Download BTS Integrated Care Position Statement October 2014

British Thoracic Society
POSITION STATEMENT
The role of the Respiratory Specialist
in the provision of Integrated Care and
Long Term Conditions Management
Summary
October 2014
contents…
Summary1
A
B
Integrated care requires a move away from responsive fragmented care given to
patients by separate individuals in separate organisations to co-ordinated, proactive continuous care in which healthcare professionals in different organisations
work across boundaries, forming a single team which includes the patient. This will
require a cultural change within the NHS.
To enable this change team members require additional knowledge and skills
concerning the care of patients with Long Term Conditions. It requires specialists
(doctors or other professionals in specialist roles) to think more in terms of their
responsibility to the whole population of patients within their local health
care economies.
C
This is not about specialists just carrying out clinics in the community, but leading
and working with teams, using well defined components of care to deliver high
quality respiratory care across populations as well as to individuals.
D
In this model, the components lead to our goal of an educated patient taking
more control, working with a trained team of healthcare professionals who
act pro-actively to improve wellbeing and to prevent exacerbations and
hospital admissions.
Introduction2
What is integrated care and why
should we strive to achieve it
3
Why respiratory specialists
have a key role to play in
integrated care
Case Studies
4
4-6
Next steps
6
References7-8
Appendix8
BTS is a membership organisation and a registered charity. We have over 2,900 members in respiratory medicine and
allied health professions (October 2014) and can lay claim to being the professional voice of respiratory medicine in the
UK. Our objectives are to develop and promote the best evidence-based standards of care for patients with respiratory
and associated disorders; to disseminate knowledge and learning about their causes, prevention and treatment; and to
raise the profile and provide information about prevention of respiratory diseases.
The role of the Respiratory Specialist in the provision of Integrated Care and Long Term Conditions Management October 2014 | 2
Introduction
a) Respiratory diseases are among the leading causes of death
worldwide accounting for 9.5 million deaths in 2008, 6 million
admissions per year and costing the European Union €380
billion a year1.
b) The UK is among those countries in Europe with the highest
rates of death from respiratory disease which is the third
leading cause of death in the UK1, 2. Respiratory disease
remains a significant cause of disability and premature
mortality with 6 million people suffering from COPD or
Asthma in the UK, and 23,000 people dying each year
from COPD in England3. However, although it has one of
the highest rates of disease, there are fewer respiratory
specialists per head of population than most other European
countries1. It is therefore particularly important to consider
how to make best use of this specialist resource.
c) Respiratory disease accounts for a substantial amount of
NHS expenditure and resources. For example, the NHS
spends around £1billion a year treating and caring for
people with asthma3,4. There is also considerable variation
in the accessibility and quality of care: - where people live
significantly affects the likelihood of being admitted
with COPD3.
d) People are living longer often with one or more chronic
diseases. This has caused a shift from an acute and
episodic model of care to one of health promotion, disease
prevention, early intervention and chronic care. This along
with the increasing cost of healthcare, rising expectations,
changing disease profile, ageing society and health
inequalities means our current model of service care is no
longer able to care appropriately for these patients.
e) In 2007 the British Thoracic Society (BTS) produced a
discussion paper on Integrated Care, what was at that time
a newly emerging phenomenon. The paper concluded that
“consultants in integrated respiratory care represents an
exciting way of enhancing the care of those with lung disease”
5
. Today, as the drive towards healthcare integration in the
United Kingdom gathers momentum, the British Thoracic
Society identified a need to further clarify the purpose and
role of integrated respiratory specialist posts.
f)
This document outlines BTS’ vision for the role of respiratory
specialists in the provision of integrated care. We will
define what we mean by integrated care and suggest key
components that should be in place for a model of care
that enables patients with chronic, long-term respiratory
conditions to be cared for in the community.
g) To enable us to form a view, we commissioned a research
project from the Institute for Applied Health Research at
Glasgow Caledonian University in the autumn of 2013.
