INTEGRATED COMMUNITY CHRONIC OBSTRUCTIVE PULMONARY DISEASE SERVICE FOR

PEOPLE WITHIN KIRKLEES

SERVICE SPECIFICATION FOR THE PROVISION OF SPECIALIST COMMUNITY CHRONIC OBSTRUCTIVE

PULMONARY DISEASE SERVICE FOR NHS KIRKLEES

July 2010

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PREFACE

This document describes the service specification for the integrated specialist community COPD service in Kirklees.

The processes of care described are based on accepted evidence and that of practitioners with expertise in COPD care from across the Kirklees health community.

The service specification is intended to support the procurement of the integrated community specialist COPD services with an aim of reducing avoidable emergency

admissions and managing people more effectively within the community

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INTEGRATED CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) SERVICE FOR PEOPLE IN KIRKLEES

TABLE OF CONTENTS

PAGE NUMBER

PREFACE Page 2

SECTION 1 PURPOSE Page 4

SECTION 2 BACKGROUND

Outcomes and Measurable benefits

Page 6

Page 8

SECTION 3 CORE SERVICE COMPONENTS:

SPECIALIST CHRONIC COPD MANAGEMENT

• NEBULISER ASSESSMENT SERVICE

• OXYGEN ASSESSMENT SERVICE

PALLIATIVE CARE

SELFCARE

Page 13

Page 16

Page 18

Page 19

Page 21

Page 22

SECTION 4 PERFORMANCE REQUIREMENTS AND INDICATORS

• Key Performance indicators

Page 29

Page 32

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SECTION 1

PURPOSE

THIS SECTION SETS OUT THE PURPOSE OF THE

SERVICE SPECIFICATION FOR INTEGRATED SPECIALIST COMMUNITY SERVICES FOR PATIENTS

WITH COPD IN KIRKLEES

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1 PURPOSE 1.1 This specification has been drawn up to describe the integrated COPD specialist

community service for people registered with a GP within the Kirklees community. The service specification acts as a blueprint for a consistent and equitable service within Kirklees and sets out the:

• range of services required;

• outcomes from the services to be provided;

• standards expected to be met by service providers;

• the performance framework;

• implementation requirements.

1.2 The service will be commissioned to ensure that a high quality, evidence based service is delivered on an equitable basis and demonstrates delivery of the planned outcomes.

1.3 The processes of care described within the specification are based on accepted evidence, published guidelines and care-pathways that have been developed by the Kirklees Respiratory Health Improvement Team (HIT) with representation from across the Kirklees health and social care system.

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SECTION 2

BACKGROUND

THIS SECTION SETS OUT THE BACKGROUND TO THE

DEVELOPMENT OF THE SERVICE SPECIFICATION AND PROPOSALS TO ENSURE APPROPRIATE

PATIENT AND CLINICAL ENGAGEMENT

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2 BACKGROUND 2.0.1 Emergency admissions are forecast to rise by 1.5% per annum due to the aging

population alone. The most common causes are chest pain, chest infections, Chronic Obstructive Pulmonary Disease (COPD) and asthma.

2.0.2 The Kirklees Respiratory HIT commissioning plan sets out to commission a service for

people with COPD that will:

• deliver improved services and health outcomes for patients; and

• ensure an integrated approach across the Kirklees health community. 2.0.3 The main outcome will be to minimise avoidable admissions to hospital and to improve

service consistency, delivery and access for people with COPD in a cost-effective manner, whilst promoting self care and well being.

2.1 Core service components of the service 2.1.1 The service provider will provide the service components of the specialist community

COPD service as set out below:

• a multidisciplinary integrated community based service to improve the care of people with COPD; ;

• a community oxygen assessment service and ongoing support for people on long term oxygen;

• a community nebuliser assessment service;

• effective links to the existing community and specialist respiratory services including other practitioners such as General Practitioners, Practice Nurses and Respiratory Physicians, Community / Practice Pharmacists

• effective links to the existing community and specialist palliative care services for people with COPD requiring care at the end of their lives;

2.2 Benefits of an integrated COPD service 2.2.1 An integrated COPD service will make a significant improvement in the care provided for

people with COPD, reduce avoidable admissions to hospital, minimise hospital length of stay and provide a model for integrated services for other long term conditions.

2.2.2 It will allow the Kirklees health community to demonstrate compliance with National

guidance for the management of COPD, NICE guidance on COPD, and strengthens the position in anticipation of the new National COPD strategy (expected Autumn 2010).

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2.3 Outcomes of an integrated COPD service 2.3.1 In commissioning an integrated specialist community COPD service, NHS Kirklees is

expecting to make a significant improvement in the care provided for people who have COPD, reduce avoidable admissions to hospital, minimise hospital length of stay and provide a model for integrated services in long term condition management

2.3.2 The expected outcomes are as follows:

• a reduction in emergency attendance and admission through partnership working with community services, the ambulance service and primary care;

• a reduction in GP and nurse referrals to secondary care for COPD management;

• a reduction in emergency in-patient bed days for COPD patients;

• increase in the number of appropriate referrals to other community based services;

• a reduction in Yorkshire Ambulance Service NHS Trust conveyance rates in response to 999 calls for people with COPD;

• improvement in the feelings of wellbeing and service satisfaction in people with COPD

• improved systems for assessing the urgency of care, ensuring an appropriate and prompt response to patient need;

• new pathways for patients with COPD, shifting the emphasis of care from hospital admission to care in the community and where possible self-care;

