Cross-Party Group on Lung Health
Grŵp Trawsbleidiol ar Iechyd yr Ysgyfaint
Minutes from 14 February 2023
MSs
Mike Hedges MS (supported by Ryland Doyle)
Huw Irranca-Davies MS
Heledd Fychan MS
Rhun ap Iorwerth MS (represented by Rhys Hughes)
Non MSs
Joseph Carter - Asthma + Lung UK Cymru (Secretariat)
Alice Spencer
Chris Davies
Chrissie Gallimore
Dave Edwards
Deborah Fossett
Hannah Bray
Jeannie Wyatt Williams
Jerome Donagh
Joanne Allen
Joanne Oliver
John Morgan
Josephine Cock
Jonathan Morgan
Julie Mayes
Kathryn Singh
Lyn Lording
Mark Dodd
Natalie Janes
Neil Harris
Nicola Perry-Gower
Pam Lloyd
Pat Vernon
Stephanie Morgan
Stephanie Woodland
Valerie Ann Tweedie
Val Maidment
Verdun Moore
1. Mike Hedges MS - Welcome and introductions
Mike Hedges MS started the meeting and thanked everyone for attending. asked if any MSs or support staff wanted to introduce themselves.
Mike Hedges MS explained that there were two presenters today, Pat Vernon (who has replaced Anthony Davies) and Natalie Janes.
He encouraged people to put any questions they had in the chat.
2. Mike Hedges MS – Apologies
The following MSs have sent their apologies:
Altaf Hussain MS
Jane Dodds MS
John Griffiths MS
Vikki Howells MS
Sarah Murphy MS
Ken Skates MS
Darren Millar MS
Mark Isherwood MS
Natasha Asghar MS
Tom Giffard MS
Llŷr Gruffydd MS
Heledd Fychan MS
Luke Fletcher MS
Sioned Williams MS
Jack Sargeant MS
Sian Gwenllian MS
3. Mike Hedges MS – Minutes of the last meeting
None of the MS present were at the previous meeting, so the minutes couldn’t be signed off. John Griffiths MS has already signed them off. Joseph Carter will speak to Altaf Hussain MS to ask him to second them.
Action: Joseph Carter to liaise with Altaf Hussain MS
4. Joseph Carter – Matters arising
The following actions had been agreed at the previous meeting
· Action: Joseph Carter to share details of Julie Mayes and Valerie Ann Tweedie with Joanne Allen.
o Shared
· Action: Joseph will draft a letter to Eluned Morgan MS summarising the results of the COPD survey and the evaluation results from the apps.
o Completed
· Action: Joseph will share the briefing from Dr Simon Barry with all MSs.
o Completed
5. Pat Vernon, Welsh Government – Quality statement for respiratory disease
Mike Hedges thanked Pat Vernon for stepping in and presenting the quality statement at short notice.
The quality statement was published on 30 November 2022. The Minister had said that this quality statement and other ones were designed to help the planning of healthcare services in accordance with the quality attributes contained in each statement and tackle unwarranted variation. Welsh Government expect these quality attributes to therefore be reflected in health board IMTPs and held to account by the new NHS Executive.
The quality attributes are listed below:
Equitable
· The Respiratory Health Implementation Group develops national datasets to support clinical decision making and improve local planning of respiratory disease services for adults and children and young people.
· The Respiratory Health Implementation Group develops and maintains national guidance, pathways and tools (including PROMs) to support health boards deliver consistent and excellent respiratory disease care.
· Health boards provide (or commission) specialist multi-professional teams, competent in the management of adult chronic respiratory disease (including tuberculosis, interstitial disease, COPD, asthma, sleep disordered breathing, and the delivery of oxygen therapy), that are appropriately resourced to meet the needs of their population.
· Health boards commission (or provide) regional specialist multi-professional teams competent in the management of chronic respiratory disease among children and young people.
Safe
· Health boards, as appropriate, admit patients with more severe single organ respiratory failure to a respiratory support unit (RSU), or intensive care unit, with staffing and equipment that meets national guidelines.
· Health boards provide (or commission) difficult-asthma services for people with severe or uncontrolled disease, which collaborate at national level to ensure consistency of provision and appropriate access to biologic therapy.
· Health boards take part in national clinical audit for respiratory disease and apply quality improvement methodology and national quality improvement resources in response to the findings.
· All patients considered for long-term oxygen therapy at home should have a standard assessment in line with British Thoracic Society guidance.
Effective
· Adults affected by chronic respiratory disease, where appropriate, receive routine care and review in primary and community care by a healthcare professional who is competent in the management of the patient’s respiratory condition.
