NHS FIFE RESPIRATORY MANAGED CLINICAL NETWORK ANNUAL ...admin.fifedirect.org.uk/...RespMCNAnnualreport2010... · MCN Annual Report 2010-2011 Version: 1.1 Date: 25 August 2011 Originator:

MCN Annual Report 2010-2011 Version: 1.1 Date: 25 August 2011

Originator: MCN Co-ordinator Page 1 of 29 Review Date: March 2012

NHS FIFE RESPIRATORY

MANAGED CLINICAL NETWORK

ANNUAL REPORT

2010-2011

Approval Record Target date Date approved

Dr Colin Selby & Gill Dennes- Clinical leads 7th July 7th July

Dr Alan McGovern 27th July 25th July

MCN Steering Group 25th August 25th August-13th September

D&WF Clinical Governance Group 20th Sept 20th Sept 2011



Contents

Page

FOREWARD 3

INTRODUCTION 4

SUMMARY OF KEY ACHIEVEMENTS 4

1 ORGANISATION 5

1.1 Managed Clinical Network 5

1.2 MCN Steering Group 5

1.3 Organisational Structure with NHS Fife 5

1.4 Clinical Leadership 5

1.5 Communication and reporting 5

2. MCN GROUPS 7

2.1 Steering Group 7

2.2 Spirometry / Education sub group 8

2.3 Children and Young People’s Asthma sub group 9

2.4 Pulmonary Rehabilitation sub group 10

3 RESEARCH & AUDIT 10

3.1 Audit - Prescribing bundle 10

3.2 Research Interest Group 10

3.2 Telepods 10

4 COMMUNICATION & INVOLVEMENT 11

4.1 Overview 11

4.2 Chest Voices Programme 11

5 EDUCATION & DEVELOPMENT FRAMEWORK 11

6 COMMUNITY PULMONARY REHABILITATION SERVICE 12

7 COPD CASE FINDING 13

8 FUTURE PLANS 15

Appendix 1 - Work plan 2010/11 16

Appendix 2 - Communication planning and reporting schedules 22

Appendix 3 - DRAFT work plan 2011/12 25



FOREWARD

This is the first annual report of the Fife Respiratory Managed Clinical Network (MCN). The major focus during 2010-11 has been supporting high quality clinical care in COPD and Asthma by enhancing and updating the resource packs for these conditions and putting in place a sustainable model for spirometry training in Fife. Our aim in taking forward this work is to take account of, and to make best use of, generalist and specialist skills across primary, community and hospital based services in order to provide accessible, personalised, integrated care for people with respiratory conditions which improve care and quality of life. There have been a number of key publications in relation to respiratory care and service improvement. These include the Quality Improvement Scotland (now Health Improvement Scotland) Clinical Standards for COPD, the update of the National Institute for Clinical Excellence (NICE) COPD guidelines update and NHS Scotland’s Delivering Quality in Primary Care National Action Plan. These have and will continue to influence the direction of work of the MCN. The main purpose of the NHS Fife Respiratory Managed Clinical Network1 is to promote and facilitate more effective working across all organisations, professions and disciplines delivering respiratory care, in order to ensure equity of access to high quality evidence based services throughout the care journey for people with respiratory conditions in Fife. This report highlights the work of the NHS Fife Respiratory Managed Clinical Network. Dr Colin Selby and Gill Dennes NHS Fife Respiratory Managed Clinical Network Clinical Leads

1 The Respiratory MCN does not cover lung cancers – the network associated with these conditions is

SCAN



INTRODUCTION

Within Fife 6.26% and 1.96% of people registered with a GP have Asthma and COPD respectively (2009/2010 Quality Outcomes Framework Registers). Respiratory conditions therefore affect the life of a significant proportion of the people of Fife The British Lung Foundation estimate that circa 75% of people with COPD are undiagnosed, COPD is responsible for the largest proportion of long term condition hospital admissions. The MCNs role, in supporting evidence based quality improvement, means the network is ideally placed to work with all in respiratory care to enhance the care pathway for this large client group. The MCN was encouraged by a very positive response from General Practice to a baseline survey; designed to give the MCN at the outset a clear understanding of respiratory care arrangements and practice across primary care in Fife. With a 57% response rate and feedback related to the survey results form each BreatheEasy group this has provided a wealth of information for the MCN to work with. SUMMARY OF KEY ACHIEVEMENTS The MCNs first work plan is attached at Appendix 1; this outlines the work undertaken and achievements in 2010-11. Key achievements have been:

• Working with prescribing colleagues to develop the ‘respiratory bundle’ which forms all or part of the QOF audit programme in every Practice in Fife

• Developing a sustainable model of spirometry training to support diagnosis and clinical care

• Initiating a Plan Do Study Act for case finding

• Working with schools to raise awareness of Asthma

• Supporting evidence based care through resource pack and guidelines development



1. ORGANISATION 1.1 Managed Clinical Network (MCN) Our role is to improve the health and wellbeing of the people (children and adults) of Fife with respiratory disease by co-ordinating the provision and development of the best possible integrated care across service and professional boundaries. To seek continual quality improvement in the care given to patients. This will be achieved by supporting the engagement of all stakeholders involved with respiratory care2, linking across respiratory medicine, primary and community care, service users, carers, and the voluntary sector across Fife. The network has created a forum for:

• sharing ideas and best practice,

• identifying solutions and methods of improvement

• initiating planning

• supporting patients, carers and professionals across Fife. 1.2 MCN Steering Group The goal of this group is to influence the development of the service and champion respiratory care in Fife. It includes the chairs of the sub-groups, patient and voluntary organisation representation and representation from the Community Health Partnerships and hospital services. This group meets every two months and is the executive group of the MCN, providing the overall direction and focus. The group is responsible for defining the strategic direction of the MCN and agreeing the work plan for the network, overseeing the work of the MCN sub-groups, decision making and reporting on the work of the MCN. Key individuals (representing the wide stakeholder group) are involved in developments across the three CHP’s and Acute services. 1.3 Organisational Structure within NHS Fife The Respiratory MCN is hosted by Dunfermline and West Fife CHP and accountability of the MCN is via the Clinical Director of Dunfermline and West Fife CHP, and through agreed reporting arrangements (see 1.5). 1.4 Clinical Leadership The NHS HDL of 2007 states an MCN should have a Lead Clinician who is recognised as having overall responsibility for the functioning of the network. Currently this role is fulfilled jointly by Dr Colin Selby (Respiratory Consultant) representing secondary care and Gill Dennes (Practice Nurse) representing primary care. 1.5 Communication and Reporting This section sets out the communication and reporting arrangements of the MCN, with specific detail in relation to clinical governance arrangements between D&WF Clinical Governance Group, NHS Fife and the MCN.