• moving care to local community settings where appropriate to secure better value for money and free capacity in hospitals to support the delivery of shorter waiting lists for more complex cases of respiratory disease;

• increased choice for patients and quicker access to specialist community COPD assessment and diagnosis;

• development of new roles for NHS staff;

• focus on prevention and improved patient outcomes through personalised care plans;

• people cared for in the community where it is clinically safe to do so;

• optimal prescribing in primary care including appropriate use of inhaled steroids, long acting bronchodilators and antibiotics;

• regular user evaluation and feedback to support continual service development and improvement;

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• improved survival for people with COPD disease

• reduction in inappropriate medication costs through planned disease management;

• reduction in the annual cost of prescribed oxygen. 2.4 Measurable benefits 2.4.1 The Kirklees Primary Care Trust expects the provider to provide:

• evidence of reduction in the number of people attending as an outpatient within a respiratory clinic in a hospital setting for COPD measured against 2010/11 baseline

• evidence that patients managed by the service provider have less emergency admissions and shorter lengths of stay in hospital when admitted;

• evidence of improved patient reported outcomes and experience with the service provider;

• evidence of reduction in the home oxygen prescribing

• evidence of excellent levels of responsiveness to patient care needs.

2.5 Evidence base for an integrated COPD service 2.5.1 Where health communities have community COPD services targeted at supporting

patients within the community and minimising lengths of stay in hospital, the number of emergency admissions for people with respiratory disease has reduced by at least 20%.

2.5.2 The NHS Institute for Innovation and Improvement has identified COPD as one of 19

conditions where there is demonstrable evidence for ambulatory care and a reduction in admission to hospital of between 20 – 30% if best practice guidelines were universally adopted by health communities.

2.6 Implementation 2.6.1 All the service outcomes described are intended to be achieved over a twelve month

timescale with service implementation starting from April 2011. 2.6.2 The service provider will demonstrate the following:

Previous experience and a proven track record in providing specialist community COPD services

• commitment and the ability to develop an effective integrated specialist community COPD service, working alongside other service providers including the patient’s

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General Practitioner, Practice Nurse, Community / Practice Pharmacists, Respiratory Physicians, Community Matrons and District Nurse

• a clear understanding of the specific challenges that patients with COPD can experience;

• evidence of a successful background and provision of oxygen and nebuliser assessment service;

• specific evidence of a background in delivering services that are sensitive to the diversity of Kirklees communities;

• that sufficient management time will be devoted to ensure the effective development of this service;

• support for the education and training needs of the staff providing the service;

• evidence of how clinical governance would be provided;

• compliance with statutory employment legislation e.g. equal opportunities legislation;

• plans for implementation, including the recruitment of staff, deployment of resources and project management;

• evidence of competence in the provision of information to support effective patient care and performance management;

• a cost effective service, able to deliver the planned benefits. 2.6.3 The service provider will demonstrate how it will:

• provide a high quality specialist service including stable disease management, acute exacerbation care and complex case management for patients with COPD (patients with other obstructive airways diseases e.g. asthma and bronchiectasis in isolation of COPD will not be expected to be referred to the service provider as part of this service specification)

• facilitate the home care of patients with exacerbations of COPD;

• improve the quality of life for people with COPD;

• educate patients and their carers on the causes and progress of COPD and agree a personalised care plan;

• provide both formal and informal education and advice for health or social services staff members;

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• reduce the number of bed days and hospital admissions due to acute exacerbations of COPD (by at least 20% from the 2010/11 baseline);

• manage individual complex cases through in depth assessment and the formulation of structured personalised care plans, to include management of exacerbations

• optimise treatment through effective evidence based medicines management;

• offer appropriate palliative support to patients and carers already known to the specialist community COPD service and to refer to specialist palliative care services;

• utilise and implement the use of evidence based treatment guidelines across Kirklees;

• help the patient have the necessary knowledge and confidence to manage their COPD effectively, reducing the need for acute management and admission to hospital;

• provide home visits in conjunction with the community nursing service and community matrons to continue community treatment and support as indicated, and utilize assistive technology where appropriate

• develop and implement approaches that will encourage and support two-way communication between the Early Supported Discharge service, respiratory specialist nurses, respiratory physicians, physiotherapists, community matrons, general practitioners and/or practice nurses, district nurses and community / practice pharmacists regarding a patient’s condition and any treatment recommendations;

• attend multidisciplinary team meetings regularly within the community

• refer patients back to their general practitioner and practice nurse for ongoing follow up once optimal care has been achieved and a ongoing clinical management plan has been developed and agreed with the patient;

• refer to other members of the multi-disciplinary team as deemed appropriate such as, district nurses, dietician, community matrons, occupational therapist, physiotherapist, palliative care and social care

• provide a community oxygen and nebuliser assessment service that demonstrates improved patient outcomes and value for money;

• provide ongoing monitoring and any reassessment of all patients receiving oxygen and nebulised therapy in the community

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SECTION 3

CORE SERVICE COMPONENTS OF AN INTEGRATED SERVICE FOR PEOPLE WITH COPD

THIS SECTION DESCRIBES THE CORE SERVICE COMPONENTS REQUIRED FOR THE SPECIALIST

COMMUNITY COPD SERVICE

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3 CORE SERVICE COMPONENTS OF THE SPECIALIST COMMUNITY COPD SERVICE

3.1.1 The service provider will be required to provide all specialist community COPD services

that will consist of the following core service components and will be required to fully integrate with existing, relevant services.

