Written evidence submitted by the British Thoracic Society (DEL0109)
1.1 The British Thoracic Society (BTS) is the largest, most authoritative and most inclusive respiratory membership body in the UK, and a registered charity. We have over 3,800 members from all areas of the respiratory workforce including doctors, nurses, respiratory physiotherapists, scientists and other professionals with a respiratory interest. We represent the professional voice of respiratory medicine in the UK.
1.2 BTS works to raise awareness of the impact of lung disease and champion the respiratory workforce while developing and promoting evidence-based standards of care in order to achieve better lung health for all.
1.3 The experience and expertise of the BTS membership is exceptionally relevant to the topic of the inquiry. During the pandemic we have been at the forefront, standing alongside intensive care colleagues. Respiratory specialists have led in opening COVID-19 wards, staffed by dedicated respiratory teams.
1.4 Since March, we have also been producing rapid urgent guidance for the care of patients with COVID-19, which can now be found on the Information for the Respiratory Community section of the BTS website[1]. This page has now been visited over 100,000 times and guidance documents downloaded over 115,000 times, providing invaluable guidance for respiratory teams as well as non-respiratory specialists needing to refresh their respiratory knowledge in order to care for COVID-19 patients.
1.5 The quality of this guidance and the speed with which it has been produced is testament to the number of key respiratory experts within the BTS team, as well as the commitment of respiratory teams to the care of patients.
1.6 Most recently, and of great relevance to this inquiry, on 4 May 2020, we published a guidance document on Respiratory Follow Up of Patients with Radiologically Confirmed COVID-19 Pneumonia[2].
1.7 The respiratory specialty is the medical specialty with the greatest responsibility for caring for COVID-19 patients both now and in the endemic phase, as well as the specialty most impacted in terms of a backlog of core services. As a result we are very pleased to submit evidence to this inquiry and would be delighted to assist in whatever way might be useful. We would be very grateful for the opportunity for senior leaders from the Society to present evidence to the Committee.
2.1 The respiratory speciality is at the forefront of the response to the COVID-19 pandemic and respiratory professionals are currently caring, and will continue to care, for a majority of COVID-19 patients. We are unique in having three components to our workload, each of which represents a very major burden:
a. Acute COVID-19 care
b. Endemic COVID-19 care
c. Meeting pre-existing respiratory need, especially the “Winter Pressures” annual increase in admissions
2.2 In order to respond to these challenges, and ensure effective delivery of core NHS services during the pandemic and beyond, significant investment and resourcing of respiratory medicine is required. This need is all the greater due to the fact that respiratory already had insufficient resource prior to the COVID-19 pandemic.
2.3 A minimum of a 20% increase in the resourcing of respiratory departments will be needed, covering the broad workforce as well as an increase in the number of beds on respiratory wards.
2.4 Additionally, we propose the following steps in order to restructure services to be better equipped to meet the challenges of delivering healthcare in a (post-)COVID-19 landscape:
- An additional COVID-19 positive ward in most hospitals.
- Structural support and funding to enable closer integration with primary care to deliver optimum respiratory care outside the hospital, in the community.
- Enhanced multi-disciplinary working to improve coordination and delivery of care.
- Annualised staff scheduling to reflect the seasonal imbalance of demand resulting from the 2-3 fold “Winter Pressures” annual increase in activity seen between October and March, which respiratory teams bear the brunt of.
- Expansion and updating of the respiratory component of the NHS England Long Term Plan in the light of COVID-19.
Word count
About BTS: 371
Executive Summary: 277
Response: 1849
Appendices: 2583
Our response takes each question from the call to evidence in turn. We have responded to the first two questions jointly.
3.1 Achieving an appropriate balance between coronavirus and ‘ordinary’ health and care demand and meeting the wave of pent-up demand for health and care services that have been delayed due to the coronavirus outbreak
3.1.1 In respiratory medicine these are uniquely difficult challenges because respiratory specialists are responsible for dealing with a majority of acute COVID-19 admissions to hospital. On 26th April 2020, only around 15% of patients in hospital beds in England were in intensive care[3], respiratory teams are looking after many of the remaining 85%. Respiratory specialists will also be expected to continue looking after endemic COVID-19 patients admitted to hospital when other specialities withdraw to focus on ‘ordinary’ health and care demand.
