16 November 2011: Impressions 21: Changes to QOF in 2012/13: What it means for respiratory services in primary care
QOF points increase in value
In 2012-13 GPs will see an income uplift of 0.5% as in 2011-12 through a change in the value of a QOF point. There are 1000 points in total and the maximum value of a point will be £133.76, an increase from £130.51 in the previous year. Those practices with low prevalence rates in the clinical domains will of course receive substantially less than the 133.76 per point which may result in some disinvestment in areas where the costs of provision of quality services for a smaller population exceed the income generated. In the case of COPD where long consultations arise from providing quality assured post bronchodilator spirometry, inhaler technique training and self-management planning we may see some rationalisation of care according to disease severity and risk of admission. We also know that COPD is underdiagnosed and this may for some practices act as stimulus to improve their disease prevalence.
Retirement of seven indicators (CHD13, AF4, Q1-5)
The most significant change to the QOF in 2011-12 was the addition of the eleven Quality and Productivity (QP) indicators. In QP 1-5, practices were expected to submit a plan for more cost-effective prescribing that required further peer-review at a locality level according to regional or PCT prescribing plans. The remaining 6 indicators also required practices to develop a similar peer approved process that would reduce both outpatient attendances and emergency admissions. As 3 out of the top 5 most costly drugs to the NHS are inhalers, QP1-5 was an opportunity to make savings within the respiratory budget. This year however the QP1-5 indicators have been removed and replaced with QP13-15 that will ask practices to make plans that will reduce A+ E attendances. There may be opportunities in this new indicator to look at the factors that cause patients with asthma, COPD or respiratory infections to attend A+E when admission is not required. We know that asthma and COPD admissions are affected by factors such as practice smoking prevalence and proximity to hospital and these may also be factors in A+E attendance.
New Indicators and replacements
Osteoporosis indicators make an entry to QOF for the first time. This was previously a national direct enhanced service (DES). Whilst not directly related to respiratory care, many of the patients with fragility fractures who practices will now be required to show evidence of bone densitometry and appropriate drug therapy may have had inhaled or oral corticosteroids for asthma or COPD as a causative factor. Reviewing older patients with asthma or COPD for previously uncoded fragility fractures may increase the prevalence factor which improves QOF point value in this indicator.
Smoking 3 and 4 in 2011-12 required patients with the long term conditions (LTCs) CHD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar affective disorder, or other psychoses to have a smoking status recorded and be offered stop smoking advice or referral. This year the indicators have been renamed Smoking 5 and 6 to include the additional LTC of peripheral arterial disease (PAD). Last year 60 points were awarded for achieving these standards but this has now been reduced to 50 points.
Smoking 8; the percentage of patients aged 15 years and over who are recorded as current smokers who have a record of an offer of support and treatment within the preceding 27 months will be an additional income stream for supporting people to stop smoking. The current indicator, Records 23 in the organisational domain requires smoking status to be recorded and will remain but move to the clinical domain in 2012-13 and be called Smoking 7. Achievement of the new Smoking 8 indicator will be rewarded with 12 points and Smoking 7 will keep its 11 points.
Asthma 6 (The percentage of patients with asthma who have had an asthma review in the preceding 15 months) has been replaced with Asthma 9 (The percentage of patients with asthma who have had an asthma review in the preceding 15 months that includes an assessment of asthma control using the 3 RCP questions). The indicator retains the same 20 points.
In the last month:
Have you had difficulty sleeping because of your asthma symptoms (including cough)? (663P)
Have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness or breathlessness)? (663q)
Has your asthma interfered with your usual activities (e.g. housework, work/ school etc? (663N)
Increasing thresholds for payment
Thresholds have changed for achieving payments both at the lower and upper ends in a number of areas. This means that practices will need to work harder on the old indicators to maintain the same level of payment. In respiratory disease the most significant change is for COPD 10; the percentage of patients with COPD with a record of FEV1 in the preceding 15 months. Previously practices were only required to achieve this annual review target in 70% of people on COPD registers but it now will be 75%. With PCTs increasingly monitoring practices exception reporting rates this threshold shift will require more proactive processes to ensure reviews are done and where spirometry is difficult onward referral to a higher tier of lung function testing expertise.
For the full list of QOF indicators go here.
Noel Baxter, GP, and PCRS-UK member of IMPRESS
12 September 2011: Impressions 20: very helpful briefing on tobacco use and cessation in BME communities
Colleagues in the London team recommend this new paper from the Race Equality Foundation highlighted by the BLF. Tobacco use among minority ethnic populations and cessation interventions A Race Equality Foundation Briefing Paper May 2011
It gives national data but also specific data and examples from Tower Hamlets and Waltham Forest in London, Leicester, Crewe, the Wirral and Buckinghamshire.
Key Messages
- While smoking rates have decreased within the general population, this pattern does not seem to be reflected among black and minority ethnic communities
- Lower socio-economic status can influence tobacco usage, which may account for the prevalence of smoking among some minority ethnic groups
- Use of different tobacco products, including shisha and smokeless tobacco, is more common among minority ethnic groups
- Compliance with and enforcement of regulations on labelling and packaging of smokeless tobacco products need to be improved to protect minority ethnic communities from the health risks associated with using these products
- Regulation and cessation outreach work must acknowledge these different products, and adapt to the specific needs of different ethnic groups.
S Williams
12 September 2011: Impressions 19: risk stratification, admission avoidance
Following Impressions 18 below, Sarah Purdy has a useful summary of the tools in her guide to admission avoidance (this links to the Impressions summary below). She has also recently published a respiratory-specific paper on admission avoidance. doi: 10.1258/jhsrp.2010.010013 J Health Serv Res Policy July 2011 vol. 16 no. 3 133-140
17 August 2011: Impressions 18: Predictive risk
In a recent study in the Journal of General Internal Medicine highlighed by the Nuffield Trust, the point is made again that doctors, nurses nor case managers are able to predict which patients are at highest risk of readmission to hospital. There is a need for predictive risk models and software that is fit for purpose.
