Evaluation of the Breathlessness Pilots, by OPM - an independent research organisation and consultancy

1. PRESENTATION BY:PRESENTATION BY:
Evaluation findings presentation
Lauren Roberts, OPM
Principal Consultant
Bethan Peach, OPM
Senior Consultant
Evaluation of the
Breathlessness Pilots
March 2016

2. CONTENTS
1. Overview of
the evaluation
brief
2. Evaluation
methodology
3. Key findings 4. Next steps
5. Q & A

3. • Did the pilot achieve its aims and objectives?
• Can the model be spread?
• Is there a convincing commissioning case?
• Which stakeholders have been involved?
• Are the new models sustainable?
• How important was clinical leadership to success?
• What are the staff and patient / carer experiences?
• What are the lessons learnt?
• What unintended outcomes are there?
• What improvements are needed?
OVERVIEW OF THE EVALUATION BRIEF
Formative and
summative learning
Case study learning
Programme-wide
learning
Build on the local
evaluations
Utilise secondary
data wherever
possible
Share emerging
insights

4. EVALUATION METHODOLOGY AND TIMEFRAME
30 Nov
31 Mar
• Project inception meeting
• Initial contact made with all site leads and key stakeholders
• Document review
• Scoping interviews – national and pilot site level
• Interim reporting
• Fieldwork with leads, clinicians, support staff and patients
• Secondary data analysis
• Case study development – drafting and validation
• Analysis and reporting
• Dissemination of the findings
12 Feb

5. FIELDWORK, DOCUMENTS AND DATA REVIEWED
- Prevalence data
- Medicines
management
savings
- IPSOS Mori
survey data
- Patient
experience
survey data
- Pilot site
applications and
Nov 2015
presentations
Report and
summaries of
background,
activities and
outcomes of the
pilot
- Patient
feedback
- Background
documents
- Secondary data
Ashton, Leigh and
Wigan
Wessex
Leicester, Leics
and Rutland
Programme
level
Interviews:
- Dame
Helena
Shovelton
- Dr. Mike
Morgan
- Dr. Erika
Denton
Steering group
meeting (Feb)
- 1-1 interviews with
the Lead Respiratory
Nurse, a GP and a
Consultant
- 2x patient
interviews
- Focus group:
Health First team
Semi-structured
interviews with 8
stakeholders,
including nurses,
programme leads
and GPs.
Site visits, inc. focus
group (5 people)
Semi-structured
interviews with 9
stakeholders,
including lead
specialist
consultants, other
clinic staff, the
programme lead
and a
commissioner.

6. SOME CAVEATS TO CONSIDER
Tight evaluation
timescales;
programme already
underway
Secondary
data
analysed /
written up
Lack of
primary
patient
experience
data
Final report
still be drafted
Case studies
being finalised
/ signed off
Interviews
and visits,
but no
observations
Small
sample sizes
in some
cases

7. Address contextual factors and challenges relating to diagnosing, treating
and managing breathlessness
Patients present with symptoms, not ‘diagnoses’, but there is a lack of
symptom-based services and interventions
Delays in diagnosis in both primary and secondary care:
•E.G. LLR: 18 week wait for clinic appointments and a further 18 week wait for some therapies.
•Primary care referral to either respiratory or cardiology can often be incorrect – yo-yoing
Breathlessness is often multi-factorial but co-morbidity is frequently
undetected in disease-specific services
Lack of knowledge across primary and secondary care of existing services;
inconsistency in available services.
BACKGROUND TO THE PILOTS

8. • Public health / lifestyle
• Improved uptake and
compliance
• Needs effectively addressed
• Capacity building for
practice nurses & GPs
• Reduced travelling and
appointments
• Understanding & chance to
ask questions
• Primary care follow up
• Active searching for
patients in primary care
• One stop shop with
different specialists
• MDT meetings
• Fewer referrals onward
• Develop breathlessness
pathway
• Diagnosis and results on
same day
• Reduced waiting times
Process
improvements
Integration of
primary and
secondary
care
Clinical
outcomes
Patient
experience
AIMS AND OBJECTIVES OF THE PILOTS

9. Breathlessness
service
Respiratory
and
Cardiology
Consultants
GPs, Practice
Nurses
Leads and
coordinators
Phsyios,
Physiologists,
Echo
Technician
Respiratory
Nurses
STAKEHOLDERS INVOLVED
Commis
-sioners
Patients

