These pages draw together examples of good practice that have undergone some form of review. For example, they have been accepted as abstracts at the BTS or PCRS UK conferences; they have been accepted by other websites and/or organisations as good examples; they have won an award in a judged competition. IMPRESS believes that it is important to develop a new space for clinicians, managers, researchers and commissioners to share evidence bases and debate their relative merits and how their findings might be implemented and rolled out across the NHS. These pages represent the start of this.
Scroll down for the evidence base for integrated care for chronic disease/long term conditions.
Use the menu below or to left hand side for examples categorised as general respiratory, asthma, COPD, sleep..
LINKS TO IMPRESS EXAMPLES
General Respiratory Service
Asthma
COPD
Sleep
Other examples - Lung Improvement Programme (LIP) and NHS Evidence
From January 2010 the Lung Improvement Programme (LIP) conducted a search for examples that "promote high standards in efficiency and effectiveness, as well as providing good quality integrated care across all stages of severity and have clearly measurable outcomes against a robust baseline of activity" in COPD and asthma. TThey requested a covering email giving permission for the example to be shared across the NHS.
May 2010: here are the first tranche of examples, categorised by theme and by SHA.
Where appropriate, examples will be shared with the Department of Health which is supporting the collection of specific examples of good practice to be published on the NHS Evidence web-site.
June 2010 National Improvement projects in England - pilots announced by Lung Improvement following calls for pilots in each region on these topics (those with asterisk tackling the whole care pathway).
• Accurate Diagnosis
• Improving Home Oxygen Services
• Transforming Acute Care
• Chronic Care Management
• Self Management Models
• End of Life Care
East of England
Hertfordshire PCT: Improving Oxygen Services
Hinchingbrooke Hospital and Papworth Hospital: Accurate Diagnosis
Norfolk and Norwich NHS Trust: Transforming Acute Care
Colchester Hospital University Foundation NHS Trust: Transforming Acute Care
Yorkshire and the Humber
NHS Hull: Improving Oxygen Services
NHS Sheffield*: Improving Oxygen Services
NHS Sheffield*: Accurate Diagnosis
NHS Sheffield*: Chronic Care Management/ Self Management Models
Leeds Teaching Hospitals NHS Trust: Accurate Diagnosis
BreathingSpace (Rotherham): End of Life Care
Breathing Space (Rotherham): Pulmonary Rehabilitation
South West
NHS Gloucestershire: Improving Oxygen Services
Veor Surgery, Camborne: Chronic Care Management/ Self Management Models
South East Coast
NHS West Sussex: Transforming Acute Care
NHS West Sussex: Chronic Care Management/ Self Management Models
Surrey Community Health: Chronic Care Management/ Self Management Models
South East Coast Ambulance Service NHS Trust: Transforming Acute Care
South Central
Milton Keynes PCT: Improving Oxygen Services
Southampton University Hospitals NHS Trust: Transforming Acute Care
Southampton University Hospitals NHS Trust: Chronic Care Management/ Self Management Models
NHS Hampshire: Chronic Care Management/ Self Management Models
Basingstoke and North Hampshire Hospital NHS Foundation Trust: End of Life Care
Heatherwood and Wexham NHS Foundation Trust: End of Life Care
North East
NHS South of Tyne and Wear Community Health Services: Transforming Acute Care
South Tyneside NHS Foundation Trust: Transforming Acute Care
North Tees and Hartlepool Foundation Trust and North Tees and Hartlepool PCTs: End of Life Care
North West
Wirral University Teaching Hospital Foundation NHS Trust: Improving Oxygen Services
NHS Blackpool: Improving Oxygen Services
NHS Blackpool: Chronic Care Management/ Self Management Models
University Hospital Aintree: End of Life Care
University Hospital Aintree: Pulmonary Rehabilitation
St Helens and Knowsley Acute NHS Trust: End of Life Care
East Midlands
Sherwood Forest Hospitals NHS Foundation Trust: Improving Oxygen Services
Leicestershire County and Rutland PCT and University Hospitals Leicester NHS Trust: Chronic Care Management/ Self Management Models
NHS Northamptonshire: Chronic Care Management/ Self Management Models
West Midlands
South Staffordshire PCT: Improving Oxygen Services
NHS Birmingham East and North: Improving Oxygen Services
NHS Stoke on Trent: Chronic Care Management/ Self Management Models
Solihull Care Trust: End of Life Care
London
NHS Newham*: Improving Oxygen Services
NHS Newham*: Transforming Acute Care
Royal Free Hospital: Improving Oxygen Services
Imperial College*: Accurate Diagnosis
Imperial College*: Transforming Acute Care
Imperial College*: Chronic Care Management/ Self Management Models
NHS Wandsworth: Transforming Acute Care
NE London, NC London and Essex HIEC: Accurate Diagnosis
NE London, NC London and Essex HIEC: Transforming Acute Care (1)
NE London, NC London and Essex HIEC: Transforming Acute Care (2)
NHS Sutton and Merton and Epsom and St Helier: Accurate Diagnosis
For more information go to the Lung Improvement pages.