2 excluding Lung cancer which falls within the SCAN network



Clinical Governance Arrangements NHS HDL (2007) 21 states that Boards should agree with MCNs the service delivery and quality improvements for which they will be accountable, and the way in which these will be delivered through the local management arrangements. The role and remit of D&WF Clinical Governance Group is to provide the NHS Fife Clinical Governance Committee and ultimately NHS Fife Board with the assurance that clinical governance and health and safety mechanisms are in place and systems exist to make these effective for the MCN managed and hosted within D&WF CHP.

The Respiratory MCN and the D&WF CHP Communication Management Process Managing communication involves proactively determining the information needs of both the MCN stakeholders and D&WF CHP Clinical Governance Group, what information needs to be collected, who needs the information, when and in what form.

The following processes will provide formal channels for the successful communication of clinical governance activity.

o Reporting Structure – D&WF CHP Clinical Governance organisation structure, dissemination, links and escalation paths

o Communication Planning – proactively determining the information needs for the MCNs/MCN stakeholders, D&WF CHP Clinical Governance and NHS Fife.

o Reporting Schedules – reporting schedules of the relevant D&WF CHP and NHS Fife Clinical Governance Groups and MCN Steering group

MCN Accreditation Process

The proposed communication plan between D&WF Clinical Governance Group and the Respiratory MCN Steering group, in relation to the reporting and dissemination of clinical governance and quality improvement information, is agreed within the context of the current MCN Quality Assurance Programme systems and processes.

Reporting Structures

The NHS Fife MCNs can participate in both local and national quality improvement initiatives with both internal/external services and external agencies participating in audit and review processes. This provides opportunities for two way communication, sharing and reporting information.

External scrutiny of local MCN performance approved by D&WF CHP Clinical Governance Group is undertaken by Healthcare Improvement Scotland through the agreed reporting arrangements for NHS Fife.

External Stakeholders

Reasons for Engagement

Healthcare Improvement Scotland

-to provide formal channels for the successful communication of MCN clinical governance and quality improvement activities where HIS is undertaking a review, audit or following on standards -to ensure the timely generation, collection, dissemination, storage, retrieval and ultimate disposition of information to the relevant stakeholders



Internal Stakeholders Reasons for Engagement

MCN Steering group

D&WF Clinical Governance Group

D&WF CHP Committee

NHS Fife Clinical Governance Committee

-to communicate essential information, discuss issues and make informed decisions -to share clinical governance and quality improvement information to assist D&WF Clinical Governance structures; supporting, decision making and monitoring role -to collect and distribute information to the relevant stakeholders in a timely manner (as outlined within the MCN Action Plan and D&WF Clinical Governance Reporting Schedule)

Communication planning and reporting schedules

This plan outlines the MCNs stakeholders, what it communicates with them and how this communication takes place. This is detailed in Appendix 2.

Reporting

To assist monitoring and decision making within D&WF Clinical Governance structures the following reporting mechanisms between the MCN Steering Group and the CHP Clinical Governance Group have been agreed:

1. MCN work plan presented and approved on an annual basis (this may also include updates on the progress and specific status of individual projects)

2. MCN annual report presented to and approved on an annual basis by D&WF Clinical Governance group

3. D&WF Clinical Governance group will approve any reports in relation to the status of individual MCN performance and progress against agreed national and local standards (this may include progress and status of specific individual projects)

4. Minutes and agendas of the MCN Steering Group to be included for noting in the D&WF Clinical Governance Group Agenda as a standing item

2. MCN GROUPS The NHS Fife Respiratory MCN has been working to deliver integrated care across Fife that responds to the need of the local population. The Shifting the Balance of Care work stream in NHS Fife identified quick wins, the MCN has taken these forward, with work ongoing that is key to meeting the Scottish Government Health Directorates aim to shift the emphasis towards preventive medicine, improve community care and provide systematic support for people with long-term conditions, with the emphasis on continuous integrated care. This involves developing a full partnership with patients in the management of their condition and providing services in accessible locations. The aim throughout is to improve communication, improve performance in relation to targets and deliver an improved service with and for the people of Fife. 2.1 MCN Steering Group The Steering Group met six times in 2010-2011, and its work concentrated on those key achievements mentioned in the introduction. It agreed a clear role and remit and



outlined governance arrangements within the CHP/NHS Fife at the outset of the year, presenting its inaugural work plan to Dunfermline and West Fife CHP (D&WF CHP) Clinical Governance Group in September 2010. The Steering Group has provided the focus and vision for the Respiratory MCN and has benefitted from good attendance from all stakeholders. 2.2 Spirometry/ Education Sub group The group met on four occasions in 2010-2011, with two additional working group meetings focused on its training trainers initiative. Its initial focus was on developing spirometry training both to support those performing and interpreting spirometry in line with the QIS 2010 Clinical Standards for COPD. In light of this the group initiated the MCN baseline survey referred to in this report’s introduction. This work has resulted in an agreed training package for interpreting spirometry delivered by one of the Respiratory Consultants, via Protected Learning Time (PLT) programmes which asks participants to indicate if this has supported them to feel competent in this task (if not advising them to seek further support). This competence will be maintained by asking participants to consider if they have retained this competence and if so to complete a short quiz for submission to the Respiratory Consultants. Alternatively if they believe they require to attend an update this will be available via PLT. One workshop has been delivered (February 2011) and it is hoped to co-ordinate with PLT colleagues to programme three workshops, one per CHP, annually. The group developed a proposal which was submitted to the NHS Fife Prescribing Quality Group for a cohort of Fife trainers to be trained to deliver spirometry training across Fife to support people in diagnosing COPD. In line with the QIS standards this would be designed to incorporate practical elements and assess participants’ competence. This proposal was approved with a cohort of trainers working with Glasgow Caledonian University and Dr Roger Carter (Consultant Physiologist) to enhance their skills and develop a training package. The initial training sessions, which evaluated favourably, were delivered at PLT in May 2011. As with interpretation training it is hoped to embed this within PLT on an ongoing basis, to ensure access to all involved in performing spirometry, thereby enabling people to gain and maintain competence in this key skill. The group has also supported the development of a “Depression Screening and Long Term Conditions” workshop for Practice Nurses in collaboration the Vascular MCNs and LTC Collaborative. This workshop was proposed in response to issues highlighted in a number of reports about the training needs of Practice Nurses to have a greater awareness of the Mental Health issues associated with long term conditions. Twenty three Practice Nurses attended and the evaluation (twenty one returned) found that participants had a great deal of enthusiasm for the knowledge gained in the workshop; this covered a wide variety of issues from awareness of resources to clinical knowledge. Participants considered they were more knowledgeable, confident and better equipped as a result of attending the workshop.

