www.england.nhs.uk 15/04/2023

The future is local

Webinar No1

30th January 2015

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GeneralPractitioner

Specialist

Patient

Public funding and public provision

Public fundingIncreasing marketisation

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• Funded through general taxation• Free at the point of need• Mixed economy of providers• Principles

• Choice• Quality• Safety• Transparency of outcomes• Value

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Constant change!

• 2012 Health & Social Care Bill• 2013 NHSEngland• 2014 Five Year Forward View• 2015 NHSE, NHSIQ, SCN, Senates etc• 2015 General Election

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Respiratory diseases

• COPD • Lung Cancer• Pneumonia• Asthma• Bronchiectasis • ILD (Pulmonary fibrosis)• TB• Respiratory failure and obstructive sleep apnoea

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Why is COPD important?

• A common long term disabling condition• One of the top five causes of premature mortality• Frequent cause of hospital admissions• Most cases remain undiagnosed in primary care• Large variations in care account for avoidable mortality• Rehabilitation and self-management work• Integrated, anticipatory care is cost effective

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Years of life lost

PYLL rate, England

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Strategic Clinical Networks

Focus on priority areas to improve outcomes and bring together users, providers and commissioners.

• Cancer

• Cardiovascular (inc Cardiac, Stroke, Diabetes )

• Maternity and children

• Mental health, dementia and neurological conditions

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COPD: Long term care

Primarily CCG responsibility

Delivered by Primary Care & Acute Trusts

Some specialised commissioning

(transplantation, LVRS, home ventilation)

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How to influence the system?

• CCGs (no national priority)• Thematic priorities (early

diagnosis etc)• Programme Boards

(rehabilitation)• Quality and financial

levers/incentives (CQIN, QOF, BPT)

• NICE, HQIP, NHSIQ,PHE etc• Local Networks• Patient organisations• Professional Societies• Colleges

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Key Targets and organisational agendas

• Public and political awareness• Early diagnosis• Long Term Conditions• Acute care

• Integrated care• Population level commissioning• Year of care • Commissioning for value• Personal healthcare budgets

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Delayed or inaccurate diagnosis

• Estimated nearly 3.7 million sufferers

• Only 900,000 diagnosed

• 85% patients with COPD have had missed diagnostic opportunities up to 20

years prior to diagnosis

• Approximately 10-30% of COPD patients admitted to hospital have new

diagnosis

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How do you get spirometry in to practices?

QOF

Case finding?

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Multiple LTCs

Asthma

Hypertension

IHD

Diabetes

COPD

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

None 1 2 3 plus

South Somerset Symphony project

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Long term conditions “House of Care”

LTCs are those conditions that cannot, at present, be cured, but can be controlled by medication or lifestyle modifications.

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Definitions

• Self care………What patients do all the time

• Action plans……Written instructions and medication for self

management of exacerbations alone

• Self management training……Providing the necessary skills,

knowledge and confidence to self-manage whole condition

• Pulmonary rehabilitation……A structured opportunity to

provide self management training.

• Integrated Care ……The commissioning framework for delivery

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• Integrated acute and community Trust

• Clinical Leadership across the spectrum

• Commissioning incentives (LES & CQUIN)

• Focus on education

• All components of care joined up

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5 year forward view

• Realistic financial analysis• Above inflation investment and 4% CIP• Focus on prevention and multi-morbidity• More individual responsibility for health care budgets• Removal of primary/secondary care barriers• Less direct commissioning• Mixed models• Local prioritisation

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New models of care

• Greater devolution• More co-commissioning• Maximising local planning• Encouragement to develop new models

of care• Revitalising small hospitals• Getting serious about prevention• Empowering patients (PHBs etc)• Focus on success not failure• Parity for mental health• Greater efficiency

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Barriers to access

Primary care Acute Trusts

GP SpecialistCare

New commissioning models

Multispecialty Community Providers (MCPs)

Primary and Acute Care Systems (PACS)

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Commissioning for value

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Problem

High undiagnosed COPD populationAbove average COPD spendHigh admission ratePoor audit results

Process

Right Care methodologyDeep Dive packStakeholder engagementRedesign of care pathways

Result

30% reduction in admissionsExceeded QIPP target by £164k

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Population level commissioning

• “Year of Care”• Stratification for:

• Risk• Need• Service provision

• Capitated budgets• Pilot sites ongoing

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Local respiratory networks can be a catalyst for change

• Working with CCGs to develop local strategy• Improve early diagnosis• New commissioning models (system wide)• Acute CQUINs (COPD, Asthma, Pneumonia, Smoking

cessation) • Generic diagnostic/therapeutic approach to

breathlessness• Improving rehabilitation capacity

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Kent, Surrey, Sussex Respiratory Network

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The future is local

• The NHS will develop from the bottom up• Local prioritisation• Common standards but local implementation• Focus on early and accurate diagnosis and case finding• Use practice informatics• Risk stratification allows population level commissioning• True integrated care requires new commissioning

models• Specialists will need to work across the spectrum• These models require wide stakeholder (including

patients) involvement