PRELIMINARY  DRAFT  FOR  DISCUSSION  

Developing  together  the     blueprint  for  a  sustainable     health  care  system     for  West  Kent  

Mapping  Event  –  Respiratory  LTCs/COPD   Case  for  Change   Jun  7,  2013  

PRELIMINARY  DRAFT  FOR  DISCUSSION  

COPD/Respiratory  Long-­‐term  condiRons  

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PRELIMINARY  DRAFT  FOR  DISCUSSION  

COPD  is  …   C  

Costly  for  the  NHS  in  West  Kent  

£40m  resp.   care,  £35m   prod.  loss  

O  

OYen  treatable  if  detected  early  

>80%  due  to   smoking  

P  

Prevalent  widely  

1  in  8  over   35;  3m  in  UK  

Deadly  and  debilitaRng  

1  death   every  20min   in  UK  

D  

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PRELIMINARY  DRAFT  FOR  DISCUSSION  

COPD  has  mulRple  debilitaRng  stages  

C   O   P   D  

•  COPD  is  characterised  by  limitaRon  of  airflow  in  the   lungs   •  However  it  also  has  other  pulmonary  effects  such  as   muscle  wasRng  and  weight  loss,  pulmonary   hypertension,  enlargement  of  the  right  side  of  the   heart,  anxiety  and  depression   •  It  is  a  chronic  condiRon  and  has  four  stages,  ranging   from  Mild  airflow  limitaRon  to  Very  Severe   respiratory  failure  

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PRELIMINARY  DRAFT  FOR  DISCUSSION  

COPD  is  a  debilitaRng  disease  

C   O   P   D  

•  COPD  is  disabling:  those  with  COPD  oYen  have  breathlessness,  reduced   exercise  tolerance,  a  cough  and  repeated  chest  infecRons.  The  overall   quality  of  life  for  people  with  advanced  COPD  is  4X  worse  than  that  for   people  with  severe  asthma   •  A  study  in  2007  found  that  90%  of  people  with  severe  COPD  were  unable   to  parRcipate  in  socially  important  acRviRes  such  as  gardening,  66%  were   unable  to  take  a  holiday  because  of  their  disease  and  33%  had  disabling   breathlessness.  For  those  with  the  disease  in  its  more  severe  forms,   rouRne  daily  acRviRes  such  as  geing  dressed,  washing  or  climbing  stairs   become  difficult  or  impossible   •  Problems  with  restricted  mobility  are  compounded  by  social  isolaRon  and   poor  self-­‐esteem.  A  significant  proporRon  of  people  with  COPD  suffer  from   depression,  anxiety  disorders  and  other  significant  social  care  needs  

5   Source:  DH  Outcomes  strategy,  2012;  Respiratory  Report  West  Midlands,  2012  

PRELIMINARY  DRAFT  FOR  DISCUSSION  

Deaths  from  COPD  are  increasing  

C   O   P   D  

•  One  person  dies  from  COPD  every  20  minutes  in  England  (30,000   deaths  a  year  in  England,  276  deaths  a  year  in  West  Kent)  (about  5%   of  all  deaths)   •  People  with  severe  (stage  4)  COPD  have  a  five-­‐year  survival  rate  of   24%-­‐30%;  Death  rates  from  COPD  in  England  are  almost  double  the   EU  average   •  15%  of  people  admined  to  hospital  with  COPD  die  within  3  months   and  an  esRmated  25%  will  die  within  a  year  of  admission   •  Over  70%  of  paRents  who  die  from  COPD  die  in  hospital,  with  only   20%  dying  at  home   •  Less  that  5%  of  paRents  with  COPD  have  access  to  palliaRve  care   •  A  study  in  2005  found  that  in  the  last  year  of  life,  40%  of  people   with  COPD  had  breathlessness  unrelieved,  68%  had  low  mood   unrelieved  and  51%  had  pain  unrelieved   6   Source:  DH  Outcomes  strategy,  2012;  Yorkshire  &  Humber  Respiratory  Programme  Report,  2013  