• specialist chronic COPD management including;

• oxygen assessment and reassessment (initial assessment/reassessment and ongoing follow up); for new patients and all receiving oxygen therapy at home

• a nebuliser assessment, recall and servicing programme

• support for integrating end of life care with existing specialist and community palliative care services.

• education, training and support for existing primary care practitioners e.g. Community Matrons, Practice Nurses and General Practitioners and Community / Practice Pharmacists.

• Respiratory clinician led community clinics

3.1.2 The service provider will provide an integrated approach to both acute and chronic

COPD management. The service provider will deliver the service to patients within their usual place of residence or within community settings. The specialist community COPD service will be expected to work across primary care and secure strong links with secondary care, with most of the work occuring in the primary and community care setting.

3.1.3 The specialist community COPD team members will be expected to form close working

links not only with individual general practices but also the Early Supported Discharge service, district nurses, community matrons and social services. They would be expected to be the “face” of COPD care across the Kirklees community

3.1.4 The service provider will demonstrate that resources are deployed in the most effective

manner taking account of the geography of Kirklees. 3.2 REFERRALS

3.2.1 The service provider will accept appropriate referrals from any appropriate health or

social care professional, including the ambulance service. Standardised referral pathways should be developed and agreed with the commissioner for all the core service components of the specialist community COPD services.

3.2.2 The service provider will be expected to provide referral guidance for referrers to ensure

referrals are appropriate and managed in a timely manner and in accordance with national and local maximum waiting time targets.

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3.2.3 The service provider will develop and provide standardised referral forms if appropriate for all of the service components of the specialist community COPD service and be responsible for these being readily available to all referrers

3.2.4 In particular, the service provider should be able to respond in a timely manner to urgent

referrals from health care professionals or patient self-referrals to reduce avoidable emergency admissions.

3.2.5 The service provider will ensure that referrals are acknowledged within ten working days

of receipt to the referrer. 3.2.6 Where the service provider rejects a referral, the provider will ensure that the referrer is

given a written explanation why the referral was not accepted. 3.2.7 The service provider will send each patient an appointment letter to confirm the date and

time of the patient’s appointment within ten days of receiving the referral 3.2.8 The appointment letter will be accompanied by a patient information package, which shall

include (for example):

• general information about the service;

• information about eligibility for and access to NHS transport;

• directions to the venue and parking;

• information about how to cancel the appointment;

• information about what to bring to the appointment, such as the patients agreed care plan, or current medication.

3.2.9 The service provider will ensure that patients who may be required to undergo a specific

diagnostic procedure will be informed of any preparation that they need to take in advance of the appointment.

3.2.10 The service provider will take reasonable steps to minimise the incidence of non-

attendance of patients to all appointments.

3.2.11 The service provider will keep records containing the patient’s telephone numbers and preferred means of communication.

3.2.12 The service provider shall notify the referring clinician within two weeks of patient non-

attendance and shall copy the letter to the patient at their last known address. The service provider shall invite the patient to contact the provider regarding the missed appointment, and shall allow a period of two weeks to allow the patient to respond, following which the referral will be cancelled and the patient returned to the care of the referring clinician.

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3.3 DIGNITY 3.3.1 The service provider shall ensure that patients are treated with privacy, dignity and

respect at all times and that all aspects of their service comply with the ten key components of ‘The Dignity Challenge’. (Department of Health, 2007), Mental Capacity Act 2005 In addition:

• the provider shall not permit documentation containing confidential patient

information to be left where it may be seen by unauthorised persons;

• patient information shall be treated confidentially by all Staff.

3.4 INFORMED CONSENT 3.4.1 The service provider shall comply with the NHS Requirements in relation to obtaining

consent from each patient to the provision of services (Informed Consent) and in particular:

• Department of Health Reference Guide to Consent for Examination or Treatment;

• Health Service Circular HSC 2001/023;

• Seeking Patient’s Consent: The Ethical Consideration: GMC November 1998.

3.5 STAFFING 3.5.1 The specialist community COPD service will be expected to comprise of a multi-

disciplinary team, including respiratory specialist nurses, specialist physiotherapists and community respiratory nurses to work in collaboration with other existing services and administrative support.

3.5.2 The service provider will be required to provide sufficient qualified and appropriately

trained staff to ensure that the specialist community COPD services is provided in accordance with the service specification and NHS employment regulations. In particular there will be a requirement to ensure that the service is fully staffed and operational to ensure service levels are maintained during staff holidays, or absences due to sickness, training or any other absence.

3.6 CLINICAL LEADERSHIP AND SPECIALIST SUPPORT 3.6.1 The community COPD service will require robust clinical leadership. Clinical leadership

will take two forms:

• continuing medical responsibility that will depend on the nature and location of each case and will be provided by the patient’s general practitioner;

• strategic and development leadership which would be the responsibility of a lead clinician allocated to the team who will have highly developed and possess the respected skills to ensure the success of the services and who will be accountable for the delivery of the identified outcomes and service benefits

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3.7 A multi-disciplinary community based service to improve the care of people with

COPD 3.7.1 The service provider will provide a specialist community multi-disciplinary COPD

disease management service for patients normally seen in the hospital outpatients clinics (as new referrals or follow-up) that it would be appropriate to assess and manage within the specialist community multi-disciplinary COPD management service. This service will not only aim to avoid admissions but will also provide:

• Comprehensive specialist COPD assessment using evidence based protocols developed by the service provider and agreed by the PCT clinical lead and clinical governance leads. The assessment should include if appropriate:

• lung function testing (peak flow, spirometry and interpretation);

• X-ray and interpretation

• Pulse oximetry

• Blood gas sampling and interpretation

• patient education and advice;

• personalised care planning

• referral on for additional services such as pulmonary rehabilitation;

• treatment review and sequential trials using evidence based protocols developed by the service provider and agreed by the PCT clinical lead and clinical governance leads

• assessment, reassessment and follow up of all patients receiving or requiring nebulised therapy in the management of both acute and chronic disease;

• assessment, reassessment and follow up of all patients receiving or requiring oxygen therapy.