However, the DH Long term conditions team has just issued a letter explaining the importance of stratifying the population by risk but says it is no longer going to fund upgrades to the predictive risk tools, such as PARR ++ and the Combined Predictive Model that it funded. There is a good blog from Geraint Lewis, one of the lead authors on this explaining the impact of the policy encouraging information plurality. It includes useful references such as the one above and guides commissioners wanting to upgrade. The DH own material is here.
Sian Williams
2 August 2011 Impressions 17: Upbeat and helpful report on shared decision-making
Making Shared Decision-Making a Reality. No decision about me, without me. Angela Coulter, Alf Collins
Kings Fund 2011 and Foundation for Informed Medical Decision Making
This paper complements the paper from the Health Foundation on self-management highlighted in Impressions 15. Its focus is on decision-making - not just for self-management - and the role of clinicians. It brings together the thinking that we've described before about the relationship between the clinician's expertise and that of the patient . They summarise the current availability of decision aids (including NHS Choices - see a new range of posters to advertise them here); Co-creating Health models, personalised care planning - citing Year of Care, and advance care planning, and make a strong argument for both the ethical imperative for shared decision-making and its benefits, stating that there's a long way to go to reduce the patchiness of use.
Better than referral management schemes?
They argue that it might be a bettter alternative to referral management schemes and is appropriate in every clinical conversation where a decision-point has been reached and the situation is not immediately life-threatening.
See our pages on Personalising Care and the webcasts on Co-Creating Health
Definition
"Shared decision-making is a process in which clinicians and patients work together to clarify treatment, management or self-management support goals, sharing information about options and preferred outcomes with the aim of reaching mutual agreement on the best course of action." Or, to quote the authors' quote from Al Mulley, so that patients receive "the care they need and no less, the care they want, and no more".
The authors suggest that shared decision-making, self-management support and personalised care planning are similar philosophies, each requiring that clinicians recognise and respect the patient’s role in managing their own health.
As well as a respect for the patient's expertise, the three philosophies also require advanced communication skills and the use of a number of tools and techniques to support information-sharing, risk communication and deliberation about options. Look out for the 2nd Edition of our Effective Care - Effective Communication programme that will be launched soon!
When to use
They summarise occasions when shared decision-making is appropriate. Whether to:
- undergo a screening or diagnostic test
- undergo a medical or surgical procedure
- participate in a self-management education programme or psychological intervention
- take medication
- attempt a lifestyle change.
They give examples of scripts to use and how to record in the notes. They cite the evidence for its effectiveness with people from disadvantaged groups and show that it tends to lead to less rather than more care and that it can be managed with existing resources of time.
They conclude that there needs to be
- greater national provision of decision aids and the development of common and consistent approaches
- the identification of decision points in care pathways and the monitoring of the quality of shared decision-making
- better provision, recording of, and support for, shared decision-making by providers
- inclusion of the subject in training; appropriate incentivisation
- the inclusion of shared decision-making in commissioning standards and contracts.
Decision-aids: have a look at the Chris Cates' site if you haven't already seen it and the Cates Plots.
For the record, we hope you've been alerted by PCRS-UK and BTS that the NICE Quality Standards for COPD have just been launched.
Siân Williams
Programme Manager
20 July 2011 Impressions 16: Respiratory outcomes strategy launched
Unfortunately media interest has been poor given other national events, but we hope everyone in the respiratory community has been alerted to the publication on Monday of An outcomes strategy for people with chronic obstructive pulmonary disease (COPD) and asthma in England It lists 6 outcomes, and a call to action in the form of REACT
R - aim to improve Respiratory and lung health
E - Early accurate diagnosis and evidence-based treatment
A - Active partnerships between clinicans and people with COPD
C - Chronic disease management
T - Tailored, evidence-based care
This is the cross-department high-level strategy, and the first of its kind. We await the guide for the NHS to follow. Meanwhile, there are IMPRESS resources to help:
How do the IMPRESS resources help?
Focus on QIPP
Focus on inequalities and variation -
Earlier diagnosis
Active partnerships and tailored care
Pages 28-29 cross-reference the NHS Outcomes Framework and respiratory outcomes, and we wait for further detail on indicators to measure progress over the summer of 2011.
Siân Williams
15 July 2011 Impressions 15: the evidence on self-management - a mixed picture
The second Health Foundation publication we flag here is on self-management. Available here.
Evidence: Helping people help themselves - A review of the evidence considering whether it is worthwhile to support self-management. The Health Foundation argues that it should be part of wider initiatives, not stand-alone. The aim should be not to reduce contact overall, but rather to support a different pattern of contact which may lead to fewer crises and inpatient admissions. The evidence shows that some approaches are significantly more effective than others. There is evidence emerging to support strategies co-created by patients and clinicians. The review also shows that " proactively supporting self-management and focusing on behaviour change can have an impact, in some circumstances, on clinical outcomes and emergency service use. Furthermore a focus on behaviour change is a necessary component in facilitating the effectiveness of other methods such as information provision." The evidence reviewed includes generic programmes as well as disease specific ones for asthma and COPD. There is no specific reference to pulmonary rehabilitation, which might have been helpful, as it is a good example of a "wider initative".
There is a useful matrix: the vertical dimension ranges from a focus on technical skills (eg diabetes self-monitoring) to a focus on self-efficacy (motivational intervewing). The horizontal dimesion ranges from information provision (written information) to behaviour change (goal setting). Care plans and patient-held records are placed in the quadrant information provision/self-efficacy; active group education and motivational interviewing are placed in the self-efficacy/behaviour change quadrant. The summary admits that the evidence is mixed and sometimes contradictory and so calls for further research.
For more detail on the Health Foundation's own scheme Co-creating Health, see the webcast from our 2011 conference.
Siân Williams
15 July 2011 Impressions 14: Under-coordination accounts for 5% of total healthcare cost (Health Foundation)
For those of you who are fans of the Health Foundations work (for their work on Co-creating Health - see the webcast from our 2011 conference) there are three publications that one of the IMPRESS implementation group, Louise Restrick, has flagged. They are all available here. Two are featured in this Impressions 14.