PRELIMINARY  DRAFT  FOR  DISCUSSION  

COPD  is  widespread  

C   O   P   D  

•  In  2009/10  there  were  861k  paRents  on  COPD  registers  in   England.  However,  there  are  thought  to  be  up  to  2  million   undiagnosed  cases  in  UK     •  One  in  8  people  over  age  of  35  has  COPD  that  has  not  been   properly  diagnosed;  over  15%  are  only  diagnosed  when  they   present  to  hospital  as  an  emergency   •  Over  50%  of  people  currently  diagnosed  with  COPD  are  under   65  years  of  age   •  There  is  no  single  diagnosRc  test  for  COPD;  oYen  spirometry  is   performed  incorrectly  leading  to  incorrect  diagnoses;  a   naRonal  survey  revealed  that  only  12%  of  nurses  undertaking   spirometry  had  received  accredited  training   7   Source:  Kent  COPD  Health  Needs  Assessment,  2010  

PRELIMINARY  DRAFT  FOR  DISCUSSION  

COPD  is  frequently  missed  

•  •  •  • 

C   O   P   D  

COPD  paRents  on  West  Kent  GP  registers:  8,720   About  ~40%  of  COPD  paRents  (~4,000)  in  West  Kent  are  missing  from  GP  registers   There  are  significant  differences  among  GP  pracRces,  with  prevalence  varying  from   0.5%  to  over  4%  (West  Kent  average:  1.3%)   10%  of  acute  admissions  for  COPD  are  in  people  without  a  prior  diagnosis  of  the   condiRon   8  

Source:  Kent  COPD  Health  Needs  Assessment,  2010  

PRELIMINARY  DRAFT  FOR  DISCUSSION  

C   O   P   D   COPD  is  oYen  present  alongside  other  condiRons  

Almost  all  Band  1  (highest   risk)  paRents  with  COPD  also   had  some  other  condiRon  

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PRELIMINARY  DRAFT  FOR  DISCUSSION  

C   O   P   D  

COPD  is  responsible  for  a  significant  proporRon  of  emergency   admissions  for  ambulatory  care  sensiRve  condiRons  

• 

Respiratory  long  term  condiRons  including  COPD  accounted  for  2,000  admissions   and  19,300  bed  days  in  2011-­‐12  for  WK  paRents  over  65  (this  makes  up  70%  of  all   Respiratory  admissions  and  bed  days)   10  

C   O   P   D   Smoking  is  the  single  biggest  risk  factor  for  COPD  

PRELIMINARY  DRAFT  FOR  DISCUSSION  

•  About  85%  of  deaths  due  to  COPD  can  be  anributed   to  smoking;  In  England,  smoking  causes  35%  of  all   respiratory  deaths  and  29%  of  all  cancer  deaths   •  Around  half  of  all  cigarene  smokers  develop  some   airflow  obstrucRon;  10%-­‐20%  develop  clinically   significant  COPD   •  EsRmated  prevalence  of  COPD  in  people  with  lung   cancer  is  between  50%  -­‐  65%   •  Cigarene  smoking  is  also  the  main  preventable  cause   of  lung  cancer:  lung  cancer  is  twice  as  common  in   men  with  COPD  and  four  Rmes  as  common  in   women  with  COPD   11   Source:    ASH  Fact  Sheet,  2011  

C   O   P   D   Smoking  cessaRon  is  oYen  the  most  effecRve  opRon  

PRELIMINARY  DRAFT  FOR  DISCUSSION  

In  terms  of  ‘Value  for  Money’,  the  most   effecRve  intervenRons  are:     Mild  to  moderate  COPD:  Exercise  or   Smoking  cessaRon     Severe  COPD:  Pulmonary  rehab     Undiagnosed  COPD:  Smoking  cessaRon  

12   Source:  Commissioning  for  value,  Impress,  Winter  BTS  2013  

PRELIMINARY  DRAFT  FOR  DISCUSSION  

Other  treatment  opRons  do  exist  

C   O   P   D  

NICE  defines  an   intervenRon  to  be  cost-­‐ effecRve  if  it  costs  less   than  £20,000-­‐£30,000   per  quality-­‐adjusted  life   year  (QALY)  gained  

13   Source:  Yorkshire  &  Humber  Respiratory  Programme  Report,  2013  

C   O   P   D   EffecRve  implementaRon  can  have  a  significant  impact  

PRELIMINARY  DRAFT  FOR  DISCUSSION  

•  Quiing  smoking  when  COPD  symptoms  are   moderate  leads  to  a  decline  in  symptoms  similar  to   that  of  healthy  never-­‐smokers   •  If  all  CCGs  in  England  were  to  achieve  the  COPD   mortality  rates  of  the  top  25%  best  performing  CCGs,   around  7,800  lives  would  be  saved  each  year  