The scope and format of this research was developed and
overseen by a multi-disciplinary Steering Group and the final
report produced6.
h) We surveyed all members of the Society to gain insight of
their understanding of integrated care. Some already work
in an ‘integrated’ way and we used in depth interviews to
determine their experience.
i)
There are already some examples of implementation of
integrated respiratory specialist posts throughout the
UK. There are some commonalities between these posts
however there are also some significant differences in areas
such as the source of funding of these roles, programme
setup, design and the core components of these posts.
j)
BTS has knowledge of integrated care and a shared
understanding with colleagues across the spectrum of
primary/secondary care gained over a number of years
within IMPRESS. IMPRESS is a joint programme that BTS ran
in partnership with the Primary Care Respiratory Society
UK (PRCS-UK) between October 2006 and March 2014.
Our shared objective was to provide the clinical leadership
required to drive improvements in care across/beyond the
traditional boundaries of primary care and secondary care in
order to achieve high quality integrated patient centred care
for the population with or at risk of respiratory disease7.
k) The recommendations that follow provide a look into the
future. We wish to promote change to a system where
the patient is at the centre of a system of care and where
organisations work as one, without clinical boundaries,
to improve care and give better value for the healthcare
communities they serve.
The role of the Respiratory Specialist in the provision of Integrated Care and Long Term Conditions Management October 2014 | 3
What is integrated care and why should we strive to achieve it?
a) Integrated care can be defined as the best possible care for the patient, delivered by the most suitable health professional, at the
optimal time, in the most suitable setting.
b) Ten years ago the steady rise in acute medical admissions linked with poor care for those with chronic illnesses led to a number
of ideas suggesting ways to promote a shift of care into the community. These ideas started with ‘Transforming Community
Services’ which promoted structural change, but omitted the role of specialist care and also the need for change in the culture of
the various organisations involved8.
c) Patients with chronic illness need the separate organisations that care for them to act as one. This requires those providing care
in all settings - primary, secondary, community, social, mental health services, private providers and voluntary/third sector – to
find ways of working in a ‘joined –up’ integrated way.
d) At present, people with Long Term Conditions lack ‘joined up’ care. Patients are passed between separate organisations, each
with different workers, separate management structures, different budgets and often very different agendas. To stay within
budget, they often pass costs and patients from one to the other, creating waste and poor care.
e) The NHS and Social Care Model in 2008 gave sound advice regarding the cultural and system changes required for the integration
of services and care9, unfortunately the changes advocated in that model were not followed through.
f)
Over the same period various ‘models of care’ described the different components required to ‘integrate/join up’ care for those
with chronic long-term conditions. Components included specialists, generalists and social care workers, working together and
co-ordinating care10,11.
g) Key components in this “model of care”10 include
a.
Education, including patient self-management and pulmonary rehabilitation.
b.
Decision support systems, including discharge and care bundles, treatment guidelines and care pathways.
c.
System design, including early supported discharge services, commissioning to incentivise integrated working between organisations. Sharing information.
d.
Clinical information, including ways of using disease registers to risk profile populations. Use of data to measure outcomes, produce audit, measure variation.
h) The latest structural reform of the NHS has also not been helpful in promoting cultural change within organisations. However, the
new Chief Executive of the NHS referred to the urgent need for culture change to be at the forefront of planning and delivery of
health and social care in his first speech on taking up post on 1st April 201412.
i)
Most recent advice has repeated the need for integration and describes the changes required to enable better and more cost
effective care for patients with long-term conditions, including chronic respiratory diseases and care at the end of life13.
j)
The culture change at the heart of recent advice advocates moving from the present system of fragmented care to a pro-active,
co-ordinated model achieved through integration of clinical systems across organisations. The core elements revolve around
organisational changes in health care delivery, better connected teams with clinical informatics and decision support, proactive
planned evidenced based care and patient and carer support and education.
k) Patients, service users and carers want continuity of care, a smooth transition between care settings, and services that are
responsive to all their needs14.
l)
The evidence is that integrated care improves quality and reduces waste and therefore cost i.e.: giving better value15. This is
significant because there is a risk that the implementation of systems which appear to be based on a cost reduction imperative
will compromise patient experience and quality of life.
m) We think that in future a hospital must work for the healthcare community as a whole, taking some responsibility for the whole
population it serves. We know that primary care and community services cannot care for patients with chronic illness alone. The
‘whole person’ approach makes the point that patients, many of whom have multiple chronic illnesses, do not want to be seen by
various separate specialist teams with further fragmentation of care13. We agree. As shown in our survey specialists can work to
pass knowledge and support into the community and interact with the generic community team as a whole. They form a bridge
between acute care and community teams, primary and social care6.
