Dr Helen Ward Consultant Respiratory Physician The Royal Wolverhampton NHS Trust Summary  Long Term Plan  Where does respiratory fit?  BTS Positional Statement  What is Integration?  Respiratory Specialists role in integrated care  BTS trainees survey 2017  What is the role of the Respiratory Integrated Consultant?  Ambulatory Care  Letter to the National Clinical Directors  Wolverhampton Experience  Next steps

Summary of the Long Term Plan  New service model  Prevention  Manage in primary/community services  Better coordination  More proactive  Boost ‘out of hospital’ care  Aligning with PCN’s  Integrated Care Systems The NHS England Long Term Plan (LTP) recognises that people with long-term respiratory conditions:

 Are often diagnosed late  are not supported to engage in the lifestyles that will keep them well  are often on multiple medications which have not been optimised  experience repeated crisis-driven hospital admissions at huge cost to the healthcare system and their well-being  are often subject to significant health inequalities. CVD – Respiratory programme structure & governance

NHS E/I Executive Boards

Critical alignment • System Transformation Group • System Leadership Forum CVD • Prevention Programme • Equalities/Health Inequalities team • Integrated Care of Older People CVD-Respiratory Programme Board Programme Chair Steve Powis (national MD) • Primary Care / PCNs • Specialised Commissioning • NHS Diabetes Prevention Programme

Programme Delivery Boards Cross-Cutting Workstreams • Digital Technology CVD Prevention/ Stroke Delivery Board • Workforce Respiratory Delivery Cardiac Delivery Co-chairs: Juliet • Self-management and rehab Board Board Bouverie, • System alignment/networks Co-chairs: Alison Cook, Co-chairs: Simon Lauren Hughes (acting • Medicines Andy Menzies-Gow Gillespie, Matt Kearney in lieu of Keith Willet) optimisation/diagnostics • Early and • Primary Care detection and management • CVD Prevention accurate • Cardiac rehab diagnosis • ISDN expansion • Medicines • Rehab pilots • Heart failure and management • SSNAP HVD • Pulmonary rehab • Workforce • Improving heart • Flexible learning • UEC attack survival • Community rate acquired pneumonia • Breathlessness Where does respiratory fit? 6 workstreams:  Pulmonary Rehabilitation  Acute and Early diagnosis  Breathlessness  Flexible Learning  Community Acquired Pneumonia  Medicines Optimisation BTS Positional Statement (2019)

 12.7m (1 in 5) asthma, COPD or other longstanding respiratory disease (BLF 2012)  1/2 took prescribed medication last year  Respiratory disease – 3rd leading cause of death in UK.  >6.1m bed days/year (Snell 2016)  £11.1 billion (2014) on respiratory disease  £1 billion on asthma alone  Variable accessibility/quality of care  People living longer with 1 or more chronic disease  Move from acute/episodic care to health promotion, disease prevention, early intervention and chronic care  Current model of service care – not appropriate Definition of Health Care Integration  Best possible care for the patient, delivered by the most suitable Health Professional, at the optimal time, in the most suitable setting.

 An integrated health care delivery system is one in which all the providers whose services affect a patient work together in a coordinated fashion, sharing relevant medical information, sharing aims or goals (often measurable and measured), sharing responsibility for patient outcomes, and for resource use. What forms does integrated care take?  the type of integration (i.e. organisational, professional, cultural, technological)  the level at which integration occurs (i.e. macro-, meso- and micro-)  the process of integration (i.e. how integrated care delivery is organised/managed)  the breadth of integration (i.e. to a whole population group or specific client group)  the degree/intensity of integration (i.e. across a continuum that spans between informal linkages to more managed care co-ordination and fully integrated teams or organisations) (The Nuffield Trust 2011) Moreover, integrated care takes a number of key forms including:

 Horizontal integration: Integrated care between health services, social services and other care providers that is usually based on the development of MDT and/or care networks that support a specific client group (e.g. for older people with complex needs)

 Vertical integration: Integrated care across primary, community, hospital and tertiary care services based on care pathways for people with specific diseases (e.g. COPD)

 Sectoral integration: Integrated care within one sector, e.g. combining horizontal and vertical programmes of integrated care within mental health services through multi-professional teams and networks of primary, community and secondary care providers

 Whole-system integration: Integrated care that embraces public health to support both a population-based and person-centred approach to care. This is integrated care at its most ambitious since it focuses on the multiple needs of whole populations, not just to care groups or diseases

Why respiratory specialists have a key role to play in integrated care  Pneumonia/COPD/asthma most frequent causes of hospital admission/primary care consultations  COPD 2nd most common emergency admissions  Most costly tariff  12% readmission <30 days (PHE Atlas of Variation 2019)  Diagnostic registers ¼ - 1/3 of time treatment or diagnosis is wrong  Most management of disease occurs in the community BTS Trainees survey 2017

 81 trainees 80% >ST5  60% no integrated training  29% single episode  21% one day session  42% regular episodes (mainly MDT)  2% integrated placement >1 week  90% agreed needed more Integrated Care experience  77% consider working in Integrated Care (in part)

 Key themes:  Lack of clear definition of Integrated Care  Lack of training opportunities What is the role of a respiratory integrated care consultant?