14   Source:  NHS  Atlas  of  VariaRon  in  Healthcare  for  People  with  Respiratory  Disease,  Sep  2012  

C   O   P   D  

PRELIMINARY  DRAFT  FOR  DISCUSSION  

COPD  has  a  significant  health  and  societal  cost  

COPD  in  West  Kent  

Asthma  in  West  Kent  

221,000  working  days  lost   each  year   £35m  lost  from  reduced   producRvity  

£9m  in  healthcare  spend   each  year   9  deaths  in  West  Kent  each   year  

15   Source:  NHS  Atlas  of  VariaRon  in  Healthcare  for  People  with  Respiratory  Disease,  Sep  2012  

PRELIMINARY  DRAFT  FOR  DISCUSSION  

West  Kent  performance  appears  good…  

C   O   P   D  

Spend and outcome relative to all other CCGs in England Higher Spend, Better Outcome

Lower Spend, Better Outcome

2.5 2.0

Health Outcome Z score

1.5 Neo

1.0 Dent

0.5 0.0

CircGastro Mat Inf Canc End,Neuro MH,Resp Vision,Trauma Blood Pois LD,Skin Hear,Soc

-0.5

Musc,GU

-1.0

Hlth

-1.5 -2.0 -2.5 -2.5

-2.0

Lower Spend, Worse Outcome

-1.5

-1.0

-0.5

0.0

0.5

1.0

1.5

2.0 Spend, 2.5 Higher Worse Outcome

Spend per head Z score

16   Source:  Spend  and  Outcomes  Analysis  Tool,  Public  Health  England,  2013  

C   O   P   D   …  but  not  as  good  as  performance  of  peer  regions  

PRELIMINARY  DRAFT  FOR  DISCUSSION  

17   Source:  Spend  and  Outcomes  Analysis  Tool,  Public  Health  England,  2013  

C   O   P   D   West  Kent  COPD  performance  can  be  improved  (1/3)  

PRELIMINARY  DRAFT  FOR  DISCUSSION  

NHS  West  Kent  CCG  

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C   O   P   D   West  Kent  COPD  performance  can  be  improved  (2/3)  

PRELIMINARY  DRAFT  FOR  DISCUSSION  

Maidstone  Hospital  

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C   O   P   D   West  Kent  COPD  performance  can  be  improved  (3/3)  

PRELIMINARY  DRAFT  FOR  DISCUSSION  

Tunbridge  Wells  Hospital  

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PRELIMINARY  DRAFT  FOR  DISCUSSION  

PracRce  benchmarking  results  

Source:  GP  PracRce  Index  2nd  Ed,  Dr  Foster  Intelligence,  2011   Note:  this  refers  to  West  Kent  PCT,  not  West  Kent  CCG  

C   O   P   D  

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PRELIMINARY  DRAFT  FOR  DISCUSSION  

Breakdown  of  spend  on  respiratory  care  

C   O   P   D  

PCT-­‐level  expenditure  (£m)  in  2010-­‐11;  Total  =  £4,272.3m   100%  

1.3%   3.4%   0.2%   4.4%  

PrevenRon  &  Health   PromoRon   Primary  care   31.1%  

Ambulance/A&E/MIU  

90%   80%   Other  

70%   60%  

OP  

50%   Secondary  care   Community  care   54.0%  

5.6%   Health  &  social  care   Non-­‐health/social  care  

40%   30%  

Non-­‐ elecRve  IP  

20%  

ElecRve  IP  

10%   0%   Secondary   care  

EsRmate  of  total  cost  of  COPD  in  West  Kent:     £39.3m   22   Source:  Impress  guide  to  relaRve  value  of  COPD  intervenRons,  Impress,  2012  

PRELIMINARY  DRAFT  FOR  DISCUSSION  

Working  groups   Bob  Bowes   Karen  Ponerton   Michael  Roberts   Paul  Sigston   Ravish  Makragod   Nikki  Clarke   George  Gammon   Derrick  Mason  

Ian  Ayres   Stefano  SanRni   MalR  Varshney   Paula  Parker   Syed  Arshad  Husein   Lawrence  Sopp   Sue  Stonbridge   Tony  Broadrick  

Amit  Kumar   Abraham  George   James  Lampert   Steven  Kowlessur   Kathryn  Coleman/Louise   Roberson   Julie  Moore   Jennifer  Paulson  Ellis  

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