Dr Steve Holmes (left) and Jane Scullion discuss how the outcomes strategy for COPD and asthma emphasises the need for integrated care and cross-boundary working
The NHS is already under financial and resource pressures and faces further challenges and demands. Increasingly, healthcare professionals are being asked to work towards the Quality, Innovation, Productivity, and Prevention (QIPP) agenda.1 As clinicians and managers, we are bombarded constantly with guidance, strategy documents, directives, and advice to change our systems and practice. Earlier this year, yet another strategy document was launched by the Department of Health—so why should healthcare professionals pay particular attention to this one compared with the myriad of other documents that are available? The Outcomes strategy for chronic obstructive pulmonary disease (COPD) and asthma in England2 is important if we believe in quality patient care and directing our healthcare resources effectively, and if we want to address the big issues in healthcare (e.g. costs, inequalities).
Impact of COPD and asthma
Chronic obstructive pulmonary disease is the second most common cause of acute hospital admissions and is responsible for over 25,000 UK deaths per year. It is a major contributor to morbidity level and funding requirements for social support.3 This condition is to a significant extent preventable, and there are effective treatments available for people living with COPD. Furthermore, many people are unaware that they have a disease which if untreated, could seriously reduce their lifespan and their quality of life.4
Asthma is the commonest symptomatic long-term condition and chronic condition in childhood, often affecting people throughout their lives. Like COPD, asthma is one of the most common reasons for hospital admission and costs the NHS £850 million annually5 and it is acknowledged that there are wide variations in the provision of its care.2
The management of COPD and asthma is a very common aspect of UK daily practice in both general practice and emergency departments. These conditions compose a substantial part of out-of-hours care and account for a significant number of hospital admissions and deaths. Asthma and COPD are also present in virtually all areas of the secondary care environment as they are common in many patients who are admitted to hospital for other causes. Therefore, the outcomes strategy impacts on all healthcare professionals.
Principles and themes of the outcomes strategy
The outcomes strategy for COPD and asthma2 builds on the recommendations in the draft consultation strategy3 and aims to bring about significant improvements in outcomes for patients with respiratory conditions. It provides healthcare professionals with a direction of travel that acts as a focus for interventions and encourages development of services. As a fundamental principle, the outcomes strategy aims to address variation in care by providing a visionary and strategic view that builds on the recommendations of the consultation document (see Table 1).6
The outcomes strategy is governed by three underpinning principles:2
- Improving quality of care
- Adopting a long-term approach
- Working across boundaries.
The strategy recognises that to improve the quality of care, a long-term plan is needed rather than the reactive 'quick-fix' approach that we have often been guilty of in the past. It is no longer considered acceptable to diagnose and initiate treatment late in disease progression when we have good evidence for the benefit of early treatments (the benefit of stopping smoking is a minimum starting point).
Diagnosis and management of respiratory conditions late in the disease trajectory results in increased admissions and more costly treatments. The strategy also recognises the:2
- value of public health, promotion of lung health and prevention, and smoking cessation interventions
- impact that COPD has on a person's social life
- importance of integrated care from the healthcare perspective, and in collaboration with social care.
Working across healthcare and social care boundaries, and primary and secondary care settings will help to drive up standards of care, and have a real impact. A strategic vision is required as many of our preventive actions will potentially not demonstrate results for many years.
Key themes in the outcomes strategy include:
- addressing variations in practice
- improving outcomes for people with COPD and asthma, with a focus on morbidity and mortality
- involving clinicians in the process.
The outcomes strategy recognises that clinicians on the frontline can drive up quality and improve outcomes for patients. Healthcare professionals, particularly those in primary care, are well placed to understand the needs of their local population, as they have contact with patients and families across their lifespan. Respiratory health is important across the whole life course, from maintaining health and wellbeing through diagnosis and proactive management of symptoms, encompassing episodes of worsening and end-of-life care.
The emphasis on provision of integrated services that are based around the needs of individuals fits within primary care as the vast majority of care for patients with respiratory conditions is undertaken in this setting. Respiratory health and chronic ill health do not exist in a vacuum, and social and psychological needs often predominate over medical requirements. Under certain circumstances, a greater increase in quality of life can be obtained from improving housing or increasing benefits, or provision of simple aids (e.g. support with bath/shower, wheelchairs, motorised scooters) compared with use of pharmacological options.
The outcomes strategy includes six shared objectives to improve outcomes that are relatively broad in range and which can be applied at a local level in terms of individual population needs. These objectives provide aspirational targets for improving the care of patients with COPD and asthma (see Table 1).2,3
It is suggested that the principles of the outcomes strategy are remembered using the acronym, REACT:
- Respiratory health and good lung health
- Early accurate diagnosis
- Active partnership between healthcare professionals and people with COPD
- Chronic disease management (or control of symptoms)
- Tailored evidence-based treatment for the individual.