Clinical co-ordination
Evidence: Does clinical coordination improve quality and save money? Volume 1: A summary review of the evidence Dr John Øvretveit June 2011T. This summary is based on his earlier publication Does improving quality save money? which we reviewed here to inform our More for Less document. "The simple answer to the question ‘Does clinical coordination improve quality and save money?’ is ‘Yes, it can.’ However, it depends on which approach is used, how well it is implemented, and on features of the environment in which a provider is operating, including the financing
system." That is, without innovations such as bundled tariffs, there may be improved quality but the costs of making and sustaining the improved coordination may be as great or greater than the status quo. It also depends on the payback timescale used to calculate savings and the scale of the change. Øvretveit also argues that there is not just an ethical reason to focus on deprived communities, but an economic one as they have poorer health and more avoidable deterioration of health that is otherwise likely to lead to high health and social care costs.
Discharge summaries, inadequate medicines reconciliation and adverse events caused by communication failure feature strongly in the examples of under-coordination. He estimates their cost at 5% of total cost; that 3% could be reduced by new models of care, "of which 1% would pay for themselves". IMPRESS discusses medicines reconciliation in our IMPRESS guide to medicines use information and gives examples of how it works. Other solutions offered by the Health Foundation are that a return on investment calculation is needed as well as perhaps a costs and savings share agreement across providers before embarking on change. There's a strong message about data. The most cost-effective approaches are those that use good data to identify those at risk of deterioration, make efforts to reach these patients and to coordinate the right care and self-care services. He advises more detailed work on patient segmentation and risk assessment, and getting them right care in the right place including virtual clinics as well as better handover systems and more medicines reconciliation. Simple low-cost improvements to discharge information. There is evidence for targeted case management and disease management but do calculate costs before embarking because they need careful patient selection eg for asthma the evidence is for people who are severely and moderately ill.
Discharge
Discharge is the focus of a separate Health Foundation publication:
Evidence: Getting out of hospital? The evidence for shifting acute inpatient and day case services from hospitals into the community June 2011 "The evidence does show that community-based services can, under the right conditions, provide quality of care that is as good as that in hospital and, in some instances, at a lower cost. Findings on patient satisfaction are less equivocal; ease of access, travel and shorter waiting times are typically cited as improvements when care is closer to home."
In line with what we know about hospital at home and early discharge schemes their potential to be an alternative to hospital care for people who no longer need intensive acute care is demonstrated. However, it cautions that if they are to be developed in order to release significant cost savings tthey need to be associated with active reductions or decommissioning of hospital-based services.
There are further cautions about the lack of robust cost information on infrastructure, planning and start-up costs and the generalisability of the studies that tend to be " on small, highly [patient] selective pilots."
I should flag our thinking about community shift in an earlier IMPRESS publication that remains valid: Delivering Respiratory Care Closer to Home
Siân Williams
14 July 2011 Impressions 13: what happens when you start looking at the programme budget?
I've started to look in more detail at the respiratory programme budget to find out why the gross expenditure increased across England by 8% between 2008/9 and 2009/10. Those of you who have pored over the national expenditure data, or PCT level data, will know that it divides into 11A (obstructive airways disease) 11B (asthma) and 11X problems of the respiratory system - other. Nationally there was a total investment of £4.59 billion on respiratory in 2009-10 representing an average of 8% increase over 2008-09 including an investment of £720 million on COPD with a 4% increase and £108 million on asthma with a 5% increase. in some places the biggest growth is in respiratory other, so then you start drilling down into the codes. The programme budgeting mapping tool shows you how prescribing, HRGs and outpatients are grouped to the programme budgets. Pneumonia and influenza are in respiratory other. It really is worth looking at this for your patch and then thinking about how activity is coded. This brings me to some very good news. The BTS has just issued a revised edition of the BTS Guide to Respiratory Coding which I commend to you. There's an accompanying podcast too. The author, consultant respiratory physician Steve Connellan, exhorts colleagues to "look more critically at our acquisition of data and liaise more closely with specialty coders and finance departments." He provides excellent case illustrations of how to code. Not only will it be valuable for hospital teams, but also commissioners who need to interpret coded activity.
Some regions have started to produce useful comparative summaries of respiratory data. London health profiles (that follow a visual model used for stroke) are available for each London borough here.
Siân Williams
28 June 2011 Impressions 12: Leadership: what will you commit to?
Helen Bevan, Director of Service Transformation at the NHS Institute for Innovation and Improvement, spoke to the respiratory clinical leads recently about contagious commitment. What can we learn from the leaders of the great social movements that have been able to unite thousands of people around a common cause and ignite change at scale? How can we apply for of the same principles in our own organisations to unleash the creativity and energy of our own workforce and of patients and their families? See here and here for examples of her thinking.
Siân Williams
28 June 2011 Impressions 11: news on the outcomes strategy, asthma and commissioning pack
We've learnt that the consultation on the strategy will be published shortly as the COPD and asthma outcomes strategy and will take a life course approach and include a section on asthma. This Impressions entry provides some updates about asthma and the Commissioning Pack.
Asthma
There are now seven asthma improvement projects – running for a year
National review of asthma deaths
We are not achieving any significant change in the numbers of deaths in England per year from asthma (more than 1000 deaths a year) therefore there will be a national review of asthma deaths led by the RCP. The first Steering Group will be in July 2011. For 12 months it will pick up every death, all ages, in England and Scotland (NI and Wales yet to confirm) and systematically investigate what happens at point of death, the hours before, care in the weeks/months before and the longer term clinical history of the patient. It will be broader than the confidential enquiries as it will involve families and non-medical professionals. There will be regional panels that undertake the review. Furthermore, some commissioners have proposed the idea that there should be a mindset shift so that every asthma (and COPD) admission is regarded as a significant event and clinical teams work together to understand the causes. Have look at the webcast of Dr Donal Hyne's presentation at the IMPRESS conference.
