Chronic obstructive pulmonary disease affects up to 4% of the population and is the fifth largest killer in the UK. It accounts for £800m of the NHS annual budget and is the single biggest cause of hospital admissions. When we started to focus on COPD in 2005, our services were fragmented, reacting to crises rather than preventing them and they had little co-ordination.

A county-wide initiative was set up to tackle rising costs. Then in 2009 our commissioning group of 16 practices was selected as an ICO pilot site. 

We knew that we had higher than expected admission rates for our population with the morbidity and mortality associated with it.

We now have an integrated COPD service that covers patients from screening and diagnosis through management in the community to hospital care.

COPD nurses run clinics, visit patients in their homes, sit in consultant appointments in the community, work with a new ‘virtual ward’ team and secondary care to ensure optimal care throughout the patient journey. 

COPD nurses

COPD nurses are at the core of all we do. Our first COPD nurse working with severely ill patients in the community was introduced in 2005. In 2008, in partnership with a pharma company, we did a seven-month pilot for an additional COPD nurse to work with practice nurses in surgeries with a higher number of emergency respiratory admissions to provide support, education and help with intensive management of patients who needed it.

When the ICO pilot began in 2009 we set up a community team of two specialist COPD nurses, a healthcare assistant and administrative support funded through our freed-up resources.

This team is now employed as part of our contract with our community services provider – County Health Partnerships – and runs clinics in one of our central primary care centres as well as visiting patients in their homes.

As well as still managing the very high-risk patients, defined initially as anyone who had been admitted to hospital for their COPD, their role has recently extended to patients who have also had an exacerbation. Where admission cannot be avoided, the
community COPD nurses work closely with secondary care to ensure the fastest possible discharge and continuity of care. And they work with GPs to
advise on medication and treatment plans.

The specialist nurses work very closely with GPs, practice nurses and other healthcare professionals in the community to prevent vulnerable patients slipping between the gaps.

But we have also introduced an extra layer of support to help patients who are showing signs of exacerbation or deterioration stay out of hospital.

Through our contract with County Health Partnerships we have split our population of 122,000 into three ‘community wards’.

Designed by the PBC, each ‘virtual’ ward is made up of a team of district nurses and healthcare assistants overseen by a community matron and with other specialist nurses they can draw upon.

Patient risk stratification software (the PARR tool) is used to identify patients with COPD who are at high risk of hospital admission, and who can then be ‘admitted’ to a community ward – essentially a multidisciplinary team that discusses what extra support might be needed to keep that patient at
home.

For these patients there is a monthly ‘community ward round’ meeting at the practice, attended by the GP, community matron, COPD nurse and district nurses.

Attached to this service is a crisis response team that can provide highly intensive support – up to four times a day if needed – over a five-day period to try to stabilise the patient’s condition without them having to go to hospital.

This is an extra level of support, not a replacement for the COPD nurse who continues to case-manage the patient through this period.

The experience of the team is that for many patients, this intensive management is enough to stabilise their condition and keep them out of hospital where they may well have deteriorated further.

Consultant clinic

Also as part of the ICO pilot, we commissioned a consultant to run monthly clinics at one of our primary care centres to save patients having to travel a considerable distance to the hospital in Nottingham.

The clinic is funded using freed-up resources and is a block contract with the acute hospital. Not only does it limit the patients’ travel, it also ensures greater collaboration between secondary and primary care. It also allows COPD nurses to sit in on the patient’s consultation to ensure consistency and compliance with management.

Patients are booked into this clinic if their disease gets to a point where they need more specialist care, for instance surgery.

There is the capacity to see six patients per month and it also provides the opportunity for clinical supervision for the COPD specialist nurses.

The consultant is also available once a week to GPs for phone advice for any issues with managing complex patients.

Exercise classes and pulmonary rehabiliation

We had long waiting times for pulmonary rehabilitation and before 2009 the service was not providing enough access. Through County Health Partnerships we now employ a respiratory physiotherapist in the specialist team.

Using NICE guidelines we also redrew the service specification to make sure patients are receiving
the best possible care and that waiting times are minimal.

