via https://nacap.org.uk/nacap/welcome.nsf/reportsSCbpt.html

Last accessed 16/07/18

CCG Name Trust

Respiratory Review

within 24 hrs (%)

Discharge Bundle

(%) BPT Passed (%) BPT >= 60%

NHS Manchester CCG University Hospital of South Manchester NHS Foundation Trust 83 91 78 1

NHS Salford CCG Salford Royal NHS Foundation Trust 77 77 66 1

NHS Manchester CCG Central Manchester University Hospitals NHS Foundation Trust 69 91 66 1

NHS Stockport CCG Stockport NHS Foundation Trust 44 71 34 0

NHS Wigan Borough CCG Wrightington, Wigan and Leigh NHS Foundation Trust 51 26 20 0

NHS Heywood, Middleton and Rochdale CCG Pennine Acute Hospitals NHS Trust 33 29 11 0

NHS Bolton CCG Bolton NHS Foundation Trust 56 15 10 0

NHS Tameside and Glossop CCG Tameside Hospital NHS Foundation Trust 28 13 5 0

Overall Attainment 37.50%

https://nacap.org.uk/nacap/welcome.nsf/reportsSCbpt.html


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3.6. Current outcomes in GM

In November 2014, the National COPD Audit Programme released their national organisation audit

report11. Contained within this report is site level data on the organisation and resources of COPD

care in acute NHS units (Appendix D). As part of this data, each unit was scored against key criteria

relating to COPD care. Components that made up a unit’s total score included:

Whether a senior review on admission as received

Whether the patient had access to specialist care

Whether a patient had access to NIV

Managing respiratory failure and oxygen therapy

Integrating care across a primary and secondary sectors

Extra items such as: having a system of early warning detection, smoking cessation services

within the unit and the availability of on-site palliative care

The highest possible score for these combined criteria is 51, the highest achieved 48 (Royal Devon & Exeter Hospital) and lowest 12 (Sandwell General Hospital). The Median Score was 33.

From analysing the scores for each of these sites, the following observations can be made about

COPD-related acute care in GM:

The median overall score of the eleven GM trusts was 34, just above the median score of 33

for all participating sites in England and Wales

Three GM sites (Trafford General, Tameside general and Stepping Hill) fell into the lowest 25%

of organisations in terms of total score

11 Royal College of Physicians & British Thoracic Society (2014) National COPD Audit: COPD: Who cares? National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme; Resources and organisation of care in acute NHS units in England and Wales 2014 via: https://www.rcplondon.ac.uk/projects/outputs/copd-who-cares-organisational-audit-2014 Last accessed 17/07/18

https://www.rcplondon.ac.uk/projects/outputs/copd-who-cares-organisational-audit-2014


31

Three GM sites (North Manchester General Hospital, Salford Royal and Royal Bolton) fell into

the highest 25% of organisations in terms of total score

Only one site (Salford Royal) received the maximum possible score for the ‘senior review on

admission’ category

Eight out of the eleven GM sites received the maximum possible score for the ‘NIV’ category;

Four out of the eleven GM sites received the maximum possible score for the ‘managing

respiratory failure and oxygen therapy’ category

Only one site (North Manchester General Hospital) received the maximum possible score for

‘integrating care across primary and secondary sectors’

No GM sites received the maximum possible score for the ‘extra items’ category, although it

should be noted that no sites in the audit actually achieved the maximum score for this

category

It is notable that three sites (Wythenshawe, Royal Albert Edward Infirmary and Tameside General

Hospital) could have potentially increased their overall score (by 2, 4 and 1 respectively) if they had

not missed submitting certain data to the audit.

In summary, it is encouraging to see that most sites in GM achieved maximum scores in at least one

of the categories, and over half of GM sites were above the median value of all participating

organisations in regards for their total score. The high scores corresponding to the use of NIV should

also be noted. However, the fact that a considerable proportion of the sites’ fall into either the top

25% or the bottom 25% in regards to their overall score shows variation in practice across GM in

regards to COPD. The lack of maximum scoring in regards to the integration between primary and

secondary sectors is also something that should be noted.

3.7. Current Respiratory sites & provision within GM

All GM trusts provide some respiratory care with high rates of emergency Finished Consultant

Episodes (FCEs) across the conurbation in all disease groupings. 10 of the 13 hospitals providing


32

respiratory services have a high rate of emergency presentations, classed as those with more than

4000 FCEs in 2016/17.

Table 02: GM Hospitals with over 4000 emergency respiratory FCEs in 2016/17*

Hospital Emergency FCEs in 2016/17

Wythenshawe Hospital 9628

Salford Royal 8711

Royal Bolton Hospital 7421

Stepping Hill Hospital 7158

Manchester Royal Infirmary 7124

Tameside General Hospital 6685

Fairfield General Hospital 6677

Royal Oldham Hospital 6135

Royal Albert Edward Infirmary 5405

North Manchester General Hospital 4417 *Categories of less than 5 FCEs supressed to ensure patient confidentiality

Interestingly this does not correlate with the population size in the respective areas during this time

(Appendix B), with a range between 3.5% of the population admitted in Salford, to 1.7% in Wigan,

again suggesting variation in the care received by these patients.

There is considerable research and development in the field of COPD management and a clear

imperative to standardise pathways to reduce length of stay and overall costs, and it is on that basis

that this case largely focuses on the opportunities related to COPD.

Total emergency FCEs for respiratory across GM amount to 71,472 in 2016/17 and 74% of these

cases were classified as chronic lower respiratory disease (which includes COPD, emphysema,

bronchitis and asthma) and influenza and pneumonia with the following percentage split:

28% chronic lower respiratory diseases;

47% influenza and pneumonia.

The high volume of cases of both COPD and influenza and pneumonia suggest that these conditions

should be the primary focus of the case for change. The nature of influenza means that demand for

services are influenced by factors such as uptake of the vaccination, public health messaging, and


33

indeed, the strain of the virus. It is critical that there is a standard pathway for influenza in GM which

focuses on best practice management, but this appears to be an area where transformation efforts

are not best targeted, as the caseload is subject to factors that are largely difficult to control. The

transformation programme may wish to consider a review of pandemic readiness and to link with

public health to ensure active promotion of the vaccination and hand hygiene prior to the flu season.

More data is required on the incidence of pneumonia. There are organisational based audits carried

out regularly, but further understanding is needed of how and when diagnosis of pneumonia are

made and its links to frailty, aspiration, hospital acquired pneumonia and production of sputum.

Although all providers are able to support COPD patients, only one is commissioned to deliver

provision of domiciliary Non-invasive ventilation (NIV), a key treatment for many of our most poorly

COPD patients. The RAEI does deliver a non-GM commissioned provision due to delays in the

referral process. Consequently this does not have the same backup team as the commissioned

service. All sites have separate arrangements for sleep (CPAP) ventilation services; in additionSalford

has a neurology service and ventilation service as part of neurological causes of ventilatory failure..

3.8. Headlines: Fixed points

The points below outline recent developments in GM which provide further context for the project:

Manchester University NHS Foundation Trust was created on 1 October 2017 following the merger of

Central Manchester Foundation Trust (CMFT) and University Hospital of South Manchester (UHSM).

It is anticipated that Manchester Foundation Trust (MFT) will acquire North Manchester General

Hospital some 12 to 18 months later. The agreement with Greater Manchester Health and Social

Care Partnership (GMH&SCP) is that in areas such as respiratory, where there is a Theme 3 project,

the Trust will align its merger plans with the wider Theme 3 programme.


34

North, Central and South Manchester CCGs have merged and integrated with the health team of

Manchester City Council to form Manchester Health and Care Commissioning

With the creation of four Healthier Together (HT) sectors Salford, Stockport, Oldham and MRI will

become “high acuity” hospitals providing 24/7 A&E services with full surgical support and

undertaking high risk emergency and elective general surgery for their sector

The North West Lung Centre based at Wythenshawe, provides a tertiary referral service for people

across the North West and whist this service forms part of the overall redesign, it will be included in a

way cognisant of this.

3.9. SWOT Analysis

Strengths Weaknesses

Very high level of specialist respiratory

expertise in GM

Wythenshawe is host to the North West Lung

Centre

Significant variation in clinical practice

pathways, quality of care and patient

experience across GM for patients with

acute respiratory conditions

Variation in length of stay

Despite good practice, disease prevalence

remains high

Lack of smoking cessation services in GM has

meant smoking rates remain high

Variation in workforce availability across the

sites

Opportunities Threats

GM wide Pulmonary Rehabilitation

Self-Management and Care Plans

Access to Secondary Care by Primary Care

when required

Individual localities already commenced

redesign work

Capacity of the service as respiratory disease

diagnosis continue to grow


35

Development of GM-wide integrated and

standardised pathways

System wide approach for areas of specialist

care such as: lung cancer, severe respiratory

failure, chronic respiratory conditions and

respiratory infections

Rollout of virtual clinic educational model for

COPD

Development of community care services to

support admission avoidance

To implement best-practice learning e.g. Royal

College of Physicians Future Hospitals

partnership project between MRI and

Wythenshawe Hospitals

Reduction in variation


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4.DE S I G N AP P R O A C H

4.1. Engagement and Co-design Process

Engagement activity continues to be a priority of this project. Whilst time has been very limited for

the initial phase of the project, engagement has already commenced with a COPD workshop on the

11th July 2018 (attendance sheet in Appendix E) Further engagement events and formal DOFs are

planned for September to ensure availability and the required 8 weeks’ notice is given for clinicians.

The scoping and design phases of the project were led through meetings with the Provider

Transformation Leads (John Wareing - Director of Strategy at Manchester University NHS Foundation

Trust), and the TU project lead. The Clinical Lead (Dr Jennifer Hoyle, Consultant Respiratory

Physician, Pennine Acute NHS Foundation Trust) joined the project on the 1st July 2018.

As documents are to be shared with the Design Oversight Forum (DOF) feedback following the initial

agreement of concept from the Clinical Reference Group, and will be formally reviewed at the DOF

meeting on the 5th September 2018.

4.2. Patient Principles and Feedback

One of the key drivers for the transformation of Respiratory Services is to improve the quality and

consistency of services for patients in GM. It has been crucial therefore to involve patients as much

as possible given the timeframe available and to use their experiences and opinions to help inform

the design of the model of care. 