3.7.2 The service provider will be expected to:

• assess and review 500 new patients per year onto the chronic disease management pathway either within a clinic based environment or domicillary visits dependant on the individuals needs.

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• adhere to a 1:2 new to follow up ratio.

• have the capacity to provide 6 monthly community service led education / case reviews within GP practices across the whole of Kirklees

3.7.3 Patients considered appropriate for assessment and ongoing management within the

specialist community COPD management service should be all individuals who;

• are admitted to hospital with COPD for who specialist hospital follow-up is not required but require further specialist respiratory follow–up

• have been discharged from COPD early supported discharge and require specialist respiratory follow up

• have complex COPD and where the GP requires specialist input to manage patients

• are at risk of further hospital admission

• require assessment and management of disordered breathing related to COPD

• require assessment or reassessment for nebulised therapy

• require assessment or reassessment for oxygen therapy

• require specialist respiratory follow-up but do not require specialist hospital intervention, review or investigation

• are on the respiratory nurse specialist caseload who do not require domiciliary visits

• are normally referred to the specialist respiratory hospital clinic who could be safely assessed and managed in the specialist community multi -disciplinary COPD service.

• have a palliative care need 3.7.4 The service provider will provide regular health and social care professional education,

training and support to improve COPD management within primary care throughout Kirklees

3.7.5 The service provider will provide regular comprehensive specialist complex COPD case

reviews alongside other primary health care professionals e.g. Community Matrons, General Practitioners, Practice Nurses and the Medicines Management team

3.7.6 The benefits of the specialist community multi-disciplinary COPD service include:

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• improved quality of life for people with COPD;

• Admission avoidance

• improved opportunities for complex COPD case reviews in the community and joint working with other members of the Primary Health Care teams

• improved education of patients and their carers on the causes and progression of their COPD;

• improved management of individual complex cases through in depth specialist assessment and personalized care plans;

• ensuring patients are provided with the necessary knowledge and confidence to appropriately manage their COPD thereby reducing demand on GP consultations, hospital admissions and accident and emergency attendances;

• reduced oxygen / nebulizer therapy prescribing

• increased and improved opportunity for education of all health and social care professionals;

• increased appropriate referrals to other multi-disciplinary teams;

• increased appropriate referrals to the hospital based respiratory consultant

• optimised treatment through medicines management;

• increased appropriate and timely referral to palliative care services. 3.8 Clinical Assessment and Follow up Services

3.8.1 The service provider will ensure that clinical assessment of people referred to the

specialist community multi-disciplinary COPD service is provided by healthcare professionals with specialist COPD knowledge, competence and understanding of relevant clinical guidance, disease management and home therapy. They should have the skills and competency to order and interpret appropriate investigations and to give an

overall assessment of the patient’s underlying COPD condition and co-morbidities 3.8.2 Provision of these services requires continuous healthcare professional training and

education to ensure staff maintain competence. 3.9 Nebuliser assessment and management service

3.9.1 The service provider will assess patients for their suitability for nebulised therapy

in the management of both acute and chronic disease using evidence based

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protocols developed by the service provider and agreed by the PCT clinical lead and clinical governance leads

3.9.2 The service provider will supply enough compressors to ensure that supplies are

adequate to meet the need, and keep accurate records of patient assessments and loan agreements. and be responsible for compressors being serviced and nebuliser chambers renewed in line with manufacturers recommendations.

3.9.3 The nebuliser assessment programme will provide the following benefits:

• an equitable service for patients across the district

• all patients receiving long term nebulised treatment have been appropriately assessed according to agreed protocol;

• equipment is replenished as required within manufacturer’s recommendations;

• patients receive education regarding, care, cleaning and use of equipment (including advice on what to do if equipment fails);

• ensures all equipment is logged and serviced annually. 3.10 Oxygen assessment and management service

3.10.1 The service provider will provide services to ensure that patients from throughout Kirklees are able to access specialist oxygen assessment and ongoing management services in the community setting. This will include assessment for all existing patients prescribed Long Term Oxygen Therapy (LTOT), Short Burst Oxygen Therapy(SBOT) or ambulatory oxygen.

3.10.2 Assessment of a patient’s need for oxygen therapy should be made by a health

care professional with appropriate expertise, so that the patient’s health and quality of life is maximised, any risk is minimised, and the right oxygen levels (including flow rates and duration) and equipment is provided to meet their clinical needs.

3.10.3 The initial clinical assessment should be followed up by further visits and regular

reviews of a patient’s need for oxygen therapy in adherence with ‘Updated Clinical Best Practice Guidance for Home Oxygen’ published by the British Thoracic Society in January 2006.

3.10.4 The service provider will need to be familiar with the contract with Air Products,

the provider of prescribed oxygen in Kirklees. Costs are charged on a per day basis and on the type of service ordered (such as SBOT, LTOT, ambulatory), the flow rate and the hours of use and not the equipment supplied as under previous service arrangements.