The role of the Respiratory Specialist in the provision of Integrated Care and Long Term Conditions Management October 2014 | 4
Why respiratory specialists have a key role to play in integrated care
a) Respiratory disease encompasses over 30 different lung
conditions, which combined with the fact that the most
common symptom of breathlessness is shared with
dysfunction of other systems, (e.g., cardiovascular disease,
or systemic disease) can make the diagnosis of lung disease
difficult. Respiratory medicine is multifaceted and requires
a level of skill and knowledge in order to effectively manage
these patients.
b) Pneumonia, COPD and asthma are the most frequent causes
of acute hospital admissions and primary care consultations.
Acute exacerbations of COPD are the second most common
cause of emergency admission and also carry one of the
most costly tariffs. In addition, half of these admissions are
in people below retirement age. Sadly, 12% are readmitted
within 30 days for the same condition3.
c) Acute medical admissions continue to rise year on year
and although the increase in the ageing population is an
important contributor this accounts for only a half of the
overall increase16.
d) Repeated studies have demonstrated that primary care,
community services and social care working alone cannot
improve this situation. It is clear that secondary care
specialist should be more aware of our responsibility for the
welfare of populations, not just the patient before us. It is
common to find that diagnostic registers looking to confirm
the diagnosis of COPD show that between a quarter and
a third of the time, that the diagnosis and treatment are
incorrect. This leads to waste, poor value and harm17,18.
e) Most management of disease is in the community and it is no
longer acceptable to ‘squirrel away’ knowledge in hospitals.
Best care comes from teams working together and sharing
expertise to a common aim, specialists supporting the
community they serve11, 19, 20.
f)
The BTS survey demonstrated that there are a few
specialists in the UK who work within the community in this
way. Working alone or as joint leads (with other consultants,
or nurse specialists or respiratory physiotherapists), they
see a role in the training and education of generic community
teams in the understanding of respiratory diagnosis and
self-management. Others have worked with primary care
teams helping to clean up diagnostic registers and interpret
NICE guidelines to produce savings to be reinvested by
commissioners in activities providing better value18, 21.
g) The survey showed others working with community clinics,
pulmonary rehabilitation and oxygen assessment. One
interviewee described the importance of working with a
medical admissions unit, using discharge bundles of care and
early discharge teams interfacing with community nurses
and community clinics6.
h) Our aim is to provide a structured model of care with
commissioned components that deliver pro-active care
given by a well-trained team to educated patients, able to
self-manage their illness.
i)
Although this document reflects the challenges for
Respiratory specialist working in this new way, it is not unique
to respiratory medicine. Integration of care impacts similarly
on other specialist area working in an integrated role, e.g.
Gerontologist etc. There is a lot we can learn/share with
other specialities to ensure this new role works to benefit
the lives of patients and the overall healthcare community.
Case Studies
The Chronic Care Model is an evidence-based framework that describes changes to the healthcare system that help to improve
outcomes for patients with chronic disease. For chronic respiratory disease the components required for patient centred co-ordinated
care, integrated across organisations have been reported to improve care, produce better outcomes and reduce hospital attendances22.
It is however important that all of the components of the model are in place, using only one or two negates the effect10, 11, 23. The Chronic
Care Model has been shown to improve patient outcomes and reduce hospital admissions for COPD by up to 30%23.
The components are in 4 main groups;
i.
Patient education and management including pulmonary rehabilitation.
ii.
Decision support systems including care and discharge bundles, guidelines and staff education.
iii.
Delivery design systems including the commissioning of different providers in a way that provides incentives for team working.
iv.
Clinical information, including risk profiling, disease registers, sharing of information. Measurement of variation and outcomes.
The role of the Respiratory Specialist in the provision of Integrated Care and Long Term Conditions Management October 2014 | 5
The following case studies demonstrate the benefit of involving respiratory specialists in integrated care pathways using the Wagner
Long Term Conditions model22.
i.