Whilst the numbers are not significant (five of twenty three participants); of those who completed the follow up evaluation it was clear that the learning supported them to develop their practice, it equipped them with the knowledge and skills to feel



confident in discussing anxiety and depression with people and to sign post them appropriately.

This workshop would be recommended to support this area of practice development to meet what is a clear need within the long term conditions population.

The group have begun to look at a wider agenda for training – this is covered in section 5 below (Education and Development).

2.3 Children and Young People’s Asthma Group The Children and Young People’s Asthma Group met on three occasions in 2010/11. Their role and remit was approved by the Steering Group in November 2010. The group focused on taking forward the work plan stemming from the Quality Improvement Scotland (QIS) 2008 Paediatric Asthma Care Review. This involved reviewing and considering the implications of relevant performance data, securing patient/carer involvement in the group, working with Education colleagues to support awareness and knowledge of asthma in schools/nurseries. The group also took forward the work from the Asthma Balance of Care Workbook, completing the paediatric sections of the asthma resource pack and supporting the application of this via educational input at two PLT sessions. The group completed an update survey response to QIS in February 2011. 2.4 Pulmonary Rehabilitation This group met on six occasions in 2010-11. The focus initially was on drawing up an evaluation of eighteen months of the Community based Pulmonary Rehabilitation pilot. This very positive evaluation was submitted to the MCN Steering Group, NHS Fife Capacity and Sustainability Group and Physiotherapy Leads. The group worked with colleagues to further develop the programme in partnership with services who contribute to the content; to prepare a bid for recurring funding; and with Physiotherapy Leads to develop an Integrated Fife Physiotherapy Respiratory Service model. The service is discussed in more detail at section 6. 3. RESEARCH & AUDIT 3.1 Audit - Prescribing Bundle GP practices in Fife undertake up to three medicines management prescribing projects as part of their General Medical Services contract. To support quality prescribing and prescribing efficiencies the MCN, working with pharmacy colleagues, developed the following three projects which were proposed by NHS Fife as the projects to be undertaken by practices in 2011. All Practices in Fife have opted to include at least one of these projects in their 2011 programme. Project 1: Review of Adult Asthma patients prescribed high dose steroids or dry powder devices The aims are to: a) Review high dose steroids for step down - Stepwise management allows patients to travel up and down the steps depending on severity of asthma symptoms.



Patients should always be managed at the lowest step for effective asthma symptom control. b) Review dry powder devices for switch to Easyhaler - Easyhaler is a range of dry powder inhalers which cover the main classes of respiratory drugs and combine ease of use with cost-effectiveness. The Fife Formulary Section 32 (Respiratory) will be updated and Easyhaler will be promoted as the first line dry powder inhaler. Project 2: Review of patients with COPD prescribed inhaled corticosteroids and/ or Tiotropium (Spiriva) The aims are to: a) Review the need for inhaled corticosteroids in COPD - The aim of this review is to ensure safe and appropriate use of licensed inhaled corticosteroid preparations in COPD in line with the Global initiative on Obstructive Lung Disease (GOLD) guidelines and Scottish Medicines Committee advice. b) Review the effectiveness and device for Tiotropium - The aim of this review is to ensure all patients prescribed Tiotropium are reviewed for evidence of improvement in symptoms and are prescribed the most cost-effective preparation. Project 3: Review of inhaled corticosteroid doses and devices in children under 17. Adrenal suppression is a dose-related class effect of all inhaled corticosteroids, the symptoms of which can be non-specific and therefore often difficult to differentiate from normal childhood complaints. The aim of this review is to ensure all children are prescribed a licensed inhaled corticosteroid dose and preparation for their age group, to reduce the risk of developing adrenal suppression. 3.2 Research Interest Group There has been considerable interest in providing a forum to consider research within respiratory care in Fife. A Research Interest Group has been set up, which met three times in 2010/11. The group has discussed how it might work and agreed that it would provide a good forum to discuss and direct potential research projects. The group discussed potential areas for research. While there has been much interest in this area it has been hard to secure a chair and for staff to commit time to this group (R&D have resource to support thematic groups but would prefer that someone working in the field take over the chair). 3.3 Telepods A research project is underway using the latest Telehealth Care technology, this has capacity for twenty one patients with COPD across the three CHPs in NHS Fife to have tailored care in their own homes thereby improving quality of life and preventing avoidable hospital admissions.

The pilot commenced 31st May. Recruitment to the pilot and training were undertaken in advance of commencement. Initially eighteen patients were recruited of a potential twenty one, however numbers have reduced to sixteen, with the team working with the clinicians to identify further recruits.

The team are compiling data and developing a patient/staff questionnaire.