Asthma - Atlas of Variation – there will be additional asthma indicators included, but see existing maps here
Medicines Use Reviews (MURs)
Medicines Use Reviews (MURs) are being reviewed as part of the new contract for MURs delivered by community pharmacists. Asthma will be one of four conditions to be included in the new contract for MURs delivered by community pharmacists and the aim is to work to standard protocols eg assessing inhaler technique. Anne Moger and Maxine Hardinge are leading on this for the DH England.
Asthma good practice guides
Asthma good practice guides – one for adults and one for children will be launched by Primary Care Contracting in August/September 2011.
Atlas of Variation – sleep
In addition, sleep studies are now also part of the Atlas of Variation. The current map shows a 60% increase in the number of sleep studies carried out per month over the last four years but there is significant variation across the country and nowhere reaches the international levels we see in Europe and North America.
Commissioning pack
There will be a web-based tool that is covering some of the parts of the pathway that most need specifying to reduce variation. In particular it will describe good models of
COPD diagnosis and assessment
Integrated COPD care service including routine care (but not focused on it), pulmonary rehabilitation and episodic care such as
Reducing avoidable admissions
Treatment in hospital
Structured/assisted discharge
It is not covering end of life
Each will include an evidence-based service specification
It will not be mandatory
Each pack is in 3 sections: planning - including costing tools, agreeing and monitoring
Commissioners must tailor it to fit local circumstance eg how much is done in practices, or what services are commissioned from elsewhere
It will also include:
Case for change
Patient packs – produced with patients organisations
Siân Williams
23 June Impressions 10: Tips to get the most from IMPRESS
With so much information to handle, it's hard to keep up to speed. Here are some tips on how to get the most from IMPRESS:
Take five minutes once a week to read one of the blog entries (http://www.impressresp.com/Impressions.aspx)
Follow up Twitter to get very short updates ((click here to download the Twitter app to your phone
Consider which bits should be read by your team so that they understand what is driving decisions of commissioners and leaders and pass the references to them
Once a week listen to one of the webcasts from the IMPRESS conferences 2011 (and even 2009) and pass the reference to at least one other person
Remind yourself periodically of policy eg Operating Framework and outcomes framework
Search by key word to find relevant links, publications and presentations eg the social care and housing jargon buster
or personalisation pages and eligibility criteria
Read the latest case studies eg integrated COPD care based on the Northumberland experience in North Tyneside and think what you could take away and apply locally
Be inspired to celebrate your own work by viewing the current IMPRESS Award winners' posters
Siân Williams
17 June Impressions 9: Government response to Future Forum, continuity of primary care and bereavement survey
It is encouraging that clinical senates and clinical networks make an appearance, given the direction most of the English regions have taken since the publication of the consultation on the national strategy for COPD. IMPRESS has long advocated the value of networks - see its resources here. We will need to see how these develop and what role they might have in providing the secondary care specialist, nurse and lay input into the governance of clinical commissioning groups (as the proposal is to avoid conflicts of interest by barring clinicians from the local trusts).
We have previously shared the findings from the Purdy review of what prevents hospital admissions including the benefit of continuity of primary care (see here and her webcast at the IMPRESS conference here). There's a new report from the RCGP to underline this. It makes the point about the cost-effectiveness of primary care with the statement one day’s GP care is equivalent in cost to one tenth of a day in hospital. It highlights, given changes in the provision of general practice, two types of continuity: Relationship Continuity (between a doctor and patient) and Management Continuity (coordinated care eg for someone with a long term condition). It also makes "the important link between access and continuity of care - with evidence that patients are actually willing to wait longer to see their preferred clinician – and suggests ways of helping patients achieve effective ‘therapeutic’ relationships."
Finally, a snippet from Health Service Journal 26 May 2011 suggesting that the DH England is developing a national indicator based on a new survey of bereaved carers. This is likely to raise the profile of advanced care planning and clinical communication skills which is timely for IMPRESS given the forthcoming publication of the second edition of our Effective Care-Effective Communication: Living and Dying with COPD. See Jane Scullion's webcast on it here.
Siân Williams Programme Manager
4 June 2011 Impressions 8: integrating COPD care
How to improve quality and productivity by integrating COPD care. This latest case study from IMPRESS is a
synthesis of current evidence and policy, illustrated by our report on North Tyneside, part of Northumbria Healthcare NHS Foundation Trust, one of two national (England) integrated care pilots focusing on COPD.
It highlights:
The bundle of activities that are needed: care planning, allocation of a key/named worker, routine measurement and feedback to primary care, robust patient assessment and referral to key services such as pulmonary rehabilitation, education and support for patients and professionals, and recording and provision of consistent information across primary and secondary care
How investment in relationships over time pays dividends and how much can be achieved outside the commissioning system, by providers alone
How general practice, supported appropriately by hospital specialists and social care specialists and working in a culture of trust can drive system change for the benefit of patients
It describes the potential for social care services such as support for carers and community alarm services as well as home support to be better integrated into care pathways to support patients
It makes the case for a consistent care approach to other long term conditions, particularly heart disease and diabetes, and for regular medication review
Finally, it demonstrates four sorts of integration: centred on an individual irrespective of long term condition(s), between primary and secondary care decision-making, between general practice and community nursing and between health and social care. It includes current policy references and also reports from organisations such as the Nuffield and Kings Fund.
