There is a high level of COPD in our small CCG which is made up of three practices on the coastal area of Lancashire.
In fact, our CCG has twice the national prevalence rate of COPD and it is the number one cause of unscheduled hospital admissions.
In my practice of 13,000 patients we have a respiratory team consisting of a full time respiratory nurse, part time health care assistant, community matron and sessional input from a community pharmacist, funded by the CCG. We had put this team in place to meet the primary care QOF standards on COPD and asthma.
We had managed to create further capacity within the practice to focus on COPD as a result of other work we had done on improving care for patients with diabetes, dementia and depression.
And we were able to use some of our commissioning savings to spend on the community matron (£57,000) and £24,000 towards a COPD rapid response team as part of improving care for COPD patients.
We set ourselves the task of reviewing some 400 COPD patients in our practice via a face-to-face review with a respiratory practice nurse or GP. It took one year to review all 400 patients which we did by booking in 10 patients a year at dedicated clinics in our practice.
The aim was to:
- Ensure we had diagnosis right using spirometry testing
- Ensure all patients had a self-management plan to implement in the event of an exacerbation
- Review medication
- Ensure using pulmonary rehabilitation services if had a recent exacerbation
This was obviously a large task so we organised accreditation of our health care assistant to undertake the spirometry and took responsibilities off the practice respiratory nurse and one of the GPs so they could focus on this.
There was also weekend spirometry testing available within our CCG being done by nurses, funded by £2,000 of pharmacy sponsorship to identify new cases of COPD. It was aimed at smokers and 70% of patients attending screening sessions had abnormal spirometry. These patients then had full spirometry, including reversibility.
The pharma funded nurses had no bearing on our prescribing protocol (see below) which is in line with NICE guidance.
As part of the review we ensured every patient had a self-management plan and explained to them the importance of early intervention if their COPD worsened.
They were given stand-by medication – a course of antibiotics and oral steroids – with written instructions on when they should be taken on their own initiative without needing to seek medical advice.
To facilitate what should happen in the event of the stand-by medication being used, we introduced the 4 Rs so patients and staff were clear what should happen:
• Ring the surgery to inform us of the
exacerbation so that an appropriate
• Review can be arranged
• We can then Read Code the exacerbation,
• Replace their standby medication.
Following the ban on inhalers with CFCs, we found some 77 patients who had previously been taking salbutamol/anticholinergic products had been switched to salbutamol alone as this was the PCT directive at the time.
Symptom control in these patients was less than satisfactory and so we looked at the evidence on whether they should be switched to a LAMA or LABA.
Current NICE guidance (2011) leaves it open for GPs to prescribe either.
We made our decision before this guidance was out and opted for LAMAs being particularly encouraged by the 2008 UPLIFT study into their effectiveness and so all 77 patients were switched to a LAMA.
This obviously pushed our prescribing costs up but we were able to offset this by switching 105 patients from a unlicensed device for COPD (25μg salmeterol plus 50μg, 125μg or 250μg fluticasone) to a cheaper licensed device containing 50μg salmeterol plus 500μg fluticasone or formoterol or 400μg budesonide plus 12μg formoterol as these were the medication doses and devices used in clinical trials.
Our prescribing budget increased by some £10,000 but has been offset by the reduction in hospital admissions.
At the time this was available at our local community hospital but unfortunately this has now moved out of town to a leisure centre and our attendance rates have fallen because of lack of transport issues.
Referral for pulmonary rehab is naturally included in our COPD protocol. All appropriate patients were offered referral with a strong encouragement to attend.
Our work on COPD showed that the prescribing of steroids and bronchodilators had been somewhat hit and miss. The consistent use of sprirometry testing ensured we had the diagnosis right and that the patient was getting the right medication for their level of COPD control.
In 2008/9 my practice had 76 acute hospital COPD admissions while Broadway practice, the other practice in the CCG at the time had 46. In 2010/11 these reduced to 48 and 27 respectively saving £105,313.00 on COPD admission costs. In 2011/12 admissions for my practice were down even further to 41 COPD admissions.
The bulk of our work has been the self-management plans and medication changes.
It is impossible to be precise as to the effectiveness of each intervention but we believe they are complementary and our hospital admissions have clearly been greatly reduced.
Dr Mark Spencer is chair of Fleetwood CCG