Fife Telehealth Group has linked with Renfrewshire for the purpose of this Pilot and the Scottish Centre for Telehealth will assist in the evaluation. 4. COMMUNICATION AND INVOLVEMENT 4.1 Communication The MCN has sought to raise its profile and that of the resources it has produced or would recommend by submitting two articles to a number of internal newsletters, BreatheEasy Groups and in forwarding an update news sheet to all GP Practices. The MCN has developed internet pages, hosted on the Dunfermline and West Fife Website. This provides background on the work of the MCN, the COPD and Asthma Resource Packs, Clinical Guidelines, Education resources and minutes. http://www.dwfchp.scot.nhs.uk/content.asp?ArticleCode=2450&par=2380 There are direct links to this from the NHS Fife intranet and internet sites, and G&NEF CHP website. The MCN has also provided information stands at two CHP Annual Conferences and the NHS Fife Staff Development Conference to raise awareness of the resources available to clinicians, patients and carers. 4.2 Chest Voices Programme The MCN has worked with Chest Heart and Stroke Scotland to deliver two ‘Chest Voices’ programmes. These programmes aim to provide patients and carers with the skills and confidence to work with health professionals to improve local respiratory services. It is hoped that a further programme will run in Glenrothes and North East Fife and people who have been on the programmes will help facilitate a wider event which uses the information from these programmes as a basis for discussion with a wider stakeholder group. 5. EDCATION AND DEVELOPMENT The Education Sub group is drawing up an education and development framework for the MCN. The MCN is committed to ensuring that staff, carers and service users are equipped with the knowledge and skills they require. The MCN is committed to:

• Ensuring that Health Care Professionals working within NHS Fife who are involved in the provision of Respiratory Care have a minimum standard of education and training i.e. minimum of diploma level, post-graduate qualification

• Ensuring that all Health Care Professionals working within NHS Fife who are involved in the provision of Respiratory Care have ongoing access to relevant, evidence-based education and training originating with and/or supported by the Respiratory MCN

• Ensuring that all specialist Medical, Nursing and Allied Health Care Professionals in the field of Respiratory care achieve the appropriate standard of skills and knowledge to enable them to provide a highly specialised Respiratory Service within NHS Fife

• Ensuring that all aspects of education and training to support the objectives, guidelines and policies of the MCN are considered and appropriate projects put in place throughout the work of the MCN



• Ensuring that those people with Respiratory conditions living in Fife have access to appropriate structured education and information to support self management

• Ensuring that all opportunities to equip Health Care Professionals to support self management are grasped

Within each discipline, staff have to be seen to develop as part of their Knowledge and Skills Framework. Staff have become involved in a number of areas nationally, for example Scottish Intercollegiate Guidelines Network.

MCN members were involved in the review of the Asthma guidelines. The Scottish Intercollegiate Guidelines Network (SIGN) develops evidence based clinical practice guidelines for NHS Scotland. A robust procedure is followed ensuring the latest evidence has been reviewed and recommendations made. The full guidelines and short guide are available at: www.sign.ac.uk/guidelines Members have also been involved in working with QIS on the Pulmonary Rehabilitation Implementation Project (Stemming from the COPD Clinical Standards). This has supported the development of our local respiratory physiotherapy pathway. 6. FIFE COMMUNITY PULMONARY REHABILITATION SERVICE In 2008/09 funding was made available via the Scottish Enhanced Services Programme to pilot the roll out of community based pulmonary rehabilitation, working to the model already in place in Dunfermline and West Fife. A robust evaluation was completed in 2010/11 of the initial eighteen months of this programme and found that the pilot met its objective to ensure equity of access by designing and delivering a community based pulmonary rehabilitation service throughout Fife. The evaluation recommended that:

• A long term funding stream for all three CHPs (currently funded short term via Scottish Enhanced Service Programme) be identified.

• NHS Fife support the development of maintenance classes.

• Continue to educate and support primary care on the necessity and requirements of a successful community based service.

• Foster and develop patient participation in programme development.

• Work with the hospital based pulmonary rehabilitation staff to develop a streamlined model of service (this recommendation has been achieved).

Funding is in place until March 2012, the MCN is liaising with colleagues across NHS Fife to seek to identify recurring funding for what it considers to be an integral and cost effective step on the respiratory care pathway.



The Pulmonary Rehabilitation group has been in discussion with Fife Sports and Leisure Trust (FSLT) to support their objective of developing tiered generic maintenance rehabilitation. A goal would be to ensure that this integrates effectively with the community pulmonary rehabilitation programme. The MCN will support this development, being involved in equipping FSLT staff where this would assist. 7. COPD CASEFINDING It is estimated that in the UK COPD is under diagnosed by about 75%3 leading to the British Lung Foundation’s ‘missing millions’ claim4. Tobacco smoking is the primary risk factor for developing COPD and early identification of the disease is important to reduce its progression5. The recently published QIS (now Health Improvement Scotland) Clinical Guidelines for COPD Services6 highlight both the estimated level of under diagnosis of COPD and the benefits to be derived from early diagnosis. Standard 2 relates to a strategy and implementation plan to identify people with undiagnosed COPD and to monitor and evaluate the effectiveness of a case finding programme. However, the best approach for primary care is yet to be identified. 7.1 MCN Case finding Plan Do Study Act Noting from research7 that simple screening of smokers can help identify one in eight who will require spirometry to confirm clinically-important COPD, the MCN has worked with colleagues to develop a simple Plan Do Study Act (PDSA) to test which methodology would be the best to promote in Fife. This has included Keep Well, Smoking Cessation, Practice Nurses and will hopefully also include Community Pharmacists. The goal of the MCN in this has been to support General Practices to identify people with COPD earlier in the disease progression. As “Early diagnosis of COPD could lead to earlier intervention which might help improve symptoms, increase activities of daily living and quality of life, reduce exacerbations and even, through smoking cessation, limit disease progression”8. It is anticipated that such case finding will reduce workload in the longer term, as “self management can reduce the impact of long term conditions on NHS services”9.

3 NICE/BTS Guideline Update, Chronic obstructive pulmonary disease: Management of chronic

obstructive pulmonary disease in adults in primary and secondary care (pages 22-23), June 2010

4 British Lung Foundation, Invisible Lives: Chronic Obstructive Pulmonary Disease (COPD) - finding

the missing millions, November 2007

5 Halbert RJ, Natoli JL, Gano A, Badamgarav E, Buist AS, Mannino DM. Global burden of COPD:

systematic review and meta-analysis. European Respiratory Journal 2006; 28: 523-532.

