Agenda item

Rotherham Respiratory Pathway

Jacqui Tuffnell, Head of Commissioning at Rotherham Clinical Commissioning Group to present.


Jacqui Tuffnell, Head of Commissioning at Rotherham Clinical Commissioning Group (CCG) delivered a short presentation to update Members on developments since September following the public consultation.



The NHS 10 year plan stresses the need to develop better integrated care pathways with emphasis upon Primary Care Networks, with practices working together at scale, with a combined workforce to better care for patients.


Right Care Data – highlights

        Rotherham has high cost respiratory services, high admission levels and poorer outcomes for our patients than our counterparts across the integrated care system – as things had moved on quicker elsewhere.

        Non elective admission levels are high particularly for chronic lower respiratory, especially COPD.

        Asthma, influenza and pneumonia were also highlighted as areas where Rotherham admitted more non-electively than the right care peer group.


Respiratory health outcomes – Under 75 mortality rate ‘preventable’

2015-17 data showed Rotherham had a rate of 25.4% and a ranking of 12th highest of 15 local authorities in Yorkshire and Humber, where the average was 22%.  The England average was 18.9%.  Deprivation was a factor in Rotherham being an outlier.


Respiratory disease in the North East and Yorkshire

Impact on Urgent and Emergency Care (2017-18)

-        Highest rate of emergency admissions for (Chronic Obstructive Pulmonary Disease (COPD)

-        Last two winters non-elective admissions (NEL) for adults up to 4.400 admissions in a single week

-        Opportunities to reduce respiratory bed days (136,000), primary care prescribing (£25m) and NEL spend (£38m)


-        Flu and pneumonia

o   33,500 more patients could receive the PPV vaccine

o   25,500 more patients aged 65+ could take up the seasonal flu vaccine

o   4,200 more patients with COPD could receive an influenza immunisation

-        COPD

o   24,400 more people with COPD could be registered

o   2,500 more people with COPD could have diagnosis confirmed by spirometry

o   6,000 more people could have a review by an HCP


Right Care was part of the NHS which looked at peers and changes achieved elsewhere.  Although people may choose not to have vaccines, Rotherham could do better on this.


Local Challenges

        Fragmentation across the respiratory pathway

        Fragmentation of the home oxygen service

        Inconsistent diagnosis across Rotherham – it was important to get the diagnosis right at the beginning

        Inconsistent management of respiratory patients across the system

        High admissions to hospital, which could have been prevented

        Low uptake of smoking cessation

        No respiratory Community team – now best practice


56% of the admissions to Breathing Space could have been avoided with support in the patient’s own home from a Community Respiratory Team, saving 156 bed days.


Patient Engagement Feedback

        Timely access to primary care  - Day time, evenings and weekends for reviews and feel unwell

        Pulmonary rehabilitation closer to home and at evenings and weekends – at more convenient times

        Alternative access to care and information via APPs and websites, phone and video – being confident to use these

        Faster discharge from hospital with specialist support at home

        Consistent information on how to manage their conditions


Rotherham Opportunities

        We could detect and diagnose 2,366 more patients with COPD

        Spirometry – diagnosis and measuring disease progression

        Annual reviews of people with COPD and asthma

        We are doing well on pneumonia and influenza vaccination over 65s compared with elsewhere in the North East and Yorkshire

        RCCG spending just over £1 million more on prescribing than lowest 5 peers – this related to types of inhaler and also to inappropriate use of inhalers that led to waste


Training in practices was not always up to date.


Proposed Model


Self care would be promoted at all levels across the system and was an important element of the model.  Community Matrons were doing and excellent job, especially this winter when the system faced greater pressures.  the Specialist Respiratory Pharmacist was a new role and would help to ensure people had the right inhaler and their expertise would be used to advise GPs.


Tier 1 – Primary Care

-   Supports patients requirements for day, evening and weekend reviews

-   Supports PCN requirements of working at scale

-   Provides consistency and equity of care

-   Good feedback from present hub services across primary care

-   Hub can be supported by a specialist respiratory clinical pharmacist , who also supports in the community

-   Hubs could support new roles such as physiology apprentices and physician associates


This would entail delivery of the right training to be able to provide better support.  New roles would supplement the existing workforce and help to address the shortage of GPs and Advanced Nurse Practitioners.  Regarding consistency and equity of care, the 30 practices in Rotherham all did things slightly differently at present, so this would lead to the same level of care in all.