Patient education and management including pulmonary rehabilitation
Isle of Wight General Practice
The practice nurse at one Isle of Wight practice reviewed patients’ medication and also discussed self-management action plans with patients
to ensure they were clear about how to recognise changes in symptoms and what to do. This was backed up with a written action plan and
where appropriate rescue medication. Changes in individual patient behaviour were anecdotally reported and data also suggested a change in
use of urgent, booked and telephone appointments as a result, particularly for high impact users. Where new COPD action plans were agreed
with 20 patients, the practice saw a reduction in their use of emergency GP appointments over the next 6 – 8 months of 33%; telephone
contacts reduced by 65% and booked appointments reduced by 31%18.
Reduction in service use
Service
Cost per visit
Low-intensity users
Medium-intensity users High-intensity users
GP visits
£34
32%
36%
Outpatient
£98
39%
44%
49%
A&E
£83
32%
36%
40%
Inpatient
£1,576
26%
29%
32%
£185
£293
£559
Savings per person
40%
ii.
Decision support systems including care and discharge bundles, guidelines and staff education
Discharge Care Bundles London
Bundles of care can be used to reduce variation in care. Evidence has demonstrated that discharge bundles that promote the use of a small
number of evidence based measures in COPD and incentivise their use have beneficial effects across organisations.
In London discharge bundles systematised care in COPD across organisations led to improved referral for smoking cessation (18.2% to 100%),
use of pulmonary rehabilitation (18.2% to 68%) and self-management (54.6% to 97.9%). The 30 day readmission rate fell to 10.8% from
16.4%24.
iii.
Delivery design systems including the commissioning of different providers in a way that provides incentives for team working.
Stoke and North Staffordshire PCT
In 2009/10 a whole system review was conducted of COPD management that included patients, carers and healthcare professional. Following
this review Stoke and North Staffs PCT commissioned a new respiratory service. This contract is held by the large community trust that have
several hospitals with imaging and clinic facilities that surrounded the single large acute trust. The community trust bought 7 consultant
sessions from the acute trust to support 6 clinics closer to the patient’s home and a Multi-disciplinary team. To facilitate these changes
educational programmes were developed and attended by both the community team and the consultants from the Acute Trust.
The community team provides a
•
diagnostic spirometry service with education and provision of spirometers
•
an oxygen service
•
pulmonary rehabilitation
•
patient support- this acts both as a step up from GP / acute community teams and step down from the acute trust
•
innovations include the widespread use of information, including self-management of exacerbations and oxygen toxicity alerts
A weekly MDT with a consultant from the acute trust, the community team and any other staff who wish to attend “virtually reviews” patients
currently being managed and also provides a strategic and governance role.
The MDT triage new referrals from primary care and over the last 3 years only 16% of patients were deemed to need an appointment at the
acute hospital, 34% being seen in one of the community medical clinics.
The role of the Respiratory Specialist in the provision of Integrated Care and Long Term Conditions Management October 2014 | 6
iv.
Clinical information, including risk profiling, disease registers, sharing of information. Measurement of variation and outcomes
Mansfield and Ashfield Clinical Commissioning Group
Mansfield and Ashfield CCG ran a project to improve management of COPD patients in primary care, from diagnosis through to selfmanagement. The project team identified three practices to work with initially and in each of the practices’ the COPD registers were reviewed.
This work was undertaken by the Respiratory Nurse Educator and a designated Primary Care Pharmacist. They used agreed COPD guidelines
and system one templates to analyse disease registers and risk profile the population.
Individual patients’ notes were reviewed, screening for patients with:
•
a dual diagnosis of asthma and COPD
•non-smokers
•
BMI >35
•
>3 exacerbations in a 12 month period
•
recurrent hospital admissions
•
FEV1 >50% and on inhaled corticosteroid, triple therapy or other inappropriately prescribed medications
•
FEV1/FVC ratio >70, MRC 3, 4 or 5 and high DOSE score >4
The Respiratory Nurse, alongside the pharmacists, reviewed the patients’ records to identify any areas of diagnosis or management that
could be improved.