6 Quality Improvement Scotland, Clinical Standards: Chronic Obstructive Pulmonary Disease

Services, March 2010

7 Check The FEV1 For All Adult Smokers, Even Patients Without Respiratory Symptoms, Primary Care Respiratory Journal (2010); 19(2): 91-92 8 QIS Clinical Standards: Chronic Obstructive Pulmonary Disease Services– Standard 2 Rationale para. 2, Quality Improvement Scotland

9 Gaun Yersel – The Self Management Strategy for Long term Conditions in Scotland, Page 6, The Scottish Government and LTCAS Aug 2008



With funding from Keep Well thirty four simple handheld screening spirometers were purchased to measure FEV1 (Forced Expiratory Volume in one Second). Staff were briefed to follow a protocol to screen people attending the services involved who were 35years of age and over, and who smoke (or had a smoking history of 10 ‘pack years’) to identify patients with reduced values who would then be advised to attend their GP for full spirometry to confirm the diagnosis of COPD. The MCN will be forwarded basic non-patient identifiable data on the basis of a month’s activity within these services regarding the number of people screened and advised to seek full spirometry to ascertain if this route has enhanced early identification. For the one month PDSA Practices will receive a letter from the service that has conducted the screening indicating that someone has been advised to seek full spirometry; this letter includes a tear off (contains only a PDSA reference number and no patient data) which they are asked to return to the MCN to indicate if COPD has been diagnosed or not. The MCN hopes that this PDSA will support the development of a strategy and implementation plan to identify people with undiagnosed COPD for Fife. The findings from this PDSA will be available in autumn 2011. 7.2 British Lung Foundation (BLF) events The Scottish Government awarded the BLF a grant to run a COPD awareness raising project to build on a project it ran in 2009/10. As the first year of the project was very successful a second series of events ran in targeted areas across Scotland. BLF utilised the Revolution bus to take case finding out to Cowdenbeath and Leven and set up shop for the day in the Mercat Centre, Kirkcaldy. The outputs from this were:

• 249 people underwent a lung function test (respiratory nurses performing spirometry)

• 58 people were referred (23% of those tested)

• 60% tested were either smokers or ex-smokers (25% smokers and 35% ex-smokers)

• 72% of those referred were either smokers or ex-smokers (approximately 28% smokers and 45% ex-smokers)

All participants referred at events were called four weeks later to see if they had visited their GP and whether or not there was a COPD diagnosis. They were also asked questions relating to behaviour change. Of the 58 participants referred to their GP, BLF were able to reach 52% (This equates to 30 participants, all subsequent figures are based on this). Of these participants 70% (21) went on to visit their GP with the remaining 30% (9) intending to go (some participants had appointments booked). Of those who visited their GP:

• 14% (3) were diagnosed with COPD,

• 24% (5) were undergoing further testing at the time of calling,

• 38% (8) were diagnosed with other lung or chest conditions, and



• 14% (3) had further tests which came back as within the normal range. Of the participants that BLF were able to reach, 83% said that the event increased their awareness of COPD and 27% went on to make behaviour changes such as taking more exercise, making dietary improvements and cutting back on or stopping smoking. Following on from this the MCN has highlighted this positive approach to CHP colleagues and recommend that COPD screening is routinely included in the work of any ‘Health Shops’ organised by health improvement colleagues. This would be building onto an established mechanism and therefore be more sustainable, avoid duplication and could draw on the skills developed by Keep Well/ Smoking cessation teams in relation to 7.1. 8. FUTURE PLANS NHS Fife is committed to continuing with the integrated, quality focused network model that has been developed in the MCNs inaugural year. At the time of writing there is a clear commitment to continue with the primary and secondary care clinical leadership arrangements in place, consideration is being given as to how the network will be supported administratively going forward into 2011/12. The objectives for 2011-2012 is outlined in the attached MCNs 2011/12 work plan (appendix 3). The priorities for 2011/12 are to:

• Embed and extend the MCN education and development portfolio

• Support the developments in the provision of home oxygen

• Develop and disseminate a detailed care pathway for asthma

• Review and disseminate local guidelines for Sleep Apnoea



Appendix 1

Respiratory MCN Work 2010-11 plan- Final update for annual report

10 10. RAG – Red- not on target, Amber- on target, Green- on course for completion/completed

Priority Action Anticipated Outcome Person Responsible

Resources involved

Update as at June 2011 Target (and trajectory)/ Objective

Risks HDL Principle/ HEAT / Quality Strategy

RAG status10

Clear management arrangements & leadership of the MCN

Agree role and remit and initial work plan

We have clarity of governance arrangements & purpose

Clinical Leads MCN Manager

_ • Complete • We have clarity of governance arrangements by 26/5 & of objectives by 29/9

HDL-Governance / Quality- Collaboration

Green

Communication: Develop various mechanisms to support service user / carer / independent contractors / staff /Vol. Orgs. involvement in the MCN

All stakeholder groups are represented & fully involved in the work of the MCN

MCN Manager Transport Training and Support

• Asthma Children & Young People Focus grps report due June 2011

• BreatheEasy agreed to act as informal reference group

• Voluntary Sector representation to Steering Group agreed

• Steering group membership is representative

• Agree mechanisms to develop reference groups via PFPI mechanisms

Green

Equip people to support their involvement

Training sessions delivered to equip people to be fully involved

MCN Manager Venue / Refreshments

• 2 of 3 Chest Voices Programmes complete – G&NEF to be rescheduled

Sessions delivered by end of financial year 2010/11

As above Green

G&NEF - Orange

Involvement and Partnership working

Develop an MCN Web presence

People have access to useful information and resources

MCN Manager _ • ongoing development

• education information now being loaded

By July people will have easy access to up to date info. & resources.

HDL-Involvement & Partnership

Quality- Collaboration

Green




Resources involved



RAG status

Consider implications of QIS Clinical Standards (QIS Steering Grp priorities are

• Case Finding

• Pulmonary Rehab

• Oxygen Therapy)

To be defined

• Clinical leads to review standards against survey results.

• Spirometry group leading on this element re standard 3a.

