Good Practice Examples

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

1 October 2010 - draft quality standard for COPD from NICE
The draft NICE quality standard for chronic obstructive pulmonary disease (COPD) is now available for consultation. The document contains 13 quality statements for the diagnosis and management of people with COPD and each one is described in detail. The consultation period will end at 5pm on 10 November 2010.

NICE quality standards are derived from the best available evidence, usually NICE guidance or other sources that have been accredited by NHS Evidence. The quality standards set out the structures and processes of care, as well as the best outcomes for patients that the standard is likely to bring about.

The draft quality standard on COPD is derived from the following evidence sources:

NICE (2010) Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update). NICE clinical guideline 101.
Department of Health (2010) Consultation on a strategy for services for COPD in England.

It a consultation, and so if commissioners and/or providers wish to offer comment, this is the time to do so.

For the full document go here.

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.
New (2010) contact at Department of Health England: Elizabeth Fellow-Smith [email protected]

January 2011 Call for good practice examples

The national mental health team are leading on a project pulling togther examples of good practice/evidencing that psychological support linked to long term conditions makes a difference.This also links to the QIPP agenda, improving outcomes, improving self management, reducing unplanned care and so on.

This psychological support can be at various levels of input and need - from someone coming to terms with their long term condition, to various degrees of depression and anxiety, to liaison psychiatry for complex disorders. The current focus is on COPD, Diabetes, Cardio vascular/Heart and medically unexplained conditions. The project is also linked to Improving Access to Psychological Therapies (IAPT).

To inform the work, the team is asking for evidence of service developments\innovations where psychological support has been integrated into the care pathways for people with COPD. An outline of the service, evidence of evaluation\success, and feedback from patients is requested.

If you would like to contribute to this work, please contact Matt Fossey on [email protected]

The deadline for this is 16th February 2011.

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

November 2010 relevant reports:

22 November 2010 report by Chris Ham and Natasha Curry Clinical and service integration The route to improved outcomes Integration can take a variety of forms, involving either providers, or providers and commissioners, who work together to deliver better outcomes at a number of levels within the system. This report summarises relevant evidence about high-profile integrated systems in the United States, such as Kaiser Permanente and Geisinger Health System and outlines examples of integrated care in North America and Europe for particular groups, such as older people or patients with long-term conditions – for example, the integrated health and social care teams in Torbay. It also explores the range of approaches to improving co-ordination for individual patients and carers – for example, the Care Programme Approach in mental health.

National pilot of 16 sites interim report

29 November 2010. Ernst and Young and RAND Europe are undertaking an independent evaluation of the 16 integrated care pilots in the NHS on behalf of DH (see below). IMPRESS is preparing a report on Northumbria's COPD pilot. An interim report has just been published. The final evaluation report is expected at the end of 2011. using quantiative supported by the Nuffield Trust, qualitative evaluation using "Living Documents" and "Deep Dives".

Findings

"We are not thus far seeing solid and distinctive models of integrated care emerging. Instead we are seeing a more fluid process of adaptation to a changing environment in pursuit of some broad overarching aims and values. Bringing care closer to patients, providing support for more preventive interventions and strengthening and simplifying informed choice are all being pursued, but in different ways."

They identify some evaluation challenges:
1. How important is context in shaping outcomes, and if each context is different, how can we generate lessons that can be more widely applied?
2. If the theory of change is one of negotiation and compromise, building trust and improving inter-disciplinary understanding; how can we isolate the ‘active ingredient’?
3. Where the improvement activities have no definitive boundaries, how can we calculate the costs associated with integration as opposed to the other costs of running a changing health and social care system?
4. How can we provide a counterfactual advising us how much better (or worse) the value for money achieved was

Read the report for more on their findings about

Context matters
Clusters not models
There exists an appetite for collaboration
Building the infrastructure can be demanding
Decision-makers work with limited cost data

Here's a little more about clusters not models: they aregue no single model is emerging. Instead, locally developed and distinct clusters have formed of "elements tied together in space and time, that may mutually reinforce and support each other, but are not logically or causally unified."

The researchers argue that this sensitivity to local history and context was also anticipated by Chris Ham and John Oldham in their recently published study of integrating health and social care in England that argues to avoid structural change but to concentrate on service users. This paper examines experience in making use of Health Act flexibilities and care trusts to achieve closer integration of health and social care in North East Lincolnshire, Torbay and Knowsley.

Social care

Read IMPRESS's views on the potential for better engagement with social care and the future of care services: Shaping the Future of Care Together The Big Care Debate - Response by IMPRESS

Evidence base - that influenced IMPRESS More For Less

A review commissioned by the Nuffield Trust included a 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 for the questionnaire. Click here for the final report - More For Less.

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?