There were a significant number of patients on triple therapy or on separate inhaled corticosteroids with an FEV1 >50% predicted. The quality
of the spirometry was varied and in some cases results were entered incorrectly on templates or Read coded incorrectly. There were patients
with recurrent exacerbations that had not been referred for further investigations. House bound patients or patients under Community
Matrons had no spirometry done - this has been identified as a training need for Community Matrons.
Of the 222 patients reviewed, 27 were removed from the register and a further 8 referred on for further investigation. For the CCG as a whole
improved quality of care was accompanied with £170,000 savings, mainly from overprescribing18.
Next Steps
iii.
a) Development of Integrated Respiratory specialist job
description with core skills, responsibilities and roles.
b) Engage with partners including other Specialist Societies to
explore the future roles of specialists in respiratory medicine
interacting with an integrated care team.
c) In this way, and building on the information gained from our
recent research, we will continue to develop and promote
our recommendations about specific model(s) of care for
people with respiratory chronic illness and at the end of life.
d) It is likely from our research to date that a “one size fits all”
model will not be appropriate. There are however some
important cross-cutting skills which Respiratory specialists
wishing to engage in integrated care will need to acquire.
i. Training in diagnostic registers, risk profiling and self-
management.
ii. Use of national data to support audit, measurement of variation in outcomes across a healthcare community.
Methods of commissioning care using ‘value chains’ or other similar ways which incentivise
providers to work together within a team. E.g. lead
provider models, or an alliance of provider models
iv. Training in chronic disease management.
v. Training in health delivery to populations, population healthcare.
e) We will seek changes to the medical training curriculum in
discussions with the SAC (Specialist Advisory Committee)
for Respiratory Medicine to cover the key components of
training that a consultant might require.
f)
The BTS website to host a collection of relevant materials
and links to other significant sources of information which
will be regularly updated.
g) Actively engage members and others using social media and
targeted messaging and a question and answer forum.
The role of the Respiratory Specialist in the provision of Integrated Care and Long Term Conditions Management October 2014 | 7
References
1. Gibson GT, Loddenkemper R, Sibille Y, Lundback B. The European Lung White Book. European Respiratory Society 2013.
http://www.erswhitebook.org/
2. Office for National Statistics. What are the top causes of death by age and gender? 2013: http://www.ons.gov.uk/ons/rel/vsob1/
mortality-statistics--deaths-registered-in-england-and-wales--series-dr-/2012/sty-causes-of-death.html
3. NHS Right Care & Eastern Region Public Health Observatory. The NHS atlas of variation on Healthcare for People with Respiratory
Disease September 2012. http://www.rightcare.nhs.uk/index.php/atlas/respiratorydisease/
4. NHS: An Outcome strategy for COPD and Asthma. NHS Companion document. May 2012
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216531/dh_134001.pdf
5. Partridge MR. Consultant Physicians in Integrated Respiratory Care -A discussion paper from the British Thoracic Society.
November 2007.
6. British Thoracic Society Steering Committee. The role of the respiratory specialist in the integrated care team. June 2014.
https://www.brit-thoracic.org.uk/delivery-of-respiratory-care/integrated-care/
7. BTS and PCRS-UK joint working group 2006
http://www.impressresp.com/index.php?option=com_content&view=article&id=96&Itemid=55#sthash.HhqfPWnX.dpuf
8. Department of Health. Transforming Community Services: Ambition, Action, Achievement Transforming Services for People with
Long Term Conditions (2009)
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215780/dh_124195.pdf
9. Department of Health. Supporting People with Long Term Conditions. An NHS and Social Care Model to support local innovation
and integration (2005) http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/
groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4122574.pdf
10. MacColl Centre for Health Care Innovation USA, The improving chronic illness care programme. The Chronic Care Model
http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2
11. Goodwin, N., Smith, J., Davies, A., Perry, C., Rosen, R., Dixon, A., & Ham, C. (2012). Integrated care for patients and populations:
Improving outcomes by working together. London: King’s Fund.
http://www.kingsfund.org.uk/sites/files/kf/integrated-care-patients-populations-paper-nuffield-trust-kings-fund-january-2012.