Quality and productivity
NHS Evidence already has several respiratory examples of ways to improve quality and productivity, two of which were submitted by the BTS:
1. Community based teams for the management of chronic obstructive pulmonary disease (COPD) have been developed in Leeds and Carmarthenshire. These teams use guideline based systematic management to reduce unwarranted variation in care as well as improving clinical effectiveness and patient experience. Emergency admissions for COPD were reduced by 36% in Carmarthenshire.
2. From BTS: Hospital at Home schemes allow patients with acute exacerbations of Chronic Obstructive Pulmonary Disease (COPD) to be treated at home instead of being admitted to hospital. Patient satisfaction with these schemes is high. Average length of stay decreased from 4.2 to 1.7 days.
3. From BTS: Specialist oxygen review and prescription services. Two nurses were trained to review the indication for and funding of patients being treated with home oxygen and assess patients under consideration for home and ambulatory oxygen therapy. Savings were made through avoiding initiating or withdrawal of inappropriate therapy and identifying inaccuracies in the PCT database.
4. Psychological management of long term conditions, including medically unexplained symptoms
Depression and anxiety are common in people with long-term physical ill health. Medically unexplained symptoms (MUS) form a heterogeneous group of long-term conditions (LTCs), which are also common. Psychological interventions can improve health outcomes and patient satisfaction in LTCs and MUS. There is the potential for significant impact on healthcare utilisation and therefore cost.
COPD Specifics: Breathlessness clinic at Hillingdon Hospital, and replicated by South West London and St George’s Trust. CBT based interventions significantly reduced health care utilisation, including accident and emergency attendance, bed usage, and pharmacy costs, with improvements in depression and anxiety. Productivity: for each £1 invested, £3 saved.
Please note that a number of the DH websites, including NHS Evidence, are being reviewed post-Election, and so some links may not work. If this is the case, please contact us to let us know and we'll correct quickly.
INTEGRATED CARE - GENERIC
Evidence base
Recent reviews commissioned by the Nuffield Trust include
Report by Dr John Ovretveit Does improving quality save money? A review of the evidence of which improvements to quality reduce costs to health service providers. Sept 2009 For Health Foundation. This categorises opportunities to improve quality in terms of the overuse, underuse, misuse of effective interventions, leading either to poor quality or adverse events. He also adds a further dimension of under-coordination that he claims is the most common cause of poor quality. Examples he gives are: overuse of antibiotics leading to adverse events, overuse of investigations leading to poor quality, misuse of prescriptions, leading to adverse events, underuse of vaccinations leading to adverse events, underuse of effective communication leading to poor quality, and under-coordination of information between providers leading to poor quality. He also argues that many of the examples of improvement in the literature do not give sufficient information about the costs of implementation. He suggests that a successful improvement requires
Evidence of effective change + supportive environment + effective implementation = improvement
In early 2010, IMPRESS called for examples of good practice, using a form based on that proposed in this study. See here.