3.1.2 The respiratory specialty is therefore responsible for three challenging areas:
a. Acute COVID-19 care
b. Endemic COVID-19 care
c. Meeting existing respiratory need
i. Especially the 2-3 fold “Winter Pressures” annual increase in admissions.
ii. Exacerbated by pre-existing workforce shortages and related long waiting times.
iii. Including a large back-log due to early reduction of elective respiratory services.
3.1.3 BTS has consistently called for an additional 100 respiratory training places per year over five years in order to address pre-existing respiratory demand[4]. In order to provide ongoing COVID-19 care alongside existing need, we now estimate a minimum of a 20% increase in resourcing of respiratory departments will be required. This must include additional physicians, nurses, physiologists, physiotherapists, pharmacists and other colleagues, as well as increased numbers of respiratory beds.
Respiratory workforce shortages
Pre-existing
3.1.4 Prior to the COVID-19 pandemic numbers of respiratory clinicians were already insufficient to meet demand. BTS surveyed respiratory leads in February 2020 and the vast majority of respondents (73%) already felt that respiratory healthcare staff shortages were impairing the ability of their local NHS organisation to cope effectively with increased emergency respiratory hospital admissions[5].
3.1.5 These staffing pressures in respiratory medicine span the whole, broad workforce. Shortages are compounded by respiratory medicine’s continuing large contribution (30-40%) to Emergency and Urgent Care, including Same Day Emergency Care.
3.1.6 BTS has recently submitted a paper on these issues to NHS England and NHS Improvement and Health Education England.
Impact of COVID-19 (pandemic and endemic)
3.1.7 These pre-existing shortages are compounded at present by COVID-19 pressures and will be worsened as we move into an endemic phase by continued respiratory responsibility for COVID-19 patients, staff illness and stress, the need to catch-up on missed annual leave, bank holidays and study leave, and the retirement of some senior team members.
3.1.8 Chronic workforce shortages will have also a major impact on post COVID-19 respiratory service delivery.
Service delivery
Backlog resulting from COVID-19 pandemic
3.1.9 Due to particular risk to respiratory patients and the need for respiratory leadership in COVID-19 care planning and provision, respiratory elective services were often the first to be reduced. Hence, the backlog will be substantial with respect to clinical reviews, delayed investigations needing to be performed and results requiring review, and morbidity and mortality reviews.
Pre-existing challenges
3.1.10 Once again, these added pressures compound existing service delivery challenges. Due to capacity issues respiratory waits have traditionally been as long as, or longer than, any other acute medical speciality. Similarly, while respiratory departments are busy throughout the year, they bear the brunt of the 2-3 fold “Winter Pressures” annual increase in activity seen between October and March. There is a particularly risk that this “normal” seasonal increase in activity may coincide with a possible second wave of COVID-19.
Recovery from and long term consequences of COVID-19
3.1.11 Respiratory teams will also be responsible for addressing the consequences of severe COVID-19 infection, and providing medium and longer term clinical assessment for people who have been hospitalised with COVID pneumonia. Our guidance on Respiratory Follow Up of Patients with Radiologically Confirmed COVID-19 Pneumonia[6] will be critical here.
Impact on ‘ordinary’ health demand
3.1.12 Certain respiratory procedures and services are more challenging to restart while mitigating the risk to staff and patients, due to their invasive nature and the fact that COVID-19 predominantly affects the respiratory system. While services such as lung function testing and bronchoscopy can be restarted in some form, the capacity is likely to be reduced by 50-80% because of the additional time measures to reduce the risk of COVID-19 transmission will take up.
Solutions
3.1.13 In order to address the respiratory backlog that existed prior to the COVID-19 pandemic, the exacerbation of this backlog due to COVID-19 and the continued requirements on respiratory specialists to provide care for endemic COVID-19, we need sustainable funding levels and a sustainable planning model in the longer term. In addition to the minimum 20% increase in resourcing outlined above, we must also see:
- Appropriate assignment of staff according to clinical need to ensure that respiratory departments are properly resourced.
- An additional, separate COVID-19 positive ward designated in most hospitals for the foreseeable future.