 Leadership  Strategic overview  Deliver care in the community  May also provide care in hospital as well  Developing and evaluating new service  Provide education  Interface between community and hospital  Governance Respiratory Ambulatory Care  Ambulatory care sensitive conditions (ACSC) are conditions where hospital admissions may be prevented by interventions in primary care (Purdy et al, 2009)  7 conditions account for three-quarters of all ACSCs spells which includes COPD, asthma, influenza and pneumonia  Strong seasonality  Admission avoidance schemes ?Respiratory input  Ambulatory care ? Respiratory Specialist input  Home Oxygen Assessment Review Letter for NCD’s December 2019  Respiratory Futures Integrated Care Clinicians Network.  Outlined problems with moving towards integrated care:  Acute trusts remain incentivised to provide services based on EoC rather than integrated clinical pathways  Payment policy – expand activity in hospitals  Regulators (CQC and NHSI) focus on episodic/single organisation care and not integration  Limited job plans support for consultants leading integrated care  No systematic care training in medicine – integrated care, population health and leadership PCNs/Outline Service Specifications From April 2020  Structured Medication Review  Use of pharmacist / GP / ANP to conduct reviews  Groups identified  Long term conditions and co-morbidities  Enhanced Health in Care Homes  Anticipatory Care  Personalised Care  Supporting Early Cancer Diagnosis Wolverhampton Integration Experience Vertical Integration • From 2016 • Integration of GP practices with the acute trust • Subcontract GMS contract to acute trust • Salaried staff • Currently 9 practices across Wolverhampton. • Incorporated into Division 3 • Streamlining back office functions and recruitment • Clinical workstream COPD • EMIS templates • Baseline data for annual reviews within primary care • 83.5% had no record of PR in patients with COPD and MRC 3 over last 12 months • Only 40% had number of exacerbations over last year recorded in notes • Only 33% had inhaler technique checked within last 12 months. • Standardised template • Embedded referrals and patient leaflets • Currently being piloted and will have further data in 6 months. • Roll out to all Wolverhampton GP’s COPD  4999 COPD patients on QOF 2015  1285 (26%) have 1 or more prognostic indicators  294 (5.9%) have 2 or more prognostic indicators  Appropriate for palliative care register  49.3% known to community matrons  15% on GP palliative care registers  19% seen by palliative care teams Chronic Respiratory MDT  Fortnightly meetings  Respiratory nurses, community matrons, palliative care, oxygen lead and myself  Readmissions  End stage respiratory disease patients  Minutes to the GPs  Encourage out of area teams to attend Joint palliative/respiratory clinics

 Worcester clinics  Reduction in length of stay and admissions  Patients more likely to die at preferred place  Identified a need in Wolverhampton  Set up joint monthly clinics since June 2015  Community matrons to be present  Clinic at hospice  Joint palliative and respiratory clinic  45 minutes appointments  1 clinic/month  iPOS questionnaire pre and post clinic  Evaluation questionnaire patients/carers  Observers  Encourage carers to be present  Community matrons Outcomes  106 patients with ≥1 appointments  50.9% male  70.8% COPD  Mean age 70 years  60 patients who have been referred have died  41.7% hospital/48.3% community  Significant improvements in feelings of anxiety/worry about illness/treatment and feeling at peace (p<0.005)  Patient and carer positive feedback Palliative care data  From 2012 to 2016 there has been an increase in the number of COPD patients seen by the palliative care team in Wolverhampton:  283% ↑ attended Hospice Day Unit  67% ↑ seen at Home and Care Home Visits  0 to 13 ↑ Inpatient stays at hospice  0 to 4 patients dying at the hospice  122% ↑ Outpatient appointments Next steps  Develop Integrated Respiratory specialist job descriptions with core skills, responsibilities and roles  Use the NHS Long Term plan as an enabler for change, developing Respiratory Strategic Clinical Networks across the country to drive change and share good practice  Encourage cross-cutting skills which Respiratory specialists wishing to engage in integrated care will need to acquire  Ensure respiratory specialists are involved with the development/delivery of ambulatory care and admission avoidance

 Support the Respiratory Futures Integrated Clinicians Network via which clinicians are sharing experiences and expertise

 BTS Integrated Care conference May 2020

 Start talking to each other……..