Several approaches have been taken to involve patients, their relatives and potential service users in

the project:  

Patient focus groups at GM based COPD and other respiratory disease patient groups;

Questionnaire to patients in target cohorts;

Identification of patients interested in further involvement, to invite to any further DOF

opportunities.


37

Feedback from the focus groups gave a unified voice to the need for localised services, describing

how difficult it is to access services further afield as disease progresses. This was further described in

the strong message that respiratory disease is something people live with, that community access to

services is essential and that people are keen to have control over their care.

A patient questionnaire was circulated across all localities between 24th July – 24th August 2018 and

52 responses were received (Appendix F). From those responses several salient points which will be

considered and incorporated into the model of care where possible, are outlined below:

43% of those who responded came from the Salford and Wigan areas

48% consider themselves to have a disability, and 79% consider themselves to have a long

term conditions

80% of those who responded are currently using respiratory services within GM

Respondents attend 13 different hospitals with 44% attending Leigh infirmary

Staff helpfulness, friendliness and professionalism was the best thing about the service for

almost half the respondents

39% said nothing could be improved about the service they received;

Neither initial waiting times after referral or waiting times between diagnosis and treatment

were an issue for 80% of those accessing the service

Of those who smoke, only half have received advice and support to stop, however only 9% of

respondents believe there is not enough support for those who wish to stop, suggesting

some disparity between perception and reality

Over a quarter of respondents have not been offered influenza vaccinations and one person

was unsure, suggesting the target group for this prevention programme are not being

reached

A specialist team, care close to home and involvement in the decision making process account

for half the answers when asked what would be important for a hospital stay

Pulmonary rehabilitation had not been offered to 65% of those who responded, however this

may not have been appropriate for all patients e.g. those with sleep apnoea, but only half

those who commenced pulmonary rehabilitation completed The most important thing to

people in terms of future respiratory services is that it remains the same and that they are

kept informed and involved in any changes. Ease of access and shorter waiting times are also

mentioned, although previous questions suggest waiting times are not a significant issue for

this cohort.


38

5.CH A L L E N G E S

5.1. Key Risks

5.1.1. Increasing Demand As the population increases, particularly in the 75+ age group, we will continue to see an increase in

the diagnosis and treatment of respiratory disorders. Without a change in how we manage these,

particularly in relation to delivery of increased and enhanced community care, smoking cessation,

the respiratory service will be overwhelmed.

By increasing the use of technology to deliver education, support and monitoring, improved

medicines management and compliance, and a shift in treatment of COPD and other exacerbations

into the community, we can start to relieve some of the pressure on secondary care, reduce the

variation we see across GM and improve outcomes.

5.1.2. Workforce Although the workforce is supporting the present service, there have been a number of challenges

recruiting to both respiratory consultant and advanced nurse specialist roles. With increasing

demand due to the aging population, the demand for these roles will increase.

Through new ways of working, particularly the use of technology, it would be possible to increase

opportunities for flexible working within these roles, as many aspects of the developing models of

care in Theme 2 which require secondary care input, could be delivered from any setting.

It would be possible for GM, with the support of local universities to train its own respiratory

specialists and advanced practitioners, particularly if a way to tie these to the GM workforce could be

identified. This could include both contractual arrangements and job enhancements e.g. rotation

through areas of clinical interest or specialist centres.


39

Whilst there is a large body of respiratory clinical expertise in GM the majority of this is based on one

site at Wythenshawe. To deliver an equitable service across all the GM population, there will need to

be a sharing of skills, and a move towards a hub and spoke, rather than solely centralised model for

respiratory services.

5.1.3. Mental health and long-term conditions As respiratory conditions are long-term, with stable periods and exacerbations, many patients

experience deterioration over time. This means the access to services is an important aspect of care.

Limited mobility, social isolation, frailty and poor prognosis all mean that the development of mental

health issues in this patient group is two to three times more likely than in people without long-term

conditions12.

Delivering support and care in local social settings, encouraging pulmonary rehabilitation as a group,

rather than as an isolated undertaking and avoiding unplanned admissions where possible with the

use of enhanced domiciliary and community support, can all reduce the incidence and impact of

mental health issues on these patients13.

5.1.4. Accessibility An inability to effectively manage their disease, coupled with an inability to access services increases

the isolation and contributes to the anxiety and depression most typical among this group6.

Additionally the increased age and frailty that often accompanies these diagnoses often make the

person less able to travel across the region for treatment and appointments.

Solutions to this could be twofold:

1. Keep services accessible, in locations older people who may have reduced mobility can access

12

Naylor C, Parsonage M, McDaid D, Knapp M, Fossey M, Galea A (2012). Long-term conditions and mental health: the cost of co-

morbidities. London: The King’s Fund and Centre for Mental Health. Via: www.kingsfund.org.uk/publications/long-term-conditions-and-mental-health Last accessed: 16/07/18 13 Naylor C, Das P, Ross S, Honeyman M, Thompson J, Gilburt H. (2016) Bringing Together Physical and Mental Health; A new frontier for

integrated care, The Kings Fund Via: https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/Bringing-together-Kings-Fund-March-2016_1.pdf Last accessed: 16/07/18

https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/Bringing-together-Kings-Fund-March-2016_1.pdf

https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/Bringing-together-Kings-Fund-March-2016_1.pdf


40

2. Where appropriate deliver services in the home and community to ease access

The majority of respiratory contacts in acute and specialist care are non-elective. For these services

patients are able to access care across most sites in GM, particularly those with an Emergency

Department (ED) or Urgent Care Centre (UCC).

Figure 13: Acute sites across GM and population who have accessed non-elective respiratory care

It is clear from the map that urgent and emergency services are available in the locality for those

needing this level of care, however the increased incidence in central and western GM also indicates

a need to ensure services are continued to be provided in these areas.

5.1.5. Multiple concurrent redesigns Although this project forms the basis of the Theme 3 redesign for GM, it has become evident that

there are a number of pieces of work on-going to deliver improved respiratory services. Some

will relate directly, having a positive impact (e.g. virtual MDT clinics), whilst others may

create pathways either synergic or disparate to the model.

Keeping the various stakeholders involved will be challenging and ensuring the transparency and

engagement required for organisations such as Health Innovation Manchester, the Respiratory


41

Strategic Clinical Network, the North West Care Alliance, the Advancing Quality Alliance (AQuA), to

name but a few will be a significant challenge during this project.

5.2. Seven Day Working

Not all sites are currently able to deliver the ‘7 Day Clinical Standards’6 in full and the model

recommends that GM works towards the provision of seven-day access to specialist respiratory

clinicians. Challenges arise concerning the following standards:

Standard Two - All emergency admissions must be seen and have a thorough clinical

assessment by a suitable consultant as soon as possible but at the latest within 14 hours

from the time of admission to hospital.

Standard Three - All emergency inpatients must be assessed for complex or on-going needs

within 14 hours by a multi-professional team, overseen by a competent decision-maker,

unless deemed unnecessary by the responsible consultant. An integrated management plan

with estimated discharge date and physiological and functional criteria for discharge must be

in place along with completed medicines reconciliation within 24 hours. (further supporting

information suggests that this should be a specialty team)

Standard Five - Hospital inpatients must have scheduled seven-day access to diagnostic

services, typically ultrasound, computerised tomography (CT), magnetic resonance imaging

(MRI), echocardiography, endoscopy, and microbiology. Consultant-directed diagnostic tests

and completed reporting will be available seven days a week:

Within 1 hour for critical patients

Within 12 hours for urgent patients

Within 24 hours for non-urgent patients

Standard Six - Hospital inpatients must have timely 24-hour access, seven days a week, to key

consultant-directed interventions that meet the relevant specialty guidelines, either on-site

or through formally agreed networked arrangements with clear written protocols. These

interventions would include:

Critical care

Interventional radiology


42

Interventional endoscopy

Standard Eight - All patients with high dependency needs should be seen and reviewed by a

consultant twice daily (including all acutely ill patients directly transferred and others who

deteriorate). Once a clear pathway of care has been established, patients should be reviewed

by a consultant at least once every 24hours, seven days a week, unless it has been

determined that this would not affect the patient’s care pathway.

Arrangements are already in place for sector working to facilitate the delivery of these standards at

some of the sites that do not currently have them in place. The challenge moving forward will be to

deliver all these standards at all the appropriate sites. Further clinical engagement will be required to

determine how GM can deliver access to a seven day specialist respiratory advice, and the

establishment of a GM on-call rota will form part of those discussions.

The model of care will be required to meet all relevant standards set out in Appendix H and in

addition meet standards such as Acute Non-Invasive Ventilation National standards at the sites

where this is delivered.


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6.R E C O M M E N D A T I O N S

6.1. Theme 3 – Acute & Specialised Care

It is critical that, in the short term, transformation in respiratory services focuses on the need to maintain responsive, emergency care across hospital sites for patients with respiratory disease. Patients will continue to present at their local hospital when experiencing acute symptoms of respiratory disease, and therefore local secondary services must remain accessible.

Whilst accessibility is a key aspect of any new respiratory care model, there are a number of

opportunities to reduce variation and escalation, including:

Opportunity to standardise the respiratory pathway, and to ensure appropriate emergency

triage, particularly where patients are experiencing breathlessness;

It is recommended that GM adopts a single model for COPD care;

An accessible Pulmonary rehabilitation service is commissioned for the population to a basic

standard to include delivery during acute admissions;

The development of community services to include suitably skilled outreach enabling patients

to access appropriate care and support when they do not require a hospital admission, this

may include specialist nurses or Allied Health Professionals (AHPs) with enhanced skills;

Creation of a single policy for care of people with influenza and commission centrally;

To gain a clearer understanding of those who present and those who die with a pneumonia

diagnosis and an agreed GM-wide policy for diagnosis;

Implementation of learning from programmes such as the Future Hospitals project to build

teams to deliver the new model;

To plug the education gap in primary and secondary care by providing opportunities for

patient review, potentially utilising the virtual clinic model described later in this document;

There is a need to explore the benefits of provision of psychosocial support for patients with

chronic respiratory disease and ensure the provision of peer support groups and social

prescribing;


44

Any impact from Theme 1 public health awareness is felt in the long or very long term, services will

require further review.