31 May Impressions 7: a great conference
We had a great conference last week. The presentations now available as webcasts covered everything you need to know about the key themes: Louise Restrick on doing the right things - the relative value of interventions; and June Roberts on doing things right - improving reliability, using data well; and Derek Thomson on integration. There were important sessions on the evidence for interventions that interest commissioners such as co-creating health, CQUINs, telehealth and reducing admissions. There was a clear message that the evidence lags behind the questions we need answered. Few of these interventions can yet demonstrate reduced healthcare utilisation. Brian McInstry's studies as part of the TeleScot programme show patients love remote monitoring, but telehealth might drive up demand for primary care. We've previously highlighted the work of Sarah Purdy (Impressions 1 below). Her presentation showed how few interventions can demonstrate reduced hospital respiratory admissions. Continuity of GP care stands out amongst the uncertainty. There is also a case for having competent teams with respiratory expertise looking after patients at key times - first contact at A&E and within the hospital. Sounds obvious, but it's not happening. Louise Restrick made a strong case for significantly greater clinical investment in stop smoking interventions and commissioner investment in pulmonary rehabilitation, as well as proper scrutiny of prescribing, with a message of responsible prescribing. The advanced and end of life stream covered a lot of ground: why COPD is different from other terminal diseases, and why end of life registers are not the way forward; how best to provide services for intractable breathlessness and to deliver oxygen and NIV to those who would benefit from it. There were powerful messages from Liam Williams on what commissioners expect from providers: they need to hear you, and hear from others about your reputation; see you trying to improve, and will trust their experience, intuition and judgement about providers, not just rely on written descriptions of success. Sign up to Twitter @ImpressLung to get an alert announcing when the webcasts will be on the website.
11 May 2011 Impressions 6: focus on QIPP
IMPRESS keeps a watching brief on the daily commentary about the pause, NHS Future Forum and alternative "kitchen cabinet" of the Prime Minister (Health Service Journal) but won't comment, except to say that the one thing that is definitely here to stay is the QIPP agenda and extracting more value from NHS investment. Our conference programme will give plenty of food for thought on this: doing the right things and doing things right. As a group we have embarked on a project to look at the relative value of different interventions for COPD, and wil be reviewing how we might add value to the commissioning and delivery of cost effective pulmonary rehabilitation in the autumn.
Meanwhile, we have reissued our Step-by-step guide to rationalising the use of oxgyen to complement the long-awaited launch of the Home Oxygen Service - Assessment and Review - Good Practice Guide issued by NHS Primary Care Commissioning on behalf of the Department of Health, British Lung Foundation, BTS and PCRS-UK and others. The IMPRESS guide covers adults only - the NHS PCC guide covers children as well as adults. We first identified oxygen assessment as an opportunity for rationalising in our More for Less guide. The provision of oxygen is mid-tender process, but the principles in the step-by-step guide remain valid.
The building blocks for understanding cost, the denominator of work on value, include both coding and the tariff. IMPRESS Jargon Buster has been updated with news and links to the 2011/12 tariff guidance. It is worth noting Para 418 of the 2011/12 guidance on the non-mandatory tariff for stop smoking. In the West Midlands where it has been tested, providers receive payments for both 4 and 12 week quitters, with higher payments available to those providers that support individuals from defined targeted populations such as those from deprived areas, routine and manual workers, people from black and minority ethnic groups, those with mental health issues, communication difficulties and people aged under 25. Higher payments are also paid to providers that incur the costs of stop smoking medications supplied to patients. Separate currencies and tariffs have been developed for stop smoking services delivered to pregnant women. We welcome news of how this tariff is being used locally.
Coding - in addition to the Audit Commission coding audit (not comprehensive, but if your trust or service has been audited, a very useful resource) and our own guide to Respiratory coding, a new report by The NHS Information Centre and endorsed by the AoRMC reiterates the serious lack of clinical engagement over the accuracy of hospital data and the implications for clinical outcomes and patient choice. Hospital Episode Statistics (HES): Improving the quality and value of hospital data suggests improvements in
clinician access to raw data
recording clinical terms
outpatient coding
clinicians working in teams
diagnoses present on admission
enhanced data linkage including primary care
NICE has launched a new Pathways website based on its guidance: The COPD pages include the Pathway shown as an algorithm, like Map of Medicine, the Guidance (NICE and other) and pages on Implementation:
Priorities
Assessment tools
Audit support
Costing tools
Slide sets
The 2011 Revision of the 2008 BTS/SIGN Asthma guidelines was published 10 May 2011.
I'm also pleased to report that a GP colleague, David Price, has had the findings from a 2-year pragmatic asthma research study published in the New England Journal of Medicine, sparking both an editorial on the value of pragmatic research and a statistical perspective. If evidence-based guidelines include the findings from pragmatic research, then they should become more relevant to real-life practice, and, so the argument goes, the outcomes achieved should be more consistent with the published findings.
Sian Williams
15 April 2011 Impressions 5 - during The Pause: data analysis
So, the Health and Social Care Bill's journey is paused, but the papers and data keep on coming. A few to know about:
The Association of Public Health Observatories general practice profiles are live. These allow for comparative analysis of perfomance against a number of indicators including respiratory ones. You can select clusters to compare. See a snapshot here. This, and the Atlas of Variation start to really build on visual displays of information. See also our guides to how to use information and medicines information.
The Audit Commission published Reducing expenditure on low clinical value treatments on 14 April 201. It estimates that nationally a reduction in PCT spending of between £179m-£441m is achievable. It used the "Croydon List" of 34 low priority treatments to estimate spending over a five-year period 2005/6-2009/10 and to forecast what could have been saved.
The "Croydon List" has 5 categories of treatment
Those considered to be relatively ineffective, eg a tonsillectomy.
Those where more cost-effective alternatives are available, eg not performing a hysterectomy in cases of heavy menstrual bleeding.
Those with a close benefit and risk balance in mild cases, eg wisdom teeth extraction.
Potentially cosmetic procedures, eg orthodontics.
Procedures cancelled after patient admitted for that procedure
They are procedure-based and none are respiratory but maybe the categories could be applied to respiratory? It's also difficult to believe that there's still scope to improve on these treatments as these have been on the "hit list" fo years. However, the general messages are pertinent (if unsurprising)
Achievement of the reductions requires senior level leadership;
Groups of PCTs working together can improve the consistency of messages to clinicians;
Put effort into the data analysis and performance monitoring;
Involve GPs and secondary care;
Produce and engage in accessible communication with the public
Use the latest clinical evidence
The Audit Commission supports the DH Right Care work to develop the required evidence base, which is seen as the main stumbling block. In the Audit Commission survey PCTs said they currently used these evidence-bases:
NICE, NHS Library, NHS Evidence, Clinical Knowledge Summaries, National Prescribing Centre, DH Evidence Based Commissioning, Turning Research into Practice, Map of Medicine , The NHS Atlas of Variation.