pdf
12. Stevens, S. Chief Executive, NHS England Department of Health (2014)
http://www.england.nhs.uk/2014/04/01/simon-stevens-speech/
13. Collins, Alf, and Anya De Longh. “Independent Commission on Whole Person Care for the UK Labour Party.” BMJ 2014: 348 doi:
http://www.yourbritain.org.uk/uploads/editor/files/One_Person_One_Team_One_System.pdf
14. What patients want from integration National Voices January 2012.
http://www.nationalvoices.org.uk/sites/www.nationalvoices.org.uk/files/what_patients_want_from_integration_national_
voices_paper.pdf
15. Michael E, Porter, PhD. What is Value in Health Care? New England Journal of Medicine 2010; 363:2477-2481 December 23, 2012.
http://www.nejm.org/doi/full/10.1056/Nejmp1011024
16. Royal College of Physicians. Hospitals on the edge? A time for action. Royal College of Physicians September 2012.
http://www.rcplondon.ac.uk/sites/default/files/documents/hospitals-on-the-edge-report.pdf
17. Jones RCM, Spillmann M, Mather MJC, Marks D, Shackell BS. Accuracy of diagnostic registers and management of chronic
obstructive pulmonary disease: the Devon primary care audit. Respiratory Research 2008; 9:61.
http://www.ncbi.nlm.nih.gov/pubmed/18710575
18. NHS Improvement Lung. NHS East Midlands COPD Network. Managing COPD in Primary care improvement toolkit 2012.
http://www.emcopdnetwork.nhs.uk/model-of-care
The role of the Respiratory Specialist in the provision of Integrated Care and Long Term Conditions Management October 2014 | 8
19. Royal College of Physicians. RCP briefing. Health reforms: The modern hospital. September 2011.
http://www.rcplondon.ac.uk/sites/default/files/health-reforms-briefing-organisation-of-modern-hospital-servicesseptember-20-11.pdf
20. Royal College of Physicians, Royal College of General Practitioners & Royal College of Paediatrics and Child Health. 2008. Teams
without walls. The value of medical innovation and leadership.
http://www.bacch.org.uk/publications/documents/teams-without-walls.pdf
21. Williams S, Baxter N, Holmes S, Restrick L, Scullion J, Ward M. British Thoracic Society Reports, Vol 4, Issue 2, 2012. IMPRESS Guide
to the relative value of COPD interventions
http://www.impressresp.com/index.php?option=com_docman&task=doc_view&gid=52&
22. Wagner EH Chronic disease management, What will it take to improve care for chronic illness Effective Clinical Practice 1998 AugSep: 1(1) 2-4
http://www.ncbi.nlm.nih.gov/pubmed/10345255
23. Adams SG, Smith PK, Allan PF et al. Systematic review of the chronic care model in chronic obstructive pulmonary disease
Prevention and management. Arch Intern Med 2007; 167:551-561. http://www.ncbi.nlm.nih.gov/pubmed/17389286
24. Hopkinson NS, Englebretsen C, Cooley N et al. Designing and Implementing a COPD discharge care bundle.2011 Thorax
doi:10.1136/thoraxjnl-2011-200233 http://thorax.bmj.com/content/67/1/90.full
Appendix
Possible elements of the role and scope for the Respiratory Specialist Consultant in integrated respiratory care:
•
Promote integration of respiratory care across primary, secondary and social care
•
Provide medical leadership and support to respiratory nursing/MDT, community teams, open access spirometry services, oxygen assessment services, and pulmonary rehabilitation
•
Support GP spirometry services for those GPs who wish to perform their own diagnostic tests
•
Provide medical leadership to the COPD admission avoidance and early discharge schemes, pulmonary rehab service
•
Act as a learning resource and to provide continuing education for primary care physicians, practice and district nurses and community matrons
•
Work with cardiologists on developing a community based breathlessness clinic
•
Work with others to promote better end of life care for those with severe lung disease
•
Develop advanced respiratory support in the community for those needing home ventilation and follow up services for those on CPAP for Obstructive Sleep Apnoea syndrome
•
Undertake ongoing local audits of respiratory care such as those recommended by the recent report of the National Review of Asthma Deaths
British Thoracic Society
Registered Office: 17 Doughty Street, London WC1N 2PL
Registered as a Charity in England and Wales with number 285174 and registered in
Scotland with number SC041209. Company Registration No. 1645201
www.brit-thoracic.org.uk