6.2. Summary of Financial and Operational Efficiency Benefits

By implementing the above recommendations GM would:

Improve further the number of bed days used for all patients as they will receive the best

practice pathway;

Admissions for COPD would not increase despite the increasing aging population as the impact

of increased secondary care support to community services and GPs enables people to be

better managed in their own homes;

A reduction people waiting in hospital for domiciliary NIV;

A reduction in readmission rates due to improved treatment, outcomes and post discharge

support;

An increase in patient satisfaction due to improved pathway and reduced bed days;

Improved short and long term outcomes, enabling people to return to their families, lives and

work faster, with more support and better informed about their condition than previously.

In turn for influenza model there will also be an:

A reduction in those contracting influenza;

Improvement in the bed days and severity of the influenza for those who require admission;

Reduction in the number who go on to develop pneumonia;

A reduction in the amount of level 2 & 3 critical care required

An improvement in the number of days people are unable to participate in their normal lives,

including childcare, work, etc.

It is recommended that further patient engagement take place during the modelling phase of this

redesign due to the constraints placed by limited time on the breadth and depth of engagement.

.


45

7.1. Model of Care

Based on equitable, improved access to acute and specialist assessment, diagnosis and treatment

services the recommended GM model of care is designed to improve patient experience and

outcomes, by reducing variation and improving access to essential diagnostics and treatment. To

deliver this a robust clinical network should be formed across all sites where respiratory services are

delivered, to continue to support and enhance the health benefits delivered by a robust public

health, primary and community care model.

 

7.1.1. Service aims  In developing the recommended model of care, the service aims to: 

reduce the unwarranted variation currently experienced by patients, their relatives and carers

in Greater Manchester by delivering consistent high-quality care regardless of where patients

access and receive their care in GM; 

maximise a patient’s functional capability and quality of life by establishing a service that

offers timely and safe access to appropriate care throughout the whole pathway, including

seamless integration with aspects that are outside of the hospital setting; 

implement standardisation in GM of processes identified as offering substantial gains in

productivity and efficiency to drive improvements in the service. 

The future service will be delivered through a specialist Respiratory multi-disciplinary team that

works in close collaboration with teams throughout the pathway. This will include forming

relationships with local health and social care providers to help optimise any care provided locally for

the patient. This will include liaison with consultants, GPs, community nurses, social workers, primary

care clinicians, voluntary organisations, patient representatives and health trainers.

7.P R E F E R R E D MO D E L O F CA R E


46

The service will achieve all the markers of high quality care set out in the NICE quality standard for

patient experience in adult NHS services.

The service will ensure that patients:

are appropriately diagnosed and treated for their condition;

are treated in a safe, clean and confidential environment;

feel well-informed about their diagnosis and the services that they are receiving;

will be treated as a member of the team to make decisions in partnership with the team;

are informed and involved in the decision about the care they receive.

7.1.2. Service objectives The objectives of the future service and model of care will be to achieve the following:

Implementation of all agreed GM Quality Standards;

Ensure equity of access and choice of treatment modalities for the whole GM population

Ensure consistency and uniformity of care, delivering improved patient outcomes and

experience of care for all patients.

Ensure consistent and timely decision making and management planning for all patients.

Ensure most effective use of Greater Manchester NHS and Social Care funding and optimise

the use of existing resources and infrastructure

A networked service that builds on existing established examples of best practice across GM

Optimised care for patients and access to clinical expertise in all cases, including patients with

co-morbidities

A sustainable future-proofed service – ensuring that future model remains viable over the

long-term, and able to withstand any changes such as population growth

or incidence rates.

Secure excellent clinical leadership, team working and real job satisfaction and maximise

opportunities for education, research and innovation to deliver excellent services

Consistent adoption of evidence-based innovation including use of technology

Carry out effective monitoring of patients to ensure that clinical treatment is safe and

effective;


47

Ensure compliance with Care Quality Commission regulations and a commitment to continual

service improvement;

Provide care with a patient and family centred focus to maximise the patient experience;

Provide high quality information for patients, families and carers in appropriate and accessible

formats and media.

This will ensure that the proposed optimal service configuration can deliver the highest international

standards in clinical outcomes, patient experience, training, research and education for patients,

carers and the next generation of clinicians.

7.2. Governance & Clinical Leadership

The model will require a combined governance to operate effectively. As the model relies on the

delivery of enhanced Theme 1 and 2 care, the relationship between all three themes will need to

remain cohesive and the clinical leadership consistent.

Governance may be managed through existing networks as long as this cohesive, consistent clinical

leadership remains.

7.3. Service Description and Care Pathway

The model of care will focus on three main areas:

1. The development of a COPD model of care, with GM-wide outcomes

2. The identification of a single GM-wide policy framework for Influenza

3. Initial audit of diagnosis of pneumonia and identification of single diagnosis criteria for all GM

patients.


48

7.4. COPD Model of Care

Patients accessing the COPD care pathway will, in the new model, be either patients with respiratory

problems who are being diagnosed with COPD, or those whose COPD is unable to be managed with

clinical support in their normal place of residence or community setting. This group may include:

People with uncontrolled exacerbations of their COPD

People with significant deterioration in condition who require specialist support

People admitted for other clinical co-morbidities significantly hindering their ability to manage

their COPD whilst acutely unwell

The model will be based on and fully support an improved, enhanced primary and community care

service by delivering specialist nurse outreach to more complex COPD patients unable to be managed

by the GP and community teams, through training of community respiratory nurses and GPs and

through MDT clinics, risk stratification and advice support. This will ensure that only those patients

who require an appropriate admission, acute Non-invasive Ventilation (NIV) and domiciliary NIV

access the Theme 3 service.

Escalation may take place from a number of sources:

GP

Community nurses/ physiotherapists or other AHP

Walk-in-centre

Patient (self-referral or 999 call)

If a GP or community team member initiates the escalation, a call will be made to the secondary care

COPD team who may offer, dependant on the information received, to commence management of

the patient on an enhanced community pathway, supporting the Theme 2 model, to avoid admission.

This pathway will include the advice and support for the GP by the hospital based respiratory

consultant led team and outreach by Specialist Respiratory (Nurse or other appropriately trained

professional) Practitioners (SR(N)P) into the person’s home; either with or additionally to the


49

community team. The person may be further escalated into an acute inpatient bed at any time by

the respiratory Consultant, GP or SR(N)P.

Should the patient not be suitable for this type of care, either on risk stratification due to severity of

the COPD, home circumstances, or if they have self-presented at the Emergency Department, then

they will be streamed directly into a respiratory pathway. This pathway will also include

resuscitation at various levels, if required, but will begin with access to a senior respiratory clinician.

For those accessing an Emergency Department directly, review by a senior respiratory clinician

(nursing or medical) will take place as soon as possible and patients not requiring admission will be

signposted to the appropriate service. This may include the community services, GP, or enhanced

community services.

Care will be delivered, at all stages, by a respiratory multi-disciplinary team (MDT) with the patient

moving onto a specialist respiratory ward as soon as possible. This ward will be managed with

infections such as chest infections and influenza taken into account, as this is likely to increase the

risk of further deterioration through spread. Prescribing for exacerbation will be managed with the

support of a respiratory pharmacist as per the developing NICE guidance16 and further treatment as

per guidance7.

The person’s baseline will be identified at admission, with the aim to create a plan to discharge and

support the person at home as soon as practicable and where appropriate; looking to return the

person as close to their usual health as possible whilst supported outside the acute environment.

Risk stratification tools will be utilised throughout the pathway to ensure that length of stay is

minimised and that patients at risk of readmission are provided with appropriate support. Pulmonary

rehabilitation, patient education, tobacco control, appropriate oxygen-prescribing and social

prescribing (including review of mental health wellbeing) will be commenced during an acute

16 NICE (2018) Chronic obstructive pulmonary disease (acute exacerbation): antimicrobial prescribing: draft guidance, Via: https://www.nice.org.uk/guidance/indevelopment/gid-ng10115/documents Last accessed: 17/07/18

https://www.nice.org.uk/guidance/indevelopment/gid-ng10115/documents


50

admission and continue along agreed pathways in primary care. Further clinical consultation is

required within GM to agree which risk stratification tools are used, however it is envisaged that

there will be a consistent and agreed approach. Examples of such tools include the DECAF17 score

(Dyspnea, Eosinopenia, Consolidation on chest x-ray, Acidemia, Atrial Fibrillation) for COPD, which

contributes to informing the development of personalised plan for acute stays.

NIV assessment and acute NIV currently takes place in 10 localities within GM. Further consultation is

required to ensure delivery meets national standards, particularly to address how to achieve

appropriate and timely review by respiratory clinicians, appropriate staff ratios and access to specific

ventilation support areas in the hospitals. Domiciliary NIV will be delivered within each locality that

provides acute NIV in a timely way and to agreed standards, with training and support from the NW

Lung Centre. The services should be limited by the patient’s disease severity, rather than service

availability. It is recommended that a dedicated NIV task group is established to review NIV provision

and develop appropriate pathways for acute and home NIV provision.

All acute sites will offer a consistent tobacco control/smoking cessation service which is linked with

primary care. The CURE programme currently piloted by MFT is an evidence-based, inpatient

treatment for tobacco addiction aimed to increase the chance of long-term smoking cessation by

60%. The pilot is based on the Ottawa Model for Smoking Cessation18 and if successful, this model

will be made available at other GM hospitals. .

Patients admitted with other conditions that render them unable to manage their COPD, will be

monitored by the SRNP and care escalated to a respiratory consultant only if required. A process will

need to be created to alert the MDT to the admission of a person who is unable to manage their

COPD due to other co-morbidities.

17 https://www.mdcalc.com/decaf-score-acute-exacerbation-copd#next-steps 18 https://ottawamodel.ottawaheart.ca/

https://www.mdcalc.com/decaf-score-acute-exacerbation-copd#next-steps


51

The MDT, through virtual clinics, outreach services or remote monitoring as appropriate, will support

discharge; this will be delivered as part of the wider MDT including community services, smoking

cessation, pulmonary rehabilitation, GP involvement and social care.

Those within the patient group experiencing psychosocial issues relating to their COPD will be able to

access the appropriate support in their area and this will be commissioned along with physical health

care and social prescribing.

All patients discharged from this service will receive smoking cessation support, influenza and

pneumococci vaccinations as appropriate described in section 7.7 Standard Respiratory Offer.

