Integrated Care Systems have introduced many new care interventions in the last year including rolling out self-management apps, to enhancing a pulmonary rehabilitation service and addressing SABA overuse.
You may also be interested in the examples given in the pulmonary rehabilitation (PR) section.
Bath + North East Somerset, Swindon + Wiltshire
Swindon Pulmonary Rehab Service (GWH) Swindon. Since April 2022 the Swindon PR service has worked on a long-term plan to reduce the service waiting times (some were waiting 2 years before), to meet the waiting time KPIS, to reduce barriers to engaging with PR and to reduce DNA rates. Heading into April 2024 all patients on the waiting list have been invited to an opt-in day where they have the opportunity to meet the team, engage with PR and decide if they are ready to commit. If they wish to attend, they will be offered an assessment for the next course.
Average waiting time is currently 12 weeks, with max being 23 weeks (one patient) and min being 9 weeks, and median being 12 weeks.
The Swindon PR team has achieved this through doubling capacity for face-to-face PR, increasing staffing support for PR using the BSW funding, increasing venue use through BSW funding.
By promoting the PR pathway of attending an opt-in day initially this has helped patients to make informed decisions about engaging with PR and offers opportunities to reduce patient barriers such as fear and anxiety around attending and other options such as attending the online course instead or taking some information booklets around symptom management for various lung conditions and taking away contact details to seek re-referral after a period of contemplation. This is reflected in the reduced DNA rates to attending PR assessment by 25%. This has supported attendance to assessment and course, on the most recent course there was 100% attendance to assessment day and 90% attendance to the course.
Birmingham + Solihull
Most impactful intervention: We have only just started our respiratory programme following appointment of the Respiratory Clinical Lead in July 2024. We are prioritising urgent care for winter, and have 4 workstreams on PR, oxygen and diagnostics which are in set up.
Bristol, North Somerset + South Gloucestershire
Most impactful intervention: COPD app.
Buckinghamshire, Oxfordshire + Berkshire West
CORE20PLUS5 – Winter 2023/24 project increased uptake of Covid-19 vaccination in immunocompromised and at-risk populations in BOB, inclusive of people with COPD and learning disabilities. An additional 270 people received Covid-19 vaccination over a period of six weeks. It included working with refugee centres, food banks and drug and alcohol addiction clinics, as well as vaccinating several housebound patients in their home.
CYP Asthma: a service developed to meet the needs of a Core20PLUS5 or seldom heard group. 1) Acute asthma pilot to address the variation in care across BOB ICS in access to specialist CYP asthma nurses. 2) PCN level pilot using a social prescriber model to review high risk CYP with asthma and offer holistic interventions where appropriate.
Cambridgeshire + Peterborough
MyAsthma app pilot.
Cheshire and Merseyside
Most impactful intervention: Development of asthma and sleep pathways bringing together individuals across the pathway.
Most impactful intervention: New programme for PR with digital offering and launch of Place by Place accreditation of services.
Devon
PCN Respiratory Champions. During 23/24 NHSE funded 23 PCN Respiratory Champions across Devon. Projects undertaken by the Respiratory Champions included: COPD and Asthma Diagnosis and Management; Treating Tobacco dependency; Breathlessness; Respiratory infections and antibiotics; Optimising Pulmonary Rehabilitation capacity and Leadership skills.
Nurses undertaking the Respiratory Champions roles reported that in addition to increasing their Respiratory Disease expertise and knowledge, they improved their quality improvement skills and improved communication about Respiratory Disease within the PCNs.
Although the Respiratory Champion roles are no longer funded, the Respiratory Champions across Devon have remained in contact and continue to promote Respiratory projects within Primary Care.
Dorset
We have reduced SABA significantly and have discovered significant variation in outcomes and processes to address COPD and asthma admissions.
Our SABA reducing initiative in Portland was the subject of a poster at the PCRS.
Proactive identification of COPD patients for lung volume reduction procedures.
Frimley
Most impactful intervention: Development of sleep services and group work for CPAP.
Business case for ILD Tier 2 Expansion. Showcased bespoke PR for ILD patients at regional meeting. Increased amount of patients transplant.
Spectra. Severe asthma project MDT running.
Gloucestershire
Most impactful intervention: We implemented consultant delivered clinics within PCNs 3/4 years ago. We believe these have the potential to make the most impact to support patients to be managed out of hospital and to upskill an engaged respiratory workforce in PC.
Greater Manchester
Most impactful intervention: Spirometry and FeNO - We have been leading a piece of work to get spirometry and FeNO commissioned. This has met barriers after barriers. The work done however has managed to restart spirometry in all but one locality in GM. There is now a task force set up with senior commissioning and finance colleagues to get this into GM Commissioning intentions. The work done has already put spirometry and FeNO in the Joint Forward Plan, Primary Care Blueprint Implementation Group, and also within Diagnostics and Pharmacy Partnership Group.
