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Using the private sector to provide a new COPD service

Dr Jonathan Hincks explains how a private provider has outbid the local acute trust to provide COPD care, including a 24-hour, seven-day urgent response service

Dr Jonathan Hincks explains how a private provider has outbid the local acute trust to provide COPD care, including a 24-hour, seven-day urgent response service

Our new community COPD service started in February this year and consists of 11 clinics across the county of Somerset.

The service aims to reduce avoidable emergency admissions, facilitate early supported discharge, and optimise COPD care through individual case management. It provides a seamless link between secondary and primary care and monitors community oxygen therapy.

The service is staffed by nursing teams led by a respiratory nurse specialist – the box below explains how the service works.
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The service started seeing patients in February this year. To date there have been 700 referrals from 70% of Somerset practices. As the cold weather arrives for this winter and acute COPD exacerbations kick off, we hope those patients with COPD who have had the benefit of accessing the new service will be less likely to require hospital admissions. We aim to cut admissions by 20%, saving £145,000.

The surprise winner

Somerset has a longstanding respiratory clinical network, but until recently we had been frustrated in our attempts to find a way to commission the best evidence-based COPD care.

We wanted a comprehensive, equitable, accessible, evidence-based COPD service that would reduce admissions, as COPD accounts for about one in eight unscheduled care admissions in our area.

Practice-based commissioning proved to be the driver to effect the necessary changes, with Somerset Practice-Based Commissioning Consortium (now www.wyvernhealth.com) producing a commissioning plan to reduce avoidable admissions in April 2007.

The service specification was produced as the result of work done by a local clinical advisory group comprising representatives of primary and secondary care and other stakeholders.

It was informed by a questionnaire sent out to 120 Somerset patients with COPD. The results showed they wanted care closer to home, more information, more education and easier access. Patient and public involvement has been a key feature of the commissioning process, in line with world-class commissioning principles.

The two local acute trusts, in partnership with Somerset PCT, put in a bid to provide the countywide integrated community COPD service – Taunton and Somerset NHS Trust and Yeovil District Hospital NHS Foundation Trust. A third bid came from Clinovia Limited – a nationwide service provider operating within the BUPA group – in partnership with Avanaula, a firm led by local GPs Dr Robin Carr and Dr Richard More.

Following a thorough and objective competitive procurement process, Somerset PCT awarded the three-year contract to the private provider, Clinovia – an outcome that I had not expected.

I had assumed the contract would go to the local NHS trusts in partnership with the PCT as they had been providing some of the service already, but in the open competitive tendering process the private provider came out top in all the three categories we looked at: a tendering documentation scored by a panel including patient representatives and me; a presentation; and a financial evaluation of the bids by the PCT, which looked at the costings of the service from each provider.

There were some shockwaves following the award of the contract to a private provider, but because the process was open and transparent in accordance with EU procurement guidance it was hard to object. However, there was some fallout.

The trusts were understandably upset that their bids had not been successful and re-engaging with secondary care has been an ongoing challenge for the new service and the PCT.

How the scheme works

The PCT has a three-year contract with Clinovia. There is an agreed set of key performance indicators around reducing oxygen spend, reducing avoidable hospital admissions, numbers going through pulmonary rehab, oxygen assessments and so on. The contract specifies regular performance monitoring and incentive payments for reduced oxygen spend and reduced admissions.

Somerset PCT has invested £1.3m pump-priming money into the PBC commissioning plan to reduce avoidable admissions and the new COPD service was funded £500,000 out of this package.

All practices in Somerset can access the service and have been given details of the referral scheme – along with the relevant paperwork such as referral proformas – by the new provider.

Results

The service has been live since April but we are only now entering the cold weather so a full evaluation will be done next year.

Initial results show a drop in admissions and we expect admissions will be reduced by at least 20%, with anticipated savings of £145,000.

Some referrals are coming from hospital consultants.

Lessons learned

• Marketing a new service is critically important. Not all GP practices have insight yet into their patients' need for this service and you need to sell the service to the people who will be using it so they realise it is something they need.

• Integration between primary and secondary care can be derailed by such events as an acute trust not being given a contract they might have been expecting to win. That is a challenge that will need to be overcome.

• There were concerns the scheme would deskill primary care clinicians but I think the opposite is true as there will be increased awareness of how to optimise respiratory management of COPD patients. It is a great opportunity to add quality to the QOF.

• Our consortium has enjoyed very successful working arrangements with the PCT. Somerset PCT manager Annabelle Walker has been brilliant, and my right- and left-hand person in all this.

• If a service like this can be successful in Somerset, which has a relatively low prevalence of COPD compared with the rest of the country, it could make an even bigger impact in other areas.

Dr Jonathan Hincks is a GP in Cheddar, Somerset, GP clinical lead for COPD services at Wyvernhealth.com and is on the General Practice Airways Group executive committee

Further resources for commissioning COPD services under PBC can be found at www.impressresp.com

Dr Jonathan Hincks: PBC proved to be the driver to produce a commissioning plan to reduce admissions Dr Jonathan Hincks: PBC proved to be the driver to produce a commissioning plan to reduce admissions How the scheme works

The following patients are referred to the service


• FEV1 <>
• MRC >30%
• Hospital admission in previous year
• Those having oxygen therapy
Any professional – including community matrons and hospital consultants – can refer to the service provided they can make a diagnosis of COPD and reasonably assess any comorbidities.

There are four main elements to the service:


1: Assessment clinics
Each patient referred has a 90-minute rigorous and evidence-based assessment with a written management plan given to the patient so that both nurses and patients know what is likely to happen in the event of an exacerbation. For instance, if the history and/or discharge notes show the patient is a carbon dioxide retainer, they will not be managed in the community. The intensive assessment also looks at how their COPD affects them psychologically and socially as well as medically. The patient's needs and expectations are included in the written plan.

The clinics also make any necessary recommendations to the patient's GP with regard to treatment optimisation and, if appropriate, manage oxygen and nebuliser treatments.


2: Pulmonary rehabilitation
This includes a structured programme of exercise and education and combination of group and one-to-one support.

3: Urgent response
A 24/7 service is available 365 days a year for patients who become unwell so they can get telephone advice and/or request a home visit. The written management plan is used by both patient and professional to help decide what should happen – the patient having previously decided at their initial assessment (see above) what should happen during an exacerbation.


4: In-hours unscheduled rapid response
This part of the service is currently being developed. It will mean the service can offer an unplanned assessment for patients who have not attended an assessment clinic and offer a home visit if necessary. Patients admitted to hospital will also be assessed to ensure they have the necessary support in place to facilitate an early discharge.

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