- Structural support and funding to enable closer integration with primary care to deliver optimum respiratory care outside the hospital, in the community (see appendices 1 and 2).
- Enhanced multi-disciplinary working to improve coordination and delivery of care.
- Annualised staff scheduling to reflect the seasonal imbalance of demand resulting from winter pressures.
- Expansion and updating of the respiratory component of the NHS England Long Term Plan in the light of COVID-19.
- Addressing of long respiratory waiting times that existed prior to the COVID-19 pandemic by increasing capacity via increased implementation of novel ways of working including non-face-to-face consultations and other IT solutions.
- Expansion of pulmonary rehabilitation services which will be vital for post-COVID-19 recovery, and will require new models and resources due to increased demand and the need to maintain social distancing.
Respiratory conditions requiring urgent care
3.1.14 We have identified the following respiratory conditions which must be prioritised when balancing COVID-19 care and ‘ordinary’ health and care demand:
- Lung Cancer and Pleural Disease
- Interstitial Lung Disease (ILD)
- Tuberculosis (TB)
- Cystic Fibrosis (CF)
- Bronchiectasis
- Severe Asthma
- Pulmonary Hypertension
- Lung transplantation
- Long-term ventilation
- Sleep
- Advanced Chronic Obstructive Pulmonary Disease (COPD)/Emphysema
- Symptom specific referrals e.g. cough and breathlessness
3.1.15 BTS has been asked by NHS England to produce guidance on meeting these urgent care demands. Appendix 3 is the foundation document for this and underpins more detailed work which is in progress at present; here we have set out the minimum targets for the areas listed above as well as the relevant key requirements and challenges.
3.2 Meeting extra demand for mental health services as a result of the societal and economic impacts of lockdown
3.2.1 Those with respiratory diseases are often more vulnerable to mental health problems due to the challenges associated with breathlessness, lack of mobility and isolation. These challenges are exacerbated significantly by the COVID-19 pandemic, and will similarly be experienced by many of those recovering from COVID-19. The recent BTS guidance on Respiratory Follow Up of Patients with Radiologically Confirmed COVID-19 Pneumonia[7] addresses these issues specifically and makes practical recommendations. All of our post-COVID work will continue to take mental health needs into account.
3.2.2 This challenge will apply equally to NHS staff who are being exposed to significant stress, over-work and hardship at present. When the first wave of COVID-19 activity settles we will have to deal with a physically and psychologically fatigued and traumatised workforce.
3.2.3 Multiple strategies will be required to rebuild resilience including the requirement mentioned above to “catch up” on annual and study leave, and Bank Holidays that have been cancelled.
3.3 Meeting the needs of rapidly discharged hospital patients with a higher level of complexity
3.3.1 As outlined above respiratory specialists will be needed to provide ongoing care and treatment for those recovering from COVID-19 and experiencing long-term health impacts.
3.3.2 BTS conducted a recent survey of members on the question of support for people recovering from COVID-19 (BMJ Open, forthcoming). The survey received over 1000 responses which emphasised the importance of the following elements in recovery programmes:
- advice on the management of fatigue and breathlessness,
- the need for psychological support for social isolation and mood disturbances,
- symptom monitoring for worsening symptoms, and
- advice on home based and, once social isolation policy is relaxed, outdoor and community exercise.
3.4 Providing healthcare to vulnerable groups who are shielding
3.4.1 This is a particular problem for respiratory medicine as many of the people most in need of regular review and intervention are those who have severe respiratory disease and are shielded.
3.4.2 As detailed below, respiratory teams have been at the forefront of integrated care where specialists work outside the hospital to deliver care in the community. This will be crucial for providing care to vulnerable groups in the light of COVID-19: reducing the requirement for patients to attend hospitals will reduce exposure risks.
3.4.3 Virtual clinic models, such as those run in relation to lung nodule screening[8], where cases are reviewed remotely by clinicians and followed up by phone calls with patients will similarly be fundamental in reducing the need for face-to-face contact.
3.4.4 Many areas of respiratory care do however, require face-to-face contact and invasive, aersol-generating procedures. In these cases sufficient, effective PPE will be critical in order to protect patients and staff.