This begs the question how do we ensure that the best respiratory evidence is in all these places?
We'd also recommend from the Audit Commission their work on coding assurance, with a lot of examples of good practice.
Did you see the Editorial in the BMJ by David Halpin about case-finding and needing to work harder to find the missing people. He's also suggesting going where the people are (see Impressions 4) and also quotes the Finnish study (Impressions 2). Can't help thinking that we need to be smarter about working with occupational health and offering an exchange - delivering what the employees want, in addition to what we want to offer. Has anyone run a successful COPD case-finding programme with occupational health? Email sian.health@gmail.com if you have!
Sian Williams
7 April 2011 - Impressions 4 Avoiding admissions again - three new reports suggesting we need to go to where the patients are
Calderon-Larranaga A et al Association of population and primary healthcare factors with hospital admission rates for chronic obstructive pulmonary disease in England: national cross-sectional study Thorax 2011;66:191-196 This shows, as Jones' commentary says that the "inverse care law is alive and well". The authors from Imperial and the Care Quality Commission integrated routinely collected data from over 8000 practices caring for over 53 million people in England. Mean annual COPD admission rates per 100 000 population varied from 124.7 to 646.5 for PCTs and 0.0 to 2175.2 for practices. Admissions were strongly associated with population deprivation at both levels. Registered and undiagnosed COPD prevalence, smoking prevalence and deprivation were risk factors for admission (p<0.001), while healthcare factors- influenza immunisation, patient-reported access to consultations within two days, and primary care staffing, were protective (p<0.05).
Another on the need to test effective case-finding comes from Nacul L. COPD in England: a comparison of expected, model-based prevalence and observed prevalence from general practice J Public Health (2010) by a team from Imperial, Cambridge and the East of England PHO. Both observed and expected prevalence of COPD varied widely between geographical areas. There was evidence of a north–south divide, with both observed and modelled prevalence higher in the north. The ratio of diagnosed to expected prevalence varied from 0.20 to 0.95, with a
mean of 0.52. Underdiagnosis was more pronounced in urban areas, and is particularly severe in London. Analysis suggests that primary care supply affects diagnosis. The team recommends the use of the APHO COPD prevalence model that contains estimates for GP practices’ registered populations,
Meanwhile, an evaluation by the Nuffield Trust Steventon et al. An evaluation of the impact of community-based interventions on hospital use: a case study of eight Partnership for Older People Projects (POPP) 2011 shows a disappointing impact on hospital admissions and recommends commissioners consider using "person-based risk-adjusted evaluation" to test whether preventive care interventions are effectively avoiding hospital admissions. When compared to matched control patients, they did not find evidence of a reduction in emergency hospital admissions associated with any of the POPP interventions studied. In some instances, there were more admissions in the intervention group than in the control group. One intervention reduced the number of bed-days, but overall they found that the interventions studied did not appear to be associated with a reduction in the use of acute hospitals. They offer one possible explanation- that the process of ‘case finding’ identified unmet need that necessitated hospital admission.
So, more dialogue needed on the best ways for case-finding, what we might expect to see happen to admissions as a result of case-finding, and the real need to focus on areas of deprivation and the factors that appear to make a difference.
Sian Williams
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31 March 2011 Impressions 3 THE STATE OF HEALTH AND SOCIAL CARE IN ENGLAND, CQC ANNUAL REPORT - HOSPITAL DISCHARGE
The Care Quality Commission (CQC) has just published (28 March 2011) its annual report on The state of health care and adult social care in England.
It finds encouraging signs and gives evidence that standards of health and social care are improving overall - which has been picked up by some of the media that has then questioned the need for so much change. Care was safer in 2009/10 than in previous years. There were fewer healthcare-associated infections and services had made improvements in protecting adults from abuse and neglect. However it claims unacceptable variation remains.
There are useful updates on the extent of progress towards personalisation in social care, and the impact of choice in terms of mixed provision of care particularly in home care, and care homes. Apart from a special report on stroke, there is no disease-specific information. However, it shows "mixed progress in avoiding unnecessary hospital admissions and ensuring effective hospital discharge, with much variation between councils. There was significant growth of intermediate care services, but the numbers of people over 75 who had repeated emergency admissions suggested a lack of effective community support. "
Hospital discharge still has considerable scope for improvement: From the patient survey data:
37% said they were not given written or printed information about what they should or should not do after leaving hospital
25% said they were not told whom to contact if they were worried about their condition
33% said that doctors and nurses did not give their family or someone close to them all the information they needed to care for them
18% said they were not given clear written or printed information about their medicines, and 45% said they were not told about possible side-effects
It will be interesting to see whether solutions such as the COPD discharge bundle start to address this.
The Department of Health’s guidance states that patients should receive copies of letters sent between clinicians. Although the majority of inpatients (53%) did not receive copies of letters sent between hospital doctors and their GPs, the proportion of those who did improved from 35% in 2005 to 47% in 2009. There had also been some improvement for outpatients - the percentage who said they had received some or all of these letters rose from 22% to 44%.
Councils are required to set eligibility criteria that determine who can receive their community care services, and to use a national framework to grade the level of need. This is one of the processes used to manage demand for services and control council expenditure on care. In 2009/10, three councils set their eligibility threshold for care-managed services at critical while 107 set their threshold at substantial. Only three councils were planning to raise their eligibility threshold in 2010/11, while one was expecting to lower its threshold from substantial to moderate. However, the number of people receiving publicly funded services in 2009/10 fell by nearly 5% against the previous year, according to (provisional) national statistics. It will be important to see how access to these services is maintained when local authorities implement their funding cuts during 2011/12.