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3.10.5 The service provider will need to be aware that inappropriate ordering of services may result in a higher cost of service without delivering the required benefits to the patient and they will need to work with prescribers to deliver value for money.

3.10.6 The service provider will demonstrate that they are able to provide the following

specialist assessments:

• assessment for Long Term Oxygen Therapy (LTOT);

• assessment for Ambulatory Oxygen; 3.10.7 The community multi-disciplinary COPD service will be responsible for ensuring

the correct assessment of patients’ oxygen needs and requirements by:

• supporting the running of regular oxygen assessment clinics at community sites ensuring consistency of results and patient care;

• accepting appropriate referrals from medical and nursing practitioners who use a standard referral form and ensuring patients are optimally managed prior to accepting the referral for oxygen assessment

• linking with other members of the multidisciplinary team

• supporting the necessary follow-up of patients on oxygen to ensure correct supply and monitoring of prescription where necessary;

• maintaining the district wide database of patients for audit and clinical governance purposes.

• Patients being referred should meet the following criterion:

� proven diagnosis of COPD;

� optimal medication prescribed;

� clinical stability for 5 weeks prior to assessment;

� consistent saturations ≤92% at rest for LTOT. On 3 separate occasions 2 weeks apart

3.10.8 The provider is required to demonstrate:

• that the oxygen assessment service will include advice and facilitation of screening to identify patients with a saturation of ≤92%;

• patients with a saturation of ≤ 92% will be referred to a formal assessment service for long term oxygen therapy (LTOT);

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• that there is a confident clinical diagnosis of the disorder associated with chronic hypoxaemia;

• that there is an optimum medical management of the particular condition and clinical stability for at least five weeks prior to assessment;

• that arterial blood gas tensions are measured and interpreted as part of formal LTOT assessment

3.11 Correspondence

3.11.1 The service provider will ensure that the referrer and/or the patient’s GP is informed in writing within 1 week, when either the results of the oxygen assessment are known or that patient fails to attend the assessment. Details of the results and subsequent recommended oxygen treatment regime should be included. Appropriate correspondence should be copied to the patient.

3.11.2 The service provider will issue all oxygen sensitive patients with a warning card to show

health care professionals as part of the agreed care plans. 3.11.3 The oxygen assessment (initial and follow up) will provide the following benefits:

• reduction in inappropriate or over-prescribing of oxygen therapy;

• reduced clinical risk;

• reduced service related costs.

� Improved patient reported outcomes measures

3.12 PALLIATIVE CARE

3.12.1 The service provider will establish agreed protocols to assess when a patient fulfils the

criteria for end of life care as this will have a significant impact on the subsequent management plan for the individual patient.

3.12.2 The prognostic indicator guidance from the National Gold Standards Framework team

may be a useful adjunct to the clinical decision making surrounding the transition from long term condition to end of life care.

3.12.3 The service provider will be responsible for ensuring that care pathways are agreed to

ensure patients needing palliative care:

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• have a clear personalised care plan in consultation with the patient and carer incorporating advance care planning

• are referred in accordance with agreed protocols to palliative care services provided by;

o Respiratory Nurse Specialists within community; (where required)

o District nurses;

o Community Palliative Care Nurse Specialists

• are entered onto their practices supportive and palliative care (Gold Standards Framework) register and their condition / needs and preferences discussed at the regular multi-disciplinary palliative care meeting and as required between times;

• have a patient-held record of their personalised care plan, available for emergency services personnel (including information about whether the patient is to be resuscitated and had an advanced directive);

• have a home care pack with information for their carer;

• have medicines prescribed for them in anticipation of symptoms arising to ensure timely access to palliative care drugs.

3.13 OPTIMAL SELF CARE AND WELLBEING

3.13.1 Self care was highlighted in the NHS plan as one of the key building blocks for a patient-

centred health service. More recently self care featured as a key component of the model

for supporting people with long term conditions. It is acknowledged that people’s beliefs and expectation about their respiratory disease and their role and behaviour of healthcare professionals in providing care and support are major determinant of health related quality of life.

3.13.2 The provider will be expected to ensure the promotion of patient self-care is an

underpinning philosophy to the care provided and an integral part of the personalised care plan including how to manage their medicines in times of exacerbation.

3.13.3 The provider will ensure their staff undertakes appropriate training in line with PCT self

care guidance and policy to ensure that they have a full understanding of the principles of promoting optimal self care.

3.13.4 The community COPD service will be responsible for ensuring that where possible

patient self care and choice become the preferred models of care. In doing so the service provider will ensure:

• consistent PCT patient information is provided to all patients;

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• Individuals referred to the community COPD service are able to access the service in a manner which fully supports self care and minimises the risk of admission to hospital;

• personalised care planning and a review of the patient’s individual action plan is integral to all consultations when appropriate

• PCT protocols and care pathways that promote and support optimal self care are adhered to by the service provider;

• Individuals referred to the community COPD service will be provided with a personal emergency management plan and “just in case” medication packs to allow self care including how to manage their medicines in times of exacerbation if appropriate and in line with their personalised care plan.

• Individuals referred to the community COPD service will be sign posted to other services that may be required to optimise opportunities for effective self care and support

3.13.5 The service provider will undertake to run regular education sessions for healthcare

professionals at surgery and other venues in the community that will promote optimal self care in order to ensure patients receive consistent messages from primary, community and secondary staff across the patient care pathway.