10. STAFF EXPERIENCE
• Enthusiastic,
passionate about
breathlessness
• Focus on solutions,
not ‘yo-yoing’
Motivation
• Awareness building
of other specialisms
• Increased
opportunities for
learning
Knowledge
• Confidence to call on
others
• Open and honest
dialogue
• Relationship building
Sense of team

11. PATIENT EXPERIENCELLR
• UHL survey of 10
patients attending
the clinic:
• All rated it as
excellent
• All were treated
with dignity and
respect
• All said their reason
for referral was
dealt with
satisfactorily
• All would
recommend the
service to F&F
WESSEX
• AHSN survey:
• 100% satisfied with
their experience
• 70% had good
compliance with
treatment
• 96% felt confidence
in managing
breathlessness
symptoms after the
clinic
ALW
• Health First survey
(136 patients):
• 94% felt the
clinician was
competent
• 94% rated the
overall experience
as excellent or very
good
• 90% felt involved in
planning their care
• 91% felt their
concerns were
addressed
• 92% felt treated
with dignity and
respect

12. PATIENT FEEDBACK
“When I asked questions I was given a direct
answer I could understand fully, which was
very reassuring.”
“There will be a check-up once
every six months, which I like. I like
to feel they’re keeping an eye on me
without having to ask.”
They specialise in one
thing and know what
they’re doing. When I
have tests done they
understand it better
than the doctor.”

13. PATIENT EXPERIENCE – CLINICIAN PERCEPTIONS
 More confidence in their diagnosis
and treatment - can see the team
working together.
 Better able to understand and
accept their diagnosis - receive
consistent messages from different
professionals on the same day.
 Misinterpretation of info is picked up
on the same day.
 Patients receive a more specific
symptom-focused approach.
 No long waiting lists, not passed
between specialists.
 Receive a more holistic picture of
their symptoms, causes, and options
for treatment and management
 Both clinical and lifestyle factors are
covered
 Improved symptoms following
treatment - QoL
 Fewer visits to hospital:
• improved patient experience
• cost savings
• patients with breathlessness are
often elderly, frail or have mobility
issues.
= Improved compliance overall

14. Enabled patients to receive an accurate diagnosis and appropriate treatment plan
more quickly than would otherwise have happened.
There has been an increase in patients on the asthma and COPD register in
practices where the pilot has taken place, due to misdiagnosed patients being
identified and correctly diagnosed. Appropriate treatment was then put in place.
CODP prevalence has increased by up to 44% in practices taking part in the
pilot.
30% increase in people classing themselves as ‘ex-smokers’ 5-months after.
There are reported medicines management savings of £40,000 over a 6-month
period across the borough, as a result of more appropriate prescribing.
There has been increased diagnosis of heart failure. One practice increased the
number of patients diagnosed as experiencing heart failure from 119 to 222 over a
10-month period after joining the pilot (an 86% increase).
Other conditions that have been diagnosed in the clinics include valve disease,
aortic fibrillation, bronchiectasis, pulmonary fibrosis; emphysema, lung cancer, and
patients eligible for lung transplants.
SNAP SHOT OF IMPACTS - ALW

15. UNINTENDED OUTCOMES AND LEARNING
“I was surprised
that all the
patients turned
up. At the clinics
at the hospital
we usually get a
lot of patients
who don’t come.
I don’t know if
it’s because
we’re not in the
practice and it’s
too far to come. I
don’t know but
that would be
something
interesting to
look into.”
Specialist clinical
team
All but 2 of the patients who
confirmed did attend
Small changes in comms can make a
big difference – ‘HDM’
Importance of 1-1 relationship with
practices
Patients will accept lifestyle advice –
holistic is key
Medicines management savings
Importance of patient perception of
their condition and experience of
diagnosis pathway = compliance
Holistic approach can tackle other
LTCs, wider benefits

16. CRITICAL SUCCESS FACTORS
Wider context and
environment
Partners and
relationships
Core team and
focus
•Engaging commissioners early on –
decision makers
•Collaboration with wider stakeholders
at an early stage
•Embedding the work in broader local
context / other programmes
•Building up trust, lead-in
•Pre-existing local links & relationships
•Making it as easy as possible for
primary care
•Emphasising opps for learning – GPs
have varying knowledge & confidence
•Passionate, motivated staff
•Clinical leaders
•In-kind resources
•Make it as easy as possible for patients
•Quantitative outcomes & KPIs

