Introduction
This programme covers the entire respiratory tract. It is the domain of the general practitioner, respiratory specialist nurse, physiotherapist, respiratory physician, thoracic surgeon, and, to a lesser extent, the ENT (ear, nose and throat) surgeon (excluding deafness which is included in programme 9, hearing problems).
The programme includes diseases of the nose and throat, pneumonia, tuberculosis, bronchitis, asthma, emphysema, chronic obstructive pulmonary disease, occupational lung diseases, and respiratory failure. Tumours are dealt with in programme 2 (cancers).
Radiological imaging and bronchoscopy are important diagnostic steps in some patient pathways.
Avoidance of smoking and promotion of physical activity are the main health promotion issues. Also important are indoor and outdoor air quality, so there are major partnership possibilities with other agencies.
Measurement of outcomes should include avoidance of premature mortality (dying before one's time, e.g., 75 years), because "bronchopneumonia" features as a common cause of death in otherwise uncomplicated and expected death in old age.
Questions for each programme budget category
Consider constructing a list or grid like the table below. This table uses examples developed from Norwich Primary Care Trust (PCT). The table is divided into aims, objectives, actions, and costs.
Patients and clinicians should be involved at every level. The tables, as they evolve should be published—for example, on the PCT website—so that everyone can see their development.
General questions to think about:
- What are the main health issues in each programme?
- Who are the major players (including patients every time, and often non-NHS agencies) and how will they be engaged?
- What are the programme's broad aims and specific objectives? Try to make the objectives ‘SMART’ (specific, measurable, ambitious, realistic, and time-bound).
- Set objectives at each stage in the patient pathway—for example: protecting good health; getting a rapid diagnosis and assessment; going for full cure; supporting chronic illness where cure is not possible; easing the passing (a well managed death).
- What are the main unmet needs and any striking inequalities?
- What are the programme inputs (programme budget) at present?
- What outputs are being generated?
- What outcomes are being generated?
- What ideas can be generated for starting and stopping programme activities to get a better fit between resources and objectives. (Start by looking within programmes before looking between programmes.)
Programme objectives for respiratory system problems
Examples of aims, objectives, and actions are based on those from Norwich PCT.
| Aims | Objectives | Action: stopping or starting | Value (£) +/– |
| TIPS: These should draw on national service frameworks or strategies where they exist. They should be limited in number, but there should be at least five that cover the steps in the patient pathway. | TIPS: These should be drawn directly from the aims. There will usually be more than one objective for each aim. Objectives should be smart. | TIPS: These should be drawn from the objectives. There may be more than one and they should relate to disinvestment (cutting back on some areas) and new investment. All these suggested actions should be formulated by a marginal analysis advisory group and tested for changes in cost and benefit at the margin. | TIPS: Every action should be costed whether that means cash releasing (saving), cash neutral, or cash requiring. The discipline is to keep the total in the cost column within the programme budget set by the PCT. |
| 1. To improve the respiratory health of the population of the PCT by attention to indoor and outdoor air quality (including smoke-free environments) | Increase smoking cessation activity | Explore greater role for community pharmacists | - |
| 2. To improve prevention of respiratory disease | Reverse the rising incidence of tuberculosis | Screen new arrivals and births from high-risk countries or families Target schools' vaccination programme for those who are at greatest risk | - |
| 3. To improve diagnosis of respiratory disease | - | Audit urgent referrals for bronchoscopy according to National Institute for Health and Clinical Excellence (NICE) guidelines | - |
| 4. To improve treatment of respiratory disease | Reduce premature mortality from respiratory diseases (e.g., under age of 75 years) Reduce "avoidable deaths" such as those shown in the regional annual asthma deaths audits | Explore greater role for community pharmacists in training and monitoring of patients' use of asthma medicines | - |
| 5. To improve rehabilitation of people with respiratory disease | Provide a safe level of treatment and follow-up for patients with tuberculosis | Offer pulmonary rehabilitation classes for all eligible patients on discharge | - |
Author
Dr Peter Brambleby
Dr Peter Brambleby has a clinical background in child health and 20 years’ experience in public health, including five years as Director of Public Health in the former Norwich PCT. He currently serves on the National Programme Budgeting Project Board and related working groups. He has a long-standing interest in trying to match health needs to health spending, and to getting public and clinical engagement in that process. From 1 July 2007, Peter will be the Director of Public Health at North Yorkshire and York PCT.