Figure 14: COPD Model of Care


52

7.4.1. Workforce Although the numbers of patients with COPD are expected to increase due to the aging population

and lifestyles, the increased community management should see maintenance of numbers attending

acute sites. The development of outreach support for both patients and healthcare practitioners will

require an initial increase in specialist nurses, however, in time, the increased knowledge and skill of

the community teams will enable this number to maintain, despite the increase in people with COPD

and the long term nature of the disease.

Considering this, a different model of workforce will need to be developed, that is able to work

across settings in both acute and community environments.


53

Table 03: Description of Workforce for COPD Pathway

Role Additional Skills requires

Respiratory

Consultant / Senior

Respiratory Clinician

Virtual clinics

Advice and guidance

Emergency department respiratory care cover

Specialist Respiratory

(Nurse) Practitioner

Spirometry

Basic chest physiotherapy skills

Expertise in inhaler usage

Relevant appropriate pharmaceutical knowledge

Advice & guidance

Training for community teams

Home visits (lone working, decision making, etc.)

Knowledge of other services and how to access them

Remote monitoring

Emergency department respiratory care cover

Ability to immunise

Oxygen prescription

Pulmonary

Rehabilitation

Support

Working in an acute setting

Pulmonary Rehabilitation links to community

Smoking Cessation training

Allied Health Occupational Therapy

Physiotherapy

Pharmacist-immunisation, smoking cessation, inhaler advice

Radiology

Voluntary groups

Professional patients


54

Where skills or roles are not available, GM will need to identify how and when this training is

accessed or provided. The respiratory network group would identify this with support from the

Respiratory Strategic Clinical Network (SCN).

7.4.2. Access to service The Theme 3 COPD Service will only be accessed if all other avenues have been considered and

judged inappropriate. If a patient attends directly at the Emergency Department they will be seen by

a specialist respiratory clinician who will then make a decision as to whether admission is appropriate

or the patient should be treated elsewhere. If admission is not considered appropriate the patient

will be referred to the community COPD service; if the patient is admitted they will go straight to a

specialist respiratory service.

Figure 15: Flow Chart of Access to COPD Secondary Care


55

7.4.3. Transition to Implementation

It is anticipated that this would need to be delivered in stages, with some aspects being more

straightforward than others.

Where good practice already exists in some CCGs, for example virtual clinics, we would see this rolled

out across the whole of GM as commissioning arrangements were being agreed. It is recognised that

some aspects of the implementation (e.g. virtual clinics) may only need to be made available for a

finite period depending on the needs of each practice, and in the long term, frequency will be

reviewed and reduced as necessary.


56

Where training would be required to develop roles, this would also be identified and commissioned

at the onset.

An outline plan for implementation will be created once the model has been agreed by an engaged

DOF and CRG.

7.5. GM Framework for Influenza

A single GM-wide framework will be created to describe how GM will manage those with suspected

or diagnosed influenza, education and communication regarding influenza, along with an influenza

immunisation plan for the vulnerable and their carers - both paid and unpaid - and a pneumococcal

immunisation plan for the most vulnerable.

Centrally commissioned, influenza management will commence much earlier in the year, with

vaccinations as soon as available, ideally over August and September. These will be offered free of

charge to the following groups:

People 65 years of age or over

Those who are pregnant

People with certain medical conditions (Appendix I)

Those living in a long-stay residential care home, nursing care or other long-stay or group living

care facility

Those who receive a carer's allowance, or you are the main carer for an elderly or disabled

person whose welfare may be at risk if you fall ill

Healthcare workers

*Medical and nursing students

*Social care workers who have regular contact with the vulnerable groups

Children – Age 0 – 9 or as evidence describes


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As the availability of pneumococcal vaccination is often significantly reduced in comparison to the

influenza vaccine, it will only be offered to the most vulnerable. This will include:

People 65 years of age or over

People with certain medical conditions

Those living in a group living or other long-stay care facility

A GM-wide protocol to include swabbing, point of care testing for influenza, the use of CRP testing,

and use of antivirals based on best practice and NICE guidance19 is currently being developed by the

Strategic Clinical Network in conjunction with Public Health England.

Reducing the severity of the influenza reduces the likelihood of development of pneumonia and

reduces the severity of the disease, improving outcomes, patient experience and saving the NHS a

significant amount financially.

Each Trust should have a plan to cohort patients with influenza based on intelligence and in line with

the GM/Public Health plan. Work is currently underway with regards to the Flu pathway and advice

about locality wide plans should be made for the cohorting and management of people presenting

with suspected influenza and other respiratory tract infections as per guidance. .

Any patients admitted with influenza will receive smoking cessation support and pneumococci

vaccination as appropriate as described in section 7.7 Standard Respiratory Offer.

7.6. Pneumonia

* New groups to receive Influenza Vaccine

19NICE (2008) Oseltamivir, amantadine (review) and zanamivir for the prophylaxis of influenza Via:

https://www.nice.org.uk/guidance/ta158 Last accessed: 17/07/18

https://www.nice.org.uk/guidance/ta158


58

The treatment and management of pneumonia is a clearly defined pathway indicated in NICE

guidance20 as is the diagnosis.

The model of care is focussed on two groups of patients:

those patients with Hospital Acquired Pneumonia (HAP)

those diagnosed with pneumonia on admission to hospital

Some patients diagnosed with Pneumonia in the community may receive their treatment, including

intravenous (IV) antibiotics through the enhanced services provided by Theme 2.

It is recognised that there are a number of pneumonia codes which complicate the pneumonia

picture and in turn skews pneumonia mortality. Anecdotal evidence comparing local pneumonia

audits to RightCare data suggests that there may be a difference between those cases which fulfil the

NICE definitions of pneumonia and those reported as death due to pneumonia. It is likely that there

is a subgroup of frailty and end of life care within the pneumonia cohort that merits further

investigation going forward.

7.6.1. Hospital Acquired Pneumonia As with most other respiratory conditions, Hospital-Acquired Pneumonia (HAP) diagnosis and

treatment will be required at each acute site. Unlike others types of pneumonia, HAP can be

prevented in some instances by appropriate cohorting of vulnerable patients and ensuring they are

not exposed to patients with chest infections, including influenza. This may prove difficult during

times of high demand, including winter months, but effort should be taken to limit or reduce

exposure.

Diagnosis is traditionally required through culture of lower respiratory tract secretions and White

Blood Cell Count alongside chest X-ray, pulse oximetry and pyrexia, however other diagnostic

investigations may be considered including Computerised Tomography (CT) of the Chest. NICE21 and

20

NICE (2016) Pneumonia Via: https://pathways.nice.org.uk/pathways/pneumonia Last accessed 17/07/18

21 NICE (2018) Management of Hospital Acquired Pneumonia Via: https://pathways.nice.org.uk/pathways/pneumonia#content=view-

node%3Anodes-management-of-hospital-acquired-pneumonia Last accessed 06/09/18

https://pathways.nice.org.uk/pathways/pneumonia

https://pathways.nice.org.uk/pathways/pneumonia#content=view-node%3Anodes-management-of-hospital-acquired-pneumonia

https://pathways.nice.org.uk/pathways/pneumonia#content=view-node%3Anodes-management-of-hospital-acquired-pneumonia


59

accepted best practice22 guidance describe the antibiotic therapy required for those patients and

although these patients are at a higher risk of contracting infections from antibiotic resistant

organisms23, this particularly rises when the patient is ventilated, further increasing their risk of

pneumonia.

This guidance is widely accepted and implemented across GM and practice - in most instances - meet

the required standard for this cohort. Further work, however, needs to be done to reduce the

incidence of HAP, other Hospital Acquired Infections (HAI), particularly influenza, and increased

exacerbation of existing respiratory disease. A model of care describing the standard offer for all

patients admitted to a hospital with any form of respiratory disease, infectious or chronic is based on

the initial COPD pathway of assessment, risk stratification, application of national standards and

appropriate intervention including tobacco control, vaccination and education. Further clinical

engagement is required to agree these pathways.

7.6.2. Diagnosis of Pneumonia on Admission Diagnosis of pneumonia will necessitate a Chest X-ray and, where possible, culture of lower

respiratory tract secretions and White Blood Cell Count as described in NICE Guidance18. Further

clinical consensus is required as to the diagnosis at end of life where chest infection is common,

however, frailty may be an overwhelming feature. Antibiotic therapy as described by the Greater

Manchester Medicines Management Group (GMMMG), will be prescribed unless contraindicated.

It is envisaged that risk stratification tools will be employed, with clinical consensus, to help

determine those who can be safely cared for in the community with or without extra support. Those

who require an appropriate inpatient admission will be reviewed by the respiratory team and be

cared for on a respiratory ward where appropriate according to stratification.

22 BMJ Best Practice, Hospital Acquired Pneumonia Via: https://bestpractice.bmj.com/topics/en-gb/720 Last accessed 06/09/18 23 Rotstein C, Evans G, Born A, Grossman R, Light B, Magder S, McTaggart B, Weiss K, Zhanel G G (2008) Clinical practice guidelines for

hospital-acquired pneumonia and ventilator-associated pneumonia in adults. Canadian Journal of Infectious Diseases and Medical Microbiology. 19(1); pg 19-53 Via https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2610276/ Last Accessed 06/09/2018

https://bestpractice.bmj.com/topics/en-gb/720

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2610276/


60

Those people who are recognised to be at the end of life should be managed through an Individual

Care Plan with involvement of the family and/or carers. It is envisaged that further engagement is

required to define the most appropriate pathway. Delivery of this care should take into account both

patient and carer wishes as well as service delivery requirements, for should involve support from

relevant services such as palliative care and oxygen provision.

Any patients admitted with pneumonia, if appropriate, will receive smoking cessation support,

influenza and pneumococci vaccination as described in section 7.7 Standard Respiratory Offer.

7.7. Standard Respiratory Offer

Each patient admitted to hospital with a respiratory disease will be offered a number of interventions

whilst they are inpatients. These will be aimed at improving health and wellbeing, reducing the risk

of infection and increasing self-management of the disease.