17. OTHER ENABLERS
•Supportive approach to engaging GPs in developing the primary
care pathway
•Use evidence: nearly 20% of patients seen in the client could have
been diagnosed in primary care; 35% had no investigations prior to
secondary care referral
LLR
•Strong local partnership network
•Fortnightly meetings - reflection
•AHSN committed to tackling respiratory conditions as a priority
Wessex
•Local staff involved; understand demographics and local population
•Open and honest dialogue – with patients and each other
ALW

18. ALW
• GP engagement – lead-in
time
• BNP testing machine
• Echo tech locum reliance
• Hard to keep on top of
GP turnover - comms
• Covered half the borough
– but no audit of ‘control
group’
• ‘Fits and starts’ in
numbers at clinics
• Commissioner buy-in /
re-tendering
LLR
• Availability of resources,
inc. staff, space,
equipment
• Identifying patients for
the clinics (going through
referrals)
• QI project = behaviour
change is vital, but takes
time to embed
• Innovative approaches
often slow to implement
locally = challenges in
getting the work up and
running.
Wessex
• Initial CCG and GP buy-in
was low. Only 1 out of 40
CCGs was interested;
limited practice interest
• 100s identified by GRASP
– need for prioritisation
of people with
overlapping COPD,
asthma and cardiac
symptoms
• GRASP tool dependent
on codes assigned by
GPs, which vary
• Patients who couldn’t
attend: holidays, post-
surgery, prior
commitments.
CHALLENGES

19. SUGGESTED IMPROVEMENTS
Funding – clear blockages in system
Improve links with lifestyle and behaviour change support.
Incorporate into clinic
Systematise the coding of conditions – to support GRASP use
Widen out to focus not just on the top priority ‘high risk’ patients
Face-to-face engagement rather than the paper based EOI initially
Roll-out across Borough – postcode lottery
Evidencing longer term outcomes

20. SUSTAINABILITY, COMMISSIONING CASE AND SPREAD
Early results indicate longer term potential for
efficiency savings:
 Shorter pathway to accurate diagnosis
 Reduced need for secondary care appts
 Reduced misdiagnosis
 Medicines management savings
 Staff retention
 Improved self-management: avoiding
exacerbations and other LTCs
 Improved patient QoL and MH
But: small dataset - be cautious about
extrapolating the benefits
Strong profile, local networks and in-kind
contributions – above the £15k
Hard to incentivise GPs sufficiently
LLR: For the next phase of the pathway,
where primary care implementation will take
place, the main challenges expected are the
geographical spread of the population,
varying GP knowledge, interest and
resources. Also, potential to use the Uni
Sports Centre?
Wessex: Clinics cost £142 per patient to run
(exc in-kind), compared with £241 tariff for
cardiac and resp outpatient referral appts.
• ASHN and partners are currently
launching MISSION ABC, making a case for
expanding this model to offer a ‘one-stop
shop’ in asthma, breathlessness and
COPD.
• Widespread interest from CCGs in
adopting the model.
• The specialist team became more
confident and familiar with the clinic
process = better gauging of appt timings.
ALW: British Oxygen Respiratory
Service, separate to diagnostic
service

21. CONCLUSIONS
Process improvements, impacts on
clinical outcomes and experience
The models improve the pathway for
patients with breathlessness
Built capacity and understanding
amongst primary care teams to
diagnose and treat breathlessness
symptoms more effectively
Improved patient experience,
understanding and self-management
Patients’ symptoms explored
holistically; potential wider impact on
other LTCs.
Improved relationships and
integrated working
Staff satisfaction – potential re
retention and morale = impact on
patient care
But – reliance on committed
staff, requires a core team
Logistical challenges
Challenge of engaging
commissioners
May take years to evidence full
impacts
Relatively small-scale pilots:
sufficient evidence for
commissioners?

22. NEXT STEPS WITH THE EVALUATION
Case study
final validation
Word report
and stand-
alone
summary
Dissemination
activity
Contact us
Lauren Roberts:
lroberts@opm.co.uk
Bethan Peach:
bpeach@opm.co.uk
Caitlin McMillan:
cmcmillan@opm.co.uk

23. Thank you
www.opm.co.uk 020 7239 7800