Dr Richard More demonstrates how Somerset GP practices combined to provide better local facilities for treatment of patients with chronic obstructive pulmonary disease
Chronic obstructive pulmonary disease (COPD) covers the group of diseases that includes chronic bronchitis, emphysema, and small airways disease. These illnesses are familiar to every general practice team but do not always receive the priority they deserve in view of the fact that COPD is the fifth greatest cause of death in the UK,1and is responsible for more than 30,000 deaths each year.2Unlike other major fatal diseases, the mortality rate from COPD is increasing rather than decreasing.3
For Somerset PCT (which serves about 520,000 patients) there were 588 admissions attributed to COPD in the year 2006/07, which represented approximately one in eight of all hospital admissions within the PCT.4
What do guidelines recommend?
Guidelines on the diagnosis and treatment of COPD have been published by NICE,5the Global Initiative for Obstructive Lung Disease (GOLD),3and the British Thoracic Society (BTS).6However, not all patients are yet receiving the best care possible.7
Currently the vast majority of COPD patients are already being cared for in general practice, based on standards in the quality and outcomes framework (QOF).8
For the busy GP and specialist practice nurse there are extra suggestions in the published guidelines that are not emphasised in the QOF. These include:
- using spirometry to make the correct diagnosis of disease severity3,5,6
- optimising medication by making appropriate use of inhaled corticosteroids and long-acting bronchodilators9
- referring the patient, where appropriate, for pulmonary rehabilitation, including education about the disease, physical training, and nutritional, behavioural, and psychological interventions.5–7This requires accurate spirometry
- emphasising self-management, particularly planning for future episodes and the early treatment of exacerbations3,5,6—in practice this means the provision of ‘just in case’ antibiotics and steroids
- referring hypoxic patients for long-term oxygen therapy, which reduces mortality.6
The Somerset response
Nationally there is a lack of provision for patients with COPD.7 From a historical perspective, care centred around a particular illness has been provided by hospitals but there is a Government drive to provide these specialist services closer to the patient’s home, not tied to an in-patient facility.10The approach in Somerset was consistent with this desire to provide care closer to the patient’s home.
In 2006, the majority of Somerset general practices came together to form a single, large, county-wide, practice-based commissioning (PBC) group (WyvernHealth.com). This group currently counts 74 of the 75 practices in Somerset as members. The move was fully supported by the PCT, and allowed development of detailed plans to make large-scale changes for healthcare. The initial priorities were aimed at reducing emergency admissions, and managing COPD in a new and better way is critical to that plan.4
At the same time, a Somerset GP, Dr Robin Carr, in his capacity as trustee of a local patient support group, was researching patient priorities for local improvements.10 The key messages from this patient group were the desire for:12
- access to free prescriptions
- better access to supported exercise
- empowerment through education
- ‘permission’ to self-manage their care.
The challenge was to deliver these aspirations. Responsibility for providing illness-centred care rests on either general practices, which are juggling wholescale organisational reform such as the ‘GP-led health centre’ initiative, or hospital outpatient departments, which have to deal with the whole gamut of serious illness.
By the Spring of 2007, the PBC group was set up and was looking to commission COPD care in new and better ways, while the providers were looking to deliver care in the same manner. A new team was needed that combined the benefits of a special interest in COPD, but which was also community based and resourced to provide detailed assessment and ongoing support for patients with COPD.
The clinicians in the new group analysed what skills and resources would be needed and realised that experienced and proficient management support was required. At the same time, the managerial input should not be allowed to detract from the clinical importance of the original ideas. It was clear this would require the creation of a brand new healthcare provider, and equally clear that creating this organisation, securing the contract to deliver services, and implementation would be a bigger challenge than defining the care pathways.
The PCT accepted in full the commissioning recommendations of the PBC group, and commenced a tender process to find a suitable provider.
After an exhaustive process of prequalification questionnaire, presentations to the appointments committee (including patient representatives, GPs, community COPD experts and PCT officers) and a detailed tender, the contract was awarded to Clinovia, working in partnership with Avanaula, the company formed by those Somerset GPs with an interest in delivering COPD care.
Clinovia had previous experience of providing complex care in the community, including caring for patients who are chronically ventilator-dependent at home. The company also provided resources to complete tenders and recruit and train skilled community nursing staff. These factors made them ideal partners to help turn these ideas into action.
Community COPD service
The Community COPD service provides structured care for those who are most likely to need hospital admission. This includes people who have:
- a forced expiratory volume (FEV1)/forced vital capacity (FVC) ratio <70% and an FEV1 <50%
- been admitted with COPD within the past year
- breathlessness rated as three or greater on the MRC dyspnoea scale
- been receiving oxygen to relieve their COPD.