3.14 CARE PATHWAYS AND PROTOCOLS 3.14.1 The specialist community COPD service will be required to demonstrate compliance with

national guidance and clinical best practice, including:

• Reference to national requirements (e.g. NICE), local best practice, Primary Care Trust formulary etc;

• Clinical Component for the home oxygen Service in England and Wales (British Thoracic Society 2006);

• National Institute of Clinical Excellence, Chronic Obstructive Pulmonary Disease: management of COPD in adults in Primary and Secondary Care (Clinical Guideline June 2010)

• National COPD Strategy (Autumn 2010)

3.15 PHARMACY & MEDICINES MANAGEMENT

3.15.1 The service provider will be required to comply with national and local prescribing regulations and formulary agreements.

3.15.2 The service provider will be required to have access to pharmacy advice and service

provision. 3.15.3 The service provider will employ the most appropriate person/s to undertake the

medicines management aspect of patient care.

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3.15.4 The service provider will ensure links with existing community pharmacist and practice pharmacist services to maximise the benefits available to patients through these practitioners’ roles in;

� medicines management. � Waste reduction, � liaison (especially discharge planning), � support for patient education and self care (including sign posting) � their holistic use of Medicines Use Reviews (MURs)/clinical medication review � addressing current unmet need by picking up early diagnosis of COPD conditions

and of exacerbations in order to improve patient outcomes. 3.16 PATIENT FEEDBACK AND SERVICE EVALUATION

3.16.1 The service provider will put in place processes to regularly elicit patient feedback and

service evaluation in a manner, which demonstrably improves service provision. 3.16.2 The service provider shall report annually on the feedback from patient satisfaction

surveys, following which initiatives will be jointly agreed to improve patient satisfaction with the services.

3.17 VENUES AND TRANSPORT FOR PATIENTS

3.17.1 It may be necessary for the service provider to ensure that it has an additional agreed

Service Level Agreement with the Yorkshire Ambulance Trust and/or other local patient transport providers.

3.17.2 For patients who do not qualify for free transport, the service provider will advise on

alternatives, such as local community transport services. 3.17.3 Venues of the service provision must provide clear, safe public parking, which allows

patients full access.

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3.17.4 Venues should demonstrate their accessibility to public transport and main road networks for those patients where private transport is not an option.

3.17.5 Venues should be compliant with the Disability and Discrimination Act (1995). 3.17.6 NHS Kirklees may be able to facilitate the service provider in sourcing appropriate venues.

The provider may be required to enter into a lease agreement for the use of community venues and relevant facilities management.

3.18 EQUIPMENT 3.18.1 The community COPD team will require access to pulse oximetry and an arterial blood gas

machine all of which must be serviced and maintained according to manufacturers guidance.

3.18.2 The service provider will provide or arrange any equipment required to appropriately

manage patients medical condition or aid their activities of daily living at home 3.18.3 The equipment loaned to the patient by the service provider will be the responsibility of the

service provider. The return of the equipment, servicing replacement and general upkeep of the equipment including applying the principles of general hygiene, decontamination and infection control is the responsibility of the service provider.

3.18.4 The service provider will keep accurate records of any loans of equipment 3.18.5 The service provider will supply enough equipment to ensure supplies of equipment are

adequate to meet the needs of the patients 3.18.6 The service provider will be responsible for educating the patients about the safe use of any

equipment that is provided and this will be supported by written information 3.18.7 The service provider will be responsible for replenishing any equipment required within

manufacturers’ recommendations

3.19 PATIENTS RECORDS 3.19.1 The service provider will be required to ensure patient records and in some cases results of

investigations or X ray imaging can be accessed on a remote basis by members of the specialist community COPD team and other members of the Primary Health Care Team

3.19.2 The service provider will maintain full records of all patient assessments. These should be

maintained in such a way that aggregated data and details of individual patients are readily accessible if requested by NHS Kirklees.

3.19.3 For the contracted period, the service provider must be able to produce accurate and

comprehensive records for each patient referred into the service.

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3.20 CONTRACT MANAGEMENT INFORMATION 3.20.1 The provider will produce monthly reports sufficient to complete the Key Performance

Indicators (KPIs). 3.20.2 The provider will collate and compile information in a format that will support NHS Kirklees

to measure and evaluate the delivery of the planned outcomes and benefits from the services.

3.21 CLINICAL GOVERNANCE FRAMEWORK AND QUALITY ASSURANCE 3.21.1 The service provider must comply with Department of Health clinical governance

requirements and, as a minimum meet the clinical governance standards laid down in the National Care Quality Standards and Standards for Better Health.

. 3.21.1 Reporting of serious untoward incidents will follow the procedure set out by NHS Kirklees.

The provider would need to demonstrate a robust clinical governance framework with audits to promote continued organisational and clinical development.

3.21.2 The service provider is expected to demonstrate plans to support any emergencies that may

arise. 3.21.3 The service provider will be required to have a quality assurance system and mechanisms

to monitor and quality assure the service.

3.22 STANDARDS / GUIDELINES

3.22.1 The community COPD service will support the requirements of and act in accordance with the National Service Frameworks for Older People and Long Term Conditions

3.22.2 The community COPD service will support the requirements of and act in accordance with the National COPD strategy (anticipated 2010)

3.22.3 An annual programme of clinical audit as an integral part of a quality improvement programme that seeks to improve patient care and outcomes will be established.