· People with respiratory disease, and parents of children with respiratory disease, who use tobacco should be given brief cessation advice, offered Nicotine Replacement Therapy, and referred to smoking cessation services.
· People with chronic respiratory disease are offered their routine vaccinations to reduce their risk of exacerbation and hospitalisation.
· Health boards and trusts collaborate with academic and industry partners, such as Respiratory Innovation Wales, to accelerate research activity and innovation in respiratory medicine.
· Health boards have a nominated clinical and corporate lead for tuberculosis and a local plan for prevention and control, to ensure services can deal with complex case management and respond to any incidents or outbreaks.
Efficient
· People presenting multiple times to hospital with airways disease are supported by an appropriate member of a multi-professional team to improve disease control and reduce their risk of further unscheduled care admissions.
· New COPD patients, and those already on a COPD register, have coded evidence in the clinical record of spirometry, performed by an appropriately trained healthcare professional.
· New asthma patients, and those already on an asthma register, have coded evidence of disease according to the national guideline.
· Medicine usage reviews support individualised and appropriate changes in prescribing practice, increasing the prescribing of lower global warming potential inhalers as a percentage of total inhaler prescribing and reducing the use of SABA and long-term oral steroid prescribing.
Person-centred
· Spirometry should be available to patients over the age of 12 in primary or community care and results should be available to all relevant clinical teams through the Welsh Clinical Portal and independent contractor systems.
· Patient apps are offered to all patients with asthma and COPD – or parents of children with asthma – as a digital patient self-management plan.
· Provide access to appropriate rehabilitation opportunities, including social prescribing, exercise referral and pulmonary rehabilitation services; and to peer-support groups, including from the third sector
Timely
· All patients admitted to hospital with a primary respiratory illness are seen by a respiratory specialist within 24 hours.
· All patients requiring non-invasive ventilation receive it within two hours of arrival at hospital and, as appropriate, are managed in a respiratory support unit or intensive care unit.
· Health boards and Trusts plan for seasonal variation in acute respiratory exacerbations and provide rapid access, community-based services, to avoid unnecessary admissions.
These expectations have been made clear to health board chairs in letters from the Minister. On 03 February 2023 Anthony Davies and Professor Chris Jones – Deputy Chief Medical Officer, met with directors of planning to discuss expectations of them with regard to the planning process. Professor Chris Jones also used the quality statement to challenge medical directors on why spirometry has not restarted in large parts of Wales.
Pat Vernon explained that there will be 13 clinical networks including one for respiratory. There will be a transition from the existing Respiratory Health Implementation Group to the new body.
Mike Hedges MS invited questions.
Joseph Carter - How does Welsh Government envisage the quality statement driving improvement?
Pat Vernon - The quality statements are there to drive services and influence IMTP documents. We shouldn’t have to rely on letters being sent from the DCMO to get something done. She said we are already seeing some of quality statements already feature in discussions between Welsh Government and health boards.
Chrissie Gallimore - when is it hoped that the Respiratory Clinical Network will be fully in place with full membership?
Pat Vernon – The NHS Collaborative have published a timeline including a transition period.
Joanne Oliver – It is hoped that the transition will be completed towards the end of Sept 2023.
Lyn Lording – Will the quality statement set targets for when people are treated? If someone received their service via a hospital in England then would the targets still apply?
Pat Vernon – The quality statements don’t set targets, but if services are delivered across the border, then the health board would need to ensure that the attributes are being applied irrespective of where care is provided.
Val Tweedie talked about her experience of being discharged from hospital in Morriston Hospital. She said they started talking to her about the Swansea Bay virtual ward, but she wouldn’t be able to access this due to living in Powys.
Joanne Allen answered the question saying that Morriston and other hospitals outside of Powys can (and should) refer to the community respiratory team in Powys. There are virtual wards in Powys as well that can be signposted to.
Nicola Perry-Gower pointed out how the old delivery plan was far more detailed and she worried about absence of accountability to deliver high quality services.
Pat Vernon – We need to ensure that a high standard of service is delivered and this will be scrutinised.
6. Natalie Janes – Spirometry Diagnostic Hubs
Mike Hedges introduced Natalie Janes and thanked her for presenting.
Natalie Janes explained that two diagnostic hubs were introduced in the North and South of Aneurin Bevan University Health Board. Each hub undertook spirometry and fractional exhaled nitric oxide (FENO) testing, interpretation, confirming diagnosis and where necessary determining appropriate treatment and management pathways.
The aim was to tackle the backlog of patients awaiting diagnostic spirometry testing within Primary and Community care Services in ABUHB.
Objectives:
· Reduce the waiting list of patients awaiting diagnostic spirometry tests and delayed diagnosis/diagnostic uncertainty.