Sian Williams
25 March 2011 Impressions 2 QUALITY AND PRODUCTIVITY IN PRIMARY CARE
There may be some opportunities in the new QOF indicators that respiratory networks may wish to discuss locally. As well as the continuation of stop smoking, asthma and COPD indicators, there are 96.5 points available out of a possible 1000 for new quality and productivity indicators that aim to ""secure more effective use of NHS resources, in particular through improvements in the quality of primary care that reduce hospital outpatient referrals, and emergency hospital admissions by providing care to patients through the use of alternative care pathways, and through more cost-efficient prescribing."
We need to understand more how this will be measured, but the negotiated position is that there are two indicators:
reducing emergency hospital admissions associated with long term conditions where there is evidence that appropriate management of these conditions in primary care reduces emergency admissions;
reducing inappropriate outpatient referrals
Practices will receive the full payments for these areas if, following internal and external practice reviews, they are implementing care pathways that are intended to have the effect of reducing unnecessary referrals and admissions.
So how might we ensure changes that benefit patients with COPD and asthma pathways are considered?
In terms of outpatient follow-ups see our work More for Less and also Delivering Respiratory Care Closer to Home
In terms of emergency admissions, see below.
Also, have a look at the new publication from 10 years of the Finnish programme on COPD: The 10-year COPD Programme in Finland: effects on quality of diagnosis, smoking, prevalence, hospital admissions and mortality
Meanwhile, I heard I heard DrJames Kingsland, DH national clinical commissioning network lead and President of the National Association of Primary Care speak this week at an internal meeting hosted by Glaxosmithkline. He has the challenge of finding 500 champions for GP commissioning. He is trying to get GPs to stop worrying about the financial and organisational implications, because form should follow function, and instead to start testing the potential for making commissioning more needs-led and also addressing the QIPP challenge by focusing decision-making on whether they should "make or buy" services to meet those needs. He had five challenges for English GPs which seem useful messages about integrated care that we could support:
How are you taking on board the "no decision without me" principle and engaging patients in commissioning decisions to ensure : have you a process for this now there is funding to support it
How are you benefiting from the collective experience of the multi-disciplinary primary care team, including the other contractors and community providers in assessing patient need?
Are you having regular meetings with your local authority colleagues to discuss integration with social care and alignment with public health?
The QIPP challenge will require more long term conditions to be managed outside hospital so have you begun a dialogue with clinicians in secondary care about how to downsize but not destabilise, and support high quality high technology hospital care?
How do you plan to restore/increase the value of list-based practice and its opportunity to manage demand by making more and buying less (including better management of out of hours)?
His second main message was also one that we could support: where's the value, defined as outcomes divided by cost. Sir Muir Gray has got a useful blog about this, referring to Michael Porter's work on this.
To see an interview with James Kingsland, have a look at this with Roy Lilley.
Sian Williams
Programme Manager
8 March 2011 1st go! 1. AVOIDING HOSPITAL ADMISSIONS AND 2. TELEHEALTH
Two really good papers have come out recently. Remote Control - see below and, Avoiding hospital admissions. What does the research evidence say? Sarah Purdy, Kings Fund, December 2010 Go here to see the full paper including all the references.
Sarah Purdy - who's speaking at the IMPRESS conference on 24 May 2011 - has reviewed the research literature about avoiding hospital admission.
Here are the main findings in relation to respiratory care:
Demographic factors
People from lower socio-economic groups are at higher risk of avoidable emergency admissions.
Practices serving the most deprived populations have emergency admission rates that are around 60–90 per cent higher than those serving the least deprived populations (Blatchford et al 1999; Purdy et al 2010a).
This is well-illustrated in COPD. Also practices with higher recorded chronic disease burden have a higher rate of admissions.
Those who live in urban areas have higher rates of emergency hospital admission than those in rural areas; Eg the authors found a 16% higher rate of asthma admissions for urban patients compared with rural patients (Purdy et al 2010a). They also found those who live closer to A&E departments have higher rates of admission (for instance, a 12 per cent higher rate of admission for asthma), even after taking into account other risk factors, including living in an urban area (Purdy et al 2010a). The reasons are less clear.
Being from a minority ethnic group is associated with a higher risk of emergency admission. For example, in the UK, asthma admission rates for South Asian patients have been double those of white patients, and are also high for black patients (Gilthorpe et al 1998). Different ways of coping with asthma exacerbations and accessing care may partly explain the increased risk of hospital admission among South Asian patients (Griffiths et al 2001).
Cold weather is associated with increased rates of admission for COPD exacerbations (Maheswaran et al 2005; Moran et al 2000; Marno 2006).
Risk prediction
There are several tools available to help identify people at high risk of future emergency admission, including computer database models and simple questionnaires. There is no clear advantage of using one tool over another. Purdy includes an appendix that describes five tools.
It is important to be clear which admissions are potentially avoidable and which interventions are likely to be effective. Clarity of disease coding is essential. IMPRESS recommends commissioners discuss with providers which diagnostic codes they class to be avoidable, what proportion of these admissions are avoidable, and how these admissions should be measured. In terms of tools, we offer:
Guide to respiratory coding including case studies
Guides to information and medicines information including reference to ways of measuring coding accuracy such as the Audit Commission HRGv4 audits and QOF exception reporting.
Services
Primary care
In primary care, higher continuity of care with a GP is associated with lower risk of admission. There is mixed evidence about size of practice: small size/single handed may be associated with increased admissions for asthma but not COPD.
Integrating health and social care may be effective in reducing admissions.
Look out for our case study from North Tyneside, one of the national integrated care pilots
Integrating primary and secondary care can be effective in reducing admissions. One of the core principles of IMPRESS. See Curry and Ham 2010. This review concludes that the evidence is supportive of the concept of integration. The authors highlight the importance of integrating not just at the health system level, but also at the disease management and individual patient levels.
Use of specialists in the community
There is very little evidence to suggest that clinics provided by hospital specialists in primary care reduce hospitalisation rates when delivered in isolation (Gruen et al 2003). However, this systematic review found that specialist outreach, as part of more complex multifaceted interventions involving collaboration with primary care, education or other services, is associated with less use of inpatient services. See the IMPRESS guidance about integrated care consultants and referral letter.