3.22.4 The audit programme should be developed according to the needs of the service, the

specialist interests of staff and requirements for any participation in national audit. The programme will include both new audit activity and the continuation of existing audits to ensure the full audit cycle is completed.

3.22.5 The service provider is responsible for ensuring that a regular audit of the service is

undertaken, analysed and submitted via the approved audit route. The audit process will involve input from NHS Kirklees.

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3.22.6 The service provider must carry out patient satisfaction and patient experience surveys that are agreed by NHS Kirklees.

3.22.7 An analysis of the results of the audit should be sent to the NHS Kirklees clinical

governance lead. 3.22.8 The service provider will be expected to adhere to national guidance, polices, protocols and

work within designed and developed integrated care pathways for the management of asthma and COPD in including guidance from:

• British Thoracic Society (BTS);

• National Institute of Health and Clinical Excellence (NICE);

• British Lung Foundation (BLF);

• National COPD Strategy due Autumn 2010

• Local Patient Advocate Groups;

• Commission for Health Improvement

• Department of Health (DOH: polices/guidance for COPD);

• Kirklees local polices & procedures (Clinical Governance).

• Nhs Better care, Better Value (2006)

• Healthy Ambitions, Better for Less (2010) 3.23 CONTINGENCY PLANS 3.23.1 The provider will be required to demonstrate contingency plans for failure of or breakdown

in the service and as a minimum these should cover:

• capacity and capability to manage peaks in demand;

• capacity and capability to manage loss of equipment or staffing.

3.24 RISK MANAGEMENT 3.24.1 The provider should be able to demonstrate an appropriate system for recording, monitoring

and reporting of risk issues. 3.25 EQUALITY AND DIVERSITY 3.25.1 The service provider will ensure that the services operate from an equality and diversity

perspective. It will be accessible by all patients who meet the service criteria and ensure equality of outcome regardless of age, ability, cultural background, ethnicity and sexuality.

3.26 POLICIES AND PROCEDURES 3.26.1 Service provider must have in place the following policies:

• equality and diversity;

• recruitment and staff training;

• health & safety;

• lone working;

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• record keeping;

• confidentiality/data protection/Caldicott;

• complaints;

• incident reporting and management of Adverse events;

• appropriate industrial relations policies, including managing sickness/absence, discipline, grievance and disputes;

• programme of compulsory and legislative training to comply with national requirements, for example Standards for Better Health and staff induction;

• human resources policies, including staff appraisal, managing stress, staff support arrangements such as occupational health support, pay protection and staff redeployment or redundancy arrangements.

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SECTION 4

PERFORMANCE REQUIREMENTS AND INDICATORS

THIS SECTION DESCRIBES THE PERFORMANCE

FRAMEWORK THAT WILL BE APPLIED TO ENSURE THAT THE PROVIDER DELIVERS THE SERVICE IN

ACCORDANCE WITH THE SERVICE SPECIFICATION AND TO ENSURE THAT THE INTENDED SERVICE OUTCOMES

AND BENEFITS ARE ACHIEVED.

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4 PERFORMANCE REQUIREMENTS AND INDICATORS 4.1 The performance framework for the service will define a set of Key Performance Indicators

(KPIs). 4.2 The KPIs will provide assurance to key stakeholders, including the Kirklees Practice Based

Commissioning Groups, local acute trusts and NHS Kirklees that the intended outcomes and benefits of the specialist community COPD services are being delivered.

4.3 Performance indicators must link into other related planning and performance processes to

avoid unnecessary duplication, such as the Vital Signs reports and performance accelerator.

4.4 It is proposed to define and quantify measurable benefits that will be systematically

managed and monitored throughout the duration of the service agreement. 4.5 For each of the KPIs, it is proposed to agree a baseline position as at April 2011 and targets

for the duration of the contract agreement. 4.6 Achieving the planned outcomes and benefits will require the specialist community COPD

services to be fully operational. Implementation will take time and is likely to require a ‘ramp up’ of service capacity and capability to ensure new care pathways are safe and robust. The level of benefits will be less during the early phase of service operation, but it is anticipated that full service delivery will be achieved after an initial six months of operation.

4.7 The service provider will provide a plan for mobilising the service across the agreed area

and delivering the identified benefits. 4.8 The service provider will be expected to provide monthly KPI reports and a quarterly

detailed performance report. 5 Quarterly performance reports 5.1 The role of the quarterly service reviews is to consider issues relating to the service

provider’s performance of the services. 5.2 The service reviews will consider:

• progress towards full service delivery;

• the service provider performance data for the preceding quarterly period;

• results of patient satisfaction surveys and service evaluation studies;

• clinical audit and governance reports;

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• patient complaints received in the immediately preceding quarterly period;

• any other relevant issues 6 Key Performance Indicators 6.1 The table on the next page is the performance indicators for the services. These are subject

to further review and consultation within the Kirklees health and social care community and finalisation with the service provider.

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Outcome Measurable benefit How measured Baseline Target

FINANCIAL BENEFITS

1. Value for money of NHS resources

• Reduction in the number

of people with COPD admitted as an emergency to acute hospitals

• Reduction in emergency bed days for those people admitted to hospital with exacerbation of COPD

• Reduction in readmissions for COPD patients

• Reduction in new to follow up ratio for outpatient appointments for people with COPD

• Reduction in GP referrals to secondary care for COPD

• Reduction in emergency admissions for COPD

• Reduction in number of inpatient bed days for COPD disorders.