The offer will include where appropriate:

i. Influenza vaccination

ii. Pneumonia vaccination

iii. Smoking Cessation support in line with Greater Manchester Medicines Management

Guidelines (GMMMG)

iv. Pulmonary rehabilitation including exercise, nutritional advice, inhaler technique, patient

education as appropriate

v. Psychosocial support

vi. Family/ carer Involvement

It is anticipated that this will capture those people who have not either had the offer of vaccination

or have refused vaccination due to not enough information or understanding about the vaccines,

thus reducing both the number people with influenza and severity of disease as less people contract

and spread both influenza and pneumonia.


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Smoking Cessation as described in section 7.4 is one of the few interventions that can improve

COPD24&25, reduce the risk of Lower Respiratory tract Infections (LRTI)26, and reduce the impact of

diseases such as pneumonia and influenza27. As such it is imperative to offer wherever possible. The

patient survey demonstrates that only half of those patients who smoke were offered smoking

cessation support, demonstrating a need to improve access to the offer.

The benefits of pulmonary rehabilitation are again well evidenced and the advantage of commencing

this programme as an inpatient long understood. By creating this package of care, used to the

appropriate extent for all respiratory inpatients, it is anticipated that the number of bed days,

severity, impact and risk of further deterioration will reduce. Aspects of pulmonary rehabilitation

will be agreed within GM by a clinical and commissioner panel and will include evidence based face

to face, virtual, and visual material as appropriate (Section 7.9). Standards for inclusion will be

agreed through the SCN and will be based on British Thoracic Society Guidelines28. It is recognised

that uptake of pulmonary rehabilitation is historically poor and may need to be delivered in a more

attractive way. Long term health benefits and educational packages should involve self-help tools,

social isolation strategies, carers and the voluntary sector.

As these interventions all require skills existing within the workforce at all levels, there would only be

a requirement for further spread of skills rather than extra staffing or resources.

Whilst vaccinations will occur in the hospital this is a cohort of patients identified and budgeted for

vaccination in the community, so this will only require a shift in resource.

24 Tønnesen P (2013) Smoking cessation and COPD. European Respiratory Review Via:

http://err.ersjournals.com/content/22/127/37 Last accessed 06/09/18 25

Willemse B, Postma D S, Timens W, ten Hacken N (2004) The impact of smoking cessation on respiratory symptoms, lung

function, airway hyperresponsiveness and inflammation. European Respiratory Journal 2004 23: 464-476 Via: http://erj.ersjournals.com/content/23/3/464.long Last accessed 06/09/18 26 Saldias F & Diaz O (2010) Cigarette Smoking and Lower Respiratory Tract Infection. Via:

https://www.intechopen.com/books/bronchitis/cigarette-smoking-and-lower-respiratory-tract-infection Last accessed 06/09/18 27 Wong CM, Yang L, Chan KP, Chan WM, Song L, Lai HK, Thach TQ, Ho LM, Chan KH, Lam TH, Peiris JS. (2013) Cigarette smoking as a risk

factor for influenza-associated mortality: evidence from an elderly cohort. Influenza and Other Respiratory Viruses, 2013 Jul;7(4):531-9 Via: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5855151/ Last Accessed 06/09/18 28 https://www.brit-thoracic.org.uk/document-library/clinical-information/pulmonary-rehabilitation/bts-guideline-for-pulmonary-rehabilitation/

http://err.ersjournals.com/content/22/127/37

http://erj.ersjournals.com/content/23/3/464.long

https://www.intechopen.com/books/bronchitis/cigarette-smoking-and-lower-respiratory-tract-infection

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5855151/


62

Psychological support for the person living with long term disease or coming to terms with a terminal

disease will be offered. Alongside this any social or other wellbeing needs will be considered and

referrals, assessments and introductions will take place as expeditiously as possible.

Family and carer involvement in aspects of the persons diagnosis, prognosis and health education

will be considered individually for each patient.

The delivery of the Standard Respiratory Offer for all respiratory inpatients should therefore be cost

neutral, save for some training regarding smoking cessation and pulmonary rehabilitation

conversations. The benefits will deliver a reduction in readmissions and hospital bed days, improved

health and self-management.

7.8. Service Access Requirements

To access the COPD pathway each patient will receive a diagnosis of COPD from a , using quality

assured Spirometry, and ensuring other causes of airflow obstruction are ruled out as described in

the NICE guidance29

The COPD service described will be delivered to the appropriate service standards and

specifications. Changing thresholds for escalation and sharing knowledge and expertise can achieve

reductions in admissions, readmissions and bed days for those we do admit.

Future pathway improvements based on developments in clinical expertise, pharmacology or

technology can be more efficiently implemented due to the increased communication and support

across Theme 2 and 3.

29 NICE (2018) Chronic obstructive pulmonary disease in over16s: diagnosis and management, Via:

https://www.nice.org.uk/guidance/gid-ng10026/documents/short-version-of-draft-guideline Last accessed 17/07/18

https://www.nice.org.uk/guidance/gid-ng10026/documents/short-version-of-draft-guideline


63

Specialist and emergency care will be more easily available to these vulnerable patients and if they

do enter hospital it will be with a reduced risk of hospital acquired respiratory tract infections or

pneumonia.

Travel and access is an important consideration for patients and carers and accessibility needs to be

considered in relation to the travel implication for patients, as many are unable to travel or walk

longer distances.

Influenza cohorts for vaccination will be identified by their GP, or employer, or in the case of carers

the Department of Work and Pensions. A GM-wide campaign will be created to not only identify

those people but also encourage them to take up the opportunity.

7.9. Follow up and aftercare

Support of the person at home following discharge will look to return the person to as close to their

baseline as is practicable whilst supported outside the acute environment by community teams. This

care will be enhanced where required by Specialist Respiratory Nurses, based in the hospital, but

providing both in-reach and outreach services will provide initial support, and be available as an

ongoing source of expertise to the community teams.

Wherever possible the use of technology will be incorporated into the pathway. This will take on a

number of forms:

Video conferencing – used for both MDT and advice, more use will be made of video calls to

engage with GPs and other clinicians, both in the community and across provider sites;

Telephone/ tablet applications – Apps may be used to remind clinicians of investigations,

referral methods or other pathway criteria both during implementation. They may also be

used by patients to monitor or manage their condition on discharge, to commence and

participate in cardiac rehabilitation, or to receive requests or instructions from the clinicians;


64

Monitoring – pulse and oxygen saturation can be l monitored remotely. Wherever possible

these and any other appropriate observations will be delivered remotely allowing the patient

as little disruption as possible to their day-to-day life, improving outcomes and wellbeing by

creating reassurance without anxiety. Results will be monitored by specialist nursing staff,

escalating to consultants only when required.

As other forms of technology are developed they will be reviewed by the network group and

incorporated into the pathway as appropriate.

Patient Reported Outcome Measure (PROMS) will be used to understand the efficacy and impact of the model of

care, Pulmonary Rehabilitation and Theme 2/3 interface.

7.10.Audit, Research and Education

By creating a single model and set of standards for care there will be increased continuity of clinical

audit. The Board will be able to deliver the oversight and identify areas of focus for both junior

doctor and senior clinical audit. There will be increased GM-wide understanding of area outcomes

and where these differ from expected, audits will focus on these, alongside the standard audits.

Share care across Theme 2 and 3 creates significant opportunities for education amongst medical,

nursing and allied healthcare professionals. The network will work with the deaneries of various

universities to create training opportunities for hospital physicians, GPs, junior doctors, nurses,

radiologists and other allied health professionals.


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8.F I N A N C I A L CO N S I D E R A T I O N S

There are a number of financial considerations immediately evident from the model described above

the detail will only become evident once the full impact is understood and a full cost benefit analysis

will be completed at that time.

8.1. Financial principles for Theme 3 

The development of the Future Model of Care will be underpinned by the following set of principles,

agreed by the Theme 3 Finance and Estates Reference Group (FERG) in September 2017.  

 

8.1.1. Financial impact: 

Demonstrable positive recurrent revenue impact across the GM Health & Social care system

when compared to actual current delivery; 

Stranded costs should be minimised, and a clear distinction should be drawn between

cashable and non-cashable benefits; 

Financial savings should not be achieved at the expense of achieving appropriate clinical

outcomes; 

To access Transformation Fund funding, be able to demonstrate a positive return on

investment within four years. 

 

8.1.2. Estates impact: 

Seek to make best use of ALL existing estate in order to minimise costs; 

The use of empty/under-utilised estate where costs are fixed/have already been committed

should be a priority; 

Stranded capacity and associated costs should be minimised; 

Capital will not be granted to build new hospital estate unless either: 

Existing estate is appropriately utilised; or 

Building new estate is demonstrably better value for money than repurposing existing empty

estate. 


66

 

8.1.3. Workforce impact: 

Additional workforce costs (e.g. redundancy and re-training costs) should be kept to a

minimum; 

Expenditure on non-substantive posts should be reduced in so far as appropriate; 

Agency costs should only be incurred after due consideration has been given as to whether

new/vacant substantive posts should be covered by agency staff or whether it may be

appropriate to delay implementation and recruit to the post substantively. 