• PR Group re standard 4

Complete self evaluation tool by 09/2011

Green

Define required action and agree programme

(possibly initially focusing on case finding)

Clinical Standards are met: People are diagnosed earlier, reduced emergency admissions and length of stay

Chair COPD Sub Group

COPD VItalograph 6 machines and tubes

Case finding

• Plan DO Study Act (PDSA) agreed and started May 2011

• 34 hand held screening spirometers purchased

We have secured data on how screening supports case finding via three different patient contact opportunities (KeepWell/Smoking Cessation/Practice Nursing) to support ongoing case finding.

HDL-Evidence based

HEAT - T: Long-term conditions admissions

Quality-Clinical excellence

Green

Chronic Obstructive Pulmonary Disease

Review and update COPD resource pack annually

Supporting primary care and self management:

• Reducing secondary referrals & hospital admissions

• Earlier diagnosis

MCN Manager Clinicians / admin. time to update

Resource Pack updated Aug 2010

Sections with drugs reviewed and approved by ADTC / final sign off by Steering Grp 25/5/11

• Revised resource pack loaded onto internet 9/10 No. of new referrals to Respiratory Medicine sent back to primary care

Period 1st Sept – 30th Mar

No. of GP referrals

No. of 'inappropriate' GP referrals

2009/10 793 172

2010/11 764 154

A p value of 0.46 indicated that the

HDL- Equip / Evidence Based

HEAT-T: Long-term conditions admissions Supports T6, T7, T12

Quality- Communication

Green




Resources involved

Update as at June 2011

Target (and trajectory)/ Objective


RAG status


Complete implementation of balance of care workbooks

• Equitable Pulmonary rehab provision- see below

• Telepod pilot – we understand their potential

• We have clear triggers into palliative care

• We increase the number of people with complex care receiving care in a community setting

Dr Selby • Pulmonary Rehabilitation evaluation complete

• Telepod pilot underway

• Palliative Care Triggers in pack and education pack for PNs being developed

•

• PR: 50% reduction in people attending an acute site for PR. – 100% Community Provision achieved

• Increase # people being referred to PR following an acute admission and with symptoms from community.

• Telepod: demonstrate at least 10% reduction in COPD hospital admissions.

• QOF measures to be updated with implementation of the Living and Dying Well Action Plan. See L&D measures.

• Increase in number of complex cases managed in the community (utilising SPARRA data as a proxy)

HDL-Equitable

/ Evidence based

/ Efficiency

HEAT- T: Long-term conditions admissions / Complex care at home

Quality- Communication / Collaboration / Clinical Excellence / Continuity of Care

PR-Green

Telepod – green

Palliative Care Triggers – Green

Complex care- Orange

Establish a sub group of the MCN

We ensure effective Fife wide representation

Clinical Education

Complete Green

Review spirometry current practice

We understand how closely spirometry practice relates to QIS COPD standards

Admin time to survey and collate

Complete By late August we have baseline information and understanding

Green

Spirometry - to meet QIS COPD guidelines

• Agree areas for improvement / support

We have an agreed, achievable plan to support the gold standard

Chair Spiro. Sub grp

Funding for training – potential seek

Complete

Increased number of referrals with correct spirometry reading, scoping exercise and reduction in diagnosis age. Also increase in time from diagnosis to death

HDL- Equip / Evidence Based


Quality- Clinical excellence

Green




Resources involved

Update as at June 2011



RAG status

Spirometry continued

• Develop, implement, monitor & maintain an education programme

Staff are equipped, competent and confident to provide the QIS standard

Training commenced 18/3/11 Delivery commenced 19/5/11

Green

• Understand pharmacy development / audit (regarding respiratory medicines and care) recently undertaken and underway throughout Fife

We have a baseline understanding of practice

MCN Pharmacy members

Staff time • Complete HDL - Evidence based

Green

• Review prescribing of respiratory medicines

We identify areas for development


Pharmacy

• Identify areas to enhance prescribing practice: Agree and implement support programme

Best Practice in prescribing is supported


Staff time

Respiratory Bundle taken up by all Fife practices

HDL - Evidence based / Efficiency

Quality – Clinical excellence

Green

• Consolidate existing programme

Chair Pul. Rehab. Sub Grp

• Evaluation complete

• Draft bid for funding ready

Green

• Review and refine referral protocols and pathways (to support SESP 21)

People are able to quickly and effectively access local Pul. Rehab. supporting a reduction in emergency admissions

Physio.

Technical Instructors

Pharm.

Fife Integrated Physiotherapy Respiratory Pathway agreed

Green

Pulmonary Rehabilitation

• Recurring funding to be identified

Programme obtains core funding

Clinical Leads / MCN Manager

Circa £125,250

• Issue highlighted to CHP MGT team May 2011

• People have equitable access to an evidence based programme.

Supports T6, T7

That this evidence programme does not receive recurring funding resulting in a loss of service and add on benefits to integrated working across sectors. That we lose staff due to uncertainty of their employment with the consequence that the service atrophies.

HDL - Evidence based / Efficiency



Red




Resources involved



RAG status

• Map existing training and education provision

We understand what is available

MCN Manager Information loaded onto website as it becomes available.

• Everyone has a clear understanding of what is available

• Needs are understood and addressed

• We can measure impact on service outcomes following training / development intervention

HDL – Equip / Quality / Evidence based


Green

• Identify gaps and agree priorities

We understand need and define how we will address

Chair Education Sub Grp

Spirometry Sub group agreed to widen remit to encompass all training & education (within MCN remit) .

• Measures are put in place to fill gaps

Green

Equipped

• Agree programme (with range of options PLT/Evening etc)

We have a clear outline of the workshops the MCN can provide – and agreed mechanisms to keep this fresh – to support high quality care

Education & Development Framework with timetable for sessions being drafted

• A clear ‘catalogue’ is in place and maintained – supporting improved patient care.

Green

Asthma • Finalise and maintain (annually) resource pack

Supporting primary care and self management: reducing referrals to secondary care and hospital admissions

MCN members / MCN Manager co-ordinate

Minimal – use existing resources and communication mechanisms

Resource Pack updated Aug 2010 Sections with drugs reviewed and approved by ADTC / final sign off by Steering Grp 25/5/11 Detailed care pathway to be developed: proposal on how this might be done being put to Child Health Management Team 19/5.