• Reduction in Ambulance call out rates for people with COPD

• Number of emergency home visits undertaken by provider

• Reduction in the number of readmission for COPD disorders

• Reduction in the number of outpatient appointments for COPD disorders

• Evidence of reduction in the number of people attending hospital respiratory outpatient clinic

20% reduction from 2010/11 baseline

95% reduction in readmissions from 2010/11

baseline

Reduce new to follow up ratio to 1:2

2. Value for money for people on long term oxygen therapy.

• Improved compliance with local and national guidance

• Number of assessments undertaken by provider

• Cost per patient of oxygen provided by Air Products

10% reduction in the annual cost of

prescribed oxygen

Key performance indicators for specialist community respiratory services

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3. Value for money for people receiving medication for COPD.

• Improved compliance with national and local prescribing guidelines

• Audit of adherence to local and national COPD guidelines of best practice.

• Number of medication reviews assessments undertaken by provider and medicine management team

• Expenditure on targeted drugs as advised by PCT Prescribing leads

5% Reduction in inappropriate prescribed medication costs through planned disease management

Outcome Measurable benefit How measured Baseline Target

NON-FINANCIAL BENEFITS

4.Patients with COPD who are suitable for alternative service to acute hospital admission will be identified and cared for in the community;

• Increased number of COPD patients identified as suitable for alternative services to acute admissions.

• Increased number of patients with COPD provided with alternatives to admission.

• Improved performance against the NHS Institute for Innovation and Improvement Directory of Ambulatory care

• Provider database of activity and admissions avoided.

• Measure change in HRGs identified in the NHS Institute for Innovation and Improvement Directory of Ambulatory care

2010/11 non elective activity for COPD

20% of patients referred provided with alternative to acute admission. 10% More patients treated in accordance to ambulatory care protocols.

5. New care pathways for patients will be agreed, shifting the emphasis of care from the acute sector to care in the community and where possible self care;

• Increase in the number of new care pathways agreed for managing COPD care in the community in line with national guidance and

• Evidence of new care pathways.

April 2011 New pathways agreed and implemented for people requiring oxygen assessment, nebuliser assessment, referral to specialist community COPD service increased referrals to pulmonary rehabilitation,

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evidence of best practice.

and end of life care 95% palliative care patients have written end of life care information

6. GPs have confidence to access and refer to the specialist community COPD services

• Improved GP satisfaction

• GP feedback via questionnaire

• Structured interviews

TBA 10% Improved GP satisfaction

7.Use of personalised care plans for people with COPD disorders;

• More people feel in control of their COPD

• Evidence of use of personalised care plans from patient evaluation and HCC survey;

• Provider performance reports

• Evidence of systematic use of tools to identify those at risk of admission throughout primary and community teams.

• care pathways include provision of personalised care plans;

July 08 HCC survey

95% of Care plans

8. Patients will have the necessary knowledge and confidence to manage their COPD effectively, reducing the need for acute management and admission to hospital.

• Individuals have increased feelings of wellbeing.

• More people feel in control of their COPD

• Reduction in crisis interventions

• More people feel able to manage their COPD

• Evidence from patient evaluation questionnaire;

• Number of rehabilitation or structured patient education sessions accessed

• Number of Expert patient programmes accessed.

• Improved utilisation of rehabilitation programmes

• Improved utilisation of Expert patient programme.

• Increased evidence of provision of information.

• Reduction in YAS conveyance rates for respiratory disorders

April 2011 Provision of information and evidence of

promoting self care in 95% of people managed by

provider

Provision of a written management plan in 95%

of people managed by the service provider

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• Reduced number of GP or OOH calls for COPD

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Outcome Measurable benefit How measured Baseline Target

SERVICE DELIVERABLES

9. Provision of multi-disciplinary COPD community team deployed effectively across PCT Area.

• Improved availability and access to specialist COPD clinical advice and support within the community

• Improved availability and access to COPD training and peer review

• Evidence of staff appointed

• Evidence of clinical and managerial leadership

• Rational for deployment of resources.

• Increased number of formal and informal COPD education peer review sessions

• Planned multidisciplinary team meetings

None All staff to be recruited and operational by April 2011

10. Clinical Leadership

• Improved availability and access to specialist respiratory clinical advice and support within the community

• Identified Clinical lead to lead strategic and development leadership.

• Agreed protocols to confirm continuing medical responsibility

None Clinical lead to be recruited and operational by April 2011

11. Appropriate and timely referral to palliative care Services.

• More patients receive care by competent workforce

• More patients are able

to chose their preferred place of death

• Evidence of implementation of care pathways that reflect the gold standard framework.

• Evidence of referral to existing palliative care Services.

• All patients at end of life cared for on Liverpool care pathway

• Reduced number of patients dying in hospital against their wishes

July 2011 50% increase in people being referred to palliative care services and commenced on Liverpool Care pathway in first year of implementation

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12. Clinical Governance

All management of COPD patients is safe and evidence based according to clinical pathways and guidelines

• Compliance against Standards for Better Health

• Reporting of incidents and Serious Untoward Event

• Evidence of Quality Assurance systems annual clinical audit report

• Evidence of risk management Evidence of Policies, Procedures and Protocols

Evidence of systems and processes in place to monitor evidence of compliance against Standards for Better Health

Reporting of incidents and Serious Untoward Events, risk management, quality assurance

13. Patient Satisfaction

Increased service satisfaction in people with COPD disease

• Results of regular patient satisfaction and evaluation.

• Complaints procedure and number of complaints

10% increase in patient satisfaction with specialist community COPD service in first year of implementation

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