8.2. Logic modelling for financial impact of new model of care 

Key: 

* Timescale column:  Timescales in this column are from the point of decision to implement, not from submission of this paper.  ǂ Financial impact columns:  

↑ = cost increases for providers/commissioners (as indicated)  ↓ = cost decreases for providers/commissioners (as indicated)  ↔ = no significant cost increase/decrease for providers/commissioners (as indicated) 

± Direct Impacts column: 

↑ = quantity increases  ↓ = quantity decreases  ↔ = no significant impact on quantity 

  Intervention…  Drives…  Direct impacts… 

±  Timescale * 

Confidence 

Financial impact on

providers ǂ  Financial impact on

commissioners ǂ 

COPD

Accessible COPD model of networked service supporting Theme 2

Better clinical outcomes for patients and shorter lengths of stay 

Quality targets ↑

 

 

Greater achievement of

Best Practice Tariff improves

income 

↓  Fewer

readmissions from variable practice

↓ 

Capacity usage ↓

   

Less use of inpatient beds

(but ? Cashable)  ↓ 

Fewer admissions for planned

investigations ↓

Workforce demand ↑

 

 

Demand on existing

workforce will increase in the

short to medium term

 ↑

Reduced number of outpatient attendances

↓


67

Staff working across sectors

Equipment & workforce 

Short term↑

Long term ↓

 

Improved access and use of diagnostic

equipment

 ↑ Reduced number of investigations

carried out ↓

Reduced patient transfers as expertise on site

Patient delays in discharge ↓

Reduced delays and bed usage

↓ Reduced number

of spells ↓

Influenza

Standardised key processes for Influenza management

Improved immunization reduces incidence

NHS Activity ↓     Reduced activity and admission 

↓     

Purchasing vaccine ↑

 

Increased initial outlay on

vaccine will reduce

admissions

↑     

Time spent in hospital ↓

 

Faster diagnosis

Less use of inpatient beds

(but ? Cashable) 

Reduced variation in

delivery

  ↓

Reduction in the number of patients treated in level 2 &

3 care

  ↓

Use of level 2&3 HDU & ICU ↓

Reduction in hospital acquired infections

Time spent in hospital↓

 

 

Reduced LoS for vulnerable

patients

(but ?cashable)

↓     

Pneumonia

Standardisation of treatment of HAP

Standardised treatment as described in NICE

Variation in treatment↓

 

 

Possible increased

demand for diagnostic activity 

↑ 

 

Standard Respiratory Offer

Influenza & Pneumonia vaccinations, smoking cessation & pulmonary rehabilitation

All respiratory patients to receive appropriate offer

Readmissions↓

Bed Days↓

Admissions↓

Short Term

Long Term

Reduction in readmissions

Reduction in admissions

↓ Reduced number

of spells ↓

The combined impact of the full implementation of the model will see:

A reduction in admissions A reduction in bed days across all sites A reduction in unnecessary testing Some increase in cost of vaccinations


68

Reduction in costs associated with high dependency care Reduction in admissions due to outreach service A reduction in outpatient costs due to use of healthcare technology in remote monitoring


69

9. KEY ENABLERS & CRITICAL SUCCESS FACTORS

9.1. Enablers

To deliver this model, based on improved patient experience, improved outcomes and reduced long-

term costs, there are a number of enabling factors that are key to deliver:

9.1.1. Further Engagement with Clinicians and Patients Although the project team has initiated clinical and patient engagement, the limited amount of time

has given limited opportunity for full and widespread engagement and involvement in the

development of this model. It is therefore proposed that the project team continue to engage

clinical colleagues and patients following agreement of the model of care.

With full engagement the further modelling, workforce and delivery phases of the project will be

more effectively and efficiently delivered.

9.1.2. Commissioning across GM As COPD and influenza services will be providing care delivered to a single set of principles/ policy for

patients across all CCGs, the service will require commissioning in a different way. By creating single

commissioning criteria across all of GM, based on basic standards and outcomes, those issues that

may have arisen, due to individual locality commissioning will not be possible.

9.1.3. Supporting Theme 2 whist still sustaining Theme 3. Much of the work that has been developed to date across GM has focussed on out of hospital care of

COPD patients. This has generally included an element of secondary care, either support or delivery,

in the community. Theme 3 acknowledges the need for cross-theme working and supports the aims

of the other pieces of work, but acknowledges the finite workforce currently delivering care in the

acute and specialist setting.

Plans will be made to support the community and primary care developments, whilst maintaining the

services within the hospital, and this will include the up-skilling and multi-skilling of the specialist

nurse, physiotherapy and pharmacy workforce, to allow them to undertake roles currently requiring

two or three different professionals.


70

9.1.4. Workforce Current difficulties in recruiting respiratory physicians and specialist nurses will significantly hinder

the delivery of the preferred model. This difficulty is, in part, due to the lack of appropriately trained

workforce available and, as part of the GM respiratory development, it is required that GM will

identify and work with local further education establishments to create opportunities for training in

these particularly affected roles.

Sharing existing skills and services across GM without the need to increase workforce, will create a

sustainable, future-proof respiratory GM network of care.

Further consideration of the voluntary sector and their role needs to be explored in particular to

social isolation.

9.1.5. Use of Technology The delivery of an improved COPD service can only be sustained through the increased use of

technology including remote monitoring, developments in NIV and virtual clinics and educational

tools. As part of the governance for the model the respiratory network will be required to assess and

recommend new technologies and equipment that will support continued delivery within GM.

9.2. Critical Success Factors

The critical success factors of the model are primarily focused on the people affected by the model.

Figure 16: Critical success factors for respiratory redesign


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The most critical factors include the engagement of those affected by the redesign. Confidence in

the model and implementation support can be created by ensuring that patients, clinicians, nurses,

and other AHPs, the organisations (including the healthcare Trusts, GPs, social care and NWAS), and

professional groups, are involved in the process of formal agreement of the model, modelling and

delivery planning.

The Project and Clinical Lead therefore recommended that a more comprehensive design and

engagement period be entered into to ensure smooth transition into the next phase of the redesign.

ENGAGEMENT

Actively involving those affected by the change in co-design, including

patients

TRUST

Developing trust between all groups

involved by honest and open discourse

OPENNESS

Transparency in both design and decision making will create

further Trust

PATIENT FOCUSSED

Developing pathways with patients and for patients listening to their priorities and

needs

IMPROVED OUTCOMES

Creating a service that delivers improved

clinical, patient experience,

perfornance and financial outcomes


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10.AP P E N D I C E S

10.1.Appendix A - Supporting Data

Respiratory medicine involves the diagnosis and treatment of conditions affecting the respiratory

system. Conditions that are diagnosed and treated under respiratory services include:

Chronic Obstructive Pulmonary Disease (COPD)

Asthma

Obstructive Lung Disease

Pneumonia

Upper and Lower Respiratory Tract Infections (RTI) including Tuberculosis

Influenza

Bronchitis

Bronchiectasis

Interstitial Lung Disease (ILD) including Idiopathic Pulmonary Fibrosis

Cystic Fibrosis

Acute Respiratory Distress Syndrome

Respiratory Failure

Pleural Effusion

Lung cancer

Sleep disorders

Occupational Lung Disease

10.1.1.Admissions The figure below illustrates how inpatient admissions (elective and non-elective) for respiratory are

split between different sites in GM. Note that inpatient respiratory admissions were also recorded at:

Manchester Royal Eye Hospital, St Mary’s Hospital, Leigh Infirmary and Manchester Skin Care North

Hub – but as their volume was much lower than the other sites (20 episodes or less) they have not

been included in the figure below.


73

Figure 16: Respiratory adult inpatient admissions 16/17

© Health and Social Care Information Centre – HES Data 2016/17

From the above figure it is evident that there is a clear variation in Respiratory related activity

across all of the GM sites. Wythenshawe Hospital is clearly accountable for the majority of

activity. You can also break these figures down further into elective and non-elective

admissions:

For elective admissions, there is an even more pronounced variation in Respiratory related

activity. Wythenshawe once again clearly accounts for the majority of activity; with almost

2,000 more episodes than the next highest site, Royal Bolton Hospital (see Appendix A Figure

16).

For non-elective (emergency) admissions, variation in Respiratory activity still exists, although

it is less pronounced than when compared to elective admissions. Wythenshawe still

accounts for the highest amount of activity (see Appendix A Figure 17).


74

An analysis of day case episodes also shows a similar level of variation across GM sites. Once again,

Wythenshawe clearly accounts for the highest amount of day case activity, with over 1,200 more

episodes than the next highest site, North Manchester General Hospital.

Respiratory activity can also be grouped by CCG for GM. This is shown in the figure below:

Figure 17: Respiratory adult inpatient episodes 16/17

© Health and Social Care Information Centre – HES Data 2016/17

From the above figure it should be noted that:

Even though those residing in South Manchester CCG account for 4,941 inpatient episodes of

the respiratory activity across GM its corresponding hospital site, Wythenshawe, accounts

for over 12,591 inpatient episodes. This means that, potentially, over 7,500 inpatient

episodes at Wythenshawe Hospital come from outside the nearest CCG.

Conversely, even though those residing in Trafford CCG account for 5,998 episodes of

respiratory activity across GM its corresponding hospital site, Trafford General only accounts

for 1,167 inpatient episodes. This means that, potentially, over 4,800 residents of Trafford

CCG do not use Trafford General for inpatient respiratory admissions.


75

This could imply that in certain cases, residents of a particular CCG may not be opting to use their

nearest hospital to access inpatient respiratory services and may instead be using inpatient services

elsewhere in GM.

10.1.2.Length of Stay

The figure below shows the average length of stay for elective respiratory inpatient admissions

across the different hospital sites in GM:

Figure 19: Average LoS for elective inpatient 16/17

© Health and Social Care Information Centre – HES Data 2016/17 *Note that Leigh Infirmary, St Mary’s, Rochdale Infirmary and Manchester Skin Care also recorded 1 admission each, but have not been included on the figure due to their low admission numbers being potentially skewed by outliers.

From the above figure a clear variation in terms of length of stay can be observed, with the longest

average length of stay at Tameside General, at a value of 10.4 days. There is a variation in average

length of stay of 8.8 days between the sites in the above figure.


76

Figure 20: Average inpatient length of stay for non-elective 16/17

© Health and Social Care Information Centre – HES Data 2016/17 Note that St Mary’s and Manchester Royal Eye Hospital had a much lower number of admissions compared to the rest of the sites (6 and 10 admissions respectively) and have not been included as their average lengths of stay are potentially more subject to being strongly skewed by outliers.

From the above figure, variation in average length of stay in a non-elective setting can also be

observed. There is variation in average length of stay of 7.0 days between the GM sites in the above

figure.

It is worth noting however, for both elective and non-elective average length of stay, that the above

two graphs do not take into account factors such as the distribution of age and sex, or the case

complexity, of individual patients visiting these sites or the community based services currently

available.

10.1.3.LOS – COPD National data suggests that hospitals should target an average LOS of 4 days for COPD, and work is

clearly needed to bring GM in line with that ambition. The National COPD Audit Programme’s 2017


77

report30 notes that, for patients discharged alive after a spell in hospital for COPD, mortality is higher

within 30 days of admission, and higher still at 90 days.