Once patients have received pulmonary rehabilitation they are offered exercise classes in a local leisure centre delivered by a respiratory-trained fitness instructor. This service helps turn the short-course rehabilitation into longer-term lifestyle changes and encourages compliance.

It was initially funded by the PBC consortium and the charity Breathe Easy, and is now self-funding with exercise classes paid for by users.

The result

Feedback from patients has been very positive, especially about their reduced anxiety levels – knowing that there is support available if their condition suddenly worsens.

In 2011/12 emergency hospital admissions for COPD sufferers dropped below 700, whereas in 2010/11 there were more than 800 and in 2009/10 more than 900. And costs for admission have gone from more than £800,000 in 2005 to less than £600,000 in 2010.

To put these figures in context, admissions over this period for the rest of Nottinghamshire rose, as did the costs of treating COPD.

We now have a clear COPD care pathway, with clinicians having access to the most up-to-date care plans.

The future

A telehealth system – Flo - is currently being piloted with COPD patients as part of a Nottinghamshire-wide study. All the patient needs is a mobile phone, and it helps provide reassurance to those struggling to cope with complex health needs.

It sends text advice and reminders. The system now has the capacity to share patient information with healthcare professionals.

The CCG will be looking at the results of the pilot to inform future roll-out.

Figures show that there is still large variation within practices in terms of the number of COPD cases that were observed compared with the number that would be expected.

During 2010/11 there were 1,463 observed cases
of COPD compared with 2,536 expected cases.

Within practices, this varied from 36% of
the expected number of COPD cases to 79%,
suggesting that not all people who have COPD
in our practices have been identified.

We have established several strategies to identify those ‘missing’ patients to ensure they are receiving optimal treatment. This includes education programmes run by the COPD nurses and screening days to replicate a successful British Lung Foundation ‘Love your lungs’ event held last year. The specialist nurses will also work with practices to address issues with the quality of spirometry.

We are starting to introduce systematic use of standardised templates and patient-held care plans across the CCG.

Most practices already have these but do it in different ways. And we are planning a COPD case-finding project through the use of FEV6 monitors and pharma support in the next few months.

In practice: how the service improves patient experience and reduces admissions

Mrs Smith was diagnosed with COPD three years ago. She visits her GP when she becomes unwell with a chest infection.

Her GP refers her to the specialist COPD nurse who visits her at home the same day and helps manage her infection. She is prescribed steroids and an antibiotic, which prevents her getting worse and needing hospital treatment.

As part of follow-up, the COPD nurse advises the GP on optimising her inhalers, organises a prescription of steroids and antibiotics to keep at home in case of another infection and teaches Mrs Smith how to monitor her condition.

It is decided that pulmonary rehabilitation would be useful and she is referred to a specialist physiotherapist at a nearby health centre. She continues to have regular reviews with her practice nurse, where she negotiates a care plan that is renewed each year.

Through this care plan she knows how to access the practice for advice at short notice and also the out-of-hours service when required.

Over the years, Mrs Smith starts to deteriorate and has more infections. Her lung function and breathlessness get worse so she is referred back to the COPD nurses for case management.

They visit her at home regularly and she is given their number to call if needed, as well as the number of the GP practice.

During one of her exacerbations she is struggling to wash and dress herself and the COPD nurse refers her to the urgent community support service who visit several times a day to help her with personal care for two weeks until she gets better.

As she is at high risk of hospital admission, her condition is regularly reviewed at community ward round meetings.

The GP seeks advice from the respiratory consultant based in the community.

A meeting with the consultant leads to medication changes but eventually Mrs Smith’s condition deteriorates to the extent that she is unable to care for herself, and requires help with personal care via a care package co-ordinated by the community matron and the GP.

The GP visits her at home and they discuss end-of-life care. Mrs Smith expresses the preference to not be admitted to hospital any more and not to be resuscitated, which with the GP’s support is discussed with family members.

Some weeks later, Mrs Smith develops another infection and, despite treatment, deteriorates quickly. The GP, district nurses and matron co-ordinate terminal care, communicating with the out-of-hours services and the family, providing medication that can be administered to relieve pain or distress.

Mrs Smith dies at home the next day.