Launch June 2010

• Pathway approved Sept 2011

HDL – Quality / Efficiency / Partnership

Quality – Clinical Excellence / Communication / Collaboration

Green




Resources involved



RAG status

• Develop and implement a programme of education and clinical skills training (asthma management of children)

Reduced emergency admissions / urgent GP consultations

MCN manager Trainers / backfill / venue

Map provision/obtain baseline- work being scoped. Follow up audit Viral Wheeze/Asthma diagnosis Update Paed Asthma Algorithm to include differential diagnosis information for children under 5. Agreed input to A&E junior doctors induction training.

Measure proposed of planned: emergency GP consultations as baseline and following prog.

Emergency admissions reducing (per 100,000 population) over time.

HDL – Equip / Quality / Evidence based


Orange

• Support compliance with SIGN Guidance on the Management of Asthma: e.g. facilitate access to psychology

We support clinical excellence in the management of Asthma

Clinical Leads Resource pack completed and awareness raising undertaken.

Encourage use of a comprehensive review screen

HDL - Evidence based Quality – Clinical Excellence

Orange

Asthma continued

• Report annually to Child Health Management Team

Ensure clear communication and good governance

Chair Asthma sub Grp

November 2011 HDL - Governance

Green



Appendix 2

Communication planning and reporting schedules

This plan outlines the MCNs stakeholders, what it communicates with them and how this communication takes place.


What is to be communicated Methods and frequency of communication

Public, Service users and carers

-Updates on the work of the MCN -Seek local feedback and informed input to the work of the MCN

There are a number of active support groups in Fife with a wide range of members: we will work with them to consult, inform and involve service users. This is a two way process, the MCN welcomes proactive engagement from all its stakeholders. The MCN Steering Group has two service user representatives. Asthma sub group has a service user/carer representative. Using a variety of means (web/groups/people’s panel, PPF etc) to reach as many people as possible. Steering group minutes, annual work plan and annual report will be posted on the website.

Voluntary sector

-Updates on the work of the MCN -Seek sector feedback and informed input to the work of the MCN

The three national groups (Asthma UK, BLF & CHSS) are included in the steering group circulation – owing to their commitments it is hoped that at least one group is able to attend each meeting.

National Advisory Group of Respiratory MCNs

-Updates on the work of the Fife MCN -Obtain information on work of MCNs throughout Scotland - Share learning (consideration being given to the NAG acting as a peer forum for considering progress against QIS COPD Clinical Standards)

Quarterly meeting attended by a Clinical Lead and MCN manager




What is to be communicated Methods and frequency of communication

Healthcare Improvement Scotland

• as required

- to meet reporting timescales for the review and dissemination of local and national Clinical Governance information -this may also include update on the progress and specific status of individual projects

Internal Stakeholders What is to be communicated Methods and frequency of communication

Steering group

D&WF CHP Clinical Governance Group

-the MCN will produce an annual report and MCN work plan. This will be presented to the D&WF CHP Clinical Governance Group for their approval as agreed

• update of MCN progress/status

• update and review of participation in both local and national quality improvement activity

• review and disseminate MCN clinical governance activity

• to be an escalation point for issue resolution - update the D&WF CHP Clinical Governance Group on MCN activity and progress/status of individual projects where required -the MCN should try to resolve any risks /issues locally -risks /issues which cannot be resolved locally are

-the steering group meets every two months and includes all stakeholders -scheduled update as specified within the approved MCN action plan to meet the reporting timescales for the review and dissemination of local and national clinical effectiveness information as defined in the D&WF CHP Clinical Governance Reporting Schedule -annual MCN Action Plan as defined in the D&WF CHP Clinical Governance Reporting Schedule -annual MCN report -this may include update on progress on the specific status of individual projects

D&WF CHP Committee

NHS Fife Clinical Governance Committee

escalated to the D&WF CHP Clinical Governance Group via the MCN Manager -the D&WF CHP Clinical Governance Group must then escalate un-resolvable risks /issues to the D&WF CHP Management Team for escalation and if necessary to the NHS Fife Clinical Governance Steering Group/ CHP Committee

-minutes from the MCN Steering Group to be included for noting on the D&WF CHP Clinical Governance Group Agenda as a standing item



Internal Stakeholders What is to be communicated Methods and frequency of communication

D&WF Localities Group (quarterly)

-Updates on the work of the MCN -Seek local feedback and input to the work of the MCN

Primary Care Clinical Lead member of Localities Group

Respiratory Consultants meeting (weekly)

-Updates on the work of the MCN -Seek local feedback and input to the work of the MCN

Secondary Care Clinical Lead member of group

General Practice and LMC

-Development and awareness of resources/processes to support clinical practice

-Resources available on website -communication regarding new resources and updates forwarded to all practices -LMC included in approval processes for new resources and consulted on programmes/projects

Area Drugs and Therapeutics Committee (ADTC)

ADTCs approval will be sought of any new resources including mention of medications/devices or processes impacting on pharmacy. Updates would only require similar approval where changes are made to medication references.

Resources to be forwarded to DATC secretary with cover paper following liaison with ADTC secretary.



Appendix 3 Respiratory MCN 2011-12 Work plan- Initial Draft The following work plan is treated as a ‘live’ document.

Priority Action Anticipated Outcome

Person Responsible

Resources involved

Update as at July 2011 Target (and trajectory)/ Objective

Risks HDL Principle / HEAT / Quality Strategy

RAG status

Clear management arrangements & leadership of the MCN

Refresh role and remit and initial work plan Complete annual report

We have clarity of governance arrangements & purpose

Clinical Leads MCN Manager

_ • Submit Draft work plan and 2010-11 annual report to July Steering group

• Role and remit to be reviewed - Sept 2011

• 2011-12 Annual work plan to be approved by CG Grp Sept 2011

HDL-Governance / Quality- Collaboration

Green

Communication: Maintain and various mechanisms to support service user / carer / independent contractors / staff /Vol. Orgs. involvement in the MCN

All stakeholder groups are represented & fully involved in the work of the MCN

MCN Manager Transport Training and Support

• Asthma Children & Young People Focus grps report to be submitted MCN steering group July 2011.