Tier 2 - Community Respiratory Service based at Breathing Space

        Outpatient clinics

        Rapid access clinic/hotline – same day appointments

        Housebound patient management

        Assessment and management

        End of life care management

        Pulmonary rehabilitation /physiotherapy

        Enhanced CTB: psychology input & support

        Discharge management for inpatients

        Early supported discharge follow up within 2 days

        Clinic reviews (caseload)

        Management plans for primary care follow up -  good, consistent plans for all patients

        Discharge to tier 1 &Community Matron

        Telephone Advice for Tiers 1 & Community Matrons

        Training for primary care (PCN footprint) – upskilling so this was uniform

        High intensity User – Targeted support

        Admission avoidance

        Virtual clinic/MDT – reviews could be by telephone or Skype


Tier 3 – Acute Care hospital based

        Acute admissions

        Inpatient pulmonary rehabilitation

        NIV assessment & management

        Inpatient discharge to tier 3

        Outpatient discharge back to tiers 1 and 3

        Complex co-morbidities

        Deterioration beyond expected rate


Positive feedback had been received regarding the respiratory unit at Rotherham Hospital which focused on all acute admissions.


Following the presentation Health Select Commission watched a short animation about the proposed service changes, which was welcomed as a positive means of presenting information:


Members commented that access to services rather than existing services would be modified and wondered what the impact would be on primary care.  It was confirmed that first and foremost people would go to primary care, as with diabetes, with support to GPs from Breathing Spaces rather than directly to a specialist team.  


This was followed up by a question around the ability of GPs to do this in a timely way given that access to GPs for an appointment was a mixed picture and whether this issue could have a negative impact on the whole model.  The CCG confirmed that a significant amount of work had gone in to increasing the number of appointments, with more available last year than ever and greater capacity in the system than the required number of appointments.  As discussed before, the issue was often one where patients wanted an appointment with a specific GP at a certain time and if that GP only worked two days each week that would create a wait.  For regular health checks patients were able to get a routine appointment in five days.  This was one of the reasons for working on a hub basis sharing resources, so not all 30 practices would be trained on spirometry as some did not see sufficient volumes of patients to undertake the diagnostics.  There would also be a hotline between Breathing Spaces and GPs for patients who needed support at home.  It was agreed that concerns about a specific practice would be taken back. 


Communications were important and there was still a lack of awareness about the hubs.  An additional extended access hub had been established on site at the hospital to support them with capacity and people would be triaged and moved to that and seen within an hour.  It would also be made clear to patients when they did not need to have gone to the Urgent and Emergency Care Centre (UECC) for care and should have been seen either by their own GP or at a hub.  The Chair asked whether take up of Sunday appointments at the hubs had increased and it was now approximately 50%.  The extended hours hub at the hospital was there seven days a week including all day on Saturdays with around 30 patients moved from the UECC and some direct bookings there from a patient’s own GP.


In terms of patients going to the hospital by ambulance, for example with a severe asthma attack, the question was asked about rapid access into hospital and whether patients would go directly to ward A3 rather than to the UECC given the potential waiting times reported recently.  It was clarified that they would go to the UECC first for assessment and once their condition was settled would then be transferred to the respiratory ward.  Reassurance was provided that patients with breathing difficulties would be seen quickly.


Regarding the statistics presented for the North East and Yorkshire, Members inquired about specific indicators for Rotherham and what success would look like and how it would be reported.  A clear specification had been developed which was an amendment to the present one as community services had been planned but not implemented.  Reduced hospital admissions would be one measure but full detail on the key performance indicators would be shared with Health Select.


With regard to the response rate to the survey, it was noted that 773 people accessed the survey but only 443 fully completed responses were received and if this signified difficulties with completion.  Some surveys were only partial responses as not all questions were relevant to all patients.  The response rate was around 62%.  Clearly it would be better to have a 100% response rate and questions had been asked about the ease of completion in some of the sessions but no-one had reported any difficulties.  It was clarified that the service was for over 18s so no children and young people had been surveyed.  Further detail around survey responses and numbers would follow. 


The new model would be implemented in a phased approach working towards the full structure being in place by winter 2020.  Recruitment processes had commenced with the hospital, the business case had been signed off and the service specification developed.  Funding for staffing resources also been agreed, with the first three staff members for the new structure recruited.  Members requested a progress update later in the year.


Members reiterated their previous concerns about digital inclusion with the focus on apps, websites and twitter and sought assurance that other means of contact and communications would continue to be employed.  Telephone calls and letters would still be used and patients would identify their preferred means of contact.


Regarding the inconsistency referred to between GPs it was clarified that some GPs proactively managed patients with respiratory conditions whereas others referred them straight to Breathing Space without attempting to manage those conditions.  So the ambition in the new pathway was to provide the same level of care.  In terms of referring to end of life care assurance was sought that this would be handled sensitively with patients due to the potential psychological impact.


In terms of asbestosis and where this fitted in the model this was a more specialised service and the Sheffield respiratory team provided support for  Rotherham patients.


The Head of Commissioning was thanked for her presentation by the Chair.




1)    To note the information provided.


2)    To schedule a further update in the work programme for October 2020 when the full new structure would be in place.

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