Figure 21: Summary detail from COPD audit

30 file:///C:/Users/rnoble/Downloads/COPD%20-%20Who%20cares%20when%20it%20matters%20most.%20Results%20and%20data%20analysis%20(1).pdf


78

10.2.Appendix B - Table 6: Population of CCGs at mid-point 201631

CCG Population Size (mid 2016)

NHS Manchester CCG 541,263

NHS Wigan Borough CCG 323,060

NHS Stockport CCG 290,557

NHS Bolton CCG 283,115

NHS Tameside and Glossop CCG 256,424

NHS Salford CCG 248,726

NHS Trafford CCG 234,673

NHS Oldham CCG 232,724

NHS Heywood, Middleton and Rochdale CCG

216,165

NHS Bury CCG 188,669

31 Office for National Statistics, Clinical Commissioning Group, Mid Year Population Estimate 2016 via: https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/datasets/clinicalcommissioninggroupmidyearpopulationestimates Last accessed: 18/07/18

https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/datasets/clinicalcommissioninggroupmidyearpopulationestimates

https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/datasets/clinicalcommissioninggroupmidyearpopulationestimates


79

10.3.Appendix C - Right Care, Commissioning for Value; Pathway on a page


80


81


82

10.4.Appendix D – Clinical COPD Audit Participants

Eleven GM sites participated in this audit:

Fairfield General Hospital (Pennine Acute Trust);

Manchester Royal Infirmary (MFT);

North Manchester General Hospital (Pennine Acute Trust);

Royal Albert Edward Infirmary (WWLFT);

Royal Bolton Hospital (Bolton Foundation trust);

Royal Oldham Hospital (Pennine Acute Trust);

Salford Royal (SRFT);

Stepping Hill Hospital (Stockport Foundation Trust);

Tameside General Hospital (Tameside Hospital Foundation Trust);

Trafford General Hospital (MFT);

Wythenshawe Hospital (UHSM).


83

10.5.Appendix E – Attendance Sheet at COPD Workshop

Lead: Dr Jennifer Hoyle

Facilitated: Alex Vincent


84

10.6.Appendix F - Patient Questionnaire


85


86


87


88


89


90


91


92


93

10.7.Appendix G - Clinical Co-dependencies

10.7.1.Services Required by Respiratory Services: Respiratory services have numerous clinical co-dependencies, specifically:

Serv

ice

sh

ou

ld b

e c

o-l

oca

ted

(bas

ed

in s

ame

sit

e a

nd

can

be

acce

sse

d w

ith

in 1

hr

Serv

ice

sh

ou

ld c

om

e t

o p

atie

nt

(pat

ien

t tr

ansf

er

no

t

app

rop

riat

e),

2-2

4hrs

. Co

uld

be

pro

vid

ed

by

visi

tin

g/in

-re

ach

fro

m a

no

the

r si

te (

ph

ysic

ally

, or

via

tele

com

m li

nks

) if

no

t b

ase

d

at t

he

sam

e s

ite

Ide

ally

on

sam

e s

ite

bu

t co

uld

alte

rnat

ive

ly b

e n

etw

ork

ed

via

rob

ust

em

erg

en

cy a

nd

ele

ctiv

e

refe

rral

an

d t

ran

sfe

r p

roto

cols

Do

es

no

t n

ee

d t

o b

e o

n s

ame

site

- m

anag

ed

via

ap

pro

pri

ate

refe

rral

pro

cess

No

t re

qu

ire

d

C O P D

Sen

ior

Re

spir

ato

ry P

hys

icia

ns

Cri

tica

l Car

e L

eve

ls 2

&3

Spe

cial

ist

Re

spir

ato

ry N

urs

e

Eme

rge

ncy

De

par

tme

nt

Hae

mat

olo

gy

Spir

om

etr

y

Co

ho

rte

d b

ed

s

NIV

Rad

iolo

gy

Rad

iolo

gy

NIV

Acu

te g

en

era

l in

tern

al m

ed

icin

e

Ph

ysio

the

rap

y

Mic

rob

iolo

gy

Spe

cial

ist

Ph

arm

acis

t

Pal

liat

ive

Car

e

Smo

kin

g C

ess

atio

n

Pu

lmo

nar

y R

eh

abil

itat

ion

Car

dio

resp

irat

ory

se

rvic

es

Spe

cial

ist

Nu

rse

Ou

tre

ach

Occ

up

atio

nal

Th

era

py

Soci

al C

are

Do

mic

ilia

ry N

IV

Pro

gram

me

d In

vest

igat

ion

Un

it

Car

dio

logy

Rh

eu

mat

olo

gy

Spe

ech

an

d L

angu

age

Th

era

py

Ou

tpat

ien

t D

ep

artm

en

t

ENT

All

erg

y Se

rvic

es

Imm

un

olo

gy

Infl

ue

nza

imm

un

isat

ion

Pn

eu

mo

cco

cial

imm

un

isat

ion

Oxy

gen

Se

rvic

e

The

atre

s

On

colo

gy

I N F L U E N Z A

Sen

ior

Re

spir

ato

ry P

hys

icia

ns

Cri

tica

l Car

e L

eve

ls 2

&3

Acu

te g

en

era

l in

tern

al m

ed

icin

e

Spe

cial

ist

Re

spir

ato

ry N

urs

e

Hae

mat

olo

gy

Mic

rob

iolo

gy (

swab

bin

g)

Co

ho

rte

d b

ed

s

Inte

nsi

vist

s

Rad

iolo

gy

Ph

ysio

the

rap

y

Spe

cial

ist

Ph

arm

acis

t

Smo

kin

g C

ess

atio

n

Pu

lmo

nar

y R

eh

abil

itat

ion

Car

dio

resp

irat

ory

se

rvic

es

Soci

al C

are

Occ

up

atio

nal

Th

era

py

Pn

eu

mo

cco

cial

imm

un

isat

ion

Infl

ue

nza

imm

un

isat

ion

Imm

un

olo

gy

Spir

om

etr

y

NIV

Rh

eu

mat

olo

gy

Pro

gram

me

d In

vest

igat

ion

Un

it

Spe

ech

an

d L

angu

age

Th

era

py

Ou

tpat

ien

t D

ep

artm

en

t

All

erg

y Se

rvic

es

Oxy

gen

Th

era

py

The

atre

s

On

colo

gy

P N E U M O N I A

Sen

ior

Re

spir

ato

ry P

hys

icia

ns

Cri

tica

l Car

e L

eve

l 2&

3

Acu

te g

en

era

l in

tern

al m

ed

icin

e

Spe

cial

ist

Re

spir

ato

ry N

urs

e

Hae

mat

olo

gy

Mic

rob

iolo

gy

Rad

iolo

gy

Inte

nsi

vist

s

Ph

ysio

the

rap

y

Spe

cial

ist

Ph

arm

acis

t

Smo

kin

g C

ess

atio

n

Pu

lmo

nar

y R

eh

abil

itat

ion

Car

dio

resp

irat

ory

se

rvic

es

Ocu

pat

ion

al T

he

rap

y

Soci

al C

are

Infl

ue

nza

imm

un

isat

ion

Pn

eu

mo

cocc

ial i

mm

un

isat

ion

Spe

ech

an

d L

angu

age

Th

era

py

Pn

eu

mo

cco

cial

imm

un

isat

ion

Infl

ue

nza

imm

un

isat

ion

Spir

om

etr

y

NIV

Co

ho

rte

d b

ed

s

Rh

eu

mat

olo

gy

Pro

gram

me

d In

vest

igat

ion

Un

it

Imm

un

olo

gy

Ou

tpat

ien

t D

ep

artm

en

t

All

erg

y se

rvic

es

Oxy

gen

se

rvic

e

The

atre

s

On

colo

gy


94

All Reparatory services require access to a number of diagnostic specialities:

Laboratory medicine – all sites providing acute, secondary or tertiary care for respiratory

patients will require access to a full suite of laboratory medicine tests. These will need to be

responsive, accurate and both point-of-care and centralised (locally or regionally) testing

should be incorporated into care.

Radiology – plain imaging, ultrasound, CT and MRI are all used for diagnosis and access along

with radiologist reporting is essential. How this is organised will depend on the model of

care.

Other specialities including cardiology and geriatric medicine may be required as the number of

people with both cardiac and respiratory disorders increases and incidence of the disease increases

beyond 75yrs.

10.7.2.Supporting other dependent services/specialties Respiratory medicine is required at all acute sites, although this may be an on-call respiratory

consultant rather than a clinician on site 24/7. Sites without an A&E may only require access to a

respiratory consultant for advice and guidance and this could be managed through virtual or

telephone contact.

Sites with cardiology services will also need access to respiratory clinicians due to the often synergies

between cardiac and respiratory disease; the level of access would depend on the acuity of the site.

Outpatient sites would require access to advice and virtual MDT, inpatient to respiratory physicians

able to see the patient on site.

Community & primary care will benefit from access to a respiratory specialist due to the expectancy

of increased referral thresholds for COPD and increased community management, which will enable

the delivery of care to the required standards. All models considered will only succeed if the

threshold of community manageable conditions increases.


95

Secondary care respiratory consultants would support this by participating in virtual MDTs or clinics

alongside the GP and community clinicians, to enable appropriate advice and guidance is available as

required to optimise the health of the individual patients and therefore reduce the need for hospital

admissions.


96

10.8.Appendix H - Service Standards

There are a number of sources available for respiratory standards and guidance, which requires

consideration and, where appropriate, incorporation into the model of care.

10.8.1.Royal College of Physicians (RCP) The RCP have one guideline useful in this project, “Non-invasive ventilation in chronic obstructive

pulmonary disease”32, however this again focuses on acute NIV, so does not inform the domiciliary

NIV standard.

10.8.2.British Lung Foundation (BLF) Whilst the BLF don not produce guidance for professionals, their information and guidance to the

patients and families of those affected by respiratory disease is clear and should be considered,

particularly when developing a more detailed GM standard for pulmonary rehabilitation. Effort will

be taken to combine the recommendations of BLF into any model produced.

10.8.3.British Thoracic Society (BTS) Standards of Care Committee The BTS have release a number of standards of care pertinent to this project33:

•Guideline for oxygen use in healthcare and emergency settings;

•Guidelines for Home Oxygen Use in Adults;

•Non-invasive ventilation in acute respiratory failure;

•Guidelines for the Management of Community Acquired Pneumonia in Adults;

•Guideline on Pulmonary Rehabilitation in Adults.