· Improve treatment outcomes for patients presenting with respiratory diseases, ensuring prudent prescribing/appropriate medicines management.
· Reduce A&E attendance, OOH, GP, and secondary care service contacts.
· Provide provision of services and care closer to home in line with “A Healthier Wales”.
· Ensure Primary and community health care professionals are appropriately trained and certified by maintaining the skills, competence/re-accreditation for spirometry, maintaining an active workforce.
Outcomes –
· Improved diagnostic assessment and management of conditions such as COPD, Asthma, pulmonary fibrosis and ILD for all patients assessed by each diagnostic hub.
· The secondary care patient waiting list for lung function tests within the respiratory directorate was reduced by 52 patients, supporting earlier diagnosis/onward care for these patients.
· Improved treatment outcomes for patients with respiratory diseases, ensuring prudent prescribing/appropriate medicines management.
· Reduction in A&E attendance, OOH, GP contacts and secondary care services.
· Maintenance of staff skills, competence/re-accreditation for spirometry, by providing training /education within hubs for future sustainability.
· 347 risk stratified patients were reviewed of which 136 patients had a change in referral diagnosis.
· 31 of these patients had an admission to hospital and 7 had admission to ITU in past 12 months.
· 104 patients had 2 more previous exacerbations in past 12 months.
· 52 patient reduction in respiratory directorate waiting list.
Mike Hedges MS invited questions.
Mark Dodd - ARTP accredited training is usually recommended for Spirometry but not required for FeNO testing. Spirometry is deemed moderate risk and FeNO low risk procedure by ARTP. Collaborative hubs seem the way forwards as per NICE, with trained teams and efficient use of resource. In England the QOF indicator for asthma incentivises the uptake of key objective tests such as Spirometry and FeNO. Is there a plan to roll these pilots out and potentially include FeNO as well?
Natalie Janes – Within Aneurin Bevan there are practices who are keen to deliver spirometry again, but I worry about the practices who won’t restart and what happens to those patients. That’s why hubs are so important. The costs of training and validating staff in primary care is a barrier. It needs to be looked at on an All-Wales basis.
Joanne Oliver commented that she felt the hubs need to be re-established at all possible and that education in practices is key.
Huw Irranca-Davies MS – In my constituency, we do have some GPs offering spirometry. If we can’t have spirometry hubs in every community, perhaps we should be asking Welsh Government how do they ensure there is comprehensive coverage in every health board?
Natalie Janes agreed and said that they are working with Agored to help train staff.
Joseph Carter talked about the letter from the DCMO to health boards asking them to restart spirometry. Welsh Government won’t share a copy of this letter, so we can’t comment on how strong the direction is. GPC Wales are clear that they do not want spirometry in primary care.
Pat Vernon - In terms of linking this work to the Quality Statement, it falls clearly within the domain of 'efficient' care. Innovative projects like this one can be looked at by the clinical network and then they can support the potential roll out of such innovation across other health boards.
Pat Vernon agreed to share the responses from health boards to the DCMO letter.
Dr Jerome Donagh thanked Natalie Janes for her presentation and the work that everyone is doing but he described the situation as a ‘dog’s dinner’ and urged Welsh Government to fix this problem. He said there are thousands of people who can’t be diagnosed. Hospitals don’t have capacity to provide it. There have been examples of hubs operating for a short period and then stopping. In his own practice, the nurses he had trained to do spirometry have all left. This is a massive problem that no one is doing anything about.
Pat Vernon agreed with many of Dr Donagh’s concerns and agreed to communicate those concerns to colleagues in Welsh Government
Natalie Janes is concerned about the poor level of coding on patient records. Even when spirometry is done it is often not recorded appropriately.
John Morgan - In Powys, we've been able to make the case for investment in accurate spirometry through reduction in inappropriate prescribing (e.g., without accurate spirometry, some individuals are misdiagnosed with COPD and then prescribed medication they don't clinically require).
7. Joseph Carter – Next meeting and the work ahead
Mike Hedges MS asked Joseph Carter to talked about the future meetings. Joseph thanked everyone for their contributions and for making the time to come and confirmed that the next meeting would be on 13 June 2023 where we will focus on the results of the new Asthma + Lung UK Life with a Lung Conditions Survey. On 02 May at 12 noon Asthma + Lung UK Cymru is hosting a Senedd reception for World asthma day. Everyone is welcome.
Joseph said he would take all the concerns raised to a meeting with the Health Minister on 20 March 2023.
8. Mike Hedges MS - Any other business
Mike Hedges MS asked if anyone had any other business. They didn’t, so he thanked everyone for attending and brought the meeting to a close.