Telemedicine seems to be effective for patients with heart failure, but there is little evidence that it is effective for other conditions.
We ask commissioners to pay particular attention to this, given our observation that a considerable number of telemedicine schemes are being introduced, at considerable expense without the evidence, and instead of interventions with good cost effectiveness data. It is worth waiting for the outcomes of the Whole Systems Demonstrator projects to see if they are cost effective, and if there are (modifiable) clinician behaviours that make them effective. However, we would recommend reading Remote Control This focuses on how digital or 'multi-channel' healthcare can have an impact on the fundamental relationships between patients and practitioners. Telephone, email and the internet can offer patients and carers choice and a rebalancing of power and control. However the tariff needs to encourage the provision of options - that email or phone consultations may be the patient's preferred option, but they won't happen if there's no suitable tariff.
Hospital at home produces similar outcomes to inpatient care, at a similar cost. Shepperd et al 2009a) Elderly patients with a medical event such as stroke or COPD, who are clinically stable and do not require diagnostic or specialist input, had slightly more subsequent admissions in the hospital at home group, but had greater levels of satisfaction, and their care at home was less expensive. Commissioners should therefore consider this.
Case management in the community and in hospital is not effective in reducing generic admissions.
We would like to see further evidence about the impact of specialist teams supporting generic workers.
Self management
There is evidence from systematic reviews that self-management seems to be effective in reducing unplanned admissions for patients with COPD and asthma. Self- management education for patients with COPD reduces the risk of at least one hospital admission by about 36 per cent compared with usual care (Effing et al 2007). This translates into a one-year number needed to treat (NNT) of 10 for patients with more severe disease (51 per cent risk of exacerbation), and 24 for those with milder disease (13 per cent risk of exacerbation). Self-management education was associated with a reduction in shortness of breath and an improved quality of life.
Education for adult patients with asthma attending A&E with an acute exacerbation significantly reduced admission to hospital by 50 per cent, but did not significantly reduce the risk of re-presentation at A&E during follow-up (Tapp et al 2007). A previous study also showed that a brief self-management programme during hospital admission reduced post-discharge morbidity and re-admission for adult asthma patients. The benefit of the programme may have been greater for patients admitted for the first time. It had a small but significant effect on medical management at discharge (use of medications in line with current guidelines) that may explain the benefits of this approach (Osman et al 2002). There is also evidence that asthma education aimed at children and carers who present at A&E with acute exacerbations can result in lower risk of A&E attendance and admission (Boyd et al 2009). Following an educational intervention delivered to children, their parents, or both, there was a significantly reduced risk (21 per cent) of subsequent hospital admissions. However, there is a suggestion that the benefits of psycho- educational interventions may not be as evident in those patients with severe and difficult asthma (Smith et al 2005).
Not all studies of self-management demonstrate reduced hospital or A&E department use, and there is some debate over which ‘active ingredient’ in self-management is the most effective. One review of 15 studies measuring the impact of adult asthma self- management education on health care utilisation and costs found that eight studies demonstrated reduced hospital or emergency department use, while seven failed to demonstrate a reduction (Bodenheimer et al 2002). Six of the eight studies that did demonstrate a reduction included a self-management action plan, compared with three of the seven that did not, suggesting that a self-management action plan is a useful component.
Ways to support this in respiratory care include asthma action plans, and pulmonary rehabilitation.
Out of hours
A fivefold variation in out-of-hours admission rates has been observed between GPs working for the same out-of-hours service and caring for the same patient population, suggesting that clinician factors play an important part in determining admission rates (Rossdale et al 2007). Qualitative research in the same group of GPs suggests this may be due to lack of confidence, feelings of isolation, aversion to risk and lack of awareness of alternatives to admission (Calnan et al 2007) – all of which are modifiable factors.
Medication review
No positive evidence for medication reviews by pharmacists
Quality of primary care
The evidence for an association between higher quality of primary care (as measured by routine data) and reduced rates of admission is mixed. Lower rates of admission for asthma were found in practices whose prescribing patterns suggest better preventive care (Giuffrida et al 1999). However, the evidence is not conclusive. More recent research did not find any association between Quality and Outcomes Framework (QOF) scores and hospital admission for patients with asthma, COPD or coronary heart disease (Downing et al 2007; Bottle et al 2008). Provision of diabetes clinics in primary care was significantly associated with reduced admission rates for diabetes, but the provision of asthma clinics was not associated with a similar reduction in admissions (Saxena et al 2006). Conversely, a systematic review showed that high standards of diabetes care in primary care do not necessarily lead to reduced hospital admissions (Griffin and Kinmonth 2006).
Acute assessment units may reduce avoidable admissions, but the overall impact on number of admissions should be considered.
A systematic review of paediatric hospital-based acute assessment units also demonstrated that they are a safe, efficient and acceptable alternative to inpatient emergency admissions (Ogilvie 2005). One study showed that after the intervention, the proportion of children with asthma who were admitted fell from 31 to 24 per cent.
Early review by a senior clinician in the emergency department is effective. GPs working in the emergency department are probably effective in reducing admissions, but may not be cost-effective.
There is a lack of evidence on the effectiveness of combinations of interventions.
Re-admissions
Developing a personalised health care programme for people seen in medical outpatients and frequently admitted can reduce re-admissions. This should be tempered by an analysis of those people with COPD whose disease will inevitably cause frequent admissions, irrespective of any programme.
Structured discharge planning is effective in reducing future re-admissions.
The COPD discharge bundle approach is worth considering. It is being tested in NHS London as a CQUIN and as a project supported by the north London HIECs.
Meanwhile A systematic review of the effectiveness of nurse-led interventions pre- and post- discharge for COPD patients showed that brief (one-month) nurse-led interventions post-discharge did not reduce admission rates (Taylor et al 2005b). The evidence for longer (one-year) interventions is equivocal.
So - worth reading carefully, and debating locally. Come and listen to Sarah Purdy at the IMPRESS conference!
Sian Williams