3.5 Ensuring that positive changes that have taken place in health and social care as a result of the pandemic are not lost as services normalise
3.5.1 Many positive changes have indeed taken place, such as the SPACES approach[9] designed by the respiratory team at Glenfield Hospital, Leicester to reduce staff-patient contact while maintaining excellence in treatment and care.
3.5.2 This juncture should also be taken as an opportunity to re-design services where challenges existed prior to the COVID-19 pandemic. Based on experience of running non-ICU COVID wards, respiratory specialists have an ideal vision for different ways of working in order to address pre-existing pressures and the compounding effects of COVID-19. Moving towards widespread adoption of integrated models of care, annualised staff scheduling and enhanced multi-disciplinary working, as outlined above, are prime examples of such opportunities.
3.5.3 BTS and the respiratory community have led the way in the development of innovative models of integrated care. Over the past six years BTS has developed our Respiratory Futures platform[10] to provide resources to support integrated respiratory care, commissioning, innovation and networking.
3.5.4 Respiratory leadership in integrated care is demonstrated by the exchange of letters at appendices 1 and 2, and we welcome Professor Stephen Powis’ closing comment: “Traditional boundaries of care shouldn’t be a barrier to achieving the best outcomes for patients, so thank you for your leadership and work in this important area.”
3.5.5 We will continue to develop and implement these models of care and believe they are vital to the future of the NHS.
Respiratory Futures Integrated Care Clinicians Network
Secretariat provided by British Thoracic Society
17 Doughty Street
London, WC1N 2PL
BTS@brit-thoracic.org.uk
2 December 2019
To:
Professor Stephen Powis, National Medical Director, NHS England and NHS Improvement
Dr Nikki Kanani, Medical Director for Primary Care, NHS England and NHS Improvement
Simon Stevens, NHS Chief Executive
Ian Dodge, National Director: Strategy and Innovation, NHS England and NHS Improvement
By email
Dear Professor Powis, Dr Kanani, Mr Stevens and Mr Dodge,
INTEGRATED RESPIRATORY CARE – BREAKING DOWN THE BARRIERS TO DEVELOPMENT
Current Care
Outcomes for respiratory disease across the UK are amongst the worst in Europe.
The NHS England Long Term Plan (LTP) recognises that people with long-term respiratory conditions:
- are often diagnosed late,
- are not supported to engage in the lifestyles that will keep them well,
- are often on multiple medications which have not been optimised,
- experience repeated crisis-driven hospital admissions at huge cost to the healthcare system and their well-being, and
- are often subject to significant health inequalities.
It is documented extensively that tobacco addiction, mental health problems, loneliness and other social determinants of health are major drivers of healthcare utilisation in this population.
Many of these factors contribute to winter pressures in all four nations of the UK with the resulting impact on all aspects of non-elective and elective care in the NHS and also Social Care sectors.
The Vision
The LTP has given a blueprint for addressing all of these aspects of sub-optimal care for people with long term respiratory conditions and a vision of how to enable us to have the best respiratory care in the world.
The NHSE National Collaboration for Integrated Care and Support states “for health, care and support to be ‘integrated’, it must be person-centred, coordinated, and tailored to the needs and preferences of the individual, their carers and family.” The NHSE LTP states that ICSs will be central to its delivery and that by April 2021 ICSs should cover all of England. It also states: “[t]he new way of working will draw together people and capabilities, resources, activities and leadership to collectively deliver greater value for the NHS and for patients. The revitalised culture of support and collaboration will be underpinned by a new approach.”
The Barriers
The NHS 5 year plan and LTP acknowledge that the current system of fragmented care does not empower nor enable clinical teams to achieve the goals detailed above.
We are a network of Specialist Consultants, GPs, nurses and allied health professionals who are passionate about developing integrated care models for people with respiratory disease.
Collectively, we have found that we are encountering the same barriers across the country:
- Acute trusts remain incentivised to providing services that are based on episodes of care rather than integrated clinical pathways.
- The payment policy encourages acute providers to expand activity within hospitals (rather than across the wider health and social care system).
- The regulators (CQC and NHSI) focus on episodic or single-organisation care and do not encourage integration.
- Limited job planning support for consultants to lead integrated care.
- No systematic core training in integrated care, population health and leadership training within medicine.