The service accepts patient referral from any clinician, but it must be based on a confident diagnosis of COPD and possible confounding co-morbidities must have been reasonably assessed. In practice this means that the bulk of referrals will either come from general practice or will be referred in conjunction with general practice.
Patients may be identified from:
- individual case findings in general practice
- systematic notes review in general practice
- hospital discharge information
- the oxygen therapy register.
Figure 1: Core service model
Care of the patient follows a core service model as shown in Figure 1.
The patient is initially seen in an assessment clinic where they may spend up to 90 minutes with a specialist nurse. This process gathers together not just the clinical knowledge but also information on the patient’s expectations and an understanding of their support network. The complete picture is essential for an understanding of the factors that may lead to hospital admission during an exacerbation of COPD. At the end of the assessment process the patient is given a detailed written management plan. This includes:
- the results of the clinical assessment
- advice on how to recognise an acute exacerbation
- a pre-agreed action plan should the patient suffer an acute exacerbation
- a record of further planned care with a section for patients to record their own wishes and points.
This written information is then available for all clinical professionals who may be involved in the patient’s care in the future, for example out-of-hours doctors, hospital doctors, paramedics, community matrons, and others.
The specialist nurse will also make recommendations about other treatments, both pharmacological and non-pharmacological, based on the assessment. These may include advising a change of medication, or a course on pulmonary rehabilitation, nebuliser therapy, or oxygen therapy. A summary is then sent to both the referring clinician and the patient’s GP. One of the commonest recommendations is for general practice to provide a ‘just in case’ course of antibiotics and steroids. Information published since release of the BTS and NICE guidance has emphasised the importance of early treatment of exacerbations.12The nurse also assesses the need for further referral to other teams such as social services, hospice care, etc.
Setting up this new service has been very time-consuming but also very rewarding. It is important that the PCT has purchased the community COPD service in addition to the existing services, which has avoided disruption to existing providers. Despite this, there have been a range of responses to this new initiative, the vast majority of which support the change because of its clear benefit for patients. Undoubtedly some unsuccessful clinical teams found the investment of time without reward difficult.
The provision of a new service, which is evidence based to reduce mortality and morbidity, has placed a new responsibility on general practice of correctly identifying patients that would benefit from this intervention. Prior to the availability of the new service there was little value in correctly using spirometry and the MRC breathlessness scale to stratify patients according to risk because there was little that could be done with the result. To help practices take on this new burden, a practice nurse education programme is also being developed.
We have learned from this project that it is simply not enough to be able to articulate the best way of caring for patients. The benefits to the taxpayer and the patients only start when the service is up and running. The ability to overcome the many problems that setting up a new service presents (see Box 1 for key advice) is just as important as being able to articulate the care pathway.
Box 1: Key advice for teams setting up a new service
- COPD is a major cause of hospital admission, morbidity, and emergency admission costs
- It is particularly suitable to structured elective intervention to prevent emergency admissions
- A coordinated evidence-based community assessment programme for more severe cases can benefit patients and reduce spend against the PBC budget
- Individual management plans are crucial to coordinate self care, primary care, and out-of-hours care
- Tariff costs:a
- thoracic medicine outpatient £217 (new), £104 (follow up)
- COPD emergency admission £1718 (2–17 days)
- National Statistics. Health Statistics Quarterly 30. Office for National Statistics: London, 2006.
- Department of Health. Annual Report of the Chief Medical Officer 2004 on the state of public health. DH: London, 2005.
- Rabe K, Hurd S, Anzueto A et al; Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med 2007; 176 (6): 532–555.
- Somerset practice based commissioning group. Somerset practice based commissioning group—the challenge of reducing avoidable emergency admissions. 2007. www.WyvernHealth.com
- National Institute for Clinical Excellence. Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in primary and secondary care. Clinical Guideline 12. London: NICE, 2004.
- The COPD Guidelines Group of the Standards of Care Committee of the BTS. BTS guidelines for the management of chronic obstructive pulmonary disease. Thorax 1997; 52 (suppl 5): S1–S28.
- Healthcare Commission. Clearing the air—a national study of chronic obstructive pulmonary disease. London: Commission for Healthcare Audit and Inspection, 2006.
- British Medical Association. www.bma.org.uk/ap.nsf/Content/focusQOF0308
- MacNee W, Calverley P. Chronic obstructive pulmonary disease. 7: Management of COPD. Thorax 2003; 58 (3): 261–265.
- Department of Health (2006) Our health, our care, our say; a new direction for community services. www.dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_4127453 Accessed 29 June 2008.
- Dr Robin Carr (2006) Personal Communication
- Wilkinson T, Donaldson G, Hurst J et al. Early therapy improves outcomes of exacerbations of chronic obstructive pulmonary disease. Am J Resp Crit Care Med 2004; 169 (12): 1298–1303.G