Table 2 Breathing SPACE—challenges for commissioners of health and social care

Invest in a population-based approach, describing aims, objectives, and criteria to evaluate the impact of a breathlessness system. Adapt and develop local provision to reduce waste and increase value: know your neighbourhood and local services (tobacco dependence, obesity and physical activity services will vary considerably in the United Kingdom and internationally).

1. Define the scope of the breathlessness system.

2. Define the population to be served, which may include sub-populations or segments at different levels of complexity and activation requiring different services. It may include people with complex needs, such as homeless people, who are known to many service providers, including General Practitioner, ambulance services, emergency departments, and respiratory departments, who would benefit from better care coordination to improve their breathlessness.

3. Reach agreement on the aim and objectives of the services provided by the system, also considering options for disinvestment.

4. For each objective, agree one or more criteria by which the performance of the service would be assessed.

5. For each of the criteria, identify levels of performance that can be used as quality standards, based on the data locally available.

6. Identify all the resources used in the system, thus creating a breathlessness budget, including clinical staff, equipment, diagnostic tests, hospital beds, prescribing budgets, estates, and administration.

7. Identify who needs to be engaged in a clinical network that will provide collective leadership for the system and be accountable for its performance.

8. Produce a breathlessness system specification, which can be used for contractual arrangements between providers and payers.

9. Agree upon an evaluation framework to assess the impact of the breathlessness system.

Commission smoking cessation services—local authority and clinical commissioners should work together to consider where smoking cessation services will have the greatest impact on their joint outcome measures. These are extremely of high value compared with other health interventions and must be protected.

Nine million people still smoke in the United Kingdom—increasingly concentrated in harder to reach groups. Incorporate smoking cessation into care pathways for mental health services, people admitted to hospital, and the homeless.

Commission pathways for breathlessness diagnostics that can address both cardiac and respiratory causes from general practice to specialist units. The IMPRESS decision support tool provides an outline of the key decision-making processes in these clinical encounters (https://www.networks.nhs.uk/nhs-networks/impress-improving-and-integrating-respiratory/news/impress-breathlessness-resources)

Systems should address the under-diagnosis and treatment of cardiac disease in people with respiratory diagnoses, and the under-diagnosis and treatment of respiratory disease in people with cardiac diagnoses

Ensure that palliative care services are also available for patients with breathlessness due to non-malignant conditions

Parity of esteem—health systems need to address physical conditions in people with mental health problems

Commission pulmonary rehabilitation, as this is an extremely high-value intervention compared with other health interventions.

Attention to breathlessness in midlife has the potential to reduce sedentarism and the accumulation of multi-morbidities.