Breaking Down The Barriers
We wish to support the LTP vision for integrated care and change the standards for people with long term respiratory conditions by enabling them to optimise their care wherever they are in the health and social care system. By moving the respiratory specialism outside of hospitals, we can support primary care in delivering preventative and proactive care as intended by the key elements of the LTP. There are excellent examples in other long term conditions e.g. diabetes, where this way of working has improved outcomes for patients and reduced demand on acute trusts.
In order to realise this vision we ask for your support to:
- Prioritise respiratory care in the development and delivery of Integrated Care Systems.
- Prioritise respiratory care in any work NHSE/I is undertaking to incentivise integrated care pathways e.g. expanding blended payment systems.
- Incentivise Acute Trusts to anticipate the LTP ambitions to enable them to support the local health community via Integrated Care Systems, including funding secondary care consultants to have dedicated time in job plans for integrated care.
- Invest in a national network of regional leads in respiratory integrated care aligned to the LTP.
- Ensure clinical respiratory networks exist in all areas of England to enable ICS working.
The inclusion of respiratory health in the LTP is welcomed as a vital step towards improving outcomes for patients but we believe that progress will be thwarted unless cross boundary working is facilitated.
Yours Sincerely,
Dr Binita Kane, Consultant Respiratory Physician and Co-Chair, Respiratory Futures Integrated Care Clinicians Network
Professor Jonathan Bennett, Consultant Respiratory Physician and Chair, British Thoracic Society
Co-signed by 52 clinicians
Professor Stephen Powis National Medical Director
Skipton House 80 London Road
SE1 6LH
Dr B Kane and Prof J Bennett
Respiratory Futures Integrated Care Clinicians Network British Thoracic Society
17 Doughty Street London
WC1N 2PL
13 February 2020
Dear Dr Kane and Prof Bennett,
Thank you for your letter of 2nd December regarding integrated respiratory care and breaking down the barriers to development.
The idea you describe of moving the respiratory specialism outside of hospitals, where primary care is delivering preventative and proactive care, is entirely consistent with the broader ambitions in the NHS Long Term Plan and the move towards creating Integrated Care Systems in every part of the country. This will deliver the ‘triple integration’ of primary and specialist care, physical and mental health services, and health with social care, together with a move towards a focus on improving population health.
As Respiratory Care is included as one of the major health conditions for improvement, each of the STP / ICS plans that are currently being finalised should be considering what this means for their population, and what their contribution will be to the ambitions in this area. The NHS England and Improvement (NHSEI) respiratory team have been supporting their colleagues across the seven regions by reviewing draft plans, advising on areas for improvement and highlighting examples of good practice.
The team have noted examples of integrated practice, for example the intention to develop virtual clinics and diagnostic hubs within Primary Care Networks (PCNs) and an emphasis on population health management to support the early detection and management of respiratory disease.
I also understand from our National Clinical Director for Respiratory Disease that integrated working was a key theme at the British Thoracic Society’s winter meeting recently, and it was encouraging to hear about so many good examples of teams and individuals working across boundaries to improve outcomes for patients.
We expect system working, where providers and commissioners are aligned around a common set of objectives which are reinforced through contracting and accountability arrangements, to help address the barriers you describe in your letter, such as making it easier for secondary care consultants to work across primary and secondary care settings. We are looking for more opportunities to encourage and facilitate this type of integrated working.
For example, we have started to change the way activity is paid for and are keen to concentrate on how we can support integrated care, delivering care outside the hospital setting and looking to encourage more preventative and anticipatory care.
We have already introduced a blended payment approach for emergency care in 2019/20 and are releasing proposals to extend these principles into outpatient and maternity care for 2020/21. As part of continuing to develop payment models, we would like to work with colleagues in the respiratory clinical community to see how redesigning reimbursement for respiratory care could help further achieve this vision and how an integrated blended payment model could support these aims.
We also recognise the importance and value of clinical networks and the national programme team is working closely with regional teams to facilitate their development.
More generally, I am aware that the National Clinical Director and the national programme team are already working with many of the co-signatories of your letter on the delivery of the NHS Long Term Plan’s ambitions for respiratory disease, for which we are very grateful.