Alongside these there are also a number of quality standards that have been considered whilst

creating the outline model34. They include:

32 Royal College of Physicians Non-invasive ventilation in chronic obstructive pulmonary disease. Via:

https://www.rcplondon.ac.uk/guidelines-policy/non-invasive-ventilation-chronic-obstructive-pulmonary-disease Last accessed 19/7/18 33 British Thoracic Society Guidelines. Via: https://www.brit-thoracic.org.uk/standards-of-care/guidelines/ Last accessed 19/07/18 34 Britich Thoracic Society Quality Standards. Via: https://www.brit-thoracic.org.uk/standards-of-care/quality-standards/ Last accessed

19/7/18

https://www.rcplondon.ac.uk/guidelines-policy/non-invasive-ventilation-chronic-obstructive-pulmonary-disease

https://www.brit-thoracic.org.uk/standards-of-care/guidelines/

https://www.brit-thoracic.org.uk/standards-of-care/quality-standards/


97

BTS Hope Oxygen Quality Standards;

BTS NIV Quality Standards;

BTS Pulmonary Rehabilitation Quality Standards.

These give clear direction as to the standards expected from the relevant aspects of the model, and

will be incorporated in at all stages of development. However the focus on acute NIV means this

standard is not relevant for domiciliary NIV.

10.8.4.Seven Day Services In 2015 NHS England (NHSE) published ‘Seven Day Services Clinical Standards’ in relation to hospital-

 based care. An update of this document was published in September 201735 and contains

recommendations in relation to cardiology-based services. The state that inpatients must have

timely 24-hour access, seven days a week, to key consultant-directed interventions that meet the

relevant specialty guidelines, either on-site or through formally agreed networked arrangements

with clear written protocols.  With regards to respiratory, this includes critical care, interventional

radiology and endoscopy.  Whilst all sites currently adhere to this standard, it is important that we

consider the implications through the lens of Healthier Together and any future model to realign

inpatient beds or interventions.

10.8.5.National Institute of Health and Care Excellence (NICE) Guidance exists for the following respiratory conditions pertinent to this project36:

Chronic obstructive pulmonary disease

Pneumonia

Respiratory conditions: general and other

Respiratory infections

35 Seven Day Services Clinical Standards, 2017, NHS England 36 NICE Guidance for respiratory conditions. Via: https://www.nice.org.uk/guidance/conditions-and-diseases/respiratory-conditions

Last accessed 19/7/18

https://www.nice.org.uk/guidance/conditions-and-diseases/respiratory-conditions


98

Sleep apnoea and snoring

Management of Hospital Acquired Pneumonia

From this guidance particular attention has been paid to ensure the outline meets a minimum

standard of the guidance set out for COPD, Pneumonia and where appropriate Respiratory

conditions: general and other, and Respiratory Infections. Sleep apnoea and snoring remains of

interest due to the use of NIV as a treatment for this condition.

10.8.6.Getting It Right First Time

The GIRFT programme is a national programme commissioned by the Department of Health to

identify areas of unwarranted clinical variation and divergence from best practice. GIRFT has

appointed a clinical lead for their respiratory workstream, and whilst they have published reports

relating to other work streams, a Respiratory report has not been released37.

37 GIRFT Respiratory care via: http://gettingitrightfirsttime.co.uk/medical-specialties/respiratory/ Last accessed 19/7/18

http://gettingitrightfirsttime.co.uk/medical-specialties/respiratory/


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10.9.Appendix I – Free Vaccination for Influenza

NHS Choices38 list those who should have free vaccines.

“The injected flu vaccine is offered free of charge on the NHS to anyone with a serious long-term

health condition, including:

chronic (long-term) respiratory diseases, such as asthma (which requires an inhaled or tablet

steroid treatment, or has led to hospital admission in the past), chronic obstructive

pulmonary disease (COPD), emphysema or bronchitis

chronic heart disease, such as heart failure

chronic kidney disease

chronic liver disease, such as hepatitis

chronic neurological conditions, such as Parkinson's disease, motor neurone

disease or multiple sclerosis (MS)

diabetes

problems with your spleen – for example, sickle cell disease or if you have had your spleen

removed

a weakened immune system as the result of conditions such as HIV and AIDS, or

medication such as steroid tablets or chemotherapy

being seriously overweight (BMI of 40 or above)

This list of conditions isn't definitive. It's always an issue of clinical judgement.”

38 NHS Choices, Who should have the flu jab? Via: https://www.nhs.uk/conditions/vaccinations/who-should-have-flu-vaccine/ Last Accessed 17/07/18

https://www.nhs.uk/conditions/asthma/Pages/Introduction.aspx

https://www.nhs.uk/conditions/Chronic-obstructive-pulmonary-disease/Pages/Introduction.aspx

https://www.nhs.uk/conditions/Chronic-obstructive-pulmonary-disease/Pages/Introduction.aspx

https://www.nhs.uk/conditions/Bronchitis/Pages/Introduction.aspx

https://www.nhs.uk/conditions/Heart-failure/Pages/Introduction.aspx

https://www.nhs.uk/conditions/Kidney-disease-chronic/Pages/Introduction.aspx

https://www.nhs.uk/conditions/Hepatitis/Pages/Introduction.aspx

https://www.nhs.uk/conditions/Parkinsons-disease/Pages/Introduction.aspx

https://www.nhs.uk/conditions/Motor-neurone-disease/Pages/Introduction.aspx

https://www.nhs.uk/conditions/Motor-neurone-disease/Pages/Introduction.aspx

https://www.nhs.uk/conditions/Multiple-sclerosis/Pages/Introduction.aspx

https://www.nhs.uk/Conditions/Diabetes/Pages/Diabetes.aspx

https://www.nhs.uk/conditions/sickle-cell-anaemia/pages/introduction.aspx

https://www.nhs.uk/conditions/HIV/Pages/Introduction.aspx

https://www.nhs.uk/conditions/Corticosteroid-(drugs)/Pages/Introduction.aspx

https://www.nhs.uk/conditions/Chemotherapy/Pages/Definition.aspx

https://www.nhs.uk/conditions/vaccinations/who-should-have-flu-vaccine/

https://www.nhs.uk/conditions/vaccinations/who-should-have-flu-vaccine/


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10.10.Appendix J - Abbreviations Table

Abbreviation Description

BLF British Lung Foundation

CCG Clinical Commissioning Group

CMFT Central Manchester Foundation Trust

COPD Chronic Obstructive Pulmonary Disease

GIRFT Getting it Right First Time

GMHSCP Greater Manchester Health and Social Care Partnership

GM Greater Manchester

HAP Hospital Acquired Pneumonia

HES Hospital Episode Statistics

ILD Interstitial Lung Disease

IPF Idiopathic Pulmonary Fibrosis

LoS Length of Stay

MRI Manchester Royal Infirmary

NICE National Institute for Health and Care Excellence

NIV Non-invasive Ventilation

NWLC North West Lung Centre

PAHT Pennine Acute Hospitals NHS Trust

RCP Royal College of Physicians

RTI Respiratory Tract Infection

SRN Specialist Respiratory Nurse

SRFT Salford Royal Foundation Trust

UHSM University Hospital of South Manchester

WWL (FT) Wrightington Wigan and Leigh Foundation Trust


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10.11 Feedback log

Governance group Feedback Response / Action

CRG1 Focus for Pneumonia should be on Hospital Acquired

Focus narrowed until DOF when discussion required widening of model to include all hospital admissions with pneumonia

CRG2 All patients require a set of interventions including smoking cessation and vaccinations

A single respiratory offer created within the model

CRG3 Influenza standards should be managed through Theme 1

This has been incorporated into the model of care

CRG4 Clear NIV standards should be agreed

Further work needed to agree standards

CRG5

CRG outcome Endorse the case for change to go to the Theme 3 Executive


FERG1 No fundamental changes in delivery

FERG2

FERG3

FERG outcome


WRG1 Lack of detailed information about GM requirements for workforce

Added some information to case for change and noted for inclusion in models of care

WRG2

WRG3

WRG outcome


ECAP1 Pneumonia proposals need further clarity

Updated to reflect the need for compliance with NICE guidance in the


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diagnosis and management of pneumonia, which is the first step towards ensuring that pneumonia is only cited as the cause of death where there is a primary diagnosis. This is the starting point in addressing the panel’s feedback that clinical coding and data accuracy are critical to informing a true picture of disease incidence.

ECAP2 Point of care testing for Influenza is imperative

The model has been updated to clarify the need for point of care testing and the isolation of patients with suspected influenza. The document will continue to reflect the capacity challenges associated with providing adequate isolation in times of high demand.

ECAP3 NIV standards and domiciliary care require further development

NIV standards are now referenced in the document, though further GM-wide engagement is needed to determine the final NIV model for GM.

ECAP4 Chest infection management of the COPD patient needs to be considered

Updated to reflect this.

ECAP5 Smoking cessation standards need to be agreed

This work is ongoing in GM and the document has been updated to reflect this. Reference has also been made to the GM CURE programme, which is based on the Ottawa Model for Smoking Cessation.

ECAP6

Fundamentally the proposed model of care is sound and would benefit from focusing on the COPD element of the pathway in the next stage of development

No changes required to the document.

ECAP7

Risk stratification Emergency

Departments and Acute Medical Units

and access to specialist respiratory

clinicians are important inclusions in

further iterations of the model of care

GM Trusts already use a range of risk stratification tools, and further clinical engagement is required to assess the available evidence and determine the most appropriate tools for adoption GM-wide.

ECAP8

Implementing this model of care will require very strong and credible medical leadership and buy in from senior NHS managers if such a profound transformation is to succeed.

No changes required to the document.


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ECAP outcome


T3E1 Needs further engagement Patient focus groups, questionnaire and DOF completed and outcomes included in the model

T3E2 Single commissioner approach to influenza needs clarification

Model amended to describe single set of standards across GM not single commissioner

T3E3 NIV hub & spoke model needs clarity

NIV to be managed through standards set by clinical experts at the hub and delivered a spoke sites. Not all sites require NIV, but one per sector.

T3E4 Consolidation and rationalisation is unclear

Consolidation of services limited to NIV

T3E5 Lack of clarity on the pathway There is no single pathway, each condition will require its own model

T3E6 The balance of advocating substantial shift of activity to out of hospital needs to be clear

Commissioning Lead and Theme 2 GMHSCP engaged, work continuing through SCN

Theme 3 Executive outcome


Theme 3 Board outcome

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