Respiratory health and good lung health
The emphasis in promotion of respiratory and lung health has shifted from a reactive to a proactive healthcare approach. This area primarily focuses on primary prevention, earlier smoking cessation interventions, and the importance of a healthy active lifestyle. The value of smoking cessation cannot be underestimated7 and there is a case for suggesting that every healthcare professional should be trained and proficient in providing brief smoking cessation advice and be aware of local stop-smoking services. Increasingly, there is recognition that other forms of inhaled drugs (e.g. cannabis) can have a significant impact on lung health.8
Early accurate diagnosis
A timely diagnosis enables clinicians to work with patients to improve their long-term outcomes by treating COPD early enough to potentially have an effect on reducing future morbidity and mortality. Practices need to be considering proactive case finding.9,10
Primary care is challenged by guidelines to improve the quality and reliability of spirometry.11 There is particular concern that despite guidance recommending the use of spirometry at diagnosis and time of discharge,12,13 this is not being implemented. The national audit on COPD care within the UK highlighted that only 55% of people discharged from hospital with a specialist diagnosis of the disease have any evidence of spirometry in their notes within the preceding 5 years (even though 42% had been seen in a specialist clinic).14,15 With barely half of patients undergoing spirometry in specialist care, we have to consider how the diagnosis was made, and review misdiagnosis, underdiagnosis, and overdiagnosis across all healthcare environments.
Active partnership between healthcare professionals and people with COPD
Chronic obstructive pulmonary disease is a long-term disease and healthcare professionals have to work with people to understand their wishes and beliefs and desires. Outcomes (including chronic disease management or control of symptoms) cannot be improved without active involvement of the patient. This partnership should include shared decision making and effective communication. There is good evidence that the quality of care provided to people with COPD needs improving particularly for individuals approaching end of life. An Improving and Integrating Respiratory Services in the NHS (IMPRESS) resource has highlighted a gap in care received by people with COPD compared to that received by those with cancer.16
Tailored evidence-based treatment for the individual
There is a growing evidence base for the care, management, and treatment of respiratory disorders.12,17 However, this evidence needs translating into the highest-quality practice to truly impact on the management of COPD and asthma. One of the major areas identified within the outcomes strategy and indeed in many publications is the unexplained variation in practice (both diagnosis and management) across the UK.4,14, 18–21
|Table 1: Recommendations and outcomes for COPD and asthma care2,6|
Recommendations from the consultation on the national strategy for COPD
Six shared objectives from the outcomes strategy
for COPD and asthma in England
Prevention and identification
|To improve the respiratory health and wellbeing of all communities and minimise inequalities between communities|
Finding the missing millions
|Reduce the number of people who develop COPD by ensuring they are aware of the importance of good lung health and wellbeing, with risk factors understood, avoided, or minimised, and address health inequalities proactively|
|Reduce the number of people with COPD who die prematurely through a proactive approach to early identification, diagnosis and intervention, and proactive care and management at all stages of the disease, with a particular focus on the disadvantaged groups and areas of high prevalence|
High-quality care and support
|To enhance quality of life for people with COPD, across all social groups, with a positive, enabling experience of care and support right through to the end of life|
|To ensure that people with COPD, across all social groups, receive safe and effective care, which minimises progression, enhances recovery, and promotes independence|
|To ensure that people with asthma, across all social groups, are free of symptoms because of prompt and accurate diagnosis, shared decision making regarding treatment, and ongoing support as they self-manage their own condition, and to reduce need for unscheduled healthcare and risk of death|
|COPD=chronic obstructive pulmonary disease
Adapted from Department of Health. An outcomes strategy for chronic obstructive pulmonary disease (COPD) and asthma in England. London: DH, 2011.
Many clinicians and commissioners across boundaries are keen to develop services in line with the standards set out in the outcomes strategy, and work towards its aspirational aims. Considerable work has already been undertaken by a collaboration between the British Thoracic Society and the Primary Care Respiratory Society UK to help inform quality and integrated service development. Additional documentation is available that provides guidance on achieving the QIPP agenda, suggestions on service specifications, and clinical practice in other environments.22–24
This outcomes strategy will have a considerable impact on our health service. It is supported by the NICE quality standard for COPD,25 giving us a framework with which we can improve the care of respiratory conditions. Healthcare professionals now have a considerable number of resources on improving respiratory care, which include the draft consultation strategy document, the outcomes strategy, and the NICE quality standard for COPD. It is anticipated that additional documentation to help guide progress will be available over the forthcoming months. There is already good-quality evidence and support available, and this article has highlighted areas for improvement (e.g. improving diagnosis and use of spirometry).