Traditional boundaries of care shouldn’t be a barrier to achieving the best outcomes for patients, so thank you for your leadership and work in this important area.
Yours sincerely,
Professor Stephen Powis
National Medical Director
NHS England and NHS Improvement
Minimum targets | Key requirements, challenges and opportunities |
Lung Cancer and Pleural Disease | |
The National Optimum Lung Cancer Pathway has mandated rapid Triage and Assessment of all patients with a high clinical suspicion of Lung Cancer with triage of initial imaging occurring within 3 days and all investigations completed within 14 days Consultations – within 1 week Procedures – within 1 week Multi-disciplinary teams (MDTs) – within 1 week | There are opportunities to streamline services consistent with the optimum patient pathway but the barriers to implementation will remain and need to be addressed. In many hospitals this is a specialised service run by a designated “Lung Cancer Team”. Instead, multiple MDTs need to be recognised in job plans, as this highly interactive case management approach is the best way to deliver the optimal pathway. The service relies on respiratory interventional procedures including endobronchial ultrasound (EBUS), bronchoscopy, medical thoracoscopy, other ultrasound guided pleural procedures. A daily regional EBUS list is needed: while all district general hospitals carry out EBUS this is often done as infrequently as once every two weeks. Pleural procedures also include empyema and pneumothorax (typically inpatients but would need review within 48 hours). Efficiency in performing some of these procedures may be reduced by strategies to manage endemic COVID-19. |
Interstitial Lung Disease (ILD) | |
Consultations – within 3 months with targeted patients within 1 month MDTs – within 1 month | There is opportunity to better establish the hub and spoke model originating from speciality commissioning. Regional services are highly specialised and dependent on a very small number of multi-professional individuals. Local services have to refer to regional hubs and MDTs for treatment of most ILD. Post COVID-19 ILD is a key risk from a severe infection (around 10%) so an unknown magnitude of additional patients will need to be reviewed though identification of these patients can be delivered by non-ILD specialists. |
Tuberculosis (TB) | |
Consultations – within 1 day Treatment – 1 week MDTs – within 1 month | Acute TB needs to be treated urgently and is a sub-acute respiratory presentation. Multi-drug resistant TB is not common but requires super-specialist advice and support via national multi-disciplinary teams such as the British Thoracic Society Multi-Drug Resistant TB Clinical Advisory Service. In many centres one specialist will see all TB cases. Contact tracing / case finding must continue along with Video Observed Therapy. |
Cystic Fibrosis (CF) | |
Consultations – within 1 month MDTs – within 1 month | Another highly specialised service dependent on a small number of individuals and complex pathways. The main challenge her is not the initial consultation but managing exacerbations. |
Bronchiectasis | |
Consultations – within 1 month (admission prevention) and 3 months (routine) MDTs – within 1 month (admission prevention) and 3 months (routine) | High risk patients with Pseudomonas colonisation and regular exacerbations are at risk of admission and need to be seen rapidly (c.f.: CF). Post COVID19 Bronchiectasis is a key risk from a severe infection so an unknown magnitude of additional patients will need to be reviewed though identification of these patients can be delivered by non-Bronchiectasis specialists. There exists the opportunity to better coordinate out-patient antibiotic services. |
Severe Asthma | |
Consultations – within 2 weeks (post-hospitalisation/A&E) and 1 month routine MDTs – within 1 month | There is opportunity to better establish the hub and spoke model originating from speciality commissioning. Regional services are highly specialised and dependent on a very small number of individuals. Local services have to refer to regional hubs and MDTs for treatment. There are not sufficient numbers of such hubs to carry out detailed assessments. Use of biological therapy prevents delivery by non-specialists. |
Pulmonary Hypertension | |
Consultations – within 1 month Procedures – within 1 week of consultation MDTs – within 1 week | A very limited number of centres nationally and the model is to deliver review, procedures and MDT within a week. Highly specialised and dependent on a small number of individuals within these centres. Therapy has to be approved by the centre. General respiratory and cardiac physicians refer from local hospitals and suspected patients there should be seen within 1 month. |