Hampshire and Isle of Wight
Most impactful intervention: Expansion of pulmonary rehabilitation services. Evaluation of the 2023/24 investment through Service Development Funding (SDF) in line with the NHS Long Term Plan showed an increase in the number of people completing the pulmonary rehabilitation programme which will, in turn, increase the number of people who experience improved exercise capacity and increased quality of life, reduced hospital admissions and reduction in respiratory related deaths.
Medicine optimisation workstream – respiratory masterclasses. The medicines optimisation teams ran two respiratory masterclasses. One introducing the new Wessex Adult and Adolescent Asthma Guidelines and the second introducing the new Wessex Paediatric Asthma Guidelines.
Asthma + Lung UK (A+LUK) respiratory champion role in place to increase primary care review of exacerbating patients. The integrated care system were one of six successful integrated care systems to work collaborative with A+LUK for a respiratory champion to be funded 1-day per week to promote better respiratory care and outcomes. The recent respiratory champion landscape report identified an area of opportunity to optimise care and outcomes for people living with asthma and COPD was to optimise the annual review process in primary care. Currently, these are often happening on the patient’s birthday month, rather than at the time of highest clinical need such as after an exacerbation of the person’s asthma or COPD when they need it most. The respiratory champion will lead on the development and implementation of a new primary care process for annual reviews.
Humber and North Yorkshire
Most impactful intervention: It is not possible to single out a single project and the cumulative effect is what achieves impact. A key success in the region has been the collective work to identify and address SABA over-use in asthma with SABA over-use having fallen faster than the national average but we recognise that more work still needs to be done.
Identifying and addressing SABA over-use in asthma. Identifying and addressing SABA over-use in asthma.
- SENTINEL Project
- Development and implementation of a GINA aligned asthma guideline
Supporting COPD self-management and support during exacerbations
- Respiratory virtual ward programme
- Digital supported self-management (DYNAMIC-ROSE)
COPD case-finding
- FRONTIER Programme
Supported access to pulmonary rehab
- @Home programme - the Ridings Medical Group
Lancashire South Cumbria
Most impactful intervention: Medicines optimisation project with Sentinel.
Virtual Wards (specifically by Place).
North East + North Cumbria
Most impactful intervention: NENC greener prescribing guide. This resulted in over 90,000 downloads.
Most impactful intervention: The CYP team: systemwide education-based intervention, uptake of elearning for health training (National Competency Framework), primary care webinars delivered and focused interventions (GP practices and pharmacy work done by the community advisors).
North East London
Most impactful intervention: The asthma practitioner pilot for CYP. We have seen network wide change. There is an IPSOS review and national evaluation as well as local outcomes.
Northamptonshire
Most impactful intervention: Providing PR at satellite locations, and use of the myCOPD app.
Breathlessness pathway in a certain part of Northampton, with link between voluntary sector, primary care, public health. Working with disadvantaged patients in that area with COPD. Awaiting the impact of this.
Norfolk + Waveney
We have new step up virtual wards which are integrating well with the step down VW from acute sector- this has produced good working relationships between community and acute Trusts and enabled patients to stay in their own homes supported by good IT links with Primary Care. More important are the relationships being built across sectors.
North West London
The London Asthma Decision Support tool (LADS) - a collaboration between North West London ICS, South East London ICS, Imperial College Health Partners, Imperial College London, and Vizify - was highly commended in the Data-Driven Transformation Award at the 2023 HSJ Awards. The LADS tool brings together air pollution, demographic and social deprivation data with routinely collected NHS data for the first time ever. Linking data in this way not only allows clinical teams to intervene much earlier in the patient pathway and improve outcomes, but also to focus on identifying and investigating areas of health inequity across the capital. This tool is built on the whole systems integrated care (WSIC) platform and maximised the capabilities of the linked, longitudinal data to take a population health management approach.
Somerset
PR and oxygen is recently commissioned and we are trying to address the current backlog of waiting times.
We have a lung health pilot for lung cancer (which was arranged regionally and caused problems with the knock-on effects of referrals to primary / secondary care - but we are trying to improve this).
We have Asthma Care Bundles and a dynamic CYP asthma lead.
South East London
A comprehensive COPD Guideline covering the entire patient pathway for use across primary and secondary care.
Asthma guides for adults and children developed for primary care.
South West London
Croydon respiratory team.
South Yorkshire
PR programme.
SABA reduction in asthma programme.
Surrey Heartlands
Integrated respiratory services have been developed at Place, with one Place being invited to showcase their work to NHS England.
West Yorkshire
Campaign to Help Improve Respiratory Prescribing (CHIRP) project
Sussex
Most impactful intervention: PR programme.
Note: review dates refer to the page content rather than the data visualisations