• Steering group membership is representative

• The MCN access available involvement mechanisms.

Green

Develop joint working with Vascular MCNs

• Utilise like models

• Simplified processes for people with dual diagnosis

Clinical Leads - •

Equip people to support their involvement

Training sessions delivered to equip people to be fully involved

MCN Manager Venue / Refreshments

• G&NEF Chest Voices Programme to be rescheduled

Session delivered by end of ??? Green

Involvement and Partnership working

Develop an MCN Web presence

People have access to useful information and resources

MCN Manager _ • ongoing development

• Sought inclusion of hyperlinks in CHP websites

People have easy access to up to date info. & resources.

HDL-Involvement & Partnership Quality- Collaboration

Green

Sleep Apnoea Review and disseminate local guidelines

Improved referral patterns

MCN Clinical lead (Secondary Care)

Clinicians time / training time

• Refreshed guidelines published 12/11

• Awareness undertaken ??/11

• Reduction in redirected referrals

HDL- Equip /Evidence based Clinical excellence HEAT – 18wks???




Resources involved



RAG status

Local Priorities from QIS Clinical Standards

To be defined

Complete self evaluation tool by 09/2011

Orange

Spirometry: Quality control Monitor & maintain an education programme

Case finding

Clinical Standards are met: People are diagnosed earlier, reduced emergency admissions and length of stay

Chair COPD Sub Group

COPD ViItalograph 6 machines and tubes

Keep well & Smoking Cessation screening PDSA complete – data being compiled Practice Nursing PDSA underway

We have secured data on how screening supports case finding via three different patient contact opportunities (KeepWell/Smoking Cessation/Practice Nursing) to support ongoing case finding.

HDL- Equip /Evidence based HEAT - 75+ bed day rates Quality-Clinical excellence Green


Review and update COPD resource pack annually

Supporting primary care and self management:

• Reducing secondary referrals & hospital admissions

• Earlier diagnosis

MCN Manager Clinicians / admin. time to update

• Review Pack initial sections Aug 2011 / medication sections May 2012

• No. of new referrals to Respiratory Medicine sent back to primary care compared to previous year

• Average age a death over time / increase time from first admission to death over time.

HDL- Equip / Evidence Based HEAT- 75+ bed day rates Quality- Communication

Green




Resources involved



RAG status

Community Pulmonary rehab - Consolidate existing programme

• We secure equitable provision

Clinical Leads / Service Managers

Circa £125,250

• Draft bid for funding ready

• People have equitable access to an evidence based programme.

• Supports T6, T7Increase # people being referred to PR following an acute admission and with symptoms from community.

That this evidence programme does not receive recurring funding resulting in a loss of service and add on benefits to integrated working across sectors. That we lose staff due to uncertainty of their employment with the consequence that the service atrophies.

Telepod pilot –

• we understand their potential of this technology to support good quality proactive clinical care

• • Telepod: demonstrate at least 10% reduction in COPD hospital admissions.

Green

COPD Continued

Complex care We increase the number of people with complex care receiving care in a community setting

• Increase in number of complex cases managed in the community (utilising SPARRA data as a proxy)

HDL-Equitable / Evidence based / Efficiency HEAT - 75+ bed day rates Quality- Communication / Collaboration / Clinical Excellence / Continuity of Care




Resources involved

Update as at July 2011



RAG status

Pharmacy • Identify areas to enhance prescribing practice: Agree and implement support programme

Best Practice in prescribing is supported


Staff time

• All NHS Fife Practices participating

• Quality prescribing is enhanced

• Information available on efficiencies secured

• Contributes to a reduction in secondary referrals

• Retain a good understanding of available resources

We understand what is available and make it accessible

Education sub group / MCN Admin

Information being loaded onto website.

• Everyone has a clear understanding of what is available

• Needs are understood and addressed

• We can measure impact on service outcomes following training / development intervention

Orange

• Agree programme (with range of options PLT/Evening etc)

We understand need and define how we will address and have a clear outline of the workshops the MCN can provide – and agreed mechanisms to keep this fresh – to support high quality care

Chair Education Sub Grp

Draft education and development framework to be approved

• Measures are put in place to fill gaps

• A clear ‘catalogue’ is in place and maintained – supporting improved patient care.

• Evidence of impact on referral / admission rates

Green

Equipped

• Contribute to the palliative care programme

Practice Nurses are supported in their role in relation to the early palliative care needs of people with COPD

PC Clinical Lead / Anticipatory Care Nurse / Practice Development

•

HDL – Equip / Quality / Evidence based Quality – Clinical excellence

Green



Glossary PDSA – Plan Do Study Act, method for trying out a process method to see if it works in local systems and structures on the basis of someone else’s research having done a fuller study.


Resources involved

Update as at July 2011



RAG status

• Maintain (annually) resource pack

Supporting primary care and self management: reducing referrals to secondary care and hospital admissions

MCN members / MCN Manager co-ordinate

Minimal – use existing resources and communication mechanisms

• Review Pack initial sections Aug 2011 / medication sections May 2012

Green

• Develop a detailed care pathway for children and young people

Everyone understands their role and routes between services

Chair Asthma Sub group

Pathway approved Sept 2011

HDL – Quality / Efficiency / Partnership Quality – Clinical Excellence / Communication / Collaboration

Orange

• Support compliance with SIGN Guidance on the Management of Asthma: e.g. facilitate access to psychology

We support clinical excellence in the management of Asthma

Clinical Leads Encourage use of a comprehensive review screen


Orange

Asthma

• Report annually to Child Health Management Team

Ensure clear communication and good governance

Chair Asthma sub Grp

November 2011 HDL - Governance

Green

National Oxygen at home service

• Support the process changes required to enable the implementation of national provision

• Participate in the development of and embed locally a nationally agreed guidance for Oxygen

• Support transition to use of national guidance

• Undertake assessments to maximise use concentrators

We support clinical excellence by working to a nationally agreed guidance People have access to expert assessment and the most effective delivery system for their needs

Clinical Lead (Secondary Care)

To be defined ?To be agreed nationally potentially April or June 2011

There is a risk that the costs of provision continue to outstrip the funding allocation – management via introduction of national guidance


Documents

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