Lung transplantation | |
Consultations – within 1 month (urgent) and 3 months (routine) MDT – within 1 week | A very limited number of centres nationally. Highly specialised and dependent on a small number of individuals within these centres. Typically involves referral from patients already under the care of local hospitals due to conditions such as CF, severe Chronic Obstructive Pulmonary Disease (COPD) and ILD, where follow-up will have been delayed increasing urgency. |
Long-term ventilation | |
Consultations – for neuromuscular disease (such as Motor Neurone Disease) within 1 week and routine 1 month Hypercapnia start ventilation within 1 week MDT – within 1 week | There is opportunity to better establish the hub and spoke model originating from speciality commissioning. Regional services are highly specialised and dependent on a very small number of individuals. Local services have to refer to regional hubs and MDTs for treatment of most ILD. A specific key issue is that ventilation specialists will be frontline even amongst respiratory specialists potentially leading to the longest delays restarting routine service. A number of individuals will require longer term inpatient weaning after ventilation for COVID19 and these services are often run by the same individuals. Efficiency and general working such as the setting up and delivery of long-term ventilation will also be affected by endemic COVID-19. The opportunity exists for greater remote working and day case set-up of ventilation but this will require significant increases in workforce numbers. |
Sleep | |
Pre-consultation diagnostics and consultations – within 1 month MDTs – within 1 week (urgent) and 1 month (routine) | Large increases in referral numbers over recent years and many centres have the worst delays in the area pre-Covid-19. Long wait times that are not acceptable due to increasing recognition of associations, e.g. Atrial Fibrillation, difficult to control hypertension leading to more referrals in setting of reduced capacity. Many sleep labs closed early for physiologists to support mask fitting re COVID19. Diagnostics Waiting Times and Activity data (DM01) returns show there are 12,000 sleep studies per month. If the change in practice continues the backlog in managing such patients, in the setting of already limited capacity will be difficult to achieve. Regional sleep services offering polysomnography are limited in number but better local services would enable the specialist centres to fulfil their role more effectively. Consideration needs to be given to redesigning areas of the sleep pathway and the use of technological innovations to reduce patient attendances. |
Advanced COPD/Emphysema | |
Pre-consultation diagnostics and consultations – within 3 months MDTs – within 1 month Long Term Oxygen Therapy assessments – within 1 month | Overlap with lung transplantation and chronic ventilation services. Includes supra-regional services for lung volume reduction procedures partly delivered by thoracic surgeons. Funding through specialised commissioning needs to be agreed in order to limit the current postcode variation. |
Symptom Specific Referrals | |
Cough - within 3 months Breathlessness - within 1 week for urgent referrals and within 3 months for routine |
|
[1] https://brit-thoracic.org.uk/about-us/covid-19-information-for-the-respiratory-community/
[2] https://brit-thoracic.org.uk/about-us/covid-19-information-for-the-respiratory-community/#bts-guidance-on-respiratory-follow-up-of-patients-with-radiologically-confirmed-covid-19-pneumonia
[3] Letter, 29 April 2020, from NHS Chief Executive Sir Simon Stevens and Chief Operating Officer Amanda Pritchard to Chief executives of all NHS trusts and foundation trusts
[4] https://brit-thoracic.org.uk/media/70309/bts-workforce-review-2018-final-7-dec-2018.pdf
[5] https://www.brit-thoracic.org.uk/about-us/pressmedia/2020/understaffed-and-overstretched-nhs-respiratory-departments-are-hit-by-continuing-and-mounting-pressures-this-winter/
[6] https://www.brit-thoracic.org.uk/about-us/covid-19-information-for-the-respiratory-community/#bts-guidance-on-respiratory-follow-up-of-patients-with-radiologically-confirmed-covid-19-pneumonia
[7] https://brit-thoracic.org.uk/about-us/covid-19-information-for-the-respiratory-community/#bts-guidance-on-respiratory-follow-up-of-patients-with-radiologically-confirmed-covid-19-pneumonia
[8] https://www.respiratoryfutures.org.uk/features/leeds-virtual-lung-nodule-service/; https://www.respiratoryfutures.org.uk/features/how-to-set-up-a-nodule-virtual-clinic/
[9] https://brit-thoracic.org.uk/about-us/covid-19-information-for-the-respiratory-community/#spaces-sharing-patient-assessments-cuts-exposure-for-staff