In addition the Nuffield Trust has highlighted the work of Professor Bert Vrijhoef, Director of Research for Dept of Integrated Care, University of Maastricht Medical Centre who undertook a meta-analysis of studies (most of which are disease specific) that included components of Wagner's chronic care model that includes 4 components that are underpinned by a productive interaction between an informed activated patient and a prepared, pro-active practice team:
- Self management support - personal care planning, information etc
- Decision support tools - guidelines, algorithms
- Clinical information systems - registers, recall systems, tele-monitoring
- Delivery systems - team working, case management, care pathways
He concluded that
- Having 3 or 4 components of Wagner model improved outcomes against the measures considered
- Patient complexity was a factor - are we measuring what matters?
See also current European study Developing and Validating Disease Management Evaluation (DISMEVAL) overview of approaches in Europe, testing possible approaches to measurement.
In addition it has published jointly with the King's Fund Where next for integrated care organisations in the English NHS? by Richard Q Lewis, Rebecca Rosen, Nick Goodwin and Jennifer Dixon (2010). It examines some of the new models for integrated care organisations. It focuses in particular on organisations that combine commissioner and provider roles. These, the authors suggest, offer the most promise for aligning incentives to produce efficient care across primary, community and acute services.
Also from Nuffield Trust, some thought-provoking presentations from its Health Summit 2010 on workforce "flexi-security", integration with social care, integration through polystems, use of information and data, and the likely trend in competition policy as well improved discharge to primary care from secondary care. For further information click here.
Literature review of chronic care models by Wagner.
October 2009: Means to an end: a new review on joint financing from the Audit Commission that states that "Organisations can usually describe how they now work better together, but often not how they have jointly improved user experience" and finds few examples of improved care or cost savings by joint working across health and social care. "Analysis of the limited national data available suggests that formal
partnership arrangements have had little or no impact on reducing the
number of older people who fall and break their hip, or on the length of
time they spend in hospital for some common conditions. The same is true
for the length of time those with mental health needs stay in hospital. "
This echoes a report from 2008 by Rebecca Rosen of the Nuffield Trust Integrated Care:Lessons from evidence and experience.
They all suggest integration must not be about structural change, but about integration of data to improve care, and integration of care pathways.
There is a good review of the evidence about integrated care by Naomi Fulop commissioned by the Department of Health in England as part of its development of a prospectus for integrated care pilots, first announced in the Darzi Review. Click here to download the review and here for the prospectus. Sixteen pilots have been underway since July 2009. For further information click here.
DH pilots
September 2009: an introductory guide to the pilots has been published. All are relevant to respiratory care. Two are COPD-specific. Principia is a social enterprise in Nottingham, piloting integration both vertically and horizontally (through virtual wards - see Jargon Buster) and aligning aspects such as formal and informal support to patients, and financial incentives. Their own website has monthly updates. Northumbria is piloting health and social care integration, working with the third sector including the BLF, allocating a named skilled key worker to patients, using individualised care plans, tailored self-management plans and patient-held records. In addition, Church View Practice is looking at a number of long term conditions for which it has a higher than average prevalence including COPD. It is piloting vertical integration between primary and secondary care; using virtual wards and considering a variation to its PMS contract (see Jargon Buster). Cumbria is piloting horizontal integration between primary and community services, and the use of community hospital beds and a virtual ward for patients with long term conditions.
Some of these providers also attended a seminar organised by the Health Services Management Centre, Birmingham earlier in 2009. Their report, including commentary from experts in from the USA on what can and can't be gained from comparison with Kaiser and Evercare models, can be found here: Integrating care and transforming community services: what works? where next?
In addition, the Institute of Public Policy Research (IPPR) has published one of its seminar series Vertical integration: who will join up primary and secondary care?