- Department of Health. The NHS Quality, innovation, productivity and prevention challenge: an introduction for clinicians. London: DH, 2010. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_113806
- Department of Health. An outcomes strategy for chronic obstructive pulmonary disease (COPD) and asthma in England. London: DH, 2011. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_127974
- Department of Health Respiratory Team. Consultation on a strategy for services for chronic obstructive pulmonary disease (COPD) in England. London: DH, 2010.
- British Lung Foundation. Invisible lives. London: British Lung Foundation, 2007.
- The Respiratory Alliance. Bridging the gap. Commissioning and delivering high-quality integrated respiratory healthcare. Berkshire: Direct Publishing Solutions, 2011.
- Scullion J, Holmes S. COPD national strategy quick reference guide. www.pcrs-uk.org/copd_qrg/ (accessed 2 November).
- Hoogendoorn M, Feenstra T, Hoogenveen R, Rutten-van Mölken M. Long-term effectiveness and cost-effectiveness of smoking cessation interventions in patients with COPD. Thorax 2010; 65 (8): 711–718.
- Tashkin D. Does cannabis use predispose to chronic airflow obstruction? Eur Respir J 2010; 35 (1): 3–5.
- Frith P, Crockett A, Beilby J et al. Simplified COPD screening: validation of the PiKo-6 in primary care. Prim Care Resp J 2011; 20 (2): 190–198.
- Jordan R, Lam K, Cheng K et al. Case finding for chronic obstructive pulmonary disease: a model for optimising a targeted approach. Thorax 2010; 65 (6): 492–498.
- Levy M, Quanjer P, Booker R et al. Diagnostic spirometry in primary care: proposed standards for general practice compliant with American Thoracic Society and European Respiratory Society recommendations: a General Practice Airways Group (GPIAG) document, in association with the Association for Respiratory Technology & Physiology (ARTP) and Education for Health. Prim Care Respir J 2009; 18 (3): 130–147.
- National Clinical Guideline Centre. Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update). Clinical Guideline 101. London: NICE, 2010. Available at: www.nice.org.uk/guidance/CG101/Guidance/pdf/English
- National Institute for Health and Care Excellence. The diagnosis and treatment of lung cancer. Clinical Guideline 121. London: NICE, 2011. Available at: www.nice.org.uk/guidance/CG121
- Royal College of Physicians of London, British Thoracic Society and British Lung Foundation. The national chronic obstructive pulmonary disease audit 2008: clinical audit of COPD exacerbations admitted to acute NHS units across the UK. RCP, BTS, BLF, 2008. Available at: www.rcplondon.ac.uk/resources/chronic-obstructive-pulmonary-disease-audit
- Royal College of Physicians of London, British Thoracic Society and British Lung Foundation. The national chronic obstructive pulmonary disease audit 2008: survey of COPD care within UK general practices. RCP, BTS, BLF, 2008. Available at: www.rcplondon.ac.uk/resources/chronic-obstructive-pulmonary-disease-audit
- Holmes S, Scullion J, McKinlay R et al. Effective care—effective communication: living and dying with COPD. Educational package. 2008. www.impressresp.com/PatientPublicengagement/LivingandDyingwithCOPDDVD.aspx
- British Thoracic Society, Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. SIGN 101. Edinburgh: SIGN, 2011. Available at: www.sign.ac.uk/guidelines/fulltext/101/index.html or www.brit-thoracic.org.uk/guidelines/asthma-guidelines.aspx
- Richards S. Should the NHS strive to eradicate all unexplained variation? Yes. BMJ 2009; 339: b4811.
- Lilford R. Should the NHS strive to eradicate all unexplained variation? No. BMJ. 2009; 339: b4809.
- Yawn B. Factors accounting for asthma variability: achieving optimal symptom control for individual patients. Prim Care Resp J 2008; 17 (3): 138–147.
- Asthma UK. The asthma divide: inequalities in emergency care for people with asthma in England. 2007.
- Williams S, Restrick L, Davison T et al. More for less: discussion paper to inform the implementation of the strategy for services for chronic obstructive pulmonary disease (COPD) in England, the service framework for respiratory health and wellbeing in Northern Ireland, service development and commissioning directive (chronic respiratory conditions) in Wales and the clinical standards programme (COPD) in Scotland within the context of limited resources. London: IMPRESS, 2010. Available at: www.impressresp.com/
- Scullion J, Gaduzo S, Restrick L et al. Rationalising oxygen use to improve patient safety and to reduce waste: the IMPRESS step-by-step guide. London: IMPRESS, 2010, revised 2011. Available at: www.impressresp.com/
- Kinnula V, Vasankari T, Kontula E et al. The 10-year COPD programme in Finland: effects on quality of diagnosis, smoking, prevalence, hospital admissions and mortality. Prim Care Respir J 2011; 20 (2): 178–183.
- NICE website. NICE COPD quality standard. www.nice.org.uk/guidance/qualitystandards/chroicobstructivepulmonarydisease/copdqualitystandard.jsp (accessed 2 November 2011). G